Eastern Mediterranean La Revue De Santé De La Health Journal

EMHJ – Vol. 24 No. 8 – 2018 Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale Editorial Implementing WHO’s global strategy in the Eastern Mediterranean Region: what next? Ahmed Al-Mandhari...... 703 Research articles Socioeconomic factors associated with tobacco smoking in Turkey: a cross-sectional, population-based study Ceyda Sahan, Turkan Gunay, Hatice Simsek, Ahmet Soysal and Gul Ergor...... 705 Factors associated with smoking contemplation and maintenance among Iranian adolescents Hamidreza Roohafza, Razieh Omidi, Tahereh Alinia, Kamal Heidari, Gholamhossein Mohammad-Shafiee, Morid Jaberifar, Masoumeh Sadeghi and Wasim Maziak...... 714 Assessing sleep quality of Lebanese high school students in relation to lifestyle: pilot study in Beirut Ramez Chahine, Rita Farah, Michèle Chahoud, Alain Harb, Rami Tarabay, Eric Sauleau and Roger Godbout...... 722 Adapting life to the reality of diabetes Hossein Areshtanab, Hossein Moonaghi, Leila Jouybari, Vahid Zamanzadeh and Hossein Ebrahimi...... 729 Assessment of hepatitis B immunization programme among school students in Qatar Hamad Al-Romaihi, Hana Al-Masri, Sherine Shawky, Mohammed Al Thani, Salah Al Awaidy, Mohamed Al Janahi, Eastern Mediterranean Health Journal Muataz Derbala, Khalid Al-Ansari and Robert Allison...... 736 Validation of an Arabic version of the Yale Food Addiction Scale 2.0 Mounir Fawzi and Mohab Fawzi...... 745 Systematic review of priority setting studies in health research in the Islamic Republic of Iran Abbas Badakhshan, Mohammad Arab, Arash Rashidian, Mahin Gholipour, Elham Mohebbi and Kazem Zendehdel...... 753 Reviews Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression Kamal Gholipour, Mohammad Asghari-Jafarabadi, Shabnam Iezadi, Ali Jannati and Sina Keshavarz...... 770

Availability and safety of blood transfusion during humanitarian emergencies Vol. 24 No. 8 Yetmgeta Abdella, Rana Hajjeh and Cees Th. Smit Sibinga...... 778 Report

Contextual challenges and solutions to undertaking a household adolescent mental health survey – in a developing country 2018 Lilian Ghandour, Al Amira S. Shehab, Pia Zeinoun, Lucy Tavitian, Fadi Halabi and Fadi Maalouf...... 789 WHO events addressing public health priorities National population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators...... 800

The Eastern Mediterranean Regional Committee takes place in Khartoum, Sudan, in 2018, where the WHO Thirteenth General Programme of Work 2019–2023 will be discussed by the Member States in relation to the achievement of agreed Sustainable Development Goals by 2030. RC65 A5 notepad.indd 1 9/12/2018 2:22:16 PM

املجلد الرابع والعرشون / عدد Volume 24 / No. 8 2018 8 أغسطس/آب August/Août

Cover 24-08.indd 1-3 10/9/2018 5:44:47 PM Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services 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 collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.

EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm

EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/

EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web Correspondence of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Editor-in-chief Medicus for the WHO Eastern Mediterranean Region (IMEMR). Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 © World Health Organization (WHO) 2018. Some rights reserved. Nasr City, Cairo 11371 This work is available under the CC BY-NC-SA 3.0 IGO licence Egypt (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Disclaimer Email: [email protected] 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 WHO 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 and dashed 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 WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Subscriptions and Permissions

If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, publication and do not necessarily represent the decisions, policy or views of the World Health Organization. Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected]). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the ISSN 1020-3397 Eastern Mediterranean, at the above address; email: [email protected].

Cover 24-08.indd 4-6 10/9/2018 5:44:47 PM Vol. 24.08 – 2018

Editorial Implementing WHO’s global strategy in the Eastern Mediterranean Region: what next? Ahmed Al-Mandhari...... 703 Research articles Socioeconomic factors associated with tobacco smoking in Turkey: a cross-sectional, population-based study Ceyda Sahan, Turkan Gunay, Hatice Simsek, Ahmet Soysal and Gul Ergor...... 705 Factors associated with smoking contemplation and maintenance among Iranian adolescents Hamidreza Roohafza, Razieh Omidi, Tahereh Alinia, Kamal Heidari, Gholamhossein Mohammad-Shafiee, Morid Jaberifar, Masoumeh Sadeghi and Wasim Maziak...... 714 Assessing sleep quality of Lebanese high school students in relation to lifestyle: pilot study in Beirut Ramez Chahine, Rita Farah, Michèle Chahoud, Alain Harb, Rami Tarabay, Eric Sauleau and Roger Godbout...... 722 Adapting life to the reality of diabetes Hossein Areshtanab, Hossein Moonaghi, Leila Jouybari, Vahid Zamanzadeh and Hossein Ebrahimi...... 729 Assessment of hepatitis B immunization programme among school students in Qatar Hamad Al-Romaihi, Hana Al-Masri, Sherine Shawky, Mohammed Al Thani, Salah Al Awaidy, Mohamed Al Janahi, Muataz Derbala, Khalid Al-Ansari and Robert Allison...... 736 Validation of an Arabic version of the Yale Food Addiction Scale 2.0 Mounir Fawzi and Mohab Fawzi...... 745 Systematic review of priority setting studies in health research in the Islamic Republic of Iran Abbas Badakhshan, Mohammad Arab, Arash Rashidian, Mahin Gholipour, Elham Mohebbi and Kazem Zendehdel...... 753 Reviews Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression Kamal Gholipour, Mohammad Asghari-Jafarabadi, Shabnam Iezadi, Ali Jannati and Sina Keshavarz...... 770 Availability and safety of blood transfusion during humanitarian emergencies Yetmgeta Abdella, Rana Hajjeh and Cees Th. Smit Sibinga...... 778 Report Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country Lilian Ghandour, Al Amira S. Shehab, Pia Zeinoun, Lucy Tavitian, Fadi Halabi and Fadi Maalouf...... 789 WHO events addressing public health priorities National population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators...... 800

Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale

0000 TOC 24-08.indd 701 10/10/2018 12:31:10 PM Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor Phillip Dingwall Managing Editor

Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk

International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf

Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics)

Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors)

Administration Iman Fawzy, Marwa Madi

Web publishing Nahed El Shazly, Ihab Fouad, Hazem Sakr

Library and printing support Hatem Nour El Din, Metry Al Ashkar, John Badawi, Ahmed Magdy, Amin El Sayed

Cover and internal layout designed by Diana Tawadros and Suhaib Al Asbahi Printed by WHO Regional Office for the Eastern Mediterranean

0000 TOC 24-08.indd 702 10/10/2018 12:31:10 PM Editorial EMHJ – Vol. 24 No. 8 – 2018

Implementing WHO’s global strategy in the Eastern Mediterranean Region: what next?

Ahmed Al-Mandhari1

1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt

Citation: Al-Mandhari A. Implementing WHO’s global strategy in the Eastern Mediterranean Region: what next? East Mediterr Health J. 2018;24(8):703–704. https://doi.org/10.26719/2018.24.8.703 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

In May 2018, the Seventy-first World Health Assembly, One paper is devoted to each of the three strategic bringing together 194 Member States of the World priorities established in the new programme of work – Health Organization (WHO), unanimously adopted also known as the “triple billion”. GPW 13 commits WHO the Organization’s thirteenth General Programme of and its Member States to ensure that 1 billion more people Work 2019–2023 (GPW 13) (1). GPW 13 will guide WHO’s benefit from universal health coverage by 2023. What work for at least the next five years. It is closely linked does that mean for the Eastern Mediterranean Region? to the 2030 Agenda for Sustainable Development (2): The first technical paper(5) provides an analysis based essentially, it specifies strategic priorities and goals that on two conceptual tools: the framework for action to need to be achieved globally by 2023 to keep on track advance UHC in the Eastern Mediterranean Region and with achievement of the health-related Sustainable the UHC service coverage index (6,7). It presents a bleak Development Goals by 2030 (3). picture of the current situation. Little more than half the Region’s people have access to the basic health services GPW 13 was developed through extensive they need – 53% compared with a world population- consultation and there is strong commitment to it weighted coverage of 64%. However, projections suggest among WHO’s Member States. Now, however, comes the that a concerted effort by WHO and Member States to challenge of translating the global priorities and goals in implement recommended measures would see coverage the GPW document into detailed plans at country and increase to 60% within five years, meeting the Region’s regional level. That will entail extensive collaboration share of the 1 billion goal. between WHO and its Member States, including both one-to-one dialogues and collective deliberations. A second paper explores the goal of 1 billion people better protected from the impact of health emergencies The process is well underway in the Eastern (8). As might be expected, this also poses many challenges Mediterranean Region. WHO’s Eastern Mediterranean in the Eastern Mediterranean – the world region worst Regional Office (EMRO) is undertaking a comprehensive affected by emergencies. Work is ongoing globally to review of its functions in each country with the aim quantify how different world regions and countries can of identifying national priority issues in the light of contribute to the 1 billion target, and the paper does not GPW 13 and determining how WHO might best support seek to pre-empt that work, but it does identify significant governments and other partners to address them. potential to improve one key aspect of emergency Meanwhile, Region-wide strategy is being systematically preparedness and response: implementation of the public revised. In September 2018, policy-makers and technical health capacities required under the International Health experts from across the Region gathered at EMRO’s base Regulations (IHR 2005). in Cairo for an intensive five-day workshop to develop The third strategic priority set by GPW 13 is strategic plans covering major priority areas of work. promoting health and well-being. As the related technical Those draft plans will be shared with Member States and, paper makes clear, this poses challenges for all WHO taking into account their feedback, the detailed road map Member States in the Region (9). Communicable diseases that guides WHO’s work will be updated (4). are a concern in many countries, while the highest- The 65th session of the Regional Committee for the income countries can make major improvements to Eastern Mediterranean, to be held in Khartoum, Sudan, public health by tackling communicable diseases. The on 15-18 October 2018, will be another crucial stage in paper does not attempt to calculate the number of people implementing GPW 13. Regional Committee is the in the Region who might reasonably be expected to main formal governance mechanism for WHO in the benefit from improved health promotion measures, but Eastern Mediterranean, and a wide range of business instead recommends four new frameworks for action – will be considered at the session, but the agenda focuses covering obesity prevention, tobacco control, health and heavily on GPW 13. Four out of five of the technical the environment, and preconception care – which should papers prepared by the WHO Secretariat for discussion help to improve outcomes across the Region. by Member States explore the implications of GPW 13 for A fourth technical paper introduces the country the Region. functional review process mentioned above, which

703

00 Editorial 24-08.indd 703 10/10/2018 12:33:11 PM Editorial EMHJ – Vol. 24 No. 8 – 2018

aims to ensure that each of WHO’s country offices in Implementing GPW 13 is a work in progress, and the Eastern Mediterranean has the optimum operating the technical papers being presented to the Regional Committee are not detailed prescriptions. Member State model and staffing, in terms of both numbers and skills input will be crucial in setting country priorities, agreeing (10). The review will also examine relationships with other actions and implementing them. WHO will collaborate United Nations agencies working in the field of health. closely with its Member States every step of the way.

References 11. Draft thirteenth general programme of work, 2023–2019. Report by the Director-General to the Seventy-first World Health Assembly, 5 April 3018, (A4/71) (http://apps.who.int/gb/ebwha/pdf_files/WHA71/A-4_71en.pdf, accessed 23 September 2018). 22. United Nations. The Sustainable Development Agenda. New York: United Nations; 2016 (http://www.un.org/ sustainabledevelopment/development-agenda/, accessed 23 September 2018). 33. Mahjour J, Mirza Z, Rashidian A, Atta H, Hajjeh R, Thieren M, et al. “Promote health, keep the world safe, serve the vulnerable” in the Eastern Mediterranean Region. East Mediterr Health J. 324–323:)4(24;2018. https://doi.org/10.26719/2018.24.4.323. 44. WHO Regional Office for the Eastern Mediterranean (EMRO). Roadmap of WHO’s work for the Eastern Mediterranean Region 2021–2017. Cairo: EMRO; 2017 (http://applications.emro.who.int/docs/EMROPUB_19695_2017_EN.pdf, accessed 23 September 2018). 55. Advancing universal health coverage (EM/RC4/65). Technical paper presented at the 65th session of the WHO Regional Committee for the Eastern Mediterranean, 2018 (WHO internal publication). 66. Framework for action on advancing universal health coverage (UHC) in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean,2016 (http://applications.emro.who.int/docs/Technical_Notes_EN_16287.pdf, accessed 23 September 2018). 77. Hogan D, Hosseinpoor AR, Boerma T. Technical note: developing an index for the coverage of essential health services. Geneva: World Health Organization, 2016 (http://www.who.int/healthinfo/universal_health_coverage/UHC_WHS2016_TechnicalNote_ May2016.pdf?ua=1, accessed 23 September 2018). 88. Protecting people from the impact of health emergencies (EM/RC5/65). Technical paper presented at the 65th session of the WHO Regional Committee for the Eastern Mediterranean, 2018 (EM RC 65) (WHO internal publication). 99. Promoting health and well-being (EM/RC6/65). Technical paper presented at the 65th session of the WHO Regional Committee for the Eastern Mediterranean, 2018 (EM RC 65) (WHO internal publication). 1010 Optimizing WHO’s performance: countries at the centre (EM/RC7/65). Technical paper presented at the 65th session of the WHO Regional Committee for the Eastern Mediterranean, 2018 (EM RC 65) (WHO internal publication).

704

00 Editorial 24-08.indd 704 10/10/2018 12:33:11 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Socioeconomic factors associated with tobacco smoking in Turkey: a cross-sectional, population-based study

Ceyda Sahan,1 Turkan Gunay,2 Hatice Simsek,2 Ahmet Soysal2 and Gul Ergor 2

1Department of Occupational Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. 2Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. (Correspondence to: Ceyda Sahan: [email protected]).

Abstract Background: Gender and lower socioeconomic status are associated with smoking. Aims: This study aimed to determine the association between socioeconomic factors and cigarette tobacco smoking in Balcova, Izmir, Turkey, with a focus on gender differences. Methods: The study population was all men and women (36 187) aged over 30 years living in Balcova from October 2007 to May 2009. Data were collected in interviews and included smoking status (current, former, never), age, gender, marital status, educational level, occupational class/working status, health insurance and having a chronic disease. Logistic regression analysis was used to evaluate the association between socioeconomic characteristics and smoking status. Results: Of the 36 187 study subjects, 16 080 (44%) agreed to participate and 15 174 (42%) with complete data were evaluated. The majority were women (66.2%); mean ages of men and women were 53.1 (SD 13.1) and 51.3 (SD 13.2) respectively. Current smoking was higher in men (41.7% versus 31.2% of women), and more men were ex-smokers (33.1% versus 13.5% of women) but more women had never smoked (55.3% versus 25.2% of men). For women, being married and having low educational level were associated with current smoking and previous smoking (P < 0.05). Current smoking was also more frequent among working women (P < 0.05). For men, low educational level and occupational class were associated with being a current smoker and an ex-smoker (P < 0.05). Conclusions: Socially disadvantaged groups, especially those with low education or unemployed men, were more likely to be current smokers and smoking cessation was lower in these groups. Smoking habits were different in men and women. Socioeconomic factors should always be considered when developing smoking cessation policies. Keywords: Tobacco smoking, gender, socioeconomic status, social class, Turkey Citation: Sahan C; Gunay T; Simsek H; Soysal A; Ergor G. Socioeconomic factors associated with tobacco smoking in Turkey: a cross-sectional, population-based study. East Mediterr Health J. 2018;24(8):705–713. https://doi.org/10.26719/2018.24.8.705 Received: 01/05/15; accepted: 03/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction been taken, such as raising the price of tobacco products, media campaigns intended for public education, People of low socioeconomic status are more likely to be and reducing the ways to get tobacco. However, the less healthy than those of higher socioeconomic status, effectiveness of such measures depends on a variety thus increasing their risk of noncommunicable diseas- of factors such as the financial, educational, social and es (NCDs) (1). Smoking is the primary cause of prevent- able NCDs and death, especially in developed countries demographic circumstances of the society (2). (2). Smoking is the biggest health risk for heart diseases, According to WHO, “The social determinants of various cancers, lung diseases and fertility problems, and health are the conditions in which people are born, it accelerates many other chronic illnesses (2). According grow, work, live, and age, and the wider set of forces and to the World Health Organization (WHO), smoking prev- systems shaping the conditions of daily life. These forces alence in different regions of the world varies between and systems include economic policies and systems, 10% and 32% (3). In Europe, 41% of men and 22% of women development agendas, social norms, social policies and smoke cigarettes, the highest rate of smoking for wom- political systems.” (7). Socioeconomic determinants of en in the world (3). In 1997, surveys demonstrated that health include age, gender and socioeconomic status. more than 42% of men over the age of 25 years and just The most common indicators of socioeconomic status in under 10% of women over 25 years were smokers in Tur- modern industrialized populations are income, education key (4). Another study showed that smoking prevalence and occupation (8). Income is often used as an indicator decreased by 42% between 1995 and 2008 in Turkey (5). of socioeconomic status, but income is closely related According to the Turkish Global Adult Tobacco Survey to education and occupation. In many studies they are conducted in 2008 and 2012, smoking prevalence had de- highly correlated and they can all be used to understand creased by 13% in adults (6). how socioeconomic status affects health behaviour (8). In In order to prevent smoking, various measures have addition, social class is defined as the degree of control

705

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 705 10/10/2018 12:37:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

over investments, decision-making, other people’s Data collection work, and one’s own work and is used to classify the Data were collected through questionnaires completed socioeconomic status of people (8). by the interviewers (16,17), and participants were inter- Reducing smoking prevalence to less than 12% was viewed at home. The interviewers were given informa- a goal of Healthy People 2020, but it has been achieved tion on the aims and background of the project and train- only for some population groups with higher education ing on the questionnaires, communication skills, and risk and income in the United States of America (USA) (9). factors of CVD diseases. A guideline was used during the Furthermore, success in decreasing smoking prevalence interviews. has been considerably slower in populations of low Data were collected on smoking status, defined as: social status, as designated by low income, low levels of education, unemployment and blue-collar work (9). ·· current smoker: those who reported cigarette smok- Smoking prevalence varies according to income level, ing every day or some days in the past month; educational status or occupational class (9–11), and ·· ex-smoker: those who reported cigarette smoking in lower socioeconomic status is a risk factor for increased their lifetime, but who had not smoked for at least 1 smoking, especially in developed countries, and people month; of lower socioeconomic status are less concerned with ·· never smoker: those who reported never smoking in smoking cessation (10,11). The smoking rate among their lifetime. individuals of a society has 4 phases. In the first phase, smoking is rare in a society and restricted to the higher Participants were asked about the type of smoking socioeconomic groups. In the second phase, smoking (cigarettes, cigars, pipes and waterpipes). In this study spreads among men and into other social classes. only cigarette smoking was evaluated because smoking Although women take up smoking 10–20 years later cigars, pipes or waterpipes was always additional to than men, smoking also spreads among women, again smoking cigarette. beginning with the higher socioeconomic groups. In the Data were also recorded on age, gender, marital third phase, smoking among the higher socioeconomic status, educational level, occupational class, working groups abruptly declines in men, but reaches a peak in status, health insurance and having a chronic disease. women. In the fourth phase, smoking declines in general, We stratified the sample by gender because smoking and but is widespread among the lower socioeconomic working status were very different in men and women as groups (12,13). reported in other studies in Turkey (6,18). Marital status Although in recent years smoking rates have been was categorized as: married and other. Educational level declining in Turkey (6), it may be important to protect was categorized as: completed primary school (or less); disadvantaged groups more than before. It is crucial to secondary school; high school; and university or higher. evaluate all the factors influencing smoking habits in Low educational level was defined as completing primary order to determine preventive public health policies. school or less. Occupational class was categorized as: Thus, the prevalence of tobacco use needs to be evaluated being an employer; self-employed; white collar worker; according to various socioeconomic factors in different blue collar worker; and unemployed or having no 19 districts of Turkey. regular income ( ). Low occupational class was defined as being unemployed or having no regular income. We The socioeconomic factors of smoking behaviour categorized the working status for women as: worker have been assessed in studies in Balcova, Turkey which (having income-generating work) and non-worker. were based on individuals in smoking cessation clinics Having a chronic disease was defined as having a disease (14,15). The aim of this community-based study was to such as hypertension, diabetes mellitus, coronary heart determine the association between cigarette smoking disease, cerebrovascular disease, hypercholesterolaemia and socioeconomic factors in Balcova, with specific focus or cancer for at least 6 months. on gender differences. Data analysis Methods Results are expressed as means and standard deviations Study design, location and population (SD) or as percentages, and odds ratios and confidence intervals in the logistic regression analysis. This cross-sectional, community-based study was a part of the BAK project which aims to reduce cardiovascular We analysed the association between educational disease (CVD) incidence and prevalence through reduc- level, marital status, having health insurance, having a ing the risk factors (16,17). The study population was 36 187 chronic disease, occupational class, working status and people over 30 years of age living in Balcova District of smoking status by using the chi-squared test and logistic İzmir, Turkey in 2007. The baseline study started in Oc- regression analysis. tober 2007 and was completed in May 2009. All the study Logistic regression analysis was performed separately population (36 187 people) were invited to participate in in men and women. A large number of women did not the survey, and 16 080 (44%) consented to participate. In work, therefore occupational class was excluded from the this analysis, people whose data were incomplete were logistic regression model for women. Smoking status was excluded so 15 174 (42%) people were finally evaluated. the dependent variable, and we included the independent

706

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 706 10/10/2018 12:37:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

variables that were significantly associated with smoking women [10 042 (66.2%)] and 8 147 (53.7%) had completed status in the univariate analysis in the logistic regression primary school or less. The mean ages of the men and analysis. women were 53.1 (SD 13.1) years and 51.3 (SD 13.2) years SPSS, version 15.0 was used for data analysis. P < 0.05 respectively. The majority of the participants (80.4%) was considered statistically significant. were married, 90.5% had a health insurance and 41.9% had a chronic disease. As regards smoking, 34.7% of the Ethical considerations participants (41.7% of men, 31.2% of women) were current smokers, 20.2% (33.1% of men, 13.5% of women) were Dokuz Eylul University Ethical Committee reviewed and ex-smokers and 45.1% (25.2% of men, 55.3% of women) had approved the study protocol (337/2007). Verbal and writ- never smoked. Being a current smoker or an ex-smoker ten consent was obtained from all the participants. was more common in men than women. Smoking status, Results age group, educational level, marital status, occupational class, working status and having a chronic disease were Of the total population of people over 30 years of age liv- significantly different in men and women P( < 0.001). ing in Balcova District of İzmir, 15 174 (42%) participated in the study. Descriptive characteristics of the partici- Tables 2 and 3 show the socioeconomic characteristics pants are shown in Table 1. Most of the participants were of the men and women according to smoking status.

Table 1 Smoking status and background characteristics in the participants by sex Variable Men (n = 5 132) Women (n = 10 042) Total (15 174) P-valuea No. % No. % No. % Smoking status < 0.001 Current smoker 21 39 41.7 3 129 31.2 5 268 34.7 Ex-smoker 1 699 33.1 1 360 13.5 3 059 20.2 Never smoker 1 294 25.2 5 553 55.3 6 847 45.1 Age groups (years) < 0.001 30–44 1 500 29.2 3 550 35.4 5 050 33.3 45–64 2 522 49.1 4 711 46.9 7 233 47.7 65+ 1 110 21.6 1 781 17.7 2 891 19.0 Educational level < 0.001 Primary school or less 2 018 39.3 6 129 61.0 8 147 53.7 Secondary school 644 12.5 1 022 10.2 1 666 11.0 High school 1 486 29.0 1 935 19.3 3 421 22.5 University or higher 984 19.2 956 9.5 1 940 12.8 Marital status < 0.001 Other 507 9.9 2 472 24.6 2 979 19.6 Married 4 625 90.1 7 570 75.4 12 195 80.4 Have health insurance 0.35 Yes 4 659 90.8 9 069 90.3 13 728 90.5 No 473 9.2 973 9.7 1 446 9.5 Have a chronic disease < 0.001 Yes 1 902 37.1 4 460 44.4 6 358 41.9 No 3 230 62.9 5 582 55.6 8 816 58.1 Occupational class < 0.001 Employer 326 6.4 66 0.7 392 2.6 Self-employed 584 11.4 180 1.8 764 5.0 White collar 1 989 38.8 1 286 12.8 3 275 21.6 Blue collar 1 789 34.9 758 7.5 2 547 16.8 Unempolyed/no regular income 444 8.7 7 752 77.2 8 196 54.0 Working status < 0.001 Working 4 688 91.3 2 290 22.8 6 978 46.0 Not working 444 8.7 7 752 77.2 8 196 54.0

aChi-squared test; significant at P < 0.05.

707

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 707 10/10/2018 12:37:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 2 Socioeconomic characteristics of the men (N = 5132), by smoking status Variable Current smoker Ex-smoker Never smoker No. % P-value a No. % P-value a No. % P-value a Educational level Primary school or less 862 42.7 < 0.001 692 34.3 > 0.05 464 23.0 < 0.001 Secondary school 275 42.7 219 34.0 150 23.3 High school 667 44.9 461 31.0 358 24.1 University or higher 335 34.0 327 33.2 322 32.7 Marital status Other 251 49.5 < 0.001 122 24.1 < 0.001 134 26.4 > 0.05 Married 1888 40.8 1577 34.1 1160 25.1 Occupational class Employer 122 37.4 < 0.001 100 30.7 < 0.001 104 31.9 0.001 Self-employed 253 43.3 180 30.8 151 25.9 White collar 697 35.0 761 38.3 531 26.7 Blue collar 812 48.1 582 34.5 295 17.5 Unempolyed/no regular 255 57.4 76 17.1 113 25.5 ncome Have health insurance Yes 1848 39.7 < 0.001 1626 34.9 < 0.001 1185 25.4 > 0.05 No 291 61.5 73 15.4 109 23.0 Have a chronic disease Yes 546 28.7 < 0.001 872 45.9 > 0.05 482 25.4 > 0.05 No 1593 49.3 827 25.6 812 25.1

aChi-squared test; significant at P < 0.05.

In both men and women, being a current smoker was higher odds of being an ex-smoker than women who had significantly more common in people who did not have completed primary school or lower (P < 0.01). Working any health insurance and who did not have a chronic status and having health insurance were not associated disease (P < 0.001). with being an ex-smoker. However, being married and Table 4 shows the results of the multivariable analysis having a chronic disease were (P = 0.02 and P = 0.001 of the characteristics associated with smoking status in respectively). Women who had university or higher men. Men who had high school education or below, were education were more likely to have never smoked than unemployed or had no regular income, who were blue those with a high-school education or less. In addition, collar workers, who had no health insurance, and who did women who were not working, were more likely never to not have a chronic disease were significantly more likely have smoked than working women (P = 0.001). to be a current smoker (P < 0.01). Men with a university or higher education, who had health insurance and who had Discussion a chronic disease had significantly higher odds of being In this study, while blue-collar workers or unemployed an ex-smoker (P < 0.01). In addition, men who worked men and men with lower education were more likely (employer, self-employed, white collar or blue collar) were to be a current smoker, in women, having a higher ed- more likely to be an ex-smoker than unemployed men (P ucation level and working were associated with higher < 0.01). Men who had a university or higher education smoking rates. were significantly more likely never to have smoked than Several studies have also reported that lower men who had a primary school or lower education (P < educational level, being a blue-collar worker and 0.001). having a lower income were associated with increased Table 5 shows the results of the multivariable analysis smoking rates in men (13,20–22). In addition, similar to of the characteristics associated with smoking status our findings, other studies have reported that higher in women. Women who had high school education or educational and social status predisposed to smoking lower had higher risk of being a current smoker than (13,21,22). Most studies report a lower smoking prevalence women who had university or higher education (P < among women than men (23–25). This may be related to 0.001). Working women were more likely to be a current women’s attitudes to smoking (26). Smoking prevalence smoker than non-working women (P < 0.001). Women is differentiated by gender. In the beginning of the 20th who had completed a university or higher education had century in Western countries, smoking was largely

708

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 708 10/10/2018 12:37:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 3 Socioeconomic characteristics of the women (N = 10 042), by smoking status Variable Current smoker Ex-smoker Never smoker No. % P-value a No. % P-value a No. % P-value a Educational level Primary school or less 1 516 24.7 < 0.001 773 12.6 < 0.001 3 840 62.7 < 0.001 Secondary school 430 42.1 155 15.2 437 42.8 High school 847 43.8 275 14.2 813 42.0 University or higher 336 35.1 157 16.4 463 48.4 Marital status Other 702 28.4 < 0.001 367 14.8 < 0.001 1 403 56.8 > 0.05 Married 2 427 32.1 993 13.1 4 150 54.8 Working status Worker b 828 36.2 < 0.001 380 16.6 > 0.05 1 082 47.2 < 0.001 Not a worker 2 301 29.7 980 12.6 4 471 57.7 Have health insurance Yes 2 741 30.2 < 0.001 1 249 13.8 < 0.001 5 079 56.0 < 0.001 No 388 39.9 111 11.4 474 48.7 Have a chronic disease Yes 1 036 23.2 < 0.001 690 15.5 < 0.001 2 732 61.3 < 0.001 No 2 093 37.5 670 12.0 2 821 50.5

aChi-squared test; significant at P < 0.05. bHaving income-generating work.

Table 4 Socioeconomic variables associated with smoking status in men (N = 5132): multivariable logistic regression analysis Characteristic Current smoker Ex-smoker Never smoker P-value OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) Educational level Primary school or less 0.001 1.84 (1.51–2.26) – 1.00 – 1.00 Secondary school 0.001 1.62 (1.29–2.03) 0.38 1.11 (0.88–1.39) 0.77 1.03 (0.83–1.28) High school 0.001 1.71 (1.43–2.04) 0.97 0.99 (0.82–1.21) 0.20 1.12 (0.94–1.34) University or higher a – 1.00 0.001 1.49 (1.17–1.89) < 0.001 1.75 (1.41–2.15) Marital status Other 0.97 0.99 (0.81–1.22) – 1.00 – 1.00 Marrieda – 1.00 0.07 1.28 (0.98–1.67) 0.45 0.92 (0.74–1.14) Occupational class Employera – 1.00 0.01 1.76 (1.16–2.67) 0.18 1.26 (0.90–1.77) Self-employed 0.25 1.19 (0.89–1.59) 0.01 1.66 (1.16–2.38) 0.95 0.99 (0.73–1.34) White collar 0.18 1.20 (0.92–1.56) 0.001 1.82 (1.30–2.56) 0.17 0.82 (0.62–1.09) Blue collar 0.03 1.33 (1.03–1.71) 0.01 1.55 (1.12–2.14) 0.12 0.81 (0.62–1.05) Unempolyed/no regular 0.01 1.60 (1.15–2.21) – 1.00 – 1.00 income Have health insurance Yes a – 1.00 0.01 1.54 (1.13–2.10) 0.28 1.15 (0.89–1.49) No 0.01 1.40 (1.11–1.76) – 1.00 – 1.00 Have a chronic disease Yes a – 1.00 0.001 1.91 (1.64–2.22) – 1.00 No 0.001 1.67 (1.47–1.91) – 1.00 0.85 1.01 (0.88–1.17)

aReference category. Variables were adjusted for all other variables and age. OR = odds ratio, CI = confidence interval.

709

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 709 10/10/2018 12:37:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 5 Socioeconomic variables associated with smoking status in women (N = 10 042): multivariable logistic regression analysis Characteristic Current smoker Ex-smoker Never smoker P-value OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) Educational level Primary school or less 0.04 1.19 (1.01–1.42) – 1.00 0.98 0.99 (0.85–1.17) Secondary school 0.001 1.99 (1.63–2.43) 0.51 0.93 (0.75–1.15) 0.001 0.55 (0.46–0.67) High school 0.001 1.66 (1.39–1.97) 0.82 0.98 (0.82–1.17) 0.001 0.65 (0.55–0.77) University or higher a – 1.00 0.01 1.43 (1.11–1.84) – 1.00 Marital status Other 0.001 1.35 (1.21–1.51) – 1.00 – 1.00 Married a – 1.00 0.02 1.22 (1.03–1.43) 0.001 1.34 (1.21–1.48) Working status Worker b 0.001 1.30 (1.15–1.46) 0.91 0.99 (0.84–1.17) – 1.00 Not a worker – 1.00 – 1.00 0.001 1.40 (1.25–1.56) Have health insurance Yes a – 1.00 0.39 1.11 (0.88–1.40) 0.05 1.15 (0.99–1.32) No 0.04 1.16 (1.01–1.35) – 1.00 – 1.00 Have a chronic disease Yes a – 1.00 0.001 1.30 (1.12–1.50) – 1.00 No 0.03 1.12 (1.01–1.23) – 1.00 0.83 1.01 (0.92–1.11)

aReference category. bHaving income-generating work. Variables were adjusted for all other variables and age. OR = odds ratio, CI = confidence interval.

restricted to males and it was an inappropriate and women in the workforce is lower than men (18). Therefore, shameful behaviour in women (26,27). This lower rate unemployment may not be an indicator of social status of smoking among women continued until smoking among women. in women became more accepted by society. Indeed, In our study, ex-smokers were defined as people who the gender gap in cigarette consumption has narrowed reported cigarette smoking during their lifetime but had because smoking among women has been spreading not smoked for at least 1 month before being interviewed. rapidly since the 1920s, especially in working women (27): Thus, we evaluated smoking cessation as being an ex- employed women have had more access to money with smoker. Our study did not show an association between which to buy cigarettes. Moreover, smoking was seen as a being an ex-smoker and educational level for either symbol of gender equality, independence and modernity gender. A study conducted in Vietnam indicated that (26). Recently, because of low rates of smoking among higher educational level increased the likelihood of the women, the tobacco industry has targeted women, decision to stop smoking (34). Studies have found that especially in developing countries (28). Some tobacco more highly educated people are more successful in companies target women through commercials with smoking cessation (21,34,35). messages that smoking signifies freedom, independence It has been reported that more employed men quit and power (29). This concurs with our finding that single smoking than unemployed men (36–38), which is what we women had a higher risk of being a current smoker. found in our study. However, there was no relationship However, a study in Serbia found that living alone or between working status and being an ex-smoker among being divorced significantly increased the prevalence of women in our study. smoking in both sexes (21). According to a Korean study, People who did not have a chronic disease were more the age-adjusted smoking rate for the unmarried was likely to be current smokers, in both men and women in higher than for the married in both sexes (30). However, our study. Furthermore, having a chronic disease was in our study, there was no relationship between men’s significantly associated with being an ex-smoker in both smoking habits and their marital status. sexes. A study in Turkey in 2009–2011 showed higher As reported in other studies (31–33), our study shows smoking cessation success among those with a chronic that unemployment was associated with a higher disease, especially among elderly people who had at least smoking prevalence in men. However, no association 1 chronic disease (14). Another study demonstrated that was seen between unemployment and being a current one of the most common reasons for smoking cessation smoker in women in our study. Although, Balcova is one was doctors’ advice after the diagnosis of a chronic of the most developed districts of Izmir, participation of disease (39).

710

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 710 10/10/2018 12:37:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Our population-based study included a very large low socioeconomic status, such as prohibiting smoking group from an urban district. This large number provided in all indoor spaces with comprehensive smoke-free air an opportunity to show the association between social laws, increasing tobacco prices, and providing accessible, characteristics and smoking habits in the community. affordable and evidence-based smoking cessation However, our study has some limitations. The data on services. Hard-hitting mass media campaigns targeting smoking habits were self-reported, and were recorded less advantaged populations can help improve awareness in face-to-face interviews with the participants. The low among this sector of society about the hazards of tobacco participation rate of men and employed women was smoking (9). the main limitation. Because of this, women’s smoking habits could not be evaluated according to occupational Conclusions class. We did not evaluate the differences of social status Socially disadvantaged groups of men, especially those between the participants and other people who live in who had a low level of education or were unemployed, Balcova who did not agree to participate to the study were more likely to be current smokers, and smoking because data were not recorded on the non-participants. cessation was lower in these groups. The relationship Although financial circumstances may indicate social between socioeconomic factors and smoking habits status, we had no data on their economic status or income. showed differences between men and women. More Our study included people over the age of 30 years, so the population-based countrywide studies should be done to social factors related to smoking in those under 30 years understand the trends in smoking as they relate to soci- of age were not evaluated. oeconomic factors. Socioeconomic factors should always be taken into consideration when planning and imple- This study highlights that the socioeconomic menting smoking cessation policies. circumstances of the population play an important role in determining their smoking habits. Tobacco control Funding: The project was jointly funded by the Balcova strategies should be devised with the characteristics of Municipality and the DEU Research Fund (grant number: the target population in mind. Some strategies are more 2007161). effective in preventing smoking among populations of Competing interests: None declared.

Facteurs socio-économiques associés au tabagisme en Turquie : étude populationnelle transversale Résumé Contexte : Le genre et un faible niveau socio-économique sont associés au tabagisme. Objectifs : La présente étude avait pour objectif de déterminer l’association entre les facteurs socio-économiques et la consommation de cigarette à Balçova, dans le district d’Izmir en Turquie, en se concentrant sur les différences entre les sexes. Méthodes : La population de l’étude était constituée de l’ensemble des hommes et des femmes (36 187) âgés de plus de 30 ans et vivant à Balçova d’octobre 2007 à mai 2009. Les données ont été recueillies au cours d’entretiens et incluaient le statut tabagique (au moment de l’étude, antérieur, jamais), l’âge, le sexe, la situation matrimoniale, le niveau d’éducation, la classe professionnelle/le statut professionnel, le fait de posséder une assurance maladie et d’être atteint d’une maladie chronique. Une analyse de régression logistique a été utilisée pour évaluer l’association entre les caractéristiques socio- économiques et le statut tabagique. Résultats : Sur les 36 187 sujets de l’étude, 16 080 (44 %) ont accepté de participer et 15 174 (42 %), pour lesquels des données complètes avaient été fournies, ont fait l’objet d’une évaluation. Il s’agissait en majorité de femmes (66,2 %) ; l’âge moyen des hommes et des femmes étaient 53,1 (ET 13,1) et 51,3 (ET 13,2) respectivement. Les fumeurs au moment de l’étude étaient plus nombreux parmi les hommes (41,7 % contre 31,2 % de femmes) et davantage d’hommes étaient des anciens fumeurs (33,1 % contre 13,5 % de femmes), tandis que davantage de femmes n’avaient jamais fumé (55,3 % contre 25,2 % d’hommes). Pour les femmes, être mariées et avoir un faible niveau d’éducation étaient associés au fait de fumer et d’avoir fumé (p < 0,05). Le tabagisme était aussi plus fréquent chez les femmes actives (p < 0,05). Pour les hommes, un faible niveau d’éducation et la classe professionnelle étaient associés au fait de fumer ou d’être un ancien fumeur (p < 0,05). Conclusions : Les groupes socialement défavorisés, particulièrement ceux ayant un faible niveau d’éducation ou les hommes sans emploi, étaient plus susceptibles d’être fumeurs et le sevrage tabagique était moins fréquent dans ces groupes. Les habitudes liées au tabagisme variaient entre les hommes et les femmes. Les facteurs socio-économiques devraient toujours être pris en compte dans l’élaboration de politiques concernant le sevrage tabagique.

711

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 711 10/10/2018 12:37:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

العوامل االجتامعية واالقتصادية املرتبطة بتدخني التبغ يف تركيا: دراسة مقطعية سكانية سيدة صحن، توركان جوناي، هاتيس سيمسك، أمحت سويسال، جول إرجور اخلالصة اخللفية: يرتبط النوع وانخفاض الوضع االجتامعي واالقتصادي بالتدخني. هدفتهذه األهداف:الدراسة إىل حتديد العالقة بني العوامل االجتامعية واالقتصادية وبني تدخني السجائر يف بالكوفا، أزمري، تركيا، مع الرتكيز عىل الفروق بني اجلنسني. طرق البحث: شملت عينة الدراسة املستهدفة ًرجاال ًونساء )وعددهم 187 ( 36تزيد أعامرهم عىل 30 ً عاماويعيشون يف بالكوفا. وقد مجعنا البيانات أثناء املقابالت، وتضمنت حالة التدخني )تدخني حايل، تدخني سابق، مل يسبق هلم التدخني ً(،أبدا والعمر واجلنس واحلالة الزواجية واملستوى التعليمي والطبقة املهنية/حالة العمل والتأمني الصحي ووجود مرض مزمن. واستخدمنا حتليل َّالت َح ُّوف اللوجستي لتقييم االرتباط بني اخلصائص االجتامعية واالقتصادية وبني حالة التدخني. النتائج:من بني 187 36 ًشخصا من السكان، وافق 080 16 منهم )44٪( عىل املشاركة يف الدراسة َّوقدم 174 15 منهم )42٪( بيانات كاملة لتقييمها. وكانت الغالبية من النساء )66.2%(؛ وكان متوسط أعامر الرجال 53.1 ًعاما )SD = (13.1 وكان متوسط أعامر النساء 51.3 )SD = (. 13.2كان التدخني احلايل أعىل عند الرجال )41.7% مقابل 31.2% عند النساء(، وكان عدد الرجال املدخنني ًسابقا أكرب )%33.1 مقابل 13.5% من النساء(، لكن عدد النساء اللوايت مل ُي َد ِّخ َّن ًأبدا أكرب )55.3% مقابل 25.2% من الرجال(. وقد ارتبط التدخني السابق والتدخني احلايل لدى النساء بالزواج واملستوى التعليمي املنخفض، فكانت )p > (، 0.05كام كان التدخني احلايل أكثر ً تواترابني النساء العامالت، فكانت )p > (،أما 0.05بالنسبة للرجال، فقد ارتبط املستوى التعليمي املنخفض والطبقة املهنية بكوهنم مدخنني حاليني ومدخنني سابقني، فكانت .)0.05 < p( االستنتاجات: يغلب أن تكون احتامالت أن تكون الفئات املحرومة ً، اجتامعياوخاصة ذات التعليم املنخفض أو الرجال العاطلني عن العمل من املدخنني احلاليني أكرب، وأن يكون اإلقالع عن التدخني يف هذه املجموعات أقل. كانت عادات التدخني خمتلفة بني الرجال والنساء. وجيب مراعاة العوامل االجتامعية واالقتصادية ً دائامعند تطوير سياسات اإلقالع عن التدخني.

References 1. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commis- sion on Social Determinants of Health. Geneva: World Health Organization; 2008. 2. Best practices for comprehensive tobacco control programs. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2014. 3. World health statistics. Geneva: World Health Organization; 2012. 4. Doganay SSK, Kalaca S, Unal B. How has the prevalence of smoking changed in Turkey? Turk J Public Health. 2012;10(2):93–115. 5. Sozmen K, Unal B, Saidi O, Romdhane HB, Abu-Rmeileh NM, Husseini A, et al. Cardiovascular risk factor trends in the East- ern Mediterranean region: evidence from four countries is alarming. Int J Public Health. 2015 Jan;60 Suppl 1:S3–11 https://doi. org/10.1007/s00038-014-0610-6 PMID:25280526 6. Global Adult Tobacco Survey Turkey 2012. Ankara: Public Health Institution of Turkey; 2014. 7. World Health Organization. Social determinants of health [webpage] (http://www.who.int/social_determinants/sdh_definition/ en/, accessed 28 February 2018). 8. Oakes JM, Rossi PH. The measurement of SES in health research: current practice and steps toward a new approach. Soc Sci Med. 2003 Feb;56(4):769–84. https://doi.org/10.1016/S0277-9536(02)00073-4 PMID:12560010 9. Garrett BE, Dube SR, Babb S, McAfee T. Addressing the social determinants of health to reduce tobacco-related disparities. Nico- tine Tob Res. 2015 Aug;17(8):892–7. https://doi.org/10.1093/ntr/ntu266 PMID:25516538 10. Watson JM, Scarinci IC, Klesges RC, Murray DM, Vander Weg M, DeBon M, et al. Relationships among smoking status, ethnicity, socioeconomic indicators, and lifestyle variables in a biracial sample of women. Prev Med. 2003 Aug;37(2):138–47. https://doi. org/10.1016/S0091-7435(03)00096-3 PMID:12855213 11. Laaksonen M, Prättälä R, Helasoja V, Uutela A, Lahelma E. Income and health behaviours. Evidence from monitoring surveys among Finnish adults. J Epidemiol Community Health. 2003 Sep;57(9):711–7. https://doi.org/10.1136/jech.57.9.711 PMID:12933778 12. Lopez AD, Collinshaw NE, Tipa P. A descriptive model of the cigarette epidemic in developed countries. Tob Control. 1994;3(3):242–7. https://doi.org/10.1136/tc.3.3.242 13. Cavelaars AE, Kunst AE, Geurts JJ, Crialesi R, Grötvedt L, Helmert U, et al. Educational differences in smoking: international comparison. BMJ. 2000 Apr 22;320(7242):1102–7. https://doi.org/10.1136/bmj.320.7242.1102 PMID:10775217 14. Gunay T, Pekel O, Simsek H, Sahan C, Soysal A, Kilinc O, et al. Smoking habits and cessation success. What differs among adults and elderly? Saudi Med J. 2014 Jun;35(6):585–91. PMID:24888658

712

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 712 10/10/2018 12:37:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

15. Pekel Ö, Ergör G, Günay T, Baydur H, Choussein B, Budak R, et al. Smoking cessation and the effect of nicotine dependence on relapse rate in Izmir, Turkey. Turk J Med Sci. 2015;45(4):895–901. https://doi.org/10.3906/sag-1408-55 PMID:26422864 16. Ergör G, Soysal A, Sözmen K, Ünal B, Uçku R, Kılıç B, et al. Balcova heart study: rationale and methodology of the Turkish cohort. Int J Public Health. 2012 Jun;57(3):535–42. https://doi.org/10.1007/s00038-011-0309-x PMID:21987028 17. Unal B, Sozmen K, Ucku R, Ergor G, Soysal A, Baydur H, et al. High prevalence of cardiovascular risk factors in a Western urban Turkish population: a community-based study. Anadolu Kardiyol Derg. 2013 Feb;13(1):9–17. https://doi.org/10.5152/akd.2013.002 PMID:23070631. 18. Bugra A, Yakut-Cakar B. Structural change, the social policy environment and female employment in Turkey. Dev Change. 2010;41(3):517–38. https://doi.org/10.1111/j.1467-7660.2010.01643.x 19. Giray Simsek H, Gunay T, Ucku R. [Effects of social inequalities on coronary heart disease risk factors: a population-based, cross-sectional study in Izmir]. Anadolu Kardiyol Derg. 2010 Jun;10(3):193–201. https://doi.org/10.5152/akd.2010.057 PMID:20538552 [In Turkish] 20. Barbeau EM, Krieger N, Soobader MJ. Working class matters: socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. Am J Public Health. 2004 Feb;94(2):269–78. https://doi.org/10.2105/AJPH.94.2.269 PMID:14759942 21. Djikanovic B, Marinkovic J, Jankovic J, Vujanac V, Simic S. Gender differences in smoking experience and cessation: do wealth and education matter equally for women and men in Serbia? J Public Health (Oxf). 2011 Mar;33(1):31–8. https://doi.org/10.1093/ pubmed/fdq080 PMID:20952438 22. El Rhazi K, Nejjari C, Berraho M, Serhier Z, Tachfouti N, El Fakir S, et al. Inequalities in smoking profiles in Morocco: the role of educational level. Int J Tuberc Lung Dis. 2008 Nov;12(11):1327–32. PMID:18926045. 23. Syamlal G, Mazurek JM, Dube SR. Gender differences in smoking among U.S. working adults. Am J Prev Med. 2014 Oct;47(4):467–75. https://doi.org/10.1016/j.amepre.2014.06.013 PMID:25049215 24. Coste J, Quinquis L, D’Almeida S, Audureau E. Smoking and health-related quality of life in the general population. Inde- pendent relationships and large differences according to patterns and quantity of smoking and to gender. PLoS One. 2014 03 17;9(3):e91562. https://doi.org/10.1371/journal.pone.0091562 PMID:24637739 25. Hitchman SC, Fong GT. Gender empowerment and female-to-male smoking prevalence ratios. Bull World Health Organ. 2011 Mar 1;89(3):195–202. https://doi.org/10.2471/BLT.10.079905 PMID:21379415 26. Flandorfer P, Wegner C, Buber I. Gender Roles and Smoking Behaviour. Vienna: Vienna Institute of Demography, Austrian Acad- emy of Sciences; 2010:7. 27. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006 May 27;367(9524):1747–57. https://doi.org/10.1016/S0140-6736(06)68770-9 PMID:16731270 28. Oztoprak SD, GT. [Gender and tobacco control for health.] Turk J Public Health. 2013;11(3):197–206. [In Turkish] 29. Influencing tobacco use among women in Surgeon General’s Report: woman and smoking. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention; 2001. 30. Cho HJ, Khang YH, Jun HJ, Kawachi I. Marital status and smoking in Korea: the influence of gender and age. Soc Sci Med. 2008 Feb;66(3):609–19. https://doi.org/10.1016/j.socscimed.2007.10.005 PMID:17996346 31. Khlat M, Sermet C, Le Pape A. Increased prevalence of depression, smoking, heavy drinking and use of psycho-active drugs among unemployed men in France. Eur J Epidemiol. 2004;19(5):445–51. https://doi.org/10.1023/B:EJEP.0000027356.71414.bd PMID:15233317 32. Fagan P, Shavers V, Lawrence D, Gibson JT, Ponder P. Cigarette smoking and quitting behaviors among unemployed adults in the United States. Nicotine Tob Res. 2007 Feb;9(2):241–8. PMID:17365755 33. Arcaya M, Glymour MM, Christakis NA, Kawachi I, Subramanian SV. Individual and spousal unemployment as predictors of smoking and drinking behavior. Soc Sci Med. 2014 Jun;110:89–95. https://doi.org/10.1016/j.socscimed.2014.03.034 PMID:24727666 34. de Walque D. Does education affect smoking behaviors? Evidence using the Vietnam draft as an instrument for college education. J Health Econ. 2007 Sep 1;26(5):877–95. https://doi.org/10.1016/j.jhealeco.2006.12.005 PMID:17275938 35. Nagelhout GE, Crone MR, van den Putte B, Willemsen MC, Fong GT, de Vries H. Age and educational inequalities in smoking cessation due to three population-level tobacco control interventions: findings from the International Tobacco Control (ITC) Netherlands Survey. Health Educ Res. 2013 Feb;28(1):83–91. https://doi.org/10.1093/her/cys101 PMID:23087009 36. Paavola M, Vartiainen E, Puska P. Smoking cessation between teenage years and adulthood. Health Educ Res. 2001 Feb;16(1):49– 57. https://doi.org/10.1093/her/16.1.49 PMID:11252283 37. Businelle MS, Kendzor DE, Reitzel LR, Costello TJ, Cofta-Woerpel L, Li Y, et al. Mechanisms linking socioeconomic status to smoking cessation: a structural equation modeling approach. Health Psychol. 2010 May;29(3):262–73. https://doi.org/10.1037/ a0019285 PMID:20496980. 38. Foulds J, Gandhi KK, Steinberg MB, Richardson DL, Williams JM, Burke MV, et al. Factors associated with quitting smoking at a tobacco dependence treatment clinic. Am J Health Behav. 2006 Jul-Aug;30(4):400–12. https://doi.org/10.5993/AJHB.30.4.6 PMID:16787130 39. Ben-Noun L, Biderman A, Shvartzman P. Patients’ smoking status: the family practice physician’s view. Isr Med Assoc J. 2000 May;2(5):351–5. PMID:10892388

713

01- Socioeconomic factors associated with tobacco smoking in Turkey.indd 713 10/10/2018 12:37:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Factors associated with smoking contemplation and maintenance among Iranian adolescents

Hamidreza Roohafza,1 Razieh Omidi,2 Tahereh Alinia,3 Kamal Heidari,2 Gholamhossein Mohammad-Shafiee,4 Morid Jaberifar,2 Masoumeh Sadeghi 5 and Wasim Maziak 6

1Tobacco Control Unit, Cardiovascular Research Center, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. 2Isfahan Province Health Center, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. 3Student Research Committee, Department of Epidemiol- ogy, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: T. Alinia: [email protected]). 4Health Education and Wellness Office, Education Institute, Isfahan, Islamic Republic of Iran.5 Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. 6Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, United States of America.

Abstract Background: Evidence is scarce on which factors contribute to cigarette and waterpipe contemplation and no previous study has examined the factors associated with waterpipe maintenance. Aims: This study aimed to determine the factors associated with cigarette and waterpipe smoking contemplation and maintenance among Iranian adolescents. Methods: Factors including depression, risky behaviour, family conflict, attitude to smoking acceptability and self-efficacy were examined using a questionnaire for 5500 adolescents at the smoking contemplation or maintenance stage. Results: Students with depression had nearly double the chance [95% confidence interval (CI): 1.41–2.72] of cigarette smoking contemplation. Risk takers had odds of 2.13 (95% CI: 1.51–2.94) and 1.49 (1.22–1.85) of cigarette and waterpipe (hookah) smoking contemplation, respectively. Those facing family conflict had odds of 1.87 (95% CI: 1.38–2.53) and 1.53 for cigarette and waterpipe smoking contemplation, respectively. The contemplation odds for students with more positive attitude to smoking acceptability were 2.12 (95% CI: 1.51–2.97) and 1.72 for cigarette and waterpipe smoking, respectively. Higher self-efficacy was associated with lower cigarette and waterpipe smoking contemplation. Risky behaviour was related to smoking maintenance. A more positive attitude to smoking acceptability was related to higher waterpipe maintenance (odds ratio = 1.57 95% CI: 1.03–2.40). Conclusions: Depression, attitude to smoking acceptability and risky behaviour are factors associated with smoking contemplation and maintenance. Keywords: adolescent, contemplation, maintenance, smoking. Citation: Roohafza H; Omidi R; Alinia T; Heidari K; Mohammad-Shafiee G; Jaberifar M; et al. Factors associated with smoking contemplation and maintenance among Iranian adolescents. East Mediterr Health J. 2018;24(8):714–721. https://doi.org/10.26719/2018.24.8.714 Received: 28/06/16; accepted: 12/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction stage (4). Those at the maintenance stage were able to sustain smoking and incorporate it into their daily lives. The transtheoretical model is a basis to explain people’s smoking behaviour. It claims that individuals go through Several factors are associated with adolescents’ a series of stages to adopt lifetime smoking. The sequenc- smoking, including familial and psychological factors es begin with the precontemplation stage, followed by (5). Depressive symptoms lead to an increased chance contemplation, preparation and action stages, and then of smoking contemplation and maintenance (6). Self- they reach the maintenance stage. According to the tran- efficacy reflects confidence in the ability to exert stheoretical model, people generally pass each stage to control over one’s own motivation, behaviour and move to the next one. Preventing adolescents from mov- social environment. Self-efficacy has been postulated to ing forward at each stage will inhibit their progression to change behaviour (7) and it is protective against smoking the next stage and regular, maintained smoking. initiation (8). A study in Turkey showed that higher self- Contemplation is characterized by a cognitive efficacy levels accompany higher negative perceptions predisposition or lack of a resolute commitment to about the disadvantages of smoking (9). A longitudinal remain smoke free (1,2). It has robust predictive ability study revealed that adolescents with risky behaviour are in smoking initiation. Adolescents in the contemplation at higher risk of behavioural problems at school (10). No stage have 2–3 times higher likelihood of cigarette previous study has determined which factors contribute smoking during the following 2 years in comparison to to cigarette and waterpipe smoking contemplation, those out of this stage (3). A study in California, United except a study in the Islamic Republic of Iran that showed States of America reported a high transition rate among different influential factors for initiation of cigarette students in the contemplation stage to the maintenance compared to waterpipe (hookah) smoking (11). There is a

714

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 714 10/10/2018 12:38:37 PM Research article EMHJ – Vol. 24 No. 8 – 2018

lack of studies about why students maintain waterpipe ers answered the question, “Is there a possibility that you smoking. will smoke in the future?” A similar question was asked Guided by the transtheoretical model, we explored the about smokers as well, “Is there a possibility that you effect of familial and psychological factors on smoking will maintain smoking in the future?” Those with a yes contemplation and maintenance. Our results could response to the first question were in the smoking con- provide invaluable information on factors that trigger templation stage and the latter group were in the smok- cigarette and waterpipe smoking contemplation and ing maintenance stage. Contemplation and maintenance maintenance among adolescents. This may help public were separately determined for cigarette and waterpipe health practitioners and policy-makers to develop new smoking. strategies to reduce students’ susceptibility and prevent them from starting smoking. Risk factors The participants completed a 13-item depression subscale Methods of the Symptom Checklist-90-R (SCL-90), by rating items Study design on how they felt in the past 4 weeks (12). The possible total score ranged from 0 to 13 (Cronbach’s α = 0.88). Risky Data were extracted from a cross-sectional survey titled behaviour was measured on a 3-item scale, with scores the Isfahan Tobacco Use Prevention Program. This study ranging from 0 to 15 points: (1) “It is worth getting into was conducted among students (grade 6–12) in Isfahan trouble for fun”; (2) “I like risk taking”; and (3) “I enjoy Province (the second most populated province of the doing things that people believe should not be done”. The Islamic Republic of Iran). The students were aged 11–19 items were scored on a 5-point Likert scale from 1 = not years. at all, to 5 = always. Cronbach’s α was 0.71. Family conflict To obtain the correct sample size using Formula 1, was measured as the sum score of a 3-item scale: (1) “My smoking prevalence was considered to be 14% based on parents nag me for any excuse”; (2) “My family does not a study among students in 2003 (2), with 95% confidence understand me”; and (3) “I have a lot of arguments with interval (CI) and 0.01 margin of error. After considering my family”. The students answered each item yes or no, attrition due to not answering or incomplete answering which scored 1 and 0, respectively. The scale ranged from (defined as > 10% of questionnaire items left blank), we 0 to 3 (Cronbach’s α = 0.73). Attitude to smoking accepta- estimated the sample size as 5500. bility was assessed via 9 items, using a 2-point response (agree or disagree). Items were: (1) “Sometimes, you feel you need to smoke a cigarette or even have a puff of wa- 2 Formula 1 n = 0.14 x 0.86 x (1.96) terpipe”; (2) “Smoking is too expensive”; (3) Children are (0.01) 2 more likely to smoke if their parents smoke; (4) “Students should be allowed to smoke cigarettes”; (5) “Sometimes, you like to show up as a smoker”; (6) “Smoking is some- Students were selected using multistage stratified thing you do when other people want you to do it”; (7) cluster random sampling. Educational districts were “Smoking makes you feel grown up”; (8) “Smoking is haz- considered as clusters. Stratified sampling was based ardous to nonsmokers’ health”; and (9) “Students should on the school level (high or middle), gender and area of be allowed to smoke a waterpipe”. Items 2 and 8 were residence (rural or urban) within each cluster. Schools scored reversely. The scores ranged from 0 to 9 (Cron- were selected randomly from among each cluster, and bach’s = 0.79). To determine self-efficacy, the partici- finally, students were selected from each selected school α pants were asked 10 questions from the General Self-Ef- using a random number table. The students gave signed consent for participation in the study and answered ficacy Scale, with responses rated from 0 (not at all) to 3 the questionnaires in a 30-minute period during class (very true). Scores ranged from 0 to 30. General self-ef- time. A total of 5408 questionnaires were completed ficacy has been demonstrated to possess good reliability and returned, with a 98.3% response rate. The study was (Cronbach’s α = 0.86). It was then categorized into three approved by Ethics Committee of Isfahan University of levels < 15, 15–25 and > 25 that indicated low, moderate Medical Science. and high self-efficacy, respectively. Higher scores showed a higher level for all the risk Background information factors. All questionnaires were investigator invented A self-administered anonymous questionnaire elicited except for depression and self-efficacy. Before the final demographic data and parental variables, including age, version of the questionnaire was adopted for use in sex, education level and smoking status. Students were the present study, a pilot study was conducted and considered to be never-smokers if they had not smoked the questionnaires were administered to a group of even a single puff; otherwise, they were classified as 30 students to assess their reliability and face validity. smokers. The validity index was appropriate. Cronbach’s α was 0.73 for family conflict, 0.71 for risky behaviour, 0.88 for Smoking contemplation and maintenance depression, 0.86 for self-efficacy and 0.86 for smoking To assess smoking contemplation, we assessed the ado- attitude. The risk factors, except self-efficacy, were lescents’ intention toward future smoking. Never-smok- categorized into 2 categories by their median.

715

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 715 10/10/2018 12:38:37 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Data analysis For risky behaviour, contemplation increased by 2.13 (95% CI: 1.51–2.94) times for cigarette and by 1.49 (95% The relationships between the covariates depression, CI: 1.22–1.85) for waterpipe smoking. For family conflict, risky behaviour, family conflict, attitude to smoking ac- contemplation increased by 1.87 (95% CI: 1.38–2.53) times ceptability, perceived self-efficacy, and smoking contem- for cigarette and by 1.53 (95% CI: 1.24–1.88) times for plation and maintenance were analysed using univariate waterpipe smoking. For more positive attitude to smoking logistic regression. Logistic regression was adjusted for acceptability, contemplation increased by 2.12 (95% CI: age, sex, parental education and parental smoking. Odds 1.51–2.97) times for cigarette and by 1.72 (95% CI: 1.41– ratio (OR) and its 95% CI were reported. P < 0.05 was con- 2.10) times for waterpipe smoking. Higher self-efficacy sidered to be statistically significant. All analyses were protected adolescents against cigarette and waterpipe performed with SPSS version 15. smoking contemplation. Risky behaviour significantly Results contributed to smoking maintenance (OR = 3.70; 95% CI: 1.85–7.14 for cigarettes; OR = 1.89; 95% CI: 1.33–3.03 for Regarding cigarette smoking, out of 5365 students who waterpipe). Attitude to smoking acceptability was linked completely answered the questionnaire, there were 4427 to waterpipe smoking maintenance (OR = 1. 57; 95% CI: (82.5%) never-smokers and 935 (17.5%) ever-smokers; 87 1.03–2.40). (2.0%) of the never-smokers were at the contemplation stage and 212 (22.7%) of the ever-smokers were at the Discussion maintenance stage. For waterpipe smoking, there were The present study explored the effect of familial and psy- 3631 (67.7%) never-smokers and 1728 (32.3%) ever-smokers. chological factors on smoking contemplation and main- There were 174 (4.8%) students at the contemplation stage tenance. Risky behaviour, family conflict, more positive and 702 (40.6%) students at the maintenance stage. attitude to smoking acceptability and lower self-efficacy Table 1 shows univariate regression analysis of were associated with cigarette smoking contemplation. the predisposing factors for smoking contemplation. Depression was only associated with cigarette smoking Students with highly educated parents had higher odds contemplation. Risky behaviour was the only factor con- of cigarette and waterpipe smoking contemplation. Male tributing to cigarette smoking maintenance, and this, gender, parental smoking, depression, risky behaviour, along with positive attitude to smoking acceptability, was family conflict, and more positive attitude to smoking linked to waterpipe smoking maintenance. acceptability were directly associated with cigarette and The present research showed that boys were more waterpipe smoking contemplation; self-efficacy was vulnerable than girls to cigarette and waterpipe smoking inversely related to cigarette and waterpipe smoking contemplation. Adolescents of parents who smoked contemplation. Risky behaviour was the strongest were more likely to contemplate and maintain smoking underlying factor for both cigarette and waterpipe behaviour. Parental smoking affects adolescent belief smoking contemplation. Students with risky behaviour that smoking is acceptable and it is a norm; students who had an OR of 5.95 (95% CI: 4.54–7.75) of cigarette smoking have smoker parents also have greater accessibility to contemplation and were 3.44 times (95% CI: 2.96–4.0) more smoking and indulge in behaviour imitation (13). likely to be at the waterpipe contemplation stage. The OR Psychological factors of intention to future smoking, of smoking contemplation for students with higher self- including depression and self-efficacy, worked at the efficacy was 0.38 (95% CI: 0.26–0.55) for cigarette and 0.56 contemplation stage; however, they were not associated (95% CI: 0.45–0.70) for waterpipe smoking. with smoking maintenance. Current literature agrees Table 2 shows univariate logistic regression analysis with the detected association between depression and of the covariates of cigarette and waterpipe smoking cigarette smoking contemplation (6,14). A longitudinal maintenance. The predisposing factors were different. study reported that ever-smokers with depression Paternal education was associated with increased odds of progressed to daily smoking after 5 years; however, we cigarette smoking maintenance. Paternal smoking raised could not find such an association, maybe because of the likelihood of cigarette smoking maintenance. Risky the different age range in our sample (15). Psychological behaviour and positive attitude to smoking acceptability factors that influence cigarette smoking contemplation elevated smoking maintenance odds by 2.14 (95% CI: 1.52– are of less importance for waterpipe smoking 3.01) and 1.41 (95% CI: 1.01–1.98) times, respectively. The contemplation (11). A recent study in the Islamic Republic higher the parental education attainment was, the higher of Iran found that psychological factors such as coping the probability of waterpipe smoking maintenance was with stress trigger students to start cigarette smoking, among ever-smokers. Students who had parents that while entertainment factors are more likely reasons for smoked had a 100% excess risk of waterpipe smoking waterpipe than cigarette smoking initiation (11). Self- maintenance (OR = 2.0, 95% CI: 1.26–3.17); risky behaviour efficacy protected students from cigarette smoking heightened waterpipe smoking maintenance by 4.17 contemplation, which agreed with earlier studies (16). times (95% CI: 2.32–7.48). However, self-efficacy has an effect at an early stage of Adjusted ORs are shown in Table 3. Cigarette smoking smoking behaviour adaptation, and biological factors contemplation among never-smokers nearly doubled such as physical or mental dependence or peer pressure (OR =1 .96; 95% CI: 1.41–2.72) for students with depression. are prominent for smoking maintenance (17).

716

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 716 10/10/2018 12:38:37 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 1 Univariate analysis of correlating factors for cigarette and waterpipe smoking contemplation Cigarette contemplation Waterpipe contemplation No Yes OR (95% CI) No Yes OR (95% CI) Sex Female 2620 (97.4) 70 (2.6) 1 2405 (89.5) 282 (10.5) 1 Male 2456 (91.4) 230 (8.6) 3.49 (2.88–4.60) 2090 (77.8) 596 (22.2) 2.43 (2.08–2.78) Maternal education, yr 0–5 2268 (94.9) 123 (5.1) 1 2049 (85.7) 343 (14.3) 1 6–12 1856 (95.1) 97 (4.9) 0.83 (0.92–1.85) 1608 (82.6) 340 (17.4) 1.06 (0.86–1.31) > 12 754 (92.3) 63 (7.7) 1.59 (1.14–2.21) 670 (81.6) 151 (18.4) 1.34 (1.09–1.66) Paternal education, yr 0–5 1799 (94.4) 106 (5.6) 1 1640 (86.0) 267 (14.0) 1 6–12 2025 (95.5) 95 (4.5) 0.86 (0.93–1.70) 1761 (83.3) 353 (16.7) 1.17 (0.97–1.41) > 12 1040 (93.1) 78 (6.9) 1.59 (1.16–2.15) 907 (81.0) 213 (19.0) 1.44 (1.18–1.75) Parental smoking No 2435 (95.8) 150 (4.2) 1 3126 (87.1) 461 (12.9) 1 Yes 1625 (91.6) 149 (8.4) 2.10 (1.66–2.65) 1354 (76.5) 415 (23.5) 2.07 (1.79–2.40) Depression Low 2696 (96.7) 93 (3.3) 1 2404 (86.5) 376 (13.5) 1 High 2172 (91.7) 196 (8.3) 2.61 (2.03–3.37) 1903 (80.2) 470 (19.8) 1.57 (1.36–1.83) Risky behaviour Low 3411 (97.8) 78 (2.2) 1 3130 (89.8) 357 (10.2) 1 High 1561 (88.0) 212 (12.0) 5.95 (4.54–7.75) 1272 (71.8) 500 (28.2) 3.44 (2.96–4.0) Family conflict Low 2298 (97.3) 63 (2.7) 1 2102 (89.0) 259(11.0) 1 High 2728 (91.0) 269 (9.0) 3.51 (2.71–4.56) 2305 (76.9) 692 (23.1) 2.43 (2.09–2.82) Smoking attitude More positive 2810 (97.7) 66 (2.3) 1 2573 (89.6) 300 (10.4) 1 Less positive 2133 (90.5) 224 (9.5) 4.47 (3.37–5.91) 1798 (76.3) 557 (23.7) 2.65 (2.28–3.09) Self-efficacy Low 1275 (90.9) 127 (9.1) 1 1112 (79.4) 289 (20.6) 1 Medium 2413 (95.5) 113 (4.5) 0.80 (0.55–1.18) 2146 (85.0) 379 (15.0) 0.83 (0.67–1.03) High 977 (96.4) 37 (3.6) 0.38 (0.26–0.55) 886 (87.2) 130 (12.8) 0.56 (0.45–0.70) CI = confidence interval; OR = odds ratio. Bold numbers with P < 0.05.

Students with family conflict were more likely to one another, according to the covariation and clustering contemplate cigarette and waterpipe smoking. Strong theory (22). Cigarette smoking is considered to be a family bonds and parental support decrease smoking risky behaviour on its own, and cigarette smokers are contemplation (18). Conflicts can result as adolescents more likely to commit other forms of risky behaviour pull away from their parents and spend more time with (23). The underlying mechanism of engagement in risky friends, and this increases the risk of peer behaviour behaviour probably lies in the adolescents’ social life imitation (19). that provides opportunities for learning risky behaviour Consistent with previous studies, adolescents with from their peers (24). Furthermore, some forms of risky more positive attitude to smoking acceptability are more behaviour serve as a way of affirming independence from likely to have a higher risk of cigarette and waterpipe parents (24). The strength of the association between smoking contemplation (20). Students with more risky behaviour and waterpipe smoking contemplation positive attitudes to smoking acceptability had greater and maintenance was weaker than for cigarette smoking. odds of waterpipe smoking maintenance. Students’ This may be due to a lower cultural taboo of waterpipe understanding of the outside world and past experiences compared with cigarette smoking and its accessibility shape their attitude to smoking acceptability and (25). Therefore, those who start or continue waterpipe determine their future behavioural choices. Social norms smoking are not necessarily those with higher-risk and peers may dramatically change students’ attitude to behaviour. In a survey of Lebanese adolescents, cigarette smoking acceptability and smoking orientation (21). smoking was associated with a range of other risky Risky behaviour was a predisposing factor for behaviours, whereas waterpipe smoking was only both contemplation and maintenance of cigarette and associated with problem drinking (26). waterpipe smoking, and our findings are in accordance This present large-scale study provides invaluable with previous studies (10). Different forms of risky information about the factors that trigger smoking behaviour coexist and frequently interact and reinforce contemplation and maintenance among adolescents.

717

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 717 10/10/2018 12:38:37 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 2 Univariate analysis of correlating factors for cigarette and waterpipe smoking maintenance Cigarette maintenance Water pipe maintenance No Yes OR (95% CI) No Yes OR (95% CI) Sex Female 43 (36.8) 74 (63.2) 1.0 29 (56.9) 22 (43.1) 1.0 Male 190 (37.9) 311 (62.1) 1.05 (0.69–1.59) 149 (57.8) 109 (42.2) 1.03 (0.56–1.90) Maternal education, yr 0–5 117 (44.2) 148 (55.8) 1.0 89 (64.5) 49 (35.5) 1.0 6–12 75 (33.5) 149 (66.5) 1.25 (0.60–1.67) 60 (60.0) 40 (40.0) 2.85 (1.49–5.46) > 12 32 (33.3) 64 (66.7) 1.58 (0.97–2.57) 21 (38.9) 33 (61.1) 2.35 (1.19–4.65) Paternal education, yr 1.0 76 (64.4) 42 (35.6) 1.0 0–5 98 (46.7) 112 (53.3) 1.79 (1.10–2.91) 60 (60.0) 40 (40.0) 1.95 (1.04–3.62) 6–12 88 (36.4) 154 (63.6) > 12 30 (24.2) 94 (75.8) 2.74 (1.67–4.48) 30 (43.5) 39 (56.5) 2.35 (1.28–4.38) Parental smoking No 133 (41.7) 186 (58.3) 1.0 115 (64.6) 63 (35.4) 1.0 Yes 100 (33.5) 198 (66.4) 1.41 (1.02–1.96) 62 (47.7) 68 (52.3) 2.0 (1.26–3.17) Depression Low 123 (38.6) 196 (61.4) 1.0 77 (63.1) 45 (36.9) 1.0 High 97 (35.7) 175 (64.9) 0.88 (0.63–1.23) 95 (54.0) 81 (46.0) 1.45 (0.91–2.34) Risky behaviour Low 108 (49.1) 112 (50.9) 1.0 69 (79.3) 18 (20.7) 1.0 High 120 (31.0) 267 (69.0) 2.14 (1.52–3.01) 102 (47.9) 111 (52.1) 4.17 (2.32–7.48) Family conflict Low 94 (42.7) 126 (57.3) 1.0 60 (65.9) 31 (34.1) 1.0 High 135 (34.5) 256 (65.5) 1.41 (1.01–1.98) 115 (54.2) 97 (45.8) 1.63 (0.98–2.72) Attitude Less positive 75 (44.6) 93 (55.4) 1.0 44 (67.7) 21 (32.3) 1.0 More positive 150 (34.8) 281 (65.2) 1.51 (1.05–2.17) 125 (54.0) 104 (45.4) 1.74 (0.97–3.11) Self-efficacy Low 78 (36.3) 137 (63.7) 1.0 61 (55.5) 49 (44.5) 1.0 Medium 100 (39.2) 155 (60.7) 0.96 (0.58–1.60) 70 (58.3) 50 (41.7) 0.90 (0.46–1.73) High 33 (35.5) 60 (46.5) 1.13 (0.77–1.64) 28 (52.8) 25 (47.2) 1.12 (0.66–1.89)

CI = confidence interval; OR = odds ratio. Bold numbers with P < 0.05.

Examination of the predisposing factors of smoking substances) may affect different responses in relation contemplation or maintenance and the high response to students’ intention to start or maintain smoking rate make this study unique in gaining new insights. in the future. Third, we did not collect information Knowledge obtained from this research delivers about all model domains. Future comprehensive messages about the predisposing factors for waterpipe prospective studies with updated data on cigarette smoking initiation. In addition, the findings concerning and waterpipe smoking are recommended to assess the predisposing factors for smoking maintenance are the causal relationships between predisposing factors novel. This may help public health practitioners and and smoking susceptibility. Finally the low number of questions for assessing some risk factors, such as risky policy-makers to develop new strategies to reduce levels behaviour or family conflict, could also be a limitation. of susceptibility. A potential recommendation could be to develop further However, a few limitations are important to consider understanding of risky behaviour and family conflict and when interpreting these findings. First, because this study how they correlate with smoking. was based on cross-sectional data, causal relationships cannot be inferred. Second, multiple conditions that were Conclusion not considered in the present study (such as culture, and The present study would be a good starting point for de- access to and use of other tobacco products and illicit veloping a risk prediction model, using identified risk

718

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 718 10/10/2018 12:38:38 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 3 Adjusted ORs (95% confidence interval) for correlating factors for smoking contemplation and maintenance Contemplation Maintenance Cigarette Waterpipe Cigarette Waterpipe Depression 1.96 (1.41–2.72) 1.09 (0.89–1.33) 1.49 (0.83–2.68) 0.87 (0.58–1.31) Risky behaviour 2.13 (1.51–2.94) 1.49 (1.22–1.85) 3.70 (1.85–7.14) 1.89 (1.33–3.03) Family conflict 1.87 (1.38–2.53) 1.53 (1.24–1.88) 1.10 (0.59–2.05) 1.25 (0.83–1.89) More positive attitude to smoking 2.12 (1.51–2.97) 1.72 (1.41–2.10) 1.46 (0.73–2.91) 1.57 (1.03–2.40) acceptability Self-efficacy Low 1 1 1 1 Medium 0.75 (0.41–0.80) 0.78 (0.61–0.96) 1.46 (0.78–2.73) 1.47 (0.95–2.26) High 0.47 (0.29–0.85) 0.79 (0.94–1.70) 0.86 (0.39–1.93) 1.14 (0.62–2.09) Log likelihood 1297.065 2713.739 1324.466 2794.327 R2 0.35 0.38 0.36 0.38 Odds ratios adjusted for age, sex, parental education and smoking. Bold numbers with P < 0.05.

factors for smoking contemplation and maintenance. above all, risky behaviour, and should be initiated for Healthcare providers may benefit from such a model in school-aged and early adolescents. Different approaches targeting at-risk adolescents for prevention programmes. should be adopted to tackle different factors associated Preventive measurements might address adolescent psy- with cigarette and waterpipe smoking contemplation chological states, attitude to smoking acceptability, and and maintenance.

Acknowledgements Special thanks to all students who took part in this study. The study was approved by the Ethics Committee of Isfahan University of Medical Science. Funding: None. Competing interests: None declared.

Facteurs associés à l’intention et au maintien du tabagisme chez les adolescents iraniens Résumé Contexte : On dispose de peu de données sur les facteurs contribuant à l’initiation de la consommation de tabac par cigarette ou pipe à eau, et aucune étude antérieure n’a examiné les facteurs associés au maintien du tabagisme par pipe à eau. Objectif : La présente étude visait à déterminer quels étaient les facteurs associés à l’initiation de la consommation de tabac par cigarette ou pipe à eau et au maintien de ce tabagisme chez les adolescents iraniens. Méthodes : Des facteurs tels que la dépression, les comportements à risque, les conflits familiaux, l’attitude concernant l’acceptabilité du tabagisme et l’efficacité personnelle ont été examinés à l’aide d’un questionnaire distribué à 5500 adolescents qui étaient au stade de l’intention ou du maintien du tabagisme. Résultats : Les adolescents souffrant de dépression avaient quasiment deux fois plus de probabilités [intervalle de confiance (IC) à 95 %: 1,41–2,72] d’envisager le tabagisme par cigarettes. Pour les adolescents adeptes des comportements à risque, la probabilité liée à l’intention de tabagisme par cigarettes et par pipe à eau (hookah) était de 2,13 (IC à 95 %: 1,51– 2,94) et 1,49 (1,22–1,85) respectivement. Pour les adolescents concernés par des conflits familiaux, cette même probabilité était de 1,87 (IC à 95 %: 1,38–2,53) et 1,53 respectivement, et elle était de 2,12 IC à 95 %: 1,51–2,97) et 1,72 respectivement pour les étudiants qui faisaient montre d’une attitude plus positive concernant l’acceptabilité du tabagisme. Une meilleure efficacité personnelle était associée à une moins forte intention de tabagisme par cigarette et par pipe à eau. Le comportement à risque était associé au maintien du tabagisme. Une attitude plus positive concernant l’acceptabilité du tabagisme était davantage associée au maintien du tabagisme par pipe à eau (odds ratio = 1,7 IC à 95 %: 1,03–2,40). Conclusion : La dépression, l’attitude concernant l’acceptabilité du tabagisme et le comportement à risque sont des facteurs associés à l’intention et au maintien du tabagisme.

719

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 719 10/10/2018 12:38:38 PM Research article EMHJ – Vol. 24 No. 8 – 2018

العوامل التي ترتافق مع قبول التدخني واملداومة عليه بني املراهقني اإليرانيني محيد رضا روح افزا، راضية اميدي، طاهرة علينيا، كامل حيدري، غال حمسني حممد-شافعي، مريد جابري فر، معصومة صادقي، وسيم مازياك اخلالصة اخللفية: تندر الدالئل حول العوامل التي ُسهم يفت قبول تدخني السجائر والشيشة، وال توجد أي دراسة سابقة حول العوامل املرتبطة باملداومة عىل الشيشة. اهلدف:هدفت هذه الدراسة إىل حتديد العوامل املرتبطة بقبول تدخني السجائر والشيشة واملداومة عليه لدى املراهقني اإليرانيني. طرق فحصنا البحث:العوامل املرتبطة بقبول تدخني السجائر والشيشة واملداومة عليه لدى املراهقني اإليرانيني ومنها االكتئاب والسلوك املحفوف باملخاطر، والرصاع األرسي، واملوقف من قبول التدخني والكفاءة الذاتية، فاستخدمنا استبيان استكمله 5500 ً مراهقاحول مراحل قبول التدخني أو املداومة عليه. – CI كان النتائج:احتامل قبول الطالب املصابني باالكتئاب لتدخني السجاير يقرتب من ِّالضعف ]95% : 1.41 [.2.72 وتبلغ احتامالت اآلخذين ملخاطر القبول بتدخني السجاير أو الشيشة CI %95( 2.13: 1.51– ( 2.94وملخاطر القبول بتدخني الشيشة CI %95( 1.49: 1.22-1.85(. أما االحتامالت بالقبول بتدخني السجاير بني الذين يواجهون ًنزاعا ًعائليا فكانت CI %95( 1.87: 1.38-2.53(، وكانت احتامالت القبول بتدخني الشيشة لدهيم .وكانت 1.53احتامالت قبول الطالب ذوي املواقف األكثر إجيابية جتاه تدخني السجائر هي 2.12 )CI %95: 1.51- ( 2.97وجتاه تدخني الشيشة هي . 1.72وكلام ارتفعت الكفاءة الذاتية انخفض ارتباطها بقبول تدخني السجاير والشيشة. وارتبط السلوك املحفوف باملخاطر باملداومة عىل التدخني. وكلام كان املوقف أكثر إجيابية جتاه قبول التدخني ازداد ارتباطه بمداومة أعىل عىل الشيشة .)2.40-1.03 :CI %95( )2.4-1.03:CI ;1.57=OR( االستنتاج:إن االكتئاب واملوقف من قبول التدخني والسلوك املحفوف باملخاطر هي العوامل املرتبطة بقبول التدخني وباملداومة عليه.

References 1. Gritz ER, Prokhorov AV, Hudmon KS, Mullin Jones M, Rosenblum C, Chang CC, et al. Predictors of susceptibility to smoking and ever smoking: a longitudinal study in a triethnic sample of adolescents. Nicotine Tob Res. 2003 Aug;5(4):493–506. https://doi. org/10.1080/1462220031000118568 PMID:12959787 2. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychol. 1996 Sep;15(5):355–61. https://doi.org/10.1037/0278-6133.15.5.355 PMID:8891714 3. Unger JB, Johnson CA, Stoddard JL, Nezami E, Chou CP. Identification of adolescents at risk for smoking initiation: validation of a measure of susceptibility. Addict Behav. 1997 Jan-Feb;22(1):81–91. https://doi.org/10.1016/0306-4603(95)00107-7 PMID:9022874 4. Gilpin EA, Emery S, White MM, Pierce JP. Changes in youth smoking participation in California in the 1990s. Cancer Causes Control. 2003 Dec;14(10):985–93. https://doi.org/10.1023/B:CACO.0000007971.36237.a5 PMID:14750538 5. Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control. 1998 Winter;7(4):409–20. https://doi.org/10.1136/tc.7.4.409 PMID:10093176 6. Roohafza H, Shahnam M, Zolfaghari B, Tavassoli A, Sadeghi M, Toloei H, et al. Stress level and smoking status in central iran: isfahan healthy heart program. ARYA Atheroscler. 2011 Winter;6(4):144–8. PMID:22577433 7. Perkins KA, Parzynski C, Mercincavage M, Conklin CA, Fonte CA. Is self-efficacy for smoking abstinence a cause of, or a reflection on, smoking behavior change? Exp Clin Psychopharmacol. 2012 Feb;20(1):56–62. https://doi.org/10.1037/a0025482 PMID:21910550 8. Chang FC, Lee CM, Lai HR, Chiang JT, Lee PH, Chen WJ. Social influences and self-efficacy as predictors of youth smoking initiation and cessation: a 3-year longitudinal study of vocational high school students in Taiwan. Addiction. 2006 Nov;101(11):1645– 55. https://doi.org/10.1111/j.1360-0443.2006.01607.x PMID:17034445 9. Ulgen H, Ozturk C, Armstrong M. Effect of self-efficacy on Turkish children’s perceptions of the advantages/disadvantages of smoking. Asian Pac J Cancer Prev. 2012;13(3):795–8. https://doi.org/10.7314/APJCP.2012.13.3.795 PMID:22631650 10. Ellickson PL, Tucker JS, Klein DJ. High-risk behaviors associated with early smoking: results from a 5-year follow-up. J Adolesc Health. 2001 Jun;28(6):465–73. https://doi.org/10.1016/S1054-139X(00)00202-0 PMID:11377990 11. Roohafza H, Sadeghi M, Shahnam M, Bahonar A, Sarafzadegan N. Perceived factors related to cigarette and waterpipe (ghely- an) initiation and maintenance in university students of Iran. Int J Public Health. 2011 Apr;56(2):175–80. https://doi.org/10.1007/ s00038-009-0107-x PMID:20020176 12. Wongpakaran T, Wongpakaran N, Boripuntakul T. Symptom checklist-90 (SCL-90) in a Thai sample. J Med Assoc Thai. 2011 Sep;94(9):1141–9. PMID:21970206 13. Distefan JM, Gilpin EA, Choi WS, Pierce JP. Parental influences predict adolescent smoking in the United States, 1989-1993. J Ado- lesc Health. 1998 Jun;22(6):466–74. https://doi.org/10.1016/S1054-139X(98)00013-5 PMID:9627817

720

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 720 10/10/2018 12:38:38 PM Research article EMHJ – Vol. 24 No. 8 – 2018

14. Brown RA, Lewinsohn PM, Seeley JR, Wagner EF. Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J Am Acad Child Adolesc Psychiatry. 1996 Dec;35(12):1602–10. https://doi.org/10.1097/00004583-199612000-00011 PMID:8973066 15. Breslau N, Peterson EL, Schultz LR, Chilcoat HD, Andreski P. Major depression and stages of smoking. A longitudinal investigation. Arch Gen Psychiatry. 1998 Feb;55(2):161–6. https://doi.org/10.1001/archpsyc.55.2.161 PMID:9477930 16. Minnix JA, Blalock JA, Marani S, Prokhorov AV, Cinciripini PM. Self-efficacy mediates the effect of depression on smoking susceptibility in adolescents. Nicotine Tob Res. 2011 Aug;13(8):699–705. https://doi.org/10.1093/ntr/ntr061 PMID:21482619 17. Islam SM, Johnson CA. Influence of known psychosocial smoking risk factors on Egyptian adolescents’ cigarette smoking behavior. Health Promot Int. 2005 Jun;20(2):135–45. https://doi.org/10.1093/heapro/dah604 PMID:15722365 18. Hill KG, Hawkins JD, Catalano RF, Abbott RD, Guo J. Family influences on the risk of daily smoking initiation. J Adolesc Health. 2005 Sep;37(3):202–10. https://doi.org/10.1016/j.jadohealth.2004.08.014 PMID:16109339 19. Yang WS, Leatherdale ST, Ahmed R. Smoking susceptibility among never-smokers: data from the 2006-07 National Youth Smok- ing Survey. Can J Public Health. 2011 Jul-Aug;102(4):254–7. PMID:21913578 20. Odukoya OO, Odeyemi KA, Oyeyemi AS, Upadhyay RP. Determinants of smoking initiation and susceptibility to future smoking among school-going adolescents in Lagos State, Nigeria. Asian Pac J Cancer Prev. 2013;14(3):1747–53. https://doi.org/10.7314/AP- JCP.2013.14.3.1747 PMID:23679268 21. Roohafza H, Sadeghi M, Shahnam M, Shokouh P, Teimori S, Amirpour A, et al. Social norms of cigarette and hookah smokers in Iranian universities. ARYA Atheroscler. 2013 Jan;9(1):45–50. PMID:23696759 22. Donovan JE, Jessor R, Costa FM. Adolescent health behavior and conventionality-unconventionality: an extension of problem-behavior theory. Health Psychol. 1991;10(1):52–61. https://doi.org/10.1037/0278-6133.10.1.52 PMID:2026131 23. Mazur J, Dzielska A, Małkowska-Szkutnik A. [The relationship between tobacco smoking and risk behaviour syndrome among 15-year-old adolescents in Poland and other European countries]. Przegl Lek. 2009;66(10):768–72 (in Polish). PMID:20301933 24. Yu M, Nebbitt VE, Lombe M, Pitner RO, Salas-Wright CP. Understanding tobacco use among urban African American adolescents living in public housing communities: a test of problem behavior theory. Addict Behav. 2012 Aug;37(8):978–81. https://doi. org/10.1016/j.addbeh.2012.03.023 PMID:22503437 25. Maziak W, Eissenberg T, Ward KD. Patterns of waterpipe use and dependence: implications for intervention development. Phar- macol Biochem Behav. 2005 Jan;80(1):173–9. https://doi.org/10.1016/j.pbb.2004.10.026 PMID:15652393 26. Tamim H, Terro A, Kassem H, Ghazi A, Khamis TA, Hay MM, et al. Tobacco use by university students, Lebanon, 2001. Addiction. 2003 Jul;98(7):933–9. https://doi.org/10.1046/j.1360-0443.2003.00413.x PMID:12814499

721

02- Factors associated with smoking contemplation and maintenance among Iranian adolescents.indd 721 10/10/2018 12:38:38 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Assessing sleep quality of Lebanese high school students in relation to lifestyle: pilot study in Beirut

Ramez Chahine,1 Rita Farah,2 Michèle Chahoud,3 Alain Harb,1 Rami Tarabay,1 Eric Sauleau 4 and Roger Godbout 5

1Faculty of Health, La Sagesse University, Beirut, Lebanon (Correspondence to: R. Chahine: [email protected]; [email protected]). 2Faculty of Pharmacy, Lebanese University, Hadath, Beirut, Lebanon. 3Doctoral School of Science and Technology, Lebanese University, Hadath, Beirut, Lebanon. 4Laboratoire ICube, Laboratoire des sciences de l’ingénieur, de l’informatique et de l’imagerie (CNRS, UMR7357), Université de Strasbourg, France. 5Laboratoire et clinique du sommeil, Hôpital Rivière-des-Prairies, Université de Montréal, Québec, Canada.

Abstract Background: Sleep problems in teenagers seriously disturb the active process of learning. Given the absence of sleep data from Lebanon, a study to determine sleep quality among adolescents is vital. Aims: To understand sleep habits and patterns that affect sleep quality, and assess the amplitude of possible sleep problems in Lebanese adolescents, raising awareness of the effects of good sleep hygiene on general health in adolescents. Methods: A cross-sectional survey of 500 high-school students in Beirut was conducted using a self-filled questionnaire inquiring about sociodemographics, health-risk behaviour and sleep quality. The effect of several factors related to sleep habits of the students was investigated using bivariate analysis and logistic regression. Results: We found that 76.5% of teenagers were not satisfied with their sleep quality; 56% did not have the appropriate amount of sleep (< 8 hours); and 82.4% used mobile phones and electronic devices in bed before falling asleep. Moreover, 3.2% faced a real problem with sleep initiation, 11.3% with sleep maintenance and 8.7% with early awakening. Conclusions: A large proportion of high-school students in Beirut have poor sleep patterns. It is therefore necessary to increase awareness of the problem in education in order to prevent its escalation. Keywords: adolescence, Lebanon, lifestyle, sleep hygiene, sleep wake disorders Citation: Chahine R; Farah R; Chahoud M; Harb A; Tarabay R; Sauleau E, et al. Assessing sleep quality of Lebanese high school students in relation to lifestyle: pilot study in Beirut. East Mediterr Health J. 2018;24(8):722–728. https://doi.org/10.26719/2018.24.8.722 Received: 08/01/17; accepted: 31/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction In adults, the average sleep time is 7–8 hours, but for some heavy sleepers, who represent ~10% of the Sleep is one of the vital body functions, along with breath- population, 9 or 10 hours of sleep are required for them ing, digestion and immunity. It brings rest and regener- to feel satisfied during the day. In contrast, 5% of short ates the mind and body, enabling us to function optimally sleepers need only 5–6 hours a night. Consequently, there the next day. Sleep is not only a factor in good health, but is no ideal amount of sleep (9,10). The only true test of it also affects the quality and rapidity of learning (1). Yet, whether sleep is sufficient is to feel satisfied during the we do not know its impact nor give it the importance it day. deserves. During adolescence, major tangible psychological Sleep disorders and deprivation are currently a major and social changes occur; the sleep–wake rhythm health problem, both in terms of frequency and social changes and the night time sleep shortens: the average and economic impacts (2–4). Detection of sleep disorders duration of sleep per night decreases from 10 hours at in adults complaining of insomnia is a daily challenge 11 years to 7.5 hours at 18 years (a loss of 1 hour of sleep for physicians and patients alike (5). Detection of sleep every 3 years) (11). However, in an American study (12), disorders in adolescents is even more difficult because the need for sleep did not seem to decrease at puberty they can have two different etiologies. On the one hand, (with an average of 9.2 hours per night), although there the sleep/wake rhythms evolve from the fetal period and was a biological tendency for teenagers to fall asleep and develop in adolescence both in structure and duration (6). wake up later than during childhood. This leads to a true During puberty, the circadian rhythm (sleep/wake cycles) sleep disorder called phase delay. The resulting lack of of teenagers becomes delayed, which is why most high- sleep could explain school failures, accidents and social school students are more active and awake in the evening, disorders. The exact prevalence of delayed sleep phase is go to bed late and like to sleep late (7). On the other hand, unknown at this time. many external factors affecting lifestyle of adolescents Lebanon has more cultural and demographic interfere with their sleep cycles. Thus, technology use diversity compared to other Middle Eastern countries. is emerging as a possible contributing factor to sleep Furthermore, over a small geographical area, Lebanon disturbance in the 21st century (8). has undergone many cultural shifts (including changes

722

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 722 10/10/2018 12:39:42 PM Research article EMHJ – Vol. 24 No. 8 – 2018

in eating habits, use of stimulants and use of electronic sleep problems (sleep initiation, sleep maintenance and devices) and socioeconomic changes that could have early awakening before getting full amount of sleep); contributed to the diversity of information extracted (4) quality of sleep (satisfaction and relaxation in the from our study, making it unique in its findings and morning, nightmares, urge to sleep during the day, and methodology. There have been several studies on sleep missing morning classes); and (5) lifestyle of adolescents disorders among adolescents, especially in developed (consumption of coffee, tea, alcohol, energy drinks and countries, but to the best of our knowledge there have hypnotics, as well as information concerning evening been no such studies in the Middle East, including activities, exercise, employment and dinner time). The Lebanon. To fill this gap we launched a pilot study to questionnaire was compiled from 2 standardized tests understand sleep habits and patterns that affect sleep used for the diagnosis of sleep disorders by the European quality, and assess the amplitude of possible sleep Sleep Center, and Sleep & Vigilance Center of Hôtel-Dieu, problems in Lebanese adolescents, raising awareness of both in Paris, France (13,14). Originally in French, the the effects of good sleep hygiene on general health in questionnaire was translated into Arabic and then inde- adolescents. pendently back-translated into French by 2 translators to verify the translation and resolve any inconsistencies. Methods Sleep patterns definition Study design and procedures Trouble in sleep initiation was defined as individuals tak- A cross-sectional study using a multistage cluster sam- ing > 30 minutes to fall asleep. Trouble in sleep mainte- ple was conducted during the school year 2015–2016. As nance was defined as individuals waking up every night. this was a pilot study, no sample size calculation was Early awakening was defined as individuals waking early performed and a sample of 500 participants was consid- without being able to sleep again almost every night. ered. From the list of schools in the Greater Beirut Area, 20 public and private schools were selected using sim- Statistical analysis ple randomization. From the list of students aged 14–19 The databases were transferred on a spreadsheet file from years, 25 participants per school were randomly selected. Windows Excel 2007. The data were analysed using SPSS A self-administered questionnaire was used to ensure to- version 17·0 (IBM Corporation, Armonk, NY, USA). The in- tal anonymity of participants. Participation in the study ternal consistency (Cronbach’s α reliability) was 0.70. We was voluntary and included no material compensation. used means with standard deviations and counts with Young working adolescents not enrolled in school were percentages to describe continuous and categorical varia- not selected. We collected data during regular days of the bles, respectively. We used Pearson’s χ² test for categorical semester, avoiding examination periods, which might variables and Student’s t test to compare means between have added new parameters not considered in the study. 2 groups. In all analyses, P < 0.05 was considered signifi- The questionnaire was specially developed for the cant. Two multivariable analyses were performed, using study and included several sections that were pilot logistic regression models to investigate the influence of tested on a sample of 30 students. Most schools had legal demographics, health-risk behaviour and teenagers’ ac- restrictions on distribution of questionnaires without tivities before sleeping on sleep maintenance and early the consent of the Ministry of Education, thus, we were awakening before getting the full amount of sleep, after not given permission to distribute questionnaires to adjustment for age and gender. Health-risk behaviour students ourselves. We were permitted to delegate this and teenagers’ activities that were significantly associat- responsibility to the biology teachers, who were trained ed with sleep patterns in the bivariate analysis were in- by us to assist students to complete the questionnaire. cluded in the multivariable models. Adjusted odds ratios The questionnaires were completed in class, collected and their 95% confidence intervals were reported. and returned to us by the trained teacher in charge. Results This study was approved by the Ethics in Research Committee of the Lebanese University. Informed consent Demographic characteristics was obtained from each school administration, which We surveyed 520 adolescents and 20 declined to answer in turn obtained written informed consent from the the questionnaire. We included 500 teenagers (297 fe- parents of students who met the inclusion criteria. The male, 203 male) with a mean age of 16.0 (0.8) years. purpose of the research, confidentiality of information and benefit to the population were explained to the Sleep duration participants verbally. Anonymity and confidentiality of More adolescents went to sleep after 22:30 hours at week- all participants were guaranteed and maintained. ends than during the week (Table 1). During the week, more adolescents woke before 06:30 hours and more Study materials slept for < 8 hours, compared with the weekend. The questionnaire consisted of 5 sections: (1) demographic characteristics of the population (e.g., age and sex); (2) Sleep disturbance and quality sleep habits of adolescents (alarm clock, and number Table 2 shows the numbers of adolescents who took > 30 of sleeping hours during weekdays and weekends); (3) minutes to fall asleep, woke during most nights, woke

723

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 723 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 1 Sleeping and waking hours and sleep duration of adolescent during the week and at weekends Sleeping after 22:30 h Waking before 06:30 h Sleep duration < 8 h n (%) n (%) n (%) WD 289 (57.9) 274 (54.8) 280 (56.0) WE 410 (82) 20 (4.0) 70 (14.0)

WD = weekdays; WE = weekends.

early most days, experienced nightmares, had no sleep and bedtime activities. The main activity of adolescents satisfaction, often felt a need to sleep during the day, and in the evening and at bedtime was unrestrained use of were absent from morning classes. the Internet (n = 300, 60%). This was followed by mobile phone (n = 72, 14.4%), reading (n = 39, 7.8%), television (n Consumption of stimulants = 37, 7.4%), other activities (n = 50, 10%) and video games Table 2 shows the consumption of tobacco, alcohol, soft (n = 2, 0.4%). drinks, energy drinks, tea and coffee in the evening prior Predictors affecting sleep maintenance to sleep. It also shows the time that the adolescents took their evening meal. In multivariable analysis, trouble in sleep maintenance was significantly associated with reporting sleeping Seventeen (3.4%) teenagers reported use of tobacco, < 8 hours during weekdays, experiencing nightmares whereas 18 (3.7%) reported drinking alcohol. This survey sometimes, drinking coffee sometimes and often in the allowed us to identify different types of stimulants that evening, and having any activity in bed before sleeping participants used frequently in the evening. The majority other than reading (Table 3). Reporting waking up satis- often consumed soft drinks (n=306, 61.2%), coffee (n=192, fied in the morning was negatively associated with trou- 38.2%), energy drinks (n=168, 33.6%) and tea (n=68, 13.0%). ble in sleep maintenance. We noted also that 335 (66.5%) teenagers ate their dinner between 19:00 and 21:00 hours, compared with only 39 Predictive factors affecting early awakening (8%) who eat dinner after 22:00 hours. In multivariable analysis, early awakening was associated with sometimes experiencing nightmares, often feeling a Evening and bedtime activities need to sleep during the day and having any activity in We shed light on different aspects of adolescent behav- bed before sleeping other than reading (Table 4). Report- iour that could be considered as predisposing factors for ing waking up moderately and very relaxed compared to poor sleep by asking the participants about their evening not at all was inversely associated with early awakening.

Table 2 Sleep disturbances, sleep quality and use of different stimulants in the evening prior to sleep Factors Categorization n (%) Time taken to fall asleep > 30 min 16 (3.2) Waking during the night Almost every night 183 (36.6) Waking early without being able to sleep Almost every day 44 (8.7) Sleep satisfaction No 382 (76.5) Waking difficulty Often 91 (18.2) Feeling need to sleep during the day Often 90 (18.1) Absence during morning school classes Often 1 (0.2) Nightmares Often 7 (1.4) Use of Stimulants Often Tobacco — 17 (3.4%) Alcohol — 18 (3.7%) Soft drinks — 306 (61.2%) Coffee — 192 (38.2%) Energy drinks — 168 (33.6%) Tea — 68 (13.6%) Dinner time Often Between 19:00 and 21:00 — 335 (66.5%) Between 21:00 and 22:00 — 81 (16.3%) Later than 22:00 — 39 (8%)

724

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 724 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 3 Multivariable analysis: predictors affecting sleep maintenance Predictors Coefficient Standard error Adjusted OR 95% CI P Sleep < 8 h during weekdays 1.79 0.60 5.98 1.78–20.07 0.004 Wake satisfied −1.27 0.29 0.28 0.15–0.51 < 0.001 Nightmares Sometimes vs. Never 1.29 0.29 3.62 1.98–6.63 < 0.001 Often vs. Never −0.33 0.95 0.72 0.11–4.77 0.7 Coffee Sometimes vs. Never 0.67 0.30 1.95 1.05–3.62 0.03 Often vs. Never 1.61 0.38 5.00 2.35–10.65 < 0.001 Activity in bed before sleep 0.78 0.25 2.19 1.30–3.71 0.003

CI = confidence interval; OR = odds ratio.

Discussion According to a survey conducted at the national level in the United States of America by the National We found that 76.5% of teens surveyed were not satisfied Sleep Foundation in 1997 (17), college students went to with their sleep quality and 56% did not have the appro- sleep between 21:00 and 22:00 hours, while high-school priate amount of sleep (< 8 hours). The main predisposing students went to sleep between 22:00 and 23:00 hours, factor was using mobile phones and electronic devices in although both groups arose around 06:30 hours. Thus, bed before falling asleep. Moreover, 3.2% had a problem 40–45% of adolescents do not get enough sleep (< 8 hours with sleep initiation, 11.3% with sleep maintenance and per night). The results also showed that sleep deprivation 8.7% with early awakening before getting the full amount is predominantly important for adolescents in general of sleep. No significant differences were found between and older adolescents in particular. As a consequence, boys and girls. Taking stimulants, Internet activity and daytime sleepiness is often observed and objective mobile phone use before sleep and late dinners seem to measures show that teenagers are really lacking sleep be the main factors that predispose to inadequate sleep. (18). We have identified studies from developed countries These results indicate that, although studies have been that show that frequency of sleep disorders was lower conducted in countries with different socioeconomic than in our study. In France, a survey conducted on and cultural backgrounds, frequency of sleep disorders 652 young people aged 13–19 years reported that 35.7% is similar. Sleep disorders in adolescence are a frequent exhibited persistent insomnia-type sleep disorders (40.2% yet insidious problem. In fact, 1 in 4 teenagers have of girls and 31.6% of boys) (15). More recently, it has been insomnia. It has also been observed that adolescents are reported that total sleep time decreased severely during secretive about their sleeping problems and do not speak adolescence (16). spontaneously to their parents, but also because they do

Table 4 Multivariable analysis: predictors affecting early awakening Predictors Coefficient Standard error Adjusted OR 95% CI P Sleep < 8 h during weekdays 0.50 0.26 1.66 0.98–2.82 0.06 Wake relaxed < 0.001 Little vs. Not at all −0.71 0.54 0.49 0.17–1.39 0.18 Moderate vs. Not at all −1.43 0.53 0.24 0.08–0.70 0.009 Very vs. Not at all −1.27 0.58 0.28 0.09–0.95 0.04 Nightmares Sometimes vs. Never 1.6 0.27 4.90 2.84–8.45 < 0.001 Often vs. Never 0.79 0.45 2.2 0.89–4.67 0.5 Feeling need to sleep during the day Sometimes vs. Never 0.67 0.35 1.95 0.98–3.86 0.54 Often vs. Never 1.32 0.41 3.74 1.67–8.34 0.01 Absence during morning classes 0.92 0.38 2.50 1.17–5.34 0.007 Activity in bed before sleep 0.76 0.26 2.14 1.27–3.62 0.004

CI = confidence interval; OR = odds ratio.

725

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 725 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

not perceive nightmares and difficulty falling asleep as and that in the hour before bedtime, 76% are watching disorders (19). television, 40% talking on the phone, 44% surfing the As we already mentioned, the presence of a phase delay Internet and 26% playing video games (17). Engaging in in circadian rhythms induced significant deprivation stimulating activities is unfavourable to the onset of of sleep that accumulated throughout the week in sleep, and the lights projected by the screen contribute adolescents. In Lebanon, as elsewhere, most classes start to maintaining wakefulness, thereby delaying melatonin in the morning (between 07:30 and 08:00 hours) at a time secretion (26). when the circadian rhythms of adolescents still promote Finally, consumption of beverages (coffee, tea, energy sleep. This time difference is greater as adolescents drinks and cola) to keep awake is common among continue to go to bed late driven by their biological adolescents. A study by Bailly et al. in 2004 reported rhythms and social activities. that ~31% of teenagers drink > 2 caffeinated beverages Sleep deprivation also affects the learning ability a day (15). Another American study by Calamaro et al. in of adolescents. A study by Crowley et al. in 2006 (20) 2008 showed that 11.2% of adolescents ingested > 400 g on this issue showed a decrease in performance in of caffeine per day, which is the equivalent of 4 cups of tests assessing memory and mathematical calculation coffee (26). after a night of sleep deprivation. One full night after a Our study had some limitations. Our presence in sleepless night did not seem enough for a full recovery. schools during completion of the questionnaires was These findings are supported by Wolfson et al. (21), who difficult. We therefore instructed the biology teachers showed that adolescents with classes starting an hour to assist the participants in case some difficulties were later than another had better educational outcomes, encountered while completing the questionnaire. which was associated with the students being less sleepy However, reporting and declaration biases were inevitable, during the day and that they slept overnight. Shortened and some associations may seem counterintuitive. sleep duration (~6 hours per night for 1 week) in Furthermore, this was designed as a pilot study and adolescents results in more daytime sleepiness, difficulty therefore the sample chosen is not representative of the concentrating, cognitive deficits (organization, planning, Lebanese population of adolescents and the conclusions and working memory) and problems in terms of cannot be generalized. Although questions on nightmares impulse control, regulation of emotions and behavioural are part of all validated questionnaires dealing with flexibility 22( ,23). sleep problems, we think that varying interpretations of To compensate for sleep deprivation during the week, nightmares might have been a source of bias in our study. it is common that teenagers arise a few hours later on In conclusion, our pilot survey demonstrated that days without school. This difference caused by school school duty and homework, as well as the modern and work time is called social jetlag (24). However, it often lifestyle adopted by present-day adolescents, cause an happens that sleep is not fully recovered, since social important sleep deprivation problem, whose impact incentives such as part-time work and going out with requires a significant multidimensional response. friends push them to sleep still later; sometimes up to > 2 This type of problem is likely to become increasingly hours the day after the weekend compared to school days important, and the establishment of good sleep hygiene (15,25). and education about the importance of a good night’s We also have to keep in mind the impact of technology sleep are necessary to improve adolescent sleep quality. A on adolescent lifestyle. It has been reported that 97% national study is warranted to assess further adolescents’ of adolescents have an electronic device in their room sleep quality in Lebanon. Acknowledgements Thanks to Dr Najib Haddad for the English editing. Funding: In part by Agence Universitaire de la Francophonie, Bureau Moyen Orient. Competing interests: None declared.

Évaluer la qualité du sommeil des élèves du secondaire au Liban en fonction de leur mode de vie : étude pilote à Beyrouth Résumé Contexte : Les troubles du sommeil chez les adolescents perturbent gravement l’activité du processus d’apprentissage. Étant donné l’absence de données concernant le sommeil au Liban, il est essentiel de mener une étude sur la qualité du sommeil chez les adolescents. Objectif : Comprendre les habitudes et les tendances qui perturbent la qualité du sommeil et évaluer l’importance des éventuels problèmes chez les adolescents libanais, alerter l’opinion sur les effets d’une bonne hygiène de sommeil sur l’état de santé général des adolescents.

726

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 726 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Méthodes : Une étude transversale a été conduite auprès de 500 élèves du secondaire à Beyrouth à l’aide d’un questionnaire d’auto-évaluation. Les thèmes recouvraient les caractéristiques sociodémographiques, les comportements à haut risque et la qualité du sommeil. Une analyse bivariée et la régression logistique ont été utilisées pour examiner l’effet que pouvaient avoir divers facteurs associés aux habitudes de sommeil. Résultats : L’étude a révélé que 76,5 % des adolescents n’étaient pas satisfaits de la qualité de leur sommeil, 56 % ne dormant pas un nombre suffisant d’heures (< 8 heures) ; et que 82,4 % utilisaient leur téléphone mobile ou des appareils électroniques dans leur lit avant de dormir. De plus, 3,2 % éprouvaient de réelles difficultés pour s’endormir, 11,3 % au niveau du maintien du sommeil et 8,7 % se réveillaient tôt. Conclusion : Une grande partie des élèves du secondaire à Beyrouth présentent de mauvaises habitudes de sommeil. Il est donc nécessaire de sensibiliser davantage la population dans le cadre de l’enseignement afin d’éviter toute aggravation de ce problème.

تقييم جودة النوم لدى طالب املدارس الثانوية اللبنانية وعالقته بنمط احلياة: دراسة ارتيادية يف بريوت رامز شاهني، ريتا فرح، ميشيل شحود، آالن حرب، رامي طراباي، إيريك سولو، روجر غودبوت اخلالصة اخللفية:تسبب مشاكل النوم عند املراهقني ً اضطرابا ًخطريا يف عملية التعلم َّالفعالة. ًونظرا لغياب البيانات الواردة من لبنان حول النوم، تعد دراسة حتديد جودة النوم بني املراهقني ًأمرا ًحيويا. اهلدف:فهم عادات النوم وأنامطه التي تؤثر عىل جودة النوم، وتقييم مدى مشاكل النوم املحتملة لدى املراهقني اللبنانيني، ورفع مستوى الوعي باآلثار الصحية اجليدة للنوم عىل الصحة العامة لدى املراهقني. طرق البحث: أجريت دراسة مسح مقطعي شملت 500 ًيف طالبااملدارس الثانوية يف بريوت باستخدام استبيان ُي ْم َل ً ذاتياحول السلوك االجتامعي السكاين والسلوك ّاملعرض للمخاطر الصحية وجودة النوم. ومتت دراسة تأثري العديد من العوامل املتعلقة بعادات النوم لدى الطالب باستخدام التحليل الثنائي املتغريات َّوالت َح ُّوف اللوجستي. النتائج: وجدنا أن % من76.5 املراهقني غري راضني عن جودة نومهم؛ وأن 56% منهم مل حيصلوا عىل القدر املناسب من النوم )أقل من 8 ساعات(؛ وأن 82.4%منهم يستخدمون اهلواتف املحمولة واألجهزة اإللكرتونية يف الرسير قبل الدخول يف النوم. عالوة عىل ذلك، واجه 3.2% مشكلة حقيقية يف بدء النوم، وواجه 11.3% مشكلة االستمرار يف النوم وواجه 8.7% مشكلة اليقظة املبكرة. االستنتاج:تعاين نسبة كبرية من طالب املدارس الثانوية يف بريوت من سوء أنامط النوم. لذلك من الرضوري زيادة الوعي باملشكلة أثناء التعليم من أجل منع تفاقمها.

References 1. Landmann N, Kuhn M, Piosczyk H, Feige B, Baglioni C, Spiegelhalder K, et al. The reorganisation of memory during sleep. Sleep Med Rev. 2014 Dec;18(6):531–41. https://doi.org/10.1016/j.smrv.2014.03.005 PMID:24813468 2. Wells ME, Vaughn BV. Poor sleep challenging the health of a nation. Neurodiagn J. 2012 Sep;52(3):233–49. PMID:23019761 3. Haapasalo-Pesu KM, Karukivi M. [Sleep disorders among adolescents – a major problem in mental health care]. Duodecim. 2012;128(22):2319–25 (in Finnish). PMID:23342478 4. Khazaie H, Chehri A, Sadeghi K, Heydarpour F, Soleimani A, Rezaei Z. Sleep hygiene pattern and behaviors and related factors among general population in west of Iran. Glob J Health Sci. 2016 08 1;8(8):53434. PMID:27045403 5. Ramar K, Olson EJ. Management of common sleep disorders. Am Fam Physician. 2013 Aug 15;88(4):231–8. PMID:23944726 6. MacLean JE, Fitzgerald DA, Waters KA. Developmental changes in sleep and breathing across infancy and childhood. Paediatr Respir Rev. 2015 Sep;16(4):276–84. PMID:26364005 7. Hagenauer MH, Perryman JI, Lee TM, Carskadon MA. Adolescent changes in the homeostatic and circadian regulation of sleep. Dev Neurosci. 2009;31(4):276–84. https://doi.org/10.1159/000216538 PMID:19546564 8. Gradisar M, Wolfson AR, Harvey AG, Hale L, Rosenberg R, Czeisler CA. The sleep and technology use of Americans: findings from the National Sleep Foundation’s 2011 Sleep in America poll. J Clin Sleep Med. 2013 Dec 15;9(12):1291–9. PMID:24340291 9. Storfer-Isser A, Lebourgeois MK, Harsh J, Tompsett CJ, Redline S. Psychometric properties of the Adolescent Sleep Hygiene Scale. J Sleep Res. 2013 Dec;22(6):707–16. https://doi.org/10.1111/jsr.12059 PMID:23682620 10. Waterhouse J, Fukuda Y, Morita T. Daily rhythms of the sleep–wake cycle. J Physiol Anthropol. 2012 03 13;31(1):5. https://doi. org/10.1186/1880-6805-31-5 PMID:22738268 11. Laberge L, Petit D, Simard C, Vitaro F, Tremblay RE, Montplaisir J. Development of sleep patterns in early adolescence. J Sleep Res. 2001 Mar;10(1):59–67. https://doi.org/10.1046/j.1365-2869.2001.00242.x PMID:11285056

727

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 727 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

12. Tarokh L, Raffray T, Van Reen E, Carskadon MA. Physiology of normal sleep in adolescents. Adolesc Med State Art Rev. 2010 Dec;21(3):401–17. PMID:21302851 13. Centre du sommeil et de la vigilance Hôtel-Dieu, Paris. Questionnaire des troubles du sommeil. www.sommeil-vigilance.fr 14. Gonçalves M, Amici R, Lucas R, Åkerstedt T, Cirignotta F, Horne J, et al. Sleepiness at the wheel across Europe: a survey of 19 countries. J Sleep Res. 2015; 24(3): 242-53. 15. Bailly D, Bailly-Lambin I, Querleu D, Beuscart R, Collinet C. [Sleep in adolescents and its disorders. A survey in schools]. Ence- phale. 2004 Jul–Aug;30(4):352–9 (in French). https://doi.org/10.1016/S0013-7006(04)95447-4 PMID:15538310 16. Léger D, Beck F, Richard JB, Godeau E. Total sleep time severely drops during adolescence. PLoS One. 2012;7(10):e45204. https:// doi.org/10.1371/journal.pone.0045204 PMID:23082111 17. National Sleep Foundation. Adolescent sleep needs and patterns: research report and resource guide. Washington (DC): National Sleep Foundation; 2000. 18. Gibson ES, Powles AC, Thabane L, O’Brien S, Molnar DS, Trajanovic N, et al. “Sleepiness” is serious in adolescence: two surveys of 3235 Canadian students. BMC Public Health. 2006 05 2;6(1):116–24. https://doi.org/10.1186/1471-2458-6-116 PMID:16670019 19. Winterton PM. Child protection and the health professional: mandatory responding is our duty. Med J Aust. 2009 Sep 7;191(5):246–7. PMID:19740042 20. Crowley SJ, Acebo C, Carskadon MA. Sleep, circadian rhythms, and delayed phase in adolescence. Sleep Med. 2007 Sep;8(6):602– 12. https://doi.org/10.1016/j.sleep.2006.12.002 PMID:17383934 21. Wolfson AR, Spaulding NL, Dandrow C, Baroni EM. Middle school start times: the importance of a good night’s sleep for young adolescents. Behav Sleep Med. 2007;5(3):194–209. https://doi.org/10.1080/15402000701263809 PMID:17680731 22. Beebe DW, Fallone G, Godiwala N, Flanigan M, Martin D, Schaffner L, et al. Feasibility and behavioral effects of an at-home multi-night sleep restriction protocol for adolescents. J Child Psychol Psychiatry. 2008 Sep;49(9):915–23. https://doi.org/10.1111/j.1469- 7610.2008.01885.x PMID:18564072 23. Bériault M, Turgeon L, Labrosse M, Berthiaume C, Verreault M, Berthiaume C, et al. Comorbidity of ADHD and anxiety disorders in school-age children: impact on sleep and response to a cognitive-behavioral treatment. J Atten Disord. 2018 Mar;22(5):414-424. https://doi.org/10.1177/1087054715605914 PMID:26396144 24. Wittmann M, Dinich J, Merrow M, Roenneberg T. Social jetlag: misalignment of biological and social time. Chronobiol Int. 2006;23(1-2):497–509. https://doi.org/10.1080/07420520500545979 PMID:16687322 25. Fischer FM, Wey D, Valente D, Luz AA, Pinheiro F, Fonseca BC, et al. Sleep patterns and sleepiness among young students: a longitudinal study before and after admission as trainees and apprentices. Chronobiol Int. 2015; 32(4): 478-85. PMID:25541361 26. Calamaro CJ, Mason TB, Ratcliffe SJ. Adolescents living the 24/7 lifestyle: effects of caffeine and technology on sleep duration and daytime functioning. Pediatrics. 2009 Jun;123(6):e1005–10. https://doi.org/10.1542/peds.2008-3641 PMID:19482732

728

03- Assessing sleep quality of Lebanese high school students in relation to lifestyle.indd 728 10/10/2018 12:39:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Adapting life to the reality of diabetes

Hossein Namdar Areshtanab,1 Hossein Karimi Moonaghi,2 Leila Jouybari,3 Vahid Zamanzadeh 1 and Hossein Ebrahimi 1

1Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran (Correspondence to: Hossein Namdar Areshtanab: [email protected]). 2Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. 3School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran.

Abstract Background: Diabetes is one of the most challenging and burdensome chronic diseases of the 21st century. Adaptation to disease is a mental, multidimensional, interactive process and is influenced by social and cultural factors. It should be explained in the cultural context of each society with qualitative studies. Aims: In this study, we explored the subjective experiences of adaptation to type 2 diabetes among Iranian patients. Methods: This was a qualitative study using a grounded theory approach. Purposeful sampling was used initially, followed by theoretical sampling based on derived codes and categories as the sampling method. Twenty patients as main participants and 7 from the healthcare system and family members were selected based on a purposeful and theoretical sampling method. Data were collected through semistructured and deep interviews. Data were analysed using the approach of Strauss and Corbin simultaneous with data collection. Results: Five categories that emerged from the data included: perceived threat of disease, reality compliance, comprehensive reconstruction, normalization of living with illness, and return to resources. Finally, data analysis on selective coding led to recognition of “endeavour to reconstruction of life” as the core variable. The core variable showed the way participants adapted to diabetes. Conclusions: This study showed that the process of adaptation to diabetes has a dynamic nature in which participants make major changes in their cognitive, emotional and behavioural structures in order to have a normal life. Keywords: Diabetes mellitus, psychological adaptation, grounded theory Citation: Areshtanab HN; Moonaghi HK; Jouybari L; Zamanzadeh V; Ebrahimi H. Adapting life to the reality of diabetes. East Mediterr Health J. 2018;24(8):729–735. https://doi.org/10.26719/2018.24.8.729 Received: 13/10/15; accepted: 12/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction and learns about the illness and its management (7). Accurate understanding of the adaptation process is Diabetes mellitus is one of the most challenging and bur- necessary in the management of the disease (8). Studies densome chronic diseases of the 21st century (1). It cur- have shown that adaptation to diabetes is a complex rently affects ~285 million adults worldwide and this is interactive, multidimensional and subjective process, expected to rise to > 400 million adults by 2030 (2). Type and is influenced by different factors and occurs in a 2 diabetes mellitus is responsible for > 90% of all cases social context (9). Available literature is based on studies of diabetes (3). Most new patients with diabetes are from conducted in western societies that differ in terms of developing countries and it seems that the Middle East is cultural and social backgrounds from Iranian society. among the regions that will have the largest increase in Moreover, the studies have shown that sociocultural prevalence by 2030. The prevalence of diabetes is ~8.7% context could influence the illness and outcome of the in Iranians (4). process of adaptation to disease (10,11). The aim of this After medical diagnosis of chronic illness (e.g., study was to explore adaptation to type 2 diabetes in diabetes), patients are confronted with new situations Iranian patients. that challenge their habitual coping strategies and go through a process of psychosocial adaptation (5). Living Methods with diabetes mellitus has been described as a dynamic personal transitional adaptation (6). The experience of Study design and participants living with chronic disease is a continuous, progressive This was a qualitative study using a grounded theory ap- and complex process that can result in adaptation to and proach. Grounded theory is especially suitable for analys- management of the disease. Adaptation and management ing social processes, as it rises above merely describing in diabetes are simultaneous and interdependent as the a topic, and instead facilitates a deeper understanding person comes to terms with the illness, gains support without losing parts and details (12). Following approval from caregivers, creates relationships with others, (No. 900603) by the Ethics Committee of the Mashhad

729

04- Adapting life to the reality of diabetes.indd 729 10/10/2018 12:40:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

University of Medical Sciences, Islamic Republic of Iran, sensation that differed from their former experiences informed consent was obtained from all participants who of adaptation. During the next step, focused coding met the inclusion criteria. All participants were assured was performed and the most meaningful codes were that their personal data would remain confidential. Time selected. At this point, the core category “endeavour and location were chosen by agreement of the partici- to reconstruction of life” was developed, as well as pants. Examples of interview questions were as follows: categories: perceived threat of disease, reality compliance, Can you tell me how and when you discovered that you comprehensive reconstruction, normalization of living had diabetes? Can you tell me how you live with diabetes? with illness, and return to resources for adapting to Can you tell me how you feel about your diabetes now? type 2 diabetes. During the entire analysis, constant A purposive sample of 20 patients was recruited. comparisons were made between parts of the data and Patients were selected on the basis of the following between different categories to capture similarities inclusion criteria: confirmed diagnosis of type 2 diabetes and differences, as well as relationships among the mellitus for ≥ 2 years; awareness of their diagnosis; various categories grounded in the data. Data collection cognitive and physical ability to participate; and progressed simultaneously with the analysis and coding willingness to participate. Theoretical sampling was process. Memos consisted of the researchers’ thoughts used to focus the data collection, enrich the categories about the respondents’ statements during the interviews, that emerged, and guide where to go for the coming and how the respondents’ statements fitted together was data collection. Therefore, there were 3 categories also analysed. An initial conceptual model was developed of participants: 20 patients with diabetes, 4 health by relating categories to each other and describing professionals and 3 spouses. processes related to “What’s going on?” and “What is it all about?” During the theoretical sampling phase, Data collection categories were refined and saturated using additional Data were collected via in-depth, semi structured, face- information acquired by conducting further interviews to-face interviews conducted between September 2013 and by recoding available data. Sample selection was and August 2014. Seventeen interviews were private and terminated when new data ceased to add anything new conducted at the participantʼs discretion with regard to to the final model. Twelve interviews were based on a place and time by the Diabetes Association of Iran, Tabriz requirement of theoretical sampling. Branch. Due to the participants’ working conditions, 3 of Results the interviews were undertaken in a private room within Tabriz Faculty of Nursing and Midwifery. Fifteen in- Among the participants, 11 (55%) were male, the average terviews were conducted in Persian and 5 in Turkish by age was 47.8 (12.0) years, and 19 (95%) were married. Eight H.N.A (native language of the authors is Turkish). Each (40%) had a lower educational background (illiterate to participant was interviewed only once. The analysis was diploma), 6 (30%) had a diploma and 6 (30%) had a higher conducted in Persian and, for the purposes of this paper, education background (college graduates). Most women translated into English. Participants were asked about were unemployed while most men were employed and their experiences of living with and confronting diabetes. 6 of them were retired. Participants averaged 10.26 (7.07) The interviews were tape-recorded and transcribed ver- years living with a diagnosis of diabetes and 10 (50%) batim. The first set of interviews lasted 60–80 minutes participants required daily insulin injection. Ten partic- and the final series lasted 40–50 minutes (mean time of ipants had a weak economic situation. Five categories each interview was 45 minutes). Data collection contin- that emerged from the data included: perceived threat of ued until saturation was achieved; that is, until no new disease, reality compliance, comprehensive reconstruc- code emerged from the analysis. tion, normalization of living with illness, and return to resources (Table 1). Analysis of the interview texts began after the first interview had been conducted and transcribed. Data Using a grounded theory approach in the qualitative were analysed as described by Strauss and Corbin (12). design of the study led to in-depth understandings of At the first level of coding, the transcribed interviews the how and why contextual changes in participant were analysed using line-by-line or segment-by-segment perceptions, activities, interactions and emotional coding guided by questions such as “What is being responses over time. All the main categories were related and subordinated to the core category. expressed here?” and “What does it mean?” This initial coding process led to segmentation of the data into Finally, data analysis on selective coding and writing codes. These codes were identified and labelled according the storyline, making use of diagrams, and reviewing to their meaning and the actions found in the data. and sorting of memos led to recognition of “endeavour Comparisons of differences and similarities were made to reconstruction of life” as the core category and the continuously, and emerging codes with similar content integration of concepts. Endeavour to reconstruction of were grouped together into categories. Categories were life appeared frequently in the data during all stages of labelled in a more abstract way, based on the phenomena the process. they represented and in relation to the meanings and The participants experienced symptoms resulting actions found in the data. The first impression during from their diseases. Most participants with exacerbating, the analysis was that participants had experienced a new continuing symptoms decided to see a doctor (perceived

730

04- Adapting life to the reality of diabetes.indd 730 10/10/2018 12:40:43 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 1 Core variable, themes and subthemes of adaptation process to diabetes Core variable Main themes Subthemes Endeavour to reconstruction of life Perceived threat of disease Confront with new symptoms and signs Personal processing Coping with signs and symptoms Receiving a diagnosis of diabetes

Acceptance of reality Acceptance of diabetes Seeking information Initial imaging of disease Initial self-management Comprehensive reconstruction Self-reconstruction Reconstruction in the understanding of disease Life reconstruction Advanced self-management Normal life with the disease Return to activities of daily living and continuing a healthy lifestyle Return to resources Individual resources Family resources Social resources

threat of disease). After receiving a diagnosis, they Personal processing had varied reactions from denial to acceptance. The Personal processing refers to the participants’ interpre- participants then began to gain information about tation of physical signs and symptoms and their causes. diabetes from different sources and processing of the There were 2 kinds: attribution of symptoms to diabetic disease in order to manage (acceptance of reality). After causes, and attribution of symptoms to nondiabetic caus- years of living with this disease, the participants found es. Most participants knew the symptoms in association that superficial management alone was not enough with nondiabetic causes. Misinterpretation of the signs and comprehensive efforts for effective control of the and symptoms can lead to a delay in healthcare-seeking disease were needed (comprehensive reconstruction). behaviour. However, some participants with a higher The outcome of comprehensive reconstruction was a education level and a positive family history of diabetes normal life with diabetes (normal life with the disease). suspected that they had the disease. A 55-year-old man Factors (such as return to resources category) can affect stated: “I was extremely thirsty. I thought I might have a cold.” the process of adjusting to diabetes. Coping with signs and symptoms Perceived threat of disease Participants engaged in activities to reduce their sign We measured the cognitive, emotional and behaviour- and symptoms. These activities included self-remedy and al reactions of participants from experiencing the first waiting to change. warning signs and symptoms to receiving a definitive “Sometimes, I did not feel good. I had fever and chill. I was diagnosis of diabetes. This category included 4 subcate- eating everything, but again I had shiver. I thought that I had gories. cold, so I took an acetaminophen tablet, and then I expected to feel better.” (60-year-old woman). Confront with new symptoms and signs “I had a feeling of fatigue and muscle soreness while I hadn’t This refers to awareness of the abnormal signs and symp- heavy physical work, I told myself wait and see.” (45-year-old toms that were expressed by most of the participants. man) These symptoms were differentiated by features such as “My husband had some numbness and weakness in his location (depending on the organs involved), frequency hands and foot. I told him to saw a doctor. But he ignored and and duration of initial symptoms. The most common did not go to the doctor.” (wife of participant) symptoms were extreme thirst, urinary frequency, visual problems and spontaneous opening of sutured wounds. Receiving a diagnosis of diabetes Women and highly educated participants had greater Exacerbation and persistence of symptoms with disrup- health awareness and were more prone to health-related tion of function, and acquisition of information from activities. However, a few of the participants did not ex- other sources, resulted in most participants deciding to press the warning signs due to a positive history of the see a doctor. A 61-year-old man stated: “After some time of illness in their family. A 35-year-old woman remarked: suffering from frequent urination and itching, I shared my prob- “After the removal of my fallopian tubes, I saw one day that my lem with my wife and she told me that I should see a doctor. I sutured incision had opened spontaneously while my wound went to see a doctor and after visiting I found out that I suffer had not recovered.” from diabetes.”

731

04- Adapting life to the reality of diabetes.indd 731 10/10/2018 12:40:44 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Acceptance of reality “For 48 years my aunt has had type 2 diabetes mellitus and she lives comfortably with it. I always use her as a model on We measured cognitive, emotional and behavioural reac- life with diabetes and I use her guidance in diabetes control.” tions of participants after receiving a diagnosis of diabe- (identification; 61-year-old woman) tes. This category included 4 subcategories. “To choose the wrong style of life I blame myself for diabetes Acceptance of diabetes now.” (internal locus of control; 57-year-old woman) Most participants reacted to their diagnosis with denial Reconstruction in the understanding of disease and protest. However, with time, repetition of tests and confirmation of the diagnosis by other doctors, they Reconstruction in the understanding of disease included eventually accepted it. finding benefits in the illness and comparison of diabetes mellitus with other diseases. “After that I became aware of my disease, because of negative history of diabetes in my family, I did not expect to have the “I already had a low physical activity level and I ate fatty disease, I asked why I was infected.” (57-year-old man) and fried foods. Now I try to walk every day for at least one half hour and I eat more low-fat and low cholesterol foods such as “The majority of patients when first time informed of their vegetables and fruits.” (50-year-old woman) disease are shocked and cry and think they have no hope for life.” (Physician) Life reconstruction Seeking information Life reconstruction included modifying goals, expectations and balance between work and leisure. A 57-year-old Information seeking can be divided into active and in- man stated: “Before my illness, I wanted to work after retire- active forms. In the active form, those participants who ment. Now I want to retire earlier so that I may buy a garden were highly educated searched for information in maga- where I can plant trees and get relaxation.” zines and online. In the passive form, participants gained information inadvertently. Advanced self-management “After my sutured incisions opened spontaneously, I searched Advanced self-management included secondary and pre- the online and found that one of the causes can be diabetes.” ventive management. (35-year-old woman, high educational level) “I felt like I was lethargic and I sweat. I noticed that my blood “When I turned my car radio on, I realized that they were sugar was low and immediately I ate some sugar and after a discussing diets for diabetics.” (50-year-old man) while I felt that I was fine.” (60-year-old woman) Initial imaging of disease “Now I find that when I go biking or hiking I have a piece of chocolate or fresh fruit in my bag that I use in case of necessity.” After obtaining initial information, most participants (60-year-old man) gained initial understanding about the causes, course and consequences of the disease. A 51-year-old man com- Normal life with the disease mented: “I thought that the disease is short-term and caused by Normal life included return to activities of daily living job stress.” and continuing a healthy lifestyle. A 45-years-old woman Initial self-management stated: “Sometimes I am so immersed in daily life that I forget I have diabetes.” Most of the participants reported taking the prescribed medication, diet and blood glucose control as the prima- Return to resources ry management of their illness. A 41-year-old woman re- Return to resources included 3 subcategories: individual, marked: family and social resources. Individual resources includ- “After daily insulin injection, I ate my breakfast and working ed beliefs, personal background, and previous experience. at home. After resting, I walking in the evening.” Social resources included family and community. Comprehensive reconstruction “Having diabetes means death.” (45-year-old woman) Comprehensive reconstruction refers to the participants’ “Following this illness, sexual problems arise; there is no reconsideration and reappraisal of themselves, their one that can give clear guidance and help you in this regard.” illness and their life, in order to control diabetes effective- (56-year-old man) ly and achieve normalization of life. “The supportive role of governmental and nongovernmental Self-reconstruction organizations is important in diabetes control. These organizations can develop training to reduce costs and prevent Self-reconstruction included modifying coping styles, diabetes”. (nurse) identification with successful patients with type 2 diabetes, disclosing your illness to others, and internal locus Discussion of control (belief that they can influence diabetes and its We aimed to understand the process of adaptation to outcomes). type 2 diabetes. Data analysis showed that participants’ “Now, I prepare to participate in scientific studies about perception was an important component in this process. diabetes mellitus in order to progress in the treatment of it, while Most participants experienced symptoms including dry previously I had no such intention.” (meaning-based coping; mouth, excessive thirst, frequent urination and visual 43-year-old man) problems resulting from other diseases. The results of

732

04- Adapting life to the reality of diabetes.indd 732 10/10/2018 12:40:44 PM Research article EMHJ – Vol. 24 No. 8 – 2018

this study were congruent with other studies (13–15). and leading a normal life are needed (27). Following the However, some participants who had previous experi- reconstruction of self, their illness and life, participants ence of diabetes in can continue to play individual, social roles and the family members, even without experiencing the disease is not a dominant preoccupation (28–30). Factors warning signs themselves, frequently saw a doctor such as communication with healthcare providers, and for a check-up. Prior experience in a family member individual, educational and family backgrounds can with diabetes could result in susceptibility to greater affect diabetes self-management (31–33). consideration of one’s own health. If a person perceives The obvious contribution of this study was in the himself susceptible to diabetes, they will tend to take generation of the social and psychological process of preventive action (16). In the present study, most endeavour to reconstruction of life that accounted for participants attempted to wait and see or resorted to variation in change over time, context and behaviour in self-remedy to reduce their symptoms, owing to their adapting to type 2 diabetes in Iranian patients. This was incorrect interpretations of their signs and symptoms. a small study and carried out in the national context of According to the self-regulatory model, individuals the Islamic Republic of Iran. Thus, caution is needed in respond to threats with cognitive representation, coping generalizing the findings to other countries. Also, the and the appraisal of consequences (17). Most participants study was performed exclusively in urban areas. We with exacerbating, continuing symptoms decided to see believe that it is necessary to conduct a population-based a doctor. Our results seemed to be congruent with other survey to confirm these findings. studies (14,18). After receiving a diagnosis, most participants began Conclusions to deny the reality and protested against it. However, with The purpose of the present study was to explore the sub- time, repetition of tests and confirmation of diagnosis by jective experiences of adaptation to diabetes among Ira- several doctors, the participants accepted their disease nian patients with type 2 diabetes. We showed that expe- (19). riencing diabetes is an event that is perceived uniquely They then began to acquire information about their by every patient that can significantly affect perception disease from different sources in order to manage it. and cause temporary and permanent changes in their Sources of information were physicians, other patients, lives. Also, the adaptation process consisted of integrated nurses, the internet, magazines and books, and personal but distinct phases that were nonlinear for each person; and social factors affected the selection of resources however, they were consistent among the participants. (20,21). Participants then began to shape their beliefs Understanding how Iranian people with diabetes become about the causes, course and consequences of their adapted is important to health professionals involved in illness. Other studies have shown that they knew caring. Health professionals can help patients cope by diabetes to be a prolonged illness with physical, mental implementing effective interventions that include rein- and social complications (22,23). Understanding the forcing facilitating factors and modifying hindering fac- nature of the disease affected participants’ behaviour tors, giving greater attention to patients’ spiritual needs, (24). Such behaviour is focused on adherence to diet, helping them find meaning in their lives, focusing more physical activity, taking prescribed medication, and daily attention on family, and considering the context of the blood sugar control (25,26). After years of living with patients. The findings could be utilized in education of this disease, patients find that superficial compliance nursing students and physicians and families of patients with medication orders, diet and physical activity is with diabetes. They could also be used to design a con- not enough and cognitive, emotional and behavioural text-adapted tool adapted to measure adjustment to type comprehensive efforts for effective control of the disease 2 diabetes.

Acknowledgements This paper is the result of an approved thesis in MUMS (no. 900603), funded by MUMS Vice Presidency for Research Pur- poses. The authors wish to thank the Vice Chancellor in Research in Mashhad and Tabriz Universities of Medical Sciences who supported this study, as well as all participants and cooperation of Tabriz Branch Diabetes Association for their help in conducting this research. Funding: None. Competing interests: None declared.

733

04- Adapting life to the reality of diabetes.indd 733 10/10/2018 12:40:44 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Adapter les habitudes de vie à la réalité du diabète Résumé Contexte : Le diabète est l’une des maladies chroniques les plus complexes et pesantes du vingt et unième siècle. L’adaptation à la maladie implique un processus mental, multidimensionnel et interactif, qui est influencé par des facteurs sociaux et culturels. Elle doit ainsi être appréhendée par le prisme du contexte culturel de chaque société, à l’aide d’études qualitatives. Objectif : Dans la présente étude, nous avons analysé les expériences subjectives de l’adaptation au diabète de type 2 parmi des patients iraniens. Méthodes : Il s’agissait d’une étude qualitative reposant sur la méthodologie de la théorie enracinée. Un échantillonnage ciblé a tout d’abord été utilisé, suivi d’un échantillonnage théorique reposant sur des codes et catégories dérivés. Vingt patients ont été sélectionnés à l’aide des méthodes d’échantillonnage ciblé et théorique. Les données ont été recueillies au moyen d’entretiens semi-structurés et approfondis, et ont été analysées simultanément à l’aide de l’approche de Strauss et Corbin. Résultats : Les cinq catégories qui se sont dégagées des données recueillies incluaient : la menace perçue de la maladie, le fait de se conformer à la réalité, la reconstruction globale, la normalisation associée au fait de vivre avec la maladie, et le retour aux valeurs de base (individuelles, familiales et sociales). Enfin, l’analyse des données portant sur le codage sélectif a mené à l’identification de « l’effort de reconstruction de sa propre existence » comme variable fondamentale. Cette variable fondamentale a montré la façon dont les participants s’adaptaient au diabète. Conclusion : La présente étude a révélé que le processus d’adaptation au diabète est de nature dynamique. Les participants modifient en effet considérablement leurs structures cognitives, émotionnelles et comportementales de façon à mener une vie normale.

تكييف احلياة مع حقيقة السكري حسني أريشتانب، حسني موناجي، ليىل جويباري، وحيد زمانزادة ، حسني إبراهيمي اخلالصة اخللفية:السكري من أكثر األمراض املزمنة التي تفرض التحديات وتسبب األعباء يف القرن احلادي والعرشين، والتكيف معه عملية تفاعلية ونفسية ومتعددة األبعاد، وتتأثر بالعوامل االجتامعية والثقافية. وجيب رشح ذلك يف السياق الثقايف لكل جمتمع مع إجراء دراسات كيفية. اهلدف: بحثنا يف هذه الدراسة اخلربات الشخصية للتكيف مع السكري من النمط 2بني املرىض اإليرانيني. طرق البحث: كانت هذه الدراسة كيفية تستند إىل استخدام مقاربة ذات أسس نظرية، واستخدمنا فيها اختيار مستهدف للعينة يف البداية، وأتبعناها بعد ذلك بأسلوب أخذ العينات النظرية ً استناداإىل الرموز ُامل ْش َت َّةق والفئات، واخرتنا 20 ًمريضا كمشاركني رئيسيني و 7مشاركني من نظام الرعاية الصحية وأفراد األرسة ًاستناداإىل الطريقة اهلادفة والنظرية ألخذ العينات، ومجعنا البيانات من خالل املقابالت ذات البنية املركبة تركيبا ًجزئيا، ّوحللنا البيانات باستخدام مقاربة شرتاوس وكوربني املتزامنة يف وقت واحد عند مجع البيانات. النتائج: أدت دراسة البيانات إىل 5 فئات هي: التهديد ُامل ْد َك رللمرض، واالمتثال للحقيقة، وإعادة البناء الشامل، وتطبيع احلياة مع املرض، والعودة إىل املوارد. ً، وأخرياأدى حتليل البيانات باستخدام ترميز انتقائي إىل ُّالتعرفعىل »مرشوع إعادة بناء احلياة« باعتباره املتغري األسايس. وقد أظهر املتغري األسايس طريقة ُّتكيف املشاركني مع السكري. االستنتاج: أظهرت هذه الدراسة أن عملية التكيف مع السكري هلا طبيعة ديناميكية يقوم املشاركون فيها بإجراء تغيريات كبرية يف ما لدهيم من بِ َنى معرفية وعاطفية وسلوكية من أجل احلصول عىل حياة طبيعية.

References 1. Tuncay T, Musabak I, Gok DE, Kutlu M. The relationship between anxiety, coping strategies and characteristics of patients with diabetes. Health Qual Life Outcomes. 2008 10 13;6(1):79. https://doi.org/10.1186/1477-7525-6-79 PMID:18851745 2. Diabetes. Fact sheet. Updated November 2017 (http://www.who.int/mediacentre/factsheets/fs312/en/, accessed 30 January 2018). 3. Olshansky E, Sacco D, Fitzgerald K, Zickmund S, Hess R, Bryce C, et al. Living with diabetes: normalizing the process of managing diabetes. Diabetes Educ. 2008 Nov–Dec;34(6):1004–12. https://doi.org/10.1177/0145721708327304 PMID:19075082 4. Harati H, Hadaegh F, Saadat N, Azizi F. Population-based incidence of type 2 diabetes and its associated risk factors: results from a six-year cohort study in Iran. BMC Public Health. 2009 06 16;9(1):186. https://doi.org/10.1186/1471-2458-9-186 PMID:19531260 5. Chan FE, Da Silva Cardoso EE, Chronister JA. Understanding psychosocial adjustment to chronic illness and disability: A hand- book for evidence-based practitioners in rehabilitation. Springer Publishing; 2009. 6. Gois CJ, Ferro AC, Santos AL, Sousa FP, Ouakinin SR, do Carmo I, et al. Psychological adjustment to diabetes mellitus: highlight- ing self-integration and self-regulation. Acta Diabetol. 2012 Dec;49(S1) Suppl 1:S33–40. https://doi.org/10.1007/s00592-010-0191-7

734

04- Adapting life to the reality of diabetes.indd 734 10/10/2018 12:40:44 PM Research article EMHJ – Vol. 24 No. 8 – 2018

PMID:20473694 7. Le Mone P, Burke K, Dywer T, Levett-Jones T, Moxham L, Reid-Searl K, et al. Medical–surgical nursing. Critical thinking for person-centred care, 3rd edition. Pearson Australia; 2014. 8. Duangdao KM, Roesch SC. Coping with diabetes in adulthood: a meta-analysis. J Behav Med. 2008 Aug;31(4):291–300. https://doi. org/10.1007/s10865-008-9155-6 PMID:18493847 9. Ambrosio L, Senosiain García JM, Riverol Fernández M, Anaut Bravo S, Díaz De Cerio Ayesa S, Ursúa Sesma ME, et al. Liv- ing with chronic illness in adults: a concept analysis. J Clin Nurs. 2015 Sep;24(17-18):2357–67. https://doi.org/10.1111/jocn.12827 PMID:25951949 10. Habib TZ, Rahman S. Psycho-social aspects of AIDS as a chronic illness: social worker role perspective. Antrocom. 2010;6(1):79– 89. 11. Gomersall T, Madill A, Summers LKM. A metasynthesis of the self-management of type 2 diabetes. Qual Health Res. 2011 Jun;21(6):853–71. https://doi.org/10.1177/1049732311402096 PMID:21429946 12. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. Sage; 2008 13. Parry O, Peel E, Douglas M, Lawton J. Patients in waiting: a qualitative study of type 2 diabetes patients’ perceptions of diagnosis. Fam Pract. 2004 Apr;21(2):131–6. https://doi.org/10.1093/fampra/cmh203 PMID:15020378 14. Obidiya OS, Chima IE, Ekadi TS, Ilodigwe EE. Health seeking behaviour among adult residents of Yenagoa city, Nigeria. Conti- nental J Pharm Sci. 2011;5(2):14. 15. Abdoli S, Ashktorab T, Ahmadi F, Parvizi S, Dunning T. The empowerment process in people with diabetes: an Iranian perspective. Int Nurs Rev. 2008 Dec;55(4):447–53. https://doi.org/10.1111/j.1466-7657.2008.00664.x PMID:19146557 16. Hjelm K, Atwine F, Hjelm K. Health-care seeking behaviour among persons with diabetes in Uganda: an interview study. BMC Int Health Hum Rights. 2011 09 26;11(1):11. https://doi.org/10.1186/1472-698X-11-11 PMID:21943099 17. Harvey JN, Lawson VL. The importance of health belief models in determining self-care behaviour in diabetes. Diabet Med. 2009 Jan;26(1):5–13. https://doi.org/10.1111/j.1464-5491.2008.02628.x PMID:19125754 18. Longo DR, Schubert SL, Wright BA, LeMaster J, Williams CD, Clore JN. Health information seeking, receipt, and use in diabetes self-management. Ann Fam Med. 2010 Jul-Aug;8(4):334–40. https://doi.org/10.1370/afm.1115 PMID:20644188 19. Corbin JM, Strauss A. Unending work and care: managing chronic illness at home. San Francisco: Jossey-Bass; 1988. 20. Kalantzi S, Kostagiolas P, Kechagias G, Niakas D, Makrilakis K. Information seeking behavior of patients with diabetes mellitus: a cross-sectional study in an outpatient clinic of a university-affiliated hospital in Athens, Greece. BMC Res Notes. 2015 Feb; 20;8:48 21. Cutilli CC. Seeking health information: what sources do your patients use? Orthop Nurs. 2010 May-Jun;29(3):214–9. PMID:20505493 22. Fukunaga LL, Uehara DL, Tom T. Perceptions of diabetes, barriers to disease management, and service needs: a focus group study of working adults with diabetes in Hawaii. Prev Chronic Dis. 2011 Mar;8(2):A32. PMID:21324246 23. Yilmaz-Aslan Y, Brzoska P, Bluhm M, Aslan A, Razum O. Illness perceptions in Turkish migrants with diabetes: a qualitative study. Chronic Illn. 2014 Jun;10(2):107–21. https://doi.org/10.1177/1742395313501207 PMID:23986085 24. Hale ED, Treharne GJ, Kitas GD. The common-sense model of self-regulation of health and illness: how can we use it to understand and respond to our patients’ needs? Rheumatology (Oxford). 2007 Jun;46(6):904–6. https://doi.org/10.1093/rheumatology/ kem060 PMID:17449488 25. Thorne S, Paterson B, Russell C. The structure of everyday self-care decision making in chronic illness. Qual Health Res. 2003 Dec;13(10):1337–52. https://doi.org/10.1177/1049732303258039 PMID:14658350 26. Ellison GC, Rayman KM. Exemplars’ experience of self-managing type 2 diabetes. Diabetes Educ. 1998 May-Jun;24(3):325–30. https://doi.org/10.1177/014572179802400307 PMID:9677950 27. Paterson B, Thorne S, Crawford J, Tarko M. Living with diabetes as a transformational experience. Qual Health Res. 1999 Nov;9(6):786–802. https://doi.org/10.1177/104973299129122289 PMID:10662259 28. Choi HJ, Hong YS. Transformational experience of a student nurse with diabetes: a case study. Taehan Kanho Hakhoe Chi. 2007 Mar;37(2):192–200. https://doi.org/10.4040/jkan.2007.37.2.192 PMID:17435403 29. Lin CC, Anderson RM, Hagerty BM, Lee BO. Diabetes self-management experience: a focus group study of Taiwanese patients with type 2 diabetes. J Clin Nurs. 2008 Mar;17(5a) 5a:34–42. https://doi.org/10.1111/j.1365-2702.2007.01962.x PMID:18093120 30. Mendenhall E, McMurry HS, Shivashankar R, Narayan KM, Tandon N, Prabhakaran D. Normalizing diabetes in Delhi: a qualitative study of health and health care. Anthropol Med. 2016 Dec;23(3):295–310. https://doi.org/10.1080/13648470.2016.1184010 PMID:27328175 31. Wilkinson A, Whitehead L, Ritchie L. Factors influencing the ability to self-manage diabetes for adults living with type 1 or 2 diabetes. Int J Nurs Stud. 2014 Jan;51(1):111–22. https://doi.org/10.1016/j.ijnurstu.2013.01.006 PMID:23473390 32. Lundberg PC, Thrakul S. Type 2 diabetes: how do Thai Buddhist people with diabetes practise self-management? J Adv Nurs. 2012 Mar;68(3):550–8. https://doi.org/10.1111/j.1365-2648.2011.05756.x PMID:21711465 33. Cotugno JD, Ferguson M, Harden H, Colquist S, Stack AA, Zimmerman JI, et al. “I wish they could be in my shoes”: patients’ insights into tertiary health care for type 2 diabetes mellitus. Patient Prefer Adherence. 2015 Nov 17;9(9):1647–55. PMID:26604714

735

04- Adapting life to the reality of diabetes.indd 735 10/10/2018 12:40:44 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Assessment of hepatitis B immunization programme among school students in Qatar

Hamad Al-Romaihi,1 Hana Al-Masri,1 Sherine Shawky,2 Mohammed Al Thani,1 Salah Al Awaidy,3 Mohamed Ahmed Janahi,4 Moutaz Derbala,4 Khalid Al-Ansari4 and Robert Allison5

1Ministry of Public Health, Doha, Qatar (Correspondence to: Hana K. Al-Masri: [email protected]). 2Social Research Center, American University in Cairo, Cairo, Egypt. 3Ministry of Health, Muscat, Oman. 4Hamad Medical Corporation, Doha, Qatar. 5Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America.

Abstract Background: In 2010, Qatar adopted the target of reducing hepatitis B prevalence to < 1% in children by 2015. The World Health Organization Region for the Eastern Mediterranean is identified with intermediate hepatitis B virus (HBV) endemicity, ranging from 2% to 7%. It is estimated that 4.3 million individuals are living with HBV infection in the Region. Aims: This study was conducted to assess hepatitis B seroprevalence in children, hepatitis B vaccination coverage, potential exposure to risk factors, and knowledge among parents/guardians about hepatitis B infection. Methods: We carried out this cross-sectional study in Qatar during the academic year 2015/16. Multistage cluster sampling was used to select a nationally representative sample of 2735 grade 1 school students aged ≥ 5 years. Blood was collected by finger prick and tested using the point-of-care test/rapid test. A self-administered, precoded questionnaire was used to assess parent/guardian knowledge about HBV and collect information on the child’s HBV vaccination coverage. Results: All blood samples were HBsAg negative. Qataris had a vaccination card and were totally vaccinated but 17.7% of non-Qataris did not hold a vaccination card and most parents/guardians were not aware of the vaccination status of their children. Children were exposed to various hepatitis B risk practices. Knowledge about hepatitis B among parents/ guardians was low. Conclusions: Qatar has averted the hepatitis B threat and maintained high vaccination coverage for children. Keywords: Qatar, hepatitis B, seroprevalence, children, vaccination Citation: Al-Romaihi H; Al-Masri H; Shawky S; Al Thani M; Al Awaidy S; Janahi MA; et al. Assessment of hepatitis B immunization programme among school students in Qatar. East Mediterr Health J. 2018;24(8):736–744. https://doi.org/10.26719/2018.24.8.736 Received: 29/03/17; accepted: 19/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction endemicity ranging from 2 to 7%. It is estimated that 4.3 million persons are living with HBV infection in the The hepatitis B virus (HBV) infection takes a heavy toll countries of the Region (11,12). Numerous studies have on lives worldwide. In 2014, the World Health Organiza- documented HBV infection as an important cause of liver tion (WHO) estimated that 30% of the world’s population, cirrhosis and hepatocellular carcinoma in the countries around 2 billion people, have been infected with HBV and around 360 million have developed chronic liver disease of the Region (13–19). In addition to the burden on people’s (1,2). Furthermore, HBV has been identified as the cause lives, HBV infection drains the resources of the health of up to 80% of all cases of hepatocellular carcinoma system because of the cost of treatment for liver cirrhosis worldwide (3–5). Although HBV-related acute hepatitis and hepatocellular carcinoma. may be asymptomatic and may resolve spontaneously, The limited number of studies on HBV infection in it may also lead to chronic lifelong infection. The main Qatar confirm that the country has not been free of the danger of HBV is in acquiring the infection early in life virus. A study in 1985 showed that 23% of adult patients as progress of the condition towards severe pathological with acute viral hepatitis admitted to Hamad General consequences, e.g. liver cirrhosis, liver failure and hepa- Hospital had HBV infection (20). During 2000–2005, tocellular carcinoma, in adulthood may reach up to 90% the pathology reports at Qatar Principal Reference of infected cases (2,6–10). Additionally, mother-to-child Laboratory indicated hepatitis B incidence was 2.5% transmission results in chronic infection later in life in among liver disease patients (21). In addition, the 90% of infants infected during the perinatal period and incidence of hepatitis B was reported in 2002–2006 as in 80–90% of infants infected in the first year of life. The 4.7% of screened and diagnosed viral hepatitis patients risk of chronic HBV infection declines with age, reaching in Hamad General Hospital (22). A study in 2010 reported 30–50% for children infected between 1 and 4 years of age HBV prevalence of 2.2% and lack of HBV immunity of and only 2–5% for adolescents and adults (6). 53.3% among professional male athletes who attended the The WHO Eastern Mediterranean Region, which Qatar Orthopaedic and Sports Medicine Hospital in Doha includes Qatar, is identified with intermediate HBV (23). As reported in these studies, HBV infection was more

736

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 736 10/10/2018 12:41:57 PM Research article EMHJ – Vol. 24 No. 8 – 2018

prevalent among non-Qataris than Qataris and among estimated to be 2279 children. As it was expected that males than females. up to 20% of the parents/guardians and/or the children The HBV vaccine has been part of the routine infant themselves may refuse to participate in the survey, the immunization programme in Qatar since August 1989, sample was inflated by 20%, thus a total sample of 2735 when a 3-dose schedule of monovalent vaccine was children was targeted. introduced. In 2000, a birth dose was added, aimed at Sampling method preventing 70–95% of HBV infections. Thereafter in July 2003, a new 4-dose vaccine was introduced in the A multistage cluster sampling technique was used to se- Expanded Programme on Immunization schedule to lect a nationally representative sample of grade 1 school accommodate the use of a pentavalent vaccine (DTwP- students attending public and private schools and their HepB-Hib) and hexavalent vaccine (DtaP, Hep B, Hib parents/guardians. There were 19 195 children enrolled and IPV) in addition to the monovalent vaccine at birth. in grade 1 in 200 public and private schools in Qatar. A Hepatitis B vaccination coverage has attained maturity total of 52 schools were selected at random from the list over the past 5 years at 93–99% of all infants. of schools. As the number of students varied markedly by nationality, type of school and sex, sampling was done In 2010, Qatar adopted the WHO target of reducing proportionately. Sampling frames and measure of size HBV prevalence among children below 5years of age were prepared for each municipality by type of school to <1% by 2015. Furthermore, Qatar aims to establish (independent, private international, private approved by a certification procedure to document national education council and private foreign community) and achievement in hepatitis B control. The certification sex (mixed, boys and girls). A total of 51 primary sampling will be based on hepatitis B surface antigen (HBsAg) units from 50 schools were selected by systematic ran- prevalence among children of at least 5 years of age who dom sampling process proportional to school type and were born after the start of the nationwide hepatitis B sex. In very few cases, notably when only 1 cluster was vaccination programme. However, current knowledge on needed per school type and sex, a simple random process the effectiveness of HBV vaccine on reducing the disease was used. prevalence notably in children is relatively slim. In the selected schools, registries were used to provide Thus, this study was conducted to monitor the the list of classes and students in grade 1. If the number of impact of the HBV vaccination programme in achieving students within a school exceeded the sample size, classes the national and regional target among children aged at were selected at random and all students within those least 5 years who received the total vaccination doses, classes were enrolled in the study. Parents/guardians of including the birth dose. In other words, the objectives selected students were also invited to participate in the of the study were to measure the HBV seroprevalence in study. children who benefited from the National vaccination programme; assess the HBV vaccination coverage for Data collection and analysis these children and the potential exposure to HBV-related Data collection was carried out during November 2015– risk factors; and assess parent/guardian knowledge about February 2016 and was consistent in all schools. There HBV infection. Thus, the study was conducted to fill the were 2 components to the data. The first was the serolog- existing gap in knowledge on hepatitis B prevalence and ic component which included HBsAg testing of students to add depth to the vaccination programme in Qatar. The using the point-of-care test/rapid test. This test was used significance of the study goes beyond its contribution to as it is easy to administer and highly flexible. It requires knowledge and regional discourse on the effectiveness of minimal training, no equipment and can be relied upon the HBV vaccination programme to draw the attention of for fast, accurate diagnosis in the most basic settings. the population to the national effort to protect children in Detecting HBsAg was conducted using the Alere Deter- Qatar from the HBV threat. mine HBsAg rapid test (Abbott Laboratories, Santa Clara, Methods California). The results were produced within 15 minutes with sensitivity 95.16% and specificity 99.95%. Blood was Study design and target population collected by finger prick to reduce fears among parents/ As it was hypothesized that the new 4-dose HBV vacci- guardians and children regarding venepuncture as this nation programme had succeeded in reducing hepati- may affect the participation rate. Chronic HBV infection tis B prevalence in children of at least 5 years of age to was assessed by measuring the proportion of HBsAg-pos- < 1% and these children are mostly enrolled in grade 1, a itive by rapid test. school-based survey was conducted during the academ- The second data collection tool was a standardized, self ic year 2015–2016 targeting children and their parents/ administered, precoded parent / guardian questionnaire. guardians. This was developed in English, translated into Arabic and adapted in order to ensure that it took into account Sample size the specific sociocultural realities of the country. The The sample size was calculated using the Epi-Info Statcalc questionnaire was used to assess parent/guardian package for prevalence of 1%, α-level 0.05 and design ef- knowledge about HBV and collect information on child fect 1.5. For the 95% confidence level, the sample size was HBV vaccination coverage and the potential exposure

737

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 737 10/10/2018 12:41:57 PM Research article EMHJ – Vol. 24 No. 8 – 2018

of children to HBV-related risk factors. Vaccination Data entry and analysis were done using the SPSS coverage data were obtained from the child’s vaccination computer package. The chi-squared test was used to card. Where the child did not hold a vaccination card, the assess significant differences between proportions, and parent/guardian was asked to provide the information. Fisher’s exact test was used for 2 × 2 tables when the chi- The survey was pilot tested in 1 school on 152 children squared test was not valid. Independent t-test was used and the questionnaire was pretested on the parents/ to detect significant difference between 2 independent guardians prior to the actual fieldwork. The results of the means. The significance level wasP < 0.05. pilot study were included in the final data analysis. Ethical considerations The vaccination status for hepatitis B vaccination at birth (HepB-birth) was defined as: The study proposal was reviewed and approved by the ethical review board of Hamed Medical Cooperation. All ·· fully vaccinated: HepB-birth administered < 24h from selected children and their parents/guardians were invit- birth; ed to participate in the study. Written informed consent ·· partial vaccinated: HepB-birth administered > 24h to from parents/guardians and assent from children were < 72h from birth; taken prior to data collection. All data were anonymous ·· not vaccinated: no full or partial HepB-birth vaccina- and confidential. Children and parents/guardians were tion. told that they could refuse to answer any question and withdraw from the study any time. The vaccination status for the 3 hepatitis B doses (HepB-3 dose) was defined as: Results ·· fully vaccinated: HBV first dose (HepB1) at 4 months, Background characteristics of the study sample second dose (HepB2) at 6 months and third dose (HepB3) at 15 months; A total of 2803 grade 1 school students were enrolled in the study, 745 (26.6%) Qataris and 2058 non-Qataris. Boys ·· partially vaccinated: invalid HepB2 and/or HepB3 accounted for 52.8% of the sample and ages ranged from vaccination; 5 to 8 years [mean = 6.2, standard deviation (SD) = 0.6]. ·· not vaccinated: no full or partial HepB-3 dose vacci- Over half of the children (58.7%) were born in Qatar and nation. 51.7% were in public schools. The vaccination status for HepB total was defined as: The majority of the non-Qatari children were from The Eastern Mediterranean Region (66.8%), and South ·· fully vaccinated: HepB-birth, HepB1, HepB2 and East Asia Region (27.8%). The rest were from Europe (3.7%), HepB3; Africa (1.1%), the United States of America and Canada ·· partial vaccination: partial Hep-birth, HepB1 and/or (0.3%) and Western Pacific Region (0.1%). HepB2 and/or HepB3; Table 1 provides the background characteristics of ·· not vaccinated: no full or partial HepB-birth and grade 1 school students in Qatar. The proportion of boys HepB-3 dose. was 55.4% among Qatari students and 51.8% among

Table 1 Background characteristics of grade 1 school students in Qatar, 2015–2016 Characteristic Qatari (n = 745) Non-Qatari (n = 2058) Total (n = 2803) No. % No. % No. % Sex Male 413 55.4 1067 51.8 1480 52.8 Female 332 44.6 991 48.2 1323 47.2 Age (years)*** 5 46 6.2 1219 10.6 265 9.5 6 528 70.9 1342 65.2 1870 66.7 7 166 22.3 448 21.8 614 21.9 8 5 0.7 49 2.4 54 1.9 Place of birth*** Qatar 734 98.5 912 44.3 1646 58.7 Outside Qatar 11 1.5 1146 55.7 1157 41.3 Type of school*** Public 579 77.7 869 42.2 1448 51.7 Private 166 22.3 1189 57.8 1355 48.3

***P < 0.001

738

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 738 10/10/2018 12:41:57 PM Research article EMHJ – Vol. 24 No. 8 – 2018

the non-Qataris. The difference was not statistically blood samples tested negative for HBsAg. These results significant. The age range for both Qataris and non- clearly indicate that none of the tested students had HBV Qataris was around 5–8 years, and Qatari students were infection. significantly slightly older than non-Qataris (Qataris: mean = 6.4, SD = 0.9 years; non-Qataris mean = 6.2, SD Hepatitis B vaccination coverage = 0.7 years). Almost all the Qataris (98.5%) were born in All Qatari students and 82.3% of non-Qataris had a vac- Qatar compared to only 44.3% of non-Qataris (P < 0.001). cination card (Table 3). All Qatari students in the sample, whether born in Qatar or outside, were fully vaccinated Hepatitis B seroprevalence with HepB-birth and HepB-3dose. For the non-Qataris As shown in Table 2, 2562 of our students (91.4% of the holding a vaccination card, 96.3% were full vaccinated study sample) agreed to have the HBsAg testing using with HepB-birth, 99.0% with HepB-3 dose, with a total of the point-of-care test, and 2538 tests (99.1%) were valid. All 96.2% fully vaccinated. There were 64 students (3.8% of

Table 2 Hepatitis B seroprevalence in grade 1 school students in Qatar, 2015–2016 Test status Qatari (n = 745) Non-Qatari (n = 2058) Total (n = 2803) No. % No. % No. % Hep B negative 666 89.4 1872 91.0 2538 90.5 Invalid 2 0.3 22 1.1 24 0.9 Sample not taken 77 10.3 164 8.0 241 8.6

Table 3 Hepatitis B vaccine status in grade 1 school students in Qatar, 2015–2016 Vaccination status Qatari Non-Qatari Total (n = 745) (n = 2058) (n = 2803) No. % No. % No. % Vaccination card holders (n =745) (n = 1694) (n = 2439) HepB-birth Fully vaccinated 745 100.0 1632 96.3 2377 97.5 Partial vaccination 0 0.0 4 0.2 4 0.2 Not covered 0 0.0 58 3.4 58 2.4 HepB-3 dose (HepB1+HepB2+HepB3)** Fully vaccinated 745 100.0 1677 99.0 2422 99.3 Partial vaccination 0 0.0 17 1.0 17 0.7 Hep B total (At birth +HepB1+HepB2+HepB3)*** Fully vaccinated 745 100.0 1630 96.2 2375 97.4 Partial vaccination 0 0.0 64 3.8 64 2.6 Non-vaccination card holders (n = 0) (n = 364) (n = 364) HepB-birth Covered – – 105 28.8 105 28.8 Not covered – – 41 11.3 41 11.3 Don’t know/no response 218 59.9 218 59.9 HepB-3 dose (HepB1+HepB2+HepB3) – – Covered – – 45 12.4 45 12.4 Not covered – – 72 19.8 72 19.8 Don’t know/no response – – 247 67.9 247 67.9 Hep B total (At birth +HepB1+HepB2+HepB3) Covered – – 27 7.4 27 7.4 Not covered – – 21 5.8 21 5.8 Don’t know/no response – – 316 86.8 316 86.8

**P < 0.01, ***P < 0.001.

739

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 739 10/10/2018 12:41:57 PM Research article EMHJ – Vol. 24 No. 8 – 2018

non-Qataris holding a vaccination card) who were par- children (0.5%) had tattoos, and this was the same for tially vaccinated as they were either partially or not vacci- Qataris and non-Qataris. nated with HepB-birth and/or HepB-3dose. They were all from India, born in their home country and 74.2% of them Parent/guardian knowledge about hepatitis B were in private schools. viral infection All of the 364 non-Qatari grade 1 school students who Table 5 shows the knowledge of parents/guardians of had no vaccination card were born outside Qatar, mainly grade 1 school students about hepatitis B viral infection. in countries of the WHO Eastern Mediterranean Region We found that 70.0% of parents/guardians had heard (69.8% of non-vaccination card holders) and South East about HBV infection, 16.8% knew of a person who had Asia (22.5%). They were from Egypt (33.8%), Syrian Arab died from the infection but just 17.0% had received infor- Republic (15.4%) and India (17.3%), and 70.9% were private mation about HBV infection in the 6 months prior to data school students. Two-thirds of the parents/guardians did collection. not know whether their children had received HepB-birth The proportion of parents/guardians who knew that and 86.8% were not able to declare the vaccination status blood was a route of transmission ranged from 49.0– of their children. However, 28.8% of these children were 58.2%. The proportion of parents/guardians who knew known to have received HepB-birth, 12.4% were known of the other routes of transmission was low, 31.0% for to have received HepB-3-dose and 7.4% were known to be sexual transmission, 38.4% for vertical mother-to-child totally vaccinated. transmission and 18.9% for transmission through breast- Previous exposure to hepatitis B risk factors feeding. In general, non-Qataris had significantly better knowledge about HBV infection than Qataris. However, As with children in this age group, grade 1 school students at least one-third of parents/guardians had a number of are liable to falling sick and receiving health care (Table misconceptions about HBV, and this was significantly 4). Around a third of the children had had dental treat- higher among non-Qataris than Qataris. ment, 21.9% were ever hospitalized, 21.4% had received injections in hospitals, 13.4% had a surgical treatment and Discussion 4.7% had received injections at home. The proportion of Since the introduction of the new 4-dose HBV vaccine Qatari children receiving dental care was significantly in the national Expanded Programme on Immuniza- higher than the non-Qatari children while the proportion tion, great progress has been achieved in Qatar towards of children receiving other medical care procedures was the elimination of HBV infection in children. All grade 1 significantly higher in non-Qataris than Qataris (Table 4). school children tested for HBsAg in our study tested neg- Around 10% of the children had received health care in the ative. There is very limited information on HBV preva- form of surgery, dental care and/or blood transfusion out- lence in children; the latest available figures document a side Qatar with significantly higher proportions among prevalence of 0.8% in 5–14-year-old children (21), which is non-Qataris (11.7%) than Qataris (4.0%). an indication that Qatar was moving towards achieving Other risk practices are detailed on Table 4. Few the regional target of reducing the prevalence of HBV in-

Table 4 Previous exposure to Hepatitis B risk factors in grade 1 school students in Qatar, 2015–2016 Previous exposure to risk factors Qatari Non-Qatari Total (n = 745) (n = 2058) (n = 2803) No. % No. % No. % Healthcare procedures Ever had any surgery 98 13.2 278 13.5 376 13.4 Ever had transfusion of blood or blood products 7 0.9 19 0.9 26 0.9 Ever got injection treatment in hospital*** 76 10.2 524 25.5 600 21.4 Ever got injection treatment at home*** 9 1.2 123 6.0 132 4.7 Ever been hospitalized 150 20.1 464 22.5 614 21.9 Ever had dental treatment* 277 37.2 671 32.6 948 33.8 Had any surgery, blood transfusion, injections or dental care 30 4.0 240 11.7 270 9.6 outside Qatar*** Other procedures Ever had ears or other body parts pierced** 170 22.8 597 29.0 767 27.4 Ever had tattoo 4 0.5 10 0.5 14 0.5 Ever shared (even sometimes) toothbrush with family 95 12.8 211 10.3 306 10.9 members*

*P < 0.05, **P < 0.01, ***P < 0.001.

740

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 740 10/10/2018 12:41:57 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 5 The knowledge of parents/guardians of grade 1 school students about hepatitis B viral infection in Qatar, 2015-2016 Knowledge question Qatari Non-Qatari Total (n = 745) (n = 2058) (n = 2803) No. % No. % No. % General Ever heard about the illness hepatitis B*** 406 54.5 1555 75.6 1961 70.0 Know anyone who is infected with hepatitis B or who has died of hepatitis B*** 82 11.0 390 19.0 472 16.8 Heard, seen, or received any information about hepatitis B in the last 6 months** 101 13.6 375 18.2 476 17.0 Blood A person can get hepatitis B from contaminated transfusions of blood or blood 306 41.1 1322 64.2 1628 58.1 products*** A person can get hepatitis B from injections with contaminated syringes in 298 40.0 1334 64.8 1632 58.2 health-care settings *** A person can get hepatitis B from contaminated needles used in ear piercing *** 233 31.3 1151 55.9 1384 49.4 A person can get hepatitis B from contaminated needles used in tattooing*** 259 34.8 1220 59.3 1479 52.8 A person can get hepatitis B by getting injections with a needle already used by 306 41.1 1325 64.4 1631 58.2 someone else*** A person can get hepatitis B by injecting drug*** 265 35.6 1109 53.9 1374 49.0 A person can get hepatitis B by sharing razors with an infected person *** 255 34.2 1218 59.2 1473 52.6 Unprotected sex A person can get hepatitis B from unprotected sex with an infected partner*** 165 22.1 704 34.2 869 31.0 Mother to child A pregnant can woman infected with hepatitis B transmit the virus to her 219 29.4 857 41.6 1076 38.4 unborn child*** A woman with hepatitis B can transmit the virus to her newborn child through 124 16.6 406 19.7 530 18.9 breastfeeding*** Misconceptions A healthy-looking person can be infected with hepatitis B*** 159 21.3 936 45.5 1095 39.1 A person can get hepatitis B by shaking hands with an infected person 75 10.1 169 8.2 244 8.7 A person can get hepatitis B from mosquito or insect bites*** 127 17.0 485 23.6 612 21.8 A person can get hepatitis B by sharing food or drink with someone who is 138 18.5 385 18.7 523 18.7 infected

**P < 0.01; ***P < 0.001.

fection to < 1% by 2015. Furthermore, there were no HBV coverage. Our findings provide evidence on the high vac- cases reported in Qatar during 2013–2015 in the 0–4-year- cination coverage in the country which reaches 100% in old children (unpublished data, Ministry of Public Health Qatari children. Our results have also shown that 82.3% national statistics, 2016). Thus, our results confirm this of non-Qatari children had a vaccination card and almost progress and demonstrate the success of Qatar in elimi- all were fully vaccinated, giving a total coverage for these nating HBV infection in children who benefited from the children of 96.2%. These results correspond with the data new 4-dose vaccine in the national Expanded Programme provided by administrative records in 2015 showing HBV on Immunization. The reason for this success resides in vaccination coverage of 95–99% in the same age group the HBV control strategy in Qatar. The country offers the (unpublished data, Ministry of Public Health, 2015). Pre- 4-dose Expanded Programme on Immunization servic- vious experience in the Region using the 4-dose sched- es free of charge to all citizens. The primary health care ule in the Expanded Programme on Immunization and a centres throughout the country offer free hepatitis B vac- similar HBV control strategy (24) has shown a dramatic cination to all children regardless of nationality. HepB- decrease in chronic HBV seroprevalence in children, as is birth is administered to all children born in hospitals, the case of Qatar. i.e. almost all births in the country. There is high-quality It is clear that despite the efforts exerted by Qatar public vaccine management in place to address shortage and health authorities, there is still a need for further action to ensure availability for all children. The Department of maintain the current success in HBV control. Qatar faces Health Protection and Communicable Diseases in the several challenges in its fight against HBV infection. Ministry of Public Health has a tracking system to count Over the past decade Qatar has offered numerous job the number of children requiring vaccination and ensure opportunities to expatriates from all over the globe to

741

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 741 10/10/2018 12:41:58 PM Research article EMHJ – Vol. 24 No. 8 – 2018

support its labour force. This strategy has attracted many related knowledge among parents/guardians, with who found a place to work and live with their families. misconceptions prevalent among both Qataris and Our results show that some countries do not have strict non-Qataris. Non-Qataris had better HBV knowledge enforcement of the vaccination programme: 31.8% of the than Qataris, yet they had more misconceptions and non-Qatari children born outside Qatar did not have a showed less appreciation to the role of vaccination in vaccination card and the majority of parents/guardians controlling HBV infection. This highlights the need for did not know the vaccination status of their children. rigorous awareness campaigns responding to the needs This makes it difficult for the health system to spot these of different traditions and cultures and directed to both children and apparently some remain unreached. This is Qataris and non-Qataris. further aggravated by the fact that around 10% of non- It is apparent from our results that some schools, Qatari children are more prone to seek health care outside Qatar. This has been demonstrated before for adults, particularly in the private sector, do not request the child a situation that put them at risk of contracting viral vaccination card upon school entry. It is, therefore, clear hepatitis (25). It was postulated that non-Qataris prefer to that with the poor knowledge base of parents/guardians, seek health care outside Qatar for several reasons such these children may remain out of the reach of the health as limited financial resources, work overload, belief that services. their home country’s healthcare system responds better This study had some limitations. As the questionnaires to their health needs and fear of losing their job. were self-administered, parents/guardians may not have Health needs and practices in the childhood period been accurate in responding to some information. Yet, cannot be neglected. Children from different countries parents/guardians were asked to copy the vaccination may have different health needs; different cultural norms status of the children from the vaccination card and and practices may put them at risk of HBV transmission. for non-vaccination card holders, results were analysed Our results have shown that Qataris are more in need separately to avoid any information bias. Furthermore, of dental care while non-Qataris are more in need of the research team had close contact with the parents/ medical care. Furthermore, ear piercing, tattooing and guardians to ensure completeness of information sharing tooth brush are practiced by both non-Qataris and avoid non-response. Chronic HBV infection was and Qataris. All these practices need effective control assessed by measuring the proportion of HBsAg-positive measures to prevent the spread of blood-borne infections, seroprevalence by the rapid test to avoid false positive including HBV. results. We planned to confirm positive results by taking Our study reports that there was a gap in HBV- a venous blood sample, however all results were negative. Acknowledgements The authors are indebted to all who contributed to make this research possible, notably Afrah Moosa Ali, Primary Health Care Corporation and Habiba Mubarak Al Kuwari, Primary Health Care Corporation. Special thanks to all physicians of Qatar Ministry of Public Health, especially Dr Mohamed Ahmed Sallam, Dr Aiman Aly Elberdiny, Dr Ahmed M. El-Sayed, Dr Menatalla Ahmed Mahmoud El-Refay, Dr Samina Fatima Hasnain, Dr Rashad Qaid Algumaei, Dr Shazia Nadeem, Head of Surveillance and Outbreaks, and Dr Jalilah Barodi Moksir. Funding: This research was fully sponsored by Qatar Ministry of Public Health. Competing interests: None declared.

Évaluation d’un programme de vaccination contre l’hépatite B parmi des élèves au Qatar Résumé Contexte : En 2010, le Qatar a adopté une cible consistant à réduire la prévalence de l’hépatite B à moins de 1 % chez l’enfant d’ici 2015. La Région OMS de la Méditerranée orientale a été identifiée comme une région d’endémicité intermédiaire pour le virus de l’hépatite B, avec un taux compris entre 2 et 7 %. On estime que 4,3 millions de personnes dans la Région vivent avec une infection par le virus de l’hépatite B. Objectif : La présente étude a été menée dans le but d’évaluer la séroprévalence de l’hépatite B chez l’enfant, la couverture vaccinale associée, le risque d’exposition aux facteurs de risque, et la connaissance de l’infection par le virus de l’hépatite B parmi les parents/tuteurs. Méthodes : La présente étude transversale a été réalisée au Qatar pendant l’année scolaire 2015-2016. L’échantillonnage en grappe à plusieurs niveaux a été la technique utilisée pour sélectionner un échantillon national représentatif de 2735 élèves de première année du primaire, âgés de cinq ans ou plus. Un prélèvement de sang a été réalisé par piqûre au doigt et un dépistage a été effectué à l’aide d’un test sur le lieu de soins/test rapide. Un questionnaire auto-administré

742

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 742 10/10/2018 12:41:58 PM Research article EMHJ – Vol. 24 No. 8 – 2018

précodé a été utilisé pour évaluer les connaissances des parents/tuteurs en matière d’hépatite B et recueillir des informations sur la couverture vaccinale des enfants contre l’hépatite B. Résultats : Tous les échantillons sanguins étaient négatifs pour l’antigène de surface du virus de l’hépatite B. Les Qataris possédaient un carnet de vaccination et étaient complètement vaccinés, mais 17,7 % des non-Qataris ne possédaient pas de carnet de vaccination et la plupart des parents/tuteurs ne connaissaient pas le statut vaccinal de leurs enfants. Les enfants étaient exposés à différentes pratiques à risque pour l’hépatite B. Les connaissances des parents/tuteurs sur l’hépatite B étaient faibles. Conclusion : Le Qatar a su écarter la menace de l’hépatite B et maintenir une couverture vaccinale élevée pour les enfants.

تقييم برنامج تطعيم طالب املدارس ضد التهاب الكبد Bيف قطر محد الرميحي، هناء املرصي، شريين شوقي، حممد آل ثاين، صالح العويدي، حممد أمحد جناحي، معتز دربالة، خالد األنصاري، روبرت أليسون اخلالصة B اخللفية: يف عام 2010، َت َب َّتن قطر هدف خفض معدل انتشار فريوس التهاب الكبد إىل أقل من %1 لدى األطفال بحلول عام 2015. ولقد قدر استيطان فريوس التهاب الكبد بإقليمB رشق املتوسط يف منظمة الصحة العاملية بدرجة متوسطة، ألن معدل انتشاره يرتاوح بني 2% و7%. وتشري التقديرات إىل أن 4.3 مليون شخص يعيشون مع العدوى بفريوس التهاب الكبد Bيف اإلقليم. اهلدف: أجريت هذه الدراسة لتقييم معدل االنتشار املصيل لفريوس التهاب الكبد Bلدى األطفال، والتغطية بالتطعيم ضد التهاب الكبد B، B ُّوالتعرض املحتمل لعوامل اخلطر، ومعرفة اآلباء/األوصياء بعدوى التهاب الكبد . طرق البحث: لقد أجرينا هذه الدراسة املقطعية يف قطر خالل العام الدرايس 2015/2016، واستخدمنا العينة العنقودية املتعددة املراحل الختيار عينة ممثلة عىل الصعيد الوطني تضم 2735 ًطالبا يف الصف األول من املدرسة بعمر 5 سنوات وأكثر، ومجعنا الدم بوخز اإلصبع وفحصناه باالختبار الرسيع/اختبار نقطة الرعاية، واستخدمنا االستبيان الذي ُيدار ًذاتيا، والذي أعددنا رموزه ًمسبقا، لتقييم معرفة اآلباء/األوصياء عن فريوس التهاب الكبد B، ومجعنا املعلومات حول التغطية بالتطعيم ضد فريوس التهاب الكبد B. النتائج:كانت مجيع عينات الدم سلبية للمستضد السطحي لفريوس التهاب الكبد B HBsAg، وكان لدى القطريني املشاركني بالدراسة بطاقات تطعيم وتم تطعيمهم بالكامل، لكن 17.7%من املشاركني بالدراسة من غري القطريني مل حيملوا بطاقة تطعيم، ومل يكن معظم آبائهم/األوصياء B عليهم عىل علم بحالة التطعيم ألطفاهلم، مما ّيعرض األطفال ملخاطر متعددة ملامرسات تنقل العدوى بالتهاب الكبد . فقد كانت معرفة اآلباء/ األوصياء بالتهاب الكبد B منخفضة. االستنتاج: لقد تفادت قطر هتديد التهاب الكبد Bوحافظت عىل تغطية عالية لتطعيم األطفال ضده.

References 1. World Health Organization. Hepatitis B vaccines. Wkly Epidemiol Rec. 2009 Oct;84(40):405–19 (http://www.who.int/wer/2009/ wer8440.pdf). PMID:19817017. 2. Hepatitis B. Fact sheet No. 204, updated. Geneva: World Health Organization; 2014. 3. Ganem D, Schneider RJ. Hepadnaviridae: the viruses and their replication In: Fields BN, Knipe DM, Howley PM, Griffin DE, eds. Fields virology, 4th ed. Philadelphia. Lippincott Williams & Wilkins; 2001: 2923–69. 4. Hepatitis B. Geneva: World Health Organization, Department of Communicable Disease Surveillance and Response; 2002 (http:// www.who.int/csr/disease/hepatitis/HepatitisB_whocdscsrlyo2002_2.pdf, accessed 20 December 2014). 5. Introduction of hepatitis B vaccine into childhood immunization services. Geneva: World Health Organization; 2001 (http:// www.wpro.who.int/hepatitis/whovb0131.pdf?ua=1, accessed 18 March 2018). 6. Documenting the impact of hepatitis B immunization: best practices for conducting a serosurvey. Geneva: World Health Organi- zation; 2011 (WHO/IVB/11.08; http://whqlibdoc.who.int/hq/2011/WHO_IVB_11.08_eng.pdf, accessed 16 March 2018). 7. WHO Regional Committee for the Eastern Mediterranean resolution EM/RC56/R.5 on the growing threats of hepatitis B and C in the Eastern Mediterranean Region: a call for action; October 2009. Fez, Morocco: WHO Regional Office for the Eastern Medi- terranean; 2009 (http://www.who.int/immunization/sage/EMRO_RC56_final_report_short.pdf, accessed 16 March 2018). 8. Hollinger FB, Liang TJ. Hepatitis B virus. In: Knipe DM, Howley PM, Griffin DE, eds. Fields virology, 4th ed. Philadelphia: Lippin- cott Williams & Wilkins; 2001:2971–3036. 9. Robinson WS. Hepatitis B viruses. General features (human). In: Webster RG, Granoff A, eds. Encyclopedia of virology. London: Academic Press Ltd; 1994:554–69. 10. Robinson WS. Hepatitis B virus and hepatitis D virus. In: Mandell GL, Bennett JE, Dolin R, eds: Principles and practice of infectious diseases, 4th ed. New York, Churchill Livingstone, 1995:1406–39.

743

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 743 10/10/2018 12:41:58 PM Research article EMHJ – Vol. 24 No. 8 – 2018

11. The growing threats of hepatitis B and C in the Eastern Mediterranean Region: a call for action (Technical paper presented at the fifty-sixth session of the WHO Regional Committee for the Eastern Mediterranean, 2009 (EM/RC56/3; http://applications.emro. who.int/docs/EM_RC56_3_en.pdf, accessed 16 March 2018). 12. Qureshi H. Hepatitis B infection in the Eastern Mediterranean Region: challenges and the way forward. East Mediterr Health J. 2013 Jul;19(7):585–6. PMID:24975300 13. Perz JF, Armstrong GL, Farrington LA, Hutin YJF, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006 Oct;45(4):529–38. https://doi.org/10.1016/j.jhep.2006.05.013 PMID:16879891 14. Triki H. [Epidemiology of hepatitis B virus, hepatitis C virus and Delta virus in the general population and in liver cirrhosis in Tunisia]. Arch Inst Pasteur Tunis. 1994 Jul-Oct;71(3-4):403–6. PMID:8801835 (in French) 15. Darwish MA, Amer AF, El-Moeity AA, Darwish NM. Association of hepatitis C virus with liver cirrhosis and hepatocellular carcinoma compared with hepatitis B virus in Egyptian patients. J Egypt Public Health Assoc. 1997;72(5-6):569–89. PMID:17214153 16. Bukhtiari N, Hussain T, Iqbal M, Malik AM, Qureshi AH, Hussain A. Hepatitis B and C single and co-infection in chronic liver disease and their effect on the disease pattern. J Pak Med Assoc. 2003 Apr;53(4):136–40. PMID:12776896 17. Hajiani E, Masjedizadeh R, Hashemi J, Azmi M, Rajabi T. Risk factors for hepatocellular carcinoma in Southern Iran. Saudi Med J. 2005 Jun;26(6):974–7. PMID:15983686 18. Ayoola EA, Gadour MO. Hepatocellular carcinoma in Saudi Arabia: role of hepatitis B and C infection. J Gastroenterol Hepatol. 2004 Jun;19(6):665–9. https://doi.org/10.1111/j.1440-1746.2003.03334.x PMID:15151622 19. El-Zayadi AR, Badran HM, Barakat EM, Attia Mel-D, Shawky S, Mohamed MK, et al. Hepatocellular carcinoma in Egypt: a single center study over a decade. World J Gastroenterol. 2005 Sep 7;11(33):5193–8. PMID:16127751 20. Glynn MJ, Rashid A, Antao AJO, Coleman JC, Howard CR, Zuckerman AJ, et al. Imported epidemic non-A, non-B hepatitis in Qatar. J Med Virol. 1985 Dec;17(4):371–5. https://doi.org/10.1002/jmv.1890170409 PMID:3935751 21. Rikabi A, Bener A, Al-Marri A, Al-Thani S. Hepatitis B and C viral infections in chronic liver disease: a population based study in Qatar. East Mediterr Health J. 2009 Jul–Aug;15(4):778–84. PMID:20187528 22. Bener A, Al-Kaabi S, Derbala M, Al-Marri A, Rikabi A. The epidemiology of viral hepatitis in Qatar. Saudi J Kidney Dis Transpl. 2009;20(2):300–6. PMID:19237827 23. Mamilton BH, Paoloni JA, Chalabi H. Epidemiology of hepatitis B among professional male athletes in Qatar. Saudi Med J. 2010;31(6):678-683. PMID:20563368 24. Al Awaidy ST, Bawikar SP, Al Busaidy SS, Al Mahrouqi S, Al Baqlani S, Al Obaidani I, et al. Progress toward elimination of hepatitis B virus transmission in Oman: impact of hepatitis B vaccination. Am J Trop Med Hyg. 2013 Oct;89(4):811–5. doi:10.4269/ajt- mh.13-0333 PMID:23958910 25. Al Romaihi HE, Farag E, Al-Hajri MA, Al Thani M, Al-Masri H, Ismail A, et al. Viral hepatitis C serological and behavioral survey among single male laborers in Qatar, J Emergency Med, Trauma & Acute Care, Special Issue of International Conference in Emergency Medicine and Public Health – Qatar, 99. 2016 https://doi.org/10.5339/jemtac.2016.icepq.99

744

05- Assessment of hepatitis B immunization programme among school students in Qatar.indd 744 10/10/2018 12:41:58 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Validation of an Arabic version of the Yale Food Addiction Scale 2.0

Mounir Fawzi1 and Mohab Fawzi1

1Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt (Correspondence to: Mounir H. Fawzi: mounir.fawzi40@gmail. com).

Abstract Background: The Yale Food Addiction Scale (YFAS) is the gold standard for assessment of food addiction based on the Diagnostic and Statistical Manual of Mental Disorders (DSM). To keep up with the DSM-5 update, the YFAS 2.0 was published in early 2016. Aims: We conducted the present study to translate, adapt and validate the DSM-5 Yale Food Addiction Scale 2.0 for use with Arabic speakers. Methods: Both the final YFAS 2.0-A, developed with a rigorous methodology, and the English YFAS 2.0 were completed by 236 Egyptian medical students fluent in English and Arabic. Three weeks later, the YFAS 2.0–A was readministered to all participants. Results: Cronbach’s alpha for the YFAS 2.0–A was 0.89. The 3-week intraclass correlation coefficients for diagnosis and symptom scores were 0.95 and 0.93, respectively. Weighted kappa statistics ranged from 0.66 to 0.95 (P < 0.001). Conclusions: Our findings indicate that the Arabic YFAS 2.0-A is a reliable tool, and that it is valid for use as equivalent to the English YFAS 2.0 in the investigation of food addiction among Arabic-speaking populations. Keywords: Arabic version; YFAS; food addiction; validity Citation: Fawzi M; Fawzi M. Validation of an Arabic version of the Yale Food Addiction Scale 2.0. East Mediterr Health J. 2018;24(8):745–752. https://doi. org/10.26719/2018.24.8.745 Received: 10/04/17; accepted: 25/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction showed a single factor structure and adequate reliability and validity (3). Relative stability and reliability over Recently, food addiction has sparked unprecedented in- time in a nonclinical population was also demonstrated terest among the scientific and lay media. This may give (6). The good psychometric properties of the YFAS were an impression that the topic is exclusively a product of replicated in subsequent studies using nonclinical and the 21st century in which the increasing availability of clinical samples (7,8). Since its first appearance, the YFAS, highly processed foods may at least partly help explain has been the tool used in most of the food addiction the contemporary serious increase of overeating and obe- researches (9), and for many studies in this field it is the sity rates (1). But in fact, it is not a new idea that food can gold standard (10). be addictive. It is 60 years since Theron G. Randolph defined the term food addiction as “a specific adaptation to The worldwide interest in measuring the food one or more regularly consumed foods to which a person addiction construct with a psychometrically validated is highly sensitive, produces a common pattern of symp- tool has led to the translation of the YFAS into many toms descriptively similar to those of other addictive pro- languages including French, German, Spanish, Italian cesses” (2). and Chinese (10–14). Food addiction has for decades been a matter of To keep up with the update of the DSM-5 (15), the controversy, albeit with sporadic production of scientific YFAS 2.0 was developed. Like its predecessors, this new literature. One reason for the lack of consensus was version was found to be a psychometrically sound tool the lack of measurable construct of food addiction. In (16). German and French versions have appeared recently, order to help appraisal of the food addiction construct replicating the good psychometric properties of the other using a standardized measure, Yale Food Addiction Scale versions (17,18). (YFAS) was devised in 2009 (3). Attention to the subject However, a validated food addiction measure is dramatically intensified after the appearance of the YFAS, still unavailable in the Arabic-speaking countries. As a as reflected in the sharp rise of the number of studies on result, important related issues such as the emerging food addiction since 2009 (4). unhealthy eating habits (19) could not be adequately The original YFAS assesses addiction to foods by investigated, despite their practical implication in the transforming the 7 DSM-IV-TR diagnostic criteria for alarming increases in rates of obesity and type 2 diabetes substance dependence (5) to exhibit eating behaviours mellitus currently prevailing throughout the Eastern associated with foods high in sugar, fat and salt. An Mediterranean Region (20,21). In Kuwait, for example, the initial validation study in a sample of university students English YFAS version (3) was applied without translation

745

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 745 10/10/2018 12:42:52 PM Research article EMHJ – Vol. 24 No. 8 – 2018

or adaptation to a sample of students who could read and ·· Use causes clinically significant impairment or dis- write in English (22). In Egypt, an attempt was made to tress (items 16,17). translate this earlier English version of the YFAS into There are 2 summary scores, first symptom count scor- Arabic (23) but validation data of the translation process ing, which is computed by the number of symptom cri- have not been published. teria met in the past year. A symptom criterion is met if We believe that up to now no Arabic version of the ≥ 1 item under this criterion is scored as 1. Each item has YFAS 2.0 has been produced. Therefore, we aimed in this a specific cut-off, which ranges from once a month to 4–6 study to translate, adapt and validate the DSM-5 Yale times a week. Criterion 12, which assesses impairment Food Addiction Scale 2.0 for use with Arabic-speaking or distress resulting from overeating (items 16,17) is not individuals. included in the symptom count score. Therefore, symptom count scoring should range from 0 to 11. The second Methods summary score is for a dichotomous diagnosis of food Participants addiction with severity level according to the number of symptom criteria met in the past year: mild (2–3 criteria), At the beginning of the 2016–2017 academic year, we re- moderate (4–5 criteria), and severe addiction (≥ 6 crite- cruited 270 consenting Egyptian bilingual (English and ria). Significant clinical impairment or distress should be Arabic) second-year medical students as volunteers from also endorsed to make any food addiction diagnosis. Zagazig University, Egypt, by convenience sampling. Thirty of these students were recruited for pretesting the Translation process for the Arabic version of final Arabic version. The rest of participants were subject- YFAS 2.0 (YFAS 2.0-A) ed to the study measures and 3 “catch” questions intend- The translation process of the YFAS 2.0 in this study was ed for testing participants’ attention to survey content. In conducted along the lines that we described previous- the first session of the study, 4 students failed to answer ly (24). In brief, 2 bilingual psychiatrists independently ≥ 1 of these questions in English and/or Arabic. They were translated the English YFAS 2.0 version into Arabic. The excluded, leaving data from 236 participants for the main 2 translations were merged into 1 reconciled version by study analysis. an Egyptian panel of 3 psychiatrists and 2 translators. Measures Emphasis was placed on conceptual and cultural equiv- alence rather than on literal translation. The resulting The YFAS 2.0 is a 35-item self-report Likert-type scale version was then translated back into English by 2 oth- with 8 frequency response options for each item, ranging er translators who had not previously seen the original from “Never” to “Every Day” (22). It assesses respondent’s YFAS. We compared the back-translated versions with addictive-like eating behaviour in accordance with the the original, and discrepancies were addressed to pro- following symptom criteria of the DSM-5 Substance-Re- duce a final version, which was tested for understand- lated and Addictive Disorders: ability and acceptability in a small pilot study. Results ·· Substance taken in larger amount and for longer peri- suggested that no further changes were needed. A copy od than intended (Items 1,2,3); of the instrument (YFAS 2.0-A) may be requested from the ·· Persistent desire or repeated unsuccessful attempts corresponding author. to quit (items 4,25,31,32); To maintain consistency with the original English ·· Much time/activity to obtain, use, recover (items YFAS and the YFAS 2.0, we followed the same scoring 5,6,7). procedure suggested by their authors (3,16). ·· Important social, occupational, or recreational activi- Catch questions ties given up or reduced (items 8,10,18,20); Three catch questions similar to those suggested by Gear- ·· Use continues despite knowledge of adverse con- hardt et al. (16) were included in English at the end of the sequences (e.g., emotional problems, physical prob- YFAS 2.0, and in Arabic at the end of the YFAS 2.0-A. An- lems) (items, 22,23); swers to all 3 questions in both languages should be “Nev- er”, otherwise the participant was judged as not carefully ·· Tolerance (marked increase in amount; marked de- reading the questions. crease in effect) (items 24,26); ·· Characteristic withdrawal symptoms; substance tak- Study procedures en to relieve withdrawal (Items 11,12,13,14,15); In the initial session of the main study, participants ·· Continued use despite social or interpersonal prob- completed the original YFAS 2.0 (English) (16), then they lems (items 9,21,35); completed the Arabic version (YFAS 2.0-A) (in the same session). Additionally, participants provided basic demo- ·· Failure to fulfil major role obligation (e.g., work, graphic information and self-report of height and weight school, home) (items 19,27); for the body mass index (BMI) computation. ·· Use in physically hazardous situations (items Participants were also asked to respond again to the 28,33,34); YFAS 2.0-A after a gap of 3 weeks under conditions as ·· Craving, or a strong desire or urge to use (items 29,30); similar as possible to those of the first session.

746

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 746 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Data analysis 1432.000; Z = –3.971; P 2-tailed < 0.001). Descriptive statistics were used to report participants’ The Kuder–Richardson alpha for the entire YFAS demographic data. The internal consistency reliability 2.0–A scale was 0.89. A similar result was obtained for of the YFAS 2.0-A scale was evaluated with Kuder–Rich- the Cronbach alpha. Table 1 demonstrates the internal ardson alpha (KR-20) and Cronbach’s alpha. A Cronbach’s consistency reliability for this scale. All item–total alpha value greater than 0.70 was considered acceptable correlation coefficients were greater than 0.50. As shown (25). Corrected item–total correlation and Cronbach’s al- in the alpha if item deleted column, none of the values pha if item deleted were also computed. A value of more was greater than the overall alpha. than 0.4 for the corrected item–total correlation or a de- Good test–retest reliability was demonstrated for the crease in Cronbach’s alpha if item deleted value is consid- YFAS 2.0-A diagnosis (ICC = 0.95; Spearman ρ = 0.95) and ered an indication of the high contribution of an item to total symptom scores (ICC = 0.93; Spearman ρ = 0.94) the scale. (Table 2). The ICC values for the individual symptoms Repeatability (test–retest reliability) of the YFAS 2.0- ranged from 0.60 to 0.92, with symptom 1 (Food taken A scale was assessed using the intraclass correlation in larger amount and for longer period than intended) coefficients (ICC), based on consistency 2-way mixed showing the greatest repeatability (ICC = 0.92). single measures [ICC (3,1) or ICC (C,1)], along with the Comparison between scores on the Arabic and English 95% confidence interval. The ICC was interpreted as poor versions for all the YFAS 2.0 items is presented in Table 3. for values < 0.5, moderate for values between 0.5 and 0.75 Weighted kappa statistics ranged from 0.66 (Item 4) to and good for ICC values > 0.75) (26). 0.95 (Total symptom score), indicating good to very good Spearman’s rank correlation coefficient, rho ρ( ), was agreement (P < 0.001 for all items). also used. Cohen’s weighted kappa statistics were applied Discussion to analyse the agreement between the Arabic and English YFAS 2.0 versions. Strength of agreement was evaluated This study aimed to produce an Arabic version of the according to the following criteria: poor agreement (K < YFAS 2.0. A rigorous methodology was applied for trans- 0.20), fair agreement (K = 0.21–0.40), moderate agreement lation/back translation and final approval of the Arabic (Κ = 0.41–0.60), good agreement (Κ = 0.61–0.80) and version of the YFAS 2.0 (YFAS 2.0-A). During this process, very good agreement (Κ > 0.80) (27). Participants with cross-cultural adaptation was performed with emphasis and without a YFAS 2.0 or YFAS 2.0-A diagnosis were on the similarity of meaning rather than the similarity of compared with Mann–Whitney U-tests. linguistic form. Both the final YFAS 2.0-A and the origi- Statistical analyses were performed with Microsoft nal English version were then completed by 236 Egyptian Excel and SPSS, version 19.0.1. Significance level for all medical students. The 100% response rate for each item analyses was set at the 5% level. indicated that all items were easily understood and acceptable. Ethical considerations In the current study, Cronbach’s alpha for the entire Ethical approval to conduct the study was obtained from YFAS 2.0–A scale was 0.89. We also found that all item– the research ethics committee at the Faculty of Medicine, total correlation coefficients were > 0.50, and that the Zagazig University. Before completing questionnaires, Cronbach’s alpha if items are deleted for each item did written informed consent was obtained from all partici- not exceed the overall Cronbach’s alpha level of 0.89. All pants, including those who participated in the pilot study. this indicates that the internal consistency reliability of the items of YFAS 2.0-A is well accepted and consistent Results with the original English version (16), and with translated Out of 236 participants who were included in the main versions in other languages (17,18). In addition, good test– study analysis, 126 (53.4%) were females, mean age 19.1 retest reliability was demonstrated. The 3-week ICC for [standard deviation (SD) 1.2] years and 110 (46.6%) were diagnosis was 0.95, and that for symptom scores was males, mean age 19.3 (SD 1.3) years. The average self-re- 0.93. This is in keeping with other studies, which indicate ported BMI was 22.3 (SD 4.1) kg/m2 and 22.1 (SD 3.9) kg/ that the diagnosis and symptom scores are stable over m2 for female and male students, respectively. Using the periods of several weeks (14). However, stability over YFAS 2.0-A, 26 (11.0%) of participants met the threshold longer periods has not been sufficiently investigated for food addiction diagnosis. Nine (3.8%) met criteria for because most of studies are cross-sectional. Yet, the study diagnosis of a mild, 5 (2.1%) a moderate, and 12 (5.1%) a by Pursey et al. (6), which extended over a period of 18 severe food addiction. Two participants with mild food months, reported a rather lower ICC than ours (0.71 for addiction diagnosis on the YFAS 2.0-A did not meet the diagnosis and 0.72 for symptom scores). criteria for diagnosis on the English YFAS 2.0. Four of the We also wanted to examine the extent of agreement participants who did not meet a diagnosis threshold on between the Arabic and English YFAS 2.0 versions to find the YFAS 2.0-A qualified for mild diagnosis on YFAS 2.0. out how similar they are. A widely used method for such Participants with a YFAS 2.0 diagnosis had a significant- purpose is Cohen’s kappa coefficient, which takes into ly higher BMI (median = 24.3 kg/m2) than those without consideration the amount of agreement expected by diagnosis (median = 21.5 kg/m2) (Mann–Whitney U = chance. Yet, Cohen’s kappa is only appropriate for binary

747

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 747 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 1 Internal consistency of the Yale Food Addiction Scale 2.0, Arabic version (YFAS 2.0 - A) Item Corrected item–total correlation Alpha if item deleted Food taken in larger amount and for longer period than intended Item 1 0.77 0.81 Item 2 0.68 0.81 Item 3 0.66 0.82 Persistent desire or repeated unsuccessful attempts to quit Item 4 0.75 0.87 Item 25 0.85 0.87 Item 31 0.76 0.85 Item 32 0.73 0.85 Much time/activity to obtain, use or recover from effects of food Item 5 0.74 0.86 Item 6 0.61 0.85 Item 7 0.58 0.85 Important social, occupational, or recreational activities given up or reduced Item 8 0.72 0.87 Item 10 0.75 0.87 Item 18 0.60 0.85 Item 20 0.52 0.86 Use continues despite knowledge of adverse consequences Item 22 0.71 0.85 Item 23 0.63 0.86 Tolerance Item 24 0.83 0.86 Item 26 0.84 0.87 Withdrawal Item 11 0.78 0.86 Item 12 0.83 0.87 Item 13 0.83 0.86 Item 14 0.74 0.86 Item 15 0.83 0.86 Continued use despite social or interpersonal problems Item 9 0.62 0.87 Item 21 0.63 0.85 Item 35 0.78 0.85 Failure to fulfil major role obligations Item 19 0.51 0.85 Item 27 0.77 0.85 Eating certain foods in physically hazardous situations Item 28 0.75 0.88 Item 33 0.79 0.87 Item 34 0.78 0.87 Craving, or a strong desire or urge to eat certain food Item 29 0.80 0.85 Item 30 0.82 0.86 Clinically significant impairment or distress Item 16 0.84 0.87 Item 17 0.72 0.87

748

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 748 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 2 Test–retest reliability of the Yale Food Addiction Scale 2.0, Arabic version (YFAS 2.0 - A) Individual YFAS symptom ICC 95% CI Spearman ρ Food taken in larger amount and for longer period than intended 0.92 0.91–0.94 0.93 Persistent desire or repeated unsuccessful attempts to quit 0.71 0.66–0.76 0.73 Much time/activity to obtain, use or recover from effects of food 0.82 0.79–0.85 0.83 Important social, occupational, or recreational activities given up or reduced 0.60 0.54–0.66 0.64 Use continues despite knowledge of adverse consequences 0.81 0.77–0.84 0.82 Tolerance 0.78 0.74–0.82 0.79 Withdrawal 0.70 0.64–0.74 0.71 Continued use despite social or interpersonal problems 0.76 0.72–0.80 0.77 Failure to fulfil major role obligations 0.72 0.68–0.77 0.73 Eating certain foods in physically hazardous situations 0.83 0.79–0.85 0.83 Craving, or a strong desire or urge to eat certain food 0.87 0.84–0.89 0.86 Clinically significant impairment or distress 0.85 0.83–0.88 0.88 Total symptom score 0.93 0.91–0.94 0.94 YFAS food addiction diagnosis 0.95 0.94–0.96 0.95

P < 0.001 for all items. ICC = intraclass correlation coefficient. CI = confidence interval.

or nominal ratings. The YFAS 2.0 has 8 ordered response apparently healthy and mostly were within normal categories for each item. Disagreements between the weight range. Because they are bilingual, these students English and Arabic YFAS 2.0 versions as regards these may not be representative of the monolingual Arabic- categories may not be all of the same importance. For speaking populations for whom the translated scale example, a disagreement between a student’s ratings on version is intended. Future validation studies of the the 2 scale versions that differed by a small amount on a YFAS 2.0-A should include other populations, particularly given item should be considered less important than if patients with eating disorders, obesity, diabetes, and other the 2 scores were farther apart on this item. To deal with conditions potentially associated with food addiction. In this situation, weighted kappa is more relevant as it takes such clinical settings, the sensitivity and the specificity into account the different levels of disagreement between of the YFAS 2.0 can be ascertained against semistructured item ordered categories. The most commonly used interviews. A further limitation in the current study is weights are the linear weights, which are proportional the calculation of the BMI from the self-reported height to the deviation of individual ratings, and the quadratic and weight rather than from actual measurements. For weights, which are proportional to the square of the the original English YFAS and the updated YFAS 2.0 deviations of the individual ratings. Although both versions, the 1-factorial solution was established (3,16). weight types are criticized, mainly for being arbitrarily To determine whether the 1-factorial solution could be defined, they are widely used. In the current study, in replicated for the Arabic version, future studies need to be which the number of categories of the scale items is large, larger to perform acceptable confirmatory factor analysis. we used the linear weights approach, as it is less sensitive than the quadratic weights to the number of categories Conclusion (28). Our comparison between the Arabic and English Interest in the study of food addiction has dramatically versions showed good to very good agreement (weighted increased since the development of the well validated kappa statistics ranged from 0.66 to 0.95; P < 0.001). YFAS. The scale has been translated and cross-culturally Therefore, this study suggests that the Arabic YFAS validated in many languages. The YFAS 2.0, which has ap- 2.0-A is a reliable tool, and that it is valid for use as peared to keep up with the update of the DSM-5, replicat- equivalent to the English YFAS 2.0 in the investigation of ed the excellent psychometric properties of the original food addiction among Arabic speaking populations. and other translated versions. Our findings suggest that There were a few limitations in this research. the translated and adapted Arabic version (YFAS 2.0-A) of Generalizability of the results is limited by recruiting the YFAS 2.0 is a reliable tool, valid for use in the investi- participants by convenience sampling from a single gation of food addiction among Arabic-speaking popula- medical college. All the students we recruited were tions.

749

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 749 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 3 Comparison between scores on the Arabic (YFAS 2.0 - A) and English (YFAS 2.0 - E) versions of the Yale Food Addiction Scale 2.0 Item YFAS 2.0 - A YFAS 2.0 - E Κ Agreement Mean (SD) Mean (SD) Food taken in larger amount and for longer period than intended 1 0.09 (0.20) 0.10 (0.21) 0.74 Good 2 0.12 (0.23) 0.11 (0.22) 0.88 Very good 3 0.10 (0.21) 0.08 (0.24) 0.86 Very good Persistent desire or repeated unsuccessful attempts to quit 4 0.06 (0.14) 0.05 (0.16) 0.66 Good 25 0.04 (0.05) 0.03 (0.06) 0.70 Good 31 0.08 (0.17) 0.08 (0.18) 0.84 Very good 32 0.03 (0.08) 0.02 (0.09) 0.76 Good Much time/activity to obtain, use or recover from effects of food 5 0.08 (0.23) 0.09 (0.21) 0.93 Very good 6 0.04 (0.10) 0.03 (0.09) 0.87 Very good 7 0.02 (0.05) 0.02 (0.04) 0.91 Very good Important social, occupational, or recreational activities given up or reduced 8 0.03 (0.06) 0.03 (0.08) 0.67 Good 10 0.04 (0.09) 0.04 (0.13) 0.73 Good 18 0.01 (0.06) 0.02 (0.06) 0.85 Very good 20 0.02 (0.05) 0.02 (0.05) 0.77 Good Use continues despite knowledge of adverse consequences 22. 0.09 (0.16) 0.07 (0.20) 0.78 Good 23 0.07 (0.15) 0.06 (0.16) 0.82 Very good Tolerance 24 0.02 (0.15) 0.03 (0.17) 0.86 Very good 26 0.04 (0.14) 0.05 (0.15) 0.89 Very good Withdrawal 11 0.02 (0.09) 0.03 (0.11) 0.76 Good 12 0.06 (0.16) 0.06 (0.19) 0.71 Good 13 0.03(0.05) 0.03 (0.07) 0.83 Very good 14 0.05 (0.14) 0.06 (0.18) 0.76 Good 15 0.02 (0.05) 0.03 (0.08) 0.78 Good Continued use despite social or interpersonal problems 9 0.05 (0.12) 0.06 (0.15) 0.89 Very good 21 0.03 (0.05) 0.03 (0.07) 0.93 Very good 35 0.07 (0.20) 0.07 (0.19) 0.91 Very good Failure to fulfil major role obligations 19 0.03 (0.04) 0.01 (0.07) 0.77 Good 27 0.05 (0.15) 0.05 (0.21) 0.87 Very good Eating certain foods in physically hazardous situations 28 0.05 (0.14) 0.05 (0.18) 0.90 Very good 33 0.06 (0.16) 0.09 (0.22) 0.86 Good 34 0.04 (0.06) 0.04 (0.08) 0.92 Very good Craving, or a strong desire or urge to eat certain food 29 0.05 (0.17) 0.06 (0.24) 0.85 Good 30 0.05 (0.12) 0.06 (0.15) 0.86 Good Clinically significant impairment or distress 16 0.06 (0.13) 0.06 (0.15) 0.93 Very good 17 0.04 (0.10) 0.04 (0.13) 0.94 Very good Total symptom score 1.74 (4.25) 1.76 (4.97) 0.95 Very good Κ = weighted kappa. P < 0.001 for all.

750

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 750 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Acknowledgements We would like to thank Ashley Gearhardt for her kind permission to translate and use the YFAS 2.0 and for providing us with helpful material. We would also like to thank our colleagues in the Psychiatry Department at Zagazig University. We thank, in particular, Professor Rafik Reda and Professor Wail Abu-Hindi for their great help and valuable suggestions throughout the study. Funding: None. Competing interests: None declared.

Validation d’une version arabe de la Yale Food Addiction Scale 2.0 (YFAS 2.0) Résumé Contexte : La Yale Food Addiction Scale (YFAS) est la référence absolue pour l’évaluation de l’addiction à la nourriture selon les critères du Manuel diagnostique et statistique des troubles mentaux (DSM). La version 2.0 de la YFAS a été publiée début 2016 afin de tenir compte de la mise à jour du DSM-5. Objectif : La présente étude avait pour objet de traduire, d’adapter et de valider la DSM-5 YFAS 2.0 pour qu’elle puisse être utilisée par des locuteurs arabes. Méthodes : Le questionnaire final en arabe (YFAS 2.0-A), mis au point à l’aide d’une méthodologie rigoureuse, ainsi que le questionnaire anglais (YFAS 2.0) ont tous deux été remplis par 236 étudiants de médecine égyptiens parlant couramment l’anglais et l’arabe. Trois semaines plus tard, le questionnaire YFAS 2.0-A a été soumis de nouveau à l’ensemble des participants. Résultats : Le coefficient alpha de Cronbach pour le questionnaire YFAS 2.0-A était de 0,89. Les coefficients de corrélation intraclasse à trois semaines des scores de diagnostic et de symptômes étaient, respectivement, de 0,95 et 0,93. Les scores kappa pondérés étaient compris entre 0,66 et 0,95 (p < 0,001). Conclusions : Nos résultats indiquent que la version arabe de la YFAS 2.0-A est un outil fiable et qu’elle peut être utilisée comme équivalent du questionnaire anglais YFAS 2.0 pour étudier l’addiction à la nourriture dans les populations arabophones.

YFAS – التحقق من صحة النسخة العربية من مقياس ييل لإلدمان الغذائي )2.0 ( منري فوزي، مهاب فوزي اخلالصة اخللفية:يعترب مقياس ييل إلدمان الغذاء املعيار الذهبي لتقييم إدمان الغذاء ً عىلاستنادا الدليل التشخييص واإلحصائي لالضطرابات النفسية، ومن أجل مواكبة حتديث الدليل التشخييص واإلحصائي لالضطرابات النفسية - ،5 ولقد تم نرش اإلصدار 2.0من مقياس ييل إلدمان الغذاء يف أوائل عام 2016. أجرينااهلدف: الدراسة احلالية حول الرتمجة والتكييف والتحقق من صحة الرتمجة ملقياس ييل لإلدمان الغذائي 2.0 ً استناداإىل الدليل التشخييص واإلحصائي لالضطرابات النفسية -5 ليستخدمه الناطقون باللغة العربية. طرق البحث:لقد تم إعداد كل من مقياس ييل لإلدمان الغذائي 2.0والدليل التشخييص واإلحصائي لالضطرابات النفسية -5 باتباع منهجية صارمة، فاستكمل 236 ًطالبامنطالب الطب يف مرص، ممن جييدون اإلنجليزية والعربية، ترمجة النسخة اإلنجليزية ملقياس ييل لإلدمان الغذائي 2.0 إىل اللغة العربية، وبعد 3 أسابيع، أعيد توزيع مقياس ييل لإلدمان الغذائي - A2.0 إىل مجيع املشاركني. A – النتائج: كانت قيمة ألفا كرونباخ 0.89ملقياس ييل لإلدمان الغذائي 2.1 .بينام كانت معامالت االرتباط داخل الصفوف ملدة 3 أسابيع ألحراز التشخيص: 0.95وألحراز األعراض: . 0.93وتراوحت القيمة اإلحصائية لكابا الرتجيحية من 0.66إىل 0.95، وكانت قيمة )0.001 < p( االستنتاجات: تشري النتائج التي توصلنا إليها إىل أن نسخة اللغة العربية ملقياس ييل لإلدمان الغذائي هي2.0 أداة موثوقة، وأهنا صاحلة لالستخدام باعتبارها مكافئة للنسخة باللغة اإلنجليزية يف جمال الدراسات حول اإلدمان عىل الغذاء بني السكان الناطقني باللغة العربية.

751

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 751 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

References 1. Cocores JA, Gold MS. The Salted Food Addiction Hypothesis may explain overeating and the obesity epidemic. Med Hypotheses. 2009;73:892–9. PMID:19643550 2. Randolph TG. The descriptive features of food addiction; addictive eating and drinking. Q J Stud Alcohol. 1956;17(2):198–224. PMID:13336254 3. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale Food Addiction Scale. Appetite. 2009;52(2):430–6. PMID:19121351 4. Gearhardt AN, Davis C, Kuschner R, Brownell KD. The addiction potential of hyperpalatable foods. Curr Drug Abuse Rev. 2011;4(3):140–5. PMID:21999688 5. Diagnostic and statistical manual of mental disorders text revision. (4th ed., DSM-IV-TR). Washington, D.C: American Psychiat- ric Association; 2000. 6. Pursey KM, Collins CE, Stanwell P, Burrows TL. The stability of ‘food addiction’ as assessed by the Yale Food Addiction Scale in a non-clinical population over 18-months. Appetite. 2016;96:533–8. PMID:26482284 7. Clark SM, Saules KK. Validation of the Yale Food Addiction Scale among a weight-loss surgery population. Eat Behav. 2013;14(2):216–9. PMID:23557824 8. Gearhardt AN, White MA, Masheb RM, Morgan PT, Crosby RD, Grilo CM. An examination of the food addiction construct in obese patients with binge eating disorder. Int J Eat Disord. 2012;45(5):657–63. PMID:22684991 9. Dimitrijević I, Popović N, Sabljak V, Škodrić-Trifunović V, Dimitrijević N. Food addiction-diagnosis and treatment. Psychiatr Danub. 2015;27(1):101–6. PMID:22684991 10. Brunault P, Ballon N, Gaillard P, Réveillère C, Courtois R. Validation of the French version of the Yale food addiction scale: an examination of its factor structure, reliability, and construct validity in a nonclinical sample. Can J Psychiatry. 2014;59(5):276–84. PMID:25007281 11. Meule A, Heckel D, Kübler A. Factor structure and item analysis of the Yale Food Addiction Scale in obese candidates for bariatric surgery. Eur Eat Disord Rev. 2012;20(5):419–22. PMID:22761046 12. Granero R, Hilker I, Agüera Z, Jiménez-Murcia S, Sauchelli S, Islam MA, et al. Food addiction in a Spanish sample of eating disorders: DSM-5 diagnostic subtype differentiation and validation data. Eur Eat Disord Rev. 2014;22(6):389–96. PMID:25139680 13. Innamorati M, Imperatori C, Manzoni GM, Lamis DA, Castelnuovo G, Tamburello A, et al. Psychometric properties of the Italian Yale Food Addiction Scale in overweight and obese patients. Eat Weight Disord. 2015;20(1):119–27. PMID:25069837 14. Chen G, Tang Z, Guo G, Liu X, Xiao S. The Chinese version of the Yale Food Addiction Scale: An examination of its validation in a sample of female adolescents. Eat Behav. 2015;18:97–102. PMID:26026613 15. The diagnostic and statistical manual of mental disorders, 5th ed. (DSM–5), Washington, D.C: American Psychiatric Association; 2013. 16. Gearhardt AN, Corbin WR, Brownell KD. Development of the Yale Food Addiction Scale Version 2.0. Psychol Addict Behav. 2016;30(1):113–21. PMID:26866783 17. Meule A, Müller A, Gearhardt AN, Blechert J. German version of the Yale Food Addiction Scale 2.0: Prevalence and correlates of ‘food addiction’ in students and obese individuals. Appetite. 2016. pii: S0195-6663(16)30505-0. doi: 10.1016/j.appet.2016.10.003. [Epub ahead of print] PMID:27717658 18. Brunault P, Courtois R, Gearhardt AN, Gaillard P, Journiac K, Cathelain S, et al. Validation of the French version of the DSM-5 Yale Food Addiction Scale in a nonclinical sample. Can J Psychiatry. 2017;62(3):199–210. PMID:28212499 19. Musaiger AO, Al-Hazzaa HM. Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. Int J Gen Med. 2012;5:199–217. PMID:22399864 20. Abuyassin B, Laher I. Diabetes epidemic sweeping the Arab world. World J Diabetes. 2016;7(8):165–74. PMID:27114755 21. Musaiger AO. Overweight and obesity in the Eastern Mediterranean Region: can we control it? East Mediterr Health J. 2004;10(6):789–93. 22. Garduño-Diaz SD, Abu-Ghazaleh H. Addictive behaviour of dietary intake among young adults in Kuwait. EC Nutrition 2015; 2(3):348–50. 23. Naguib RM. Personality profile and affect regulation in relation to food addiction in a sample of obese females [thesis]. Cairo: Faculty of Medicine, Ain Shams University; 2014. 24. Fawzi MH, Fawzi MM, Abu-Hindi W. Arabic version of the Major Depression Inventory as a diagnostic tool: reliability and con- current and discriminant validity. East Mediterr Health J. 2012;18(4):304–10. PMID:22768690 25. Nunnally JC, Bernstein J. Psychometric theory. New York, NY: McGraw Hill; 1994. 26. Portney LG, Watkins MP. Foundations of clinical research: applications to practice, 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000. 27. Altman, DG. Practical statistics for medical research. London: Chapman and Hall; 1991. 28. Brenner H, Kliebsch U. Dependence of weighted kappa coefficients on the number of categories. Epidemiology. 1996;7(2):199– 202. PMID:8834562

752

06- Validation of an Arabic version of the Yale Food Addiction Scale 2.0.indd 752 10/10/2018 12:42:53 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Systematic review of priority setting studies in health research in the Islamic Republic of Iran

Abbas Badakhshan,1 Mohammad Arab,1 Arash Rashidian,1,2 Mahin Gholipour,3 Elham Mohebbi4 and Kazem Zendehdel4,5

1Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Department of Information, Evidence and Research, Regional Office for the Eastern Mediterranean, World Health Organization, Cairo, Egypt. 3Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran. 4Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 5Cancer Biology Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: K. Zendehdel: kzendeh@tums. ac.ir).

Abstract Background: ‎Several research priority-setting studies have been conducted in different countries, including ‎the Islamic Republic of Iran. Aims: We conducted a systematic review and evaluated the quality of the priority-setting ‎reports about health research in the Islamic Republic of Iran. ‎ Methods: English and Farsi databases were searched from January to July 2016 to extract reports (up to December 2015) about priority setting in ‎health research in the Islamic Republic of Iran. We constructed a checklist to extract data from the identified studies. Articles were studied in detail ‎and content analysis was carried out. Relevant items were scored and analysed ‎using Microsoft Excel.‎ Results: ‎We identified 36 articles. Eight articles involved all the main stakeholders. About half the‎articles used valid criteria for ranking. Transparency was fulfilled in 13 articles. Upstream rules and ‎regulations were ignored in 26 articles. An implementation plan was ‎considered in 9 articles and context analysis was demonstrated in only 3. ‎ Conclusions: ‎Developing standard packages for priority setting, training of researchers and ‎improving the capacity of organizations may improve the quality of priority-setting studies in the future.‎ Keywords: ‎health research, priority setting, Islamic Republic of Iran, systematic review Citation: Badakhshan A; Arab M; Rashidian A; Gholipour M; Mohebbi E; Zendehdel K. Systematic review of priority setting studies in health research in the Islamic Republic of Iran. East Mediterr Health J. 2018;24(8):753–769. https://doi.org/10.26719/2018.24.8.753 Received: 11/08/16; accepted: 12/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction innovation to deliver sustainable solutions for health and development problems of low- and middle-income The World Health Report 2013 has identified priorities countries. According to an estimate in 1992, total spending for research for universal health coverage that require on medical research in the public and private sectors national and international support. National research was ~56 billion US dollars but < 10% of the amount was agendas are needed in order to increase funds, improve research capacity and to make appropriate and effective allocated to problems that are responsible for 90% of the use of research findings 1( ,2). Health research has the global disease burden (4). This imbalance is called the potential to address constantly changing health status, 10/90 gap by the Global Forum for Health Research, and especially in vulnerable populations (2). According to the is mainly due to researchers’ individual preferences (4, Global Forum for Health Research, health researchers try 5) and the role of the private sector and pharmaceutical to develop policies, plans, processes, activities and events industry (6,7). Health research priority setting can reduce in each healthcare subsector and enhance proper devel- this gap by making research more efficient in solving the opment of health interventions. Health research also has health problems of countries (8). a role in achieving universal health coverage through Several definitions have been suggested for priority making health services more accessible and affordable. It setting. It is defined as a method for resource allocation also has a significant role in achieving Target 3 of Sus- or the process of choosing between competing research tainable Development Goals: “ensure healthy lives and institutes, programmes or projects (9,10). It is also promote wellbeing for all at all ages” (3). defined as the application of appropriate principles and In 1990, a mismatch between health-research mechanisms for evaluation of investment in research (11). expenditure and the most important diseases was Priority setting is an important element in the research reported by the Council on Health Research for management cycle (12) and can be seen as the efficient Development; a global, nonprofit organization allocation of scarce research resources using explicit established to maximize the potential of research and decision criteria (11,13).

753

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 753 10/10/2018 12:44:05 PM Research article EMHJ – Vol. 24 No. 8 – 2018

According to some studies, health research in base and Web of Science, with a cutoff date of December developing countries is not in line with the priorities of 2015. Keywords were: “research priority” or “priority” and the health system (14) nor is it easily available to all (15,16). “Iran” or “I.R.”. In addition, Magiran and SID, the most Some experts believe that priority-setting activities in popular Persian research databases, were searched for all health research in the Islamic Republic of Iran have expressions that contained the Persian equivalent of the failed for a variety of reasons, including inefficient word “priority”. Each article was assessed by 2 reviewers budget allocation, administrative bureaucracy and for its relevance. The references of each article were ex- ignoring problem-solving techniques (17,18). In addition amined for new articles. Finally, 36 articles were selected to input failures, the studied priority settings have some for analysis (Figure 1). shortcomings in their process (15). The present study was designed to assess the strengths and weaknesses of We included all articles that were related to health health research priority setting in the Islamic Republic of research priority setting in the Islamic Republic of Iran, Iran. in printed or electronic publications. Articles that were not related to health research, such as health technology Methods assessment or healthcare prioritization or those that had We conducted this systematic review from January to not been formally published were excluded. July 2016. We searched Google Scholar, PubMed, Em- Data were collected using a checklist that was

Figure 1 Search strategy of health research priority-setting articles conducted in the Islamic Republic of Iran until 2016.

Number of Number of searched searched articles articles: Web of science: 109 Magiran: 500 PubMed: 46 SID: 492 Embase: 75 Google scholar: 553

After abstract After abstract screen screen Web of science: 15 Magiran: 64 PubMed: 7 SID:56 Embase: 14 Google scholar: 40

After full-text screen Magiran: 24 After full-text screen SID: 32 Web of science: 5 PubMed: 1 Embase: 3 Google scholar: 15 Number of duplicate studies: 18 Total: 38 Number of duplicate studies: 8 Number of Total: 16 duplicate studies: 18 Total: 20

Final: 36

754

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 754 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

designed by the current authors (Table 1). It comprised The checklist was piloted through data extraction from the main principles of similar global studies (10,20). The 10 articles. Data were entered into Microsoft Excel 2016. checklist was validated by sending it to 10 researchers and The following steps were conducted to gather data then the checklist was revised based on their opinions. on priorities in health research. (1) All included articles

Table 1 Researcher-made checklist to assess priority setting activities Criteria Options Definition Rank Score Date High 3 After 2010 Moderate 2 2000–2010 Low 1 Before 2000 Composition of Excellent 3 Stakeholders analysis and all stakeholders engagement such as researchers, managers, stakeholders policy-makers, private sector, nongovernmental organizations and community Appropriate 2 All stakeholders engagement but no analysis Moderate 1 Just researchers, managers and policy-makers Inappropriate 0 Only researchers Transparency Excellent 3 Using or providing guidelines, justification of stakeholders by workshops, meetings Appropriate 2 Using guidelines Moderate 1 Just workshops Inappropriate 0 Nothing Considering high- Excellent 3 National development plans, organizational plans, especially strategic plans, completely level documents considered and priorities conformity is checked Good 2 Above-mentioned plans are considered without monitoring plan Moderate 1 Considering upstream plans just mentioned Weak 0 No reference to any plan Appeal/publicizing Excellent 3 Using mechanisms such as public meetings amd newsletters, with a mechanism for getting feedback Good 2 Using ordinary mechanisms such as listing priorities in websites, and a mechanism for getting feedback Moderate 1 Just mechanisms for presenting results to community and stakeholders – no feedback Weak 0 No mechanism or evidence Vulnerable groups Excellent 3 Full consideration of vulnerable groups as one of the stakeholders and criteria Good 2 Consideration at criteria definition or as one of stakeholders Moderate 1 Implicitly referred Weak 0 Not mentioned System analysis & Excellent 3 Target population health status, health research system and health system analysis and implementation plan implementation plan Good 2 Target population health status, health research system and health system analysis or implementation plan Moderate 1 Just health research system analysis Weak 0 No analysis Literature review Excellent 3 Literature review, scope of priority setting, users, values and principles, political and and political, health context evaluation socioeconomic Good 2 Literature review and context analysis context analysis Moderate 1 Just literature review Weak 0 Nothing Using criteria Excellent 3 Valid criteria are used with complete explanation about score points and scoring systems identification Good 2 Valid criteria are used without any explanation about score points and scoring systems identification Moderate 1 Criteria are used but without referring to their validity Weak 0 Prioritization is done based on participants scores without any criteria

755

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 755 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

were read in depth. (2) Content was analysed, which the results of each article. means that at the same time that each article was read, every part that was consistent with the definition of each Results criterion was highlighted and coded with the name of the The questionnaire was the most important tool used in criterion. (3) Extracted parts of all articles were entered 7 of the studied articles. Our results showed that the fo- in an Excel spreadsheet and scored based on the range cus group discussion (FGD) and Delphi techniques were of scales of each criterion. (4) The fulfilment of each used in 6 and 5 articles, respectively. Brainstorming and criterion was calculated and presented as a score. Tables interviews were used in 7 articles each. A workshop was 2 and 3 show the scores and all statements included in utilized in 3 articles. the checklist criteria, respectively. Table 2 summarizes In terms of methodology, the Essential National Health

Table 2 Strengths and weaknesses of published health research priority setting studies in Islamic Republic of Iran up to 2016‎ 1st author (Ref) Year Stakeholders Transparency High-level Appeal/ Vulnerable System Context Criteria documents publicizing groups analysis & analysis implementation plan

Abachizadeh (30) 2011 0 0 2 0 0 0 2 1 Emami (31) 2003 0 0 0 0 0 0 0 0 Karimi (4) 2005 2 1 2 1 0 0 2 3 Aminoroaia (32) 2010 0 0 0 0 0 0 0 0 Kolahi (33) 2008 3 1 0 0 0 2 1 3 Majidpour (34) 2003 3 3 0 1 0 0 1 3 Yazdanpanah (14) 2004 3 0 0 1 0 0 1 3 Owlia (35) 2011 1 0 0 0 0 1 3 1 Kolahi (36) 2011 3 0 2 0 2 0 2 3 Sohrabi (37) 2014 3 1 2 0 0 0 3 3 Hakimzadeh (38) 2014 1 0 0 0 0 0 0 1 Bahadori (39) 2012 1 0 0 0 0 0 0 1 Khadivi (40) 2006 0 0 0 0 0 0 1 0 Pourhosseini (13) 2015 1 0 2 0 0 2 0 3 Ravaghi (41) 2014 1 0 1 0 0 0 1 1 Sohrabi (18) 2011 3 1 0 0 0 0 1 3 Nemati (42) 2013 1 3 0 0 0 2 0 0 Azizi (8) 2002 1 0 1 0 0 2 1 2 Damari (43) 2006 2 0 2 1 2 2 2 3 Zargham (44) 2002 0 0 0 1 0 2 1 2 Yazdankhah Fard 2008 0 0 0 0 0 0 0 1 (45) Farsar (46) 2013 2 1 2 0 0 2 1 3 Hatmi (47) 2006 1 0 0 0 0 0 0 3 Bahadori (5) 2009 2 0 0 0 0 0 0 2 Tootoonchi (48) 2012 1 0 0 0 0 0 0 0 Kolahi (49) 2010 3 1 2 0 1 2 3 3 Raeisi (50) 2006 2 0 0 0 2 0 1 0 Yasini (51) 2006 2 3 0 0 2 0 0 0 Majidi (52) 2016 2 2 1 0 0 2 0 2 Bahadori (53) 2014 1 0 0 0 0 0 0 2 Haghdoost (54) 2012 1 0 0 0 0 0 1 0 Khambeh-Bini (55) 2000 1 3 0 0 0 0 1 0 Kolahi (56) 2008 3 3 0 0 0 0 1 3 Tavana (57) 2015 1 0 0 0 0 0 0 0 Ghanbari (58) 2009 0 0 0 0 0 0 0 0 Owlia (59) 2011 2 3 0 1 0 0 1 2

756

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 756 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018 ‎ ‎ and impact ‎ ‎ , political ‎ , economic Criteria Appropriateness, Appropriateness, chance of relevance, impact of success, result research NA ENHR criteria innovation, Relevance magnitude feasibility, etc. Relevance, appropriateness, success, chance of research impact of result. Appropriateness, prevalence, magnitude, feasibility, urgency, acceptability Relevance, chance appropriateness economic success, of of impact justification, result research Relevance, appropriateness, time success, chance of justification result research of COHRED criteria applicability, Relevance, appropriateness, research impact of ethical result, acceptance acceptance justification NA NA NA NA NA NA NA NA NA Nursing home Nursing Vulnerable group Vulnerable NA NA NA NA NA NA NA NA NA Appeal & Newsletter publicizing Development plan, Development strategic scientific plan, plan Upstream documents Upstream NA NA core IBTO duties, IBTO institutional process, planning strategic NA NA NA & research of Deputy plan technology strategic plan Strategic plan Strategic Transparency Guidelines NA Training programme NA Workshop Training NA Workshop Meeting NA Stakeholders Scientists managers, Scientists managers, sector, private politicians, organization, students, industry community, Community policy-makers, Scientists, providers, Health-care community healthcare Scientists, providers students, Scientists, providers, healthcare community managers, Scientists, providers healthcare managers, Scientists, sector, private politicians, community, students, people, underprivileged industry, scientists, Politicians, students, sector, private organizations, people, underprivileged community industry, mangers, Scientists, healthcare community, providers scientists, Managers, of board of representation trustees Study design, Study tools & techniques tools COHRED research, Participatory FGD ENHR, workshops, literature interviews, review Cross-sectional, study descriptive delphi questionnaire, method workshop, COHRED, FGDs, brain storming, Delphi ENHR strategy workshop COHRED FGD, storming, Brain Delphi, voting HSR, Brain COHRED, Delphi, FGD, storming, Voting NGT, Delphi, COHRED, FGD, brainstorming, weighting voting, NGT, Documentary and study method, content analysis and checklist questionnaire ) ) ) ) ) ) ) ) 31 4 Assessment of research priority setting activities according to checklist items designed by researchers by designed items checklist to setting activities according priority Assessment research of 56 33 36 49 46 35 ) ) 32 13 Author (Ref)Author Kolahi ( Emami ( Karimi ( Aminoroaia ( Kolahi ( Owlia ( Kolahi ( ( Farsar Kolahi ( Pourhosseini ( Table 3 Table

757

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 757 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018 ‎ , ‎ , ‎ Criteria Relevance, Relevance, appropriateness, success, chance of research impact of result NA NA mentioned that Just used some criteria feasibility Importance, Time justification align with goals, organizational applicability feasibility, NA Relevance, appropriateness, success, chance of research impact of result Cost–benefit, time justification acceptability NA NA NA NA NA NA NA NA NA NA youth contribution workers union workers Women, elderly Women, and youth people and youth Representative of of Representative people, women and women people, Vulnerable group Vulnerable Contribution of elderly Contribution of NA NA NA NA NA NA NA NA NA NA Appeal & publicizing Just mentioned Just ) continued NA NA NA Strategic plan, 4th Strategic plan, the development organization, of statute main social security laws NA NA NA Globocan 2012, guidelines on cervical of management lesions precancerous plan Strategic NA Health World research Organization results Upstream documents Upstream Transparency NA NA NA setting Priority training guidelines, workshop Training NA NA workshop Training NA NA NA Stakeholders Managers Scientists Managers Scientists, authorities, authorities, Scientists, community, managers, providers healthcare managers, Scientists, students, Authorities, authorities, Community, trustees trustees, Community, managers, NGOs, scientists, providers policy makers, Scientists, providers care health healthcare Scientists, students, funders, providers, community Community authorities, Managers, scientists Study design, Study tools & techniques tools COHRED (small module) COHRED (small questionnaire study, Descriptive Delphi, brainstorming, workshop, expert questionnaires, panel, numerical scale research, Participatory appraisal, rapid FGD, Interview, observation COHRED FGD, questionnaire, workshop, Action Likert research, expert zone, go scale, panel and cross-sectional Mixed study, interview and questionnaire session, Brainstorm questionnaire brain storming, COHRED, voting Delphi, NGT, FGD, AHP FGD interview, & research Participatory appraisal rapid interview & FGD Delphi FGD questionnaire, ) ) 54 ) ) ) ) ) 53 39 ) ) 41 ) 40 37 43 52 Assessment of research priority setting activities according to checklist items designed by researchers ( researchers by designed items checklist to setting activities according priority Assessment research of 50 51 ) 48 Author (Ref)Author Damari ( Tootoonchi ( Khadivi ( ( Yasini Majidi ( Bahadori ( ( Haghdoost Sohrabi ( Bahadori ( Raeisi ( ( Ravaghi Table 3 Table

758

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 758 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018 ‎ , and ‎ , Criteria Appropriateness, Appropriateness, chance of relevance, impact of success, result research NA Acceptability time justification cost–benefit module) ENHR (small NA Maintaining and of health improving alignment employees, with policies and applicability objectives, be strategic, To market inclusiveness, potential, quick impact help result, research of to self-sufficiency, moving along national security Importance, in public changes accessibility, health, availability, to nursing change potential practice, collaboration, for orientation, community laws, supporting economic justification, applicability NA NA NA NA NA NA NA NA Vulnerable group Vulnerable NA NA NA NA NA NA NA Appeal & 1 or 2 years publicizing ) Journal, interviews every interviews every Journal, continued NA NA NA NA NA NA NA NA Upstream documents Upstream Transparency NA Workshop Guidelines NA NA Guidelines, workshop NA NA Stakeholders Authorities, Authorities, nongovernmental organization managers Scientists, scientists Managers, managers Scientists, experts managers, Scientists, Experts and researchers Scientists providers Healthcare Study design, Study tools & techniques tools Health system research system Health Delphi, brain storming, FGD, Questionnaire, workshop, & cross- Descriptive sectional Delphi, questionnaire, with Likert weighting scale descriptive, Qualitative, AHP cross-sectional, in- needs assessment, FGD depth interviews, module), ENHR (small FGD study Descriptive method study Mixed and FGD interviews, Delphi weighting Classic expert questionnaire, committees Descriptive-analytic, study cross-sectional Delphi, questionnaire, with Likert weighting scale ) ) ) ) 44 5 ) 18 42 Assessment of research priority setting activities according to checklist items designed by researchers ( researchers by designed items checklist to setting activities according priority Assessment research of ) 47 45 ) ) 55 38 Author (Ref)Author Sohrabi ( ( Nemati Bahadori ( ( Hatmi Khambeh-bini ( Hakimzadeh ( ( Zargham Yazdankhah ( Fard Table 3 Table

759

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 759 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018 ‎ , ‎ , magnitude, ‎ magnitude, Criteria Prevalence, severity severity Prevalence, consensus urgency, stakeholders of sustainability, political acceptance, related acceptability,. to be modifiable, costs, magnitude, appropriateness, chance of relevancy, impact of success, result research Intensity of and cost ability solving problem, urgency, prevalence, political acceptance acceptability, commitment be strategic, To national regarding plan, maintaining and community improving capability, health, independence, relying innovation, on domestic organizations practicality, Feasibility, achievability, appropriateness NA NA acceptability, Political cost- ability, executive effectiveness NA NA NA NA NA NA NA Vulnerable group Vulnerable NA NA NA NA Appeal & publicizing National TV National stakeholders ) presented to all presented TV & local media research have been have research Results completed of concluded NA NA NA NA NA 3rd national 3rd Map of Sciences of Map development plan development The National Road The National and Technology, The and Technology, International Cancer Research Portfolio (ICRP) Research Portfolio Upstream documents Upstream NA NA NA NA NA training workshop Guidelines, Guidelines, Guidelines & Transparency Nurses Scientists Authorities Community private sector, private Stakeholders Community, experts, experts, Community, Researchers, managers, managers, Researchers, scientists, organizations scientists, community, policy-makers, policy-makers, community, 15 academic experts and staff Study design, Study tools & techniques tools Qualitative study, study, Qualitative surveys, interviews, workshop questionnaire, assessment Need FGD questionnaire, Expert opinion, eclectic option, morphological method option, weighting Qualitative, Likert questionnaire, scale cross- Descriptive, sectional study study Qualitative ENHR ) ) ) 34 59 58 ) 57 Assessment of research priority setting activities according to checklist items designed by researchers ( researchers by designed items checklist to setting activities according priority Assessment research of ) 8 ) ) 14 30 Author (Ref)Author Majidpour ( Yazdanpanah ( Azizi ( Abachizadeh ( ( Tavana Ghanbari ( Owlia 2011 ( Table 3 Table AHP = Analytic Hierarchic Process; COHRED = Council on Health Research for Development; ENHR = Essential National Health Research; FDG = focus group discussion; HSR = health service research; IBTO = Iranian Blood Transfusion Organization; NA = not available; NGT = available; NGT = not Organization; NA Transfusion Blood = Iranian IBTO service discussion; HSR = health group research; Research; Health FDG = focus Development; National Process; ENHR = Essential Research on Health for COHRED = Council AHP = Analytic Hierarchic Organization. Health WHO World technique; nominal group

760

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 760 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Research approach was the most frequently applied articles on priority setting in the Islamic Republic of Iran. method for setting priorities in 11 articles. Descriptive The majority of them had methodological limitations, studies and qualitative methods were ranked as second including inappropriate range and composition of stake- (6 articles) and third (4 articles), respectively. Three of holders, lack of strict criteria for ranking, little attention the included studies used the participatory research to transparency, failure to disseminate results, failure method. The Analytic Hierarchical Process, Health to provide a mechanism for appeals, failure to consider System Research, mixed methods, and need assessments high-level national and international documents, ab- were each used in 2 of the studies. The documentary or sence of context analysis and lack of planning for imple- econometrics method was used in 1 of the articles. Four menting priorities. articles used other types of methods. Although a sufficient number of published articles Table 2 shows that across 36 reviewed articles, 17 on priority setting in the Islamic Republic of Iran were performed priority setting at the national level and 19 reviewed, there are many priority settings that are not at the local level. Also, half the articles that prioritized published (known as grey literature). Those lists of subjects were related to disease, risk factors, health status priorities that were found through searching Google did or specific parts of a health system, and the other half not have methodology, and therefore did not meet the prioritized all health sectors. Seventeen of the reviewed inclusion criteria, and were excluded from the analysis. articles determined their priorities at both levels of area Another limitation was the different levels of proceedings and subject, 8 worked only on domain and 11 were limited used. Some of them were conducted at the national to the subject of priority setting. level and others were at lower levels. To understand the Of the 36 articles, 8 included 4 recommended extent of this limitation, national documents were fully groups including researchers, managers, providers analysed. There was no significant difference between and the community among their stakeholders (Table the results of the analysis of national documents and 3). Investigating the frequency of involvement for each findings that resulted from analysis of all the studies. group separately showed that researchers, managers, To the best of our knowledge, this is the first providers and community members participated in 25, 22, comprehensive systematic review of priority setting 17 and 15 studies, respectively. Only 4 articles considered in health research in the Islamic Republic of Iran. vulnerable individuals (e.g., elderly or homeless people Internationally, there were 9 systematic reviews that dealt or female-headed households) as stakeholders (Table with priority setting of health research among different 3). In terms of transparency, in 14 articles that provided countries (2, 19–25). The current systematic review differs different forms of explanation, only 6 presented from previous reviews because of being country specific guidelines and others merely justified their stakeholders and the large number of included studies. using workshops or other methods. The rest (22) did not According to our results, 1 of the observed problems follow a method and only listed priorities (shown by “NA” was lack of appropriate attention to the level of determined in Table 3). priorities, as well as lack of correct definition of terms such Eight articles considered international, national and as axis, domain, topic, subfield, field, subarea and area. institutional plans; however, none of them provided a Although we tried to show all items in the form of area and mechanism to ensure conformity of results according subject in Table 4, investigating all articles showed that to those plans (Table 2). Three articles implicitly referred some mentioned a priority as “domain” while others, at a to the importance of national or institutional plans. The similar level, mentioned it as “topic”. Although 17 articles rest of the articles (25) did not mention any point about categorized their priority in the form of domain (or other important rules or plans in their priority-setting process names), only 7 performed prioritization of domains, and (Table 2). Out of 36 studied articles, only 6 implicitly others only categorized priorities in terms of subjects or pointed to the dissemination of priority-setting results, proposed group. Since domains on their own can help but none of them mentioned an effective mechanism with horizontal distribution of resources among groups to comment upon and critique priority-setting results and departments, it seems that their prioritization should (Tables 3 and 4). Two articles conducted a complete be included in priority setting. analysis of political, social and economic contexts of According to our findings, the involvement rate activities, 19 conducted a brief analysis, and 15 did not of the main groups of stakeholders (i.e., researchers, have a context analysis of activities (Table 2). Among 36 managers, providers and community members) was 22%. articles, only 9 comprised an analysis of the population This is consistent with the study that showed that 7 of 9 health status, health system, and health research system countries experienced limited or moderate involvement and provided recommendations about implementation of acceptable stakeholders and only 3 (33%) included (Table 2). Sixteen of the investigated articles did not lay public consultation (19). In line with the findings of the out strict criteria for priority-setting processes. Among current study, 3 other studies found that only 37, 21 and them, there were 11 articles that completely ignored 25% of articles were truly representative of different ranking criteria (Table 2). disciplines (23–25). A review of 165 articles showed that, Discussion while there was close involvement of the government and researchers, the participation of other key stakeholders In this study, we reviewed a large number of published was limited (22). This is consistent with our findings that

761

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 761 10/10/2018 12:44:06 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 4 Results of research priority setting activities (continued) Author (ref) No. of Ranking Ranking Scope Top 5 priorities priorities of area of subjects Karimi (4) 16 areas, 99 ×  National– 1. Inviting, maintaining and training blood donors who are subjects general donating their blood continuously and are healthy. 2. Global standards of blood transfusion. 3. Collecting blood, storing and transporting blood and blood products. 4. Essential laboratory tests on donated blood with new screening approach. 5. Consuming blood and blood products. Owlia (36) 9 areas ×  National– 1. Communicable diseases. 2. Noncommunicable diseases. 3. Health general system research. 4.Drug and industry. 5. Basic science. Damari (43) 9 areas, 37 ×  National– 1. Human resources management. 2. Health technology (medical subjects general equipment, medicine and para-clinic). 3. Statistical system and electronic health information. 4. Direct and indirect provision of health. 5. Industrial and occupational health affairs. Tootoonchi (48) 129 ×  National– 1. Methods of faculty members' development. 2. Faculty members' subjects general motives. 3. Satisfaction and welfare. 4. Criteria and procedures of faculty members' promotion. 5. Teaching methods and learning techniques. Bahadori (53) 191 topics ×  National– 1. Assessing existing standards and criteria in the construction in 7 areas specific and running health centres (treatment area). 2. Determining the role and position of military healthcare centres in national family physician programme. 3. Investigating the satisfaction of patients who were visited in military health centres. 4. Investigating the basics of health survey programme. 5. Examining the performance of managers of health centres. Haghdoost (54) 4 areas, 11   National– 1. New vaccination. 2.New preventive methods (overall). 3. New subareas, specific treatments in pre-AIDS phase. 4. Incidence and prevalence in high- 37 subjects risk groups/general population. 5. Education. Bahadori (39) 8 subjects ×  National– 1. Design strategic model of social insurer organization. 2. general Investigating the organizational structure of social insurer organization. 3. Examining the referral system and ‎family physician. 4. Design disaster management model in social insurer organization. 5. Conducting cost–benefit analysis for common and expensive diseases that are under the coverage of social insurer organization. Ravaghi (41) 4 areas , 45   National– 1. Investigation and epidemiology of threats to patient safety. 2. subjects specific Rooting the patient safety threats. 3. Promotion of patient safety. 4. Evaluation and feedbacks of actions. 5. Patient safety solutions. Bahadori (5) 12 subjects ×  National– 1. Designing standard treatment protocols. 2. Designing model of specific ranking health care centres that are under contract. 3. Investigating the roots of payment system. 4. Designing mechanisms for quality control in healthcare centres. 5. Establishing incentive mechanisms to develop the quantity and quality of contractual services. Hakimzadeh 8 areas, 102   National– 1. Labour market. 2. Finance and insurance. 3. Technology (38) subjects specific assessment. 4. Health economics, cost, income and producing healthcare centres. 5. Payment methods. Azizi (8) 4 areas, 21 ×  National– 1. Estimating burden of diseases. 2. Improving referral system subjects general management. 3. Improving data processing management and information. 4. Reproductive health and population growth. 5. Reducing malnutrition. Abachizadeh 28 subjects ×  National– 1. Cancer surveillance and registration. 2. Exogenous factors in (30) specific the origin and cause of cancer. 3. Surveillance-patient care and survivorship issues. 4. Issues of end-of-life care. 5. Cost analyses and healthcare delivery of cancer services. Tavana (57) 4 areas, 26 ×  National– 1. Explore the role of private sector in health system. 2. Comparative subjects specific study of payment systems in other countries and localize them. 3. Identify barriers to implementation of general practice and referral system and determine administrative guidelines. 4. Design health technology assessment system. 5. Conducted a comprehensive study on the use of the most appropriate method of payment for the healthcare system.

762

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 762 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 4 Results of research priority setting activities (continued) Author (ref) No. of Ranking Ranking Scope Top 5 priorities priorities of area of subjects Ghanbari (58) 20 subjects ×  National– 1. Psychosocial and economic effect of diagnosis on family. 2. Oral specific health in patients undergoing chemotherapy. 3. Nutritional needs in cancer patients. 4. Communication with cancer patients in all stages of disease. 5. Ways of continuing hospital and home care. Owlia (59) 9 areas, 45 ×  National– 1. Communicable diseases. 2. Noncommunicable diseases. 3. Health subareas general system research. 4. Pharmaceutical sciences and Industry. 5. Basic science. Zargham (44) 6 areas, 74 ×  National– 1. Biological products (biologics) for diseases diagnosis. 2. Biological subjects general products for diseases prevention. 3. Molecular medicine (molecular diagnosis and genetic treatment). 4. Biological products for diseases treatment. 5. Using transgenic creatures. Majidi (52) 26 subjects ×  National– 1. Developing national guidelines and defining appropriate specific screening tests. 2. Starting age and interval for regular screenings. 3. Developing quality control protocols for follow-up and management of patients with precancerous lesions and cervical cancer patients. 4. Conducting a cost-effectiveness study for human papilloma virus vaccination in Islamic Republic of Iran. 5. Coverage of the cervical screening by insurance companies. Kolahi (56) 25 area, 99 ×  Local– 1. Hospital infections. 2. HIV/AIDS and sexually transmitted subjects specific infections, seasonal. 3. H1N1 and avian influenza, 4. Infectious diseases registration and reporting system. 5. Immigrants’ role in drug resistance and infectious disease dissemination in Islamic Republic of Iran. Emami (31) 4 areas, 15  × Local– 1. Road accidents. 2. Need to promote people’s knowledge about subjects general addiction. 3. AIDS and mental issues and healthy ways of life. 4. Training about healthy heart and healthy nutrition by service providers. 5. Establishing population screening system in Bushehr Aminoroaia (32) 134 subjects ×  Local– 1. Addiction in physicians. 2. Addiction in health professionals. 3. specific Drug abuse eradication centres and rural areas. 4. Addiction in adolescence. 5. Investigating sexual needs of adolescents and ways to control it and balancing it based on religious culture. Kolahi (33) 25 areas ×  local–specific 1. HIV/AIDS. 2. Tuberculosis. 3.Drugs. 4. Infections in special hosts. 5. Avian influenza. Kolahi (36) 20 areas   local–specific 1. Myocardial infarction. 2. Hypertension. 3.Unstable angina. 4. Atherosclerosis. 5. Dyslipidaemia. Farsar (46) 7 areas, 43   local–specific 1. Paediatric trauma. 2.Paediatric cancer. 3. Paediatric urological subjects diseases. 4. Undescended testes in boys. 5. Developmental genetics and congenital defects. Kolahi (49) 841 area,   Local– Priorities are not mentioned but concluded that the Council on 1900 general Health Research for Development model is suitable for setting subjects research priority in educational departments. Pourhosseini 2 areas, 92 ×  Local– 1. Health supporting environment. 2. Community empowerment. 3. (13) subjects general Quality of services. 4. Human resources. 5. Budget management. Khadivi (40) 20 subjects ×  Local– 1. Large scale of mourning ceremonies. 2. Misdirection of general investments. 3. Unemployment. 4. Addiction and easy access to narcotics. 5. Investment insecurity. Yasini (51) 10 research ×  Local– 1. Investigating car accidents and determining the share of each subjects general motor vehicles in the incidence. 2. Identifying educational needs of community in terms of good behaviour with adolescents. 3. Determining educational needs of society in terms of healthy nutrition. 4.Determining educational needs of society in terms of marital relations. 5. Studying how to raise public awareness about routes of AIDS transmission. Sohrabi (37) 7 areas, 31   Local– 1. Health-threatening risk factors. 2. Health-affecting behavioural subareas general factors. 3. Family health. 4. Community health promotion. 5. Chronic diseases and cancer. Raeisi (50) 9 groups, ×  Local– 1. Mental health. 2. Limited knowledge of women about health 40 general and nutrition. 3. Addiction. 4. Inadequacy of health education. 5. problems Environmental health and unsafe disposal of waste.

763

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 763 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Table 4 Results of research priority setting activities (concluded) Author (ref) No. of Ranking Ranking Scope Top 5 priorities priorities of area of subjects Sohrabi (18) 89 subjects, ×  Local– 1. Design university research road map and priority setting. 2. 15 fields specific Psychological problems in students. 3. Criteria for workforce planning. 4. Automation of services. 5. Hospital infections. Nemati (42) 89 topics in ×  Local– 1. Role of graduates and accordance of their specialty with 6 areas Specific community needs. 2. Assessing compliance of training programmes with objectives of departments. 3. Investigating ways to support outstanding professors in terms of education and research. 4. Reviewing the curricula at various levels of medical education and how to optimize them. 5. Assessing the efficacy of new educational methods in interns’ and residents’ education. Hatmi (47) 30 area ×  Local– 1. Epidemiological investigations. 2. Burden of disease. 3. Research Specific on treatment. Khambeh-bini 7 area, 336 ×  Local– 1. Failure of treatment in addicted tuberculosis patients. 2. Patients (55) subjects general and nutrition. 3. Medical emergencies. 4. Trauma. 5. Effect of medicinal plants on heart. Yazdankhah 10 subjects ×  Local– 1. Nursing and education. 2. Nursing and client education. 3. Fard (45) specific Nursing status in health system. 4. Nursing and medication. 5. Nursing management and quality promotion. Majidpour (34) 34 subjects ×  Local– 1. Under-5 mortality rate. 2. Accidents. 3. Failure to thrive. 4. general Ischemic heart disease. 5. Health education (individual and environmental health). Yazdanpanah 95 subjects ×  Local– 1. Increased prevalence of communicable and noncommunicable (14) general diseases with high priority (cardiovascular diseases. 2. Mental diseases. 3. Digestive diseases and cancer. 4. Increased prevalence of accidents. 5. High unemployment, poverty, illiteracy and welfare problems.

showed that managers and researchers participated in in our study did not mention criteria. Our results were 21 (58%) and 24 (67%) of articles, respectively. In another consistent with those that showed 69, 56 and 62% study, although 4 groups of recommended stakeholders of investigated articles applied criteria to determine did not participate, other players such as funders, the research priorities (2). However, 1 study reported that private sector and industry participated (20). These 3 only 18% of studies were conducted using criteria. One effective groups were included in 5 of the articles of the possible reason for ignoring criteria is the simplicity of current study. We believe that, in the Islamic Republic of using other tools, such as questionnaires or subjective Iran, the fact that the majority of research funds come rankings, compared to challenging features of criteria- from government departments is the main reason for based ranking methods. Generally, it can be concluded ineffective participation of funders in priority setting. that defining a criterion, particularly in scientific Moreover, 15 (41%) of studies included some forms of contexts that inherently suffer from high degrees of public participation. Consistent with our results, other autonomy, has a constructive role in achieving consensus. studies reported that 29 and 25% of studies considered the Furthermore, in contexts where information is limited, opinions of patients or community members, respectively having criteria could help us to conduct priority setting (2). One study demonstrated that 18% of documents in a more deliberative and rationale way. It would also directly considered public inputs and 36% involved help in providing some justification to satisfy funders, vulnerable groups (25). Among the articles investigated in policy-makers and managers so that they might finance, our study, such participants were found only in 4 (11%). support and utilize the priorities. It seems that academic members’ awareness of common In terms of transparency, an acceptable priority methods of priority setting, more communication setting should not only create a list of priorities but it between different stakeholders, and being aware of the should also present a clear report about the used approach needs and capabilities of other participants are important and how and by whom priorities were identified (14). factors in conducting priority setting with a broad range The current study revealed that only 13 articles met the of participation. transparency criteria. This is consistent with 2 studies in Almost all known priority-setting models use criteria which transparency was fulfilled in 22 (8%) articles 19( ,23). for guiding participants (20), considering important In contrast, another study noted that 69% of studies met values of different disciplines, matching proposals with transparency criteria (24). The latter study concluded that the main subject, and that the important issues are not lack of coordination between patients and researchers, ignored. Eleven (30%) articles that were investigated and the bias resulting from funders’ influence, are the

764

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 764 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

main causes of ignoring transparency. It seems, because in the authenticity of these documents and the absence of the higher proportion of governmental health research of an effective tool for monitoring their application. funds, researchers do not feel the need to attract funders’ Therefore, making the process of high-level planning and attention. Besides that, policy-makers usually ignore the monitoring more acceptable can address the problem. role of health research in policy-making and decision- Undoubtedly, setting an appropriate time horizon, making processes. This could lead to discouragement defining the targeted population and characterizing among researchers, thus decreasing their incentive to the political, social and economic aspects of the context attract the attention of decision-makers. in which the prioritization is conducted is essential. Dissemination of information as an ethical aspect Exploration of the targeted audience ensures that of priority setting (9,10) will be achieved if society has appropriate language and communication methods access to decisions and reasons of prioritization (21). In are used for a realistic priority-setting process and other words, the decision-making process should be final implementation 19( ). In the present study, 2 of the clearly stated, and decisions and reasons about them documents conducted a complete context analysis and 19 should be broadly publicized (26). Publicizing the results conducted a partial one. In contrast with these results, a of priority setting leads to promotion of accountability study reported that all investigated articles conducted a in the decision-making process (27). According to the context analysis at the beginning of priority setting (25). findings of the current study, 8 (16%) of the articles met Another study reported that 92% of studies conducted a the publicizing criterion, which is consistent with a study context analysis (23). Since realistic context analysis has that showed 11% of studied articles had met the criterion an important role in determining the scope and focus (19). In conclusion, it can be claimed that researchers do of the priority setting, time horizon, allocated budget not believe in the necessity of informing the general and other resources that are required, we recommend population about the results of priority setting, and are that it should be considered as a mandatory task in the concerned about their inability to respond to increased preparatory phase of health research priority setting. public expectations. A system analysis (of health status, health system and The process of revision based on appeals can be defined health research system) should be conducted to propose as “explicit mechanisms for revising decisions based an implementation plan. In our study, 9 (25%) articles on emerging issues or arguments” (19). Disregarding indirectly mentioned this analysis and presented an the appeal mechanism in all investigated articles in the unlimited implementation plan. A systematic review of current study can be compared with a study in which the priority setting in research in nursing indicated that 8% mechanism for appeal was not considered in any of the of articles directly proposed an implementation plan (25). investigated countries (19). In contrast to our results, a In another review about national health research priority review of studies that were related to priority setting in setting in Latin America and the Caribbean, 12% of Panama indicated that 2 of 3 studies had considered the articles seriously proposed an implementation plan (25). appeal mechanism (21). All of the priority-setting studies We believe that system analysis, which comprises related that were investigated in the current study were one-time data, health system infrastructure, health research system efforts, which is an indication of the lack of a revision capability and some scientometrics, should be carried out mechanism. Based on the above-mentioned study (19), by experts and should be reported as a statement paper at a precise mechanism for revising a decision should be the beginning of the process. This information provides included in the appeal process. It also provides a platform a proper view for stakeholders to make the best choices. for hearing the voices of other stakeholders. Many research-priority settings in the Islamic Based on our findings, 25 reviewed articles ignored Republic of Iran have been shown merely as a list of high-level documents, which is another weakness of priorities on the websites of organizations or published priority settings. Some studies have declared that high- in nonacademic journals and newsletters. So, this level documents, including strategic plans, could be study was limited due to lack of access to the methods helpful in providing policies and legislative frameworks, of conducting these studies. We found that health- guiding priorities, and creating mechanisms to encourage priority settings in the Islamic Republic of Iran suffer and support research (28). In their opinion, decisions from weak stakeholder composition and participation, about priority setting should be made on the basis of lack of ranking criteria, little attention to transparency, explicit values, and stakeholders should gain insight into no results dissemination, no mechanism for appeal, the goals of priority setting and the logic behind it as well ignoring high-level documents, and absence of context as about missions, visions, values and strategic plans of analysis and implementation plans. We recommend the organization (9). Other studies have mentioned that that stakeholders minimally should consist of 4 groups lack of compatibility with high-level goals and strategic (researchers, decision-makers, managers and community guidance can lead to an imbalance in investment in health members). Inviting funders, industry and private sector research (19,29). A study about priority setting in nursing can make it better. It is necessary to provide acceptable was consistent with the current research and reported guidelines to explain major components of setting each that 57% of articles considered high-level documents in priority and to increase transparency and comparability. identifying priorities (23). In fact, ignoring high-level Ranking criteria ought to be identified because they documents is predominantly due to lack of confidence make decisions sensible and help to achieve a consensus

765

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 765 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

easily. We recommend that a newsletter could publicize system conditions, and health research system should be the results of the priority setting. By holding workshop carefully analysed, through which we could find the most sessions and discussion fora with a broader range of important health problems of the community, strengths stakeholders, an effective revision mechanism would be and weaknesses of the health system, and capabilities provided. Most importantly, as a strategy that provides and limitations of the health research system. Finally, it guidance toward an efficient resource allocation, priority setting should be in line with high-level documents. The should be noted that priority assessment by designing extent of the study, time frame, budget constraints and well-established indicators to monitor and evaluate target population should be analysed and identified from compliance of performed actions with standards should the outset. It must be noted that the health status, health pave the way to achieving goals. Acknowledgements Tehran University of Medical Sciences (TUMS) Research Department (International Campus) funded and approved this study (contract number: 92/240/D/818; PhD dissertation code number: 9011482001). This study also was supported by the Cancer Research Center of TUMS and National Institute of Cancer Research. The authors are grateful to all those who contributed to this research, directly or indirectly. Our thanks also go to Dr. Haghdoost (President of Kerman University of Medical Sciences), Dr. Ali Asghar Kolahi (Social Determinants of Health Research Center at Shahid Beheshti University of Medical Sciences), Dr. Ali Khamesipour (President of the Leishmaniasis Research Institute), Dr. Reza Goodarzi (Ker- man University of Medical Sciences), Dr. Alireza Mahboob-Ahari (Tabriz University of Medical Sciences), and Dr. Esmaeil Moshiri (Semnan University of Medical Sciences) who helped in improving the checklist. Funding: None. Competing interests: None declared.

Analyse systématique des études concernant l’établissement des priorités en matière de recherche en santé en République islamique d’Iran Résumé Contexte : Plusieurs études sur l’établissement des priorités ont été menées dans différents pays, notamment en République islamique d’Iran. Objectif : Nous avons effectué une analyse systématique et avons évalué la qualité des rapports concernant l’établissement des priorités en matière de recherche en santé en République islamique d’Iran. Méthodes : Des recherches ont été effectuées dans les bases de données en anglais et en farsi entre janvier et juillet 2016 afin de trouver des rapports (jusqu’à décembre 2015) concernant l’établissement des priorités en matière de recherche en santé en République islamique d’Iran. Nous avons établi une liste de contrôle pour les critères en vue de l’extraction des données des études identifiées. Les articles ont été examinés en détail et une analyse de contenu a été effectuée. Les points pertinents ont été notés et analysés à l’aide de Microsoft Excel. Résultats : Nous avons identifié 36 articles. Huit articles impliquaient l’ensemble des principales parties prenantes. Près de la moitié des articles utilisaient des critères de classification valides. Treize (13) articles faisaient preuve de transparence ; 26 articles ignoraient les règles et réglementations en vigueur. Un plan d’application était suivi dans 9 articles et seuls 3 mettaient en avant une analyse du contexte. Conclusion : L’élaboration d’ensembles de normes en matière d’établissement des priorités, la formation des chercheurs et l’amélioration de la capacité des organisations pourraient avoir des répercussions positives sur la qualité des prochaines études concernant l’établissement des priorités.

مراجعة منهجية لدراسات حتديد األولويات يف البحوث الصحية يف مجهورية إيران اإلسالمية عباس بدخستان، حممد عرب، آرش رشيديان، مهني قيل بور، إهلام حمبي، كاظم زنده دل اخلالصة اخللفية:أجريت عدة دراسات حول حتديد األولويات يف البحوث يف بلدان خمتلفة، بام يف ذلك مجهورية إيران اإلسالمية. اهلدف: أجرينا مراجعة منهجية َوق َّيمنا جودة تقارير حتديد األولويات يف البحوث الصحية يف مجهورية إيران اإلسالمية. طرق البحث: بحثنا يف قواعد البيانات باللغتني اإلنجليزية والفارسية من يناير/كانون الثاين إىل يوليو/متوز 2016 الستخراج التقارير )التي يعود تارخيها حتى ديسمرب/كانون األول (حول 2015حتديد األولويات يف البحوث الصحية يف مجهورية إيران اإلسالمية. أنشأنا قائمة تساعد يف استخراج البيانات من الدراسات املحددة. ودرسنا املقاالت بالتفصيل وأجرينا ًحتليال للمحتوى. َّوسجلنا العنارص ذات الصلة َّوحللناها باستخدام برنامج ميكروسوفت - إكسل. 766

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 766 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

النتائج: حددنا 36 مقالة. وشملت مقاالت 8مجيع أصحاب املصلحة الرئيسيني. وقد استخدم ما يقرب من نصف املقاالت معايري صاحلة للرتتيب. وتبني لنا أن الشفافية متحققة يف مقالة.13 وقد الحظنا أنه تم جتاهل القواعد واللوائح املعمول هبا يف األصل يف 26مقالة. بينام روعيت خطة التنفيذ يف 9مقاالت، وتم توضيح حتليل السياق يف 3 مقاالت فقط. إن االستنتاج:تطوير حزم معيارية لتحديد األولويات وتدريب الباحثني وحتسني قدرة املنظامت قد ِّ ن حيسمن جودة دراسات حتديد األولويات يف املستقبل.

References 1. Health in 2015: from MDGs, Millennium Development Goals to SDGs. Sustainable Development Goals. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf?ua=1, accessed 14 February 2018). 2. McGregor S, Henderson KJ, Kaldor JM. How are health research priorities set in low and middle income countries? A systematic review of published reports. PLoS One. 2014;9(10):e108787. https://doi.org/10.1371/journal.pone.0108787 3. The world health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013 (http://apps.who. int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf?ua=1, accessed 14 February 2018). 4. Karimi Gh GBA, Rahbari M, Vafaiyan V, Minab Salemi E, Damari B. ‎Need assessment and research priorities setting in IBTO Research Center‎. Blood. 2005;2(4):123–34. 5. Bahadori M, Ravangard R, Farzaneh A, Hakimzadeh SM. Research needs assessment in the health insurance organization: Level of health care provider. Electron Physician. 2009;3(2):436–41. 6. Damari B, Hasanzadeh A, Poorreza A. Need assessment and priority setting for health research in social sequrity organization. Soc Secur. 2006;25:219–46. 7. Dresser R. Priority setting in biomedical research. Virtual Mentor. 2009;11(4):322–5. https://doi.org/10.1001/virtualmen- tor.2009.11.4.msoc1-0904 8. Azizi F. National priorities in medical sciences. Rahyaft J. 2002;12(27):14–26. 9. Sibbald SL, Singer PA, Upshur R, Martin DK. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Serv Res. 2009;9(1):43. https://doi.org/10.1186/1472-6963-9-43 10. Fleurence RL, Torgerson DJ. Setting priorities for research. Health Policy. 2004;69(1):1–10. https://doi.org/10.1016/j.health- pol.2003.11.002 11. Strengthening health systems: the role and promise of policy and systems research. Geneva: Alliance for Health Policy and Sys- tems Research; 2004 (http://www.who.int/alliance-hpsr/resources/Strengthening_complet.pdf, accessed 14 February 2018). 12. Zendehdel K. The formation origin of comprehensive development plan of medical research networks. Newsletter of Compre- hensive Development Plan of Medical Sciences Research Networks. 2013;1:4–6. 13. Pourhosseini SS, Dehnavieh R, Mehrolhassani MH. [Research priorities of Kerman Medical Sciences University: a documentary study]. J Health Dev. 2014;3(4):293-0 (in Persian) http://jhad.kmu.ac.ir/article-1-88-en.pdf. 14. Yazdanpanah B, Pourdanesh F, Safari M, Rezai M, Ostavar R. Health research priority setting by needs assessment in Kohgiloyeh and Boyerahmad province. Armaghan Danesh. 2003;8(21):1–20. 15. Malek-Afzali H BF, Alaaddini F, Forouzan AS. [Health system priorities based on needs assessment & stakeholders’participation in IR Iran]. Hakim Res J. 2007;10(1):13–9 (in Persian). http://hakim.hbi.ir/article-1-326-en.pdf 16. Davey S. The 10/90 report on health research 2003–2004: Global Forum for Health Research; 2004. 17. Mohammadi M, Mesgarpour B. Systemic approach to health research in Iran and the world. Bull World Health Organ. 2001;79(9):834–41. 18. Sohrabi MRRM, Souri H, Mortazavi MGS. NazarAli S, Baladast M, Bahadori ASS, et al. Research Priorities of Health Sys- tem Research (HSR) in Vice-Chancellors of the Shahid Beheshti University of Medical Sciences. J Isfahan Med Sch. 2011 Feb;28(119):1324–36. 19. Tomlinson M, Chopra M, Hoosain N, Rudan I. A review of selected research priority setting processes at national level in low and middle income countries: towards fair and legitimate priority setting. Health Res Policy Syst. 2011;9:19. https://doi. org/10.1186/1478-4505-9-19 20. Bryant J, Sanson-Fisher R, Walsh J, Stewart J. Health research priority setting in selected high income countries: a narrative review of methods used and recommendations for future practice. Cost Eff Resour Alloc. 2014;12(1):23. https://doi.org/10.1186/1478- 7547-12-23 21. Romero LI, Quental C. Research for better health: the Panamanian priority-setting experience and the need for a new process. Health Res Policy Syst. 2014;12(1):38. https://doi.org/10.1186/1478-4505-12-38 22. Yoshida S, Cousens S, Wazny K, Chan KY. Approaches, tools and methods used for setting priorities in health research in the 21st century. J Glob Health. 2016;6(1):1–8 https://doi.org/10.7189/jogh.06.010302 23. Garcia AB, Cassiani SHDB, Reveiz L. A systematic review of nursing research priorities on health system and services in the

767

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 767 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

Americas. Rev Panam Salud Publica. 2015;37(3):162–71. 24. Tong A, Chando S, Crowe S, Manns B, Winkelmayer WC, Hemmelgarn B, et al. Research priority setting in kidney disease: a systematic review. Am J Kidney Dis. 2015;65(5):674–83. https://doi.org/10.1053/j.ajkd.2014.11.011 25. Reveiz L, Elias V, Terry RF, Alger J, Becerra-Posada F. Comparison of national health research priority-setting methods and characteristics in Latin America and the Caribbean, 2002-2012. Rev Panam Salud Publica. 2013;34(1):1–13. 26. Viergever RF, Terry R, Matsoso M. Health research prioritization at WHO: an overview of methodology and high level analysis of WHO led health research priority setting exercises. Geneva: World Health Organization; 2010 (http://www.who.int/rpc/publications/Health_research_prioritization_at_WHO.pdf, accessed 2 March 2018). 27. Varkevisser CM, Pathmanathan I, Brownlee AT. Designing and conducting health systems research projects. Ottawa: Interna- tional Development Research Centre; 1993. 28. Essential national health research in South Africa. Towards national consensus building in health research. The Council on Health Research for Development (http://www.cohred.org/downloads/669.pdf, accessed 14 February 2018). 29. Rudan I, Gibson J, Kapiriri L, Lansang MA, Hyder AA, Lawn J, et al. Setting priorities in global child health research investments: assessment of principles and practice. Croat Med J. 2007;48(5):595. 30. Abachizadeh K, Mohagheghi M-A, Mosavi-Jarrahi A. Setting research priorities to reduce burden of cancer in Iran: an institutional experience. Asian Pac J Cancer Prev. 2011;12:2365–70. 31. Emami R TF, Nabipour I, Azizi F, Zafarmand MH, Nakhaei K. Community health needs assessment to develop higher priorities for research using focus group discussion in Bushehr. Iran South Med J. 2003;2:176–80. 32. Aminoroala M, Attari A., Hasanzadeh A‎. [Research priorities in behavioral sciences from the viewpoint of mental health professionals in Isfahan]. Iran J Psychiatry Clin Psychol. 2010;16(2):127–34 (in Persian). http://ijpcp.iums.ac.ir/article-1-1044-en.pdf 33. Kolahi AA, Tahmooreszadeh S, Gachkar L, Mardani M. Research priority setting of Shaheed Beheshti Medical University Infec- tious Diseases and Tropical Medicine Research Center in 2007. Iran J Clin Infect Dis. 2008;3(2):79–87. http://journals.sbmu.ac.ir/ infectiousinvisible/article/view/195/140 34. Majidpour A, Adalatkhah H, Sezavar S, Aminisani N, Shabani M, Nemati A. Research priorities in health field in Ardabil Prov- ince: an experience. J Ardabil Univ Med Sci. 2003;3(3):7–22. 35. Owlia P, Bahreini FS, Baradaran Eftekhar M, Ghanei M, Farahani M. Health research priority setting in Iran. J Sch Public Health Inst Public Health Res. 2011;9(2):9–20. 36. Kolahi AA, Moatamedi MR, Beyranvand MR, Farsar AR, Gachkar L. [Research priority of cardiovascular research center of Shahid Beheshti University of Medical Sciences in 2009]. Pajoohandeh J. 2011;16(4):178–86 (in Persian). https://pajoohande.sbmu. ac.ir/article-1-1184-en.pdf 37. Sohrabi M-R, Tahmoreszadeh S, Mohammadi F, Kolahi A-A. Research priority setting for Social Determinants of Health Research Center of Shahid Beheshti University of Medical Sciences in 2013. Community Health (Bristol). 2015;1(1):32–44. 38. Hakimzadeh SM, Shokouh H, Morteza S, Bahadori M, Tahernezhad K. Research needs assessment and priority setting for health economics: a mixed method study in Iran. Journal Mil Med. 2014;16(1):23–8. 39. Bahadori MK. Determining the research needs of social insurer: using analytical hierarchy ‎process (AHP)‎. Holistic Nurs Mid- wifery. 2012;22(2):11–7. 40. Khadivi R, Raeesi R, Habibi S, Ghaderi S, Shirvani H, Yousefi H, et al. [Capacity building for priority setting in Farrokhshahr population]. J Shahrekord Univ Med Sci. 2006;8(1):27–45 (in Persian). http://journal.skums.ac.ir/article-1-693-en.pdf 41. Ravaghi H SH. Research priorities for patient safety in Iran. Hakim Res J. 2014;16(4):358-66. 42. Nemati SAF, Heidarzadeh A, Saberi A, Bahadouri M, Haddadi S‎. Priorities of medical education research based on Delphi method in medical school of Guilan University ‎of Medical Sciences.‎. Hakim Res J. 2013;16(4):358–66. 43. Damari B, A H, Pourreza A. Need assessment and research priority setting of social security organization deputy of health affair. Tamin (Soc Sec Q). 2006;1(8):219–46. 44. Zargham N. [Research priorities of biotechnology commission]. Rahyaft J. 1381(27):46–56 (in Persian). 45. Yazdankhah Fard MR, Kamalli F, Sharifi S, Motamed N, Hajinejad f. Determining nursing research priorities according to view- points of nurses in Bushehr City using Delphi technique. Iran South Med J. 2008;10(2):182–9. 46. Farsar A-R, Khaleghnejad-Tabari A, Sadeghian N, Roozroukh M, Sohrabi M-R, Monfared AB, et al. Research priority setting for Pediatric Surgery Research Center of Shahid Beheshti University of Medical Sciences in 2010. Pajoohandeh J. 2013;18(3):139–47. 47. Hatmi Z, Mohammadi N, Sedaghat M. Determination research priorities in the medical faculty departments. Tehran Univ Med J. 2006;63(11):913–9. 48. Tootoonchi M, Yamani N, Changiz T, Yousefy A. Research priorities in medical education: a national study. J Res Med Sci. 2012 Jan;17(1):83–91. PMID:23248661 49. Kolahi A-A, Sohrabi M-R, Abdollahi M, Soori H. Setting research priority in Shahid Beheshti University of Medical Sciences: methods, challenges, limitations. Pajoohandeh J. 2010;15(4):143–51. 50. Raeisi R, Yosofi, Habibi S, Shirvani H, Ghaderi S, Shams F, et al. [Need assessment in Research Development and Health Promo- tion Center of Farrokhshahr in 2004]. J Shahrekord Univ Med Sci. 2006;8(1):1–6 (in Persian). http://journal.skums.ac.ir/article-1-

768

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 768 10/10/2018 12:44:07 PM Research article EMHJ – Vol. 24 No. 8 – 2018

690-en.pdf 51. Yasini M, Mozaffari-Khosravi H. Health problems and research priorities based on the needs assessment in Yazd. J Toloo-e-beh- dasht. 2006;3/4(2):10–9. 52. Majidi A, Ghiasvand R, Hadji M, Nahvijou A, Mousavi A-S, Pakgohar M, et al. Priority setting for improvement of cervical cancer prevention in Iran. Int J Health Policy Manag. 2015;5(4):225–32. https://doi.org/10.15171/ijhpm.2015.201 53. Bahadori M, Izadi M, Karamali M, Teymourzadeh E, Yaghoubi M. Research priorities in a military health organization using multi criteria decision making techniques. Journal Mil Med. 2014;16(1):37–44. 54. Haghdoost A, Sadeghi M, Nasirian M, Mirzazadeh A, Navadeh S. Research priorities in the field of HIV and AIDS in Iran. J Res Med Sci. 2012;17(5):481. 55. Khambeh-bini Z, Kazemi S, Keshtkar A, Khoddam H. Identification of health research areas in Golestan province. Faraz Res Q Stud Res Committee. 2000;11:17–21. 56. Kolahi AA, Zahraei M, Abdi P, Gachkar L. Research priorities of network of infectious and tropical disease of Iran in 2009. Iran J Infect Dis Trop Med. 2010 Fall;15(50):9–18. 57. Tavana AM, Hatamlo H, Teymourzadeh E, Ebrahimnia M, Tofighi S, Bahadori M, et al. Determining research priorities based on four main areas: stewardship, creating resources, financing and delivering services in health care system in Iran. J Health Policy Sustainable Health. 2015 Winter;2(1):179–81. http://journals.bmsu.ac.ir/jhpsh/index.php/jhpsh/article/view/45/pdf_10 58. Ghanbari KA, Baghalee M. [Nurses’ perspectives of nursing research priorities about cancer patients]. Iran J Nurs. 2009 Apr;22(57):87–97 (in Persian). http://ijn.iums.ac.ir/article-1-614-en.pdf 59. Owlia P, Eftekhari MB, Forouzan AS, Bahreini F, Ghanei M, Farahani M. Health research priority setting in Iran: introduction to a bottom up approach. J Res Med Sci. 2011 May;16(5):691–8. PMID:22091294

769

07- Systematic review of priority setting studies in health research in the Islamic Republic of Iran.indd 769 10/10/2018 12:44:07 PM Review EMHJ – Vol. 24 No. 8 – 2018

Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression

Kamal Gholipour,1,2 Mohammad Asghari-Jafarabadi,3,4 Shabnam Iezadi,5 Ali Jannati1,2 and Sina Keshavarz 6

1Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 2Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 3Road Traffic Injury Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Is- lamic Republic of Iran. 4Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 5Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran (Correspondence to: S. Iezadi: [email protected]). 6Public Health and Preventive Medicine, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran.

Abstract Background: Type 2 diabetes mellitus (T2DM) is a metabolic disease with complex causes, manifestations, complications and management. Understanding the wide range of risk factors for T2DM can facilitate diagnosis, proper classification and cost-effective management of the disease. Aims: To compare the power of an artificial neural network (ANN) and logistic regression in identifying T2DM risk factors. Methods: This descriptive and analytical study was conducted in 2013. The study samples were all residents aged 15–64 years of rural and urban areas in East Azerbaijan, Islamic Republic of Iran, who consented to participate (n = 990). The latest data available were collected from the Noncommunicable Disease Surveillance System of East Azerbaijan Province (2007). Data were analysed using SPSS version 19. Results: Based on multiple logistic regression, age, family history of T2DM and residence were the most important risk factors for T2DM. Based on ANN, age, body mass index and current smoking were most important. To test for generalization, ANN and logistic regression were evaluated using the area under the receiver operating characteristic curve (AUC). The AUC was 0.726 (SE = 0.025) and 0.717 (SE = 0.026) for logistic regression and ANN, respectively (P < 0.001). Conclusions: The logistic regression model is better than ANN and it is clinically more comprehensible. Keywords: artificial neural network, diabetes mellitus, multiple regression, risk factors. Citation: Gholipour K; Asghari-Jafarabadi M; Iezadi S; Jannati A; Keshavarz S. Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression. East Mediterr Health J. 2018;24(8):770–777. https://doi.org/10.26719/emhj.18.012 Received: 08/09/15; accepted: 12/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction prevented or delayed by lifestyle changes in high-risk individuals (2,6). Therefore, identifying such risk factors Type 2 diabetes mellitus (T2DM) is a complex metabolic using the right models is the first stage in successful disease with complex causes, manifestations, complica- intervention. tions and management (1,2). The chronic complications of Logistic regression is an efficient and powerful T2DM include accelerated development of cardiovascular tool to assess independent variable contributions to a disease, end-stage renal failure, blindness and lower limb binary outcome and it is used to analyse the relationship amputations, which can result in excess morbidity and between 1 or more predictors and a dichotomous outcome mortality (3). These chronic complications not only have a (8–10). Simultaneous analysis of multiple explanatory major impact on patients and their families but also con- variables and reducing the effect of confounding sume an increasing share of health system resources (4). factors are some important advantages of logistic Three hundred and forty-seven million people worldwide regression (9). However, its accuracy strongly depends suffer from this serious and costly disease. Diabetes now on careful variable selection with satisfaction of basic affects both high- and low-income countries but > 80% assumptions, as well as appropriate choice of model- of people with diabetes live in low- and middle-income building strategy and validation of results (10). Important countries (5). However, based on World Health Organiza- considerations when conducting logistic regression tion (WHO) reports, diabetes mortality will have doubled include adopting independent variables, ensuring that between 2005 and 2030 and the prevalence of T2DM is relevant assumptions are met, and selection of the right increasing worldwide (3,5,6). modelling strategy (10). Logistic regression can be used Understanding the wide range of risk factors for to study the factors that predict improvement after an T2DM can facilitate diagnosis, proper classification and intervention (8). cost-effective management of the disease (6,7). Recent An artificial neural network (ANN) is a nonlinear, intervention studies have indicated that T2DM can be computational and complex mathematical model that is

770

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 770 10/10/2018 12:45:04 PM Review EMHJ – Vol. 24 No. 8 – 2018

constructed to simulate processes of the central nervous considered if fasting plasma glucose (FPG) level was ≥ system of higher animals, distantly based on the human 126 mg/dl. Impaired fasting glucose was defined by FPG neuronal structure (11–15). ANNs represents a new method ≥ 100 mg/dl (5.6 mmol/l) but < 126 mg/dl (7.0 mmol/l). for predictive modelling in medical sciences and they are At the first stage, during a home visit, health centre useful to predict complex, nonlinear and time-dependent staff collected information about sociodemographic, relationships. ANNs also can be used when the measures lifestyle and health status through interview. A structured influencing an event are not completely known 14( ,15). In questionnaire (18) was used to explore demographic and contrast with traditional statistical techniques, ANNs are ecological characteristics of participants, nutritional capable of automatically resolving these relationships status, diabetes risk factors such as high blood pressure without the need for a priori assumptions about the and family history of T2DM, and patients’ physical nature of the interactions between variables. ANNs use activities, based on WHO guidelines. data to model and find relationships between factors Anthropometric measurements were conducted by (11). Another important difference in comparison with proficient and skilled healthcare staff of Tabriz University traditional statistical methods such as logistic regression of Medical Sciences, Tabriz, Islamic Republic of Iran. is the learning ability of an ANN. A trained network has Body height and weight were measured using a portable pooled regulations that are represented by the matrix electronic weighing scale and portable height-measuring of the weights between the neurons. This characteristic instrument. Participants were asked to remove their allows the ANN to forecast cases that have never shoes and any bulky clothing. Waist circumference been presented to the network before and it is called was measured at the midpoint between the lower part generalization (16). of the lowest rib, and blood pressure was measured When predicting and prioritizing risk factors of with a calibrated sphygmomanometer. The average of 3 T2DM, it is questionable which one of these models measurements, with a mean time of 5 minutes, was used is better. To respond to this question, we compared the for analysis. Finally, blood samples (10 ml from every power of these 2 models in terms of sensitivity, specificity participant) were collected in 4 tubes and centrifuged and accuracy. For this purpose, we used receiver immediately for measurement of FPG (≥ 126 mg/dl), total operating characteristic (ROC) analysis, which included cholesterol (TC), high-density lipoprotein cholesterol sensitivity, specificity and accuracy of models to indicate and triglycerides. A cold chain was preserved while the predictive power of models. The ROC curve is a transferring blood samples to the Central Reference graphical plot that illustrates the performance of a binary Laboratory in Tabriz. classifier system as its discrimination threshold is varied ANN modelling and logistic regression were used to (17). In this study, we investigated the power of logistic analyse the data. Variables associated with T2DM in the regression and ANNs to identify T2DM risk factors and univariate analysis were included in multiple logistic compared them to establish which one was better. regression models. The P values for entry and removal of Methods variables in the logistic regression model were 0.05 and 0.1, respectively. The significant variables in univariate This descriptive and analytical study was conducted in analyses along with confirmatory factors were used 2013 to determine the risk factors for T2DM using 2 sep- to calculate the individual T2DM risk with the ANN. arate statistical methods. The study sample comprised Uncontrolled hypertension, gender and raised TC > 200 all residents aged 15–64 years of rural and urban areas of mg/dl were considered as confirmatory factors. The East Azerbaijan Province, Islamic Republic of Iran who variable importance in the logistic regression analysis were willing to participate. We used a clustered rand- was calculated based on standardized coefficient (Wald). omized sampling method. The data were divided into a training set (67.1%) and test Neighbourhoods and parishes were considered as set (32.9%). Automatic architecture selection was used to clusters. In urban settings, a cluster contained 1 or more determine hidden layers. One hidden layer with 7 units or parts of a neighbourhood. In rural settings, a cluster was determined. A scaled conjugate gradient option was contained 1 or more or parts of a village. Cluster heads used to optimize the algorithm. Modelling was continued were selected based on the last digit of the postal code. until the relative error of testing was less than that of Each cluster had 20 individuals; 10 males and 10 females training. Description and diagram network structures living in neighbouring households. From each cluster, we were used as the network structure. selected 2 men and 2 women from each age group (15–24, We compared the importance of T2DM predictors 25–34, 35–44, 45–54 and 55–64 years). Every individual in revealed by logistic regression and ANN. For the ANN each cluster was selected randomly based on the postal and logistic regression models, the area under the ROC address. We included the nearest right side neighbours to curve (AUC) was calculated in the test set. ROC curve the cluster heads, who were eligible based on age group. is a technique for visualizing, organizing and selecting Participants gave full informed consent after the study possibly optimal models based on their performance. objectives and process were explained. Ethical approval This technique illustrates the performance of a binary was obtained from the Center for Disease Control of Iran. classifier by considering sensitivity, specificity and T2DM was defined as having a diagnosis or receiving accuracy of models (17). Data were analysed using SPSS a prescription for antidiabetic drugs. New T2DM was version 19 (IBM Corp., Armonk, NY, USA). P < 0.05 was

771

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 771 10/10/2018 12:45:04 PM Review EMHJ – Vol. 24 No. 8 – 2018

considered to be statistically significant. Table 1 Importance of independent variables (artificial neural network) Results Parameter Importance Normalized We used data from 990 participants to identify the T2DM importance risk factors using 2 separate methods of logistic regres- (0–100) sion and ANN. Selected risk factors were prioritized and Age 0.34 100.0% the 2 methods were compared to determine how they dif- BMI 0.17 51.8% fered. Table 1 shows the importance of T2DM predictors Current smoking 0.13 38.3% according to their priority using the ANN method. Age Residence 0.09 26.0% had the highest score of 0.34, which means that age can predict 34% of T2DM. Raised TC had the lowest score of Controlled HTN 0.08 23.2% 0.02. Figure 1 shows the sequence of predictors based on Uncontrolled HTN 0.08 22.6% their importance. Family history of DM 0.06 17.8% In multiple logistic regression, after adjusting for Sex 0.04 11.9% other factors, there was a significant association between Raised TC > 200 mg/dl 0.02 5.7% T2DM and age [odds ratio (OR): 1.05, 95% confidence BMI = body mass index; DM = diabetes mellitus; HTN = hypertension; TC = total interval (CI): 1.03–1.08; P < 0.001). People living in urban cholesterol.

Figure 1 Artificial neural network diagram of relationship between selected risk factors and having had type 2 diabetes mellitus

Bias

Residence = 0

Residence = 1

Sex = 1

Sex = 2 Bias Family History of DM= 1 H (1:1) Family History of DM= 1 H (1:2) Uncontrolled HTN = 0 H (1:3) Diabetes = 0 Uncontrolled HTN = 1 H (1:4) Diabetes = 1 Raised Total Cholesterol < 200=0 H (1:5) Raised Total Cholesterol < 200=1 H (1:6)

Smoke = 1 H (1:7)

Smoke = 2

Controlled HTN = 0

Controlled HTN = 1

Age

BMI

Hidden layer activation function: Hyperbolic tangent

772

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 772 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

compared with rural areas were more likely to develop factors were not significant. T2DM (OR: 2.06, 95% CI: 1.26–3.37; P = 0.004). According To test the generalization of the results, we evaluated to the association between having T2DM and a positive ANN and logistic regression in the test set using AUC family history of the disease (OR: 2.56, 95% CI: 1.52–4.31; values (Table 4). The AUC values were 0.726 (standard P < 0.001), people with a diabetes patient in their family error 0.025) and 0.717 (standard error 0.026) for logistic had greater odds of developing the disease (Table 2). regression and the ANN, respectively. So, the ability of Considering the results of univariate and multiple the logistic regression model to predict those with and logistic regression, age, positive family history of T2DM without T2DM was significantly greater than that of the and residence, by adjusting for body mass index (BMI), ANN model (P < 0.001). gender, uncontrolled hypertension, raised TC, controlled hypertension and current smoking were significant and Discussion independent risk factors of T2DM (Tables 2 and 3). Comparison of the power of an ANN and logistic regres- We compared the importance of predictors of T2DM sion indicated that the latter is a statistically better pre- based on ANN and logistic regression modelling. For dictor. In both methods, age was predicted as the most ANN, age, BMI and current smoking were the 3 most important risk factor in East Azerbaijan Province. There- important predictors of T2DM, followed by residence, fore, we suggest paying attention to aged people in the controlled hypertension, uncontrolled hypertension, diagnosis and management of T2DM. According to the family history of T2DM, gender and raised TC (> 200 mg/ results of both models together, people who smoke or live dl). The estimated errors of testing and training were 11% and 15%, respectively, so the goodness of the model was in rural areas and those with a family history of T2DM confirmed. For logistic regression modelling, age, family are more at risk of developing T2DM. Also, the risk may history of T2DM and residence were the most important increase with BMI. predictors of T2DM, followed by current smoking, Logistic regression is easier than ANN to apply and controlled hypertension, uncontrolled hypertension, understand. In contrast, ANN can be applied without BMI, raised TC (> 200 mg/dl) and gender. The latter 5 assumptions used in logistic regression (such as residual

Table 2 Univariate logistic regression analysis for association between selected risk factors and having had DM Parameter DM yes (+) Univariate logistic regression n N (%) OR (95% CI) P value Age 1.04 (1.02–1.06) < 0.001 BMI 990 105 (10.6) 1.05 (1.01–1.10) 0.018 Gender Female 496 48 (9.67) 1 0.230 Male 494 57 (11.54) 0.77 (0.51–1.18) Residence Urban 593 75 (12.65) 2.21 (1.40–3.47) 0.001 Rurala 397 30 (7.56) 1 Uncontrolled HTN Yes 98 18 (18.4) 1.29 (0.74–2.25) 0.376 Noa 585 87 (14.9) 1 Raised TC >200 mg/dl Yes 205 36 (17.56) 1.37 (0.87–2.13) 0.169 Noa 476 64 (13.44) 1 Positive family history of DM Yes 160 34 (21.25) 2.67 (1.67–4.26) < 0.001 Noa 830 71 (8.55) 1 Controlled HTN Yes 150 30 (20.0) 1.94 (1.20–3.11) 0.006 Noa 840 75 (8.93) 1 Current smoking Yes 160 22 (13.75) 1.60 (0.95–2.72) 0.076 Noa 830 83 (10.0) 1

aReference category. BMI = body mass index; CI = confidence interval; DM = diabetes mellitus; HTN = hypertension; OR = odds ratio; TC = total cholesterol.

773

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 773 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

Table 3 Multiple logistic regression analysis for association between risk factors and having had DM Parameter Multiple logistic regression OR (95% CI) β coefficient P value Age 1.05 (1.03–1.08) 20.66 < 0.001 BMI 1.04 (0.98–1.09) 1.88 0.170 Gender Female 0.90 (0.53–1.54) 0.136 0.712 Male 1 Residence Urban 2.06 (1.26–3.37) 7.10 0.004 Rurala 1 Uncontrolled HTN Yes 0.54 (0.25–1.14) 2.62 0.105 Noa 1 Raised TC >200 mg/dl Yes 1.33 (0.82–2.16) 1.37 0.242 Noa 1 Positive family history of DM Yes 2.56 (1.52–4.31) 12.48 < 0.001 Noa 1 Controlled HTN Yes 1.87 (0.99–3.54) 3.70 0.054 Noa 1 Current smoking Yes 2.05 (1.06–3.96) 4.51 0.034 Noa 1

aReference category. The Hosmer–Lemeshow goodness-of-fit test:χ 2= 14.17, degrees of freedom = 8, significance = 0.077. BMI = body mass index; CI = confidence interval; DM = diabetes mellitus; HTN = hypertension; OR = odds ratio; TC = total cholesterol.

normality, homogeneity of residual variances, residual (e.g., t test and regression), and it is better explored in this independence and collinearity). Several studies have context than newer data analysis procedures (e.g., neural shown that ANN models have several advantages over nets) (8). conventional statistical methods (19,20). Such models It should be noted that due to the simplicity of can rapidly recognize linear patterns, categorical and interpretation of the variables in the logistic regression stepwise linear patterns, nonlinear patterns with model, applying it clinically is more comprehensible. threshold impacts, and contingency effects. ANN Rahman et al. compared the accuracy of ANN and binary analyses do not need to be started with a hypothesis or logistic regression models for predicting glucose status preselected key variables. Therefore, undocumented or (21). They showed a significantly better performance of quantified potential predictors may be specified if they ANN for detection of impaired glucose tolerance and already exist in the various datasets, although they may T2DM patients from disease-free ones (21). Omurlu et al. have been neglected in the past (19,20). Logistic regression compared performance of logistic regression and ANN as a recognized approach is able to predict clinically for prediction of albuminuria in T2DM and demonstrated relevant dichotomous outcomes. It has some advantages that multilayer perceptron had the highest predictive over more traditional approaches to analyse such data capability for the presence of albuminuria (22). Zandkarim

Table 4 Comparison of logistic regression and ANN by area under the ROC curve Models Sensitivity Specificity Accuracy Area SE Asymptotic Asymptotic 95% CI significance Lower Upper boundary boundary ANN 3.9% 99.5% 83.9% 0.717 0.026 < 0.001 0.666 0.768 Logistic regression 7.1% 99.1% 85.4 0.726 0.025 < 0.001 0.676 0.776

ANN = artificial neural network; CI = confidence interval; ROC = receiver operating characteristic; SE = standard error.

774

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 774 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

et al. suggested that logistic regression was more powerful the small sample size. The second was that a glucose than discriminant analysis for distinguishing T2DM and tolerance test was not done and a single FPG test was prediabetes (23). In communities where there is high used. Nevertheless, our study had some strengths, such dependency among case and control groups, recognizing as inclusion of broad age groups, and it is believed to be the differences needs stronger methods. Kazemnejad the first study to compare 2 models in identifying and et al. demonstrated that there was no performance prioritizing T2DM risk factors in the Islamic Republic of difference between models based on logistic regression Iran. and ANN in differentiating impaired glucose tolerance and diabetes patients from disease-free patients (24). Conclusion Zandkarim and Safavi recommended ANNs for medical Comparison of the power of ANN and logistic regression research in comparison to logistic regression (25). models indicated that the latter is better than ANN and is clinically more comprehensible. Logistic regression can The present study suggests that statistical analysis provide coefficients such as probability ratio to express of the importance of T2DM risk factors differs using 2 the impact of each independent variable on the model and separate models; however, age was the most important it is better to be used in medicine. However, we should predictor in both models. Raised TC and sex had less bear in mind that ANNs can easily be used and analysed. importance in comparison with other risk factors. Rezaei It is possible to enter a large number of variables into an et al. showed that age, FPG, BMI and mobility variables in ANN and there is no need for assumptions such as nor- their logistic regression model were significant, and FPG, mality. Thus, if there is no assumption, we recommend glucose tolerance, BMI and mobility variables indicated using an ANN model. Our results also showed that age, the highest predictive power in the neural network model BMI, family history of T2DM, current smoking and resi- (26). A national survey in 2009 in the Islamic Republic of dence are the most important predictors of T2DM in East Iran showed that sex, age and residence were significant Azerbaijan Province. A comprehensive programme of di- predictors of diabetes (27). Logistic regression analysis agnosis and management of T2DM, as well as providing in a survey in Qatar showed that smoking and family consultation for high-risk individuals, which is based on history of DM had a significant association with DM (28). prioritizing people, can be an appropriate initiative to de- Our study had 2 major limitations. The first was crease the prevalence of T2DM in East Azerbaijan.

Acknowledgements We would like to acknowledge the co-operation of health centre staff, in East Azerbaijan Province. Funding: Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. Competing interests: None declared.

Modélisation de la prévalence des facteurs de risque du diabète sucré sur la base d’un réseau de neurones artificiels et d’une régression multiple Résumé Contexte : Le diabète sucré de type 2 est une maladie métabolique dont les causes, les manifestations, les complications et la prise en charge sont complexes. La compréhension de la vaste palette de facteurs de risque de ce type de diabète peut faciliter le diagnostic, l’établissement de la classification et améliorer la prise en charge de la maladie avec un bon rapport coût-efficacité. Objectif : Comparer la performance d’un réseau de neurones artificiels (RNA) et de la régression logistique dans l’identification des facteurs de risque du diabète sucré de type 2. Méthodes : La présente étude descriptive et analytique a été menée en 2013. Tous les sujets de l’étude résidaient dans des zones urbaines ou rurales de la partie orientale de l’Azerbaïdjan et de la République islamique d’Iran ; ils avaient entre 15 et 64 ans et tous avaient consenti à participer à l’étude (n = 990). Les données les plus récentes ont été recueillies par l’intermédiaire du Système de surveillance des maladies non transmissibles de la Province orientale de l’Azerbaïdjan (2007). Elles ont été analysées à l’aide du logiciel SPSS (version 19). Résultats : Pour la régression logistique, l’âge, les antécédents familiaux de diabète sucré de type 2 et le lieu de résidence se sont avérés être les facteurs de risque les plus importants. En ce qui concerne le RNA, l’âge, l’indice de masse corporelle et le tabagisme étaient les facteurs de risque de diabète sucré de type 2 les plus importants. Afin d’établir un test servant de base à une généralisation, le RNA et la régression logistique ont été évalués en utilisant la zone située sous la courbe ROC (caractéristique du fonctionnement du récepteur). La ROC était à 0,726 (erreur-type= 0,025) et 0,717 (erreur- type= 0,026) pour la régression logistique et le RNA respectivement (p < 0,001). Conclusion : Le modèle de régression logistique est meilleur que celui du RNA et cliniquement plus compréhensible.

775

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 775 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

إعداد نامذج ملعدالت انتشار عوامل اخلطر لإلصابة بالسكري ًاستنادا إىل شبكة عصبية اصطناعية وإىل َّالت َح ُّ فو املتعدد کامل قلی پور؛ حممد اصغری جعفرآبادی؛ شبنم. ایزدی؛ علی. جنتی؛ سینا کشاورز اخلالصة اخللفية: يعترب السكري من النمط 2 من أمراض التمثيل الغذائي )أييض( وأسبابه ومظاهره ومضاعفاته وتدبريه العالجي تتسم بأهنا معقدة. ويمكن لفهم املجموعة الواسعة من عوامل اخلطر لإلصابة بالسكري من النمط 2 أن ُي َس ِّهل تشخيص املرض والتصنيف املناسب والتدبري العالجي العايل اجلدوى مقابل التكلفة. اهلدف: مقارنة قوة شبكة عصبية اصطناعية َّبالت َح ُّوف اللوجستي يف حتديد عوامل خطر اإلصابة بالسكري من النمط 2. طرق البحث: أجريت هذه الدراسة الوصفية والتحليلية يف عام 2013. ولقد ضمت عينة الدراسة مجيع َم ْن السكان الذين ترتاوح أعامرهم بني 15 و 64سنة يف املناطق الريفية واحلرضية يف أذربيجان الرشقية، مجهورية إيران اإلسالمية، والذين أخذنا موافقتهم عىل املشاركة يف الدراسة )وعددهم 990(. وقد مجعنا أحدث البيانات املتاحة من نظام ُّترصد األمراض غري السارية يف مقاطعة أذربيجان الرشقية )2007(. كام قمنا بتحليل البيانات باستخدام نظام SPSS، اإلصدار 19. النتائج: ً استناداإىل َّالت َح ُّوف اللوجستي املتعدد، اتضح أن عوامل اخلطر األكثر أمهية يف اإلصابة بالسكري من النمط 2 هي العمر والتاريخ العائيل لإلصابة بالسكري من النمط 2 ومكان السكن. بينام اتضح ًاستنادا إىل شبكة عصبية اصطناعية أن العمر ومنسب كتلة اجلسم والتدخني احلايل هي عوامل اخلطر األكثر أمهية. ومن أجل اختبار التعميم، َق َّيمنا الشبكة العصبية االصطناعية َّوالت َح ُّوف اللوجستي باستخدام املنطقة الواقعة حتت املنحنى املميز ُللم َت َق ِّبل العامل SE SE SE فوجدنا أنه كان 0.726 ) = 0.025(، يف َّالت َح ُّوف اللوجستي = 0.025(( وأنه كان = 0.026(( 0.717يف الشبكة العصبية االصطناعية SE = 0.026((، وكان )p > 0.001(. االستنتاج: إن نموذج َّالت َح ُّوف اللوجستي أفضل من نموذج الشبكة العصبية االصطناعية، وهو أكثر قابلية للفهم رسيري ًا.

References 1. Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J Diabetes. 2013 Dec 15;4(6):270–81. https://doi.org/10.4239/ wjd.v4.i6.270 PMID:24379917 2. Narayan KMV, Benjamin E, Gregg EW, Norris SL, Engelgau MM. Diabetes translation research: where are we and where do we want to be? Ann Intern Med. 2004 Jun 1;140(11):958–63. https://doi.org/10.7326/0003-4819-140-11-200406010-00037 PMID:15172921 3. Kahn R; American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000 Mar;23(3):381–9. https://doi.org/10.2337/diacare.23.3.381 PMID:10868870 4. Dyck R, Karunanayake C, Pahwa P, Hagel L, Lawson J, Rennie D, et al.; Saskatchewan Rural Health Study Group. Prevalence, risk factors and co-morbidities of diabetes among adults in rural Saskatchewan: the influence of farm residence and agriculture-related exposures. BMC Public Health. 2013 01 5;13(7):7. https://doi.org/10.1186/1471-2458-13-7 PMID:23289729 5. Screening for type 2 diabetes. Report of a World Health Organization and International Diabetes Federation meeting. Geneva: Department of Noncommunicable Disease Management, World Health Organization; 2003 (http://www.who.int/diabetes/publications/en/screening_mnc03.pdf, accessed 6 February 2018). 6. Lindström J, Tuomilehto J. The diabetes risk score: a practical tool to predict type 2 diabetes risk. Diabetes Care. 2003 Mar;26(3):725–31. https://doi.org/10.2337/diacare.26.3.725 PMID:12610029 7. Copeland KC, Becker D, Gottschalk M, Hale D. Type 2 diabetes in children and adolescents: risk factors, diagnosis, and treatment. Clin Diabetes. 2005;23(4):181–5. https://doi.org/10.2337/diaclin.23.4.181 8. Reed P, Wu Y. Logistic regression for risk factor modelling in stuttering research. J Fluency Disord. 2013 Jun;38(2):88–101. https:// doi.org/10.1016/j.jfludis.2012.09.003 PMID:23773663 9. Sperandei S. Understanding logistic regression analysis. Biochem Med (Zagreb). 2014 02 15;24(1):12–8. https://doi.org/10.11613/ BM.2014.003 PMID:24627710 10. Stoltzfus JC. Logistic regression: a brief primer. Acad Emerg Med. 2011 Oct;18(10):1099–104. https://doi.org/10.1111/j.1553- 2712.2011.01185.x PMID:21996075 11. Wei JT, Zhang Z, Barnhill SD, Madyastha KR, Zhang H, Oesterling JE. Understanding artificial neural networks and exploring their potential applications for the practicing urologist. Urology. 1998;52(2):161–72. PMID:9697777 12. Agatonovic-Kustrin S, Beresford R. Basic concepts of artificial neural network (ANN) modeling and its application in pharmaceutical research. J Pharm Biomed Anal. 2000 Jun;22(5):717–27. https://doi.org/10.1016/S0731-7085(99)00272-1 PMID:10815714 13. Rodvold DM, McLeod DG, Brandt JM, Snow PB, Murphy GP. Introduction to artificial neural networks for physicians: taking the lid off the black box. Prostate. 2001 Jan 1;46(1):39–44. https://doi.org/10.1002/1097-0045(200101)46:1<39::AID-PROS1006>3.0.CO;2-M PMID:11170130

776

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 776 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

14. Traeger M1 EA, Geldner G, Morin AM, Putzke C, Wulf H, Eberhart LH. Artificial neural networks. Theory and applications in anesthesia, intensive care and emergency medicine. Anaesthesist. 2003 52(11):1055–61. 15. Gamito EJ, Crawford ED. Artificial neural networks for predictive modeling in prostate cancer. Curr Oncol Rep. 2004 May;6(3):216–21. https://doi.org/10.1007/s11912-004-0052-z PMID:15066233 16. Traeger M, Eberhart A, Geldner G, Morin A, Putzke C, Wulf H, et al. Artificial neural networks. Theory and applications in anesthesia, intensive care and emergency medicine. Anaesthesist. 2003;52(11):1055-61. 17. Fawcett T. An introduction to ROC analysis. Pattern Recognit Lett. 2006;27(8):861–74. https://doi.org/10.1016/j.patrec.2005.10.010 18. Bonita R, Winkelmann R, Douglas KA, de Courten M. The WHO stepwise approach to surveillance (steps) of non-communicable disease risk factors. In: McQueen DV, Puska P, editors. Global behavioral risk factor surveillance. Boston: Springer; 2003:9–22. 19. Zhu L, Luo W, Su M, Wei H, Wei J, Zhang X, et al. Comparison between artificial neural network and Cox regression model in predicting the survival rate of gastric cancer patients. Biomed Rep. 2013 Sep;1(5):757–60. https://doi.org/10.3892/br.2013.140 PMID:24649024 20. Levine RF. Clinical problems, computational solutions: a vision for a collaborative future. Cancer. 2001 Apr 15;91(8 Sup- pl):1595–602. https://doi.org/10.1002/1097-0142(20010415)91:8+<1595::AID-CNCR1172>3.0.CO;2-P PMID:11309757 21. Rahman A, Nesha K, Akter M, Uddin SG. Application of artificial neural network and binary logistic regression in detection of diabetes status. Sci J Public Health. 2013;1(1):39–43. https://doi.org/10.11648/j.sjph.20130101.16 22. Omurlua IK, Tureb M, Unubolc M, Katrancid M, Guney E. Comparing performances of logistic regression, classification & regression trees and artificial neural networks for predicting albuminuria in type 2 diabetes mellitus. Int J Sci Basic Appl Res. 2014;16(1):173–87. 23. Zandkarimi E, Safavi AA, Rezaei M, Rajabi G. References comparison logistic regression and discriminant analysis in identifying the determinants of type 2 diabetes among prediabetes of Kermanshah rural areas. J Kermanshah Univ Med Sci. 2013;17(5):300– 8. 24. Kazemnejad A, Batvandi Z, Faradmal J. Comparison of artificial neural network and binary logistic regression for determination of impaired glucose tolerance/diabetes. East Mediterr Health J. 2010 Jun;16(6):615–20. PMID:20799588 25. Zandkarim EI, Safavi AA. Comparison of artificial neural network predictive power with multiple logistic regressions to determine patients with and without diabetic retinopathy. Razi J Med Sci. 2014;21(124):79–90. 26. Rezaei M. Zandkarimi e, Hashemian A. Comparison of artificial neural network, logistic regression and discriminant analysis efficiency in determining risk factors of type 2 diabetes. World Appl Sci J. 2013;23(11):1522–9. 27. Esteghamati A, Meysamie A, Khalilzadeh O, Rashidi A, Haghazali M, Asgari F, et al. Third National Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009 May 29;9:167. https://doi.org/10.1186/1471-2458-9-167 PMID:19480675 28. Bener A, Zirie M, Janahi IM, Al-Hamaq AO, Musallam M, Wareham NJ. Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar. Diabetes Res Clin Pract. 2009 Apr;84(1):99–106. https://doi. org/10.1016/j.diabres.2009.02.003 PMID:19261345

777

08- Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.indd 777 10/10/2018 12:45:05 PM Review EMHJ – Vol. 24 No. 8 – 2018

Availability and safety of blood transfusion during humanitarian emergencies

Yetmgeta Abdella,1 Rana Hajjeh 1 and Cees Th. Smit Sibinga 3

1World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Y.E. Abdella: [email protected]). 2International Quality Management (IQM) Consulting, Zuidhorn, Netherlands.

Abstract Background: Availability and safety of blood transfusion is a major concern in countries affected by humanitarian emergencies. These emergencies increase demand for blood transfusion and make its delivery challenging and complex. Nev- ertheless, there is a lack of information on emergency preparedness and response capacity of blood transfusion services and on the challenges in meeting patients’ needs. Aims: To assess availability and safety of blood transfusion during humanitarian emergencies. Methods: We searched PubMed and Index Medicus for the World Health Organization Eastern Mediterranean Region for data on availability and safety of blood transfusion during humanitarian emergencies. We also gathered information through a survey and during a regional consultation in Tunisia. Results: We found 24 publications on disaster from 5 countries in the Region and 16 publications on disaster preparedness and blood transfusion in casualties and severe trauma outside the Region. However, none dealt with availability and safety of blood transfusion during humanitarian emergencies. Armed conflicts and terrorism, flooding and earthquakes are the most frequent emergencies with 10–85% of the injured requiring blood transfusion. There are gaps in emergency preparedness and response, including human resources, transport and cold chain, supply of consumables and maintenance of equipment, power supply, and finances. Conclusions: There is a need to integrate blood transfusion services in the overall national emergency preparedness and response, and provide assistance to affected countries to address identified gaps. Recommendations for individual countries need to be tailor made, along the lines of the regional strategic framework for blood safety and availability. Keywords: blood transfusion, blood safety, armed conflicts, humanitarian emergency, preparedness Citation: Abdella Y; Hajjeh R; Smit Sibinga C. Availability and safety of blood transfusion during humanitarian emergencies. East Mediterr Health J. 2018;24(8):778–788. https://doi.org/10.26719/2018.24.8.778 Received: 16/02/17; accepted: 17/10/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction displaced people (5), which places a significant burden on the national health systems and blood transfusion service An average of 700 emergencies were reported annually programmes. Approximately 76 million people in the during the first decade of this century (1). More than 250 Region live in countries with humanitarian emergencies million people are affected by emergencies with 110 000 and > 10 million people are internally displaced (6). The deaths every year from emergencies, excluding deaths Region includes some of the most challenging countries in from conflict 2( ). During humanitarian emergencies the world with humanitarian emergencies. Public health caused by conflicts, health care is increasingly under at- is facing a lot of challenges, currently driven mainly by tack with violence against patients, health facilities and political developments. Comparison of health provision workers (3). This is a major concern and the World Health with the provision of other needs during emergencies, Organization (WHO) regularly raises this issue with such as water and food, shows that delivering health Member States and advocates appropriate measures to is challenging because health is more complex and has be taken to protect healthcare services. Damage to health several determinants, and humanitarian emergencies and health systems causes setbacks to a range of global make health a more urgent priority. health targets. Right now an unprecedented 130 million WHO has been at the forefront of the movement people are in need of aid globally, including the highest to improve blood safety and availability as mandated number of internally displaced people and the second by successive World Health Assembly Resolutions of largest number of refugees ever recorded globally (4). 1975, 2005 and 2010 and Regional Committee for the The Eastern Mediterranean Region has the largest Eastern Mediterranean Resolutions of 1987 and 2016 (7). number of high-level and protracted emergencies and A lot of progress has been made in the Region, although carries the largest burden of displaced populations many countries still face major challenges in ensuring (refugees and internally displaced people) globally. It availability, safety, quality, accessibility, affordability has almost 30 million (52%) of the worldwide 58 million and clinical efficacy of blood transfusion. Humanitarian

778

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 778 10/10/2018 12:46:13 PM Review EMHJ – Vol. 24 No. 8 – 2018

emergencies and armed conflicts have increased the Results demand for blood transfusion and made its delivery challenging and complex, requiring disaster-specific Literature review blood delivery systems and management approaches, An extensive search was done using PubMed and the as well as close coordination and cooperation among all specialized search machine of Index Medicus for the stakeholders (8). This is partly because health systems have WHO Eastern Mediterranean Region (14) for 2000–2016. been weakened as a result of armed conflict, displacement The key reference word “humanitarian emergency” did of populations, and other complex emergencies. Also, not exist in both indexes, therefore the search focused the degree of development of the health systems differs on “disaster”, “armed conflict” and “war” in combination among countries, with some being more advanced than with “blood availability”, “blood safety”, “blood supply”, others when emergencies have arisen. “blood procurement”, “blood processing” and “blood The WHO Regional Office for the Eastern transfusion”. Publications on disaster were identified Mediterranean is actively engaged in assisting people from Afghanistan (n = 2), Egypt (n = 2), Islamic Repub- affected by humanitarian emergencies through risk lic of Iran (n = 11), Pakistan (n = 8) and Tunisia (n = 1). mitigation and robust emergency preparedness, Additionally, several international publications (n = 18) response and recovery efforts (9–11). Despite a variety of regarding disaster preparedness and blood transfusion operational challenges, the Regional Office looks forward in casualties and severe trauma due to war, armed con- to supporting the creation of a resilient national action flict, bomb blasts and civilian mass casualty events were plan for the provision of blood transfusion services in studied (15–24). However, none dealt with the questions emergencies, and using a robust monitoring framework of availability and safety of blood transfusion during hu- to improve these plans iteratively as part of the overall manitarian emergencies. There were some publications national emergency preparedness and response efforts. related to transport and accessibility of blood. The Irani- The purpose of this study was to collect available an and Pakistani publications were almost exclusively literature from the Region on availability and safety of related to natural disasters such as earthquakes (25–41), blood in humanitarian emergencies, and collect data from and bomb blasts and terrorist attacks (42,43). Some of the the Member States on the current status of availability publications provide information on administrative and organizational structures for the management of disas- and safety of blood in humanitarian emergencies to ters (25,30,31,40–45) and on health problems arising from allow gap analysis, identification of challenges, and internal population displacement (36). These describe the recommendations for improvements. managerial structure for natural disasters, with a small Methods paragraph on terrorist attacks and bomb blasts. A literature review was conducted on availability and WHO has published policies and technical guidelines safety of blood transfusion in humanitarian emergencies on emergency risk management and humanitarian using PubMed and Index Medicus for the WHO Eastern response, including the 2016 WHO Humanitarian Mediterranean Region. The search included publications Response Plan (46) and the 2016 WHO Health from countries in the Region and beyond. Information on Emergencies Programme (WHE) update documents on the status of availability and safety of blood transfusion progress and priorities (47,48). None of these documents during humanitarian emergencies in the Region was also pays attention to the problems of availability and safety collected using a survey questionnaire that was developed of blood transfusion during humanitarian emergencies in collaboration with International Quality Management and specific approaches for the management of blood Consulting, the Netherlands (12). This questionnaire was service delivery in emergencies. The 2016 Humanitarian sent to the 22 countries in the Region and covered: (1) type Response Plan describes the situation in 25 countries, of emergencies over the past 10 years; (2) current strate- of which 9 (36%) are in the Eastern Mediterranean gies to ensure availability and safety of blood transfusion Region. The WHE has classified emergencies into 4 during emergencies; (3) coordination and collaboration grades for acute crises (Table 2). There were 3 countries between countries; and (4) gaps and challenges (Table in the Region with grade 3 emergencies, 1 with a grade 1). In addition, a regional consultation on the availabili- 2 emergency, 3 with grade 1 emergencies and 6 with ty and safety of blood transfusion during humanitarian ungraded emergencies (Table 3). In 2016, WHO responded emergencies was organized in May 2016 in Tunis, Tunisia to 47 emergencies, among which, 31 were acute and 16 by the WHO Regional Office for the Eastern Mediterra- were protracted. nean in collaboration with WHO headquarters (13). The Among the international publications are 3 instructive objective of the consultation was to provide an overview manuscripts in the category “How do I …?” that might be of the status of blood transfusion service preparedness useful in the practical clinical support of blood and blood and response during humanitarian emergencies and to products during protracted humanitarian emergencies, develop recommendations to strengthen the capacity provided blood and blood products are available (49–51). of national blood transfusion services to respond to in- Survey on availability and safety of blood creased demand during humanitarian emergencies. Data entry and analysis of the survey was done using Micro- transfusion during humanitarian emergencies soft Office Excel (2010 version). The WHO Eastern Mediterranean Region comprises 21

779

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 779 10/10/2018 12:46:13 PM Review EMHJ – Vol. 24 No. 8 – 2018

Table 1 World Health Organization Eastern Mediterranean Region survey on availability and safety of blood transfusion during humanitarian emergencies 2006–2016 Type of emergency Natural – earthquake (n = 2), flooding (n = 4), drought (n = 1), landslide (n = 1), avalanche (n = 1), fire (n = 1) Human-made – terrorism (n = 10), war (including war in neighbouring countries) (n = 9), insurgency (n = 2), blockade (n = 2) These emergencies affect 20–100% of the community with estimated 10–85% of the injured requiring blood transfusion Need for blood transfusion has increased in all countries due to the humanitarian emergencies Type of emergencies has also changed over t he years – increasing conflicts and wars, explosions, acts of terrorism, refugees and population movements Emergencies affect both military personnel and civilians – women, men, children and old people. Main reasons for transfusion were: – Trauma (armed conflict) (n = 11) – Trauma (civil accident) (n = 9) – Trauma (natural disaster) (n = 1) – Obstetric (n = 6) – Surgical (regular) (n = 6) – Paediatric anaemia (e.g., malaria, thalassaemia and haemophilia) (n = 4) – Other (oncology) (n = 3) Current strategies Seven countries have a national emergency plan and strategy Potential blood donors are mobilized through: – Public media (n = 11) – Calling known donors (n = 5) – Calling family/replacement donors (n = 3) – Supply from neighbouring blood centres (n = 7) – Other (n = 1) – inter country collaboration Only in 7 countries does the plan include emergency stocks in the blood centres and hospitals – Coordinated by ministries of health, provincial health departments, and NGOs – All countries process blood and test for ABO antigens, Rhesus D antigen, HBV, HCV, HIV and syphilis before issuing except: – One country where syphilis testing is not done – Two countries issued blood with incomplete crossmatch Operational cold chain in place for transportation of blood and blood products in 9 countries Power supply during emergencies has variable reliability Coordination and collaboration Central coordinating organization is in place in 10 countries Collaboration between different blood supply organizations and between the different medical and emergency providers is limited In 8 countries, NGOs are involved in humanitarian emergency responses Only in 5 countries are NGOs involved in blood supply and transfusion (including donor mobilization) – covering 20–30% of the total supply Gaps and challenges Most common weak points in the blood supply during emergencies are: – Fragmented organization (n = 9) – Shortcomings in numbers and competence of human resources (n = 9) – Shortages in supply of consumables (n = 8) – Shortcomings in infrastructure (n = 7) – Transport and cold chain deficits (n = 7) – Financial shortage (n = 7) – Ineffective coordination (n = 6)

HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus; NGO = nongovernmental organization.

Member States and the occupied Palestinian territory Syrian Arab Republic and Tunisia responded to the (West Bank and Gaza Strip), with a population of near- survey assessing the status of availability and safety of ly 583 million people, which in 2012, according to World blood transfusion during humanitarian emergencies, Population Prospects, United Nations, New York, 2013 (52) including 10 countries (those listed, with the exception of was around 606 million. There are currently 12 countries Islamic Republic of Iran and Tunisia) currently affected suffering from humanitarian emergencies with disrup- by humanitarian emergencies. The survey response tion of infrastructure including health care, education, covers countries with a combined population of > 500 transportation and access to clean water and energy. million (84% of the population in the Region). Some of The literature review shows that information is these countries have absorbed huge numbers of refugees, lacking on the status, successes and challenges in for example, Jordan with a population of 6.6 million ensuring the availability and safety of blood transfusion Jordanians hosts 3 million refugees from Iraq, occupied during humanitarian emergencies. Afghanistan, Egypt, Palestinian territory and the Syrian Arab Republic, and Islamic Republic of Iran, Jordan, Lebanon, Libya, Lebanon with 4.5 million Lebanese hosts 1.5–2 million Pakistan, occupied Palestinian territory, Somalia, Sudan, refugees from the Syrian Arab Republic (5,53), adding a

780

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 780 10/10/2018 12:46:13 PM Review EMHJ – Vol. 24 No. 8 – 2018

considerable burden to the host health system. and provinces. Collaboration and coordination with Type of emergencies over the past 10 years and between various groups to mobilize blood donors is reported by Afghanistan, Islamic Republic of Iran, Jordan, Among the natural emergencies reported there were Lebanon, Pakistan and occupied Palestinian territory. earthquakes (Afghanistan, Islamic Republic of Iran and Potential blood donors are mobilized through public Pakistan), flooding (Afghanistan, Pakistan, Somalia media (8 countries) or direct appeal to regular donors (3 and Sudan), drought (Afghanistan), landslide (Afghan- countries) and family/replacement donors (3 countries). istan), avalanche (Afghanistan) and fire (Somalia). The Seven of the responding countries to the survey do keep human-made emergencies included terrorism (Egypt, an emergency or strategic blood stock (Egypt, Jordan, Jordan, Pakistan, Lebanon, Libya, occupied Palestinian Pakistan, occupied Palestinian territory, Sudan, Syrian territory, Syrian Arab Republic and Tunisia); war, includ- Arab Republic and Tunisia), coordinated in 5 countries by ing armed conflict in neighbouring countries (Islamic the Ministry of Health or Ministry of Interior Affairs. In Republic of Iran, Jordan, Lebanon, Libya, occupied Pales- Pakistan the coordination is in the hands of the Provincial tinian territory, Sudan and Syrian Arab Republic); insur- Health Departments and in Lebanon there is no regular gency (Lebanon); and blockade (Lebanon and Syrian Arab emergency stock. However, in case of emergencies Republic). These emergencies affect between 20 and 100% coordination is done by the Lebanese Red Cross Society. of the communities with an estimated 10–85% of the injured requiring blood transfusion. All responding countries process and test blood during humanitarian emergencies, although Lebanon, The main reasons for blood transfusion were increased Libya, Pakistan, the occupied Palestinian territory, Sudan numbers of injuries and trauma as a result of war and and the Syrian Arab Republic still issue whole blood for armed conflict (Afghanistan, Egypt, Jordan, Lebanon, trauma and surgical indications. Testing for ABO and Libya, Pakistan, occupied Palestinian territory, Somalia, Rhesus D antigens, hepatitis B virus, hepatitis C virus Sudan, Syrian Arab Republic and Tunisia); civil accident and human immunodeficiency virus is done in all trauma (Afghanistan, Egypt, Islamic Republic of Iran, countries even during emergencies. In Somalia, testing Jordan, Lebanon, Libya, Pakistan, Sudan and Syrian Arab for transfusion-transmitted infection markers is done Republic); and trauma due to natural disaster (Islamic exclusively by rapid tests, whereas Afghanistan, Pakistan, Republic of Iran and Pakistan). Due to limited availability the occupied Palestinian territory, Sudan and the Syrian of blood during these emergencies, the need for blood Arab Republic use both rapid tests and enzyme-linked transfusion could not be met for emergency obstetric immunosorbent assays. Libya, Pakistan and the occupied care (Afghanistan, Lebanon, Libya and Pakistan); elective surgery (Afghanistan, Lebanon, Libya, Pakistan, Somalia Palestinian territory use chemiluminescence assays and Syrian Arab Republic); paediatric anaemia due to for viral markers. For transportation of blood and blood malaria, haemoglobinopathy (thalassaemia and sickle cell products over long distances, Afghanistan, Lebanon and disease) and haemophilia A and B (Afghanistan, Lebanon, Somalia do not have an operational cold chain in place. Pakistan and Syrian Arab Republic); and other reasons, Under emergency situations, particularly when for example, oncology (Egypt, Lebanon and Sudan). protracted, power supply becomes a serious problem, due to system failure as well as fuel shortage. Poor Current strategies to ensure availability and safety of blood transfusion during emergencies to non-reliability of power supply was reported in Afghanistan and Pakistan. Egypt, the Islamic Republic of National emergency/contingency plans to respond to Iran, Jordan, the occupied Palestinian territory and the threatening and disastrous events were reported from Syrian Arab Republic reported acceptable or satisfactory Afghanistan (2015), Egypt (2014), Islamic Republic of Iran reliability. However, Lebanon reported a major problem (2014), Jordan (2009), Lebanon (2006), Pakistan (2010), oc- during terrorist attacks and blockades. Libya reported a cupied Palestinian territory (1994), Syrian Arab Republic reasonably reliable power supply. Sudan reported variable (2011) and Tunisia (2004). In Libya, Somalia and Sudan no reliability of the power supply and Somalia reported that emergency or contingency plan has yet been developed. some blood centres suffered from absence of a reliable These plans vary between countries and include power supply. Operational emergency power supply was a disaster risk management system (Afghanistan), reported in 8 countries (Egypt, Islamic Republic of Iran, emergency preparedness plan (Afghanistan and Lebanon), Jordan, Lebanon, Libya, Pakistan, occupied Palestinian disaster response management plan (Islamic Republic territory and Syrian Arab Republic). Afghanistan and of Iran), emergency blood donation teams (Lebanon), Somalia reported the absence of a stand-alone emergency and various responsible bodies such as High National power supply in the blood bank or hospital. In Sudan and Council of Crisis Management (Jordan), National Disaster Tunisia, a stand-alone emergency power supply in the Management Commission and Authority (Pakistan) and blood bank or hospital is not always available. Red Cross/Crescent (Lebanon and occupied Palestinian territory). The main immediate actions focus on blood Coordination and collaboration donor mobilization through public and social media, Central coordinating organization for blood transfusion mosques, increased mobile blood collection team service emergency response is in place in 10 of 12 coun- sessions, use of emergency or strategic blood stocks, tries, but is not well structured in Afghanistan and Libya. and support from blood centres in neighbouring cities Central coordination is accomplished in Egypt by the Na-

781

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 781 10/10/2018 12:46:13 PM Review EMHJ – Vol. 24 No. 8 – 2018

Table 2 WHO health emergencies programme grade classification

Ungraded An event that is being assessed, tracked or monitored by WHO but that requires no WHO response at the time.

Grade 1 A single or multiple country event with minimal public health consequences that requires a minimal WCO response or a minimal international WHO response. Organizational and/or external support required by the WCO is minimal. The provision of support to the WCO is coordinated by a focal point in the regional office.

Grade 2 A single or multiple country event with moderate public health consequences that requires a moderate WCO response and/ or moderate international WHO response. Organizational and/or external support required by the WCO is moderate. An Emergency Support Team, run out of the regional office, coordinates the provision of support to the WCO.

Grade 3 A single or multiple country event with substantial public health consequences that requires a substantial WCO response and/ or substantial international WHO response. Organizational and/or external support required by the WCO is substantial. An Emergency Support Team, run out of the regional office, coordinates the provision of support to the WCO.

WCO = WHO country office.

tional Blood Transfusion Center in Cairo; in the Islamic 30% of the total supply. These NGOs were all reported to Republic of Iran by the Iranian Blood Transfusion Organ- have formal permission, with the exception of in Libya. ization in Tehran; in Jordan by the National High Com- Gaps and challenges mission for Crisis Management in Amman; in Lebanon by the joint Red Cross Blood Banks; in Pakistan by the More than half of the countries indicated the following Safe Blood Transfusion Program and the Federal Minis- weaknesses in their blood supply during humanitarian try of National Health Services, Coordination and Regu- emergency situations: political instability (n = 6), frag- lation in Islamabad; in the occupied Palestinian territory mented organization (n = 9), ineffective coordination (n by the Ministry of Health; in Sudan by the National Blood = 6), shortcoming in numbers and competence of human Transfusion Centre in Khartoum; in the Syrian Arab Re- resources (n = 8), transport and cold chain deficits (n = public by the Establishment for Blood Transfusion and 8), shortages in supply of consumables (n = 7), mainte- Medical Industries in Damascus; and in Tunisia by the nance of equipment (n = 6) and shortage in finances (n = Unité de Transfusion Sanguine et des Banques de Sang at 7). Afghanistan, Libya, Somalia and Sudan reported seri- the Ministry of Public Health in Tunis. Information from ous challenges. There was commonality in the top chal- Somalia was not provided. lenges indicated by countries such as competent human resources, political commitment, finances and shortages Collaboration between different blood supply of consumables. organizations exists only in Jordan, Lebanon, Pakistan, Sudan and Tunisia; Afghanistan did not respond to this Regional consultation on blood availability question. Collaboration between the different medical and and safety during humanitarian emergencies emergency care providers does not exist in Afghanistan, Egypt, Libya, Somalia and Sudan. In the 7 countries The regional consultation was held in Tunis, Tunisia, where there is collaboration, responsibilities are with from 15 to 16 May 2016. The consultation was attended by the Ministry of Health in the Islamic Republic of Iran, directors of national blood transfusion services from 10 of occupied Palestinian territory and Syrian Arab Republic. the 12 countries involved in humanitarian emergencies. Responsibility for cooperation is with the National High Iraq and Yemen were not represented. Also in attendance Council of Crisis Management in Jordan, the Coordinator were experts from Indonesia, the Netherlands, Tunisia, of the Senior Emergency Committee in Lebanon, and the United Kingdom of Great Britain and Northern Ireland, Provincial Health Departments and their Blood Programs and Zimbabwe, and representatives of international and with the Pakistan Red Crescent Society in Pakistan. and regional organizations including Africa Society of In Afghanistan, Islamic Republic of Iran, Lebanon, Blood Transfusion, Arab Transfusion Medicine Forum, Libya, Pakistan, occupied Palestinian territory, Sudan, Médecins Sans Frontières, as well as from WHO head- Syrian Arab Republic and Tunisia, nongovernmental quarters. The participants reviewed the status, successes, organizations (NGOs) are involved in blood transfusion challenges and lessons learned in ensuring the availabil- services during humanitarian emergency responses. ity and safety of blood transfusion during humanitarian In most of these countries the NGO is the national Red emergencies through a semistructured group discussion, Cross/Red Crescent Society, but in Sudan the Youth and adopted a set of recommendations to strengthen Organization is involved in donor motivation and blood transfusion services to respond to the increased mobilization, and in Afghanistan and Pakistan, apart demand during humanitarian emergencies. from the Red Crescent Society, there are other NGOs with which collaboration has been established. Only in Discussion Afghanistan, Lebanon, Libya, Pakistan and Tunisia are Humankind has faced many hazards, some of which have NGOs involved in actual blood supply and transfusion developed into disaster situations where a humanitarian (including donor mobilization) – covering at least 20– response has been necessary. The extent of the humani-

782

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 782 10/10/2018 12:46:13 PM Review EMHJ – Vol. 24 No. 8 – 2018

Table 3 WHO Health Emergencies Programme country emergency classification Grade 3 emergencies (n = 5) Grade 2 emergencies Grade 1 emergencies Ungraded protracted (n = 12) (n = 14) emergencies (n = 16) Iraq a Angola Afghanistan a Burkina Faso Nigeria Cameroon Bangladesh Chad South Sudan Central African Republic Democratic People’s Republic of Korea Colombia Syrian Arab Republic a Democratic Republic of the Fiji Djibouti a Congo Yemen a Ecuador Indonesia Egypt a Ethiopia Kenya Gambia Haiti Mali Guatemala Libya a Nepal Honduras Myanmar Pakistan a Jordan a Niger Papua New Guinea Lebanon a Ukraine Philippines Mauritania United Republic of Tanzania Sri Lanka Senegal Thailand Somalia a West Bank and Gaza Strip a Sudan a Turkey Zimbabwe

aWHO Eastern Mediterranean Region.

tarian situation has varied depending on the level of re- and at risk of fatal obstetric bleeding, and thousands silience of the various systems in which the hazards have of children with haemoglobinopathy like thalassaemia occurred. Healthcare systems have developed over the and sickle cell disease or inherited coagulopathy such years to respond better to these situations, with the aim as haemophila A and B and von Willebrand disease or of having a system that is robust enough to prevent the malaria anaemia. hazard from spiralling into a disaster situation. In order Protracted humanitarian emergency situations to achieve this, basic infrastructure, sustained and com- and population displacement cause serious healthcare mitted governance and leadership, integrated healthcare problems, not only because of the difficulties in reaching planning and technical and scientific understanding are some areas, but also because of crumbling infrastructure, needed. economic blockades hampering adequate supplies of WHO has responded to many humanitarian crises, essential medical consumables, including blood bags, test assessing risks, analysing, prioritizing and responding kits and spare parts, and limited availability of competent to critical health situations with relevant resources personnel and budgetary restrictions. and focused relief missions. Obviously, there are more The survey conducted showed a clearer picture of organizations such as the International Federation of the problems faced in maintaining availability and Red Cross and Red Crescent Societies, and Médecins sans safety of the blood supply in the 12 affected countries. Frontière that are involved in providing support during There were major deficiencies observed in their current humanitarian emergencies and natural disasters. So far, strategies to respond to humanitarian emergencies, and the relief missions and reports related to humanitarian coordination between and collaboration with different emergency situations have paid only limited attention to parties and organizations involved. Major gaps and the need to document and publish the important aspects challenges, including shortage of finance, reliable power of supportive haemotherapy through availability and supply, regular supplies and equipment maintenance safety of blood transfusion during emergencies. were identified that may lead to a focused and stepwise The 2016 Humanitarian Response Plans (54) listing approach in planning for action. the health priorities and WHO health sector projects in Critical aspects needed for securing availability and 25 countries (9 from the Eastern Mediterranean Region safety of blood and blood products in humanitarian and 10 from the African Region) and 3 Regional Response emergencies include maintaining hygiene, disinfection, plans (Sahel Regional Response Plan, South Sudan asepsis and infection prevention, cold chains, waste Regional Response Plan, and Syria Regional Refugee disposal, absence of a regular donor panel and and Resilience Plan) do not explicitly mention the management, high prevalence of hepatitis B and C viruses, importance of availability and safety of blood transfusion supply lines, and maintenance and repair. Problems faced during humanitarian emergencies, to meet the needs also include the logistics of supply, particularly into areas of wounded and injured individuals, women in labour with limited or no access. In the Syrian Arab Republic

783

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 783 10/10/2018 12:46:14 PM Review EMHJ – Vol. 24 No. 8 – 2018

blood and blood products are parachuted into besieged Committee for the Eastern Mediterranean (7). In addition cities, but it is not known whether and in what conditions to implementing the priority interventions described in the supplies reach their intended destination. Currently, the Regional Strategic Framework, the following recom- experiments are ongoing using drones for transportation mendations were agreed during the Regional Consulta- over long distances into otherwise inaccessible places tion to achieve sustained availability and safety of blood (53,54). The first results reported are promising, although during humanitarian emergencies. the experiments were done under normal peaceful circumstances. Availability of blood products, in particular 1. Identify and work closely with authorities responsible red cells, can be achieved without the need for electricity for national emergency preparedness and response in or centrifuges. The use of gravity has long been practised, order to highlight the importance of including blood but never well standardized and studied. Gravity transfusion services in overall national emergency sedimentation has been used in Burkina Faso since 2008 preparedness and response activities. and a recent academic study has provided evidence of the 2. Collect updated information on factors affecting quality of the red cells produced using a closed triple bag provision of blood transfusion during humanitarian system containing 100 ml SAGM (saline, adenine, glucose emergencies, and strategies, measures, procedures and mannitol) solution (55). A more recent development and priority actions to meet the increased demand allows standardized separation by gravity within a closed for blood and blood products and blood transfusion blood bag system with an integrated leukocyte depletion during humanitarian emergencies. filter that is easy to handle (56). A major problem is the limitation in funding and shortages due to interruption 3. Identify technical and financial assistance needs to of supplies of consumables. However, increasingly when improve capacity of blood transfusion services for power supply allows, there is use of social media to emergency preparedness and response. communicate with potential blood donors as well as with 4. Strengthen coordination and collaboration among personnel in difficult-to-access areas. relevant stakeholders internally and between coun- The other major gaps and challenges experienced tries to integrate blood safety and availability meas- are the still fragmented and hospital-based organization ures in the overall health response mechanisms and of the blood supply; shortcomings in numbers and other relevant sectors. competence of available human resources; shortages in supplies of consumables; shortcomings in infrastructure, 5. Review existing guidelines and tools to see what in- including power supply; dependence on fuel, transport formation may be leveraged for future guidance on and cold chain deficits and risks; financial shortages; this topic, and develop a short guidance document and ineffective coordination. Seasonal climate changes on managing blood transfusion services in humani- may cause problems in logistics of supply and reaching tarian settings, including global minimum standards. potential donors with mobile teams for collection. 6. Establish an emergency blood service system and Conclusions and recommendations management expertise. These recommendations need to be formulated for The data presented reveal shortcomings and gaps in most each country individually on a tailor-made basis along of the countries in ensuring the availability and safety of blood transfusion during humanitarian emergencies. the lines of the Strategic Framework (58), and guided These shortcomings and gaps are of different weight and and advised on the short, medium and long term by importance for each of the contributing countries. WHO WHO regional and country offices, and experienced Regional Office for the Eastern Mediterranean developed and committed experts in the field of international a Regional Strategic Framework for Blood Safety and development of transfusion medicine, with an emphasis Availability 2016–2025 (57) that recognizes the needs of on quality management. Countries should be advised the population suffering in humanitarian emergencies. to collaborate and cooperate actively, exchanging The Strategic Framework was discussed in depth and experiences and solutions to problems and challenges, agreed in consensus by all representatives of the Member coordinated through the Regional Office on a regular States and was endorsed unanimously by the Regional biannual accounting scheme.

Acknowledgements The authors wish to express their thanks to the countries that participated in the survey; participants of the regional consultation on availability and safety of blood transfusion during humanitarian emergencies for their contributions; staff of the Regional Office for the Eastern Mediterranean Library for facilitating the literature review; Junping Yu, Adelheid Marschang, Hyo Jeong Kim and Valentina Hafner from WHO headquarters for reviewing the manuscript; and Humayun Asghar for providing guidance at the initial phase of development of the paper. Funding: None. Competing interests: None declared.

784

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 784 10/10/2018 12:46:14 PM Review EMHJ – Vol. 24 No. 8 – 2018

Approvisionnement en sang et sécurité transfusionnelle dans les situations d’urgence humanitaire Résumé Contexte : L’approvisionnement en sang et la sécurité transfusionnelle sont des préoccupations majeures dans les pays affectés par les situations d’urgence humanitaire. Ces situations d’urgence sont à l’origine d’une augmentation de la demande en transfusions sanguines et rendent la réalisation de cette procédure difficile et complexe. Néanmoins, il existe un manque d’informations sur les capacités de préparation et de riposte des services de transfusion sanguine aux situations d’urgence, ainsi que sur les difficultés à répondre aux besoins des patients. Objectifs : Évaluer l’approvisionnement en sang et la sécurité transfusionnelle dans les situations d’urgence humanitaire. Méthodes : Nous avons effectué des recherches dans PubMed et l’Index Medicus pour la Région OMS de la Méditerranée orientale afin de trouver des données sur l’approvisionnement en sang et la sécurité transfusionnelle dans les situations d’urgence humanitaire. Nous avons également recueilli des informations au moyen d’une enquête et au cours d’une consultation régionale en Tunisie. Résultats : Nous avons trouvé 24 publications sur les catastrophes naturelles dans cinq pays de la Région, et 16 publications sur la préparation aux catastrophes naturelles et la transfusion sanguine pour les blessés et les cas traumatologiques graves en dehors de la Région. Cependant, aucune ne traitait de l’approvisionnement en sang et de la sécurité transfusionnelle dans les situations d’urgence humanitaire. Les conflits armés et le terrorisme, les inondations et les séismes sont les situations d’urgence les plus fréquentes, avec 10 à 85 % de blessés nécessitant des transfusions sanguines. Des lacunes existent en matière de préparation et de riposte aux situations d’urgence, notamment en ce qui concerne les ressources humaines, le transport et la chaîne du froid, l’approvisionnement en consommables et l’entretien des équipements, l’approvisionnement en électricité et les finances. Conclusions : Il est nécessaire d’intégrer les services de transfusion sanguine au processus global de préparation et de riposte aux situations d’urgence au niveau national, ainsi que d’apporter une assistance aux pays affectés pour leur permettre de combler les lacunes identifiées. Les recommandations pour chaque pays doivent être faites sur mesure, conformément au cadre stratégique régional pour la sécurité transfusionnelle et la disponibilité des produits sanguins.

مدى توافر وسالمة نقل الدم أثناء الطوارئ اإلنسانية إيتمجيتا عبداهلل، رنا حاجة، سيس سيبينجا اخلالصة إنتوافر اخللفية:وسالمة نقل الدم مصدر اهتامم كبري يف البلدان املترضرة من حاالت الطوارئ اإلنسانية. إذ تزيد هذه احلاالت الطارئة من الطلب عىل نقل الدم وجتعل تقديمه ًصعبا ً.ومع ومعقداذلك، هناك نقص يف املعلومات حول التأهب حلاالت الطوارئ والقدرة عىل االستجابة خلدمات نقل الدم والتحديات التي تواجه تلبية احتياجات املرىض. األهداف: تقييم مدى توافر وسالمة نقل الدم أثناء الطوارئ اإلنسانية. طرق البحث:بحثنا يف برنامج PubMed وبرنامج Index Medicusإلقليم منظمة الصحة العاملية لرشق املتوسط للحصول عىل بيانات حول مدى توفر وسالمة نقل الدم أثناء الطوارئ اإلنسانية. كام مجعنا املعلومات من خالل استبيان ومن خالل املشاورات اإلقليمية يف تونس. النتاﺋﺞ: وﺟدﻧﺎ 24 وثيقة ﻣﻧﺷورة ﺣول الكوارث من 5 ﺑﻟدان ﻲﻓ اإلقليم و16 وثيقة ﻣﻧﺷورة ﺣول التأهب للكوارث وﻧﻘل اﻟدم ﻲﻓ اإلصابات ويف الرضوح الشديدة ﺧﺎرج اإلقليم. ومع ذلك، مل يتطرق أي منها إىل توافر وسالمة نقل الدم أثناء حاالت الطوارئ اإلنسانية. تعترب النزاعات املسلحة واإلرهاب والفيضانات والزالزل من أكثر حاالت الطوارئ ش ًيوعا والتي يتطلب 10- % 85من املصابني فيها نقل الدم. وهناك ثغرات يف التأهب للطوارئ واالستجابة هلا، بام يف ذلك املوارد البرشية والنقل وسلسلة التربيد وتوفري املواد املستهلكة وصيانة املعدات وإمدادات الطاقة والشؤون املالية. االستنتاجات:هناك حاجة ماسة إىل دمج خدمات نقل الدم يف التأهب واالستجابة الوطنية الشاملة حلاالت الطوارئ، وتقديم املساعدة إىل البلدان املترضرة مللء الثغرات املحددة. جيب أن تكون التوصيات اخلاصة بكل بلد عىل حدة، بام يتام َ ىمع شاإلطار االسرتاتيجي اإلقليمي لسالمة الدم وتوافره.

785

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 785 10/10/2018 12:46:14 PM Review EMHJ – Vol. 24 No. 8 – 2018

References 1. Emergency risk management and humanitarian response. Report 2013–2014. Geneva: World Health Organization; 2015 (http:// www.who.int/hac/erm_report2013_2014.pdf, accessed 27 March 2018) 2. World disasters report. Focus on hunger and malnutrition. Geneva: International Federation of the Red Cross and Red Crescent Societies; 2011 (http://www.ifrc.org/PageFiles/99868/Photos/wdr.pdf, accessed 27 March 2018) 3. WHO health emergencies. Attacks on health care [website]. Cairo: World Health Organization Regional Office for the Eastern Mediterranean (http://www.emro.who.int/eha/attacks-on-health-care/index.html, accessed 27 March 2018) 4. WHO’s new health emergencies programme. World Health Organization; 2016 (http://www.who.int/about/who_reform/emergency-capacities/WHO-one-emergency-programme-24October2016.pdf?ua=1, accessed 27 March 2018) 5. WHO health emergencies. Displaced populations [website]. Cairo: World Health Organization Regional Office for the Eastern Mediterranean http://www.emro.who.int/eha/displaced-populations/index.html, accessed 27 March 2018) 6. Refugees and internally displaced persons in the Eastern Mediterranean Region: a health perspective. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2015 (http://www.emro.who.int/images/stories/eha/documents/ migrants_refugees_position_paper.pdf?ua=1, accessed 27 March 2018) 7. Resolution. Regional Committee for the Eastern Mediterranean. Strategic framework for blood safety and availability 2016–2025. EM/RC63/R.5 October 2016 (http://applications.emro.who.int/docs/RC63_Resolutions_2016_R5_19126_EN.pdf?ua=1, accessed 27 March 2018) 8. Universal access to safe blood transfusion. Geneva: World Health Organization; 2008 (WHO/EHT/08.03; http://www.who.int/ bloodsafety/publications/UniversalAccesstoSafeBT.pdf?ua=1, accessed 27 March 2018) 9. Shaikh IA, Musani A. Emergency preparedness and humanitarian action: the research deficit. Eastern Mediterranean Region perspective. East Mediterr Health J. 2006;12 Suppl 2:S54–63. PMID:17361678 10. Van Wassenhove LN. Humanitarian aid logistics: supply chain management in high gear. J Oper Res Soc. 2006;57(5):475–89. https://doi.org/10.1057/palgrave.jors.2602125 11. Loruntoba R, Gray R. Humanitarian aid: an agile supply chain? Supply Chain Manage Int J. 2006;11(2):115–20. https://doi. org/10.1108/13598540610652492 12. International Quality Management Consulting [website] (http://www.iqmconsulting.nl/, accessed 27 March 2018) 13. Summary report on the regional consultation on the availability and safety of blood transfusion during humanitarian emergencies. Tunis, Tunisia 15–16 May 2016 (WHO-EM/LAB/387/E; http://applications.emro.who.int/docs/IC_Meet_Rep_2016_EN_18967. pdf?ua=1, accessed 27 March 2018) 14. Library and Information Networks for Knowledge. Index Medicus for the Eastern Mediterranean Region [website]. World Health Organization (http://www.who.int/library/databases/emro/en/, accessed 27 March 2018) 15. Information resources. Index Medicus for the Eastern Mediterranean Region (IMEMR) [website]. World Health Organization Regional Office for the Eastern Mediterranean (http://www.emro.who.int/information-resources/imemr/imemr.html, accessed 27 March 2018) 16. Hess JR, Thomas MJG. Blood use in war and disaster: lessons from the past century. Transfusion. 2003 Nov;43(11):1622–33. https://doi.org/10.1046/j.1537-2995.2003.00576.x PMID:14617324 17. Schmidt PJ. Blood and disaster – supply and demand. N Engl J Med. 2002 Feb 21;346(8):617–20. https://doi.org/10.1056/ NEJM200202213460813 PMID:11856803 18. Spinella PC, Dunne J, Beilman GJ, O’Connell RJ, Borgman MA, Cap AP, et al. Constant challenges and evolution of US military transfusion medicine and blood operations in combat. Transfusion. 2012 May;52(5):1146–53. https://doi.org/10.1111/j.1537- 2995.2012.03594.x PMID:22575063 19. Gonzales R, Taylor AL, Atkinson AJ, Malloy WW, Macdonald VW, Cap AP. US Army blood program: 2025 and beyond. Transfu- sion. 2016 Mar;56 Suppl 1:S85–93. https://doi.org/10.1111/trf.13338 PMID:27001366 20. Resar LMS, Wick EC, Almasri TN, Dackiw EA, Ness PM, Frank SM. Bloodless medicine: current strategies and emerging treatment paradigms. Transfusion. 2016 Oct;56(10):2637–47. https://doi.org/10.1111/trf.13736 PMID:27473810 21. Quillen K, Luckey CJ. Blood and bombs: blood use after the Boston Marathon bombing of April 15, 2013. Transfusion. 2014 Apr;54(4):1202–3. https://doi.org/10.1111/trf.12642 PMID:24724792 22. Sandler SG, Ouellette GJ. Transportation and other blood system issues related to disasters: Washington, DC experience of Sep- tember 11, 2002. Vox Sang. 2002 Aug;83 Suppl 1:367–70. https://doi.org/10.1111/j.1423-0410.2002.tb05336.x PMID:12617171 23. Glasgow S, Davenport R, Perkins Z, Tai N, Brohi K. A comprehensive review of blood product use in civilian mass casualty events. J Trauma Acute Care Surg. 2013 Sep;75(3):468–74. https://doi.org/10.1097/TA.0b013e318298efb9 PMID:23928738 24. Doughty H, Glasgow S, Kristoffersen E. Mass casualty events: blood transfusion emergency preparedness across the continuum of care. Transfusion. 2016 04;56 Suppl 2:S208–16. https://doi.org/10.1111/trf.13488 PMID:27100758 25. Rastegari H, Ajami A. An overview of the management of the crisis. J Inform Manag Health. 2005;2:73–8. 26. Haqqi S. Mental health consequences of disasters. Med Today (Karachi). 2006;4:102–6.

786

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 786 10/10/2018 12:46:14 PM Review EMHJ – Vol. 24 No. 8 – 2018

27. Ahmed J, Mehraj V. Are we prepared to meet the growing challenges of disasters? J Ayub Med Coll Abbottabad. 2007 Oct– Dec;19(4):140–1. PMID:18693620 28. Khankeh HR, Mohammadi R, Ahmadi F. Health care services at time of natural disasters: a qualitative study. Iran J Nursing. 2007;20:85–96. 29. Rezaeian M. Epidemiological approaches to disasters and emergencies within the Middle East Region. Middle East J Emerg Med. 2007;7:54–6. 30. Razapour R. Role of GIS in disaster management. Homa-ye-Salamat (A Journal on Policy, Quality and Management in Health System). 2008; 4(22):18–22. 31. Ojaghi S, Nourizad S, Mahboobi M, Khazaei AAR, Najafi GHA. Disaster crisis handling preparedness level of hospitals in Ker- manshah. J Kermanshah Univ Med Sci. 2009 Fall;13(3):267–74 32. Klanmehr N, Mofidi M, Nejati A. Assessment of physician’s knowledge about disaster. J Med Counc Islamic Rep Iran. 2009;27:264–73. 33. Jahangiri K, Tabibi SJ, Maleki M, Alamdari S. A comparative study on community-based disaster management (CBDM) in selected countries and proposing a model for Iran. J Iranian Inst Health Sci Res. 2009;8:49–57. 34. Nasiri Pour A, Reisi P, Nouri S. [Providing a standard operating process for health & care rapid response team in Iran]. Q Sci J Relief Rescue. 2010;2:11–26 (in Persian). 35. Izadkhah Y. [Women and natural hazards: vulnerable in disasters or capable of disaster management]. Q Sci J Relief Rescue. 2010;2:71–80 (in Persian). 36. Shameen Ejaz S, Ara A. Trauma scale for disaster situations. Pak J Psychol. 2010;41:3–21. 37. Bile KM, Shadoul AF, Raaijmakers H, Altaf S, Shabib K. Learning through crisis: development and implementation of a health cluster strategy for internally displaced persons. East Mediterr Health J. 2010;16 Suppl:S82–90. PMID:21495593 38. Nekooei Moghadam M, Saeed S, Khanjani N, Arab M. What do we need to do for better casualty support in disasters. Iranian Red Crescent Med J 2011;13:512–13 39. Rashidi M, Rameshat M, Safe A, Gharib H. Disaster management in order to offset losses caused by the earthquake. Q Sci J Rescue Relief. 2011;3:40–7. 40. Zaheer HA. Blood management in disaster situations in Pakistan. ISBT Sci Ser. 2012;7(1):1–5. https://doi.org/10.1111/j.1751- 2824.2012.01550.x 41. Zaheer HA, Waheed U. Blood transfusion service in disasters. Transfus Apheresis Sci. 2016 Oct;55(2):186–90. https://doi. org/10.1016/j.transci.2016.09.007 PMID:27665156 42. Zafar A, Cheema K, Yousaf A, et al. Major disasters – first-hand experience at DHQ Hospital in Rawalpindi. Rawal Med J. 1991;19:9–12. 43. Choudry ZA, Mahmood I, Khan AFA, Choudhry AM. Management of a mass disaster: An experience at Mayo Hospital in Lahore. Pak J Surg. 1996;12:156–9. 44. Abd El-Aziz M, Elbeih AA. Disaster preparedness during Hajj Season: Effect of training program on nurses knowledge and performance. New Egypt J Med. 1998;19:21–30. 45. Hussein E, Teruya J. Evaluation of blood supply operation and infectious disease markers in blood donors during the Egyptian revolution. Transfusion. 2012 Nov;52(11):2321–8. https://doi.org/10.1111/j.1537-2995.2012.03592.x PMID:23163293 46. Department for Emergency Risk Management and Humanitarian Response. 2016 WHO humanitarian response plans. Summary of health priorities and WHO projects in interagency humanitarian response plans. Geneva: World Health Organization; 2016 (http://www.who.int/hac/donorinfo/who_humanitarian_response_plan_2016_may.pdf?ua=1, accessed 27 March 2018) 47. Update. WHO Health Emergencies Programme: progress and priorities. Geneva: World Health Organization; 2016 (http://www. who.int/about/finances-accountability/funding/financing-dialogue/whe-update.pdf, accessed 27 March 2018) 48. Progress Report on the development of the WHO Health Emergencies Programme. 30 March 2016 (http://www.who.int/about/ who_reform/emergency-capacities/who-health-emergencies-programme-progress-report-march-2016.pdf?ua=1, accessed 27 March 2018). 49. Yuan S, Ziman A, Anthony MA, Tsukahara E, Hopkins C, Lu Q, et al. How do we provide blood products to trauma patients? Transfusion. 2009 Jun;49(6):1045–9. https://doi.org/10.1111/j.1537-2995.2009.02150.x PMID:19389035 50. Berg M, Justison G. How would I establish a perioperative blood salvage program? Transfusion. 2013 Sep;53(9):1888–93. https:// doi.org/10.1111/j.1537-2995.2012.03780.x PMID:22804916 51. Stubbs JR, Zielinski MD, Berns KS, Badjie KS, Tauscher CD, Hammel SA, et al. How we provide thawed plasma for trauma patients. Transfusion. 2015 Aug;55(8):1830–7. https://doi.org/10.1111/trf.13156 PMID:26013588 52. World population prospects. The 2012 revision. Highlights and advance tables. New York: United Nations, 2013 (ttp://esa.un.org/ unpd/wpp/publications/Files/WPP2012_HIGHLIGHTS.pdf, accessed 27 March 2018) 53. Amukele T, Ness PM, Toblan AAR, Boyd J, Street J. Drone transportation of blood products. Transfusion. 2017 Mar;57(3):582-8 54. Anonymous. Drones begin delivering blood in Rwanda. Blood is Life. AfSBT News Lett. 2016;2:2–3.

787

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 787 10/10/2018 12:46:14 PM Review EMHJ – Vol. 24 No. 8 – 2018

55. Sawadogo S, Nébié K, Kafand E, et al. Preparation of red cell concentrates in low-income countries: efficacy of whole blood set- tling method by simple gravity in Burkina Faso. Int J Blood Transfus Immunohematol. 2016;6:20–9. 56. Bonn F, Büttner B, Krieter DH, Lemke H, Sauvant C. Blood separation and storage with a new gravity-driven device: performance with and without leukodepletion filter. Transfusion. 2016;56 Suppl S4:54A. 57. Strategic framework for blood safety and availability 2016–2025. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2017 (WHO-EM/LAB/389/E; http://applications.emro.who.int/dsaf/EMROPub_2017_EN_19608.pdf?ua=1, accessed 27 March 2018). 58. Refugees and internally displaced persons in the Eastern Mediterranean Region. A health perspective. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2015 (http://www.emro.who.int/images/stories/eha/documents/ migrants_refugees_position_paper.pdf, accessed 27 March 2018).

788

09- Availability and safety of blood transfusion during humanitarian emergencies.indd 788 10/10/2018 12:46:14 PM Report EMHJ – Vol. 24 No. 8 – 2018

Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country

Lilian A. Ghandour,1 Al Amira S. Shehab,2 Pia Zeinoun,3,4 Lucy Tavitian,4 Fadi Halabi3 and Fadi T. Maalouf 3

1Department of Epidemiology and Population Health, Faculty of Health Sciences; 3Department of Psychiatry, Faculty of Medicine, American University of Beirut, Beirut, Lebanon (Correspondence to: Fadi Maalouf: [email protected]).2Queens College, City University of New York, New York, United States of America. 4Department of Cross-cultural Psychology, Tilburg University, Tilburg, Netherlands.

Abstract Recent epidemiological evidence for Lebanese adults along with the increased efforts for policy and service planning have demonstrated the importance of screening for rates of psychiatric disorders in the adolescent population. In response to this need, the Beirut Epidemiological Investigation of the Psychological Status of Youth was conducted in a community sample to estimate the prevalence of psychiatric disorders and their correlates among adolescents. The main aim of this report is to provide a synthesis of the research process and challenges faced in completing the first population-based mental health survey among children and adolescents in Lebanon. This report discusses the challenges faced and the lessons learnt in conducting such a survey. Themes discussed include working around the absence of a proper sampling framework, conducting a sound study with limited funding and the absence of a research culture. This report presents evidence-informed recommendations for similar future surveys. The report also establishes that a sound epidemiological survey is possible even where there are limited resources and challenging contexts such as security issues or the absence of a research culture. Keywords: household survey, challenges, mental health, adolescents, Lebanon Citation: Ghandour LA; Shehab AS; Zeinoun P; Tavitian L; Halabi F; Maalouf FT. Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country. East Mediterr Health J. 2018;24(8):789–799. https://doi.org/10.26719/2018.24.8.789 Received: 20/06/16; accepted: 17/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction The strategy covers 5 domains, including the use of evidence to inform mental health policy, practice and There have been multiple attempts in Lebanon, main- development, and improving access to care for vulnerable ly driven by nongovernmental organizations, to raise groups such as children and adolescents. Local available awareness and spread knowledge on the importance of epidemiological data for children and adolescents have the surveillance, prevention and management of men- emanated mostly from targeted samples (e.g. children tal illness among the Lebanese population. Recently, the exposed to war), or have focused on specific disorders, Ministry of Health has partnered with the World Health Organization (WHO) to launch the Mental Health Gap clearly illustrating the necessity of better understanding Action Programme (mhGAP) aimed at scaling up mental the mental health profile and needs of youth in the health care services. Another critical milestone for Leba- general population. Previous research has shown that non’s mental health care sector has been the recent launch almost 1 in 6 (16%) of middle school students in public of the Mental Health and Substance Use Prevention, Pro- and private schools reported suicide ideation in 2005 (7). motion, and Treatment Strategy for Lebanon (2015–2020) Attention deficit hyperactivity disorder was also found in (1), whose goals are in line with the WHO Global Action 3% of schoolchildren aged 6–10 years using teacher and Plan for Mental Health. parent rating scales (8). Moreover, and quite importantly, the onset of many mental health disorders among a Lebanon is a small country in the Middle East at representative sample of Lebanese adults aged ≥ 18 years the crossroad between oriental and western cultures. had occurred during adolescence or young adulthood The country has experienced years of irregular bouts (average 11 years for specific phobia, 14 years for social of political instability, security threats and civil wars, and this exposure to wars and war-related factors phobia, and 14 years for impulse control disorders) (9). (e.g. displacement) has been linked to earlier onset of In an effort to gather population–based epidemio- suicidal ideation and attempt (2), a greater likelihood logical evidence on youth that could feed into the of experiencing at least 1 mental health disorder (3) development and evaluation of youth-friendly national or specific disorders, including post-traumatic stress policies and programmes, a household face-to-face disorder, depression/anxiety and eating disorders (4–6). survey was conducted in 2011–2012 among children Despite the clear linkage between the deleterious effects and adolescents (aged 11 years to 17 years 11 months) of war on mental health in Lebanon and elsewhere (2,5), residing in the capital city, Beirut (10). The study, the a national mental health strategy was only recently Beirut Epidemiological Investigation of the Psychiatric launched. Status of Youth (BEI-PSY), examined the previous 30-day

789

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 789 10/10/2018 12:47:26 PM Report EMHJ – Vol. 24 No. 8 – 2018

prevalence and correlates of several psychiatric disorders. Table 1 Areas and neighbourhoods used in the BEI-PSY Despite the challenges faced at various levels of the survey, Beirut, 2012 research process, some unique to Lebanon and others Area Neighbourhood cross-cultural, BEI-PSY was successfully completed. Achrafieh Al Nasra In general, sampling can been challenging in many Al Seryan contexts where official household listings, population Al Syoufi registries or census information are unavailable; Feren El Hayek Karm El Zaytoun examples include studies from Ireland (11), the United Mar Meter Arab Emirates (12,13) and Bangladesh (14). Other challenges Mar Nicolas may be more specific to fieldwork, and can include fraud Ain Mreisseh by interviewers (15), difficulty in recruiting or reaching cases (16), low response rate (17), lack of resources to Bachoura Basta El Fawka Basta El Tahta carry out structured assessments (14) or to conduct Khandaa El Ghamie community surveys drawn from a wide variety of urban Mazraa Bourj Abi Haydar and rural areas (15). Reporting issues may also prevail Ras El Nabea such as underreporting of religiously and morally taboo Tarik El Jdideh issues like alcohol or drug use in predominantly Muslim Msaytbeh Aicha Bakkar societies (14). Surveying a sensitive topic like mental Sanayea health could also pose its own challenges. In Pakistan, Wata El Msaytbeh for example, the low response rate was attributable Ras Beirut Hamra to the stigma surrounding mental health, as well as Rawche general lack of awareness and concerns from parents Sakyat Al Janzeer Snoubra on how results would be used (18). In a 2012 review of mental health research in the Arab world, a few potential Rmeil Gaaitawi Jemmayzeh factors contributing to the scarcity of mental health Mar Mkhayel research endeavours in the region were identified; they included the lack of governmental support to conduct Zkak El Blat such research along with other more general factors such as lack of research infrastructure and limited research funding (19). and then equally divided across the various neighbour- Specific challenges in conducting research in the hoods within the area. Neighbourhoods were purposive- Middle East region include low research support by both ly selected to include a diversity of socioeconomic levels. governmental and nongovernmental bodies, limited Full details of the survey methodology are given in the resources and difficulty in obtaining probability samples, BEI-PSY (12). However, the selection of households was not to mention instability and violence in some countries not entirely conducted using probability sampling for (20). In fact, conducting surveys in armed conflict areas, logistical reasons, and the implications are addressed which includes countries that have experienced civil in the Discussion section. The research company con- strife and wars such as Lebanon, may be challenged by ducting the fieldwork had acquired all maps from the lack of, or outdated, sampling frames impeding proper Lebanese Army through their Directorate of Geographic sample design and selection, or higher noncontact and/ Affairs and GIS/Transport, a specialized geographic in- or non-response rates during data collection (21). formation system company in Lebanon. This paper provides a synthesis of the research process A total of 9061 households were approached and 510 and challenges faced as well as main lessons learnt completed adolescent/parent pair questionnaires were after completing BEI-PSY, the first population-based collected. In cases where there was a specific disability, mental health survey among children and adolescents such as severe mental retardation (3 cases), the surveyors in Lebanon. We feel that such a transparent and detailed tried as much as possible to interview the selected child, documentation and synthesis detailing evidence- focusing on the parent interview. Eligible adolescents informed potential ways of addressing such challenges with hearing problems were excluded. Data collectors is important for knowledge-sharing and guiding future recorded all fieldwork details and outcomes (Table 2). research endeavours. Among the households approached, 3517 were identified as ineligible, including units that were Methodology: exposé and outcomes nonresidential or under construction and those that did not have an adolescent in the specified age range Sampling and fieldwork (Figure 1). A total of 1004 households included eligible Beirut was divided first into areas, and then into neigh- children; 510 (51%) completed interviews, 363 (36%) were bourhoods (Table 1). The Central Administration of Sta- refusals, and the remaining 13% were either breakoffs or tistics provided estimates of the number of households cases where the randomly selected child was unavailable available by area (22); these were proportionately sampled during both visits.

790

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 790 10/10/2018 12:47:26 PM Report EMHJ – Vol. 24 No. 8 – 2018

Table 2 Interview template used in the BEI-PSY survey, Beirut, 2012 First attempt Second attempt Date & time:______Date & time: ______Outcome Outcome Interview Interview Complete interview Complete interview Partial interview – but asked to return on _____ Partial interview – but asked to return on ______Partial interview – but asked not to come back – circle also 2.1 Partial interview – but asked not to come back – circle also 2.1

Eligible HH, but non-interview (non-response) Eligible HH, but non-interview (non-response) Refusals : a responsible person refused Refusals: a responsible person refused at screening (before any explanation) at screening (before any explanation) after screening (after some explanation of the study) after screening (after some explanation of the study) No one was at HH (non-contact) No one was at HH (non-contact) R was selected but R was not at HH/could not be reached (non-contact) R was selected but R was not at HH/could not be reached (non-contact) Language barrier: selected R cannot speak/read Arabic (do not come Language barrier: selected R cannot speak/read Arabic (do not come back) back) Selected R mentally disabled: interview parent only and child as Selected R mentally disabled: interview parent only and child as possible possible Selected R physically disabled with a temp condition Selected R physically disabled with a temp condition

Unknown HH eligibility Unknown HH eligibility Unable to access building Unable to access building Able to access building but unable to reach anyone at HH (no one Able to access building but unable to reach anyone at HH (no one answered the door) answered the door) Able to access HH, no one at home (maid answered the door) Able to access HH, no one at home (maid answered the door) Other reason ______Other reason ______

HH not eligible (do not come back): HH not eligible (do not come back): Office Office HH is occupied, but no child fits eligibility criterion HH is occupied, but no child fits eligibility criteria Other reason ______Other reason ______

See Table 2 for definitions of codes. HH = household. R = respondent.

Response rates (RRs) were calculated assuming a 3.5 bic by the team and back-translated. The SDQ is a meas- ratio of ineligibility to eligibility, which was deduced ure of social, emotional and behavioural functioning from the pilot surveys. The formula used to make these (24). The selected parents completed the demographic calculations is: sheet (including questions related to history of treatment RR = I/ [(I + P) + (R+NC+O) +e(UH)] seeking), the Attitudes towards psychiatric illness (ATPI) questionnaire (27), and the parent version of the SDQ. The where: I = completed interview, P = partial interviews ATPI is composed of 4 items assessing stigma associated (ones without enough data to consider), R = refusals, NC = no contact, O = other, UH = unknown households, and with mental illness (27). e = estimated proportion of unknown eligible who are The parent and child were also administered the eligible (23). Rates varied by area ranging between 10% Development and well-being assessment (DAWBA) (28), and 32% (Tables 3 and 4). The RR was calculated as 22%, a structured interview used to formulate a psychiatric with 9% being the minimum [total completed interviews diagnosis of a child/adolescent based on the Diagnostic (n = 510) divided by “all households except ineligible”] and and statistical manual of mental disorders (DSM-IV-TR) 51% the maximum, assuming all households of “unknown and the International classification of diseases (ICD-10) eligibility” were ineligible. criteria (28,29). Clinical raters integrated information from the structured questions, the DAWBA-generated Study tools diagnoses, and from subjective transcripts, to come up Participants completed a structured interview and a se- with a clinical diagnosis that either accepts or overturns ries of Arabic rating scales. The randomly selected child the computer diagnosis. Each DAWBA interview was completed the self-report version of the Strengths and rated individually by either a child and adolescent difficulties questionnaire (SDQ) 24( ), and the Peer rela- psychiatrist (FM) or a psychologist (PZ); the 2 raters had tions questionnaire (PRQ) (25). The PRQ measures 3 con- confirmed inter-rater reliability (29). The Arabic version of structs: bullying, being victimized, and pro-social behav- the interviewer-based paper and pencil DAWBA was used, iour (26) .We used the Arabic version of the SDQ which which has good inter-rater reliability with coefficients of has been validated among a sample of Yemeni children 0.93 for disruptive disorders, 0.82 for mood disorders, 0.72 (26); the original English PRQ (25) was translated to Ara- for anxiety disorders and 0.68 for other disorders (29).

791

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 791 10/10/2018 12:47:26 PM Report EMHJ – Vol. 24 No. 8 – 2018

Figure 1 Sampling frame used in the BEI-PSY survey, Beirut, 2012

510 Completed interviews

363 Refusals

1004 Eligible 14 Breakoff

54 Child not available

63 Fieldworker could not undertake interview

214 Selected apartment nonresidential

9061 Total knocks on 3517 Ineligible 3146 No qualified adolescent doors

157 Household did not qualify for other reasons (under construction)

132 Parents not available

544 Fieldworkers could not access building

2700 No one answered the door 4540 Unknown eligibility

711 Only helper present

421 Parents refused before establishing eligibility

32 Fieldworkers could not tell if household qualified

792

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 792 10/10/2018 12:47:26 PM Report EMHJ – Vol. 24 No. 8 – 2018

Table 3 Detailed responses of the randomly selected households in the third pilot phase of the BEI-PSY survey, Beirut, 2012 Description Codea No. of households Eligibility Field workers could not access the building 3.1 9 Unknown eligibility No one opened the door 3.2 86 Unknown eligibility Only the helper was present in the house 3.3 6 Unknown eligibility Field workers could not tell whether the households was an applicable 3.4 9 Unknown eligibility case as the parents refused before hearing any explanation about the study Filed workers could not tell whether the household was qualified: The 3.5 1 Unknown eligibility household residents only come in the summer The selected apartment was an office (non-residential unit) 4.1 15 Not eligible The house was inhabited, but there was no qualified adolescent in the 4.2 139 Not eligible specified age range The households did not qualify: households still under construction 4.3 6 Not eligible Partial interview and asked to come back later to complete it 1.2 1 Incomplete Partial interview and asked not to come back later 1.3 1 Refusal The selected child was not available at the time of the interview 2.2 4 Non-response The parents were not available at home at the time of the interview 2.3 10 Non-response The parents refused before hearing any explanation about the study 2.1.1 11 Refusal although the household was an applicable case The parents refused after hearing some explanation about the study 2.1.2 11 Refusal although the household was an applicable case The child refused to participate 2.1.3 1 Refusal

aDefinition of codes in Figure 1

Data collectors: training and quality control preparedness. The second part of the evaluation consisted of an open-ended section evaluating the different After successfully completing the required Collaborative phases of recruitment, including the introduction and Institutional Training Initiative course (30), data collec- random selection procedure and the administration of tors were trained for a full day by a child and adolescent psychiatrist (FM), a clinical and counselling psychologist each questionnaire. The interviewers were shadowed (PZ), and an epidemiologist (LG). Initially, 2 separate full and observed by the research team for two household training sessions were held for about 30 fieldworkers to visits and an evaluation form was filled out based on train them on general interviewing techniques and spe- this observation. Based on these supervisions and cific survey procedures, followed by an interview simula- evaluations, some data collectors were released. Booster tion. A total of 22 data collectors, 12 females and 10 males, information sessions were held to exchange experiences were finally involved in the fieldwork, 19 of whom (86%) and input among the retained data collectors and other were undergraduate university students. members of the research team; a closed Facebook group was also created to allow for regular group discussions Following the training, the pilot phase was conducted, and feedback, particularly during data collection. during which the data collectors were closely supervised and evaluated by one of the research team (LT). The pilot Quality control was implemented independently by phase was carried out in 3 waves to accommodate all the research company and by our team. A random sample newly recruited and trained data collectors, given the of participants with completed interviews was called back large turnover. The first 2 waves of piloting were mainly by the research company and asked specific questions used to assess the feasibility of the sampling process, to validate the answers against their original survey residual problems in administering the scales and/or response. Specific questions inquired whether anyone in interviewing, performance of data collectors, and other the household was interviewed, and cross checked details logistics. The results of the third wave of piloting were of the participating child (e.g. age, whether s/he went to used to calculate potential response rates for our survey. school, current class, if child were receiving treatment for Debriefing sessions took place with all data collectors, a medical psychological or nervous case), the time spent both individually and collectively. conducting the interview, and whether the interview was During the pilot study, data collectors were also completed or not. General feedback was also solicited quantitatively evaluated by members of our team using (i.e. whether the participants had any comments on a structured form consisting of 2 parts: the first included the interview and/or interviewer). Quality reports were items on a 5-point Likert scale assessing the different regularly generated by the research company and shared aspects of the interaction with the selected participant, with our team. The research team also randomly selected including body language, politeness, sticking to the 10% of the sample to call-back for quality control. scripts and questions, noting down answers verbatim, and During the entire fieldwork, progress reports were

793

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 793 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

Table 4 Study response rate (RR) in the areas used in the BEI- create new lists and/or maps of Beirut, we capitalized in PSY survey, Beirut, 2012 the present study on the experience and expertise of a re- Area Minimum Maximum Probable nowned research company in assisting with the creation RR (%) RR (%) RR (%) of the sampling frame. Future surveys, mental health or

Ashrafieh 9 66 22 other, should budget for complete household listing of the areas to be surveyed (e.g., using GPS or satellite im- Ain Mreisseh 4 71 11 agery) to generate a more complete sampling frame and Bashoura 13 49 28 enable a robust probability sampling technique (21). Mazraa 13 58 32 When less than ideal sampling is employed, it Msaytbeh 11 50 26 is crucial for validity purposes to compare sample Ras Beirut 6 54 14 characteristics with that of the target population. In the Rmeil 6 44 16 BEI-PSY study, the sample appears to reflect the general Zkak El Blat 8 16 10 demographic and socioeconomic trends within Lebanon. The ratio of males to females was only slightly higher than national estimates, and parental level of education was in line with Central Administration of Statistics data sent periodically by the research company detailing the on maximal education levels in the Lebanese population total number of households completed until the report (22), with about a third of the sample having less than date, and the outcomes of the contacts made (e.g. number secondary level education and a third of the adolescent of refusals, number of households that could not be sample having one or both of their parents complete accessed, number of completed interviews, etc.). a college education. The average monthly income per Ethical considerations producer in Beirut in 2007 was US$ 606 (22); our sample was average in terms of socioeconomic status with the The survey was granted ethical approval by the Institu- median households (yearly) income US$1000 or less; tional Review Board of the American University of Beirut. only 12% reported a household income of more than Informed consent and assents were obtained from partic- $US 2000. However, comparing the sample to national ipating parents and children/adolescents. All procedures distribution of residents by sex, education and income performed in studies involving human participants were does not guarantee lack of bias, or address fully the in accordance with the ethical standards of the institu- representativeness of the sample. tional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or Household access and response rates comparable ethical standards. Access to households was a major source of constraint Fieldworkers were provided with an emergency in the survey. Noteworthy are the number of households number to contact in case they encountered an adolescent that remained of unknown eligibility after 2 contact at- who responded positively to one of the self-harm or tempts; 4540 households were labelled as such, e.g. be- suicidal ideation questions. The clinician who received cause no one answered or opened the door (n = 2700; these calls spoke with the adolescent, assessed the level of 59%), parents were not available (n = 132; 3%), fieldworkers risk of self-harm and, if necessary, spoke with the parent could not access the building (n = 544; 12%), etc. (Figure 1). and recommended referral accordingly. In addition, all One possibility is that there was really no one home, but participating parents were provided with a referral list of another quite probable reason could be the country’s un- nongovernmental organizations that offer psychological certain security level, rendering residents both cautious services, and hospitals that have psychiatric departments and reluctant to open their doors to strangers. Quite chal- in Beirut. Parents and adolescents were also given the lenging were also the gated buildings and areas restricted option of meeting with the investigators 2 or 3 months for security or political reasons (it is not uncommon in following data collection in order to be briefed about the Lebanon for politicians to have a restricted-access radius psychiatric symptoms of the adolescent. around their residences). As a token of appreciation, participants were Inability to determine eligibility after 2 visits has provided with a small stationery kit. All authors certify repercussions on survey results, both in terms of low responsibility for this manuscript. response rate and selection bias. Eligibility remained undetermined in almost half of the households Discussion approached, particularly in areas perceived to be of a higher socioeconomic status. This is similar to a study Sampling frames and target sample in Brazil where researchers also found it hard to recruit Many international population-based surveys have used respondents from more affluent areas, possibly because national registries and databases for their household sur- they were suspicious of surveyors and afraid of being veys (15,31,32), or have been conducted by governments robbed (31). In such circumstances, and when noncontact or government-funded agencies or institutions (33,34). is high, techniques to improve outcomes could entail In Lebanon, the last population census was conduct- increasing the number of households contacts (which in ed in 1932, and given the lack of sufficient resources to our case were limited to two due to budget constraints)

794

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 794 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

(35). In the NEMESIS study, for instance, a minimum institutions, such as ministries of health, hospitals of 10 calls or visits were made to establish contact and universities could also improve response rates. For with participants and achieve a response rate of 64% example, the New Zealand Mental Health Survey was (36). Similarly in the National Comorbidity Survey – conducted following consultation and support from the Replication, unlimited in-person contact was attempted, Ministry of Health as well as groups of experts from reaching a 71% response rate for primary respondents and the mental health field 39( ). In countries where armed 80% when taking into account secondary predesignated conflict or political instability may prevail, establishing respondents (16). Other strategies for optimizing contact good relationships with key community members (gate rates include mixing and adjusting interviewing hours keepers) can prove especially useful for enhancing access (between weekdays/weekends, daytime/evening) (21,35), to communities and subsequently households (21,38). increasing the length of the data collection period if Other suggested techniques to overcome field challenges possible, and/or seeking supplemental information about include offering higher monetary incentives at the households of unknown eligibility (information about second contact (36,40). at-home patterns from neighbours, doormen or building If initial contacts do result in a refusal, refusal managers) (21,35). conversion methods could be attempted by mailing a The response rate in this study (22%) is considerably letter for example to reiterate the importance of their lower than that reported for another household survey participation to the overall success of the study (35). As conducted in 2002–2003 among adults in Beirut (60%) a worst case scenario, attempts should be made to seek a (3), but low response rates are certainly not unique to very short interview that collects the basic data necessary this study or to Lebanon, with declining response rates for post survey adjustments (35). becoming a major global concern for all data collection modes, including household interviews (37). Reasons Funding constraints and their implications for this global phenomenon could be the rise in the Given no prior estimates for child mental health disor- number of requests to participate in research (some of ders in the general population of Lebanon, a prevalence which are marketing rather than scientific surveys), or of 50% was assumed when calculating sample size, which the general time and energy demands of participating yields the largest possible sample size (n = 384). Given the in surveys. The low response rate in this particular study clustered sampling technique, a design effect (deff = 2) could additionally be attributed to the growing, but not was considered (i.e. n = 768); in the absence of an availa- yet established, research-oriented culture in Lebanon ble design effect, the rule of thumb has been to use either (29). Efforts to educate the local community about the 1.5 or 2 (41). Originally, we had aimed at interviewing 1000 value of participating in research are limited to academic participants from Greater Beirut, including its south- centres and universities and little is being done on the ern and northern suburbs; however, due to budget con- national level to educate the general public. In the Irish straints, the target sample size was reduced to 500, and Longitudinal Study on Ageing, several strategies were the study was restricted to administrative Beirut. Pilot employed to improve response rates including a series survey results (number of non-responders, refusals, and of advertisements on local radio, appearing on television non-eligible) were used to estimate the number of house- interviews and sending information brochures about the holds needed to be approached to achieve 500 completed study to local religious, community and nongovernmental interviews, and about 11 000 households were estimated institutions (11). Enhancing cooperation rates in surveys to be needed (9061 were actually approached). could thus begin pre-contact, by publicizing the Evidently, budget constraints have several survey through press releases and media (11,38). Other repercussions on the design and implementation of mechanisms could include sending advance letters, for household surveys including but not limited to working example to alert household members of an upcoming visit with a non-optimal sampling frame, reducing desired by interviewers (35); the detailed sealed letter could be sample size, restricting target areas, and/or inability to mailed or delivered to the doormen or building manager enhance contact rates. Tight research budgets have indeed to be distributed to the selected floors and apartments. been identified as one of the challenges of conducting During data collection, recruiting interviewers who research in the Middle East and Africa regions, and are known to or trusted by the community members, potential future solutions may include establishing a or using a neutral agency or media outlet to support specific budget for research at governmental level 20( ). the survey and encourage participation, could also help One decision taken by the investigators to cut down reduce refusals (21). Governmental support, whether on the study expenses and implement the study with financial and/or pragmatic assistance in the field by the available budget was to volunteer their time. The publicly endorsing the study and encouraging people research team also engaged in several negotiations with to participate in it, could be useful only in contexts the research company to help them see the value of where governments are perceived favourably; otherwise, undertaking this work meticulously at a relatively low members of the community may become even more cost. reluctant to participate in government funded or supported research initiatives (20). Tool selection and validation Successful collaborations between public and private Using Arabic language instruments in this study required

795

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 795 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

significant preparation that spanned approximately 2 useful when the purpose of the study is comparative years. First, instruments in Arabic were difficult to ob- (cross-cultural) with a primary aim of comparing data tain because many are published in journals not readily across countries and cultures. available in online databases. Second, tools translated The choice of the diagnostic interview is definitely into Arabic and tested in a given society are not readily transferable to another Arabic-speaking country, the worth discussion. The DAWBA was chosen due to its Arabic language varies by geography to the extent that unique features that make it particularly useful, including vernacular Arabic is not mutually comprehensible across the solicitation of open-ended responses following close- countries. Arabic also varies by purpose: a formal variety ended questions, which can help detect and resolve of Arabic, referred to as Modern Standard Arabic (MSA), possible inconsistencies vis-à-vis the close-ended is used in literature, education and formal media outlets questions (due to language, culture, etc.). Nonetheless, while vernacular Arabic is used in everyday life, and dif- the DAWBA is a long structured interview with many skip fers across countries. Therefore, a tool developed using rules; the interviewer-administered paper-and-pencil Yemeni Arabic may not be readily understood in Lebanon version used in this survey (versus the online version) is and vice-versa. Although MSA is thought to be mutual- particularly time-consuming and liable for more random ly familiar in all Arabic speaking countries, instruments human errors at the level of the interview and/or data written in MSA risk being too formal and even prohib- itive to people with low educational attainment. Tools entry. The decision not to use the computerized version written strictly in MSA have been described as being “dis- was made considering a few factors such as the cost of tant” from everyday experiences and not “user-friendly” purchasing the equipment, or the reduced fluency of in accessing psychological constructs (42). In view of typing in Arabic. these language challenges, existing Arabic instruments such as the DAWBA had to be customized to the Lebanese Conclusion dialect, while new instruments such as the PRQ had to be This was the first attempt to survey children and adoles- developed using a balanced approach to MSA that is clear cents in the general population of Lebanon, using a struc- and familiar to native speakers in Lebanon. Adaptation tured interview, rating scales and open-ended questions was also necessary at the level of administration method. that allow for the establishment of baseline prevalence During piloting, the DAWBA section on substance-use estimates for various mental health disorders, and the was judged to be intrusive, and unlikely to yield honest responses in an interview format. Therefore, this section identification of correlates among non-institutionalized was reformatted to be self-administered in order to en- community sample of adolescents (10). Despite the many hance the validity of responses. methodological challenges faced, the study was complet- When necessary, tools were translated from English to ed and its findings have significantly contributed to the Arabic, back-translated, and reviewed by content experts local, as well as global prevalence data for mental disor- with sequential changes in wording until the Arabic ders among youth (44). version was successfully piloted. It is worth noting that The study also sets the example that a sound there is new and growing evidence that recommends epidemiological survey is possible even where resources a “team translation approach” for survey instrument are limited and contexts challenging, either due to security production, in contrast to back translation. Briefly, the issues or absence of a research culture. Documentation approach entails that a group of people work together to produce, independently from each other, initial and dissemination of the main challenges faced and the translations, which are thereafter assessed by reviewers lessons learned is greatly needed and crucial for ensuring along with the translators, and finally regarded by one that future surveys, particularly within the same or (or more) adjudicator as being ready for pretesting and similar contexts, are conducted with the fewest possible finalized for fieldwork (43). This approach is particularly methodological issues. Acknowledgement We would like to thank Dr Robert Goodman for his guidance and support during this study. Funding: This study was funded by the Medical Practice Plan at the American University of Beirut. Competing interests: None declared.

Problèmes et solutions contextuels à la réalisation d’une enquête sur la santé mentale des adolescents dans les ménages vivant dans un pays en développement Résumé Les données épidémiologiques obtenues auprès des adultes libanais et les efforts accrus de planification des politiques et des services ont démontré l’importance de l’étude des troubles psychiatriques au sein de la population adolescente. En réponse à ce besoin, l’enquête épidémiologique de Beyrouth sur l’état psychologique des jeunes a été menée auprès d’un

796

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 796 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

échantillon communautaire pour estimer la prévalence des troubles psychiatriques et leurs corrélats chez les adolescents. L’objectif principal de ce rapport est de fournir une synthèse du processus de recherche et des problèmes rencontrés lors de la réalisation de la première enquête sur la santé mentale de la population adolescente au Liban. Le présent rapport examine les difficultés rencontrées et les enseignements tirés suite à la réalisation d’une telle enquête. Parmi les thèmes abordés, l’on peut mentionner l’absence d’un cadre d’échantillonnage adéquat, la réalisation d’une étude solide avec un financement limité et l’absence d’une culture de recherche. Le présent rapport présente des recommandations fondées sur des données probantes à des fins d’enquêtes futures similaires. Le rapport établit également qu’une enquête épidémiologique solide est possible, même lorsque les ressources sont limitées et dans le cadre de contextes difficiles tels que des problèmes de sécurité ou l’absence d’une culture de recherche.

ِّ يات التحدواحللول السياقية إلجراء مسح صحي نفيس للمراهقني يف أحد البلدان النامية ليليان غندور، األمرية شهاب، بيا زينون، لويس تافيتان، فادي حلبي، فادي معلوف اخلالصة لقد أثبتت األدلة الوبائية احلديثة للبالغني اللبنانيني بجانب اجلهود املتزايدة املبذولة لتخطيط السياسات واخلدمات أمهية ِّالتحري عن معدالت االضطرابات النفسية بني املراهقني. واستجابة هلذه االحتياجات، أجري تقيص وبائي للحالة النفسية للشباب يف بريوت عىل عينة جمتمعية لتقدير مدى انتشار االضطرابات النفسية والعوامل املرتبطة هبا بني املراهقني. واهلدف الرئييس من هذا التقرير هو تقديم توليفة لعملية البحث ِّوالتحديات التيجرى مواجهتها يف إنجاز أول مسح صحي نفيس مرتكز عىل السكان بني األطفال واملراهقني يف لبنان. ويناقش هذا التقرير التحديات املاثلة والدروس املستفادة يف إجراء هذا املسح. وتتضمن املوضوعات التي نوقشت العمل بشأن عدم وجود إطار مناسب الختيار العينات، والقدرة عىل إجراء دراسة سليمة بتمويل حمدود، وغياب الثقافة البحثية. ِّ مهذا ويقدالتقرير توصيات تسرتشد باألدلة للمسوحات املستقبلية املامثلة. كام ينص التقرير عىل إمكانية إجراء مسح وبائي سليم برغم املوارد املحدودة والسياقات الصعبة كاملشاكل األمنية أو غياب الثقافة البحثية.

References 1. Mental health and substance use- prevention, promotion, and treatment. Situation analysis and strategy for Lebanon 2015–2020. Beirut: Ministry of Public Health; 2015. (http://www.mhinnovation.net/sites/default/files/downloads/resource/MH%20strate- gy%20LEBANON%20ENG.pdf, accessed 14 March 2018). 2. Karam EG, Salamoun MM, Mneimneh ZN, Fayyad JA, Karam AN, Hajjar R, et al. War and first onset of suicidality: the role of mental disorders. Psychol Med. 2012 Oct;42(10):2109–18. https://doi.org/10.1017/S0033291712000268 PMID:22370047 3. Karam EG, Mneimneh ZN, Karam AN, Fayyad JA, Nasser SC, Chatterji S, et al. Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. Lancet. 2006 Mar 25;367(9515):1000–6. https://doi.org/10.1016/S0140-6736(06)68427-4 PMID:16564362 4. Farhood LF, Dimassi H. Prevalence and predictors for post-traumatic stress disorder, depression and general health in a population from six villages in South Lebanon. Soc Psychiatry Psychiatr Epidemiol. 2012 Apr;47(4):639–49. https://doi.org/10.1007/ s00127-011-0368-6 PMID:21455787 5. Husain F, Anderson M, Lopes Cardozo B, Becknell K, Blanton C, Araki D, et al. Prevalence of war-related mental health conditions and association with displacement status in postwar Jaffna District, Sri Lanka. JAMA. 2011 Aug 3;306(5):522–31. https://doi. org/10.1001/jama.2011.1052 PMID:21813430 6. Aoun A, Garcia FD, Mounzer C, Hlais S, Grigioni S, Honein K, et al. War stress may be another risk factor for eating disorders in civilians: a study in Lebanese university students. Gen Hosp Psychiatry. 2013 Jul-Aug;35(4):393–7. https://doi.org/10.1016/j. genhosppsych.2013.02.007 PMID:23557894 7. Mahfoud ZR, Afifi RA, Haddad PH, Dejong J. Prevalence and determinants of suicide ideation among Lebanese adolescents: results of the GSHS Lebanon 2005. J Adolesc. 2011 Apr;34(2):379–84. https://doi.org/10.1016/j.adolescence.2010.03.009 PMID:20434762 8. Richa S, Rohayem J, Chammai R, Kazour F, Haddad R, Hleis S, et al. ADHD prevalence in Lebanese school-age population. J Atten Disord. 2014 Apr;18(3):242–6. https://doi.org/10.1177/1087054712445065 PMID:22628148 9. Karam EG, Mneimneh ZN, Dimassi H, Fayyad JA, Karam AN, Nasser SC, et al. Lifetime prevalence of mental disorders in Leb- anon: first onset, treatment, and exposure to war. PLoS Med. 2008 Apr 1;5(4):e61. https://doi.org/10.1371/journal.pmed.0050061 PMID:18384228 10. Maalouf FT, Ghandour LA, Halabi F, Zeinoun P, Shehab AA, Tavitian L. Psychiatric disorders among adolescents from Lebanon: prevalence, correlates, and treatment gap. Soc Psychiatry Psychiatr Epidemiol. 2016 08;51(8):1105–16. https://doi.org/10.1007/ s00127-016-1241-4 PMID:27246607 11. Whelan BJ, Savva GM. Design and methodology of the Irish Longitudinal Study on Ageing. J Am Geriatr Soc. 2013 May;61 Suppl 2:S265–8. https://doi.org/10.1111/jgs.12199 PMID:23662718

797

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 797 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

12. Eapen V, Jakka ME, Abou-Saleh MT. Children with psychiatric disorders: The Al Ain community psychiatric survey. Can J Psychia- try. 2003 Jul;48(6):402–7. https://doi.org/10.1177/070674370304800607 PMID:12894615. 13. Eapen V, Swadi H, Sabri S, Abou Saleir M. Childhood behavioural disturbance in a community sample in Al-Ain, United Arab Emirates. East Mediterr Health J. 2001 May;7(3):428–34. PMID:12690763 14. Mullick MSI, Goodman R. The prevalence of psychiatric disorders among 5-10 year olds in rural, urban and slum areas in Bang- ladesh: an exploratory study. Soc Psychiatry Psychiatr Epidemiol. 2005 Aug;40(8):663–71. https://doi.org/10.1007/s00127-005-0939- 5 PMID:16091858 15. Viana MC, Teixeira MG, Beraldi F, Bassani IdS, Andrade LH. Sao Paulo Megacity Mental Health Survey – a population-based epidemiological study of psychiatric morbidity in the Sao Paulo metropolitan area: aims, design and field implementation. Rev Bras Psiquiatr. 2009 Dec;31(4):375–86. PMID:20098829 16. Kessler RC, Berglund P, Chiu WT, Demler O, Heeringa S, Hiripi E, et al. The US National Comorbidity Survey Replication (NCS-R): design and field procedures. Int J Methods Psychiatr Res. 2004;13(2):69–92. https://doi.org/10.1002/mpr.167 PMID:15297905 17. Slade T, Johnston A, Oakley Browne MA, Andrews G, Whiteford H. 2007 National Survey of Mental Health and Wellbeing: methods and key findings. Aust N Z J Psychiatry. 2009 Jul;43(7):594–605. https://doi.org/10.1080/00048670902970882 PMID:19530016 18. Syed EU, Hussein SA, Mahmud S. Screening for emotional and behavioural problems amongst 5-11-year-old school children in Karachi, Pakistan. Soc Psychiatry Psychiatr Epidemiol. 2007 May;42(5):421–7. https://doi.org/10.1007/s00127-007-0188-x PMID:17450455 19. Jaalouk D, Okasha A, Salamoun MM, Karam EG. Mental health research in the Arab world. Soc Psychiatry Psychiatr Epidemiol. 2012 Nov;47(11):1727–31. https://doi.org/10.1007/s00127-012-0487-8 PMID:22388974 20. Lages CR, Pfajfar G, Shoham A. Challenges in conducting and publishing research on the Middle East and Africa in leading journals. Int Mark Rev. 2015;32(1):52–77. https://doi.org/10.1108/IMR-12-2014-0374 21. Mneimneh Z, Axinn WG, Ghimire D, Cibelli KL, Alkaisy MS. Conducting surveys in areas of armed conflict. In: Tourangeau R, Edwards B, Johnson TP, Wolter KM., Bates N. eds. Hard-to-survey populations. Cambridge: Cambridge University Press; 2014:134–56. 22. Central Administration of Statistics. The national survey of household living conditions. Beirut: Presidency of the Council of Ministers; 2007. 23. AAPOR TAAfPOR. Standard definitions – final dispositions of case codes and outcome rates for surveys. Oakbrook Terrace, Illinois: American Association for Public Opinion Research; 2011 (https://www.esomar.org/uploads/public/knowledge-and-standards/codes-and-guidelines/ESOMAR_Standard-Definitions-Final-Dispositions-of-Case-Codes-and-Outcome-Rates-for-Surveys. pdf, accessed 17 March 2018). 24. Goodman R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997 Jul;38(5):581–6. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x PMID:9255702 25. Rigby K, Slee PT. Dimensions of interpersonal relation among Australian children and implications for psychological well-being. J Soc Psychol. 1993 Feb;133(1):33–42. https://doi.org/10.1080/00224545.1993.9712116 PMID:8464217 26. Alyahri A, Goodman R. Validation of the Arabic strengths and difficulties questionnaire and the development and well-being assessment. East Mediterr Health J. 2006;12(Suppl. 2):S138–46. PMID:17361685 27. Mojtabai R. Mental illness stigma and willingness to seek mental health care in the European Union. Soc Psychiatry Psychiatr Epidemiol. 2010 Jul;45(7):705–12. https://doi.org/10.1007/s00127-009-0109-2 PMID:19680588 28. Goodman R, Ford T, Richards H, Gatward R, Meltzer H. The Development and Well-Being Assessment: description and initial validation of an integrated assessment of child and adolescent psychopathology. J Child Psychol Psychiatry. 2000 Jul;41(5):645– 55. https://doi.org/10.1111/j.1469-7610.2000.tb02345.x PMID:10946756 29. Zeinoun P, Bawab S, Atwi M, Hariz N, Tavitian L, Khani M, et al. Validation of an Arabic multi-informant psychiatric diagnostic interview for children and adolescents: development and Well Being Assessment-Arabic (DAWBA-Arabic). Compr Psychiatry. 2013 Oct;54(7):1034–41. https://doi.org/10.1016/j.comppsych.2013.04.012 PMID:23763871 30. CITI. Research ethics and compliance training. CITI. Miami: Collaborative Institutional Training Initiative; (https://www.citipro- gram.org/, accessed 1 July 20180). . 31. Fleitlich-Bilyk B, Goodman R. Prevalence of child and adolescent psychiatric disorders in southeast Brazil. J Am Acad Child Ado- lesc Psychiatry. 2004 Jun;43(6):727–34. https://doi.org/10.1097/01.chi.0000120021.14101.ca PMID:15167089 32. Ravens-Sieberer U, Kurth BM; KiGGS study group; BELLA study group. The mental health module (BELLA study) within the German Health Interview and Examination Survey of Children and Adolescents (KiGGS): study design and methods. Eur Child Adolesc Psychiatry. 2008 Dec;17(S1) Suppl 1:10–21. https://doi.org/10.1007/s00787-008-1002-3 PMID:19132300 33. AlBuhairan FS, Tamim H, Al Dubayee M, AlDhukair S, Al Shehri S, Tamimi W, et al. Time for an adolescent health surveillance system in Saudi Arabia: findings from “Jeeluna”. J Adolesc Health. 2015 Sep;57(3):263–9. https://doi.org/10.1016/j.jadohealth.2015.06.009 PMID:26299553 34. Graham PL 3rd, Lin SX, Larson EL. A U.S. population-based survey of Staphylococcus aureus colonization. Ann Intern Med. 2006 Mar 7;144(5):318–25. https://doi.org/10.7326/0003-4819-144-5-200603070-00006 PMID:16520472 35. Groves RM, Couper MP. Nonresponse in household interview surveys. New York: John Wiley & Sons; 2012.

798

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 798 10/10/2018 12:47:27 PM Report EMHJ – Vol. 24 No. 8 – 2018

36. Bijl RV, van Zessen G, Ravelli A, de Rijk C, Langendoen Y. The Netherlands mental health survey and incidence study (NEME- SIS): objectives and design. Soc Psychiatry Psychiatr Epidemiol. 1998 Dec;33(12):581–6. https://doi.org/10.1007/s001270050097 PMID:9857790 37. Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol. 2007 Sep;17(9):643–53. https://doi.org/10.1016/j. annepidem.2007.03.013 PMID:17553702 38. Kessler RC, Avenevoli S, Costello EJ, Green JG, Gruber MJ, Heeringa S, et al. Design and field procedures in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Int J Methods Psychiatr Res. 2009 Jun;18(2):69–83. https://doi. org/10.1002/mpr.279 PMID:19507169 39. Wells JE, Oakley Browne MA, Scott KM, McGee MA, Baxter J, Kokaua J; New Zealand Mental Health Survey Research Team. Te Rau Hinengaro: the New Zealand mental health survey: overview of methods and findings. Aust N Z J Psychiatry. 2006 Oct;40(10):835–44. https://doi.org/10.1111/j.1440-1614.2006.01902.x PMID:16959009 40. Monshouwer K, VAN Dorsselaer S, Verdurmen J, Bogt TT, DE Graaf R, Vollebergh W. Cannabis use and mental health in secondary school children. Findings from a Dutch survey. Br J Psychiatry. 2006 Feb;188(2):148–53. https://doi.org/10.1192/bjp.188.2.148 PMID:16449702 41. Lai MH, Kwok O. Examining the rule of thumb of not using multilevel modeling: The “design effect smaller than two” rule. J Exp Educ. 2015;83(3):423–38. https://doi.org/10.1080/00220973.2014.907229 42. Daouk-Öyry L, Zeinoun P, Choueiri L, van de Vijver, FJR. Integrating global and local perspectives in psycholexical studies: a GloCal approach. J R Personality. 2016;62:19–28. https://doi.org/10.1016/j.jrp.2016.02.008 43. Mohler P, Dorer B, Jong J, Mengyao H. Cross-Cultural Survey guidelines; team translation. translation overview. In: Guidelines for best practice in cross-cultural surveys. Ann Arbor: Survey Research Center, Institute for Social Research, University of Michi- gan; 2016. http://ccsg.isr.umich.edu/index.php/chapters/translation-chapter/translation-overview#Team_translation 44. Erskine H, Baxter A, Patton G, Moffitt TE, Patel V, Whiteford HA, et al. The global coverage of prevalence data for mental disorders in children and adolescents. Epidemiol Psychiatr Sci. 2017 Aug;26(4):395-402. PMID:26786507

799

10- Contextual challenges and solutions to undertaking a household adolescent mental health survey in a developing country NEW.indd 799 10/10/2018 12:47:27 PM WHO events addressing public health priorities EMHJ – Vol. 24 No. 8 – 2018

National population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators1

Citation: National population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators. East Mediterr Health J. 2018;24(8):800–801. https://doi.org/10.26719/2018.24.8.800 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

The strengthening of health information systems is a The objectives of the meeting were to: priority for the World Health Organization (WHO) in • discuss current initiatives and future plans by WHO the Eastern Mediterranean Region. Intensive work with and other agencies to improve health statistics countries since 2012 has resulted in a framework for through national population-based surveys in the health information systems (1) and 68 core indicators Region; that focus on three main areas, which are: monitoring health determinants and risks; assessing health status, • present results of an agreed programme of work including morbidity and cause-specific mortality; and by external consultants on prioritizing surveys and assessing health system response. Key Sustainable make them applicable to the countries in the Region; Development Goals’ (SDG) indicators (2) have been • discuss modalities and capacities to report on WHO recently incorporated in the regional core indicators list regional core indicators, SDG 3 indicators and other to provide countries with a unified approach for reporting SDG health-related indicators; and on health-related indicators. This brings the current list of • review recommended modules and plans for national core indicators to 75. A recent assessment of the capacity population-based surveys and the needed resources of countries in the Region to report on the initial 68 core for improving the reporting and quality of health health indicators showed that most of the indicators indicators in the Region. within the area of health determinants and risks come The meeting was inaugurated by Dr Arash Rashidian, from population-based surveys that should be conducted Director, Information, Evidence and Research, WHO every 3–5 years (3). Furthermore, a majority of countries Regional Office for the Eastern Mediterranean, use international funds to conduct the population-based Cairo, Egypt. In his opening remarks, he reiterated surveys, thereby limiting their ability to conduct surveys the commitment of WHO in supporting countries to according to their needs (3). strengthen their national health information systems Within the context of the SDGs, population-based and enhance reporting on the regional core health surveys still play a key role as sources of data for most indicators to monitor progress towards universal health of the SDG 3 and other SDG health-related indicators. In coverage. He noted that strengthening national health August 2016, the WHO Regional Office for the Eastern information systems is part of the overarching agenda Mediterranean (WHO/EMRO) organized an intercountry of implementing the regional framework for health meeting to review the results of the assessment and map information systems and improving civil registration out strategies to better support countries to report on the and vital statistics reporting. core indicators and the SDG 3 indicators on health (4). In working groups, the experts discussed the following During the meeting, participants recommended the need key areas related to the implementation of population- to document the available national population-based based surveys: a recommended list and timetable for surveys in the Region and identify those surveys that are population-based surveys for better reporting of core expected to generate data for the core health indicators health indicators; main survey modules to be considered and SDG 3 indicators. as part of survey plans; the number of recommended A team of consultants then developed options for a surveys to be conducted and the ideal inter-survey period; prioritized list of national household surveys in response and survey and data needs for countries experiencing to recommendations by meeting participants. Following humanitarian emergencies. this, WHO Regional Office for the Eastern Mediterranean convened an expert consultative meeting to discuss Recommendations priority population-based surveys for better reporting of Recognizing the critical role of population-based WHO regional core indicators and SDG 3 indicators in surveys in generating data for most of the core health Cairo, Egypt, 11–12 December 2017 (5). and SDG health-related indicators, experts agreed the

1 This report is extracted from the Summary report on the Expert consultative meeting to discuss priority national population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators, Cairo, Egypt, 11–12 December 2017 (http://applications.emro.who. int/docs/IC_Meet_Rep_2018_EN_16792.pdf).

800

0 WHO events 24-08.indd 800 10/10/2018 12:34:31 PM WHO events addressing public health priorities EMHJ – Vol. 24 No. 8 – 2018

following recommendations to facilitate implementing a • Supporting development of realistic national survey prioritized list of national population-based survey plans plans for population-based surveys that can be ef- and modules, and enhancing efforts to improve health fectively implemented using available expertise and information systems. resources. To Member States • Providing guidance on implementing population-based surveys in countries with humanitarian • Enhancing efforts to increase awareness of the role of emergencies. health information systems in policy planning. • Supporting countries in developing data sharing poli- • Aligning survey plans with national health strate- cies and databases to enhance public access to data in gic plans to effectively monitor implementation of conformity with each country’s statistics legislation. health strategies. • Supporting countries to establish national coordi- To WHO nation mechanisms or working groups to mobilize • Providing further guidance on the following key resources and expertise for implementing popula- components of population-based survey implementation-based surveys. tion: survey modules; time intervals between surveys; geographical coverage; and suitable representative sample sizes.

References 1. World Health Organization. Eastern Mediterranean Region: Framework for health information systems and core indicators for monitoring health situation and health system performance. Geneva: World Health Organization; 2017 (http://applications.emro. who.int/docs/EMROPUB_2017_EN_16766.pdf?ua=1). 2. United Nations. Sustainable Development Goals: SDG Indicators. New York: United Nations; 2015 (https://unstats.un.org/sdgs/ indicators/indicators-list/). 3. World Health Organization. Global Health Observatory Data Repository (Eastern Mediterranean Region): catastrophic out-of- pocket health spending (SDG indicator 3.8.2) estimates by UN region. Geneva: World Health Organization; 2017 (http://apps.who. int/gho/data/view.main-emro.FINANCIALPROTECTIONUNREG01v?lang=en). 4. WHO Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the Intercountry workshop on country capacity to report on core indicators. Cairo: WHO/EMRO; 2016 (http://applications.emro.who.int/docs/IC_Meet_rep_2016_ en_19340.pdf?ua=1). 5. Expert consultative meeting to discuss priority national population-based surveys for better reporting of WHO regional core indicators and SDG health-related indicators, Cairo, Egypt, 11–12 December 2017 (http://applications.emro.who.int/docs/IC_Meet_ Rep_2018_EN_16792.pdf).

801

0 WHO events 24-08.indd 801 10/10/2018 12:34:31 PM Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services 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 collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.

EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm

EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/

Cover 24-08.indd 4-6 10/9/2018 5:44:47 PM EMHJ – Vol. 24 No. 8 – 2018 Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale Editorial Implementing WHO’s global strategy in the Eastern Mediterranean Region: what next? Ahmed Al-Mandhari...... 703 Research articles Socioeconomic factors associated with tobacco smoking in Turkey: a cross-sectional, population-based study Ceyda Sahan, Turkan Gunay, Hatice Simsek, Ahmet Soysal and Gul Ergor...... 705 Factors associated with smoking contemplation and maintenance among Iranian adolescents Hamidreza Roohafza, Razieh Omidi, Tahereh Alinia, Kamal Heidari, Gholamhossein Mohammad-Shafiee, Morid Jaberifar, Masoumeh Sadeghi and Wasim Maziak...... 714 Assessing sleep quality of Lebanese high school students in relation to lifestyle: pilot study in Beirut Ramez Chahine, Rita Farah, Michèle Chahoud, Alain Harb, Rami Tarabay, Eric Sauleau and Roger Godbout...... 722 Adapting life to the reality of diabetes Hossein Areshtanab, Hossein Moonaghi, Leila Jouybari, Vahid Zamanzadeh and Hossein Ebrahimi...... 729 Assessment of hepatitis B immunization programme among school students in Qatar Hamad Al-Romaihi, Hana Al-Masri, Sherine Shawky, Mohammed Al Thani, Salah Al Awaidy, Mohamed Al Janahi, Eastern Mediterranean Health Journal Muataz Derbala, Khalid Al-Ansari and Robert Allison...... 736 Validation of an Arabic version of the Yale Food Addiction Scale 2.0 Mounir Fawzi and Mohab Fawzi...... 745 Systematic review of priority setting studies in health research in the Islamic Republic of Iran Abbas Badakhshan, Mohammad Arab, Arash Rashidian, Mahin Gholipour, Elham Mohebbi and Kazem Zendehdel...... 753 Reviews Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression Kamal Gholipour, Mohammad Asghari-Jafarabadi, Shabnam Iezadi, Ali Jannati and Sina Keshavarz...... 770

Availability and safety of blood transfusion during humanitarian emergencies Vol. 24 No. 8 Yetmgeta Abdella, Rana Hajjeh and Cees Th. Smit Sibinga...... 778 Report

املجلد الرابع والعرشون / عدد Volume 24 / No. 8 2018 8 أغسطس/آب August/Août

Cover 24-08.indd 1-3 10/9/2018 5:44:47 PM