Cover 24-11.pdf 1 22/01/2019 10:43:44
EMHJ – Vol. 24 No. 11 – 2018 Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale Editorial WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement
Arash Rashidian, Ahmed Mandil, Samar ElFeky and Ahmed Al-Mandhari ...... 1035 Letter to the editor The neglected role of stewardship in strategic purchasing of health services: who should buy? Djavad Ghoddoosi Nejad, Ali Janati and Morteza Arab-Zozani ...... 1038
Research articles Characteristics of women applying for a legal abortion in the Islamic Republic of Iran Seyedeh Fatemeh Vasegh Rahimparvar, Asieh Jafari, Fatemeh Hoseinzadeh, Faezeh Daemi and Fatemeh Samadi ...... 1040 Identifying hotspots of viral haemorrhagic fevers in the Eastern Mediterranean Region: perspectives for the Emerging and Dangerous Pathogens Laboratory Network Mathias Altmann, Karen Nahapetyan and Humayun Asghar ...... 1049
Prevalence and determinants of Caesarean delivery in Punjab, Pakistan Eastern Mediterranean Health Journal Faisal Abbas, Rafi Amir ud Din and Maqsood Sadiq ...... 1058
C Dépistage de l’hypothyroïdie congénitale au Maroc : étude pilote
M Saâd Maniar, Chadia Amor et Abbas Bijjou ...... 1066 Antibiotic Y Study protocol for promoting physical activity among women based on the MAPP process CM Leila Amiri Farahani, Soroor Parvizy, Mohsen Asadi-Lari, Eesa Mohammadi, Batool Hasanpoor Azghadi and Ziba Taghizadeh 1074 MY Repellency effect of flumethrin pour-on formulation against vectors of Crimean–Congo haemorrhagic fever overprescribing contributes to
CY Eslam Moradi Asl, Hassan Vatandoost, Zakie Telmadarreiy, Mehdi Mohebali and Mohammad Reza Abai ...... 1082 Vol.
CMY Quality of life in Iranian elderly population using the SF36- questionnaire: systematic review 24 No. ANTIBIOTIC RESISTANCE K
and meta-analysis 11
– Amin Doosti-Irani, Saharnaz Nedjat, Sima Nedjat, Parvin Cheraghi and Zahra Cheraghi ...... 1088 2018 Knowledge, attitudes, behaviours and practices towards diabetes mellitus in Kuwait
Manuel Carballo, Anwar Mohammad, Elizabeth C. Maclean, Noureen Khatoon, Mohammad Waheedi and Smitha Abraham ...... 1098 A retrospective study of small molecule disorder types of metabolism in paediatric patients in intensive care Ahmed El-Nawawy, Mohamed Dawood and Omneya Omar ...... 1103 WHO events addressing public health priorities Consultation on the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region ...... 1112
The World Health Organization Regional Office for the Eastern Mediterranean is running its campaign for World Antibiotic Awareness Week under the theme “Change Can’t Wait. Our Time with Antibiotics is Running Out”. Taking place 12–18 November 2018, the campaign aims to target the general public, health professionals, governments, and the food, animal and agricultural sectors to raise awareness of the problem of antibiotic resistance.
١١ Volume 24 / No. 11 2018 November/Novembre / Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.
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
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Cover 24-09 special issue.indd 4-6 1/13/2019 1:56:33 PM Vol. 24.11 – 2018
Editorial WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement Arash Rashidian, Ahmed Mandil, Samar ElFeky and Ahmed Al-Mandhari...... 1035 Letter to the editor The neglected role of stewardship in strategic purchasing of health services: who should buy? Djavad Ghoddoosi Nejad, Ali Janati and Morteza Arab-Zozani...... 1038 Research articles Characteristics of women applying for a legal abortion in the Islamic Republic of Iran Seyedeh Fatemeh Vasegh Rahimparvar, Asieh Jafari, Fatemeh Hoseinzadeh, Faezeh Daemi and Fatemeh Samadi...... 1040 Identifying hotspots of viral haemorrhagic fevers in the Eastern Mediterranean Region: perspectives for the Emerging and Dangerous Pathogens Laboratory Network Mathias Altmann, Karen Nahapetyan and Humayun Asghar...... 1049 Prevalence and determinants of Caesarean delivery in Punjab, Pakistan Faisal Abbas, Rafi Amir ud Din and Maqsood Sadiq...... 1058 Dépistage de l’hypothyroïdie congénitale au Maroc : étude pilote Saâd Maniar, Chadia Amor et Abbas Bijjou...... 1066 Study protocol for promoting physical activity among women based on the MAPP process Leila Amiri Farahani, Soroor Parvizy, Mohsen Asadi-Lari, Eesa Mohammadi, Batool Hasanpoor Azghadi and Ziba Taghizadeh.1074 Repellency effect of flumethrin pour-on formulation against vectors of Crimean–Congo haemorrhagic fever Eslam Moradi Asl, Hassan Vatandoost, Zakie Telmadarreiy, Mehdi Mohebali and Mohammad Reza Abai...... 1082 Quality of life in Iranian elderly population using the SF-36 questionnaire: systematic review and meta-analysis Amin Doosti-Irani, Saharnaz Nedjat, Sima Nedjat, Parvin Cheraghi and Zahra Cheraghi...... 1088 Knowledge, attitudes, behaviours and practices towards diabetes mellitus in Kuwait Manuel Carballo, Anwar Mohammad, Elizabeth C. Maclean, Noureen Khatoon, Mohammad Waheedi and Smitha Abraham...... 1098 A retrospective study of small molecule disorder types of metabolism in paediatric patients in intensive care Ahmed El-Nawawy, Mohamed Dawood and Omneya Omar...... 1103 WHO events addressing public health priorities Consultation on the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region...... 1112
Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale
Book 24-11.indb 1033 23/01/2019 10:04:04 Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor Phillip Dingwall Managing Editor
Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk
International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf
Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics)
Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors)
Administration Iman Fawzy, Marwa Madi
Web publishing Nahed El Shazly, Ihab Fouad, Hazem Sakr
Library and printing support Hatem Nour El Din, Metry Al Ashkar, John Badawi, Ahmed Magdy, Amin El Sayed
Cover and internal layout designed by Diana Tawadros and Suhaib Al Asbahi Printed by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
Book 24-11.indb 1034 23/01/2019 10:04:04 Editorial EMHJ – Vol. 24 No. 11 – 2018
WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement
Arash Rashidian 1, Ahmed Mandil 2, Samar ElFeky 3 and Ahmed Al-Mandhari 4
1Director, Information, Evidence and Research, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.2 Coordinator, Research, Development and Innovation, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3Technical Officer, Research Promotion and Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. Citation: Rashidian A; Mandil A; ElFeky S; Al-Mandhari A. WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement. East Mediterr Health J. 2018;24(11):1035–1037. https://doi.org/10.26719/2018.24.11.1035 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
The World Health Organization (WHO) is the key United assessing health trends” (e.g. conducting surveys, Nations specialized agency dedicated to promoting burden of disease studies) population health and health outcomes. In order for the Nevertheless, WHO collaborating centres face Organization to achieve its strategic objectives, WHO important challenges in their functions from both the designates selected institutions as collaborating centres Organization and regional governments. Dr Ahmed to assit with carrying out WHO core activities. The Al-Mandhari, WHO Regional Director for the Eastern Eastern Mediterranean Region (EMR) currently hosts Mediterranean, has committed to expanding the number 45 collaborating centres (as of December 2018), which and scale-up functions of the collaborating centres is only 5% of the 832 WHO collaborating centres located in the Region, and address the following challenges worldwide (1), and yet EMR countries host about 10% of the appropriately (5), namely technical capacity and planning global population. The reason for this discrepency could challenges; financial and resource challenges; and be a reflection of the limited public resources allocated administrative and communication challenges. to health research in the Region (2). However, it may also highlight the fact that resources and opportunities for Technical and planning challenges stem from the establishing effective collaborating centres in the EMR capacity ability of collaborating centres in response to still remain untapped. WHO needs and population health priorities in the Region, as well as globally. These challenges often start before the There are country variations within the Region; for designation of “collaborating centre” by WHO, since the example, the Islamic Republic of Iran alone hosts 35% majority of such institutions are already established in (16) of collaborating centres, followed by Jordan, Morocco response to existing national demands. Therefore, such and Pakistan (each hosting four centres) (3). This clearly centres that have already excelled at the national level in highlights that other EMR countries may have potential response to country needs may not necessarily be equally institutions and organizations that could provide further prepared to expand their technical support for the wider support for WHO’s programme of work through the needs of WHO. Hence, the focus is usually on what the establishment of new collaborating centres, as well as centre can already offer the Organization, rather than expanding the work of existing centres. Moreover, WHO adapting to the priority needs of WHO. Moreover, lack collaborating centres are ideally positioned to contribute of attention to the proper planning of collaborative work to the development of institutional capacity in Member following designation by WHO may result in missed States and regions, and are a reflection of an international opportunities for effective collaborative actions. collaborative network for promoting population health equitably and effectively. Thus, collaborating centres can Financial and human resource challenges are effectively support WHO in at least four of its six core also among the key barriers. By definition, WHO functions at regional or global levels (4), namely: collaborating centres use their capacity and resources to 1. Generation, translation and dissemination of valuable support WHO’s programme of work. While they benefit knowledge (e.g. research conduct and dissemination from close work with the Organization, the centres also of its outcomes); require key infrastructure for productive action. As many health research institutions in the Region lack long-term 2. Production of research evidence and supporting the funding streams from public resources, they may not processes required in “setting norms and standards” be well-placed to respond to WHO’s needs. Also, when (e.g. supporting guideline development and funded by national public resources, such centres may adaptation); find it politically difficult to justify those actions that 3. Development and evaluation of evidence for go beyond national remits. To help mitigate this, WHO “evidence-based policy options” (e.g. developing should provide further recognition for the collaborating policy briefs and guidelines for policy dialogue); and centres’ wider work and perceived impact in order to 4. Contribution to “monitoring the health situation and support national institutions for regional or global action.
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While administrative and communication challenges Still, it is also important that WHO acts proactively are an extrapolation of what has been described, there in the identification of priority areas of action for the are some particular aspects of working with the centres Organization, as well as identifying those potential that require further attention. In fact, the processes institutions of excellence that can act as collaborating of designation, continuation (re-designation), or centres. As an example of the former, we are developing discontinuation (termination) of a WHO collaborating a list of priority areas for collaboration that can be taken centre follow a set of relatively strict rules and regulations up by existing collaborating centres or those that may (6). The regulations are based on the decisions of WHO governing bodies, and are formulated to ensure that wish to be designated as such. These priority areas are such high-level decisions are not abused or misused focused on the needs of the Region and include health in any form. This means that the setting up of a WHO and healthcare in emergency settings (10), neglected collaborating centre work plan, based on specific terms tropical diseases and priority communicable diseases(10), of reference and related activities, not only requires noncommunicable diseases and risk factors that have attention to the technical and resource-related aspects, received less attention (10), maternal and child health but also recognition of what is permissible as part of and vulnerable groups (10), health system development its agenda of work. However, the imposition of such (10), as well as health information and evidence informed regulations may also result in important time lags in the decision-making (11). In addition, for the first time we implementation of the agenda, as well as in submission are also planning pro-active events in a number of or ratification of a centre’s reports. Member States in which we invite high calibre academic In support of the Eastern Mediterranean Vision for and research institutions in the country to raise their 2023 (7) and WHO’s 13th General Programme of Work (GPW13) (8), the WHO Eastern Mediterranean Regional understanding of WHO collaborating centres. Three Office (WHO/EMRO) is following a set of strategic such events are already scheduled for 2019. actions to enhance the number and functions of WHO Looking forward, we expect to see more resources collaborating centres in the Region. This follows the from those countries with higher research and analytical ambitious agenda of furthering collaborative work for capabilities made available in support of WHO activities. health by 2023 via tapping into the existing academic However, this does not preempt the need for expansion and policy development and implementation capacity of WHO collaborating centres in the Region. All these in the Region. In addition, it also offers recognition of factors are the focus of an upcoming meeting of WHO the existing quality work in the Region and enhances regional and national institutional capacity for improving collaborating centres, scheduled to be held in Muscat, population health. The regular conduct of WHO Oman, during January 2019. The deliberations and collaborative centre meetings, as well as implementing outcomes of the meeting will be used to finalize a regional innovative approaches to promote excellence, are plan of action for improvement in light of WHO GPW13 important directions for action (9). and EMR Vision 2023.
References 1. World Health Organization. WHO collaborating centres global database. Geneva: World Health Organization; 2018 (http://apps. who.int/whocc/List.aspx?cc_region=EMRO&). 2. Røttingen JA, Regmi S, Eide M, Young AJ, Viergever RF, Årdal C et al. Mapping of available health research and development data: what’s there, what’s missing, and what role is there for a global observatory? Lancet 2013; 382: 1286–307. https://doi.org/10.1016/ S0140-6736(13)61046-6 PMID: 23697824 3. Sharifi H, Akbarein H, Akhondzadeh S, Amirkhani M, Asadi-Lari M, Ayatollahi Mousavi SA, et al. Establishment of the Nation- al Network of WHO Collaborating Centres in Iran to Contribute to the National Public Health Needs. Arch Iran Med. 2015; 18(8):558-9 https://doi.org/015188/AIM.0017 PMID: 26265527 4. Singh PK. Collaborating centres: Rediscovering an extended arm of World Health Organization. Indian J Med Res. 2018; 147(1):11- 13. https://doi.org/10.4103/ijmr.IJMR_118_18 PMID: 29749355 5. Mandil A, ElFeky S, Rashidian A. Assessment of World Health Organization collaborating centres in the Eastern Mediterranean Region. East Mediterr Health J. 2017; 23(10):711-714. https://doi.org/10.26719/2018.23.10.711. 6. World Health Organization. Guide for WHO collaborating centres. Geneva: World Health Organization; 2018 (http://www.who. int/collaboratingcentres/Guide_for_WHO_collaborating_centres_2018FINAL.pdf). 7. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Vision 2023 – Eastern Mediterranean Region. Cairo: WHO/EMRO; 2017 (http://www.emro.who.int/about-who/vision2023/vision-2023.html). 8. Mahjour J, Mirza Z, Rashidian A, Atta H, Hajjeh R, Thieren M, et al. “Promote health, keep the world safe, serve the vulnerable” in the Eastern Mediterranean Region. East Mediterr Health J. 2018; 24(4):323-324. https://doi.org/10.26719/2018.24.4.323
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9. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Third meeting of the WHO collabo- rating centres in the Eastern Mediterranean Region, Meeting report. Cairo: WHO/EMRO; 2015 (http://applications.emro.who.int/ docs/IC_Meet_Rep_2015_16727_EN.pdf?ua=1). 10. Fikri M. Roadmap 2017–2021: Stronger organization and better response to the needs of Member States in the Eastern Mediter- ranean Region. East Mediterr Health J. 2017; 23(5): 327-328. https://doi.org/10.26719/2017.23.5.327 11. Rashidian A, Mandil A, Mahjour J. Improving evidence informed policy-making for health in the Eastern Mediterranean Region. East Mediterr Health J. 2018; 23(12): 793-794. https://doi.org/10.26719/2018.23.12.793.
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Book 24-11.indb 1037 23/01/2019 10:04:04 Letter to the editor EMHJ – Vol. 24 No. 11 – 2018
The neglected role of stewardship in strategic purchasing of health services: who should buy?
Djavad Ghoddoosi Nejad 1, Ali Janati 2 and Morteza Arab-Zozani 2,3
1Social Determinants of Health Research Center, Department of public health, Faculty of health, Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran. 2Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. (Correspondence to: Morteza Arab-Zozani: [email protected]). 3Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran.
Citation: Ghoddoosi Nejad D; Janati A; Arab-Zozani M. The neglected role of stewardship in strategic purchasing of health services: who should buy? East Mediterr Health J. 2018;24(11):1038-1039. https://doi.org/10.26719/2018.24.11.1038 Received: 26/11/17; accepted: 28/06/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Sir, (5), severe stewardship challenges can be found (3). In The World Health Organization (WHO) introduced a Cambodia (2), Kenya (6) and the Islamic Republic of Iran framework to evaluate performance of every health (3,7), lack of well-defined duties, roles and legislation is obvious. In aggregate, it is not clear “who should buy” the system in its World Heath Report 2000 (1). This interventions. framework includes three goals: good health, financial protection against healthcare costs, and responsiveness The answer to this question is, in fact, the “sixth to nonmedical needs. In order to achieve these goals dimension” of successful strategic purchasing. Failure to four functions have been outlined: 1) resources creation answer this question leads to complications for the health and generation; 2) financing; 3) service delivery; and system such as: fragmentation, wastage of resources, 4) stewardship of health system (1). The financing parallel works, conflict of interest, and finally, failure in function consists of three sub-functions; revenue obtaining potential benefits of strategic purchasing of collection, pooling, and purchasing. Based on this health services. function, it is recommended that strategic purchasing According to the principles of the economic market, should be used instead of inactive (passive) purchasing purchaser/provider split reform was developed to give (1,2). economic incentives to both providers and purchasers (8). Health systems use tools and approaches such As defined by WHO, strategic purchasing implies a as licensing, accreditation, full recognition and continuous search for finding means to taking maximum classification of mechanisms to manage health services advantage of the lowest cost and resources in order to providers. From the other side, it is also advisable to reach cost-effectiveness in a health system. Strategic identify purchasers and their financial strengths, and purchasing can be ensured by responding correctly and design and implement a mechanism for their licensing, precisely to five classical questions: what should we validation and accreditation. This will ensure provision of buy? From whom should we buy? At what price should health services as a result of a suitable contract between we buy? How should we buy? For whom should we buy purchasers and providers in order to optimize patients’ the interventions? (1). In fact, strategic purchasing of outcomes and costs of health services, and forms a healthcare services/interventions is fundamental to the perquisite for good stewardship in every health system. holistic reform in a health care system, which involves all Regarding the above mentioned factors, it may be stakeholders. Therefore, clarity in the roles of purchaser/ suggested that before implementing strategic purchasing purchasers and other actors is very important (3). in a health context, the structure of healthcare system In this regard, since most low- and middle-income stewardship should be reviewed and strengthened. If countries use a “public assistance system” for an array stewardship perquisites of strategic purchasing are of healthcare operations, there is no unique defined ensured (including robust and accurate intelligence for organization to handle the stewardship and to organize policy and regulation generation) (1), and a rigorous and and manage purchaser/purchasers (4). In fact, in low- clear answer to “who should buy” can be provided, then and middle-income countries that have experienced the health system can accurately position itself to answer some level of strategic purchasing of healthcare services the five classical questions.
References 1. World Health Organization. The world health report 2000: health systems: improving performance. Geneva: World Health Organization; 2000.
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2. Bigdeli M, Annear PL. Barriers to access and the purchasing function of health equity funds: lessons from Cambodia. Bull World Health Organ. 2009;87(7):560–4. http://dx.doi.org/10.2471/BLT.08.053058 3. Janati A, Nejad DG, Doshmangir L, Imani A. Challenges of Implementing Strategic Purchasing Of Health Services in Iran: A Qualitative Study. Acta Med Mediter. 2016;32:1033–8. 4. Preker AS. Public ends, private means: strategic purchasing of health services. Washington, DC: World Bank Publications; 2007. http://dx.doi.org/10.1596/978-0-8213-6547-2 5. Ghoddoosi-Nezhad D, Janati A, Arab-Zozani M, Doshmagir L, Sadeghi Bazargani H, Imani A. Is strategic purchasing the right strategy to improve a health system’s performance? A systematic review. Bali Med J. 2017;6(1):102–13. http://dx.doi.org/10.15562/ bmj.v6i1.369 6. Munge K, Mulupi S, Barasa EW, Chuma J. A critical analysis of purchasing arrangements in Kenya: the case of the National Hos- pital Insurance Fund. Int J Health Policy Manag. 2017 Mar;7(3):244–54. http://dx.doi.org/10.15171/ijhpm.2017.81 7. Ghoddoosi-Nejad D, Jannati A, Doshmangir L, Arab-Zozani M, Imani A. Stewardship as a fundamental challenge in strategic purchasing of health services: a case study of Iran. Value in health regional issues. 2019 May;18:54-8. https://doi.org/10.1016/j. vhri.2018.06.005. 8. Tynkkynen LK, Keskimäki I, Lehto J. Purchaser–provider splits in health care—The case of Finland. Health Policy. 2013 Aug 1;111(3):221–5. http://dx.doi.org/10.1016/j.healthpol.2013.05.012
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Book 24-11.indb 1039 23/01/2019 10:04:04 Research article EMHJ – Vol. 24 No. 11 – 2018
Characteristics of women applying for a legal abortion in the Islamic Republic of Iran
Seyedeh Fatemeh Vasegh Rahimparvar 1, Asieh Jafari 2, Fatemeh Hoseinzadeh 3, Faezeh Daemi 4 and Fatemeh Samadi 2
1Nursing and Midwifery Care Research Centre, Midwifery Department, Nursing and Midwifery School, Tehran University of Medical Sciences, Teh- ran, Islamic Republic of Iran (Correspondence to: S. Fatemeh Vasegh Rahimparvar: [email protected]). 2Iran Legal Medicine Organization Research Centre, Tehran, Islamic Republic of Iran. 3School of Medicine, Gilan University of Medical Sciences, Rasht, Islamic Republic of Iran. 4School of Fine Arts, University of Tehran, Tehran, Islamic Republic of Iran.
Abstract Background: Legal abortion has been permitted in the Islamic Republic of Iran since 2003 if there is serious and incurable disease that would cause the mother or the fetus suffering. Aims: This study evaluated the characteristics of women applying for a legal abortion licence to the Tehran Province Gen- eral Office of Legal Medicine, and compared the findings with earlier studies to evaluate changes over time. Methods: All women visiting the office between August 2011 and 2012 to apply for a legal abortion licence were inter- viewed and sociodemographic data, reason for the application and outcome of the application were recorded. Results: A total of 1378 women applied for a licence, and 48% were issued. Most applications (80.6%) were for fetal rather than maternal indications and 90.2% of the licences issued were for fetal indications. Most of the applications for fetal indications (53.7%) were granted a licence, while 75.7% for maternal indications were rejected. Neurological abnormalities in the fetus were the most common reason for the application (24.6%) and licences issued (30.7%). Neurological and psy- chological disorders were the most common maternal reason in all applications (25.7%) and in unsuccessful applications (28.6%). Cardiac disease (23.1%) was the most common maternal reason in successful applications. Conclusions: Comparison of the results with those of earlier studies shows an increase in the number of women applying for a legal abortion licence and in the number of licences issued. Similar studies are recommended to provide information on the effect of national abortion laws and help improve the legal abortion process in the Islamic Republic of Iran. Keywords: Pregnancy; abortion, legal; abortion licence; Iran Citation: Vasegh Rahimparvar SF; Jafari A; Hoseinzadeh F; Daemi F; Samadi F. Characteristics of women applying for a legal abortion in the Islamic Republic of Iran. East Mediterr Health J. 2018;24(11):1040–1048. https://doi.org/10.26719/emhj.18.001 Received: 11/12/15; accepted: 16/11/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction abortion law was prepared in 2003, revised and ratified by the Islamic Parliament in 2005 (6,7), and approved by Abortion refers to the termination of pregnancy before the Guardian Council on 15 June 2005. The law states that: the 20th week of gestation or a fetus less than 500 g of weight, and may be spontaneous or induced (medical- legal abortion is allowed provided that three specialists make ly, non-medically or criminally) (1). Therapeutic or legal definite diagnoses about the fetus being malformed or re- abortions are performed for medical reasons related to tarded, thus causing the mother to suffer severely, or about the mother or the fetus (2). In some countries there are le- the mother’s own life-threatening conditions, and given the gal restrictions on abortion (3). Given its integration with general office of legal medicine’s final approval, provided legal, judicial, moral and social issues, abortion is not just the fetus is not yet four months old, the time at which spirit a medical problem (4). Before the 1979 Islamic Revolution is breathed into it, and provided the mother’s consent, and in Iran, abortion was legal for the purposes of saving a the superintendent doctor has no responsibilities toward the mother’s life or her mental and physical health, or after matter and will not be punishable by law with regard to this diagnosis of fetal defects. After the revolution, however, action. abortion regulations were abolished, and abortion was Based on this law, the Iranian Legal Medicine allowed only in the few cases in which the pregnancy Organization has adopted procedures in recent years for threatened the life of the mother (5,6). authorizing legal abortion, which require at least one of a The legal vacuum on legal abortions was problematic list of 51 conditions to be met for a licence to be issued; 22 in the Islamic Republic of Iran because many fetal relate to the health of the mother and 29 to the health of anomalies and diseases existed. This became a subject the fetus. These 51 conditions are serious and incurable of discussion in 1997 following a fatwa by the Supreme diseases that will cause the mother, the fetus or the Leader of the Islamic Revolution authorizing legal future child to suffer (6,8,9). The Supreme Leader of Iran, abortion for fetuses with major thalassemia. Based on Ayatollah Khamenei, issued a fatwa on this matter in 2003, Islamic law and guided by modern medicine, the medical stating that, “if the fetal condition can be definitively
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diagnosed, and if the survival of this fetus causes serious apply for a legal abortion licence between 23 August 2011 suffering, which is typically the case, performing an (1/6/1390 Iranian calendar) and 21 August 2012 (31/5/1391 abortion is permitted before the spirit is breathed into Iranian calendar). the fetus. However, to take precaution, the blood money (dieh) for the fetus should be paid” (6,8). To summarize, Data collection the therapeutic abortion law was approved by the Iranian In Tehran Province General Office of Legal Medicine, parliament in 2003. Before this law, abortion permissions women applying for a legal abortion are referred to the were severely restricted in the Islamic Republic of Iran. Women’s Office. The outcome of the application is usu- At that time, a guideline on indications for abortion ally received after one or two visits and on the same day was presented by the Legal Medicine Organization of in the case of fetal indications for a legal abortion licence. Iran. Parliament and the Islamic Consultative Assembly For applications based on indications of the mother, the approved this in 2005 (2). outcome takes three days to one week. Epidemiological studies are important to determine For data collection, the women were approached on the current status of a condition and estimate the their last visit when the outcome of their application facilities needed to manage it (10). Given the undeniable for a legal abortion licence was confirmed. Most of the problems and complications caused by induced abortion, women agreed to be interviewed and for their data to understanding the different aspects of the issue and be reviewed; 11 women did not wish to be interviewed devising appropriate strategies to eliminate or reduce but some information was available for them, namely: these problems is essential (11). reason for applying for an abortion licence, fetal or With the ratification of the abortion law in 2003, maternal indication for the abortion, fetal age, issuance various studies have been conducted on abortion in of the abortion licence or not, if not, the reason for not general in Iran and the effect of the abortion laws (7,12). issuing the licence. The data were collected by two of the Sadr and colleagues conducted a study to examine researchers of this study (AJ and FS) who worked at the abortion licences issued by the Iranian Legal Medicine Women’s Office. Organization from 22 December 2003 to 20 December The researchers interviewed the women at the 2004. They found that a substantial number of Women’s Office and data were also obtained from the individuals who would have previously have sought an women’s medical documents. The data recorded for each illegal abortion began to apply for a legal abortion after women included: age, husband’s age, level of education, the law was passed, and concluded that this change had occupation, husband’s occupation, gravidity, parity, a significant positive effect on the health of mothers (7). number of living children, history of abortion, number of Another study on abortion licences issued by Kerman abortions, reason for requesting an abortion, type of fetal Province General Office of Legal Medicine in 2005 or maternal indication for the abortion, history of using compared the results with those obtained in previous medications for every acute/chronic disease or exposure years and concluded that the increase in the number of to radiation during pregnancy, fetal age, person or place legal abortion licences issued had reduced the number of referring the woman, issuance of the abortion licence illegal abortions, which had in turn improved the health or not, if not, the reason for not issuing the licence, and and safety of pregnant women (12). reason for any delays in applying for the licence. These studies have undoubtedly contributed to the Statistical analysis decisions made by the authorities for new abortion acts. Studying the characteristics of women applying for The data obtained were analysed using descriptive statis- tics. Participants were divided into 2 groups – those who legal abortion licences, the reasons for their application were issued the licence and those who were not. Differ- and the result of the application would be useful to the ences between the 2 groups were compared according authorities to help them better evaluate the current to socioeconomic and obstetric characteristics using the status of abortion and compare them with previous independent t-test (for continuous variables) and the chi- or future years and take appropriate action to address squared test (for categorical variables). any limitations. Therefore, the aim of our study was to evaluate applications for a legal abortion licence made Mother’s medication use, her diagnosis of through the Tehran Province General Office of Legal communicable diseases that could cause fetal anomalies Medicine in 2011–2012. Our specific objectives were to and her exposure to radiation were considered fetal assess the characteristics (socioeconomic and obstetric) indications for an abortion in the analysis of the data as of the women applying for legal abortion, the reasons for they could have adverse effects on the fetus. Some fetal applying for an abortion and the result of the application problems that did not require an abortion licence or that (issuance or non-issuance of the abortion licence). should have been followed up by a hospital were also taken to be fetal indications, including partial moles, Methods intrauterine growth restriction, abnormal amniotic fluid, intrauterine fetal death and a blighted ovum. Study design and sample This was a prospective study of all the women who visited Ethical considerations the Tehran Province General Office of Legal Medicine to The study was approved by the Ethics Committee of Teh-
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ran University of Medical Sciences. ovum were conditions/factors for which an abortion A letter of introduction was provided by the licence was never issued (Table 3). authorities of Tehran University of Medical Sciences to Neurological and psychological disorders were the the Tehran Province General Office of Legal Medicine. most frequent reasons for applying for an abortion The researchers explained the objectives of the study to licence because of maternal indications (25.7%). In the the office authorities and obtained their consent before group issued a licence, the most frequent reason for collecting data on the women. requesting an abortion was cardiac disease (23.1%), while The researchers explained the objectives of the study in the group that was not issued a licence, neurological/ to the women visiting the office to apply for a legal psychological disorders (28.6%) was the most common abortion licence and recorded their data. The women reason. No abortion licences were issued for women with were assured that the information they gave would be lung disease, thyroid disorders, unwanted pregnancy, old kept confidential and they gave their verbal, informed age, abnormalities in their other children and paternal consent to participate. problems, such as abnormalities or medical disorders (Table 4). Results The most frequent reasons for non-issuance of an Over the study period (23 August 2011 to 21 August 2012), abortion licence were gestational age over 19 weeks 1 378 women visited the Tehran Province General Office (23.4%), fetal anomalies not confirmed (16.9%) and the of Legal Medicine to apply for a legal abortion licence; absence of life-threatening risks for the mother (16.6%). of these, 661 women (48%) were issued the licence and The most frequent reasons for the 19-week delay in 717 women (52%) were not. Tables 1 and 2 show the soci- visiting the office included failure to undergo ultrasound oeconomic and obstetrics characteristics of the women imaging before the gestational age of 19 weeks (36.2%) and categorized according to their licence status (issued or failure to have the anomaly diagnosed by the ultrasound not). The majority of the women in both groups had a images obtained before this date (27.5%). high school diploma and above, were housewives, had a history of abortion, used medication or were exposed to Discussion radiation during the pregnancy, had similar problems in During the year surveyed (23 August 2011 to 22 August the family, and were referred by a gynaecologist. There 2012) in our study, 1 378 women visited the Tehran Prov- were significant differences between the 2 groups for the ince General Office of Legal Medicine to apply for a le- women’s age, husband’s age, number of living children, gal abortion licence, and almost half (48%) were issued number of sons and daughters, medication use or expo- a licence. A previous study of 245 women applying for sure to radiation during pregnancy, referral person/place, a legal abortion licence at this office, from May 1999 to gestational age based on ultrasound, gravidity, parity, May 2000, reported that 126 (51.4%) of the women were number of spontaneous abortions, and gestational age issued a legal abortion licence, while 119 (48.6%) were not, based on abdominal examination (Tables 1 and 2). because of a lack of sufficient indications 13( ). The per- A total of 1 110 women (80.6%) had applied for an centage of licences issued in this earlier study is similar abortion licence for fetal indications, while 268 women to ours. However, the number of women applying for a li- (19.4%) had requested it for maternal indications. In the cence was different; far more women applied for an abor- group issued a licence, 596 women (90.2%) had requested tion licence in our study indicating a 5.6 times increase in an abortion licence for fetal indications while 65 (9.8%) abortion licence applications in 2011–2012 compared with had requested it for maternal indications. In the group 1999–2000. In the General Office of Legal Medicine in not issued a licence, 514 women (71.7%) had requested Kerman Province in 2005, 24 out of the 47 women apply- an abortion licence for fetal indications and 203 women ing for a licence in that year were issued one (12), which (28.3%) for maternal indications. Just over half (53.7%) of is also consistent with our results, suggesting that almost the women applying for a licence for fetal indications half of the women have been successful in their applica- were granted the licence, while only 24.3% requesting a tion for a licence. licence for maternal indications were given a licence. Our study also showed that more women requested The greatest proportion of the women applying an abortion licence for fetal rather than maternal for an abortion licence for fetal indications had a fetus indications (80.6% versus 19.4%), and similarly more with neurological abnormalities (26.0%); neurological licences were issued (90.2% versus 9.8%) for fetal than abnormalities were the most frequent reason for maternal indications. Moreover, most of the applications applying for an abortion licence in both the group that for a licence for fetal indications were granted a licence was issued a licence (33.9%) and the group that was not (53.7%), while most applications for maternal indications (16.9%). Eye anomalies, mother’s medication use, mother’s were rejected (75.7%). Our findings differ from other diagnosis of communicable diseases that could cause studies. A study conducted on legal abortion licences fetal anomalies, mother’s exposure to radiation, positive issued by the Iranian Legal Medicine Organization in screening test results for fetal anomalies without 2004 showed that the reasons for issuing a licence to 1 confirmation (i.e. without ultrasound or amniocentesis), 101 women included fetal anomalies and diseases in partial moles, intrauterine growth restriction, abnormal 64% of the cases and maternal conditions in 36% (7). In amniotic fluid, intrauterine fetal death and a blighted the study in 2005 in Kerman, 68% of the licences issued
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Table 1 Socioeconomic characteristics of women applying for a legal abortion licence at the Tehran Province General Office of Legal Medicine from 23 August 2011 to 22 August 2012, according to issuance or not of the licence Socioeconomic characteristic Licence issued (n = 661) Licence not issued (n = 717) P-value No. % No. % Level of education Illiterate 19 2.9 26 4.0 0.203a Elementary school 65 10.1 80 12.4 Middle school 78 12.1 78 12.1 High school 25 3.9 39 6.0 Diploma 270 41.8 255 39.4 University degree 189 29.3 169 26.1 Total 646 100 647 100 Occupation Housewife 556 85.7 561 85.0 0.886a Employed 70 10.8 76 11.5 Labourer 1 0.2 2 0.3 Self-employed 11 1.7 13 2.0 Other 11 1.7 8 1.2 Total 649 100 660 100 Husband’s occupation Employed 207 32.1 206 31.5 0.988a Labourer 147 22.8 147 22.5 Self-employed 269 41.7 276 42.3 Other 22 3.4 24 3.7 Total 645 100 653 100 Mean (SD) Mean (SD) Age (years) 29.5 (6.45) 30.7 (6.56) 0.001b Husband’s age (years) 33.3 (6.58) 35.0 (7.45) < 0.001b No. of living children 0.8 (0.91) 1.1 (1.00) < 0.001b No. of sons 0.5 (0.62) 0.6 (0.69) 0.020b No. of daughters 0.5 (0.76) 0.7 (0.76) 0.005b
aChi-squared test; bIndependent t-test. SD = standard deviation
were because of fetal indications (12) and in the previous in cases with fetal indications (24.6%). Applications on study at the Tehran office in 1999–2000, 17% were issued this basis also had the highest rate of success in having because of fetal indications (13). the licence issued (30.7%). The time differences in the studies may be responsible The greatest proportion of the women in our for this difference; in 1999–2000, the legal abortion law study who applied for an abortion licence because of had not yet been ratified, which would explain why only maternal indications did so because of neurological 17% of abortion licences were issued for fetal indications. and psychological conditions (25.7%). For those issued However, in 2003–2004, i.e. a year after the ratification of a licence, the reasons included cardiac disease (23.1%), the law, the number of licences issued for fetal indications cancer (18.5%), and neurological and psychological increased to 64% and then to 68% 2 years after execution diseases (16.9%). In the group not issued a licence, 28.6% of the law. It is therefore only natural for the number of were for neurological and psychological diseases. No women applying to the Office of Legal Medicine for an abortion licences were issued for applications because abortion licence for fetal indications to have increased of lung disease, thyroid disorder, unwanted pregnancy, 9 years after the law took effect. In fact, increased old age, abnormalities in the other children and paternal awareness in mothers and medical personnel about this problems. The previous study at the Tehran Office of Legal law and the more frequent referral of mothers to legal Medicine in 1999–2000 reported cardiovascular diseases medicine offices have played a key role in this increase. in the mother (27%), fetal problems (17%) and renal In our study, fetal neurological abnormalities were the disease in the mother (11%) as the most frequent reasons most frequent reason for requesting an abortion licence for visiting the office, and cardiovascular diseases in the
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Table 2 Obstetric characteristics of women applying for a legal abortion licence at the Tehran Province General Office of Legal Medicine from 23 August 2011 to 22 August 2012, according to issuance or not of the licence Obstetric characteristic Licence issued (n = 661) Licence not issued (n = 717) P-value No % No. % History of abortion Yes 470 73.7 514 78.1 0.172a No 167 26.2 143 21.7 Total 638 100 658 100 Medication regimen or exposure to radiation during pregnancy Yes 556 86.7 419 63.5 < 0.001a No 85 13.3 241 36.5 Total 641 100 660 100 Similar problems in the family Yes 521 90.6 422 87.7 0.80a No 54 9.4 59 12.3 Total 575 100 481 100 Referred by: Gynaecologist 479 75.8 468 73.2 < 0.001a Midwife 33 5.2 29 4.5 Medical centre 10 1.6 5 0.8 General physician 1 0.2 9 1.4 Radiologist 4 0.6 5 0.8 Other specialists 105 16.7 123 19.3 Total 632 100 639 100 Mean (SD) Mean (SD) GA based on ultrasound (weeks) 15.4 (3.16) 14.7 (7.72) 0.027b Gravidity 1.9 (1.34) 1.2 (1.46) 0.006b Parity 0.8 (0.93) 1.1 (1.05) 0.001b Number of abortions 0.4 (0.74) 0.4 (0.78) 0.244b Number of spontaneous abortions 1.2 (0.63) 1.5 (1.07) 0.019b Number of legal abortions 1.0 (0.40) 0.9 (0.24) 0.165b Number of illegal abortions 0.7 (0.50) 1.0 (0.43) 0.345b GA based on abdominal 15.9 (3.02) 18.9 (4.83) < 0.001b examination (weeks)
aChi-squared test; bIndependent t-test. SD = standard deviation, GA = gestational age
mother (36%), major thalassaemia in the fetus (17%) and major thalassaemia; in 2003–2004, anencephaly and malignancies in the mother (17%) as the most frequent major thalassaemia were the most common fetal indications among women who were granted a licence indications; and in 2005, major thalassaemia was the most (13). The 2003–2004 study found the most common fetal common fetal indication. In our study, fetal neurological indications for issuance of an abortion licence were abnormalities was the most frequent reason for the anencephaly and major thalassaemia, and the most issuance of an abortion licence for fetal indications. common maternal indication was cardiovascular diseases The preparation of the legal abortion law by the (7). The 2005 study in Kerman also reported major beta Iranian Legal Medicine Organization in 2003 and its thalassaemia as the most common fetal indication and ratification by the Islamic Parliament in 2005 appear cardiovascular diseases as the most common maternal to have greatly increased the issuance of legal abortion indication for applying for an abortion licence (12). licences for fetal indications, as applications with a variety These studies are consistent with our study in terms of fetal indications were granted the licence after 2005. of the maternal indications reported for issuance of legal Therefore, based on the results of our study, it appears abortion licences—cardiovascular diseases. However, only reasonable that fetal neurological abnormalities their findings about fetal indications differ from our and genetic disorders would be the most frequent fetal findings. In 1999–2000, the only fetal indication was indications for an abortion licence being issued.
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Table 3 Fetal indications for the application for a legal abortion licence at the Tehran Province General Office of Legal Medicine from 23 August 2011 to 22 August 2012, according to issuance or not of the licence Fetal indication for the abortion licence Licence issued Licence not issued Total P-value request No. % No. % No. % Cardiac anomaly 18 3.0 15 2.9 33 3.0 0.921a Neurological anomaly 202 33.9 87 16.9 289 26.0 < 0.001a Gastrointestinal anomaly 16 2.7 2 0.4 18 1.6 0.003a Skeletal deformity 51 8.6 28 5.4 79 7.1 0.045a Urinary abnormality 23 3.9 18 3.5 41 3.7 0.753a Blood disorder (not major thalassaemia) 2 0.3 0 0 2 0.2 0.502b Major thalassaemia 33 5.6 2 0.4 35 3.2 < 0.001a Eye anomalies 0 0 3 0.6 3 0.3 0.099b Genetic disorders 116 19.5 46 9.0 162 14.6 < 0.001a Multisystem involvement 39 6.6 13 2.5 52 4.7 0.001a Hydrops 77 13.0 15 2.9 92 8.3 < 0.001a Mother on a medication regimen 0 0 84 16.3 84 7.6 < 0.001a Mother’s diagnosed with a disease that could 0 0 20 3.9 20 1.8 < 0.001a cause fetal abnormalities Mother’s exposure to radiation 0 0 42 8.2 42 3.8 < 0.001a Ultrasound signs 1 0.2 45 8.8 46 4.1 < 0.001a Positive screening test results for fetal anomalies 0 0 24 4.7 24 2.2 < 0.001a Partial moles 0 0 4 0.8 4 0.4 0.046b Intrauterine growth restriction 0 0 5 1.0 5 0.5 0.021b Amniotic fluid disorder 0 0 32 6.2 32 2.9 < 0.001a Intrauterine fetal death 0 0 5 1.0 5 0.5 0.021b Blighted ovum 0 0 6 1.2 6 0.5 0.010b Conjoined twins 4 0.7 1 0.2 5 0.5 0.381b Other 14 2.3 17 3.3 31 2.3 0.334a Total 596 100 514 100 1110 100
aChi-squared test; bFisher exact test.
Our results showed that a gestational age over 19 increase was mostly in applications for fetal rather than weeks was the most common reason for the not granting maternal indications. The laws introduced on abortion an abortion licence (23.4%). No similar studies were found for fetal reasons seem to have led to this increase. on this subject. In each country, policies on abortion greatly affect Our study had some limitations. Because of the high the related implementation. Our findings can help volume of attendees, not all the information on the policy-makers to modify existing guidelines for better women and their application was complete. However, this implementation. For example, the most frequent reason problem was kept to a minimum. Nonetheless, for some for the non-issuance of a licence was gestational age women, data were missing for some questions and they over 19 weeks because aborting a fetus after 19 weeks were therefore excluded in the percentage calculation for is forbidden in the Islamic Republic of Iran. Therefore, that question. As the sample of women was large, losing early detection of fetal malformations is important and such a small number in each question would not likely directives should be formulated to encourage and allow affect the findings and conclusion. for this. Similar studies are recommended to examine trends Conclusion over time in the Tehran office and also to examine other Comparison of the results obtained from this study with offices across the country. Such findings can be used those from previous studies conducted in the Islamic to determine the effect of national abortion laws and Republic of Iran showed an increase in the number of to provide information that can help policy-makers to women applying for a legal abortion licence and conse- change the abortion laws in the Islamic Republic of Iran quently an increase in the number of licences issued. The based on the existing problems .
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Table 4 Maternal indications for the application for a legal abortion licence at the Tehran Province General Office of Legal Medicine from 23 August 2011 to 22 August 2012, according to issuance or not of the licence Maternal indication for the abortion Licence issued Licence not issued Total P-value license request No. % No. % No. % Cardiac disease 15 23.1 12 5.9 27 10.1 < 0.001a Renal disease 6 9.2 9 4.4 15 5.6 0.143a Neurological and psychological disease 11 16.9 58 28.6 69 25.7 0.062a Rheumatic disorder 2 3.1 19 9.4 21 7.8 0.096a Lung disease 0 0 3 1.5 3 1.1 0.999b Blood disorder 2 3.1 6 3.0 8 3.0 0.960a Skeletal disorder 4 6.2 9 4.4 13 4.9 0.523b Gastrointestinal disease 1 1.5 5 2.5 6 2.2 0.999b Cancer 12 18.5 8 3.9 20 7.5 < 0.001b Hypertension 2 3.1 11 5.4 13 4.9 0.740b Diabetes 1 1.5 5 2.5 6 2.2 0.999 Thyroid disorder 0 0 3 1.5 3 1.1 0.999b Uterus and its appendages problem 2 3.1 13 6.4 15 5.6 0.534b HIV-positive 7 10.8 5 2.5 12 4.5 0.010b Unwanted pregnancy 0 0 9 4.4 9 3.4 0.119b Old age 0 0 3 1.5 3 1.1 0.999b Abnormalities in the other children 0 0 5 2.5 5 1.9 0.340b Paternal disorders 0 0 5 2.5 5 1.9 0.340b Other 0 0 15 7.4 15 5.6 0.026b Total 65 100 203 100 268 100 -
aChi-squared test; bFisher exact test.
Acknowledgements Our special thanks go to all the women whose participation made this research possible. We thank the Tehran University of Medical Sciences for their funding and the Iranian Legal Medicine Organization for their support. Funding: This study was funded by Tehran University of Medical Sciences. Competing interests: None declared.
Caractéristiques des femmes présentant une demande d’avortement légal en République islamique d’Iran Résumé Contexte : L’avortement légal est autorisé depuis 2003 en République islamique d’Iran dans les cas de maladie grave ou incurable qui causerait une souffrance à la mère ou au fœtus. Objectifs : La présente étude a analysé les caractéristiques des femmes effectuant une demande pour obtenir une autorisation d’avortement légal auprès du Bureau général de médecine légale de la Province de Téhéran, et a procédé à une comparaison des résultats avec des études précédentes de façon à mesurer les changements au fil du temps. Méthodes : Toutes les femmes se rendant au Bureau entre août 2011 et 2012 pour faire la demande d’une autorisation d’avortement légal ont été interrogées, et les données socio-démographiques, les raisons et l’issue de la demande ont été répertoriées. Résultats : Au total,1378 femmes ont fait la demande d’une autorisation, et 48 % ont été délivrées. La plupart des demandes (80,6 %) reposaient sur des indications fœtales plutôt que sur des indications maternelles, de même que 90,2 % des autorisations délivrées. La plupart des demandes reposant sur des indications fœtales (53,7 %) se sont vues octroyer une autorisation, tandis que 75,7 % des indications maternelles ont été rejetées. Des anomalies neurologiques chez le fœtus étaient la raison la plus fréquente à l’origine d’une demande (24,6 %) et des autorisations délivrées (30,7 %). Des troubles neurologiques et psychologiques chez la mère étaient la raison la plus fréquente à l’origine de l’ensemble des
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demandes (25,7 %) et des refus (28,6 %). La présence d’une maladie cardiaque chez la mère (23,1 %) était la raison la plus fréquente pour une acceptation des demandes. Conclusions : La comparaison des résultats avec ceux d’études précédentes montre une augmentation du nombre de femmes faisant une demande d’autorisation pour un avortement légal, ainsi qu’une augmentation du nombre des autorisations délivrées. Des études similaires sont recommandées afin de produire des informations sur l’effet des lois nationales relatives à l’avortement, et afin d’accompagner l’amélioration du processus d’avortement légal en République islamique d’Iran.
خصائص السيدات املتقدمات بطلبات اإلجهاض القانوين يف مجهورية إيران اإلسالمية فاطمة واثق رحيم برور، آسية جعفري، فاطمة حسني زادة، فائزه دائمي، فاطمة صمدي اخلالصة اخللفية: تسمح مجهورية إيران اإلسالمية باإلجهاض القانوين منذ عام 2003عندما هيدد مرض خطري وغري قابل للعالج األم أو اجلنني. األهداف:قيمت هذه الدراسة خصائص السيدات اللوايت يتقدمن للحصول عىل ترخيص باإلجهاض القانوين من املكتب العام للطب الرشعي يف حمافظة طهران، كام قارنت النتائج بام أسفرت عنه دراسات أخرى لتقييم التغيري الذي يطرأ بمرور الزمن. طرق أجرت البحث:الباحثات مقابالت مع مجيع السيدات اللوايت زرن املكتب العام للطب الرشعي يف الفرتة بني أغسطس/آب 2011 و2012 وتقدمن بطلبات ترخيص اإلجهاض القانوين، وحصلت الباحثات منهن عىل بياناهتن االجتامعية والسكانية وأسباب تقدمهن هبذه الطلبات مع تسجيل نتيجة تلك الطلبات. النتائج:بلغ عدد السيدات اللوايت تقدمن بطلباهتن للحصول عىل ترخيص باإلجهاض القانوين 1378 سيدة، حصل 48% منهن عىل الرتاخيص. وكانت معظم الطلبات ) % منها(80.6 مقدمة ألسباب تعود إىل اجلنني وليس إىل األمهات، بينام صدرت 90.2% من الرتاخيص ألسباب جنينية. كام حصلت معظم الطلبات املقدمة ألسباب جنينية )و53.7%( عىل الرتاخيص، بينام ُر ِف َضت % 75.7من الطلبات املقدمة ألسباب تعود إىل األمهات. وكانت التشوهات العصبية يف اجلنني هي السبب األكثر ًشيوعا لتقديم السيدات لطلباهتن ) %( 24.6وللحصول عىل الرتخيص باإلجهاض القانوين )30.7%(. بينام كانت االضطرابات النفسية والعصبية هي األسباب األكثر ً ا شيوعبني األمهات، من جممل الطلبات )%25.7( و % 28.6من الطلبات التي مل َحتظ باملوافقة عليها. وكانت األمراض القلبية والوعائية من أكثر األسباب لدى األمهات التي وردت يف الطلبات الناجحة )%23.1(. االستنتاجات: بمقارنة نتائج هذه الدراسة مع دراسات سابقة، َتب َّني زيادة أعداد السيدات الاليت يقدمن طلبات احلصول عىل تراخيص لإلجهاض القانوين، وزيادة أعداد الرتاخيص التي ُمنِحت هلن. ُويص وتالدراسة بإجراء املزيد من الدراسات حول تأثري القوانني الوطنية لإلجهاض، هبدف حتسني عملية إجراء اإلجهاض القانوين يف مجهورية إيران اإلسالمية.
References 1. Cunningham FG, Williams JW. Williams’s obstetrics. New York: McGraw-Hill Medical; 2010. 2. Bazmi Sh, Behnoush B, Kiyani M, Bazmi E. Comparison of legal abortion licenses issued by the Legal Medicine Center in Tehran before the ratification of the legal abortion act in Iran with those after ratification of the act. Iran J Pediatr. 2008;18(4):315–22. 3. Parry J. Screening the genes. Bull World Health Organ. 2012 Aug 1;90(8):564–5. https://doi.org/10.2471/BLT.12.030812 PMID:22893738 4. Shamshiri M. [The health, dimensions of health, and the abortion’s stand on the health. Abortion]. Tehran: Research and Develop- ment Center for Humanities, Organization for Researching and Composing University Textbooks in the Humanities; 2007. [In Farsi] 5. Behjati Ardekani Z, Akhondi M, Sadeghi MR, Sadri Ardekani H. [The necessity for examining different aspects of abortion. Abortion]. Tehran: Research and Development Center for Humanities, Organization for Researching and Composing University Textbooks in the Humanities; 2007. [In Farsi] 6. Abbasi M, Shamsi Gooshki E, Allahbedashti N. Abortion in Iranian legal system: a review. Iran J Allergy Asthma Immunol. 2014 Feb;13(1):71–84. PMID:24338232 7. Sadr Sh, Aabedi H, Ghadiyani H, Aabedi M. [Determining abortion licenses issued by the State Legal Medicine Organization from December 22nd, 2003 to December 20th, 2004]. Iranian J Forensic Med. 2005;11(4):198–200. [In Farsi] 8. [Abortion is currently one of the threats to women’s health]. Tehran: Family Planning Association of the Islamic Republic of Iran; 2007. [In Farsi] 9. [Legal abortion]. Ministry of Health and Medical Education. [webpage] (http://www.behdasht.gov.ir/index.aspx?siteid=1&page- id=3176, accessed 12 December 2013. [In Farsi]
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10. Keshavarzi F, Khashay M, Alikhani M, Abbasi N. [Examining the causes and complications of the legal abortion in Kermanshah, Iran, in 1996-2001. Abortion]. Tehran: Research and Development Center for Humanities, Organization for Researching and Com- posing University Textbooks in the Humanities; 2007. [In Farsi] 11. Ehdayivand F, Majidpour A. [The examination of 82 women with septic abortion in Alavi Hospital in Ardebil, Iran, in 1999–2001]. Journal of Medical Council of Iran. 2004;22(1):15–8. [In Farsi] 12. Ghadi Pasha M, Aminiyan Z. [Examining abortion licenses issued by the Legal Medicine General Administration in Kerman Province in 2005 and comparing them with those in previous years]. Journal of Kerman University of Medical Sciences. 2007;14(2):147–52. [In Farsi] 13. Toghifi H, Mousavipour F, Barouni Sh. [Determining the women going to the Medicine Center in Tehran to request for a legal abortion license from May 1999 to May 2000. Abortion]. Tehran: Research and Development Center for Humanities, Organiza- tion for Researching and Composing University Textbooks in the Humanities; 2007. [In Farsi]
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Identifying hotspots of viral haemorrhagic fevers in the Eastern Mediterranean Region: perspectives for the Emerging and Dangerous Pathogens Laboratory Network
Mathias Altmann,1 Karen Nahapetyan 2 and Humayun Asghar 2
1Independent consultant epidemiologist, Paris, France. 2Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Mathias Altmann; [email protected]).
Abstract Background: The emergence and re-emergence of viral haemorrhagic fevers (VHFs) is a growing concern worldwide. They are associated with major epidemics with an estimated 51–101 million cases each year, of which around 67 000 are fatal. In 2007, 13 countries in the Eastern Mediterranean Region reported VHF cases. Aims: The main purpose of the study was to review the epidemiological situation in the Region vis-à-vis VHFs to obtain baseline epidemiological information for the establishment of the Emerging Dangerous Pathogen Laboratory Network (EDPLN). Methods: A literature search was performed using PubMed, ProMED-Mail and GIDEON databases. Reported data in- cluded disease burden (reported cases and deaths), human prevalence (general population, high–risk groups), vectors and reservoirs. A scoring method was employed to divide countries into 4 groups (very highly, highly, medium and low affected countries). Results: Very highly affected countries were Afghanistan, Egypt, Islamic Republic of Iran, Saudi Arabia and Sudan. High- ly affected countries were Djibouti, Morocco, Oman, Pakistan, Tunisia and Yemen. Medium affected countries were Iraq, Somalia and United Arab Emirates. Low affected countries were Bahrain, Jordan, Lebanon, Libya, Palestine, Qatar and Syrian Arab Republic. Conclusions: This study contributes in prioritizing countries to be part of EDPLN and in addressing specific needs relat- ed to outbreak investigations, surveillance and research. Keywords: viral haemorrhagic fevers, Eastern Mediterranean Region, prevalence, Emerging Dangerous Pathogen Laboratory Network Citation: Altmann M; Nahapetyan K; Asghar H. Identifying hotspots of viral haemorrhagic fevers in the Eastern Mediterranean Region: perspectives for the Emerging and Dangerous Pathogens Laboratory Network. East Mediterr Health J. 2018;24(11):1049-1057. https://doi.org/10.26719/emhj.18.002 Received: 08/03/17; accepted: 01/10/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction and private stakeholders to accelerate progress toward a world safe and secure from infectious disease threats Viral haemorrhagic fevers (VHFs) are among the most and to promote global health security as an international important pathogens that may cause public health emer- priority. Developing and deploying novel diagnostics and gencies of international concern (PHEIC) as defined by strengthening laboratory systems are part of the strategy. the International health regulations (2005) (IHR) (1). It is esti- Early confirmation of VHF diseases requires mated that VHFs cause between 51 and 101 million (most- specialized laboratories with appropriate biosafety ly dengue fever) cases each year, of which around 67 000 levels, a capacity for accurate diagnosis of emerging are fatal (2). The emergence and re-emergence of VHFs is viral pathogens and a functional regional network a growing concern worldwide. They are associated with of laboratories to provide a service that covers all the the occurrence of major epidemics with high case fatality countries in the Region. The World Health Organization rates. In the past 2 decades, the Eastern Mediterranean (WHO) Emerging and Dangerous Pathogens Laboratory Region has witnessed several major outbreaks of differ- Network (EDPLN) is made up of global and regional ent VHFs. In 2007, 13 countries of the Region reported networks of high security human and veterinary VHF cases (3). Lack of timely laboratory diagnosis and diagnostic laboratories (4). The EDPLN was established functional epidemiological surveillance, inadequate in- to assist WHO in enhancing both the readiness and the fection control practices at health care facilities, lack of response of countries for timely laboratory detection specific vaccines and weak vector control programmes and management of outbreaks of novel, emerging and could result in prolonged outbreaks. re-emerging pathogens and in facilitating the transfer of The Global Health Security agenda is an effort safe and appropriate diagnostic technologies, practices between the government of the United States of America, and training to laboratories in affected countries, as other nations, international organizations and public outlined in the IHR (2005) (1).
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The WHO Regional Office for Africa established Literature review its EDPLN networks in 2010 (5). Building the human A literature search was performed in PubMed, ProMED- and institutional capacities of designated laboratories Mail and GIDEON databases using country name and for preparedness and response to emerging dangerous disease/virus specific terms. Additional sources of infor- pathogens (EDP) (such as Ebola virus disease, MERS-CoV mation included WHO and Centers for Disease Control or Zika virus) is one of the priorities of the Member States and Prevention webpages. The analysis period was re- of the Eastern Mediterranean Region. Currently, there are stricted to 1995–2015. All information/studies older than some laboratory networks in the Region operating under 1995 were excluded. Epidemiological information consid- different clusters within the WHO Regional Office. These ered in this review included reported cases and deaths include the Poliomyelitis Laboratory Network (EPLN), (including notable outbreaks), prevalence and seropreva- Measles and Rubella Laboratory Network, Yellow Fever lence studies among humans and/or accidental hosts and Laboratory Network, Japanese Encephalitis Laboratory associated individual risk factors, vectors and reservoirs, Network, HPV Laboratory Network (LabNet), Rotavirus environmental risk factors (e.g. flooding, drought) and Laboratory Network, Invasive Bacterial Vaccine- geographical distribution (literature review available on Preventable Diseases (IB-VPD) laboratory network. request from the corresponding author). Data were ana- However, diagnosis capacities for EDP remain extremely lysed by country and by disease/virus. All available epide- limited in most Member States. The issue is further miological information considered above was reported. exacerbated by the lack of WHO collaborating centres or Particular attention was paid to the date of the report/ reference laboratories in the Region with the capacity for study, its location and its result (number of cases, sero- and experience of EDP testing that could provide support prevalence/prevalence). and technical assistance to other countries. Hence there is an urgent need to establish a functional EDPLN system Analysis in the Region, providing reliable, accurate and timely The analysis aimed at identifying “hotspots” of VHF in diagnosis at all levels. the Region in order to inform the establishment of ED- The network will include national EDP reference PLN. To our knowledge, there is no standardized meth- laboratories among the 22 countries of the Region. od that applies to this particular objective, therefore, for It will serve for laboratory surveillance, detection of the purposes of this study, a simple working method was and response to EDP and as reference laboratories established. This method consisted in using 6 epidemio- for confirmation of cases and capacity-building in logical criteria (i.e. number of reported cases, number of all countries of the Region. Effective design of the reported deaths, prevalence in general population, prev- laboratory network critically depends on the availability alence in high–risk groups, prevalence in vectors and of information on the epidemiologic situation, patterns prevalence in reservoirs) to score each country. and hotspots of VHF in the Region. Epidemiological criteria The main purpose of this study was to review the epidemiological situation in the Eastern Mediterranean For reported number of cases and deaths, the total num- ber for each pathogen was approximated by adding all re- Region vis-à-vis VHFs to obtain baseline epidemiological ported cases and deaths from the literature review. When information for the establishment of the Emerging numbers were approximated in the literature review (e.g. Dangerous Pathogen Laboratory Network. n > 500), the nearest rounded number was selected (e.g. Methods n = 500). Outbreaks without a specified number of cases were not included in the calculation. Equine populations Setting are not a reservoir for West Nile Fever viruses but rather The WHO’s Eastern Mediterranean Region comprises 22 an “end host”. As such, there were considered as human countries: Afghanistan, Bahrain, Djibouti, Egypt, Islamic cases for the purposes of this study. Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, For the prevalence, estimates were separated between Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, general population and high-risk groups among humans. Somalia, Sudan, Syrian Arab Republic, Tunisia, United Equine populations were considered as a high-risk Arab Emirates and Yemen. group. Other high–risk groups included animal workers, military, people in care settings and sewage workers. The Viral haemorrhagic fevers highest prevalence was selected if different estimates The present work does not address the exhaustive list of were available. This method does not aim to provide the diseases which are diagnosed routinely: the target was true estimate but rather to compare countries with each biosafety levels 2 and 3 (BSL2/BSL3) diagnostic facilities. other. Furthermore, calculation of a mean prevalence Viral haemorrhagic fevers served as a reference for the would need to weight each estimate by the total establishment of the EDPLN; they include Crimean–Con- population, which was beyond the scope of this study. go haemorrhagic fever, dengue/dengue haemorrhagic fe- For vectors and reservoir, the highest estimate was ver, West Nile fever, Rift Valley fever, yellow fever, Hanta selected as well. Vectors included ticks, mosquitoes and fever, Alkhurma haemorrhagic fever, tick-borne encepha- fleas. Reservoirs included livestock, birds, rodents, dogs, litis and Ebola. camels and other mammals.
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Cut-off values and score . . 7 7 The aim was to define a scoring system No. Deaths in order to compare countries on their VHF epidemiological criteria. First, we Ebola . . defined a cut-off value as the median val- 17 17
ue among all countries for each criterion Cases No. and by pathogen. Then, the estimate for a
criterion (number of cases or prevalence) No.
was compared to this median value and a Deaths score was attributed. The scoring system Tick-borne Tick-borne
encephalitis was: 0 points when no data were available 20 20 or the estimate was zero; 1 point when the Cases No. estimate was greater than 0 but under the median value; 2 points when the estimate 12 12 No.
was equal to or greater than the medi- Deaths an value. Finally, the total score for each country was calculated by combining the Alkhurma 2 307 total score of the 6 criteria for all patho- 1545 haemorrhagic fever gens. Cases No. The 22 countries were divided into 4 287 287 groups (very high, high, medium and low No. Deaths affected countries) according to their total score. We first calculated the median of Yellow fever Yellow
the total score and the interquartile range. 1454 1454
Then, we compared the total score of each Cases No. country to the median and interquartile Pathogen 17 131 121 124 124 230
range values in order to classify each No.
country into one of the 4 categories: low Deaths affected country when total score was
between zero and the first quartile value; 6 45 163 747 455 883 27 500 medium affected country when total fever Rift Valley Cases No. score was greater than the first quartile value and under the median value; high
4 55 23 23 No.
affected country when total score was Deaths greater than the median value and under the third quartile value; and very high
3 5 4 31 10 201 100 227 249
affected country when total score was Nile fever West
equal or greater than the third quartile Cases No. value. 3 6
87 87 500 600 No.
Results Deaths dengue Reported cases and deaths Dengue/ 6 8 64 150 1 075 4 738 2 000 31 873 Total numbers and median of reported 20 000 haemorrhagic fever Cases No. cases and deaths for viral haemorrhagic fevers, Eastern Mediterranean Region, 1995–2015 Mediterranean Eastern haemorrhagic fevers, viral and deaths for cases cases and deaths for VHFs during 1995– a 2015 are summarized in Table 1. Human 3 8 15 14 14 14 23 121 cases for at least 1 pathogen were reported No. Deaths in 13 (59%) countries. Considering equine cases, 14 (64%) countries reported VHF fever . . 3 15 35 54 42 44 40 661 768 cases. Reported cases ranged from 2 for haemorrhagic Crimean–Congo Crimean–Congo
Alkhurma fever in Egypt to more than Cases No. 30 000 for dengue fever in Pakistan. While the highest number of actual reported cas- es was for dengue fever, the VHFs which had the widest geographical distribution were Crimean–Congo haemorrhagic fe- Country
ver, dengue and West Nile fever with 8 reported of numbers and median Total countries each. The median for reported cases ranged from 42 for Crimean–Congo Afghanistan Djibouti Egypt Islamic Republic Iran of Iraq Morocco Oman Pakistan Arabia Saudi Somalia Sudan Tunisia Arab Emirates United Yemen Median From a literature review performed in PubMed, review performed ProMED-Mail a literature databases using country and GIDEON From name and disease/virusrequest). (available upon terms specific Table 1 Table a
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haemorrhagic fever to 1454 for yellow fe- ver. The total reported deaths ranged from 22.7 22.7. 8 in the Islamic Republic of Iran to 720 in HRG Yemen. While Crimean–Congo haemor- rhagic fever had the widest geographical Tick-borne Tick-borne distribution among countries, dengue encephalitis GP was responsible for the greatest number of deaths: the number of reported deaths ranged from 3 Crimean–Congo haemor-
rhagic fever cases in Egypt to more than 1.3 1.3 HRG 500 dengue cases in Pakistan.
Prevalence in the general Alkhurma
population and in high–risk GP groups haemorrhagic fever The highest VHF seroprevalence in the 1.3 4.0 4.0 11.0
general population and in high–risk HRG groups during 1995–2015 is summarized in Table 2. Only 7 countries (31.8%) reported Hanta fever Hanta data on seroprevalence for at least 1 path- ogen in the general population. Seropreva- GP lence ranged from 0% for Crimean–Congo haemorrhagic fever to 21.8% for dengue 9.9 8.0 0.0 11.0 fever, both in Djibouti. Medians ranged 81.8 from 2.1% for Rift Valley fever to 21.8% for HRG dengue fever. Seroprevalence was most
frequently reported for West Nile fever; Pathogen 2.1 2.2 2.0 GP seroprevalence was not reported at all for fever Rift Valley some diseases (yellow fever, Alkhurma, tick-borne encephalitis and Ebola). Twelve countries (54.5%) reported data on sero- 27.7 23.7 54.1 19.2 12.8 24.9 65.0 30.4 58.0 prevalence in high–risk groups for at least HRG 1 pathogen, ranging from 2.4% for Crime- an–Congo haemorrhagic fever in Oman to 0.6 13.7 11.8 11.0 GP 35.0 West Nile fever West 81.8% for Rift Valley fever in Sudan, with a 118.0 median of 36.0%. Vectors and reservoirs 31.7 19.2 19.2 14.0 Highest and median prevalence of VHF HRG among vectors (ticks, mosquitoes) and reservoirs (livestock, birds, rodents, cam- els) are summarized in Table 3. Only 3 GP 21.8 21.8 Dengue/dengue Dengue/dengue
(13.6%) countries reported a prevalence haemorrhagic fever for vectors, Islamic Republic of Iran (28% for Crimean–Congo haemorrhagic fever 2.4 0.8 0.8 0.0 0.0 in ticks), Oman (13% for Crimean–Congo 17.5 HRG haemorrhagic fever in ticks) and Egypt (1.7% for West Nile virus in ticks). Addition- ally, 4 countries reported the presence of 0.0 11.2 11.2 GP 12.0 VHF viruses in vectors without prevalence Crimean–Congo haemorrhagic fever estimates. The remaining 15 countries did not report the presence or prevalence of vectors. Eleven (50%) countries reported data on reservoirs for at least 1 pathogen. For Yemen, no prevalence was reported, however, as more than 9000 deaths Region, 1995–2015 Mediterranean Eastern population and in high–risk groups, in general haemorrhagic fevers viral of seroprevalence reporteda and median Highest due to Rift Valley fever were reported Afghanistan Djibouti Egypt Islamic Republic Iran of Jordan Kuwait Morocco Oman Pakistan Arabia Saudi Sudan Tunisia Arab Emirates United Median Country From a literature review performed in PubMed, review performed ProMED-Mail a literature databases using country and GIDEON From name and disease/virusrequest). (available upon terms specific a population. in general GP = prevalence in high–risk groups. HRG = prevalence among livestock, a prevalence of 50% was 2 Table
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attributed to this country. Distribution ranged from 1% for West Nile virus in birds in Tunisia and Crimean–Congo Res haemorrhagic fever in livestock in Egypt
to 75% for Crimean–Congo haemorrhagic Kadam
fever in livestock in Afghanistan. The Vec > 0.0 > 0.0 median ranged from 3.6% for Hanta virus to 20.5% for Crimean–Congo haemorrhagic fever. Crimean–Congo haemorrhagic fever Res was also the most frequently reported VHF among the countries, followed by Rift Alkhurma . Vec > 0.0 Valley fever and West Nile fever. > 0.0 Scoring Scoring results for the 6 epidemiological 3.6 3.6. criteria are presented in Table 4. Total scores Res ranged from 0 for Bahrain, Libya, Palestine and Qatar to 26 for Saudi Arabia. The me- Hanta Fever Hanta
dian score was 6.0, with an inter-quartile Vec range from 1.0 to 11.75. Countries above the third quartile were Afghanistan, Egypt, Is- lamic Republic of Iran, Pakistan, Saudi Ara- 15.1 15.0 16.8 16.8 50.0 50.0 Res bia and Sudan. Scores were calculated for 63 (47.7%) of the 132 possible scores (6 × 22). The information most frequently missing Pathogen
was prevalence in both the general popula- Vec Rift Valley fever Rift Valley tion and in vectors, followed by prevalence in the reservoir.
Using the scoring results on prevalence 1 15.0 15.0 29.0 Res in humans and accidental hosts, countries were divided into 3 groups (high, medium and low relative prevalence). Countries with 1.7 1.7 Vec the highest relative prevalence for VHFs Nile Fever West were Afghanistan, Djibouti, Egypt, Islamic Republic of Iran and Saudi Arabia. Countries with a medium relative prevalence for VHFs Res were Kuwait, Morocco, Oman, Pakistan, Sudan and Tunisia. Low affected countries were Bahrain, Iraq, Jordan, Lebanon, Libya, Vec >0.0 > 0.0 > 0.0 Palestine, Qatar, Somalia, Syria, United Arab Dengue/dengue Emirates and Yemen. haemorrhagic fever Using the scoring results on prevalence 4.1 1.0 19.0 75.0 20.5 22.0 58.0 in vectors and reservoirs, countries were Res divided into 3 groups (high, medium and
low relative prevalence). Countries with Region, 1995-2015 Mediterranean Eastern and reservoirs, in vectors haemorrhagic fever viral of prevalence a the highest relative prevalence for VHFs 13.0 13.0 Vec 28.0 > 0.0 in vectors/reservoirs were Egypt, Islamic Crimean–Congo Republic of Iran, Oman, Morocco and Saudi haemorrhagic fever Arabia. Countries with a medium relative prevalence for VHFs in vectors/reservoirs were Afghanistan, Kuwait, Lebanon,
Somalia Sudan, Syrian Arab Republic, Tunisia and Yemen. Countries with a low relative prevalence for VHFs in vectors/ reservoirs were Bahrain, Djibouti, Iraq, reported and median Highest Jordan, Libya, Pakistan, Palestine, Qatar and Country Afghanistan Egypt Islamic Republic Iran of Kuwait Lebanon Morocco Oman Saudi Arabia Saudi Somalia Sudan Syria Tunisia Yemen Median From a literature review performed in PubMed review performed ®, ProMED-Mail® a literature databases using country and GIDEON® From name and disease/virusrequest). (available on terms specific Table 3 Table United Arab Emirates. a in vector. = prevalence Vec Res in reservoir. = prevalence
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Table 4 Scores for epidemiological criteria for viral haemorrhagic fever in countries of the Eastern Mediterranean Region, 1995–2015 Country Criterion Reported Reported Prevalence Prevalence Prevalence in Prevalence in Total score cases deaths in general in high–risk vectors reservoir population groups Afghanistan 6 2 2 7 0 2 19 Bahrain 0 0 0 0 0 0 0 Djibouti 2 0 5 1 0 0 8 Egypt 4 2 2 5 2 1 16 Iraq 2 2 0 0 0 0 4 Islamic Republic of Iran 3 1 3 3 2 4 16 Jordan 0 0 0 1 0 0 1 Kuwait 0 0 0 3 0 2 5 Lebanon 0 0 0 0 1 0 1 Libya 0 0 0 0 0 0 0 Morocco 2 2 2 0 1 3 10 Oman 2 3 0 2 2 2 11 Pakistan 6 4 0 2 0 0 12 Palestine 0 0 0 0 0 0 0 Qatar 0 0 0 0 0 0 0 Saudi Arabia 6 5 2 8 2 3 26 Somalia 3 2 0 0 0 2 7 Sudan 9 9 0 2 0 1 21 Syrian Arab Republic 0 0 0 0 1 0 1 Tunisia 2 2 2 2 0 1 9 United Arab Emirates 1 2 0 1 0 0 4 Yemen 3 3 0 0 0 2 8
Discussion ·· Saudi Arabia and Yemen border: Rift Valley fever, dengue fever, Alkhurma haemorrhagic fever; Global classification ·· United Arab Emirates and Oman border: Crimean– Our scoring results for VHFs allowed for dividing the Congo haemorrhagic fever. 22 countries from the East Mediterranean Region into 4 By providing laboratory capacity, EDPLN should groups (very high, high, medium and low affected coun- enhance the possibility of increasing outbreak tries). This global classification should help in prioritiz- investigations. This support might include mobile ing countries to be part of EDPLN. Nevertheless, each laboratory capacities, including mobile BSL3 and the country had specific epidemiological patterns of VHF: rapid diagnostic test (RDT) for field investigation of while some countries were more affected by outbreaks, VHF outbreaks. The EDPLN should play a critical role others had higher prevalence among risk groups, vectors in building a roster for a multidisciplinary team during or reservoirs. Accordingly, specific recommendations for outbreak investigations. The One Health initiative should outbreak investigations, surveillance and research are ad- be used as an opportunity for this purpose as well as the dressed. IHR (1). Outbreak investigation Emerging dangerous pathogens surveillance Likewise, for the scoring results on disease burden only By providing laboratory capacity, EDPLN should enhance (reported cases and deaths), countries were divided into the ability of countries to strengthen and/or set up labora- 4 groups. Each country had specific epidemiological pat- tory surveillance in the general population and high–risk terns of VHF. However, some pathogens were common groups. According to the scoring results on prevalence in between neighbouring countries. Cross-border investi- humans and accidental hosts, countries were divided into gations should be particularly relevant for the following 3 groups (high, medium and low relative prevalence). By borders and pathogens: providing laboratory capacities, EDPLN should also en- ·· Afghanistan, Islamic Republic of Iran and Pakistan hance the capacity of countries to strengthen and/or set borders: dengue fever and Crimean–Congo haemor- up laboratory surveillance in animals. According to the rhagic fever; scoring results on prevalence in vectors and reservoirs,
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countries were divided into 3 groups (high, medium and that reliability of data was prioritized for this work, and low relative prevalence). The role of livestock (Crimean– that unreliable data sources might lead to erroneous es- Congo haemorrhagic fever, Rift Valley fever, rickettsia timates. and leptospirosis) and camels (MERS-CoV) as reservoirs Unpublished surveillance data from ministries for many VHFs makes livestock/camels an important of health were not included. While they would have focus and target for EDP surveillance. Since VHFs are improved the completeness of our study for some almost always zoonotic, there is a need for focused sur- countries, it would have been difficult to combine both veillance at the human, livestock and wildlife interface. data sources (published and unpublished) without It is essential for EDPLN to conduct further serological possible double counting. studies in collaboration with the animal health sector. Another challenge was to summarize each criterion. Environmental investigation (e.g. water and food storage) Although outbreaks were reported, the number of cases may also help in public health decisions. and deaths were not always reported. Numbers were There is a need for differential diagnoses for VHFs. reported from different sources with probable double An appropriate algorithm and syndromic approach needs counting. Some numbers were simple estimations while to be developed and harmonized within the EDPLN. An others were confirmed cases. For this study, confirmed example would be the development of multiplex panels cases were used when available. For prevalence, general for screening and confirmation of suspected VHF cases population and high–risk groups, as well as vectors and using the Integrated Disease Surveillance and Response reservoirs were separated because they should provide 2 case definition. A referral system for confirmation has distinct indicators. Information on the general population been proposed for AFRO EDPLN (5). and among vectors was so scarce that a single criterion Research might have been an option. The challenge was finally to find the right balance between having a single criterion Information was scarce for many pathogens and coun- that might not capture all available information and too tries, highlighting the need to perform operational re- many criteria that might not inform our objective. search on VHFs. Discrepancies were noticed between Another issue was the methodology for scoring each criteria inside countries. For example, Afghanistan had criterion. Although today there are a number of published a large number of cases but information on vectors and tools to guide the process of setting priorities, only a few reservoirs was weak. This is an indication of the poten- publications describe the methodology in sufficient detail tial for research. Recommendations on research include and transparency to allow reproducibility or adaptation in performing, in order of priority: other settings (7–9). The concept of hotspots in infectious ·· prevalence studies in humans: for Crimean–Congo disease epidemiology varies widely in current research, haemorrhagic fever (Iraq), for dengue fever and Rift and may include aspects, such as incidence or prevalence, Valley fever (Somalia); transmission efficiency or risk, or probability of disease ·· vector and reservoir studies for Crimean–Congo emergence (10). For our study, the objective was neither to haemorrhagic fever (Afghanistan, Iraq, Pakistan), assess socioeconomic level nor health system capacity, but dengue fever (Afghanistan, Pakistan, Somalia, Yem- rather the disease burden and its potential transmission en), West Nile Fever (Afghanistan, Pakistan) and Rift in order to compare multiple diseases between multiple Valley fever (Yemen). countries. Therefore, we used a working method for the specific purposes of this study. The aim was to compare Limitations countries according to available information rather than Analyses were based on available information, mainly trying to provide absolute and precise estimates. The from PubMed, ProMED-Mail and GIDEON databas- median value of available information for each pathogen es. These 3 sources of information are reliable and well was used with this aim. This method has the advantage known. While ProMED-mail and GIDEON are robust of being simple and reproducible. Other methods include and sensitive mechanisms for the discovery of emerging the use of spatiotemporal techniques and geographic disease outbreaks involving humans, animals and plants information systems (11–13). But the objective in those around the world (6), PubMed is a robust and specific studies is to assess factors responsible for outbreak mechanism for publishing data on surveillance and re- emergence and spread in a specific area. Furthermore, it search. Other databases were not used. Some data might is rare to have a complete databases with geopositioning not have been captured because they were not included of all cases, such as the one for Crimean–Congo among our data sources. Embase is somewhat similar to haemorrhagic fever (14). Compared to the method used PubMed, however, it has more of a European focus and in Germany (15,16), our methodology did not weight each concentrates to a greater degree on the pharmacological criterion: the availability of the data alone weighted each literature. The Cochrane Library is a collection of databas- criterion. Alternatively, weighting would require a Delphi es that bring together in one place research on the effec- process, which was not possible for this study. tiveness of health care treatments and interventions, so it was not appropriate for our study. Furthermore, by using Conclusion few key words for searching, we remained very sensitive The results of this study highlighted hotspots for VHFs among the 3 databases we used. It is worthwhile noting in the Region, including Afghanistan, Egypt, Islamic
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Republic of Iran, Saudi Arabia and Sudan. This global research were separately addressed. classification should help in prioritizing countries to be Funding: this research was funded by the World Health part of EDPLN. Nonetheless, each country had specific Organization Regional Office for the Eastern Mediterra- epidemiological patterns of VHFs. Accordingly, recom- nean. mendations for outbreak investigations, surveillance and Competing interests: None declared.
Identification des foyers de transmission de fièvres hémorragiques virales dans la Région de la Méditerranée orientale : perspectives pour le Réseau des laboratoires travaillant sur les agents pathogènes émergents et dangereux (EDPLN) Résumé Contexte : L’émergence et la réémergence des fièvres hémorragiques virales (FHV) est une préoccupation mondiale croissante. Ces fièvres sont associées à la survenue d’épidémies majeures. On estime qu’entre 51 et 101 millions de cas surviennent chaque année, dont environ 67 000 sont mortels. En 2007, 13 pays de la Région de la Méditerranée orientale ont rapporté des cas de FHV. Objectifs : Le principal objectif de la présente étude était d’examiner la situation épidémiologique dans la Région eu égard aux FHV afin d’obtenir des informations épidémiologiques de base pour la mise en place du Réseau des laboratoires travaillant sur les agents pathogènes émergents et dangereux (EDPLN). Méthodes : Une recherche documentaire a été réalisée sur les bases de données PubMed, ProMED-Mail et GIDEON. Les données fournies incluaient la charge de morbidité (cas et décès signalés), la prévalence humaine (population générale, groupes à haut risque), les vecteurs et les réservoirs. Une méthode de notation a été utilisée pour diviser les pays en quatre groupes (pays très gravement touchés, gravement touchés, moyennement touchés et faiblement touchés). Résultats : Les pays très gravement touchés étaient l’Afghanistan, l’Arabie saoudite, l’Égypte, la République islamique d’Iran et le Soudan. Les pays gravement touchés étaient Djibouti, le Maroc, Oman, le Pakistan, la Tunisie et le Yémen. Les pays moyennement touchés étaient les Émirats arabes unis, l’Iraq et la Somalie. Les pays faiblement touchés étaient Bahreïn, la Jordanie, le Liban, la Libye, la Palestine, le Qatar et la République arabe syrienne. Conclusions : La présente étude aide à classer par ordre de priorité les pays destinés à faire partie de l’EDPLN et à répondre à des besoins spécifiques en lien avec les investigations des flambées, la surveillance et la recherche.
ُّالتعرفعىل مواقع اخلطر للحميات النزفية الفريوسية يف إقليم رشق املتوسط: وجهات نظر نحو إنشاء شبكة خمتربات لكشف مسببات األمراض املستجدة واخلطرية ماثياس ألتامن، كارين هنابيتيان، مهايون أصغر اخلالصة اخللفية: تثري ُاحل َّميات النزفية الفريوسية َّاملستجدة واملعاودة للظهور ًقلقا ًمتزايدايف مجيع أرجاء العامل. إذ تسبب أوبئة ضخمة يصل تعداد املصابني هبا كل عام إىل 51 -101 مليون شخص، ينتهي ما يقرب من 67 ًا ألفمنهم باملوت. ويف عام 2007، أبلغ 13 ًبلدا من إقليم رشق املتوسط عن حاالت مصابة ُباحل َّميات النزفية الفريوسية. متثل األهداف:اهلدف الرئييس من هذه الدراسة يف مراجعة األوضاع الوبائية يف اإلقليم ُللح َّميات النزفية الفريوسية للحصول عىل املعلومات األساسية الوبائية لتأسيس شبكة خمتربات مسببات األمراض املستجدة اخلطرية. طرق البحث: أجرى الباحثون ًبحثا ً شاماليف قواعد البيانات PubMed وProMED-Mail وGIDEON، وشملت البيانات التي تضمنتها التقارير عبء املرض )عدد احلاالت وعدد الوفيات التي ُأ ْب ِلغعنها( ومعدل االنتشار بني البرش )يف جممل السكان ويف املجموعات املعرضة ملخاطر عالية(، ونواقل األمراض ومستودعاهتا. واستخدم الباحثون طريقة لتعيني الدرجات، لتقسيم البلدان إىل 4 جمموعات )بلدان مرتفعة الترضر ًجدا، وبلدان مرتفعة الترضر، وبلدان متوسطة الترضر، وبلدان خفيفة الترضر(. النتائج: كانت البلدان املرتفعة الترضر ًجدا هي: أفغانستان ومرص ومجهورية إيران اإلسالمية واململكة العربية السعودية والسودان. وكانت البلدان املرتفعة الترضر هي: جيبويت واملغرب ُوع َ ن اموباكستان وتونس واليمن. وكانت البلدان املتوسطة الترضر هي: العراق والصومال واإلمارات العربية املتحدة. وكانت البلدان اخلفيفة الترضر هي: البحرين واألردن ولبنان وليبيا وفلسطني وقطر واجلمهورية العربية السورية. االستنتاجات: تساهم هذه الدراسة يف وضع البلدان وفق أولويتها لتكون ًامن جزءشبكة خمتربات مسببات األمراض املستجدة اخلطرية، ويف معاجلة االحتياجات املحددة ذات الصلة بعمليات استقصاء األوبئة، وترصدها، وبحثها.
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References 1. International health regulations, 2nd ed. Geneva: World health Organization; 2005. 2. Zapata JC, Cox D, Salvato MS. The role of platelets in the pathogenesis of viral hemorrhagic fevers. PLoS Negl Trop Dis. 2014 06 12;8(6):e2858. https://doi.org/10.1371/journal.pntd.0002858 PMID:24921924 3. Growing threat of viral haemorrhagic fevers in the Eastern Mediterranean Region : a call for action. Cairo: World Health Organi- zation, Regional Office for the Eastern Mediterranean; 2007. 4. WHO Emerging and Dangerous Pathogens Laboratory Network (EDPLN). Geneva: World Health Organization; 2015 (http:// www.who.int/csr/bioriskreduction/laboratorynetwork/en/, accessed 8 July 2018) 5. Report of the meeting of heads of Emerging and Dangerous Pathogens Reference Laboratories in the WHO African Region 27–30 May 2013, Harare-Zimbabwe. Harare: WHO Regional Office for Africa; 2013. 6. Madoff LC, Woodall JP. The internet and the global monitoring of emerging diseases: lessons from the first 10 years of ProMED- mail. Arch Med Res. Jan;36(6):724–30. PMID:16216654 7. Ghaffar A. Setting research priorities by applying the combined approach matrix. Indian J Med Res. 2009 Apr;129(4):368–75. PMID:19535830 8. Sibbald SL, Singer PA, Upshur R, Martin DK. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Serv Res. 2009 03 5;9(1):43. https://doi.org/10.1186/1472-6963-9-43 PMID:19265518 9. Viergever RF, Olifson S, Ghaffar A, Terry RF. A checklist for health research priority setting: nine common themes of good prac- tice. Health Res Policy Syst. 2010 12 15;8(1):36. https://doi.org/10.1186/1478-4505-8-36 PMID:21159163 10. Lessler J, Azman AS, McKay HS, Moore SM. What is a hotspot anyway? Am J Trop Med Hyg. Am J Trop Med Hyg. 2017 Jun;96(6):1270–3. doi: 10.4269/ajtmh.16-0427. PMID:28719289 11. Khalid B, Ghaffar A. Environmental risk factors and hotspot analysis of dengue distribution in Pakistan. Int J Biometeorol. 2015 Nov;59(11):1721–46. https://doi.org/10.1007/s00484-015-0982-1 PMID:25869291 12. Pezeshki Z, Tafazzoli-Shadpour M, Mansourian A, Eshrati B, Omidi E, Nejadqoli I. Model of cholera dissemination using geographic information systems and fuzzy clustering means: case study, Chabahar, Iran. Public Health. 2012 Oct;126(10):881–7. https://doi.org/10.1016/j.puhe.2012.07.002 PMID:22884859 13. Abdo-Salem S, Gerbier G, Bonnet P, Al-Qadasi M, Tran A, Thiry E, et al. Descriptive and spatial epidemiology of Rift valley fever outbreak in Yemen 2000-2001. Ann N Y Acad Sci. 2006 Oct;1081(1):240–2. https://doi.org/10.1196/annals.1373.028 PMID:17135517 14. Messina JP, Pigott DM, Duda KA, Brownstein JS, Myers MF, George DB, et al. A global compendium of human Crimean–Congo haemorrhagic fever virus occurrence. Sci Data. 2015 04 14;2:150016. https://doi.org/10.1038/sdata.2015.16 PMID:25977820 15. Balabanova Y, Gilsdorf A, Buda S, Burger R, Eckmanns T, Gärtner B, et al. Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011. PLoS One. 2011;6(10):e25691. doi: 10.1371/journal.pone.0025691 PMID:21991334 16. Krause G, the working group on prioritisation C; Working Group on Prioritisation at the Robert Koch Institute. Prioritisa- tion of infectious diseases in public health–call for comments. Euro Surveill. 2008 10 2;13(40):18996. https://doi.org/10.2807/ ese.13.40.18996-en PMID:18831949
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Prevalence and determinants of Caesarean delivery in Punjab, Pakistan
Faisal Abbas 1, Rafi Amir ud Din 2 and Maqsood Sadiq 3
1Department of Economics, George August University, Goettingen, Germany (Correspondence to: F. Abbas: [email protected]). 2Department of Management Sciences, COMSATS University of Information Technology, Lahore Campus, Pakistan. 3Population Council, Islamabad, Pakistan
Abstract Background: Caesarean section (C-section) is a life-saving obstetric procedure that reduces maternal mortality and im- proves reproductive health. Although, vaginal delivery is still an important safe and low-cost method of delivery, C-section is sometimes performed when it is not even required, which creates health challenges for pregnant women and their newborn infants. Aims: To estimate the effect of a set of institutional, demographic, socioeconomic and spatial variables on C-section de- livery (n = 2424) in Punjab, Pakistan. Methods: We used data from the Multiple Indicator Cluster Survey Punjab 2014 and multiple logistic regression analysis. Analysis was carried out using STATA version 12. Results: Higher maternal age at first marriage, higher number of antenatal care visits, and higher wealth quintiles were associated with higher risk of C-section. Women in Punjab were more likely to deliver through C-section in private health facilities and there was no significant difference between urban and rural areas. There was a significant difference in the risk of C-section in different divisions of Punjab, for example, DG Khan and Rawalpindi showed the lowest risk compared with the reference division of Bahawalpur, which is partially explained by the developmental disparities and access to public healthcare facilities. Conclusions: The government should facilitate access to healthcare facilities in areas that are easily accessible, especially, to rural women. Keywords: Caesarean section; institutional delivery; maternal health; Punjab; health services. Citation: Abbas F; Amir ud Din R; Sadiq M. Prevalence and determinants of Caesarean delivery in Punjab, Pakistan. East Mediterr Health J. 2018;24(11):1058–1069. https://doi.org/10.26719/2018.24.11.1058 Received: 30/08/16; accepted: 17/08/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction especially in developing countries (5). As a reference, the World Health Organization, in its 1985 report, suggested Pakistan is the fifth largest contributor to global mater- an optimal range for C-section rates of 5–15% (6). nal mortality and 6% of the world’s maternal deaths oc- cur in Pakistan (1). Maternal mortality rate in Pakistan is Many studies have found that the likelihood of delivery 276 deaths per 100 000 live births (2,3). Pregnancy-related through C-section depends on a number of institutional, complications are a major cause of maternal and infant demographic and socioeconomic factors. The availability morbidity and mortality (3) and in 2013, ~8000 wom- of facilities, obstetricians and the place of birth, that is, en (age 15–45 years) died in Pakistan. The reduction in private or public sector institutions, is associated with maternal mortality observed in high-income countries C-section rate (7,8). C-section is significantly associated has been achieved by providing access to skilled care with multiple conception, maternal age at birth, rise in during pregnancy and childbirth, and by provision of institutional deliveries, number of previous deliveries, safe interventions such as assisted vaginal delivery and site of prenatal care (private or public), socioeconomic caesarean section (C-section), which are also achievable status of household and access to antenatal care (9–11). in developing countries (4). C-section is a life-saving ob- Some maternal characteristics such as education and stetric procedure that reduces maternal mortality and access to antenatal care are also strongly associated with improves reproductive health outcomes for both mothers the likelihood of C-section (4,10,12). and newborn infants. Even though delivery by C-section In view of the recent understanding about the factors has become increasingly safe in the past decade, it still associated with C-section, this study identified a set of cannot replace vaginal delivery in terms of low mortali- socioeconomic, demographic, spatial and institutional ty, neonatal mortality and cost. However, during the last indicators associated with C-section delivery. We used three decades this surgical intervention has been un- data from the Multiple Indicator Cluster Survey (MICS) necessarily performed (for reasons other than obstetric conducted in Punjab province of Pakistan during 2014. We complications), leading to an increase in C-section rates focused on Punjab Province because it accounted for 53%
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of the total population of Pakistan according to the last 31–35 and ≥ 36 years. Maternal age at birth was divided census in 2017. The developments in Punjab are therefore into 4 categories: < 20, 20–29, 30–39 and ≥ 40 years. Birth expected to affect significantly national progress towards order of the child was divided into 3 categories: first, sec- achieving the United Nations Sustainable Development ond to fourth, and fifth and above. Socioeconomic vari- Goals. We expect that our results will make a significant ables included the education and wealth quintile of the contribution to public health policies in Punjab. mother (7,8,12). Maternal education was grouped into 5 categories: no education or preschool, which was equiva- Methods lent to incomplete primary education; primary (5 years of Study design, setting and sample size education); middle (8 years of education); secondary (10 years of education); and higher (> 10 years of education MICS is an international household survey developed by including college or university education of profession- the United Nations Children’s Fund (UNICEF). The Punjab al, vocational and general categories). Maternal wealth Province is divided into 9 administrative divisions and 36 quintile was divided into 5 categories: poorest, poor, mid- districts. The universal set for MICS Punjab 2014 consist- dle, rich and richest. ed of all the households and their members in all urban and rural areas of Punjab. Fieldwork for MICS Punjab The institutional variables included 3 dimensions: 2014 was carried out between June and September 2014. place of delivery; number of times the mother received A 2-stage, stratified cluster sampling approach was used antenatal care; and whether or not the mother received for sample selection. In urban areas, the first-stage selec- antenatal care (8,9,12,19). The variable of place of delivery tion unit is the enumeration block and in rural areas, it is consisted of 2 outcomes: birth at a public or private health the village. The first-stage units are selected with proba- facility. The number of times a mother received antenatal bility proportional to size. From each first-stage sample care consisted of 4 categories: 1–5, 6–12, 13–18 and ≥ 18. We unit, a sample of 20 households was selected with equal used 2 types of spatial variables in our analysis: area and probability, in both rural and urban areas, as secondary division. Area referred to the urban and rural residence. sampling units for urban and rural domains. The entire The division variable consisted of 9 administrative sample of households (secondary sampling units) was divisions of Punjab: Bahawalpur, DG Khan, Faisalabad, drawn from 2050 primary sampling units, of which, 774 Gujranwala, Lahore, Multan, Rawalpindi, Sahiwal and were urban and 1276 were rural, according to a system- Sargodha. atic sampling technique with a random start. The final Data analysis allocation was 2050 clusters with 20 households in each, giving a total sample of 41 000 households. The response We carried out bivariate analysis and logistic regression rate was almost 98% across Punjab Province. Further de- analysis to identify the determinants of C-section and to tails on MICS Punjab 2014 are provided elsewhere (13). predict the likelihood of the delivery by C-section. The The present study was based on publicly available data general logit model took the form: from MICS Punjab 2014 (http://mics.unicef.org/surveys). yt=x’t β+μt The study was not funded research or part of any other where yt was a binary response variable of delivery project, and it did not involve any human or animal ex- through C-section: periments, therefore, ethical approval was not required. yt= {(1 if a woman delivers through C–Section 0 Variables otherwise )
Dependent variable and xt was a vector of exogenous variables. The The dependent variable, binary in nature, was the mode conditional probability Pr (yt=1|xt) measured the of delivery, that is, normal delivery was coded as 0 (n = probability that a woman would give birth through th 8178) and delivery through C-section was coded as 1 (n = C-section. μt was the error for the t observation and 2424). We initially selected women who completed their coefficient β measured the change in probability of interview (n = 53 668) and then selected only those wom- delivery through C-section because of a unit change in en who gave birth within the last 2 years (n = 10 602) at xt. Assuming that the error term μt followed independent any of the public or private healthcare facilities. and identically distributed logistic distribution, the conditional probability was given as follows: Covariates Pr (yt=1 xt)=exp(x_t^’ β)/(1+ exp(x_t^’ β)) The covariates were classified into the following catego- | ries after literature review: demographic (maternal age at This model could be estimated by the maximum first marriage, maternal age at first birth and birth order likelihood estimation technique (20). of child); socioeconomic (maternal education level and wealth quintile); institutional (place of delivery and an- Results tenatal care visits); and spatial (area and administrative Table 1 gives descriptive statistics of women who un- divisions) (4,14–18). The demographic variables included derwent C-section according to a set of demographic, maternal age at first marriage, maternal age at birth and socioeconomic, institutional and spatial characteristics. birth order of the child (9,12). Maternal age at first mar- The proportion of women undergoing C-section mono- riage was divided into 5 categories: 15–19, 20–25, 26–30, tonically increased with age at first marriage from 18.9%
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Table 1 Percent delivered by C-section, various demographic, socioeconomic, institutional and spatial characteristics, MICS Punjab 2014 Selected variables Women delivered through No. of ever-married women who had C-section (%) a live birth in the last 2 yr Demographic variables Maternal age at first marriage (yr) 15–19 18.9 3965 20–25 26.1 4879 26–30 33.5 1107 31–35 39.2 167 ≥ 36 14.6 13 Maternal age at birth (yr) < 20 18.3 348 20–29 24.9 5936 30–39 23.1 3924 ≥ 40 14.7 446 Birth order of child 1 26.6 4182 2–4 21.1 4911 ≥ 5 17.3 867 Socioeconomic variables Education None/preschool 13.5 4816 Primary 21.1 1961 Middle 29.7 1096 Secondary 36.8 1467 Higher 44.6 1311 Wealth quintile Lowest 9.4 2327 Second 14.2 2166 Middle 23.5 2144 Fourth 31.8 2065 Highest 42.4 1951 Institutional variables Place of delivery Public facility 32.5 1909 Private facility 41.5 4565 Home 0.0 4125 No. of antenatal care visits None 5.4 1838 1–5 20.3 5867 6–12 41.4 2765 13–18 53.0 110 ≥ 18 50.2 30 Missing 14.5 43 Antenatal care received Yes 27.4 8815 No 5.5 1838 Spatial variables Area Urban 32.7 3284 Rural 19.7 7369 Administrative divisions Bahawalpur 20.1 1068 DG Khan 8.5 1181 Faisalabad 24.8 1237 Gujranwala 26.6 1578 Lahore 30 1914 Multan 24.6 1162 Rawalpindi 24.5 882 Sahiwal 30.5 827 Sargodha 19.2 804 Totala 23.6 10 653 aTotal number of women (weighted) who gave birth in the last 2 yr. MICS, Multiple Indicator Cluster Survey.
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in the 15–19 years’ age group to 39.2% in the 31–35 years’ risk, however, decreased when we controlled the institu- age group, and then decreased again for those > 36 years. tional variables with the spatial variable (Model 2) and When we considered maternal age at birth, the pattern of for demographic, spatial and socioeconomic variables delivery through C-section was broadly similar to that for combined (Model 3). The number of antenatal care visits maternal age at first marriage. Less than one fifth (18.3%) significantly affected the risk of C-section. Women who of women aged < 20 years at the time of delivery under- had 6–12 antenatal visits were 57% more likely to undergo went C-section but nearly 1 in 4 women aged 20–29 and C-section, and this increased further when women made 30–39 years (24.9% and 23.1%, respectively) underwent 13–18 antenatal visits compared to the reference catego- C-section. ry. This may have been due to known complications in Women giving birth to their first child were most likely the delivery, so the women needed more antenatal visits. to undergo C-section (26.6%) compared with subsequent Although, the category of 18+ antenatal visits was insig- births. Nearly 17% of the women giving birth to fifth or nificant, a possible explanation is that there was a limited subsequent children underwent C-section. Nearly 13.5% number of observations (i.e., 30). of the uneducated women compared to 44.6% of those with higher education had a C-section. Similarly, 9.4% of Demographic factors the women in the lowest wealth quintile and 42.4% in the The risk of undergoing C-section increased with age at highest quintile underwent C-section. The proportion of first marriage (Table 2). When the age at first marriage women who had a C-section at a private health facility was 20–25 years, the odds of delivery through C-section (41.5%) was higher than that at a public health facility were 1.26 times higher compared with those in the 15–19 (32.6%). Around 20% of the women who received antenatal years’ category (reference group). When age at first mar- care between 1 and 5 times underwent C-section, but > riage was 26–30 years, the odds increased further (OR 40% of women who had a C-section received antenatal 1.8). When age at first marriage was 31–35 years, women care 6–12 times. Over 50% of the women who received were 2.6 times more likely to deliver through C-section. antenatal care for ≥ 13 times underwent C-section. There was only a small change in the odds of undergoing The proportion of women undergoing C-section in C-section when we included additional control variables urban areas (32.7%) was significantly different from that (Models 2 and 3). The order of birth was a significant in rural areas (19.7%). According to administrative division, predictor of the risk of C-section. The second to fourth the smallest proportion of women had a C-section (8.5%) children were significantly less likely to be born through in D G Khan, while the highest (30.5%) was in Sahiwal. C-section compared with the first child (reference group). Lack of access to C-section facilities partially explains the Spatial and socioeconomic factors small percentage of women undergoing C-section, and easier access to facilities in Lahore (30%) and Rawalpindi There was no significant difference in the risk of C-sec- (24.5%) explains why a larger proportion of women tion for women living in urban and rural areas. However, underwent C-section. there were marked differences in the risk of C-section Table 2 gives the odds ratios (OR) from the logistic among the administrative divisions. The risk of C-section regression models that we estimated using a set of in Sahiwal was similar to that in Bahawalpur (reference institutional, demographic, socioeconomic and spatial division). Rawalpindi and DG Khan showed a significant- characteristics. Model 1 estimated OR using demographic ly lower risk of C-section, around 41 and 36%, compared and institutional explanatory variables. Model 2 included with the risk in Bahawalpur (reference division). Further variables of Model 1 and additional spatial explanatory research is called for to analyse the specific factors lead- variables. Model 3 included all variables combined. The ing to marked disparities in different geographical ad- Wald χ2 test statistics showed if the parameters of all the ministrative units in Punjab. The women in the highest variables in the estimated equation were simultaneously wealth quintile were almost 1.6 times more likely to un- equal to 0. Based on the P value associated with the dergo C-section (Model 3). Similarly, the risk of C-section χ2 values generated by the Wald test for Models 1, 2 also increased (in this case, significantly) with the wealth and 3, we rejected the null hypothesis, indicating that status of women. variables included in the estimated equation were not simultaneously 0. We also reported Hosmer–Lemeshow Discussion goodness of fit statistics and correspondingP values. P > Multivariate logistic regression analysis showed that 0.05 in all the estimated Models 1, 2 and 3 showed that the institutional variables including place of delivery and models fitted the data well. number of antenatal care visits had a significant impact on the rate of C-section. As the number of antenatal care Institutional factors visits increased, the risk of C-section decreased because Model 1 in Table 2 shows the association between insti- the women were expected to become more informed tutional variables (antenatal care and place of delivery) about their pregnancy-related issues and take precau- and risk of C-section after controlling for the demograph- tionary measures to avoid complications necessitating ic variables. Considering the place of delivery, a wom- C-section. This is contrary to the common believe that an was 40% more likely to undergo C-section when she access to healthcare services increases the likelihood of went to a private compared to public health facility. The C-section (4). Unlike some other studies (10), the risk of
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Table 2 Logistic regression of the effects of demographic, socioeconomic, institutional and spatial variables on C-section, MICS Punjab 2014 Variables Model 1 Model 2 Model 3 Odds ratio (95% confidence interval) Maternal age at birth (yr) < 20 Ref — — — — — 20–29 1.17 (0.75,1.82) 1.12 (0.71,1.77) 1.14 (0.72,1.81) 30–39 0.97 (0.61,1.54) 0.93 (0.58,1.50) 0.98 (0.61–1.57) ≥ 40 0.73 (0.41–1.31) 0.70 (0.38–1.27) 0.80 (0.44–1.46) Maternal age at first marriage (yr) 15–19 Ref — — — — — 20–25 1.26** (1.08–1.47) 1.27** (1.08–1.48) 1.18* (1.00–1.38) 26–30 1.80*** (1.41–2.30) 1.82*** (1.42–2.34) 1.62*** (1.26–2.10) 31–35 2.59*** (1.51–4.42) 2.72*** (1.58–4.68) 2.56*** (1.49–4.39) Birth order of child 1 Ref — — — — — 2–4 0.84* (0.73–0.96) 0.83** (0.72–0.95) 0.83* (0.72–0.96) ≥ 5 0.89 (0.68–1.18) 0.88 (0.67–1.17) 0.89 (0.67–1.17) Place of delivery Public Ref — — — — — Private 1.40*** (1.19–1.64) 1.36*** (1.16–1.60) 1.34*** (1.14–1.58) No. of antenatal care visits 1–5 Ref — — — — — 6–12 1.57*** (1.37–1.81) 1.62*** (1.40–1.88) 1.49*** (1.28–1.73) 13–18 2.76*** (1.61–4.73) 3.01*** (1.76–5.14) 2.73*** (1.60–4.64) ≥ 18 1.82 (0.71–4.63) 1.81 (0.69–4.74) 1.60 (0.59–4.31) Area Urban Ref — — — — — Rural 0.92 (0.80–1.06) 0.89 (0.76–1.04) Division Bahawalpur Ref — — — — — DG Khan 0.36*** (0.25–0.51) 0.38*** (0.26–0.55) Faisalabad 0.44*** (0.32–0.60) 0.42*** (0.31–0.57) Gujranwala 0.57*** (0.43–0.76) 0.49*** (0.37–0.65) Lahore 0.70* (0.57–1.05) 0.62** (0.46–0.84) Multan 0.77 (0.57–1.05) 0.76 (0.55–1.03) Rawalpindi 0.41*** (0.29–0.56) 0.35*** (0.25–0.49) Sahiwal 1.03 (0.76–1.41) 1.01 (0.74–1.39) Sargodha 0.46*** (0.33–0.64) 0.47*** (0.34–0.65) Maternal education None/preschool Ref — — — — — Primary 0.95 (0.77–1.17) Middle 1.11 (0.87–1.43) Secondary 1.15 (0.91–1.45) Higher 1.21 (0.94–1.56) Wealth index Lowest Ref — — — — — Second 1.02 (0.77–1.35) Middle 1.35* (1.02–1.79) Fourth 1.60** (1.18–2.17) Highest 1.65** (1.17–2.31) Constant 2.74*** (1.76–4.27) 1.51 (0.89–2.56) 2.20** (1.23–3.93) Observations 5211 5211 5209 χ2 217.39 1323.04 3816.1 Probability > χ2 0.0020 0.0090 0.0363 Hosmer–Lemeshow χ2 18.38 9.52 6.69 (Significance) 0.0186 0.3007 0.5702 *P < 0.05, **P < 0.01, ***P < 0.001. MICS, Multiple Indicator Cluster Survey.
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C-section was smaller in the private health facilities com- in our study, which contrasts with previous studies (4,16). pared with public health facilities, possibly because fewer There was a significant difference in the risk of C-section women could afford the high cost of C-section in the pri- among the divisions in Punjab Province. The DG Khan vate health facilities. Maternal age was a risk factor for division has the lowest while Rawalpindi is among the complications during pregnancy and it was estimated highest per capita income divisions in Punjab (13). Even that women aged > 30 years at the time of birth were at though Rawalpindi and DG Khan differ widely in many higher risk of C-section compared with those aged < 20 ways, such as the level of economic development and the years, as reported in previous studies (11,25). The risk of rate of school enrolment, both these divisions had the undergoing C-section decreased as the age of first mar- lowest incidence of C-section. It is plausible to believe that riage increased, supporting the long-held view that early better access to and provision of health services explain marriages (15–19 years) are associated with birth compli- the low C-section rate in Rawalpindi division (0.41 times cations (24–27). A significant number of studies has high- lower than the Bahawalpur reference division). However, lighted the risks involved in early marriages (21–23). Even the low proportion of women in DG Khan (0.36 times though the effect of maternal age at birth on the C-sec- lower than Bahawalpur) undergoing C-section counters tion risk is not significant, the risk of C-section associat- the impression that lack of access to basic health care, ed with older maternal age at birth is well documented distance and remoteness partly explain these findings, (8,11,18). There was a negative association between birth and this needs further investigation. order and the likelihood of C-section, indicating that the The present study had some limitations. First, it was likelihood was greater for the first child. However, many cross-sectional, thus, we cannot draw any conclusions studies have found that primiparous mothers are more about causality between the factors associated with likely to deliver through C-section (11,18). As the MICS C-section. Second, this study used data from the MICS Punjab 2014 data did not provide information about the Punjab 2014, which are representative of Punjab Province; frequency and number of pregnancies per woman, these hence we cannot generalize the results at a national level. issues were beyond the scope of this study. Third, it is not possible with the available data to establish The risk of C-section decreased with an increase whether the C-section was necessary. in maternal education. Although this effect could not In conclusion, we recommend that the Pakistani be precisely estimated in this study, there was strong Government should facilitate access to healthcare empirical evidence to suggest that higher education facilities that are easily accessible, especially, to rural was associated with lower risk of C-section. Maternal women. From programme and policy perspectives of education was expected to affect the risk of C-section healthcare interventions, it is imperative to investigate directly and indirectly. More-educated mothers are more further the disparities among administrative divisions. informed about hygiene and health standards (29,30). Confronting health challenges at a microgeographic level Maternal education is also assumed to indirectly affect will help develop public policy that better meets the goals the risk of C-section through social status (9). More- of Punjab Health Sector Plan 2018, Punjab Economic educated women are less likely to undergo C-section, Growth Strategy 2018 and Federal Government Vision possibly because they belong to social groups that can 2025. afford better nutrition and are, therefore, less likely to suffer from the complications that necessitate C-section Funding: None. (4). Wealthier women were more likely to opt for C-section Competing interests: None declared.
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Prévalence et déterminants de la pratique de la césarienne au Pendjab, Pakistan Résumé Contexte : La césarienne est une intervention obstétricale pouvant sauver des vies qui permet de réduire la mortalité maternelle et d’améliorer la santé génésique. Bien que l’accouchement par voie basse demeure une méthode d’accouchement recommandée, sûre et peu coûteuse, la césarienne est parfois pratiquée sans être pour autant nécessaire, ce qui crée des problèmes de santé pour les femmes enceintes et leurs nouveau-nés. Objectifs : La présente étude avait pour objectif de mesurer les effets d’un ensemble de variables institutionnelles, démographiques, socio-économiques et spatiales sur la pratique de la césarienne (n = 2424) au Pendjab (Pakistan). Méthodes : Les données issues de l’enquête à indicateurs multiples menée au Pendjab en 2014 et une analyse de régression logistique multiple ont été utilisées. Une analyse a été menée à l’aide du logiciel STATA (version 12). Résultats : Un âge maternel plus avancé lors du premier mariage, un nombre plus important de consultations prénatales, et des quintiles de richesse supérieurs étaient associés à un risque plus élevé de césarienne. Au Pendjab, les femmes étaient davantage susceptibles de donner naissance par césarienne dans les établissements de santé privés et aucune différence notable n’a été observée entre les zones urbaines et rurales. Une différence importante existait quant au risque de césarienne entre les différents districts du Pendjab. Par exemple, Dera Ghazi Khan et Rawalpindi affichaient le risque le plus bas en comparaison à Bahawalpur, le district de référence, ce qui s’explique en partie par des disparités de développement et la possibilité d’être pris en charge dans des établissements de soins de santé publics. Conclusion : Le gouvernement devrait faciliter l’accès aux établissements de soins de santé dans les régions faciles d’accès, notamment pour les femmes vivant dans les zones rurales.
معدل انتشار الوالدة القيرصية ِّوحمدداهتا يف البنجاب، باكستان فيصل عباس، رفيع أمري الدين، مقصود صادق اخلالصة تنقذاخللفية: الوالدة القيرصية حياة األمهات وتنقص معدالت الوفيات بينهن ِّوحتسن الصحة اإلنجابية. ورغم أن الوالدة املهبلية ال تزال من طرق الوالدة اآلمنة واهلامة والقليلة التكاليف، فإن العملية القيرصية ُترى ًا حتىأحيان عندما ال تستدعي احلاجة إجراؤها، مما خيلق حتديات صحية للحوامل وألطفاهلن حديثي الوالدة. األهداف:هدفت الدراسة إىل تقدير تأثري جمموعة من املتغريات املؤسسية والسكانية واالجتامعية االقتصادية واملكانية يف الوالدة القيرصية، ُوأجريت الدراسة عىل 2424سيدة يف البنجاب يف باكستان. طرق البحث:استخدم الباحثون بيانات من مسح عنقودي متعدد املؤرشات ُأجري يف البنجاب عام 2014، ومن حتليل ُّ فالتحو اللوجستي املتعدد. وقد أجروا التحليل باستخدام النسخة 12 من برنامج STATA. النتائج:ترافقت املخاطر العالية للعملية القيرصية مع تقدم عمر األم وقت زواجها، وبزيادة عدد الزيارات السابقة للوالدة إىل املركز الصحي، وعلو الرشحية املئوية للثروة. وبدا احتامل أن تلد املرأة يف البنجاب بعملية قيرصية أكرب يف املرافق الصحية اخلاصة، ومل يكن هناك فرق بني املناطق الريفية واحلرضية. وكان هناك فرق ملحوظ يف خماطر العملية القيرصية باختالف املقاطعات يف البنجاب، فعىل سبيل املثال أبدت منطقتي ديرة غازي خان وراولبندي أقل املخاطر مقارنة باملنطقة املرجعية يف باهاوالبور، ويمكن تفسري هذا االختالف ًجزئيا بالتفاوت يف التطور ويف الوصول إىل املرافق الصحية العامة. االستنتاجات:جيب عىل احلكومة أن ِّل تسهالوصول إىل مرافق الرعاية الصحية يف املناطق التي تتاح فيها تلك املرافق، وال ّسيام للسيدات الريفيات.
References 1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010 May 8;375(9726):1609–23. https://doi. org/10.1016/S0140-6736(10)60518-1 PMID:20382417 2. Pakistan Demographic and Health Survey 2006-07. Islamabad: National Institute of Population Studies Islamabad, Pakistan and Calverton, MD: Macro International Inc.; 2007 (https://dhsprogram.com/pubs/pdf/fr200/fr200.pdf, accessed 15 August 2018). 3. Bhutta ZA, Hafeez A. What can Pakistan do to address maternal and child health over the next decade? Health Res Policy Syst. 2015 Nov 25;13(1) Suppl 1:49. https://doi.org/10.1186/s12961-015-0036-5 PMID:26792061 4. Leone T, Padmadas SS, Matthews Z. Community factors affecting rising caesarean section rates in developing countries: an anal- ysis of six countries. Soc Sci Med. 2008 Oct;67(8):1236–46. https://doi.org/10.1016/j.socscimed.2008.06.032 PMID:18657345 5. Feng XL, Xu L, Guo Y, Ronsmans C. Factors influencing rising caesarean section rates in China between 1988 and 2008. Bull World Health Organ. 2012 Jan 1;90(1):30–9. https://doi.org/10.2471/BLT.11.090399 PMID:22271962
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6. Appropriate technology for birth. Lancet. 1985 Aug 24;2(8452):436–7. PMID:2863457 7. Neuman M, Alcock G, Azad K, Kuddus A, Osrin D, More NS, et al. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ Open. 2014 Dec 30;4(12):e005982. https://doi.org/10.1136/bmjopen-2014-005982 PMID:25550293 8. Padmadas SS, Kumar S, Nair SB, Kumari A. Caesarean section delivery in Kerala, India: evidence from a National Family Health Survey. Soc Sci Med. 2000 Aug;51(4):511–21. https://doi.org/10.1016/S0277-9536(99)00491-8 PMID:10868667 9. Khawaja M, Kabakian-Khasholian T, Jurdi R. Determinants of caesarean section in Egypt: evidence from the demographic and health survey. Health Policy. 2004 Sep;69(3):273–81. https://doi.org/10.1016/j.healthpol.2004.05.006 PMID:15276307 10. Khawaja NP, Yousaf T, Tayyeb R. Analysis of caesarean delivery at a tertiary care hospital in Pakistan. J Obstet Gynaecol. 2004 Feb;24(2):139–41. https://doi.org/10.1080/jog.24.2.139.141 PMID:14766448 11. Mishra US, Ramanathan M. Delivery-related complications and determinants of caesarean section rates in India. Health Policy Plan. 2002 Mar;17(1):90–8. https://doi.org/10.1093/heapol/17.1.90 PMID:11861590 12. Khawaja M, Jurdi R, Kabakian-Khasholian T. Rising trends in cesarean section rates in Egypt. Birth. 2004 Mar;31(1):12–6. https:// doi.org/10.1111/j.0730-7659.2004.0269.x PMID:15015988 13. Bureau of Statistics. Planning & Development Department, Government of the Punjab and UNICEF Punjab. Multiple Indicator Cluster Survey, Punjab 2014, Final Report. Lahore: Bureau of Statistics Punjab, Planning & Development Department, Govern- ment of the Punjab and UNICEF Punjab; 2016 (https://mics-surveys-prod.s3.amazonaws.com/MICS5/South%20Asia/Pakistan%20 %28Punjab%29/2014/Final/Pakistan%20%28Punjab%29%202014%20MICS_English.pdf, accessed 15 August 2018). 14. Ahmad-Nia S, Delavar B, Eini-Zinab H, Kazemipour S, Mehryar AH, Naghavi M. Caesarean section in the Islamic Republic of Iran: prevalence and some sociodemographic correlates. East Mediterr Health J. 2009 Nov–Dec;15(6):1389–98. PMID:20218129 15. Lauer JA. BetránAna P, Merialdi M, Wojdyla D. Determinants of caesarean section rates in developed countries: supply, demand and opportunities for control. World Health Report (2010) Background Paper, No 29. Geneva: World Health Organization; 2010 (http://www.who.int/healthsystems/topics/financing/healthreport/29DeterminantsC-section.pdf, accessed 15 August 2018). 16. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet. 2006 Oct 28;368(9546):1516–23. https://doi.org/10.1016/S0140-6736(06)69639-6 PMID:17071285 17. Stanton CK, Holtz SA. Levels and trends in cesarean birth in the developing world. Stud Fam Plann. 2006 Mar;37(1):41–8. https:// doi.org/10.1111/j.1728-4465.2006.00082.x PMID:16570729 18. Abebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review. Reprod Health. 2016 Jan 20;13(1):6. https://doi.org/10.1186/s12978-015-0114-8 PMID:26792611 19. Najmi RS, Rehan N. Prevalence and determinants of caesarean section in a teaching hospital of Pakistan. J Obstet Gynaecol. 2000 Sep;20(5):479–83. https://doi.org/10.1080/014436100434640 PMID:15512631 20. Greene WH. Econometric analysis, 5th edition. Upper Saddle River, NJ: Pearson Education; 2003. 21. Duflo E, Dupas P, Kremer M. Education, HIV, and early fertility: experimental evidence from Kenya. Am Econ Rev. 2015 Sep;105(9):2757–97. https://doi.org/10.1257/aer.20121607 PMID:26523067 22. Kamal SM. What is the association between maternal age and neonatal mortality? An analysis of the 2007 Bangladesh De- mographic and Health Survey. Asia Pac J Public Health. 2015 Mar;27(2):NP1106–17. https://doi.org/10.1177/1010539511428949 PMID:22186392 23. Pandya YP, Bhanderi DJ. An epidemiological study of child marriages in a rural community of Gujarat. Indian J Community Med. 2015 Oct–Dec;40(4):246–51. https://doi.org/10.4103/0970-0218.164392 PMID:26435597 24. Cavallaro FL, Cresswell JA, França GV, Victora CG, Barros AJ, Ronsmans C. Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013 Dec 1;91(12):914–922D. https://doi.org/10.2471/BLT.13.117598 PMID:24347730 25. Karkee R, Lee AH, Khanal V, Pokharel PK, Binns CW. Obstetric complications and cesarean delivery in Nepal. Int J Gynaecol Obstet. 2014 Apr;125(1):33–6. https://doi.org/10.1016/j.ijgo.2013.09.033 PMID:24447414 26. Nasrullah M, Zakar R, Krämer A. Effect of child marriage on use of maternal health care services in Pakistan. Obstet Gynecol. 2013 Sep;122(3):517–24. https://doi.org/10.1097/AOG.0b013e31829b5294 PMID:23921855 27. Raj A, Boehmer U. Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries. Violence Against Women. 2013 Apr;19(4):536–51. https://doi.org/10.1177/1077801213487747 PMID:23698937 28. Sikder SS, Labrique AB, Shamim AA, Ali H, Mehra S, Wu L, et al. Risk factors for reported obstetric complications and near misses in rural northwest Bangladesh: analysis from a prospective cohort study. BMC Pregnancy Childbirth. 2014 Oct 4;14(1):347. https://doi.org/10.1186/1471-2393-14-347 PMID:25282340 29. Greco G, Skordis-Worrall J, Mkandawire B, Mills A. What is a good life? Selecting capabilities to assess women’s quality of life in rural Malawi. Soc Sci Med. 2015 Apr;130:69–78. https://doi.org/10.1016/j.socscimed.2015.01.042 PMID:25687242 30. Tsai SY, Lee CN, Wu WW, Landis CA. Sleep hygiene and sleep quality of third-trimester pregnant women. Res Nurs Health. 2016 Feb;39(1):57–65. https://doi.org/10.1002/nur.21705 PMID:26650922
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Dépistage de l’hypothyroïdie congénitale au Maroc : étude pilote
Saâd Maniar 1, Chadia Amor 2 et Abbas Bijjou 3
1Observatoire régional d’épidémiologie, Hôpital Al Ghassani, Fès (Maroc) (Correspondance à adresser à S. Maniar : [email protected]). 2Service de pédiatrie, Hôpital Ibn Al Khatib, Fès (Maroc). 3Service de la Santé publique, Direction régionale de la Santé de Fès-Boulemane, Fès (Maroc).
Résumé Contexte : Au Maroc, nous ne disposons pas d’informations fiables sur la fréquence de l’hypothyroïdie congénitale (HC) . Objectifs : La présente étude visait à évaluer la faisabilité d’un programme de dépistage néonatal de la maladie au Maroc. Méthodes : Nous avons mené une campagne de dépistage de l’HC chez 15 615 nouveau-nés à la wilaya de Fès au Centre- Nord du Maroc. Résultats : Douze cas d’hypothyroïdie ont été confirmés, soit une fréquence de 1 pour 1301 naissances. Lorsqu’on exclut les quatre cas d’hypothyroïdie transitoire, la fréquence de l’HC est de 1 pour 1952 naissances. L’athyréose représente 25 % des cas, l’agénésie partielle 25 % des cas et 50 % des cas présentent une glande en place ; 67 % des cas d’HC sont de sexe féminin et 33 % de sexe masculin. La moyenne d’âge de dépistage est de 17,1 (écart type [ET] 6,6) jours et celle du début du traitement est de 43,4 (ET 8,7) jours. Le suivi des cas mis sous traitement substitutif a montré une bonne évolution des paramètres anthropométriques et psychomoteurs. L’étude qualitative a permis de constater que les parents prennent le suivi de leur bébé très au sérieux en dépit du niveau socio-économique très bas de la grande majorité d’entre eux. Conclusion : les résultats de notre étude soulignent la nécessité de la mise en place d’un programme de dépistage néonatal de l’hypothyroïdie congénitale au Maroc. Mots clés : hypothyroïdie congénitale, dépistage, dosage combiné TSH-T4, traitement substitutif Citation : Maniar S; Amor C; Bijjou A. Dépistage de l’hypothyroïdie congénitale au Maroc : étude pilote. East Mediterr Health J. 2018;24(11):1066-1073. https://doi.org/10.26719/2018.24.11.1066 Reçu : 02/02/15 ; accepté : 04/06/18 © Organisation mondiale de la Santé 2018. Certains droits réservés. La présente publication est disponible sous la licence Creative Commons Attribution – Pas d’utilisation commerciale – Partage dans les mêmes conditions 3.0 IGO (CC BY‑NC–SA 3.0 IGO ; (https://creativecommons.org/ licenses/by–nc–sa/3.0/igo).
Introduction et 1997 n’a pas été achevée en raison de divers problèmes. En effet, elle n’a touché que 3300 nouveau-nés au lieu de L’hypothyroïdie congénitale (HC) est la plus fréquente 15 000 prévus initialement (14). des maladies endocriniennes (1,2). Sa fréquence se situe entre 1/3500 et 1/4000 naissances dans la majorité Notre travail a pour but de connaître la fréquence des pays ayant instauré un programme de dépistage de l’hypothyroïdie congénitale dans la wilaya de Fès qui systématique (2-13). Cette affection est caractérisée par est considérée comme une zone d’endémie goitreuse, des troubles de la morphogenèse et de l’hormonogenèse d’étudier la faisabilité d’un programme de dépistage de la thyroïde avec une insuffisance totale ou partielle de systématique au niveau régional avec une éventuelle la sécrétion des hormones thyroïdiennes. L’évolution de la généralisation au niveau national et d’évaluer la maladie se fait vers un retard mental sévère et irréversible, perception, le comportement et les attitudes des parents associé à un nanisme et à d’autres manifestations d’enfants dépistés positifs. cliniques et métaboliques, ce qui constitue un lourd fardeau pour la famille et la société (2). Méthodes Les premières expériences de dépistage menées Type d’étude depuis les années soixante-dix au Canada (3), aux États- Notre projet comporte essentiellement deux types Unis d’Amérique (4) et en Europe (6,10) avaient montré d’études : l’efficacité d’un dépistage néonatal par le dosage de la TSH (thyroid-stimulating hormone – thyréostimuline) ·· un dépistage qui a permis de constituer une cohorte et/ou de la T4 (thyroxine). En fait, le dépistage n’a de nouveau-nés confirmés hypothyroïdiens qui ont pas fait disparaître la maladie, mais il en a modifié fait l'objet d'un suivi prospectif pendant sept ans ; l’expression (1,12). ·· une étude qualitative rétrospective dont le but est Au Maroc, nous ne disposons pas de données sur de dégager les forces, les faiblesses et les contraintes la fréquence de l’hypothyroïdie congénitale, et peu rencontrées lors de l’exécution du dépistage. Elle d’études se sont intéressées à ce sujet. La première a concerné les parents des nouveau-nés dépistés campagne de dépistage néonatal de l’hypothyroïdie positifs et les professionnels de santé impliqués dans congénitale (DNHC) qui s’est déroulée à Rabat entre 1995 le projet.
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Lieu d’étude et éventuelle prise en charge thérapeutique. Une fiche d’identification et un dossier médical sont Notre étude s’est déroulée au niveau de la ville de constitués pour chaque cas. Fès et de la province de Sefrou ; 34 centres de santé ont été impliqués dans le dépistage de février 2001 à En cas de prélèvement insuffisant, le nouveau-né janvier 2003. est convoqué pour un deuxième prélèvement sur papier buvard. Population cible La campagne de dépistage de l’hypothyroïdie congénitale Éthique a ciblé une population attendue de 15 000 nouveau-nés Ne disposant pas d’un comité d’éthique institutionnel, recrutés à l’occasion de la première vaccination (BCG – et afin de valider le protocole du projet, nous avons mis Bacille Calmette et Guérin). Ont été exclus de notre étude en place un comité de gestion et de suivi regroupant des tous les enfants qui se sont présentés à la vaccination représentants de la Direction régionale de la Santé de Fès- par le BCG avec un âge supérieur à un mois. Les parents Boulemane, de la Direction de l’Épidémiologie et de Lutte des nouveau-nés dépistés positifs ont été aussi ciblés par contre les Maladies et du Centre national de l’Énergie, notre étude qualitative. des Sciences et des Techniques Nucléaires (CNESTEN). Les exigences que nous nous sommes imposés avant Supports de recueil des données et sources le démarrage du projet sont le consentement éclairé d’information des parents des nouveau-nés recrutés, l’offre de soins Pour le recueil des données, nous avons utilisé : en respectant l’éthique et la déontologie médicale, et ·· les fiches d’identification et les dossiers médicaux des l’assurance d’une prise en charge complète des nouveau- nouveau-nés positifs ; nés dépistés positifs pendant toute la durée du projet. ·· les registres et les cartes des prélèvements ; Résultats ·· des questionnaires destinés aux parents des nouveau- Données sur le dépistage de l’HC au niveau de nés dépistés positifs et aux professionnels de santé impliqués dans le projet. la wilaya de Fès Durant la campagne de dépistage de l’hypothyroïdie Prélèvements et méthodes de dosage congénitale réalisée au niveau de la wilaya de Fès, Les prélèvements consistent en des gouttes de sang 15 615 prélèvements ont été effectués au niveau des capillaire, recueillies au niveau de la face latérale du talon 34 centres de santé impliqués dans le projet. par scarification au moyen d’un vaccinostyle et déposées Comme le montre le tableau 1, 6688 nouveau-nés, sur papier buvard (Whatman body fluid collection paper – soit 42,83 %, sont de sexe masculin et 8927 sont de sexe BFC180) selon la procédure reconnue par l’Organisation féminin, soit 57,16 %. Sur les 15 615 nouveau-nés soumis mondiale de la Santé (OMS) (15). Pour le dépistage, au dépistage, 82 ont été recontrôlés, soit un taux de rappel nous avons adopté le dosage combiné de la TSH selon la de 0,52 %. méthode radio-immunométrique TSH-IRMA néonatale et le dosage de la T4 par méthode radio-immunologique Sur les 82 nouveau-nés dépistés positifs sur papier T4-RIA sur sang total (16). buvard, 46 se sont avérés normaux lors du contrôle sur sérum, soit 56,09 % de faux positifs. Douze cas d’HC Seuil décisionnel et protocole de dépistage ont été confirmés, soit un cas pour 1301 nouveau-nés ; Tout nouveau-né ayant une TSH ≥ 20 µUI/mL et une T4 24 nouveau-nés, soit 29,26 %, ont été perdus de vue et totale ≤ 60 nmol/L est suspecté comme ayant une HC. Un donc n’ont pas pu être contrôlés sur sérum. L’âge moyen deuxième contrôle est effectué sur les tâches de sang du des nouveau-nés au premier prélèvement était de même spécimen : 17 jours. ·· si la TSH est ≤ 20 µUI/mL, le nouveau-né est considéré Répartition des cas d’HC dépistés positifs normal ; selon le sexe, l’âge et les indicateurs ·· si la TSH est ≥ 20 µUI/mL, le nouveau-né subit un anthropométriques au moment du diagnostic second prélèvement sur papier filtre (dosage de la Sur les 12 cas positifs, 67 % sont de sexe féminin et 33 % TSH et de la T4) et un premier prélèvement sur sérum de sexe masculin. Tous avaient un poids, une taille et (dosage de la TSH et de la FT4) : un périmètre crânien normaux pour l’âge au moment –– si la TSH est ≤ 20 µUI/mL sur papier filtre et la du diagnostic. La moyenne d’âge de dépistage est de TSH sur sérum est ≤ 4 µUI/mL, le nouveau-né est 17,1 (écart type [ET] 6,6) jours avec un âge maximum de considéré normal ; 28 jours et minimum de 7 jours. De même, la moyenne –– si la TSH est ≥ 20 µUI/mL sur papier filtre et la d’âge de début du traitement est de 43,4 (ET 8,7) jours avec TSH sur sérum est ≥ 4 µUI/mL, le nouveau-né un âge maximum de 55 jours et minimum de 30 jours. La est considéré ayant une HC (HC+) ; il est envoyé moyenne du délai entre dépistage et début du traitement immédiatement au service régional de pédiatrie de est de 26,0 (ET 9,7) jours avec un maximum de 41 jours l’hôpital Ibn Al Khatib de Fès pour examen clinique et un minimum de 13 jours.
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Tableau 1 Résultats quantitatifs du dépistage de l’hypothyroïdie congénitale (HC) Sexe Total Masculin Féminin Prélèvements 6688 8927 15 615 (42,83 %) (57,16 %) Suspects 46 36 82 (Taux de rappel) (0,52 %) Contrôle – 30 16 46 (Faux positifs) (56,09 %) Contrôle + 4 8 12 Incidence HC 1/1672 1/1951 1/1301 Perdus de vue 8 16 24 (29,26 %)
Bilan radiologique des cas dépistés positifs au à des troubles de la morphogenèse. Lorsqu’on exclut moment du diagnostic les cas transitoires, l’athyréose représente 25 % des cas, l’agénésie partielle 25 % des cas et 50 % des cas présentent Comme le montre le tableau 2, chez les neuf cas pour une glande en place (Figure 1). lesquels la radiographie du poignet a été faite, l’âge osseux est compatible avec l’âge chronologique. Chez Suivi clinique les dix cas pour lesquels la radiographie du genou a été Un cas d’hypothyroïdie congénitale confirmée associé faite, le point de Béclard est présent chez tous les cas. à une hydrocéphalie dérivée sur myéloméningocèle est Le point de Todd est absent chez deux cas (cas 1 et 4) décédé à l’âge de quatre mois après hospitalisation au présentant une athyréose/agénésie totale. L’échographie Centre Hospitalier Universitaire (CHU) de Rabat-Salé et cervicale, réalisée chez dix cas, a montré une agénésie un cas d’hypothyroïdie transitoire a été perdu de vu (cas totale chez deux cas, une agénésie partielle chez deux 9 et 12). cas et une glande en place pour six cas. La scintigraphie D’après les courbes du poids, de la taille et du périmètre lorsqu’elle a été réalisée (six cas) a confirmé les résultats crânien, nous constatons que : de l’échographie cervicale. ·· pour les trois cas d’hypothyroïdie transitoire non Fréquence de l’HC selon l’étiologie traités, l’évolution du poids, de la taille et du périmètre Comme le montre le tableau 3, la fréquence des cas crânien en fonction de l’âge est normale ; dépistés positifs est de 1 pour 1301 naissances. Si nous ·· pour les sept cas d’hypothyroïdie confirmée mis excluons les formes transitoires, la fréquence des cas sous traitement substitutif, 71 % ont une évolution d’hypothyroïdie congénitale confirmée est de 1 pour du poids normale pour l’âge et 29 % ont présenté 1952 naissances. un excès pondéral (+2 ET) vers l’âge de neuf mois. L’étiologie est répartie comme suit : 66,6 % sont liés L’évolution de la taille et du périmètre crânien de ces à des troubles de l’hormonogenèse et 33,4 % sont liés cas n’a pas révélé d’anomalies à sept ans.
Tableau 2 Bilan radiologique des cas dépistés positifs au moment du diagnostic Nouveau-né Point Béclard Point Todd Âge osseux Échographie Scintigraphie
Cas 1 P A compatible Agénésie totale Athyréose Cas 2 P P compatible Glande en place Glande en place Cas 3 P P compatible Agénésie partielle Lobe unique Cas 4 P A compatible Agénésie totale NF Cas 5 P P compatible Glande en place Glande en place Cas 6 P P compatible Glande en place NF Cas 7 P P compatible Agénésie partielle NF Cas 8 P P - Glande en place NF Cas 9 - - - - - Cas 10 P P compatible Glande en place Glande en place Cas 11 P P compatible Glande en place Glande en place Cas 12 - - - - -
P : présent ; A : absent ; NF : non fait.
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Tableau 3 Fréquence de l’hypothyroïdie congénitale (HC) dans la wilaya de Fès selon l’étiologie (n = 15 615) Étiologie Ensemble des HC dépistées Estimation en excluant les HC transitoires Nombre % Fréquence % Fréquence Athyréose 2 16,7 1/7808 25 Agénésie partielle 2 16,7 1/7808 25 Glande en place 4 33,3 1/3904 50 HC transitoire 4 33,3 1/3904 Total 12 1/1301 1/1952
Suivi biologique effectuer une scintigraphie. Le montant global des dépenses engagées par les familles (transport et certaines D’après le suivi biologique des sept cas d’hypothyroïdie confirmée mis sous traitement substitutif, on constate investigations) varie de 15 à 325 dollars des États-Unis qu’à deux mois, quatre cas sur sept ont normalisé leur TSH. pour une famille qui préférait faire ses analyses à son À quatre mois, tous les cas ont une TSH normale ou basse, propre compte. ce qui a nécessité des réajustements thérapeutiques. Discussion Suivi psychomoteur Dans notre étude, le dépistage a été domicilié au niveau L’évolution psychomotrice, jusqu’à 24 mois pour quatre de la cellule de santé maternelle et infantile des centres cas et jusqu’à 18 mois pour trois cas, est normale pour de santé au lieu des maternités, comme c’est le cas la majorité des cas (six sur sept). La station assise a été dans d’autres pays qui ont instauré un programme de acquise en moyenne entre six et sept mois, la station dépistage systématique de l’HC (1,2). Ceci est dû à deux debout entre neuf et 12 mois, la marche sans aide entre faits importants : 14 et 15 mois et le langage (gazouillement) entre quatre et ·· un faible taux de couverture des accouchements en cinq mois. milieu surveillé ne dépassant pas 50 % aussi bien au À l’âge de sept ans, sur les sept cas mis sous traitement niveau régional que national (17) ; substitutif, six avaient une scolarité normale. Un seul cas (cas 3) a présenté à 25 mois un retard manifeste avec ·· une courte durée de séjour des femmes en post- hypotonie axiale, impossibilité de se mettre debout et partum, ne dépassant généralement pas 24 heures position assise avec aide. pour un accouchement normal, alors que le prélèvement pour le dosage de la TSH et de la T4 doit Déterminants rapportés par les parents des nouveau-nés dépistés positifs Sur les 12 cas positifs, on s’est entretenu avec les parents de 11 cas, dont neuf mères et deux grands-mères ; un seul cas était inaccessible pour cause de changement d’adresse. La maladie est perçue comme une fatalité ; elle engendre un désarroi et une incertitude sur l’avenir des Athyréose enfants. 25 % L’accueil des parents aux différents niveaux de diagnostic, de prise en charge et de suivi était très Glande en place satisfaisant pour 91 % des parents interrogés ; 82 % des parents ont déclaré ne pas avoir reçu une information 50 % suffisante sur le dépistage au niveau des centres de santé. Cependant, ils ont affirmé l’avoir reçue au niveau Agénésie partielle de l’Observatoire régional d’épidémiologie (ORE) et du 25 % Service de pédiatrie. Concernant le consentement pour le prélèvement, selon les parents, il n’a pas été demandé systématiquement. Les parents prennent le suivi très au sérieux en dépit du niveau socio-économique très bas de la grande majorité d’entre eux. Concernant la prise en charge, 44 % des cas avaient bénéficié d’une prise en charge totale avec l’aide de Figure 1 Répartition des cas dépistés positifs selon l'étiologie en bienfaiteurs tandis que 56 % des cas n’avaient pas pu excluant les cas transitoires (wilaya de Fès, n = 8)
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se faire à partir du 3e jour de vie à distance de la crise cette stratégie n’est pas en bonne adéquation avec le hypothalamo-hypophyso-thyroïdienne qui a lieu à la dépistage de masse. naissance (1). Les patients peuvent être rappelés pour un deuxième Sachant qu’au Maroc, la prestation vaccinale par le contrôle pour plusieurs raisons : valeur suspecte, BCG est légalement obligatoire avant le premier mois, prélèvement insuffisant, problème de dosage, etc. Dans qu’elle est disponible gratuitement au niveau de tous les notre campagne, le taux de rappel a été de 0,52 %. Ce centres de santé et que le taux de recrutement avoisine taux est relativement élevé par rapport aux taux des pays 95 % au niveau de la région Fès-Boulemane (17), le choix industrialisés (3-6, 22). Par contre, il est du même ordre des centres de santé pour instaurer le dépistage s’est que celui des pays en développement. Ceci peut être imposé. expliqué par : Plusieurs programmes de dépistage systématique ·· le seuil de rappel est plus bas dans notre de l’HC sont instaurés à travers le monde. Cependant, il étude (20 µUI/mL) alors qu’il est entre 25 et 30 µUI/ n’existe pas de consensus quant à l’approche du dépistage mL dans la plupart des pays européens. Notre taux de l’HC (1,3-6,18). En effet, la méthode de dépistage de rappel serait de 0,3 % si on avait choisi un seuil diffère selon le site de collecte des échantillons de sang de 30 µUI/mL. (cordon ombilical ou sang capillaire), le moment de la ·· La carence en iode : le taux de rappel peut passer de collecte du sang, les différentes stratégies adoptées pour 0,1 % chez les populations non carencées en iode à les tests et les critères de rappel. 20 % chez les populations carencées en iode (24). La plupart des pays européens (mis à part la Finlande), le Japon et le Canada réalisent le prélèvement ·· La surcharge en iode chez les nouveau-nés, qui peut du sang capillaire, contrairement à beaucoup de pays être responsable de cette hypothyroïdie transitoire. asiatiques (18,19) et d’Amérique centrale (20). Pour le Cette surcharge peut être consécutive à l’utilisation moment de prélèvement sur sang capillaire, le sang abusive d’antiseptiques iodés chez le couple mère- est collecté au 3e-5e jour après la naissance afin d’éviter enfant (24). l’augmentation de la TSH pendant les premières Parmi les 82 nouveau-nés rappelés pour un contrôle, 48 heures après la naissance. 24 (soit 29,26 %) ont été perdus de vue. Le manque à Pour les stratégies de test, trois approches sont l’appel est dû à différents facteurs : fausses adresses, utilisées à travers le monde : pauvreté, ignorance, certains tabous et croyances relatifs aux bébés, etc. ·· mesure de la T4 en premier et de la TSH uniquement L’incidence de l’hypothyroïdie congénitale est de pour les cas suspectés, c’est-à-dire ceux ayant une 1/1301. En excluant les cas d’HC transitoire dont la TSH T4 inférieure au seuil prédéfini, comme c’est le cas s’est normalisée après le contrôle sur sérum, la fréquence des États-Unis d’Amérique (4,16). Le désavantage de retrouvée dans notre étude est de 1/1952. Cette fréquence cette stratégie est la faible sensibilité du test, d’où un est supérieure à celle retrouvée dans la plupart des pays niveau de rappel très élevé donc beaucoup de faux développés où la carence iodée a été corrigée depuis positifs. Par ailleurs, le dosage de la T4 seule ignore longtemps. En effet, quel que soit le continent, elle varie certains cas d’HC primaire ou transitoire où le taux de entre 1/3500 et 1/4000 (5,6). Par contre, elle est proche T4 est normal mais la TSH est élevée. de celle rapportée par des études faites dans des pays à ·· Mesure de la TSH en premier et de la T4 uniquement carence iodée modérée comme la Turquie (1/2736) (25) pour les cas suspectés, c’est-à-dire ceux ayant une et la Tunisie (1/2000) (26). Lorsqu’on sait que le Maroc TSH supérieure au seuil prédéfini. C’est de loin la est classé comme zone à carence iodée modérée, notre méthode la plus utilisée en Europe (7,8,10,21) pour résultat coïncide donc avec les données de la littérature diverses raisons, à savoir un taux de rappel plus faible internationale. et une plus grande sensibilité, un coût faible et la Quant aux données nationales, nous constatons que détection de l’HC surtout primaire. Par contre, cette notre fréquence est inférieure à celle retrouvée lors de la méthode ignore l’HC secondaire et l’HC tertiaire, campagne pilotée à Rabat entre 1995 et 1997 (1/1138) l’HC transitoire ou celle due à la déficience de la (14). Ceci peut être expliqué par : TBG (thyroxine-binding globulin). La fréquence de ces pathologies est, heureusement, faible (1/60 000, ·· la taille trop réduite de l’échantillon soumis au 1/100 000, 1/37 370 et 1/50 000 respectivement) (4). dépistage à Rabat, ce qui mettrait en doute la valeur Avec cette méthode, la valeur du seuil en Europe et au de la fréquence rapportée ; Japon est de 25 à 30 µUI/mL (8,22). Au Maroc, nous ·· la mise sur le marché du sel enrichi en iode à partir de ignorons la nature du terrain, d’où un abaissement 1997, ce qui aurait put corriger la carence en iode au de ce seuil à 20 µUI/mL. Ceci va nous assurer une niveau de la population de notre région. couverture plus large même si on va augmenter le Sur la plan étiologique, 50 % des cas sont dus à des niveau de rappel. troubles de la morphogenèse (athyréose 25 % et agénésie ·· Mesure combinée de la TSH et de la T4. C’est la partielle 25 %) alors que 50 % des cas avaient une meilleure approche même si 5 à 10 % de l’HC ont glande en place et donc probablement des troubles de été ignorés (4,16,21,23). Cependant, le coût élevé de l’hormonogenèse. Si le pourcentage d’athyréose coïncide
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avec les données de la littérature, celui des troubles de avant l’apparition des manifestations cliniques. Pour l’hormonogenèse est plus élevé que celui décrit dans des groupes européens (12), les enfants qui ont été plusieurs études (15 à 20 %) (1,2,9). Cependant, il faut suivis pour HC et traités dans les 25 jours (+/- 15 jours) noter que dans notre étude, la scintigraphie n’a été ont un quotient intellectuel (QI) normal. Les fonctions réalisée que pour six nouveau-nés, et même dans ces cas neurophysiologiques à six ans sont identiques à celles elle n’a pas permis d’affiner l’étiologie, ce qui soulève un des enfants sains. Toutefois, pour certains nouveau- problème de compétence technique. La prédominance nés avec des signes cliniques indiquant une sévère HC, du sexe féminin (75 %) et l’absence de l’influence des le pronostic intellectuel est sombre. D’autres facteurs saisons dans notre étude confirment ce qui a été rapporté peuvent influencer ce résultat de faible QI : le taux initial par d’autres auteurs (1,2). Nous avons dépisté un seul de T4 et de T3, la maturation osseuse au diagnostic, la cas familial dont le frère et le cousin, qui ne faisaient présence ou l’absence de tissu thyroïdien et un traitement pas partie de notre cohorte, avaient également une inadéquat (27). Il est à noter que dans notre étude nous HC qui a été diagnostiquée tardivement, à dix et sept avons été limités par l’impossibilité de réaliser certaines mois respectivement. Malgré le traitement démarré explorations paracliniques pour affiner l’étiologie (bilan au moment du diagnostic, ces deux enfants gardent thyroïdien complet, scintigraphie, marqueurs génétiques, un certain retard psychomoteur. La prédominance du etc.). Sur le plan somatique, l’évolution des indicateurs sexe féminin et la présence de cas familiaux suggèrent, anthropométriques suit celle des standards normaux comme cela a été décrit, l’existence d’une susceptibilité pour la majorité des cas, ce qui témoigne de l’efficacité génétique (1,2). thérapeutique. L’âge moyen de dépistage des cas positifs dans notre En l’absence d’un psycho-pédiatre, le suivi série est de 17,1 (ET 6,6) jours et l’âge moyen de début du psychologique a été évalué subjectivement sur la traitement est de 43,4 (ET 8,7) jours. Le retard de la prise réactivité, l’éveil, le langage et la scolarité, donc on ne peut en charge thérapeutique dans certains cas est lié au fait se prononcer sur le niveau du QI. que : Le résultat de l’étude qualitative menée auprès des ·· certains parents ne vaccinaient leurs enfants que parents des nouveau-nés dépistés positifs et du personnel deux à trois semaines après la naissance ; de santé impliqué dans la campagne nous a permis de constater une méconnaissance de la maladie qui a été ·· parfois les parents donnaient de fausses adresses ou des adresses incomplètes, ce qui rendait difficile leur perçue par les parents comme une fatalité engendrant un relance ; lourd fardeau familial, d’autant plus que le niveau socio- économique de la majorité des familles est très bas. ·· la réception des prélèvements au niveau du CNESTEN accusait un certain retard, surtout au début de la Conclusion campagne ; À travers les résultats de notre étude qui a montré que ·· durant la phase initiale du projet, la confirmation sur le dépistage est facilement acceptable par la population sérum se faisait au niveau d’un laboratoire privé à et qu’il y a un impact positif sur la cohorte de cas d’HC Rabat. dépistés lors de notre campagne, on peut dire que la Une sensibilisation des femmes enceintes en mise en place d’un programme de dépistage néonatal de consultation prénatale, une amélioration des circuits l’hypothyroïdie congénitale se justifie parfaitement dans d’acheminement des prélèvements et des résultats notre région et au Maroc en général. ainsi que la disponibilité des moyens d’investigation Ainsi, si un dépistage est instauré au Maroc, sachant au niveau local, notamment le laboratoire d’analyses, que le nombre de naissances annuelles attendues est diminueraient considérablement le délai de prise en de 32 170 dans notre région et de 671 862 à l’échelle charge. Le délai entre le prélèvement et la prise en nationale (17), on pourrait éviter respectivement 17 et charge par le traitement substitutif est très important. 345 handicapés par an. Donc, quel que soit le coût, les En effet, il est primordial de démarrer le traitement avantages du dépistage de l’HC priment.
Remerciements Nous remercions tous ceux qui ont participé de près ou de loin à la réussite de cette campagne de dépistage qui a été financée en partie par l’Agence internationale de l’énergie atomique (AIEA) et le Centre National de l’Énergie, des Sciences et des Techniques Nucléaires (CNESTEN). Financement : partiel. Conflit d'intéret : aucun.
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Screening of congenital hyperthyroidism in Morocco: a pilot study Abstract Background: In Morocco we have no reliable information on the incidence of congenital hypothyroidism (HC). Aims: The aim of our study was to explore the feasibility of a neonatal screening program for this disease in Morocco. Methods: We conducted a screening campaign in the HC 15 615 newborns in the wilaya of Fez in north-central Morocco. Positive cases have been followed up during seven years. Over the same period, we conducted a retrospective qualitative study among parents of newly screened positive newborns and health professionals. Results: Twelve cases of hypothyroidism have been confirmed, a frequency 1p1301 births. When excluding 4 cases of hy- pothyroidism transients, the frequency of HC becomes 1p1952 births, athyreosis represents 25% of cases, partial agenesis 25% of cases and 50 % of cases had normal thyroid glands in place; 67% are female and 33% male. The average age of test- ing was 17.1 ± 6.6 days and the start of treatment was 43.4 ± 8.7 days. Tracking cases brought under replacement therapy showed a good evolution of anthropometric parameters and psychomotor. The qualitative study found that parents are monitoring their babies very seriously despite the very low socio-economic class of the vast majority of them. Conclusions: The results of our study support the need for the establishment of a neonatal screening programme for congenital hypothyroidism in Morocco.
الكشف عن قصور الغدة الدرقية اخللقي يف املغرب. دراسة جتريبية يف والية فاس سعد منيار، شادية عمور، عباس بجو اخلالصة معلومات ليسأساسية: لدينا، يف املغرب، معلومات موثوق هبا عن معدل وقوع قصور الغدة الدرقية اخللقي. األهداف: اهلدف من دراستنا هو استكشاف جدوى إنشاء برنامج لفحص حديثي الوالدة خاص هبذا املرض يف املغرب. طرق البحث: أجرينا محلة للتحري عن قصور الغدة الدرقية اخللقي بني 15615 ًمولودا ًايف حديثوالية فاس يف شامل-وسط املغرب. وقد توبعت احلاالت اإلجيابية طوال سبع سنوات. وخالل الفرتة نفسها، أجرينا دراسة نوعية بأثر رجعي بني أولياء أمور املواليد اجلدد اإلجيابيني الذي جرى التحري عنهم ًحديثا واملهنيني الصحيني. النتائج: تأكد وجود 12 حالة من حاالت قصور الغدة الدرقية، أي حالة واحدة لكل 1301 والدة. وباستبعاد 4حاالت من حاالت قصور الغدة الدرقية العابر، يصبح تواتر قصور الغدة الدرقية حالة واحدة لكل 1952 والدة، ويمثل عدم ختلق الغدة الدرقية 25٪ من احلاالت، ويمثل عدم ختلق الغدة اجلزئي 40٪من احلاالت، وكانت الغدة الدرقية طبيعية ويف مكاهنا يف 50٪ من احلاالت. وكان 67٪ من احلاالت من اإلناث و ٪33 من الذكور. وكان متوسط عمر األطفال عند الفحص 17.1 ± 6.6يوم، وكان متوسط العمر عند بدء العالج 43.4 ± 8.7 يوم. وأظهر تتبع احلاالت التي عوجلت ببدائل هرمونية ًتطورا ًجيدايف القياسات األنثروبومرتية النفسية واحلركية. ووجدت الدراسة النوعية أن اآلباء يراقبون أطفاهلم عىل حممل اجلد بالرغم من االنخفاض الشديد للطبقة االجتامعية واالقتصادية للغالبية العظمى منهم. االستنتاجات:تدعم نتائج دراستنا احلاجة إىل إنشاء برنامج فحص حلديثي الوالدة خاص بقصور الغدة الدرقية اخللقي يف املغرب.
References 1. Toublanc JE. Hypothyroïdie de l’enfant. In: Encycl Med Chir (Endocrinologie-Nutrition, Pédiatrie). Paris: Éditions scientifiques et médicales Elsevier; 2000 (10-005-A-10, 4-106-A-10),15 p. 2. Toublanc JE, Boileau P. Le dépistage de l’hypothyroïdie congénitale 20 ans après. Médecine thérapeutique / Endocrinologie. Dec 1999;1(3):284–7. 3. Dussault JH, Coulombe P, Laberge C, Letarte J, Guyda H, Khoury K. Preliminary report on a mass screening program for neonatal hypothyroidism. J Pediatr. 1975 May;86(5):670–4. PMID:1133648 4. Fisher DA, Dussault JH, Foley TP Jr, Klein AH, LaFranchi S, Larsen PR, et al. Screening for congenital hypothyroidism: results of screening one million North American infants. J Pediatr. 1979 May;94(5):700–5. PMID:87512 5. Barnes ND. Screening for congenital hypothyroidism: the first decade. Arch Dis Child. 1985 Jun;60(6):587–92. doi:10.1136/ adc.60.6.587 PMID:4015179 6. Delange F. Neonatal screening for congenital hypothyroidism: results and perspectives. Hormon Res 1997 Feb;48(2):51–61. PMID:9251921 7. Aynsley-Green A. Screening for congenital hypothyroidism in the U.K. Lancet. 1981 Feb 21;317(8217):447–8. doi:10.1016/ S0140-6736(81)91834-1
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8. Farriaux JP, Dhondt JL. French screening programs for congenital hypothyroidism. Am J Dis Child. 1988 Nov;142(11):1137. doi:10.1001/archpedi.1988.02150110015002 9. Miyai K, Connelly JF, Foley TP Jr, Irie M, Illig R, Lie SO, et al. An analysis of the variation of incidence of congenital dysgenetic hypothyroidism in various countries. Endocrinol Jpn. 1984 Feb;31(1):77–81. doi:10.1507/endocrj1954.31.77 PMID:6734525 10. Grant DB, Smith I. Survey of neonatal screening for primary hypothyroidism in England, Wales, and Northern Ireland 1982-4. Br Med J (Clin Res Ed). 1988 May;296(6633):1355–8. doi:10.1136/bmj.296.6633.1355 PMID:3134984 11. New England Congenital Hypothyroidism Collaborative. Neonatal hypothyroid screening: Status of patients at 6 years of age. J Pediatr. 1985;107(6):915–19. doi:10.1016/S0022-3476(85)80188-8 12. New England Congenital Hypothyroidism Collaborative. Effects of neonatal screening for hypothyroidism: prevention of mental retardation by treatment before clinical manifestations. Lancet. 1981 Nov 14;318(8255):1095–8. doi:10.1016/S0140- 6736(81)91287-3 PMID:6118534 13. Glorieux J, Dussault JH, Morissette J, Desjardins M, Letarte J, Guyda H. Follow-up at ages 5 and 7 years on mental develop- ment in children with hypothyroidism detected by Quebec Screening Program. J Pediatr. 1985 Dec;107(6):913–5. doi:10.1016/ S0022-3476(85)80187-6 PMID:4067749 14. Zahidi A, Thimou A, Ibnmajah M, El Abbadi N, Mestassi M, Draoui M, et al. Dépistage néonatal de l’hypothyroïdie congénitale par dosage de la TSH et de la T4. (Programme pilote). Maroc Med. 2002 Mar;24(1):4–7. 15. Blood collection on filter paper for neonatal screening programs. Approved Standard. Villanova, PA: The National Committee for Clinical Laboratory Standards (NCCLS);1988 (NCCLS publication LA4-A). 16. American Academy of Pediatrics (AAP) Section on Endocrinology and Committee on Genetics, and American Thyroid Association Committee on Public Health. Newborn Screening for Congenital Hypothyroidism: Recommended Guidelines. Pediatrics.1993 Jun;91(6):1203-09. PMID:8502532 17. Évaluation des performances des programmes de la maternité sans risque et de l’immunisation. Rabat: Ministère de la Santé, Direction de la Population; 2002. 18. Desai MP, Colaco MP, Ajgaonkar AR, Mahadik CV, Vas FE, Rege C, et al. Neonatal screening for congenital hypothyroidism in a developing country: problems and strategies. Indian J Pediatr. 1987 Jul-Aug;54(4):571–81. doi:10.1007/BF02749056 PMID:3653961 19. Lakhani M, Khurshid M, Naqvi SH, Akber M. Neonatal screening for congenital hypothyroidism in Pakistan. J Pak Med Assoc. 1989 Nov;39(11):282–4. PMID:2516533 20. Vela M, Gamboa S, Loera-Luna A, Aguirre BE, Pérez-Palacios G, Velázquez A. Neonatal screening for congenital hypothyroidism in Mexico: experience, obstacles, and strategies. J Med Screen. 1999;6(2):77–9. doi:10.1136/jms.6.2.77 PMID:10444724 21. Dussault JH, Morissette J. Higher sensitivity of primary thyrotropin in screening for congenital hypothyroidism: a myth? J Clin Endocrinol Metab. 1983 Apr;56(4):849–52. doi:10.1210/jcem-56-4-849 PMID:6833464 22. Farriaux JP, Dhondt JL, Cartigny B. Le dépistage néonatal de l’hypothyroïdie. Ses raisons et résultats à propos de 70 000 tests [Neonatal diagnosis of hypothyroidism. Reasons and results apropos of 70,000 studies]. Lille Med. 1979 Aug-Sep;24(7):506–13. PMID:545042 23. Rovet JF. Congenital hypothyroidism: long-term outcome. Thyroid. 1999 Jul;9(7):741–8. doi:10.1089/thy.1999.9.741 PMID:10447023 24. Zahidi A, Draoui M, Mestassi M. Statut en iode et utilisation d’antiseptiques iodés chez le couple mère-nouveau-né [Iodine sta- tus and the used of Iodised antiseptics in the mother-newborn pair]. Therapie. 1999 Sep-Oct;54(5):545–8. PMID:10667087 25. Yordam N, Calikoğlu AS, Hatun S, Kandemir N, Oğuz H, Tezic T, et al. Screening for congenital hypothyroidism in Turkey. Eur J Pediatr. 1995 Aug;154(8):614–6. doi:10.1007/BF02079061 PMID:7588958 26. Screening for health: Tunisia. Vienna: International Atomic Energy Agency (IAEA), Department of Technical Cooperation programmes; 2003 (https://inis.iaea.org/collection/NCLCollectionStore/_Public/34/028/34028287.pdf, consulté le 5 novembre 2018). 27. Pharoah PO. Perspectives on cretinism and disability. Lancet. 1996 Nov;348(9040):1521–2. doi:10.1016/S0140- 6736(05)65944-2 PMID:8942810
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Study protocol for promoting physical activity among women based on the MAPP process
Leila Amiri Farahani 1, Soroor Parvizy 2, Mohsen Asadi-Lari 3, Eesa Mohammadi 4, Batool Hasanpoor Azghadi 1 and Ziba Taghizadeh 5
1Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. 2Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. 3 Oncopathology Research Centre, IUMS, Tehran, Islamic Republic of Iran. 4Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares Uni- versity, Tehran, Islamic Republic of Iran. 5Nursing and Midwifery Care Research Center, Nursing and Midwifery School, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: Z. Taghizadeh: [email protected]).
Abstract Background: The participation of all stakeholders is necessary when a community-based intervention is designed. For running a practical intervention, it is necessary to have a framework to design the programme while considering all stag- es of planning, implementation and evaluation. Aims: To describe a study protocol based on the MAPP process (Mobilizing for Action through Planning and Partnerships) for promoting physical activity (PA). Methods: This protocol is implemented in 6 distinct phases. The goal of the first and second phase is to organize the pro- gramme and increase participation, and to determine the vision of the programme, respectively. The third phase provides a comprehensive picture of a community. The fourth and fifth phases identify strategies for the programme. The sixth phase is about the action cycle. Conclusion: The framework considers all factors on PA improvement and, consequently, results in a culture-based pro- gramme for women. Keywords: Islamic Republic of Iran, MAPP process, methods, physical activity, women Citation: Amiri Farahani L; Parvizy S; Asadi-Lari M; Mohammadi E; Hasnapoor Azghadi B; Taghizadeh Z. Study protocol for promoting physical activity among women based on the MAPP process. East Mediterr Health J. 2018;24(11):1074–1081. https://doi.org/10.26719/2018.24.11.1074 Received: 21/09/16; accepted: 15/08/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction Although the health benefits of PA are now well established, there is not enough knowledge about the Despite the numerous health benefits of regular physical effectiveness of interventions designed for promoting activity (PA), physical inactivity is a major health issue in PA at the community level (7). The majority of PA developed and developing countries such as the Islamic interventions have been delivered at the individual level Republic of Iran (1). There is strong evidence that physical with the goal of changing personal behaviour (8). inactivity increases the risk of chronic conditions such as stroke, cancer, coronary heart disease, type 2 diabetes, Since individual lifestyles are formed in different obesity and mental health problems (1–3). social, physical and cultural contexts, when designing a community-based multilevel intervention, it is According to the World Health Organization (WHO) necessary to include the participation of all stakeholders report (4), globally, around 28% of men and 34% of women (9). Community-based interventions may be more aged ≥ 15 years were insufficiently active in 2008. The prevalence of insufficient PA was highest in the WHO effective and successful than traditional and clinic-based Region of the Americas and the Eastern Mediterranean programmes (10–12). Community-based interventions Region, which includes the Islamic Republic of Iran. In consider multilevel approaches on the basis of ecological all WHO Regions, men were more active than women, perspectives and include interventions at different levels with the biggest difference in prevalence between the such as group, organization, community and policy. sexes in the Eastern Mediterranean Region (4). Other These make community-based interventions suitable studies reported 31.6% of adult men and 48.6% of adult and practical for health promotion programmes (7, women belonged to the low PA category (5). According to 13). Involvement of community members in planning, the Second Report of Urban Health Equity Assessment implementation and evaluation of community-based and Response Tool (Urban HEART) project in 2011 in interventions means that they can be more effective and Tehran, Islamic Republic of Iran, only 20.5% of women sustainable than individual interventions (14, 15). and 24.3% of men exercised for at least the minimum time Action research is a community-based approach in recommended in the PA guidelines (6). These guidelines which researchers follow the action and results of the recommend a minimum of 150 minutes of moderate study simultaneously (16–18). In this type of study, the intensity exercise or 75 minutes of vigorous intensity researchers cooperate as observers and as agents of exercise per week (3). change. The researchers gather and analyse the data,
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report the results to specialists, apply changes to the The first phase, “Organizing success and partnership study, and evaluate the effects of any changes (16–19). development” is part of the planning phase. This phase WHO is the first organization to initiate community- identifies who should be involved in the process and how based activity for promotion of PA. One of the voluntary the partnership will be approached in order to organize global targets is 10% relative reduction in prevalence of the process. insufficient PA. WHO-proposed policy options include: The second phase, “Visioning”, is a collaborative and (1) adoption and implementation of national guidelines; creative approach that leads to a shared community (2) establishment of a multisectorial committee to provide vision and common values. strategic leadership and coordination; (3) development The third phase, “Four assessments” brings in a of appropriate partnerships and engagement of all comprehensive picture of a community by using both stakeholders, across governments, nongovernmental qualitative and quantitative methods. Most planning organizations, and civil society; (4) development of processes look only at quantitative statistics and policy measures in cooperation with relevant sectors to anecdotal data. The four assessments consist of the promote PA through activities of daily living, including following. (1) Community health status assessment to active transport, recreation, leisure and sport; (5) provide quantitative data on a broad array of health improved provision of quality physical education; (6) indicators, such as behavioural risk factors, and other actions to support and encourage PA for all initiatives measures that reflect a broad definition of health. (2) for all ages; (7) promotion of community involvement in Forces of change assessment provides an analysis implementation of local actions aimed at increasing PA; of positive and negative external forces that affect and (8) conduct of evidence-informed public campaigns promotion and protection of public health. (3) Community through mass media, social media and at the community themes and strengths assessment provides qualitative level to motivate adults about the benefits of PA (20). information on how communities perceive their health Multiple-stage action research takes a long time. and quality of life concerns, as well as their knowledge of It includes problem assessment, action planning, community resources and assets. (4) Local public health observation, giving and receiving feedback, and problem system assessment is a comprehensive assessment of reassessment that all are carried out with discussion all organizations and entities that contribute to public among participants (21). To design the programme, it health. is necessary to achieve a framework that considers all The Fourth phase, “Identify strategic issues”, uses stages of multiple-stage action research. information collected in the Four assessments phase to The framework utilized for this study is the MAPP determine which strategic issues should be addressed by process (Mobilizing for Action through Planning a community in order to reach its vision. It is necessary and Partnerships). MAPP is a comprehensive, that this phase answers the following questions. What multicomponent, strategic planning model developed are the factors identified in the assessments that must as a tool by the National Association of County and City be addressed in order to achieve the vision? What are the Health Officials (NACCHO) and the Centers for Disease consequences of not addressing them? Control and Prevention (CDC) in 2001. The MAPP process plans a health promotion programme by designing a The fifth phase, “Formulate goals and strategies”, framework. The framework aggregates organizations, assigns goals to each of the strategic issues identified groups of people, stakeholders and key informants that in the previous phase. Many communities create a are assigned with available resources in the community. community health improvement plan at the end of this Continuous involvement of the community leads phase. This phase answers the following questions. What to ownership of the process, and ownership by the do we want to achieve by addressing this strategic issue? community increases the sustainability and validity of How do we want to achieve it? What action is needed? health promotion efforts. The MAPP process prioritizes The sixth phase, “Action cycle”, includes planning, public health issues in the community, identifies implementation and evaluation of a community-based available resources, and designs appropriate strategies in strategic plan. Participants contribute to the action by community context (22, 23). These are the goals in action determining what will be done, who will do it, and how research. it will be done, in the implementation by carrying out This paper describes a study protocol based on the the activities identified at the planning stage, and in the MAPP process for promoting PA among women aged evaluation by determining what will be accomplished. 18–65 years. The study protocol is a part of a PhD thesis First phase: Organizing success and (24). The overarching goal of this project is to develop a programme with community-based interventions for partnership development promoting PA among Iranian women. A wide range of collaborators is selected to support the programme and each person can bring resources and Methods capital, and the method of supplying them is identified. This is a multiphase, mixed-method action research To achieve the objectives of this phase, the following peo- method based on the MAPP process, which includes the 6 ple should be involved in the process: core research com- phases shown in Figure 1. mittee; steering committee composed of policy-makers
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Phases of MAPP process Method of MAPP process
Phase 1: Organize for success/partnership Informal discussions, meetings
Focus group and informal discussions, Phase 2: Visioning Literature search
Focus group discussions, secondary data, surveys Phase 3: Four MAPP assessments Community health status Key informant interviews/discussions, Forces of change expert work group Community themes and strengths
Local public health system Focus group discussions, surveys, lay and key informant interviews/discussions
Focus group discussions
Phase 4: Identify strategic issues Focus group discussions, systematic review, informal discussions
Informal discussions, meetings, focus Phase 5: Formulate goals and strategies group discussions
Focus group discussions, lay and key informant interviews/discussions, quasi- Phase 6: Action cycle experimental study
Figure 1 Flow chart of different methods used in the six phases of the MAPP process
and officials from within or outwith Khaneh Salamat1; Second phase: Visioning and research population members. Focus group discus- The vision can help to focus and set goals and paths in sions (FGDs) are held between participants and experts the MAPP process. MAPP creates partnerships to achieve involved in the programme. They talk about their percep- that vision in the future. The core research committee tion of the problem of insufficient PA and the necessity to and research population members organize FGDs to promote it, expertise, ability to overcome obstacles, and identify the vision of the PA promotion programme. The funds that can be devoted to the programme.
1 Khaneh Salamat is a community centre that provides preventive care and health promotion programmes.
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identified vision needs to be in agreement with the vision the organization and threats outside the organization. In set by the steering committee. addition to qualitative data, quantitative data are collect- ed using the Exercise Benefit and Barrier Scale (EBBS). Third phase: Four assessments Barriers and facilitators of PA are identified thorough the The Four assessment phase evaluates community health cross-sectional study defined in the community health status, the forces of change, community themes and status assessment section. strengths, and local public health systems. The assess- Local public health system assessment and community themes ments are a scan of the internal and external environ- and strengths assessment ment of the PA programme to identify strengths and All assessments focus on the organizations and entities weaknesses that are internal to the programme and op- that contribute to public health and provide a deep under- portunities and threats external to the programme in the standing of the PA status in Khoramrudi neighbourhood, environment in which it operates. It is a useful tool for and what assets do we have that can be used to improve reducing a large amount of data into a more managea- it. These assessments evaluate community themes and ble profile for the health programme, and it provides a strengths and the local public health system through framework for identifying the issues that affect the stra- FGDs among the core research committee, steering com- tegic plan. The assessments are as follows. mittee and research population members. Community health status assessment Fourth phase: Identify strategic issues This part has 2 sections: one to assess prevalence of PA and another to reach to stakeholders’ consensus about The fourth phase identifies strategic issues of the PA pro- the importance of PA improvement. In the first section, gramme using information gathered from the Four as- prevalence of PA in women is obtained from available sessments phase. Strategic issues of a community must statistical evidence at the national, regional, state, district be addressed to achieve the vision of the PA programme. and zone level; in this case, Zone 2 of District 2 in Tehran. This phase is planned using data collected in previous This is located in the northwest of the city and according phases and shows important and changeable strategies to self-perceptions, the residents are mediocre in socioec- for PA enhancement. The best and most suitable strate- onomic status. To establish prevalence of sufficient PA, a gies are identified in this phase by a systematic review cross-sectional survey is conducted among women aged and FGDs among the core research committee, steering 18–65 years residing in Khoramrudi neighbourhood in committee and research population members. the Second Municipal District of Tehran. The sample size Fifth phase: Formulate goals and strategies of the current study is 300, according to the studies con- ducted on PA for the Urban HEART project (6), with P = The fifth phase involves specifying goals for each of the 23%, d = 0.05%, _ = 0.05 and Z = 1.96 and _ = 0.2. According strategic issues identified in the previous phase. Many communities create a community health improvement to the Second Report (2011) of the Urban HEART project plan at the end of this phase. Potential barriers, required in Tehran, every neighbourhood of 22 municipal districts actions, available resources, and a time plan must be con- of Tehran is divided into several blocks. We use availa- sidered in this phase. ble information about the blocks located in Khoramrou- di neighbourhood. Khoramroudi has numerous blocks; Sixth phase: Action cycle however, we only select some blocks using a systemat- The Action cycle, includes planning, implementation and ic sampling method in which women aged 18–65 years evaluation of the community strategic plan. Each strategy are interviewed. If a woman declines to take part, her is implemented and then evaluated by quantitative and neighbour will be invited to participate and complete the qualitative methods. The quantitative method is based questionnaire. In the second section, the core research on a quasi-experimental study in which the assessment committee, steering committee and research population is carried out before interventions and 1 and 3 months members discuss the importance of PA and it is neces- after. To improve the quality of the study and design a sary to reach consensus. more inclusive programme, the qualitative assessments Forces of change assessment of the study are conducted during the programme, fo- The Forces of change assessment focuses on identifying cus groups, individual interviews, and through feedback forces such as legislation, technology and other impend- from participants throughout and after the study. These ing changes that affect the context in which the com- assessments are performed at 1-month intervals through- munity and its public health system operate. The core out and after the study. research committee collects data about barriers and fa- Data collection cilitators of PA for written and/or verbal documents via individual interviews and/or FGDs with research popu- Scales and quantitative data collection lation members and managers. It is necessary to ask all 1. The international PA questionnaire (IPAQ) was de- the stakeholders to share their experiences about preven- signed to measure PA level within the last 7 days. tive forces of change that are the facilitators inside the The IPAQ is an interview-administered instrument organization and opportunities outside the organization, and contains 4 domains: work, transportation, do- and positive forces of change that are the barriers inside mestic chores and gardening, and leisure time (25,
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26). The validity and reliability of the questionnaire statistics including the mean, standard deviation and fre- in the Islamic Republic of Iran was measured by quency are calculated. Statistical tests such as the χ2 test Moghaddam et al. through the forward–backward are used to estimate prevalence of PA. Structural equa- translation method (27). The validity of IPAQ was con- tion modelling analysis is used to identify the most im- firmed by the face, content and constructs validity. portant constructs that determine the priorities among For the reliability of IPAQ, Cronbach’s α coefficient benefits and barriers constructs. was used to calculate internal consistency and the Qualitative data analysis Spearman–Brown coefficient was used to assess the stability over time. In terms of internal consistency, Qualitative data are analysed using a theme development Cronbach’s α of the questionnaire was 0.7 and the procedure. Data management is conducted using MAX- Spearman correlation coefficient of IPAQ was 0.9 in QDA version 10. Audio interview files are transcribed. test–retest reliability (27). In the current study, the Then, researchers examine the content and extract the reliability of IPAQ will be assessed from internal con- face and latent themes. Each transcribed word or ex- sistency and stability. pression is considered as an individual unit of analysis. Further scrutiny of transcripts and accompanied inter- 2. The EBBS was originally designed by Sechrist et al. as pretative notes may contribute to recognition of initial a general and self-administered scale to evaluate bar- relationships among the concepts extracted from the riers and facilitators of PA (28). It consists of 43 items; expressions. Collected notes and codes also help forma- 14 barriers scales that are composed of 4 subscales of tion of themes. As interviews progress and relationships exercise milieu, time expenditure, physical exertion among the themes emerge, it will be possible to recognize and family discouragement; and 29 benefits scales patterns and the main concepts. Moreover, the constant that are composed of 5 subscales of life enhancement, comparison method is used during the research. physical performance, psychological outlook, social interaction and preventative health (28). EBBS was The trustworthiness of qualitative studies is based translated in the Islamic Republic of Iran by Farahani on Guba’s criteria (30). Credibility is established through et al., using the forward–backward translation meth- prolonged engagement with participants and extended od (29). It has also been adapted to the Persian cul- immersion. Member checking and peer reviewing ture and its validity has been confirmed by the face, are done to verify the findings. Triangulation of data content and constructs validity. For the reliability of collection methods is done using field notes and diaries EBBS, Cronbach’s α coefficient was used to calculate to collect data. Transferability is facilitated by purposive internal consistency and the Spearman–Brown co- sampling of women who have experienced regular and efficient was used to assess the stability over time. irregular PA. Detailed description of the findings and Cronbach’s α coefficient for the total scale and the reviewing the literature when interpreting the data subscales of benefits and barriers was 0.927, 0.94 and are done to support the study findings. An audit trail is 0.82 and the Spearman–Brown coefficient was 0.76 conducted to assure confirmability. (P = 0.004), 0.79 (P = 0.046) and 0.74 (P = 0.008) for the total scale, benefits and barriers subscales, respec- Ethical considerations tively (29). In the study phases, it is necessary for participants to give 3. The demographic characteristics questionnaire was written informed consent. The Ethics Committee of Teh- designed by a research team while considering the ran University of Medical Sciences approved the protocol following factors: age, ethnicity, education level, of this study (code number: 92-02-28-23311) before the col- occupational status, mother, father and spouse if lection of samples. married, marital status, family size and sufficiency Discussion of income. The current action research is designed to provide a Qualitative data collection community-based programme for promoting PA among Data are collected through FGDs and individual in- women in Khoramrudi neighbourhood, Tehran. Promot- depth interviews, if required. The FGDs are conducted ing PA helps countries to reach the CDC recommenda- in Khaneh Salamat and individual interviews are held in tion of a minimum of 150 minutes of moderate intensity places that are convenient for women. The research team exercise or 75 minutes of vigorous intensity exercise per reviews the interview questions before conducting FGDs week. The present study provides information and robust and interviews, and practices ways to help gain valid data. data to plan, implement and evaluate a PA programme Data are recorded during FGDs and interviews by a tape thorough a culturally sensitive approach. The collection recorder. Decisions about the number of participants are of quantitative and qualitative data facilitates a better un- taken based on data saturation. derstanding of research goals. Data analysis This study also provides some insights about the PA behaviour that need to be considered if effective Quantitative data analysis strategies and intervention programmes are to be Data are analysed using SPSS version 20 through descrip- designed to promote PA, and subsequently, the health tive and inferential statistical methods. Basic descriptive of families in the Islamic Republic of Iran and those
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of other women who may have similar beliefs and the gaps in the current literature and provide new practice that need to be dealt with effectively. The insights about urban PA. The study uses innovative findings of the study can help to identify community- designs to evaluate interventions and develop col- based strategies for promoting PA among women in laboration between researchers and practitioners for Khoramrudi neighbourhood. Follow-up is done at the end of the programme in order to assess the short- evaluating experiments. Therefore, the results of this term effectiveness of the programme. Evaluation of study contribute to the body of evidence about com- the results determines the support that is necessary munity-level interventions, and can be useful for re- for designing programmes that are accessible, searchers and practitioners for future evaluation of affordable and effective in promoting PA and health complex public health interventions. If the interven- among women in Khoramrudi neighbourhood. tion proves itself as a successful method for improv- Conclusion ing PA in a population, this type of intervention could It is believed that the current action research can fill be disseminated in similar contexts.
Acknowledgements This study was funded and supported by Tehran University of Medical Sciences (grant no. 92-02-28-23311). The authors would like to express their gratitude to Kayla J. Power for her valuable and kind assistance with English language editing of the article. Funding: None. Competing interests: None declared.
Protocole d’étude fondé sur le processus MAPP visant à promouvoir l’activité physique chez les femmes, République islamique d’Iran Résumé Contexte : La participation de toutes les parties prenantes est nécessaire durant l’élaboration des interventions communautaires. Pour mettre en œuvre une intervention pratique, il faut disposer d’un cadre afin de concevoir le programme et de prendre en compte toutes les étapes de la planification, de la mise en œuvre et de l’évaluation. Objectifs : La présente étude visait à décrire un protocole d’étude fondé sur le processus MAPP (Mobilizing for Action through Planning and Partnerships) et ayant pour but de promouvoir l’activité physique. Méthodes : Le protocole est mis en œuvre en six phases distinctes. La première phase vise à organiser le programme et à accroître la participation, tandis que la deuxième a pour objectif de déterminer la vision du programme. La troisième phase présente un portrait complet d’une communauté. Les quatrième et cinquième phases établissent des stratégies pour le programme. La sixième phase concerne le cycle d’action. Conclusion : Le cadre considère tous les facteurs qui influent sur l’amélioration de l’activité physique et permet par conséquent de concevoir un programme pour les femmes qui s’appuie sur la culture locale.
بروتوكول دراسة لتعزيز النشاط البدين بني السيدات ًاستنادا إىل عملية استنهاض اهلمم ملامرسة النشاط من خالل التخطيط والرشاكات )MAPP( ليىل فراهاين، ُسور برويزى، حمسن أسدي-الري، عيسى حممدي، بتول حسن بور ازقدى، زيبا تقي زادة اخلالصة تعترب اخللفية:مشاركة مجيع األطراف املعنية رضورية عند تصميم تدخل جمتمعي، إذ تقتيض اإلدارة العملية للتدخل أن يكون له إطار هيكيل لتصميم الربنامج مع األخذ باالعتبار مجيع مراحل التخطيط والتنفيذ والتقييم. األهداف:هتدفالدراسةإىل وصف بروتوكول للدراسة يستند إىل عملية استنهاض اهلمم ملامرسة النشاط من خالل التخطيط والرشاكات ) (MAPP من أجل تعزيز النشاط البدين. طرق البحث:يتم تنفيذ برتوكول الدراسة يف ست مراحل متاميزة. واهلدف من املرحلة األوىل هو تنظيم الربنامج وزيادة املشاركة فيه، واهلدف من املرحلة الثانية هو حتديد رؤية الربنامج، وتقدم املرحلة الثالثة صورة شاملة للمجتمع، وحتدد املرحلتان الرابعة واخلامسة اسرتاتيجيات الربنامج، أما املرحلة السادسة فتتعلق بدورة العمل. االستنتاجات:يأخذ اإلطار اهليكيل يف احلسبان مجيع العوامل التي تتعلق بتحسني النشاط البدين فيؤدي بالتايل إىل برنامج خمصص للنساء يستند إىل الثقافة السائدة.
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References 1. Lee DC, Artero EG, Sui X, Blair SN. Review: Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol. 2010 Nov;24(4_suppl):27–35. https://doi.org/ 0.1177/1359786810382057 PMID:20923918 2. Start active, stay active: a report on physical activity from the four home countries’ Chief Medical Officers. London: Department of Health; 2011. 3. Physical Activity Guidelines Advisory Committee. Physical activity guidelines advisory committee report. Washington (DC): U.S. Department of Health and Human Services; 2008 (https://health.gov/paguidelines/report/pdf/CommitteeReport.pdf, accessed 8 March 2018). 4. Global strategy on diet, physical activity and health: a framework to monitor and evaluate implementation. Geneva: World Health Organization; 2006 5. Esteghamati A, Khalilzadeh O, Rashidi A, Kamgar M, Meysamie A, Abbasi M. Physical activity in Iran: results of the third nation- al surveillance of risk factors of non-communicable diseases (SuRFNCD-2007). J Phys Act Health. 2011 Jan;8(1):27–35. https://doi. org/10.1123/jpah.8.1.27 PMID:21297182 6. Asadi-Lari M, Vaez-Mahdavi MR. An overview on Urban-HEART Tehran experience. World Health Organization. 7. Foster C, Hillsdon M, Thorogood M. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005. Jan 25;(1): CD003180. https://doi.org/10.1002/14651858.CD003180.pub2 PMID:15674903 8. House of Lords Science and Technology Select Committee. Behaviour change. London: House of Lords; 2011. 9. Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults’ participation in physical activity: review and update. Med Sci Sports Exerc. 2002 Dec;34(12):1996–2001. https://doi.org/10.1097/00005768-200212000-00020 PMID:12471307 10. Stokols D. Establishing and maintaining healthy environments. Toward a social ecology of health promotion. Am Psychol. 1992 Jan;47(1):6–22. https://doi.org/10.1037/0003-066X.47.1.6 PMID:1539925 11. McKinlay JB. The new public health approach to improving physical activity and autonomy in older populations. In: Heikkinen E, Kuusinen J, Ruoppila I, editors. Preparation for aging. Boston: Springer; 1995:87–103. 12. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Man- ag Care. 2005 Aug;11(8):478–88. PMID:16095434 13. Bopp M, Fallon E. Community-based interventions to promote increased physical activity: a primer. Appl Health Econ Health Policy. 2008;6(4):173–87. https://doi.org/10.1007/BF03256132 PMID:19382818 14. Harding AH, Griffin SJ, Wareham NJ. Population impact of strategies for identifying groups at high risk of type 2 diabetes. Prev Med. 2006 May;42(5):364–8. https://doi.org/10.1016/j.ypmed.2006.01.013 PMID:16504278 15. Guttmacher S, Kelly PJ, Ruiz-Janecko Y. Community-based health interventions. San Francisco: Jossey-Bass; 2010. 16. Nieswiadomy RM. Foundations of nursing research. Stamford, CT: Appleton & Lange; 1998. 17. Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. Philadelphia: Lippincott Williams & Wilkins; 2011. 18. Dempsey PA, Dempsey AD. Using nursing research: process, critical evaluation, and utilization. Philadelphia: Lippincott Wil- liams & Wilkins; 2000. 19. Pilemalm S, Timpka T. Third generation participatory design in health informatics–making user participation applicable to large-scale information system projects. J Biomed Inform. 2008 Apr;41(2):327–39. https://doi.org/10.1016/j.jbi.2007.09.004 PMID:17981514 20. Earl-Slater A. The superiority of action research? Br J Clin Governance. 2002;7(2):132–5. https://doi.org/10.1108/14664100210427633 21. Global action plan for the prevention and control of non-communicable diseases 2013–2020. Geneva: World Health Organiza- tion; 2013 (http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1, accessed 8 March 2018). 22. National Association of County and City Health Officials (NACCHO). Mobilizing for Action through Planning and Partnership. Achieving Healthier Communities through MAPP, A user’s handbook. http://www.naccho.org/topics/infrastructure/mapp/up- load/MAPP_Handbook_fnl.pdf 23. Fact sheet: mobilizing for action through planning and partnerships: a community approach to health improvement. Washing- ton, DC: National Association of County and City Health Officials; 2008 (https://www.naccho.org/programs/public-health-infra- structure/performance-improvement/community-health-assessment/mapp, accessed 8 March 2018) 24. Farahani LA. Improving PA among women: a mixed-method action research in Iran [thesis]. Tehran University of Medical Sciences; 2015. 25. IPAQ. (2005). 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27. Baghiani Moghaddam MH, Bakhtari Aghdam F, Asghari Jafarabadi M, Allahverdipour H, Dabagh Nikookheslat S, Safarpour S. The Iranian Version of International Physical Activity Questionnaire (IPAQ) in Iran: Content and Construct Validity, Factor Structure, Internal Consistency and Stability. World Appl Sci J. 2012;18(8):1073–80. 28. Sechrist KR, Walker SN, Pender NJ. Development and psychometric evaluation of the exercise benefits/barriers scale. Res Nurs Health. 1987 Dec;10(6):357–65. https://doi.org/10.1002/nur.4770100603 PMID:3423307 29. Amiri Farahani L, Parvizy S, Mohammadi E, Asadi-Lari M, Kazemnejad A, Hasanpoor-Azgahdy SB, Taghizadeh Z. The Psycho- metric Properties of Exercise Benefits/Barriers Scale among Women. Electronic Physician journal 2017. 30. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks, CA: Sage; 1985
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Repellency effect of flumethrin pour-on formulation against vectors of Crimean–Congo haemorrhagic fever
Eslam Moradi Asl 1,2, Hassan Vatandoost 2,3, Zakie Telmadarreiy 2, Mehdi Mohebali 4, Mohammad Reza Abai 2,3
1Department of Public Health, School of Public Health, Ardabil University of Medical Sciences, Ardabil, Islamic Republic of Iran. 2Department of Medi- cal Entomology and Vector Control, School of Public Health and National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: H. Vatandoost: [email protected], [email protected]). 3Department of Chemical Pollutants and Pesticides, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Department of Medical Parasitology and Mycology, School of Public Health and National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
Abstract Background: Ticks are able to transmit important diseases to humans, including Rocky Mountain spotted fever, Q fever, Crimean–Congo haemorrhagic fever, summer Russian encephalitis, and relapsing fever. Aims: To determine the repellency effect of 1% flumethrin pour-on formulation against hard ticks. Methods: The concentration of flumethrin pour-on formulation was 1 mg/10 kg body weight and was administered on the dorsal midline from the head to the base of the tail. The livestock included cows, goats, oxen and sheep in 2 villages in Ardabil Province, Islamic Republic of Iran. Results: We studied 200 livestock comprising 5 age groups (< 2, 3–4, 5–6, 7–8 and >8 years). The main hard ticks identified were Hyalomma species (62.5%) and Rhipicephalus bursa (37.5%). In the treatment village, the maximum number of ticks per animal was 11.6 in oxen, 9.5 in sheep, 8.9 in goats and 8.6 in cattle. The repellency effect of flumethrin remained for 2 months. Conclusions: Flumethrin provided 2 months protection against hard ticks. Therefore, it could be used in the livestock industry. Control of ticks is important for prevention of disease transmission. Keywords: flumethrin, Islamic Republic of Iran, livestock, repellency, ticks Citation: Moradi Asl E; Vatandoost H; Telmadarreiy Z; Mohebali M; Reza Abai M. Repellency effect of flumethrin pour-on formulation against vectors of Crimean–Congo haemorrhagic fever. East Mediterr Health J. 2018;24(11):1082–1087. https://doi.org/10.26719/emhj.18.004 Received; 19/10/16; accepted: 02/08/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction evaluated in 1939 (7). A total of 901 products are available: 872 synthetic oils and 29 plant oils. The United States De- Ticks are important in human and veterinary medicine. partment of Agriculture tested some repellents against 4 Hard ticks include > 650 species. Diseases that are trans- types of cockroaches in Germany during 1953–1973 (8). mitted by ticks have a major economic impact on the livestock industry worldwide. Ticks are able to transmit Flumethrin is a pyrethroid insecticide. It is used several important diseases to humans, including Rocky externally in veterinary medicine against parasitic Mountain spotted fever, Q fever, Crimean–Congo haem- insects and ticks on cattle, sheep, goats, horses and dogs, orrhagic fever (CCHF), summer Russian encephalitis, as well as for control of parasitic mites in honeybee and relapsing fever (1–4). Control of ticks is important for colonies. Flumethrin is applied in a line from the base of prevention of disease transmission. Chemical methods the skull along both sides of the spine to the tail in cattle. are the most commonly used for control of ectoparasites. The median lethal dose for rats by ingestion is 500–1000 Chemical insecticides, biological control, environmental mg/kg. Flumethrin is toxic to fish and aquatic animals management and repellent agents are the most impor- (9). It acts on the nervous system of the target arthropods tant methods for tick control. However, the stability of (10–12). some insecticides in nature and their adverse effects on humans and the environment are major concerns (5, 6). Methods For farmers and consumers, the important factors for Study area insecticides are ease of application, low cost and long- term protection. Repellent compounds are derived from This study was conducted in 2014–2015 in Meshkinshahr plant oils, smoke and tars, and they can be used for kill- County, which is located in the centre of Ardabil Province, ing and repelling insects. Before World War II, there were in the northwest of the Islamic Republic of Iran (Figure 4 major repellents that had been in use for repellency of 1). This region has a cool climate (maximum 35°C) during insects and animals for several years: Citronella oil was the hot summer months. The winter is cold (minimum used for head lice; dimethyl phthalate was discovered in −25°C). A total of 25 000 people are involved with rearing 1929; indole was invented in 1937; and Rutgers 612 was livestock.
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and type of livestock and living conditions, and climate. Livestock in the control village were not treated with fl- umethrin. The results were analysed using the χ2 test and t test. Tick identification All the collected ticks were identified according to the valid identification keys of Janbakhsh (1956), Hoogsteraal (1956) and Walker et al. (2007). Results Animal infestation During the study period, 1975 ticks were collected and identified. In Ur, the maximum number of ticks per an- imal was 11.6 in oxen, 9.5 in sheep, 8.9 in goats and 8.6 in cattle (Table 1). The highest infestation rates were ob- served in age groups < 4 years. Tick species We identified 200 hard ticks morphologically: 80Hya - lomma marginatum (40%), 25 Hyalomma anatolicum (12.5%), 15 Hyelomma dromedarii (7.5%), 5 Hyelomma detritum (2.5%) and 75 Rhipicephalus bursa (37.5%). Figure 1 Map of study area: Ardebil Province, Northwestern Repellency of flumethrin Islamic Republic of Iran The repellency of flumethrin for up to 60 days is shown in Figure 2. The repellency of flumethrin according to age of Study design livestock is shown in Table 2. This ranged from 100% for animals aged > 8 years to 91.2% for those aged 5–6 years. This was a case–control study of the repellency effect The repellency effect of flumethrin in different types of of 1% flumethrin pour-on against vectors of CCHF. The livestock is shown in Table 3. This ranged from 97.3% for efficacy of flumethrin was evaluated in in 2 randomly goats to 90.5% for oxen. selected villages with similar ecological features, Ur as treatment village and Majandeh as control village. One Discussion hundred livestock were selected randomly from each village, including cattle, sheep, oxen and goats, in 5 age We studied the repellent effect of flumethrin insecticide. groups (< 2, 3–4, 5–6, 7–8 and > 8 years). Tick survival Tick infestation of cattle was related to the age of host rate was determined by examining the whole body of animals, with old cattle having fewer ticks. We showed the animals at different times. In the treatment village, that there was a direct relationship between livestock age 50 livestock were sprayed with 1% flumethrin pour-on. and efficacy of flumethrin. The repellency effect of 1% -flu The same number of livestock without flumethrin was methrin pour-on showed a significant difference in oxen checked as controls. The number of ticks on the livestock and sheep (P < 0.01). However, there was no significant was counted prior to the experiment. At 1, 2, 3, 7, 14, 30 difference between the number of ticks remaining on and 60 days after application, the tick density was deter- cows compared with other livestock (P > 0.01). mined. The control village was similar to the treatment Other studies have shown that 1% flumethrin pour- village, in terms of lifestyle, livestock keeping, number on also provides long-term protection of livestock
Table 1 Frequency of ticks on livestock in the study area 2 < age 3–4 5–6 7–8 > 8 Total of ticks Total of Tick/livestock livestock frequency Villages Ur-Majandeh Ur-Majandeh Ur-Majandeh Ur-Majandeh Ur-Majandeh Ur-Majandeh Ur-Majandeh Ur-Majandeh Livestock 86–149 117–195 42–95 37–159 27–27 309–625 36–51 8.6–11.4 Cow 82–58 179–109 78–74 53–35 8–21 400–297 42–36 9.5–9.5 Sheep 53–17 46–39 15–7 0–0 10–0 124–63 14–9 8.9–7 Oxen 10–0 31–15 33–19 19–30 0–0 93–64 8–4 11.6–16 Total 231–224 373–358 168–195 109–224 45–48 926–1049 100–100 9.26–10.49
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Table 2 Repellency effect of flumethrin according to age of livestock Age (years) Repellency Time of tick survey before and after application of flumethrin Index Before 1 day 2 days 3 days 7 days 14 days 30 60 days days < 2 Survivors (ticks) 231 187 143 93 60 26 17 4 Repellency (%) — 19.7 39.1 57.8 70.6 87.9 92.3 98.1 3–4 Survivors (ticks) 373 303 232 148 76 43 21 17 Repellency (%) — 17.4 37.3 57.4 76.4 87.3 94 94.8 5–6 Survivors (ticks) 168 162 130 96 61 39 25 14 Repellency (%) — 9.2 27.8 43.2 61 76.3 85.2 91.2 7–8 Survivors (ticks) 109 97 74 54 33 21 15 5 Repellency (%) — 11.7 33.3 48.1 65.7 79.3 85.6 94.9 > 8 Survivors (ticks) 45 41 32 23 15 6 3 0 Repellency (%) — 9.6 30.1 46.5 62.3 85.7 93 100 Total 926 — — — — — — —
Table 3 Repellency effect of flumethrin according to type of livestock Livestock Repellency Time of controls before and after application of flumethrin Index Before 1 day 2 days 3 days 7 days 14 days 30 days 60 days Oxen Survivors (ticks) 93 80 60 39 22 19 15 8 Repellency (%) — 14.6 36.6 56.1 73.2 78 83.1 90.5 Cattle Survivors (ticks) 309 251 199 137 83 55 30 14 Repellency (%) — 19.4 36.7 53.6 69.6 80.9 89.8 95 Sheep Survivors (ticks) 400 337 260 174 98 83 26 15 Repellency (%) — 16.4 36.1 54.5 72.3 77.7 93.2 95.8 Goats Survivors (ticks) 124 122 92 64 42 18 10 3 Repellency (%) — 2.4 27.1 46 61.7 84.4 91.6 97.3 Total Survivors (ticks) 926 790 611 414 245 175 81 40 Repellency (%) — 15.3 35.1 53.2 70 79.7 90.9 95.2
against ticks worldwide (13, 14). In Jeddah, Saudi Arabia, toxicant for a long time (18). A combination of flumethrin 1% flumethrin pour-on was used to controlH. dromedarii and imidacloprid was administered to dogs in a collar, in dromedaries. For animals with high density of ticks, and after 6 and 12 hours, the insecticides had 94–100% 2 ml/10 kg body weight was used, and 1 ml/10 kg for repellent and lethal effects on Dermacentor variabilis and those with only mild contamination. In comparison Amblyomma americanum ticks. The protection time of these with control animals, there was a high level of tick animals against ticks was estimated at 28–48 days. The control with both doses (15). In another study in Riyadh, repellent rate of flumethrin was estimated at > 2 months Saudi Arabia, 2 insecticides, 1% flumethrin pour-on under field conditions (19–22). In a study in Namibia of formulation and 20% coumaphos WP formulation, were sheep contaminated with Hyalomma truncatum treated used topically against different stages of H. dromedarii on with 1% flumethrin pour-on, ticks disappeared for 4 camels (16). The toxicity of flumethrin was 8 times higher weeks and full protection was provided (23). than that of coumaphos against ticks. Some studies have Flumethrin is effective against a broad range of shown that 1% flumethrin pour-on has 95–100% lethality ectoparasites. In endemic areas for visceral leishmaniasis for ectoparasites (17). Flumethrin can prevent disease it can have repellent and antinutritional properties transmission by ticks, fleas, mites and other ectoparasites against the sandfly vectorPhlebotomus (Larrossius due to its repellent property (preventing blood feeding) group). In a study from Southern Italy, 4.5% flumethrin (17). In the present study, the repellent property of and 10% imidacloprid achieved 90.5–100% prevention of flumethrin was evaluated against hard ticks on cows, dog leishmaniasis. It had a significant antinutritional sheep, water oxen and goats. Flumethrin repelled hard effect on Phlebotomus and reduced Leishmania infantum ticks of Hyalomma species and Rhipicephalus bursa from in young dogs. This combination achieved 8 months of livestock for 2 months. protection in comparison to 5 months with deltamethrin In other studies, a combination of different toxicants (24). Another study examined the effect of 1% flumethrin increased the lethal and retention properties of this pour-on on visceral leishmaniasis in dogs. The ratio
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index of blood feeding by Phlebotomus in the dogs treated Conclusion with flumethrin pour-on was 12.26–25%, compared with We recommend the use of 1% flumethrin pour-on formu- 53.8–58.7% in the control group. This difference was lation for livestock every 2 months in cold and mountain- significant. Also, the index of preventing blood feeding ous climates (like Northwest Islamic Republic of Iran). by Phlebotomus was 75–87.74 and 41.29–46.45% in the Appropriate use of this insecticide at the recommended treatment and control groups, respectively. Again, this dose provides effective protection against important difference was significant 25( ). ticks on livestock.
Acknowledgements Our special thanks go to all the women whose participation made this research possible. We thank the Tehran University of Medical Sciences for their funding and the Iranian Legal Medicine Organization for their support. Funding: This study was funded by Tehran University of Medical Sciences. Competing interests: None declared.
Effet répulsif de la fluméthrine en application épicutanée contre les vecteurs de la fièvre hémorragique de Crimée-Congo Résumé Contexte : Les tiques peuvent transmettre des maladies graves aux humains, y compris la fièvre pourprée des montagnes Rocheuses, la fièvre Q, la fièvre hémorragique de Crimée-Congo, l’encéphalite verno-estivale russe et la fièvre récurrente. Objectif : La présente étude visait à déterminer l’effet répulsif de la fluméthrine 1 % en application épicutanée contre les tiques dures. Méthodes : La concentration de la formulation de fluméthrine épicutanée était de 1 mg/10 kg de poids. Elle était administrée sur la ligne médiane dorsale, de la tête à la base de la queue. Les animaux étudiés comprenaient des vaches, des chèvres, des bœufs et des moutons de deux villages de la province d’Ardabil, en République islamique d’Iran. Résultats : Nous avons examiné 200 animaux appartenant à cinq groupes d’âge (<2, 3-4, 5-6, 7-8 et >8 ans). Les principales tiques dures identifiées appartenaient aux espèces Hyalomma (62,5 %) et Rhipicephalus bursa (37,5 %). Dans le village où le traitement était appliqué, le nombre maximum de tiques par animal était de 11,6 pour les bœufs ; 9,5 pour les moutons ; 8,9 pour les chèvres ; et 8,6 pour les bovins. L’effet répulsif de la fluméthrine s’est dissipé au bout de deux mois. Conclusion : La fluméthrine offre une protection de deux mois contre les tiques dures. Elle pourrait donc être utilisée dans l’industrie de l’élevage. Le contrôle des tiques est un aspect important de la prévention de la transmission de la maladie.
التأثري ُامل َن ِّفر ّلصب مستحرض فلوميثرين املضاد لنواقل ُ َّحى القرم-الكونجو النزفية اسالم مرادى اصل، حسن وطن روست، زكي تلامداري، مهدي حمبعىل، حممد رضا عبائي اخلالصة اخللفية: يمكن ُللقراد نقل أمراض هامة إىل اإلنسان، ومنها ُ َّى محاجلبال الصخرية ُامل َب ّقعة، ومحى كيو، ومحى القرم-الكونجو النزفية، والتهاب الدماغ الرويس الصيفي، واحلمى الراجعة. األهداف: هتدف الدراسة إىل التعرف عىل التأثري ُامل َن ِّفر لصب مستحرض فلوميثرين برتكيز %1 عىل ُالقراد القايس. طرق البحث: كان تركيز مستحرض فلوميثرين 1 مييل جرام/10 كيلو جرام من وزن احليوان، ُوي َص ّب عىل طول اخلط الظهري املتوسط ًبدءا من الرأسحتى قاعدة الذيل. وتضمنت املاشية األبقار واملاعز والثريان واألغنام يف قريتني من قرى والية أردبيل يف مجهورية إيران اإلسالمية. النتائج: درسنا 200 رأس ماشية تنتمي إىل 5 فئات عمرية )أصغر من سنتني، 3-4 سنوات، 5-6 سنوات، 7-8 سنوات، أكرب من 8 سنوات(. كانت أنواع ُالقراد القايس التي أمكن التعرف عليها هي قراد َاحل ْدراء )62.5%( والقراد َم ْر َو ِح ُّي الرأس الكييس )37.5%(. وبلغ العدد األقىص للقراد يف كل حيوان 11.6 يف الثريان، و9.5 يف الغنم، و8.9 يف املاعز، و يف8.6 البقر. وقد تواصل التأثري ُامل َن ِّفر ملستحرض فلوميثرين ملدة شهرين. االستنتاجات:يقدم فلوميثرين محاية تدوم شهرين من القراد القايس. لذا يمكن استخدامه يف تربية املاشية. فمكافحة القراد عمل مهم للوقاية من انتقال األمراض.
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References 1. Vatandoost H. Hanafi Bojd AA. Ectoparasites of medical and veterinary importance. Tehran: Tehran University of Medical Sciences; 2002: 45–50 (in Persian). 2. Servis M. Medical entomology. Tehran: Tehran University; 1995 (in Persian). 3. Oormazdi H. Medical parasitology: arthropods. Iran: Bahar Publications; 1995:178–190 (in Persian). 4. Kia E, Moghddas-Sani H, Hassanpoor H, Vatandoost H, Zahabiun F, Akhavan A, et al. Ectoparasites of rodents captured in bandar abbas, southern iran. Iran J Arthropod Borne Dis. 2009;3(2):44–9. PMID:22808381 5. Rozendaal, Jan A. Vector control: methods for use by individuals and communities. Geneva: World Health Organization; 1997 (http://apps.who.int/iris/handle/10665/41968, accessed 23 March 2018). 6. Tapia-Perez G, García-Vazquez Z, Montaldo H, George J. Inheritance of resistance to flumethrin in the Mexican Aldama strain of the cattle tick Boophilus microplus (Acari: Ixodidae). Exp Appl Acarol. 2003;31(1-2):135–49. https://doi.org/10.1023/B:AP- PA.0000005143.90681.82 PMID:14756408 7. Prakash S, Srivastava CP, Kumar S, Pandey KS, Kaushik MP, Rao KMN. N,N-diethylphenylacetamide–a new repellent for Periplaneta americana (Dictyoptera: Blattidae), Blattella germanica, and Supella longipalpa (Dictyoptera: Blattellidae). J Med Entomol. 1990 Nov;27(6):962–7. https://doi.org/10.1093/jmedent/27.6.962 PMID:2280397 8. Klun JA, Ma D, Gupta R. Optically active arthropod repellents for use against disease vectors. J Med Entomol. 2000 Jan;37(1):182– 6. https://doi.org/10.1603/0022-2585-37.1.182 PMID:15218925 9. Nabian S, Rahbari S, Changizi A, Shayan P. The distribution of Hyalomma spp. ticks from domestic ruminants in Iran. Med Vet Entomol. 2009 Sep;23(3):281–3. https://doi.org/10.1111/j.1365-2915.2009.00804.x PMID:19712158 10. Fourie LJ, Kok DJ, Peter RJ. Influence of sheep breed and application site on the efficacy of a flumethrin pour-on formulation against ticks. J S Afr Vet Assoc. 2001 Sep;72(3):143–6. https://doi.org/10.4102/jsava.v72i3.637 PMID:11811701 11. Aghighi Z, Assmar M, Piazak N, Javadian E, Seyedi Rashti MA. Kia EB, et al. Distribution of soft ticks and their natural infec- tion with Borrelia in a focus of relapsing fever in Iran. Iran J Arthropod Borne Dis. 2007;1(2):14–8. http://www.sid.ir/FileServer/ JE/120220070203. 12. Telmadarraiy Z, Bahrami A, Vatandoost H. A survey on fauna of ticks in West Azerbaijan Province, Iran. Iran J Public Health. 2004;33(4):65–9. 13. Liebisch A, Beder G. [Control of ticks (Ixodidae: Dermacentor marginatus) in sheep with flumethrin 1% pour-on]. Vet Med Rev. 1988;1:9–17 (in German). 14. Parrodi F, Bhushan C, Neri S, Ramirez E. Efficacy of fluazuron and flumethrin combination pour-on formulation against Boophi- lus microplus on artificially and naturally interested cattle. Proceeding of the 26th World Buiatrics Congress, Santiago, Chile; 2010. 15. el-Azazy OM. Camel tick (Acari:Ixodidae) control with pour-on application of flumethrin. Vet Parasitol. 1996 Dec 31;67(3-4):281–4. https://doi.org/10.1016/S0304-4017(96)00938-7 PMID:9017876 16. Alahmed AM, Hussein HI, Kheir SM, Al-Rajhy D. Efficacy of flumethrin and coumaphos against the camel tick Hyalomma drom- edarii L. (Acari: Ixodidae). J Egypt Soc Parasitol. 2001 Dec;31(3):791–8. PMID:11775105 17. Josephus JF, Ivan GH. Christa d V, Katrin D, Bettina S. Comparative speed of kill, repellent (anti-feeding) and acaricidal efficacy of an imidacloprid/flumethrin collar (Seresto®)and a Fipronil/(S)-methoprene/eprinomectin/praziquantel spot-on (Broadline®) against Ixodes ricinus (Linné, 1758) on cats. Parasitol Res. 2015;114(Suppl 1):S109–16. https://doi.org/10.1007/s00436-015-4517-9 PMID:26152412 18. Ivan GH, Josephus J. Dorothee St. Efficacy of slow-release collar formulations of imidacloprid/flumethrin and deltamethrin and of spot-on formulations of fipronil/(s)-methoprene, dinotefuran/pyriproxyfen/permethrin and (s)–methoprene/amitraz/ fipronil against Rhipicephalus sanguineus and Ctenocephalides felis felis on dogs. Parasit Vectors. 2012 Apr 22;5:79. https://doi. org/10.1186/1756-3305-5-79 PMID:22520338 19. Ohmes CM, Hostetler J, Davis WL, Settje T, McMinn A, Everett WR. Comparative efficacy of an imidacloprid/ flumethrin collar (Seresto®) and an oral fluralaner chewable tablet (Bravecto®) against tick (Dermacentor variabilis and Amblyomma americanum) infestations on dogs: a randomized controlled trial. Parasitol Res. 2015;114:95–108. https://doi.org/10.1007/s00436-015-4516-x PMID:26152411 20. Stanneck D, Rass J, Radeloff I, Kruedewagen E, Le Sueur C, Hellmann K, et al. Evaluation of the long-term efficacy and safety of an imidacloprid 10%/flumethrin 4.5% polymer matrix collar (Seresto®) in dogs and cats naturally infested with fleas and/ or ticks in multicentre clinical field studies in Europe. Parasit Vectors. 2012 Mar 31;5:66. https://doi.org/10.1186/1756-3305-5-66 PMID:22463745 21. Stanneck D, Kruedewagen EM, Fourie JJ, Horak IG, Davis W, Krieger KJ. Efficacy of an imidacloprid/flumethrin collar against fleas, ticks, mites and lice on dogs. Parasit Vectors. 2012 May 30;5:102. https://doi.org/10.1186/1756-3305-5-102 PMID:22647530 22. Stanneck D, Ebbinghaus-Kintscher U, Schoenhense E, Kruedewagen EM, Turberg A, Leisewitz A, et al. The synergistic action of imidacloprid and flumethrin and their release kinetics from collars applied for ectoparasite control in dogs and cats. Parasit Vectors. 2012 Apr 12;5:73. https://doi.org/10.1186/1756-3305-5-73 PMID:22498105
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23. Hamel HD. Efficacy of flumethrin 1% pour-on against Hyalomma truncatum in Karakul sheep in Namibia. Vet Med Rev. 1987;1:43–50. 24. Brianti E, Gaglio G, Napoli E, Falsone L, Prudente C, Solari Basano F, et al. Efficacy of a slow-release imidacloprid (10%)/flume- thrin (4.5%) collar for the prevention of canine leishmaniasis. Parasit Vectors. 2014 Jul 14;7(1):327. https://doi.org/10.1186/1756-3305- 7-327 PMID:25023573 25. Jalilnavaz MR, Abai MR, Vatandoost H, Mohebali M, Akhavan AA, Zarei Z et al. Application of flumethrin pour-on on reservoir dogs and its efficacy against sand flies in endemic focus of visceral leishmaniosis, Meshkinshahr. Iran J Arthropod Borne Dis. 2016;19(1):35–42.
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Quality of life in Iranian elderly population using the SF-36 question- naire: systematic review and meta-analysis
Amin Doosti-Irani 1,2, Saharnaz Nedjat 3,4, Sima Nedjat 5, Parvin Cheraghi 6,7 and Zahra Cheraghi 2,8
1Research Center for Health Sciences, Hamadan University of Medical Science. Hamadan, Islamic Republic of Iran. 2Department of Epidemiology, School of Public Health, Hamadan University of Medical Science, Hamadan, Islamic Republic of Iran (Correspondence to: Z. Cheraghi: z.cheraghi@ umsha.ac.ir). 3Knowledge Utilization Research Center, University of Social Welfare and Rehabilitation, Tehran, Islamic Republic of Iran. 4Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 5Knowledge Uti- lization Research Center, University of Social Welfare and Rehabilitation, Tehran, Islamic Republic of Iran. 6Department of Health Education and Pro- motion, School of Public Health, Hamadan University of Medical Sciences, Islamic Republic of Iran. 7Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 8Modeling of Non-Communicable Disease Research Center, Hamadan University of Medical Science. Hamadan, Islamic Republic of Iran.
Abstract Background: Ageing is a major known risk factor that is a threat to human health. To date, many studies have inves- tigated quality of life (QOL) among the elderly population in the Islamic Republic of Iran. However, their results were inconsistent. Aims: We designed this systematic review and meta-analysis to estimate the overall mean score of QOL based on the Short Form 36 Health Survey Questionnaire (SF-36) among the Iranian elderly population. Methods: We searched international databases (Medline, Scopus and Science Direct) and national databases (Science In-formation Database, MagIran, IranMedex and Irandoc) up to February 2015. We included all cross-sectional studies that evaluated QOL among the Iranian elderly population using SF-36. Results: Of 2150 studies identified, 15 were included in the meta-analysis. The mean scores for QOL in the 8 scales were: 47.58, 51.75, 55.42, 55.78, 59.55, 51.54, 47.85 and 51.31 for physical-role, physical function, mental health, bodily pain, social functioning, emotional-role, general health, and vitality, respectively. Conclusions: Our results indicated that health-related QOL decreased with increasing age. QOL was worse in women than in men, especially in physical-role and general health scales. Elderly people who lived in a nursing home had lower QOL than those who lived in their own home. So, health policy-makers should design comprehensive programmes to improve health-related QOL for the Iranian elderly population. Keywords: ageing, elderly, quality of life, SF-36, Islamic Republic of Iran. Citation: Doosti-Irani A, Nedjat S, Nedjat S, Cheraghi P and Cheraghi Z. Quality of life in Iranian elderly population using the SF-36 questionnaire: systematic review and meta-analysis. East Mediterr Health J. 2018;24(11):1088–1097. https://doi.org/10.26719/2018.24.11.1088 Received: 28/05/18; accepted 06/08/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction 36 Health Survey Questionnaire (SF-36) is a standardized and widely used tool for assessing health-related QOL Ageing is an inevitable biological phenomenon and indi- worldwide (8). cates the aggregation of changes in a person over time in the physical, mental and social dimensions (1). Elder- As the ageing population increases, attention needs ly people (aged ≥ 60 years) are exposed to diseases more to be given to physical, social and mental health to than younger adults are (2). About 100 000 deaths occur improve QOL among this population. Many studies annually due to ageing-related diseases worldwide (3). Ac- have investigated QOL among the elderly population in cording to the United Nations, if the proportion of elderly the Islamic Republic of Iran, although the results were people (aged ≥ 60 years) in a country is ≥ 7%, that country inconsistent (9–16). We designed this study to estimate is considered to have an elderly population (4). According the overall mean score of QOL based on SF-36 among the to the 2011 census, the Islamic Republic of Iran had 8.26% Iranian elderly population. of people aged ≥ 60 years and it was added to the list of countries with an ageing population (5). Methods According to the World Health Organization definition, We searched international databases (Medline, Scop- people’s quality of life (QOL) is related to culture, value us and Science Direct) and national databases (Science system by which they live, goals, expectations, standards In-formation Database, MagIran, IranMedex and Iran- and priorities. Physical and mental health, level of doc) up to February 2015 using the following keywords: independence, social relationships, personal beliefs and “quality of life” AND (“aging” OR “aged” OR “elderly”) the environment all affect the perceived QOL (6). QOL is AND “Iran”. We included all studies that addressed QOL one of the theoretical frameworks for assessing the living among the healthy Iranian elderly population (aged ≥ 60 conditions of different communities (7). The Short Form years) using the SF-36 questionnaire, irrespective of sex,
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time of study and language of publication. The main out- derly participants with a mean age of 70.31 (3.63) years. It come of interest was the mean score for QOL in the dif- is necessary to mention that 7 studies (9, 10, 12, 14–16, 27) ferent domains of SF-36. reported the QOL scores for men and women separately, SF-36 has 36 items in 8 sections: physical function, so we divided those studies into 2 independent studies, role-physical, bodily pain, general health, vitality, social which gave a final 23 studies for the data analysis. functioning, role-emotional and mental health. Each There was considerable heterogeneity among the scale involves 2–10 questions and low scores indicate low results of the included studies. The χ2 test results were QOL (17). For data collection, two authors (ZCH and ADI) highly significant (P < 0.001) for all QOL scales, and the I2 screened the title and abstract of retrieved references statistic was high for all QOL scales (Tables 2 and 3). We independently to assess the relevancy. In the next stage, estimated the QOL for each scale in SF-36. The highest they reviewed the full text of selected studies to extract and lowest pooled mean scores for QOL were related to the studies that met the eligibility criteria for the meta- social functioning and role-physical scales among the analysis. Any disagreement between the authors in the Iranian elderly population (Table 2). selection of studies was resolved by discussion with and The pooled mean score for the role-physical scale adjudication of a third author. The overall agreement decreased significantly with increasing age (Table 3); between the authors was 86.76%, and the kappa statistic the highest and lowest scores were observed among was 72.44%. In the cases of missing data, we made contact participants aged 60–64 years and aged ≥ 75 years, with the corresponding authors of the studies. The respectively. The pooled mean score of the role-physical variables included the year and location of the studies, scale was higher in men than in women; however, this mean age and sex of the participants, residence of the difference was not significant. The pooled mean score of participants, sample size, and mean QOL score, and its the role-physical scale was higher for participants who standard deviation (SD) was extracted for data analysis. lived in nursing homes compared with their own homes, Seven selected items from the STROBE (Strengthening or in a mixture of the two; however, this difference was the Reporting of Observational Studies in Epidemiology) not significant. (18) checklist were used for assessing the risk of bias and The pooled mean score for the physical function quality of reporting. These items (1) presented the key scale decreased significantly with ageing; the highest elements of the study design; (2) explained the inclusion and lowest scores were observed among those aged and exclusion criteria; (3) defined the outcome, that is, 60–64 years and aged ≥ 75 years, respectively (Table 3). QOL; (4) explained how the sample size was calculated; The pooled mean score of the physical function scale (5) described the setting, location and date of the study; was higher among men than women; however, this (6) reported the precision of estimates, that is, SD or difference was not significant. The pooled mean score of confidence interval; and (7) explained the statistical the physical function scale among participants who lived methods for data analysis. Studies that satisfied all the in nursing homes was higher than for those who lived in mentioned criteria were classified as having a low risk of their own homes or in mixed accommodation; however, bias. Studies that did not meet 1 item were classified as this difference was not significant. intermediate, and studies that did not meet > 1 item were classified as high risk of bias. In the mental health scale, there was no overall significant trend with ageing; the highest pooled mean The statistical heterogeneity was explored using the χ2 score was for participants aged 65–69 years and the test at the 10% significance level. Also, the heterogeneity lowest for those aged ≥ 75 years (Table 3). The pooled across the included studies was quantified using theI 2 mean score of the mental health scale was higher in statistic. Variance between studies was estimated using men than in women; however, this difference was not I2 statistics (19). Meta-analysis was performed to estimate significant. The pooled mean score of the mental health the summary measure of mean score of QOL among scale among participants who lived in their own home the elderly population. The random effects model (20) was higher than for those who lived in nursing homes was used for data analysis, and results were reported or in mixed accommodation; however this difference was with 95% confidence interval. Subgroup analysis was not significant. accomplished according to the results of meta-regression analysis. We performed subgroup analysis based on age According to the bodily pain scale, there was no overall groups, sex, residence, and quality of included studies. trend with ageing. The highest pooled mean score was in We used Stata version 11 (Stata Corp., College Station, TX, participants aged 65–69 years and the lowest score was USA) and Review Manager 5.3 for data analysis. in participants aged ≥ 75 years (Table 3). The pooled mean score was higher in men than in women; however, this Results difference was not significant. The pooled mean score We retrieved 2150 records; 470 were excluded because of of the bodily pain scale was higher for participants who duplication, 1000 because they were not related to the aim lived in mixed accommodation compared with those who of the review and 655 because they were not eligible for lived in nursing homes or their own home; however, this inclusion in the meta-analysis after checking the full text. difference was not significant. Finally, 15 articles (9–16, 21–27) remained for meta-analy- In the social functioning scale, there was no overall sis (Figure 1 and Table 1), which involved 16 914 Iranian el- trend with ageing. The highest and lowest pooled mean
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1800 of records identified 350 of records identified through through search of other sources: 150: reference list; international database 200: related website of conferences
2150215 retrieved
retrieved
470 excluded because of duplication
16801680 remained for checking the title and abstract
remained for checking the title and abstract
1000 excluded because not related to the objective of review
680 remained for checking full text
655 excluded because were not eligible to include in meta-analysis
15 remained for meta-analysis
Figure 1 Flow chart of study identification process
scores were in participants age 65–69 years and ≥ 75 lowest scores were among those aged 60–64 years and years, respectively (Table 3). The pooled mean score of aged ≥ 75 years, respectively (Table 3). The pooled mean this scale was higher among men than women. The score of this scale was significantly higher among pooled mean score of social functioning scale was men than women. The pooled mean score of the role- higher among participants who lived in their own home emotional scale was higher among participants who compared with those who lived in nursing homes or in lived in their own home compared with those who lived mixed accommodation; however, this difference was not in nursing homes or in mixed accommodation; however, significant. this difference was not significant. The pooled mean score for the role-emotional scale For the general health scale, the pooled mean score decreased significantly with ageing; the highest and decreased significantly with ageing, although the score
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Table 1 Characteristics of studies included in meta-analysis Author Year City Gender Resident Habitat Mean Sample age (yr) size
Abbasimoghadama 2009 Tehran Male Own home City 71 5600 Own home Abbasimoghadamb 2009 Tehran Female City 71 5600 Own home Aghanooria 2011 Markazi Female City 70.7 91 Own home Aghanoorib 2011 Markazi Male City 70.7 74 Ahmadi 2004 Zahedan Both Mixedb City 72.3 200 Albokordia 2005 Shahinshahr Female Mixed City 67.2 34 Albokordib 2005 Shahinshahr Male Mixed City 67.2 66 Own home Farhadia 2010 Boushehr Female Rural — 16 Own home Farhadib 2010 Boushehr Male Rural — 53 Farzianpoura 2012 Marivan Both Mixed City — 2433 Farzianpourb 2012 Masjed Soleiman Both Mixed City 74.51 349 Own home Hekmatpoua 2014 Arak Female City 67.5 271 Own home Jaafarzadeh Fakhari 2010 Sabzevar Both Both 69.3 304 Naseha 2014 Chaharmahal Both Nursing home Both 73.13 87 Bakhteiari Own home Nejatia 2008 Kashan Female City 69.8 193 Own home Nejatib 2008 Kashan Male City 69.8 196 Rafaatia 2005 Tehran Female Nursing home City 76.8 118 Rafaatib 2005 Tehran Male Nursing home City 76.8 84 Rostamai 2010 Masjed Soleiman Both Own home City 74.51 349 Salehia 2013 Tehran Female Nursing home City 64.07 298 Salehib 2013 Tehran Male Nursing home City 64.07 102 Vahdania 2005 Tehran Male Mixed City 67.9 157 Vahdanib 2005 Tehran Female Mixed City 67.9 239 aStudies provided all 6 STROBE items (low risk of bias). bBoth own home and nursing home.
for those aged ≥ 75 years was higher than for those aged The pooled mean score for the vitality scale decreased 70–74 years (Table 3). The pooled mean score of this significantly with ageing (Table 3). The pooled mean score scale was higher among men than women; however, this of this scale was higher in men than women; however, difference was not significant. The pooled mean score of this difference was not significant. The pooled mean the general health scale was higher among participants score of vitality scale was higher among participants who who lived in nursing homes or mixed accommodation lived in their own home compared to those who lived in compared with those who lived in their own home; nursing homes or mixed accommodation; however, this however, this difference was not significant. difference was not significant.
Table 2 Pooled estimation for mean score of QOL according the each scale Scale of QOL No. of studies Pooled mean score (95% CI) P* I2 Role-physical 23 47.58 (43.95–51.21) <0.001 99.1 Physical function 23 51.75 (46.78–56.71) <0.001 99.3 Mental health 23 55.42 (51.32–59.52) <0.001 99.3 Bodily pain 23 55.78 (50.79– 56.78) <0.001 98.0 Social functioning 22 59.55 (56.78–62.31) <0.001 97.9 Role-emotional 23 51.54 (48.59–54.49) <0.001 97.8 General health 24 47.85 (45.25–50.46) <0.001 99.2 Vitality 21 51.31 (48.93–53.69) <0.001 97.9 *Test for heterogeneity. CI = confidence interval; QOL = quality of life.
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Table 3 Subgroup analysis of QOL among elderly population Scale Variable Subgroup No. of Pooled mean Pa I2 Pb studies score (95% CI)
Role-physical Age (yr) 60–64 8 63.26 (48.16–84.36) < 0.001 99.8 < 0.001 65–69 4 49.61 (48.57–50.65) < 0.001 95.4 70–74 8 49.03 (48.65–49.40) < 0.001 98.8 ≥ 75 3 35.03 (33.94–36.13) < 0.001 90.4 Gender Male 8 50.52 (42.29–58.75) <0.001 99.3 0.53 Female 9 46.71 (38.21–55.22) < 0.001 99.4 Both 6 44.90 (41.99–47.81) < 0.001 87.7 Residence Own home 11 47.19 (43.52–50.87) < 0.001 98.6 0.99 Nursing home 7 48.20 (36.54–59.85) < 0.001 99.6 Mixed 5 47.34 (35.64–59.04) < 0.001 96.7 Physical function Age (yr) 60–64 3 62.63 (51.58–87.67) < 0.001 99.8 0.003 65–69 8 52.98 (43.23–62.74) < 0.001 98.6 70–74 8 52.03 (47.18–56.89) < 0.001 98.6 ≥ 75 4 34.56 (24.27–44.86) < 0.001 93.9 Gender Male 8 59.77 (51.81–67.74) < 0.001 98.6 0.08 Female 9 47.51 (36.13–58.89) < 0.001 98.6 Both 6 46.98 (39.78–54.17) < 0.001 98.6 Residence Own home 11 50.13 (44.84–55.43) < 0.001 99 0.75 Nursing home 7 55.04 (43.31–66.77) < 0.001 99.6 Mixed 5 50.45 (36.99–63.92) < 0.001 96.7 Mental health Age (yr) 60–64 3 62.55 (60.88–64.23) 0.003 82.8 <0.001 65–69 8 63.00 (46.33–79.68) < 0.001 99.3 70–74 7 50.70 (46.79–54.61) < 0.001 98.6 ≥ 75 4 42.55 (35.36–49.74) < 0.001 94.1 Gender Male 8 62.58 (53.33–71.82) < 0.001 99.2 0.18 Female 9 53.43 (38.31–63.03) < 0.001 99.5 Both 5 47.47 (38.42–56.23) < 0.001 99.1 Residence Own home 10 57.22 (49.98–64.45) < 0.001 99.6 0.74 Nursing home 7 53.79 (48.82–58.77) < 0.001 98.3 Mixed 5 54.29 (42.99–65.57) < 0.001 97.5 Bodily pain Age (yr) 60–64 3 57.53 (49.39–65.68) < 0.001 98.9 0.01 65–69 8 60.07 (52.35–67.79) < 0.001 97.6 70–74 8 49.34 (44.22–54.47) < 0.001 98.7 ≥ 75 4 46.99 (42.1–51.85) 0.053 61 Gender Male 8 58.84 (53.82–63.85) < 0.001 95.3 0.27 Female 9 54.66 (49.20–60.11) < 0.001 97.9 Both 6 46.28 (41.89–50.66) < 0.001 95.8 Residence Own home 11 52.13 (48.0–56.26) < 0.001 98 0.58 Nursing home 7 52.01 (46.75–57.28) < 0.001 97.5 Mixed 5 60.99 (44.55–77.3) < 0.001 98.8
According to the risk of bias, 56.52%, 21.74% and role-physical scale may have been due to ageing problems. 21.74% of the included studies were classified in the low, The highest mean score for the social functioning scale intermediate and high risk of bias, respectively. may have been due to better relationships with members of the community and their families. Culturally in the Discussion Islamic Republic of Iran, most elderly men are respect- We found that the highest pooled mean score was relat- ed in their families and communities. This may be due ed to the social functioning scale and the lowest score to the higher QOL in the social functioning rather than to the role-physical scale. The lowest mean score for the other scales of QOL. According to our results, in general,
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Table 3 Subgroup analysis of QOL among elderly population (concluded) Scale Variable Subgroup No. of Pooled mean Pa I2 Pb studies score (95% CI)
Social Functioning Age (yr) 60–64 3 61.74 (59.47–64.00) < 0.001 92 0.001 65–69 7 68.85 (60.03–77.68) < 0.001 97.5 70–74 8 56.8 (52.65–60.29) < 0.001 97.8 ≥ 75 4 47.49 (37.86–57.12) < 0.001 91.2 Gender Male 8 65.66 (60.66–70.66) < 0.001 97.2 0.05 Female 9 58.67 (53.67–63.67) < 0.001 98.3 Both 5 51.63 (45.33–57.94) < 0.001 97.7 Residence Own home 10 64.06 (59.87–68.26) < 0.001 98.1 0.001 Nursing home 7 52.49 (47.96–57.02) < 0.001 97.9 Mixed 5 62.15 (48.29–75.99) < 0.001 98 Role-emotional Age (yr) 60–64 3 57.38 (36.67–78.09) < 0.001 99.5 0.01 65–69 7 57.06 (51.11–63.01) < 0.001 93 70–74 8 50.88 (47.81–53.95) < 0.001 97.1 ≥ 75 4 39.44 (30.46–48.41) 0.001 82.01 Gender Male 8 58.71 (53.70–63.73) < 0.001 96.6 0.01 Female 9 49.33 (43.99–54.66) < 0.001 94.3 Both 5 44.74 (39.42–50.05) < 0.001 95.9 Residence Own home 10 52.27 (49.23–55.30) < 0.001 97.3 0.82 Nursing home 7 49.97 (39.91–60.03) < 0.001 98.7 Mixed 5 54.78 (43.82–65.73) < 0.001 92.6 General health Age (yr) 60–64 3 60.31 (46.01–74.60) < 0.001 99.8 0.007 65–69 8 51.07 (45.50–56.65) < 0.001 98.4 70–74 8 42.05 (37.85–6.25) < 0.001 98.9 ≥ 75 4 43.22 (40.30–46.13) 0.003 78.8 Gender Male 8 54.60 (48.68–60.51) < 0.001 98.4 0.06 Female 9 47.59 (43.11–52.07) < 0.001 99.5 Both 6 39.55 (34.29–44.81) < 0.001 98.1 Residence Own home 11 47.34 (44.79–49.89) < 0.001 98.9 0.97 Nursing home 7 48.30 (38.78–57.82) < 0.001 99.6 Mixed 5 48.10 (41.13–55.08) < 0.001 95.5 Vitality Age (yr) 60–64 3 57.62 (50.99–64.25) < 0.001 98.7 0.03 65–69 7 52.39 (45.62–59.15) < 0.001 97.4 70–74 7 49.61 (46.09–53.13) < 0.001 98.3 ≥ 75 4 46.73 (43.39–50.07) 0.028 67 Gender Male 8 54.18 (48.94–59.43) < 0.001 96.9 0.28 Female 9 50.17 (45.21–55.13) < 0.001 98.5 Both 4 48.16 (44.87–51.46) < 0.001 93.4 Residence Own home 10 52.67 (49.35–55.98) < 0.001 98.2 0.50 Nursing home 6 51.85 (46.56–57.13) < 0.001 98.1 Mixed 5 47.59 (39.82–55.36) < 0.001 96.3 aTest for heterogeneity. bTest for subgroup difference.
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the QOL score (in all scales of the SF-36 questionnaire) inconsistent with other scales, for example, Acree et al. decreased with increasing age. Men had higher pooled found that the highest mean score of QOL was related to mean scores of QOL than women. people aged 60–64 years (29). Better social functioning Our results showed that the pooled mean score for QOL in people aged 65–69 years may have been due to the role-physical and physical function scales decreased more activities, resulting in better social activity and significantly with age. These results are consistent with community and family relationships. In contrast, social the biological changes in the physical dimensions of vulnerability is associated with increasing age, female elderly people (1). The pooled mean scores among men sex, and frailty (32). Therefore, a lower mean score for were more than in women in both those scales. The better QOL based on the social functioning scale in older people QOL among men may have been due to greater physical may have been related to greater social vulnerability. activity in Iranian men than women. Physical activity In addition, our results indicated that the pooled mean has beneficial effects on QOL28 ( ). Regular physical score for QOL in women was lower than in men, which activity was associated with better QOL in all domains is consistent with greater social vulnerability among among older adults, and physical activity among women women. Elderly people who were living in their own was lower than in men. The mean score for QOL among home had a significantly higher pooled mean score older adults with higher physical activity was significantly compared to those living in nursing homes. This finding more than in adults with lower physical activity (29). This may be related to better support of elderly people by their finding is consistent with the results of a meta-analysis of families in their own homes. Another study has shown randomized control trials that showed that physical activity that greater life satisfaction is associated with receiving improves the self-reported physical function in older adults more family support (33). (30). Like other scales of SF-36, the pooled mean score for We showed that the mean score for mental health QOL based on the role-emotional scale was lowest in QOL decreased with ageing. The lowest mental health people aged ≥ 75 years. The lower role-emotional QOL QOL was related to participants aged ≥ 75 years. One in older people may have been related to other scales reason for lower mental health QOL may be lower of QOL such as role-physical, physical function, mental physical activity in older people. Some studies have health and social functioning. Therefore, it seems that the indicated a positive association between physical activity reasons for lower QOL in older people are common in the and mental health QOL (28, 29). In our study, the pooled SF-36 scales. mean score for the role-physical and physical function Factors such as age, chronic disease, smoking, alcohol scales decreased with ageing. Therefore, there may be an consumption, insufficient exercise and lack of physical association between these scales and the mental health examination are associated with low health-related QOL scale. Another reason may be due to lower social activity (34). Also, increasing age and decreasing physical activity in older people. The mean score for mental health QOL in are common risk factors for some chronic diseases, so men was higher than in women, but the difference was the lower mean score for QOL may be related to higher not significant. The better mental health status in men prevalence of chronic diseases in older people. may have been due to more social and physical activities. We explored evidence of heterogeneity in the results of The mean score for mental health QOL in elderly people our included studies. We performed subgroup analysis based who lived in their own home was higher than in those on the potential source of heterogeneity, but heterogeneity who lived in a nursing home. A randomized control trial remained in the subgroups. The high heterogeneity in the in 5 nursing homes showed that the intervention group results may have been related to different study settings. who received meals family style had better QOL than the The studies included in our analysis were conducted in control group who received the usual service (31). The different geographic regions, with different cultures and results of that trial are in line with our present results. lifestyles. So, the QOL may have been affected by such The QOL of elderly people who are living in their own factors in different regions of the Islamic Republic of Iran. home is better than in those who are living in a nursing However, we pooled the results of the included studies home, because elderly people in their own home received using the random effects model in order to estimate the emotional and physical support from their family. overall QOL, because of the public health importance of Our results indicated that mean score of QOL based QOL in elderly people and for health policy-makers. If on bodily pain decreased with age. This is consistent with the results of a meta-analysis are to be a guide for health other scales of QOL in this meta-analysis. Like the role- decision-making, it is possible to pool the results of physical and physical function scales, the lower mean heterogeneous studies (35). score for bodily pain may have been due to the biological There were some limitations to our meta-analysis. changes in the physical dimensions of elderly people (1). First, only 56.52% of the included studies were in the Older people have a higher risk for chronic diseases and low risk of bias group; this may have increased the syndromes compared with younger adults (2, 3), so the probability of information bias. Second, there was a lack lower mean score for bodily pain in elderly people was of data regarding potential factors related to QOL such expected. as education, job and income in some of the included For social functioning, the highest mean score for studies. Therefore, we could not perform subgroup QOL was in people aged 65–69 years. This finding is analysis based on those variables.
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Conclusion home had lower QOL than those who lived in their own home. The Islamic Republic of Iran has been added to the Our results indicated that health-related QOL decreased list of countries with an ageing population, therefore, with increasing age. QOL was worse in women than in health policy-makers should design comprehensive pro- men, especially in the role-physical and general health grammes to improve the health-related QOL for the Irani- scales. Moreover, elderly people who lived in a nursing an elderly population.
Acknowledgements We would like to thank the Vice-Chancellor of Research and Technology of Tehran University of Medical Sciences (TUMS) for financial support. Funding: Tehran University of Medical Sciences (Code: 94-01-27-28359). Competing interests: None declared.
Qualité de vie des personnes âgées iraniennes mesurée à l’aide du questionnaire SF- 36 : analyse systématique et méta-analyse Résumé Contexte : Le vieillissement est l’un des principaux facteurs de risque pour la santé humaine. À ce jour, de nombreuses études ont enquêté sur la qualité de vie des personnes âgées en République islamique d’Iran, mais leurs résultats ne concordent pas. Objectifs : Nous avons conçu les présentes analyse systématique et méta-analyse afin d’estimer le score moyen global de la qualité de vie des personnes âgées iraniennes à l’aide du questionnaire d’évaluation de la santé SF-36 en version abrégée. Méthodes : Nous avons mené des recherches dans des bases de données internationales (Medline, Scopus et Science Direct) et nationales (Science In-formation, MagIran, IranMedex et Irandoc) pour les études produites jusqu’en date de février 2015. Nous y avons inclus toutes les études transversales qui avaient évalué la qualité de vie des personnes âgées iraniennes à l’aide du questionnaire SF-36. Résultats : Sur 2150 études identifiées, 15 ont été incluses à la méta-analyse. Les scores moyens pour la qualité de vie sur les huit échelles du questionnaire étaient les suivants : 47,58, 51,75, 55,42, 55,78, 59,55, 51,54, 47,85 et 51,31 pour les limitations dues à l’état physique, l’activité physique, la santé psychique, la douleur physique, la vie et les relations aux autres, les limitations dues à l’état psychologique, la santé perçue et la vitalité respectivement. Conclusions : Nos résultats ont indiqué que la qualité de vie liée à la santé diminuait avec l’âge. Elle était moins bonne chez les femmes, notamment pour les échelles de limitations dues à l’état physique et de la santé perçue. Les personnes âgées résidant dans des maisons de retraite avaient une qualité de vie inférieure à celles vivant chez elles. À ce titre, les décideurs politiques devraient mettre au point des programmes complets visant à améliorer la qualité de vie liée à la santé des personnes âgées iraniennes.
جودة حياة املسنني اإليرانيني باستخدام نموذج االستبيان املخترص للمسح الصحي: مراجعة منهجية وحتليل ُب ْعدي أمني دوستي إيراين، سحرناز نجات، سيام نجات، بروين جراغى، زهرا جراغى اخلالصة اخللفية:الشيخوخة هي عامل خطر رئييس معروف هيدد صحة اإلنسان. وحتى اآلن، درست أبحاث عدة جودة حياة كبار السن يف مجهورية إيران اإلسالمية، إال أن نتائجها مل تكن متسقة مع بعضها البعض. األهداف:لقد صممنا هذه املراجعة املنهجية والتحليل ُالب ْعدي لتقدير املتوسط العام لقيمة جودة حياة كبار السن اإليرانيني ًاستنادا إىل نموذج االستبيان املخترص للمسح الصحي )36-SF(. طرق البحث: بحثنا يف قواعد البيانات الدولية )Medline, Scopus, Science Direct( وقواعد البيانات الوطنية )Science In-formation Database, MagIran, IranMedex, Irandoc ( حتى فرباير/شباط . 2015وقمنا بتضمني مجيع الدراسات املقطعية التي َق َّيمت جودة احلياة للسكان املسنني اإليرانيني باستخدام االستبيان 36-SF. النتائج:من بني 2150 دراسة من الدراسات التي حددناها، أدرجنا 15 دراسة يف التحليل ُالب ْعدي، وكان متوسط درجات جودة احلياة يف 8
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مقاييس هي: ]47.58[ لدور النشاط البدين و]51.75[ للقدرة البدنية و]55.42[ للصحة النفسية و]55.78[ آلالم اجلسد و]59.55[ لألداء االجتامعي و]51.54[ للدور العاطفي و]47.85[ للصحة العامة و]51.31[ للحيوية. االستنتاجات: أشارت نتائجنا إىل أن جودة احلياة التي ترتبط بالصحة قد انخفضت مع تقدم العمر، وكانت جودة احلياة أسوأ يف النساء منها يف الرجال، السيام حسب مقاييس النشاط البدين والصحة العامة، وكانت جودة احلياة لدى كبار السن الذين يعيشون يف دار لرعاية املسنني أقل مما هي عليه لدى الذين يعيشون يف منازهلم، وبالتايل ينبغي لراسمي السياسات الصحية تصميم برامج شاملة لتحسني جودة احلياة املرتبطة بصحة املسنني اإليرانيني. References 1. Bowen RL, Atwood CS. Living and dying for sex. A theory of aging based on the modulation of cell cycle signaling by reproduc- tive hormones. Gerontology. 2004 Sep–Oct;50(5):265–90. https://doi.org/10.1159/000079125 PMID:15331856 2. Boyd DR, Bee HL, Johnson PA. Lifespan development. London: Pearson; 2006. 3. de Grey ADNJ. Life span extension research and public debate: societal considerations. Stud Ethics Law Technol. 2007;1(1): https:// doi.org/10.2202/1941-6008.1011 4. World Health Organization. Proposed working definition of an older person in Africa for the MDS Project (http://www.who.int/ healthinfo/survey/ageingdefnolder/en/, accessed 13 September 2018). 5. Atlas of selected results of the 2011 National Population and Housing Census. Tehran: Statistical Centre of Iran; 2014 (http:// www.amar.org.ir/Default.aspx?tabid=1242&articleType=ArticleView&articleId=1733, accessed 12 July 2018). 6. Measuring quality of life. Geneva: World Health Organization. Division of Mental Health and Prevention of Substance Abuse (http://www.who.int/mental_health/media/68.pdf, accessed 12 July 2018). 7. Basakha M, Kohneshahri LA, Masaeli A. Ranking the quality of life in Iran provinces. Soc Welfare (India). 2010;10(37):95–112. 8. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992 Jun;30(6):473–83. https://doi.org/10.1097/00005650-199206000-00002 PMID:1593914 9. Abbasimoghadam MA, Dabiran S, Safdari R, Djafarian K. Quality of life and its relation to sociodemographic factors among elderly people living in Tehran. Geriatr Gerontol Int. 2009 Sep;9(3):270–5. https://doi.org/10.1111/j.1447-0594.2009.00532.x PMID:19702937 10. Agha nouri A, Mahmoudi M, Salehi H, Jafarian K. Quality of life in the elderly people covered by health centers in the urban areas of Markazi Province, Iran. Iran J Ageing. 2012;6(4):20–9. 11. Ahmadi F, Salar A, Faghihzadeh S. Quality of life in Zahedan elderly population. Hayat (Tihran). 2004;10(3):61–7. 12. Farhadi A, Froghan M, Mohammadi F. Rural quality of life of the elderly: a study on the city of Dashti in Bushehr province. Iran J Ageing. 2011;6(20):38–46. 13. Farzianpour F, Arab M, Hosseini SM, Pirozi B, Hosseini S. Evaluation of quality of life of the elderly population covered by healthcare centers of marivan and the influencing demographic and background factors in 2010. Iran Red Crescent Med J. 2012 Nov;14(11):695–6. https://doi.org/10.5812/ircmj.1834 PMID:23397047 14. Nejati V, Ashayeri H. Health related quality of life in the elderly in Kashan. Iran J Psychiatry Clin Psychol. 2008;14(1):56–61 (in Persian). 15. Salehi L, Salaki S, Alizadeh L. Health-related quality of life among elderly member of elderly centers in Tehran. Iran J Epidemiol. 2012;8(1):14–20 (in Persian). 16. Vahdaninia M, Goshtasebi A, Montazeri A, Maftoun F. Health-related quality of life in an elderly population in Iran: a popula- tion-based study. Payesh. 2005;4(2):113–20 (in Persian). 17. Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992 Jun;30(6):473–83. PMID:1593914 18. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Report- ing of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Prev Med. 2007 Oct;45(4):247–51. https://doi.org/10.1016/j.ypmed.2007.08.012 PMID:17950122 19. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60. https://doi.org/10.1136/bmj.327.7414.557 PMID:12958120 20. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986 Sep;7(3):177–88. https://doi.org/10.1016/0197- 2456(86)90046-2 PMID:3802833 21. Albou Kordi M, Ramezani MA, Arizi F. A study on the quality of life among elderly Shahinshahr Area of Isfahan Province in year 2004. Jundishapur Sci Med J. 2007 Winter;4(5):701–7 (in Persian). 22. Baraz S, Rostami M, Farzianpor F, Rasekh A. Effect of Orem Self Care Model on ederies’ quality of life in health care centers of Masjed Solaiman in 2007–2008. Arak Med Univ J. 2009;12(2):51–9 (in Persian). 23. Farzianpour F, Hosseini S, Rostami M, Pordanjani SB, Hosseini SM. Quality of life of the elderly residents. Am J Appl Sci. 2012;9(1):71–4. https://doi.org/10.3844/ajassp.2012.71.74
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24. Hekmatpou D, Jahani F, Behzadi F. Study the quality of life among elderly women in Arak in 2013. Arak Med Univ J. 2014;17(2):1–8 (in Persian). 25. Jafarzade Fakhari M, Behnam Vashani H, Vahedian Shahroudi M. The quality of life of the elderly in Sabzevar, Iran. J Sabzevar Univ Med Sci. 2010 Fall;17(3):213–7 (in Persian). 26. Naseh L, Shaikhy R, Rafii F. Quality of life and its related factors among elderlies living in nursing homes. Iran J Nurs. 2014;27(87):67–78. 27. Rafati N. Yavari P, Mehrabi Y, Montazeri A. Quality of life among Kahrizak charity institutionalized elderly people. J Sch Public Health Inst Public Health Res. 2005;3(2):67–75 (in Persian). 28. Rejeski WJ, Mihalko SL. Physical activity and quality of life in older adults. J Gerontol A Biol Sci Med Sci. 2001 Oct;56(Spec No 2) Suppl 2:23–35. https://doi.org/10.1093/gerona/56.suppl_2.23 PMID:11730235 29. Acree LS, Longfors J, Fjeldstad AS, Fjeldstad C, Schank B, Nickel KJ, et al. Physical activity is related to quality of life in older adults. Health Qual Life Outcomes. 2006 Jun 30;4(1):37. https://doi.org/10.1186/1477-7525-4-37 PMID:16813655 30. Kelley GA, Kelley KS, Hootman JM, Jones DL. Exercise and health-related quality of life in older community-dwelling adults: a meta-analysis of randomized controlled trials. J Appl Gerontol. 2009;28(3):369–94. https://doi.org/10.1177/0733464808327456 31. Nijs KA, de Graaf C, Kok FJ, van Staveren WA. Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial. BMJ. 2006 May 20;332(7551):1180–4. https://doi. org/10.1136/bmj.38825.401181.7C PMID:16679331 32. Andrew MK, Fisk JD, Rockwood K. Social vulnerability and prefrontal cortical function in elderly people: a report from the Cana- dian Study of Health and Aging. Int Psychogeriatr. 2011;23(3):450–8. 33. Cybulski M, Krajewska-Kulak E, Jamiolkowski J. Preferred health behaviors and quality of life of the elderly people in Poland. Clin Interv Aging. 2015 Sep 29;10:1555–64. https://doi.org/10.2147/CIA.S92650 PMID:26491271 34. Dai H, Jia G, Liu K. Health-related quality of life and related factors among elderly people in Jinzhou, China: a cross-sectional study. Public Health. 2015 Jun;129(6):667–73. https://doi.org/10.1016/j.puhe.2015.02.022 PMID:25796292 35. Poole C, Greenland S. Random-effects meta-analyses are not always conservative. Am J Epidemiol. 1999 Sep 1;150(5):469–75. https://doi.org/10.1093/oxfordjournals.aje.a010035 PMID:10472946
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Knowledge, attitudes, behaviours and practices towards diabetes mellitus in Kuwait
Manuel Carballo 1,2, Anwar Mohammad 1, Elizabeth C. Maclean 2, Noureen Khatoon 1, Mohammad Waheedi 3 and Smitha Abraham 1
1Dasman Diabetes Institute, Kuwait. 2International Centre for Migration, Health and Development, Geneva, Switzerland (Correspondence to: M. Car- ballo: [email protected]). 3Department of Pharmacy Practice, Kuwait University, Kuwait
Abstract Background: Rates of diabetes in Kuwait are among the highest in the world. Aims: To inform prevention initiatives, this study assessed diabetes knowledge, attitudes towards it, and personal behav- iour relating to risk factors among the Kuwaiti population. Methods: A cross-sectional knowledge, attitudes, beliefs and practices survey of 1124 people was performed between July and September 2015. Descriptive analysis and χ2 tests were performed. Results: Although most participants (94%) had heard of diabetes and 87% believed type 2 diabetes to be preventable, knowledge of risk factors was poor [family history (87%), age (44%), low exercise (10%), obesity (4%), diet (0%) and stress (0%)]. Dietary patterns in Kuwait were variable and, of concern, 42% of those with diabetes had been eating more since diagnosis. Lifestyle, particularly among Kuwaitis and people with diabetes, was sedentary – 47% of participants walked < 20 minutes per day. Conclusions: Despite the importance of diet and exercise for diabetes prevention, significant gaps in public education clearly exist. At a policy level, much remains to be done and intensified intersectoral programmes are required to improve public awareness. Keywords: diabetes mellitus, diet, exercise, Kuwait, prevention. Citation: Carballo M; Mohammad A; Maclean EC; Khatoon N; Waheedi M; Abraham S. Knowledge, attitudes, behaviours and practices towards diabe- tes mellitus in Kuwait. East Mediterr Health J. 2018;24(11):1098–1102. https://doi.org/10.26719/2018.24.11.1098 Received: 20/04/17; accepted: 15/08/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction believe are its causes and how their personal behaviour may relate to diabetes and its risk factors. Type 1 and type 2 diabetes have become a major health and healthcare challenge in Kuwait and other parts of the Methods world. Globally, over 415 million people are thought to be now living with the disease, and up to 12% of health ex- Ethics statement penditure is currently taken up by its treatment and care The study was approved by the Ethical Review Commit- (1). In the Gulf Cooperation Council region (Bahrain, Ku- tee and International Scientific Advisory Board of the wait, Oman, Qatar, United Arab Emirates and Saudi Ara- Dasman Diabetes Institute, Kuwait. All participants gave bia) where the prevalence of obesity has increased in the signed informed consent. last 3 decades, diabetes rates have also risen and are now among the highest anywhere in the world (2,3). Study design The fact that type 2 diabetes, which is by far the more A random-sample, cross-sectional KABP survey was de- common form of the disease, is largely preventable with signed, and a standardized questionnaire was developed a mix of dietary management and physical exercise, and pretested by the Dasman Diabetes Institute, build- calls for an understanding of how people perceive the ing on previous validated KABP surveys and guidelines threat of diabetes and what they feel can be done to (7,8). Face validity of questions was determined by expert prevent it. A growing body of evidence from surveys on review. Medical students from the University of Kuwait the knowledge, attitudes, beliefs and practices (KABP) were trained in the reliable use of the questionnaire that of people in different parts of the world suggests that was then used in face-to-face interviews or self-complet- sizable gaps exist with respect to public awareness of ed by participants selected in shopping malls and gov- the risk factors for diabetes and how these factors can be ernment offices. Questionnaires were available in both avoided or mitigated (4–6). English and Arabic, so as to cover the large expatriate In order to inform and guide national prevention population in Kuwait as well as Kuwaiti nationals. The initiatives in Kuwait, this study looked at what people survey was undertaken between July and September know about diabetes, what their attitude to it is, what they 2015. A total of 1124 people were invited to participate.
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Only adults over the age of 21 years (n = 1088) were in- diet as a factor, and the preventative role of exercise was cluded in the analysis. only recognized by 112 (10.3%) respondents. Among those who acknowledged the preventative role of exercise, a Data analysis higher proportion (16.8%) was aged 21–30 years (P < 0.001). Data were analysed using SPSS version 21, with P = 0.05 Stress was not seen by anyone as a contributing factor, as the significance level. Frequencies and descriptive sta- and no one agreed with fatalistic statements such as “just tistics were used to assess the data, with χ2 and odds ra- God’s will” and “it just happens”. tios being used to compare groups. Confidence intervals (CIs) were assessed at 95%. For height, weight and body Dietary beliefs and practices mass index, outliers were removed based on z scores > 3 Almost half (498, 46.7%) of all participants felt that food standard deviations from the mean. was expensive in Kuwait, and 372 (35%) felt that pre-pre- pared food was often cheaper than buying ingredients. Results Many (433, 40.8%) also said they did not have time to pre- Demographics pare food themselves and that it was easier than trying to cook at home (643, 60.7%). Most (712, 67.2%) respondents Of the 1088 people who were selected, 566 were female nevertheless agreed that home-cooked meals tasted bet- and 522 were male. The higher proportion of women ter, and only 25% said it was hard to find the types of food may reflect that most of the interviews were conducted that they liked. No significant differences were observed in shopping malls. In all, 647 (59.5%) participants were between Kuwaiti and non-Kuwaitis (P = 0.428) in their non-Kuwaiti and 441 (40.5%) were Kuwaiti. The main ability to find food that they liked. countries of origin for non-Kuwaitis were Egypt (17%), In- Food consumption patterns are shown in Table 1. dia (12%), Philippines (6%), Pakistan (4%), Syrian Arab Re- Almost half the participants stated that they usually do public (4%), Lebanon (3%) and Jordan (2%). The mean num- not drink soft drinks, and people living with diabetes ber of years that expatriates had spent in Kuwait was 14.4 were more likely to drink fewer soft drinks per day than (standard deviation 11.4; 95% CI 13.5–15.3). According to other people were (P = 0.005). However, no differences national estimates, 69% of the Kuwait population is expa- were found between people with and without diabetes triate (8); therefore, non-Kuwaitis were underestimated regarding the number of meals/snacks consumed per in our sample. The educational level of the participants day (P = 0.260). Although almost a third (30.4%) of people was high; 642 (60%) had completed a university educa- living with diabetes said that they had been eating less tion and 123 (12%) had postgraduate degrees. According since being diagnosed with the disease, 42.2% said they to self-reported height and weight measures, 36% of the had been eating more. respondents were overweight and 24% were obese. Fur- thermore, 101 participants (9.3%) stated that they had Attitude and behaviour towards exercise been diagnosed with diabetes. Lifestyle in Kuwait has become sedentary, and 183 (17.2%) Diabetes knowledge respondents indicated that they almost never walk, and another 319 (29.9%) said that they only walked 1–20 min- The vast majority (806, 93.9%) of the respondents said utes per day. Walking and exercise patterns are summa- they had heard of diabetes before the interview, and 662 rized in Table 2. Different trends were found among Ku- (65.5%) had a family member who had been diagnosed waitis and non-Kuwaitis, with the former spending less with diabetes; in 64% of these cases the family member time on physical activity such as walking (P < 0.001) or was a parent or sibling. Indeed, 944 (86.8%) respondents other forms of exercise (P < 0.001). People living with di- said that they saw diabetes as a disease that runs in the abetes were more sedentary than others; out of 100 peo- family, and respondents who had a relative with diabetes ple diagnosed with diabetes, 34% stated that they never were significantly more likely to recognize the hereditary traits of the disease (P < 0.001). All participants with fami- walk compared to 14.9% among those who did not have P ly members with diabetes stated that it ran in the family. diabetes ( = 0.001). In all, only 31 (30.1%) of those living with diabetes stated that they had increased their level of Almost half (474, 44%) of the respondents also saw age exercise since being diagnosed. No significant difference as a risk factor for diabetes, agreeing with the statement was seen in changes in physical activity over the past that “you get it when you get older”. Older participants year between those with and without diabetes (P = 0.631). were nevertheless more likely than younger people to Over half (52%) of the people with diabetes and 48.9% see age as a risk factor for diabetes (P = 0.048), and non- who did not have diabetes said they were now spending Kuwaitis were more likely than Kuwaitis (51.5% and 32%) less time walking or exercising compared to the previous to see age as a risk factor (P < 0.001) (OR = 2.256; 95% CI year. Reasons for not doing more exercise varied and are 1.75–2.9). summarized in Table 3; 11.3% of people with diabetes said Despite 36% of participants being overweight and 24% they were too tired to exercise and 60.1% said that since being obese, only 41 (3.8%) respondents saw obesity as a their diagnosis they had been sleeping more. risk factor for diabetes. While 865 (87%) respondents recognised that type 2 Discussion diabetes is preventable, none of them highlighted poor KABP surveys can provide valuable insights into how
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Table 1 Dietary behaviour patterns in Kuwait Table 2 Exercise patterns in Kuwait Dietary behaviour Frequency Valid % Exercise behaviour Frequency Valid % No. of meals/snacks per day Time spent walking per day 1 or 2 420 38.6 (almost) never walk 183 17.2 3 or 4 572 52.6 1–20 min 319 29.9 5 or 6 76 7.0 21–30 min 193 18.1 > 6 14 1.3 31–60 min 141 13.2 Fruit eating habits > 1 h 109 10.2 Never 74 6.8 > 2 h 122 11.4 Once weekly 255 23.5 Average time per day spent doing other physical exercises Twice weekly 236 21.8 None 462 42.5 Three times or more weekly 518 47.8 1–20 min 229 21.0 Vegetable eating habits 21–30 min 151 13.9 Never 43 4.0 31–60 min 127 11.7 1 or 2 times weekly 158 14.6 > 1 h 91 8.4 3 or 4 times weekly 239 22.1 > 2 h 28 2.6 > 4 times weekly 642 59.3 Other physical exercises Red meat eating habits Fast walking 141 13.4 Never 123 11.4 Jogging 106 10.1 1 or 2 times weekly 516 47.8 Swimming 63 6.0 3 or 4 times weekly 350 32.4 Cycling 30 2.8 5 or 6 times weekly 64 5.9 Yoga 28 2.7 > 6 times weekly 27 2.5 Other 141 13.4 White meat eating habits Changes in time spent walking or doing Never 33 3.0 physical exercises in the past year 1 or 2 times weekly 416 38.4 Less 470 49.1 3 or 4 times weekly 460 42.5 About the same 264 27.6 5 or 6 times weekly 111 10.3 More 223 23.3 > 6 times weekly 62 5.7 Dairy eating/drinking habits tions could have biased our sample, particularly in terms Never 83 7.7 of educational attainment and socioeconomic status. As 1 or 2 times weekly 245 22.9 such, the results of this study should be considered as a 3 or 4 times weekly 295 27.9 pilot for future research in the region using randomized selection methods. This initial KABP study has, neverthe- 5 or 6 times weekly 172 16.1 less, highlighted several concerns and challenges facing > 6 times weekly 274 25.6 Kuwait, where a combination of diabetes and obesity has Sweet soft drink consumption habits become a major threat to public health. None 530 49.6 While most people in this study had heard about 1 or 2 drinks daily 375 35.1 diabetes and knew of people within their social network 3–5 drinks daily 118 11.0 who were living with the condition, there appeared to > 5 drinks daily 45 4.2 be little sensitivity to many of the key factors involved. Most people saw family history of diabetes as a risk factor, but fewer seemed to see obesity, lack of exercise, people view health and healthcare problems, and if and dietary behaviour and ageing as associated with the risk to what extent their personal behaviour may be placing of diabetes. Despite the importance of diet and exercise them at risk. In our study, participants were selected at in the prevention and management of diabetes, few shopping malls and government offices. This method study participants seemed to see a need to change their was used in order to maximize the likelihood of obtain- diet, and there was little difference in dietary behaviour ing a representative cross-section of the Kuwaiti popula- between people living with diabetes and others. Even tion. Reaching the expatriate community can be difficult more strikingly, almost half of those living with diabetes using other sampling methods and previous experience said they had been eating more since being diagnosed. with epidemiological surveys in Kuwait has also pointed Another concern is the large numbers of participants to serious difficulties in recruiting Kuwaitis by telephone who said that they were not engaged in any exercise that and household surveys. However, selection at these loca- might help them to avoid diabetes. Approximately two
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Table 3 Reasons for not increasing exercise routine among education, major gaps in knowledge have emerged with people living with diabetes respect to factors contributing to diabetes. Thus, despite Reason for not exercising more Frequency Valid % the magnitude of the problem, a significant proportion (n = 80) of the lay community remains ignorant of the way in Not enough time 31 38.8 which diabetes develops and what steps can be taken to Too hot 24 30.0 avoid or mitigate its impact. Tailoring information and education around the KABP characteristics that have been Too tired 9 11.3 identified in this study will be a step toward overcoming Do not like doing exercise 7 8.8 these gaps. Developing ways of seeding factual and Not in my culture 1 1.3 socially acceptable information and then segmenting it Not in the culture of Kuwait 1 1.3 by social KABP features will be equally important, and Other 7 8.8 in this regard diabetes information/education strategies should take into consideration the demographic and ethnic diversity of Kuwait and identify ways of reaching thirds of people living with diabetes indicated that this different age groups as well as country-of-origin groups. was either because they did not have the time or because At a policy level, there is also much to be done. The it was too hot. The latter reason is understandable given promotion of physical exercise as a public health measure the climate in Kuwait, where, for ≥ 4 months of the year calls for commitment by a mix of government and extreme heat makes outdoor exercise difficult. However, employers as well as the public at large. Making physical the advent of many large air-conditioned shopping malls exercise and education a more central and routine part and gyms in most neighbourhoods of Kuwait City has of school activity, for example, is key to helping ensure made year-round walking feasible. Given the results the health of adolescents in Kuwait. Similarly, more of this study, however, there is a clear need to enhance needs to be done to bring employers and employees the promotion of exercise in these facilities, especially together in public–private programmes of education among Kuwaiti nationals and people living with diabetes; information and exercise in the workplace. Intensified both of whom were less likely than others to be regularly programmes of intersectoral action by ministries of exercising. health, education and labour are now called for if public In a society where 20% of the population is now awareness about diabetes is to be improved and if people estimated to be living with diabetes (1), and where the are to be encouraged to take action to avoid diabetes, or key to avoiding an even larger epidemic is primary and manage it well if they have already developed it. With the secondary prevention, it is difficult not to conclude success of this initial survey, similar studies should now that the response to diabetes has been passive at best, be implemented in other Arabic countries where research and has clearly not been given the priority it calls of this kind could inform regionwide initiatives to tackle for. Certainly, in the area of public information and the growing diabetes epidemic. Acknowledgements The authors thank Kuwait University medical students for their help in the collection of survey data. Funding: None. Competing interests: None declared.
Connaissance, attitudes, comportements et pratiques associés au diabète sucré au Koweït Résumé Contexte : Les taux de diabète au Koweït sont parmi les plus élevés au monde. Objectifs : La présente étude avait pour objectif d’évaluer les initiatives de prévention en examinant les connaissances relatives au diabète, les attitudes associées, et les comportements personnels liés aux facteurs de risque parmi la population koweïtienne. Méthodes : Une étude transversale portant sur les connaissances, les attitudes, les croyances et les pratiques a été menée auprès de 1124 individus entre juillet et septembre 2015. Une analyse descriptive et des tests du χ2 ont été réalisés. Résultats : Même si la plupart des participants (94 %) avaient entendu parler du diabète et 87 % pensaient que le diabète de type 2 pouvait être évité, la connaissance des facteurs de risque était faible [antécédents familiaux (87 %), âge (44 %), peu d’activité physique (10 %), obésité (4 %), régime alimentaire (0 %) et stress (0 %)]. Les habitudes alimentaires étaient variables au Koweït, et 42 % des personnes diabétiques mangeaient plus depuis que la maladie avait été diagnostiquée, ce qui était préoccupant. Le mode de vie, particulièrement parmi les citoyens koweïtiens et les personnes diabétiques, était sédentaire (47 % des participants marchaient moins de 20 minutes par jour).
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Conclusion : Malgré l’importance du régime alimentaire et de l’activité physique dans la prévention du diabète, des écarts significatifs existent dans l’éducation du public. Au niveau politique, un travail considérable reste à effectuer et une intensification des programmes intersectoriels est nécessaire afin de sensibiliser davantage le public.
املعلومات واالجتاهات والسلوكيات واملامرسات جتاه السكري يف الكويت مانويل كاربالو، أنور حممد، إليزابيث ماكلني، نورين خاتون، حممد وحيدي، سميثا أبراهام اخلالصة اخللفية:تعترب معدالت السكري يف الكويت من أعىل املعدالت يف العامل. األهداف:هدفت الدراسة إىل تقييم مبادرات الوقاية من السكري من خالل فحص املعلومات واالتاهات حول السكري والسلوك الشخيص املتعلق بعوامل اخلطر التي هتدد الناس يف الكويت. طرق البحث: أجرى الباحثون ًمسحا ً مقطعياللمعلومات واالتاهات واملعتقدات واملامرسات لدى 1124 ًشخصا يف الفرتة بني يوليو/متوز χ وسبتمرب/أيلول 2015. ثم أجروا حتلي ًال ًوصفيا واختبارات2 . النتائج: عىل الرغم من أن معظم املشاركني )94٪( قد سمعوا بمرض السكري وأن 87٪ منهم يعتقدون أن السكري من النمط 2 يمكن الوقاية منه، كانت املعلومات حول عوامل اخلطر ضعيفة [تاريخ العائلة )87٪(، العمر )44٪(، النشاط القليل )10٪(، السمنة )4٪(، النظام الغذائي )0٪(، التوتر )0 (].٪ وكانت األنامط الغذائية يف الكويت متفاوتة، وكان 42٪ من مرىض السكري يأكلون كمية أكرب من الطعام منذ تشخيصهم، األمر الذي يثري القلق. وكان نمط احلياة، ال ّامبني سيالكويتيني واألشخاص املصابني بالسكري، يتسم بقلة احلركة؛ فال يامرس 47٪ من املشاركني يف الدراسة امليش إال ملدة أقل من 20دقيقة يف اليوم. عىل االستنتاجات:الرغم من أمهية النظام الغذائي وممارسة الرياضة يف الوقاية من السكري، فإن من الواضح أن هناك فجوات كبرية يف الثقافة العامة. وعىل مستوى السياسة العامة، ال يزال هناك الكثري الذي يتعني القيام به، وهناك حاجة إىل برامج مكثفة مشرتكة بني القطاعات لتحسني الوعي العام.
References 1. Diabetes atlas. 7th edition. Brussels: International Diabetes Federation; 2015 2. Ziyab AH, Mohammad A, Maclean E, Behbehani K, Carballo M. Diabetes: a fast evolving epidemic. Kuwait Med J. 2015;47(4):291– 301. 3. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014 Feb;103(2):137–49. https://doi.org/10.1016/j.diabres.2013.11.002 PMID:24630390 4. Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N, Yeatts KB. Knowledge, attitude and practices of diabetic patients in the United Arab Emirates. PLoS One. 2013;8(1):e52857. https://doi.org/10.1371/journal.pone.0052857 PMID:23341913 5. Demaio AR, Otgontuya D, de Courten M, Bygbjerg IC, Enkhtuya P, Oyunbileg J, et al. Exploring knowledge, attitudes and prac- tices related to diabetes in Mongolia: a national population-based survey. BMC Public Health. 2013 Mar 18;13(1):236. https://doi. org/10.1186/1471-2458-13-236 PMID:23506350 6. Islam FMA, Chakrabarti R, Dirani M, Islam MT, Ormsby G, Wahab M, et al. Knowledge, attitudes and practice of diabetes in rural Bangladesh: the Bangladesh Population based Diabetes and Eye Study (BPDES). PLoS One. 2014 Oct 14;9(10):e110368. https:// doi.org/10.1371/journal.pone.0110368 PMID:25313643 7. Mehryar A, Carballo M, Carael M, Muhondwa E. KABP surveys: an introduction to basic concepts, methodology and references. Geneva: Global Programme on AIDS; 1989 8. The World Fact Book: Kuwait [website]. Central Intelligence Agency (https://www.cia.gov/library/publications/the-world-fact- book/geos/ku.html, accessed 8 August 2018).
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A retrospective study of small molecule disorder types of metabolism in paediatric patients in intensive care
Ahmed El-Nawawy 1, Mohamed Dawood 1 and Omneya Omar 1
1Department of Paediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt (Correspondence to: Omneya M. Omar: drmonymagdy@ yahoo.com).
Abstract Background: Although inborn errors of metabolism (IEM) are rare individually, collectively IEM cause substantial mor- bidity and mortality and the diagnosis is challenging. Aims: To analyse epidemiological and clinical data, final diagnosis and clinical outcomes of patients with a suspected diagnosis of IEM (small molecule disorders type) admitted to a paediatric intensive care unit (PICU). Methods: We collected and analysed medical records data of all patients admitted to the PICU at Alexandria University Children’s Hospital, from January 2010 to December 2014, with a suspected or confirmed diagnosis of small molecule dis- orders, including clinical presentations, laboratory results and clinical outcomes. Results: A total of 34 patients had a suspected or confirmed diagnosis of small molecule disorders at PICU admission. Diagnosis was confirmed in 22.7% of suspected cases at admission and in 25% of suspected cases during PICU stay. Con- sanguineous marriage was found in 50% of cases with confirmed small molecule disorders. Conclusions: A high index of suspicion is important for diagnosing and categorizing small molecule disorders in screen- ing of high-risk individuals in low- and middle-income countries. Keywords: small molecule disorders, inborn errors of metabolism, paediatric intensive care, consanguinity, organic acadaemia Citation: El-Nawawy A; Dawood M; Omar O. A retrospective study of small molecule disorder types of metabolism in paediatric patients in intensive care. East Mediterr Health J. 2018;24(11):1103–1111. https://doi.org/10.26719/emhj.18.056 Received: 09/08/16; accepted: 27/02/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction No statistics on small molecule disorders of IEM are available in Egypt. The aim of this retrospective study Inborn errors of metabolism (IEM) are a diverse hetero- was to analyse the epidemiological and clinical data, final geneous group of inherited disorders that usually present diagnoses and clinical outcomes of patients admitted to in the paediatric population as varied clinical manifesta- the paediatric intensive care unit (PICU) at Alexandria tions of defects in catabolism or anabolism of nutrients or energy-producing molecules. Although rare individ- University Children’s Hospital with a suspected or ually, collectively IEM cause substantial morbidity and confirmed diagnosis of small molecule disorders. mortality (1). They can be classified as disorders involv- Methods ing either large molecules (complexes or organelles) or small molecules. Organelle diseases are characterized by In this 5-year retrospective study, we collected medical a gradual, often insidious, onset of symptoms, a relative- records of all patients admitted to the PICU at El-Shatby ly slowly progressive clinical course and specific clinical Children’s Hospital, a tertiary care teaching hospital af- signs, which may be characteristic enough to make a di- filiated to Alexandria University (serving 4 governorates agnosis. Response to supportive therapy is generally only comprising 14 million people), from 1 January 2010 to 31 fair or poor. In contrast, IEM involving small molecules December 2014 (n = 1417). Ages ranged from 1 month to 6 tend to be characterized by a rapid onset of symptoms years. The policy of our hospital is that all cases of small and a clinical course featuring remissions and relaps- molecule disorders presented at the emergency room es. Physical findings are generally non-specific, which are admitted to PICU. Inclusion criteria were: confirmed makes their diagnosis challenging at first presentation. diagnosis of small molecule disorders and suspected di- However, small molecule disorders tend to respond well agnosis of small molecule disorders at the time of PICU to aggressive supportive therapy (2). admission or during PICU stay, with no subsequent con- Diagnosis of small molecule disorders is challenging firmation of diagnosis (according to PICU protocol). The due to the episodic nature of the metabolic illness, wide exclusion criterion was previous diagnosis of small mol- range of non-specific clinical symptoms also associated ecule disorders in patients admitted to the PICU during with common clinical conditions, general lack of the study period. Out of 1417 PICU admissions, 34 pa- experience among paediatric subspecialists and the need tients (2.4%) had a suspected or confirmed small molecule for expensive investigations (3). disorder.
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To identify patients with suspected small molecule determine the best cut-off value for the variable tested. disorders and determine their management, according Pair-wise comparison of areas under the ROC was carried to our PICU policy, paediatric intensivists were required out using MedCalc, version 14, for PIM2 and PELOD for to enter specific information on patient symptoms and discrimination for death (8,9). signs as well as laboratory investigations undertaken into The calibration was assessed by directly comparing a computer-based protocol. The symptoms and signs of the observed and customized predicted mortality. We clinical suspicion of small molecule disorders comprise employed the Hosmer–Lemeshow goodness-of-fit test, a history of consanguinity, siblings with a history of where a P-value > 0.1 indicates acceptable calibration (10). similar illness or previous unexplained death, respiratory distress, apnoea, unexplained neurological symptoms, Results unexplained acute liver failure, feeding difficulties, Out of 1417 PICU admissions from January 2010 to De- failure to thrive, hepatomegaly and splenomegaly. Initial cember 2014, 34 patients (2.4%) had a suspected or con- simple laboratory investigations performed immediately firmed small molecule disorder. The age of onset ranged on admission to the PICU included random blood from 1.17 to 72.00 [median (IQR) 9.00 (2.88–24.00)] glucose, ketone bodies, arterial blood gases, anion gap, months. The male to female ratio was 1:1.27 (15:19 cases). blood lactate, pyruvate and lactate/pyruvate ratio, blood Patient weight ranged from 1.55 to 20 [median (IQR) 7.00 ammonia and uric acid. Results from the laboratory (4.78–10.25)] kg. Patient length of stay in PICU ranged investigations helped to classify small molecule from 1 to 26 [median (IQR) 3.50 (2.00–10.00)] days. PIM2 disorders into 5 categories: aminoacidopathies, organic ranged from 20.00 to 90.80 [median (IQR) 44.95 (27.60– acidopathies, fatty acid oxidation defects, primary lactic 85.00)].The mortality rate in the study group (18/34, 52.9%) acidosis and urea cycle defects. was more than twice the general mortality in the PICU From the medical records, we gathered demographic at Alexandria University Children’s Hospital (24.1%).There data, clinical data and laboratory findings suggesting were 7 deaths within 24 h, and the PELOD score on day 2 small molecule disorders. Other data that were recorded for the remaining 27 cases ranged from 4 to 31 [median by the residents were the Paediatric Index of Mortality (IQR) 10.00 (5.00–20.00)] (Table 1). 2 (PIM2) at admission, a scoring system for rating the Eight of the 34 cases (23.5%) were confirmed assmall severity of medical illness for children encompassing 10 molecule disorders, whether suspected on admission physiological variables collected from the time of first or not suspected on admission and subsequently physical contact between the patient and the PICU team confirmed during PICU stay. The diagnosis ofsmall up until 1 hour after physical PICU admission (4,5), and molecule disorders was confirmed in 22.7% of cases (5/22) paediatric logistic organ dysfunction (PELOD) score on suspected on PICU admission, and in 25.0% of cases (3/12) day 2 in the PICU, a scoring system covering of physical not suspected on PICU admission (Table 2). Of the 8 and laboratory variables representing 6 organ systems: confirmed cases, 3 were diagnosed as organic acidaemia, nervous, cardiovascular, renal, respiratory, haematologic 2 as urea cycle defects, 2 as aminoacidopathies and 1 as and hepatic systems. Each variable is assigned points primary lactic acidosis. The best clinical outcome was (0, 1, 10, or 20) based on the level of severity, each organ obtained with cases of urea cycle defects and organic dysfunction receives points for the variable associated acidaemia where all patients, except 1 who died, were with the highest number of points (6). The final diagnosis discharged. is documented as either a case of small molecule disorder A significantly higher rate of consanguinity was (i.e. confirmed) or a non-small molecule disorder (i.e. not evident among cases confirmed as small molecule confirmed or proven to be an alternative diagnosis) and disorders compared to unconfirmed cases [4 cases patient clinical outcome (i.e. PICU discharge, death or (50.0%) vs 3 (11.5%) respectively, P = 0.037]. No statistically death within ≤ 24 h of PICU admission). significant difference were found in terms of sex, age on All data were analysed using SPSS, version 20.0 (7). presentation to PICU, history of sibling death in infancy The Kolmogorov–Smirnov test of normality revealed (unknown cause or stillbirth) and place of residence significance in the distribution of some variables, so (Table 3). the non-parametric statistics were adopted. Qualitative There was a significantly higher rate of jaundice in data are presented as numbers and percentages, and the confirmed compared with the non-confirmed small quantitative data as minimum, maximum, median and molecule disorders groups [3 cases (37.0%) vs 1 case (3.8%) interquartile range (IQR). Comparison between different respectively, P = 0.033] (Table 4). In addition, from the groups of category variables was made using the chi- laboratory results obtained from initial investigations squared test. When > 20% of the cells had an expected on PICU admission, there was a significantly higher count < 5, correction for chi-squared was made using rate of hyperammonaemia and hyperuricaemia in the Fisher’s exact test or the Monte Carlo correction. confirmed compared with the non-confirmed cases Multivariate logistic regression analysis was done of small molecule disorders group [5 cases (62.5%) vs 3 for prediction of mortality with PIM2 and PELOD as cases (11.5%,), P = 0.009, respectively; 7 cases (87.5%) vs independent predictors. Area under the ROC Youden 8 cases 30.8%, P = 0.011, respectively] (Table 5). No other index (the vertical distance between the 45 degree line clinical presentations or laboratory results showed any and the point on the ROC curve) was performed to statistically significant difference between the groups.
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Table 1 Anthropometric and clinical data for patients Using the predictive model of mortality, examining with suspected or confirmed diagnosis of small molecule the PIM2 and PELOD score as independent covariates, the disorders on admission to a paediatric intensive care unit classification accuracy of the model (block 0, i.e. before (PICU) (n = 34) implementation of the statistical model) was 59.25%, with Characteristic Value variations in the PELOD and PIM2 scores accounting for Age at PICU presentation (months) 50.1% of the variation of occurrence of death in the study 2 Min–max 1.17–72.00 sample (–2 Log likelihood = 23.975, Nagelkerke R = 0.501). Median (IQR) 9.00 (2.88–24.00) The regression model was well calibrated. The Hosmer– Lemeshow χ2 value was 4.954 (P = 0.666). The overall Sex, No. (%) model was statistically significant χ( 2 = 12.524, P = 0.002) Males 15 (44.1 %) (independent covariates had predictive capacity). The Females 19 (55.9 %) predictive capacity of the model increased from 59.2% Residence, No. (%) (of the basic “null” model) to 81.5%. Only the PIM2 score Rural 19 (55.9 %) was a statistically significant predictor of mortality [odds ratio (OR) = 1.050, 95% CI: 1.008–1.094] (P = 0.019). The Urban 15 (44.1 %) PELOD score was not a statistically significant predictor Weight (kg) of mortality (OR = 1.100, 95% CI: 0.976–1.240) (P = 0.118). Min–max 1.55–20 (Table 6). Median (IQR) 7.00 (4.78–10.25) We found that PIM2 was a statistically significant Paediatric Index of Mortality 2 (on admission) discriminator of death: area under the ROC curve = 0.849 Min–max 20–90.80 (95% CI: 0.685–0.948) (Z = 5.411, P < 0.0001). The diagnostic Mean (SD) 53.10 (27.14) criterion using the Youden index is the level of > 71.6, Median (IQR) 44.95 (27.60–85.00) with sensitivity 64.71% (95% CI: 38.3–85.8), specificity Length of stay (d) 94.12% (95% CI: 71.3–99.9), positive predictive value 91.7% and negative predictive value 72.7%. The PELOD score Min–max 1–26 was a statistically significant discriminator of death: Mean (SD) 6.97 (6.11) area under the ROC curve = 0.759 (95% CI: 0.556–0.901) Median (IQR) 3.50 (2.00–10.00) (Z = 2.600, P = 0.0093). The diagnostic criterion using the PELOD score on day 2a Youden index is the level of > 10.0, with sensitivity 72.73% Min–max 4–31 (95% CI: 39.0–94.0), specificity 68.75% (95% CI: 41.3–89.0%), positive predictive value 61.5% and negative predictive Mean (SD) 13.52 (8.03) value 78.6%. Pair-wise comparison for the 2 ROC curves Median (IQR) 10.00 (5.00–20.00) showed no statistically significant difference (Figure 1). Outcome, No. (%) Discharged 16 (47.1) Discussion Died 11 (32.3 ) Over 500 known IEMs, over 100 involving neonates, have Died ≤ 24 hours following admission 7 (20.6) been described (11). The frequencies for each individual IQR = interquartile range. IEM vary; although most are very rare, collectively they PELOD score = Paediatric Logistic Organ Dysfunction score. are common (12). In Egypt, 1 in every 32 individuals is SD = standard deviation. reported to harbour a gene for an IEM (13). An extended a7 cases died ≤ 24 hrs of admission Min = minimum; Max = maximum metabolic screen carried out in 2004 on 231 suspected paediatric cases of IEM (44 neonates and 187 children) in Egypt revealed that abnormal results were detected in 8.56% (14).
Table 2 Relationship between status of provisional and final diagnoses Provisional diagnosis Final diagnosis: small molecule disorder Total Confirmed Not confirmed Suspected on Not suspected Suspected on Not suspected on admission; on admission; admission; not admission, became confirmed confirmed later confirmed suspected but not confirmed Not suspected No. (%) 3 (25.0%) 9 (75.0) 12 Suspected No. (%) 5 (22.7) 17 (77.3) 22 Total No. (%) 8 (23.5) 26 (76.5) 34
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Table 3 Comparison of demographic data for children with confirmed and non-confirmed small molecule disorders Characteristic Small molecule disorders P-value Confirmed cases n( = 8) Not confirmed n( = 26) No. % No. % Sex Male 2 25.0 13 50.0 0.257 Female 6 75.0 13 50.0 Age at PICU presentation Infant, 1–12 months 5 62.5 15 57.7 1.000 Toddler, 12–36 months 3 37.5 8 30.8 Preschool, 3–5 years 0 0.0 2 7.7 School age, > 5 years 0 0.0 1 3.8 History of consanguinity Yes 4 50.0 3 11.5 0.037* No 4 50.0 23 88.5 History of sibling death in infancy of unknown cause or stillbirth Yes 1 12.5 1 3.8 0.421 No 7 87.5 25 96.2 Residence Rural 4 50.0 15 57.7 1.000 Urban 4 50.0 11 42.3 Weighta Average 2 25.0 8 30.8 0.440 Below 3rd percentile 5 62.5 8 30.8 Below 15th percentile 1 12.5 8 30.8 Above 85th percentile 0 0.0 2 7.6 Lengtha Average 2 25.0 4 15.4 0.783 Below 3rd percentile 6 75.0 20 76.9 Above 97th percentile 0 0.0 2 7.7 Head circumferencea Average 3 37.5 15 57.7 0.655 Below 3rd percentile 3 37.5 6 23.1 Below 15th percentile 2 25.0 4 15.4 Above 85th percentile 0 0.0 1 3.8 History of affected cases among siblings Yes 1 12.5 0 0.0 0.235 No 7 87.5 26 100.0
*Statistically significant, P ≤ 0.05. aPlot in specific curve using WHO percentiles (WHO child growth standards, 2006)
The majority of IEMs from various countries have In Egypt, the rate of consanguineous marriage is very been reported to be small molecule disorders. A study in high (35.3%), especially among first cousins (86%), and in Thailand showed that 74.3% of diagnosed IEM cases were rural areas, Upper Egypt and Cairo (19). small molecule disorders (15), and a 25-year retrospective In our 5-year study, the incidence of suspected or study in Saudi Arabia described a cumulative incidence of confirmed cases of small molecule disorders was 2.4% 150 IEM cases per 100 000 live births (0.15%), of which 54% (34/1417) of all PICU admissions, with only 8 confirmed were small molecule disorders (16). The incidence of IEMs cases of small molecule disorders of the 34 cases (0.56% is reportedly lower in Western countries, e.g. 1 in 2500 live of all 1417 PICU admissions). This low incidence could births (0.04%) in British Columbia, Canada (17) and 1 in be explained by a high pre-admission mortality rate 2555 live births (0.04%) in Italy (18). The difference may be of patients with small molecule disorders. This is related to consanguineous marriage and intermarriage. comparable with the results from a 5-year study of PICU
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Table 4 Comparison of clinical presentations for confirmed and non-confirmed cases of small molecule disorders among children admitted to paediatric intensive care, January 2010–December 2014 Characteristic Small molecule disorders cases P-value Confirmed n( = 8) Non-confirmed n( = 26) No. % No. % Encephalopathy 5 62.5 11 42.3 0.429 Unexplained neurological symptomsa 3 37.5 12 46.2 1.000 Coma 1 12.5 4 15.4 1.000 Fever 2 25 10 38.5 0.681 Sepsis-like picture 4 50 10 38.5 0.689 Respiratory distress 3 37.5 12 46.2 1.000 Apnoea 0 0.0 4 15.4 0.551 Vomiting 5 62.5 11 42.3 0.429 Refusal of feeding 1 12.5 7 26.9 0.645 Hepatomegaly 5 62.5 11 42.3 0.429 Jaundice 3 37.5 1 3.8 0.033* Cardiac manifestationsb 1 12.5 2 7.7 1.000 Splenomegaly 1 12.5 0 0.0 0.2
*Statistically significant, P ≤ 0.05. aIncludes irritability, convulsion, hypotonia, hypoactive, history of ataxia and developmental delay. bCardiac manifestations mean heart failure.
Table 5 Comparison of laboratory results for confirmed and non-confirmed small molecule disorders on admission to paediatric intensive care, January 2010–December 2014 Laboratory test Small molecule disorders cases P-value Confirmed n( = 8) Non-confirmed n( = 26) No. % No. % Hyperammonaemia 5 62.5 3 11.5 0.009* Hyperuricaemia 7 87.5 8 30.8 0.011* Hyperlactataemia 4 50.0 6 23.1 0.195 High pyruvate 1 12.5 1 3.8 0.421 High lactate/pyruvate ratio 3 37.5 2 7.7 0.072 Arterial blood gas Metabolic acidosis 6 75.0 15 57.7 Normal arterial blood gas 0 0.0 3 11.5 Respiratory acidosis 0 0.0 2 7.7 0.903 Compensated respiratory alkalosis 2 25.0 6 23.1 Blood glucose 0.133 Normal 3 37.5 11 42.3 Hypoglycaemia 3 37.5 2 7.7 Hyperglycaemia 2 25.0 13 50.0 Ketononuria 3 37.5 2 7.7 0.072
*Statistically significant, P ≤ 0.05.
admissions in a French teaching hospital (incidence In contrast, in a 3-year study in Pakistan 26% of suspected 2.2% of all PICU admissions) (20) and a 1-year PICU cases were diagnosed as IEM, including small molecule study in India (incidence 2.6% of all PICU admissions) of disorders (23). In our study, 1.5% (22/1417) of all PICU suspected or diagnosed IEM, including small molecule admissions were suspected cases of IEM, and only 22.7% disorders (21). (5/22) of these were confirmed to be small molecule In a study from Brazil, only 6.7% (4/59) of suspected disorders. cases admitted to the PICU were diagnosed as IEM (22). In developed countries, small molecule disorders
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Table 6 Multivariate logistic regression analysis for predicting mortality in children with small molecule disorders on admission to paediatric intensive care, January 2010–December 2014 Predictor B P-value OR 95% CI PIM2 0.049 0.019 1.050* 1.008–1.094 PELOD score 0.095 0.118 1.100 0.976–1.240
*Statistically significant, P ≤ 0.05. Constant = –4.273 OR = odds ratio. CI = confidence interval. PIM2 = paediatric index of mortality 2. PELOD = paediatric logistic organ dysfunction.
are typically diagnosed using high-performance States, respectively, to confirm the final diagnosis. liquid chromatography (HPLC) and tandem mass Thus, screening for IEM without primary selection is spectrophotometry (3). Gas chromatography/mass a costly process for developing countries with limited spectroscopy is an advanced technique for diagnosing resources. Patients with small molecule disorders are and confirming metabolic disorders and also for mass usually diagnosed following PICU admission and are neonatal screening (18). Enzyme assays with leukocytes considered acute emergencies amenable to lifesaving or erythrocytes are used to confirm a specific enzyme therapy (20). However, their prognosis is very poor due deficiency 3( ). These diagnostic techniques are expensive to the delay in diagnosis and management (15). Therefore, and beyond the financial capacity of many developing small molecule disorders warrant heightened attention, countries. Therefore, in developing countries, diagnosis as early diagnosis is essential for early treatment and of IEM relies on simple clinical and laboratory tests improved clinical outcome. for the selective screening of high-risk individuals A French study reported a mortality rate of 28.6% suspected of IEM, in order to identify the small molecule (20/70) of confirmed IEM cases among PICU admissions, disorders so that early empirical supportive treatment which was twice that observed for all PICU admissions can be initiated. This approach is often supported by and 4 times that observed in European PICUs (20). A other approaches to confirm the final diagnosis. For retrospective study in Italy reported a PICU mortality rate example, in Thailand, clinicians work in collaboration of 25.3% of confirmed IEM cases 18( ). A study from India with the Chulabhorn Research Institute in Bangkok for found a mortality rate of 36% among PICU admissions of the use of high-performance liquid chromatography (15), confirmed IEM cases (21). Consistent with these findings and in Pakistan (23) and Saudi Arabia (16) samples are from previous studies, in our study, the mortality rate sent to specialized laboratories in Japan and the United among the 34 patients we studied was 52.9%, whereas the
Figure 1 Area under the receiver operator characteristics (ROC) curve: comparison of paediatric index of mortality (PIM2) and paediatric logistic organ dysfunction (PELOD) score for discriminating outcomes (the dashed line represents a non-discriminatory test)
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mortality rate among confirmed cases of small molecule small molecule disorders and not confirmed cases disorders was 37.5% (3/8), which was higher than our total revealed a significantly higher rate of hyperammonaemia PICU mortality rate of 24.1%. We should, however, take and hyperuricemia in the confirmed group. This may into consideration the very small number in the sample. be because of urea cycle defects and organic acidaemia, The high mortality rate may be due to delayed diagnosis, which represented 62.5% (5/8) of cases, usually present encephalopathy, respiratory distress, heart failure or with hyperammonaemia. This finding is in agreement dehydration. with prior findings of a significantly higher rate of The rate of various clinical presentations did not hyperammonaemia in the IEM group, including small show any statistically significant differences between molecule disorders, compared to the non-IEM group, confirmed and non-confirmed small molecule disorders although, contrary to our findings, metabolic acidosis groups, except for the presence of jaundice, which was and ketosis were also found to be frequent (15). significantly higher in the confirmed groups. This may We evaluated the performance of the PELOD score be explained by the presence of severe illness in patients compared with PIM2 for predicting mortality in small with small molecule disorders, who usually present molecule disorders in PICU; most research uses these with multiple organ dysfunction syndromes, including scores generally for survival in PICU (24,25), however pre-hepatic failure, which manifests as jaundice. Our in our study, only the PIM2 score was a statistically finding is in contrast to those of a prior report in which significant predictor of mortality. Similarly, a 2013 study about half of the IEM patients, including those with in India reported the under-prediction of mortality by small molecule disorders, had acute encephalopathy PELOD-2 compared to PIM2 (24); it is possible that the as the most common clinical presentation (15). A 3-year predictive mortality models could be population sensitive, study in Pakistan showed that respiratory distress and so validation studies are necessary before application in developmental delay were the most common clinical other settings and populations. presentations in cases diagnosed with IEM, including A limitation of our study is the small sample size; this en- small molecule disorders (23). This difference could be sues from the rarity of small molecule disorders. explained by the variability of symptoms and severity and the non-specificity of small molecule disorders. Funding: None. Comparison of laboratory results between confirmed Competing interests: None declared.
Étude rétrospective des maladies du métabolisme des petites molécules chez les patients pédiatriques admis aux soins intensifs Résumé Contexte : Si les erreurs innées du métabolisme (EIM) sont rares au plan individuel, elles sont collectivement à l’origine d’une morbidité et d’une mortalité élevées. Elles sont en outre difficiles à diagnostiquer. Objectifs : La présente étude visait à analyser les données épidémiologiques et cliniques, les diagnostics définitifs et les résultats cliniques des patients ayant un diagnostic suspecté d’EIM (de la catégorie des troubles du métabolisme des petites molécules) admis dans une unité de soins intensifs pédiatriques (USIP). Méthodes : Nous avons recueilli et analysé les données des dossiers médicaux de tous les patients admis à l’USIP de l’hôpital universitaire pour enfants d’Alexandrie entre janvier 2010 et décembre 2014 ayant un diagnostic suspecté ou confirmé de troubles du métabolisme des petites molécules, y compris les manifestations cliniques, les résultats de laboratoire et les résultats cliniques. Résultats : Au total, 34 patients avaient un diagnostic suspecté ou confirmé detroubles du métabolisme des petites molécules au moment de leur admission à l’USIP. Le diagnostic a été confirmé au moment de l’admission dans 22,7 % des cas suspectés et pendant le séjour à l’USIP dans 25 % des cas suspectés. Le mariage consanguin a été associé à 50 % des cas confirmés de troubles du métabolisme des petites molécules. Conclusion : Le diagnostic et la classification des troubles du métabolisme des petites molécules chez les individus à risque vivant dans les pays en développement exigent un indice de suspicion élevé.
دراسة ّاسرتجاعيةألنواع اضطرابات اجلزيئات الصغرية يف أمراض التمثيل األيىض لدى املرىض من األطفال يف وحدة الرعاية ُالـمركزة باالسكندرية، مرص أمحد النواوي، حممد داوود، أمنية عمر ُاخلالصة اخللفية: عىل الرغم من ُندرة حدوث األخطاء يف خلل التمثيل الغذائى بصورة ّة، فرديفإن األخطاء يف خلل التمثيل الغذائى التي حتدث بصورة ّمجاعية تتسبب يف معدالت عالية للمراضة والوفيات، كام أن تشخيصها ُي ُّعد ًأمرا بالغ الصعوبة.
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األهداف:حتليل البيانات ّالوبائية ّوالرسيرية، و التشخيص النهائي واملخرجات ّالرسيرية للمرىض ُامل َه ـشتبيف تشخيصهم باألخطاء يف خلل التمثيل الغذائى )من نوع اضطرابات اجلزيئات الصغرية(، والذين ُأ ْدخلوا إىل وحدة رعاية األطفال ُامل ّـركزة. ُ طرق البحث: قمنا ْبجمع وحتليل بيانات السج ّالت ّالطبية املأخوذة جلميع املرىض الذين أدخلوا وحدة الرعاية املركزة لألطفال يف مستشفى األطفال التابع جلامعة اإلسكندرية، وذلك يف الفرتة من يناير/كانون الثاين 2010 وحتى ديسمرب/كانون األول ،2014 ّممن ْاش ُتبِه أو تأكد تشخيصهم باضطرابات اجلزيئات الصغرية، ِوشمل ذلك املظاهر ّالرسيرية، ونتائج املختربات، واملخرجات ّالرسيرية. النتائج: بلغ إمجايل عدد املرىض الذين ْاش ُتبِ َه أو َّ تأكدتشخيصهم باضطرابات اجلزيئات الصغرية، حال دخوهلم وحدة الرعاية املركزة لألطفال 34 ًمريضا. ّوتأكد ُالتشخيص لدى 22.7% من احلاالت ْاملش َه تبهبا وقت الدخول، كام ّتأكد لدى 25% من احلاالت ُاملـشتبه هبا أثناء مكوثها يف وحدة الرعاية املركزة لألطفال. ْواك ُت ِش َف ُزواج األقارب يف 50% من احلاالت التي ّتأكدت ُإصابتها باضطرابات اجلزيئات الصغرية. االستنتاجات:يلزم وجود مؤرش ٍعال لالشتباه من أجل تشخيص وتصنيف اضطرابات اجلزيئات الصغرية عند حتري األفراد ُالـم ّعرضني ملخاطر صحية مرتفعة يف ُالبلدان النامية.
References 1. Kumta NB. Inborn errors of metabolism (IEM) – an Indian perspective. Indian J Pediatr. 2005 Apr;72(4):325–32. https://doi. org/10.1007/BF02724016 2. Clarke J. A stepwise clinical approach to inherited metabolic diseases. HK J Paediatr. 2004;9(3):261–7. 3. Rao AN, Kavitha J, Koch M, Suresh Kumar V. Inborn errors of metabolism: Review and data from a tertiary care center. Indian J Clin Biochem. 2009 Jul;24(3):215–22. https://doi.org/10.1007/s12291-009-0041-y PMID:23105838 4. Slater A, Shann F, Pearson G; Paediatric Index of Mortality (PIM) Study Group. PIM2: a revised version of the Paediatric Index of Mortality. Intensive Care Med. 2003 Feb;29(2):278–85. https://doi.org/10.1007/s00134-002-1601-2 PMID:12541154 5. Netto AL, Muniz VM, Zandonade E, Maciel ELN, Bortolozzo RN, Costa NF, et al. Desempenho do Pediatric Index of Mortality 2 em unidade de cuidados intensivos pediátrica [Performance of the Pediatric Index of Mortality 2 in a pediatric intensive care unit]. Rev Bras Ter Intensiva. 2014 Jan-Mar;26(1):44–50. https://doi.org/10.5935/0103-507X.20140007 PMID:24770688 6. Leteurtre S, Duhamel A, Grandbastien B, Proulx F, Cotting J, Gottesman R, et al. Daily estimation of the severity of multiple organ dysfunction syndrome in critically ill children. CMAJ. 2010 Aug 10;182(11):1181–7. https://doi.org/10.1503/cmaj.081715 PMID:20547715 7. Kirkpatrick LA, Feeney BC, editors. A simple guide to IBM SPSS statistics for version 20.0. 12th ed. Belmont (CA): Wadsworth, Cengage Learning; 2013. 8. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteris- tic curves: a nonparametric approach. Biometrics. 1988 Sep;44(3):837–45. https://doi.org/10.2307/2531595 PMID:3203132 9. Schoonjans F, Zalata A, Depuydt CE, Comhaire FH. MedCalc: a new computer program for medical statistics. Comput Methods Programs Biomed. 1995 Dec;48(3):257–62. https://doi.org/10.1016/0169-2607(95)01703-8 PMID:8925653 10. Keegan MT, Gajic O, Afessa B. Severity of illness scoring systems in the intensive care unit. Crit Care Med. 2011 Jan;39(1):163–9. https://doi.org/10.1097/CCM.0b013e3181f96f81 PMID:20838329 11. Saudubray JM, Nassogne MC, de Lonlay P, Touati G. Clinical approach to inherited metabolic disorders in neonates: an overview. Semin Neonatol. 2002 Feb;7(1):3–15. https://doi.org/10.1053/siny.2001.0083 PMID:12069534 12. Scalco FB, Oliveira MLC, Simoni RE, Aquino Neto FR. Inborn errors of metabolism, an important group of orphan neglected dis- eases:Investigation of 8,000 patients in Rio de Janeiro, Brazil. J Braz Chem Soc. 2014;25(10):1914–7. http://dx.doi.org/10.5935/0103- 5053.20140203 13. Hashem N. Thalassemia syndromes and other haemoglobinopathies prevalent among Egyptians. In: Proceedings of the first international conference on preventable aspects of genetic morbidity, vol. 1. Cairo, Egypt; 1978:54–7. 14. Elsobky E, Elsayed SM. Extended metabolic screen in sick neonates and children. Egypt J Med Hum Genet. 2004;2(2):71–91. 15. Wasant P, Vatanavicharn N, Srisomsap C, Sawangareetrakul P, Liammongkolkul S, Svasti J. Retrospective study of patients with suspected inborn errors of metabolism at Siriraj Hospital, Bangkok, Thailand (1997-2001). J Med Assoc Thai. 2005 Jun;88(6):746– 53. PMID:16083213 16. Moammar H, Cheriyan G, Mathew R, Al-Sannaa N. Incidence and patterns of inborn errors of metabolism in the Eastern Prov- ince of Saudi Arabia, 1983-2008. Ann Saudi Med. 2010 Jul-Aug;30(4):271–7. https://doi.org/10.4103/0256-4947.65254 PMID:20622343 17. Applegarth DA, Toone JR, Lowry RB. Incidence of inborn errors of metabolism in British Columbia, 1969-1996. Pediatrics. 2000 Jan;105(1):e10. https://doi.org/10.1542/peds.105.1.e10 PMID:10617747 18. Dionisi-Vici C, Rizzo C, Burlina AB, Caruso U, Sabetta G, Uziel G, et al. Inborn errors of metabolism in the Italian pediatric popu- lation: a national retrospective survey. J Pediatr. 2002 Mar;140(3):321–9. https://doi.org/10.1067/mpd.2002.122394 PMID:11953730 19. Shawky RM, Elsayed NS, Ibrahim DS, Seifeldin NS. Profile of genetic disorders prevalent in northeast region of Cairo, Egypt. Egypt J Med Hum Genet. 2012;3:45–62. https://doi.org/10.1016/j.ejmhg.2011.10.002
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20. Jouvet P, Touati G, Lesage F, Dupic L, Tucci M, Saudubray JM, et al. Impact of inborn errors of metabolism on admission and mortality in a pediatric intensive care unit. Eur J Pediatr. 2007 May;166(5):461–5. https://doi.org/10.1007/s00431-006-0265-2 PMID:16941128 21. Kamate M, Chetal V, Kulgod V, Patil V, Christopher R. Profile of inborn errors of metabolism in a tertiary care centre PICU. Indian J Pediatr. 2010 Jan;77(1):57–60. https://doi.org/10.1007/s12098-010-0008-2 PMID:20135269 22. Wajner M, Wannamacher C, Gaidzinski D. Detection of inborn errors of metabolism in patients of pediatric intensive care units of Porto Alegre, Brazil: comparison of the prevalence of such disturbances in a selected and an unselected sample. Brazil J Genet. 1986;9:331–40. 23. Satwani H, Raza J, Hanai J, Nomachi S. Prevalence of selected disorders of inborn errors of metabolism in suspected cases at a tertiary care hospital in Karachi. J Pak Med Assoc. 2009 Dec;59(12):815–9. PMID:20201170 24. Gandhi J, Sangareddi S, Varadarajan P, Suresh S. Pediatric index of mortality 2 score as an outcome predictor in pediatric Inten- sive Care Unit in India. Indian J Crit Care Med. 2013 Sep;17(5):288–91. https://doi.org/10.4103/0972-5229.120320 PMID:24339640 25. El-Nawawy A, Mohsen AA, Abdel-Malik M, Taman SO. Performance of the pediatric logistic organ dysfunction (PELOD) and (PELOD-2) scores in a pediatric intensive care unit of a developing country. Eur J Pediatr. 2017 Jul;176(7):849–55. https://doi. org/10.1007/s00431-017-2916-x PMID:28492972
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Consultation on the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region
Citation: Consultation on the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region. East Mediterr Health J. 2018;24(11):1112-11123 https://doi.org/10.26719/2018.24.11.1112 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).
Introduction disorders in countries, the evidence underpinning the draft regional framework, as well as the priority areas, The global burden of disease attributable to alcohol and proposed strategic interventions and indicators of the drug use combined is estimated to be higher than the draft regional framework, which led to the revision of the burden attributable to any other risk factor, and in the framework. Eastern Mediterranean Region this burden is largely attributable to drug use (1). According to the World Drug The plenary sessions were focused on introducing Report 2018, in 2016 an estimated 275 million people (5.6% the main domains of the proposed regional framework, of the global adult population) used drugs at least once followed by group work to review the strategic in the previous year, mainly a substance belonging to interventions and indicators to monitor progress in the cannabinoid, opioid, cocaine or amphetamine type their implementation. The group work and subsequent stimulant (ATS) groups (1). Among these, 30.5 million discussions also provided opportunities to review the were problem drug users and suffered from drug use experiences of countries of our Region and other regions. disorders, including drug dependence (1). Participants identified several overarching challenges In order to address this, an intercountry consultation that hinder the adoption of a public health approach to to review and finalize the draft regional framework for substance use disorders. Civil unrest and instability action for strengthening the public health response to in many countries of the Region affects the capacity substance use and substance use disorders in the Eastern of governments to exert their authority in parts of Mediterranean Region was held by the World Health their territory, coupled with an increasing diversion of Organization (WHO) in Abu Dhabi, United Arab Emirates, resources from the social sector towards security. from 11 to 13 September 2018 (2). The consultation brought National policies and legislation are skewed towards together focal points on substance use from countries of supply reduction, with little emphasis on a public the Region, civil society organizations, the Joint United health response, resulting in resource constraints. As Nations Programme on HIV/AIDS (UNAIDS), the United a result, substance use treatment services have limited Nations Office on Drugs and Crime (UNODC), and reach and capacity to provide an acceptable quality of international and regional experts who, in preparation service. There is also a lack of a control system that both for the meeting, had been engaged in the development ensures an adequate availability of controlled substances of the draft regional framework. The objectives of the for the management of substance use disorders, and meeting were to: simultaneously prevents an increasing misuse of • review and finalize the draft regional framework for psychotropic medicines. action for strengthening the public health response to There is limited engagement of the health sector substance use and substance use disorders; and in the current debates around the issues of substance • establish a platform for effective regional collabo- use, and a relative lack of engagement across sectors, ration to strengthen the public health response to especially between the public sector and civil society. substance use problems in the Region and contribute There is also a paucity of research and research capacity to the global dialogue on substance use policy, within in countries of the Region to inform policies and the public health context. strategies. Weak monitoring and surveillance systems are unable to provide valid, reliable, comparable and Summary of discussions timely information to inform current policies regarding Over the three days of the meeting, the participants interdiction, prevention and treatment. Participants reviewed the currently available capacities and resources called for the development of balanced and integrated for the prevention and treatment of substance use substance use policies incorporating public health
1 This report is extracted from the Summary report on the Intercountry consultation to review and finalize the draft regional framework for strength- ening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region, Abu Dhabi, United Arab Emirates, 11–13 September 2018 (http://applications.emro.who.int/docs/IC_Meet_Rep_2018_EN_20767.pdf?ua=1).
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perspectives, and supported by legislative and regulatory Recommendations provisions. These are important enablers for a robust public health response to the problem of substance use in For Member States the countries of the Region. • Ensuring that national focal points on substance use The discussion focused on the development engage with their counterparts in relevant ministries, or updating of strategies, policies and regulatory as well as with their diplomatic missions in Geneva frameworks, including adapting and implementing and New York, so that a public health perspective is the draft regional framework. This will underpin the reflected in the ongoing dialogue around substance development of integrated and balanced care service use and substance use disorders. models, within and between sectors, and should include For WHO the engagement of all relevant stakeholders, across the • Finalizing the draft regional framework for action domains of prevention, early recognition, management, for strengthening the public health response to sub- rehabilitation and harm reduction. To support this, robust stance use and substance use disorders over the next health information systems are needed that collect and four weeks through virtual consultation with nation- report data using standard internationally comparable al counterparts, civil society and United Nations (UN) indicators. sister organizations. The participants also identified the need to adopt/ • Ensuring buy-in at the highest possible level of na- adapt UNODC/WHO treatment and prevention tional policy/decision-making for the regional frame- standards, and the need to integrate substance use care in work by presenting it to the Sixty-sixth Session of the existing health systems through inclusion of substance WHO Regional Committee for the Eastern Mediterra- use interventions in the universal health coverage nean in October 2019. benefit packages currently being developed in countries across the Region. The need to strengthen the component • In collaboration with UN agencies, providing contin- of substance use and its disorders in pre-service teaching ued advocacy with organizations such as the League and training for health and social sector care providers of Arab States, Gulf Cooperation Council and the was also highlighted, as was the need to quantitatively and Group of Five (G5). qualitatively improve specialist training programmes. • In collaboration with UN agencies, enhancing the ca- A particular area of concern was the limited availability pacities of substance use units/directorates to engage of the essential medicines needed for the management in policy dialogue and support implementation of the of substance use disorders, such as methadone and regional framework. buprenorphine/naltrexone, and the need for a system • In collaboration with UN agencies, facilitating the for the adequate monitoring and surveillance of the active engagement and participation of public health prescription of psychoactive drugs. representatives in the ongoing national and interna- The participants strongly supported the embedding tional dialogue, including briefing health attachés of age- and setting-specific substance use prevention from countries in the permanent missions in Geneva in health promotion and prevention policies and and New York. programmes across life course. The need to strengthen • Exploring avenues for setting up and maintaining a the capacities of institutions in countries to undertake regional network for strengthening the public health operational research to guide policy and service response to substance use and substance use disor- development was also pointed out. ders.
References 1. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2018. New York: UNODC; 2018 (https://www.unodc. org/wdr2018/). 2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Intercountry consultation to review and finalize the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region. Cairo: WHO/EMRO; 2018 (http://applications.emro.who.int/docs/IC_Meet_ Rep_2018_EN_20767.pdf?ua=1).
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Book 24-11.indb 1113 23/01/2019 10:04:11 Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.
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
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EMHJ – Vol. 24 No. 11 – 2018 Eastern Mediterranean La Revue de Santé de la Health Journal Méditerranée orientale Editorial WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement
Arash Rashidian, Ahmed Mandil, Samar ElFeky and Ahmed Al-Mandhari ...... 1035 Letter to the editor The neglected role of stewardship in strategic purchasing of health services: who should buy? Djavad Ghoddoosi Nejad, Ali Janati and Morteza Arab-Zozani ...... 1038
Research articles Characteristics of women applying for a legal abortion in the Islamic Republic of Iran Seyedeh Fatemeh Vasegh Rahimparvar, Asieh Jafari, Fatemeh Hoseinzadeh, Faezeh Daemi and Fatemeh Samadi ...... 1040 Identifying hotspots of viral haemorrhagic fevers in the Eastern Mediterranean Region: perspectives for the Emerging and Dangerous Pathogens Laboratory Network Mathias Altmann, Karen Nahapetyan and Humayun Asghar ...... 1049
Prevalence and determinants of Caesarean delivery in Punjab, Pakistan Eastern Mediterranean Health Journal Faisal Abbas, Rafi Amir ud Din and Maqsood Sadiq ...... 1058
C Dépistage de l’hypothyroïdie congénitale au Maroc : étude pilote
M Saâd Maniar, Chadia Amor et Abbas Bijjou ...... 1066 Antibiotic Y Study protocol for promoting physical activity among women based on the MAPP process CM Leila Amiri Farahani, Soroor Parvizy, Mohsen Asadi-Lari, Eesa Mohammadi, Batool Hasanpoor Azghadi and Ziba Taghizadeh 1074 MY Repellency effect of flumethrin pour-on formulation against vectors of Crimean–Congo haemorrhagic fever overprescribing contributes to
CY Eslam Moradi Asl, Hassan Vatandoost, Zakie Telmadarreiy, Mehdi Mohebali and Mohammad Reza Abai ...... 1082 Vol.
CMY Quality of life in Iranian elderly population using the SF36- questionnaire: systematic review 24 No. ANTIBIOTIC RESISTANCE K
and meta-analysis 11
– Amin Doosti-Irani, Saharnaz Nedjat, Sima Nedjat, Parvin Cheraghi and Zahra Cheraghi ...... 1088 2018 Knowledge, attitudes, behaviours and practices towards diabetes mellitus in Kuwait
Manuel Carballo, Anwar Mohammad, Elizabeth C. Maclean, Noureen Khatoon, Mohammad Waheedi and Smitha Abraham ...... 1098 A retrospective study of small molecule disorder types of metabolism in paediatric patients in intensive care Ahmed El-Nawawy, Mohamed Dawood and Omneya Omar ...... 1103 WHO events addressing public health priorities Consultation on the draft regional framework for strengthening the public health response to substance use and substance use disorders in the Eastern Mediterranean Region ...... 1112
The World Health Organization Regional Office for the Eastern Mediterranean is running its campaign for World Antibiotic Awareness Week under the theme “Change Can’t Wait. Our Time with Antibiotics is Running Out”. Taking place 12–18 November 2018, the campaign aims to target the general public, health professionals, governments, and the food, animal and agricultural sectors to raise awareness of the problem of antibiotic resistance.
١١ Volume 24 / No. 11 2018 November/Novembre /