Eastern Mediterranean Health Journal
La Revue de Santé de la Méditerranée orientale
Although morbidity and mortality from noncommunicable diseases (NCDs) mainly occur in adulthood, exposure to risk factors begins in early life and interventions to prevent and control NCDs at this stage of life often offer the best chance for primary prevention
Volume 19 / No. 9 September / Septembre 2013 ÄØ{L PL HnUÐ{dCÐ FeH édxÌ GBÐçOTogZTÐocBÐ x{bUFfYwí phCn_UÐp[UÐpe^fe=HCÐçPUehdSüÐocCÐLÚ{[>UÐpheH}UÐpdCÐw phýn=UÐÓnh]_CÐíhwnaCÐíÊÐÚùÐéØnUíºn4sxíGUÐíph[UÐÓnY{#Ð;Ò{x{!ÐÓÐÚØnCÐíÓnHnhUÐ TOÎpg@Ywí HCÐç hdSl=ngfYd_xnYpÉnBíºÓnYd_CÐYUÙEQíÔn=úÐsýnií ~TÐ}CÐíºphf_CÐphYc"ÐEQÓ5^fCÐÐ|Tíºphehd_UÐ{wn_CÐ}ýnHíph]UÐÓnhdcUÐíºph[UÐgCÐÊn\LÌ @ÚnBíhdSüÐ;p[Un=NegCÐØÐ}RúÐíphCn_UÐp[UÐpe^fY Ypiín_CÐ
EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region.
LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région.
EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/
EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR).
©World Health Organization 2013 All rights reserved
Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mentionof specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event halls the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.
ISSN 1020-3397
Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale
Vol. 19 No. 9 r r ÄØ{LPL HnUÐ{dCÐ Contents Editorial The United Nations Political Declaration on on-communicableN Diseases: are countries of the Eastern Mediterranean Region ready to respond? Ala Alwan...... 757 Research articles Physical activity and perceived barriers among high-school students in Muscat, Oman R.M. Youssef, K. Al Shafie, M. Al-Mukhaini and H. Al-Balushi ...... 759 Epidemiology of autistic disorder in Bahrain: prevalence and obstetric and familial characteristics A.M. Al-Ansari and M.M. Ahmed ...... 769 Comparison of maternal characteristics in low birth weight and normal birth weight infants M. Nazari, S.Y. Sharifah Zainiyah, M.S. Lye, M.S. Zalilah and M. Heidarzadeh ...... 775 Users of withdrawal method in the Islamic Republic of Iran: are they intending to use oral contraceptives? Applying the theory of planned behaviour P. Rahnama, A. Hidarnia, F.A. Shokravi, A. Kazemnejad, A. Montazeri, F.R. Najarkolaei and A.Saburi ...... Key role players in health care quality: who are they and what do they think? An experience from Saudi Arabia M.S. Mahrous ...... 788 Health-care professionals’ perceptions and expectations of pharmacists’ role in the emergency department, United Arab Emirates S.A. Fahmy, B.K. Abdul Rasool and S. Abdu ...... 794 Compliance with the guidelines of prescription writing in a central hospital in the West Bank Y.I. Tayem, M.A. Ibrahim, M.M. Qubaja, R.K. Shraim, O.B. Taha and E. Abu Shkhedem ...... What do we need to eradicate rubella in the Islamic Republic of Iran? F. Almassinokiani, S. Noorbakhsh, M. Rezaei, A. Almasi, H. Akbari, S. Asadolla, P. Rahimzadeh and M. Saberifard ...... Seroprevalence of rubella among pregnant women in Khartoum state, Sudan O. Adam, T. Makkawi, A. Kannan and M.E. Osman ...... National guidelines for outbreak investigation: an evaluation study M. Fararouei, S. Rezaee, A. Raigan Shirazi, M. Naghmachi, K. Karimzadeh Shirazi, A. Jamshidi and J. Jafari ...... 816 Reports Unusual sex differences in tuberculosis notifications across Pakistan and the role of environmental factors M.S. Khan, M.S. Khan, R. Hasan and P. Godfrey-Faussett ...... Addressing maternal and child health in post-conflict Afghanistan: the way forward P.K. Singh, R.K. Rai and M. Alagarajan ...... Dr Ala Alwan, Editor-in-chief Editorial Board Professor Zulfiqar Bhutta Professor Mahmoud Fahmy Fathalla Professor Rita Giacaman Dr Ziad Memish Dr Sameen Siddiqi Professor Huda Zurayk International Advisory Panel Dr Mansour M. Al-Nozha Professor Fereidoun Azizi Professor Rafik Boukhris Professor Majid Ezzati Dr Zuhair Hallaj Professor Hans V. Hogerzeil Professor Mohamed A. Ghoneim Professor Alan Lopez Dr Hossein Malekafzali Professor El-Sheikh Mahgoub Professor Ahmed Mandil Dr Hooman Momen Dr Sania Nishtar Dr Hikmat Shaarbaf Dr Salman Rawaf Editors Fiona Curlet, Guy Penet Eva Abdin, Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky
Book 19-9.indb 756 10/7/2013 2:40:22 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Editorial The United Nations Political Declaration on Non- communicable Diseases: are countries of the Eastern Mediterranean Region ready to respond? Ala Alwan1
Noncommunicable diseases (NCDs), A large proportion of NCDs can be countries have varying weaknesses in mainly cardiovascular diseases, diabe- prevented by reducing the four main the three essential elements of the sur- tes, cancers and chronic respiratory risk factors: tobacco use, physical inac- veillance framework: a) motoring risk diseases, are the leading causes of death tivity, unhealthy diet and the harmful factors and determinants, b) monitor- globally and in the World Health Or- VTFPGBMDPIPM<>.VDIPGUIFEJTFBTF ing outcomes, specifically mortality and ganization’s Eastern Mediterranean Re- Through implementation of the global morbidity, and c) monitoring health gion (WHO-EMR) [1]. These diseases strategy for the prevention and control system capacity and response. Although have reached epidemic proportions, of noncommunicable diseases and by most countries have conducted risk fac- yet they could be significantly reduced, adopting the tools to reduce the risk fac- tors studies, surveys are not carried out with millions of lives saved and untold tors [4], much of the burden of NCDs at regular intervals, they are not institu- suffering avoided, through prevention, and the human suffering they cause can tionalized and the results are not neces- early detection and timely treatment. be avoided. In that regard, the Political sarily linked with policy and programme Declaration of the High-Level Meeting As the extent of NCDs increases, and development. Furthermore, the major- of the United Nations General Assem- ity of the countries of the Region face as populations age, annual deaths from bly on the Prevention and Control of considerable challenges in generating these diseases are projected to continue Non-communicable Diseases, adopted reliable cause-specific mortality rates to rise worldwide; however, together by Heads of State and Government for NCDs. In the area of prevention and with Africa, EMR is estimated to see JO4FQUFNCFS QSPWJEFTBSPBE control of risk factors, much work still the greatest increase [1]. NCDs kill at map for Member States to address the needs to be done by countries to control a younger age in developing countries NCD epidemic [5]. Among the com- the main risk factors. There are gaps in including our Region where, in some mitments made by governments was the adoption, implementation and en- DPVOUSJFT VQUPPGUIPTFXIPEJF strengthening national action against forcement of control policies and meas- from such diseases die below the age NCDs in the three key components of ures. This is reflected in persistently high PGZFBST DPNQBSFEUPMFTTUIBO the global strategy: surveillance, preven- rates of tobacco use, the unrestrained in Western Europe [1]. Morbidity, tion and health care. marketing of foods and non-alcoholic disability and premature death reduce While our Region is increasingly beverages to children and the high levels productivity and have a serious negative recognizing the importance of NCDs of salt and fat intake in many countries impact on sustainable development. as a leading health challenge, action has [7]. Lack of sufficient physical activ- In poorer populations most health been generally slow and fragmented in ity and overweight and obesity are also care costs must be paid directly out many countries. National policies and widely prevalent. As regards health care, of pocket by patients; thus the cost of plans for NCDs are often underdevel- efforts to integrate care for common health care for patients with NCDs can oped or non-operational. Engagement conditions such as high blood pressure, be a significant burden on household of key non-health sectors is weak in al- diabetes and breast cancer into primary budgets of lower income families and most all countries. National institution- health care are still ongoing. At the same may drive them below the poverty line. al capacity is frequently inadequate and time, there are widespread inequities Many countries of the Region have very programmes are typically underfunded in access to health care that affect out- high rates of out-of-pocket expenditure, without clear budgetary allocations [6]. comes of NCDs, while several countries SFBDIJOHMFWFMTBTIJHIBTXIJMFOJOF Major gaps exist in all three key in the Region are experiencing acute DPVOUSJFTIBWFSBUFTPWFS<> component of the strategy [7]. All the or chronic humanitarian emergencies
1Regional Director, World Health Organization Regional Office for Eastern Mediterranean, Cairo, Egypt
757
Book 19-9.indb 757 10/7/2013 2:40:22 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
where access to care for NCDs is a ma- A three-year review of the progress NCDs will reach levels well beyond the jor challenge. made by Member States in implement- capacity of countries and their interna- All countries need to tackle the ing the commitments of the UN Po- tional partners to manage. existing gaps and scale up action to litical Declaration is scheduled for the An outline of the action needed by combat NCDs. Multisectoral national MBTURVBSUFSPGBUUIF6/(FOFSBM the countries of the Region was clearly policies and plans need to be developed Assembly. It is therefore imperative for articulated and endorsed during the and strengthened in partnership with Member States and WHO to plan 59th WHO Regional Committee key actors in non-health sectors. Top ahead and work together with other for the Eastern Mediterranean in the priorities include the implementation regional and international partners both strategic framework for action which of cost-effective measures for tobacco within and outside the health sector, in covers the commitments of Member control, diet and physical activity as well order to make the necessary progress States to respond to the Political Dec- as action to control the promotion of and demonstrate a credible record of laration of the UN General Assembly unhealthy dietary patterns to children. achievements in the prevention and on NCDs [8]. The framework pro- Strengthening national systems for dis- control of NCDs in the Region. vides a practical and evidence-based ease surveillance is also crucial in order In conclusion, the NCD epidemic list of priority interventions to guide to understand the current situation and exacts an enormous toll on this Region, national authorities in responding monitor progress. Improved health care in terms of disease burden, human suf- to the NCD challenge in four areas: for people with NCDs requires action at fering and human development. The governance, surveillance, prevention all levels of the health system, although response has not been commensurate and health care. If implemented, the integration of priority interventions for with the magnitude and seriousness of framework provides an historic and NCDs at the primary health care level the challenge. This must be redressed unique opportunity for our Region holds the greatest promise for impact and committed, serious action taken by to demonstrate leadership and take and return on investment. the countries; otherwise the burden of decisive action.
References
1. The Political Declaration of the United Nations General Assembly 5. Political Declaration of the High-level Meeting of the General on the Prevention and Control of Non-Communicable Diseases: Assembly on the Prevention and Control of Non-communi- Commitments of Member States and the way forward. Technical cable Diseases. Sixty-sixth session of UN General Assembly, Discussion paper, Fifty-ninth session of the Regional Commit- January 2012 (Resolution 66/2). tee for the Eastern Mediterranean, October 2012 (EM/RC59/3) 6. Assessing national capacity for the prevention and control of (http://applications.emro.who.int/docs/RC_technical_pa- noncommunicable diseases: report of the 2010 global survey. pers_2012_3_14578_EN.pdf, accessed 30 September 2013). Geneva, World Health Organization, 2012 (http://www.who. 2. Health systems strengthening in countries of the Eastern Medi- int/cancer/publications/national_capacity_prevention_ncds. terranean Region: challenges, priorities and options for future pdf, accessed 30 September 2013). action. Technical Discussion paper, Fifty-ninth session of the 7. Implementing the United Nations Political Declaration on Regional Committee for the Eastern Mediterranean, October Prevention and Control of Noncommunicable Diseases 2012 (EM/RC59/Tech.Disc.1) (http://applications.emro.who. based on the regional framework for action (EM/RC60/9) int/docs/RC_technical_papers_2012_Tech_Disc_1_14613_ (http://applications.emro.who.int/docs/RC_Techn_pa- EN.pdf, accessed 30 September 2013). per_2013_9_15001_EN.pdf, accessed 30 September 2013). 3. Global status report on noncommunicable diseases 2010. Gene- 8. Framework for action to implement the United Nations Political va, World Health Organization, 2011 (http://whqlibdoc.who. Declaration on Noncommunicable Diseases: Annex to resolution int/publications/2011/9789240686458_eng.pdf, accessed 30 EM/RC59/R.2. Fifty-ninth session of the Regional Committee September, 2013). for the Eastern Mediterranean, October 2012 (http://ap- 4. Follow-up to the Political Declaration of the High-level Meet- plications.emro.who.int/docs/RC_Resolutions_2012_2_An- ing of the General Assembly on the Prevention and Control nex_14778_EN.pdf, accessed 30 September 2013). of Non-communicable Diseases. Sixty-Sixth World Health Assembly, May 2013 (WHA66.10) (http://apps.who.int/gb/ ebwha/pdf_files/WHA66/A66_R10-en.pdf, accessed 30 September 2013).
758
Book 19-9.indb 758 10/7/2013 2:40:23 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Physical activity and perceived barriers among high- school students in Muscat, Oman R.M. Youssef,1 K. Al Shafie,1 M. Al-Mukhaini 1 and H. Al-Balushi 1
ë5KºaX9owhmTÐoc@|BÐoô có IM<oSó Úzó dåTÐýÐ^TÐíoghzTÐo\YhúÐô ¡dUÐ{e7hwÐ}=Îp[AºfhCÐ{@nYÒEfYº haZUÐcYJ}?TºHxØe7Ð{iÚ :pxinUÐpdA}CÐpdó JYó 439î{Uphi{UÐp]ZiúÐÓÐØ{7íÕÙ5ipHÐÚ{Un}_Yð nYð 2011ÜÚnY ÚÐÙË:ëAnUÐî}@ÌoåÉ°#Ð 95.9 52.9 Ld=Ì{SgfY% ëÌíºphnx}UÐph=GUÐ[A:ëªnx% pdó ]UÐ[iëÌy\>Ðí ó nh>ÐÙÚÐ{ð xënhHÐDLô ÐØnfHкbYp^Rn7ð nYphi{UÐp]ZiúÐY=¥CÐîCÐÐTÚØÌ{SÑĆ]UÐY%23.9ëÌn\xÌNAndUy\>Ðí pHÚ{CÐYæÐWiøÐ{_=phi{=p]ZiúpHÚn,ð ÑĆ]UÐî{UngnaiÐY}TÌ%9.8ÓnUn]UÐî{Up\afYpfUÐì|wëÌøÎÅâHÌTýnS{UÐYnh=ĆbHÐð nþRncYð 1680DL{x~xíÌéØn_x YFTÌØ{L=nbY:ºÓnfx}eUn=ênhbUn=%26.7EcaUÐpdA}Y:í%5.8EcaUÐSnYpdA}Y:ÓnUn]UÐYFTÌØ{LënTí %38.8) Ónfx}edUgýÐØÌx}J:b>ýÐLLÓnUn]UÐq`d=Ì{Sí %36.0pYíÐ{CÐpdA}Y:íº%15.4Ónfx}eUn=_aUn=ëYbxÐinTÑĆ]UÐ d_>ýÐLíºghUÎÓÐ}^fUÐYæ#Ðíº hZUÐ{bRíºî}BúÐp]Ziún=ê5wøÐíÌpSn]UÐ{baUØ_xnYngfYºnhýn[AÎhªj=ð {_x´ Ú{SDLò ÒPLpxØn"ÐpfUÐ:ÑĆ]UÐëÌYncUÐ@dUÐæUÐÕÙei}gKÌí phdýn_UÐÓnYÐ~UøÐíphexØnTúÐÓnhUíkCÐo=´ pHÚ5CÐÓnSíj= ëÛUÐYn)¥CÐÓnxedUgdÉ>n¹Ìë_SxUÐphi{UÐp]ZiúÐpHÚn,éĆBY¹Ûíh^f>ëUín²
ABSTRACT A cross-sectional survey was conducted in March 2011 to study the patterns and determinants of physical activity among 439 secondary-school students in Muscat governorate based on a self-administered questionnaire. Half of the students (52.9%) were enrolled in physical education classes and 95.9% reported after- school physical activities. The recommended level of physical activity (≥ 1680 MET minutes/week) was met by 23.9% of students, being significantly lower among girls (9.8%) than boys (38.8%). More girls were in the stages of pre-contemplation (5.8%) and contemplation (26.7%) of adopting exercise while more boys were in the action (15.4%) and maintenance stages (36.0%). Girls reported significantly more barriers to exercise, related to lack of energy, interest in other activities, lack of encouragement, worries about looks, and time constraints from academic responsibilities and family obligations. The full model logistic regression revealed that boys, 11th-grade students and attempts to regulate weight significantly predicted physical activity meeting the recommended levels.
Activité physique des lycéens et obstacles perçus par ces derniers à Mascate (Oman)
RÉSUMÉ Une enquête transversale a été menée en mars 2011 pour étudier les caractéristiques et les facteurs déterminants de l'activité physique de 439 lycéens dans le gouvernorat de Mascate à l'aide d'un auto-questionnaire. La moitié des lycéens (52,9 %) ont été recrutés dans le cours d'éducation physique et 95,9 % déclaraient avoir des activités sportives après l'école. Le niveau d'activité physique recommandé (t 1680 minutes MET [équivalence métabolique] par semaine) était atteint par 23,9 % des élèves, mais il était nettement inférieur chez les filles (9,8 %) que chez les garçons (38,8 %). Les filles étaient plus nombreuses à être au stade de la pré-réflexion (5,8 %) et de la réflexion (26,7 %) au sujet de l'adoption d'une activité physique tandis que les garçons étaient plus nombreux à être au stade de l'action (15,4 %) et du maintien (36,0 %). Les filles déclaraient rencontrer davantage d'obstacles à la pratique d'une activité physique, tels qu'un intérêt pour d'autres activités, l'absence d'encouragement, l'inquiétude vis-à-vis du regard des autres, et des contraintes de temps par rapport aux obligations scolaires et familiales. Le modèle de régression logistique appliqué a permis de découvrir que le fait d'être un garçon, ou d'être en avant dernière année de lycée ou de tenter de réguler son poids étaient des facteurs fortement prédictifs d'une activité physique à la hauteur des niveaux recommandés.
1Department of Family Medicine and Public Health, Sultan Qaboos University, Muscat, Oman (Correspondence to R.M. Youssef: rahman.randa@ gmail.com). Received: 07/05/12; accepted: 02/09/12
759
Book 19-9.indb 759 10/7/2013 2:40:23 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Introduction survey of college students revealed the estimated minimum sample size UIBUPOMZPGUIFNXFSFQIZTJ- XBTTUVEFOUT Noncommunicable diseases (NCDs) DBMMZBDUJWFGPSNJOVUFTQFSEBZ<> A multistage sampling technique have emerged as a global public health Anshel pointed to a number of factors was used to select schools and enrol concern. Of the 56 million deaths that that predict physical activity, including students. Out of the 6 education re- PDDVSSFEJO XFSFEVFUP attitudes towards physical exercise, level gions, 4 with the highest population /$%BOEOFBSMZPGUIFTFEFBUIT and stage of motivation as well as the size were selected. From each region, occurred in low- and middle-income QFSDFJWFECBSSJFSTUPFYFSDJTJOH<> TFDPOEBSZQVCMJDTDIPPMT GPSHJSMT countries [1]. Oman is no exception, Previous studies in Oman have fo- and 1 for boys) were randomly selected. BTPGUIFEFBUITUIBUPDDVSSFEJO cused on the rates of physical activities Two classes (1 of each grade) were XFSFEVFUP/$%BOEPG and exercise, without addressing the randomly selected from each school these deaths were due to cardiovascular determinants. Detailed investigation of and all Omani national students were EJTFBTFT<>ĉFIJHISBUFTPGNPSCJE- the obstacles is indispensable for pro- requested to participate. Non-Omani ity and mortality from chronic diseases moting physical activity among Omani students were excluded. threaten the gains in health and longev- children. This study aimed to describe Data collection ity achieved over the past 4 decades the patterns and determinants of physi- and the sustainability of the health-care cal activity among secondary-school A self-administered, pre-tested and pre- system. Expenditure on health care in students and to identify the perceived coded questionnaire was developed 0NBOSPTFCZCFUXFFOBOE barriers to exercise. The findings of the for data collection in the classroom BOECZUIFZFBSUSFBUNFOU current study will guide the planning of setting with the presence of one of the of cardiovascular diseases alone is pre- relevant programmes promoting physi- investigators. It included the demo- EJDUFEUPBDDPVOUGPSPGUIFUPUBM cal activity by addressing effectively the HSBQIJDDIBSBDUFSJTUJDTPGTUVEFOUT IFBMUIDBSFFYQFOEJUVSF<> perceived barriers and the stage of moti- questions), physical education classes The predominant factors in the vation of schoolchildren. in school (including the number and emergence of NCD in Oman are duration of classes per week), pattern assumed to be the changes in the nu- of participation and types of activities tritional habits of the population and Methods (5 questions), the frequency and inten- the decline in habitual physical activi- sity of 14 types of out-of-school hours ties brought by the economic leap of A cross-sectional survey was conducted physical activities (15 questions) and UIFTBOET<>4ZTUFNBUJD JO.BSDIJO.VTDBUHPWFSOPSBUF the time spent in small-screen sedentary analysis of population health data has targeting Omani students enrolled in BDUJWJUJFT RVFTUJPOT "TFUPGRVFT- revealed that these factors are amenable secondary public schools. tions was used to assess the internal to modification [5–7] by implement- (6 questions) and external barriers (6 Sample ing large-scale community intervention questions) to exercising [15,16]. All programmes focusing on increased The sampling frame consisted of a list questions were negatively phrased with physical activity and healthier food of all secondary public schools in each 5 responses ranging from strongly disa- options, particularly for children [8]. educational region. The primary sam- gree (score 1) to strongly agree (score Childhood can be a period of acquir- pling unit was the educational region, 5). Respondents were also asked about ing healthy habits that last across the the secondary sampling unit was the attempts to maintain or lose weight in lifespan and schools offer the best schools and the third was the classes. UIFEBZTQSFDFEJOHUIFTVSWFZ opportunity, as physical education is The unit of enquiry was school students questions). The weight and height of one of the 8 components of the school FOSPMMFEJOUIBOEUIHSBEFTĉF each student was obtained following IFBMUIQSPHSBNNF<>BOEOFBSMZ sample size was estimated using the Epi standard procedures. of the Omani population between 5 and InfoQSPHSBN WFSTJPO<> CBTFE Students were informed about the ZFBSTDBOCFSFBDIFE<>%FTQJUF on the number of students in 11th and purpose of the study and its implica- the opportunities for exercise offered UIHSBEFTJO.VTDBUHPWFSOPSBUF tions for health programmes planning. in Omani schools a study reported GPSUIFTDIPMBTUJDZFBS n = Emphasis was placed on voluntary UIBUPOMZPGUIUPUIHSBEF 16 676) [14] and prevalence of physical participation, the anonymity of the TUVEFOUTXFSFQIZTJDBMMZBDUJWFGPS BDUJWJUZPGSFQPSUFECZUIF(MPCBM questionnaire and the confidentiality minutes per day [9]. Apparently the pat- School Based Health Study [9], with of the information during all phases of tern of physical activities extends to late BEFHSFFPGQSFDJTJPOBOEBEFTJHO the study. The study was approved by adolescence and adulthood, as a recent effect of 1.5. Based on this assumption, the ethics committee at Sultan Qaboos
760
Book 19-9.indb 760 10/7/2013 2:40:23 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
University and the Ministry of Educa- and that for the scale of external barriers GPSNJOVUFTQFSXFFL)PXFWFS DPO- tion and a written informed consent was XBT TJEFSBCMFQSPQPSUJPOTPGHJSMT obtained from students prior to data SPSS, version 16 was used for data BOECPZT XFSFJSSFHVMBSJOBU- collection. analysis. The odds ratio (OR) and as- tending these physical education class- TPDJBUFEDPOėEFODFJOUFSWBM $* es. Although boys were not significantly Data analysis were computed. The chi-squared and more likely to opt for physical education The intensity of all activities performed the t-test for independent samples were DMBTTFTSFMBUJWFUPHJSMT 03 in after-school hours combined was the tests of significance used. Univariate $*m UIFZXFSFUJNFTNPSF calculated as the sum of each type of and multivariate logistic regression anal- likely to attend physical education class- activity weighted by its energy equiva- yses were used to identify the predictors FTFJUIFSBMXBZT 03 $* lent and expressed as the metabolic of physical activity. The significance of m PSTPNFUJNFT 03 equivalent of task (MET) per week as the obtained results was judged at the $*m #BMMHBNFTXFSF GPMMPXT.&5NJOVUFTXFFL Ϗ FO- MFWFM the predominant type of activity during ergy equivalent of the task × number physical education classes among boys of days × duration per minute). The BOEHJSMT XJUIOPEJĎFSFODF FOFSHZFRVJWBMFOUXBTGPSXBMLJOH Results between the sexes. Types of exercises for moderate activity and 8 for vigorous more frequently reported by girls were activity. Multiples of 1 MET indicated Background characteristics KPHHJOH BFSPCJDT BOE higher energy expenditure in a specific ĉFTUVEZJODMVEFETUVEFOUT SPQFKVNQJOH activity [17,18]. The recommendation HJSMT BOECPZT PGNJOVUFTQFSEBZPGNPEFSBUFBD- XJUIFOSPMMFEJOUIHSBEF Physical activity in after- tivity for school-age children [18,19], BOEJOUIHSBEF ĉF school hours FRVJWBMFOUUP.&5NJOVUFT majority were in the age group 15–< Physical activities in after-school hours XFFLBOEDBMDVMBUFEBTϏ NJOVUFT 17 years (n BOEm for recreation or exercising were re- ¤.&5¤EBZT <> XBTUBLFO 19 years (n XIJMFBGFX QPSUFECZPGCPZTBOEPG to classify students. “Physically active” XFSFJOUIFBHFHSPVQmZFBST n HJSMTBOEJUXBTUJNFT $* students were those who accumulated ĉFNBKPSJUZPGTUVEFOUT m NPSFMJLFMZBNPOHCPZT ɓ .&5 NJOVUFTXFFL XIJMF (n SFQPSUFEBNPOUIMZ 5BCMF (JSMTXFSFOFBSMZUJNFT “physically inactive” were those who family income sufficient to cover their more likely to report walking (OR = BDDVNVMBUFE .&5NJOVUFT expenses, either with savings (n $*m DMJNCJOH week. PSXJUIPVUTBWJOHT n TUBJST 03 $*m Body mass index (BMI) was cal- XIJMFBTNBMMQSPQPSUJPOSFQPSU- BOEDZDMJOH 03 $*m culated from weight and height data ed a monthly family income insufficient 4.47). Boys were nearly 8 times (OR = and the participants were classified into in most (n PSBMMNPOUIT n $*m NPSFMJLFMZ VOEFSXFJHIU #.* LHN), nor- to report weight lifting and were nearly NBMXFJHIU #.*mLHN ), Chronic health problems requiring UJNFTNPSFMJLFMZUPQBSUJDJQBUFJOCBMM PWFSXFJHIU #.*mLHN ) and NFEJDBMDBSFXFSFSFQPSUFECZPG HBNFT 03 $* m PCFTF #.* LHN ). The latter HJSMTBOEPGCPZTĉFNPTUGSF- BOETXJNNJOH 03 $* group was further classified into class quently reported health problems were 1.78–4.59). They were also more likely #.*mLHN DMBTT #.* BOBFNJB IFSFEJUBSZCMPPE UPSFQPSUSVOOJOH 03 $* mLHN BOEDMBTTPCFTJUZ EJTPSEFST CSPODIJBMBTUINB m BOEKPHHJOH 03 #.* LHN <> EFQSFTTJPOPSBOYJFUZ $*m -FTTUIBOBRVBSUFS Separate scales were generated for KPJOUQBJO EJBCFUFTNFMMJUVT PGTUVEFOUT NFUUIFSFDPN- internal and external barriers to exercis- BOE IZQFSUFOTJPO mended level of physical activity equiva- ing by summing the responses of the 6 among others. MFOUUPɓ.&5NJOVUFTXFFL BOE related questions. The scores on each the rate was significantly lower among scale ranged from a minimum of 6 to a Physical education during HJSMT UIBOCPZT NBYJNVNPG)JHIFSTDPSFTSFĚFDUFE school hours greater barriers to exercising. All items Table 1 reveals that only half of the boys Readiness to adopt regular in each scale were positively correlated BOEHJSMT FOSPMMFEGPSQIZTJDBM exercising and the Cronbach alpha reliability for education classes during school hours Enrolled students were at different stag- UIFTDBMFPGJOUFSOBMCBSSJFSTXBT BOEUIFNBKPSJUZPGUIFN PQUFE es of motivational readiness to adopt
761
Book 19-9.indb 761 10/7/2013 2:40:23 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 1 Frequency and patterns of physical education during school hours among boys and girls in Muscat, Oman Physical education in school hours Boys Girls Total No. % No. % No. % Participation in physical education classes (n = 214) (n = 225) (n = 439) No 103 48.1 104 46.2 207 47.1 Yes 111 51.9 121 53.8 232 52.9 Duration of exercise per week (min) (n = 111) (n = 121) (n = 232) 30 1 0.9 5 4.1 6 2.6 80 104 93.7 108 89.2 212 91.4 150 2 1.8 6 5.0 8 3.4 ≥ 240 4 3.6 2 1.7 6 2.6 Type of exercisea Ball gamesb 102 91.9 111 91.7 213 91.8 Jogging 8 7.2 48 39.7 56 24.1 Aerobics 3 2.7 18 14.9 21 9.1 Rope jumping 0 0.0 11 9.1 11 4.7 Weight lifting 4 3.6 1 0.8 5 2.2 Martial arts 1 0.9 2 1.7 3 1.3 Frequency of participation Rarely 6 5.4 22 18.2 28 12.1 Sometimes 34 30.6 33 27.3 67 28.9 Always 71 64.0 66 54.5 137 59.0
aCategories are not mutually exclusive. bIncludes football, basketball and volleyball.
Table 2 Rates and types of after-school hours physical activities among boys and girls After-school hours activities Boys Girls OR 95% CI No.%No.% Participation in after-school (n = 214) (n = 225) activities No 4 1.9 14 6.2 Yes 210 98.1 211 93.8 3.48 1.05–12.75 Types of activitiesa (n = 210) (n = 225) Walking 117 55.7 168 79.6 0.32 0.20–0.51 Climbing stairs 140 66.7 179 84.8 0.36 0.22–0.59 Ball gamesb 165 78.6 117 55.5 2.95 1.88–4.62 Running 143 68.1 111 52.6 1.92 1.27–2.92 Jogging 119 56.7 88 41.7 1.83 1.22–2.74 Aerobics 72 34.3 57 27.0 1.41 0.91–2.18 Swimming 81 38.6 38 18.0 2.86 1.78–4.59 Weight lifting 85 40.5 16 7.6 8.29 4.50–15.5 Cycling 61 29.1 115 54.5 0.34 0.22–0.52 Rope jumping 27 12.9 41 19.4 0.61 0.35–1.08 Martial arts 14 6.7 8 3.8 1.81 0.69–4.88 Racket gamesc 17 8.1 14 6.6 1.24 0.56–2.74 Table tennis 6 2.9 1 0.5 6.18 0.73–137.33
aCategories are not mutually exclusive. bIncludes football, basketball and volleyball. cIncludes tennis and squash. OR = odds ratio; CI = confidence interval.
762
Book 19-9.indb 762 10/7/2013 2:40:23 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
regular exercise. More than a third of Body weight and attempts to proportions of students expressed TUVEFOUT IBEQMBOTUPFYFSDJTF control weight agreement that other recreational regularly within the next 6 months More than a quarter of students were activities were more entertaining than QSFQBSBUJPOTUBHF XPVMEUIJOL PWFSXFJHIU PSPCFTF FYFSDJTJOH IBWJOHMJNJUFEFO- of exercising regularly in the coming 6 Attempts to lose or control weight in FSHZUPFYFSDJTF BOEUIJOLJOH months (contemplation phase) and UIFEBZTQSFDFEJOHUIFTVSWFZXBT that exercise was difficult and too tiring XFSFOPUUIJOLJOHPGFYFSDJTJOH SFQPSUFECZPGCPZTBOEPG 0OMZXFSFOPUUIJOLJOH regularly (pre-contemplation). A girls. Exercising was the most frequently that exercise has positive health effects. statistically significant difference was cited method of losing weight, while As for external barriers, a high propor- observed between boys and girls in food restriction and starving for a day tion of students agreed that parents give QSJPSJUZUPBDBEFNJDTVDDFTT this respect (χ 4 = 47.87, P or more were the next most common Higher percentages of girls were in the methods (Table 4). Relative to students or that they lacked leisure time due TUBHFTPGQSFDPOUFNQMBUJPO BOE with normal BMI, obese students were UPBDBEFNJDSFTQPOTJCJMJUJFT DPOUFNQMBUJPO XIJMFIJHIFS UJNFT $*m NPSF Other perceived external barriers were percentages of boys were in the action likely to report never participating in lack of exercise equipment in the home TUBHF PGFYFSDJTJOHSFHVMBSMZGPS QIZTJDBMFEVDBUJPODMBTTFT DPN- BOEMBDLPGMFJTVSFUJNFCFDBVTF < 6 months and the maintenance stage QBSFEXJUI BOEUJNFT of social and family responsibilities PGFYFSDJTJOHSFHVMBSMZGPS $*m NPSFMJLFMZUPSFQPSU NPOUIT 5BCMF attempts to control or lose weight in The mean scores of students on the UIFMBTUEBZT DPNQBSFEXJUI scale measuring internal and external Small-screen recreational barriers for exercising were low (Ta- activities ble 5). The mean scores of girls was As for small-screen recreational activi- Perceived barriers to significantly higher than that of boys UJFT PGTUVEFOUTSFQPSUFETQFOE- exercising on the scale measuring internal barri- JOHmIPVSTEBJMZXBUDIJOHUFMFWJTJPO Variable proportions of students ex- FST< 4% WFSTVT 4% BOEPGUIFNSFQPSUFETQFOEJOH pressed agreement with statements > P BOEFYUFSOBMCBSSJFST mIPVSTEBJMZPODPNQVUFSBDUJWJUJFT representing barriers to exercising. GPSFYFSDJTJOH< 4% WFSTVT 5BCMF Regarding internal barriers, substantial 4% > P ĉFTDPSFT
Table 3 Daily time spent in small-screen sedentary activities and stages of motivation for adopting exercise among boys and girls Time spent in sedentary activities/stage of Boys (n = 214) Girls (n = 225) Total (n = 439) motivation No. % No. % No. % Daily time spent watching television (hours) < 0.5 48 22.4 49 21.8 97 22.1 1–2 121 56.5 119 52.9 240 54.7 3–4 29 13.6 41 18.2 70 15.9 5–7 16 7.5 16 7.1 32 7.3 Daily time spent on computer (hours) < 0.5 65 30.4 62 27.6 127 28.9 1–2 92 43.0 92 40.9 184 41.9 3–4 30 14.0 30 13.3 60 13.7 5–7 27 12.6 41 18.2 68 15.5 Stage of motivation for adopting exercise Pre-contemplation 10 4.7 13 5.8 23 5.1 Contemplation 22 10.3 60 26.7 82 18.7 Preparation 72 33.6 99 44.0 171 39.0 Action 33 15.4 27 12.0 60 13.7 Maintenance 77 36.0 26 11.5 103 23.5
763
Book 19-9.indb 763 10/7/2013 2:40:23 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 4 Body weight and attempts to control weight among boys and girls Body weight and attempt at weight loss Boys Girls Total No. % No. % No. % Classification of body weight (n = 212) (n = 221) (n = 433)a Underweight 50 23.6 45 20.4 95 21.9 Normal 111 52.3 110 49.8 221 51.0 Overweight 27 12.7 34 15.4 61 14.1 Obese class 1 18 8.5 16 7.2 34 7.9 Obese class 2 5 2.4 12 5.4 17 3.9 Obese class 3 (morbid) 1 0.5 4 1.8 5 1.2 Attempts to control weight (in last 30 days) (n = 214) (n = 225) (n = 439) No 111 51.9 99 44.0 210 47.8 Yes b 103 48.1 126 56.0 229 52.2 Methods of weight controlb,c (n = 103) (n = 126) (n = 229) Exercising 72 69.9 65 51.6 137 59.8 Food restriction 35 34.0 60 47.6 95 41.5 Starving for days 1 1.0 10 7.9 11 4.8 Slimming pills 1 1.0 4 3.2 5 2.2 +Induction of vomiting 0 0.0 2 1.6 2 0.9
a6 cases were excluded due to missed information. bCategories are not mutually exclusive;. Denominator is total attempting to control weight;
of girls were significantly higher than BOEXPSSJFTBCPVUMPPLT P < (P BOEMJNJUFEMFJTVSFUJNF those of boys on internal barriers related ĉFJSTDPSFTXFSFTJHOJėDBOUMZ because of academic responsibilities to lack of energy (P JOUFSFTU higher on external barriers related to (P BOEGBNJMZPCMJHBUJPOT P in other recreational activities (P < lack of encouragement for exercising
Table 5 Scores on perceived barriers to exercising among boys and girls Barrier and stage of motivation Boys (n = 214) Girls (n = 225) P-value Mean score SE Mean score SE Internal barrier Total 13.36 0.25 14.21 0.27 0.023 Thinking exercise is difficult and too tiring 2.35 0.08 2.22 0.07 0.252 Never having energy for exercise 1.79 0.06 2.03 0.07 0.014 Other recreational activities are more entertaining 3.01 0.08 3.48 0.09 0.000 Not thinking that exercise has positive health effects 1.82 0.08 1.65 0.07 0.116 Worrying about looks when exercising 1.94 0.07 2.32 0.08 0.000 Limited abilities to exercise 2.45 0.08 2.51 0.08 0.595 External barrier Total 14.91 0.25 16.13 0.26 0.001 No fitness centre to exercise 2.21 0.08 2.17 0.08 0.767 No exercise equipment at home 2.74 0.09 2.75 0.08 0.945 No encouragement to exercise 1.76 0.07 2.13 0.08 0.000 Parents give priority to academic success 3.15 0.08 3.18 0.08 0.775 No leisure time because of academic responsibilities 2.80 0.09 3.43 0.08 0.000 No leisure time because of social & family responsibilities 2.25 0.07 2.47 0.08 0.039
SE = standard error.
764
Book 19-9.indb 764 10/7/2013 2:40:23 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Determinants of physical Discussion hours in small-screen recreational activity in after-school hours activities, namely watching television Table 6 illustrates the determinants of Health promotion activities by the gov- BOEDPNQVUFSSFMBUFEBDUJWJUJFT physical activity in after-school hours. ernment of Oman focus on physical XIJDIJTTMJHIUMZMPXFSUIBOUIF The recommended level of physical activity at school [9] and in the commu- SFQPSUFECZUIF(MPCBM4DIPPM activity was 5 times more likely to be OJUZ<>"MUIPVHIQIZTJDBMFEVDBUJPO )FBMUI4VSWFZJO0NBOJO<> NFUCZCPZT 03 $*m is an integral part of the school health Rosenberg et al. demonstrated that the *UXBTBMTPNPSFMJLFMZUPCFNFUCZ programme it is not part of the core cur- accessibility of electronic equipment TUVEFOUTJOUIHSBEF 03 riculum. Half of the students enrolled in such as television and computers was $*m UIPTFXIPBĨFNQUFEUP our study opted for physical education associated with sedentary behaviour DPOUSPMPSMPTFXFJHIUJOUIFEBZTQSF- DMBTTFTBUTDIPPMBOEPOMZPGUIFN BNPOHDIJMESFO<> DFEJOHUIFTVSWFZ 03 $* were attending classes regularly. This Obesity is of major concern in m BTXFMMBTUIPTFXIPPQUFE finding reflects the lack of students’ in- Oman and it has its roots during the for exercise to lose or control their body terest in physical education classes that DIJMEIPPEQFSJPE*O FTUJNBUFT XFJHIU 03 $*m engage them mostly in ball games. It SFWFBMFEUIBUPGUIF0NBOJQPQ- Students in the maintenance stage of also indicates the limited role of schools ulation were overweight and another NPUJWBUJPOSFBEJOFTTXFSFUJNFTNPSF in fostering an acceptable level of physi- XFSFPCFTF<>"NPOHVOJWFS- likely to meet the recommended level of cal activities, as those students who were sity students, the combined prevalence physical activity relative to those in the regular in attending physical education PGPWFSXFJHIUBOEPCFTJUZXBT QSFDPOUFNQMBUJPOTUBHF 03 classes were not more likely to be physi- [11]. More than a quarter of students $*m *ODPOUSBTU IJHIFS cally active in after-school hours. It has in this study were overweight or obese scores on the scale measuring external been shown that the success of schools and the rate was higher among girls barriers to exercise lowered the like- in promoting physical activity is not than boys. Students seem to be aware lihood of meeting the recommended so much accomplished by providing of their body image, as a half of the MFWFMPGQIZTJDBMBDUJWJUZ 03 physical education classes but by having boys and girls reported that they were $*m a written policy defining goals to be attempting to lose weight or maintain achieved through specific plans to in- a normal body weight using different Independent determinants of crease students’ level of physical activity means. This study, as well as that of physical activity <>BOECZQSPWJEJOHEJWFSTFBDUJWJUJFT Chen et al., revealed that the desire to Physical activity in after-school hours to attract and maintain students’ inter- lose weight or maintain an ideal body was modelled as a function of the scores est in physical education classes. Haug weight increased the likelihood of par- on the scale measuring internal and et al. pointed to the higher likelihood UJDJQBUJOHJOQIZTJDBMBDUJWJUZ<> external barriers as well as the significant of participation in physical activities Generally the level of perceived determinants identified in univariate among students attending schools with barriers for exercising was low and the analysis (Table 7). The stage of motiva- multiple facilities, playgrounds and perception of the beneficial effects of ex- tion for adopting physical activity was XFJHIUMJěJOHFRVJQNFOU<> ercising was high. The most prominent excluded as it was related to the scores " NJOJNVN PG NJOVUFT QFS internal barriers were a high interest in on the scale measuring barriers to ex- day of moderate physical activity or activities other than exercising and a ercise. Adjusted for other factors, the its equivalent of vigorous activity is lack of energy. This study, as well as oth- model revealed that boys, 11th-grade recommended for school-age children ers, underscored the role of external bar- students and those who attempted to achieve beneficial effects on physi- riers as a deterrent to exercising, notably to control or lose weight significantly DBMBOENFOUBMIFBMUI< > time constraints because of academic increased the likelihood of physical ac- Our study revealed that the majority PCMJHBUJPOT< m>BOEQSJPSJUZ tivity meeting the recommended levels. of students reported different types of HJWFOUPBDBEFNJDTVDDFTT< >ĉJT Scores on the scale measuring internal physical activities but less than a quarter XBTQBSUJDVMBSMZUSVFGPSUIHSBEFTUV- and external barriers for exercise fell just met the recommended level equiva- dents, whose future career depends on behind significance. This model clas- MFOUUP.&5NJOVUFTXFFLĉJT their achievement in this final school TJėFEDPSSFDUMZPGTUVEFOUTXIP rate is similar to the national figure of year. These students can overcome met the recommended levels of physi- BNPOHUIUPUIHSBEFTUV- time constraints by integrating physi- DBMBDUJWJUJFTBOEFYQMBJOFEPGUIF EFOUTSFQPSUFEJOVTJOHEJĎFS- cal activity into their daily routine with variability between physically active and ent methods [9]. Nearly a quarter of the added knowledge of its favourable physically inactive students. TUVEFOUTSFQPSUFETQFOEJOHPSNPSF impact on school achievement.
765
Book 19-9.indb 765 10/7/2013 2:40:23 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 6 Determinants of recommended level of physical activity in after-school hours Determinants of recommended level of Inactive (n = 334) Active (n = 105) OR 95% CI physical activity No. % No. % Sex Male 203 60.8 22 20.9 1 Female 131 39.2 83 79.1 5.85 3.48–9.82 Age group (years) 15–16 79 23.6 37 35.2 1.63 0.36–7.46 17–18 243 72.8 66 62.9 2.81 0.59–13.20 19–20 12 3.6 2 1.9 1 Education grade Grade 11 163 48.8 66 62.9 1.78 1.13–2.79 Grade 12 171 51.2 39 37.1 1 Family income Sufficient 302 90.4 94 89.5 1 Insufficient 32 9.6 11 10.5 1.10 0.54–2.28 Chronic health problems Yes 72 21.6 18 17.1 1 No 262 78.4 87 82.9 1.33 0.75–2.35 Physical education in school Never 157 47.0 50 47.6 1 Rarely or sometimes 74 22.2 21 20.0 0.89 0.50–1.59 Always 103 30.8 34 32.4 1.04 0.63–1.71 Daily time spent watching television (hours) < 0.5 69 20.6 28 26.7 1 1–2 193 57.8 47 44.8 0.60 0.35–1.03 3–4 46 13.8 24 22.8 1.29 0.66–2.49 5+ 26 7.8 6 5.7 0.57 0.21–1.53 Daily time spent on computer (hours) < 0.5 96 28.7 31 29.5 1 1–2 143 42.8 41 39.1 0.89 0.52–1.51 3– 4 47 14.1 13 12.4 0.86 0.41–1.79 5–7 48 14.4 20 19.0 1.29 0.67–2.50 Body weight classificationa Overweight or obese 86 26.1 31 30.1 1 Normal 168 50.9 53 51.5 0.90 0.36–1.33 Underweight 76 23.0 19 18.4 0.69 0.36–1.33 Attempt to control weight (in last 30 days) No 169 50.6 41 39.0 1 Yes 165 49.4 64 61.0 1.60 1.02–2.50 Method of weight control None 169 50.6 41 39.0 1 Other methods 75 22.5 17 16.2 0.93 0.49–3.52 Exercising 90 26.9 47 44.8 2.15 1.32–3.52 Motivation stage for adopting physical activity Pre-contemplation 18 5.4 5 4.8 1 Contemplation 75 22.4 7 6.7 0.34 0.96–1.18 Preparation 146 43.7 25 23.8 0.62 0.21–1.81 Action 40 12.0 20 19.0 1.80 0.58–5.55 Maintenance 55 16.5 48 45.7 3.14 1.08–9.10 Barriers to physical activity Mean (SD) Mean (SD) Internal barriers 13.9 (3.7) 13.4 (4.4) 0.96 0.91–1.02 External barriers 15.8 (3.8) 14.8 (3.9) 0.93 0.88–0.98 a6 cases excluded due to missing information. SD = standard deviation; OR = odds ratio; CI = confidence interval.
766
Book 19-9.indb 766 10/7/2013 2:40:24 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Table 7 Full model of the independent determinants of recommended level of physical activities in after school hours Independent determinant B SE Wald statistic Adjusted OR 95% CI Sex Femalea Male 1.809 0.275 43.24 6.11 3.56–10.47 School grade Grade 12a Grade 11 0.532 0.250 4.523 1.70 1.04–2.78 Attempt to control weight (in last 30 days) Noa Yes 0.601 0.251 5.719 1.82 1.12–2.99 Barriers to physical activity Internal barriers –0.021 0.033 0.417 0.98 0.92–1.05 External barriers –0.019 0.34 0.312 0.98 0.92–1.05
Model sensitivity = 75.9%; Nagelkerke R2 = 21.1% aReference category. SE = standard error; OR = odds ratio; CI = confidence interval.
Girls had greater internal barriers swimming. Less than one-tenth of girls degree of objectivity. The use of a self- related to lack of energy, interest in ac- met the recommended level of physi- administered, pretested questionnaire tivities other than exercising and worries DBMBDUJWJUZFRVJWBMFOUUP.&5 eliminated interview bias, but recall bias about looks while exercising, as well as NJOVUFTXFFLĉFWBSJBUJPOJOUIF cannot be totally eliminated. Despite external barriers related to lack of en- levels of physical activity between boys these limitations, the rates and levels couragement and time constraints due and girls has been previously reported of physical activity found in this study, to studies and family obligations. Worry GSPN0NBO<>BOEFMTFXIFSF< > particularly among girls, were low. Fur- about looks reflects low self-confidence Rosenberg et al. demonstrated an in- thermore, even lower rates of exercise <>UIBUTIPVMECFDIBMMFOHFEĉF verse relationship between the presence would be expected from school stu- other barriers mirror the cultural norm of exercise equipment in the home and dents outside the capital city of Muscat. in Oman that values home-centred ac- TFEFOUBSZCFIBWJPVS<>BOEUIFVTFPG Students in Oman do have opportuni- tivities for girls and encourages their in- such equipment at home may promote ties for exercising, and therefore further volvement in household chores. These acceptable levels of physical activity tailoring of programmes and activities barriers are probably the reason for among girls in Oman. Also encourage- to surmount barriers and constraints finding a significantly higher percentage ment will result in the desired behaviour would be expected to promote accept- of girls in the pre-contemplation and through increasing girls’ perception of able levels of physical activity. Maximiz- contemplation stage, which is subse- UIFJSTQPSUTDPNQFUFODF<> ing the role of schools is indispensable. quently reflected in their behaviour. The use of metabolic equivalents The focus of future studies should be on Girls were less likely to participate in to express the levels of physical activ- investigating the barriers to participa- after-school hours activities, especially ity allowed the identification of the tion in physical education classes and those of moderate and vigorous intensi- proportion of students who met the exploring means of addressing these ty such ball games, running, jogging and recommended levels with a certain barriers.
References
1. Global status report on noncommunicable diseases, 2010. Ge- Mediterranean and the United Nations Children’s Fund, neva, World Health Organization, 2011. 2000. 2. Non-communicable diseases: country profile 2011. Geneva, 5. Lopez A et al. Global and regional burden of disease and risk World Health Organization, 2011. factors, systematic analysis of population health data. Lancet, 3. Al-Lawati JA, Mabry R, Mohammed AJ. Addressing the threat 2001, 360:1747–1757. of chronic diseases in Oman. Preventing Chronic Disease, 2008, 6. Mokdad AH et al. Prevalence of obesity, diabetes, and obesity- 5:1–7. related health risk factors. JAMA, 2003, 289:76–79. 4. Hill AG, Muyeed AZ, Al-Lawati JA. The mortality and health 7. Diabetes roadmap for the UN summit on non-communicable transitions in Oman: patterns and processes. Muscat, Oman, diseases: IDF member association consultation report. Brussels, World Health Organization Regional Office for the Eastern Belgium, International Diabetes Federation, 2011.
767
Book 19-9.indb 767 10/7/2013 2:40:24 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
8. Misra A, Khurana L. Obesity and the metabolic syndrome in 21. Obesity: preventing and managing the global epidemic. Report developing countries. Journal of Clinical Endocrinology and of a WHO consultation. Geneva, World Health Organization, Metabolism, 2008, 93:S9–S30. 2000 (WHO Technical Report Series No. 894). 9. Global based health survey. Muscat, Oman, Ministry of Health, 22. Belal AM, Al-Hinai HG. Community-based initiatives for 2005. prevention of non-communicable diseases: Nizwa healthy 10. Mehana M, Kilani H. Enhancing physical education in omani life style project planning and implementation experience in basic education curriculum: rationale and implications. In- Oman. Sudanese Journal of Public Health, 2009, 4:225–228. ternational Journal for Cross-Disciplinary Subjects in Education, 23. Haug H, Torsheim T, Samdal O. Local school policies increase 2010, 1:99–104. physical activity in Norwegian secondary schools. Health Pro- 11. Al Kilani H, Waly M, Youssef R. Trends of obesity and over- motion International, 2009, 25:63–72. weight among college students in Oman: a cross sectional 24. Haug H, Torsheim T, Samdal O. Physical environmental char- study. Sultan Qaboos University Medical Journal, 2012, 12:69– acteristics and individual interests as correlates of physical ac- 76. tivity in Norwegian secondary schools: The health behaviour 12. Anshel MH. Conceptualizing applied exercise psychology. in school-aged children study. International Journal of Behavio- Journal of the American Board of Sport Psychology, 2007 [on- ral Nutrition and Physical Activity, 2008, 5:47. doi:10.1186/1479- line journal] (http://www.americanboardofsportpsychology. 5868-5-47. org/journalofabsp/tabid/1259/default.aspx, accessed 9 July 25. Martinez-Gomez D et al.; HELENA Study Group. Recom- 2013). mended levels of physical activity to avoid excess of body fat 13. Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epide- in European adolescents: the HELENA Study. American Journal miologic statistics for public health, version 2.3.1 [online] (www. of Preventive Medicine, 2010, 39:203–211. OpenEpi.com, accessed 9 July 2013). 26. Strong WB et al. Evidence based physical activity for school- 14. Summary of education statistics 2010/2011. Muscat, Directorate age youth. Journal of Pediatrics, 2005, 146:732–737. of Statistics and Indicators, Ministry of Education, 2010. 27. Rosenberg DE et al. Brief scales to assess physical activ- 15. Allison KR, Dweyer JJ, Makin S. Perceived barriers to physical ity and sedentary equipment in the home. International Jour- activity among high school students. Preventive Medicine, 1999, nal of Behavioral Nutrition and Physical Activity, 2010, 7:10. 28:608–615. doi:10.1186/1479-5868-7-10. 16. Hovell MF et al. Identifying correlates of walking for exercise: 28. Chen LJ, Haase AM, Fox KR. Physical activity among adoles- an epidemiologic prerequisite for physical activity promotion. cents in Taiwan. Asia Pacific Journal of Clinical Nutrition, 2007, Preventive Medicine, 1989, 18:856–866. 16:354–361. 17. Guidelines for data processing and analysis of the International 29. Daskapan A, Tuzun EH, Eker L. Perceived barriers to physical Physical Activity Questionnaire (IPAQ). Short and long forms. activity in university students. Journal of Sports Science and November2005. IPAQ group [online] (http://www.ipaq.ki.se/ Medicine, 2006, 5:615–620. scoring.pdf, accessed 9 July 2013). 30. Kelishadi R et al. Barriers to physical activity in a population- 18. Ainsworth BE et al. The compendium of physical activities track- based sample of children and adolescents in Isfahan, Iran. ing guide. Phoenix, Arizona, Arizona State University, Healthy International Journal of Preventive Medicine, 2010, 1:131–137. Lifestyles Research Center, College of Nursing and Health 31. Gómez-López M, Gallegos AG, Extremera AB. Perceived bar- Innovation (https://sites.google.com/site/compendiumof- riers by university students in the practice of physical activities. physicalactivities/home, accessed 9 July 2013). Journal of Sports Science and Medicine, 2010, 9:374–381. 19. Kesäniemi A et al. Advancing the future of physical activity 32. Al-Nuaim AA et al. The prevalence of physical activ- guidelines in Canada: An independent expert panel interpreta- ity and sedentary behaviours relative to obesity among tion of the evidence. International Journal of Behavioral Nutrition adolescents from Al-Ahsa, Saudi Arabia: rural versus ur- and Physical Activity, 2010, 7:41. doi:10.1186/1479-5868-7-41. ban variations. Journal of Nutrition and Metabolism, 2012, 20. Al-Hazzaa HM, Musaiger AO; ATLS Research Group. Arab doi:10.1155/2012/417589. teens lifestyle study (ALT): objectives, design, methodology 33. Biddle S, Gouda M. Analysis of children’s physical activity and and implications. Diabetes, Metabolic Syndrome and Obesity, its association with adult encouragement and social cognitive 2011, 4:417–426. variables. Journal of School Health, 1996, 66:75–78.
768
Book 19-9.indb 768 10/7/2013 2:40:24 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Epidemiology of autistic disorder in Bahrain: prevalence and obstetric and familial characteristics A.M. Al-Ansari 1 and M.M. Ahmed 2
owzgTTÐíogcým^TÐýmZ#ÐíÚmYhøÐéz^Xw|TÐ9z@TÐow=Ð{TÐÑÐ|\ÐÓmgým<í´ {1ÌØe7{e7ºïÚn[iúÐāÐénY{1Ì ì|wënAnUÐî}@Ì{Sí ØnxØÛøn=|BË{AUÐpx>Ð|UÐÓn=Ð}]øÐÚnZiÐé{_YëÌncx}YÌé5I:ín=íÚíÌ:ÓnHÐÚ{UÐÓ}gKÌoåÉ°#Ð º{wÐZUÐíÓøndU5he[>ënAnUÐê{HÐí n4pxúÐíphRÐ}`ex{UÐýn[#ÐDLæ}_dUíð ºx}UÐ:nwÚnZiÐé{_YDLæ}_dUpHÐÚ{UÐ 100 ºphafUÐÓn=Ð}]ĆUýn[AüÐíľhZUÐhU{dUnbRí{ð AUÐpx>Ð|UÐÑÐ}]n=N=n[Y¹ÌDLÐ[IaJ´ 5gHÐÚØqdeIí 2010 2000 (DSM-IV-TR) DLg[hZ>>x|UÐ{wÐZUÐYnxínYð ÐØ{LënAnUÐÚnBÐí ð í N=ÒGaUÐ:UÙíº ybfCÐö [ö iíºp_=Ð}UÐ_]=ó é{_YënAnUÐÚ{Sí Óøn"Ð Y}e_UÐíf!ÐrhAYgbRÐ> Yº¢aiéĆLÐgfY ïÌî{UëcxëÌëíØMhdUÐéUÐd=ë=n[Y¹ÌĄ 1 4 10000 4.3 UÐÓøn"ÐØ{LëÌNAndUy\>Ðí OÎ ÔniüÐOÎÚT|UÐpiqinTíºpei cU pf={AUÐï>Ð|UÐÑÐ}]øÐÚnZiд }x{b>ënTí nhýn[AÎ=ð {_xÚÐ{be=UÙí{wÐZUÐY}TÌÒØøUÐSÓnaLn\YYÐinL{Sö *ngYÌëÌíº{wÐZUÐØ{LY}TÌpxWhbUn=Ó{Uí cexpxWhSphde_=ÒØøUÐípx{hUUÐÓnaLn\CÐëÌënAnUÐsfHÐí ç}]UÐaiq_>Ðpb=nH}xÚnb>:ØÚínCĆ?n,x}UÐ:ÚnZiøÐé{_Yð {AUÐï>Ð|UÐÑÐ}]øn==ÐG>ëÌ´
ABSTRACT European and North American studies show that the prevalence of autistic disorder is increasing. This study was performed to identify the prevalence of autistic disorder in Bahrain, and determine some of the demographic and family characteristics. Using a case–control design, 100 children who received a diagnosis of autistic disorder according to DSM-IV-TR during the period 2000–2010 were selected. An equal number of controls who had received a diagnosis of nocturnal enuresis and no psychopathology were selected, matched for sex and age group. The prevalence of autistic disorder was estimated as 4.3 per 10 000 population, with a male:female sex ratio of 4:1. Significantly more cases than controls were delivered by caesarean section and had mothers who suffered prenatal complications. The prevalence estimate in Bahrain is comparable to previous reports using similar methods. Obstetric complications and caesarean section delivery may be associated with autistic disorder.
Épidémiologie du trouble autistique à Bahreïn : prévalence et caractéristiques obstétricales et familiales
RÉSUMÉ Des études européennes et nord-américaines indiquent que la prévalence du trouble autistique est en augmentation. La présente étude a été réalisée afin de connaître la prévalence du trouble autistique à Barheïn, et de déterminer certaines caractéristiques démographiques et familiales. À l'aide d'un plan d'étude cas-témoins, 100 enfants ayant reçu un diagnostic de trouble autistique selon le Manuel diagnostique et statistique des troubles mentaux (quatrième édition) au cours de la période 2000-2010 ont été sélectionnés. Des témoins en nombre équivalent ayant reçu un diagnostic d'énurésie nocturne mais qui étaient exempts de psychopathologie ont été sélectionnés, appariés pour le sexe et la tranche d'âge. La prévalence du trouble autistique a été estimée à 4,3 pour 10 000 dans la population, avec un rapport de masculinité de 4 pour 1. Le nombre de nourrissons nés par césarienne et dont la mère avait souffert de complications prénatales était nettement supérieur dans le groupe des cas par rapport aux témoins. L'estimation de la prévalence à Bahreïn était comparable aux rapports antérieurs ayant utilisé des méthodes similaires. Des complications obstétricales et une naissance par césarienne pourraient être associées à un trouble autistique.
1Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain (Correspondence to A.M. Al- Ansari: [email protected]). 2Department of Ear, Nose and Throat, Head and Neck, King Hamad University Hospital, Al Muharraq, Bahrain. Received: 18/04/12; accepted: 19/06/12
769
Book 19-9.indb 769 10/7/2013 2:40:24 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Introduction autistic disorder and advancing pa- the Modified Checklist for Autism in rental age. In this paper we report an Toddlers [9], the Diagnostic and Sta- Autistic disorder is a chronic and se- estimate of the prevalence of autistic tistical Manual of Mental Disorders vere neurodevelopmental disorder disorder in Bahrain, together with the UIFEJUJPO UFYUSFWJTJPO <>BOE characterized by impairments in sex distribution and possible associ- the Childhood Autism Rating Scale social interaction, reciprocal com- ated factors such prenatal and post- [11]. The control group consisted of an munication, patterns of stereotyped natal complications, type of delivery equal number of children and youths CFIBWJPVSBOEPOTFUCFGPSFBHFZFBST and other personal and familial char- attending the unit over the same time [1]. Although its etiology remains un- acteristics. period, randomly selected from a pool known, there is evidence to suggest PGJOEJWJEVBMTNBUDIFEGPSBHF JO that it is common among the same 5-year age groups), sex, social class, families and possibly influenced by en- Methods parent's education and family history. WJSPONFOUBMGBDUPST< >1SFWBMFODF The controls were children and youths Study setting FTUJNBUFTIBWFJODSFBTFEJOUIFMBTU receiving a diagnosis of nocturnal enu- EFDBEFTBOESBOHFGSPNQFS Bahrain is an archipelago situated in resis (n = 64), mild behaviour disorder QPQVMBUJPOUPQFSXJUIB the Gulf region, east of Saudi Arabia. (n BOEOPQTZDIPQBUIPMPHZ n = NFBOPGQFS"DDPSEJOH *UDPWFSTBOBSFBPGBQQSPYJNBUFMZ ĉFTUVEZSFDFJWFEUIFBQQSPWBM to the Centers for Disease Control’s km, and has an estimated population of the ethics committee of the Minis- Autism and Developmental Disabili- PGNJMMJPOJO)FBMUITFSWJDFT try of Health of Bahrain. ties Monitoring Networkabout 1 in are free and accessible to all residents. 88 children in the United States of The country is characterized by a low Data collection America (USA) is identified with au- JOGBOUNPSUBMJUZSBUF QFS BOE Medical records from CAPU and tism spectrum disorder [4]. The mean high life expectancy of 74.8 years. social records from participating cen- NBMFGFNBMFSBUJPJT<>'BDUPST "OOVBMMZ OFBSMZ OFX DBTFT tres were reviewed by the co-author playing a major role in this increase of autistic disorder are diagnosed in and related data were abstracted. The in prevalence include broadening of CAPU, the only referral unit for au- data were entered into a form specially the definition of autistic disorder and tistic disorder in Bahrain, and referred designed for the study by a co-author. improved awareness of the disorder UPDPNNVOJUZDFOUSFTUIBUDBSFGPS The items on the form aimed to collect with a concomitant development of autistic disorder. In the school year data on child’s age and sex, birth order, services; other factors such as sample mBTNBMMHSPVQPGBVUJTUJDEJT- language development (based on par- size, publication year and geographic order children were integrated into the ent’s reports), sleeping and eating pat- location of the studies play a role in regular public school system. The cen- terns, and on the mother’s pregnancy variations in estimates [6–8]. USFTDBOBDDPNNPEBUFBSPVOE and delivery, including duration of *OUIFTBVUJTUJDEJTPSEFSXBT BVUJTUJDEJTPSEFSQFSTPOTBHFEm pregnancy (term or preterm), type rarely referred to or diagnosed in the ZFBST:PVUITBCPWFUIFBHFPGZFBST of delivery (normal, lower segment Child and Adolescent Psychiatric can join an afternoon social club that is caesarean section or assisted delivery), Unit (CAPU) in Bahrain. In the last open 6 days a week. and any prenatal, natal and postnatal 5 years, however, autistic disorder is complications and stressful life events diagnosed on weekly basis and today Study design and sample around the time of delivery (based on CAPU uses a set of formal instruments The prevalence of autistic disorder was parents reports). The parents’ section for autistic disorder diagnosis. To the estimated by dividing the number of included age at birth of the child, edu- author’s knowledge, the prevalence of DBTFT CZUIF#BISBJOJQPQVMB- cational level, employment, family his- autistic disorder was never estimated UJPOGPSNVMUJQMJFECZ tory of autistic disorder, consanguinity in Bahrain. Studies on the prevalence The study of associated factors uti- TUPSOEEFHSFF BOEBOZIJTUPSZ of autistic disorder in the region are lized a case–control design. The study of psychiatric or medical disorders TDBSDF*O0NBO"M'BSTJFUBMJO group were all cases attending the (based on parents’ reports) The social reported an autistic disorder estimate CAPU, the Alwafa centre, Al Rashad class was constructed following Hol- PGQFSXJUIBNBMFGFNBMF centre and youth club, who received a lingshead and Redlich’s 5-point scale ratio of 4:1 [9]. diagnosis of autistic disorder over the <> The present study was a part of UJNFQFSJPEmBOEXIPNFU Neither the cases nor their parents prospective case–control study inves- the inclusion criteria (n ĉF were interviewed. Parents of 9 cases tigation of the relationship between diagnosis was reached according to BOEDPOUSPMTXFSFDPOUBDUFECZ
770
Book 19-9.indb 770 10/7/2013 2:40:24 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
telephone or home visits by the CAPU Table 1 Characteristics of autistic disorder cases by study factor social worker to complete some miss- Variable % of cases ing data. All parents gave informed (n = 100) consent prior to inclusion in the study. Sex Only 1 case from the study group was Male 80 excluded due to doubtful diagnosis. Female 20 Sleepa Analysis No disturbance 54 The data were entered and analysed Insomnia 38 WFSTJPOĉFEBUBXFSF using SPSS Hypersomnia 1 presented as simple frequencies and Eating behavioura mean and standard deviation (SD). No disturbance 68 Odds ratios (OR) were calculated Increased appetite 6 and the chi-squared test of significance Decrease appetite 24 was used to assess differences between cases and controls wherever applica- Speech ble. No speech 38 Words only 34 Sentences 13 Results Occasional use of communicative language 15 Prevalence Stressful events The case register method revealed a Absent 83 QSFWBMFODFPGQFSQPQV- Divorce 8 lation using an estimated Bahraini Death 4 QPQVMBUJPOGPSUIFZFBS Others 5 Consanguinity Characteristics of autistic 1st degree 17 disorder cases 2nd degree 12 Table 1 shows that males outnum- Not related 71
bered females among cases by a ratio aMissing data in some cases. ĉFNFBOBHFXBT 4% ZFBST SBOHFmZFBST0OFUIJSEQSF- sented with sleep and eating disorders history of autistic disorder was present EFMJWFSZ WFSTVTGPSDPO- BOESFTQFDUJWFMZ 4QFFDI JOPGUIFTUVEJFEGBNJMJFT"TNBMM USPMT 03 $*m XBTUPUBMMZBCTFOUJOPGDBTFT OVNCFSPGGBNJMJFT SFQPSUFE (P *OBEEJUJPOPGNPUI- had some language production and the presence of psychiatric disorders ers of autistic disorder cases had pre- XFSFBCMFUPDPNNVOJDBUFPD- BNPOHQBSFOUTDPNQBSFEXJUI natal complications compared with casionally using short sentences. The with chronic physical disorders. The DPOUSPMDBTFT 03 $* HSFBUNBKPSJUZPGNPUIFST EJE NBKPSJUZPGDBTFT DBNFGSPN m P not report any stressful events dur- the lower social classes 4 and 5. ing pregnancy, delivery and the early postpartum period. Nearly one-third Case–control comparisons: Discussion PGBVUJTUJDEJTPSEFSDBTFT IBE mother’s pregnancy and birth blood-related parents. history Results from this case register study 5BCMFTIPXTUIBUNPSFUIBO Cases did not differ from controls in in Bahrain estimated a prevalence of three-quarters of parents had received the mother’s duration of pregnancy BVUJTUJDEJTPSEFSPGQFS either high school or college educa- and rate of postnatal complications which is similar to other studies us- UJPO NPUIFSTBOEGBUIFST 5BCMF )PXFWFSBVUJTUJDEJTPSEFS ing similar data collecting methods Most fathers were employed while cases had a significantly higher inci- < m>ĉJTSBUFJTOFBSMZGPME PGNPUIFSTXFSFIPVTFXJWFT dence of delivery complications (i.e. the rate reported from the Gulf region PGGBUIFSTXFSFSFUJSFE"GBNJMZ lower caesarean section or assisted [19]. In spite of the fact that the case
771
Book 19-9.indb 771 10/7/2013 2:40:24 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 2 Characteristics of parents of autistic disorder cases register method is usually accused of Variable % of cases (n = 100) VOEFSFTUJNBUJPO<> UIFBVUIPST Mothers Fathers do not believe that this applies to our Educationa study. First, because the coverage of Illiterate 4 0 services by our unit involves all the is- Read & write 1 1 lands of Bahrain, as CAPU is located in Primary education 7 10 a central area and people reside within LNJOFJUIFSEJSFDUJPO4FDPOEMZ UIF Secondary education 36 42 level of awareness among professionals College education 41 40 and the population is high as CAPU re- Current employment ceives on a daily basis children referred Housewife/unemployed 68 0 with delays in language development Employed 31 89 GSPNUIFOFUXPSLPGIFBMUIDFOUSFT Student 0 1 attached to the main general hospital. Retired 1 10 Thirdly, all suspected cases of autistic Family history of autism disorder are assessed in CAPU by one Present 3 9 team and so case definition does not Absent 97 91 present an obstacle. However, we do be- Psychiatric illness lieve that a small number of cases within Present 4 3 wealthy families are treated abroad, and Absent 96 97 that there may be other unidentified Chronic physical illness individuals with autistic disorder who Present 2 10 have higher intellectual functioning and Absent 98 90 who might escape detection and enter aMissing data in some cases. directly to the public school system.
Table 3 Distribution of autistic disorder cases and non-autistic controls by social class, pregnancy, type of delivery and pre/ postnatal complications Variable Cases Controls OR 95% CI P-value (n = 100) (n = 100) %% Duration of pregnancy Preterm 9 8 n/a n/a n/a Term 91 92 Type of delivery Normal 76 89 2.51 1.12–5.63 0.025 Caesarean section or assisted birth 24 11 Prenatal complications Present 15 4 4.19 1.34–13.1 0.014 Absent 85 96 Postnatal complications Present 6 7 0.84 0.27–2.59 0.760 Absent 94 93 Social class Class 3 15 12 n/a n/a n/a Class 4 14 21 Class 5 71 67
n/a = not assessed; OR = odds ratio; CI = confidence interval.
772
Book 19-9.indb 772 10/7/2013 2:40:24 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
The background characteris- factor with the control group because its own known limitations. Ideally, the tics of the cases revealed an overall we controlled for social class (which is control group should be derived from a male:female sex ratio of 4:1, in line with to some extent a proxy for consanguin- representative community cohort, as es- many other studies [7]. The proportion ity) because of its relevance to both timates of autistic disorder calculated by PGDBTFT XIPIBETPNFMBOHVBHF groups. case–controlled studies will not be the production is considered high. This The rate of family history of autistic same as those derived from population- could be explained by the fact that disorder among the relatives of cases based studies. Other limitations include many cases had received several years TVQQPSUTUIFSPMFPGHFOFUJDGBD- lack of comparable data from the region of extensive training in communication tors, which has been suggested by and the unavailability of some data such skills and by the wide range of ages PUIFSTUVEJFT<>ĉFQSFWBMFODFPG as age of marriage and rates of obstetric studied. The rate of sleep and eating psychiatric disorders was not compared complications. EJTUVSCBODFTBNPOHDBTFT BOE between the relatives of cases and con- XBTMPXFSUIBOėHVSFTPGm trols. The types of disorders could not BOESFQPSUFECZPUIFSTUVEJFT be investigated further. The majority of Conclusions < >ĉFQSFWBMFODFPGTUSFTTGVMMJGF parents of cases were healthy individu- events is probably similar to that in the als. The present study adds to the avail- society at large and is considered to be In the case –control comparisons able knowledge regarding an important relatively small. prenatal obstetric complications (OR public health concern in the Eastern The figure for consanguinity among BTXFMMBTDBFTBSFBOTFDUJPO Mediterranean Region. The prevalence the parents of autistic disorder cases BTTJTUFEEFMJWFSZ 03 XFSFTJH- of autistic disorder in Bahrain was TFFNTUPCFIJHI ĉFPWFSBMMSBUF nificantly more common among cases; within the range reported by other of consanguinity in Bahrain is declining this finding is in accordance with other studies using similar method. Boys PWFSUJNF BUQSFTFOUJUJTBSPVOE SFQPSUFETUVEJFT<>ĉFSBUFPGDBF- outnumbered girls by a ratio of 4 to which is a decrease from the higher level sarean section deliveries among cases 1. Risk factors associated with autistic PGJO<>ĉFėHVSFPG FYDFFEFEUIFBDDFQUBCMFSBUFPG disorder were prenatal complications is probably typical for parents who got TVHHFTUFECZUIF8PSME)FBMUI BOEDBFTBSFBOTFDUJPOBTTJTUFEEFMJWFSZ NBSSJFEJOUIFTBOEOPUGPSUIF 0SHBOJ[BUJPO<>BOEBSFDFOUSFQPSU Future research should be directed present population. Consanguinity was from the main referral general hospital towered studying risk factors derived found to be an associated factor for mild JO4BVEJ"SBCJB<> from a population-based sample, and intellectual disability in a community- The study had some limitations. evaluation of rehabilitation efforts. CBTFE DBTFmDPOUSPMTUVEZ<>*OUIF The nature of the study design being Funding: None present study, we did not compare this a retrospective analysis of events has Competing interests: None declared.
References
1. Diagnostic and statistical manual of mental disorders, 4th ed. 9. Al-Farsi YM et al. Brief report: prevalence of autistic spectrum Washington DC, American Psychiatric Association, 1994. disorders in the Sultanate of Oman. Journal of Autism and 2. Fombonne E. Epidemiological survey of autism and other Developmental Disorders, 2011, 41:821–825. pervasive developmental disorder: an update. Journal of Au- 10. Diagnostic and statistical manual of mental disorders, 4th ed, tism and Developmental Disorders, 2003, 33:365–382. text revision (DSM-IV-TR). Arlington, Virginina, American 3. Freitag CM. The genetics of autistic disorders and its clinical Psychiatric Association, 2002. relevance: a review of the literature. Molecular Psychiatry, 11. Shopler E, Reichler RJ, Renner BR. The Childhood Autism 2007, 12:2–22. Rating Scale (CARS). Los Angeles, Western Psychological 4. New data on autism spectrum disorders. Centers for Disease Services, 1988. Control and Prevention [online] (http://www.cdc.gov/fea- 12. Hollingshead AB, Redlich FC. Social class and mental illness. tures/countingautism/, accessed 27 June 2013). Wiley, New York, 1958. 5. Fombonne E. Epidemiology of pervasive developmental dis- 13. Kielinen M, Linna SL, Moilanen I. Autism in Northern Finland. orders. Pediatric Research, 2009, 65:591–598. European Journal of Child and Adolescent Psychiatry, 2000, 6. Fombonne E. Epidemiology of autistic disorder and other 9:162–167. pervasive developmental disorders. Journal of Clinical Psy- 14. Magnússon P, Saemundsen E. Prevalence of autism in Ice- chiatry, 2005, 66(Suppl. 10):3–8. land. Journal of Autism and Developmental Disorders, 2001, 7. Fombonne E. The epidemiology of autism: a review. Psycho- 31:153–163. logical Medicine, 1999, 29:769–786. 15. Scott FJ et al. Prevalence of autism spectrum conditions in 8. Chakrabarti S, Fombonne E. Pervasive developmental disor- children aged 5-11 years in Cambridgeshire, UK. British Jour- ders in preschool children, 2010. JAMA, 2001, 285:3093–3099. nal of Psychiatry, 2009, 194:500–509.
773
Book 19-9.indb 773 10/7/2013 2:40:25 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
16. Steinhausen HC et al. A community survey of infantile autism. 22. Schreck KA, Williams K, Smith AF. A comparison of eating Journal of the American Academy of Child Psychiatry, 1986, behaviors between children with autism and without au- 25:186–189. tism. Journal of Autism and Developmental Disorders, 2004, 17. Wing L. The definition and prevalence of autism. the defini- 34:433–438. tion and prevalence of autism: a review. European Child and 23. Al-Arrayed SS. The frequency of consanguineous marriage in Adolescent Psychiatry, 1993, 2:61–74. the State of Bahrain. Bahrain Medical Bulletin, 1995, 17:63–66. 18. Wong VCN, Hui SLH. Epidemiological study of autism spec- 24. Al-Ansari A. Etiology of mild mental retardation among Bah- trum disorder in China. Journal of Child Neurology, 2007, raini children: a community-based case control study. Mental 23:67–72. Retardation, 1993, 31:140–143. 19. Modified Checklist for Autism in Toddlers (M-CHAT) follow-up 25. Glasson EJ et al. Perinatal factors and the development of au- interview™ Georgia State University [online] (http://www2. tism: a population study. Archives of General Psychiatry, 2004, gsu.edu/~psydlr/Diana_L._Robins,_Ph.D._files/M-CHATInt- 61:618–627. erview.pdf, accessed 27 June 2013). 26. The National Sentinel Section audit report. London, Royal Col- 20. Bristol M et al. State of the science in autism: report to the Na- lege of Obstetricians and Gynaecologists, 2001. tional Institute of Health. Journal of Autism and Developmental 27. Bondok WM. El-Shehry SH, Fadlallah SM. Trends in cesarean Disorders, 1996, 26:121–154. section rate. Saudi Medical Journal, 2011, 31:41–45. 21. Johnson KP, Malow BA. Assessment and pharmacologic treatment of sleep disturbance in autism. Child and Adolescent Psychiatric Clinics of North America, 2008, 17:773–785.
Executive Board resolution on “Comprehensive and Coordinated Efforts for the Management of Autism Spectrum Disorders”
ĉFSE&YFDVUJWF#PBSEPGUIF8PSME)FBMUI0SHBOJ[BUJPOBEPQUFEBSFTPMVUJPOPOi$PNQSFIFOTJWFBOE $PPSEJOBUFE&ĎPSUTGPSUIF.BOBHFNFOUPG"VUJTN4QFDUSVN%JTPSEFSTu "4%T PO.BZUIĉFSFTPMVUJPO XBTDPTQPOTPSFECZNPSFUIBODPVOUSJFTBOETVQQPSUFECZBMM
The resolution sets out a clear set of actions to facilitate comprehensive intersectoral response to the needs of persons with ASD and other developmental disorders in all countries, with high-, middle- and low-income. The resolution urges Member States to increase the capacity of health and social care systems to provide services for individuals and families with autism spectrum disorders and other developmental disorders. It highlights the importance of implementing SFTPMVUJPO8)"POUIFDPNQSFIFOTJWFNFOUBMIFBMUIBDUJPOQMBOm BTXFMMBTSFTPMVUJPO8)"PO disability, in order to scale up care for individuals with autism spectrum disorders and other developmental disorders and as an integrated component of the scale-up of care for all mental health needs.
Source: Child and Adolescent Mental Health (http://www.who.int/mental_health/women_children/child_adolescent/en/index.html).
774
Book 19-9.indb 774 10/7/2013 2:40:25 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Comparison of maternal characteristics in low birth weight and normal birth weight infants M. Nazari,1,2 S.Y. Sharifah Zainiyah,2 M.S. Lye,2 M.S. Zalilah 3 and M. Heidarzadeh 4
ëÛTÐÊmwGúÐém`IúÐÓmfXÌýmZAM<íëÛTÐľRmeTÐém`IúÐÓmfXÌýmZAM<ohÚmaX ìØÐÛÚ{hA{e7ºĆhUÛx ØnwYºïøënHëYºh²{hHqf=nhfxÛnax ºï}^iënT~Y ëAnUÐî}@Ì{Sí pUa]UÐÒGRéĆBí{hUUÐÒGR:ÓnhRUÐípÐ}CÐ}JnCphhý}UÐÓÐØ{CÐYÒØøUÐ{fLëÛUÐbiF_xoåÉ°#Ð ýn[BN=íëÛUÐľSnfUÐénaJúÐÓngYÌýn[BN=piÚnbedUºphYĆHüÐëÐ}xÎpxÚg+ºëÐ{ª:pbRÐCÐEQ{wÐZUÐíÓøndUpHÐÚØ ºpxPUÐÓnHnhbUÐíºe"Ð=ÐHOÎpRnün=ºÓngYúÐYphRÐ}`ex{UÐíphL5@øÐÓnh]_CÐëAnUÐ +{Sí ëÛUÐÊnxHúÐénaJúÐÓngYÌ 134 134 Aøí ÒØøUÐqSíïHëÛ=ðønaJÌë{÷ Uó íó nYÌð íºëÛUÐľSniðønaJÌë{÷ Uó íó nYÌð YUÙíºïUÐ"Ð5HĆ=:i~UÐîYí î{UëÛUÐÒØnxÛíº!ÐpdTofYíºÓÐØøUÐØ{Líºén1úÐØ{L5hHøíºÓngYúÐýn[B: nhýn[AÎn)ð {´ ó _÷ xÓnRĆBÐØ@íëAnUÐô 3í ëÛUÐÊnxHúÐénaJúÐÓngYÌíëÛUÐľSnfUÐénaJúÐÓngYÌN=UÙíÅïUÐ"Ð5HĆ=:i~UÐîYíºe"ÐéĆBÓngYúÐ =nUÐßnCÐíº=nHànbHÎØ@ííºÒúÐBØíºngdeLíºn4ehd_UÐîCÐíºêúÐH:nhýn[AÎn)ð {´ ó _÷ xÓnRĆBÐëAnUÐAĆxô ÓngYúÐYö N÷ LeCÐN=ºpYnSüÐëncYíºÒØnh_UÐeiíºén1úÐN=pdÉnaUÐÓÐGaUÐó íºiÐíú
ABSTRACT Low birth weight is a key determinant in the risk of morbidity and mortality in the neonatal period and during childhood. This unmatched case–control study in Hamadan, Islamic Republic of Iran, compared the characteristics of mothers of low- and normal-birth-weight infants. Maternal sociodemographic data, pregnancy history, anthropometric data and cord plasma zinc level were collected from 134 mothers of low-birth-weight infants and 134 mothers of normal infants at the time of delivery. Significant differences in maternal characteristics namely gravida, parity, body mass index, maternal weight gain during pregnancy and plasma cord blood zinc were found between low- and normal-birth-weight infants. There were no significant differences in maternal age, maternal education, maternal occupation, family income, previous abortion, previous preterm labour, birth interval, type of clinic and place of residence between the 2 groups.
Comparaison des caractéristiques des mères de nourrissons ayant un poids de naissance faible et un poids de naissance normal
RÉSUMÉ Un faible poids de naissance constitue un facteur déterminant du risque de morbi-mortalité pendant la période néonatale et l'enfance. La présente étude cas–témoins non appariés menée à Hamadan (République islamique d'Iran) a comparé les caractéristiques des mères de nourrissons ayant un poids de naissance faible ou normal. Les données sociodémographiques, anthropométriques et les antécédents gravidiques ont été recueillis et le taux de zinc plasmatique dans le cordon a été analysé à l'accouchement chez 134 mères ayant donné naissance à un nourrisson de faible poids et chez 134 mères ayant donné naissance à un nourrisson de poids normal. Des différences significatives dans les caractéristiques maternelles, à savoir la gestité et la parité, l'indice de masse corporelle, la prise de poids de la mère pendant la grossesse et le taux de zinc plasmatique dans le sang de cordon, ont été observées entre les deux groupes. En revanche, aucune différence importante n'a été retrouvée pour l'âge, le niveau d'études, la profession, le revenu familial, les antécédents d'avortement et de travail prématuré, l'espacement des naissances, le type d'établissement de soins choisi et le lieu de résidence des mères des deux groupes.
1Research Centre for Child and Maternity Care; Hamadan University of Medical Sciences, Hamadan, Islamic Republic of Iran (Correspondence to M. Nazari: [email protected]; [email protected]). 2Department of Community Health; 3Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia. 4Department of Neonatology, Faculty of Medicine and Health Sciences, Tabriz University of Medical Sciences, Islamic Republic of Iran. Received: 26/04/12; accepted: 19/06/12
775
Book 19-9.indb 775 10/7/2013 2:40:25 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Introduction hence to achieve the goal of healthy "TBNQMFTJ[FPGQFSHSPVQXBT normal birth weight (NBW) babies. required to detect an odds ratio (OR) of Low birth weight (LBW), defined as This unmatched case–control study GPSBOVONBUDIFETUVEZ XJUIBQPXFS XFJHIU HBUUIFUJNFPGCJSUI in Hamadan, Islamic Republic of Iran, PGBOEBMQIBMFWFMPG [1], predicts normal growth during part of a larger study, compared the JOGBODZBOEDIJMEIPPE<>BOEJTB NBUFSOBMDIBSBDUFSJTUJDTPGHSPVQTPG Data collection key determinant in the risk of morbid- infants (LBW and NBW) at the time The study was conducted from 6 De- ity and mortality in this period. The of birth. DFNCFSUP0DUPCFS World Health Organization (WHO) Recruitment was conducted by 6 SFQPSUFE UIBU PG JOGBOUT JO trained midwives who assisted in ob- the Eastern Mediterranean Region Methods taining informed consent, recruiting, (EMR) have LBW and that LBW and filling the proforma and taking blood Study setting and sample QSFNBUVSJUZXBTUIFDBVTFPGPG samples. mortality in children < 5 years of age This study was carried out in the labour The gestational age of infants was JOUIF3FHJPO<>"TUIFJODJEFODF ward of Fatemieh hospital, a referral determined by the first day of the last of LBW is one of the best indicators and teaching hospital for the Hama- menstrual period, ultrasound in the for evaluating the success of maternal dan University of Medical Science in first and third trimester of pregnancy and child programmes [4,5] LBW Hamadan, Islamic Republic of Iran. The and also using the new Ballard score. has featured in the health targets of hospital receives pregnant women who All premature infants and those with a number of international organiza- are referred from peripheral antenatal intrauterine growth restriction with tions. Reducing the incidence of LBW care and other smaller hospitals in the CJSUIXFJHIU HXFSFJODMVEFE CBCJFTCZBUMFBTUPOFUIJSECZ province after screening for risks of in this study. The infant’s weight was was one of the goals of WHO [6] and obstetric complications. It has 1 labour determined to the nearest 1 g by an B6OJUFE/BUJPOTSFTPMVUJPOJO XBSEXJUIBDBQBDJUZPGCFETBOE electronic infant scale, calibrated <>4JODFPGDIJMENPSUBMJUZ neonatal intensive care unit ward. There XFFLMZĉFON-PGDPSECMPPEXBT occurs during the first month of birth BSFOFBSMZEFMJWFSJFTQFSEBZ taken through the umbilical cord vein and is directly related to birth weight, In this study infants with birth immediately after delivery and before LBW is also an important indicator XFJHIU HBOEUIFJSNPUIFSTXFSF placenta delivery to avoid clotting by for monitoring the achievement of selected as cases and infants with birth using 5 mL disposable plastic zinc-free Millennium Developmental Goal 4, XFJHIUCFUXFFOmHXFSF syringe with a stainless needle of the to reduce child mortality by two-thirds selected as controls. Infants with any same batch. The blood was put into a CZ< > obvious congenital anomalies were ex- [JODGSFFVODPOUBNJOBUFE&%5", In the Islamic Republic of Iran cluded from this study. Mothers with polyethylene tube labelled with the PGJOGBOUTBSFCPSOFXJUI-#8 any known risk factor for delivering serial number of the mother. The blood and this represents the most im- LBW infants were excluded from this TBNQMFTXFSFDFOUSJGVHFEBUSQN portant cause of infant mortality in study. We therefore excluded: moth- for 15 minutes. The maximum time UIFQBTUEFDBEFT<>*UIBTCFFO ers who were suffering from hyperten- from taking specimen to freezing was established that LBW infants are at sion, renal disease, respiratory disease, < 1 hour. The plasma was kept frozen greater risk for certain diseases such diabetes, lupus, anaemia or other sig- JOQMBTUJDNJDSPUVCFTBUm$VOUJM as cardiovascular and metabolic dis- nificant medical complications such atomic absorption spectrophotometry eases in adulthood [11]. LBW may as heart disease, gastrointestinal dis- was used to determine the concentra- also lead to a vicious cycle beginning ease, infectious diseases; mothers with tion of zinc. with a stunted child, followed by a multiple pregnancy, prolonged labour, ;JODTUBUVTXBTEJWJEFEJOUP thin adolescent and leading to thin fever during labour or malformations categories: severe zinc deficiency < NPUIFSTEVSJOHQSFHOBODZ<> UIFTF of the reproductive system which cause HE- NJMEUPNPEFSBUF[JODEF- mothers are at increased risk of ma- fetal growth retardation (e.g. unicorn ėDJFODZCFUXFFOmHE-BOE UFSOBMNPSCJEJUZBOENPSUBMJUZ<> uterus, bicorn uterus); mothers who OPSNBM[JODMFWFMCFUXFFOm It is therefore important to study the were smokers or consumed alcohol or HE-<> characteristics of pregnant women illicit drugs; and mothers who had or so that interventions can be under- previous record of trauma or any abuse Ethical considerations taken aimed at promoting mothers’ or severe stress such as death of family Ethical approval for the study was health during the antenatal period and member. obtained from the ethics committee
776
Book 19-9.indb 776 10/7/2013 2:40:25 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
of the Faculty of Medicine and Health Results there were no significant differences Sciences, University Putra Malaysia between previous abortion, previous as well as the ethics committee of Mothers’ demographic LBW, birth interval and previous the Medical Science University of characteristics preterm labour among cases and con- Hamadan, Islamic Republic of Iran. %BUBXFSFDPMMFDUFEGSPNOFX- trols. Primigravida and primiparous Informed consent was obtained from CPSOT DBTFT DPOUSPMT 5BCMF mothers were more at risk of having the mothers before participating in this 1 shows a comparison between LBW a LBW infant than multigravida and study. To avoid pricking the subjects, and NBW infants in terms of maternal multiparous mothers. cord blood was used. sociodemographic characteristics. The NFEJBOBHFXBTZFBST SBOHFm Mothers’ anthropometric Analysis ZFBST BOE ZFBST SBOHF m characteristics The data were revised, coded and years) in cases and controls respectively. Fewer mothers in the LBW group analysed using SPSS, version 16. There were no significant differences in than the mothers of NBW infants Descriptive statistics were computed mother’s age, education or occupation XFSFDMBTTJėFEBTVOEFSXFJHIU for all variables. Non-parametric tests or family income between cases and WFSTVT PG-#8JOGBOUT were used since the distributions of controls. had normal weight mothers compared some variables were not normal. Chi- XJUIPG/#8NPUIFSTBOEGFXFS squared or Fisher exact tests were used Mothers’ obstetric history LBW than NBW infants had over- to test the differences between maternal 5BCMFTIPXTUIFDPNQBSJTPOCF- XFJHIUPSPCFTFNPUIFST WFSTVT characteristics among LBW and NBW tween the obstetric history of mothers ĉFSBOHFPGNBUFSOBM#.*JO for categorical variables, while Student in the case and control groups. There the LBW infants group was between t-test was used for continuous variables. were significant differences in gravida BOELHN and in the NBW P XBTDPOTJEFSFETUBUJTUJDBMMZ (P BOEQBSJUZ P HSPVQXBTCFUXFFOmLHN. significant. between cases and controls, whereas Mean maternal pre-pregnancy BMI
Table 1 Sociodemographic characteristics of mothers of low-birth-weight (LBW) and normal-birth-weight (NBW) infants Maternal characteristic Infant birth weight group χ2-test P-value LBW (n = 134) NBW (n = 134) No. % No. % Age (years) a 0.262 0.877 < 20 21 15.8 21 15.9 21–35 104 78.2 101 76.5 > 35 8 6.0 10 7.6 Education b 7.01 0.220 Non-formal education 11 8.3 9 6.7 Primary school or literate 50 37.6 49 36.6 Middle school certification 20 15.0 36 26.9 High school certification 12 9.0 11 8.2 Intermediate or post high school diploma 32 24.1 25 18.7 Graduate or postgraduate 8 6.0 4 3.0 Occupation 2.06 0.357 Housewife 127 94.8 131 98.0 Clerical 7 5.2 3 2.2 Family income (×103 rials/month) c 6.95 0.326 ≤ 1000 9 6.7 6 4.5 1000–< 3000 42 31.3 37 28.0 3000–< 5000 56 41.8 71 53.8 5000–< 7000 18 13.4 15 11.4 ≥ 7000 8 3.8 3 2.3
aMissing = 3 cases; bMissing = 1 case; c10 000 rials = approx. US$ 1.
777
Book 19-9.indb 777 10/7/2013 2:40:25 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 2 Obstetric history of mothers of low-birth-weight (LBW) and normal-birth-weight (NBW) infants Maternal obstetric history Infant birth weight group P-value LBW NBW (n = 134) (n = 134) No. % No. % Gravida < 0.001b Primigravida 92 68.7 59 44.0 Multigravida 42 31.3 75 56.0 Parity < 0. 001b Primipara 100 74.6 64 47.8 Multipara 34 25.4 70 52.2 History of abortion 0.260c No 121 90.3 115 85.8 Yes, 1 12 9.0 17 12.7 Yes, ≥ 2 1 0.7 2 1.5 Birth interval (years) a 0.714b < 3 3 6.2 7 10.4 ≥ 3 30 93.8 60 89.6 Previous LBW 0.103b No 126 94.0 132 98.5 Yes 8 6.0 2 1.5 Previous preterm labour 0.622b No 131 97.8 133 99.3 Yes 3 2.2 1 0.7
aThere were 4 missing values, and because birth interval was only relevant for multiparous women and there were 100 multiparas, values for primiparous mothers were not computed; bFisher exact test; cχ2 = 4.015.
XBTTJHOJėDBOUMZMPXFSJO-#8< NBW groups some mothers had hy- different between LBW and NBW in- 4% LHN] than NBW infants peremesis gravidarum in first trimester fants. Significantly more LBW infants < 4% LHN] (t EG of pregnancy, so their weight loss was had severe zinc deficiency than NBW P 5BCMF more than weight gain during preg- infants (χ P nancy. In this study we had 4 mothers Mean maternal weight gain dur- XJUIXFJHIUMPTTEVSJOHQSFHOBODZ Mothers’ antenatal care ing pregnancy was lower in mothers of mothers in NBW group and 1 mother Almost all mothers in both case and LBW than NBW infants. Mean weight in LBW group), but the effect of weight control groups had attended govern- gain during pregnancy was also signifi- loss was not taken into consideration. ment clinics. There was no association DBOUMZMPXFSJONPUIFSTPG-#8< between the type of clinic and infant 4% LH>UIBO/#8< 4% Cord plasma zinc concentration birth weight (χ P ĉF 5.68) kg] infants (t EG P Table 4 showed the cord blood plasma percentage of NBW infants was higher 5BCMF *OCPUI-#8BOE zinc concentration was significantly in urban mothers. However Fisher exact
Table 3 Pre-pregnancy body mass index (BMI) and weight gain characteristics of mothers of low-birth-weight (LBW) and normal-birth-weight (NBW) infants Variable Infant birth weight group t-test df P-value LBW NBW (n = 134) (n = 134) Mean (SD) Range Mean (SD) Range Pre-pregnancy BMI (kg/m2) 21.9 (3.14) 17.0 to 35.2 22.8 (4.01) 15.6 to 37.7 2.14 244 0.003 Weight gain during pregnancy (kg) 10.2 (4.36) –3 to +22 12.2 (5.68) –5 to +34 3.25 265 < 0.001
SD = standard deviation; df = degrees of freedom.
778
Book 19-9.indb 778 10/7/2013 2:40:25 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Table 4 Cord blood plasma zinc levels in low-birth-weight (LBW) and normal-birth-weight (NBW) infants Cord blood plasma zinc level Infant birth weight group χ2-test P-value LBW Normal (n = 134) (n = 134) No. % No. % Normal 116 86.6 121 90.3 6.93 0. 031 Mild to moderate zinc deficiency 9 6.7 12 9.0 Severe zinc deficiency 9 6.7 1 0.7
test did not show any significant as- smoking, alcohol use, illicit drug use ZFBSTBOE ZFBSTBSFDPOTJEFSFE sociation between place of maternal and pregnancy outside of marriage in an at-risk group and receive special residence and infant birth weight (P = teenage groups. Generally the risk of prenatal care during pregnancy, which 5BCMF -#8JONPUIFSTBHFECFUXFFOm may compensate for the effect of age years is lower than in teenage mothers on infant birth weight. as well as older mothers due to many The present study showed that there Discussion reasons. A possible explanation for were no significant differences between higher risk of LBW among younger maternal education among LBW and Our study showed that there was no mothers is that they are still develop- NBW infants, which is consistent with significant difference in maternal age ing and their need for minerals and some other studies suggesting that among LBW and NBW infants, a vitamins is greater than among older mothers’ levels of education did not finding which is consistent with some mothers. Another reason may be the affect infants’ birth weight [4,15]. Other previous research [15,16], although limited knowledge of these younger studies showed that a low level of mater- other studies suggested that maternal mothers about healthy lifestyles and nal education was a predictor of LBW age was a risk factor for LBW infants preparation during the antenatal pe- < >.BUFSOBMiEJFUBSZMJUFSBDZu < >"TUVEZJO1PMBOETIPXFEUIBU riod. The risk of LBW among older NPUIFSTBHF ZFBSTXBTBQSPUFD- mothers may be related to many risk has been shown to influence the zinc tive factor against LBW infants [16]. factors such as cardiovascular disease, status of mothers [14,18]. Conversely, in Taiwan LBW was hypertension, diabetes and other dis- Our data also indicated that ma- NPSFDPNNPOJONPUIFST ZFBST eases that frequently affect older moth- ternal occupation was not different PMEBOE ZFBSTPME<>.PUI- ers. The reason for the non-significant between the case and control groups FSTBHF ZFBSTDBOCFBTUSPOHSJTL difference in maternal age between and this supports the findings of other factor for extremely LBW [15]. This LBW and NBW groups in this study SFTFBSDIFST< >"QPTTJCMFSFB- contradictory effect may be related to may be the new protocol for high-risk son for this finding is the homogenous the socioeconomic status of teenage mothers during prenatal care in the Is- nature of occupation, as the great ma- mothers and other risk factors such as lamic Republic of Iran. Mothers aged < jority of the mothers in our study were
Table 5 Location of clinic and place of residence of mothers with low-birth-weight (LBW) and normal-birth-weight (NBW) infants Variable Infant birth weight group χ2-test P-value LBW NBW (n = 134) (n = 134) No. % No. % Clinic 3.06 0.217 Government 127 94.8 124 92.5 Private 7 5.2 7 5.3 Both 0 0.0 3 2.2 Place of residence 0.434a Urban 40 29.9 47 35.1 Rural 94 70.1 87 64.9
aFisher exact test.
779
Book 19-9.indb 779 10/7/2013 2:40:25 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
housewives. Hence it was not possible of the best ways to reduce the risk of mLHGPSOPSNBMXFJHIUNPUI- to study the effect of job on birth weight -#8JOGBOUT<>"DDPSEJOHUPUIF FSTBOE LHGPSPWFSXFJHIUBOE in this study. new protocol for prenatal care in Is- PCFTFNPUIFST<>*OUIJTTUVEZUIF Mean family incomes for LBW lamic Republic of Iran mothers with maternal weight gain during pregnan- and NBW infants were similar. Other a history of previous LBW or preterm cy in the case and control groups was studies showed that higher socioeco- labour receive increased prenatal care significantly different. This result was nomic status reduced the risk of LBW under the supervision of an obstetri- similar to the findings of several studies especially very LBW and prematu- DJBOHZOBFDPMPHJTUEVSJOHQSFHOBODZ which demonstrated that maternal rity [18]. The findings of Aydemir et so this extra level of care may have weight gain during pregnancy was an al. showed that there were significant decreased the risk of LBW and prema- important risk factor for LBW infants differences between plasma zinc levels ture birth. < >ĉFSJTLPG-#8XBTTJHOJė- among mothers of different socioeco- Our study also showed that ma- cantly lower in mothers who had suf- nomic status. Moreover, they did not ternal pre-pregnancy BMI was sig- ficient weight gain during pregnancy find any relationship between plasma nificantly different between the case compared with mothers who did not zinc levels and infant anthropometric and control groups. Likewise, obese IBWFBEFRVBUFXFJHIUHBJO<m> parameters [19]. Maternal nutritional women were at more risk for deliver- The type of clinic and place of resi- needs increase during pregnancy. Un- ing LBW infants, because obesity in- dence were not significantly different fortunately, lack of knowledge about creases the risk of hypertensive disease between case and control groups. diet and lower family income are BOEEJBCFUFT<>)PXFWFS ėOEJOHT important risk factors for inadequate by other researchers suggested that intake of nutrients in the majority of the maternal pre-pregnancy BMI is Conclusion pregnant mothers. associated with infant birth weight Our study showed significant dif- < >#PUIVOEFSXFJHIUBOEPWFS- Maternal pre-pregnancy BMI, ma- ferences between the case and control weight in mothers can affect preg- ternal weight gain during pregnancy, groups for mothers’ gravida and parity. OBODZPVUDPNFT<>)JHIFS#.* gravida, parity and cord blood plasma Primiparous mothers were more at and multiparity were associated with zinc were significantly different be- risk having LBW infants in compari- increased risk of having large gesta- tween LBW and NBW infants, but son with multiparous mothers. The tional age infants. Also the risk of LBW there was no significant difference risk of very LBW in these mothers was higher in thin and normal weight in maternal age, maternal education, is greater than multiparous mothers mothers compared with overweight maternal occupation, family income, [1,17]. The possible explanation for BOEPCFTFNPUIFST<>ĉFėOE- previous abortion, previous preterm higher birth weight in multiparous ings by Goldenberg et al. showed labour, birth interval, type of clinic or mothers compared with primiparous that a lower pre-pregnancy BMI may place of maternal residence between mothers, except in older mothers, is DBVTFQSFUFSNJOUIFTFNPUIFST<> LBW and NBW infants. the higher uterine blood circulation in Conversely the association between NVMUJQBSPVTNPUIFST<> maternal pre-pregnancy BMI and Other obstetric history vari- LBW infants was not significant in a Acknowledgements ables—birth interval, previous LBW study in Rasht, Islamic Republic of and previous preterm labour—were *SBO<>ĉFQPTTJCMFFYQMBOBUJPOGPS We would like to extend our gratitude not significantly different between higher risk of LBW among overweight to the mothers who participated in case and control groups. This non- and obese mothers in our study may this study, as well as the medical staff significant difference may be related be related to advice on weight gain in Fatemieh hospital for their invalu- to the small sample size in the group of limitation given by health-care work- able assistance in this research. NPUIFSTXJUI ZFBSTCJSUIJOUFSWBM ers to overweight and obese mothers Funding: We would like to express Conversely, the results of Roudbari et during pregnancy. Tamura et al. also our deepest gratitude to the Iranian al. and Bernabe et al. were contradic- found that there was a negative and Ministry of Health and Medical UPSZ< >ĉFZSFQPSUFEUIBUCJSUI significant relationship between pre- Education, as well as the Mother JOUFSWBMTPG ZFBSTIBEBTJHOJėDBOU pregnancy BMI and maternal zinc and Child Care Research Centre of effect on pregnancy outcome and in- DPODFOUSBUJPO<> Hamadan University of Medical and creased risk of LBW. O’Connor et al. According to WHO the recom- Health Sciences for supporting this also stated that adequate birth interval mended weight gain during pregnancy research. and using family planning were one is ≥ 15 kg for underweight mothers, Competing interests: None declared.
780
Book 19-9.indb 780 10/7/2013 2:40:25 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
References
1. Cunningham L, Bloom H, Rouse S. Williams’ obstetrics, 23 ed. w tym tempa przyrostu masy ciała w ciazy i masy przed ciaza, New York, McGraw-Hill, 2010. na mała mase urodzeniowa noworodka. Ginekologia Polska, 2. Roberfroid D et al.; MISAME Study Group. Effects of maternal 2008, 79:415–421. multiple micronutrient supplementation on fetal growth: a 17. Li Y-M, Chang T-K. Maternal demographic and psyhosocial double-blind randomized controlled trial in rural Burkina factors associated with low birth weight in eastern Taiwan. Faso. American Journal of Clinical Nutrition, 2008, 88:1330– Kaohsiung Journal of Medical Sciences, 2005, 21:502–510. 1340. 18. Schulpis KH et al. The effect of nutritional habits on maternal- 3. Maddah M et al. Social factors and pregnancy weight gain in neonatal zinc and magnesium levels in Greeks and Albanians. relation to infant birth weight: a study in public health cent- European E-Journal of Clinical Nutrition and Metabolism, 2009, ers in Rasht, Iran. European Journal of Clinical Nutrition, 2005, 4(4):e176–e180. 59:1208–1212. 19. Aydemir F et al. Plasma zinc levels during pregnancy and 4. Vahdaninia M, Tavafian S, Montazeri A. Correlates of low birth its relationship to maternal and neonatal characteristics: a weight in term pregnancies: a retrospective study from Iran. longitudinal study. Biological Trace Element Research, 2003, BMC Pregnancy and Childbirth, 2008, 8:1–5. 91:193–202. 5. Zulfiqar AB et al. Outcomes in developing countries: a review 20. Rosenberg TJ et al. Maternal obesity and diabetes as risk fac- of the evidence community-based interventions for improving tors for adverse pregnancy outcomes: differences among 4 perinatal and neonatal health. Pediatrics, 2005, 115:519–617. racial/ethnic groups. American Journal of Public Health, 2005, 6. Wardlaw T et al. Low birth weight country regional and global 95:1545–1551. estimates. New York; United Nations Children’s Fund/World 21. Valero De Bernabé J et al. Risk factors for low birth weight: a Health Organization, 2004. review. European Journal of Obstetrics, Gynecology, and Repro- 7. Haggaz AD, Radi EA, Adam I. Anaemia and low birthweight ductive Biology, 2004, 116:3–15. in western Sudan. Transactions of the Royal Society of Tropical 22. O’Connor J, Nolan K, O’Neill C. State-level health policy to Medicine and Hygiene, 2010, 104:234–236. improve birth outcomes and reduce infant mortality. Health 8. Khor GL. Importance of nutrition in achieving the Millennium Promotion Practice, 2005, 6:12–22. Development Goals. Malaysian Journal of Medicine and Health 23. Williamson CS. Nutrition in pregnancy. Nutrition Bulletin, Sciences, 2008, 4(1):1–21. 2006, 31:28–59. 9. World health statistics 2011. Geneva, World Health Organiza- 24. Cruz ML et al. Association of body mass index of HIV-1-in- tion, 2011. fected pregnant women and infant birth weight, body mass 10. Roudbari M, Yaghmaei M, Soheili M. Prevalence and risk fac- index, length, and head circumference: the National Institute tors of low-birth-weight infants in Zahedan, Islamic Republic of of Child Health and Human Development International Site Iran. Eastern Mediterranean Health Journal, 2007, 13:838–845. Development Initiative Perinatal Study. Nutrition Research, 11. Romano T et al. Prenatal growth restriction and postnatal 2007, 27:685–691. growth restriction followed by accelerated growth indepen- 25. Goldenberg RL et al. Epidemiology and causes of preterm dently program reduced bone growth and strength. Bone, birth. Lancet, 2008, 371:75–84. 2009, 45:132–141. 26. Tamura T et al. Relationship between pre-pregnancy BMI and 12. Elizabeth KE, Krishnan V, Zachariah P. Auxologic, biochemi- plasma zinc concentrations in early pregnancy. British Journal cal and clinical (ABC) profile of low birth weight babies- a of Nutrition, 2004, 91:773–777. 2-year prospective study. Journal of Tropical Pediatrics, 2007, 27. Ota E et al. Maternal body mass index and gestational weight 53:374–382. gain and their association with perinatal outcomes in Viet 13. Friis H et al. Effect of multimicronutrient supplementation Nam. Bulletin of the World Health Organization, 2011, 89:127– on gestational length and birth size: a randomized, placebo- 136. controlled, double-blind effectiveness trial in Zimbabwe. 28. Ricketts SA, Murray EK, Schwalberg R. Reducing low birth- American Journal of Clinical Nutrition, 2004, 80:178–184. weight by resolving risks: results from Colorado’s prena- 14. Borna S et al. A comparative study of Zinc deficiency preva- tal plus program. American Journal of Public Health, 2005, lence in pregnant and non pregnant women. Tehran University 95:1952–1957. Medical Journal, 2009, 67:360–367. 29. Siega-Riz AM et al. A systematic review of outcomes of ma- 15. Farajzadegan Z et al. Could zinc supplementation in preg- ternal weight gain according to the Institute of Medicine nancy improve infancy outcomes? Shiraz E-Medical Journal, recommendations: birth weight, fetal growth, and postpartum 2007; 8 (2):80–86. weight retention. American Journal of Obstetrics and Gynecol- 16. Borkowski WO, Mielniczuk H. [The influence of social and ogy, 2009, 201:331–339. health factors including pregnancy weight gain rate and 30. Hulsey TC et al. Maternal prepregnant body mass index and pre-pregnancy body mass on low birth weight of the infant]. weight gain related to low birth weight in South Carolina. Wpływ wybranych czynników społecznych i zdrowotnych, Southern Medical Journal, 2005, 98:411–415.
781
Book 19-9.indb 781 10/7/2013 2:40:26 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Users of withdrawal method in the Islamic Republic of Iran: are they intending to use oral contraceptives? Applying the theory of planned behaviour P. Rahnama,1 A. Hidarnia,2 F.A. Shokravi,2 A. Kazemnejad,3 A. Montazeri,4 F.R. Najarkolaei 5 and A.Saburi 6
T\BÐècTÐow|]hg\=Èowd`TÐd"ÐÓm^hmXé5^GÐëíewvo¬ gX°GüÐëÐ|wÎowÚf+9d"ÐeBng[aTÐnGoaw|I^Xö ïÚÉNY̺xĆTÚni1ÚeJnRºï}^fYMLºØniKnTëÐíEIi̺ïÚí}cINYÌì{fB}RºnhiÚ{hAnEdLº5fwÚxí}= ì|wYëAnUÐæ{0í e"Ð fY@ÌYâ5!ÐÊnf?Ìoh\bUÐoHDLphYĆHüÐëÐ}xÎpxÚg+:ÕÐíÛúÐY{x{_UÐ{e_xoåÉ°#Ð e"Ð iÐYOÎédUwnxÐiíoh\bUÐoHpbx}J xY:}?k>UÐYÐ_UÐDLæ}_dUU´ ]CÐèdUÐYÒØnaHøÐOÎpHÐÚ{UÐ 336 YwÚnhBÐ>{Síºe"Ð fCoh\bUÐoHpbx}JY{xö,nhf@p]hZip@í~YÒÌ}YÐð pHÐÚ{UÐ:NTÚnZCÐØ{Ld={Sí pxeaUÐ SÐCÐU]CÐèdUÐpx}^f=pÉn#ÐE=Ð{UÐ\>ÓninhHÐëAnUÐâÛí{Sí ëÐ}gJ:ên_UÐân]bdUp_=n>ÒúÐh^fUÓÐØnhL2 \UкénYøÐDLr_>UÐ~RÐ"кæÐ}LúÐ:ÓÐ{b_CÐphLCÐEQíph[ZUÐæÐ}Lúкýn["ÐÓ5hhb>ºphTdUÐÓÐ{b_CÐ ºèddUTÐÚØüÐ\UÐíºĽnCÐ:èdUÐëÌ}gKÌnh]Bð nhRð Ļ´ ĆhdĻëAnUÐî}@Ìí phTdUÐ{ÉnbCÐíĽnCÐ:èdUкèddUTÐð ÚØüÐ sfHÐí %36pxeaUÐe"Ð iÐYêÐ{Hø{ÉnbCÐ:AĆCÐÓínaUÐYpxþCÐofUÐDLÌLpUíkCÐwph[ZUÐßÐ}LúÐíSÐCÐí e"Ð fCoh\bUÐoHpbx}J xCUAÒÚZCÐx{b>íÒúÐh^f>:ÓÐ{b_CÐDL~c>}CÐhbUÐhe[>`fxiÌOÎëAnUÐ
ABSTRACT Many couples in the Islamic Republic of Iran rely on coital withdrawal for contraception. The purpose of this cross-sectional study was to use the theory of planned behaviour to explore factors that influence withdrawal users’ intent to switch to oral contraception (OC). Participants were 336 sexually active, married women, who were current users of withdrawal and were recruited from 5 public family planning clinics in Tehran. A questionnaire included measures of the theory of planned behaviour: attitude (behavioural beliefs, outcome evaluations), subjective norms (normative beliefs, motivation to comply), perceived behaviour control, past behaviour and behavioural intention. Linear regression analyses showed that past behaviour, perceived behaviour control, attitude and subjective norms accounted for the highest percentage of total variance observed for intention to use OC (36%). Beliefs-based family planning education and counselling should to be designed for users of the withdrawal method.
Utilisateurs de la méthode du retrait en République islamique d'Iran : ont-ils l'intention d'utiliser des contraceptifs oraux ? Application de la théorie du comportement planifié
RÉSUMÉ De nombreux couples en République islamique d'Iran comptent sur le retrait coïtal pour leur contraception. L'objectif de la présente étude transversale était d'utiliser la théorie du comportement planifié pour étudier les facteurs influant sur l'intention de passer à une contraception orale chez les utilisateurs du retrait. Les participantes, 336 femmes mariées, sexuellement actives et utilisatrices de la méthode du retrait, ont été recrutées dans cinq établissements publics de planification familiale à Téhéran. Le questionnaire administré mesurait les paramètres de la théorie du comportement planifié suivants : l'attitude (croyances comportementales, évaluations des résultats), les normes subjectives (croyances normatives, motivation pour s'y conformer), les croyances du sujet en sa capacité comportementale, le comportement antérieur et l'intention comportementale. Des analyses de régression linéaires ont révélé que le comportement antérieur, les croyances sur la capacité comportementale, l'attitude et les normes subjectives représentaient le plus fort pourcentage de la variance totale observée pour l'intention d'utiliser une contraception orale (36 %). Des sessions de formation et de conseil en matière de planification familiale prenant en compte les croyances devraient être élaborées pour les utilisateurs de la méthode du retrait.
1Department of Midwifery, Shahed University, Tehran, Islamic Republic of Iran. 2Department of Health Education; 3Department of Biostatistics, Faculty of Medicine, Tarbiat Modares University, Tehran, Islamic Republic of Iran (Correspondence to A. Hidarnia: [email protected]; [email protected]). 4Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, Academic Centre for Education, Culture and Research, Tehran, Islamic Republic of Iran. 5Health Research Centre; 6Atherosclerosis and Coronary Artery Research Centre, Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran. Received: 17/01/12; accepted: 22/05/12
782
Book 19-9.indb 782 10/7/2013 2:40:26 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction TPB contains the same components as other type of recording was used for the TRA, and adds perceived behaviour these interactions, which were carried Despite the many successes of the fam- control as a third major construct in out confidentially. ily planning programme in the Islamic the prediction of both intention and Approval for the study was obtained Republic of Iran (total fertility declined CFIBWJPVS<>3FTFBSDIFSTIBWFVTFE from the Office for Protection of Re- GSPNUPQFSXPNBOCFUXFFO the TPB to predict intention to per- search Subjects in Tarbiat Modares BOE<> BCPVUPOFUIJSE GPSNQIZTJDBMBDUJWJUZ<> TBGFSTFY University. Oral informed consent was PGQSFHOBOUXPNFOJOTBJEUIFJS behaviour [14] and Muslim women’s obtained from each participant prior QSFHOBODJFTXFSFVOJOUFOEFE<>0SBM intention to use OC [15,16]. Both the to the study and after assuring them contraceptives (OC), distributed free TRA and TPB have shown predictive that their identity would remain confi- by the government programme, are the abilities [17,18]. dential. most popular contraceptive method in The aim of the current study was to Questionnaire the Islamic Republic of Iran, used by use the framework of the TPB to inves- Since a standard TPB questionnaire was PGNBSSJFEXPNFO"MNPTUBT tigate the predictors of woman’s intent NBOZDPVQMFT IPXFWFS SFMZ not available in the Islamic Republic of to switch from coital withdrawal to OC. on the traditional method of coital with- *SBO JOEFQUIJOUFSWJFXTXJUIXPNFO Previous research suggests that habit or drawal, even though this method is not were conducted to elicit their salient past behaviour is one of the most im- promoted by the Iranian national family beliefs concerning OC use among portant predictors of future behaviour QMBOOJOHQSPHSBNNF<>8JUIESBXBMJT VTFSTPGDPJUBMXJUIESBXBM<>ĉF < >BOETPQBTUCFIBWJPVSXBTBMTP known to be associated with high rates data from this qualitative study were included in the current study. of unintended pregnancy [4], with the used to develop the questionnaire. The risk that women resort to unsafe, illegal RVFTUJPOOBJSFIBEQBSUTĉFėSTUQBSU abortions [5]. contained questions about the woman’s Methods demographic characteristics and repro- Method of choice and the effec- ductive health background. The second tive use of contraceptive methods are Study design and participants part was designed to measure TPB complex issues influenced by differ- This was a cross-sectional study car- constructs including: attitude (behav- ent factors [6,7]. When specific clini- ried out in Tehran, Islamic Republic of ioural beliefs, outcome evaluations), cal outcomes are desired, well-known Iran. Participants were recruited from subjective norms (normative beliefs, concepts from behavioural theories can attendees at 5 family planning clinics of help guide new clinical care guidelines. motivation to comply), perceived be- the public health services in the Eastern Several studies have shown that beliefs haviour control, behavioural intention district of Tehran, Islamic Republic and attitudes about OC affect correct and past behaviour. These are explained of Iran (the area serves as the training use of OC [8,9]. In the current study, as follows: area for the Iran University of Medi- the research approach was based on Attitudes: The attitude scale had the Theory of Reasoned Action (TRA), cal Sciences). The criteria for inclusion JUFNT JUFNTPOCFMJFGTBCPVUUIF augmented by the Theory of Planned were: women aged 18–49 years, cur- outcome of using OC including 5 items #FIBWJPVS 51# <> CPUIPGXIJDI rent withdrawal users, married, sexually (e.g. How likely do you think taking the require examining personal and contex- active, did not intend to be pregnant, oral pill for the next 4 months will cause tual influences [11]. In the case of the no identifiable risks to the participants hirsutism?) and 5 items on evaluation 5Ć JOUFOUJPOTBSFUIPVHIUUPIBWF beyond OC use. of a given belief including 5 items (e.g. components: attitudes and subjective How would you rate the importance of Data collection norms. Attitudes are beliefs that engag- hirsutism to yourself?). Respondents ing in the behaviour will be associated An oral informed consent was ob- rated each item on a 5-point scale rang- with positive outcomes (behavioural tained from each participant prior to ing from 1–5. Then for each item, belief beliefs), as well as an assessment of how the interview. Data were collected us- was multiplied by its importance and much one values these outcomes (eval- ing a structured face-to-face interview UIFSFTVMUTGSPNJUFNTXFSFBEEFEUP uation). Subjective norms comprise administered by trained interviewers obtain the score for attitude [11]. both beliefs about whether other indi- not involved in the women’s care or Subjective norms: The subjective viduals approve or disapprove of the the family planning programme. In- OPSNTTDBMFJODMVEFEJUFNT JUFNT behaviour (normative beliefs), as well UFSWJFXTMBTUFEGPSmNJOVUFT on beliefs about the expectations of as one’s motivation to comply with such with responses recorded on the paper significant others (e.g. My husband individuals (motivation to comply). The questionnaires by the interviewer. No would approve using OC for the next
783
Book 19-9.indb 783 10/7/2013 2:40:26 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
4 months) and 5 items that measured -JLFSUTDBMF< >*UFNDPOUFOUWBMJE- correlation coefficient, chi-squared test motivation to comply with significant JUZJOEFYWBSJFEGSPNUP XJUIB and analysis of variance as appropri- others’ expectations (e.g. My husband’s NFBOPGGPSUIFUPUBMTDBMFĉFO ate. Then, linear regression analysis was approval for taking OC would be im- withdrawal users were asked to evaluate performed to indicate variables that portant for me). These were scored on the readability and format of the ques- contributed to variances observed in a 5-point scale ranging from 1–5. Then tionnaire. In addition, Cronbach alpha intention to use OC. Intention was the for each item belief was multiplied by coefficient was used to assess the inter- dependent variable and demographic its important motivation to comply and nal consistency of the questionnaire and variables and TPB constructs were UIFOUIFSFTVMUTPGUIFJUFNTXFSF JUTTVCTDBMFT"MQIBSBOHFEGSPN USFBUFEBTJOEFQFOEFOUWBSJBCMFT<> added to obtain the score for subjective UP XFMMBCPWFUIFSFDPNNFOEFE norms [11]. value. Furthermore 15 withdrawal users Perceived behavioural control: The completed the questionnaire again after Results perceived behavioural control scale BXFFLJOUFSWBMUPBTTFTTUIFTUBCJMJUZPG comprised 4 items (e.g. Using the con- the questionnaire over time. ĉFNFBOBHFPGUIFXPNFOXBT traceptive pill within the 4 next months 4% ZFBST"NBKPSJUZ IBE is difficult for me because I have to take Analysis secondary school level of education. The the pill on time and daily without forget- Data were analysed using the SPSS mean number of children per woman ting to take it). Respondents were asked for Windows, version 16. Descriptive XBT 4% SBOHFm IBE to indicate their agreement on a 5-point analyses were conducted for all vari- ɓDIJMESFOĉFBWFSBHFOVNCFSPG Likert scale ranging from strongly agree ables [percentages, mean and standard years that they had used the withdrawal to strongly disagree. To obtain the score deviation (SD)]. Bivariate analysis of method was 9.8 (SD 5.9) years. The for perceived behavioural control the variables was conducted using Pearson average length of previous OC use was results for 4 items were added. Past behaviour: Past behaviour was measured by asking respondents to in- Table 1 Characteristics of study sample of married women using coital withdrawal dicate for how long they had used OC (n = 336) in the past 4 years. Variable Mean (SD) No. of % value women Intention: In health behaviour re- search, intention has been assessed in Age (years) 32.4 (6.8) several ways. The present study meas- ≤ 35 227 67.6 VSFEUIJTWBSJBCMFXJUIJUFNT%PZPV <35 109 32.4 intend to use OC for the next 4 months? Duration of woman’s education (years) 11.4 (2.7) and Might you decide to use OC for the 5 30 8.9 next 4 months? These were scored on 11 245 64.0 5-point scales ranging from completely ≥ 12 91 27.1 agree to completely disagree. To obtain Time since marriage (years) 11.5 (7.1) UIFTDPSFGPSJOUFOUJPOUIFSFTVMUTGPS ≤ 10 185 55.1 items were added. <10 151 44.9 Content validity No. of children 1.6 (1.0) 0–1 151 44.9 The content validity of the question- 2 138 41.1 naire was established through making DIBOHFTTVHHFTUFECZFYQFSUTJO ≥ 3 47 14.0 obstetrics and health education with Experience of unwanted pregnancy – wide experience in the areas of survey Yes 95 28.3 development and behavioural theory. No 241 71.3 In addition, a content validity index Experience of OC use – was calculated. The experts were asked Yes 99 29.5 to evaluate the relevance, clarity and No 237 70.5 simplicity of each item based on the Duration of use of OC (months) 9.1 (5.5) conceptual definition provided. The Duration of use of coital withdrawal (years) 9.8 (5.9) panel assessed each item using a 4-point OC = oral contraceptives; SD = standard deviation.
784
Book 19-9.indb 784 10/7/2013 2:40:26 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Table 2 Pearson correlation matrix between intention (dependent variable) and the independent variables studied among coital withdrawal users (n = 336) Variable Age (years) Woman’s Attitude Subjective Perceived Past Intention education norms behavioural behaviour (years) control Age (years) 1.00 – – – – – – Woman’s education (years) 0.05 1.00 – – – – – Attitude 0.05 0.08 1.00 – – – – Subjective norms 0.06 0.02 0.07 1.00 – – – Perceived behavioural control 0.03 0.04 0.24** 0.15** 1.00 – – Past behaviour 0.05 0.04 0.10 0.13* 0.30** 1.00 – Intention 0.05 0.09 0.33** 0.24** 0.45** 0.44** 1.00 Mean (SD) value 32.4 (6.8) 11.5 (7.1) 22.8 (13.1) 47.8 (15.5) 10.6 (3.1) 9.1 (5.5) 4.5 (2.1)
*P < 0.05; **P < 0.01. SD = standard deviation.
9.1 (SD 5.5) months. Of the women, 95 indicated past behaviour was the most of intended OC use, followed by at- SFQPSUFEIBWJOHIBEBUMFBTU JNQPSUBOUQSFEJDUPSPGJOUFOUJPOT ϩ titudes and subjective norms. Thus, unwanted pregnancy (Table 1). GPMMPXFECZQFSDFJWFECFIBWJPVS- the addition of perceived behavioural 5BCMF TIPXT UIF DPSSFMBUJPOT BMDPOUSPM ϩ BĨJUVEFT ϩ control improved the performance of among the constructs of the model BOETVCKFDUJWFOPSNT ϩ ĉVT the model in predicting intended OC for intended OC use and descriptive hierarchical regression analyses with use as compared to the performance of statistics for the various variables for the components of the TRA accounted the TRA. These results are consistent the theoretical constructs. All of the GPSPGWBSJBODFJOJOUFOEFE0$ with a number of studies across a wide variables except age and duration of use in this community. However, in range of health behaviours [14,15], education presented significant bivari- the second and third steps inclusion of where perceived behavioural control ate associations with intended OC use, perceived behavioural control and past was found to be the strongest predictor with past behaviour (r TIPXJOH behaviour increased the multiple R2 PGCFIBWJPVSBMJOUFOU< >"OPUIFS the highest correlation. significantly. study revealed that intention to use con- To predict intentions, a hierarchi- doms was significantly predicted by atti- cal regression analysis was conducted tudes, subjective norms and perceived with age, female education, attitude Discussion CFIBWJPVSBMDPOUSPM<>*OBTUVEZ and subjective norms entered at step 1, of Ethiopian adolescents, the results QFSDFJWFECFIBWJPVSBMDPOUSPMBUTUFQ The findings from this study revealed TIPXFEUIBU51#BDDPVOUFEGPSPG BOEQBTUCFIBWJPVSBUTUFQ 5BCMF that attitude and subjective norms the variance in contraceptive intention Overall, the 4 variables accounted for BDDPVOUFEGPSPGUIFWBSJBODFJO <> BOEJOUIF*TMBNJD3FQVCMJDPG*SBO PGUPUBMWBSJBODFJOJOUFOUJPOT P intentions of withdrawal users to use it was found that TPB was useful to pre- "UTUFQBĨJUVEFBOETVCKFD- OC. Therefore the results indicated dict continued OC use, with perceived tive norms were found to account for that the TRA could be used to predict behavioural control as the strongest PGUIFWBSJBODFJOJOUFOUJPOT P < intent of withdrawal users in Tehran to predictor [16]. ĉFϩXFJHIUGPSBĨJUVEFBOE switch to OC use. The TRA assumes In our study OC use intentions were subjective norms was significant. At step that behaviours are under volitional predicted by past behaviour, perceived JODMVTJPOPGQFSDFJWFECFIBWJPVSBM control and that a person’s intent is the behavioural control, attitude and sub- control increased the R2 significantly most important direct determinant of jective norms. It has been suggested BOEFYQMBJOFEPGUIFWBSJBODFJO QFSGPSNJOHBQBSUJDVMBSCFIBWJPVS<> that if a person has performed the JOUFOEFE0$VTF)PXFWFS JOTUFQJO- The present study showed that the behaviour before the commitment to clusion of past behaviour increased the 51#FYQMBJOFEPGUIFWBSJBODFJO perform the behaviour in the future is multiple R2 significantly (R2 adjusted intended OC use. When perceived QSPCBCMZTUSFOHUIFOFE<>4JNJMBSMZ P &YBNJOBUJPOPGUIF behaviour control was included in the other investigators reported that the ϩXFJHIUTGPSUIFTJHOJėDBOUWBSJBCMFT model, it was the strongest predictor best predictor of future behavioural
785
Book 19-9.indb 785 10/7/2013 2:40:26 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 3 Hierarchical linear regression analysis for predicting oral contraceptive use intention (dependent variable) among coital withdrawal users (n = 336) Step/predictor R² R² adjusted Regression Partial correlations coefficient (β) Step 1 0.16 0.15 Attitude 0.31** 0.32 Subjective norms 0.21 0.22 Step 2 0.28 0.27 Attitude 0.23** 0.25 Subjective norms 0.17** 0.19 Perceived behavioural control 0.37** 0.38 Step 3 0.37 0.36 Attitude 0.22** 0.27 Subjective norms 0.14** 0.17 Perceived behavioural control 0.28** 0.30 Past behaviour 0.31** 0.34
*P < 0.05; **P < 0.01.
measures is an earlier measure of the the first study that has investigated the In addition past behaviour was found TBNFCFIBWJPVS<> belief-based theory among women who to be the most contributing factor for According to the TPB, demographic used the withdrawal method related intention to use OC. Beliefs-based fam- and personality variables and individual to OC in Tehran and therefore, de- ily planning education and counselling differences primarily play an indirect spite these limitations, our findings are should be designed for users of the role in influencing behaviour. These dis- important for making informed policy withdrawal method. tal variables such as cultural and person- decisions in reproductive health. ality differences should be reflected in UIFVOEFSMZJOHCFMJFGTUSVDUVSF< > Acknowledgements This study had some limitations. Conclusions First, the sample size was small. Sec- This research was originated from a ondly, this study had an exclusive focus The current study provided evidence PhD thesis in health education. The on intentions instead of behaviours. for the utility of the belief-based meas- authors gratefully acknowledge the in- "MUIPVHIPG*SBOJBOXPNFOVTF ures of the TPB in prediction of coital stitutional review board of the Tarbiat DPOUSBDFQUJWFT<> NPTUPCUBJOFEGSPN withdrawal users’ intent to use OC. The Modares University, which approved providers in the public sector, our find- study revealed that past behaviour, per- and supported this project. They also ings may not be generalizable to women ceived behaviour control, attitudes and wish to thank the participants for their who do not seek health care or who seek subjective norms were the significant cooperation. health care elsewhere. However, this is predicators of intention to use OC. Competing interests: None declared..
References
1. Country profiles: Islamic Republic of Iran. World Health Organi- 6. Kunz J, Bitzer J. Verhutung aus Sicht der Frauen (Teil 1): Die zation Regional Office for the Eastern Mediterranean [online Beratung durch den Hausarzt wird als „sehr gut“ eingestuft. database] (http://www.emro.who.int/emrinfo/index.asp, Frauen schatzen die Pille als effektive und sichere kontrazep- accessed 12 June 2013). tive Methode ein. Eine reprasentative Umfrage [Pregnancy 2. Abbasi-Shavazi JM et al. Unintended pregnancies in the Is- prevention from the viewpoint of women (1): Patient coun- seling by the general practitioner is rated as "very good". lamic Republic of Iran: levels and correlates. Asia-Pacific Popu- Women assess the pill as an effective and safe contraception lation Journal, 2004, 19:27–38. method. A representative survey]. Praxis, 2000, 89:1142–1146. 3. Demographic and Health Survey (DHS) Iran. Tehran, Iranian 7. Bianchi-Demicheli F et al. Contraceptive practice before and Ministry of Health, 2000 [in Farsi]. after termination of pregnancy: a prospective study. Contra- 4. Hatcher RJ et al. Contraceptive technology, 19th ed. Atlanta, ception, 2003, 67:107–113. Georgiam Ardent Media, 2004. 8. Guthrie BJ et al. Using cognitive theory to improve nurse prac- 5. Larijani B, Zahedi F. Changing parameters for abortion in Iran. titioners’ anticipatory guidance with contraceptive pill users. Indian Journal of Medical Ethics, 2006, 3:130–131. Journal of Community Health Nursing, 2001, 18:223–234.
786
Book 19-9.indb 786 10/7/2013 2:40:26 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
9. Khan MA. Oral contraceptive non-compliance in rural Bangla- 22. Lynn MR. Determination and quantification of content validity. desh. Journal of Biosocial Science, 2004, 36:647–661. Nursing Research, 1986, 35:382–386. 10. Ajzen I. The theory of planned behavior. Organizational Behav- 23. Waltz CF, Strickland OL, Lenz ER. Measurement in nursing and ior and Human Decision Processes, 1991, 50:179–211. health research, 3rd ed. New York, Springer, 2005. 11. Ajzen I, Fishbein M. Understanding attitudes and predicting so- 24. Sutton S. Theory of planned behavior. In: Baum A et al. Cam- cial behavior. Englewood Cliffs, New Jersey, Prentice-Hall 1980. bridge handbook of psychology, health and medicine. Cam- 12. Noar SM. A health educator’s guide to theories of health be- bridge, Cambridge University Press, 1997:177–179. havior. International Quarterly of Community Health Education, 25. Lugoe W, Rise J. Predicting intended condom use among Tan- 2005, 24:75–92. zanian students using the theory of planned behavior. Journal 13. Hagger MS, Chatzisarantis NLD, Biddle SJH. The influence of of Health Psychology, 1999, 4:497–506. autonomous and controlling motives on physical activity inten- 26. Theodorakis Y. Planned behavior, attitude strength, role iden- tions within the Theory of Planned Behaviour. British Journal of tity, and the prediction of exercise behavior. Sport Psychologist, Health Psychology, 2002, 7:283–297. 1994, 8:29–46 14. White KM, Terry DJ, Hogg MA. Safer sex behavior: the role of 27. Kashima Y, McCamish M. Safe sexual intentions and behavior attitudes, norms, and control factors. Journal of Applied Social among heterosexuals and homosexuals: testing the theory of Psychology, 1994, 24:2164–2192. reasoned action. Psychology and Health, 1994, 10:1–16. 15. Kridli SAO, Libbus K. Establishing reliability and validity of an 28. Fekadu Z, Kraft P. Predicting intended contraception in a sam- instrument measuring Jordanian Muslim women’s contra- ple of Ethiopian female adolescents: the validity of the theory ceptive beliefs. Health Care for Women International, 2002, of planned behavior. Psychology & Health, 2001, 16:207–222. 23:870–881. 29. Sutton S. The past predicts the future: Interpreting behavior- 16. Peyman N, Oakley D. Effective contraceptive use: an explora- relationship in social psychological models of health behavior, tion of theory-based influences. Health Education Research, In: Rutter DR, Quine L, eds. Social psychology and health: Euro- 2009, 24:575–585. pean perspectives. Newcastle, Athenaeum Press, 1995:71–88. 17. Godin G, Kok G. The theory of planned behavior: a review of 30. Conner M, Sparks P. The theory of planned behaviour and its applications to health-related behaviors. American Journal of health behaviours. In: Conner M, Norman P, eds. Predicting Health Promotion, 1996, 11:87–98. health behaviour. Buckingham, England, Open University Press 18. Albarracín D et al. Theories of reasoned action and planned 1996: 121–162. behavior as models of condom use: a meta-analysis. Psycho- 31. Fishbein M, Marco CY. Using theory to design effective health logical Bulletin, 2001, 127:142–161. behavior interventions. International Commuication Associa- 19. Conner M, Armitage CJ. Extending the theory of planned be- tion, 2003, 30:164–183. havior: a review and avenues for further research. Journal of 32. Stephenson R et al. Contextual influences on modern contra- Applied Social Psychology, 1998, 28:1429–1464. ceptive use in sub-Saharan Africa. American Journal of Public 20. Conner M, McMillan B. Interaction effects in the theory of Health, 2007, 97:1233–1240. planned behaviour: studying cannabis use. British Journal of Social Psychology, 1999, 38:195–222. 21. Rahnama P et al. Why Iranian married women use withdrawal instead of oral contraceptives? A qualitative study from Iran. BMC Public Health, 2010, 10:289.
787
Book 19-9.indb 787 10/7/2013 2:40:26 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Key role players in health care quality: who are they and what do they think? An experience from Saudi Arabia M.S. Mahrous 1
owØ^TÐog<|^TÐobcdBÐXÓÐEAÈëí|b`wgSívXogZTÐowmK|TÐÒØ?9Ò|>jBÐoggý|TÐæÐ|IúЫ Üí}7{_H{e7 2009 hhb>OÎíºph[UÐpxnL}UÐên^i:Ò}?kCÐphhý}UÐæÐ}JúÐDLæ}_UÐOδ ênLÒÚfCÐpfx{CÐ:qx}@ÌUÐpHÐÚ{UÐì|wæ{*oåÉ°#Ð p}_YphahTpHÐÚØ:Ónh]_CÐ e=rAnUÐênS{Sí pxØ_UÐph=}_UÐpcdeCÐ:ph[UÐpxnL}UÐÒØ@NĻi}^iÓng@íYn0{UnY Y0{UnYOÎÐØnfHÐÒ}?kCÐphhý}UÐæÐ}JúÐrAnUÐÚnBÐí ëe\CÐhdĻÑdHÌð êÐ{Hn=ngdhdĻíºpZSnfedUpxÚk=pLe6qdeI ênSúÐíºpd[CÐÓÐÙÓnL5!ÐíºÓ5^fCÐYëd,wíºph[UÐpxnL}Un=pd[UÐÓÐÙÓønCÐéAphLn9ÚøÐÓnYd_CÐx{b>:ÓÐFB q/í ph[UÐÓÐÚÐØüÐíênSúÐ Yén_RcZ=ëde_x , eCÐØÐ}RÌYØ{Líºî}BÌphYcAÓ5^fYíºêĆLüÐýnHííºph[UÐ ân]bUÐÚíغp[UÐ:ÓĆYn_UÐ}^iÓng@íºp[UÐ@ÌYh]UкêĆLüÐýnHííp[Uк eCÐíp[UÐphUnUÐÓnLCÐpZSnfY î}BúÐphYc"ÐÓønTUÐÚíغ[UÐÞn#Ð
ABSTRACT The aim of this study in Medina city in 2009 was to identify key role players who influence the health- care system and to assess their views regarding the improvement of the quality of health care in Saudi Arabia. In a qualitative, cross-sectional study data were collected from focus group discussions and analysed using a content analysis approach. Key role players were chosen based on their previous experience in providing feedback in health care-related areas: representatives from organizations, interest groups, departments, the media, other governmental organizations and members of the public who actively worked with the Department of Health. The topics discussed were: health and community; health and media; planning for health; female staff views; role of the private health sector; and the role of other governmental agencies. The discussions highlighted the importance of improvement of health facility infrastructure, the implementation of staff training and education, the initiation of quality assurance and safety standards and the extension of the scope of primary care and community health educational programmes.
Acteurs clés dans la qualité des soins de santé : qui sont-ils et quelle est leur opinion ? Une expérience en Arabie saoudite
RÉSUMÉ La présente étude menée dans la ville de Médine en 2009 visait à identifier les acteurs clés influant sur le système de soins de santé et à évaluer leurs opinions concernant l'amélioration de la qualité des soins de santé en Arabie saoudite. Dans une étude qualitative transversale, des données ont été recueillies à partir de discussions par groupes thématiques à l'aide d'une approche analytique du contenu. Des acteurs clés ont été sélectionnés en fonction de leur expérience en matière de retour d'information dans des domaines liés aux soins de santé : des représentants d'organisations, des groupes d'intérêts, des services, des médias, d'autres agences gouvernementales et des membres du public qui ont activement travaillé au Département de la santé. Les sujets abordés étaient les suivants : la santé et la communauté ; la santé et les médias ; la planification de la santé ; les opinions du personnel féminin ; le rôle du secteur des soins de santé privé ; et le rôle d'autres agences gouvernementales. Les discussions ont mis en évidence l'importance de l'amélioration des infrastructures des établissements de santé, de la mise en oeuvre de la formation et de l'éducation des personnels, de la mise en route de l'assurance qualité et des normes de sécurité et de l'élargissement du champ des programmes de soins primaires et d'éducation sanitaire communautaire.
1Department of Medical Education, College of Dentistry, Taibah University, Medina, Saudi Arabia (Correspondence to M.S. Mahrous: [email protected]). Received: 18/04/12; accepted: 11/07/12
788
Book 19-9.indb 788 10/7/2013 2:40:26 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction urban areas [8]. The Ministry of Health areas, either as a patient or guardian PQFSBUFTPGUIFIPTQJUBMTBOE using health facilities or as a member Those working in health care today face of the clinics and centres; the remaining of another specialized interest group. the challenge, more than ever before, facilities are operated by government Representatives from organizations, of efficiently utilizing data to improve agencies, including the Ministry of interest groups, departments, media services and the delivery of care [1]. A Defence medical service department, and local newspapers, other govern- key tool is one that provides health plan- the National Guard Health Affairs, the mental organizations and members of ners with feedback about the quality of Ministry of Interior and several other the public who actively worked with the health services provided and with sug- ministries, as well as by private entities. Department of Health were recruited to gestions about how to implement further Finding effective ways to identify provide feedback and participate in the improvements that satisfy the needs of and involve key role players from the assessment of health services. the community. Progress towards im- community in health planning and im- provement in the quality of health care Obtaining key role players’ provement is a long-standing challenge views on health-care services is a complex process in which numerous in Saudi Arabia. The aim of this study key players have unique roles. Managers, in Medina city was to identify key role Key role players were grouped into 6 health professionals, patients and other players who influence the health-care GPDVTHSPVQTUIBUDPOTJTUFEPGUP members of the community are all con- system and to assess their views regard- members each and included a represent- sidered to be integral parts of reforming ing the improvement of the quality of ative from the Department of Health and improving health-care quality. The health care in Saudi Arabia. Medina is to facilitate the discussion and to docu- opportunity to participate in decisions POFPGUIFIPMZTJUFTPG*TMBN WJTJUFECZ ment the views of the group. Each group regarding how to improve the quality of large number of visitors throughout the was formed to include people from the TBNFBSFBPGJOUFSFTUBOEPSFYQFSUJTFUP health care must be given to all those who year, especially during times of the Hajj ensure the generation of useful informa- have the knowledge and skills to contrib- and Umra pilgrimage seasons. This has tion that could guide health leaders in VUF<m>4PVUI<>BOEPUIFST< > the potential to overload the health-care planning services in that area. have set out the advantages of involving system and jeopardize the high-quality key role players in planning and assess- services supposed to be delivered to Focus group discussions (FGD) ment of health care. The importance of both residents and visitors [9]. were used to generate ideas and feed- incorporating the views of the public as back for improving the quality of health a central element in the development of services and minimizing the gap between health systems has been emphasized [7] Methods what was being provided and the pub- and studies show that increased public lic’s needs and expectations. Each group involvement leads to increased respon- This was a qualitative, cross-sectional was to discuss one main topic related to siveness of the health-care system to the study in which data collected from a the areas of speciality or interest of its needs of its users and thus to provision of survey carried out in Medina city in members. The following topics were dis- higher quality services [5,6]. 4BVEJ"SBCJBJOXFSFBOBMZTFE cussed: health and community; health Health-care providers and planners VTJOHBDPOUFOUBOBMZTJTBQQSPBDI<> and media; planning for health; female in developing countries face huge chal- This study lays the foundation for the staff views; role of the private health sec- lenges as a result of the increased cost selection and identification of key role tor; and the role of other governmental of health services and the need for a players. The methods used in this study agencies. After having the approval of all clear vision in the planning of quality DBOCFEJWJEFEJOUPQBSUTėSTUXBTUIF participants, each group was observed health-care services. In Saudi Arabia the identification of key players who were and guided using the FGD technique. Ministry of Health supervises health considered to be effectively participat- The discussions were continued until care and hospitals in both the public ing in the process of assessment and saturation, when the views and thoughts and private sectors. The system offers feedback; the second was the engage- expressed began to be duplicated. universal health-care coverage in a sys- ment of these key players in the assess- Opinions expressed by each group were UFNDIBSBDUFSJ[FECZBOFUXPSLPG ment of the quality of health services. documented in writing and followed by primary health-care centres and clinics qualitative analysis for the findings that provide preventive and curative ser- Selection and nomination of vices, as well as mobile clinics for remote key role players Ethical considerations rural areas, and at the secondary level by Key role players were chosen based This study was approved by the local IPTQJUBMTBOETQFDJBMJ[FEUSFBUNFOU on their previous experience in pro- research ethics committee and waiver of GBDJMJUJFTMPDBUFEXJUICFETJO viding feedback in health care-related consent form was approved.
789
Book 19-9.indb 789 10/7/2013 2:40:27 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Results stressed the need for health awareness driven missions, visions and values that and health education programmes that involve serving as a channel between The results of the different FGD can be are directed to them to increase their the community and health facilities. classified according to the main topic knowledge and attract their attention to To that end, it was recommended that discussed, as follows: various health subjects. every media source establish a training The second issue brought up by this programme to enhance the skills of its Health and community focus group was the need for primary staff in health journalism and teach the In this FGD, selected representatives care services such as disease prevention staff how to work with health-care facili- from the public (who had been a patient programmes, as well as the continuity of ties in a way that benefits the health-care or someone accompanying a patient), well-baby care clinics and dental caries system. It was decided that direct con- including representatives from non- prevention programme. tact and clear communication between governmental organizations, discussed The third issue discussed high- the media and health-care facilities was issues related to public and commu- lighted the importance of rehabilita- the best way to accomplish these aims. nity views on how the quality of services tion services. The group brought up the Planning for health could be improved. The results of this need for more efficient rehabilitation '(%XFSFDMBTTJėFEJOUPNBJOQBSUT programmes. This FGD can be considered a “control what was needed from the Department group” because the group was largely Role of the public of Health to assure service quality; and composed of health planners and what was needed from the public to The second aspect, related to what is people interested in health planning allow their continued participation in needed from the public to support and assessment, whose views were improving the services provided to the role of the Department of Health, correlated with the results from other them. was described by the focus group as groups’ discussions to assure the validity the need for more connection and of the methodology of this study. The Role of the Department of Health direct communication between health- SFTVMUTIFSFXFSFHSPVQFEJOUPTFD- Regarding the views of the public about care facilities and the public in order tions: health facilities and infrastructure; what was needed from the Department to maintain healthy relationships that human resources; and health policy and PG)FBMUI NBJOJTTVFTFNFSHFE'JSTU- support service development. Financial systems. ly, the Department of Health should support and volunteers are urgently provide quality services through the needed for effective operation of health- Health facilities and foundation of modern infrastructure care facilities. For example, the need for infrastructure such as hospitals and primary-care cen- keeping the health-care facilities clean This group’s discussion about health fa- tres fully equipped with all necessary and tidy was noted by the public when cilities and infrastructure and their role equipment and located strategically to they visited the facilities. Finally, public in improving service quality resulted match the public health needs of differ- appreciation for the services provided in many issues being raised, such as ent geographic areas. To operate such by health-care facilities can play a role the need for more hospitals and health health facilities efficiently, the Depart- in motivating facilities to strive for im- centres in order to respond to the grow- ment should recruit highly qualified provements and this could be done by ing population in a way that assures and competent staff that can run these client satisfaction surveys which can be equity in providing health care to all facilities in accordance with the new a routine activity done by the health- members of the community, taking health plan’s goals and objectives. A care facilities. into consideration the large number health information system was also of people present in the holy city of highly recommended as a way of reduc- Health and media Medina during the Hajj time and Umra ing the cost of health care and increasing The FGD surrounding this topic seasons.. International standards and the efficiency of health facilities. Preven- yielded innovative ideas about the need guidelines should be consulted when tive and regular maintenance was also for the media to play an important establishing new health facilities to important to the public, as this keeps role in partnering with health facilities assure that they comply with modern the infrastructure efficient and ensures by providing correct information to standards and satisfy the needs of the that it is prepared to provide the needed the community, especially regarding community. Certain expansion projects services. The public also highlighted the information about the scope of services should be permitted for some of the issue of staff education and training with provided by health-care facilities. The PMEFS TNBMMFS CFE IPTQJUBMTUIBU regard to advances in health knowledge discussion emphasized the need for the XFSFFTUBCMJTIFEZFBSTBHP UPTBUJTGZ and technology. Members of the public different media sources to have ethically this need for more and better services.
790
Book 19-9.indb 790 10/7/2013 2:40:27 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Refurbishment and replacement of old vision and job descriptions that were The discussions also pointed out the equipment with modern equipment documented in writing. The group importance of opportunities for women was also discussed. The introduction discussed the need for an approved, to participate in postgraduate study as of health information technology was efficient organizational chart and job well as in continuing training and edu- viewed as very important for supporting description manuals that organize and cational programmes. Raising commu- health planners and professionals in define every single job and process nity awareness about the role of Saudi making decisions regarding how to im- clearly. The discussion pointed out the female health professionals was badly prove health services. Tertiary health- need to use the electronic solutions needed for service improvements and care centres such as oncology centres to streamline work processes and for community support for women in were highly recommended to care for eliminate unnecessary pathways, giv- these types of positions. The group also cancer patients and reduce the high ing health leaders the ability to assess stressed the importance of utilizing a referral rate of such patients to other and monitor performance through an health information technology system centres outside Medina city. Due to the electronic system using performance to improve record keeping and man- high volume of visitors to Medina city indicators. Full implementation of agement of patient files, which would all year long, it was noted that there was quality assurance standards, manuals reduce costs and improve the efficiency a great need for accident and emergency and professional guidelines as well as of health services. specialized centres positioned along the assessing the need for training courses motorway to Medina. for the staff on how to implement Role of the private health sector Human resources management quality measures in their institutions would facilitate the provision of qual- This FGD centred on the partnership The second section of this FGD gener- ity services and the recognition of style between governmental and private ated ideas and views from participants these facilities by the accreditation health institutions. It was agreed that to about human resources management organization. improve the quality of services, public and how this can play an important role and private sector institutions needed in health care improvement. Issues such Female staff views to work together and support each as the formation of new jobs and filling This FGD was considered unique other in a common goal. The discussion vacancies were very important to the because it reflected the views of Saudi also revealed the need to establish a overall goal of creating new or extended female health professionals. Recently, clear policy that recognized the value health facilities. Redistribution of health an increase in the number of health of expertise within both systems and professionals and staff according to the colleges within Saudi Arabia, including facilitated the exchange of both ideas actual needs of different health facilities, colleges of medicine, dentistry, health and goods, such as medications, vac- rather than the personal preferences applied science and pharmacy, have cinations and other items that were of health professionals, should be un- played a major role in graduating female urgently needed but not available within dertaken. Providing financial support Saudi health professionals, whereas the institution that needs them. There for continuing education and training previously health institutions were was a need for an effective policy for programmes would play an important operated by non-Saudi female health circulating new regulations, instructions role in improving health services, and professionals. The researcher conduct- and work policies from the Department create more opportunity for staff to par- ing this study very much appreciated of Health to the private health sector. ticipate in postgraduate or specialized the participation of this group in con- This group also stressed the importance fellowship programmes. The establish- tributing ideas about how to improve of utilizing a health information tech- ment of a system for staff appreciation the quality of health care. nology system on both sides to improve would reflect on staff performance and The discussion of this group focused record keeping and management of pa- loyalty. These ideas could be supported on the need for more female staff en- tient files, which would reduce costs and by satisfaction surveys by health-care gagement at all levels of health planning improve the efficiency of health services providers to be part of the health deliv- and decision-making by giving them a provided from both sides. The group ery process by all health-care facilities in chance for equal participation in all de- brought up the idea of introducing a Saudi Arabia. partments and committees, where men national health insurance system simi- Policies and systems have traditionally taken the lead. More- lar to that implemented in developed The third section of the FGD was re- over, this group emphasized the need countries. This would ensure the avail- lated to policies and systems and high- for social support systems for female ability of affordable, quality health-care lighted the lack of guidelines on policy staff, allowing them to balance their services to all clients in Saudi Arabia, and procedures, including mission, work duties and family responsibilities. alongside the involvement of the private
791
Book 19-9.indb 791 10/7/2013 2:40:27 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
health-care facilities in national preven- study were valid and that the FGD for health professionals to be engaged tion programmes which might have were pertinent to issues related to the in postgraduate or continuing educa- a great impact on the health for all in improvement of health-care quality. tion programmes was brought up by Saudi Arabia. The FGD highlighted the impor- many groups, and all groups agreed tance of improvement of health facil- about the need for heath information Role of other governmental ity infrastructure, the implementation technology. agencies of staff training and education, the It is important to integrate the This FGD reflected the views of gov- initiation of quality assurance and safety results of all of these studies and use ernmental agencies that work in coop- standards and the extension of the scope them as a roadmap for change in the eration with the Department of Health of primary care and community health health-care system. In a society such as either directly or indirectly, including educational programmes. This was in Saudi Arabia, people may believe that the Saudi Red Crescent Society, the De- accordance with the results in England their participation is not important be- partment of Justice and the Police De- from Campbell et al. [6]. The FGD cause it is their perception that health partment. The discussion emphasized also emphasized the role of the public planners and professionals already the role of these agencies as external in maintaining communication with know how best to manage the provi- auditors that monitored and assessed health facilities and providing feedback sion of quality health-care services. It service quality and communicated the to improve the quality of health services; is therefore essential to involve various views of different service users. The role this was also was in accordance to what groups in the decision-making process. of these agencies should be highlighted was found in England by South [11], If this is not accomplished, the gap to increase community awareness $BNQCFMM<>BOE%BWJTFUBM<>ĉF between what is being provided and about the complexity of the health ser- FGD emphasized the need to attract what is really needed will only increase. vice industry. There was a need for a and recruit highly qualified health-care It is therefore increasingly necessary to more efficient e-Government system professionals who are one of the main identify and recruit key role players to of communication electronic system pillars of quality health-care services participate in discussions about health of communication that would facilitate < >"MMHSPVQTTUSFTTFEUIFJNQPS- care. We believe that the process of efficient sharing of data between the tance of utilizing a health information selection of these key role players Department of Health and other gov- technology system to improve record- is of utmost importance and that a ernment departments. Additionally, as keeping and management of patient comfortable atmosphere is crucial for previously mentioned in other FGD, files, which would reduce costs and im- encouraging these key players to par- the group stressed the importance of prove the efficiency of health services. UJDJQBUFQSPEVDUJWFMZ< m>"E- utilizing a health information technolo- This agrees with the study conducted ditionally, this is not the only method gy system on all sides to improve record by Zschorlich et al. which revealed that that should be employed in involving keeping and management of patient the application of electronic medical key role players in this process: it is files. Such a system would reduce costs records had great impact on the quality believed that the formation of com- and improve the efficiency of health and cost of health-care services deliv- mittees composed of key role players services. ered [7]. coming from different backgrounds Successful selection and nomina- would also be an invaluable tool in tion of participants will lead to valuable UIFTFFOEFBWPVST< > Discussion results and feedback that can answer the question concerning defining and The quality of a service can be meas- nominating key role players: “Who Conclusions ured in terms of the level of satisfac- are they?” Results generated from Progress towards improvement in the tion of the recipients of that service. FGD can demonstrate that all ideas quality of health care is a complex pro- This necessitates the collection of put forth are valued and important for cess in which numerous key players views and feedback from clients who improving the quality of health care. have unique roles. A key tool is one are able to make clear judgments. A re- The results generated from each of that provides health planners with view of the literature showed that the the FGD followed similar patterns of feedback about the quality of health results of this study were logical and thought and insight as other similar consistent with the findings reported studies [15,16]. The similar format of services provided and with suggestions from other studies and suggested that the discussions meant that the same about how to implement further im- the methods for selection and classifi- views were frequently expressed by provements that satisfy the needs of cation of key role players used in this multiple groups. For example, the need the community. The FGD approach is
792
Book 19-9.indb 792 10/7/2013 2:40:27 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
an applicable and appropriate tool for acceptable standard of health care and Acknowledgements evaluating and generating suggestions customer satisfaction. Good selection and feedback for the improvement of and classification of key role players is The author expresses sincere appre- the quality of health-care services. Many very important for the assessment of ciation to the participants in the focus areas in health-care services in Saudi health care quality issues and for gener- group discussions. Arabia must be improved to reach an ating constructive ideas. Competing interests: None declared.
References
1. Perla RJ, Provost LP, Murray SK. The run chart: a simple ana- 11. South J. Rising to the challenge: a study of patient and public lytical tool for learning from variation in health care processes. involvement in four primary care trusts. Primary Health Care BMJ Quality and Safety, 2011, 20:46–51. Research and Development, 2004, 5:125–134. 2. Farrel C. Patient and public involvement in health: the evidence for 12. Davies R, Sevdalis N, Vincent C. Patient involvement in patient policy implementation, London, Department of Health, 2004. safety: How willing are patients to participate? BMJ Quality and 3. Gosling L, Edwards M. Toolkits: a practical guide to planning, Safety, 2011, 20:108–114. monitoring, evaluation and impact assessment. London, Save 13. King G et al. Exploring public perspectives on e-health: find- the Children, 2003, ings from two citizen juries. Health Expectations, 2011, 14(4):351– 4. Campbell S. Public involvement in community health. Primary 360. Health Care, 2005, 15:42–50. 14. Wallcraft J. The person in health care policy development. 5. Florin D, Dixon J. Public involvement in health care. British Journal of Evaluation in Clinical Practice, 2011, 17:347–349. Medical Journal, 2004, 328:159. 15. Lowes L et al. Involving lay and professional stakeholders in 6. Campbell SM et al. Changes in patient experiences of primary the development of a research intervention for the DEPICTED care during health service reforms in England between 2003 study. Health Expectations, 2010, 14(3):250–260. and 2007. Annals of Family Medicine, 2010, 8:499–506. 16. South J. Rising to the challenge: a study of patient and public 7. Zschorlich B, Knelangen M, Bastian H. [The development of involvement in four primary care trusts. Primary Health Care health information with the involvement of consumers at the Research and Development, 2004, 5:125–134. German Institute for Quality in Health Care (IQWiG).] Die 17. Gooberman-Hill R, Horwood J, Calnan M. Citizens’ juries in Entwicklung von Gesundheitsinformationen unter Beteiligung planning research priorities: process, engagement and out- von Burgerinnen und Burgern am Institut fur Qualitat und Wirt- come. Health Expectations, 2008, 11:272–281. schaftlichkeit im Gesundheitswesen (IQWiG). Gesundheitswe- 18. Krist AH et al. Patient education on prostate cancer screening sen, 2011, 73:423–429. and involvement in decision making. Annals of Family Medi- 8. Healthcare and nursing jobs in Saudi Arabia, Qatar and the UAE. cine, 2007, 5:112–119. Helen Ziegler and Associates [website] (http://www.hziegler. 19. Jones PV, Hughes D, Mullen C. New Labour’s PPI reforms: com, accessed 9 July 2013). patient and public involvement in health care governance? 9. National project for total and integrated health care. Riyadh, Modern Law Review, 2009, 72:247–271. Saudi Arabia, Ministry of Health, 2010. 20. Thompson J et al. Health researcher attitudes towards public 10. Bowling A. Research methods in health: Investigating health and involvement in health research. Health Expectations, 2009, health services, 2nd. Milton Keynes, England, Open University 12:209–220. Press, 2009.
793
Book 19-9.indb 793 10/7/2013 2:40:27 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Health-care professionals’ perceptions and expectations of pharmacists’ role in the emergency department, United Arab Emirates S.A. Fahmy,1 B.K. Abdul Rasool 2 and S. Abdu 3
ÒzBÐog<|^TÐÓÐÚmXüÐ9ºÏÚÐ\TÐR9oTØmgZTÐÚíØé@*m^R=íogZTÐowmK|TÐ9MgefBÐÓmSÚzX í{Lëng@nIºéH}UÐ{LKnTpQÛn=ºegRÚnUÐ{L}H _=pehSiph[UÐpxnL}UÐ:NhfgCÐÓnTÚ{YíSÐYhhb=Ò{CÐph=}_UÐÓÐÚnYüÐ:qx}@ÌUÐpHÐÚ{UÐì|wæ{wex oåÉ°#Ð p_=ÚÌ:ëde_xx|UÐNh[UÐNhfgCÐYwEQíp},ínhJð 396pHÐÚ{UÐqdeI{Sí ÏÚÐ]UÐS:pUØnh[UÐn0ØkxUÐýnKUÐ pU{h[UÐÓnY{BëÌÐ`d=ÌpHÐÚ{dUNhCÐY%83.6ëÌ YiÌëAndUy\>Ðí -Ø:pÉnBÓnhaZYÒPLíphYcAÓnhaZY ëÌDL%75.7NhCÐ^_Ya>Ð{Sí ýÐØï}x<{hÉnghRe_xoRÏÚÐ]UÐênSÌY%30.7ëÌøÎÅÏÚÐ]UÐS:}RÐ> 45 % \RºpxíØúÐÊn]LÎp_@Ð}YphdeL:Nx}xUÐpUØnh[UÐÚíØéAí pxnL }UÐÒØ@YhHÏÚÐ]UÐênSÌ:Nx}xpUØnhÉ}RÐ>¬ \a>}^fUÐÓng@íYö ÐETð ëÌëAnUÐ{@íí ÏÚÐ]UÐênSÌ:phUn_UÐÒÚ]#ÐÓÐÙpxíØúÐÓnö dJp_@Ð}YDLÚn[SøÐNhCÐY ÒÚZCÐx{b>íºp!n_edU}CÐénYÐpSÐ}Yíngýn]LÎípeýĆCÐpxíØúÐÉíë5@ÌYÏÚÐ]UÐênSÌ:Nx}xUÐpUØnh[dUÚíØØ@í n)p!n_CÐýn[Aíºn4}CÐp=nHÐpSÐ}YíºpxíØúÐéAÓnYd_CÐí
ABSTRACT The objective of this study was to assess health-care professionals’ attitudes and perceptions towards the value of certain pharmacist functions in the emergency department (ED). The study was conducted among 396 physicians, nurses and other professionals in 4 government hospitals and 10 private hospitals in Dubai. While 83.6% of respondents reported that pharmacy services were available in the ED only 30.7% had a permanent clinical pharmacist working there. A majority (75.7%) agreed that the availability of clinical pharmacists in the ED would improve quality of care. On the role of clinical pharmacists in the medication review process, 45.0% of respondents favoured the review of only high-risk medication orders in the ED. The study found favourable views towards a role for clinical pharmacists in the ED for assuring appropriate medicine prescribing and administration, monitoring patient adherence, providing drug information consultation and monitoring patient responses and treatment outcome.
Perceptions et attentes des professionnels de santé vis-à-vis du rôle du pharmacien dans des services des urgences (Émirats arabes unis)
RÉSUMÉ La présente étude visait à évaluer les attitudes et les perceptions des professionnels de santé vis-à- vis de certaines fonctions des pharmaciens dans des services des urgences. L'étude a été menée auprès de 396 médecins, infirmières et autres professionnels dans quatre hôpitaux publics et dix hôpitaux privés à Dubaï. Si 83,6 % des répondants ont déclaré que les services d'un pharmacien étaient disponibles aux urgences, seuls 30,7 % pouvaient compter sur un pharmacien clinicien en poste de manière permanente. La majorité (75,7 %) reconnaissait que la disponibilité de pharmaciens cliniciens dans les services des urgences serait un facteur d'amélioration de la qualité des soins. Concernant le rôle des pharmaciens cliniciens dans le processus de contrôle des médicaments, 45,0 % des répondants préféraient une vérification uniquement lorsque les commandes de médicaments portaient sur des produits à haut risque dans les services des urgences. L'étude a révélé que les perceptions vis-à-vis du rôle des pharmaciens cliniciens dans les services des urgences étaient positives, notamment pour la garantie de la prescription et de l'administration appropriées de médicaments, pour le suivi de l'observance du patient, pour la fourniture d'informations sur les produits proposés en consultation, pour la surveillance de la réponse du patient au traitement et du résultat thérapeutique.
1Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Helwan University, Cairo, Egypt (Correspondence to S.A. Fahmy: [email protected]; [email protected]). 2Department of Pharmaceutics and Pharmacy Practice, Dubai Pharmacy College, Dubai, United Arab Emirates. 3Department of Quality and Risk, ADNOC Medical Services, Abu Dhabi, United Arab Emirates. Received: 08/05/12; accepted: 28/06/12 794
Book 19-9.indb 794 10/7/2013 2:40:27 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction delivered and transform patients’ ex- Data collection periences. To be licensed and work ĉFRVFTUJPOOBJSFDPOTJTUFEPG Over the years, the role of the phar- in hospital settings in the UAE clinical DMPTFERVFTUJPOTJOTFDUJPOTĉFėSTU macist has progressively changed pharmacists should have a bachelor section recorded general demograph- from a mere dispenser towards more degree in pharmacy with postgradu- ic information about the respondents. involvement in patient care [1]. This ate qualifications in clinical pharmacy The second section focused on assess- expanded role, resulting in greater from an accredited college of pharma- ing the respondents’ interactions, if interaction between physicians and cy, preferably with residency in clinical any, with clinical pharmacists in their pharmacists, has culminated in safer, QIBSNBDZ<>$MJOJDBMQIBSNBDJTUT day-to-day practice within the ED. more effective and less costly therapy have significantly expanded their role The third section assessed respond- JOUIFOFXFSBPGQBUJFOUDBSF<> as critical members of the health-care ents’ perceptions towards the role of Pharmacists, as integral members team in the UAE. However, sustained clinical pharmacists in the ED and of the multidisciplinary team in the efforts are required to further develop exploring the possible benefits that emergency department (ED), have clinical pharmacy services to all EDs pharmacists may bring to the ED. also demonstrated their contribu- in UAE hospitals, and to set optimal Questions were answered either using tion to reductions in morbidity and standards of performance and excel- ZFTOPEPOULOPXPSBMXBZTPěFO NPSUBMJUZBTXFMMBTJOESVHDPTUT<> lence in practice. TPNFUJNFTSBSFMZOFWFSPQUJPOTĉF Various studies have demonstrated This descriptive survey was the first questionnaire was distributed to par- that participation of pharmacists in in the UAE to examine the perceived ticipants after a direct interview with intensive care units and internal medi- the researchers and completed under cine teams contribute to improved value of this role from the perspective their direct supervision to ensure clar- patient outcomes through reduction of health-care professionals across ity and therefore limit response bias. of preventable adverse drug events by public and private sector health-care BOESFTQFDUJWFMZ<> facilities The aim of the study was to The test–retest reliability of the describe the current hospital phar- Pharmacy services in the ED have RVFTUJPOOBJSFXBTBTTFTTFEPOEJG- CFFOEPDVNFOUFETJODFUIFT macy services in EDs in the UAE and ferent occasions by administering the [5]. Nowadays clinical pharmacy is to identify potential roles and possible RVFTUJPOOBJSFUPSBOEPNMZTFMFDUFE an established component of ED ser- benefits pharmacists may bring to the health-care professionals. The second vices in many developed countries ED. The study also intended to assess UFTUJOHUPPLQMBDFXFFLTBěFSUIF [6,7]. In Eastern Mediterranean Re- the perceptions of health-care work- initial one and was not included in gion countries pharmacy education ers towards pharmacists working in the final survey analysis as the survey and pharmacy practice continues to the ED. was modified based on the feedback evolve. While changes in pharmacy obtained from the participants in education have been relatively rapid the pilot testing. Test–retest reliabil- over the past decade, the advance- Methods ity was calculated and the resulting Spearman correlation coefficient (r = ment of pharmacy practice, particu- Study design and participants larly in the private sector, appears to JNQMJFEBDDFQUBCMFUFTUmSFUFTU be slower [8]. The commencement The study was conducted during a reliability. of pharmacy education in the United QFSJPEPGNPOUITGSPN%FDFNCFS Arab Emirate (UAE) dates back to UP'FCSVBSZBUBMMUIF Data analysis XJUIUIFFTUBCMJTIJOHPG%VCBJ government hospitals and a random The participants’ responses were ana- Pharmacy College. Since then more TFMFDUJPOPGPVUPGUIFUPUBMQSJ- lysed using SPSS, version 16. Three pharmacy training programmes have vate hospitals in Dubai, UAE. The par- categories of responses were used so been put in place to meet the high ticipants in the study were limited to UIBUDPOėEFODFJOUFSWBMTDPVME demand for pharmacists in the coun- health-care professionals working in be calculated. Descriptive analysis try [9]. these hospitals, including physicians, was used to calculate the proportion Health-care services have been nurses and other allied health-care of each group of respondents who radically redesigned in UAE following professionals. A clinical pharmacist BHSFFEEJTBHSFFEXJUIFBDIPGUIF government policy and establishment in the context of this paper is a phar- statements in the questionnaire. The of the health authorities in Abu Dhabi macist who has a bachelor degree in chi-squared test was used to iden- and Dubai, which highlighted a clear pharmacy with a postgraduate degree tify any significant difference among need to improve the quality of care in pharmacy (PharmD). the participants’ responses in the
795
Book 19-9.indb 795 10/7/2013 2:40:27 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
questionnaire with a significant level Table 1 Demographic and practice characteristics of the study sample of of PWBMVFPG health-care professionals in emergency department (ED) and hospital inpatient departments (IPD) (n = 396) Variable No. % Results Sex Male 260 65.7 Participants’ demographics Female 136 34.3 "NPOHUIFQBSUJDJQBOUTDPO- Profession UBDUFE SFTQPOEFOUTBHSFFEBOE Physician ED 170 42.9 completed the questionnaire, a re- Nurse ED 82 20.7 TQPOTFSBUFPGĉFSFTQPOEFOUT Physician IPD 3 0.8 DPNQSJTFENBMFTBOE Nurse IPD 65 16.4 GFNBMFT XJUIBNFEJBOBHFPGZFBST Other 76 19.2 "NPOHUIFSFTQPOEFOUTXFSF Hospital type &%QIZTJDJBOT &%OVSTFT Teaching hospital 159 40.2 JOQBUJFOUIPTQJUBMOVSTFTBOE Tertiary care public hospital 101 25.5 XFSFIPTQJUBMQIBSNBDJTUT BOE Private hospital 136 34.3 other allied health-care profession- Years of work experience als.. The majority of the respondents XPSLFEJOUFBDIJOHIPTQJUBMT < 2 73 18.4 JOUFSUJBSZDBSFQVCMJDIPTQJ- 2–5 88 22.2 UBMTBOEJOQSJWBUFIPTQJUBMT 5–10 102 25.8 0GUIFSFTQPOEFOUTIBEFJUIFS > 10 133 33.6 practised or resided in the UAE for Health-care professionals’ workload NPSFUIBOZFBSTBOEIBEB (patients/week) XPSLMPBEPG QBUJFOUWJTJUTQFS < 50 119 30.1 week at their facility. Table 1 illustrates 50–100 88 22.2 the demographic information of the > 100 189 47.7 participants.
Current practice Analysing the frequency of con- Clinical pharmacists’ role The majority of the respondents TVMUBUJPOTSFWFBMFEUIBUPGUIF SFQPSUFEUIBUBDFSUBJOMFWFM A majority of the respondents respondents had consulted a clinical of pharmacy services were provided in CFMJFWFEUIBUUIFBWBJMBCJM- UIF&%)PXFWFS POMZ pharmacist at least a few times during ity of clinical pharmacists in the ED had a clinical pharmacist working the last 5 shifts, while the majority would improve quality of care and permanently in the ED and of these SFQPSUFEOPUUIBUUIFZIBE QBUJFOUTBGFUZ"MUIPVHIPGUIF SFQPSUFE IBWJOH B DMJOJDBM not consulted a clinical pharmacist respondents believed that clinical QIBSNBDJTUJOUIF&%POBIPVST in the ED during their last 5 shifts pharmacists played a vital role in the 7-days-a-week basis. 5BCMF &% POMZBDUVBMMZGBWPVSFEUIFJS
Table 2 Health-care professionals’ current practice and involvement with clinical pharmacists in the emergency department (ED) Item Yes No Don’t know No. % No. % No. % Do you have pharmacy services (provided) in the ED? 331 83.6 34 8.6 31 7.9 Do you have a clinical pharmacist in the ED? 122 30.7 218 55.0 56 14.3
Have you consulted a clinical pharmacist in the ED at least a few times during your last 5 shifts? 124 31.4 204 51.4 68 17.1
796
Book 19-9.indb 796 10/7/2013 2:40:27 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
presence in the ED. Moreover, only Cost savings PGIBEUIJTTFSWJDFBWBJMBCMFPOB CFMJFWFEDMJOJDBMQIBSNBDJTUT The response of the participants about CBTJT were capable of offering primary care the perceived financial reduction in This lack of clinical pharmacists par- to certain patients once the diagnosis health-care costs through clinical ticularly in the private sector may be at- had been made by the physician. pharmacists’ interventions varied USJCVUFEUPUIFMJNJUFEVOBWBJMBCJMJUZPG 0OMZPGUIFSFTQPOEFOUT among health-care professionals when institutions providing clinical pharmacy favoured levying additional charge compared among different types of courses in the region, and in particular (on patients) for using clinical phar- facilities. A significant difference (P in the UAE. It is worth mentioning in macy services in the ED. However, a DIJTRVBSFEUFTU XBTGPVOE this context that the first pharmacy col- NBKPSJUZPGUIFSFTQPOEFOUT when comparing the opinion of the lege in the UAE was established only believed that clinical pharmacist in- participants among those working in JOBOEUIBUPOMZQPTUHSBEVBUF tervention would reduce the overall teaching hospitals and private hospi- clinical pharmacy programmes are health-care costs and provide health- tals. A comparatively high percentage currently offered through colleges in care institutions with a financial of respondents in the public sector UAE. A previous study done in the UAE BEWBOUBHF5PUIJTFOE PGUIF BDDFQUFEUIFQIBSNBDJTUT had also reported a shortage of clini- respondents also agreed that the pres- role in reducing health-care costs DBMQIBSNBDJTUTJO6"&IPTQJUBMT<> ence of clinical pharmacists in the ED DPNQBSFEXJUIPOMZPGUIPTF with the very few available pharmacists would contribute to better dispensing working in the private sector (Table deployed in hospitals managed by in- and use of ED and discharge (take- 4). ternational institutions, such as Johns home) medications. Hopkins Hospital and the Cleveland Improving quality of care $MJOJD<>ĉJTMBDLPGDMJOJDBMQIBSNB- Reduce incidence of adverse Additionally, there was no statisti- cists in UAE hospitals is similar to the reactions and medication review cally significant difference between situation in other countries, as reported the responses when the perceptions CZUIF*OTUJUVUFPG.FEJDJOFJO "NBKPSJUZPGUIFQBSUJDJQBOUT of different health-care professionals which demonstrated the need for clini- agreed about the role of clinical with different workloads were assessed cal pharmacists as part of the ED team pharmacists in possibly reducing the about the role of clinical pharmacists to improve safety but also recognized incident of adverse drug reactions in in improving quality of care and patient the lack of pharmacists as part of inter- UIF&%0GUIFSFTQPOEFOUTBMTP safety in the ED (P DIJTRVBSFE disciplinary emergency medicine teams preferred a clinical pharmacist to be test) (Table 4). at most institutions [14]. available during peak volume hours in- cluding evening shifts and weekends. Health-care professionals’ )PXFWFS PGQBSUJDJQBOUTGB- Discussion perceptions voured limiting the medication review Interestingly, the study demonstrated process in the ED to only high-risk The pharmacy profession has evolved that there was a strong belief and con- medication orders. Nevertheless, the slowly in the UAE, with more and more sensus among all health-care profes- value of having a clinical pharmacist at pharmacy schools and pharmacists sionals on the collaborative role of ED all times during resuscitation (to pro- making efforts towards providing more clinical pharmacists to be able to con- vide clinical advice) was reinforced by patient-centred services. This has neces- tribute to enhanced and comprehensive BNBKPSJUZPGUIFSFTQPOEFOUT sitated a change in education and train- patient care. It also revealed that health- *UJTBMTPXPSUINFOUJPOJOHUIBU ing, and may require allocation of more care professionals expected pharmacists of the respondents were resistant to time and resources to better prepare to have a shared responsibility in disease the idea of having a clinical pharmacist clinical pharmacists to take up addi- management especially by providing JOUIF&% 5BCMF tional responsibilities at the prescribing patient education, monitoring adher- The perception of different profes- and dispensing stages [11]. ence to medication therapy, detecting sionals who participated in the study adverse events, etc., in order to facilitate did not reveal marked variations when Current practice earlier determination of therapeutic assessed about their perception to- Ensuring a round-the-clock supply of outcomes [15]. wards the role of clinical pharmacists medicines for patients in the ED is still a in the ED (P DIJTRVBSFEUFTU DIBMMFOHF0VUPGPGUIFSFTQPOE- Reducing adverse events on all questionnaire statements (Ta- ents who reported to have a permanent Unlike most health-care settings, medi- CMF clinical pharmacist working in ED, only cations in the ED are usually ordered,
797
Book 19-9.indb 797 10/7/2013 2:40:27 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 3 Health-care professionals’ beliefs and perceptions towards the role of clinical pharmacists in the emergency department (ED) based on respondents’ profession Statement/Profession Yes No Don’t know P-valuea No. % No. % No. % Clinical pharmacists improve the quality of care and 0.505 improve patient safety Physician ED 119 70.0 28 16.5 23 13.5 Nurse ED 68 82.9 11 13.4 3 3.7 Other 113 78.5 15 10.4 16 11.1 Total 300 75.7 – – – – Clinical pharmacists are very important component of 0.045 the ED team Physician ED 116 68.2 23 13.5 31 18.2 Nurse ED 57 69.5 22 26.8 3 3.7 Other 110 76.4 28 19.4 6 4.2 Total 283 71.4 – – – – Favour the presence of clinical pharmacist in ED 0.287 Physician ED 102 60.0 45 26.5 23 13.5 Nurse ED 62 75.6 6 7.3 14 17.1 Other 91 63.2 28 19.4 25 17.4 Total 255 64.3 – – – – Clinical pharmacists are capable of offering primary care 0.832 to patients Physician ED 88 51.8 62 36.5 20 11.8 Nurse ED 48 58.5 23 28.1 11 13.4 Other 82 56.9 39 27.1 23 16.0 Total 218 55.0 – – – – Willing to have patients charged for clinical pharmacy 0.494 services Physician ED 82 48.2 74 43.5 14 8.2 Nurse ED 40 48.8 25 30.5 17 20.7 Other 62 43.1 62 43.1 20 13.9 Total 184 46.4 – – – – Involvement of clinical pharmacist will reduce costs 0.786 Physician ED 111 65.3 42 24.7 17 10.0 Nurse ED 59 72.0 14 17.1 9 11.0 Other 85 59.0 40 27.8 19 13.2 Total 255 64.3 – – – – Involvement of clinical pharmacist will ensure proper 0.659 dispensing of ED take-home medicines Physician ED 107 62.9 49 28.8 14 8.2 Nurse ED 54 65.9 25 30.5 3 3.7 Other 102 70.8 28 19.4 14 9.7 Total 263 66.4 – – – – Involvement of clinical pharmacist will reduce adverse 0.55 drugs reactions Physician ED 121 71.2 42 24.7 7 4.1 Nurse ED 51 62.2 26 31.7 5 6.1 Other 99 68.8 34 23.6 11 7.6 Total 271 68.6 – – – –
798
Book 19-9.indb 798 10/7/2013 2:40:28 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Table 3 Health-care professionals’ beliefs and perceptions towards the role of clinical pharmacists in the emergency department (ED) based on respondents’ profession (concluded) Statement/Profession Yes No Don’t know P-valuea No. % No. % No. % Clinical pharmacist should be available during peak 0.16 volume hours Physician ED 122 71.8 42 24.7 6 3.5 Nurse ED 45 54.9 26 31.7 11 13.4 Other 93 64.6 28 19.4 23 16.0 Total 260 65.7 – – – – Clinical pharmacist should review only orders that 0.16 contain high-risk medications Physician ED 91 53.5 65 38.2 14 8.2 Nurse ED 42 51.2 34 41.5 6 7.3 Other 45 31.3 88 61.1 11 7.6 Total 178 45.0 – – – – Clinical pharmacist should be present at all 0.344 resuscitations to provide clinical advice Physician ED 99 58.2 51 30.0 20 11.8 Nurse ED 59 72.0 14 17.1 9 11.0 Other 79 54.9 54 37.5 11 7.6 Total 273 60.0 – – – – Resistant to clinical pharmacists’ presence in ED 0.478 Physician ED 71 41.8 91 53.5 8 4.7 Nurse ED 28 34.2 42 51.2 12 14.6 Other 45 31.3 79 54.9 20 13.9 Total 144 36.4 – – – –
aChi-squared test.
dispensed and administered at the reduce the incidence of adverse drug those in the US, where the majority of point of care. There is also a higher reactions in ED settings. the health-care professionals favour prevalence of verbal orders, particu- clinical pharmacists being a part of the larly in urgent and high-stress situa- Disease management patient care team. It is believed that in- UJPOT"TNBOZBTQFPQMFEJF Resistance of physicians to a greater corporating relevant concepts of col- each year in the United States (US) role for clinical pharmacists in disease laborative patient care in the existing BTBSFTVMUPGNFEJDBUJPOFSSPST<> management has been reported in medical and pharmacy curricula, with Similar studies done in the US also some studies [7,18]. It is important due emphasis on inter-professional SFQPSUUIBUPGQBUJFOUTSFDFJWFBO to note that the perceptions in the relationships, would further enhance inappropriate medication in the ED UAE in this regard are different from physician–pharmacist collaboration <>BOEBSFQSFTDSJCFEBOJOBQ- those in other Arab countries, such as in the provision of patient care. We propriate medication on discharge in Kuwait, where physicians showed may conclude from our study that from the ED [17]. This is particularly high resistance towards the involve- health-care professionals’ resistance important as several studies showed ment of clinical pharmacists in patient to the pharmacists’ role in the ED in that, as members of an inpatient care care [19]. This may be attributed to UAE should not constitute a barrier to team, pharmacists contribute to re- physicians’ lack of knowledge about instituting clinical pharmacy services ducing the number of adverse drug the role of clinical pharmacists and in UAE hospitals. events [18]. More than two-thirds of limited exposure in collaborative dis- the physicians who participated in this ease management. The perceptions of Cost analysis survey also believed that the involve- UAE health-care professionals in this Many authors have reported estimates ment of clinical pharmacists would regard are very much comparable to of cost savings related to pharmacist
799
Book 19-9.indb 799 10/7/2013 2:40:28 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 4 Health-care professionals’ perceptions towards clinical pharmacists’ role in reducing cost and improving quality of care in the emergency department (ED) according to type of hospital and workload Statement/Respondent’s workplace or Yes No Don’t know P-valuea workload No.%No.%No.% Clinical pharmacist intervention will reduce costs and be financially advantageous for health care institutions Hospital type: Teaching hospital 122 76.7 23 14.5 14 8.8 0.035 Tertiary care hospital 65 63.7 31 30.4 6 5.9 Private hospital 68 50.4 25 31.1 25 11.4 Total 255 64.3 Presence of clinical pharmacist in ED will improve quality of care and patient safety Workload: < 50 patients/week 91 72.8 17 13.6 17 13.6 0.679 50–100 patients/week 62 72.9 17 20.0 6 7.1 > 100 patients/week 147 79.0 20 10.8 19 10.2 Total 300 75.7
aChi-squared test.
interventions in EDs and the available from the perception of physicians in and counselling. They also accepted, as literatures also suggests that emer- UIF64 XIFSFPGUIFQIZTJDJBOT demonstrated in previous studies, that gency pharmacist programmes have were willing to have their patients the involvement of clinical pharmacists the potential to be cost-effective in charged for this service [5]. in patient care in the ED setting would &%T<>1IZTJDJBOTCFMJFGTBCPVU In summary, the findings from this result in safer and more cost-effective the role of ED pharmacists in reduc- study reveal that health-care profes- medication use. JOHIFBMUIDBSFDPTUT DMFBSMZ sionals in the UAE acknowledged the undermine the need to involve clinical role of clinical pharmacists in improv- pharmacists in the ED. These results ing therapeutic outcomes in ED. This Acknowledgements also have implications for the ED, and may have evolved from their own hospital leadership teams may con- experience of interacting with clinical The authors would like to thank Dubai sider implementing an ED pharmacist pharmacists as their responses clearly Pharmacy College undergraduate programme in their facilities. However, acknowledged the unique set of skills students; Ayesha Mohamed Saif Bin respondents’ reaction towards the idea delivered by pharmacists. They expect- Shafar, Mays Sarmed Taher and Asama of charging patients for availing phar- ed pharmacists to play an important Abdo Ali Ali for their efforts in distribut- macy services were mixed, with around role in direct patient care by provid- ing and collecting of the survey. PGUIFQIZTJDJBOTBOEOVSTFTGB- ing a supportive role in therapeutic Funding: None. vouring the idea. This is very different treatment and in patient education Competing interests: None declared.
References
1. Jones EJ et al. Pharmaceutical care in community pharmacies: 4. Leape LL et al. Pharmacist participation on physician rounds practice and research in Canada. Annals of Pharmacotherapy, and adverse drug events in the intensive care unit. Journal of 2005, 39:1527–1533. the American Medical Association, 1999, 282:267–270. 2. Mitchell JL. Building cooperation with physicians: an in- 5. Elenbaas RM et al. The clinical pharmacist in emergency medi- terview with Charles Fortner. American Pharmacy, 1990, cine. American Journal of Hospital Pharmacy, 1977, 34:843–846. NS30:24–26. 6. Foreshew G. A career as an A&E department pharmacist. Hos- 3. Society of Critical Care Medicine and American College of pital Pharmacy, 2005, 12:61–64. Clinical Pharmacy. Position paper on critical care pharmacy 7. Witsil JC et al. Strategies for implementing emergency depart- services. Pharmacotherapy, 2000, 20(11):1400–1406. ment pharmacy services: Results from the 2007 ASHP Patient
800
Book 19-9.indb 800 10/7/2013 2:40:28 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Care Impact Program. American Journal of Health-System Phar- 14. Hospital-based emergency care: at the breaking point. Washing- macy, 2010, 67:375–379. ton DC, Institute of Medicine of the National Academies, 2007. 8. Kheir N, et al. International pharmacy education supplement; 15. Spencer JA et al. Pharmacy beyond the dispensary: general pharmacy education and practice in 13 Middle Eastern Coun- practitioners' views. British Medical Journal, 1992, 304:1670– tries. American Journal of Pharmaceutical Education, 2008, 1672. 15:72(6):133. 16. Hafner JW et al. Adverse drug events in emergency department 9. PharmD. Faculty of Medicine and Health Sciences, United patients. Annals of Emergency Medicine, 2000, 39:258–267. Arab Emirates University [online] (http://www.fmhs.uaeu. 17. Chin MH et al. Appropriateness of medication selection for ac.ae/Program.asp?PROG=PHARMD&pgid=491-654, ac- older persons in an urban academic emergency department. cessed 28 May 2013). Academic Emergency Medicine, 1999, 6:1232–1242. 10. Professional qualifications requirements. PQR 2011. Health 18. Abduelkarem A et al. Current levels of interaction between Authority Abu Dhabi [online] (http://www.haad.ae/HAAD/ the physician and pharmacist: A comparative study in Libya LinkClick.aspx?fileticket=T0ncoVDrFz8%3d&tabid=927, ac- and UAE. Jordan Journal of Pharmaceutical Sciences, 2008, cessed 28 May 2013). 1:146–155. 11. Dameh M. Pharmacy in the United Arab Emirates. Southern 19. Matowe L et al. Physicians’ perceptions and expectations of Med Review, 2009, 2:15–18. pharmacists’ professional duties in government hospitals in 12. Abu-Gharbieh M et al. Attitudes and perceptions of healthcare Kuwait. Medical Principles and Practice, 2006, 15:185–189. providers and medical students towards clinical pharmacy ser- 20. Lada P et al. Documentation of pharmacists' interventions in vices in United Arab Emirates. Tropical Journal of Pharmaceuti- an emergency department and associated cost avoidance. cal Research, 2010, 9(5):421-30. American Journal of Health-System Pharmacy, 2007, 64:63–68. 13. Tahaineh LM et al. Perceptions, experiences and expectations of physicians in hospital settings in Jordan regarding the role of the pharmacist. Research in Social and Administrative Pharmacy, 2009, 5:63–70.
801
Book 19-9.indb 801 10/7/2013 2:40:28 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Compliance with the guidelines of prescription writing in a central hospital in the West Bank Y.I. Tayem,1 M.A. Ibrahim,1 M.M. Qubaja,1,2 R.K. Shraim,1,2 O.B. Taha 1 and E. Abu Shkhedem 1
og<|_TÐo`[TÐ9ï}S|X`YX9Óm`ÉTÐo
ABSTRACT This retrospective, cross-sectional study was carried out to evaluate the quality of 2208 outpatient prescriptions in a central hospital in the West Bank, Palestine. The physicians’ handwriting was poorly readable or illegible in one-third of the prescriptions. The prescriber’s name and signature and patient’s name were mentioned in almost all orders whereas the patient’s age was stated in 54.9%. The vast majority of physicians (95.5%) prescribed drugs using their trade (brand) names. Drug strength, quantity and dose/frequency were stated in 61.1%, 76% and 73.8% of prescriptions respectively. Only 33 prescriptions (1.5%) contained full directions for use for all drugs. Correlation analysis revealed that the presence of certain prescription elements was statistically significantly associated with the clinic of origin and the number of drugs prescribed. The overall poor legibility and incompleteness of the prescriptions is of concern.
Respect des recommandations de rédaction d'ordonnance dans un hôpital central de Cisjordanie
RÉSUMÉ La présente étude rétrospective et transversale a été menée pour évaluer la qualité de 2208 ordonnances rédigées en consultation externe dans un hôpital central de Cisjordanie (Palestine). L'écriture des médecins était difficile à lire, voire illisible dans un tiers des cas. Le nom du médecin prescripteur, sa signature et le nom du patient étaient mentionnés sur presque toutes les ordonnances mais l'âge du patient n'était précisé que dans 54,9 % des cas. La grande majorité des médecins (95,5 %) avaient prescrit des médicaments en utilisant leur nom commercial (de marque). La concentration, la quantité, la posologie/la fréquence étaient indiquées dans 61,1 %, 76 % et 73,8 % des ordonnances, respectivement. Seules 33 ordonnances (1,5 %) donnaient des instructions complètes pour la prise de tous les médicaments prescrits. Une analyse de la corrélation a révélé que la présence de certains éléments de prescription était associée de manière statistiquement significative au centre de santé à l'origine de l'ordonnance et au nombre de médicaments prescrits. La mauvaise lisibilité globale et le caractère incomplet des ordonnances sont préoccupants.
1Faculty of Medicine, Al-Quds University, Abu Dis, West Bank, Palestine (Correspondence to Y.I. Tayem: [email protected]). 2Department of Pathology, Beit Jala Hospital, Bethlehem, West Bank, Palestine. Received: 14/05/12; accepted: 07/08/12
802
Book 19-9.indb 802 10/7/2013 2:40:28 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction illegibility, incompleteness, or omission summer and autumn. In each season, all of any of these elements could result in prescriptions from 1 randomly selected Most medical consultations culminate misinterpretation of the prescription by week (7 working days) were analysed in writing a prescription. This order the dispenser, and may lead to poten- systemically. Analysis was carried out from the physician to the dispenser is tially serious prescription errors [1]. GSPN+BOVBSZUP.BSDI considered a medico-legal document, Because the art of prescription- Prescriptions were assessed for the so it must be written clearly, accurately writing is not sufficiently addressed in presence of the essential elements which and completely to avoid potentially undergraduate medical education <>, should be present in the order. Compli- preventable but serious prescription many physicians do not have appro- ance with these elements was judged by errors, which are frequent causes of priate prescription-writing skills. As a the degree to which physicians had met morbidity and mortality < >. Several result, the need to promote the acqui- the obligations of all the elements in factors account for the increased inci- sition of the proper skills in medical the prescription order according to the dence of prescription errors including, undergraduates has been highlighted World Health Organization (WHO) but not limited to, illegible prescriber’s <>. Moreover, the prescribing habits guidelines which are the official guide- handwriting <>, increased number of of physicians working in health institu- lines in Palestine [15]. A prescription drugs in a prescription [4] and irrational tions should be assessed periodically element was labelled partially readable prescribing habits [5]. These errors can to identify any defects and introduce if it was partly legible and unreadable if result in an increase in the number of corrective measures such as educational none of the investigators present in that adverse drug events, inappropriate or programmes on rational prescribing, analysis session could read it. Instruc- unsafe treatment, prolongation of ill- followed by reminders and feedback to tions for drug use were partial if they ness or hospital stay and escalation of assess the physicians’ response [14]. were mentioned either partly or fully for healthcare expenditure [6]. Dormann The major objective of this study some drugs on the prescription or full if et al. reported that adverse drug reac- was to evaluate the quality of prescrip- they were fully mentioned for all drugs UJPOTXFSFUIFSFBTPOGPSPGIPTQJUBM tions ordered by physicians in outpa- on the prescription. BENJTTJPOTBOEPGSFBENJTTJPOT tient clinics and emergency rooms in Ethical approval for this study was in Germany, causing additional cost of a central hospital in the West Bank. In provided by Al-Quds University Hu- several hundred million euros [7]. Since particular, we assessed the presence of man Research Ethics Committee, West good quality prescriptions comprise the essential elements related to the Bank, Palestine. Physicians in the target the main factor for minimizing dispens- prescriber, the patient and the main hospital were not aware that the study ing errors, physicians should adhere to body of the prescription. We speculate was being carried out. guidelines for prescription writing to that the results of this study will guide ensure patient safety [8]. intervention programmes focusing on Statistical analysis The drug prescription and admin- physicians working at health facilities to Data generated were fed into SPSS, ver- istration process in most hospitals improve the quality of medical prescrip- sion 17 and simple descriptive statistics worldwide is still based on handwritten tions in Palestine. were utilized to analyse the results. The medical chart entries [9]. Several steps statistical significance was set at P in this complex and unchecked process Pearson’s correlation coefficient analy- can engender a high number of relevant Methods sis was quoted to reflect the magnitude errors which may be a significant source of association. of adverse drug events <>. Certain This study was carried out in Beit Jala elements must be written legibly, accu- hospital, the central governmental rately and completely on the prescrip- hospital in Bethlehem district, which Results tion order; these include the physician’s IBTBQPQVMBUJPOPG NBLJOH name, address, telephone number and VQPGUIFQPQVMBUJPOPGUIF8FTU 0VS TBNQMF DPNQSJTFE QSF- signature, as well as the patient’s name, Bank. Emergency room and outpa- scription orders. The majority of the address, age, weight (especially in chil- tient prescriptions, irrespective of the prescriptions were issued from the dren and the elderly), and the date of clinic of origin, received and kept by PVUQBUJFOUDMJOJDT GPMMPXFE the prescription, drug name (preferably the pharmacy department during the CZUIFFNFSHFODZSPPN JOUIF generic), formulation, strength, dose, QFSJPE%FDFNCFSm%FDFN- SFTU UIFTPVSDFXBTNJTTJOH frequency of administration, quantity, CFSXFSFBOBMZTFETZTUFNJDBMMZ The number of drugs included in the reason for prescribing and directions for and retrospectively. This period was prescriptions ranged from 1–9 but the use in the patient’s language [11]. The divided into 4 seasons: winter, spring, NBKPSJUZ DPOUBJOFEɒESVHT
803
Book 19-9.indb 803 10/7/2013 2:40:28 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
The distribution of the prescriptions the guidelines of prescription writing. far better than that reported in studies PWFSUIFTFBTPOTXBTXJOUFS The clinic of origin was strongly cor- JO4VEBO [17] and Ethiopia TQSJOH TVNNFS BOE related with the presence of patient’s [18]. Poor legibility and illeg- BVUVNO "DDPSEJOHUPDMJOJDPG age (P ESVHTTUSFOHUI P < ibility are serious deficiencies since they PSJHJO PGUIFQSFTDSJQUJPOTXFSF EPTFGSFRVFODZ P BOE increase the risk of misinterpretation of sent by the oncology clinic, followed by directions for drug’s use (P the information by the dispenser and NFEJDJOF PSUIPQBFEJDT However, the number of drugs pre- increase the likelihood of serious dis- TVSHFSZ &3 QBFEJBUSJDT scribed was significantly associated with pensing errors [9]. BOEPCTUFUSJDTHZOBFDPMPHZ mentioning patient’s age (P None of the prescriptions we exam- drug’s strength (P BOEEPTF ined contained the prescriber’s address The handwriting of the prescrib- frequency (P or telephone number. Sawalha et al. ing physician was partially readable in showed that, in private practice in the BOEJMMFHJCMFJOPGUIFQSF- Discussion West Bank, these details were present scriptions. (Table 1), the prescriber’s on all prescriptions [19]. However, al- name and signature were present in By and large, our results revealed a high most all the prescriptions in our study BOEPGUIFPSEFST SFTQFD- had the prescriber’s name and signa- tively. However, all prescriptions were rate of noncompliance with the recom- mendations for prescription writing ture; this is consistent with the findings deficient in the prescriber’s address and from a study in a teaching hospital in telephone number. Patient’s name was provided by the WHO which could Nigeria where the prescriber’s name present in all orders, whereas patient’s lead to serious errors in both dispensa- XBTNFOUJPOFEPOPGQSFTDSJQ- BHFXBTQSFTFOUJOPOMZ/POFPG tion and drug use [15]. tions and the physician’s signature was the prescriptions included the patient’s The vast majority of orders con- QSFTFOUPO<>*OBTUVEZGSPN address, telephone number or weight. UBJOFEɒESVHT JOEJDBUJOHUIBUUIFQSF- Sudan, in contrast, the physician’s name Minority of drugs were prescribed scribing physicians had little tendency XBTNFOUJPOFEJOPOMZPGQSFTDSJQ- VTJOHUIFJSHFOFSJDOBNFT CSBOE towards polypharmacy. tions <>. These details are essential OBNFTXFSFVUJMJ[FEJO XIJMF Almost all the prescriptions were elements and can be used if further con- UIFSFTUDPOUBJOFECPUIOBNFT dated but the patient’s diagnosis was tact with the prescriber is needed by the 5BCMF ĉFEBUFPGUIFQSFTDSJQ- NJTTJOHJO"MNPTUPOFUIJSEPG dispenser for any clarification. tion was mentioned in almost all orders the prescriptions were rated as partially 8JUISFHBSEUPUIFNBJOCPEZ readable or illegible. In comparison, in Almost all prescriptions contained PGQSFTDSJQUJPO 5BCMF ESVHTUSFOHUI a study from a central hospital in Saudi the patient’s name but age was men- XBTNFOUJPOFEGPSBMMESVHTJO "SBCJB PGPVUQBUJFOUQSFTDSJQ- tioned in less than half. None of the JODMVEFEGPSTPNFESVHTJOBOE tions were dated, the diagnosis was prescriptions stated the patient’s con- XBTNJTTJOHJOUIFSFTU ĉF NFOUJPOFEJOBOEBMNPTUUXP tact information or weight. In a study dose and frequency of administration thirds were poorly legible [16]. The lege- from Nigeria, almost all prescriptions XFSFNFOUJPOFEGPSBMMESVHTJO ibility of prescriptions in our study was were deficient in patient’s address but, NFOUJPOFEGPSTPNFESVHTJOBOE OPUNFOUJPOFEGPSBMMESVHTJO Less than two thirds of the prescriptions Table 1 Analysis of identifying information for patients and prescribers on 2208 prescriptions ordered by outpatient clinics and emergency rooms at a central contained the quantity that the pharma- hospital in the West Bank DJTUTIPVMEEJTQFOTFGPSBMMESVHT Element No. % for some drugs and in the remainder Prescriber’s information UIJTFMFNFOUXBTNJTTJOHĉF Name 2124 96.2 instructions for patient’s use were not Signature 2203 99.8 mentioned for all drugs in the majority Address 0 0 PGUIFQSFTDSJQUJPOT XFSFQBS- UJBMJOBOEXFSFGVMMJOPOMZ Tel number 0 0 Lastly, the patient’s diagnosis was miss- Patient’s information JOHJOPGUIFQSFTDSJQUJPOT Name 2207 100.0 Pearson’s correlation coefficient Age 1212 54.9 was utilized to identify the factors that Address 0 0 affected physician’s adherence with Telephone number 0 0
804
Book 19-9.indb 804 10/7/2013 2:40:28 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Table 2 Analysis of details of the main body of 2208 prescriptions ordered by promoting rational use of drugs [15]. outpatient clinics and emergency rooms at a central hospital in the West Bank Furthermore, the use of generic names Element No. % contributes to cost reduction and pro- Prescription date vides more alternatives for drug pur- Mentioned 2195 99.4 DIBTFT<> Not mentioned 13 0.6 ĉFTUSFOHUIBOEEPTFGSFRVFODZ Drug name of administration were complete in Generic 71 3.2 two-thirds of the prescriptions in our Trade (brand) 2109 95.5 TUVEZBOEBMNPTUPGUIFPSEFST Mixed 28 1.3 indicated the quantity to be dispensed Drug strength GPSBMMESVHT)PXFWFS POMZPGUIF Mentioned for all drugs 1349 61.1 prescriptions contained full instruc- Mentioned for some drugs 501 22.7 UJPOTGPSESVHTVTFXIJMFDPO- Not mentioned for all drugs 358 16.2 tained partial instructions. In a study from Saudi Arabia, drug strength and Drug’s dose units XFSFNFOUJPOFEJOBOEEPTBHF Mentioned for all drugs 1630 73.8 VOJUTJOPGQSFTDSJQUJPOTXIJMF Mentioned for some drugs 328 14.9 POMZPGPSEFSTDPOUBJOFEESVH Not mentioned for all drugs 250 11.3 RVBOUJUZ<>*OBEEJUJPO POMZ Drug’s quantity of the prescriptions contained full di- Mentioned for all drugs 1677 76 rection for use [16]. In a study from Mentioned for some drugs 332 15 4VEBO PGQSFTDSJQUJPOTXFSFOPU Not mentioned for all drugs 199 9 accompanied by instructions to pa- Patient’s instructions UJFOUTBOEMBDLFEESVHRVBOUJUZ Full 33 1.5 [17]. In private practice in the West Partial 92 4.2 Bank, the strength was missing in over Missing for all drugs 2083 94.3 XIJMFGSFRVFODZBOEJOTUSVDUJPOT Diagnosis GPSVTFXFSFQSFTFOUJOPWFSPG Mentioned 1444 65.4 prescriptions [19]. The considerable Not mentioned 764 34.6 of lack of recommendations for use is Prescriber’s handwriting worrisome since this information is an Unreadable 93 4.2 essential part of the prescription and Partially readable 630 28.5 should be written in a clear, objective, Readable 1485 67.3 and accurate fashion. Such information can foster patient compliance with drug use, ensure safe use of medications and in contrast to our results, almost all con- The vast majority (95.5) of the results in a fewer complications and adverse reactions. tained the patient’s age <>. In another drugs on the prescriptions we examined Sudanese hospital study, the patient's were ordered by their brand names. This study has certain limitations GVMMOBNFXBTNFOUJPOFEJOPG Similarly, in a hospital study conducted which should be taken into consid- eration when interpreting the find- prescriptions only <>*OBTUVEZ JO#SB[JM JOPGQSFTDSJQUJPOT CSBOE ings. First, prescriptions analysis was in the private health sector in the West names were utilized <>. In a Sudanese restricted to the outpatient setting TUVEZ IPXFWFS PGESVHTXFSF Bank, less than half of the orders con- while the inpatient situation remained tained patient’s age [19]. The omission prescribed by their generic names [17] unknown. Second, this investigation of patient’s weight increases errors in and a similar figure was reported in a targeted a single hospital in the West drug dosing, especially at age extremes. study from Saudi Arabia [16]. In the Bank so the results may not be gener- Similarly, lack of patient’s contact infor- private sector in Palestine, only brand alizable. A larger scale study targeting mation is also serious when problems in names were used in a study carried hospitals throughout the West Bank the prescription are discovered after dis- out in Nablus [19]. The use of generic is needed to identify the true rates of pensing and the dispenser needs to con- names is recommended by the WHO adherence to rational prescription tact the patient to correct the problem. and regarded as an important factor for writing.
805
Book 19-9.indb 805 10/7/2013 2:40:28 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Conclusions obvious and follow-up on the matter Acknowledgements is needed. Moreover, to minimize pre- In summary, a considerable proportion scribing errors due to illegibility and We express our appreciation to the ad- of prescriptions reviewed in this study incompleteness of prescriptions, we ministration and pharmacy staff at Beit suffered from serious deficiencies and recommend updating the prescription Jala hospital for their cooperation with the were not properly written. The need form to include all items recommended investigators. The support of the Ministry for reinforcing physicians’ awareness by the WHO, or utilizing computerized of Health is also gratefully acknowledged. on the importance of adhering to the prescribing in governmental hospitals Funding: None guidelines for prescription writing is in the West Bank. Competing interests: None declared.
References
1. Meyer TA. Improving the quality of the order-writing process 13. Heaton A, Webb DJ, Maxwell SR. Undergraduate preparation for inpatient orders and outpatient prescriptions. American for prescribing: the views of 2413 UK medical students and re- Journal of Health-System Pharmacy, 2000, 57Suppl 4;S18–S22. cent graduates. British Journal of Clinical Pharmacology, 2008, 2. Wunsch MJ et al. Prescription drug fatalities among women 66:128–134. in rural Virginia: a study of medical examiner cases. Journal of 14. Qureshi NA et al. Effectiveness of three interventions on Opioid Management, 2009, 5:228–236. primary care physicians' medication prescribing in Riyadh 3. Hartel MJ et al. High incidence of medication documentation City, Saudi Arabia. Eastern Mediterranean Health Journal, 2011, errors in a Swiss university hospital due to the handwritten pre- 17(2):172–179. scription process. BMC Health Services Research, 2011, 11:199. 15. De Vries TPGM et al. Guide to good prescribing: a practical manr- 4. Atanasova I, Terziivanov D. Investigation on antibiotics in a ual. Geneva, World Health Organization, Action Programme hospital for a one-year period. International Journal of Clinical on Essential Drugs, 1994 (WHO/DAP/94.11). Pharmacology and Therapeutics, 1995, 33:32–33. 16. Irshaid YM et al. Compliance with good practice in prescrip- 5. Al Khaja KA et al. Rational use of antimicrobials in infants in tion writing at outpatient clinics in Saudi Arabia. Eastern Medi- primary care of Bahrain. Journal of Tropical Pediatrics, 2006, terranean Health Journal, 2005, 11(5–6):922–928. 52:390–393. 17. Yousif E et al. Deficiencies in medical prescriptions in a Su- 6. Blatt A, Chambon R, Lemardeley P. Forme légale et cout des danese hospital. Eastern Mediterranean Health Journal, 2006, prescriptions a l'Hôpital Central de Yaoundé, Cameroun [Le- 12(6):915–918. gal format and costs of prescriptions at the Central Hospital in 18. Makonnen E, Yoseph M, Berhane Y. Quality of prescription Yaounde, Cameroon]. Médecine tropicale : revue du corps de at a tertiary care pharmacy in Addis Ababa. Ethiopian Medical sante colonial, 1997, 57(1):37–40. Journal, 2002, 40:233–239. 7. Dormann H et al. Readmissions and adverse drug reactions 19. Sawalha AF et al. Analysis of prescriptions dispensed at com- in internal medicine: the economic impact. Journal of Internal munity pharmacies in Nablus, Palestine. Eastern Mediterranean Medicine, 2004, 255:653–663. Health Journal, 2010, 16(7):788–792. 8. Francois P et al. Evaluation of prescription-writing quality in 20. Erhun WO et al. Legal issues in prescription writing: a study of a French university hospital. Clinical Performance and Quality two health institutions in Nigeria. International Journal of Phar- Health Care, 1997, 5:111–111. macy Practice, 2009, 17:189–193. 9. Bobb A et al. The epidemiology of prescribing errors: the po- 21. Yousif MA et al .Investigation of medication prescribing errors tential impact of computerized prescriber order entry. Archives in Wad Medani, Gezira, Sudan. International Journal of Risk & of Internal Medicine, 2004, 164:785–792. Safety in Medicine, 2011, 23:11–16. 10. Barber N, Rawlins M, Dean Franklin B. Reducing prescribing 22. Siqueira JS et al. Analysis of the quality of prescriptions at error: competence, control, and culture. Quality & Safety in a cardiovascular ward in Brazil: a pilot study. International Health Care, 2003, 12(Suppl. 1):i29–i32. Journal of Clinical Pharmacology, Therapy and Toxicology, 2011, 11. Williams BR, Kim J. Medication use and prescribing considera- 33:260–263. tions for elderly patients. Dental Clinics of North America, 2005, 23. Ladue L et al. Generic psychotropic medications: issues of 49:411–427. cost-effectiveness and patient benefit. Southern Medical Jour- 12. Avorn J. The prescription as final common pathway. Interna- nal, 2011, 104(10):711–714. tional Journal of Technology Assessment in Health Care, 1995, 11:384–390.
806
Book 19-9.indb 806 10/7/2013 2:40:29 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
What do we need to eradicate rubella in the Islamic Republic of Iran? F. Almassinokiani,1 S. Noorbakhsh,2 M. Rezaei,3 A. Almasi,4 H. Akbari,5 S. Asadolla,1 P. Rahimzadeh 6 and M. Saberifard 1
ÈogX°GüÐëÐ|wÎowÚf+XoghmBúÐoZ"ÐémZþGøc^QmegcK_ewmX Ø}Rï}=nÉp=7ºìØÐÛhAÚ==ºUÐ{HÌÐÚnHºïFTÌNAºnCÌnEdLºxnÚÚ[fYº=Úipdhe?º©nhTinCÌnx}R ÓÐfH©5?Úí}Y{_=ïUÐ"ÐêØYÓnfhL:phinCúÐp["ÐØÐ{Ìph=n«Îé{_YDLæ}_Un=pHÐÚ{UÐì|w:NAnUÐæ{wexoåÉ°#Ð phinCúÐp["ÐpYÛĆYYpxnSdUp@n"Ðî{Yhhb>@ÌYUÙíºphYĆHüÐëÐ}xÎpxÚg+:phinCúÐp[dUíp[dUØn\CÐLe!ÐyhbdUÐDL ÓnfhU=d`UÐYphinCúÐp["ÐØÐ{ÌZcUïUÐ"ÐêØÓnfhLDLp}_YpHÐÚØëAnUÐî}@Ì{Sí phfJUÐph[UÐsYÐFUÐ:phbd#Ð " " " " ëÐ}gJ:ph_Yn!ÐÓnhaZCÐ{AÌ:ÒØøí145pfh_UÐqdeIíx~iün=>}CÐLnfCÐ~eCÐpxnbYÐ~hUüÐpbx}JêÐ{Hn= êÎ í @ phLnfCÐ " " 5TºphdHqinTngfY%27.3ëÌíº @ phLnfCÐÓnfhU=d`UÐYphinCúÐp["ÐØÐ{úph=n«ÎïUÐ"ÐêØÓnfhLY%72.7ëÌNAndUy\>Ðí " " ºphinCúÐp["Ð{yhbd>=ÐH0{UÓngYÌYÒÙBjCÐÓnfh_UÐ:nYÌ êÎ phLnfCÐÓnfhU=d`dUphinCúÐp["ÐØÐ{úphdHÓnfh_UÐ h+qinT " " Önbd=}BËL+yhbd=ênhbdUp@n"ÐOÎsýnfUÐì|wEZ>í bR @ phLnfCÐÓnfhU=d`UÐYp["ÐØÐ{úph=n«ÎgfY%87.5î{UënT{bR phinCúÐp["ÐØÐ{ÌZcUYÐ~UüÐÚnBøÐ:}^fUÐoin@OκénaJ±Ufh>í}UÐyhbdUÐ:ÚÐ}eHøÐ YÑniüÐH:ÊnfdUphinCúÐp["Ð " " e"ÐSÊnfUÐyhbd>ÒÚí¦:}^fUÐU|TíºphinCúÐp["ÐÖnbUN÷ bdx3.ĆUÐÊnfUÐî{Ue"ÐS @ phLnfCÐÓnfhU=d`UÐY
ABSTRACT To evaluate the need for congenital rubella syndrome prevention in our national health programme we aimed to determine the rate of anti-rubella positivity in umbilical cord blood samples 8 years after measles– rubella mass vaccination in the Islamic Republic of Iran. In a cross-sectional study we tested umbilical cord blood samples for anti-rubella IgG and IgM by ELISA in 154 deliveries at a university hospital in Tehran. Overall 72.7% of umbilical cord blood samples were positive for anti-rubella IgG and 27.3% were negative. All of the samples were negative for anti-rubella IgM. In the samples with a history of mothers’ rubella vaccination, only 87.5% were positive for anti-rubella IgG. The results suggest the need for another mass vaccination for rubella in women of child-bearing age and continuation of routine vaccination of infants, plus consideration of obligatory anti-rubella IgG testing before pregnancy in women who were not vaccinated and vaccination of women before marriage.
De quoi avons-nous besoin pour éradiquer la rubéole en République islamique d'Iran ?
RÉSUMÉ Pour évaluer la nécessité d'intégrer la prévention du syndrome de rubéole congénitale dans notre programme de santé national, nous avons tenté de déterminer le taux de positivité aux anticorps antirubéoleux dans des échantillons de sang de cordon ombilical huit ans après la campagne de vaccination de masse contre la rougeole et la rubéole en République islamique d'Iran. Au cours d'une étude transversale, nous avons utilisé la méthode ELISA pour analyser des échantillons de sang de cordon ombilical de 154 accouchements dans un hôpital universitaire de Téhéran afin de dépister des anticorps antirubéoleux de type IgG et IgM. Globalement, 72,7 % des échantillons de sang de cordon étaient positifs pour les anticorps antirubéoleux de type IgG et 27,3 % étaient négatifs. Tous les échantillons étaient négatifs pour les anticorps antirubéoleux de type IgM. Seuls 87,5 % des échantillons prélevés sur des mères ayant été vaccinées contre la rubéole étaient positifs pour les anticorps antirubéoleux de type IgG. Les résultats semblent indiquer la nécessité de mener une nouvelle campagne de vaccination de masse contre la rubéole chez les femmes en âge de procréer et de poursuivre la vaccination systématique des nourrissons, mais aussi d'envisager un test obigatoire de dépistage des anticorps antirubéoleux de type IgG avant une grossesse chez les femmes qui n'ont pas été vaccinées et la vaccination des femmes avant le mariage.
1Department of Obstetrics and Gynaecology; 2Department of Paediatrics; 4Department of Radiology; 5Department of Plastic and Reconstructive Surgery; 6Department of Anaesthesiology, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A. Almasi: [email protected]). 3Department of Statistics, Kermanshah University of Medical Sciences, Kermanshah, Islamic Republic of Iran. Received: 18/04/12; accepted: 25/06/12
807
Book 19-9.indb 807 10/7/2013 2:40:29 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Introduction XFSFBENJOJTUFSFEUPmZFBSPME mXFFLT BOE XPNFO NBMFTBOEGFNBMFT PGWBDDJOFFT XFSFɒXFFLT Infection of pregnant women without were immune against rubella before -FTTUIBOUISFFRVBSUFST PG immunity to the rubella virus at the WBDDJOBUJPOBOEXFSFTVTDFQ- the umbilical cord samples were posi- early stages of pregnancy often induces UJCMF0GUIFTVTDFQUJCMFHSPVQ UJWFGPSBOUJSVCFMMB*H(BOEXFSF abortion or congenital anomalies in the acquired immunity against rubella after negative. All of the samples were nega- fetus, and is termed congenital rubella vaccination [11]. After this mass vac- tive for anti-rubella IgM. Of the mothers syndrome (CRS). Rubella immuniza- DJOBUJPO ..3WBDDJOBUJPOGPSBOE IBEOPIJTUPSZPGSVCFMMB tion programmes are designed to pre- 18-month-old infants was instituted WBDDJOBUJPOBOE IBECFFO vent intrauterine rubella infection and into our national health programme. vaccinated. In those mothers who had lower the risk of future rubella outbreaks The purpose of present study was to been vaccinated for rubella (based on BOE$34DBTFT< >"SFQPSUQVCMJTIFE evaluate the seroprevalance of rubella mother’s recall) the rate of anti-rubella in 1997 found that the proportion of antibodies in cord blood samples of IgG in the umbilical cord blood was women who remained susceptible to newborn infants in Rasoul Akram hos- P 5BCMF SVCFMMBXBTɓJOEFWFMPQJOH pital in Tehran University of Medical *OUIFNPUIFSTBHFE ZFBSTUIF DPVOUSJFT<>4FWFSBMNFUBBOBMZTFT Sciences, to evaluate the need for CRS rate of anti-rubella IgG positivity in the have concluded that rubella immuniza- prevention in our national health pro- VNCJMJDBMDPSECMPPEXBT tion is a cost-effective means to reduce gramme 8 years after the mass vaccina- BOEJONPUIFSTBHFE ZFBSTUIF CRS in both developing and developed tion against MR started. rate of anti-rubella IgG positivity was 58 countries and has economic benefits BOEUIFSFXBTOPTUBUJTUJDBMMZ comparable to those associated with significant difference between age and hepatitis B vaccine and Haemophilus Methods IgG positivity (P influenzae type B vaccine [4–6]. Vaccination of children with In this cross-sectional, descriptive- mumps, measles and rubella (MMR) analytical study between September Discussion JO'JOMBOEXBTTUBSUFEJOBOE BOE+BOVBSZXFIBEBUPUBM rubella had been eradicated by 1997. of 154 deliveries in Rasoul Akram uni- The rate of anti-rubella IgG positivity /FWFSUIFMFTT ZFBSTGSPNUIFTUBSUPG versity hospital which were sequentially in umbilical cord blood samples in this this programme, 6 cases of CRS were included in the study. In all sera of cord TUVEZXBTBOEBMMPGUIFTBNQMFT reported and the risk of rubella was blood samples, anti-rubella antibod- were negative for anti-rubella IgM. Just increasing due to the growing num- ies (IgG and IgM) were assayed by PWFSIBMGPGNPUIFST IBEBIJT- bers of the unvaccinated people in the enzyme-linked immunosorbent assay tory of rubella vaccination. In samples population [7]. In Japan the number of (ELISA) method using Radim kits with a history of rubella vaccination in CRS cases decreased remarkably after (Rubella IgG and IgM Radim EIA well) NPUIFST XFSFBOUJSVCFMMB*H( an immunization law revision in 1994 and interpretation was according to the positive. This is less than the immuniza- to change the focus of immunization manufacturer’s instructions. tion rate after the mass rubella vaccina- from junior high-school girls to infants The data were analysed bySPSS , UJPODBNQBJHOJO <> of both sexes [8]. In Poland vaccination WFSTJPO VTJOHIJTUPHSBNDIBSUT 'JOEJOHTPGBTUVEZJOUIF*T- PGZFBSPMEHJSMTXBTJOUSPEVDFEJO mean and standard deviation (SD) and lamic Republic of Iran indicated that 1989, resulting in vaccination cover- percentages. Chi-squared and Fisher PGWBDDJOFFT XFSF BHFPG:FUJOBNPOH exact tests were used for descriptive data susceptible to rubella before vaccination XPNFOJOWFTUJHBUFEEJEOPUIBWF analysis. (IgG avidity assay was used to evaluate protective levels of anti-rubella antibod- UIFSVCFMMBJNNVOJUZBOEPGUIF JFT<>*OBTVSWFZJOJOQVCMJD TVTDFQUJCMFHSPVQ BDRVJSFE TDIPPMTJO*OEJBPGmZFBS Results immunity against rubella after vaccina- PMEHJSMTXFSFTFSPOFHBUJWFBOE tion [11]. The higher rate of seropositiv- became seropositive post-vaccination ĉFNPUIFSTBHFSBOHFXBTmZFBST ity than in our study may be due to a <> BOEUIFJSNFBOBHFXBT 4% number of reasons. First, in our study In the Islamic Republic of Iran in mode 19 years (Figure 1). Almost half more than 8 years had passed since vac- %FDFNCFSEVSJOHBNBTTWBDDJOB- PGUIFNPUIFST HBWFBIJTUPSZ cination (antibody decay). Secondly, tion for measles–rubella (MR), more of 1 previous delivery. Mean gestational the women in our study were a sample UIBONJMMJPOEPTFTPGUIFWBDDJOF BHFXBT 4% XFFLT SBOHF of Iranian women giving birth; perhaps
808
Book 19-9.indb 808 10/7/2013 2:40:29 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
(FSNBOZPGQSFHOBOUXPNFO 20 had history of rubella vaccination and PGTBNQMFTXFSF*H(QPTJUJWFGPS rubella [14]. 15 After mass vaccination for MR in JO*TMBNJD3FQVCMJDPG*SBO of the susceptible group that were IgG 10 negative before vaccination became Frequency IgG positive for anti-rubella antibody [11]. In another study in our country 5 mNPOUITBěFS.3NBTTWBDDJOBUJPO POMZPGWBDDJOBUFEXPNFOIBEOP rubella-specific IgG response [15]. In 0 our study, the rate of anti-rubella IgG 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 40 positivity in umbilical cord blood of Age (years) babies whose mothers had a history of WBDDJOBUJPOXBTĉJTEFDSFBTF Figure 1 Age distribution of the study mothers in the anti-rubella IgG positive rate in vaccinees may be due to antibody de- cay that is reported in other studies. in another study with a larger popula- immunizations reduces public health Although some studies have shown that tion the results may be a little different. costs. CRS leads to deafness, heart dis- vaccination-induced rubella antibodies Thirdly, those people who participated ease and cataract and a variety of other are detectable in almost all persons up JOUIFSVCFMMBDBNQBJHOXFSFm permanent manifestations. Rubella im- to 16 years after successful vaccination years old at the time of the study, but munization programmes are designed [16], other studies have not. In a longitu- some of our sampled women were out to prevent intrauterine rubella infection. dinal study after MR vaccination a mini- of this age range group. Although we In 1969, the first rubella vaccine was NBMBOUJCPEZEFDBZSBUFPGmXBT had rubella mass vaccination 8 years ago licensed for use, and the US Centers reported for rubella and it was suggested GPSUIFBHFHSPVQmZFBSTGPMMPXFE for Disease Control and Prevention UIBUEPTFWBDDJOBUJPOXBTOFFEFEUP CZSPVUJOFWBDDJOBUJPOPGBMMJOGBOUTBU CFHBOJUTOBUJPOBM$34SFHJTUSZ<> protect women from rubella infection and 18 months, these infants have still In 1969 the US established its national [17]. In a study from Finland, antibody not reached reproductive age. There- SVCFMMBWBDDJOBUJPOQSPHSBNNF decay was determined 15 years after the fore, this routine vaccination had not yet years later, reports of rubella reached second MMR dose and MMR-induced affected the rate of rubella in pregnant low numbers. The incidence of rubella antibodies waned significantly after the women. Now we have a situation in EFDSFBTFETJHOJėDBOUMZGSPNQFS TFDPOEEPTF<>*O4XFEFOZFBST which some women in reproductive age QPQVMBUJPOJOUP after introduction of rubella vaccina- that have not been vaccinated and also QFSQPQVMBUJPOJO<m> UJPOBOEZFBSTBěFSTUBSUJOH..3 have not environmental immunity and In Greece in 1999 the incidence of CRS vaccination in the national health pro- are sensitive to rubella. XBTQFSMJWFCJSUITBOEJO gramme, IgG activity in antenatal sera Vaccinations are one of the most BMUIPVHImPGUFFOBHFST XBT*UXBTTVHHFTUFESPVUJOF important effective preventive means XFSFWBDDJOBUFE mPGXPNFO screening for rubella immunity prior to for protection against infective dis- of child-bearing age were susceptible the first pregnancy and routine admin- eases. The high cost–benefit ratio of UPSVCFMMB<>*OBTVSWFZJOJO istration of additional dose of MMR vaccine to all young adults before they left the educational system [19]. In a Table 1 History of mothers’ vaccination and IgG seropositivity in umbilical cord TVSWFZGSPN5VSLFZJOBOUJSVCFMMB blood *H(XBTQPTJUJWFJOBOE*H.JO Vaccination history Negative IgG Positive IgG Total PGUIFUFTUFEXPNFO<> No. % No. % No. Positive antibody titres are signifi- Positive 6 12.5 56 87.5 64 DBOUMZIJHIFSJOUIPTFXIPSFDFJWF Negative 34 37.8 56 62.2 90 EPTFTPG..3<>*OUIF6OJUFE Total 42 27.3 112 72.7 154 Kingdom, rubella vaccination started
809
Book 19-9.indb 809 10/7/2013 2:40:30 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
JOBOEJOPOFTUVEZ UIFGSFRVFODZ an important problem in the Islamic priority must be given to protection PGXPNFOXJUIBOUJSVCFMMB*H( Republic of Iran. of women of child-bearing age. Our *6N- JODSFBTFE CZPWFSUIF In a WHO position paper on rubella results suggest the need for another ZFBSTUVEZQFSJPE<>*OBTVSWFZJO vaccines, it was suggested that because mass vaccination for rubella in women 1997 from 45 developing countries, the of the high response rate to a single of child-bearing age and continuation proportion of women who remained EPTFPGSVCFMMBWBDDJOF ɓ SPVUJOF of routine vaccination MMR of infants, TVTDFQUJCMFUPSVCFMMBXBT JO injection of a second dose is not neces- plus consideration of obligatory anti- countries (including the Islamic Re- sary and the Eastern Mediterranean rubella IgG testing before pregnancy in public of Iran, Oman, Kuwait, China, Region has established a goal of CRS women who have not been vaccinated Chile, Saudi Arabia and Gambia) and prevention without a target date for and of MMR vaccination of women mJODPVOUSJFTBOEɓJO countries that had incorporated rubella before marriage. An appropriate sur- DPVOUSJFT JODMVEJOHĉBJMBOE *OEJB vaccination in their national vaccination veillance system is needed because .BMBZTJB 4JOHBQPSFBOE1BOBNB <> QSPHSBNNFT<> without epidemiological data before In the current study the rate of anti- the introduction of the rubella vaccine rubella IgG negativity in umbilical cord an adequate monitoring programme CMPPEXBTIJHI Conclusions cannot be successful. In our study all the samples were negative for anti-rubella IgM and this Each country should assess its rubella may be due to the small sample size. In situation and find appropriate ways to Acknowledgements a recent survey in the Islamic Republic prevent CRS. The rate of anti-rubella of Iran the rate of CRS was estimated IgG negative in umbilical cord blood Funding: The study was supported BTQFSMJWFCJSUIT<>*OPOF TBNQMFTJOPVSTUVEZXBT XIJDI by the Paediatrics Infectious Diseases TVSWFZGSPNmPG1BMFTUJO- is high, and the majority of cases were Research Centre, Tehran University ian women attending forin vitro fertiliza- in unvaccinated women. This situation of Medical Sciences, Tehran, Islamic tion, positive results for anti-rubella IgM shows that a preventive CRS policy Republic of Iran. XBT<>ĉFSFGPSF SVCFMMBNBZTUJMM should be implemented in which the Competing interests: None declared.
References
1. Reef SE et al. The epidemiological profile of rubella and con- 9. Wysokiñska T et al. The prevalence of anti-rubella antibod- genital rubella syndrome in the United States, 1998-2004: the ies in women of childbearing age in Poland. Vaccine, 2004, evidence for absence of endemic transmission. Clinical Infec- 22:1899–1902. tious Diseases, 2006, 43(Suppl. 3):S126–S132. 10. Sharma H et al. Sero-surveillance to assess immunity to rubella 2. Herrmann KL. Rubella in the United States: toward a strategy and assessment of immunogenicity and safety of a single dose for disease control and elimination. Epidemiology and Infec- of rubella vaccine in school girls. Indian Journal of Community tion, 1991, 107:55–61. Medicine, 2010, 35:134–137. 3. Cutts FT et al. Control of rubella and congenital rubella syn- 11. Hamkar R et al. Evaluation of immunity against rubella in Iranian drome (CRS) in developing countries, Part 1: Burden of disease after mass campaign for measles-rubella vaccination on Decem- from CRS. Bulletin of the World Health Organization, 1997, ber 2003. American Journal of Infection Control, 2006, 34:588–592. 75:55–68. 12. Edlich RF et al. Rubella and congenital rubella (German mea- 4. Demicheli V et al. Vaccines for measles, mumps and rubella sles). Journal of Long-Term Effects of Medical Implants, 2005, in children. Cochrane Database of Systematic Reviews, 2005, 15:319–328. (4):CD004407. 13. Panagiotopoulos T, Georgakopoulou T. Epidemiology of ru- 5. Robertson SE et al. Control of rubella and congenital rubella bella and congenital rubella syndrome in Greece, 1994–2003. syndrome (CRS) in developing countries, Part 2: Vaccination Eurosurveillance, 2004, 9:17–19. against rubella. Bulletin of the World Health Organization, 1997, 14. Sauerbrei A et al. Antibodies against vaccine-preventable 75:69–80. diseases in pregnant women and their offspring in the east- 6. Hinman AR et al. Economic analyses of rubella and rubella ern part of Germany. Medical Microbiology and Immunology, vaccines: a global review. Bulletin of the World Health Organi- 2002, 190:167–172. zation, 2002, 80:264–270. 15. Hamkar R et al. Distinguishing between primary infection and 7. Peltola H et al. Measles, mumps, and rubella in Finland: 25 reinfection with rubella vaccine virus by IgG avidity assay in years of a nationwide elimination programme. Lancet Infec- pregnant women. Eastern Mediterranean Health Journal, 2009, tious Diseases, 2008, 8:796–803. 15:94–103. 8. Katow S. Surveillance of congenital rubella syndrome in Japan, 16. Chu SY et al. Rubella antibody persistence after immunization. 1978–2002: effect of revision of the immunization law. Vaccine, Sixteen-year follow-up in the Hawaiian Islands. Journal of the 2004, 22:4084–4091. American Medical Association, 1988, 259:3133–3136.
810
Book 19-9.indb 810 10/7/2013 2:40:30 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
17. Kremer JR, Schneider F, Muller CP. Waning antibodies in mea- 22. Byrne L et al. Seroprevalence of low rubella IgG antibody levels sles and rubella vaccinees—a longitudinal study. Vaccine, 2006, among antenatal women in England tested by NHS Blood and 24:2594–2601. Transplant: 2004–2009. Is rubella susceptibility increasing? 18. Davidkin I et al. Persistence of measles, mumps, and rubella Vaccine, 2012, 30:161–167. antibodies in an MMR-vaccinated cohort: a 20-year follow-up. 23. Sadighi J, Eftekhar H, Mohammad K. Congenital rubella syn- Journal of Infectious Diseases, 2008, 197:950–956. drome in Iran. BMC Infectious Diseases, 2005, 5:44. 19. Kakoulidou M et al. Serum levels of rubella-specific antibod- 24. Al-Hindi A, Al-Helou T, Al-Helou Y. Seroprevalence of Toxo- ies in Swedish women following three decades of vaccination plasma gondii, cytomegalovirus, rubella virus and Chlamydia programmes. Vaccine, 2010, 28:1002–1007. trachomatis among infertile women attending in vitro fertiliza- 20. Ocak S et al. Seroprevalence of Toxoplasma gondii, rubella and tion center, Gaza Strip, Palestine. Journal of the Egyptian Society cytomegalovirus among pregnant women in southern Turkey. of Parasitology, 2010, 40:451–458. Scandinavian Journal of Infectious Diseases, 2007, 39:231–234. 25. Rubella vaccines: WHO position paper. Weekly Epidemiologi- 21. Vandermeulen C et al. Long-term persistence of antibod- cal Record, 2011, 86(29):301–316. ies after one or two doses of MMR-vaccine. Vaccine, 2007, 25:6672–6676.
Global measles and rubella strategic plan : 2012-2020
The Global measles and rubella strategic plan : 2012-2020 builds on years of experience in implementing immunization programmes and incorporates lessons from accelerated measles control and polio eradication initiatives. The Plan stresses the importance of strong routine immunization systems supplemented by campaigns, laboratory-backed surveillance, outbreak preparedness and case management, as well as research and development. It also reminds us that public health is about people, above all, and that our work to build public trust and demand for vaccination is as important as the work to build and maintain measles and rubella vaccine supply and cold chains.
Further information about this and other WHO publications can be found at: IĨQBQQTXIPJOUCPPLPSEFST BOHMBJTIPNFKTQ
811
Book 19-9.indb 811 10/7/2013 2:40:30 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Seroprevalence of rubella among pregnant women in Khartoum state, Sudan O. Adam,1 T. Makkawi,1 A. Kannan 2 and M.E. Osman 1
ëÐØTÐ9ºêI|#Ðowøí9XÐ"ÐM<oghmBúÐoZcTLZBÐÚmYhøÐ ë5LïØn4ÐngYºënfTāÐ{LºïíncY{hA>ºêØË}eL
p[dUM[CÐÚnZiøÐÓø{_YéAÓnh]_CÐëÌ5Tº hfedU©ÐØUÐfJUÐsYniFUÐeÕÚ{YEQphinCúÐp["ÐÖnbUëÎô oåÉ°#Ð :YÐ"ÐN=phinCúÐp[dUM[CÐÚnZiøÐDLæ}_UÐwp}_CÐpHÐÚ{UÐì|wYæ{4Ðí phRnTEQÑniüÐH:ÊnfUÐN=phinCúÐ OÎ2008FeRi ©nUÐxP>YÒGaUÐ:YÐ"ÐpxnL}UÓÐØnhL H_@ÐÚ,YnA500pHÐÚ{UÐqdeI{Sí ëÐØUÐ:ºêJ}#Ðpxøí " " " " ó ÷ ó ~eCÐpxnbYïÌ Ð~hUüÐ pbx}JêÐ{Hn=phinCúÐp[dU @ LnfCÐNU=d`UÐØÐ{ÌZcUÓÐÚnBÐ4qx}@jRº2009ÜÚnY ÚÐÙË Ð|w=Ð}>{Sí %97í%93.2N=ÖíÐG>º%95pbUÐpdÉnRÊnfUÐY%95.1î{UØÐ{úÐd>ëAnUÐZTÐ{Sí x~iün=>}CÐLnfCÐ ßGaxí ÒØøUÐÓÐ}YØ{Lí̺pfgCÐí̺cUÐpb]fYí̺}e_UÐ Y=ÐGx3fcUíºhd_UÐîY Ynhýn[AÎ=ð {´ ó _÷ xô n]=Ð}>M[CÐÚnZiøÐð phiÐØHÓnxøí:pd?n,ÓnHÐÚØÊÐ}@ÎëÌíºêJ}#Ðpxøí:phinCúÐp["ÐÜíERëÐÚíØOÎEZxM[CÐÚnZiĆU
ABSTRACT Rubella vaccine is not included in the Sudanese national immunization programme, and data on the prevalence of rubella among women of childbearing age are inadequate. The objective of this cross-sectional study was to determine the seroprevalence of rubella among pregnant women in Khartoum state, Sudan. A total of 500 pregnant women who visited 7 antenatal clinics from November 2008 to March 2009 were examined for the presence of rubella IgG antibodies using ELISA. Rubella IgG antibodies were detected in 95.1% (95% CI: 93.2%–97.0%) of women. This seroprevalence was significantly associated with education level, but not with age, residence area, occupation or parity. We presume this high seroprevalence indicates a high circulation of wild rubella virus in Khartoum state. Similar studies in other Sudanese states would be important for informing a decision to introduce rubella vaccine to Sudan.
Séroprévalence de la rubéole chez les femmes enceintes dans l'État de Khartoum (Soudan)
RÉSUMÉ Le vaccin contre la rubéole ne fait pas partie du programme national de vaccination du Soudan, et les données sur la prévalence de la rubéole chez les femmes en âge de procréer sont insuffisantes. L'objectif de la présente étude transversale était de déterminer la séroprévalence de la rubéole chez les femmes enceintes dans l'État de Khartoum (Soudan). Au total, 500 femmes enceintes ayant consulté dans sept établissements de soins prénatals entre novembre 2008 et mars 2009 ont été examinées pour le dépistage des anticorps antirubéoleux de type IgG à l'aide de la méthode ELISA. Des anticorps antirubéoleux de type IgG ont été détectés chez 95,1 % des femmes (IC à 95 % : 93,2 %–97,0 %). La séroprévalence était significativement associée au niveau d'études, mais pas à l'âge, ni à la zone de résidence, ni au métier, ni à la parité. Nous avons supposé que cette forte prévalence reflétait une forte circulation du virus sauvage de la rubéole dans l'État de Khartoum. Des études similaires dans d'autres états du Soudan seraient essentielles pour appuyer la décision d'introduction du vaccin contre la rubéole dans le pays.
1Department of Medical Biotechnology, Commission for Biotechnology and Genetic Engineering, National Centre for Research, Khartoum, Sudan (Correspondence to O. Adam: [email protected]). 2Department of Obstetrics and Gynaecology, Faculty of Medicine, Alzaiem Alazhari University, Khartoum, Sudan. Received: 24/05/12; accepted: 19/06/12
812
Book 19-9.indb 812 10/7/2013 2:40:30 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction Methods Data analysis The statistical analysis was performed Rubella is an infectious viral disease Study setting and subjects using SPSSTPěXBSF WFSTJPO$BU- caused by the rubella virus. The disease The study was conducted in Khartoum egorical data were analysed by the chi- commonly occurs in childhood and is state, the national capital of Sudan, squared test or Fisher exact method characterized by a mild, maculopapular XIJDIDPWFSTBOBSFBPGLN. The as appropriate. A PWBMVFPG XBT rash. However, if rubella occurs during TUBUFJTDPNQSJTFEPGNBJOSFHJPOT considered statistically significant. the early months of pregnancy, the virus Khartoum, Bahry and Omdurman, and may infect the fetus and result in miscar- is administratively divided into 7 locali- riage, stillbirth or an infant with congeni- ties with an estimated population of 5 Results tal rubella syndrome (CRS). The most NJMMJPOJO common clinical manifestations of CRS This cross-sectional study was con- The main characteristics of the pregnant include cardiac, ophthalmic, auditory EVDUFECFUXFFO/PWFNCFSBOE women are presented in Table 1. The and neurological defects [1]. Rubella is .BSDIBUBOUFOBUBMDMJOJDTJO NFBOBHFPGUIFQBSUJDJQBOUTXBT a vaccine-preventable disease where the those 7 different localities of the state. years, ranging between 16–47 years, and primary purpose of vaccination against "UPUBMPGIFBMUIZQSFHOBOUXPNFO IBMGPGUIFN XFSFɒZFBST rubella is to prevent the occurrence of at any gestational age and permanently .PTUPGUIFTUVEJFEXPNFO $34<>%VFUPFĎFDUJWFWBDDJOBUJPO resident in Khartoum state were en- were resident in Omdurman. Of the programmes, rubella and CRS have rolled. This sample size was determined XPNFO XFSFJMMJUFSBUFBOE become rare diseases in many indus- CBTFEPODPOėEFODFJOUFSWBM $* had completed primary or secondary trialized countries [1]. However, CRS MFWFMPGQSFDJTJPO BEFTJHOFĎFDUPG school education. The majority of the remains a major cause of developmental BOEBQSFWJPVTTFSPQSFWBMFODFPG XPNFOXFSFIPVTFXJWFT ĉF anomalies in many developing coun- [5]. analysis of obstetric profile revealed that tries where rubella vaccine has not yet PGUIFQSFHOBOUXPNFOXFSF JOUSPEVDFE<>*UJTFTUJNBUFEUIBUNPSF Ethical approval multigravida, and the mean number of UIBOJOGBOUTBSFCPSOXJUI The study protocol was reviewed and QSFHOBODJFTXBT SBOHJOHCFUXFFO CRS each year, mostly in developing approved by the Health Research Eth- 1–14 pregnancies. Two-thirds of the countries [4]. Hence, the World Health ics Committee of the Federal Ministry XPNFO XFSFFOSPMMFE Organization (WHO) recommended of Health, Sudan. All subjects were in- at their third trimester of pregnancy all countries not using rubella vaccine formed about the study and consented XIJMFPOMZ XFSFBUUIFJSėSTU to assess their rubella situation and to before enrolment. trimester. History of miscarriage was make plans for the introduction of the SFQPSUFECZ PGUIFJOWFTUJ- vaccine. In this regard, it is helpful to as- Data collection gated women. It was clearly stated that sess the susceptibility profile of women 'PMMPXJOHBTFQUJDUFDIOJRVFT N- none of the tested women had been of childbearing age by conducting ante- of venous blood were obtained from vaccinated against rubella before. OBUBMTFSPTVSWFZTJOTVDIDPVOUSJFT<> each subject and sera were extracted 0GUIFQSFHOBOUXPNFO Rubella vaccine is not included in BOETUPSFEBUm$VOUJMUFTUFE*O XFSFQPTJUJWFGPSSVCFMMB*H( XFSF the Sudanese national immunization addition, a questionnaire including negative and 11 were equivocal. Those programme, and data on the prevalence information on demographic character- with equivocal results were excluded of rubella among women of childbear- istics and history of rubella vaccination from the study, leaving a total of 489 ing age are inadequate [5]. Further- was administered for each subject. To women for further analysis. Accord- more, there is no routine surveillance screen for rubella IgG antibodies in sera ingly, the seroprevalence of rubella in for CRS, and data on its incidence are samples, a commercial enzyme-linked ,IBSUPVNTUBUFXBTGPVOEUPCF extremely scarce [6]. Sudanese surveil- immunosorbent assay kit (rubella virus $*m XIJMFUIF MBODFGPSNFBTMFTBOESVCFMMBTJODF IgG ELISA, DRG GmbH) was used. susceptibility to rubella among the ex- has reported that rubella infection is a Based on the manufacturer’s instruc- BNJOFEXPNFOXBT $* frequent cause of none-measles rash UJPOTTFSBTBNQMFTXJUIBUJUSF m [7]. In the light of this situation, we *6N-XFSFDMBTTJėFEBTOFHBUJWFGPS The statistical analysis of categorical conducted this study to determine the rubella IgG; samples with titres of ≥ 15 data did not show significant association seroprevalence of rubella among preg- *6N-XFSFDMBTTJėFEBTQPTJUJWF BOE between the seroprevalence of rubella nant women attending antenatal clinics TBNQMFTXJUIBUJUSFPGUP *6N- and each of age (Pearson χ EG in Khartoum state, Sudan. were classified as equivocal. = 1, P SFTJEFODFBSFB 1FBSTPO
813
Book 19-9.indb 813 10/7/2013 2:40:30 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 1 Seroprevalence of rubella among pregnant women attending 7 antenatal previously reported in many develop- clinics in Khartoum state, Sudan (n = 489) ing countries that were not using ru- Variable Total Rubella seroprevalence bella vaccine [8], including countries Positive Negative from the World Health Organization No.%No.%No.%Eastern Mediterranean Region, such Age (years) as the Islamic Republic of Iran, where ≤ 25 247 50.5 235 95.1 12 4.9 UIFTFSPQSFWBMFODFPGSVCFMMBXBT > 25 242 49.5 230 95.0 12 5.0 among pregnant women [9]. In addi- χ2 = 0.003, df = 1, P = 0.959 tion, a similar high rubella prevalence Residence area PGIBTCFFOSFQPSUFEJOTPNF Khartoum 106 21.7 98 92.5 8 7.5 African countries, such as South Af- SJDBBOE.P[BNCJRVF< > CFTJEFT Bahry 172 35.2 161 93.6 11 6.4 BTMJHIUMZIJHIFSQSFWBMFODFPG Omdurman 211 43.1 206 97.6 5 2.4 BNPOH/JHFSJBOQSFHOBOUXPNFO<> χ2 = 5.31, df = 2, P = 0.070 Several factors may influence the se- Education roprevalence of rubella among and with- Illiterate 69 14.1 60 87.0 9 13.0 JODPVOUSJFT< >/FWFSUIFMFTT UIJT Primary 186 38.0 183 98.4 3 1.6 study showed an insignificant association Secondary 145 29.7 138 95.2 7 4.8 between rubella seroprevalence and age, University 89 18.2 84 94.4 5 5.6 residence area, occupation and parity. χ2 = 14.2, df = 3, P = 0.003 Such a result is expected in countries with Occupation BIJHISVCFMMBQSFWBMFODF< >)PX- Not working 445 91.0 422 94.8 23 5.2 ever, the seroprevalence of rubella was Working 44 9.0 43 97.7 1 2.3 significantly associated with education χ2 = 0.719, df = 1, P= 0.396 level (P ĉFTFSPQSFWBMFODFXBT Parity IJHIFSBNPOHFEVDBUFEXPNFO m Primigravida 123 25.2 113 91.9 10 8.1 DPNQBSFEXJUIJMMJUFSBUFXPNFO Multigravida 366 74.8 352 96.2 14 3.8 JOXIPNUIFTFSPQSFWBMFODFXBT χ2 = 3.66, df = 1, P = 0.056 $*m ĉJTDPVMECF Total 489 100.0 465 95.1 24 4.9 attributed to the increased probability of acquiring rubella infection during the early school years [1]. χ EG P PDDVQBUJPO surveillance for measles and rubella, On the other hand, the current study (Pearson χ EG P where significant numbers of rubella demonstrated a low rubella susceptibil- and parity (Pearson χ EG P cases were detected among the sus- JUZSBUFPG $*m )PXFWFS UIFFEVDBUJPOMFWFM QFDUFEDBTFT*O UIJTTVSWFJMMBODF among the investigated subjects. This was significantly associated with rubella DPOėSNFESVCFMMBJOGFDUJPOJOPG result does not exclude the risk of CRS seroprevalence (Pearson χ EG the investigated febrile rash cases [7]. in our population, as CRS can occur even when susceptibility levels are be- P To our knowledge, this study is the MPX<>*OBDDPSEBODFXJUIUIJT first published antenatal rubella sero- fact, we have recently documented the survey in Khartoum state since 1997 Discussion occurrence of CRS in Sudan, when 11 [5]. Our current findings differed from CRS case were laboratory confirmed Our findings demonstrated a high an earlier report that showed a lower in a hospital-based study during June SVCFMMBTFSPQSFWBMFODFPG SVCFMMBTFSPQSFWBMFODFPGBNPOH UP.BZ<>$POTFRVFOUMZ $*m BNPOHQSFHOBOU Sudanese pregnant women [5]. Pos- it is highly recommended to assess the women in Khartoum state. We presume sibly this is due to outbreaks that oc- burden of CRS in Sudan because a this indicates a heavy circulation of wild curred during the long period between high number of CRS cases might occur rubella virus in Sudan, since rubella UIFTFTUVEJFT TJODFSVCFMMBPDDVST if this low susceptibility is due to recent vaccination is not yet practised in the in a seasonal pattern with epidemics rubella outbreaks. The burden of CRS country. This presumption is supported FWFSZmZFBST<>.PSFPWFS TJNJMBS can be assessed through conducting by the recent reports of the Sudanese high rubella seroprevalence has been active CRS surveillance and testing for
814
Book 19-9.indb 814 10/7/2013 2:40:30 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
rubella IgM in suspected infants aged in women of childbearing age in other Engineering, Sudan, for offering his ɒNPOUIT FJUIFSOBUJPOXJEFPSJO Sudanese regions, which will provide time during the preparation of this selected urban and rural populations an indirect measure of the burden of manuscript. We are also grateful to <>"OPUIFSNFUIPEGPSBTTFTTJOHUIF CRS and will help the Sudanese health the women who participated in this CRS burden would be a retrospective authorities in considering the inclusion study and to the doctors, nurses and review of hospital records [15]. of rubella vaccine in Sudan. technicians at the antenatal clinics for In conclusion, this brief report is one their cooperation and help during the of the most recent studies document- collection of samples. ing the situation of rubella in Sudan. It Acknowledgements showed a high seroprevalence of rubella Funding: This study received a finan- among pregnant women in Khartoum We would like to thank Dr Ahmed cial support from the Sudan Academy state. We recommend conducting K.M. Ali, from the Commission of Sciences, Sudan. more studies on rubella seroprevalence for Biotechnology and Genetic Competing interests: None declared.
References
1. Best J. Rubella. Seminars in Fetal and Neonatal Medicine, 2007, 9. Majlessi F et al. Rubella serology in pregnant women attending 12:182–192. health centres of Tehran University of Medical Sciences. East- 2. World Health Organization. Rubella vaccines: WHO position ern Mediterranean Health Journal, 2008, 14:590–594. paper. Weekly Epidemiological Record, 2000, 75:161–169. 10. Corcoran C, Hardie D. Seroprevalence of rubella antibodies 3. Banatvala JE, Brown DW. Rubella. Lancet, 2004, 363:1127–1137. among antenatal patients in the Western Cape. South African Medical Journal, 2005, 95:688–690. 4. Cutts FT, Vynnycky E. Modelling the incidence of congenital rubella syndrome in developing countries. International Jour- 11. Barreto J et al. Antenatal rubella serosurvey in Maputo, Mo- nal of Epidemiology, 1999, 28:1176–1184. zambique. Tropical Medicine and International Health, 2006, 11:559–564. 5. Elbushi AM. Sero-epidemiology of rubella in Sudanese pregnant women in Khartoum state [PhD thesis]. Khartoum, Sudan, Uni- 12. Mohammed-Durosinlorun A et al. Prevalence of rubella IgG versity of Khartoum, 1997. antibodies among pregnant women in Zaria, Nigeria. Interna- tional Health, 2010, 2:156–159. 6. Adam O et al. Primary investigation of 31 infants with suspected congenital rubella syndrome in Sudan. Clinical Microbiology 13. Guidelines for surveillance of congenital rubella syndrome and Infection, 2010, 16:678–682. and rubella. Field test version 1999. Geneva, World Health Organization, 1999 (WHO/V&B/99.2). 7. Measles bulletin. December 2009. World Health Organiza- tion Regional Office for the Eastern Mediterranean [online]. 14. Palihawadana P et al. Seroprevalence of rubella antibodies (http://www.emro.who.int/vpi/measles/media/pdf/Mea- among pregnant females in Sri Lanka. Southeast Asian Journal slesBulletin_December09.pdf, 11 June 2013). of Tropical Medicine and Public Health, 2003, 34:398–404. 8. Cutts FT et al. Control of rubella and congenital rubella syn- 15. Bloom S et al. Congenital rubella syndrome in Morocco: a drome (CRS) in developing countries, part 1: burden of disease rapid retrospective assessment. Lancet, 2005, 365:135–141. from CRS. Bulletin of the World Health Organization, 1997, 75:55–68.
815
Book 19-9.indb 815 10/7/2013 2:40:30 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
National guidelines for outbreak investigation: an evaluation study M. Fararouei,1 S. Rezaee,2 A. Raigan Shirazi,2 M. Naghmachi,3 K. Karimzadeh Shirazi,4 A. Jamshidi 2 and J. Jafari 5
ogdgga=oGÐÚØÓmgHm`TÐÊmZaGøogeITÐowØmHÚüÐýøzTÐ ï}a_@pdh+ºï{hZ+ëĆHÚ̺ïÛÐEIìØÐ~ex}T~hYnTº@5`i7ºïÛÐEIëncxÐÚnEdLºxnÚĆhgHº©íÚÐ}R{e7 _Yn@ê}A:Ên_YúÐíÒ{_CÐÑngUÐYphInRéAeHÚÊn[bHÐsýnipÉhhbUpdbYphýn=ípHÐÚØpSÚUÐì|wß}_>oåÉ°#Ð éA[UÐ~T}CÐ:ßÐ}YúÐpRncYSìÚ{ÉÌï|UÐeH}UÐ}x}bUÐe\>{bR phYĆHüÐëÐ}xÎpxÚg+HíÑf@:º@Hnx: 65 nYUÙ:í ÓnUn]UÐpYnSÎpf@Ì:ebx.ĆUÐÔniüÐYng_h+ºênxÌp2éĆBq?{A{SbRpUnAô ëÌpxøUÐ{h_ÉDLphInaUÐ pUnJ203ínUnJð 192pd]UÐY395ëÌYºp_Yn!Ðai:ÑĆ]UÐY963qdeIUÐphinhHøÐÓnACÐhUÎqdÉ>nY YßÚn_x ÒGaUÐd>éĆBaR nLHÌð 12î{YDLÊn_YúÐíÒ{_CÐÑngUÐßÐ}LÌY}TÌíÌ{AÐíLÐ`d=Ì{SºéÛnfCÐ:íÌpYnSüÐpf@Ì:ëZh_x ÜnfUÐpYnLíph[UÐÓnY{#Ðëj=AxphUn"ÐpHÐÚ{UÐsýniN=íeH}UÐ}x}bUÐN=×Ún[UÐßÚn_UÐÐ|wYëÎ SúÐDLënhInRq?{A phInadUpeýĆCÐp=nHøÐéAÐdd¬ {Sëicx5=Úô
ABSTRACT This paper reports an independent epidemiological study to evaluate the validity of the results of an official investigation into an outbreak of gastroenteritis at a university campus in Yasuj, central-south Islamic Republic of Iran. The official report of the outbreak by the Department for Disease Control at the provincial health centre found only 65 cases over a 5-day period, all females, living in the student halls of residence. This contrasts with a questionnaire survey of 963 students at the same university, which found 395 students (192 males and 203 females), living in residences and at home, who reported at least 1 gastrointestinal symptom over a 12-week period. Within this period at least 2 outbreaks occurred. Such a large discrepancy between the official report and the current study suggests that the health services and the public may have been misled about the proper response to the outbreak.
Lignes directrices nationales en matière d'investigation des flambées : une étude d'évaluation
RÉSUMÉ Les présents travaux rendent compte d'une étude épidémiologique indépendante qui visait à évaluer la validité des résultats d'une investigation officielle d'une flambée de gastroentérite sur un campus universitaire de Yasuj (République islamique d'Iran). Dans le rapport officiel sur la flambée, le Service chargé de la lutte contre les maladies au centre de santé provincial avait répertorié uniquement 65 cas sur une période de 5 jours, tous de sexe féminin, vivant dans des résidences universitaires. Ces résultats sont contradictoires avec ceux d'une enquête par questionnaire auprès de 963 étudiants de la même université, au cours de laquelle 395 étudiants (192 de sexe masculin et 203 de sexe féminin), vivant dans des résidences universitaires ou à domicile, ont affirmé avoir présenté au moins un symptôme gastro-intestinal au cours d'une période définie de 12 semaines. Au cours de ladite période, au moins deux flambées ont été observées. Une telle différence entre le rapport officiel et la présente étude suggère que les services sanitaires et les personnes interrogées ont été induits en erreur au sujet de la réponse appropriée à la flambée.
1Department of Epidemiology and Biostatistics, School of Health; 2Department of Environmental Health, School of Public Health; 3Department of Nutrition, School of Public Health; 4Department of Public Health, School of Public Health; 5Student Research Centre, Yasuj University of Medical Sciences, Islamic Republic of Iran (Correspondence to M. Fararouei: [email protected]). Received: 24/04/12; accepted: 05/07/12
816
Book 19-9.indb 816 10/7/2013 2:40:31 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Introduction at University of Yasuj student halls of over a 5-day period from 18 October residence—to the emergency ward of UP0DUPCFS The strategies for epidemic investiga- Shahid Beheshti general hospital. The Independent evaluation tions and control measures are deter- students were suffering from gastroin- mined, evaluated and revised at the testinal symptoms, mostly vomiting, In order to estimate the incidence of national level predominantly by the nausea, diarrhoea and abdominal pain. gastroenteritis among all students on same organization. Independent studies According to the national guidelines the campus of the University of Yasuj are rarely carried on the same epidemics for control of foodborne diseases is- a specially designed, self-administered to evaluate the validity of the reports sued by the Iranian Ministry of Health, questionnaire was developed by the published by the responsible health BOZPSNPSFDBTFTXJUITJNJMBSHBTUSP- research team. This asked about any sectors. Gastroenteritis, an infectious intestinal symptoms who consumed gastrointestinal symptoms (nausea, di- disease transmitted predominantly food or drink from common sources arrhoea, vomiting and abdominal pain) via food and water, is one of the most should be considered as an outbreak. FYQFSJFODFEXJUIJOBNPOUIQFSJPE DPNNPODPNNVOJDBCMFEJTFBTFT< > Therefore, this was considered as a gas- 4FQUFNCFSUP/PWFNCFS However, many investigations into trointestinal disease outbreak and was ĉFRVFTUJPOTSFHBSEJOHUIF gastrointestinal disease outbreaks and investigated immediately. Accordingly, symptoms were designed to be similar epidemics fail to reach conclusive and all patients were interviewed by trained to the ones used by the health centre in unbiased results due to a number of staff from the Department for Disease the official investigation questionnaire. issues including improper investigation Control and the foodborne outbreak In addition the questionnaire included, guidelines, delayed response and short- questionnaire from the Ministry of EFNPHSBQIJDEBUBBOEPQFO ZFTOP age of laboratory and logistic facilities Health was filled out. Stool specimens questions regarding sources of foods, <m> (from 6 patients) were collected and drinks and other relevant factors. *O0DUPCFSTFWFSBMDBTFTPG sent to the central library for diagnosis 0OUIF/PWFNCFSUIF gastroenteritis requiring hospitaliza- of the responsible agents. The results questionnaire was distributed to the tion were reported at the women’s halls of testing for parasites eggs, blood, Es- university students by volunteer stu- of residence at a university campus in cherichia coli and Entamoeba histolytica dents of public health, at 4 major access Yasuj, central-south Islamic Republic XFSFOFHBUJWFGPSQBUJFOUT E. coli was points in the campus: restaurant, bus of Iran. This triggered an official inves- GPVOEJOTBNQMFTBOE CPUIE. coli and stations, library and dormitories. At the tigation at the local health centre, with Entamoeba histolytica were reported in UJNFPGUIFTUVEZ TUVEFOUTXFSF follow-up to identify further cases and 1 sample. studying at University of Yasuj. The finally publication of an outbreak report %VSJOHUIFOFYUEBZT BTTVNJOH RVFTUJPOOBJSFXBTEJTUSJCVUFEUP from the Department for Disease Con- that the agent was spread from girls’ TUVEFOUT PGUIFUPUBMTUVEZQPQVMB- trol. This paper reports an independent dormitories, the health staff visited the UJPO GSPNXIJDIRVFTUJPOOBJSFT epidemiological study to evaluate the residence halls at the university campus XFSFDPNQMFUFEBOESFUVSOFE PG validity of the results of the official in- from which the patients were referred, UPUBMTUVEFOUQPQVMBUJPO SFTQPOTF vestigation. A questionnaire survey was searching for any other students with rate). made of students at the university to the same symptoms. As a result, 47 Analysis estimate the total incidence of gastroen- more women were found suffering teritis and dates of illness for compari- GSPNHBTUSPJOUFTUJOBMTZNQUPNT0O Descriptive methods, as well as chi- son with the frequencies and dates of October, health staff from the Depart- squares, Fisher exact and Student t-tests the official report of the outbreak. ment for Disease Control revisited the were used to analyse the data. residence halls for follow-up investiga- tions. Due to the panic caused by the Methods PVUCSFBL POMZTUVEFOUTSFNBJOFEJO Results residence. Again, 6 more students with Background to the official related symptoms were found, from Independent evaluation report whom stool specimens were tested for *OUPUBM DPNQMFUFERVFTUJPOOBJSFT 0O0DUPCFSBSFQPSUXBT the previously named agents with no were collected and used for the inde- received by the Department for Dis- pathogens reported. In total, as a result pendent analysis. Out of these, a total of ease Control at the provincial health of the epidemic investigation based on TUVEFOUT SFQPSUFEBUMFBTU centre in Yasuj city about the referral the national guidelines, 65 cases with at HBTUSPJOUFTUJOBMTZNQUPNPWFSUIF PGTUVEFOUTãBMMGFNBMFTSFTJEJOH least 1 digestive symptom were reported XFFLQFSJPEGSPN4FQUFNCFSUP
817
Book 19-9.indb 817 10/7/2013 2:40:31 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 1 Sex-specific incidence of gastrointestinal illness among students in the evaluation study and the official report from the health centre Sex Evaluation study Official report No. of No. of cases Rate (%) No. of people No. of cases Rate (%) respondents exposed Male 414 192 46.4 n/a 0 n/a Female 549 203 37.0 n/a 65 n/a Total 963 395 41.0 n/a 65a n/a
aP < 0.001, Fisher exact test, comparing the sex distribution of cases reported by evaluation study and official report. RR = 1.26, P = 0.003, males versus females. n/a = not applicable.
/PWFNCFS$BTFTXFSFTPNF- located at the university campus (Table identified in the current evaluation, not what equally distributed among males 4). Always consuming foods provided just one. BOEGFNBMFT 5BCMF by the restaurant significantly increased Although the official report sug- 1). The sex-specific incidence of dis- the risk of acquiring the disease com- gested that all the cases recorded were FBTFBNPOHNBMFTUVEFOUT pared with never using or occasionally among females, the results from the XBTTJHOJėDBOUMZIJHIFSUIBO using self-service food (SJTLSBUJP present study found cases in both males BNPOH GFNBMF TUVEFOUT $*m P and females (Table 1). No comparison NBMFUPGFNBMF33 Comparison with the official of the sex-specific incidence of disease $*m P )BMGPGUIF DPVMECFNBEFCFUXFFOUIFSFQPSUT TUVEFOUT SFQPSUFEEJBSSIPFB report because no population at risk was re- BOEIBEBCEPNJOBMDSBNQT 5B- The number of cases found and the ported by the formal investigation. CMF outbreak patterns in the current evalu- The spatial distribution of the cases The incidence of symptoms report- BUJPO TUVEFOUTPWFSBXFFL SFQPSUFECZUIFTUVEJFTXBTBMTPNBSL- FETVHHFTUTUIBUGSPN4FQUFNCFS period) contrasted with the official edly different, as all patients reported by UP/PWFNCFS HBTUSPJOUFT- report from the Department for Dis- tinal outbreaks occurred. Accordingly, ease Control of only 65 cases over a the official investigation were residents the first outbreak began on 6 October 5-day period. of girls’ residence halls located at the BOEFOEFEPO0DUPCFS The time trends of the cases were university campus whereas the current EBZT ĉFTFDPOEPVUCSFBLCFHBO also different. Although during a short study reported cases among both girls PO/PWFNCFSBOEFOEFEPO period of time both sources reported a and boys resident in university resi- /PWFNCFS EBZT 'JHVSF similar frequency of cases (Figure 1), dence halls or private houses. Moreover, a significant difference was the overall trends were dramatically dif- On the other hand, comparison found in the duration of the symptoms ferent, as the official report suggested of the prevalence of symptoms (di- CFUXFFOUIFPVUCSFBLT P a considerably shorter period for the arrhoea, vomiting and abdominal 5BCMF outbreak (5 days) compared with the cramps) among cases reported by the A significant association was found QSFTFOUFWBMVBUJPO EBZT GPSUIF official report and the current evalua- between the incidence of the disease and second outbreak identified). Further- tion showed similar distributions (P > consumption of food at the restaurant NPSF HBTUSPJOUFTUJOBMPVUCSFBLTXFSF 5BCMF
Table 2 Incidence of gastrointestinal symptoms reported from cases in the evaluation study and the official report from the health centre Symptom Evaluation study Official report Data sources (n = 395) (n = 65) compared No. with % No. with % P-value symptoms symptoms Diarrhoea 204 51.6 34 52.3 1.00 Vomiting 137 34.7 20 30.8 0.58 Abdominal cramps 307 77.7 53 81.5 0.63
n = total number of cases.
818
Book 19-9.indb 818 10/7/2013 2:40:31 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
25 Evaluation study
Reported to the health centre
20
15
Frequency 10
5
0
14-10-2009 18-10-2009 01-11-2009 08-11-2009 12-11-2009 16-11-2009 02-09-2009 25-09-2009 30-09-2009 10-10-2009 22-10-2009 26-10-2009 Date of onset of symptoms
Figure 1 Time trends of the outbreak investigated by the evaluation study (n = 163), those reported the exact starting date of the symptoms) and the official epidemic investigation conducted by the health centre (n = 65)
Table 3 Duration of gastrointestinal illness among students in the evaluation study Discussion according to the date when symptoms started Date symptoms started No. of cases Duration of illness (days) Despite extensive experiences and de- Mean (SD) 95% CI velopment in the diagnosis and manage- Before 6 Oct 2009 7 10.9 (9.4) 2.2–19.6 ment of epidemics, numerous epidemic 6–26 Oct 2009a 97 4.4 (3.5)a 3.7–5.1 investigations are terminated without 26 Oct–5 Nov 2009 5 3.4 (2.6) 0.2–6.6 TBUJTGZJOHSFTVMUT< >ĉFSFBTPOT 5–16 Nov 2009a 28 2.6 (2.0)a 1.9–3.4 especially in developing countries, in- 16–23 Nov 2009 1 2.0 – – clude insufficient guidelines for diseases All specified 138 4.3 (4.0) 5.0–3.7 surveillance and epidemic investigation, All unspecified 257 – – delayed and improper response due Total 395 – – to lack of required facilities and insuf-
aP < 0.02, comparing the 2 outbreaks. ficient training of health staff [4]. The SD = standard deviation; CI = confidence interval. results of present epidemiological study
819
Book 19-9.indb 819 10/7/2013 2:40:32 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 4 Incidence of gastrointestinal illness among students in the evaluation occurrence and exact timing of symp- study according to consumption of foods at the university campus restaurant toms. However, this is likely to have Food consumption habits No. of No. of % reduced the number of cases reported respondents cases and as a result should have decreased Always consumed the restaurant food 753 241 32.0 UIFEJĎFSFODFTCFUXFFOUIFSFQPSUT Sometimes consumed the restaurant food 330 95 28.8 regarding the incidence of symptoms. Never consumed the restaurant food 190 38 20.0 There is no reason to assume that there Unspecified 85 21 24.7 were systematic errors in reporting the Total 963 395 41.0 time of the occurrence of the symptoms Risk ratio = 1.80, P < 0.001, always consumed versus never or occasionally consumed the restaurant food. that would affect the findings about the temporal pattern of the outbreak. among students of University of Yasuj the patients was also significantly dif- Irrespective of the shortage of facili- JOBVUVNOXFSFVTFEUPFWBMVBUF GFSFOUJOUIFSFQPSUT TVHHFTUJOHB ties and appropriate laboratory services which were may have been the case at the results of an official outbreak inves- biased presentation of the situation in the local health centre, it seems that tigation conducted by the Department the official report. government action strategies are un- for Disease Control in the local health Regarding the risk factors, due to centre. able to respond timely and efficiently the time gap between the occurrence to outbreaks and that the results of epi- $PNQBSJTPOPGUIFSFTVMUTPGUIF of the outbreak and the conduction studies revealed significant differences demic investigations may be biased and of the present study no attempt was misleading [ ]. in the reported number of cases and made to find the pathogens responsi- the temporal and spatial pattern of the ble for the outbreak. However, being outbreak during the study period, sug- male and eating food prepared by the Acknowledgements gesting a serious biased presentation university campus restaurant signifi- of the situation by the official report. cantly raised the risk of disease among We especially thank the students of In contrast to the official report from the students. public health who voluntarily helped the Department for Disease Control to accomplish this study. We also thank indicating occurrence of a short gastro- A number of limitations to the study the health staff from Yasuj health cen- intestinal disease outbreak, the results should be noted. First, we were unable tre, Mr Vali Nosrati and Mr Ebrahim of the present study suggested the oc- to take microbiological samples. Sec- DVSSFODFPGBUMFBTUPVUCSFBLTXJUIJO ondly, many students returned home Rostami who provided us with the data UIFNPOUITPGUIFTUVEZQFSJPEĉF in the panic caused by the outbreak and the report of epidemic investigation significant difference in the duration and this prevented the researchers from published by Yasuj health centre. of the symptoms suggests the possible carrying out the evaluation immediately Funding: This work was supported by involvement of different pathogens in after the outbreak. This delay may have Yasuj University of Medical Sciences. the outbreaks. The sex distribution of introduced recall bias in reporting the Competing interests: None declared.
References
1. Flint JA et al. Estimating the burden of acute gastroenteritis, of foodborne outbreaks: an analysis of foodborne disease foodborne disease, and pathogens commonly transmitted outbreaks in FoodNet catchment areas, 1998–1999. Clinical by food: an international review. Clinical Infectious Diseases, Infectious Diseases, 2004, 38(Suppl. 3):S297–S302. 2005, 41:698–704. 5. Wu J-SJ et al. Evaluation of an adjustable epidemiologic infor- 2. Gauci C et al. Challenges in identifying the methodology to es- mation system. PLoS ONE, 2011, 6:e14596. timate the prevalence of infectious intestinal disease in Malta. 6. Fisichella M et al. Unsupervised public health event detec- Epidemiology and Infection, 2006, 134:393–399. tion for epidemic intelligence. In: Proceedings of the 19th ACM 3. Hall JA et al. Epidemiologic profiling: evaluating foodborne International Conference on Information and Knowledge Man- outbreaks for which no pathogen was isolated by routine agement. Toronto, Ontario, 26–30 October 2010. New York, laboratory testing: United States, 1982–9. Epidemiology and Association for Computing Machinery, 2010. Infection, 2001, 127:381–387. 7. Hedberg CW, Osterholm MT. Outbreaks of food-borne and 4. Jones TF et al.; Emerging Infections Program FoodNet Working waterborne viral gastroenteritis. Clinical Microbiology Reviews, Group. Limitations to successful investigation and reporting 1993, 6:199–210.
820
Book 19-9.indb 820 10/7/2013 2:40:32 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Report Unusual sex differences in tuberculosis notifications across Pakistan and the role of environmental factors M.S. Khan,1 M.S. Khan,2 R. Hasan 2 and P. Godfrey-Faussett 1
ogþgTÐXÐ^TÐÚíØíºëmSm<9TÐK gcTÐ9Me!ÐM<ÒØm^XDPÓmQ°AÐ qhHR ï}RØQGh=ºAnfhYíÚºënBoh_I{e7ºënBEeHénZhYó é{_YënTnYÐÙÎyÐUÐYhUí rdUÐÚÐ{bYÊnfUÐî{UngfLdxUÐÒ{x{!ÐUÐÓønAØÐ{LÌÛín>øphYnfUÐëÐ{dUÐ:oåÉ°#Ð /í ÊnfUÐN=UÐÓønAZT:n[bic_>ngfLhdUÐxUÐÓøn"ÐØÐ{LÌëÌê̺én@}UÐî{Uð fYÊnfUÐî{UaBÌUÐâSí ÐØ{LÓnxøí =ÚÌN=YÑnfUÐí{fUÐnªënxøíê{b>NAaR ð UÐLhdUÐ:Nf!ÐN=ÓnRĆBĆUØn_YEQn@ÙeiënTn=ð 2009 0.89 0.81 N÷ x}Bó ôúÐNxøUÐëlRº ênL: ÑnfUÐ:í {fUÐ:én@}UÐOÎÊnfUÐpién@}UÐî{UUÐÓønALÓnQĆUÐYFTÌ :1.37én@}UÐî{Un,ÊnfUÐî{UpBn]dUÐph=n«üÐUÐÓøn"nLna>ÚÐ}TÌênSÚÌLÚÐ}eHn=ën`ð d>ënhId=íÐiBn=FhBnªí¬ 1.40 î}BÌípb]fYN=Nf!ÐN=pfUÐ:EcUÐæĆBøÐÐ|wYx{Uëj=æ}_x}BË{d=YènfwhUí ënhId=:ô íÐiBn=FhB n,}TÌphþh=YÐLOÎEZx{S{AÐí{d=epad8JnfY:pBn]dUÐph=n«üÐÓn`hdUÐïíÙén@}UÐOÎÊò nfUÐpi:EcUÐæĆBøÐëÌDL UÐÓønALhdUÐén6:Nf!ÐN=p^AĆCÐÓnRĆBøÐDLE?jUÐ:pYnwYÐLwíºpdÉjYph@Uh=YÐLOÎEZx
ABSTRACT In developing countries, only one-third of new tuberculosis cases notified are from women. It is not clear whether tuberculosis incidence is lower in women than men, or whether notification figures reflect under-detection of tuberculosis in women. Pakistan, however, presents an unusual pattern of sex differences in tuberculosis notifications. While 2 of the 4 provinces (Sindh and Punjab) report more notifications from men (female to male ratios 0.81 and 0.89 respectively in 2009), the other 2 provinces (Khyber-Pakhtunkhwa and Balochistan) consistently report higher numbers of smear-positive tuberculosis notifications from women than men (1.37 and 1.40). No other country is known to have such a large variation in the sex ratios of notifications across regions. Large variations in female to male smear-positive notification ratios in different settings across a single country may indicate that environmental factors, rather than endogenous biological factors, are important in influencing the observed sex differences in tuberculosis notifications.
Différences inhabituelles liées au sexe dans les notifications de cas de tuberculose sur l'ensemble du territoire pakistanais et rôle des facteurs environnementaux
RÉSUMÉ Dans les pays en développement, seul un tiers des nouveaux cas de tuberculose notifiés concerne des femmes. On ne sait pas si l'incidence de la tuberculose est plus faible chez les femmes que chez les hommes ou si les chiffres des notifications reflètent un dépistage insuffisant de la tuberculose chez ces dernières. Toutefois, le Pakistan présente une répartition inhabituelle des notifications de cas de tuberculose entre les deux sexes. Si deux provinces sur quatre (le Sindh et le Pendjab) transmettent un plus grand nombre de notifications concernant des hommes (rapport femme-homme de 0,81 et 0,89 en 2009 dans chaque province respectivement), en revanche les deux autres provinces (le Khyber-Pakhtunkhwa et le Baloutchistan) transmettent de manière permanente des chiffres de notifications de cas de tuberculose à frottis positif plus élevés chez les femmes que chez les hommes (rapport femme-homme de 1,37 et 1,40 dans chaque province respectivement). Aucun autre pays n'est connu pour présenter une telle différence entre les sexes dans les notifications entre les régions. De grandes différences dans les chiffres de notifications de tuberculose à frottis positif entre les hommes et les femmes dans des environnements différents sur l'ensemble d'un territoire national peuvent être le signe que des facteurs environnementaux, plutôt que des facteurs biologiques endogènes, pèsent sur les différences observées entre les deux sexes pour les notifications de cas de tuberculose.
1London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom (Correspondence to M.S. Khan: [email protected]). 2Aga Khan University Hospital, Karachi, Pakistan. Received: 26/12/11; accepted: 19/06/12 821
Book 19-9.indb 821 10/7/2013 2:40:32 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Sex differences Prevalence surveys, by eliminating immunological and physiological in tuberculosis barriers to access to health centres, development that affect the risk of notifications are assumed to provide an answer to disease post-infection. This would lead whether more men or women in the to true differences in disease incidence The topic of sex differences in tuber- population have TB; but even these between men and women. Environ- culosis (TB) notifications generates may not provide a gender-neutral as- mental factors can also influence ac- considerable debate, be it among sessment of TB. For instance, preva- cess to diagnosis for men and women, academics, doctors or fieldworkers. lence surveys usually do an initial leading to a bias in the diagnosis or It is well documented that in most screen of the population looking for reporting of TB between the sexes. symptoms suggestive of TB (pro- regions of the world more adult men Much of the debate therefore has longed cough, sputum expectoration are diagnosed with and die from TB focussed on whether sex differences in and haemoptysis), all of which are UIBOXPNFO< >#FDBVTFPGUIJT notifications are “real” or “observed”. reported to be less common among the impact of TB on women is often This may not be the most important GFNBMF5#QBUJFOUTUIBONBMFT<> underestimated, and TB is perceived point though. It may be more useful They also use a similar protocol for to be a disease that affects men more from an intervention planning point diagnosing smear-positive TB as do than women. The World Health Or- of view to understand the extent to most diagnostic centres, i.e. smear- ganization (WHO) estimates that which environmental factors contrib- microscopy without gender-sensitive there were 9.4 million new cases of ute to observed sex differences in TB sputum submission instructions. The 5#HMPCBMMZJO#BTFEPOUIFPC- notifications. If environmental rather use of smear-microscopy has been than endogenous factors are largely served sex difference in notifications, shown to selectively under-diagnose it is estimated that women would responsible for the sex differences smear-positive TB in women unless (in incidence or diagnosis of TB), it BDDPVOU GPS PG BMM DBTFT <> good sputum submission instructions However, since reasons for lower TB would mean that interventions to ad- and a private space for expectoration dress these environmental factors will notification among women are poorly are provided [9]. If women with TB understood, it is not clear whether be useful and necessary to address the have atypical symptoms or find it dif- discrepancy between sexes. TB incidence is lower in women than ficult to expectorate good sputum men, or whether notification figures specimens, this will introduce a gender reflect under-detection of TB in bias in smear-positive case detection The case of Pakistan women. at diagnostic centres and in prevalence Broadly, there are 4 categories of surveys. The unusual pattern of TB notifica- explanations for the sex differences in It remains unclear not only which tions across Pakistan raises questions case notifications: of the 4 categories of explanation con- about the role of environmental fac- r variations in levels of exposure to tribute most to observed sex differenc- tors influencing sex differences in TB. TB [ ]; es in TB notifications but also whether Pakistan has a population of approxi- environmental or endogenous factors mately 175 million [11] with a female r immunological and physiologi- are more important determinants to male ratio (F:M) in the population cal factors leading to differences in of the sex difference. “Endogenous PGĉFDPVOUSZJTTVCEJWJEFE susceptibility to developing disease into 4 provinces as well as some post-exposure [5,6]; factors” are intrinsic biological differ- ences that occur in individuals owing federally administered areas. Khyber- r discrepancies in access to health to their sex, and are less likely to vary Pakhtunkhwa (formerly North-West care for diagnosis and treatment across different settings. Their influ- Frontier province) and Balochistan [7,8]; ence would result in true differences in provinces are in the western part of r differences in the probability of be- the incidence of TB. “Environmental the country bordering Afghanistan ing correctly diagnosed by existing factors” is a broad term encompassing and Islamic Republic of Iran, while health-systems [9]. the social, economic, geographical and Sindh and Punjab provinces are in ĉFėSTUFYQMBOBUJPOTTVHHFTU infrastructural characteristics of an in- the eastern part bordering India (Fig- a true difference in the incidence of dividual’s surroundings. It includes ure 1). The latest census indicated disease between men and women, living conditions and health-service that the population ratios of females XIFSFBTUIFTFDPOETVHHFTUUIBUUIF quality. Environmental factors can to males in Khyber-Pakhtunkhwa, observed sex difference is due to cases influence sex differences in exposure Balochistan, Sindh and Punjab were being selectively missed in women. to TB infection or sex differences in BOESFTQFDUJWFMZ
822
Book 19-9.indb 822 10/7/2013 2:40:32 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
[11]. Unlike sub-Saharan Africa, where a higher prevalence of human immu- nodeficiency virus (HIV) in women affects sex differences in TB incidence, the prevalence of HIV in Pakistan is low. Pakistan is therefore one of the few countries in which sex differences in TB can be studied with minimal influence PGUIF)*7FQJEFNJD<> Although the vast majority of de- veloping countries report fewer TB cases from women, Pakistan presents an unusual pattern of sex differences in TB notifications. Of the 4 prov- inces, Khyber-Pakhtunkhwa and Ba- ISLAMIC lochistan consistently report higher REPUBLIC smear-positive TB notifications from OF women than men, and Punjab and Sindh report higher smear-positive notifications from men (Table 1). This pattern of sex differences in notifica- tions is consistent across several years of data. Interestingly, the sex differ- ence between provinces is most pro- nounced for smear-positive cases. An Figure 1 Map showing the 4 provinces of Pakistan and its neighbouring countries analysis of new notifications of all form with their respective female to male ratios (F:M) of smear-positive tuberculosis PG5#JO 5BCMF TIPXFEUIBU notifications compared with smear-negative and extra-pulmonary TB, the difference in F:M notification ratios between prov- A particularly interesting observa- women would be consistent with fewer, inces is most pronounced for smear- tion is that Sindh and Punjab provinces not more, notifications from women positive TB. have similar F:M notification ratios to than men in these areas. Of course fac- Apart from the present analysis of India, which they share a border with. tors such as the use of private sector TB notifications, a South Asian As- Khyber-Pakhtunkhwa and Balochistan, health-care providers that do not report sociation for Regional Cooperation UIFQSPWJODFTXIJDIIBWFNPSF5# TB cases to the NTP and migration study of sex differences in 7 countries notifications from females than males, of men out of some regions in search also highlighted Pakistan as being the border Islamic Republic of Iran and of employment may also play a role; only one to have more cases diagnosed Afghanistan, which also report higher unfortunately information on this is in women than men. This was due to notifications from females than males. poorly documented. a higher number of female than male These are among very few develop- A recent review on sex inequalities TB suspects undergoing sputum ex- ing countries that diagnose more TB in TB proposes that biological sex-relat- amination in the national TB control cases in females. Khyber-Pakhtunkhwa ed factors such as sex steroid hormones, programme (NTP) centres included and Balochistan are the least socioeco- the genetic makeup of the sex chro- in the study in Pakistan (F:M ratio nomically developed provinces and are mosomes and sex-specific metabolic CVUOPUJOUIFPUIFSDPVOUSJFTĉF considered the most conservative as features may play an important role in proportion of male and female sus- far as women’s education, travel and making women more resistant to My- pects testing smear-positive in Pakistan empowerment are concerned. It is cobacterium tuberculosis than men [14]. XBTWFSZTJNJMBS BQQSPYJNBUFMZ therefore surprising to those working However, endogenous factors intrinsic leading to an overall higher number in TB control that these provinces, as to men and women would be expected of female smear-positive cases being well as Afghanistan, report more cases to act across the whole of Pakistan, if not detected in the centres sampled in Pa- from women than men. Lower mo- across men and women in all settings. It LJTUBO<> bility and access to health services of should therefore be considered that
823
Book 19-9.indb 823 10/7/2013 2:40:33 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Table 1 Sex ratios of smear-positive tuberculosis cases reported in the 4 provinces higher notifications from women than of Pakistan from 2006 to 2009 men, are also the poorer provinces. Year/province No. of cases F:M ratio Females Males 2006 Conclusions Sindh 8 153 10 646 0.77 Punjab 13 788 15 947 0.86 The unusual case of Pakistan highlights the fact that we still have a long way to Khyber-Pakhtunkhwa 5 844 4 278 1.37 go in understanding sex differences in Balochistan 1 978 1 367 1.45 TB notifications and reasons for them. 2007 The perception that women are less Sindh 9 585 12 006 0.80 likely to have TB than men should be Punjab 22 459 25 331 0.89 challenged as it could turn out to be a Khyber-Pakhtunkhwa 6 844 5 030 1.36 self-fulfilling prophecy. Looking at pre- Balochistan 2 094 1 564 1.34 vious years’ notification figures, those 2008 working in TB control tend to assume Sindh 9 848 12 099 0.81 that fewer women have TB than men. Punjab 27 558 30 370 0.91 Planners of TB control strategies and Khyber-Pakhtunkhwa 7 110 5 232 1.36 physicians screening TB suspects may Balochistan 2 040 1 519 1.34 then consciously or subconsciously 2009 put more emphasis on detecting TB Sindh 7 734 9 539 0.81 in men and less attention on interven- Punjab 27 963 31 249 0.89 tions to improve case detection among Khyber-Pakhtunkhwa 7 572 5 547 1.37 women. At the end of the year, more Balochistan 1 938 1 384 1.40 cases of TB may be detected in men
F:M = female to male. than women, reinforcing the original perception. It is therefore important to keep the debate alive on this topic, large variations in F:M smear-positive Mediterranean Region, and in other particularly in the light of data from high notification ratios in different settings settings with higher TB notifications TB-burden countries such as Pakistan across a single country may indicate that from women than men have not been and Afghanistan. Hypotheses about environmental factors are important in thoroughly studied as yet. Environmen- potentially important environmental influencing the observed sex differences tal factors that may be influencing the factors influencing the observed sex dif- in TB notifications. For example, the observed provincial differences in TB ferences in TB notifications need to be only study looking at sex differences sex ratios across Pakistan include differ- tested, and it is hoped that this paper will in diagnostic centres across Pakistan ences in poverty levels, climate, socio- initiate interest in studying this topic. found that health centre characteristics cultural practices, smoking and use of such as accessibility by foot had a sig- private health providers between the 4 nificant effect on the number of female provinces. For example, indicators of Acknowledgements suspects registered [15]. poverty such as household wealth, fertil- Determinants of sex differences ity and literacy indicate that Balochistan Funding: None. in TB notifications in the Eastern and Khyber-Pakhtunkhwa, which have Competing interest: None declared.
Table 2 Female to male (F:M) sex ratios of smear-positive (+ve), smear-negative (–ve) and extrapulmonary tuberculosis cases reported across the 4 provinces of Pakistan in 2007 Province F:M ratio All new cases Smear +ve cases Smear –ve cases Extrapulmonary cases Sindh 0.93 0.80 1.00 1.33 Punjab 0.98 0.89 1.01 1.19 Khyber-Pakhtunkhwa 1.32 1.36 1.33 1.24 Balochistan 1.34 1.34 1.38 1.24
824
Book 19-9.indb 824 10/7/2013 2:40:33 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
References
1. Howson CP et al. In her lifetime: female morbidity and mortal- 9. Khan MS et al. Improvement of tuberculosis case detection ity in sub-Saharan Africa. Washington DC, National Academy and reduction of discrepancies between men and women Press, 1996. by simple sputum-submission instructions: a pragmatic ran- 2. Gender and tuberculosis. Gender and Health Research Series. domised controlled trial. Lancet, 2007, 369:1955–1960. Geneva, World Health Organization, 2004. 10. Long NH, Diwan VK, Winkvist A. Difference in symptoms 3. Global tuberculosis control 2010. Geneva, World Health Or- suggesting pulmonary tuberculosis among men and women. ganization, 2010. Journal of Clinical Epidemiology, 2002, 55(2):115–120. 4. Holmes CB, Hausler H, Nunn P. A review of sex differences 11. Pakistan Census Organization. Islamabad, Government of in the epidemiology of tuberculosis. International Journal of Pakistan, 2011 (http://www.census.gov.pk/, accessed 9 July Tuberculosis and Lung Disease, 1998, 2(2):96–104. 2013). 5. Dolin P. Tuberculosis epidemiology from a gender perspec- 12. Global report. UNAIDS report on the global AIDS epidemic 2010. tive. In: Diwan V, Thorson A, Winkvist A, eds. Gender and Geneva, Joint United Nations Programme on HIV/AIDS, 2010. tuberculosis. Göteborg, Sweden, Nordic School of Public 13. Gender differences among TB patients in national TB control Health, 1998. programmes within SAARC countries. Kathmandu, Nepal, 6. Radhakrishna S, Frieden TR, Subramani R. Association of South Asian Association for Regional Cooperation TB Centre, initial tuberculin sensitivity, age and sex with the incidence of 2004. tuberculosis in south India: a 15-year follow-up. International 14. Neyrolles O, Quintana-Murci L. Sexual inequality in tuberculo- Journal of Tuberculosis and Lung Disease, 2003, 7(11):1083– sis. PLoS Med, 2009, 6(12):e1000199. 1091. 15. Khan MS et al. Factors influencing sex differences in numbers 7. Cassels A et al. Tuberculosis case-finding in Eastern Nepal. of tuberculosis suspects at diagnostic centres in Pakistan. Tubercle, 1982, 63(3):175–185. International Journal of Tuberculosis and Lung Disease, 2012, 8. Needham DM et al. Socio-economic, gender and health 16:172–177. services factors affecting diagnostic delay for tuberculosis patients in urban Zambia. Tropical Medicine and International Health, 2001, 6(4):256–259.
825
Book 19-9.indb 825 10/7/2013 2:40:33 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
Report Addressing maternal and child health in post-conflict Afghanistan: the way forward P.K. Singh,1 R.K. Rai 2 and M. Alagarajan 1
êmXúÐNÎw|\TÐëmhm_QÌ9âÐVTÐz^<mXoc@|X9ém`IúÐíÓmfXúÐoÉXIm^TÐ @ÐÚn`UÐÕfYºýÐÚó Ú5Th@ÐÚºfHÚ5TqinIÐ}=÷ YÐ}CÐãd=S}_>ÒETÓnx{Ļ{dUÐ@ÐxÙÎ 3n_UÐ:DLúÐÓø{_CÐN=Yënin`RÌ:énaJúÐíÓngYúÐÓnhRíÓø{_YF_>ö oåÉ°#Ð Ð|wß}_xí nw}RÐ>íngahUnc>xíºph[UÐpxnL}UÐÓnY{BpAn>l=d_>ÒØ{_YÑnHÌØ@íOÎUÙî~_xíÅ2015ên_UphaU±Uphý5iüÐ pxnLÚx{b>ë5@ÌeR phªúÐn4O>ëÌ`fxUÐÓønCÐSnfx5Tºënin`RÌ:pUa]UÐípYYúÐpxnLÚ@Ð>UÐÓnx{UÐ}x}bUÐ pxnLÚN=YncUÐíº{ÉGUÐí{É}Uд ^ô i*nxUíÌ:Ð_\xëÌnhUÐÚÐ}bUÐÑnÉÌDL`fxënin`RÌ:ô énaJ±UíÓngY±UphÉ ºÊnfdUpJíPYphUnYÓøÐAx{b>Y~RÐ"Ðx{b>íºpxPUÐØÚÐCÐÊnf=íºçb"ÐDLphfCÐÒúÐh^f>ç}JN=íénaJúÐíÓngYúÐ hH>íº<í{UÐëín_UÐh^f>íºphUÐphfUÐNĻDL~hTGUÐ`fxº HÐUÐçn]fUÐDLí Me_UÐØíØ}CÐÓÐÙph_eCÐÓĆB{UÐ~x~_>í xeUÐØÚÐYçn]i
ABSTRACT Afghanistan’s maternal and child mortality rates are among the highest in the world. The country faces challenges to meet the Millennium Development Goals set for 2015 which can be attributed to multiple causes related to accessibility, affordability and availability of health-care services. This report addresses the challenges in strengthening maternal and child health care in Afghanistan, as well discussing the areas to be prioritized. In order to ensure sound maternal and child health care in Afghanistan, policy-makers must prioritize monitoring and surveillance systems, integrating maternal and child health care with rights-based family planning methods, building human resources, offering incentives (such as the provision of a conditional cash transfer to women) and promoting action-oriented, community-based interventions. On a wider scale, the focus must be to improve the health infrastructure, organizing international collaboration and expanding sources of funding.
Prise en charge de la santé de la mère et de l'enfant en Afghanistan après les conflits : orientations futures
RÉSUMÉ Les taux de mortalité maternelle et infantile en Afghanistan comptent parmi les plus élevés au monde. Le pays est confronté à des défis pour réaliser les objectifs du Millénaire pour le développement fixés pour 2015. Les causes sont multiples, mais on peut citer l'accessibilité géographique et économique et la disponibilité des services de soins de santé. Le présent article traite des difficultés qui se posent en matière de renforcement des soins de santé maternelle et infantile en Afghanistan, et détaille les domaines à rendre prioritaires. Afin d'assurer des soins de santé de qualité aux femmes et aux enfants en Afghanistan, les décideurs politiques doivent accorder la priorité aux systèmes de surveillance et de suivi, en intégrant les soins de santé maternelle et infantile aux méthodes de planification familiale fondées sur les droits de l'homme, en renforçant les ressources humaines, en proposant des avantages (tels que des programmes de transfert conditionnel de fonds aux femmes) et en favorisant des interventions pratiques dans la communauté. À plus large échelle, l'accent doit être mis sur l'amélioration des infrastructures de santé, en organisant une collaboration internationale et en élargissant les sources de financement.
1International Institute for Population Sciences, Mumbai, India (Correspondence to P.K. Singh: [email protected]). 2Tata Institute of Social Sciences, Mumbai, India. Received: 06/03/12; accepted: 04/07/12
826
Book 19-9.indb 826 10/7/2013 2:40:33 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
Background in MCH care and suggest strategies that reported to be the major cause of ma- can ameliorate the situation. UFSOBMEFBUIJO"GHIBOJTUBOBTXFMM<> Afghanistan is the most dangerous place followed by eclampsia and prolonged or for a child to be born in Asia, according obstructed labour [11]. Although over UPB8PSME)FBMUI0SHBOJ[BUJPO three-fifths of women in Afghanistan (WHO) and United Nations Children’s Maternal and utilize some form of antenatal care ser- Fund (UNICEF) joint report [1]. The child health: the WJDFTGSPNTLJMMFEQSPWJEFST POMZ long-term conflict in Afghanistan has current scenario met the World Health Organization adversely affected the health status of (WHO) recommendation of at least 4 Afghanistan is committed to the un- the population in general, and maternal antenatal care visits. The latest estimates precedented global consensus Millen- and child health (MCH) in particular. TIPXUIBUKVTUPGXPNFOIBEUIFJS nium Development Goals (MDG) The situation is further confounded by birth attended by skilled birth attend- of reducing the child mortality rate by barriers to access to health-care services BOUTJOBIFBMUIGBDJMJUZ BOEOFBSMZ two-thirds (MDG 4) and improving <>.JMMJPOTPGQFPQMFEJFEEVSJOHUIF of women had not received any post- NBUFSOBMIFBMUI .%( CZ DJWJMXBSBOEUIFQPMJUJDBMVOSFTU natal checkups following delivery [11]. goals which present a great challenge to that followed still remains a serious Currently, just 1 in 5 women in the Afghan health care system. Shortly DPODFSO<>ĉF"GHIBOIFBMUIDBSF Afghanistan use any form of contra- after the establishment of the Transi- ceptive, and this rate was even lower system, which was destroyed during the tional Islamic Republic of Afghanistan 5BMJCBOSFHJNFJO IBTDPOUJOVFE JO BNPOHXPNFOJOUIFBHF an interim national health policy and to suffer [4]. It is therefore not surpris- group 15–19 years. The adolescent national health strategy were developed birth rate, expressed as the number of ing that Afghanistan has some of the EVSJOHm.PSFPWFS BDLOPXM- poorest MCH indicators worldwide. births among girls aged 15–19 years edging the immediate response to poor QFSHJSMTJT BNPOHUIFIJHIFTU In the special edition of the State of the health status of Afghani people, and HMPCBMMZ<>"HFBUNBSSJBHFSFMJBCMZ world’s children report 2009, UNICEF addressing the country’s worst health predicts childbearing practices and the expressed concern over Afghanistan’s statistics, the Ministry of Public Health status of women in a given society [14]. infant mortality rate, which is the high- launched the basic package of health *O"GHIBOJTUBO BQQSPYJNBUFMZ est in the world [5]. Furthermore, in the TFSWJDFT #1)4 JO<> PGXPNFOBHFEmZFBSTBSFNBS- global mothers’ index ranking, which Despite some improvement in SJFECZBHFPGZFBSTBOEPWFS includes 176 countries, Afghanistan was MCH indicators, the Maternal Mortali- of women have had their first birth by ranked 145 in the world in terms of ty Estimation Inter-Agency Group have age 19 years, raising concerns about NPUIFSTXFMMCFJOHJO<> highlighted that the maternal mortality maternal and child morbidity as well as "DDPSEJOH UP UIF )VNBO ratio (defined as the number of mater- mortality at an early age [11]. Inequality Development Report, Afghanistan nal deaths during a given time period in service utilization is also a major con- was the 11th least developed country QFSMJWFCJSUITEVSJOHUIFTBNF DFSO BTKVTUPGXPNFOJOSVSBMBSFBT (ranked 175 out of 186 countries) in UJNFQFSJPE JO"GHIBOJTUBOXBTQFS utilized institutional delivery compared the world [7]. Additionally, if a child is MJWFCJSUIT VODFSUBJOUZ with over three-fifths of women from fortunate enough to survive birth, the JOUFSWBMm ĉJTEFNPOTUSBUFT urban areas. Similarly, utilization of de- child could only expect to live for 44 insufficient progress towards achiev- livery care amongst the richest Afghan years in Afghanistan, while the global life JOHUIF.JMMFOOJVN%FDMBSBUJPO<> women is 6 times higher that of the expectancy at birth is approximately 67 The pregnancy-related mortality ratio poorest women [11]. ZFBSTGPSUIFQFSJPEm3FDFOU JTQMBDFEBUQFS VO- 'SPNUP "GHIBOJTUBOT estimates have confirmed that deaths DFSUBJOUZJOUFSWBMm XIJMFJO mortality rate for children under 5 years from noncommunicable diseases are SVSBMBSFBTJUJT VODFSUBJOUZ EFDSFBTFEGSPNUPEFBUITQFS highest in Afghanistan [8]. While the JOUFSWBMm PWFSUJNFTUIBUJO MJWFCJSUIT<>ĉJTSFQSFTFOUT new government, along with its interna- UIFVSCBOBSFBTBU VODFSUBJOUZ an average annual rate of reduction of tional partners, has begun to rebuild the JOUFSWBMm <> 'VSUIFS UIF TVHHFTUJOHPOMZNBSHJOBMQSPHSFTT public health system since the Taliban lifetime risk of maternal mortality in However, Afghanistan is one of the top SFHJNFFOEFEJO BHSFBUEFBMPG "GHIBOJTUBOJTJO<> DPVOUSJFTXJUIUIFNPTUVOEFS work remains to be done in MCH care. Haemorrhage, which is by far the deaths. Despite the overall reduction in This report aims to describe the current leading cause of maternal death in the VOEFSNPSUBMJUZSBUFTGSPNUP scenario, explain the present challenges majority of developing countries, was UIFBCTPMVUFOVNCFSPGVOEFS
827
Book 19-9.indb 827 10/7/2013 2:40:33 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
EFBUITIBTJODSFBTFEGSPNJO 'PSJOTUBODF BěFS UIF"GHIBO to prevent unintended pregnancies, UPJO<>"CPVUIBMG Ministry of Public Health has launched reduce maternal and child mortality of under-5 deaths in Afghanistan are due several programmes and interventions and improve the overall MCH status to acute respiratory infections, followed including the BPHS; however the ac- <>*OUFHSBUJOH'1BOE.$)TFSWJDFT CZTFWFSFJOGFDUJPOT QSFOBUBM tual extent of these services coverage typically means offering women a broad SFMBUFEEJTPSEFST JOKVSZ remains unclear [18]. Previous studies set of FP and MCH services during the BOEEJBSSIPFB <>*O CBSFMZ have confirmed that there is a lack of same appointment, at the same service PGUIFDIJMESFOXFSFGVMMZJNNV- standardized national system for en- delivery site, from the same service nized before their second birthday [15]. suring quality during the delivery of QSPWJEFS<>*OBEEJUJPO FĎFDUJWFDPO- $ISPOJDNBMOVUSJUJPO JTBMTPWFSZ the BPHS in Afghanistan and it varies sultations about specific MCH needs IJHIGPSDIJMESFOVOEFSZFBSTPME<> across regions and providers. Thus, a should be provided to women during proper monitoring system may ensure their first antenatal care visit, in order to standard practices and encourage pro- ensure subsequent service utilization. Challenges and viders to pursue standardized norms What are proper MCH care practices recommendations for service delivery. It also helps to un- and how to implement them should be derstand the magnitude and nature of explained in detail. For countries with 4JODF .$)TUBUVTJO"GHIBOJ- huddles that restricts the coverage of established traditions of administering stan has been improving slowly due to MCH care services. FP and MCH programmes separately, humanitarian efforts by several inter- JOUFHSBUJPOPGUIFQSJPSJUZBSFBTNBZ national agencies, but much remains Importance of databases for CFNFUXJUISFTJTUBODF<>)PXFWFS planning and evaluation to be done. Given that Afghanistan since Afghanistan is in the initial stage has the poorest MCH indicators in To reach the maximum population in of establishing its health-care system, it the world, coupled with a post-conflict need of essential MCH care services, has the unique advantage of being able environment and widespread poverty, a particularly those who are uneducated, to introduce a system that integrates FP comprehensive action-based approach poor and residing in remote places, the and MCH effectively. is needed in order to achieve the MCH importance of timely and adequate da- targets of the MDG. Policy-makers tabase management for better planning Recognizing MCH needs as a must work towards an accessible, effec- and evaluation should not be ignored. human right and as a means to achieve the MDGs tive and sustainable MCH care system It is essential, since the distribution of in Afghanistan, despite the numerous health services in any country is based Accessing health care represents a challenges that are present. on demand and supply side factors. unique challenge for Afghan women. Thus, an independent MCH analysis The social system in Afghanistan is Need to strengthen MCH unit established under the Ministry of strongly patriarchal and men largely information and monitoring/ Public Health in Afghanistan could control women’s mobility [4]. Access surveillance system FYBNJOFEJĎFSFOUTPVSDFTPGEBUBJOGPS- to education and health care remains Minimizing the MCH knowledge gap mation and how to integrate them with poor, while forced marriage and domes- is an essential component for effective a wider health system. tic violence are experienced by a large programme and policy implementa- percentage of Afghan women [14]. This tion, particularly in post-conflict na- Integrating family planning oppressive environment has a profound tions such as Afghanistan [16]. Low and MCH care impact on women’s self-confidence, levels of knowledge about MCH care, The high total fertility rate of 5 births self-esteem and ability to take control DIBSBDUFSJ[FECZJODPNQMFUFBOEPS per woman, leading to rapid population of their lives and engage in public affairs. contradictory data, could divert the increases, coupled with a low rate of Nearly 1 in 5 women reported that they entire resource allocation pattern, as contraceptive use, could adversely affect did not get permission to utilize ANC witnessed in the Congo [17]. In the the efforts to improve health, educa- and safe delivery care [11]. The process case of Congo, the World Bank empha- tion and employment. An important of creating a safe environment that will sized the need to examine health-care way to confront population growth encourage women to seek health care, delivery systems developed during the and spur economic development is education and other economic oppor- conflict [17]. In addition, establishment through the provision of integrating tunities must be initiated at the fam- of proper monitoring and surveillance rights-based family planning (FP) ily and societal level. Promoting higher systems is crucial to assess the cover- and MCH care [19]. This approach education for women is perhaps the best age of ongoing programmatic efforts. is recognized as a cost-effective way possible way to promote rights-based
828
Book 19-9.indb 828 10/7/2013 2:40:33 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
interventions for health care utilization. Ministry of Public Health and Ministry TZTUFN BTPOMZPG"GHIBOTIBWFBD- Education of girls should be the new gov- of Higher Education, recognizing both cess to reliable electricity sources and ernment’s primary goal. There should workforce requirements and educa- KVTUPGSVSBMIPVTFIPMETIBWFBD- also be provision for re-enrolment for tional standards, is perhaps the best ap- DFTTUPTBGFESJOLJOHXBUFS<>ĉF women and girls who have dropped proach for meeting the need for skilled extreme climate and terrain combined out of school. In addition, promotion of IVNBOSFTPVSDFTGPSPCTUFUSJDDBSF<> with the lack of roads in many parts of distance learning could be an effective Afghanistan makes it difficult to access way to reach remote areas as it does not Addressing poverty and health health facilities. Effective and efficient gaps in MCH require students to be physically present, health-care systems require investment allowing for a flexible educational envi- Socioeconomic and regional inequality in transportation, electricity, safe wa- ronment alongside regular housework. in health services utilization is a major ter and hygiene and communication, Educational curricula should promote global concern and Afghanistan is no particularly in rural areas and remote re- health awareness, including knowledge exception. The Afghanistan mortality gions. Ensuring quality of care in MCH of common diseases and how to prevent TVSWFZ DPOEVDUFEJO SFWFBMFEIVHF must be prioritized. The Afghanistan them. Educational courses in conflict socioeconomic and regional inequalities mortality survey found that a substan- resolution could perhaps contribute to in MCH [11]. The rates of safe delivery in UJBMQSPQPSUJPO PGXPNFOIBE a calm and safe home environment, as urban areas were more than twice that in not utilized maternity services due to well as improved negotiation skills for SVSBMBSFBT BOESFTQFDUJWFMZ quality-related issues that included poor women and girls. Similarly, safe delivery care was about service quality, inconvenient service 6 times higher among women belong- hours, long waiting periods and lack of Improving human resources JOHUPUIFIJHIFTUXFBMUIRVJOUJMF female providers [11]. A recent study in for health DPNQBSFEXJUIUIFMPXFTU ĉF Afghanistan observed that the quality of Shortage of health-care workers poses under-5 mortality rate was higher among care in provincial hospitals fell below the a major challenge for Afghanistan’s UIFNPTUSFNPUFRVJOUJMF QFS Integrated Management of Childhood IFBMUIDBSFTZTUFNĉFSFBSFPOMZ births) compared to the least remote *MMOFTTTUBOEBSET<> BOEQSFTFOUFE QIZTJDJBOTBOEOVSTFTTFSWJOHB RVJOUJMF QFSCJSUIT 3FDFOU a compelling reason to include such QPQVMBUJPOPGNJMMJPOQFPQMF<> estimates confirm that more than half of training standards developed by WHO Female providers currently constitute Afghan women reported lack of money BOE6/*$&'<>*NQSPWJOHDPNNV- POMZPGUIFXPSLGPSDF XJUIDPOTJE- as a reason for not delivering in a health nication between health professionals FSBCMFWBSJBUJPOTBDSPTTQSPWJODFT<> GBDJMJUZBOEUIJTėHVSFJTBTIJHIBT and pregnant women could also raise Another obstacle is the lack of qualified among women from the poorest wealth women’s confidence with respect to the IFBMUIDBSFXPSLFST"CPVUPGUIF quintile [11]. Similarly, children born to utilization of health facilities. nurses, midwives and laboratory techni- mothers in the highest wealth quintile cians do not meet minimum knowledge have half the risk of mortality compared Encouraging family and and skills standards. Further, for various with those born to mothers in the poor- community support/ reasons, health-care workers prefer to FTUXFBMUIRVJOUJMF BOEQFS participation in MCH XPSLJOVSCBOBSFBT<>ĉFSFJTB live births respectively). The issue of pov- Family and community support for need for a comprehensive policy on hu- erty as a barrier to obtaining MCH could women during pregnancy and child- man resources for health, which ensures perhaps be addressed by introducing a birth must be a key component of planning the national health workforce, financial mechanism, such as a voucher safe motherhood programmes. In this estimating the size and composition or conditional cash transfer. This voucher regard, midwives and local nongovern- of the future workforce, defining the system, which has been adopted by sev- mental organizations (NGOs) could roles of health workers, developing eral countries, could be used to provide play a vital role in disseminating health standardized training programmes and services and transportation to facilities promotion at the family and com- minimum staffing standards for health free of charge or at a highly subsidised munity levels. Additionally, the effect facilities at different levels. In addition, rate, which may increase the utilization of of traditional cultural health practices developing undergraduate public IFBMUITFSWJDFT<> among several tribes (such as the Turk- health degree programmes and evaluat- men, Uzbek, Baloch, Pashai who are ing the performance of health workers Providing basic infrastructure geographically isolated) and of religious on a periodic basis will ensure a trained and ensuring quality of care beliefs should not be overlooked by pool of public health professionals. A The lack of basic infrastructure in the ongoing health programme efforts. collaborative approach between the country adversely affects the health care Evidence from South Asian countries,
829
Book 19-9.indb 829 10/7/2013 2:40:33 PM EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
JODMVEJOH*OEJB<> 1BLJTUBO<>BOE performance of the health-system even maternity services and this figure was #BOHMBEFTI<>TVHHFTUTUIBUSFMJHJPOJT in poor resource settings. Experiences BTIJHIBTJOUIFFBTUFSOBOETPVUI an important predictor of demographic from these countries can help Afghan eastern regions of Afghanistan [11]. and health outcomes. Further, certain political establishment to optimize *O BCPVUPG"GHIBOJTUBOT norms and characteristics of some the efforts in support with experiences districts were inaccessible to United ethnic groups may encourage negative from international agencies working in Nations missions for extended peri- attitudes toward modern medicines Afghanistan to ensure a higher reach of ods of time due to security constraints and health service utilization. Studies essential MCH services. BOENPWFNFOUSFTUSJDUJPOT<>ĉF have shown that collaboration between security conditions have worsened in religious leaders and health officials are Other issues certain parts of Afghanistan, including vital for changes in health and risky be- Although Afghanistan has been sup- the southern region, where the latest IBWJPVS<>*OPSEFSUPFOIBODFGBN- ported by several international donors, mortality survey was not conducted ily and community level efforts, cultural it is uncertain whether the support owning to security reasons. and religious misconceptions regarding will be continued, given the persistent health care must be addressed. Target- economic hardship in donor countries ing senior males (including husbands) <>*OUIFDBTFPGQPTUDPOĚJDUOBUJPOT Conclusion and females of households, along with such as Afghanistan, continued fund- other influential community stakehold- ing for health system development is Afghanistan has a long way to go in ers (including religious leaders) are essential. Along with financial support, achieving acceptable standards of essential aspects of communication UIFSFJTOFFEGPSOBUJPOBMJOUFSOBUJPOBM MCH care. However, there are several activities for behaviour change. In ad- interagency coordination. An effective opportunities that must be considered dition, women advocacy groups and and efficient coordination mechanism in deciding how to pace development self-help groups at the village level could between different agencies requires the efforts. There is a need to capitalize on serve as effective communication tools generation of more robust information the opportunity for the Afghan govern- in spreading awareness about the impor- in order to create a sustainable, nation- ment’s work with international partners tance of timely and proper MCH care. wide health care system. In Afghanistan, such as the United States Agency for OFBSMZPGNFEJDBMQSPHSBNNFTIBWF International Development, WHO, Political commitment and been implemented by aid organizations the World Bank, UNICEF and the willingness in MCH <> BOENFEJDBMTFSWJDFTIBWFCFFO European Union. These organizations The importance of strong political provided mostly by NGOs contracted provide valuable knowledge and ex- commitment to encourage good health through the Ministry of Public Health perience that can be effectively used was highlighted first by Rosenfield in [8]. In Afghanistan, contracting with towards building a sustainable health <>BOEQVUQPMJUJDTėSNMZPO NGOs has proved to be a way for the care system in Afghanistan. In addition, the map as an important explanatory government to gain and maintain policy learning from the successes and failures factor of good health in low-income MFBEFSTIJQ<>)PXFWFS UIFSFBSFOP of other post-conflict countries such countries. The significance of political guidelines or mechanisms to encour- as the Congo, Haiti and Sudan could commitment in health was also high- age international NGOs to build the facilitate improved MCH care. lighted by the WHO Commission on capacity of local NGOs [18]. By setting Health policies must focus on strate- Social Determinants of Health, which priorities, establishing the division of gies that reach the poor and those in stated that poor health was not a natural responsibility, providing financing and underserved regions. This calls for suf- state of affairs but the result of “a toxic monitoring, NGOs could be given a ficient willing and well-trained health- combination of poor social policies and fair degree of autonomy while still being care workers. With the help of local programmes, unfair economic arrange- held accountable for achieving national NGOs, midwives and other stakehold- NFOUT BOECBEQPMJUJDTu<>"MUIPVHI goals. This could be one of the key issues ers, families and communities can be the evidence supporting political com- in reorienting the health delivery system mobilized to improve MCH care by mitment as a key to good health has JOUIFDPVOUSZ<>&OTVSJOHBTBGFBOE creating awareness through effective not been compelling, experiences from secure environment for health-care pro- communication strategies, and provid- some South and East Asian countries viders and those trying to seek health ing information about the benefits of such as Bangladesh, Sri Lanka, Thailand care, particularly women, is one of the proper and timely utilization of MCH and other countries such as Ethiopia greatest challenges for the new govern- services. An essential component of any have shown that strong political com- NFOU"QQSPYJNBUFMZPGXPNFOSF- long-term safe motherhood programme mitment profoundly strengthens the ported security reasons for not utilizing is to educate and empower women at the
830
Book 19-9.indb 830 10/7/2013 2:40:33 PM PL HnUÐ{dCÐ HCÐçPUph[UÐpdCÐ HnUÐØ{_UÐ
community level. This will increase their services. The long-term goal of improv- specific action-based approach, foreign economic opportunities and overall ing MCH care in Afghanistan can be aid and domestic accountability. willingness to seek maternal health-care met only through a combination of a Competing interests: None declared.
References
1. Accountability for maternal, newborn and child survival: the 2013 20. Headey D, Hodge A. The effect of population growth on eco- update. Geneva, World Health Organization/United Nations nomic growth: a meta-regression analysis of the macroeco- Children’s Fund, 2013. nomic literature. Population and Development Review, 2009, 2. Reilley B, Puertas G, Coutin AS. The battle for access—health 35:221–228. care in Afghanistan. New England Journal of Medicine, 2004, 21. Waddington C, Egger D. Integrated health services—what and 350:1927–1929. why? Geneva: World Health Organization, 2008. 3. Bohannon J. The war in Afghanistan. Counting the dead in 22. Global Health Observatory: Country profile, Afghanistan. World Afghanistan. Science, 2011, 331:1256–1260. Health Organization (http://www.who.int/gho/countries/ 4. Hirose A et al. Difficulties leaving home: a cross-sectional afg/country_profiles/en/index.html, accessed 8 June 2013). study of delays in seeking emergency obstetric care in Herat, 23. Country cooperation strategy for WHO and Afghanistan, 2006– Afghanistan. Social Science and Medicine, 2011, 73:1003–1013. 2013. Cairo, World Health Organization Regional Office for the 5. The state of the world’s children 2009: maternal and newborn Eastern Mediterranean, 2010 (EM/ARD/043/E). health. New York, United Nations Children’s Fund, 2009. 24. Mansoor GF, Hill PS, Barss P. Midwifery training in post-conflict 6. Surviving the first day: state of the world’s mothers 2013. West- Afghanistan: tensions between educational standards and port, Connecticut, Save the Children, 2013. rural community needs. Health Policy and Planning, 2012, 27:60–68. 7. Human development report 2013. The rise of south: human pro- gress in a diverse world. New York, United Nations Develop- 25. Fiszbein A, Schady N. Conditional cash transfers: a World Bank ment Programme, 2013. policy research report. Washington DC, World Bank, 2009. 8. Zarocostas J. Deaths from non-communicable diseases are 26. Lind A et al. Quality of outpatient hospital care for children highest in Afghanistan, lowest in Sweden. British Medical Jour- under 5 years in Afghanistan. International Journal for Quality in nal, 2011, 343:d5876. Health Care, 2011, 23:108–116. 9. A basic package of health services for Afghanistan 2005/1384. 27. Armstrong Schellenberg JR et al. Effectiveness and cost of Kabul, Afghanistan, Ministry of Public Health, 2005. facility-based integrated management of childhood illness (IMCI) in Tanzania. Lancet, 2004, 364:1583–1594. 10. Trends in maternal mortality: 1990 to 2010. Geneva, World Health Organization/ United Nations Children’s Fund/United 28. Singh PK et al. Determinants of maternity care services utiliza- Nations Population Fund/The World Bank, 2012. tion among married adolescents in rural India. PLoS ONE, 2012, 7:e31666. 11. Afghanistan mortality survey 2010. Calverton, Maryland, Macro for Public Health Institute, Afghan Ministry of Public Health/ 29. Nasir JA, Hinde A. Factors associated with contraceptive ap- Central Statistics Organization (Afghanistan)/Indian Institute proval among religious leaders in Pakistan. Journal of Biosocial of Health Management Research/World Health Organization Science, 2011, 43:587–596. Regional Office for the Eastern Mediterranean, 2011. 30. Miah MMR. The cultural–structural contexts of high fertility 12. Bartlett LA et al.; Afghan Maternal Mortality Study Team. Where in Bangladesh: A sociological analysis. International Review of giving birth is a forecast of death: maternal mortality in four dis- Modern Sociology, 1992, 22:99–110. tricts of Afghanistan, 1999–2002. Lancet, 2005, 365:864–870. 31. Islamic Medical Association of Uganda. AIDS education 13. World health statistics 2011. Geneva, World Health Organiza- through Imams. A spiritually motivated effort in Uganda. UN- tion, 2011. AIDS case study. Geneva, Joint United Nations Programme on 14. Raj A, Gomez CS, Silverman JG. Multisectorial Afghan per- HIV/AIDS, 1998. spectives on girl child marriage: foundations for change 32. Rosenfield P. Social and political factors. In: Halsted SB, Walsh do exist in Afghanistan. Violence Against Women, 2011, doi: JA, Warren KS, eds. Good health at low cost: proceedings of a 10.1177/1077801211403288. conference held at the Bellagio Conference Centre. New York, 15. Johns Hopkins University Bloomberg School of Public Health, Rockefeller Foundation, 1985:173–180. Indian Institute of Health Management Research. Afghanistan 33. Commission on Social Determinants of Health. Closing the gap health survey 2006: estimates of priority health indicators. Kabul, in a generation: health equity through action on the social deter- Afghanistan, Ministry of Public Health, 2008. minants of health. Geneva, World Health Organization, 2008. 16. Smith JM, Burnham G. Conceiving and dying in Afghanistan. 34. Leach-Kemon K et al. The global financial crisis has led to a Lancet, 2005, 365:827–828. slowdown in growth of funding to improve health in many 17. The Inspection Panel Report and Recommendation on Request for developing countries. Health Affairs, 2012, 31:228–235. Inspection—Democratic Republic of Congo: transitional support 35. Yusufzai A. Poor medical facilities in Afghanistan mean pa- for economic recovery credit operation and emergency economic tients turn to hospitals in Pakistan. British Medical Journal, and social reunification support project. Washington DC, World 2008, 337:a2291. Bank, 2006. 36. Loevinsohn B, Sayed GD. Lessons from the health sector in 18. Sabri B et al. Towards sustainable delivery of health services in Afghanistan: how progress can be made in challenging cir- Afghanistan: options for the future. Bulletin of the World Health cumstances. Journal of the American Medical Association, 2008, Organization, 2007, 85:712–718. 300:724–726. 19. Cecatti JG et al. The associations between inter-pregnancy in- 37. Funding appeals and humanitarian action updates. United terval and maternal and neonatal outcomes in Brazil. Maternal Nations Children’s Fund [online] (http://www.unicef.org/ and Child Health Journal, 2008, 12:275–281. infobycountry/afghanistan_31224.html, accessed 8 June 2013).
831
Book 19-9.indb 831 10/7/2013 2:40:33 PM Members of the WHO Regional Committee for the Eastern Mediterranean
Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . South Sudan Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen
GBÐçOTogBm^TÐoZTÐod]eBogdgcRüÐoecTÐÊm[KÌëÐzcTÐ
phYĆHüÐëÐ}xÎpxÚg+ nhhU i> x}UÐ ënTn= Ò{CÐph=}_UÐÓÐÚnYüÐ ënin`RÌ ëØÚúÐ WY ënfU qxcUÐ }]S N]dR ë5Lô çÐ}_UÐ énY[UÐ ëÐØUÐ .h@ ëÐØUÐÑf@ ehUÐ pxÚUÐph=}_UÐpxÚge!Ð pxØ_UÐph=}_UÐpcdeCÐ Ñ}`CÐ
Membres du Comité régional de l’OMS pour la Méditerranée orientale
Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Soudan du Sud . Tunisie . Yémen
Correspondence
Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: [email protected]
Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: [email protected]; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494
Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: [email protected] Contents
Editorial
Universal health coverage in the context of emergencies ...... 757
Research articles Physical activity and perceived barriers among high-school students in Muscat, Oman ...... 759 Epidemiology of autistic disorder in Bahrain: prevalence and obstetric and familial characteristics ...... 769
Comparison of maternal characteristics in low birth weight and normal birth weight infants ...... 775 Users of withdrawal method in the Islamic Republic of Iran: are they intending to use oral contraceptives? Applying the theory of planned behaviour ...... 782
Key role players in health care quality: who are they and what do they think? An experience from Saudi Arabia ...... 788 Health-care professionals’ perceptions and expectations of pharmacists’ role in the emergency department, United Arab Emirates ...... 794
Compliance with the guidelines of prescription writing in a central hospital in the West Bank ...... 802
What do we need to eradicate rubella in the Islamic Republic of Iran? ...... 807
Seroprevalence of rubella among pregnant women in Khartoum state, Sudan ...... 812
National guidelines for outbreak investigation: an evaluation study ...... 816
Reports Unusual sex differences in tuberculosis notifications across Pakistan and the role of environmental factors ...... 821
Addressing maternal and child health in post-conflict Afghanistan: the way forward ...... 826