Eastern Mediterranean Health Journal La Revue De Santé De La Méditerranée Orientale

Eastern Mediterranean Health Journal

La Revue de Santé de la Méditerranée orientale

املجلد العرشون / عدد Volume 20 / No. 9 9 أيلول / سبتمرب September/Septembre 2014 Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab السياسات واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية Republic . Tunisia . United Arab Emirates . Yemen ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق 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.

EASTERN MEDITERRANEAN HEALTH JOURNAL البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية .cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region اجلمهورية العربية السورية . اليمن . جيبويت . السودان . الصومال . العراق . عُ ام ن . فلسطني . قطر . الكويت . لبنان . مرص -It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col laborating Centres and individuals within and outside the Region. املغرب . اململكة العربية السعودية LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres Membres du Comité régional de l’OMS pour la Méditerranée orientale informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran teurs de l’OMS et personnes concernés au sein et hors de la Région. Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen

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

EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). Correspondence

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Cover 20-10 (69 Cyan - 37 Yellow).indd 4-6 14/10/2014 10:20 Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale

املجلد العرشون عدد Vol. 20 No. 9 • 2014 • 9 Contents

Editorial Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean Sameen Siddiqi, Awad Mataria and Eduardo Banzon...... 527 Research articles Pattern of cigarette and waterpipe smoking in the adult population of Jordan M. Jaghbir, S. Shreif and M. Ahram...... 529 Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey M. Jaghbir, S. Shareif and M. Ahram...... 538 Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran B. Foroutan and R. Foroutan...... 547 Use of complementary and alternative medicine among midlife Arab women living in Qatar L.M. Gerber, R. Mamtani, Y.-L.Chiu, A. Bener, M. Murphy, S. Cheema and M. Verjee...... 554 Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt W. Al-Darzi, F. Al-Mudares, A. Farah, A. Ali and D. Marzouk...... 561 Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from Pakistan F. Jahan, R. Roshan, K. Nanji, U. Sajwani, S. Warsani and S. Jaffer...... 569 Interobserver variations in reporting of prostatic adenocarcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia A.C. Al-Rikabi and H. Alkhalidi...... 578 Dr Ala Alwan, Editor-in-chief Editorial Board Professor Zulfiqar Bhutta Professor Mahmoud Fahmy Fathalla Professor Rita Giacaman Dr Ziad Memish Dr Sameen Siddiqi Professor Huda Zurayk International Advisory Panel Dr Mansour M. Al-Nozha Professor Fereidoun Azizi Professor Rafik Boukhris Professor Majid Ezzati Dr Zuhair Hallaj Professor Hans V. Hogerzeil Professor Mohamed A. Ghoneim Professor Alan Lopez Dr Hossein Malekafzali Professor El-Sheikh Mahgoub Professor Ahmed Mandil Dr Hooman Momen Dr Sania Nishtar Dr Hikmat Shaarbaf Dr Salman Rawaf Editors Fiona Curlet, Guy Penet (French) Freelance: Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

Editorial Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean Sameen Siddiqi,1 Awad Mataria 1 and Eduardo Banzon 1

Countries of the Eastern Mediterranean mix between obligatory insurance insurance contributions and have man- Region (EMR) of the World Health contributions and general government aged to expand coverage to the poor Organization have never been as com- revenues. This change has come about and part of the informal sector using mitted as they are today to ensure that in high-income countries as popula- government subsidies; for example, the all people have access to needed health tions have aged and the ratio of those Islamic Republic of Iran. As an alter- services without the risk of financial who pay contributions to those who do nate approach, Morocco and Tunisia hardship – the message of universal not has fallen, so general government implement a separate subsidized SHI health coverage (UHC) (1). The aver- revenues have been mixed with obliga- scheme to cover the poor and vulner- age share of out-of-pocket payments for tory contributions. Similarly, in low- and able population. As for Jordan and EMR countries stands at around 40% middle-income countries – with their Palestine, SHI is managed by the Min- and in some countries is close to 70% of large informal sector1 and vulnerable istry of Health. Despite the multitude of total health expenditure (2). This con- populations, the concept of SHI has SHI arrangements, the share of out-of- stitutes a major hindrance to pursue the evolved into a prepayment arrangement pocket spending remains unacceptably goal of UHC and calls for establishing that is not only funded by premium high in many Group 2 countries due prepayment and pooling arrangements contributions but also financed from to a relatively small benefit package, that guarantee financial protection to government allocations to subsidize substantial co-payments, and vulner- all population groups. In their quest contributions on behalf of the poor and able population groups who are not for equitable, efficient and sustainable vulnerable populations, including those covered. Group 1 or the Gulf Coopera- forms of prepayment, countries can in the informal sector. Many elements tion Council countries rely mainly on choose from multiple arrangements of this new definition of SHI make it an general government revenues gener- that include allocations from general attractive arrangement that countries ated primarily from natural resources government revenues, obligatory health worldwide are employing or consider- to cover a generous package of health insurance, and modalities such as vol- ing implementing. This is also the case services for their citizens. In recent years, untary health insurance and medical with most EMR countries. Qatar and the United Arab Emirates – saving accounts. In EMR, countries have been dis- in particular in Abu Dhabi and Dubai Traditionally, obligatory health tributed into three groups2 that are at – have shifted from general government insurance financed through premium different stages of introducing or ex- revenue to SHI to cover nationals for all contributions (from employers and/ panding this new vision of raising and or selected services. The large expatriate or employees) was called social health pooling funds for health, frequently populations in these countries are either insurance (SHI), but these days SHI called SHI. Many countries in Group 2, covered by private health insurance or describes a variety of ways of raising which are mostly middle income, have are granted access to a limited pack- and pooling money that involves a a long tradition of obligatory health age against nominal payment and in

1 The informal sector covers a wide range of employment categories including the self-employed and those with casual, temporary and unpaid jobs, etc. Source: World Bank http://lnweb90.worldbank.org/eca/eca.nsf/1f3aa35cab9dea4f85256a77004e4ef2/4e4ede543787a0c085256a9 40073f4e4). 2 EMR countries are commonly categorized into three health system groups based on population health outcomes, health system performance and the level of health expenditure. Group 1 (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates); Group 2 (Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Syrian Arab Republic and Tunisia); Group 3 (Afghanistan, Djibouti, Pakistan, Somalia, South Sudan, Sudan and Yemen).

1Department of Health System Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

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many cases are left without cover. As that remains flexible and protected from allowed the country to move closer to for Group 3 countries, Sudan is more budgetary negotiations. UHC (4). Similarly, Thailand, backed advanced in terms of implementing If not properly designed or imple- by a high level of political commitment, SHI, where the poor and those in the in- mented, however, SHI can suffer from managed to achieve UHC by adding formal sector are partially covered using several pitfalls. For example, the benefit a Universal Coverage scheme for the government subsidies and zakat funds. package may be limited to curative care poor and informal sector, paid entirely In these countries, the overall level of without emphasis on health promotion from general government revenues. financing is inadequate, large segments and prevention. When implemented This scheme avoided fee-for-service of the population are not covered and in its classical form, SHI may leave out payments, thereby covering a large the share of out-of-pocket spending the poorest segments of the population population with a wide range of quality hovers at around 60% of total health and those in the informal sector. In addi- services at an affordable cost (5). expenditure. tion, if fragmented with too many funds, While designing or expanding SHI, Several features make SHI a power- SHI may become inefficient with high policy-makers need to ensure that: it re- ful instrument for financing the health administrative costs and delayed reim- mains obligatory and not voluntary for system and enhancing the move to- bursements. High levels of co-payments people who can pay, with general gov- wards UHC. The obligatory nature of and low tariffs to attract private providers ernment revenues covering those who SHI results in no opt-outs and ensures may perpetuate financial hardship 3( ). cannot; it is inclusive and seeks non-risk- social solidarity where the rich, healthy, It is important to recognize the dif- related contributions; the benefit package young and employed subsidize the ferences between the types of SHI ar- has a promotive and preventive compo- poor, sick, elderly and unemployed. The rangements and the way pooled funds nent; it fosters a single-payer arrangement clear linkage between contributions and are used to pay for services. When as far as possible; and it enjoys a degree benefits empowers the individuals to designing obligatory health insurance, of autonomy in its implementation to demand “paid-for” benefits rather than it is necessary to consider the package ensure efficiency. SHI means covering seek “free” care. Indeed, having an insur- and provider payment methods in ways not only those who are in the formal sec- ance membership card is an enabling that ensure efficiency and quality and tor or those who contribute to payroll tool. Members of SHI are more willing utilization of services. Countries that taxes but all population groups through to pay premium contributions as they attend to these potential pitfalls manage government subsidies and other innova- perceive their payment as a “benefit tax”. to progress “quickly and surely” towards tive financing mechanisms. Ultimately SHI can improve efficiency by facilitat- UHC. The experience of Turkey in it is the responsibility of governments to ing strategic purchasing. The presence merging its five SHI schemes into a ensure that all people in their countries of an independent or quasi-independ- single-payer system in less than 10 years, are protected from the risk of financial ca- ent fund that enjoys autonomy from the while also integrating its “Green Card” tastrophe and impoverishment. SHI is an government enables mobilizing money scheme for the poor into the same pool, effective instrument to achieve this goal.

References

1. The World Health Report 2010. Health systems financing: the 4. Atun R, Aydın S, Chakraborty S, Sümer S, Aran M, Gürol I, et al. path to universal coverage. Geneva: World Health Organiza- Universal health coverage in Turkey: enhancement of equity. tion; 2012. The Lancet. 2013;382(9886):65–99. 2. Towards universal health coverage: challenges, opportunities 5. Maeda A, Cashin C, Harris J, Ikegami N, Reich M. Universal and roadmap. Cairo: World Health Organization Regional health coverage for inclusive and sustainable development: Office for the Eastern Mediterranean; 2013 (EM/RC60/Tech. a synthesis of 11 country case studies. Washington DC: World Disc.2 Rev.1). Bank Publications; 2014:2–14. 3. Liu X, Tang S, Yu B, Phuong NK, Yan F, Thien DD, et al. Can rural health insurance improve equity in health care utilization? A comparison between China and Vietnam. Int J Equity Health. 2012 (doi: 10.1186/1475-9276-11-10).

528 املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

Pattern of cigarette and waterpipe smoking in the adult population of Jordan M. Jaghbir,1 S. Shreif 1 and M. Ahram 2

طراز تدخني السجائر والنرجيلة لدى السكان البالغني يف األردن مايض توفيق اجلغبري، سمر لطفي الرشيف، مأمون أمحد أهرام اخلالصــة:لقــد لوحــظ تزايــد انتشــار التدخــن يف األردن، وهــذا يتطلــب فهــم الســلوكيات االجتامعيــة التــي تــؤدي إىل هــذه العــادة. وقــد َّدتحــد هــذه الدراســة الوصفيــة املســتعرضة انتشــار التدخــن بــن األردنيــن فيــام يتعلــق بالرتكيبــة الســكانية، مــع الرتكيــز عــى أربعــة أنــامط مــن منتجــات التبــغ - هــي: الســجائر والنرجيلــة والســيجار والغليــون. وقــد أجابــت عينــة مــن الســكان ضمــت 3196 ً بالغــاتزيــد أعامرهــم 32.3 18 عــى ســنة، عــى اســتبيان مقابلــة حــول عــادة التدخــن لدهيــم، وأنــامط وكميــات التبــغ التــي يســتهلكوهنا. فذكــر مــا ُّإمجاليــه % مــن 2.9 8.3 54.9 َاملســتطلعي أهنــم مدخنــون ُّحاليــون ) % مــن الذكــور و %مــن اإلنــاث(، وكان % منهــم مدخنــن ســابقي. وكان تدخــن الســجائر 20 93.0 النمــط األكثــر ًشــيوعا مــن أنــامط تدخــن التبــغ ) %(، وكان ثلــث مدخنــي الســجائر يســتهلكون أكثــر مــن ســيجارة يف اليــوم. وكان 8.6 تدخــن النرجيلــة ثــاين أكثــر العــادات ًشــيوعا ) %(، وكان ًمقرتنــا- بشــكل ملحــوظ - بأعــامر أقــل لــدى كل مــن الذكــور واإلنــاث. وخلــص الباحثــون إىل أن َخ ْــض فاملعــدل املرتفــع للتدخــن يف األردن جيــب أن يكــون مــن األولويــات.

ABSTRACT An increasing prevalence of smoking in Jordan has been noted and this necessitates understanding the social behaviours that have lead to this habit. This cross-sectional, descriptive study determined the prevalence of smoking among Jordanians in relation to demographics with a focus on 4 types of tobacco products—cigarettes, waterpipes, cigars and pipes. A population sample of 3196 adults aged 18+ years answered an interview questionnaire about their smoking habit and types and amounts of tobacco consumed. Overall 32.3% of the respondents reported being current smokers (54.9% of males and 8.3% of females) and 2.9% were ex-smokers. Cigarette smoking was the most frequent type of tobacco smoking (93.0%) and one-third of cigarette smokers consumed more than 20 cigarettes per day. Waterpipe smoking was the second most common habit (8.6%) and was significantly associated with lower age in both males and females. Reducing the high rate of smoking in Jordan must be a priority.

Caractéristiques de la consommation de cigarettes et du narguilé dans la population adulte de Jordanie

RÉSUMÉ Une prévalence accrue de la consommation de tabac a été observée en Jordanie et cette augmentation nécessite une compréhension des comportements sociaux qui conduisent à cette habitude. La présente étude transversale descriptive a déterminé la prévalence de la consommation de tabac chez les Jordaniens axée sur quatre types de produit —les cigarettes, les narguilés, les cigares et les pipes, en tenant compte des données démographiques. Un échantillon de population de 3196 adultes âgés de 18 ans et plus a répondu à un questionnaire administré pendant un entretien sur les habitudes de consommation de tabac et les types et quantités de tabac consommés. Dans l'ensemble, 32,3 % des répondants ont déclaré être des fumeurs actifs (54,9 % d'hommes et 8,3 % de femmes) et 2,9 % étaient d'anciens consommateurs de tabac. Fumer des cigarettes était la forme de consommation de tabac la plus fréquente (93,0 %) et un tiers d’entre eux fumaient plus de 20 cigarettes par jour. Fumer le narguilé arrivait en deuxième position dans les habitudes de consommation (8,6 %) et était significativement associé à un âge plus jeune chez les hommes comme chez les femmes. Réduire le fort taux de consommation de tabac en Jordanie doit être une priorité.

1Department of Family and Community Medicine; 2Department of Physiology and Biochemistry, Faculty of Medicine. University of Jordan, Amman, Jordan (Correspondence to M. Jaghbir: [email protected]; [email protected]). Received: 30/12/13; accepted: 14/04/14

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Introduction increase. Due to the relatively low age stage, random selection of individual of the population, the rate of smoking- interviewees from each household was The World Health Organization related disease is expected to increase. carried out using Kish tables (11). The (WHO) has described tobacco In order to learn more about public final sample size in this survey was 3196 smoking as an epidemic (1). Strong smoking habits including the rates and participants (a response rate of 93%). evidence links tobacco smoking to types of products smoked, a question- Overall, the characteristics of survey mortality and numerous diseases, naire was conducted as part of a national participants correlated well with na- primarily cardiovascular diseases and survey of knowledge, attitudes and prac- tional estimates, as published earlier cancer (2,3). The estimated number tices (KAP) towards cancer prevention (12). of smoking-related annual deaths from and care in Jordan that included ques- Instrument smoking-attributable diseases are ex- tions about smoking habits. Overall, the pected to increase to 10 million within focus of the study was to help identify A structured questionnaire was de- the next 30 years or so, of which 70% the current smoking practices among signed by a national advisory committee will occur in developing countries (4). the population of Jordan in an effort to that consisted of research experts from In Jordan, an Eastern Mediterranean better control this life-threatening habit. different research, clinical and academic Region (EMR) country, cardiovas- This was the first study of its kind at the institutions in Jordan. The design of cular disease is the leading cause of national level in Jordan. the survey was based on international mortality (36.1%), followed by cancer references/tools that were used as a (15.6%) (5). In fact, cancer cases in guide to the development of the ques- Jordan are steadily increasing. For ex- Methods tionnaire and to ensure appropriate ample, according to the Jordan Cancer themes and adaptation to the local Registry, there has been a 4% increase Study design context. Face-to-face interviews were in cancer cases between 2008 and This was a quantitative, cross-sectional, conducted in interviewees’ households 2009 (6). Lung cancer ranked second descriptive survey. Data collection and took an average of 30 minutes to among males (11.2%), closely follow- spanned 2 months from 24 January to complete. Verbal informed consent was ing colorectal cancer (12.7%) (6). It is 19 March 2011. The survey consisted obtained; agreement to host interviews well accepted that at least one-third of of 10 sections starting with a section in the participants’ house is a culturally all the new cases of cancer every year about demographic characteristics. appropriate method to obtain consent can be prevented and that tobacco is One section enquired about the lifestyle in Jordan. one of the most preventable causes of of participants and included questions A pilot study was conducted to test cancer. Hence, tobacco control should about smoking habits. The results of the survey tool, sampling technique, be established as the top priority in this part of the survey form the focus of survey methods and interviewers’ level public health programmes for disease this paper. of work. The pilot study spanned a day prevention, including cancer. and was carried out in one area in the Participants Rates of smoking and tobacco capital city, Amman. The pilot sample consumption are variable across the The KAP survey sample was based consisted of 56 randomly selected sub- EMR, with a high smoking prevalence on the 2004 Jordan Population and jects. Following the pilot, a 2-day review in some countries, such as Lebanon, Jor- Housing Census as the sampling frame. session was conducted and resulted dan, Egypt, Tunisia and the Syrian Arab The sampling frame was stratified by in implementation of minor modifica- Republic (7). A review of 36 studies governorate, major cities (each city with tions. related to the prevalence of smoking in a population of more than 100 000 was Saudi Arabia has indicated rates of up to considered a stratum, i.e. 6 cities) and Measures 52.3% (8). Among EMR countries, Jor- other urban and other rural areas. A Respondents were first asked if they dan had the highest age-standardized 3-stage sampling procedure was em- considered themselves as non-smokers, rate of smoking (36.5%) followed by ployed. First, blocks were selected sys- current smokers or ex-smokers. Those Tunisia (25.7%) (9). Significantly, the tematically as primary sampling units who described themselves as current rate of smoking has been on the increase (PSUs) with a probability proportional smokers were asked about the types in the EMR countries (9,10). The same to the size of the PSU. In the second of tobacco they used and 4 options trend is expected to be occurring in Jor- stage, a fixed number of 15 households were provided: cigarettes, cigars, pipes dan, which suggests that the number of were selected as final sampling units in and waterpipes (nargile). In addition, Jordanians who will die or be disabled as each PSU, resulting in a sample size of respondents were asked about the a result of tobacco-related diseases will about 4500 households. In the third amount of tobacco consumed (i.e.

530 املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

number of times each type of tobacco participants being between 18 and 49 whereas 32.3% were current smokers product was smoked daily). years of age. The highest percentage and 2.9% were ex-smokers (Table of participants had attained prepara- 1). The prevalence of current smok- Data collection tory to high-school education (51.3%), ing varied greatly according to sex, Data collection was carried out in the with the remainder having a diploma whereby 54.9% of male respondents 3 regions of Jordan (North, Middle degree and above (29.5%) or elemen- reported being current smokers com- and South). The face-to-face inter- tary education and below (19.2%). pared with only 8.3% of females (P views were conducted by 18 trained Approximately half of respondents had < 0.001). A significant difference in teams. Each team consisted of 3 data a monthly household income below smoking habits was also noted with collectors, 1 controller, 1 field supervi- 300 Jordanian dinar (JD) (US $430). age, with the highest prevalence being sor and 1 driver. The controllers and Individuals with the medium income in the 40–49 years age group (40.0%) supervisors conducted spot checks (300–599 JD) represented 38.7% and and the lowest among those aged 60+ by randomly visiting some sampled those with high income (above 600 years (16.3%) (P < 0.001). Intermedi- households. In order to facilitate data JD) represented 14.2%. The majority ate educational status had a significant collection, each interviewing team of respondents were married (73.1%), association with smoking habits, with was assigned a number of blocks in and most of the rest were single more than one-third of them (36.9%) the sample area. Interviewers made (19.9%); the “other” category (7.0%) being current smokers versus approxi- repeated attempts to obtain the re- included those who were widowed, mately 27% of the groups of lower and sponses of eligible respondents by divorced or separated. higher educational status (P < 0.001). calling back to interview respondents No significant relationship was found who were not home at the time of the Pattern of smoking habits between smoking habits and income first visit or by attempting to persuade When participants were asked about (P = 0.379). A significant effect of respondents who were reluctant to be their smoking habits, 64.8% of them marital status on smoking habits was interviewed. reported that they had never smoked, found; those who were divorced, Data processing and analysis

Data entry using Oracle software Table 1 Demographic characteristics of the participants (n = 3196) started 1 week after the initiation Characteristic No. % of data collection. After editing and Sex cleaning, the data were exported to Male 1647 51.5 SPSS, version 17.0. SPSS was used to Female 1549 49.5 run univariate and bivariate analyses Age (years) to describe all the survey variables. 18–29 964 30.1 As most of the variables in the study 30–39 915 28.6 were measured on a nominal and/or 40–49 627 19.6 ordinal level, descriptive statistics were 50–59 271 8.5 used to describe the basic features of 60+ 419 13.1 the data. The chi-squared test was used to correlate demographic data with Education smoking habits. Elementary or less 614 19.2 Preparatory to high school 1638 51.3 Diploma and above 944 29.5 Results Monthly income (JD) a < 300 1495 4 7. 1 Demographic characteristics 300–599 1227 38.7 A total of 3196 respondents participat- 600+ 452 14.2 ed in the survey. Their demographic Marital status b characteristics are summarized in Single 636 19.9 Table 1. There was an approximately Married 2338 73.1 equal distribution of males and fe- Othera 222 7. 0

males. The respondents’ mean age a22 respondents refused to declare their income; bThis category included divorced, widowed and separated. was 39 years, with about 78% of the JD = Jordanian dinar.

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widowed or separated were more only among those 60+ years old higher income (P < 0.001). Income likely to be non- or ex-smokers than (P < 0.001), the lowest percentage did not show any significant effect were single and married individuals of female smokers was among the on the prevalence of smoking among (P < 0.001). The latter 2 groups, single youngest (18–29 years) and oldest females (P = 0.894). It is noteworthy and married respondents, appeared (60+ years) age groups (P < 0.001). that more males with intermediate to have similar smoking habits; 61.9% Similarly, the prevalence of smoking education smoked than those with versus 63.9% respectively were non- by single and married male smokers lower and higher educational status smokers, while 36.5% versus 33.0% was higher than among those who (P < 0.001). The prevalence of smok- respectively were current smokers. were divorced, widowed or separated ing was significantly different among (P < 0.001). On the other hand, more females according to level of educa- Pattern of smoking according married females smoked than the tion (P = 0.046). to sex single or other categories (P = 0.01). When analysing the data in more de- When looking at the aforementioned Type of smoking tail to look at differences in smoking overall smoking habits, there was no Current smokers (n = 1032) were habits between males and females association between smoking and asked about the type of tobacco some interesting associations were income among females. However, products they smoked daily (Table noted (Table 2). Whereas the per- males with lower income were more 3). The majority indicated that they centage of males smoking was low likely to be smokers than those with smoked cigarettes (93.0%). There

Table 2 Smoking habits of the study group in relation to socioeconomic characteristics How would you describe your smoking Non-smoker Current smoker Ex-smoker habits of any tobacco products? No. % No. % No. % Total 2072 64.8 1032 32.3 93 2.9 Sex Male 669 40.6 904 54.9 75 4.6 Female 1403 90.6 128 8.3 18 1.2 χ2 = 876.2; P < 0.001 Age (years) 18–29 652 67.7 295 30.6 16 1.7 30–39 555 60.6 336 36.7 25 2.7 40–49 362 57.7 251 40.0 14 2.2 50–59 179 66.3 82 30.4 9 3.3 60+ 322 77.0 68 16.3 28 6.7 χ2 = 97.1; P < 0.001 Education Elementary or less 411 66.8 167 27.2 37 6.0 Preparatory to high school 996 60.8 604 36.9 38 2.3 Diploma and above 664 70.3 262 27.8 18 1.9 χ2 = 56.2; P < 0.001 Monthly income (JD) a < 300 946 63.3 502 33.6 47 3.1 300–599 804 65.5 390 31.8 33 2.7 600+ 307 67.9 135 29.9 10 2.2 χ2 = 4.2; P = 0.379 Marital status Single 394 61.9 232 36.5 10 1.6 Married 1495 63.9 772 33.0 71 3.0 Other 182 82.0 28 12.6 12 5.4 χ2 = 50.4; P < 0.001

a22 respondents refused to declare their income.

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Table 3 Smoking habits of males and females in relation to socioeconomic characteristics How would you describe your Males Females smoking habits of any tobacco Non-smoker Current Ex-smoker Non-smoker Current Ex-smoker products? smoker smoker No. % No. % No. % No. % No. % No. % Age (years) 18–29 199 40.8 276 56.6 13 2.7 453 95.4 19 4.0 3 0.6 30–39 163 34.1 293 61.3 22 4.6 392 89.7 43 9.8 2 0.5 40–49 123 35.4 213 61.4 11 3.2 239 85.7 37 13.3 3 1.1 50–59 36 34.0 66 62.3 4 3.8 143 86.7 17 10.3 5 3.0 60+ 147 65.0 56 24.8 23 10.2 175 91.1 12 6.2 5 2.6 χ2 = 108.1; P < 0.001 χ2 = 35.65; P < 0.001 Education Elementary or less 93 36.2 137 53.3 27 10.5 318 88.6 30 8.4 10 2.8 Preparatory to high school 317 35.5 544 60.9 32 3.6 680 91.2 60 8.0 6 0.8 Diploma and above 259 52.0 223 44.8 16 3.2 405 90.6 39 8.7 3 0.7 χ2 = 62.06; P < 0.001 χ2 = 9.69; P = 0.046 Monthly income (JD) a < 300 255 34.7 442 60.1 38 5.2 691 90.8 60 7. 9 10 1.3 300–599 288 44.0 338 51.7 28 4.3 516 89.9 52 9.1 6 1.0 600+ 123 49.2 120 48.0 7 2.8 185 91.1 15 7. 4 3 1.5 χ2 = 22.26; P < 0.001 χ2 = 1.10; P = 0.894 Marital status Single 190 44.8 224 52.8 10 2.4 204 44.8 8 3.8 0 0.0 Married 457 38.6 669 56.5 58 4.9 457 38.6 669 56.5 58 4.9 Other 22 56.4 10 25.6 7 17.9 160 87.9 17 9.3 5 2.7 χ2 = 32.56 ; P < 0.001 χ2 = 16.02; P = 0.003

a22 respondents refused to declare their income.

was a significant difference in the Smoking waterpipes daily rated Type of smoking habit prevalence of cigarette smoking by second among the 4 types of tobacco according to sex sex, in which 93.7% of males smoked products; 89 respondents (8.6%) in- We examined the types of smoking cigarettes in comparison with 88.3% dicated that they smoked this type of (cigarettes and waterpipes) accord- of females (P = 0.025). A significant tobacco product. Waterpipe smoking ing to sex (Table 6). Whereas there difference was also found across the had a significant negative association was no significant difference among different age groups (P = 0.042). The with age, with the highest percentage females in the percentage smoking rate of cigarette smoking was high- (13.3%) among the age group 18–29 cigarettes by age P( = 0.062), the per- est among age groups 40–49 years years and the lowest among those aged centage of males smoking cigarettes (96.4%), 50–59 years (95.2%) and 60+ years (1.5%) (P < 0.001) (Table tended to be lowest in the youngest 60+ years (95.6%), and lowest among 5). No significant difference, however, age group (18–29 years) and peaked the age groups 18–29 years (90.5%) was found between waterpipe smok- at the middle age group (40–49 and 30–39 years (91.4%). On the ing and sex, level of education, income years) (P = 0.024). In contrast, the other hand, income, level of education or marital status (P = 0.072, P = 0.254, prevalence of waterpipe smoking and marital status were not associated P = 0.514 and P = 0.065 respectively). was significantly higher at lower ages with cigarette smoking P( = 0.361, P Smoking cigars and pipes were the among both males and females (P = = 0.167 and P = 0.267 respectively). least common habits, with a rate of 0.014 and 0.004 respectively). There Approximately half of smokers con- 0.5% (n = 5) and 0.2% (n = 2) respec- was a significant difference in water- sumed 11–20 cigarettes a day and tively. Only 23 (2.4%) respondents pipe smoking by females according almost one-third consumed more indicated that they smoked both ciga- to marital status, whereby single than 20 cigarettes a day (Table 4). rettes and waterpipes daily. females were more likely to smoke

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Table 4 Number of cigarettes consumed daily by cigarette smokers (n = 960) Discussion No. of cigarettes No. % Cumulative % 1–10 165 17.2 17.2 This study offers 3 important find- 11–20 461 48.0 65.2 ings. First of all, the overall preva- 21–30 114 11.9 7 7. 1 lence of current smoking in Jordan 31–40 176 18.3 95.4 was 32.3% and this reached 54.9% 41–50 8 0.8 96.2 among males above 18 years old. 51–100 36 3.8 100.0 These figures are higher than previous reports from the country as will be discussed below. Second, a major concern was the degree of consump- this type of tobacco product than low number of females admitting to tion as almost 80% of the smokers married women or other categories smoking waterpipes. No significant consumed more than 10 cigarettes (P = 0.031), a trend that was not differences were noted in smoking a day. The third important finding is observed among males (P = 0.175). either cigarettes or waterpipes be- that the rate of waterpipe smoking However, we need to be cautious tween males and females according was the highest among the young in interpreting these data due to the to education or income. females and males.

Table 5 Types of tobacco consumed by the study group in relation to socioeconomic characteristics What kind of tobacco do you Cigarettes Waterpipes Cigars Pipes a smoke? No. % No. % No. % No. % Total 960 93.0 89 8.6 5 0.5 2 0.2 Sex Male 846 93.7 73 8.1 3 0.3 2 0.2 Female 113 88.3 16 12.5 2 0.6 0 0.0 χ2 = 5.0; P = 0.025 χ2 = 2.8; P =0.072 χ2 = 3.5; P = 0.120 χ2 = 0.28; P =0.767 Age (years) 18–29 267 90.5 39 13.2 0 0 0 0.0 30–39 307 91.4 33 9.8 2 0.6 0 0.0 40–49 242 96.4 14 5.6 1 0.4 0 0.0 50–59 79 95.2 3 3.6 1 1.2 1 1.2 60+ 65 95.6 1 1.5 1 1.5 1 1.5 χ2 = 9.9; P = 0.04 χ2 = 18.2; P = 0.001 χ2 = 3.8; P = 0.430 χ2 = 11.8; P = 0.02 Education Elementary or less 155 92.8 13 7. 8 0 0.0 1 0.6 Preparatory to high school 568 94.0 47 7. 8 3 0.5 1 0.2 Diploma and above 237 90.5 29 11.1 2 0.8 0 0.0 χ2 = 3.6; P = 0.17 χ2 = 2.7; P = 0.25 χ2 = 1.2; P = 0.53 χ2 = 2.0; P = 0.38 Monthly income (JD) b < 300 472 94.0 40 8.0 1 0.2 1 0.2 300–599 359 92.1 34 8.7 2 0.5 1 0.3 600+ 123 91.1 15 11.1 1 0.7 0 0.0 χ2 = 2.0; P = 0.361 χ2 = 1.3; P = 0.51 χ2 = 1.1; P = 0.592 χ2 = 0.34; P = 0.84 Marital status Single 213 91.8 27 11.6 0 0.0 0 0.0 Married 719 93.1 63 8.2 5 0.6 2 0.3 Other 28 100.0 0 0.0 0 0.0 0 0.0 χ2 = 2.6; P = 0.27 χ2 = 1.69; P = 0.43 χ2 = 0.68; P = 0.71 χ2 = 5.46; P = 0.07

a23 respondents indicated they smoked both cigarettes and waterpipes daily; b7 respondents refused to declare their income.

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Table 6 Types of tobacco consumed by males and females in relation to socioeconomic characteristics What king of tobacco do you Cigarettes Waterpipes a smoke? Males Females Males Females No. % No. % No. % No. % Age (years) 18–29 253 91.7 14 70.0 31 11.2 8 42.1 30–39 268 91.8 39 90.7 29 9.9 4 9.3 40–49 209 98.1 33 89.2 11 5.2 3 8.1 50–59 63 95.5 16 94.1 2 3.0 1 5.9 60+ 53 94.6 12 100.0 1 1.8 0 0.0 χ2 = 11.22; P = 0.024 χ2 = 8.95; P = 0.062 χ2 = 12.5; P =0.01 χ2 = 15.5; P = 0.004 Education Elementary or less 126 92.0 29 96.7 12 8.8 1 3.3 Preparatory to high school 517 95.0 51 85.0 39 7. 2 9 15.0 Diploma and above 203 91.4 34 87.2 23 10.3 7 17.9 χ2 = 4.25; P = 0.119 χ2 = 2.73; P =0.256 χ2 = 2.15; P =0.34 χ2 = 3.49; P = 0.175 Monthly income (JD) b < 300 418 94.8 54 90.0 34 7. 7 7 11.7 300–599 315 93.2 44 84.6 26 7. 7 8 15.4 600+ 109 90.8 15 93.8 13 10.8 1 6.7 χ2 = 2.68; P = 0.262 χ2 = 1.31; P = 0.520 χ2 = 1.37; P = 0.51 χ2 = 0.893; P = 0.640 Marital status Single 206 92.0 6 85.7 24 10.7 3 37.5 Married 630 94.2 89 86.4 49 7. 3 13 12.7 Other 10 100.0 17 100.0 0 0.0 0 0.0 χ2 = 2.06; P = 0.357 χ2 = 2.63; P = 0.268 χ2 = 3.49; P = 0.175 χ2 = 6.96; P = 0.031

a23 respondents indicated they smoked both cigarettes and waterpipes daily; b7 respondents refused to declare their income.

The prevalence of smoking for current smoking varied greatly between 24.1% at ages 25–44 years, both of which both sexes was higher than previously the sexes with the gap being highest at the were the highest rates across all age reported figures. For example, in Jordan youngest age group (14-fold) and lowest groups (13). The prevalence of smok- a survey 30 years ago reported that the at the age groups 40–49 years (4.6-fold) ing in our study varied significantly with rate of smoking was 29% (7). This is in and 60+ years (4-fold), in contrast to age, reaching a peak at age 40–49 years. contrast to data published in the United the aforementioned reports. The low However, a major concern is the finding States of America (USA), where smok- prevalence of smoking among Jordanian that both male and female youngsters ing rates among adults halved from 42% women probably reflects cultural norms were more likely to smoke waterpipes to 20.8% between 1965 and 2011, with that dissuade women from starting to compared with older age groups. Such 23.9% of men smoking compared with smoke. Therefore, awareness campaigns a trend has been consistently reported 18.1% of women (13). Rates of smoking and stricter policies should be considered in Jordan and neighbouring countries, are generally 5 times higher among men in Jordan to decrease the rate of smoking, where both cigarette and waterpipe than women as described in our study as as is the case in most developed coun- smoking was common among young well as in other reports from the region tries. In addition, the creation of primary college students (16–19). Cafes that (10). However, the gap between the prevention programmes that promote facilitate smoking of waterpipes are be- sexes declines with younger ages (14). In non-smoking among Jordanian women coming widespread especially in areas developed countries, smoking rates for might be useful in maintaining this low surrounding colleges and universities. men have peaked and have begun to de- prevalence in the future. These observations have recently led cline; on the other hand, the rate of smok- The prevalence of current smoking to the implementation of strict regula- ing among women continues to increase among adults in the USA was 24.4% tions by the Ministry of Health and the (15). In our study, the prevalence of among those aged 18–24 years and municipality of Amman.

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In this study, smoking habits also With regards to marital status, smoking Reducing the prevalence of smoking showed significant differences according prevalence among single and married in- can be approached through education, to educational status, with a trend towards dividuals was very similar (36.5% versus particularly among the youth. In ad- higher prevalence of smoking among 33.0% respectively), whether analysing dition, creation of smoking cessation those with intermediate educational level. males, females or both sexes. This is in con- programmes and primary prevention Our findings are not in line with the overall trast to a Swedish study showing a higher programmes that promote non- trend of declining prevalence of smoking prevalence of smoking among single than smoking can be useful. Official action with increasing education in the USA, in married people (23). through activating current laws and which smoking prevalence was found to It is important to note that, consist- regulations and imposing new ones is be high among adults who had earned a ent with other self-reporting interview of vital importance. general educational development diploma methods, individuals may be reluctant (43.2%) and those with 9–11 years of edu- to explicitly state their smoking practices cation (32.6%) (20). In the USA, Finland and may rather provide answers that are Acknowledgements and Australia smoking rates correlated socially acceptable. However, a significant inversely with educational level (20–22). strength of our study was the involvement Funding: This work was supported by Initially we did not find a significant of a representative sample of the Jordanian the Arab Fund for Economic and Social association between income status and population. Development (AFESD). The KAP sur- smoking prevalence in Jordan. However, vey was implemented by King Hussein we found that males with lower income Institute for Biotechnology and Cancer were more likely to smoke than those with Conclusion and (KHIBC) under the National Life higher incomes. This accords with has Recommendations Science Research and Biotechnology been reported in the USA and Finland, Promotion (LSR/BTP) Initiative in where a higher prevalence of smoking was Reducing the prevalence of smoking Jordan. associated with lower income (20,21). in Jordan must be set as a priority. Competing interests: None declared

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537 EMHJ • Vol. 20 No. 9 • 2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey M. Jaghbir,1 S. Shareif 1 and M. Ahram 2

اإلقالع عن التدخني واالستفادة من خدمات اإلقالع عن التدخني يف األردن: مسح سكاين مايض توفيق اجلغبري، سمر لطفي الرشيف، مأمون أمحد أهرام لقــد اخلالصــة:تــم توثيــق ارتفــاع معــدالت التدخــن يف األردن، ولــذا فإنــه مــن املهــم أن نفهــم االجتاهــات والعوامــل املرتبطــة بمحــاوالت اإلقــاع عــن التدخــن؛ مثــل االســتفادة مــن عيــادات اإلقــاع عــن التدخــن ومــناخلطــوط الســاخنة اخلاصــة بذلــك. وقــد َأجريــت مقابــات 32.3 1032 18 3196 مــع عينــة مؤلفــة مــن مــن الســكان البالغــن ممــن تزيــد أعامرهــم عــن ً عامــابشــأن عــادات التدخــن لدهيــم؛ فــكان ) %( 8.7 2.9 منهــم مدخنــن حاليــن، و93 ) %( قــد أقلعــوا عــن التدخــن بنجــاح ) % مــن املدخنــن يف وقــت مــا ًســابقا(. وإن نســبة مئويــة كبــرية 62.8 مــن املدخنــن احلاليــن ) ( %كانــوا قــد حاولــوا اإلقــاع عــن التدخــن ومل ينجحــوا. وكان نصفهــم ً تقريبــاقــد ســمعوا بعيــادات اإلقــاع 2.4 عــن التدخــن واخلطــوط الســاخنة اخلاصــة بذلــك، لكــن % منهــم فقــط اســتفادوا منهــا يف وقــت مــا ًســابقا. وبعــد أن تــم إطلعهــم عــى 19.9 53 هــذه اخلدمــات َّأقــر %مــن املدخنــن احلاليــن بأهنــا كانــت مــن املحتمــل أن تفيدهــم. وكان % فقــط مــن املدخنــن احلاليــن قــد تلقــوا يف وقــت مــا ًســابقا نصيحــة مــن ممــارس يف جمــال الرعايــة الصحيــة تتعلــق باالتصــال هبــذه اخلدمــات. فينبغــي هلــذه الدراســة أن توجــه صنــاع القــرار إىل وضــع اســراتيجيات ترمــي إىل احلــد مــن معــدالت التدخــن املرتفعــة يف األردن.

ABSTRACT Increasing rates of smoking in Jordan have been documented. It is therefore important to understand the trends and factors associated with attempts to quit smoking, such as the utilization of smoking cessation clinics and hotlines. A population sample of 3196 adults aged 18+ years were interviewed about their smoking habits; 1032 (32.3%) were current smokers and 93 (2.9%) had successfully quit smoking (8.7% of ever-smokers). A high percentage of current smokers (62.8%) had tried, unsuccessfully, to quit smoking. Almost half of them had heard of smoking cessation clinics and hotlines, but only 2.4% had ever utilized them. After being informed about these services, 53.0% of current smokers agreed that they were likely to utilize them. Only 19.9% of current smokers had ever received advice from a health-care practitioner about contacting these services. The study should guide decision-makers on strategies to reduce the high smoking rates in Jordan.

Arrêt de la consommation du tabac et recours aux services de sevrage tabagique en Jordanie : enquête en population

RÉSUMÉ L'augmentation des taux de tabagisme en Jordanie est avérée. Il est par conséquent important de comprendre les tendances et les facteurs associés aux tentatives d'arrêt de la consommation de tabac, tels que le recours à des cliniques de sevrage tabagique et aux services d’écoute téléphonique. Un échantillon de population de 3196 adultes âgés de 18 ans et plus a été interrogé sur les habitudes de consommation de tabac ; 1032 (32,3 %) étaient des consommateurs actifs et 93 (2,9 %) avaient réussi à arrêter de fumer (8,7 % d'adultes ayant déjà fumé). Un fort pourcentage de fumeurs actifs (62,8 %) avait essayé, sans succès, d'arrêter. Près de la moitié d'entre eux avait entendu parler des cliniques de sevrage tabagique et des services d'écoute téléphonique, mais seuls 2,4 % les avaient déjà utilisés. Après avoir été informés à propos de ces services, 53,0 % des fumeurs actifs convenaient qu'il était probable qu'ils les utilisent. Seuls 19,9 % des fumeurs actifs avaient déjà reçu des conseils d'un professionnel de santé les incitant à contacter ces services. La présente étude devrait orienter les décisionnaires sur les stratégies visant à réduire les taux élevés de consommation de tabac en Jordanie.

1Department of Family and Community Medicine; 2Department of Physiology and Biochemistry, Faculty of Medicine, University of Jordan, Amman, Jordan (Correspondence to M. Jaghbir: [email protected]; [email protected]). Received: 16/01/14; accepted: 14/04/14

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Introduction would inform efforts to promote smok- Instrument ing cessation in Jordan. A structured questionnaire was de- Numerous studies have reported a sub- signed by a national advisory committee stantial health benefit of quitting smok- that consisted of research experts from ing. For example, similar mortality rates Methods different research, clinical and academic have been documented between those Study design institutions in Jordan. The design of who quit cigarette smoking and those the survey was based on international who have never smoked (1,2). The This was a quantitative, cross- references/tools that were used as a benefits of quitting reach beyond -im sectional, descriptive survey. Data guide to the development of the ques- provements in individuals’ own health collection spanned 2 months from tionnaire and to ensure appropriate and quality of life; Parrott and Godfrey 24 January to 19 March 2011. The themes and adaptation to the local have shown that there are major reduc- survey consisted of 10 sections start- context. Face-to-face interviews were tions in the cost of health care, with ing with a section about demographic conducted in interviewees’ households consequent savings for the national characteristics. One section enquired and took an average of 30 minutes to gross domestic product of countries about the lifestyle of participants in- complete. Verbal informed consent was (3). As a result, a growing number of cluding smoking habits and quitting obtained; agreement to host interviews countries have campaigned to reduce patterns among smokers as well as in the participants’ house is a culturally the number of smokers and are report- their knowledge, attitude and practice appropriate method to obtain consent ing higher proportions of ex-smokers towards smoking cessation clinics and in Jordan. than smokers (4). The United States hotlines, which was the focus of this A pilot study was conducted to test of America (USA), as an example, has study. the survey tool, sampling technique, successfully reduced the prevalence Participants survey methods and interviewers’ level of cigarette smoking among adults of work. The pilot study spanned a day from 42.4% to 19.3% between 1965 The KAP survey sample was based and was carried out in one area in the and 2010, in part due to an increase on the 2004 Jordan Population and capital city, Amman. The pilot sample in the number of those who have quit Housing Census as the sampling consisted of 56 randomly selected sub- smoking (5). frame. The sampling frame was strati- jects. Following the pilot, a 2-day review Both older and more recent sur- fied by governorate, major cities (each session was conducted and resulted veys have indicated a high prevalence city with a population of more than in implementation of minor modifica- of smoking among Jordanians, in 100 000 was considered a stratum, i.e. tions. particular among males, who have a 6 cities) and other urban and other smoking rate as high as 55% (6–8). rural areas. A 3-stage sampling pro- Measures This correlates well with the rate of lung cedure was employed. First, blocks Respondents were first asked if they cancer in Jordan, which ranks second were selected systematically as pri- considered themselves as non-smokers, among all cancers in males (9). In the mary sampling units (PSUs) with a current smokers or ex-smokers. Those current study, we utilized data from a probability proportional to the size who described themselves as smok- national survey of knowledge, attitudes of the PSU. In the second stage, a ers were then asked whether they had and practices (KAP) towards cancer fixed number of 15 households were tried to quit smoking or not, whether prevention and care in Jordan based selected as final sampling units in they had heard about smoking cessa- on a sample representing the Jordanian each PSU, resulting in a sample size of tion clinics and whether they had ever population. Our analyses attempted about 4500 households. In the third utilized them. After the smokers had to offer a deeper understanding of at- stage, random selection of individual been informed about the availability tempts to quit smoking by Jordanians, interviewees from each household was of smoking cessation clinics they were their knowledge of cessation clinics and carried out using Kish tables (10). The asked about the possibility of their con- hotlines and their previous and poten- final sample size in the KAP survey was sulting one in the future. The latter were tial utilization of these services. The role 3196 participants (a response rate of measured on a 4-point Likert scale, with of health-care providers is critical for 93%): 1647 males and 1549 females. scores ranging from very likely to very advising patients and persuading smok- The demographic distribution of the unlikely. Then they were asked whether ers to quit. We therefore investigated whole interviewed sample are shown any physician or health-care provider whether smokers had ever been advised in our earlier paper (8). The number of had ever suggested these services to by a health-care provider to quit smok- current smokers on which this report them in the previous 12 months to help ing. It was hoped that the data generated is based was 1032. them to quit smoking.

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Data collection Table 1. Current smokers were mainly educational status (P = 0.003) (Table Data collection was carried out in the males (87.6%) and the majority were 2). 3 regions of Jordan (North, Middle young and middle-aged adults (28.6%, 32.6% and 24.2% respectively). Indi- Potential utilization of and South). The face-to-face interviews smoking cessation clinics and were conducted by 18 trained teams. viduals with intermediate education hotlines Each team consisted of 3 data collec- (58.5%) constituted the majority of cur- Current smokers were asked about their tors, 1 controller, 1 field supervisor and rent smokers compared with those with knowledge of smoking cessation clinics 1 driver. The controllers and supervisors lower (16.2%) and higher (25.4%) edu- or hotlines before this survey. Approxi- conducted spot checks by randomly cational levels. Current smokers were mately half of them (50.6%) had never visiting some sampled households. also mainly within the low (48.5%) and heard of such services. Males (50.6%) In order to facilitate data collection, intermediate (37.8%) income groups had significantly better knowledge of each interviewing team was assigned rather than the higher income group smoking cessation clinics or hotlines a number of blocks in the sample area. (13.1%). than did females (41.4%) (P = 0.044) Interviewers made repeated attempts Attempts to quit smoking (Table 3). As for age, although there to obtain the responses of eligible respondents by calling back to interview Self-reported current smokers were was no significant difference among respondents who were not home at asked if they had ever attempted to quit the age groups (P = 0.065), a significant the time of the first visit or by attempt- smoking. A considerable proportion of trend towards increasing knowledge ing to persuade respondents who were them (62.8%) had attempted to quit with increasing age (r = 0.09; P = 0.006) reluctant to be interviewed. but had failed to do so. This compares was found. In addition, there was a sig- with 384 individuals (37.2%) who had nificant association of knowledge with Data processing and analysis never tried to quit. There were no sig- better levels of education P( < 0.001) Data entry using Oracle software started nificant associations between attempt- and income (P < 0.001). Only 25 cur- 1 week after the initiation of data collec- ing to quit smoking and sex, age or rent smokers (2.4%) had ever called tion. After editing and cleaning, the data income. However, a significantly higher a smoking cessation clinic or hotline, were exported to SPSS, version 17.0. proportion of those with intermediate with no significant associations by sex, SPSS was used to run univariate and bi- educational level had never tried to quit education, age or income (Table 3). variate analyses to describe all the survey smoking (41.6%) in contrast to those Interestingly, a significant association variables. As most of the variables in the with lower (31.7%) and higher (30.9%) was found between attempting to quit study were measured on a nominal and/ or ordinal level, descriptive statistics Table 1 Participants’ demographic characteristics ( 1032) were used to describe the basic features n = of the data. Responses to questions were Characteristic No. % analysed using the chi-squared and/or Sex Pearson correlation coefficients when Male 904 87.6 comparing sociodemographic groups Female 128 12.4 or ranked data respectively. Age (years) 18–29 295 28.6 30–39 336 32.6 Results 40–49 250 24.2 50–59 83 8.0 Of the 3196 participants interviewed 60+ 68 6.6 about their smoking habits in the main Education KAP survey 2071 (64.8%) reported that Elementary or less 167 16.2 they had never smoked, 1032 (32.3%) were current smokers and only 93 (2.9%) Preparatory to high school 604 58.5 were ex-smokers. The ex-smokers there- Diploma and above 262 25.4 a fore represented 8.7% of ever-smokers. Monthly income (JD) < 300 501 48.5 Demographic characteristics 300–599 390 37.8 The demographic characteristics of the 600+ 135 13.1 1032 current smokers are shown on a6 respondents refused to declare their income.

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Table 2 Attempts to quit smoking in relation to socioeconomic characteristics among current smokers Variable Ever tried to quit smoking No Yes, but failed No. % No. % Total 384 37.2 648 62.8 Sex Male 329 36.4 575 63.6 Female 55 43.0 73 57.0 χ2 = 2.08; P = 0.090 Age (years) 18–29 110 37.2 186 62.8 30–39 108 32.1 228 67.9 40–49 106 42.4 144 57.6 50–59 35 42.2 48 57.8 60+ 25 36.8 43 63.2 χ2 = 7.46; P = 0.114 (r = –0.04; P = 0.265) Education Elementary or less 53 31.7 114 68.3 Preparatory to high school 251 41.6 352 58.4 Diploma and above 81 30.9 181 69.1 χ2 = 11.46; P = 0.003 (r = 0.02; P = 0.455) Monthly income (JD) a < 300 177 35.3 324 64.7 300–599 147 37.3 243 62.3 600+ 58 43.0 77 57.0 χ2 = 2.71; P = 0.258 (r = –0.05; P = 0.112)

a6 respondents refused to declare their income.

smoking and knowledge of smoking seek help from a cessation clinic (P < A correlation was found between cessation clinics or hotlines (χ2 = 7.035; 0.001) (Table 4). A significant trend attempting to quit smoking and the P = 0.005), but not the actual practice was also observed between decreas- likelihood of calling a smoking cessation of utilizing them (χ2 = 3.268; P = 0.051) ing age and the likelihood of calling a clinic or hotline (r = –0.207; P < 0.001) (detailed data not shown). In addition, cessation clinic (r = 0.13; P < 0.001). (Table 4). the practice of calling a smoking cessa- Significant differences across the 3 tion clinic or hotline did not show any income groups were noted, whereby Role of health-care providers trend with age (r = 0.001; P = 0.980), the likelihood of calling a smoking We asked current smokers whether education (r = 0.03; P = 0.392) or in- cessation clinic was lowest at the high- they had ever been advised by a health- come (r = –0.007; P = 0.815). est income (43.0%) in comparison care provider to quit smoking by calling After informing them about the with 52.8% and 56.4% for the low- and a cessation clinic or hotline. Only 19.9% existence of smoking cessation clinics middle-income levels, respectively (P of current smokers had ever received and hotlines, we assessed the intention < 0.001). Despite the lack of a signifi- any advice to quit smoking (Table of smokers to utilize these services in cant trend between increasing educa- 5). There were significant disparities the future; 53.0% of current smokers tion and the likelihood to call these in receiving advice from health-care agreed that they were likely or very services (P = 0.076), individuals with providers among individuals accord- likely to do so. There was no significant the highest educational level (43.1%) ing to income, educational level and difference by sex in intention to use were significantly less likely to utilize age. More specifically, individuals in the services (P = 0.499). However, young- such services than those in the low higher income and education catego- er individuals were more likely than (53.9%) and intermediate (56.9%) ries were more likely to be advised by older smokers to agree that they would educational levels (P = 0.011). their physicians to quit smoking than

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Table 3 Knowledge and utilization of smoking cessation clinics and hotlines among current smokers in relation to sociodemographic characteristics Variable Ever heard of a smoking cessation clinic or Ever called a smoking cessation clinic or hotline hotline No Yes No Yes No. % No. % No. % No. % Total 522 50.6 510 49.4 1007 97.6 25 2.4 Sex Male 447 49.4 457 50.6 883 97.7 21 2.3 Female 75 58.6 53 41.4 125 96.9 4 3.1 χ2 = 4.048; P = 0.044 χ2 = 0.289; P = 0.382 Age (years) 18–29 168 56.9 127 43.1 291 98.3 5 1.7 30–39 169 50.3 167 49.7 326 97.0 10 3.0 40–49 117 46.8 133 53.2 243 96.8 8 3.2 50–59 40 48.2 43 51.8 82 98.8 1 1.2 60+ 28 41.2 40 58.8 67 98.5 1 1.5 χ2 = 8.84; P = 0.065 (r = 0.09; P = 0.006) χ2 = 2.52; P = 0.642 (r = 0.001; P = 0.980) Education Elementary or less 96 57.5 71 42.5 164 98.2 3 1.8 Preparatory to high school 323 53.6 280 46.4 589 97.7 14 2.3 Diploma and above 103 39.3 159 60.7 254 96.9 8 3.1 χ2 = 18.76; P < 0.001 (r = 0.13; P < 0.001) χ2 = 0.75; P = 0.688 (r = 0.03; P = 0.392) Monthly income (JD) a < 300 280 55.9 221 44.1 490 97.8 11 2.2 300–599 183 46.9 207 53.1 380 9 7. 4 10 2.6 600+ 56 41.5 79 58.5 133 95.5 2 1.5 χ2 = 12.40; P = 0.002 (r = 0.11; P < 0.001) χ2 = 0.55; P = 0.761 (r = –0.007; P = 0.815)

a6 respondents refused to declare their income.

were individuals with lower income and in advising smokers to utilize smoking Health concerns were reported to be educational level (P = 0.003 and P < cessation clinics or hotlines was not a common motivational factor to quit 0.001 respectively). As for age, younger only minimal but was also biased to- smoking in different studies including individuals were less likely to receive ad- wards certain subsets of the population. those in Saudi Arabia and Lebanon vice from their physicians (P < 0.001). The quit rate in the Jordanian (13–15). Another study illustrated population on which this study was the importance of setting a model for children as the primary reason for quit- Discussion based (2.9% of the total sample were ex-smokers) was close to the estimated ting smoking, rather than the cost or We found a high number of current figures in Britain of 1–2% in the last 40 family pressure (13). It would therefore smokers in our survey who had at- years and 2–3% in 2005 (11), but lower be interesting to investigate further the tempted to quit smoking but had failed. those in the USA, which had a success reasons for attempts to quit smoking Although knowledge of smoking cessa- rate of 6.2% in 2009 (12). However, or the lack of such attempts. Initially, it tion clinics and hotlines existed among more of the current smokers (62.8%) seems that cost was unlikely to be a mo- half of respondents, it did not translate interviewed in Jordan had attempted tivational factor to quit smoking among into action, as less than 3% had ever to quit smoking than those in the USA, Jordanians, as income level was not as- utilized them. However, the potential where 52.4% of smokers had made a sociated with attempting to quit smok- use of these services was indicated by quit attempt in 2009 (12). Overall, nu- ing. However, this observation could around half of respondents. Further- merous different factors are likely to be due to the low price of cigarettes more, the role of health-care providers play important roles in quitting tobacco. not only in Jordan but also in other

542 املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

Table 4 Likelihood of calling smoking cessation clinics and hotlines among current smokers in relation to sociodemographic characteristics Variable Likelihood of calling a smoking cessation clinic or hotline Very likely Likely Unlikely Very unlikely No. % No. % No. % No. % Total 132 12.8 415 40.2 249 24.1 236 22.9 Sex Male 113 12.5 370 40.9 219 24.3 202 22.4 Female 19 15.0 45 35.4 30 22.8 34 26.8 χ2 = 2.37; P = 0.499 Age (years) 18–29 47 15.9 119 40.3 81 27.5 48 16.3 30–39 53 15.8 140 41.7 62 18.5 81 24.1 40–49 26 10.4 93 37.2 67 26.8 64 25.6 50–59 2 2.4 38 45.8 18 21.7 25 30.1 60+ 4 5.9 25 36.8 21 30.9 18 26.5 χ2 = 34.40; P < 0.001 (r = 0.13; P < 0.001) Education Elementary or less 17 10.2 73 43.7 36 21.6 41 24.6 Preparatory to high school 83 13.5 261 42.6 137 22.3 132 21.5 Diploma and above 32 12.2 81 30.9 76 29.0 73 27.9 χ2 = 16.64; P = 0.011 (r = 0.06; P = 0.076) Monthly income (JD) a < 300 56 11.2 208 41.5 140 27.9 97 19.4 300–599 71 18.2 149 38.2 74 19.0 96 24.6 600+ 5 3.7 53 39.3 35 25.9 42 31.1 χ2 = 33.94; P < 0.001 (r = 0.07; P = 0.038) Ever tried to quit smoking No 31 23.3 117 28.3 122 49.2 115 48.5 Yes, but failed 102 76.7 297 71.7 126 50.8 122 51.5 χ2 = 53.36; P < 0.001 (r = –0.21; P < 0.001) a6 respondents refused to declare their income.

countries in the Eastern Mediterranean attempting to quit smoking was associ- importance of such services is illustrated Region (16). We agree with the sug- ated with a higher level of education by a study conducted among Jorda- gestions of Abdullah and Husten that (12). We also found no significant dif- nian university students, who reported increasing the cost of cigarette smoking ference according to sex. This is con- that lack of knowledge on how to quit in developing countries by increasing trary to what has been shown earlier that was a reason for not quitting smoking taxes would have an impact on reducing females are less likely to quit smoking (19). Two studies, one from the USA smoking and increasing the readiness to than males due to higher behavioural and another from Hong Kong, found quit (17). It is worth mentioning that an dependence (18). positive results from smoking cessation important barrier to utilizing smoking Importantly, we found strong corre- support (20,21). Similarly, a multina- cessation intervention is the higher cost lations of between attempts to quit and tional cohort study found that lack of of tobacco quitting services compared knowledge about smoking cessation assistance to quit was predictive of re- with the price of cigarettes (16). The clinics/hotlines and the probability of lapses (22). The success rate of smoking role of education seems perplexing, as seeking help. . In addition, the likelihood cessation clinics has been variable (23). those with intermediate education in of utilizing these services was higher It is likely that the modest success of our study were less likely to attempt to among those who had made unsuc- these clinics is due to their low recogni- quit smoking. In a study in the USA, cessful attempts to quit smoking. The tion by the public. This is exactly the

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Table 5 Role of health-care providers in advising smokers to use smoking cessation clinics or hotline services in relation to sociodemographic characteristics Variable Referred to cessation clinic or hotline by health-care provider No Yes Have not visited health-care provider recently No. % No. % No. % Total 680 65.9 205 19.9 147 14.2 Sex Male 600 66.4 176 19.5 128 14.2 Female 80 62.5 29 22.7 19 14.8 χ2 = 0.865; P = 0.649 Age (years) 18–29 207 69.6 45 15.2 44 14.9 30–39 229 68.2 61 18.2 46 13.7 40–49 150 59.8 60 23.9 41 16.3 50–59 56 67.5 19 22.9 8 9.6 60+ 39 5 7. 4 21 30.9 8 11.8 χ2 = 15.97; P = 0.043 Education Elementary or less 111 66.9 19 11.4 36 21.7 Preparatory to high school 388 64.2 124 20.5 92 15.2 Diploma and above 181 69.3 61 23.4 19 7. 3 χ2 = 24.19; P < 0.001 Monthly income (JD) a < 300 339 6 7. 4 84 16.7 80 15.9 300–599 262 67.2 77 19.7 51 13.1 600+ 78 5 7. 4 43 31.6 15 11.0 χ2 = 16.13; P = 0.003 a6 respondents refused to declare their income.

trend we found, whereby more than revealed that the role of physicians is clinic or hotline. It is also unfortunate half of our survey respondents had not vital when it comes to smoking cessa- that younger individuals were less likely heard about these facilities and only tion (26,27). According to a Centers to be targeted for advice by health-care 2.4% of smokers had ever utilized them. for Disease Control report, over 50% providers as this group were more A reason for lack of knowledge could of smokers received advice from their likely to report that they would seek be the existence of only 2 such clinics health-care provider to quit smoking assistance from smoking cessation clin- in the capital, Amman, one of which is (28). In a sample of mostly long-term ics or hotlines. In a recently published government-run and lacks sufficient cancer survivors drawn from the 2000 study, 46.7% of Jordanian physicians funding. One solution is to strengthen, National Health Interview Survey, were current smokers (31) and, based integrate and/or increase public knowl- 42.3% of individuals who visited a on a previous study, a high percentage edge of these services. Other solutions health-care provider in the previous (81%) of them smoked in front of their include the integration of counselling year reported being asked about their patients (32). Shishani et al. found that into clinical practice including follow- smoking status (29). In addition, two- Jordanian physicians and nurses lacked up and medications, as suggested previ- thirds of individuals smoking at the time knowledge about the addictive effects ously (17,24). In addition, the provision of diagnosis reported being advised of smoking (33). Collectively, these of multiple forms of smoking cessation to quit smoking by a health-care pro- data suggest a limited involvement of assistance is needed (25). vider (30). Unfortunately, in our study, physicians in advising patients to quit Previous studies have highlighted only one-fifth of smokers who had smoking in Jordan. It is interesting to the role of health-care providers in at- visited any health-care providers had note that Jordanian (33) and Egyptian tempts to quit smoking. Recent studies been advised to call a smoking cessation (34) health-care providers requested

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education and training to increase their Conclusion and was not associated with desire to quit knowledge and counselling capabilities Recommendations smoking, which suggests that an in- in smoking cessation. Previous studies crease in the price of tobacco products conducted in Saudi Arabia and Jordan There was a large difference in our is warranted. found that health education is an ef- study between the proportion of fective means of smoking cessation current smokers who wished to quit (15,19). This enforces the need to smoking and those who had suc- Acknowledgements establish educational programmes to cessfully quit. It is also important to Funding: promote smoking cessation efforts. highlight the missed opportunities for This work was supported by It is important to note that, con- health-care providers to advise smok- the Arab Fund for Economic and Social sistent with other self-report interview ers to quit. Concerted efforts need to Development (AFESD). The KAP sur- methods, individuals may be reluctant be initiated among the various social vey was implemented by King Hussein to state their views objectively and may and health groups in Jordan, along Institute for Biotechnology and Cancer provide biased answers that are socially with government policies to increase (KHIBC) under The National Life acceptable. However, a major strength knowledge about smoking cessation Science Research and Biotechnology of our study was the involvement of a services among the public and health- Promotion (LSR/BTP) Initiative in representative sample of the Jordanian care providers and to support smok- Jordan. population. ing cessation programmes. Income Competing interests: None declared.

References

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Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran B. Foroutan 1 and R. Foroutan 2

التخزين املنزيل لألدوية وممارسات التطبيب الذايت يف جنوب رشق مجهورية إيران اإلسالمية هبزاد فوروتان، رضا فوروتان اخلالصــة:إن التطبيــب الــذايت والتخزيــن غــر املالئــم لألدويــة يف املنــزل يشــكالن خماطــر صحيــة حمتملــة. وقــد هدفــت دراســة أجريــت يف جنــوب رشق مجهوريــة إيــران اإلســالميةإىل حتديــد األماكــن التــي حتفــظ هبــا األرس أدويتهــا، وإىل تقييــم وتــرة التطبيــب الــذايت ِّوحمدداتــه. ففــي مســح مســتعرض أجــري عــام 2010 متــت زيــارة أرس مــن مناطــق خمتلفــة مــن مدينــة بيجنــد )العــدد = 500( وتــم مــلء اســتبيان شــبه منظــم. فكانــت املســكنات أكثــر األدويــة التــي ختــزن يف املنــزل ًشــيوعا، تلتهــا أدويــة عــالج نــزالت الــرد لــدى البالغــن واملضــادات احليويــة. وكانــت الثالجــة 50.6 املــكان األكثــر ًشــيوعا لتخزيــن األدويــة ) %(. َّوتبــنأن معظــم األرس مل تطلــع عــى النــرات املدرجــة يف العبــوات. وذكــرت أرس كثــرة 53.6 ) %( أهنــا متــارس التطبيــب الــذايت، وكانــت وتــرة إعــادة اســتخدام املضــادات احليويــة املوصوفــة مــن قبــل األطبــاء عاليــة. وكان هنــاك ُترابــط كبــر بــن التطبيــب الــذايت واملســتوى التعليمــي. مل يكــن هنــاك ترابــط مــع الســنواجلنــس واملهنــة ونــوع التأمــن وكذلــك الوضــع العائــي. وخلصــت الدراســة إىل أن هنــاك حاجــة إىل حتســن معرفــة اجلمهــور ومعلوماهتــم بشــأن ختزيــن األدويــة وخماطــر إعــادة اســتخدام أدويــة الوصفــات الطبيــة.

ABSTRACT Self-medication and inappropriate storage of medicines at home are potential health risks. This cross- sectional study in south-east Islamic Republic of Iran in 2010 aimed to determine where householders kept their medicines and to assess the frequency and determinants of self-medication. Householders from different parts of Birjand city (n = 500) were visited and completed a semi-structured questionnaire. Analgesics were the most common medicines stored at home, followed by adult cold remedies and antibiotics. The refrigerator was the most common place for storing medicines (50.6%). Most householders did not consult the package inserts. Many householders (53.6%) reported that they practised self-medication, and the frequency of reuse of physician- prescribed antibiotics was high. There was a significant association between self-medication and educational level but not with age, sex, martial status, occupation and type of insurance. Better public knowledge and information about storage and risks of reuse of prescription medications is needed.

Conservation de médicaments à domicile et pratiques d'automédication dans le sud-est de la République islamique d'Iran

RÉSUMÉ L'automédication et la conservation inappropriée de médicaments à domicile représentent des risques potentiels pour la santé. La présente enquête transversale réalisée en 2010 dans le sud-est de la République islamique d'Iran visait à déterminer où les ménages conservaient leurs médicaments et à évaluer la fréquence de l'automédication et ses déterminants. Des ménages dans différents quartiers de la ville de Birjand (n = 500) ont fait l'objet d'une visite et ont rempli un questionnaire semi-structuré. Les analgésiques étaient les médicaments les plus couramment conservés à domicile, suivis par les médicaments contre le rhume chez l'adulte et les antibiotiques. Le réfrigérateur était l'endroit le plus fréquent pour la conservation des médicaments (50,6 %). La plupart des ménages ne consultaient pas les notices des médicaments. De nombreux ménages (53,6 %) ont affirmé qu'ils pratiquaient l'automédication, et la fréquence de réutilisation des antibiotiques prescrits par un médecin était élevée. Il existait une forte association entre l'automédication et le niveau d'études, contrairement à l'âge, au sexe, à la situation matrimoniale, au métier et au type d'assurance. La population a besoin d'accroître ses connaissances et son niveau d'information sur la conservation des médicaments et sur les risques liés à la réutilisation des médicaments prescrits.

1Department of Pharmacology, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Islamic Republic of Iran (Correspondence to B. Foroutan: [email protected]). 2School of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. Received: 10/06/13; accepted: 16/04/14

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Introduction economically deprived communities, families would not be recorded. Each most episodes of illnesses are treated by household was given a code and con- Self-medication is a global concern, in self-medication (19), which provides sidered as a unit. When a householder both developed and developing coun- a low-cost alternative for people who was not willing to participate the next tries (1–9) including those of the Mid- cannot afford the high cost of clinical household in the sampling frame was dle East (10–12). It has been estimated services and also as many medicines taken until the sample size was reached that about 60–80% of health problems in developing countries are dispensed (n = 500). are treated by self-medication (13). This over-the-counter. Data collection is a practice in which individuals utilize The present study in a city in the any types and dosages of medication south-east of the Islamic Republic of The survey was conducted by 2 students for treating themselves, without profes- Iran aimed to find out where medicines who were trained by the researcher by sional supervision, to control an illness were kept at home, to investigate the conducting several household visits in or an abnormal condition (14,15). frequency and determinants of self- the presence of the researcher before Based on the official figures, annual medication among family members the actual start of the study. sales of non-prescription products in and to explore whether or not the Householders completed a pre- the United States of America exceed medication package inserts were used. tested, researcher-designed question- US$ 31 billion, although these sales The study would inform strategies such naire which collected data about their represent less than 20% of total spend- as educational programmes aiming demographic characteristics (age, sex, ing on prescription pharmaceuticals to promote public knowledge about marital status, education, occupation (16). Concerns about self-medication medicines. These strategies would help and insurance coverage/organization) include sharing prescription medicines householders to pay more attention to and asked about use of medicines at with other members of the family, using storing medicines at home and raise home. They were asked: whether they leftovers from previous prescriptions awareness of self-medication practices. kept medicines in the house; whether or disrespecting the medical prescrip- they read the package inserts; where tion by prolonging or interrupting the they kept the medicines (refrigerator, dosage and the administration period Methods kitchen cabinet, bedroom, bathroom, prescribed (1). elsewhere); whether they stored pre- Sampling Inappropriate storage and use of scription medicines for re-use; what medicines at home could have a direct The study was conducted in March kinds of medicines were reused (pain, influence on public health, the environ- 2010 in the city of Birjand, south-east fever, antibiotics, cold cures, herbal med- ment and the health-care services and of Islamic Republic of Iran. A sample icines); whether they returned unused it increases the risk of self-medication of 500 householders were recruited by medicine to the pharmacy; whether (17). Previous studies have identified stratifying the local regions of the city they knew about self-medication; what a link between medicine storage and (north, south, east, west and central) formulations of medicines they kept self-medication practices (18). This in- into different sections to cover fami- (tablets, drops, syrup capsules injec- cludes medications stored intentionally lies of different socioeconomic status. tions suppositories, creams/ointment); while they remain in use or medications Householders from each section were how many times in the past 3 months that are incompletely used. Storing selected through a systematic, random they self-medicated without consulting medicines at home might increase the sampling technique to cover all parts of the doctor (once, twice, three times, risk of self-medication, and some au- the city. Local authorities were contact- more than three times); and whether thors have reported a high frequency of ed to obtain formal permission to con- they paid attention to the expiry date exchange of self-medication between duct the study and householders were of the medicines. The questionnaire family members (11). Self-medication informed in advance about the study contained both open-ended questions is influenced by many factors, such to ensure their agreement to participate and questions with a list of possible an- as local legislation and accessibility of in the study. Selected households were swers. We defined leftover medicines as medicines; advertisements by pharma- visited and the data collection super- medications prescribed by the doctor ceutical companies; individuals’ level of visors explained the objectives of the over the previous 3 months and kept education, number of family members study. Heads of households were asked by the householder. Medicine names, and income; and local societal and cul- to consent for their home to be included strength, dosage form, expiry date and tural norms. One of the main reasons in the study and for them to participate quantity were recorded. We did not for self-medication is often the finan- in filling the questionnaires. They were record householders’ income because cial burden of consulting a doctor. In told that their names and those of their most of participants were employed

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within a similar range of annual in- Overall, 268 (53.6%) householders prescribed by the doctor, one-third come and there were few unemployed reported that they practised self-med- reported that they reused them. Of householders. Educational status was ication for self-diagnosed disorders those who reused antibiotics, 70.7% analysed in 2 categories: no formal or symptoms. Table 2 also shows the reported that they did not know this education or primary school only; and most commonly reported therapeutic type of use was self-medication. The secondary school or higher. categories used for self-medication. results also showed that tablets were Analgesics (e.g. non-steroidal anti- the most commonly used formulation Data analysis inflammatories, paracetamol and its for self-medication (35.6%), followed The data were reviewed, organized, related compounds or combinations by capsules (24.4%); syrup (21.4%), tabulated and analysed using Microsoft such as paracetamol plus codeine) ointments (10.8%); ampoules (4.0%) Excel, 2010 version. Descriptive analysis were the main therapeutic group, used and suppositories (3.8%). was conducted by calculating means by 59.6% of respondents for self-medi- Table 3 shows self-medication and standard deviation (SD) and pro- cation. The number of times within the practices by age, sex, occupation portions for continuous and discrete last 3 months that householders had and insurance coverage/organiza- data respectively. The chi-squared and self-medicated themselves and their tion name. There was a significant t-tests were used to analyse statistical families with analgesics were as fol- association between self-medication significance. The cut-off for statistical lows: 1 time (19.4%); 2 times (22.4%); practices and educational level (P = significance wasP < 0.05. 3 times (16.8%) and ≥ 3 times (41.4%). 0.007). Respondents with secondary/ Adult cold remedies were used for self- higher education were less likely to medication by 11.6% of respondents, use self-medication than those who Results antibiotics (left-overs from doctors’ had none/primary education only. prescriptions) by 9.8%, herbal rem- There was no significant association A total of 500 householders completed edies by 9.2% and corticosteroids between self-medication and age, sex, the questionnaires: 231 (46.2%) fe- by 7.0% (Table 2). In answer to the marital status, occupation or type of males and 269 (53.8%) males. Table question related to reuse of antibiotics insurance. 1 shows their demographic characteristics. Of the householders, 62.8% had completed secondary school or higher Table 1 Demographic characteristics of participants (n = 500) levels and 37.2% had no schooling or Variable No. % only primary school level. Most of the Sex participants (73.6%) were married and Female 231 46.2 living with their families, while 26.4% Male 269 53.8 were single. One-third (34.4%) of Mean (SD) age (years) 29.4 (1.32) householders had no insurance cover- Marital status age/organization to support and cover Married 368 73.6 medication costs and 5.0% of partici- Single 132 26.4 pants were unemployed. Occupation All the households reported that Government employee 260 52.0 they kept medicines at home. Table NGO employee 101 20.2 2 shows the places where medicines Housewife 60 12.0 were kept at home. The most common Retired 54 10.8 place was the refrigerator (50.6%) or a Unemployed 25 5.0 kitchen cupboard (42.6%); the remainder kept medicines in the bedroom. Insurance cover/organization None of the households kept medi- Social security insurance 196 39.2 cines in the bathroom. Only 6.8% of the Iran health insurance 122 24.4 householders said that they had read Other health insurance 10 2.0 the instructions in the manufacturers’ No insurance 172 34.4 patient information leaflets (package Education inserts) and 93.2% did not (some par- Secondary school/higher 314 62.8 ticipants admitted that they threw away None/primary school only 186 37.2 the leaflets). NGO = nongovernmental organization.

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Table 2 Storage of medicines at home and self-medication practices of earlier than the expiry date, or even be- participants (n = 500) come toxic, especially antibiotics. Places Variable No. % such as cabinets and kitchen cupboards Storage place of medications might be suitable although humidity Refrigerator 253 50.6 should also be considered. Kitchen cupboard 213 42.6 Pharmaceutical companies in the Other 34 6.8 Islamic Republic of Iran are required to Consulted package inserts 34 6.8 include a leaflet with medication pack- Practises self-medication ages which briefly explains about the Yes 268 53.6 drug, its indications and side-effects. No 232 46.4 This covers most outpatient prescrip- Frequency of self-medication in last 3 months tion and some non-prescription medi- (n = 268) cines and medical supplies. Only 6.8% 1 52 19.4 of householders said that they had read 2 60 22.4 the package inserts. 3 45 16.8 Even if medicines are stored cor- ≥ 3 111 41.4 rectly, it does not mean that these Therapeutic class used for self-medication medicines would be suitable for a fam- (n = 268) ily member to start self-medication and Analgesics 159 59.3 reuse them. None of the householders Adult cold remedies 31 11.6 in our study reported routinely returned Antibiotics 26 9.7 unwanted medications to a pharmacy Herbal remedies 25 9.3 for proper disposal. Furthermore, a high Corticosteroids 18 6.7 prevalence of self-medication was noted Other 9 3.4 among householders (53.6%). Muras et Formulation used for self-medication (n = 268) al. reported that antibiotic self-medica- Tablets 95 35.4 tion for respiratory tract infection was Capsules 65 24.3 common in Poland (22). Syrup 57 21.3 Previous studies have documented Ointments 29 10.8 the link between medicine storage plac- Ampoules 11 4.1 es at home and frequency of self-med- Suppositories 11 4.1 ication (23,24). Medicines prescribed for one symptom/disease may be used both as self-medication for (repeated) Discussion (20,21). Our findings raise concerns episodes of the same symptom/dis- about how medications are stored ease or for a member of the family with Our study revealed that nearly half of and disposed of in the community. the same symptom/disease but not by households stored medicines in the None of the participants said that they consultation with a physician. Find- refrigerator, whether this was the cor- returned unused medicines to a local ing unused prescription medicines in rect place or not. The correct place for pharmacy and keeping them in their homes in the Islamic Republic of Iran is storage depends on the medicine; for home could be a risk of potential harm. not surprising because self-medication example, after preparation of antibiotic The refrigerator is not a suitable place practices are common among people suspensions they must be kept cool but for all medicines, and even if, based on of all educational levels (11,12,25–27). not frozen, whereas adult cold remedies the recommendations of the package Other research has found that the should be kept at room temperature in inserts, those medicines should be majority of householders keep unused a kitchen or bedroom cupboard. The kept in a refrigerator, freezing must be medicines at home either to use them in kitchen cupboard was the second most avoided. Also it is necessary to ensure the future or to give them to someone common storage place. This finding that children are not able to get access to else who has similar symptoms (28). contrasts with that of other countries. medicines that are kept in a refrigerator. Furthermore, leftover medications may In a study in Qatar, for example, most Most medicines are sensitive to light be a result of non-completion to treat- medicines were kept in the bedroom and heat, and may need to be destroyed ment regimens (29).

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Table 3 Participants’ self-medication practices by demographic data and type of insurance Variable Practises self-medication P-value (χ2 test) Yes No No. % No. % Sex 0.704 Male 142 54.4 119 45.6 Female 126 52.7 113 47.3 Age (years) 0.832 20–29 58 50.4 57 49.6 30–39 69 53.5 60 46.5 40–49 71 53.8 61 46.2 ≥ 50 70 56.4 54 43.6 Marital status 0.613 Married 199 54.1 169 45.9 Single 68 51.5 64 48.5 Occupation 0.544 Employed 253 53.3 222 46.7 Unemployed 15 60.0 10 40.0 Insurance coverage/organization 0.728 Social security insurance 103 52.6 93 4 7. 4 Iran health insurance 62 50.8 60 49.2 Other health insurance 5 50.0 5 50.0 None 98 57.0 74 43.0 Educational level 0.007a Secondary/higher 153 48.7 161 51.3 None/primary 115 61.2 73 38.8

aSignificant at P < 0.05.

There was a significant asso- (33). Adult cold formulations (a com- 14.3% respectively) (34). In contrast, ciation between self-medication and bination of phenylephrine, chlorphe- a British study revealed that among educational level. Lower educated niramine maleate and paracetamol) medicines returned to pharmacies, householders were more likely to self- are also widely consumed products in 28.0% were cardiovascular medicines, medicate. Self-medication provides a the Islamic Republic of Iran. Nearly 19.1% were CNS agents, 14.8% were lower cost alternative for people who 10% of households in the present study respiratory agents, 11.4% were gastro- cannot afford the cost of clinical servic- reported that they used antibiotics for intestinal agents and only 4.0% were es (30,31). Based on a study in India, self-medication and one-third reported antibiotics (35). the prevalence of self-medication was that reused them. It should be noted Tablets were the formulations most 37% in urban and 17% in rural popula- that this study refers to antibiotics origi- commonly used for self-medication tions (32). nally prescribed by the doctor and then (35.6%). However, it should be em- The results showed that stored kept and reused, as antibiotics are not phasized that tablets might be the medicines belonged mostly to 3 cat- sold over-the counter in the Islamic most frequently used dosage form in egories: analgesics, adult cold remedies Republic of Iran. This may be in order self-medication simply because most and antibiotics. In the Islamic Republic to save money because antibiotics are medicines for self-medication come in of Iran, analgesics are the most com- expensive to buy. In Saudi Arabian tablet form. monly procured over-the-counter households Abou-Auda found that res- It is not surprising that nearly 10% of medicines and self-medication with piratory medicines, followed closely by households kept herbal remedies. Self- them is frequent. They are usually the central nervous system (CNS) agents medication with herbal preparations is first-line of medicines used by com- and antibiotics, were the most common likely to be frequent in south-east Islam- munity members in event of illness reused medicines (16.8%, 16.4% and ic Republic of Iran because people in

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this area are proud of their background Conclusions to keep several prescription medicines related to traditional medicine. Previous in their homes. These patients are po- studies in the Islamic Republic of Iran Keeping medicines at home and self- tential providers to their friends and show that people take herbs as supple- medication are important health is- relatives of medicines that are poten- ments to promote health, prevent illness sues. Very few householders in our tially unsafe for self-medication. Better (especially the common cold), boost study consulted the package inserts public knowledge and information the immune system, prevent stress and or stored their medicines according about the risks of reuse of prescription to supplement regular nutrition and to the manufacturers’ instructions. It medications is needed. they believe that use of herbs is part of a is important for patients to be aware healthy lifestyle (36,37). of information about manufacturers’ One of the strengths of the present recommended storage conditions for Acknowledgements study was that it was carried out in the medicines. There is a need for more pa- community and was not based on a tient awareness about the safe handling The authors would like to express their specific target group. However, an ab- and storage of medicines at home. A gratitude towards all the respondents sence of a standard definition of self- high prevalence of self-medication for showing concern towards this issue medication and the study design which was also noted among householders, and also to thank Mr Javadinia for his did not include a comparison group especially those who were less well- contribution to data collection. mean the results should be interpreted educated. Doctors have to take into Funding: None. with caution. account that their patients are likely Competing interests: None declared.

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553 EMHJ • Vol. 20 No. 9 • 2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Use of complementary and alternative medicine among midlife Arab women living in Qatar L.M. Gerber,1 R. Mamtani,2 Y.-L.Chiu,1 A. Bener,3 M. Murphy,4 S. Cheema 2 and M. Verjee 2

استخدام الطب املتمم والبديل لدى النساء العربيات يف منتصف العمر اللوايت َ يعشنيف َق َطر ليندا غربر، رافيندر ممتاين، يالني تشو، عبد الباري بنر، مادوفانتي ماريف، سهيلة شيام، حممود فريجي اخلالصــة: إن اســتخدام الطــب املتمــم والبديــل منتــر عــى نطــاق واســع، وهــو يف تزايــد يف مجيــع أنحــاء العــامل. وقــد قامــت هــذه الدراســة املســتعرضة يف َق َطــر بدراســة اســتخدام الطــب املتمــم والبديــل وارتباطاتــه لــدى نســاء عربيــات يف ســنوات منتصــف أعامرهــن. فقــد تطوعــت 814 60-40 نســاء بأعــامر ســنة )العــدد = ( يف مراكــز الرعايــة الصحيــة األوليــة يف َق َطــر، َوقمــن بمــلء اســتبيان َّمصمــم ًخصيصــا تــم اختبــاره ً.مســبقا فــكان مــا إمجاليــه 38.2% مــن النســاء يف منتصــف العمــر يف َق َطــر قــد اســتخدمن الطــب املتمــم والبديــل يف الـــ 12 ًشــهرا الســابقة. وكانــت العالجــات الغذائيــة والعالجــات العشــبية أكثــر معاجلــات الطــب املتمــم والبديــل ً شــيوعايف االســتخدام، تلتهــا الطــرق الفيزيائيــة. وكانــت اجلنســية القطريــة ومســتوى التعليــم األعــى مرتبطــة - بشــكل مســتقل - مــع اســتخدام الطــب املتمــم والبديــل. ومل تكــن حالــة ســن اإليــاس االنتقاليــة مرتبطــة - بشــكل مســتقل - مــع اســتخدام الطــب املتمــم والبديــل. وكان انتشــار اســتخدام الطــب املتمــم والبديــل مــن ِ ق َبــل النســاء يف َق َطــر ًمرتفعــا، بــام يتفــق مــع تقاريــر أخــرى مــن مجيــع أنحــاء العــامل. وخلصــت الدراســة إىل أن مــن الــروري تثقيــف املــرىض ِّومقدمــي الرعايــة الصحيــة وإطالعهــم عــى الفوائــد والقيــود املرتبطــة بالطــب املتمــم والبديــل.

ABSTRACT The prevalence of use of complementary and alternative medicine (CAM) is widespread and is growing worldwide. This cross-sectional study in Qatar examined the use of CAM and its correlates among Arab women in their midlife years. Women aged 40–60 years (n = 814) were recruited at primary care centres in Qatar and completed a specially designed, pre-tested questionnaire. Overall, 38.2% of midlife women in Qatar had used CAM in the previous 12 months. Nutritional remedies and herbal remedies were the most commonly used CAM therapies, followed by physical methods. Qatari nationality and higher level of education were independently associated with CAM use. Menopause transition status was not independently associated with use of CAM. The prevalence of CAM use by women in Qatar was high, consistent with other reports worldwide. It is essential to educate and inform patients and health-care providers about the benefits and limitations associated with CAM.

Recours aux médecines complémentaires et parallèles chez des femmes arabes en milieu de vie au Qatar

RÉSUMÉ L’utilisation des médecines complémentaires et parallèles est largement prévalente et en augmentation dans le monde. La présente étude transversale au Qatar a examiné le recours aux médecines complémentaires et parallèles et ses corrélats chez des femmes arabes en milieu de vie. Des femmes âgées de 40 à 60 ans (n = 814) ont été recrutées dans des centres de soins de santé primaires au Qatar et ont rempli un questionnaire spécialement conçu ayant été testé au préalable. Au total, 38,2 % des femmes en milieu de vie interrogées vivant au Qatar avaient eu recours aux médecines complémentaires et parallèles durant les 12 mois précédents. Des remèdes nutritionnels et à base de plantes étaient les traitements complémentaires et parallèles les plus fréquemment utilisés, suivis par des méthodes physiques. La nationalité qatarie et un niveau d'études plus élevé étaient indépendamment associés à l'utilisation de médecines complémentaires et parallèles. Le statut de transition ménopausique n'était pas indépendamment associé à l'utilisation de ces médecines. La prévalence de leur utilisation chez les femmes au Qatar était élevée et concordait avec les études menées sur le sujet dans d'autre pays du monde. Il est essentiel d'éduquer et d'informer les patientes et les prestataires de soins de santé sur les bénéfices et les limites associés aux médecines complémentaires et parallèles.

1Weill Cornell Medical College, New York, United States of America (Correspondence to L.M. Gerber: [email protected]). 2Weill Cornell Medical College in Qatar, Doha, Qatar. 3Hamad Medical Corporation, Doha, Qatar. 4The University of the West Indies, St. Michael, Barbados. Received: 25/09/13; accepted: 22/04/14

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Introduction CAM use by cancer patients in Arab years. It was a 2-phase, mixed-methods countries (11). A 2008 household study conducted in Doha, Qatar. A The demand for complementary and study in Saudi Arabia found that the report on the qualitative phase of the alternative medicine (CAM) is strong majority of participants using CAM study has previously been reported and growing worldwide. The reported were women (60.9%) and that of the (15). prevalence of CAM use spans a wide persons sampled aged 50 years and Data for this study were derived range (40–70%), possibly due to vary- over (n = 238) 72% used alternative from a cross-sectional study conducted ing definitions of CAM(1,2) . The Na- medicine; the most frequently used from July 2011 to May 2012. Women tional Center for Complementary and CAM by Saudi Arabians included were recruited from 9 primary care Alternative Medicine (NCCAM) of prayer and nutritional/herbal remedies centres. The health centres were se- the National Institutes of Health defines such as honey and black seed (12). lected to represent geographically, east, CAM as “a group of diverse medical and In another study in Turkey, research- west, north, south and central locations health care systems, practices and prod- ers found that 76% and 24% of the of the population in Qatar. Participants ucts that are not presently considered study sample reported using prayer were eligible for inclusion if they were part of conventional medicine” (3,4), and herbal remedies respectively (13). between 40 and 60 years of age, were although it has been noted that there CAM use was also found to be preva- of Qatari nationality or a national of may be cultural differences in terms of lent in Palestine; in one study, 77% of another Arab country, and were Ara- what is considered complementary or women and 67% of men reported using bic or English speaking. Participants alternative (5). CAM in the previous year (14). Lit- were excluded if they had a history of In general, women use CAM more tle is known, however, about the use bilateral oophorectomy. A total of 951 often than men do(6) . The use of of CAM by Middle Eastern women women were approached to participate CAM by women during midlife has specifically during midlife, and a search in the study. Of these, 64 were found been found to be higher than during of the literature found no studies on this to be ineligible and 46 women (4.8% other stages of the lifespan (7). In the subject focusing on Qatari women. of a total of 887 eligible) declined to United States of America (USA), Qatar is a rapidly developing nation participate in the study. Interviewer- CAM use during midlife by women is and a member of the Gulf Cooperation administered, structured surveys were in keeping with the global trend (8). A Council (GCC). The purpose of this then conducted at the health centres cross-sectional study by Upchurch et study was to investigate the use of CAM and a total of 841 women completed al. which utilized data from the Nation- and the correlates of its use among the evaluation. al Health Interview Survey found that women in their midlife years who were The protocol and consent form were 46% of women ages 40–59 years used attending primary care centres in Qatar. approved by the institutional review CAM in the previous year, with bio- Specifically, this report compared the committees at Weill Cornell Medical logical therapies being used the most use of CAM between Qatari and non- College–Qatar and at Hamad Medical and prayer being frequently reported Qatari Arab women and among women Corporation, Qatar. (9). That study also found ethnic dif- reporting vasomotor, somatic and ferences in CAM use in the USA, con- psychological symptoms. In addition, Survey instrument sistent with reports that analysed data this report evaluated the independent During the qualitative phase of this from the Study of Women’s Health associations of nationality, educational study, 6 focus group discussions were Across the Nation (SWAN) over mul- level and menopause status to CAM conducted as a precursor to the quanti- tiple collection points (10). In the 5 use. The findings from this study could tative survey data collection to guide the ethnic groups studied in the SWAN be instructive in guiding public health development of the survey instrument. (white, black, Hispanic, Japanese and policy and health professional educa- The focus groups examined the experi- Chinese), white and Japanese women tion programmes in this region. ences of midlife transition in Qatari and between the ages of 42 and 52 years Arabic women and explored whether were more likely to use CAM than any nationality differences needed to the other ethnic groups, with white Methods be considered in the development of women using psychological remedies the quantitative measures. A total of 41 and Japanese women using herbal and Study design and sampling Arabic-speaking women between the physical remedies the most. The Study of Women’s Health in Qatar ages of 40 and 60 years (a mix of pre-, In Middle Eastern countries such as (SWIQ) aimed to examine the physi- peri-, and postmenopausal women) Qatar, CAM has been gaining popular- cal, biological, psychological and social participated, with 3 Qatari and 3 non- ity. A number of studies have examined changes in women in their middle Qatari groups (15).

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The survey instrument, which was use was analysed as any CAM use if aged 50–59 years. Qataris comprised developed using the existing SWAN respondents reported use of any of the 45.2% of the sample while non-Qatari survey as a foundation, was piloted by 5 CAM types or as the specific type Arab women originated from many a trained moderator and assistant mod- reported. neighbouring countries. erator, who were both culturally and lin- Symptom experience Overall, 321 (38.2%) of midlife guistically matched to the focus group To assess the presence or absence of women in Qatar had used CAM in the participants. The survey instrument was 22 health-related symptoms, women previous 12 months. CAM use was sig- first developed in English, translated were asked “Thinking back over the nificantly associated with educational into Arabic and then back-translated past 2 weeks, how often have you been status; significantly more CAM users into Arabic to confirm the quality of the bothered by any of the following?” were university graduates and profes- translation. Themes and issues perti- (16,17). Each symptom was treated as sionals (55.1%) than were non-users nent to survey development were iden- a binary categorical variable (scored yes (39.7%) (P < 0.001). Women reporting tified during the focus groups through or no), and symptoms were analysed CAM use did not differ by age group or discussions held with participants in 3 categories: vasomotor symptoms by menopause status from women who immediately after piloting the survey, (hot flashes or night sweats); somatic did not report CAM use. More CAM and appropriate revisions were made to symptoms (aches/stiffness in joints users than non-users were of Qatari the instrument (i.e. length, cultural and or headaches); psychological symp- nationality (50.5% versus 41.9% respec- social acceptability of questions, ease of toms (feeling blue or depressed, mood tively) (P = 0.02). There was no differ- understanding questions, etc.) before it changes, irritability or nervous tension) ence in CAM use among non-Qatari was used in the field. (10). Participants were categorized Arabs by nationality. Measures as being symptomatic in any of the 3 For those who reported CAM symptom categories if they reported use, nutritional remedies and herbal Menopause status having at least 1 of the symptoms in the remedies were the most frequently Questions about menopause status category. used types of CAM, followed by included: the time of the last menstrual physical methods (Table 2). Non- Statistical methods cycle, whether the woman had men- Qataris more often used nutritional struated in the last 12 months, regular- The chi-squared test was used to test remedies (P = 0.01), while Qataris ity of menstruation and whether cycles for the difference in the distribution of more often used physical methods changed in length. Menopause status categorical variables (any CAM use and (P < 0.001) and folk medicine (P = was categorized into premenopausal, use of specific CAM types) between 0.02). More Qatari women than non- perimenopausal and postmenopausal. Qatari and non-Qatari Arab women Qataris reported use of more than 1 Women having a hysterectomy but at and between women reporting recent CAM therapy (15.8% versus 8.5%) (P least 1 ovary were categorized sepa- experience of symptoms and those who = 0.003) (Figure 1). rately. did not. Multivariable logistic regres- Vasomotor symptoms were report- Use of CAM sion analyses were used to evaluate ed by 348 women, somatic symptoms the independent associations between The SWIQ included questions about by 739 and psychological symptoms nationality, education level, menopause by 716. Overall, women who reported CAM use that were derived from the status and CAM use. The odds ratios vasomotor symptoms were more likely SWAN (10). Participants were asked (OR), 95% confidence intervals (CI) to use CAM than women who did not whether, in the previous 12 months, and P-values of the covariates were re- (41.7% versus 35.7%), although this they had used any of 5 types of self-care ported. All statistical tests were 2-sided, difference did not reach statistical sig- therapies: special diets or nutritional and P < 0.05 was considered statistically nificance (P = 0.08) (Table 3). There remedies, such as macrobiotic or veg- significant. Analyses were performed was also a trend towards greater CAM etarian diets, or vitamin supplements using SAS, version 9.2 software. or therapy; herbs or herbal remedies, use among women reporting somatic such as homeopathy or Chinese herbs symptoms compared with women not or teas; psychological methods, such Results reporting those symptoms (P = 0.08). as meditation and mental imagery A description of symptom reporting and relaxation techniques; physical The characteristics of the sample are by CAM use category is presented in methods such as massage, acupres- presented in Table 1. Close to half Table 4. Women reporting vasomotor, sure, acupuncture; or folk medicine or (51.7%) of the participants were aged somatic and psychological symptoms traditional Chinese medicine. CAM 40–49 years, and the remainder were reported use of nutritional remedies

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Table 1 Selected characteristics of the study population, by complementary/alternative medicine (CAM) use status Characteristic Total sample Any CAM use No CAM use P-value (n = 841) (n = 321) (n = 520) No. % No. % No. % Age (years) 40–49 435 51.7 169 52.7 266 51.2 0.67 50–59 406 48.3 152 47.3 254 48.8 Nationality Qatari 380 45.2 162 50.5 218 41.9 0.02 Non-Qatari 461 54.8 159 49.5 302 58.1 Egyptian 144 17.1 55 34.6 89 29.5 0.12 Jordanian 76 9.0 30 18.9 46 15.2 Palestinian 56 6.7 14 8.8 42 13.9 Sudanese 42 5.0 9 5.7 33 10.9 Lebanese 34 4.0 16 10.1 18 6.0 Syrian 33 3.9 12 7.6 21 7.0 Other 76 9.0 23 14.5 53 17.6 Education Illiterate 57 6.8 12 3.7 45 8.7 < 0.001 Primary 66 7. 9 16 5.0 50 9.6 Elementary 99 11.8 33 10.3 66 12.7 Secondary 235 28.0 83 25.9 152 29.3 University graduate & above 383 45.6 177 55.1 206 39.7 Menopause status Premenopausal 197 23.4 79 24.6 118 22.7 0.80 Perimenopausal 353 42.0 135 42.1 218 41.9 Postmenopausal 265 31.5 99 30.8 166 31.9 Hysterectomy 26 3.1 8 2.5 18 3.5

Table 2 Prevalence of use of any type and specific types of complementary/alternative medicine (CAM), by nationality Use of CAM Total sample Qatari Non-Qatari P-value (n = 841) (n = 380) (n = 461) No. % No. % No. % Any type 321 38.2 162 42.6 159 34.5 0.02 Nutritional remedies Yes 158 18.8 68 17.9 90 19.5 0.01 No 163 19.4 94 24.7 69 15.0 Herbal remedies Yes 134 15.9 67 17.6 67 14.5 0.89 No 187 22.2 95 25.0 92 20.0 Psychological methods Yes 25 3.0 14 3.7 11 2.4 0.56 No 296 35.2 148 38.9 148 32.1 Physical methods Yes 97 11.5 69 18.2 28 6.1 < 0.001 No 224 26.6 93 24.5 131 28.4 Folk medicine Yes 38 4.5 26 6.8 12 2.6 0.02 No 283 33.7 136 35.8 147 31.9

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Qatari Non-Qatari CAM therapies most commonly used by midlife women in Qatar (10). 70 65.5 Based on our study findings and 60 57.4 observations made in other studies, it is evident that CAM use is quite prevalent 50 in Qatar and other Arab states in the 40 Middle East (11–14). While our study did not focus on reasons for their use, 30 26.8 26.0 it has been reported that people use % of respondents of % 20 15.8 CAM remedies for a variety of reasons. These include the availability of CAM 8.5 10 in local communities, the lower cost 0 of CAM compared with conventional 0 (n = 520) 1 (n =222) > 1 (n = 99) treatments and the perceived effec-

No. of types of CAM used tiveness and safety of CAM therapies (18). The perceptions of the public and Figure 1 Number of types of complementary/alternative medicine (CAM) used, by more specifically of patients about the nationality (P = 0.003, chi-squared test) effectiveness and safety of CAM are of concern, since there are questions about the benefits and side-effects associated with commonly used CAM treatments and herbal remedies most frequently, were not independently associated with (19–21). and then physical methods. It should use of CAM. be noted that these categories were not In our study sample, it should be mutually exclusive and women often noted that non-Qatari women repre- used more than one type of CAM. Discussion sented a diverse and heterogeneous A multivariable logistic regression group of women from 18 different model predicting CAM use is shown This study found that, overall, 38.2% of nationalities, the most frequent being in Table 5. Qatari nationality was midlife women in Qatar used CAM in those from Egypt, Jordan, Palestine, a significant predictor of CAM use the previous year, which was in the range Sudan, Lebanon and Syrian Arab Re- (OR = 1.75; 95% CI: 1.29–2.37), after (20–64%) reported from the SWAN public. Thus, they represented women controlling for age, education level, using the same survey about CAM use of many backgrounds, who may vary in menopause status and vasomotor, so- (10). The use of CAM by women in Qa- their use of particular types of self-care matic and psychological symptoms. tar follows the global trend, with 42.6% therapies. Level of education was an additional of Qatari women in our study reporting This study had several limitations. independent significant predictor of CAM use, compared with 34.5% of other First, since the survey ascertained CAM CAM use, whereby increasing level of Arab women in Qatar. Also in line with use among patients who were attending education was associated with increas- previous research findings (6), this study primary care centres, we cannot general- ing use of CAM; university graduates found that CAM use was more prevalent ize these findings to all women of similar and above were 3.75 times more likely in women of higher educational status. ages. Second, the CAM classification and to use CAM. Age, menopause transi- Similar to findings of the SWAN, nu- questions used in this study were derived tion status and symptom experience tritional and herbal remedies were the from the SWAN study questionnaire,

Table 3 Prevalence of use of any type of complementary/alternative medicine (CAM), by menopause symptom category Use of any type of CAM Vasomotor symptoms Somatic symptoms Psychological symptoms Yes No Yes No Yes No (n = 348) (n = 493) (n = 739) (n = 102) (n = 716) (n = 125) No. % No. % No. % No. % No. % No. % Yes 145 41.7 176 35.7 290 39.2 31 30.4 273 38.1 48 38.4 No 203 58.3 317 64.3 449 60.8 71 69.6 443 61.9 77 61.6 P = 0.08 P = 0.08 P = 0.95

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Table 4 Prevalence of use of any type and specific types of complementary/alternative medicine (CAM), by menopause symptom category Use of CAM Vasomotor symptoms Somatic symptoms Psychological symptoms Yes Yes Yes (n = 348) (n = 739) (n = 716) No. % No. % No. % Any type 145 41.7 290 39.2 273 38.1 Nutritional remedies 69 19.8 138 18.7 132 18.4 Herbal remedies 69 19.8 127 17.2 118 16.5 Psychological methods 10 2.9 22 3.0 20 2.8 Physical methods 44 12.6 86 11.6 84 11.7 Folk medicine 15 4.3 35 4.7 34 4.8

Table 5 Multivariable logistic regression analysis of any type of complementary/ Coffee enemas, ozone therapy, mega- alternative medicine (CAM) use doses of vitamins, certain herbs and Predictor variable Adjusted OR (95% CI) P-value shark cartilage are examples of such Age (years) therapies (19,21). It is therefore imper- 50–59 0.97 (0.68–1.39) 0.89 ative to educate and inform patients 40–49 Ref. about the benefits and limitations as- Nationality sociated with CAM. It is also neces- Qatari 1.75 (1.29–2.37) < 0.001 sary to educate medical doctors about Non-Qatari Ref. CAM (23) so that they can become Education level better informed to help patients differ- entiate between safe, beneficial treat- University graduate & above 3.75 (2.28–6.16) < 0.001 ments and those that are harmful and Secondary 2.35 (1.39–3.99) 0.002 ineffective. Our recommendations are Elementary 1.90 (1.03–3.49) 0.04 consistent with the views of NCCAM, Illiterate/primary Ref. as well as other organizations whose Menopause status mission is to define and disseminate Postmenopausal 1.01 (0.63–1.61) 0.98 the safety and efficacy of these prac- Perimenopausal 0.91 (0.62–1.34) 0.63 tices (24,25). Premenopausal Ref. Vasomotor symptoms Yes 1.30 (0.96–1.76) 0.09 Acknowledgements Somatic symptoms Yes 1.48 (0.93–2.36) 0.10 The authors would like to thank the re- Psychological symptoms search team in Qatar: Darine Dimassi, Yes 1.07 (0.70–1.62) 0.77 Nadia Omar and Hala Al-Ali, for their

Ref. = reference group; OR = odds ratio; CI = confidence interval. assistance with this project, and to all the women who generously gave their time to participate in the Study of Women’s which has some idiosyncrasies, as previ- There is no doubt that some CAM Health in Qatar. ously reported (22). For example, it clas- treatments are beneficial. Examples of Funding: This research was supported sifies homeopathic treatments as herbal these include use of acupuncture for by the Qatar National Research Fund, remedies. Additionally, it is recognized nausea and chronic musculoskeletal National Priorities Research Program. that there is not one standard definition pain, massage therapy for anxiety, and Support was also provided by the of CAM. However, these particularities mind–body techniques such as medi- Clinical Translational Science Center do not affect our estimate of the overall tation for pain and anxiety (19–21). (CTSC), National Center for Advanc- use of CAM in this study population. There are many CAM therapies, ing Translational Sciences (NCATS) Third, this study did not enquire about however, which are either ineffective grant #UL1-TR000457-06. the reasons for use of CAM. or might even be harmful to patients. Competing interests: None declared.

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560 املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt W. Al-Darzi,1 F. Al-Mudares,1 A. Farah,1 A. Ali 1 and D. Marzouk 2

املعرفة باستخدام محض الفوليك يف الفرتة املحيطة باحلمل لدى النساء احلوامل يف مستشفى جامعة عني شمس، القاهرة، مرص وليد الدرزي، فائق املدرس، عمرو فرح، عبد الرمحن عيل، ضياء مرزوق لوحــظاخلالصــة: يف مــر وقــوع مرتفــع لعيــوب األنبــوب العصبــي. ومــن املعــروف أن املعاجلــة التكميليــة بحمــض الفوليــك يف الفــرة املحيطــة باحلمــل تقلــل مــن خماطــر مثــل هــذه العيــوب. وقــد هدفــت هــذه الدراســة املســتعرضة إىل قيــاس مســتوى املعرفــة حــول اســتخدام محــض الفوليــك يف الفــرة املحيطــة باحلمــل لــدى النســاء احلوامــل الالئــي يــرددن عــى الرعايــة الســابقة للــوالدة يف مستشــفى جامعــة عــن شــمس 62.4 660 2012 بالقاهــرة يف مــر يف عــام . فتــم مــلء اســتبيانات مــن خــالل مقابــالت شــخصية مــع امــرأة حامــل. َّفتبــن أن % مــن َاملســتطلعات 39.2 قــد َســمعن بحمــض الفوليــك، و % منهــن عــى علــم بــدور املعاجلــة التكميليــة بحمــض الفوليــك يف الوقايــة مــن الشــذوذات اخللقيــة. وكانــت املعرفــة عــن اســتخدام محــض الفوليــك قبــل احلمــل ويف األشــهر الثالثــة األوىل منــه أعــى بــن النســاء اللــوايت تلقــن ًتعليــا ًجامعيــا ِ 18.8 8.8 والنســاء اللــوايت يعملــن يف مهــن ح َر ّفيــة. وقــد أفــادت % فقــط مــن النســاء بتنــاول محــض الفوليــك، و % منهــن َّكــن قــد اســتخدمنه قبــل احلمــل. وتــم اقــراح القيــام بحمــالت توعيــة لتحســن املعرفــة عــن محــض الفوليــك لــدى النســاء اللــوايت ّ يفهــن فــرة اإلنجــاب يف مــر.

ABSTRACT Egypt has a high incidence of neural tube defects. Folic acid supplementation in the periconceptional period is known to lower the risk of such defects. This cross-sectional study aimed to measure the level of knowledge about periconceptional folic acid use among pregnant women attending for antenatal care at Ain Shams University Hospital, Cairo, Egypt in 2012. Questionnaires were filled through personal interviews with 660 pregnant women. Of the respondents, 62.4% had heard of folic acid and 39.2% knew about the role of folic acid supplementation in prevention of congenital anomalies. Knowledge about using folic acid before and in the first trimester of pregnancy was highest among university-educated women and those working in professional occupations. Only 18.8% of women reported taking folic acid, and 8.8% had used it before conception. Awareness campaigns are suggested to improve knowledge about folic acid among women in the childbearing period in Egypt.

Connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes à l'hôpital universitaire Ain Shams, au Caire (Égypte)

RÉSUMÉ En Égypte, l'incidence des malformations du tube neural est élevée. La supplémentation en acide folique durant la période périconceptionnelle est connue pour réduire le risque de telles malformations. La présente étude transversale visait à mesurer le niveau de connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes consultant à l'hôpital universitaire Ain Shams au Caire (Égypte) pour des soins prénatals en 2012. Des questionnaires ont été remplis pendant des entretiens individuels avec 660 femmes enceintes. Parmi les répondantes, 62,4 % avaient entendu parler de l'acide folique et 39,2 % connaissaient le rôle de la supplémentation en acide folique dans la prévention des anomalies congénitales. Les femmes ayant fait des études universitaires et celles exerçant une activité professionnelle possédaient les connaissances les plus élevées sur l'utilisation de l'acide folique avant et pendant le premier trimestre de grossesse. Seules 18,8 % des femmes ont déclaré prendre de l'acide folique, et 8,8 % y avaient eu recours avant la conception. Des campagnes de sensibilisation sont suggérées pour améliorer les connaissances sur l'acide folique chez les femmes en âge de procréer en Égypte.

1Faculty of Medicine; 2Department of Public Health, Ain Shams University, Cairo, Egypt (Correspondence to W. Al-Darzi: [email protected]). Received: 03/01/13; accepted: 23/06/13

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Introduction 0.05% to 0.36% (2,15). To date, there knowledge and use (ever heard about had been very little evidence in the folic acid before, from where she heard Neural tube defects (NTDs) are birth literature about knowledge and prac- about it, recommended period of intake defects of the brain and spinal cord that tice of folic acid use among pregnant according to her knowledge, whether can cause death, or permanent damage women in Egypt. The aim of this study she took folic acid in the current preg- to the nervous system (1). The most was to measure the level of knowledge nancy and if so when, benefits of folic frequent forms of NTDs are spina bifida about periconceptional use of folic acid acid intake, and different food sources and anencephaly (2). Such defects are among pregnant women at Ain Shams of folic acid). The number of ANC visits among the most common birth defects University hospital, Cairo, Egypt. The in the current pregnancy was classified worldwide (3), occurring in an estimat- current study will provide a baseline as sufficient or insufficient, according ed 300 000 newborns each year (2,4). description about folic acid knowledge the recommendations of the Royal Col- Evidence of the relationship between which can be used to assess the need for lege of Obstetricians and Gynaecolo- insufficient intake of maternal folic acid awareness campaigns. gists (16). and the risk of NTDs led to the United The validity of the questionnaire States Public Health Service recom- was tested by translating a pre-existing mendation in 1992 that women with Methods questionnaire (17) to Arabic language the capacity to become pregnant need and comparing the findings of both to consume 400 µg folic acid on a daily Study design and sample questionnaires. The reliability of the basis (5). The incidence of NTDs falls This cross-sectional, observational questionnaire was evaluated by inter- by 50%–80% when women consume study was conducted in the antenatal viewing 20 patients from the inpatient folic acid supplements daily, and there is care (ANC) clinic at Ain Shams Uni- clinic twice with different interviewers now a consensus that supplementation versity Hospital, Cairo, Egypt. This is and separated by 5 days. The findings should begin not only during the first considered one of the main hospitals in of both interviews were compared. Af- trimester but also earlier, before concep- north-east Cairo, receiving a variety of ter the pilot study, the questions were tion (6–8); this was supported by a patients from different regions of Cairo rearranged, modified by adding more cohort study in 1999 by Berry et al. (9). and even from other governorates. Any choices or substituting open questions. In view of the benefits of consuming pregnant women aged 18–45 years The questionnaire was written in folic acid for women in the childbearing who sought medical consultation at the common Egyptian Arabic dialect years, several studies have been con- the ANC clinic were included. The and each interviewer followed the ques- ducted in different parts of the world to diagnosis of pregnancy was confirmed tion structure strictly with agreed-upon assess women’s awareness of the role by viewing patients’ files, previous his- alternative explanations. Each interview of folic acid in fetal development. In tory, examination and investigations was conducted by one of the trained the United States of America (USA), [previous urine beta-human chorionic authors. The pregnant women were there has been an increasing trend in the gonadotropin (βHCG), blood βHCG interviewed while they were waiting for percentage of women who are aware of or ultrasound]. Pregnant woman who their ANC visit, in a separate area from the benefits of folic acid, up to 85% 10( ), were younger than 18 or older than 45 the other participants to ensure privacy whereas in Qatar 53.7% of women had years were excluded. Data were collect- and confidentiality. Participants who heard about folic acid and only 15% of ed by questionnaires from 670 pregnant agreed to participate were interviewed them knew its role in preventing birth women during the period from June to regardless of whether if was their first or defects (11). With regard to preconcep- August 2012; 10 pregnant women did follow-up visit. The interviewers visited tional use of folic acid, a study conduct- not give consent for participation in the the ANC clinic 4 times per week for a ed in Taipei among pregnant women study, giving a response rate of 98.2%. 9-week period. showed that only 15.6% of them had Verbal consent was taken from each Data collection taken folic acid before conception (12). participant (n = 660) before filling the In Egypt, neurological disorders are An anonymous, standardized question- questionnaire. The study protocol has the most common birth defects, with naire was filled through an interpersonal been approved by the ethics committee NTDs forming 10.2% of neurological interview. This included 15 questions of Ain Shams University. The question- disorders (13). One study found the about the following: sociodemographic naire was developed by the authors of incidence of NTDs in Egypt to be data (age, residency, occupation, educa- this study in consultation with the com- 1.38% (14), which is high compared tional level); obstetric history (gravid- munity department at Ain Shams Uni- with other parts of the world, where ity, previous ANC; number of ANC versity. Then it received ethical approval the reported incidence ranges from visits; gestational age); and folic acid from 2 different faculty staff members.

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Data analysis media, books and the Internet (8.0%). for 3 groups: those who knew about The collected data were revised, coded The highest knowledge rates about preconceptional use of folic acid (n = and tabulated using SPSS, version 15.0.1 folic acid were found among women 79), those who knew about 1st trimes- for Windows. Quantitative continuous working in professional jobs (90.9%). ter use of folic acid (n = 324) and those variables are expressed as mean and Women with university education who knew the recommended period of standard deviation (SD). Qualitative (88.3%) and of women with history intake of folic acid, i.e. knew about folic variables are expressed as frequencies of ≥ 6 pregnancies (84.4%) were the acid intake during both the preconcep- and percentages. Student t-test was most aware about folic acid. The lowest tional and 1st trimester periods (n = 54) used to compare continuous vari- knowledge rates were among illiterate (Table 2). Highly significant relation- ables between the 2 study groups. Chi- women and those with only primary ships between the educational level of squared and Fisher exact tests were used school educational (25.0% and 35.6% pregnant women and their knowledge to examine the relationship between respectively). When the participants about folic acid intake were seen in all 3 categorical variables. Both univariate who reported knowing about folic acid groups (P < 0.01). Occupational status and multivariate logistic regression were asked about sources of folic acid, and number of previous pregnancies analyses were done to examine the as- 92.0% reported folic acid supplements, were significantly related to women’s sociation of awareness and intake of 2.9% fish, 1.1% liver and 4.0% green awareness of folic acid utilization pre- folic acid supplements with selected vegetables conception (P = 0.011 and P = 0.0001 sociodemographic and obstetric char- The relationship between the so- respectively) and in both recommend- acteristics of the studied women. P < ciodemographic characteristics of the ed intake periods (P = 0.004 and P = 0.05 was considered as the cut-off value pregnant women and their knowledge 0.046 respectively). Having a sufficient for significance. about the use of folic acid was analysed number of ANC visits for the current

Results Table 1 Sociodemographic characteristics and obstetric history of the study women in relation to their general awareness of folic acid Sociodemographic Variable All women Heard about folic acid characteristics and folic acid No. % No. % knowledge Total 660 100.0 412 62.4 Table 1 shows the sociodemographic Age group (years) characteristics of all the pregnant 18–24 209 31.7 111 53.1 women in the study and of the women 25–29 359 54.4 238 66.3 who had heard about folic acid before. 30–34 74 11.2 51 68.9 From the total sample of 660 women, 35–45 18 2.7 12 66.7 412 (62.4%) had heard about folic Education acid. Only 79 (12.0%) women knew it Illiterate 116 17.6 29 25.0 was important to take folic acid before Primary school 45 6.8 16 35.6 pregnancy and 53 (8.2%) knew about Preparatory school 106 16.1 56 52.8 taking it in both the preconception and 1st trimester periods. Out of the Secondary school 299 45.3 228 76.3 whole sample of women, 259 (39.2%) University 94 14.2 83 88.3 mentioned its role in prevention of birth Job defects. Not working 600 90.9 360 60.0 Out of the total sample of respond- Skilled work 27 4.1 22 81.5 ents, 124 (18.8%) reported taking folic Professional 33 5.0 30 90.9 acid in the current pregnancy; 58 (8.8%) Gravidity (no.) had taken it before pregnancy and 80 ≤ 2 432 65.5 266 61.6 (12.1%) took it in the 1st trimester. 3–5 196 29.7 119 60.7 For the women who had heard ≥ 6 32 4.8 27 84.4 about folic acid their main source of ANC visits in current pregnancy knowledge was the physician, reported Insufficient 99 15.0 43 43.4 by 92.0%; other sources of knowledge Sufficient 561 85.0 369 65.8 were the family, nurses, pharmacists, n/a = not applicable; ANC = antenatal care.

563 EMHJ • Vol. 20 No. 9 • 2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Table 2 Relationship between women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception (n = 79) 1st trimester (n = 324) Both periods (n = 54) No. %a P-value No. %a P-value No. %a P-value Age (years) 18–24 15 13.5 0.098 87 78.4 0.694 9 8.1 0.190 25–29 53 22.3 187 78.6 38 16.0 30–34 7 13.7 42 82.4 5 9.8 35–45 4 33.3 8 66.7 2 16.7 Education Illiterate 1 3.4 0.002 15 51.7 < 0.001 0 0.0 < 0.001 Primary school 1 6.3 12 75.0 1 6.3 Preparatory school 6 10.7 36 64.3 1 1.8 Secondary school 45 19.7 189 82.9 29 12.7 University 26 31.3 72 86.7 23 27.7 Occupation Not working 63 17.5 0.011 280 77.8 0.486 40 11.1 0.004 Skilled work 4 18.2 18 81.8 4 18.2 Professional 12 40.0 26 86.7 10 33.3 Gravidity (no.) ≤ 2 39 14.7 < 0.001 206 7 7. 4 0.101 27 10.2 0.046 3–5 28 23.5 100 84.0 21 17.6 ≥ 6 12 44.4 18 66.7 6 22.2 ANC visits in current pregnancy Insufficient 5 11.4 0.164 29 65.9 0.029 3 6.8 0.191 Sufficient 74 20.1 295 80.2 51 13.9

aPercentage of women in each sociodemographic and obstetric category who had heard about folic acid. ANC = antenatal care.

pregnancy was significantly related to women were 3-fold more aware about who had sufficient ANC visits during knowledge of folic acid intake during folic acid than non-working women their current pregnancy were twice as the 1st trimester (P = 0.029). (OR = 3.14, 95% CI: 1.44–6.85). aware about folic acid than those who Women who had a pregnancy history of had insufficient ANC visits (OR = 2.09, Univariate analysis ≥ 3 were 1.8–4.6 times more aware than 95% CI: 1.07–4.10). Table 3 shows the univariate analysis women with history of ≤ 2 pregnancies. The relationship of sociodemo- of sociodemographic characteristics Secondary school/diploma and graphic characteristics of the women of the study women and their knowl- university levels of education were high- with their knowledge about the both edge about folic acid intake. Knowl- ly significantly associated with knowl- periods of folic acid intake showed very edge about folic acid intake during edge about folic acid intake during the similar results as for knowledge about the preconceptional period showed 1st trimester. Women with secondary folic acid during the preconceptional significant relationships with age group school and university educational period. (25–29 years), university education level were more than 4-fold (OR = 4.52, level, professional occupation and his- 95% CI: 2.02–10.1) and 6-fold (OR = Multivariate analysis tory of ≥ 2 pregnancies. Women with 6.11, 95% CI: 2.33–16.1) more aware The multivariate analysis of sociode- university education level were about than illiterate women respectively. Suf- mographic characteristics is shown in 13-fold more aware about folic acid ficient ANC visits during the current Table 4. The relationships between the than illiterate women (OR = 12.8, 95% pregnancy was significantly related to women’s knowledge of folic acid and CI: 1.65–99.0), while specialist working knowledge about folic acid, as women their sociodemographic characteristics

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Table 3 Univariate analysis of association of women’s sociodemographic and obstetric characteristics with their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Crude OR P-value Crude OR P-value Crude OR P-value (95% CI) (95% CI) (95% CI) Age (years) 18–24 (Ref.) 25–29 1.83 (0.98–3.42) 0.057 1.01 (0.59–1.75) 0.967 2.15 (1.00–4.63) 0.049 30–34 1.02 (0.39–2.67) 0.971 1.29 (0.55–3.01) 0.560 1.51 (0.51–4.50) 0.458 35–45 3.20 (0.86–12.0) 0.084 0.55 (0.15–1.99) 0.363 2.27 (0.43–12.0) 0.335 Education Illiterate (Ref.) Primary school 1.87 (0.11–32.0) 0.667 2.80 (0.73–10.8) 0.134 1.87 (0.11–32.0) 0.667 Preparatory school 3.36 (0.39–29.3) 0.273 1.68 (0.68–4.18) 0.264 0.51 (0.03–8.45) 0.638 Secondary school 6.89 (0.91–52.0) 0.061 4.52 (2.02–10.1) < 0.001 4.08 (0.54–31.1) 0.175 University 12.8 (1.65–99.0) 0.015 6.11 (2.33–16.1) < 0.001 10.7 (1.38–83.5) 0.023 Occupation Not working (Ref.) Skilled work 1.05 (0.34–3.20) 0.935 1.29 (0.42–3.91) 0.658 1.73 (0.56–5.36) 0.343 Professional 3.14 (1.44–6.85) 0.004 1.86 (0.63–5.48) 0.262 3.89 (1.70–8.88) < 0.001 Gravidity (no.) ≤ 2 (Ref.) 3–5 1.79 (1.04–3.08) 0.035 1.53 (0.87–2.71) 0.141 1.90 (1.02–3.52) 0.042 ≥ 6 4.66 (2.03–10.7) < 0.001 0.59 (0.25–1.37) 0.213 3.10 (1.20–8.00) 0.019 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.96 (0.75–5.16) 0.171 2.09 (1.07–4.10) 0.032 2.25 (0.67–7.53) 0.189

OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category.

in the multivariate analysis were similar Cairo, Egypt showed that 62.4% of the who knew about the benefits of folic to those in the univariate analysis, ex- pregnant women surveyed knew about acid in prevention of birth defects was cept for occupational status which was folic acid in pregnancy. Looking at differ- 39.2%. This percentage is higher than not significant in multivariate analysis. ent studies conducted in the Middle East, in other nearby countries in the Middle the level of awareness ranged from 46.6% East (8.7%–14%) (11,18,21), but lower to 85% (11,18,19). In Taiwan the aware- than in Israel and Abu Dhabi, United Discussion ness rate among pregnant women was Arab Emirates (UAE) (46.6%–77.7%) 89.1% (12). In a study in Kansas, USA, (19,22), which shows that there is room The impact of NTDs is considered a the level of general awareness about folic for improvement. When compared with global health-care issue affecting huge acid was 88% among women of child- Israel our women’s knowledge about number of newborns each year (4). bearing ages (20). A small percentage of taking folic acid both preconception Fortunately, the risks of NTDs can be women in the present study had some and in the 1st trimester was considerably reduced by using folic acid before and university education (14.2%) whereas in lower (Egypt: 8.2%, Israel: 77.7%) (19). during the 1st trimester of pregnancy the Kansas study 65.6% of women had Although in the present study the (6,8,9). In Egypt, the high incidence of some college education or were college nature of the women’s occupation af- NTDs (14) points to a need for preven- graduates (20), which might explain their fected their knowledge about use of tion by increasing women’s awareness higher general awareness level. folic acid before conception, it was sig- of periconceptional use of folic acid. The The present study demonstrated nificant in univariate analysis but not present study at a tertiary care clinic in that the proportion of all participants in multivariate analysis, which suggests

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Table 4 Multivariate analysis of association of women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Adjusted OR P-value Adjusted OR P-value Adjusted OR P-value (95% CI) (95% CI) (95% CI) Age (years) 18–24 (Ref.) 25–29. 1.42 (0.72–2.81) 0.313 1.04 (0.57–1.88) 0.906 1.69 (0.73–3.87) 0.218 30–34 0.71 (0.24–2.11) 0.536 1.44 (0.55–3.77) 0.461 0.99 (0.28–3.45) 0.983 35–45 2.07 (0.46–9.38) 0.343 0.68 (0.17–2.77) 0.589 1.58 (0.25–9.96) 0.628 Education Illiterate (Ref.) Primary school 1.94 (0.11–35.0) 0.653 2.66 (0.66–10.8) 0.171 1.85 (0.10–33.4) 0.676 Preparatory school 3.00 (0.33–27.2) 0.329 2.11 (0.82–5.44) 0.124 0.47 (0.03–8.12) 0.605 Secondary school 7.65 (1.00–58.7) 0.050 5.67 (2.44–13.2) < 0.001 4.62 (0.60–35.8) 0.143 University 15.33 (1.88–124) 0.011 7.23 (2.52–20.7) < 0.001 13.1 (1.59–108) 0.017 Occupation Not working (Ref.) Skilled work 0.77 (0.23–2.54) 0.666 1.07 (0.33–3.48) 0.906 1.11 (0.33–3.75) 0.865 Professional 1.53 (0.61–3.84) 0.370 1.03 (0.31–3.47) 0.959 1.40 (0.53–3.74) 0.499 Gravidity (no.) ≤ 2 (Ref.) 3–5 2.17 (1.18–4.00) 0.013 1.73 (0.93–3.23) 0.083 2.30 (1.13–4.67) 0.021 ≥ 6 6.23 (2.37–16.4) < 0.001 0.61 (0.24–1.57) 0.307 4.83 (1.59–14.7) 0.006 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.90 (0.68–5.29) 0.220 2.21 (1.08–4.52) 0.030 2.01 (0.57–7.10) 0.281

OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category.

that as a variable it has less influence decrease the incidence of NTDs. revealed that 92.0% of women knew than educational level or number of This is an important consideration for about folic acid from the physician. This pregnancies. Knowledge about the use policy-makers. Besides the emotional, finding should be considered in folic of folic acid during both the preconcep- psychological and physical effects of acid promotion campaigns. Amtai et al. tional and 1st trimester periods was very spina bifida, the total cost of lifetime suggested that every family planning high among women with university management of the cases who survive consultation and every child vaccina- education, and increased significantly is high and causes a huge burden on tion should be used as an opportunity to with the number of pregnancies. the community (23). Further studies promote folic acid use (19). This is also In the present study 18.8% of the should be done to study the cost–ben- applicable in Egypt, especially during pregnant women reported consuming efit of providing folic acid free of charge visits for obligatory childhood immuni- folic acid during the current pregnancy. in Egypt. zations. Another method of spreading In the UAE the percentage was much A study in Qatar demonstrated that folic acid awareness is through aware- higher, at 68% (18,22), which may be the physician was the main source of ness campaigns, which could include due to the fact that the UAE govern- women’s knowledge about folic acid posters, announcements in the media ment ANC facilities provided folic (63.4%) (11), although in Taipei the and sessions for high-school or even acid free of charge. Supplying folic acid percentage was 44.4% (12). Other university students. These campaigns supplements for all visitors to ANC sources of knowledge in those studies should educate women about foods clinics is likely to raise the percent- included newspapers, books, nurses, that are rich in folic acid, in addition to age of females using them and hence pharmacists and the family. Our study encouraging the consumption of the

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recommended daily dose of folic acid as women attending for ANC in pri- health-care providers should be given supplements or as part of multivitamin mary or secondary health-care facilities. guidelines about raising awareness of fo- tablets. Thirdly, women below age 18 years and lic acid among women of reproductive Fortification of foods with folic older than 45 years were not included age. Additionally, awareness campaigns acid is another strategy for decreasing in our sample and therefore our results about folic acid should be held, targeting NTDs. Data has revealed an association might not accurately reflect the level of women in the reproductive age groups. between folic acid fortification and a knowledge about folic acid in all women Further studies need to be conducted in decrease in the risk of NTDs (24). It of childbearing ages. Finally, women Egypt to demonstrate the cost–benefit is noteworthy that the fortification of were included regardless their previous of providing folic acid supplementation some foods, including enriching cereals number of ANC visits. free of charge to all women at ANC and grains with folic acid, was mandated In conclusion, there is room for im- clinics and for a programme of food in the USA since 1998 (25). After folic provement regarding the knowledge fortification with folic acid. acid fortification was implemented the about folic acid among women in the reduction in the prevalence of NTDs in childbearing years in Egypt. The present the country was 23% (26). study revealed that a small propor- Acknowledgements There were some limitations that tion of women were aware about the may have affected the study findings. importance of preconceptional folic We thank Dr Waleed Salah El-Din, First, the study may have been subjected acid, and even fewer had consumed fo- lecturer in the Department of Commu- to population bias, as the data were lic acid in the preconceptional period. nity, Occupational and Environmental collected from only one health-care Knowledge about folic acid intake was Medicine, Ain Shams University, for centre in Cairo, Egypt. Secondly, the significantly higher among women with his role in the statistical analysis in our study women were attending a tertiary university education and high gravid- research. health-care facility and they may not ity. Although doctors were the main Funding: None. have had the same level of knowledge source of knowledge, we suggest that Competing interests: None declared.

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Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from Pakistan F. Jahan,1 R. Roshan,2 K. Nanji,3 U. Sajwani,4 S. Warsani 5 and S. Jaffer 6

العوامل التي تؤثر عىل عملية احلصول عىل موافقة مسبقة عىل عملية جراحية لدى املرىض وأقارهبم يف البلدان النامية: نتائج من باكستان فردوس جهان، روزينا روشان، كشمرية نانجي، ُع ْظ َى مسجواين، شاهني َو ْرساين، سلمى جعفر اخلالصــة: لقــد بذلــت جهــود ًيف مؤخــراباكســتان مــن أجــل وضــع دالئــل إرشــادية أخالقيــة للبحــوث واملامرســة الطبيــة. وقــد استكشــفت هــذه الدراســة التصــورات عــن عمليــة احلصــول عــى موافقــة مســبقة عــى عمليــة جراحيــة، َ والعوامــلالتــي تؤثــر عــى هــذه العمليــة لــدى مــرىض داخليــني وعائالهتــميف مستشــفى للرعايــة الثالثيــة يف كراتــي. ففــي دراســة مســتعرضة أجريــت عــام 2010 أجابــت عينــة عشــوائية مكونــة مــن 400 مريــض بالــغ بعــد اجلراحــة عــى اســتبيان َّمنظــم تــم اختبــاره ً.مســبقا فــكان مــا إمجاليــه 233 ًمريضــا )58.3 %( قــد َّوقعــوا عــى اســتامرة املوافقــة عــى 41.7 167 اجلراحــة بأنفســهم، يف حــني َّوقــع مــن األقــارب ) %( نيابــة عــن املريــض. وكانــت العوامــل َّاملتصــورة التــي ارتبطــت - بشــكل ملحــوظ - بعــدم توقيــع املــرىض عــى اســتامرة املوافقــة بأنفســهم: اللغــة املســتخدمة )OR املعدلــة =4.6(، واملصطلحــات الطبيــة املســتخدمة )OR املعدلــة =2.7(، وعــدم كفايــة الوقــت املخصــص )OR املعدلــة = 3.8(، وأســباب ثقافية/تقليديــة )OR املعدلــة = 1.5(، والتعليــم املنخفــض )OR املعدلــة= 2.4 (. وكان التوقيــت غــري املناســب ألخــذ املوافقــة، وعــدم اإلبالغ/الســؤال عــن املوافقــة َعاملــني غــري َّمهمــني ً.إحصائيــا فينبغــي أن يكــون ممارســو الرعايــة الصحيــة عــى علــم بالعوامــل التــي تؤثــر يف عمليــة املوافقــة املســبقة، وأن يشــجعوا املــرىض عــى التوقيــع عــى اســتامرة املوافقــة بأنفســهم.

ABSTRACT Efforts have been made in Pakistan to create ethical guidelines for research and medical practice. This study explored the perceptions of and factors affecting the process of obtaining informed consent to surgery among inpatients and families at a tertiary-care hospital in Karachi. A random sample of 400 post-surgery adult patients answered a pre-tested, structured questionnaire. Overall, 233 patients (58.3%) had signed the surgery consent form themselves, while 167 relatives (41.7%) had signed on behalf of the patient. Perceived factors significantly associated with patients not signing the consent form themselves were: language used (adjusted OR = 4.6), medical terminology used (aOR = 2.7), insufficient time allocation (aOR = 3.8), cultural/traditional reasons (aOR = 1.5) and low education (aOR = 2.4). Inappropriate timing for taking consent and not being informed/asked about consent were not statistically significant factors. Health-care practitioners should encourage patients to sign the consent form themselves.

Facteurs influant sur le processus d'obtention d'un consentement éclairé pour une intervention chirurgicale chez des patients et des parents dans un pays en développement : résultats du Pakistan

RÉSUMÉ Des efforts récents ont été réalisés au Pakistan en vue de créer des lignes directrices pour l'éthique en recherche et pratique médicales. La présente étude a évalué les perceptions relatives au processus d'obtention d'un consentement éclairé pour une intervention chirurgicale et les facteurs d’influence chez des patients hospitalisés et leur famille dans un hôpital de soins tertiaires à Karachi. Un échantillon aléatoire de 400 patients adultes postopératoires a répondu à un questionnaire prétesté et structuré. Au total, 233 patients (58,3 %) avaient signé eux-mêmes le formulaire de consentement à une intervention chirurgicale, tandis que 167 parents (41,7 %) avaient signé pour le patient. Les facteurs perçus comme fortement associés aux patients qui n'avaient pas signé eux-mêmes le formulaire de consentement étaient les suivants : la langue utilisée (OR ajusté = 4,6), la terminologie médicale utilisée (OR ajusté = 2,7), l'insuffisance du temps alloué (OR ajusté = 3,8), des raisons culturelles/traditionnelles (OR ajusté = 1,5) et un faible niveau d'études (OR ajusté = 2,4). Un moment inopportun pour demander le consentement et l’absence d’information/d’interrogation à ce sujet n'étaient pas des facteurs statistiquement significatifs. Les professionnels de santé doivent encourager les patients à signer eux-mêmes le formulaire.

1Department of Family Medicine, Oman Medical College, Sohar, Oman (Correspondence to F. Jahan: [email protected]).2 Division of Nursing Services; 3Department of Family Medicine; 4B1-Surgical Unit; 5Neurosurgery Unit; 6Office of the Chief Operating Officer, Aga Khan University Hospital, Karachi, Pakistan. Received: 24/12/12; accepted: 25/09/13

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Introduction ethics in Pakistan (6). This is because excluded. The sample size was calcu- crucial decisions are often made by fam- lated using Epi-Info, version 6, and based The most important goal of informed ily members or are left entirely up to on a prevalence of 50% with 5% error consent is that patients have an oppor- the physician, and there seems to be bound and 5% level of significance; the tunity to be informed participants in a general acceptance of this practise required sample size was estimated as at decisions about their health care (1). among the public. Patients’ awareness least 385 subjects. It is generally accepted that complete of their rights to informed consent and The patients were selected through informed consent includes a discussion privacy is often low (7). Previous quali- simple random sampling. The study of the following elements: the nature tative research has shown that many statistician used computer-generated of the decision/procedure; reasonable physicians do not think it is necessary to random numbers to identify patients alternatives to the proposed interven- obtain a formal consent after providing from the daily list of patients requiring tion; the relevant risks, benefits and the patients with thorough information surgery. Patients were identified on the uncertainties related to each alternative (8,9). In view of these observations, this day of the surgery and were recruited (2); assessment of the patient’s under- study was conducted to identify the and interviewed on the 2nd day of the standing; and the patient’s acceptance perceptions of and factors affecting the surgery. Written informed consent for of the intervention. It originates from process of obtaining informed consent participation in this survey was obtained the legal and ethical right the patient has to surgery among inpatients and fami- from each participant (verbally with to direct what happens to his/her body lies attending a tertiary care hospital in thumb impression from those who and from the ethical duty of the physi- Karachi, Pakistan. could not read or write). The study was cian to involve the patient in health-care reviewed and approved by the ethics decisions. review committee of the Aga Khan Uni- Informed consent recognizes not Methods versity and Hospital. only patients’ autonomy in decision- Study setting making but also their right to complete Data collection information. The informed consent This hospital-based, cross-sectional Data were collected while ensuring process requires the physician to ex- study was conducted between July and strict confidentiality for the participants. plain in sufficient detail the diagnostic, October 2010 in Aga Khan University The patients were interviewed in an therapeutic and prognostic reasoning Hospital, Karachi, Pakistan. Karachi is environment where their privacy could that leads to his/her expert decision on the largest city of Pakistan and is the be ensured (attendants were asked to what is in the best interest of the patient capital city of Sind Province. The Aga leave the area and ambulant patients (3). In most cases, it is clear whether Khan University is a 563-bed not-for- were interviewed in a separate room or not patients are competent to make profit, private institution in Pakistan adjacent to the ward). Two nursing their own decisions (4). However, if providing high-quality health care. graduates were trained for screening the patients are judged to be incapacitated The hospital has also been awarded eligible patients and administration of /incompetent to make health care deci- the prestigious Joint Commission the questionnaire. sions, a surrogate decision-maker must International accreditation and ISO speak for them (5). 9001:2008 certification. The study Questionnaire development Most developed countries have patients were selected from the surgi- The questionnaire was formulated after enshrined these concepts of informed cal ward of the hospital. This ward has an extensive literature search (Medline) consent, privacy and confidentiality in 56 beds and provides comprehensive and consensus by the study investiga- federal or state laws and codes of eth- inpatient services for general surgery, tors, who are involved in the hospital ics. In Pakistan there have been some urology, otolaryngology and head and quality management committee. The recent efforts to create ethical guide- neck surgery, ophthalmology, cardio- questionnaire comprised 3 sections: lines for research and medical practice. thoracic and dental surgery. section A dealt with the descriptive Significantly, the Pakistan Medical and characteristics of the study participants; Dental Council, the regulatory body of Sample selection section B consisted of 12 questions medical practitioners, has formulated a Post-surgery patients, over the age of 18 about to the consent process and 9 code of ethics for all doctors, although years, admitted to the surgical ward and questions about the important clauses no concrete steps have been taken giving consent to participate were in- of the surgical informed consent form; to ensure its application. At the same cluded in the study. Those patients who and section C was about the factors as- time, cultural values in Pakistan offer required special care, intensive care unit sociated with not signing of the consent a challenge to the practice of medical or coronary care unit admission were form by patients themselves, and future

570 املجلة الصحية لرشق املتوسط املجلد العرشون العدد التاسع

recommendations. To enhance its Table 1 Sociodemographic characteristics of the study respondents (n = 400) comprehensibility the English version Variable No. % of the questionnaire was translated into Sex the local Urdu language and was back- Male 214 53.5 translated into English to check for Female 186 46.5 consistency; any discrepancies found Age [median (IQR) years] 37 (14–78) were removed. Pre-testing of the Urdu Marital status version was done on 5% of the sample Married 100 25.0 size (n = 25). The final questionnaire was shared with experts in the field of Single 300 75.0 family medicine and the quality control Occupation department to obtain their suggestions Earning 171 42.8 for improvement. Housewife 165 41.3 Retired 16 4.0 Data analysis Student 31 7. 8 Statistical analysis was carried out using Unemployed 17 4.3 SPSS software, version 17. Proportions Educational status were reported for all the variables such Cannot read or write 37 9.3 as age, sex and occupation. Univariate Primary (1–5 years) 56 14.0 and multivariate logistic regression was Secondary (6–10 years) 167 41.8 done to identify the perceived factors Intermediate and above (> 10 years) 140 35.0 associated with the consent process. Consent form signed by: The results are reported in form of odds Self 233 58.3 ratio (OR) and 95% confidence interval Parent 36 9.0 (CI). P-values < 0.05 were considered Spouse 56 14.0 statistically significant throughout the Child 51 12.8 study. Sibling 24 6.0

IQR = interquartile range. Results

A total of 490 eligible patients were ap- 9.3% participants were unable to read sibling or child). There was no statisti- proached, out of whom 400 consented or write. cally significant difference in the pro- to participate and were included in Table 2 presents the perceptions of portion of males and females whose the final analysis, yielding a response patients regarding the informed con- relatives signed on their behalf [data not rate of 81.6% (400/490). Missing in- sent process. Although in most cases shown]. formation was handled through mean information about surgery was given in Table 2 compares the perceptions imputation. the clinic (70.0%), the consent for sur- of patients who signed for themselves Table 1 shows the sociodemo- gery was signed in the ward (76.8%) and and relatives who signed on their be- graphic characteristics of the study sam- 14.8% of respondents stated that con- half regarding the informed consent ple. Out of the total 400 participants sent was only signed in the operating process. When asked about the impor- a majority were males (53.5%). The theatre. Just over half of the respondents tance of obtaining consent before any median age was 37 years, range 14–78 (57.3%) agreed that informed consent surgery 63.8% of patients who signed years. Most of the participants were sin- was important to obtain before any sur- the consent form themselves agree that gle, divorced or widowed (75.0%) and gery. About one-third of the patients consent before any surgery was impor- one-quarter were married. Less than (32.9%) said they were influenced by tant, whereas only 48.2% of the relatives half of the participants (42.8%) were family and friends to proceed to surgery. signing agreed that it was important (P in paid employment, while 7.8% were In this study 233 (58.3%) of the pa- < 0.01). A majority of patients (84.3%) students and 4.0% were retired. Of the tients signed the surgery consent form and relatives (79.6%) agreed that the participants 41.8% had education to themselves, while for 167 (42.8%) of consent form has a medico-legal mean- secondary level, 35.0% had education patients the form was signed on their ing and wanted detailed information to intermediate level and above, while behalf by a relative (spouse, parent, (86.5% and 78.4% respectively). Of

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Table 2 Perceptions of patients and relatives who signed the surgery consent form regarding the informed consent process Statement/ characteristics of Total Self-signed Relative signeda P-value consent (n = 400) (n = 233) (n = 167) No. % No. % No. % Who explained the information Doctor 271 67.8 168 72.1 103 61.7 0.01 Resident 129 32.3 65 27.9 64 38.3 Where information was given Operating theatre 32 8.0 14 6.0 18 10.8 Ward 88 22.0 45 19.3 43 25.7 0.04 Clinic 280 70.0 174 74.7 106 63.5 Where consent was taken Operating theatre 59 14.8 28 12.0 31 18.6 Ward 307 76.8 183 78.5 124 74.3 > 0.05 Clinic 34 8.5 22 9.4 12 7. 2 Informed consent influenced your decision to proceed with surgery Yes 135 33.8 72 31.9 63 37.7 < 0.01 No 265 66.3 161 69.1 104 62.3 Influenced by anyone to proceed with surgery No 67 17.0 40 17.7 27 16.2 Yes, family/friends 74 32.9 51 22.6 23 13.8 0.04 Yes, doctor 252 64.1 135 59.7 117 70.1 Informed consent is important before any surgery Yes 225 57.3 146 63.8 79 48.2 < 0.01 No 168 42.7 83 36.2 85 51.8 Know about medico-legal significance of informed consent Yes 326 82.3 193 84.3 133 79.6 < 0.01 No 70 17.7 36 15.7 34 20.4 Amount of information preferred Detailed 329 83.1 198 86.5 131 78.4 0.02 Limited 67 16.9 31 13.5 36 21.6 Amount of information preferred if going for same surgery Detailed 303 7 7. 1 164 71.6 139 84.8 < 0.01 Limited 90 22.9 65 28.4 25 15.2 Received educational materials about pre- & post-operative management Yes 78 19.6 49 21.3 29 1 7. 4 > 0.05 No 319 80.4 181 78.7 138 82.6 Materials were helpful (n = 81) Yes 62 76.5 39 79.6 23 71.9 < 0.01 No 19 23.5 10 20.4 9 28.1 Satisfied with information provided Yes 367 91.8 227 9 7. 4 140 83.8 < 0.001 No 33 8.3 6 2.6 27 16.2

aRelatives: parent, spouse, sibling, other relative.

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the patients who signed the consent patients who signed for themselves includes understanding that one is form themselves 89.7% said they were (89.7%) were given the opportunity being asked to authorize surgical given the opportunity to ask ques- to ask questions whereas 76.6% of the management and understanding the tions compared with 76.6% of relatives relatives were given the opportunity. nature of that surgery as well as its who signed for them. Many patients Table 4 shows the univariate and clinical benefits and risks. and relatives reported that they were multivariate regression analysis of the Just over half of the patients not informed about the complica- factors associated with not signing of (58.3%) signed the consent form tions (51.1% and 56.9% respectively), the surgical consent form by patients themselves and for the rest consent length of stay in the hospital (21.2% themselves. When adjusted for other was given by a relative. The literature and 16.8% respectively), alterna- confounders in multivariate logistic supports our finding that signing con- tives to surgery (44.7% and 44.3% regression analysis the statistically sent forms by relatives and not only respectively) and type of anaesthesia significant factors associated with pa- by patients is also common practice (28.8% and 20.4% respectively). Few tients not signing the consent form in other countries (11). In practice, patients (21.3%) or relatives (17.4%) themselves were: language, medical surgeons and physicians in Pakistan had received any educational materi- terminology, insufficient time, cul- prefer to fill out the consent form in als regarding pre- and post-operative ture/traditions and educational status. the outpatient clinic where they can management and care/information When there were language barriers the explain the procedure and ask the pa- guidance, but those who received patient was 4.6 times more likely to tients to sign the relevant forms (12). them found the information very help- not sign the form themselves, whereas However, this may not allow adequate ful (79.6% and 71.9% respectively). when there were cultural barriers the time for deliberation and reflection, Almost all the patients signing for patients were 1.5 times more likely to as outlined by the United Kingdom themselves (97.4%) were satisfied not sign the form. Those patients who General Medical Council guidelines with the information they had been had lower educational status were (2). In our study, although a major- given, compared with 83.8% of rela- 2.4 times more likely not to sign the ity of patients (70.0%) had received tives who were satisfied P( < 0.001). consent form themselves. Moreover, information from the consultant in Table 3 presents responses to when inappropriate medical termi- the outpatient clinic, in fact signature the important clauses of the surgery nologies were used patients were was taken on the ward for 76.8%, while informed consent form. All the pa- 2.7 times more likely to not sign the 14.8% claimed that signature was tients who signed the consent form consent form. If patients were given taken in the operating theatre. reported they were informed about insufficient time to understand the In clinical situations it is important the indications for surgery, whereas contents of the consent form, they to have informed consent to make 7.8% of the relatives who signed the were 3.8 times more likely to not sign important decisions; however con- consent said they were not informed the consent form themselves. Factors sent practices vary in different institu- about the indications (P < 0.001). Of that were not significant in the regres- tions and countries. There is a lack of the patients 83.8% said that they were sion analysis were: inappropriate tim- awareness about consent even among informed about possible complica- ing for taking consent and not being educated patients in Pakistan (13,14). tions if surgery were not done, com- informed about or asked for consent. Previous studies have also looked at pared with only 69.5% of the relatives the consent practices in surgery pa- (P < 0.001). Overall, in only 14.8% tients (15). In a study in Pakistan and of cases were respondents informed Discussion the United Kingdom written consent about the alternatives to surgery and was routinely obtained for surgical 59.8% were informed about the type Informed consent is more than treatment by the staff (16). This prac- of anaesthesia to be used in the sur- simply getting a patient to sign a writ- tice has previously been pointed out gery. Most of the patients who signed ten consent form. It is a process of in another study in Pakistan, in which the consent form themselves (82.4%) communication between a patient only 29% patients signed their own were informed about the nature of the and the physician that results in the consent (8). surgery as compared with only 59.9% patient’s authorization or agreement A great majority of patients and of the relatives who signed on their to undergo a specific medical inter- relatives agreed that the consent form behalf, whereas 89.3% versus 73.1% of vention (10). An important part of has a medico-legal meaning and want- the patients and relatives respectively such a clinical, ethical judgement is ed detailed information. Few patients were informed about the expected the patient’s capacity to participate in (21.3%) or relatives (17.4%) had benefits of the surgery. Most of the the informed consent process, which received any educational materials

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Table 3 Attitudes of patients and relatives who signed the surgery consent form towards the important clauses of the consent form Statement Total Self-signed Relative signeda P-value (n = 400) (n = 233) (n = 167) No. % No. % No. % Informed about nature of surgery Yes 292 73.0 192 82.4 100 59.9 No 75 18.8 32 13.7 43 25.7 < 0.001 Don’t know 33 8.3 9 3.9 24 14.4 Informed about indications for surgery Yes 383 95.8 233 100.0 150 89.8 No 13 3.3 0 0.0 13 7. 8 < 0.001 Don’t know 4 1.0 0 0.0 4 2.4 Informed about possible complications of surgery Yes 177 44.3 105 45.1 72 43.1 No 214 53.5 119 51.1 95 56.9 > 0.05 Don’t know 9 2.3 9 3.9 0 0.0 Informed about length of hospital stay after surgery Yes 291 74.0 169 74.8 122 73.1 No 76 19.3 48 21.2 28 16.8 0.037 Don’t know 26 6.6 9 4.0 17 10.2 Informed about alternatives to surgery Yes 58 14.8 35 15.5 23 13.8 No 175 44.5 101 44.7 74 44.3 > 0.05 Don’t know 160 40.7 90 39.8 70 41.9 Informed about possible complications if surgery was not done Yes 306 77.9 192 83.8 114 69.5 No 58 14.8 27 11.8 31 18.9 < 0.001 Don’t know 29 7. 4 10 4.4 19 11.6 Informed about expected benefits of surgery Yes 330 82.5 208 89.3 122 73.1 No 27 6.8 9 3.9 18 10.8 < 0.001 Don’t know 43 10.8 16 6.9 27 16.2 Informed about type of anaesthesia Yes 239 59.8 144 61.8 95 56.9 No 101 25.3 67 28.8 34 20.4 0.01 Don’t know 60 15.0 22 9.4 38 22.8 Given opportunity to ask questions Yes 337 84.3 209 89.7 128 76.6 No 28 7. 0 12 5.2 16 9.6 < 0.001 Don’t know 35 8.8 12 5.2 23 13.8

aRelatives: parent, spouse, sibling, other relative.

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Table 4 Factors associated with patients not signing the surgery informed consent form for themselves (n = 400) Variable Self-signed Relative signed OR (95% CI) AOR (95% CI) P-value No. % No. % Language factors No 33 44.6 41 55.4 1 1 Yes 200 61.3 126 38.7 2.3 (1.6–3.3) 4.6 (1.9–5.2) < 0.01 Better educational statusa Yes 177 57.7 130 42.3 1 No 56 62.2 34 37.8 2.6 (1.8–3.9) 2.4 (1.8–5.0) 0.01 Insufficient time allocated No 41 45.1 50 54.9 1 1 Yes 192 62.1 117 37.9 1.9 (1.4–2.6) 3.8 (2.8–4.7) 0.02 Medical terminology used No 59 56.7 45 43.3 1 1 Yes 174 58.8 122 41.2 1.8 (1.3–2.5) 2.7 (1.1–6.7) 0.03 Cultural/traditional reasons No 133 71.5 53 28.5 1 1 Yes 100 46.7 114 53.3 1.6 (1.2–2.3) 1.5 (1.1–3.5) 0.04 Inappropriate timing No 184 5 7. 1 138 42.9 1 Yes 49 62.8 29 37.2 1.3 (1.0–1.8) – – Not informed/asked No 208 63.0 122 37.0 1 Yes 25 35.7 45 64.3 1.2 (1.0–1.7) – –

aYes: > 6 years of education. OR = odds ratio; CI = confidence interval; AOR = adjusted odds ratio;.

regarding pre- and post-operative were given the opportunity to ask influences patients’ understanding management and care/information questions. Other research has shown about the information given regarding guidance. However, satisfaction with that knowledge regarding consent is procedures (18). In Pakistan the high the information provided was high deficient not only in patients, but also rates of illiteracy among the popula- among both patients (97.4%) and among health-care professionals, who tion obstructs patients’ ability to read relatives (83.8%). are often unaware of some of the im- the informed consent forms. People Regarding perceptions and knowl- portant aspect of consent (17). Many with regional dialects sometimes do edge about the important clauses of of our patients and relatives reported not understand either the national informed consent for surgery there that they were not informed about the (Urdu) or official (English) languages, were significant differences between complications, length of stay in the and this makes communication dif- the patients and relatives. In the cur- hospital, alternatives to surgery and ficult (8). Another factor identified in rent study 82.4% of patients who type of anaesthesia. the study was cultural/traditional rea- signed the consent form themselves In this study the multiple regres- sons. In this part of the world women were informed about the nature of sion analysis shows that the significant are commonly not given autonomy the surgery as compared with only factors associated with not signing of to take decisions. Usually a male or 59.9% of the relatives who signed on the consent form by patient them- the head of the family takes impor- the patient’s behalf. Slightly higher selves were language problems, medi- tant decisions and, since the consent proportions of patients and relatives cal terms used during explanation, form is seen as a legal document, it reported that they were informed insufficient time allocated, cultural/ is mostly men who sign it on behalf about the expected benefits of the traditional reasons and low educa- of their wives. However, in this study surgery (89.3% versus 73.1% respec- tional status. The literature has shown there was no significant difference in tively). Not all the patients or relatives before that a low level of literacy the proportion of males and females

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whose relatives signed on their behalf. about their right to informed consent Conclusions This could be because the study pri- and privacy is essential in health care vate hospital mainly serves an urban (23). Previous qualitative research has This study showed the perceptions population, who tend to be better edu- shown that a significant number of of patients and their relatives to sign- cated (only 9.3% of our patients were physicians do not think it is necessary ing a surgery consent form. Health illiterate) and therefore more likely to to obtain a proper consent and that care practitioners need to be aware understand and acknowledge wom- signing a document is sufficient, but and knowledgeable about the various en’s autonomy. It would be interesting the literature has shown that shared factors affecting informed consent in to note the practice in government and decision-making and proper com- order to improve the informed con- rural hospitals, where patients may have munication will lead to better out- sent process. In this study language lower literacy levels. comes in terms of patient satisfaction, was identified as the greatest bar- There is evidence that if the smooth recovery from procedures rier to informed consent. Therefore consent process is communicated and surgery as well as better compli- translation of the informed consent properly patient satisfaction levels ance with doctors’ advice (9, 24). form into various regional languages during and after surgery are higher This study had some limitations. It and providing translators is recom- (19,20). Taking consent at the ap- was a quantitative study and the results mended. Health-care practitioners propriate time and in the correct could have been more meaningful also need to be aware of particular manner can resolve many issues after if patients’ perceptions had been as- items in the consent form (such as surgery (21,22). This was evident sessed qualitatively to determine the medical terminology) that may be from the results of our study, in which subjective perceptions of the patients problematic and to ask potential a majority of the patients (86.5%) regarding the barriers faced during subjects direct questions about their and their relatives (78.4%) wanted signing of the consent form. In addi- understanding of those items. Further to have detailed information about tion, this study was conducted in a comparative studies regarding the the surgery. Moreover, the patients private hospital, so extrapolation of informed consent process should (63.8%) and relatives (48.2%) who the results to government and semi- be carried out between government signed the consent form knew that private hospitals should be done with and private hospitals to improve the obtaining consent before any surgery caution as there could be differences process. is important. Making patients’ aware in practices. Competing interests: None declared.

References

1. McCullough LB, Chervenak FA. Informed consent. Clin Perina- 10. Ruhnke GW, Wilson SR, Akamatsu T, Kinoue T, Takashima tol. 2007 Jun;34(2):275–85, vi. PMID:17572234 Y, Goldstein MK, et al. Ethical decision making and patient 2. Consent: patients and doctors making decisions together. autonomy: a comparison of physicians and patients in Ja- London: General Medical Council; 2008 (http://www.gmc- pan and the United States. Chest. 2000 Oct;118(4):1172–82. uk.org/static/documents/content/Consent_-_English_0911. PMID:11035693 pdf, accessed 12 June 2014). 11. Sypher B, Hall RT, Rosencrance G. Autonomy, informed con- 3. Moskop JC, Marco CA, Larkin GL, Geiderman JM, Derse sent and advance directives: a study of physician attitudes. W AR. From Hippocrates to HIPAA: privacy and confidential- V Med J. 2005 May-Jun;101(3):131–3. PMID:16161532 ity in emergency medicine–Part I: conceptual, moral, and 12. Moazam F. Families, patients, and physicians in medical de- legal foundations. Ann Emerg Med. 2005 Jan;45(1):53–9. cision nmaking: a Pakistani perspective. Hastings Cent Rep. PMID:15635311 2000 Nov-Dec;30(6):28–37. PMID:11475993 4. Courtney MJ. Information about surgery: what does the public 13. Shiraz B, Shamim MS, Shamim MS, Ahmed A. Medical ethics want to know? ANZ J Surg. 2001 Jan;71(1):24–6. PMID:11167593 in surgical wards: knowledge, attitude and practice of surgi- 5. Del Carmen MG, Joffe S. Informed consent for medical treat- cal team members in Karachi. Indian J Med Ethics. 2005 Jul- ment and research: a review. Oncologist. 2005 Sep;10(8):636– Sep;2(3):94–6. PMID:16276659 41. PMID:16177288 14. Mahmood K. Informed consent and medical ethics. Ann King 6. Jafarey A. Informed consent: views from Karachi. East Mediterr Edward Med Coll. 2005;11:247–9. Health J. 2006;12 Suppl 1:S50–5. PMID:17037689 15. Qidwai W, Qureshi H, Azam SI, Ali SS, Ayub S. Perception of 7. Bhurgri H, Qidwai W. Awareness of the process of informed bioethics among general practitioners in Karachi. Pak J Med consent among family practice patients in Karachi. J Pak Med Sci. 2002;18:221–6. Assoc. 2004 Jul;54(7):398–401. PMID:15449928 16. Samad A, Khanzada TW, Kumar B, Rajput A. Perception of 8. Khan RI. Informed consent and some of its problems in Paki- consent among house surgeons: differences between Pakistan stan. J Pak Med Assoc. 2008 Feb;58(2):82–4. PMID:18333527 and United Kingdom hospitals. J Coll Physicians Surg Pak. 9. Paterick TJ, Carson GV, Allen MC, Paterick TE. Medical in- 2008 Dec;18(12):789–90. PMID:19032899 formed consent: general considerations for physicians. Mayo 17. Shamsa Z, Rizwan HM, Ahmed NS, Ayesha RA, Ahsan A, Fatima Clin Proc. 2008 Mar;83(3):313–9. PMID:18315998 NM. The awareness of 'informed consent', among medical

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students and the current consent practices at a tertiary care 21. Amin FM, Jawaid M, Rehman S. An audit of information pro- hospital objective: our study aims to document. Ann Pak Inst vided during Preoperative informed consent. Pak J Med Sci. Med Sci. 2011;7(4):176–9. 2006;22:10–3. 18. Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, 22. Imam SZ, Syed KS, Ali SA, Ali SU, Fatima K, Gill M, et al. Patients’ Crigler B, et al. Influence of patient literacy on the effective- satisfaction and opinions of their experiences during admis- ness of a primary care-based diabetes disease management sion in a tertiary care hospital in Pakistan—a cross sectional program. JAMA. 2004 Oct 13;292(14):1711–6. PMID:15479936 study. BMC Health Serv Res. 2007;7:161. PMID:17915023 19. Yousuf RM, Fauzi ARM, How SH, Rasool AG, Rehana K. Aware- 23. Schildmann J, Cushing A, Doyal L, Vollmann J. Informed con- ness, knowledge and attitude toward informed consent among sent in clinical practice: pre-registration house officers’ knowl- doctors in two different cultures in Asia: a cross-sectional com- edge, difficulties and the need for postgraduate training. Med parative study in Malaysia and Kashmir, India. Singapore Med Teach. 2005 Nov;27(7):649–51. PMID:16332561 J. 2007 Jun;48(6):559–65. PMID:17538757 24. Whitney SN, McGuire AL, McCullough LB. A typology 20. Boisaubin EV. Observations of physician, patient and fam- of shared decision making, informed consent, and sim- ily perceptions of informed consent in Houston, Texas. J Med ple consent. Ann Intern Med. 2004 Jan 6;140(1):54–9. Philos. 2004 Apr;29(2):225–36. PMID:15371189 PMID:14706973

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Interobserver variations in reporting of prostatic adeno carcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia A.C. Al-Rikabi 1 and H. Alkhalidi 1

تقييــم االختلفــات بــن الفاحصــن يف اإلبــاغ عــن الرسطانــة الغديــة يف الربوســتات باســتخدام عينــات خزعــات لبيــة: دراســة اســتعادية مــن مستشــفى إحالــة جامعــي يف اململكــة العربيــة الســعودية ّ ر عمالركايب، هشام اخلالدي اخللصــة: يتــم يف الســنوات األخــرة إرســال أعــداد أكــرب مــن اخلزعــات اللبيــة للربوســتات مــن أجــل التقييــم اهليســتوباثولوجي، مــع مــا يصاحــب ذلــك مــن زيــادة يف عــبء العمــل بالنســبة الختصــايص الباثولوجيــا. وقــد هدفــت هــذه الدراســة االســتعادية إىل تقييــم التوافــق واالختــاف بــن الفاحصــن مــن اختصاصيــي اهليســتوباثولوجيا يف اإلبــاغ عــن الرسطانــة الغديــة يف الربوســتات باســتخدام مــواد تــم احلصــول عليهــا مــنعينــات خزعــات لبيــة مــنالربوســتات. فقــد تــم جلــب مــا جمموعــه 810 عينــات خلزعــات لبيــة باإلبــرة مــن الربوســتات تــم احلصــول عليهــا مــن مريــض100 يشــتبه بإصابتهــم برسطانــة غديــة يف الربوســتات، وذلــك مــن املــواد األرشــيفية يف مستشــفى جامعــة امللك ِ خالــد بالريــاض، وتــم تصنيفهــا - بشــكل مســتقل - مــن ق َبــل ثلثــة مــن اختصاصيــي اهليســتوباثولوجيا ذوي اخلــربة، والذيــن ُع ِّمــي عليهــم التشــخيص األصــي. فــكان هنــاك اتفــاق كبــر بــن الفاحصــن مــن اختصاصيــي الباثولوجيــا، َتراف َــق مــع أحــراز كابــا غــر ِّمرجحــة تــراوح مــا 0.85 0.69 بــن و . وخلــص الباحثــان إىل تشــجيع اختصاصيــي الباثولوجيــا يف مستشــفيات أخــرى عــى أن يراجعــوا - بشــكل دوري - َت َو ُافــق التشــخيصات يف حماولــة لتحســن ممارســاهتم يف جمــال باثولوجيــا غــدة الربوســتات.

ABSTRACT In recent years, greater numbers of prostate biopsy cores are being submitted for histopathological assessment, with a concomitant increase in workload for the pathologist. This retrospective study aimed to assess the concordance and interobserver variation between histopathologists in reporting prostatic adenocarcinoma using material obtained from prostatic core biopsy specimens. A total of 810 prostatic needle core biopsy specimens obtained from 100 patients with suspected prostatic adenocarcinoma were retrieved from the archival material at King Khalid University Hospital, Riyadh, and classified independently by 3 experienced histopathologists who were blinded to the original diagnosis. There was considerable interobserver agreement between the pathologists, with unweighted kappa scores ranging from 0.69–0.85. We would encourage other hospital pathologists to review periodically the uniformity of diagnoses in an attempt to improve their practices in prostate gland pathology.

Évaluation des variations inter-observateurs dans la notification des adénocarcinomes prostatiques à partir d'échantillons de microbiopsie : étude rétrospective dans un hôpital de soins tertiaires en Arabie saoudite

RÉSUMÉ Ces dernières années, le nombre d'échantillons de microbiopsie de la prostate soumis à une analyse histopathologique a augmenté, ainsi que la charge de travail concomitante du pathologiste. La présente étude rétrospective visait à évaluer la concordance et la variation inter-observateurs parmi les histopathologistes dans la notification de l'adénocarcinome prostatique à partir d'échantillons de microbiopsie prostatiques. Au total, 810 échantillons prostatiques de microbiopsie au trocart de 100 patients chez qui un adénocarcinome prostatique était suspecté, ont été extraits des archives de l'hôpital universitaire King Khalid à Riyad, puis classifiés indépendamment par trois histopathologistes expérimentés qui ignoraient le diagnostic initial. La concordance entre les observateurs pathologistes était élevée, avec des scores kappa non pondérés compris entre 0,69 et 0,85. Nous encourageons d'autres pathologistes hospitaliers à examiner périodiquement l'uniformité des diagnostics afin d'améliorer leurs pratiques dans la pathologie de la prostate.

1Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.C. Al-Rikabi: ammar_rikabi12@ yahoo.com). Received: 20/06/12; accepted: 08/07/12

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Introduction of prostatic adenocarcinoma among 3 Analysis histopathology consultants. The results were tabulated and analysed Apart from skin cancer, carcinoma using the multiple-reader Cohen kappa of the prostate is the most common statistical analysis method (7,11) using internal malignancy among men in Methods SPSS, version 18. The aim was to assess Western countries. It is responsible Sample the precision pertaining to agreement for 10% of cancer deaths (1) and is on between observers (interobserver the increase in most countries (2). The In this retrospective study a total of agreement). The Gleason score (grade rate of prostate cancer in Saudi Arabia 810 prostatic needle biopsies obtained of malignant cases) was not, however, ranked sixth among male patients with from 100 patients from 2005 until the recorded as this parameter was outside a crude annual incidence of 5.7 per end of 2011 were retrieved from the the scope of this retrospective study. 100 000 (3). archives of the histopathology unit The diagnosis of prostate cancer re- at King Khalid University Hospital, quires the estimation of prostate-specif- Riyadh. The number of needle cores Results ic antigen and multiple cores obtained obtained from each patient varied The results obtained by the 3 partici- by thin-bore needle biopsies. Increasing from 6 to 12 cores. This was due to an pating pathologists are summarized in the number of needle cores analysed to evidence-based change in the policy (in Table 1. The kappa score for interob- between 6 to 12 has been shown to im- the last 10 years) regarding the number server agreement between pathologists prove prostate cancer detection by 29% of needle cores that should be obtained A and B was 0.71 (P < 0.001), between (4,5). For this reason, a greater number per patient. pathologists A and C was 0.69 (P < of prostate biopsies are obtained nowa- Data collection 0.001) and between pathologist B and days and more biopsy cores are being C was 0.85 (P < 0.001). submitted than ever before and this has All biopsies were processed and stained created a huge interpretive burden for using haematoxylin and eosin stain in Our results also showed that almost the diagnostic histopathologist (6), a our laboratory. We routinely obtain 6 all cases of diagnostic uncertainty and burden that is exacerbated by the diffi- cuts (2 adjacent sections from 3 sepa- interobserver differences in interpretation were due to the presence of small culties of prostate biopsy interpretation rate levels) from the paraffin block for atypical or atrophic acini areas consist- (6,7). routine staining. ing of 5 or fewer acini. The percentages The subject of interobserver varia- Three experienced general histo pathologists were asked to examine of such cases varied between 2% and 6% tion in cytological and histological diag- and were mainly due to the presence of each of the 810 stained needle noses of cancer and its epidemiological small atypical acinar proliferation. implications has become increasingly biopsies without their knowledge of relevant in the last 20 years. Various the previous clinical, radiological or studies have shown highly reproducible histopathological findings of the 100 Discussion diagnoses of uterine cervical neoplasia patients from whom those biopsies (8), while there was considerable inter- were obtained. The results obtained It may sometimes be challenging for observer variation in the reporting of from each pathologist (A, B and C) the pathologist to deliver a definite di- anal intraepithelial neoplasia (9) and were independently documented as agnosis of adenocarcinoma in prostate in certain types of breast carcinomas being either negative for malignancy biopsies, particularly if the size of the (10). With this in mind, this study in (normal), positive for malignancy (ab- lesion is too small to judge the pres- Saudi Arabia aimed to assess the diag- normal) or inconclusive, i.e. in need of ence of an infiltrative pattern. This issue nostic reproducibility and interobserver further immunohistochemical stains has become more pertinent in recent variation in histopathological reporting or repeat biopsies. years due to clinical stage reduction of

Table 1 Frequency distribution of prostatic specimen observations among the 3 pathologists (n = 810) Observation Pathologist A Pathologist B Pathologist C No. % No. % No. % Normal 558 68.9 575 71.0 562 69.4 Abnormal 200 24.7 214 26.4 231 28.5 Inconclusive 52 6.4 21 2.6 17 2.1

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prostate cancer, which occurred as a (0.85) fell within the kappa range of Conclusions consequence of widespread prostate- 0.81–1, which is generally interpreted specific antigen testing and increased as almost perfect agreement (11). In- This study show good interobserver numbers of biopsies leading to “early” conclusive interpretations were mostly agreement in the interpretation of diagnosis of smaller cancerous foci (6). due to the presence of small atypical or prostatic and needle biopsies among Also repeat biopsies in the context of ac- atrophic acini. These findings are keep- the participating histopathologists tive surveillance treatment might lead to ing with those reported in the literature (kappa ranges 0.69–0.85). Incon- an increased frequency of small foci of (7,12–15). clusive interpretations were mostly adenocarcinoma, high-grade prostatic Despite the interpretative difficul- due to the presence of small atypical intraepithelial neoplasia and lesions ties and the burden of an increasing or atrophic acini. The establishment reported as suspicious for malignancy workload, experienced surgical pathol- of an intradepartmental system of or atypical small acinar proliferation. ogists have a high level of accuracy in consultation with joint reporting and In this study of prostate core biopsy prostatic needle biopsy interpretation signing out of prostatic carcinoma by specimens the degree of concordance and Gleason grading. Interobserver at least 2 experienced histopatholo- among the 3 histopathologists was es- reproducibility of Gleason grading gists will help maintain a high degree timated using the kappa coefficient. among urologic pathologists has been of diagnostic concordance. Based on This is the most commonly reported shown to acceptable (5,16–19). The the results presented, we would en- measure in the medical literature, and greater differences of interpretation courage other hospital pathologists, can provide more information than a result from low-grade cancers (6), in collaboration with their urologists, simple calculation of the raw propor- cancers with small cribriform pattern to review periodically the uniformity tion of agreement. The method is excel- (20) and cancers whose histology is on of their diagnoses in an attempt to im- lent for comparing results obtained by the border between Gleason patterns prove their prostate gland pathology individuals but is slightly affected by (16,17). The false-negative rate (missed practices. prevalence (11). The study showed a prostate cancer) was 0.6–1% and the good degree of concordance in the in- false-positive rate (overdiagnosis of terpretation of prostatic needle biopsies prostate cancer) was 0.3 (6,18). These Acknowledgements among the 3 participating histopathol- numbers indicate a small but significant ogists, with interobserver agreements error level that could be avoided by sec- The authors would like to express their which varied between kappa 0.69 and ondary pathology review (18,19). The gratitude to Dr Abdulmalik Al-Sheikh 0.85. There was substantial interob- findings obtained from the biopsies in who kindly agreed to participate in server agreement between pathologists the current study were not compared this study. The secretarial help of Ms A and B (0.71) and A and C (0.69) with those seen in the excision speci- Roxanne Alamares during the typing (kappa values 0.61–0.80 are generally mens (prostatectomies) as we aimed to of this manuscript is also greatly ap- interpreted as substantial agreement) assess the reproducibility of the results preciated. (11), while the interobserver agree- and not measure the accuracy of the Funding: None. ment between pathologist B and C initial diagnoses. Competing interests: None declared.

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581 Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab السياسات واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية Republic . Tunisia . United Arab Emirates . Yemen ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق 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.

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Editorial

Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean...... 527 Research articles

Pattern of cigarette and waterpipe smoking in the adult population of Jordan...... 529 Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey...... 538 Eastern Mediterranean Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran...... 547 Use of complementary and alternative medicine among midlife Arab women living in Qatar...... 554 Health Journal Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt...... 561 Factors affecting the process of obtaining informed consent to surgery among patients and La Revue de Santé de relatives in a developing country: results from Pakistan...... 569 Volume 20 Number 9 la Méditerranée orientale Interobserver variations in reporting of prostatic adenocarcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia...... 578 September 2014

All people should have access to needed health services without having to risk financial hardship. Social health insurance (SHI) is an effective instrument for countries to achieve this. SHI is a principal method of health financing to raise and pool money through a mix of obligatory insurance contributions and government revenues so everyone can have health care cover.

املجلد العرشون / عدد Volume 20 / No. 9 9 أيلول / سبتمرب September/Septembre 2014

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