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EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region.

LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région.

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ISSN 1020-3397

Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Cover photograph ©World Health Organization Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale

املجلد الثاين و العرشون عدد Vol. 22 No. 9 • 2016 • 9 Contents

Editorial Closer to a polio-free Eastern Mediterranean Region A. Alwan and C. Maher...... 645 Research articles Validation of Persian version of WHOQOL-HIV BREF questionnaire in Islamic Republic of Iran M. Salehi, S. Niroumand, M.R. Erfanian, R.B. Sajjadi and M. Dadgarmoghaddam...... 647 Effect of anti-smoking advertisements on Turkish adolescents E. Unal, M.E.Gokler, S. Metintas and C. Kalyoncu...... 654

أثر اإلعالم واإلعالن يف الرتويج التجاري لألغذية عىل السلوك الغذائي للمراهقات بمدينة جدة 662...... إهلام اجلعلي Prevalence and correlates of metabolic syndrome in pre-crisis Syria: call for current relief efforts H. Ramadan, F. Naja, F.M. Fouad, E. Antoun, M. Jaffa, R. Chaaban, M. Haidar, A.M. Sibai...... 668 Trends in outpatient cataract surgery in the Islamic Republic of Iran, 2006–2010 H. Hashemi, A. Fotouhi, F. Rezvan, H. Gilasi, S. Asgari, S. Mohazzab-Torabi, K. Etemad, A. Yekta, M. Khabazkhoob...... 676 The status of serum vitamin D in the population of the United Arab Emirates K. Yammine and H. Al Adham...... 682 Association between body mass index, diet and dental caries in Grade 6 boys in Medina, Saudi Arabia A. Bhayat, M.S. Ahmad, H.T. Fadel...... 687 Report Essential public health functions: the experience of the Eastern Mediterranean Region Ala Alwan, Olla Shideed, Sameen Siddiqi...... 694 Invited commentary The growing threat of antibiotic resistance in the Eastern Mediterranean Region – what does it take to control it? R. Hajjeh and A. Mafi...... 701 Short communication Primary oral health care: a missing link in public health in Pakistan S.Basharat, B.T. Shaikh...... 703 WHO events addressing public health priorities Detection and screening of priority cancers in the Eastern Mediterranean Region...... 707 Ala Alwan, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-Josee Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics) Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy

Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Cover photograph ©World Health Organization املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Editorial Closer to a polio-free Eastern Mediterranean Region A. Alwan 1 and C. Maher 2

After a long hard struggle, the start of bring under control. Similarly in Octo- the world has never been closer to being this decade saw the fight to eradicate ber 2013, the first cases were detected polio-free (6). polio from the Eastern Mediterranean in Syria after the importation of wild In Pakistan and Afghanistan, ag- Region appearing to bear fruit. In 2011 poliovirus originating in Pakistan. This gressive new National Emergency Ac- and 2012, only two countries in the outbreak also spread into neighbouring tion Plans for polio eradication (7,8), Region were reporting wild poliovirus countries, in this case Iraq, where the coordinated by national Emergency – Pakistan and Afghanistan, two of the final case was not recorded until April Operations Centres (EOCs) that bring last endemic countries in the world. 2014. The World Health Organization together government and partners un- By the end of 2012, when only 95 (WHO) declared in 2014 the interna- der the one roof, have opened the way cases were reported in total from the tional spread of wild poliovirus as a Pub- to major programme improvements. Region, it seemed that finally stopping lic Health Emergency of International Coupled with a massive surge in part- the transmission of poliovirus was just Concern (2). At that time many saw ner agency technical support – WHO around the corner. The number of cases eradication as far away as ever. alone has more than doubled the size and countries were at the lowest-ever But this impression was also incor- of the teams working on polio in the recorded levels (1). rect. Despite conflict, insecurity and two countries since the start of 2014, However, progress was not as solid massive population displacement, and now has nearly 2500 technical and as it seemed, and a number of factors coordinated multi-country outbreak operational experts in the field – these aligned that endangered the achieve- responses involving the multiple im- improvements have had a significant ment of polio eradication. Constant munization of more than 27 million operational impact. At the time of writ- conflict in Afghanistan and bans on im- children in the Middle East and millions ing, only 30 cases of polio have been munization campaigns in some areas more in the Horn of Africa brought a de- recorded by Pakistan (18 cases) and had led to the build-up of numbers of finitive stop to both outbreaks. WHO, Afghanistan (12 cases) combined so far susceptible children. In Pakistan, even the United Nations Children’s Fund in 2016 – a far cry from the 334 cases in 2011 and 2012 when environmental (UNICEF), and partners deployed recorded by these countries in 2014 sampling designed to detect the overall strong surge teams to support respons- (9). Similarly, in 2016 only about one in presence of wild poliovirus in commu- es even in conflict affected and secu- 10 environmental samples in Pakistan nities commenced, up to two-thirds of rity compromised areas. By November has been positive for wild poliovirus, all the samples collected were positive. 2015 the evidence was clear enough for compared to one in every two in 2014. In late 2012, when attacks began on vac- international review teams to declare cinators, the virus was prevalent enough both outbreaks closed. In September The evidence now points to a won- to take advantage of the disruption to 2015, the Polio Oversight Board of the derful opportunity to finally stop the the delivery of the programme that ex- Global Polio Eradication Initiative re- transmission of wild poliovirus in the tended through 2013 and into 2014. As viewed progress and concluded that Eastern Mediterranean Region, and the a result, by the end of 2014 Pakistan had wild poliovirus transmission is more coming months of the low transmis- recorded the highest annual number of likely to be interrupted in 2016 than in sion season offer our best hope ever. polio cases for 10 years. 2015 (3). The response in the Middle This must be the time when everyone, Additionally, conflicts and insecu- East, despite the tremendously difficult governments, civil society, and partners rity in polio-free countries in the Region situation presented by the conflicts in alike, redouble efforts to implement the had opened up gaps in immunization Syria and Iraq, succeeded in stopping strategies we know now to be effective that wild poliovirus was able to exploit. the outbreak within 6 months of de- in stopping polio. We have to seize this In April 2013, virus imported from Ni- tection of the first case, and is widely chance, and fulfill our promise to the geria caused the first case of an outbreak regarded as a model response (4,5). Ac- children of our Region, and to the chil- in Somalia that was to spread into neigh- cording to the 2015 Annual Report of dren of the world, to become polio-free, boring countries and take 18 months to the Polio Global Eradication Initiative, forever.

1Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Manager, Polio Eradication Programme, Eastern Mediterranean Region. 645 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

References

1. WHO Executive Board. Poliomyelitis: intensification of the 2015. Polio Global Eradication Initiative. Geneva: World global eradication initiative. (EB132/17). Geneva: World Health Health Organization; 2016 (http://polioeradication.org/wp- Organization; 2012 (http://apps.who.int/gb/ebwha/pdf_ content/uploads/2016/07/02E.pdf). files/EB132/B132_17-en.pdf). 6. Global Polio Eradication Initiative. Annual Report 2015 – Eradi- 2. WHO statement on the meeting of the International Health cation within reach. Geneva: World Health Organization; 2016 Regulations Emergency Committee concerning the interna- (http://polioeradication.org/wp-content/uploads/2016/10/ tional spread of wild poliovirus. May 5, 2014. Geneva: World AR2015.pdf). Health Organization; 2014 (http://www.who.int/mediacen- 7. National Emergency Action Plan for Polio Eradication - Islamic tre/news/statements/2014/polio-20140505/en). Republic of Afghanistan 2016-2017 (http://polioeradication. 3. Sixty-ninth World Health Assembly. Poliomyelitis. (A69/25). org/wp-content/uploads/2016/10/NEAP2016-2017_Afghani- Geneva: World Health Organization; 2016 (http://apps.who. stan-1.pdf). int/gb/ebwha/pdf_files/WHA69/A69_25-en.pdf). 8. National Emergency Action Plan for Polio Eradication - Islamic 4. Polio Global Eradication Initiative. Major multi-country epi- Republic of Pakistan 2015-2016 (http://polioeradication.org/ demic prevented in the Middle East. Geneva: World Health wp-content/uploads/2016/07/5.2_14IMB.pdf). Organization; 2015 (http://polioeradication.org/news-post/ 9. WHO Executive Board. Poliomyelitis. (EB136/21). Geneva: major-multi-country-epidemic-prevented-in-the-middle- World Health Organization; 2015. (http://apps.who.int/gb/ east). ebwha/pdf_files/EB136/B136_21-en.pdf). 5. Independent Monitoring Board of the Global Polio Eradica- tion Initiative. The rocky road to zero – eleventh report May

646 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Validation of Persian version of WHOQOL-HIV BREF questionnaire in Islamic Republic of Iran M. Salehi 1,2, S. Niroumand 1, M.R. Erfanian 1, R.B. Sajjadi 3 and M. Dadgarmoghaddam 1

توثيــق مصدوقيــة النســخة الفارســية الســتبيان منظمــة الصحــة العامليــة اخلــاص بجــودة احليــاة لــدى املصابــن بفــروس َالع َ زــو املناعــي البــري يف مجهوريــة إيــران اإلســامية مريم صاحلي، شبنم نريومند، جميد رضا عرفانيان، رامني هبرامي زاده سجادي، مليحة دادكر مقدم

اخللصــة: تعت�بر ج��ودة احليــاة ِّمكو ًنــا ًأساســيا يف التدبــري العالجــي لألشــخاص املصابــني بفــريوس َالع َــوز املناعــي البــري )اإليــدز(. وكان اهلــدف مــن هــذه الدراســة املقطعيــة توثيــق مصدوقيــة النســخة الفارســية األوىل الســتبيان منظمــة الصحــة العامليــة اخلــاص بجــودة احليــاة لــدى املصابــني بالفــريوس. وقــد شــملت عينــة الدراســة 61 ًمريضــا يراجعــون بانتظــام العيــادات اخلارجيــة يف مركــز استشــارات األمــراض ُاملعديــة املعنــي باملــرىض الذيــن يعانــون مــن اضطرابــات ســلوكية يف عامــي 2013-2014. فأجــري تقييــم لالتســاق الداخــي هلــذه النســخة باســتخدام نســبة مصدوقيــة املحتــوى ً وفقــاملعادلــة الوش. فكانــت نســبة مصدوقيــة املحتــوى < 0.51ومتوســط احلكــم < 2 ذا داللــة إحصائيــة عنــد p . = 0.05وكان معامــل ألفــا كرونبــاخ جلميــع املجــاالت < 0.7 و = 0.87بالنســبة ملجمــل األحــراز، ممــا يــدل عــى موثوقيــة جيــدة. وكان بنــد 0.23 0.87-0.39 ُمعامـ�ل االرتبـ�اط اإلمجـ�ايل بــني كل بنـ�د وبــني املجـ�ال اخلـ�اص بـ�ه ، باســتثناء األمل واالنزعــاج بالنســبة للمجــال املــادي )- (، ومعنــى احليــاة يف املجــال الروحــي ) (.0.25 وكان االرتبــاط ًممتــازا بــني كل جمــال مــن املجــاالت وبــني جــودة احليــاة إمجــاالً. توضــح هــذه الدراســة أن النســخة الفارســية الســتبيان منظمــة الصحــة العامليــة اخلــاص بجــودة احليــاة لــدى املصابــني بفــريوس َالع َــوز املناعــي البــري تعتــر أداة ذات مصدوقيــة وموثوقيــة لتقييــم جــودة احليــاة عنــد املــرىض املصابــني بفــريوس َالع َــوز املناعــي البــري.

ABSTRACT The aim of this cross-sectional study was to validate the first Persian version of the WHOQOL-HIV BREF questionnaire. The study sample comprised 61 patients regularly attending the outpatient infectious disease clinic consultation centre for patients with behavioural disorders in 2013–2014. The internal consistency, content related validity and reliability of WHOQOL-HIV BREF were evaluated. Content validity was quantified using the content validity ratio (CVR) according the to Lawshe formula. CVR > 0.51 and mean judgment > 2 were significant at P = 0.05. The Cronbach alpha score was > 0.7 for each domain and = 0.87 for the whole scale, indicating good reliability. Item-to-total correlation coefficient between each item and its respective domain was 0.39–0.87. The correlation between each domain and overall QOL was excellent. This study demonstrates that the Persian version of WHOQOL-HIV BREF is a valid and reliable tool for evaluation of QOL in HIV-infected patients.

Validation de la version en langue perse du questionnaire WHOQOL-HIV BREF en République islamique d’Iran

RÉSUMÉ La présente étude transversale avait pour objectif de valider la première version en langue perse du questionnaire Qualité de vie et VIH – WHOQOL-HIV BREF. L’échantillon de l’étude comprenait 61 patients qui consultaient régulièrement au centre de consultations externes spécialisé dans le traitement des maladies infectieuses pour les patients ayant des troubles comportementaux en 2013-2014. La cohérence interne, la validité de contenu et la fiabilité du questionnaire WHOQOL-HIV BREF ont été évaluées. La validité de contenu a été quantifiée au moyen du ratio de validité de contenu à partir de la formule de Lawshe. Un ratio de validité de contenu supérieur à 0,51 et un jugement moyen supérieur à 2 étaient significatifs à p = 0,05. L’α de Cronbach pour tous les domaines était supérieur à 0,7 et égal à 0,87 pour l’ensemble de l’échelle, ce qui indique une bonne fiabilité. Le coefficient de corrélation de l’item avec le score total entre chaque item et son domaine respectif était compris entre 0,39 et 0,87. La corrélation entre chaque domaine et la qualité de vie globale était excellente. La présente étude montre que la version en langue perse du questionnaire WHOQOL-HIV BREF est valable et constitue un outil fiable pour l’évaluation de la qualité de vie chez les patients infectés par le VIH.

1Department of Community Medicine, School of Medicine, Mashhad University of Medical Science, Mashhad, Islamic Republic of Iran (Correspondence to: M. Dadgarmoghaddam: [email protected]). 2Research Center for Patient Safety Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. 3Legal Medicine Research Center, Legal Medicine Organization, Mashhad, Islamic Republic of Iran. Received: 26/05/15; accepted: 22/05/16

647 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Introduction has not been translated into Persian and were reversed [recode Q3, Q4, Q5, Q8, validated in the Iranian population. The Q9, Q10 and Q31 (1 = 5) (2 = 4) (3 = Currently, UNAIDS estimates that aims of this study were to validate the 3) (4 = 2) (5 = 1)] higher score. Domain > 35 million people are infected with Persian version of WHOQOL-HIV scores were calculated as means of their HIV around the world (1). In 2011, an BREF in Mashhad, Iran, and to use it to items scores multiplied by 4, so that estimated 2.5 million people worldwide determine QOL in patients with HIV/ each domain was reported on a scale of were newly infected with HIV (2). The AIDS. 4–20, with higher scores demonstrat- World Health Organization (WHO) ing better QOL. Thus, Domain 1 was reported that the prevalence rate of calculated as: HIV infection was 129 per 100 000 Methods Q3 + Q4 + Q14 + Q21 / 4 × 4 population in 2011 (2). Healthy People Subjects and settings According to the original version, 2000, 2010 and 2020 identified qual- sociodemographic information such as ity of life (QOL) improvement as a This was a cross-sectional study of 61 patients living with HIV/AIDS who sex and age, education, marital status central public health goal. Nowadays, and HIV-related information, including it is important to assess health-related regularly attended the outpatient infec- tious disease clinic consultation centre mode of transmission, HIV status and QOL for chronic conditions like cancer, year of being infected and diagnosis was diabetes, multiple sclerosis and other for patients with behavioural disorders in 2013–2014 in the North East of the obtained. life-long diseases (3). Islamic Republic of Iran. The patients QOL is a broad multidimensional Data analysis gave signed informed consent after the concept that usually includes subjec- aims of the study were explained. The A descriptive analysis was performed for tive evaluation of positive and negative study was approved by the Mashhad the sociodemographic and HIV-related aspects of life. QOL consists of domains University of Medical Science Ethics information and ceiling and floor effects such as overall health, occupation, hous- Committee. that could have threatened the internal ing, schooling, neighbourhood, culture, All patients with a confirmed diag- validity of the instrument. Measure- moral values and spirituality. Neverthe- nosis of HIV/AIDS and aged ≥ 18 years ment instruments do not always have less, researchers have developed a useful entered the study. Exclusion criteria the same level of precision. Ceiling and questionnaire that helps to measure included evidence of another major floor effects occur when the highest these multiple domains (4). medical disease; cognitive or any se- and lowest scores are unable to assess With effective highly active antiret- vere mental or psychotic disorders; or a patient’s level of ability. According roviral treatment (HAART) and in- evidence of AIDS-related dementia. to statistical references, when ≥15% of creased life expectancy, people living Illiterate patients completed the ques- patients respond with a highest or low- with HIV/AIDS are facing more co- tionnaire with the assistance of an expe- est score, the ceiling and floor effects morbidity. There is no curative treat- rienced physician who was cooperating occur (15). ment for HIV/AIDS, therefore, people with the study. The other patients com- To assess the translation validity of will continue to bear the burden of this pleted the questionnaires by themselves the questionnaire, we used a backward– disease, and measurement of QOL will under the supervision of a clinician. forward translation method, which was remain a key factor in these patients. done in 5 steps (16). To translate the The relationship between HIV Instruments WHOQOL-HIV BREF instrument infection and QOL has been studied The WHOQOL-HIV BREF question- into Persian, permission was acquired between 2011 and 2013 in the Islamic naire consisted of 6 domains with a from the WHO by e-mail. In the first Republic of Iran and other countries total 29 items: physical (4 items), psy- stage, the initial WHOQOL-HIV BREF (5–9). Measurement of QOL is com- chological (5 items), level of independ- questionnaire was translated from plex and a reliable and valid instrument ence (4 items), social relationship (4 English into Persian by 2 independent is necessary. The WHO developed a items), environmental (8 items) and bilingual qualified translators; one of specific questionnaire (WHOQOL- spiritual (4 items), and 2 general items whom had a medical background, and HIV BREF) to assess QOL in HIV-in- that measured overall QOL and general the native language of both was Persian. fected patients. The WHO QOL-HIV health. Each item was rated on a 5-point In the second stage, the 2 translated questionnaire has been translated into Likert scale, where 1 denoted very poor Persian versions were reviewed by 5 Persian and other languages and as- and negative impression and 5 denoted community medicine specialists to re- sessed for its reliability and validity (10- very good and positive impression. For solve any conflict by consensus, check 14). However, WHOQOL-HIV BREF negative perception items, the scores that they were easily understandable,

648 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

and confirm face validity. At the end of Table 1 Demographic characteristics of HIV/AIDS patients this step, a reconciled Persian version n (%) on the basis of the 2 forward translations Gender was produced. In the third step, 2 pro- Male 44 (72.1) fessional translators, who were native Female 17 (27.9) English speakers and fluent in Persian, Age (yr), mean (SD) 38.06 (9.32) who did not have any knowledge of the Marital status original instrument, back translated the Single 13 (21.3) questionnaire into English. In the fourth Married 30 (49.2) step, these two original language docu- ments were reviewed by another expert Divorced/widowed/separated 18 (29.5) panel and a reconciled back-translation Education version was produced. In the final step, Illiterate 5 (8.2) for pilot testing and assessing the face Elementary school 15 (24.6) validity, the Persian translated version Middle school 25 (41) was evaluated among 10 random sam- High school 13 (21.3) ples of patients and healthy individuals. University 3 (4.9) Content validity was quantified us- Employment ing the content validity ratio (CVR), Employed 31 (50.9) which is one of the earliest and most Unemployed 15 (24.6) widely used methods. To calculate Housewife 15 (24.6) CVR, 14 subject experts independently Mode of HIV transmission judged the item as assessing content Intravenous drug use 27 (44.3) that was essential (E), helpful (H) or Unprotected sex 21 (34.5) unnecessary (U). Lawshe suggested Unknown 13 (21.3) the following formula for determining Total 61

CVR: CVR = SD = standard deviation.

domains and overall QOL were cal- a CVR of 0–0.51. In these items, the culated for WHOQOL-HIV BREF. mean of judgments was considered. All where ne is the number of panellists The reliability was assessed using Cron- theses items had a mean > 2 and were indicating “essential” about a specific bach’s α for internal consistency. Data accepted (Table 2). item, and N is the total number of panel- analysis was done by SPSS version 11.5 lists (17). The minimum CVR to be and the statistical significance level was Reliability significant with 14 panellists was 0.51 fixed atP = 0.05. per defined item. When CVR was equal Internal consistency of WHOQOL- or larger than the minimum acceptable HIV BREF was evaluated using Cron- bach’s α for the total questionnaire and value, an item was accepted uncondi- Results tionally, and if CVR was < 0, an item was for each domain separately. As shown in α rejected. For items with CVR between All 61 enrolled patients were in the Table 3, Cronbach’s for the summary 0 and minimum acceptable value, we AIDS stage of their disease and used score was 0.87, indicating a high level of replaced E by 3, H by 2 and U by 1, HAART. Their demographic character- internal consistency. The psychological and then calculated the mean of the istics are summarized in Table 1. domain with Cronbach’s α 0.83 had the judgments. Items with a mean > 2 were highest internal consistency ,whereas accepted. Content validity the spiritual domain had the lowest The structural validity was meas- Content validity was evaluated by a (0.71). The other coefficients were- ac ured using item/total correlation coef- panel of 14 experts to review WHO- ceptable for the remaining domains. ficients to determine the strength of QOL-HIV BREF. The minimum ac- the relationship between each item and ceptable CVR to be significant with 14 Structural validity its domain total score, and Pearson’s panellists was 0.51 per item. CVR in 24 To assess the structural validity of correlation coefficients between the of 31 items was ≥ 0.51. Seven items had WHOQOL-HIV BREF, we calculated

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Table 2 WHOQOL-HIV BREF scale: CVR according to expert panellists (n = 14) Ne CVR Mean of Judgment Q1: How would you rate your quality of life? 13 0.85 –

Q2: How satisfied are you with your health? 13 0.85 –

Q3: To what extent do you feel that physical pain prevents you from doing what you 12 0.71 – need to do?

Q4: How much are you bothered by any physical problems related to your HIV 12 0.71 – infection?

Q5: How much do you need any medical treatment to function in your daily life? 14 1.0 –

Q6: How much do you enjoy life? 11 0.57 –

Q7: To what extent do you feel your life to be meaningful? 11 0.57 –

Q8: To what extent are you bothered by people blaming you for your HIV status? 13 0.85 –

Q9: How much do you fear the future? 11 0.57 –

Q10: How much do you worry about death? 12 0.71 –

Q11: How well are you able to concentrate? 8 0.14 2.5

Q12: How safe do you feel in your daily life? 14 1.0 –

Q13: How healthy is your physical environment? 9 0.28 2.5

Q14: Do you have enough energy for everyday life? 12 0.71 –

Q15: Are you able to accept your bodily appearance? 11 0.57 –

Q16: Have you enough money to meet your needs? 9 0.38 2.5

Q17: To what extent do you feel accepted by the people you know? 12 0.71 –

Q18: How available to you is the information that you need in your day-to-day life? 8 0.14 2.5

Q19: To what extent do you have the opportunity for leisure activities? 12 0.71 –

Q20: How well are you able to get around? 9 0.28 2.6

Q22: How satisfied are you with your ability to perform your daily living activities? 11 0.57 –

Q23: How satisfied are you with your capacity for work? 12 0.71 –

Q24: How satisfied are you with yourself? 13 0.85 –

Q25: How satisfied are you with your personal relationships? 13 0.85 –

Q26: How satisfied are you with your sex life? 13 0.85 –

Q27: How satisfied are you with the support you get from your friends? 13 0.85 –

Q28: How satisfied are you with the conditions of your living place? 9 0.28 2.5

Q29: How satisfied are you with your access to health services? 14 1.9 –

Q30: How satisfied are you with your transport? 9 0.28 2.5

Q31: How often do you have negative feelings such as blue mood, despair, anxiety, 14 1.0 – depression?

Ne = number of experts who indicated “essential”. CVR = content validity ratio.

the total correlation coefficients between discomfort item with physical domain, correlation coefficients. The correla- each domain and its corresponding item and also spiritually item with its do- tion coefficients of all domains were > (Table 3). Item/total correlation had a main. Association between all domains, 0.8 except for the physical and spiritual lower limit of 0.55 for all items except including overall QOL and general domains. Analysis of the score distribu- for the association between pain and health was estimated using Pearson’s tion in our patients demonstrated that

650 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

there was no ceiling and floor effect for each item measures the QOL in HIV/ their domains (20). For example, they any of the domains of WHOQOL-HIV AIDS patients as intended. Also, the found that the item that was relevant BREF. The frequency of patients with experts judged that the instrument had to medication was loaded on to the highest and lowest score for all domains good face validity and that all the items psychological domain rather than its were nearly achieved less than 4.9% and were relevant. The final scale was pre- own domain. 6.6% respectively. pared after making minor modifications The correlation between each do- in the wording and language according main and overall QOL was excellent, to the suggestions of the panellists. with all of the coefficients > 0.8. Only Discussion The internal consistency was satis- the physical (r = 0.44, P < 0.001) and factory for all domains and excellent for spiritual (r = 0.33, P = 0.1) domains The present study aimed to assess the the total scale. The Cronbach’sα scores showed lower reliability than the other psychometric validation of the Persian for each domain was > 0.7 and = 0.87 for domains. Both of these domains con- version of a short form of WHOQOL- the summary scores. Traditionally, an sisted of 4 items and the lower reliability HIV (31 items) in a sample of patients acceptable level of internal consistency may have been due to the low number who developed HIV/AIDS. Similar to is Cronbach’s α 0.70–0.95. (21,22) Our of questions in these domains that can the results reported in Portugal, Taiwan results are similar and to some extent affect the coefficients. Furthermore, all and Malaysia, our study shows that better than the validation of this instru- of our patients were receiving HAART the WHOQOL-HIV BREF has good ment in other languages. In one study, and the low coefficient in the physi- psychometric properties (18–20). Cronbach’s α ranged from 0.65 to 0.86 cal domain could be attributed to drug The long form of this instrument, (18) and 0.67 to 0.80 in another (19). complications, especially physical pain. WHOQOL-HIV 120, was originally Our results demonstrate that Similarly, the spiritual domain consisted standardized by Razavi et al. in the Is- WHOQOL-HIV BREF reveals mod- of perceptual items such as HIV stigma lamic Republic of Iran in 2012 (9). To erate to high structural validity. Item to or being concerned about the future translate and validate WHOQOL-HIV total correlation coefficients between and death. In line with prior validation BREF in the Iranian population, per- each item and its respective domain studies (20,24), we did not observe ceil- mission was obtained from the WHO, were in the range 0.39–0.87, with the ing and floor effects in our patients for which was the original developer of the exception of 2 items. A correlation co- any domain. Therefore, the validity was questionnaire. The translation process efficient > 0.3 is an acceptable result favourable with discriminative extreme of the questionnaire showed that all (23). Only pain and discomfort in the values. forward and backward translations were physical domain (–0.23) and life mean- consistent with each other and with the ingful in the spiritual domain (0.25) Limitations and strengths original version. demonstrated low validity. The present Although the results from this investiga- The CVRs for individual items of results were in accordance with those tion demonstrated the psychometric WHOQOL-HIV BREF were in the of Saddki et al., who found that many of validity of the WHOQOL-HIV BREF acceptable range, which indicates that the items were not best correlated with questionnaire, there were several

Table 3 Domain mean Cronbach’s α and correlation of mean scores with participants’ overall QOL scores Cronbach’s α Item/total Pearson Mean (SD) Floor (%) Ceiling (%) correlation correlation (min–max) coefficient with overall QOL Domain 1 (physical) 0.72 −0.23–0.66 0.44* 11.57 (1.83) 6.6 4.9 Domain 2 (psychological) 0.83 0.69–0.83 0.88* 11.73 (3.35) 1.6 1.6 Domain 3 (level of independence) 0.82 0.75–0.87 0.81* 12.4 (3.48) 1.6 1.6 Domain 4 (social relationship) 0.78 0.68–0.86 0.82* 12.08 (3.43) 3.3 1.6 Domain 5 (environmental) 0.77 0.55–0.69 0.82* 12.05 (2.67) 1.6 4.9 Domain 6 (spiritual) 0.71 0.25–0.68 0.33** 11.77 (2.36) 1.6 1.6 All domains 0.87 – – 11.95 (2.07) 1.6 1.6

*Pearson P < 0.001 **Pearson P = 0.1 QOL = quality of life. SD = standard deviation.

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Conclusion limitations. As a result of the low preva- on a variety of patients and in differ- lence of HIV/AIDS and its stigma in ent stages of disease could assess the The WHOQOL-HIV BREF question- our region, we had to select our patients other psychometric properties of the naire has been translated into Persian and evaluated among Iranian patients. from the outpatient HIV/AIDS clinic questionnaire. Nevertheless, our study It provides a reliable and valid scale that consultation center. These patients provides an important instrument to were under the supervised care of the can be implemented in future investiga- make progress in improving the QOL of tion to assess QOL in HIV/AIDS pa- clinic and were receiving HAART, so HIV/AIDS patients. WHOQOL-HIV tients, as well as to measure the impact they had special therapeutic assistance BREF is a brief and multidimensional of HAART and other interventions. for minor emotional disturbance and scale that can be used in practical and had better information about their con- comprehensive assessment of QOL in dition. This could limit the degree to clinical and research settings. Also, it can Acknowledgements which our results can be generalize and help policymakers who want to address This paper is part of a dissertation of are representative of the whole popula- health disparities. Thus, WHOQOL- the second author. Our special thanks tion of Iranian HIV/AIDS patients. All HIV BREF is especially recommended to the Health Service Center, HIV/ of the psychometric characteristics of for community-based studies that are AIDS Clinic Consultation Center and a scale cannot be confirmed in a sin- interested in measuring QOL as an ad- Department of Public Health, and gle study (25), as we did not evaluate junct to well-being and functional and WHO for giving permission to use and clinical validity and factor analysis of environmental status, and for evaluating translate the WHOQOL-HIV BREF. WHOQOL-HIV BREF. A population- policy impact and implications for these Funding: None. based study patients. Competing interests: None declared.

References

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Effect of anti-smoking advertisements on Turkish adolescents E. Unal,1 M.E.Gokler,1 S. Metintas1 and C. Kalyoncu1

تأثري إعالنات مكافحة التدخني عىل املراهقني األتراك أكامان أونال، حممد أنس كوكالر، سلمى متني طاش، مجال الدين قاليونجو اخلالصــة: لقــد كان اهلــدف مــن الدراســة احلاليــة حتديــد النظــرة إىل عــرة إعالنــات ملكافحــة التدخــني لــدى 1434 ًمراهقــا ًتركيــا. فاســتخدمنا 6 ً مقياســالفعاليــة إعالنــات مكافحــة التدخــني يشــتمل عــى بنــود لــكل إعــالن، ِّوقيــم كل بنــد مــن البنــود عــى مقيــاس مــن نمــط ليكــرت 5 َّمكــون مــن نقــاط. ُواســتخدم حتليــل ُّالتحــوف اللوجســتي املتعــدد لتحديــد العوامــل املرتبطــة بتأثــر اإلعالنــات. فكانــت مجيــع اإلعالنــات أكثــر فعاليــة لــدى املراهقــني الذيــن مل يدخنــوا قــط مقارنــة مــع املدخنــني الســابقني واملدخنــني احلاليــني. والحظنــا كذلــك أن حالــة التدخــني قللــت مــن فعاليــة مجيــع اإلعالنــات، بغــض النظــر عــن العمــر. لقــد أظهــرت دراســات ســابقة أن املدخنــني هلــم موقــف ســلبي مــن رســائل مكافحــة التدخــني. لقــد كانــت اإلعالنــات األكثــر فعاليــة يف الدراســة احلاليــة لــدى املراهقــني تلــك التــي ُيذكــر فيهــا "اإلســفنج والقطــران" و"أرضار التدخــني يف كل َنفــس" و"األطفــال يريــدون أن ينمــوا". واخلالصــة أنــه عــى الرغــم مــن أن محــالت مكافحــة التدخــني موجهــة للبالغــني، إال أن هلــا ًتأثــرا ً قويــاعــى املراهقــني. وينبغــي أن َّتوجــه اإلعالنــات - ًأساســا- إىل األشــخاص الذيــن تقــل إعامرهــم عــن 15 ســنة ومل يبــدؤوا بالتدخــني بعــد.

ABSTRACT The aim of the present study was to determine the perception of 10 anti-smoking advertisements in 1434 Turkish adolescents. We used the Effectiveness of the Anti-smoking Advertisements Scale, which included 6 items for each advertisement; each item was assessed on a 5-point Likert-type scale. Multiple logistic regression analysis was used to determine the factors associated with the impact of the advertisements. All the advertisements were more effective for adolescents who had never smoked compared to ex-smokers and current smokers. We also noted that, regardless of age, smoking status decreased the effectiveness of all the advertisements. Previous studies have shown that smokers have a negative attitude towards anti-smoking messages. In the present study, the most effective advertisements among adolescents were those with “Sponge and tar”, “Smoking harms in every breath” and “Children want to grow”. In conclusion, although anti-smoking campaigns are targeted towards adults, they also have a strong influence on adolescents. The main target population for advertisements should be individuals aged < 15 years who have not yet started smoking.

Influence des publicités antitabac sur des adolescents turcs

RÉSUMÉ La présente étude avait pour objectif de déterminer la façon dont 10 publicités antitabac étaient perçues par 1434 adolescents turcs. Nous avons utilisé l’échelle d’efficacité des publicités antitabac qui inclut six items par publicité, chaque item étant évalué sur une échelle de Likert reposant sur un système de cinq points. L’analyse de régression logistique multiple a été utilisée afin de déterminer les facteurs associés à l’impact des publicités. Toutes les publicités étaient plus efficaces auprès des adolescents qui n’avaient jamais fumé qu’auprès des anciens fumeurs ou des fumeurs actuels. Nous avons également noté que, indépendamment de l’âge, le statut tabagique avait une influence sur l’efficacité de toutes les publicités. Les études précédentes ont montré que les fumeurs ont une attitude négative face aux messages antitabac. Dans la présente étude, les publicités ayant démontré la plus grande efficacité parmi les adolescents étaient celles avec « L’éponge et le goudron », « Fumer nuit à chaque respiration », et « Les enfants veulent pouvoir grandir ». En conclusion, bien que les campagnes antitabac ciblent les adultes, elles ont également une forte influence sur les adolescents. La cible principale des publicités dans la population devrait être les individus âgés de moins de 15 ans qui n’ont pas encore commencé à fumer.

1 Department of Public Health, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey (Correspondence to: egemenunal28@ hotmail.com) Received: 27/10/14; accepted: 26/07/16

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Introduction found in smoking rates among adoles- is important, although there are few cents (1). studies on this issue (12). Tobacco use continues to be the leading In fulfilling implementation of the The aim of the present study was cause of preventable death worldwide WHO criteria, a national media cam- to determine the perception of anti- (1). The World Health Organization paign was launched in Turkey with the smoking advertisements in adolescents (WHO) adopted the Framework Con- slogans of “Smoke-free air” and “Protect in Turkey. vention on Tobacco Control (FCTC) your air”. Anti-smoking advertisements in 2003 and highlighted the need for an involving visual media were one of the effective programme to protect people tools used in this campaign. Advertise- Methods from the damage associated with to- ments have been shown to be effec- Research area bacco use (2). tive for quitting smoking; ensuring the The study was performed in Eskisehir, The fight against tobacco-related motivation needed and maintaining which is a province in Turkey with a deaths includes methods with well- cessation (5,6). The impact of the adver- population of ~800 000 in 2014. There established effectiveness. In 2008, the tisements on individuals varies based on WHO defined criteria to assess tobacco are ~130 000 adolescents living in the keynote messages of advertisement control methods. These criteria, also Eskisehir (13). After 8 years of basic and the sociodemographic characteris- known as Monitoring, Protect, Offer, education, the students are selected tics of the audience (7). It is important Warn, Enforce and Raise (MPOWER), by an examination to the Anatolian or to evaluate the impact of the messages ensure that the implementations de- vocational high schools. fined in the FCTC can be achieved 3( ). given via advertisements on smokers and on adolescents who do not cur- Study group According to the WHO report, rently smoking but are at risk of starting. Turkey has achieved significant success An estimated study sample size of at least in the implementation of these criteria Many adolescents use cigarettes out of 1225 individuals was calculated based and in the control of tobacco use (2). curiosity, to reduce stress, to feel grown on an estimated 15% of the adolescents The WHO Report on the Global To- up or to experience the camaraderie being not affected by the anti-smoking bacco Epidemic 2013 indicated that of being in a group (8). Moreover, the advertisements (14), a 2% of margin the smoking rate in Turkey was 10.2% tobacco industry lies about the health of error and a 95% confidence interval in males, 5.3% in females and 8.4% in risks of smoking and uses all commu- [Sample Size = 1.962×p×(1 − p)/d2, adolescents (4). In Turkey, 33.0% of the nication channels including social me- were p = probability and d = sample population is under the age of 18 years. dia to direct children and adolescents error]. To select the study sample, we Although the smoking rate among towards using tobacco (2,9–11). The used a 2-stage stratified cluster sampling adults decreased by 4.1% between 2008 impact of the messages given by adver- procedure. There are two provinces in and 2012, no significant decrease was tisements on the adolescent age group the city centre (urban) and 12 at the

Table 1 Description of ADs ADs Description Rejuvenation in all aspects (V1) Describes the discomfort resulting from smoking to a smoker and his/her family Smoking in daily living (V2) Describes the negative effects of cigarettes on the daily living of a smoker Smoke-free air (V3) Emphasises smoke-free air in a taxi COPD and regret (V4) Describes the history of a heavy smoker who quit smoking as a result of noticing the harmful effects of cigarettes on him/her and his/her family A bad example of a father (V5) Describes the harmful effects of passive smoking and the bad influence of a smoking father on his child Grandfather and grandson (V6) Describes the role of a grandson in leading his grandfather to quit smoking Non-smoking is happiness (V7) Describes the effects of a smoking-related disease, COPD, on quality of life Smoking harms in every breath (V8) Simulates the damage induced by smoking in the lungs Children want to grow (V9) Describes the mental and physical harmful effects of smoking towards children Sponge and tar (V10) Describes the cigarette-induced pathological changes and the accumulation of tar in the lungs

The first, fifth and eighth videos can be viewed at http://tv.thsk.saglik.gov.tr/index.php/component/contushdvideoshare/player/15/11, and the others can be viewed at http://www.youtube.com/user/burakfilm/videos?view=0&flow=grid&sort=p. AD = anti-smoking advertisements; COPD = chronic obstructive pulmonary disease.

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peripheral area (semirural) of Eskisehir. Table 2 Distribution of students in the study group according to their The schools were classified as Anatolian sociodemographic characteristics and vocational high schools by their Sociodemographic na (%) educational curricula. One province Gender (Odunpazari) and two schools were Male 611 (42.6) randomly selected from the city cen- Female 823 (57.4) tre. One province (Sivrihisar) and two Age (yr) schools were randomly selected from 15 580 (40.4) the semirural area. A total of 1434 Class 16 496 (34.6) 1–3 students present during the school 17 358 (25.0) visits were included. Residence Rural 542 (37.8) Study design Urban 892 (62.2) In Turkey, according to “Law of The Socioeconomic status Prevention and Control of Harm from Poor 126 (9.6) Tobacco Products”, television and Moderate 854 (60.4) radio organizations must broadcast Good 420 (30.0) advertisements about the health risks Smoking status associated with the use of tobacco prod- Never smoked 896 (62.8) ucts and other substances for at least Initiator 211 (15.0) 90 minutes monthly (15). A research Smoker 313 (22.2) team examined all the smoking-related Close friend smokes advertisements on television and clas- Yes 926 (64.6) sified them according to their topics. No 508 (35.4) Then, among the advertisements under Adult in household smokes the same topic, the 10 with the highest Yes 943 (65.8) scores were identified and randomly No 491 (34.2) arranged (Table 1). aThere were some differences in the totals due to unanswered questions. Study procedure The first part of our questionnaire -fo score of each item, with a possible score for each advertisement. There cused on the sociodemographic char- between 6 and 30 points. were 1-minute intervals be- acteristics and smoking status of the After obtaining the necessary per- tween each advertisement. students. The second part consisted of mission from the school administra- It would have been diffi- the Effectiveness of the Anti-smoking tion and consent form from parents of cult to assess the impact of Advertisements Scale (EAAS), which students, the students were gathered advertisements viewed on included 6 items for each anti-smoking in a meeting hall at a specified date and television during daily living. advertisement. Cronbach’s alpha value, time. After providing information about Thus, we showed a video of the scale ranged between 0.792 and the study and obtaining verbal consent, recording to remind the 0.891 for each advertisement, with a the students were placed in suitable students about the advertise- median of 0.841 showing good reli- locations where they could not see or ment; then, the reactions of ability (16). The content of the scale was influence each other. All students were the students were assessed. validated by expert opinion. The EAAS grouped by school and each group con- This process enabled us to items assessed the clarity, persuasive- sisted of 30–40 students. The sessions compare the reactions of the ness, reminder, stop and think, scaring were managed by the researchers. The students to different video and dissuasive features of the ADs. Each students were asked to fill out the first recordings. item was assessed on a 5-point Likert- part of the questionnaire in 10 minutes type scale, with scores of 5=strongly under supervision. In the second part of Measurements agree, 4=agree, 3=don’t know, 2=disa- the questionnaire, each advertisement Students who had never gree, and 1=strongly disagree. The total was shown on a screen, and all groups of smoked, even a puff, were score was calculated by summing the students were asked to fill out the EAAS classified as never-smokers;

656 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Table 3 Mean (SD), median (IQR) and affected percentages of the ADs ADs Median Mean (SD) Affected by the AD (IQR 25–75%) (%) Rejuvenation in all aspects 21 (18–24) 20.83 (5.19) 70.6 Smoking in daily living 21 (18–25) 20.69 (5.55) 68.2 Smoke-free air 22 (19–26) 21.71 (5.68) 69.7 COPD and regret 22 (18–26) 21.66 (5.57) 68.2 A bad example of a father 22 (18–26) 21.64 (5.74) 67.2 Grandfather and grandson 22 (18–25) 21.14 (5.55) 66.3 Non-smoking is happiness 22 (18–25) 21.33 (5.67) 66.6 Smoking harms in every breath 26 (22–30) 24.81 (5.45) 83.0 Children want to grow 25 (22–28) 24.19 (5.12) 81.2 Sponge and tar 27 (23–30) 25.36 (5.54) 81.0

AD = anti-smoking advertisements; COPD = chronic obstructive pulmonary disease; IQR = interquartile range; SD = standard deviation.

those who had attempted to smoke value of 0.0001 was derived from the the smoking prevalence by gender was with at least one puff but who were not EAAS scores using the Minitab pro- 32.5% and 17.3% among male and fe- currently smoking were classified as gramme. The knowledge scores of the male students, respectively (P < 0.001). initiators; and those who were currently students were classified into two clusters The smoking prevalence among high using cigarettes were classified as smok- through a k-means clustering analysis school students was not different sta- ers (17). and by using the dummy variable. The tistically between rural and urban areas Smoker close friends were defined scores calculated in reference to these (P = 0.284). The smoking prevalence as having at least one close friend who cluster features were then used in the was found to increase with age (18.6%, used cigarettes, and a smoker adult ROC analysis to determine the cut-off 21.7% and 28.1% for students aged family member was defined as hav- point, and the impact score cut-off value 15, 16 and 17 years, respectively) (P = ing a mother and/or father who used was determined for each advertisement. 0.008). cigarettes. The family income level was Multiple logistic regression analy- The rate of being affected by the ad- classified as low, moderate or high. sis was used to determine the factors vertisements ranged between 66.3% and associated with the impact of the ad- 83.0% (Table 3). The highest score was Statistical analysis vertisements. Odds ratios and 95% reported for the advertisement “Smok- The data were analysed using IBM- confidence intervals were calculated ing harms in every breath”, followed by SPSS version 20.0. Cronbach’s alpha, for the variables associated with each “Sponge and tar” and “Children want was calculated for each anti-smoking advertisement. to grow” (P < 0.001). The cut-off point advertisement using the reliability Ethical approval of the scale was calculated as 21.5. The analysis. area under the curve was 0.693. The The EAAS scores were expressed as This study was approved by the Ethics advertisements with a score greater than Committee of Eskisehir Osmangazi the mean (SD) and median (interquar- the cut-off point were considered to University, Medicine Faculty, Non- tile range). A new data set was created have an impact on the audience. Drug Clinical Research Committee to compare the EAAS scores for the In our multiple logistic regression (14.05.2013 Number: 80558721/184 advertisements. Kruskal–Wallis and Decision no: 17). model (Table 4), the only factor as- Bonferroni corrected Mann–Whitney sociated with the effectiveness of all U tests were used to compare the me- the advertisements was smoking status. dian scores between the advertisements Results Initiators or smokers were less affected and to determine the differences be- by all the advertisements compared 2 tween the groups. X test was used for Of the 1434 students included in the to the never-smokers. Except for the the comparison of frequency data. study, 823 (57.4%) were female, 580 “Smoke-free air” and “Children want To determine the impact level for (40.4%) were 15 years old, 496 (34.6%) to grow” advertisements, the effective- each advertisement, a dummy variable were 16 years old (Table 2). The overall ness decreased with increasing stu- with a normal distribution and a mean smoking prevalence was 22.2%, and dent age. The rates of being affected

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Table 4 Variables associated with participants that were affected by each AD, OR and 95% CI calculated by multiple logistic regression analysis ADs Residence Gender Age Socioeconomic Adult in Close friend Smoking status status household smokes smokes OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Rejuve-nation – – 0.81* 0.74* 0.76* 0.67* 0.69** in all aspects (0.69–0.94) (0.60–0.91) (0.58–0.98) (0.51–0.89) (0.60–0.81) Smoking in – 1.37* 0.76** 0.79* – 0.67* 0.71** daily living (1.06–1.76) (0.65–0.88) (0.64–0.97) (0.51–0.88) (0.61–0.82) Smoke-free air 1.31* – – 0.79* 0.75* 0.64* 0.64** (1.01–1.70) (0.64–0.98) (0.58–0.97) (0.48–0.84) (0.55–0.74) COPD and – – 0.83* – – – 0.72** regret (0.71–0.96) (0.62–0.83) A bad example – – 0.86* 0.73* – – 0.75** of a father (0.74–0.99) (0.60–0.90) (0.65–0.87) Grandfather – – 0.83* 0.76* 0.77* – 0.68** and grandson (0.71–0.96) (0.62–0.93) (0.60–0.99) (0.58–0.78) Non-smoking is – – 0.80* 0.78* – 0.79** happiness (0.69–0.92) (0.64–0.96) (0.68–0.91) Smoking harms – – 0.80* – – – 0.73** in every breath (0.67–0.96) (0.62–0.87) Children want – 1.67** – – – – 0.71** to grow (1.24–2.26) (0.60–0.84) Sponge and tar – 1.52* 0.75** – – – 0.73** (1.12–2.05) (0.63–0.89) (0.62–0.86)

*P < 0.05; **P < 0.001. AD = anti-smoking advertisements; CI = confidence interval; COPD = chronic obstructive pulmonary disease; OR = odds ratio.

by the advertisements in the age 15 the socioeconomic level. However, the smoking addiction. Therefore, youth- and 17 years groups were as follows: effectiveness of the “Rejuvenation in all oriented anti-smoking campaigns 65.6–75.5% (V1); 61.5–73.3% (V2); aspects”, “Smoke-free air” and “Grand- should be initiated without delay. 64.0–73.4% (V4); 66.6–72.4% (V5); father and grandson” advertisements The smoking rate in the study group 62.9–71.0% (V6); 63.2–73.0% (V7); decreased among the students whose appeared to be higher than that in the 80.6–86.7% (V8) and 80.3–87.4% mother and/or father smoked, while the general population in Turkey, which (V10). The effectiveness of the “Smok- effectiveness of the “Rejuvenation in all might have resulted from including ing in daily living”, “Children want to aspects”, “Smoking in daily living” and adolescents aged between 15 and 17 grow” and “Sponge and tar” advertise- “Grandfather and grandson” advertise- years and because the rate of smoking ments were more pronounced in female ments decreased among the students initiation is high in this age group. Near- than male adolescents. The rates of be- whose close friends were smokers. ly 90% of cigarette smokers first tried ing affected by the advertisements in smoking by age 18 years (19). In light of male and female adolescents were as this information, our study group had a follows: 62.4–72.2% (V2); 74.8–86.4% Discussion high rate of attempting to smoke and a (V9) and 78.0–87.5% (V10). The high risk of smoking initiation. “Smoke-free air” advertisement was In this study, the anti-smoking advertise- In the present study, the “Sponge more effective on students living in ur- ments “Smoking harms in every breath”, and tar” advertisement was most effec- ban areas compared with those living followed by “Sponge and tar” and “Chil- tive among the adolescents. This adver- in rural areas. Socioeconomic status dren want to grow” were most effective tisement describes smoking-induced was associated with the effectiveness in adolescents. Therefore, determining pathological changes and tar accumula- of the advertisements, with the highest adolescents’ perception of smoking is tion in the lungs. The next most effective three EAAS scores and the “COPD and crucial because tobacco use usually be- advertisements were “Smoking harms regret” advertisement. The effectiveness gins in adolescence (18). Adolescents in every breath”, which describes the of the advertisements decreased with have specific characteristics and risks for lung damage caused by smoking, and

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“Children want to grow”, which uses al. reported that the anti-smoking mes- The association of age with the effect of the theme that cigarettes have a nega- sages for parents of the adolescent age advertisements in adolescents may be tive influence on child growth. In the group increased the effectiveness of the related to the dose-duration–response “Sponge and tar” advertisement, an ex- campaign (21). effect of the manipulation of the indus- perimental model was used to demon- None of the advertisements that try on adolescents. strate smoking-induced accumulation were effective were related to the long- Women represent ~20% of the 1 of tar in the lungs that were simulated term outcomes of smoking. It is impor- billion smokers in the world and the by a sponge, and the amount of tar ac- tant to focus on this discovery when prevalence of tobacco use among cumulation in a year was demonstrated. preparing anti-smoking advertisements women is increasing in developed and The “Smoking harms in every breath” for young people. Pechmann et al. have developing countries (25). Women advertisement simulated the course also reported that the causes of the as- with economic freedom in developed of cigarette smoke reaching the lungs sociated risks should be the focus of the countries smoke at nearly the same rate and demonstrated how the smoke fills advertisements rather than the associ- as men (26). However, the increase the lungs and penetrates the tissues, ated health risks and long-term serious of smoking among women has been resulting in fragmentation of the alveoli. outcomes (21). attributed not only to social factors Both these advertisements aimed to In the present study, all of the anti- and to increasing economic freedom, demonstrate visually, graphically and smoking advertisements were more but also to the marketing strategies of audibly the damage caused by cigarettes effective for never-smokers than ex- the tobacco industry for women (27). to the organs and tissues. It is possible smokers and current smokers. It was The tobacco industry emphasises the that adolescents might have been in- also important that, regardless of age, independence and attractiveness of fluenced by the themes, particularly in smoking behaviour decreased the ef- women and targets vulnerable adoles- the presentation and visual quality of fectiveness of all the advertisements. cent women by equating cigarettes with these advertisements. Cotter et al. have The literature has shown that smok- independence, elegance, body weight demonstrated that the “Sponge and tar” ers have a negative attitude towards control, culture and power (28). In the advertisement provides information anti-smoking messages (22). Therefore, present study, the advertisement de- for adolescents regarding the damage it would be more beneficial to show scribing smoking-related difficulties in caused by smoking and is effective in specific advertisements to individuals daily living (V2), such as smelling bad, providing motivation to quit smoking in an age group in which smoking be- had a greater effect on women than (20). Another study has reported that haviour has not begun. Videos with on men. This association might occur the videos using experimental and visual greater effectiveness should be used to because women usually perceive their methods to describe organ and tissue prevent attempts by smokers to ignore external environment in greater detail damage are more effective in terms of the advertisements. than men. However, the advertisements making viewers feel uncomfortable Also influence of most of the anti- about the harmful effects of smoking on and message acceptance compared to smoking advertisements decreased children (V9) also had a greater effect videos including the smoking-related with increasing age. In a study by Varda- on women (29,30). experiences of smokers (7). vas et al., the effectiveness of the health The higher effectiveness found for The third most effective advertise- warnings on the tobacco packages was the “Smoke-free air” advertisement in ment, “Children want to grow”, de- found to decrease with increasing age in urban compared with rural areas might scribes the harmful effects of smoking adolescents (23). Likewise, Biener and have occurred because adolescents on children and was found to be more Sieger have found a decreased effective- living in urban areas are usually more effective than videos that described the ness of advertisements with increas- exposed to smoking-related restrictions past experiences of smokers. This might ing age in adolescents (24). This trend in city life compared with those living in have been because the students real- might occur because, with increasing rural areas. We emphasized that, com- ized that children view their parents as age, adolescents usually attempt smok- pared with adolescents living in rural role models, and may acquire unhealthy ing because they equate cigarettes areas, those living in urban areas can behaviours such as smoking or be ex- with being an adult, and cigarettes are easily access locations for social interac- posed to passive cigarette smoke from perceived to represent social status. tion that encourage smoking behaviour. their parents, resulting in mental, social It is known that the tobacco industry In our study, the lower effectiveness and physical damage. This opinion particularly targets individuals aged of the anti-smoking advertisements on among adolescent non-smokers can 12–17 years, with the aim of influenc- individuals with low socioeconomic help identify the target population for ing positive attitudes and behaviour status might be related to the higher anti-smoking campaigns. Pechmann et towards tobacco in adolescents (19). global prevalence of smoking among

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such individuals (31). However, there and the fact that the adolescents self- years. Because there were significant was no difference in socioeconomic assessed the effects of the anti-smoking differences in the effectiveness of the level among the adolescents affected by advertisements. Additionally, the ef- advertisements, the theme, content, the three most effective advertisements, fectiveness of the advertisements was characteristics, presentation and spe- which suggests that those advertise- assessed in an unnatural manner by cific features for adolescents should be ments should be used more intensively showing the videos in an experimental considered. in countries with evident differences in setting. Moreover, the adolescents were income levels, such as Turkey. not asked how many times they had Having a mother and/or father or watched the advertisements on televi- Acknowledgements close friends who smoke usually leads sion. to adolescents trying smoking (32). In conclusion, although the anti- Our main thanks go to the hundreds of In the present study, both situations smoking campaigns were targeted to- students who participated in this study. resulted in a decreased effectiveness of ward the adult population, they also had We also thank the other participants the “Rejuvenation in all aspects” and a large influence on adolescents. How- and colleagues. Finally, we thank the “Grandfather and grandson” advertise- ever, campaigns including messages for interns who contributed to this study ments, which may be a result of less adolescents should be prepared. The through the acquisition of the data. empathy felt by these adolescents. main target population for these new The major limitations in this study anti-smoking advertisements should Funding: None. were the cross-sectional study design be non-smoker individuals aged <15 Competing interests: None declared.

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661 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

أثر اإلعالم واإلعالن يف الرتويج التجاري لألغذية عىل السلوك الغذائي للمراهقات بمدينة جدة إهلام اجلعلي1

اخلالصــة: هتــدف هــذه الدراســة إىل بيــان االختالفــات يف الســلوكيات الغذائيــة لــدى الفتيــات املراهقــات بمدينــة جــدة باململكــة العربيــة الســعودية، ِ 1519 كــا يعكــس تأثــر وســائل اإلعــالم ْعــر اإلعالنــات التلفزيونيــة التجاريــة. واســتخدمت الدراســة ًمســحا ًمقطعيــا شــمل فتــاة مــن عرشيــن مدرســة للبنــات بمدينــة جــدة. ّوتضمنــت أســئلة املســح معلومــات حــول اإلعالنــات التجاريــة وتأثيهــا عــى الســلوكيات الغذائيــة. ُوأ َجريــت chi square حتليــالت ثنائيــة الـمـُــتغ ِّي لتحديــد اختالفــات الســلوك الغذائــي نتيجــة التأثــر اإلعــالين مــع اســتخدام اختبــار مربــع كاي ) - ( لبيــان العالقــات ذات الداللــة اإلحصائيــة. وأبــرزت النتائــج وجــود ارتبــاط قــوي بــن تنــاول احللويــات والتعــرض لإلعالنــات التجاريــة )P = 0.035(. 48.5 299 وبلــغ عــدد املراهقــات اللــوايت ّتعرضــن لتلــك الدعايــة التجاريــة، ُوك َّ ــنعــى األرجــح أكثــر ًاســتهالكا للحلويــات ًفتــاة )% (، وعــدد مــن 59.5 373 50.7 316 َّتســوقن لــرشاء املــواد الغذائيــة ًفتــاة )% (، وعــدد مــن ْحاولــن َ إنقــاصأوزاهنــن ًفتــاة ) %(. وتؤكــد الدراســة عــى الــدور الــذي يلعبــه صانعــو القــرار والتزامهــم بحميــة شــباب املســتهلكي عــر زيــادة الترشيعــات وفــرض رقابــة عــى املحتــوى اإلعالمــي الــذي يســتهدف الشــباب )ال ّســيم اإلعالنــات عــن األغذيــة(.

The impact of media and advertising of food on the eating behaviour of adolescent girls in Jeddah, Saudi Arabia

ABSTRACT This study aims to detect differences in eating behaviours demonstrated by adolescent girls in Jeddah Saudi Arabia, according to the influence of the media through TV advertisements. A cross-sectional survey was conducted of 1519 girls from 20 schools in Jeddah. Survey questions included information regarding media advertising and its effect on eating behaviour. Bivariate analyses were performed to define differences in eating behaviour according to media influence and Chi-square analyses to detect significant relationships. The results indicated a significant correlation between dessert consumption and advertising exposure (P = 0.035). Adolescent girls exposed to such advertising were more likely to consume dessert [n=299 (48.5%)], to shop for food [n=316 (50.7%)], and had attempted to lose weight [n=373 (59.5%)]. The results emphasize the role and obligation of decision-makers to protect young consumers through increased legislation and control of media content (particularly food advertisements) targeting young people.

Impact des médias et de la publicité pour les produits alimentaires sur les comportements alimentaires des adolescentes à Djeddah (Arabie saoudite)

RÉSUMÉ La présente étude a pour objectif de détecter les différences de comportements alimentaires démontrées par des adolescentes à Djeddah (Arabie saoudite), en fonction de l’influence des médias dans les publicités télévisées. Une enquête transversale a été réalisée auprès de 1519 jeunes filles de 20 écoles de Djeddah. Les questions de l’enquête concernaient des informations sur la publicité dans les médias et son impact sur le comportement alimentaire. Des analyses bivariées ont été conduites pour définir les différences en matière de comportement alimentaire en fonction de l’influence des médias, et des analyses du Chi carré ont été effectuées pour détecter les relations significatives. Les résultats ont indiqué une corrélation significative entre la consommation de desserts et l’exposition à la publicité (p= 0,035). Les adolescentes exposées à ce type de publicité étaient plus susceptibles de consommer des desserts [n=299 (48,5 %)], de vouloir acheter des produits alimentaires [n=316 (50,7 %)], et avaient essayé de perdre du poids [n=373 (59,5 %)]. Les résultats soulignent le rôle et l’obligation des responsables de la prise de décision en matière de protection des jeunes consommateurs en augmentant la législation et en contrôlant les contenus médiatiques (notamment pour les publicités alimentaires) ciblant les jeunes gens.

1 استشارية التغذية ووكيلة كلية العلوم الطبية التطبيقية، جامعة امللك عبد العزيز، جدة، اململكة العربية السعودية، البيد اإللكرتوين: )[email protected]/[email protected]( االستالم: 15/12/22، القبول: 16/07/18 1Elham Al-Jaaly, The Vice-Dean for Female Section, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.

662 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

املقدمة أهنن يتعرضن لإلعالن التجاري تعرضاً كبياً املنتج بواسطة بعض املشاهي من الشخصيات وذلك بسبب وجودهن باملنزل لساعات طويلة املحبوبي لدى هذه الفئة )3(. خالل اليوم حيث قد يصل مشاهدة الفتيات هدفت هذه دراسة إىل مراجعة الدراسات كذلك أثبتت الدراسات يف منطقة اخلليج السعوديات إىل 21إعالناً عن كل ساعة بث اخلاصة بوضع األمراض غي املعدية واملرتبطة واململكة العربية السعودية بأن هنالك سلوك عام يشاهد فيها التلفزيون ووجدنا أن ٪18 من هذه بالتغذية وعوامل اخلطر املرتبطة هبذه األمراض لدى املراهقات وميل يف تقليد اجلنسيات األخرى يف إقليم رشق املتوسط تأثي التلفزيون عل اإلعالنات خمصصة لرتويج منتجات غذائية يف نمط معيشتهم. وأن لدى بعض الفتيات االستهالك الغذائي ونمط احلياة عند األطفال باستخدام أساليب تروجيية خمتلفة لتحفيز هذه عادات غذائية غي صحية مثال: تناول املأكوالت 3 يف ثالث طرق هي: أستهالك أعل كمية من الفئات العمرية عل رشائها ) ( والتي تتفق اتفاقاً الرسيعة واملرشوبات الغازية، وعدم االنتظام يف الطاقة والدهون إضافة إىل قلة النشاط البدين كبياً معاألساليب املستخدمة يف الدول املتقدمة الوجبات الغذائية وكذلك عدم االهتمم بتناول 4 ونمط احلياة األكثر مخوالً بسبب مشاهدة ) (. كم شمل التحليل هلذه اإلعالنات حتليل كميات كافية من اخلرضوات والفواكه واالعتمد التلفزيون لفرتات طويلة، ومشاهدة اإلعالنات املادة الغذائية املعلن عنها وتصنيفها من حيث عل أنظمة محية لتخفيف الوزن مأخوذة من التلفزيونية، وخاصة اإلعالنات عن الوجبات املكونات الغذائية كالسعرات احلرارية، وكمية القنوات الفضائية واملجالت وهي ذات صبغة الرسيعة واألطعمة غي الصحية والتي بدورها الدهون ونوعيتها، وكمية السكريات واألمالح جتارية ال تعتمد عل أسس صحية معتمدة من قبل تؤثر عل اخليارات الغذائية لألطفال وتغرهيم وذلك حسب التعريف اخلاص بوكالة أساسيات إخصائيي )7–11 (. بتناول كميات كبية من الدهون والطاقة )1(. الغذاء البيطاين)5(، ووجدت الدراسة أن ما ونجد أن العديد من الدول قد وضعت نسبته ٪ 70منها صُ نِفَت من ضمن األطعمة غي وهناك العديد من العوامل التي تؤثر عل قواعد وأسس منظمة لعملية اإلعالن التجاري الصحية الحتوائها عل نسب عالية من الدهون السلوك الغذائي والنمط املعييش للمراهقي، عل وجه العموم واإلعالنات املوجه للصغار املشبّعة والسكريّات واألمالح. كم أشارت دراسة ويعت باإلعالن الغذائي من أهم هذه العوامل. واملراهقي عل وجه اخلصوص وحتديد أوقات أخرى خاصة بنفس عينة الدراسة احلالية تعنى حيث نجد أن معظم هذه اإلعالنات الغذائية بثها، مما جيعل املادة اإلعالنية املوجهة إىل هذه بدراسة العوامل الشخصية والبيئية املؤثرة عل تروّ جألطعمة غنية بالسعرات احلرارية وقليلة الفئة العمرية منتقاة بعناية، ولكن نجد يف العديد السلوك الغذائي للمراهقات بالسعودية والتي تم يف القيمة الغذائية بطرق مغرية مثل: الشوكوالتة من البلدان النامية ودول اخلليج العريب انعدام االسرتشاد بنتائجها وخمرجاهتا يف الدراسة احلالية واحللويات املختلفة والبطاطا الغنية باألمالح األسس واللوائح املنظمة التي حتدد نوعية املادة 96٪ 1519 واملرشوبات الغازية، حيث تعتب القنوات إىل أن ما نسبته من املشاركات من إمجايل اإلعالنية املوجهة إىل الصغار أو قصورها أو عدم الفضائية من أكثر الوسائل اإلعالمية املستخدمة طالبة يقضي أوقات طويلة يف مشاهدة التلفزيون كفايتها يف كثي من األحيان )12( وذلك من حيث يف اإلعالن وخاصة اإلعالن عن األغذية املوجه مقارنة بالوسائل األخرى كاإلنرتنت وألعاب نوعية املادة املعلن عنها ووقت البث حيث إنه من 5 لفئة األطفال واملراهقي وذلك بسبب وجود الكمبيوتر واملجالت والصحف ) (. الناحية السلوكية والصحية والرتبوية فالبد من جهاز التلفزيون تلقائياًضمن مقتنيات األجهزة وتعتب الوجبات اخلفيفة الغنية بالسعرات املراقبة اللصيقة من اجلهات ذات االختصاص. املنزلية )2(. احلرارية والدهون والسكريات مثل الشوكوالتة والدليل عل ما سبق هو عدم وجود دراسات وأبحاث علمية كافية حتوضّ نوعية املادة ولقد أثبتت العديد من الدراسات عل والكيك والبطاطا اململّحة هي األكثر شعبية اإلعالنية وكميتها ومدى تأثيها عل النَشْ ء من مدى الثالثي عاماً املاضية أن تعرّض األطفال يف اململكة العربية السعودية لدى األطفال 6 حيث الفوائد أو املحظورات خاصة فيم خيتص واملراهقي ألجهزة التلفزيون، ومداومتهم عل واملراهقي) (، هذا باإلضافة إىل بعض أنواع بتأثيها عل السلوك الغذائي هلذه الفئة العمرية مشاهدة بعض البامج قد يؤدي إىل تكوين احللويات وأن أعل نسبة من اإلعالن املوجه هلذه والتي تعتب من أكثر مراحل حياة األنسان أمهية سلوك معي لدهيم بسبب تأثي العديد من البامج الفئات العمرية يركّز عل بث إعالنات خاصة حيث يبدأ فيها تشكيل السلوك الغذائي الذي ومقدميها وقد حياولون تقليد أنمطهم احلياتية، هبذه األطعمة والتي متثل ٪ من18 مجلة اإلعالنات يرافق اإلنسان إىل فرتة ما بعد البلوغ. هذا باإلضافة اىل تعرضهم لإلعالنات التجارية املبثوثة يف حي أن اإلعالن عن احلبوب يمثل – املغرية التي تروّ ج لألطعمة واملرشوبات غي ٪12 من املعلن)3(، وأن معظم الرشكات املعلنة –إن التطوّ ر الكمي والنوعي الذي حدث يف البث التلفزيوين باململكة العربية السعودية الصحية مما يؤثر عل سلوكهم ونمطهم الغذائي. يف القنوات التلفزيونية بالسعودية وبنسبة )58٪( يعتب تطوراً كبياً، فلم تكن هنالك سوى ولقد أشارت دراسة حتليلية لإلعالن عن ال تدرج أي معلومات عن املكوّ نات الغذائية قناتان تلفزيونيتان فقط حتى هناية الثمنينات 3 األغذية املوجة لألطفال واملراهقي والتي اختي عل عبّوات منتجاهتا ) (، مما يستوجب وجود من القرن املايض وتداران وتبثان حتت

فيه التلفزيون كأداة إعالمية واعالنية وتم حتليل قواني ملزمة يف اململكة العربية السعودية تلزم اإلرشاف املبارش من قبل وزارة اإلعالم 600 مضمون ما يروّ ج عنه يف اإلعالنات التجارية الرشكات املنتجة واملعلنة عل رضورة إدراج مجيع ولكننا نجد اآلن ما يربو عل قناة فضائية جمانية تبث عل أنظمة عربسات ونايل بالقنوات األكثر مشاهدة من قبل الفتيات املواد املستخدمة يف املنتج ونسبها، كم نجد أن سات وغيها من األقمر الصناعية ويمكن السعوديات )نفس عينة الدراسة احلالية( وهي استهداف فئة األطفال واملراهقي هبذه اإلعالنات للجميع التقاطها ومشاهدهتا بحرية كاملة MBC3 MBC4 MBC1 قنوات و و وتتبع ملجموعة يصاحبه استخدام أساليب حمفّزة لعملية الرشاء )13(، وتعتمد ىف استمراريتها عل اإلعالنات قنوات تلفزيون الرشق األوسط )MBC( إىل مثل تقديم حوافز سعرية، وهدايا جمانية وعرض التجارية لتغطية مرصوفاهتا، وكذلك بيّنت

663 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

316 50.7 – أبحاث جمموعة املرشدين العرب بتاريخ –تضمن االستطالع الذي صُ مم للحصول عل نسبة )٪ ( من املشاركات )بعدد (

)2009/6/11( )14( أن القنوات العامة معلومات بشأن العوامل التي تؤثر عل السلوك مقارنة بالاليت ال يعتقدن هبذا التأثي السلبي p =0.002 اململوكة للقطاع اخلاص تتصدر قائمة الغذائي للفتيات يف عينة الدراسة عل عامل خيص لإلعالنات )داللة إحصائية (، القنوات املجانية مقارنة بالقنوات الرسمية تأثي اإلعالم واإلعالن الغذائي والذي أختص إضافة إىل أن هناك عالقة كبية بي بعض

اململوكة للقطاع العام حيث تتصدر اململكة بمشاهدة التلفزيون واإلعالن التجاري املبثوث املمرسات املتعلقة باتباع أنظمة غذائية وبي

العربية السعودية وحدها النصيب األكب من من خالله ومدى تأثيه عل السلوك الغذائي القوة املؤثرة لإلعالنات عند التعرّ ض هلا، وذلك من خالل توجيه السؤال للمشاركات القنوات الفضائية اململوكة للقطاع اخلاص. فعل سبيل املثال إن الفتيات الاليت يعتقدن " ومن ضمن هذه القنوات قنوات مركز هل تعتقدين أن اإلعالن التلفزيوين لديه تأثي بالقوة املؤثرة لإلعالنات التلفزيونية كن " تلفزيون الرشق األوسط )MBC( والذي بدأ عل سلوكيات تناول الطعام اخلاصة بك؟ األكثر التزاماً باتباع أنظمة غذائية لتخفيف )114 ( 18 بثه يف سبتمب 1991م ومن ثم تطورت حيث الوزن بلغت نسبتهن ٪ بعدد مقارنة التحليل اإلحصائي للدراسة . إهنا يف العرش سنوات األخية انبثقت منها مع زميالهتن الاليت ال يؤمن هبذا التأثي – عدة قنوات، وهي تعتب من قنوات التلفزيون –أُدخلت نتائج االستطالع يف احلاسب اآليل

الفضائية املجانية والتي يبث من خالهلا معظم وحلّلت باستخدام البنامج االحصائي : )18 ( SPSS اإلعالنات التجارية. وهدفت هذه الدراسة النسخة لبيان مناقشة النتائج والتوصيات

اىل التعرّف عل مدى التأثي املبارش لإلعالم – –التكرار والنسب املئوية لعرض البيانات الوصفية. واإلعالن التجاري عن األغذية عل السلوك عند مناقشة النتائج اخلاصة هبذه الدراسة – –استخدام املتغي املسحي واملتعلق باإلعالن "هل الغذائي عل مستوى الفرد واجلمعة، والذي وكذلك العوامل الشخصية والبيئية املختلفة تعتقدين أن اإلعالن التلفزيوين لديه تأثي عل تم التعرّف عليه من خالل بعض اإلجابات " والتي هلا تأثي يف السلوك الغذائي وكيفية تناول سلوكيات تناول الطعام اخلاصة بك؟ وذلك اخلاصة بأسئلة االستبانة املتعلقة بمدى تأثي لقياس ودراسة االختالف يف السلوكيات الطعام والسلوكيات اخلاصة به )5(، وحسب اإلعالم واإلعالن التجاري عن املنتجات الغذائية للمشاركات ما أشار إليه حتليل املواد املعلن عنها بالقنوات الغذائية عل سلوك الفتيات الغذائي ومن – –استخدم يف عملية التحليل اإلحصائي ثنائي الفضائية األكثر مشاهدة )3( لنفس العينة من ثم ربطها إحصائياً بعوامل شخصية وبيئية املتغيات لتحديد مدى االختالف يف السلوكيات خمتلفة هلا تأثيعل تناول الطعام والسلوكيات املشاركات بالدراسة احلالية تبي أن املراهقات 5 اخلاصة بتناول الطعام للمشاركات واملشاهدات اخلاصة به . خاصة وأنه تم التعرّف عل نوعية يف السعودية يعشن يف وسط يرتبط ارتباطاً وثيقاً لبامج التلفزيون، ومدى تأثيها عل اختيار اإلعالن املشاهد وكميته للفتيات يف عينة باإلعالم واإلعالن التجاري والذي يقدم من املواد الغذائية وذلك باستخدام اختبار مربع كاي الدراسة يف دراسة أخرى أُجريت بالتزامن خالل وسائل خمتلفة عب القنوات الفضائية )chi-square( لدراسة العالقة بي متغيين مع هذه الدراسة )3(. مها: )أثر اإلعالن التلفزيوين( كمتغي و)السلوك التلفزيونية باعتباره من أهم مصادر املعلومات الغذائي( كمتغي تابع الصحية والغذائية لدهين، وحسب ما أوضحته 2 الطرق املتبعة يف الدراسة ومنهجها الدراسة التحليلية لإلعالنات الغذائية من نتائج وجدنا أن نسبة ٪ من70 األغذية املعلن عنها نتائج الدراسة ومن خالل حتليلها أن غالبيتها ضار صحياً )أي عينة الدراسة وطرق البحث – غنية بالدهون والسكريات واألمالح( مقارنة – 1519 –أثبتت هذه الدراسة وجود عالقة ذات –أجريت الدراسة عل عدد ) ( طالبة فئاهتم باألطعمة الصحية املعلن عنها األخرى وأشارت 13-18 داللة إحصائية مؤكدة تربط بي مدى العمرية ترتاوح ما بي ) سنة( واختيت التعرّض لإلعالن التلفزيوين وبي السلوك نفس الدراسة إىل أن أعل نسبة من اإلعالنات الطالبات من عرشين مدرسة )متوسطة االستهالكي والغذائي، مثال عل ذلك كانت خمصصة للحلويات واملرشوبات والتي متثل وثانوية( بطريقة عشوائية تشمل القطاعي كثرة تناول املرشوبات الغازية، وتفضيل ٪18، يف حيأن اإلعالنات عن احلبوب املسكرة احلكومي واخلاص وذلك بالعام الدرايس 12 2009 2010 تناول نوعية معينة من األطعمة وتفضيل شكلت ٪ ، عل ً مبأن تعرّض الفتيات ملثل هذا ) / م( وقد استخدمت العينة الطعام خارج املنزل وبأماكن مفضلة النوع من اإلعالنات التلفزيونية يكون أطول ألن العشوائية الطبقية املتعددة يف اختيار الفتيات لدى الفتيات الصغيات حسب املشاهد من خمتلف املناطق اجلغرافية بمدينة جدة. كم الوقت املخصص لعرضه عل شاشة التلفزيون الواردة يف اإلعالن وكذلك تناول األطعمة 2 استخدم إطار نظري تكاميل بغرض دراسة واملرشوبات )أمام التلفاز عل سبيل املثال( أطول ) (، وخاصة اإلعالنات عن الوجبات السلوك الغذائي للمراهقات السعوديات وذلك حسب ما هو م و ضّ ح بجدول رقم الرسيعة حيث كان معدل الوقت اخلاص والتعرّف عل بعض العوامل الشخصية والبيئية 1. حيث أوضحت الداللة اإلحصائية أقل باإلعالن عنها )33.8 ±8.3ثانية( واملرشوبات املؤثرة عل ذلك السلوك ومن ضمنها عامل تأثي 0.05 0.035 6.7±27.1 من ) ( بي استهالك الفتيات الغازية ) ثانية( واحللويات والسكريات اإلعالم واإلعالن عن األغذية، وقد رصحت األسبوعي للحلويات والسكريات وبي )24.9 13.6± ثانية( مقارنة بمعدل الوقت جلنة األخالقيات والبحوث يف جامعة امللك االعتقاد بمدى التأثي السلبي لإلعالم عل عبد العزيز بجدة عل الدراسة قبل إجرائها املخصص لالعالن عن الفواكه واخلرضوات نمطهن الغذائي نتيجة التعرّ ض لإلعالن )16.3 ±6.5 ثانية( كم أن هذه اإلعالنات تتكرر وكذلك وافقت وزارة الرتبية والتعليم عليها الغذائي. كم أن الفتيات الاليت يعرتفن باإلضافة اىل املوافقة اخلطية للمشاركات من بالتأثي السلبي لإلعالن الغذائي عل دورياً كبي مقارنة باإلعالن عن األطعمة أولياء أمورهن وذلك كرشط أسايس للمشاركة سلوكهن الغذائي نادراً ما يشاركن عائالهتن واملرشوبات القليلة يف بالدهون والسكريات يف هذه الدراسة )5(. يف التسوّ ق لرشاء املواد الغذائية ويمثلن واألمالح. كم أكدت الدراسة بأن املواد الغذائية

664 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

اجلدول 1 يوضح العالقة بني تصوّرات املراهقات بمدينة جدة عن تعرّضهن لإلعالنات التلفزيونية والسلوك الغذائي هلن السلوك الغذائي هل تعتقدين بأن مشاهدتك لإلعالن التجاري اخلاص باملنتجات الغذائية تأثري يف سلوكك الغذائي *النتائج تعكس بيانات االستجابة اإلجيابية )بنعم( العدد النسبة )%( قيمة الداللة اإلحصائية كم مرة يف األسبوع ً غالباما تتناولني وجباتك خارج املنزل؟ )العدد = 1441( من مرة إىل مرتي يف األسبوع )P=0.01 425)69 190)30.9( 3 مرات أو أكثر يف األسبوع د = 0.01 أين تأكلني عادة؟ )العدد = 1447( غرفة الطعام )P<0.001 179)29 21)3.4( غرفة النوم د >0.001 يف املطبخ )3.5(22 أمام التلفاز )59( 370 أي نوع من الطعام تتناولني يف الغالب؟ )العدد = 1447( الطعام املصنوع باملنزل )P=0.004 273)44 94)15( الطعام املصنوع خارج املنزل د =0.004 املأكوالت الرسيعة )40( 248 P=0.02 503 )80( هل تتناولني املرشوبات الغازية مثل البيبيس والكوال )العدد = 1453( د = 0.02 كم مرة يف األسبوع تتناولني احللويات مثل الكيك والشوكوالتة )العدد = 1468( وال مرة باألسبوع )P=0.035 39 )6.3 279)45( من مرة إىل مرتي باألسبوع د =0.035 3 مرات أو أكثر يف األسبوع )48.5( 299 P=0.008 114 )18.3( هل تتبعني أي نظام غذائي خاص يف الوقت احلارض؟ )العدد = 1475( د =0.008 هل سبق لك أن حاولت فقدان الوزن؟ )العدد = P<0.001 373 )59.5( )1482 د >0.001 هل تقومي بأي أعمل منزلية مثل غسيل املالبس أو تنظيف املنزل؟ )العدد = P=0.002 316)50.7( )1499 د =0.002 P=0.002 316)50.7( هل تقومي ّبالتسوق لرشاء األغذية أو العنارص األخرى؟ د =0.002

*القيمة اخلاصة بمستوى الداللة اإلحصائية )د( أقل من 0.05

واملرشوبات املعلن حتمل بعض الرسائل ذات > ( 0.001وتناول املرشوبات الغازية )داللة عنها من خالل السؤال املبارش هلذه الفئة واخلاص 15 0.001= العالقة بالصحة، وعل سبيل املثال إضافة أو إحصائية ( ) (. بمدى تأثي اإلعالن الغذائي التجاري املروّ ج تدعيم املنتج بالفيتامينات واملعادن )٪37(، وتوفي للمنتجات الغذائية وتأثيه عل سلوكهن الغذائي كم أن معظم هذه اإلعالنات تعرض وتقدم املواد الغذائية األساسية الطبيعية )٪25(، وإدراج من خالل مشاهدهتن له. بواسطة مراهقي مما يعطي داللة واضحة بأهنا 29٪ 15 رسائل صحية بسيطة ) ( ) (. موجهة مبارشة إىل هذه الفئة. إن األبحاث العلمية يف هذا املجال خاصة يف أوروبا بميف ذلك اململكة املتحدة والواليات إضافة إىل تأكيد وجود عالقة ذات داللة ومن ذلك اتضح لنا التأثي املبارش لإلعالن املتحدة األمريكية قامت بدراسات شاملة إحصائية مؤكدة تربط بي الوقت الذي متضيه التجاري اخلاص باألطعمة واملنتجات الغذائية ومراجعة لألدلة عل أثر اإلعالن عن األغذية يف الفتيات املشاركات يف مشاهدة التلفزيون والذي عل السلوك والنمط الغذائي للعديد من التأثي عل سلوك األطفال واملراهقي يف اختيار تم حتديده كوقت مستقطع كساعتي او أكثر وبي املشاهدين خاصة الفئة املستهدفة يف الدراسة بعض األطعمة واملرشوبات وتفضيلها. وكذلك، نوعية بعض األطعمة غي الصحية التي تتناوهلا من املراهقات الاليت ترتاوح أعمرهن بي سن حتققت القليل من الدراسات السعودية وغيها 18–13 الفتيات مثل تناول املأكوالت الرسيعة ومشاهدة ) ( باإلضافة اىل األرضار الصحية األخرى من دول اخلليج العريب عن تأثي وسائل اإلعالم التلفزيون لساعتي أو أكثر )داللة إحصائية = ذات العالقة بالنمط الغذائي والتي تم االستبانة عل السلوكيات اخلاصة بتناول الطعام لفئة

665 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

املراهقي كم نجد أن بعضها قد جتاهل نسبياً مدى نوعية األغذية وتفضيل الفتيات للمرشوبات واحلد من عبء األمراض ذات الصلة بالنظام قدرة تأث يوسائل اإلعالم عل سلوكيات تناول الغازية )بداللتي إحصائيتي 0.001 و0.02( الغذائي بي املراهقي يف اململكة العربية السعودية. الطعام واحلالة التغذوية للمراهقي. عل التوايل، حيث اتضح بأن الفتيات األكثر ومن وجهة النظر البحثية، فالبد من عمل تعرضاً للتلفزيون ولدهين نظرة إجيابية لإلعالنات لقد أوضحت األدلة والباهي احلالية أن دراسات للمتابعة واملراجعة املستمرة مما يساعد التلفزيونية هم األكثر عرضة لتناول املرشوبات الرتويج لألطعمة بالطرق اإلعالنية املختلفة عل التقييم املستمر لتطبيق سياسات وإجراءات الغازية. باإلضافة إىل تفضيلهن لتناول الطعام له تأثي كبي عل كيفية اختيار األغذية وعل متعلقة بمبادئ توجيهية ولوائح إلجياد حلول خارج املنزل، بل هن أيضاًاألكثر احتم الًيف السلوك االستهالكي بل توف يهذه األغذية علمية للمشاكل املتعلقة بالتغذية والوقاية من املشاركة يف رشاء األطعمة وزيادة استهالك ورشائها بواسطة األطفال واملراهقي وبتسهيل األمراض ذات الصلة احللويات والشوكوالتة، مقارنة بالفتيات الاليت طرق احلصول عليها حتى إيصاهلا هلم باملنزل. ال يعتقدن بتأثي اإلعالنات. ولقد استعرضت ولتحقيق األهداف، ينبغي العمل عل تذليل وتتبع البلدان النامية، بم يف ذلك اململكة العربية العديد من األدلة والباهي مدى تأثي العروض بعض العقبات: السعودية نفس أساليب التسويق والرتويج التي الرتوجيية للغذاء املوجه لألطفال يف كل من البلدان تستخدمها البلدان املتقدمة )16(. تلعب احلكومات دوراً كبياً، بالتأثي عل املتقدمة والنامية )17 (وأشارت األدلة بأن لوسائل البيئة املادية التي بسببها توفر األغذية للمراهقي، وقد أوصت دراسات هتدف إىل تقييم مدى أثر اإلعالم املروِّ جة للغذاء املوجه لألطفال وجوداً والعمل عل تقني واستحداث أنظمة حتدّ من اإلعالن يف اختيار األطعمة بواسطة املراهقي أن ملحوظاً كم أن هلا تأثياً قوياً عل السلوكيات تأثي اإلعالن التجاري الغذائي عل سلوك ال ينظر هلذا النوع من الدراسات بشكل منفصل واألنمط الغذائية لألطفال واملراهقي. إال أنه من واختيار املراهق يللمواد الغذائية واملرشوبات وإنم ينظر أيضاً إىل تفاعل العوامل األخرى ذات املمكن أن يلعب املروجون لإلعالنات الغذائية واحلث عل رضورة زيادة النشاط البدين وتوفي التأثي املبارش كالعوامل الشخصية والبيئية )17(. املختلفة وصانعو األغذية املوجه لألطفال دوراً وهتيئة األماكن اخلاصة له. لذلك وملتابعة املشورة بي اخلباء، وملقارنة النتائج مساعداًملشاهدي التلفزيون من هذه الفئات التي توصلت إليها الدراسة احلالية، تم االستفادة العمرية وذلك بعرض مواد ورسائل صحية من نتائج دراسة حتليلية وصفية عن مدى املواد مصاحبة لعرض اإلعالنات الرتوجيية كالتعريف التوصيات الغذائية املروجة وطبيعتها بالقنوات الفضائية بأمهية الرياضة واحلركة يف سن مبكرة وعرض 2 األكثر مشاهدة من الفتيات لنفس العينة ) ( أمهية تناول بعض األطعمة واملرشوبات الصحية تويص الدراسة احلالية باآليت: ودراسة أخرى مسحية وتضم سؤال الفتيات باستخدام نفس الطرق الرتوجيية لألطعمة – –وضع أسس ولوائح منظّ مةلعملية اإلعالن األخرى من خالل اإلعالن مما سيكون له أثر عن تصوراهتن حول تأثي وسائل اإلعالم التجاري من حيث املادة املبثوثة والفئة املستهدفة عل اختيارهن لطعامهن ومن ثم تم استخدام إجيايب عل العديد من املشاهدين واحلد من بعض وأوقات البث ووضع جهة رقابية ملتابعة عملية 18 " املتغي املسحي واملتعلق بشؤون اإلعالن هل العادات الغذائية غي الصحية ) (. اإلعالن التجاري وذلك للحد من األرضار تعتقدين أن اإلعالن التلفزيوين لديه تأثي عل والسلبيات التي قد تنجم عنه. " سلوكيات تناول الطعام اخلاصة بك؟ وذلك – –إْدخال مادة االعالم من ضمن املناهج الدراسية امللخص واآلثار والتوصيات لقياس ودراسة مدى االختالف يف السلوكيات يف املدارس حتى يطّلع الطالب والطالبات الغذائية للمشاركات للتعرّ ف عل كيفية تأثي البامج املختلفة وأنواع اإلعالنات وبخاصة بالنظر لإلعالم وطرق اإلعالن الغذائي املوجّ ة اإلعالن عل سلوكهن الغذائي )كمتغي تابع(. عل البامج التجارية منها ملعرفة مدى تأثيها لألطفال واملراهقي باململكة العربية السعودية والفائدة والرضر من الرسالة اإلعالنية املرسلة وأظهرت الدراسة عدداًمن العالقات بوجود ومدى تأثيه عل النمط والسلوك الغذائيي هلذه عب البامج واإلعالن. دالالت إحصائية تؤكد عل تأثي التعرّ ض الفئة العمرية فإهنا البد من وضع سياسات تنظّ م – –التشجيع واملتابعة من اجلهات املختصة للمعلني لإلعالنات التجارية واالعتقاد بذلك التأثي عل املادة املعلنة لألطفال واملراهقي لعدم وجود عل أن يتضمن اإلعالن التجاري تثقيفاً صحىاً االختيار والسلوك الغذائي من ضمنها التأثي توصيات أو إجراءات واضحة حتكم هذا األمر للمشاهدين ومتلقي الرسائل اإلعالنية بأمهية عل السلوكيات اخلاصة باتباع األنظمة الغذائية اتباع السلوك الغذائي الصحيح وممارسة التمرين أسوة ببعض الدول األخرى، عليه فإنه البد املختلفة. فالفتيات األكثر اعتقادا باإلعالنات واألنشطة الرياضية وطرق وكيفية التمييز بي من االستفادة من املبادئ التوجيهية الدولية التلفزيونية األكثر عرضة ملتابعة أنواع خمتلفة من املواد الضارة أو ذات املنفعة الغذائية. هبذا اخلصوص وذلك من أجل االنضم إىل األنظمة الغذائية اخلاصة باحلمية وختفيض الوزن – –رضورة املراقبة اللصيقة من قبل من يعرض جهود املجتمع الدويل يف معاجلة املشاكل املرتبطة وممارستها. املادة املشاهدة وتبصي وتعريف النشء بمدى بالتغذية، إضافة إىل أمهية تضامن العديد من فائدهتا أو رضرها حتى ال يكونوا ضحية كذلك ارتبط االعتقاد من قبل العينة بمدى اإلدارات املعنية بأمور الناشئة للقيام بعمل علمي لبعض اإلعالنات التجارية التي تروج ملنتجات تأثي اإلعالن التلفزيوين ارتباطاً كبياً باختيار وعميل شامل إلعادة التوازن يف النظام الغذائي تستهدفهم.

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املراجع References

1. 1. Musaiger A, Al-Hazzaa HM. Prevalence and risk factors Arabia (A comparison between governmental and private associated with nutrition-related noncommunicable dis- schools). The Second Conference of Obesity; Manama, Bah- eases in the Eastern Mediterranean region. Int J Gen Med. rain, T. S. C. O.(ed.), Conference paper; 2005. 2012;5:199–217. 11. Al-Sheri SN. Health profile of Saudi adolescent school girls. 2. Story M, French S. Food Advertising and Marketing Directed Riyadh: Health Affairs Directorate, Presidency of Girls Educa- at Children and Adolescents in the US. Int J Behav Nutr Phys. tion, Riyadh, Saudi Arabia, King Saud Library Book. PhD thesis; 2008;1(3). 1996. 3. Stearns N. Fat History: Bodies and Beauty in the Modern West. 12. Al-Jaaly E, Lawson M, Hesketh T. Overweight and its determi- 2nd ed. New York: New York University press; 2002. nants in adolescent girls in Jeddah City, Saudi Arabia. Int J Food 4. Al Jaaly E. Food Advertising Watched by Adolescent Girls in Saf Nutr Publ Health. 2011; 4(2): p. 95-108. Saudi Arabia. IJFNPH. 2012;5(2):249–63. 13. Hawkes. Marketing food to children : the global regulatory 5. Food Standard Agency. The Review of the Nutrient Profiling environment. WHO; 2004. Report No.:9241591579. Model: Paper for Information; 2008. 14. Kraidy MM. Youth, Media and Culture in the Arab World. In 6. Al-Jaaly, E. Personal and Environmental Influences on Eat- Drotner K, Livilavengstone S. International handbook of chil- ing Behaviours of Adolescent Girls in Saudi Arabia. World dren, media and culture. London: Sage;2008:330–40. Sustainable Development Outlook. 2015:1–11. (http:// 15. Aljaaly E. Factors affecting nutritional status and eating behav- worldsustainable.org/index.php/component/docman/ iours of adolescent girls in Saudi Arabia. Published PhD the- cat_view/210-world-sustainable-development-outlook/211- sis. University College London (University of London), 2012. outlook-2015?Itemid=). (https://www.google.com.sa/search?tbo=p&tbm=bks&q=ina 7. US Department of Commerce and Department of Agriculture uthor:"E.+A.+M.+Aljaaly). (DoA.) US Snack Foods - Saudi Arabia Marketing Research; 16. Arab Advisors group. 11 June, 2009. (http://www.arabadvi- 2011. sors.com/arabic/Pressers/presser-110609.htm). 8. Al-Shoshan A. Some Sociodemographic Factors Influencing 17. Cairns G, Angus K, Hastings G. The extent, nature and effects the Nutritional Awareness of the Saudi Teens and Adults: Pre- of food promotion to children: a review of the evidence to liminary Observation. J R Soc Promot Health. 1990;110(6):213– December 2008. Geneva: WHO. 2009. 16. 18. Livingstone S, Helsper E. Advertising foods to children: Under- 9. Al-Sudairy A, Howard K. Dietary habits of technical and voca- standing promotion in the context of children's daily lives. A tional students in Riyadh, Saudi Arabia. Part I. Meal skipping. J review of the literature prepared for the Research Department R Soc Health. 1992;112(5):217–18. of the Office of Communications (OFCOM). London: London 10. Musaiger A, Zagzouk N, Almaaie M. The nutrition habits. Life School of Economics. 2004. (http://www.lse.ac.uk/collec- style and obesity among adolescents in Jeddah city. Saudi tions/media@lse/).

667 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Prevalence and correlates of metabolic syndrome in pre-crisis Syria: call for current relief efforts H. Ramadan1, F. Naja2, F.M. Fouad 1,3, E. Antoun1, M. Jaffa 1, R. Chaaban 1, M. Haidar 1, A.M. Sibai 1

انتشار "متالزمة التمثيل الغذائي "والعوامل املرتبطة هبا يف سورية قبل األزمة: نداء إىل جهود اإلغاثة احلالية هال رمضان، فرح نجا، فؤاد م. فؤاد، إدوينا أنطون، مريان جافا، روان شعبان، حممد حيدر، عبلة سباعي

اخلالصــة:هدفــت هــذه الدراســة إىل تقييــم انتشــار "متالزمــة التمثيــل الغذائــي" ِّومكوناهتــا والعوامــل املرتبطــة هبــا لــدى البالغــن قبــل األزمــة يف حلــب باجلمهوريــة العربيــة الســورية. فاســتخدمنا طريقــة اختيــار عينــة عنقوديــة ســكانية املرتكــز ذات مرحلتــن لــدى جمموعــة ســكانية ضمــت 557 رجــ ًال و611 امــرأة، جــرى انتقاؤهــم ًعشــوائيا مــن 83 ًحيــا ً، ســكنيابــا يف ذلــك العديــد مــنســكان األريــاف. وقيســت اخلصائــص االجتمعيــة والســكانية ومميــزات أســلوب احليــاة واملراضــة واألنثروبومرتيــة )الطــول والــوزن( واملقاييــس الكيميائيــة احليويــة. ُفق ِّــدر انتشــار 39.6 "متالزمــة التمثيــل الغذائــي" بـــ % ، مــع تقــارب معــدالت االنتشــار بــن الرجــال والنســاء. وكان أكثــر ِّاملكونــات ًانتشــارا زيــادة ضغــط الــدم ) % 56.6(، تليــه الســمنة املركزيــة ) % (.51.4 ويف أوســاط النســاء كانــت هنــاك عالقــة عكســية بــن التعليــم )12 ًعامــا( وبــن خطــر اإلصابــة بـــ "متالزمــة التمثيــل الغذائــي"، يف حــن كان هنــاك ارتبــاط بــن وجــود تاريــخ عائــي للســمنة والســكري وبــن زيــادة خطــر اإلصابــة. إن ارتفــاع معــدل انتشــار "متالزمــة التمثيــل الغذائــي" ِّومكوناهتــا يؤكــد عــبء األمــراض القلبيــة الوعائيــة يف أوســاط البالغــن يف حلــب قبــل األزمــة. جيــب أن ُي َــدرج ضمــن االســتجابة اإلنســانية احلاليــة ٌ نظــاملرتصــد وتدبــري األمــراض األقــل ًظهــورا.

ABSTRACT This study aimed to assess the prevalence, components and correlates of metabolic syndrome (MetS) in adults in pre-crisis Aleppo, Syrian Arab Republic. We used a population-based, 2-stage cluster sampling method in a population of 557 men and 611 women, randomly selected from 83 residential neighbourhoods including many rural settlers. Sociodemographic and lifestyle characteristics, comorbidity, anthropometry and biochemical indices were measured. Prevalence of MetS was estimated at 39.6%, with comparable rates in men and women. Hypertension was the most prevalent component (56.6%), followed by central obesity (51.4%). Among women, education (12 years) was inversely associated with risk of MetS, while family history of obesity and diabetes was associated with an increased risk. The high prevalence of MetS and its components emphasizes the burden of cardiovascular diseases among adults in pre-crisis Aleppo. A system of surveillance and management for cardiovascular diseases needs to be incorporated into the current humanitarian response.

Prévalence et corrélats du syndrome métabolique en Syrie d’avant la crise : justification des efforts de secours actuels

RÉSUMÉ La présente étude avait pour objectif d’évaluer la prévalence, les composantes et les corrélats du syndrome métabolique chez l’adulte à Alep avant la crise, en République arabe syrienne. Nous avons utilisé une méthode d’échantillonnage en grappe à deux degrés basée sur une population de 557 hommes et 611 femmes, choisis de manière aléatoire dans 83 zones résidentielles, comprenant de nombreux habitants de zones rurales. Les caractéristiques socio-démographiques et relatives au mode de vie, les comorbidités, l’anthropométrie et les indices biochimiques ont été évaluées. La prévalence du syndrome métabolique a été estimée à 39,6 %, avec des taux comparables entre hommes et femmes. L’hypertension était la composante la plus prévalente (56,6 %), suivie par l’obésité centrale (51,4%). Parmi les femmes, l’éducation était inversement associée au risque de syndrome métabolique, alors que des antécédents familiaux d’obésité et de diabète étaient associés à un risque accru. La forte prévalence du syndrome métabolique et de ses composantes met en évidence la charge des maladies cardio-vasculaires chez l’adulte à Alep avant la crise. Un système de surveillance et de prise en charge des maladies cardio-vasculaires doit être incorporé à la riposte humanitaire actuelle.

1Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon (Correspondence to: [email protected]). 2Department of Nutrition and Food Science, Faculty of Agriculture and Food Sciences, American University of Beirut, Beirut, Lebanon. 3Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic. Received: 09/03/15; accepted: 26/07/16

668 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Introduction prevalence rates of self-reported CVDs residential neighbourhoods obtained (45.0%), hypertension (40.6%) and from the records of the Aleppo Mu- Metabolic syndrome (MetS) refers to a obesity (38.2%) (6,7). Based on such nicipality Office. Only 1 adult aged 25 cluster of physiological risk factors that a population risk profile, Maziak and years was selected randomly from the identifies individuals at particularly high colleagues cautioned against a likely in- household roster, excluding pregnant risk for cardiovascular disease (CVD). crease in morbidity and mortality from or lactating women. Face-to-face inter- The International Diabetes Federation CVD, and called for more studies and views were conducted with 1168 par- (IDF) notes that one quarter of the reliable estimates to inform interven- ticipants who gave informed consent to world population has MetS, and ~80% tions and policies (6). A second AHS enrol in the study, yielding a response of these are at risk of death from CVDs was conducted 2 years later by the same rate of 92.1%. There were 557 men and (1). While the debate around the defini- researchers using the World Health 611 women, with a mean age of 44.7 tion of MetS is still ongoing, a joint in- Organization (WHO) STEPWise ap- [standard deviation (SD 12.7)] years. terim statement by the IDF, American proach to Surveillance (STEPS), with Participants were also asked to attend Heart Association, and National Heart, data collected through face-to-face the SCTS laboratory within the next 7 Lung and Blood Institute in 2009 de- interviews, anthropometric and blood days to provide fasting blood samples fined it as 3 or more of the following: pressure measurements, and assess- for biochemical analysis. Eight hundred central obesity, hypertension, elevated ment of blood lipid profile. The survey and six participants consented and gave fasting glucose, hypertriglyceridaemia, indicated a high level of behavioural fasting blood samples (69.0%). The and low high-density lipoprotein–cho- and clinical risk factors (8). Around study protocol was approved by the lesterol (HDL-C) levels (2). one third of those with type 2 diabetes Institutional Review Board of the SCTS High prevalence of MetS is a com- were unaware of their condition, and and the University of Memphis, USA. mon trend worldwide (3). Over one only 16.7% of the treated cases were third of the population in the Gulf coun- under control (9). In March 2011, a Instruments and measures tries has MetS (4), and recent evidence protracted political and civil crisis erupt- A questionnaire, adapted from the suggests an increase in dietary energy ed in the country, resulting in severe WHO STEPS for NCDs and their risk supply and rise in sedentary lifestyle, deterioration of living conditions, and factors, was administered by trained in- with alarming rates of obesity and major waves of displacement and out- terviewers, covering sociodemographic diabetes, exceeding in some countries migration. As life-threatening injuries characteristics: gender, age, education, those in Europe and the United States continue to receive higher priority in an marital status and employment status. of America (USA) (5). The present overwhelmed health care system, treat- It also included questions on health- study collected data from a household ment for chronic illnesses is becoming related characteristics: lifestyle indica- survey in pre-crisis Aleppo, Syrian Arab increasingly rare (10). Although the tors (smoking and physical activity), Republic, and aimed to establish the current study was based on data from family history of obesity and diabetes, prevalence components and correlates the pre-crisis Syrian Arab Republic, the and medication. Smoking was defined of MetS among the adult population. findings may be relevant to the current as self-reported cigarette or water pipe We conducted a biochemical analysis displaced population. The findings are smoking in the past month. Physical ac- that provided an opportunity to exam- also likely to shed light on the often- tivity was defined as any form of leisure ine MetS based on objective measures overlooked toll of noncommunicable activity for > 30 minutes at least 3 times of its components. diseases (NCDs) among refugees, and per week. to be of use to relief agencies in plan- ning humanitarian responses and health Anthropometric and blood pressure Methods service needs. measurement Anthropometric measurements were Setting and context Study design and participants taken using standardized techniques Aleppo is located in the Northwest Data were based on secondary analyses and calibrated equipment. Weight was of the Syrian Arab Republic. It is of the cross-sectional population-based measured to the nearest 0.1 kg in light the second largest city and the most second AHS conducted in 2006 by clothing and with bare feet or stockings. populous, compromising 20% of the the Syrian Center for Tobacco Studies Height and waist circumference were Syrian population of ~23 million. The (SCTS) and the University of Aleppo measured to the nearest centimetre. first Aleppo Household Survey (AHS) (9). Briefly, a 2-stage cluster sampling Participants were classified as obese if was conducted in 2004 among adults method was used, and 1268 house- their body mass index (BMI) was ≥ 30 aged 18–65 years and yielded alarming holds were randomly selected from 83 kg/m2 and overweight if their BMI was

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≥ 25 and < 30 kg/m2. Blood pressure Statistical analysis 8.3%). Family history of obesity was was measured by averaging 2 or 3 blood Frequencies and means (SD) were significantly higher among women than pressure readings taken by a standard used to describe sociodemographic and men (45.4% vs 39.4%). mercury sphygmomanometer, with health-related variables. Mean values Participants at risk for the various participants in a seated position after 5 of the various components of MetS components of MetS are presented in minutes rest. and the proportions of the population Table 2, stratified by gender. Overall, hypertension was the most common Biochemical assessment at risk were also calculated. All data are presented for the whole sample and for risk factor (56.6%), followed by cen- Fasting venous blood was collected ac- men and women separately. Gender tral obesity (51.4%). Elevated fasting cording to the European Health Risk differences in baseline characteristics blood glucose (33.7%) and hypertri- Monitoring Project and the WHO and prevalence rates of MetS and its glyceridaemia (31.8%) were the least Multinational Monitoring of Trends components were examined using X 2 prevalent. Women were significantly and Determinants in Cardiovascular and independent-samples t tests for more likely to have central obesity than Disease project protocols. Plasma glu- categorical and continuous variables, men were (65.5% vs 36.6%). A higher cose and lipid profiles [total cholesterol, respectively. Multivariable logistic re- proportion of men than women had low-density lipoprotein–cholesterol, gression analysis was carried out, with reduced HDL-C (43.4% vs 35.7%) HDL-C and triglyceride (TG)] were MetS as the outcome variable and and hypertriglyceridaemia (38.4% vs tested using an automated random baseline sociodemographic charac- 25.9%). No significant gender differ- access analyser of clinical chemistry– teristics, lifestyle variables and family ences were observed for hypertension turbidimetry (A25; BioSystems, Barce- history as the covariates. These included and elevated fasting blood glucose. The lona, Spain). age: (25–39, 40–59 and ≥ 60 years); prevalence of MetS (3 risk factors) was education (< 6, 6–11 and 12 years of 39.6% overall, 38.9% in men and 40.2% Diagnostic criteria for MetS schooling); marital status; employment in women. Close to 15.5% of the sample MetS diagnosis was based on the status; cigarette and/or water pipe had none of the risk factors and 7.4% definition made by the Joint Interim smoking; physical activity; and family had all five. Statement of several major organiza- history of obesity and diabetes. Logistic The results of the univariate and tions (2). Participants were considered regression models were fitted in blocks multivariate logistic regression models to have MetS if they had 3 or more of of sociodemographic characteristics, that evaluated the association between the following CVD risk factors: central lifestyle variables and family history of the predictor variables and MetS are obesity, hypertriglyceridaemia, low obesity and diabetes. Unadjusted and shown in Table 3. In the univariate HDL-C, hypertension and elevated adjusted prevalence odds ratios (ORs) analysis, age, education, marital status fasting blood glucose. Central obesity and 95% confidence intervals (CI) were and employment status were associated was defined as waist circumference > calculated. SPSS for Windows version significantly with MetS for both men 102 cm for men and > 88 cm for women 20.0 was used for all calculations, and P and women. Family history of obesity according to WHO recommendations < 0.05 was considered significant. and diabetes was associated significant- (2). Diagnosis of hypertriglyceridaemia ly with MetS among women only. In was defined as TG level > 150 mg/dL the fully adjusted model, the prevalence or being on medication for elevated Results odds of MetS increased with age and TG. Reduced HDL-C was defined as showed a negative trend with increasing Baseline sociodemographic and health < 40 mg/dL for men and < 50 mg/dL education level among women, reach- characteristics of the participants are ing significance when comparing 12 for women or being on drug treatment shown in Table 1. Compared to men, for reduced HDL-C. Participants were with < 6 years of schooling. Family his- women were significantly more likely to tory of obesity and diabetes remained considered to have hypertension if they have lower education level; to include significant risk factors for MetS among were taking antihypertensive medica- a higher proportion of divorced and women. tion or had systolic blood pressure > widowed; and to be not working at the 130 mmHg or diastolic blood pressure time of the survey. Women had a higher > 85 mmHg. They were considered to mean BMI (32.2 ± 6.9 vs 28.6 ± 4.8 kg/ Discussion have elevated fasting blood glucose if m2). Men were ~3 times more likely they were on medication for elevated to be ever smokers than women were This study is believed to be the first to glucose or had fasting plasma glucose > (73.4% vs 25.2%) and ~1.5 times more explore the prevalence and correlates 100 mg/dL. likely to be physically active (12.2% vs of MetS in the pre-crisis Syrian Arab

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Table 1 Baseline sociodemographic and health characteristics for total sample and men and women separately, Aleppo Household Survey, 2006 Sociodemographic characteristics Total Men Women P-value* (n =1168) (n = 557) (n = 611) n % n % n % Age, years, mean (SD) 44.7 (12.7) 45.3 (12.9) 44.2 (12.6) 0.131 25–39 442 37.9 203 36.5 239 39.1 0.557 40–59 549 47.0 264 47.5 285 46.6 ≥ 60 176 15.1 89 16.0 87 14.2 Education, years < 6 351 30.1 127 22.8 224 36.7 < 0.001 6–11 509 43.6 256 46.0 253 41.4 ≥ 12 308 26.4 174 31.2 134 21.9 Marital status Single 72 6.2 36 6.5 36 5.9 < 0.001 Married 1000 85.6 511 91.7 489 80.0 Divorced/widowed 96 8.2 10 1.8 86 14.0 Employment status Not working 624 53.4 116 20.8 508 83.1 < 0.001 Working 544 46.6 441 79.2 103 16.9 Health characteristics BMI, kg/m2, mean (SD) 30.4 (6.3) 28.6 (4.8) 32.2 (6.9) < 0.001 Normal 215 19.1 132 24.0 83 14.4 < 0.001 Overweight 374 33.2 216 39.3 158 27.3 Obese 538 47.7 201 36.6 337 58.3 Mean waist circumference, cm (SD) 97.1 (13.9) 98.5 (12.7) 95.8 (14.8) <0.001 Mean SBP, mmHg (SD) 133.3 (20.4) 134.3 (19.6) 132.3 (21.1) 0.089 Mean DBP, mmHg (SD) 81.8 (12.6) 81.8 (12.7) 81.9 (12.4) 0.955 Smoking (% ever) 563 48.2 409 73.4 154 25.2 < 0.001 Physical activity (% yes) 119 10.2 68 12.2 51 8.3 0.009 Family history of obesity (% yes) 495 42.5 218 39.4 277 45.4 0.037 Family history of diabetes (% yes) 479 41.0 225 40.4 254 41.6 0.683

*Significance based onX 2 and independent-samples t tests, for categorical and continuous variables, respectively. BMI = body mass index; DBP = diastolic blood pressure; SBP = systolic blood pressure; SD = standard deviation.

Republic. Prevalence of MetS was countries of Bahrain, Kuwait, Oman, (16). The prevalence rate of MetS in our examined in relation to baseline soci- Saudi Arabia, Qatar and United Arab study needs to be contextualized within odemographic characteristics, behav- Emirates, demonstrated comparable the circumstances in Aleppo at the time iour, and family history of obesity and prevalence rates of 36.3–39.6% for of the survey, which was conducted a diabetes. Around 40% of adults aged ≥ men and 36.1–45.9% for women (4, few years before the current conflict 25 years had MetS, with no significant 11,12). These figures are also compa- erupted. Aleppo was once considered a gender difference in prevalence. Hy- rable to those estimated from western centre for international trade and manu- pertension and central obesity were the and more industrialized countries, with facture and the major contributor to main factors contributing to the MetS a prevalence of 38.9% in France and the Syrian agricultural economy, which burden. Education and family history of 43.4% in Greece (13,14). Results have made it one of the richest cities in the obesity and diabetes were significantly varied in Russia, with a disproportion- country. Globalization had influenced it associated with MetS among women. ately low figure of 18.9% in Arkhangelsk strongly, causing major economic shifts. A review of the prevalence of MetS according to the IDF definition (15) With the increase in free trade in Aleppo, in the neighbouring countries of Tur- and 34.7% in Moscow according to the high-energy diets and processed food key and Lebanon, as well as the Gulf Adult Treatment Panel III definition became increasingly available to the

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Table 2 Metabolic syndrome by gender: biochemical and anthropometric indices and prevalence rates Metabolic syndrome indices Total Men Women P value* n % n % n % Hypertension 661 56.6 322 57.8 339 55.5 0.423 Central obesity 582 51.4 202 36.6 380 65.5 < 0.001 Reduced HDL-C 460 39.4 242 43.4 218 35.7 0.007 Elevated glucose 394 33.7 194 34.8 200 32.7 0.449 Hypertriglyceridaemia 372 31.8 214 38.4 158 25.9 < 0.001 Number of indices 0 176 15.5 89 16.1 87 15.0 0.910 1 261 23.1 128 23.2 133 22.9 2 247 21.8 120 21.7 127 21.9 3 207 18.3 105 19.0 102 17.6 4 157 13.9 71 12.9 86 14.8 5 84 7. 4 39 7. 1 45 7. 8 Metabolic syndromea 448 39.6 215 38.9 233 40.2 0.674 (95% confidence interval) 36.8–42.5 34.9–43.0 36.3–44.4

*Significance based onX 2 and independent-samples t tests, for categorical and continuous variables, respectively. a Defined according to the criteria of the Joint Interim Statement of major organizations, as having 3 of the 5 major risk factors for cardiovascular disease: central obesity, hypertriglyceridaemia, reduced high-density lipoprotein–cholesterol, hypertension, and elevated glucose.

once-agricultural economies, replacing higher prevalence rates in women than could have additionally contributed to traditional diets and reducing concerns in men, tracing them to the significant the decreased plasma levels of HDL-C of food shortages (7). As elsewhere, this gender difference in prevalence of cen- and increased TG in men, because of nutritional transition and introduction tral obesity (11,15,16,21). Our find- the pathogenic effect of smoking on of western dietary patterns to agricul- ing that central obesity (51.4%) and plasma lipid profile 28( ,29). tural economies have been mostly as- hypertension (56.6%) were the most Covariate associations with MetS sociated with increases in obesity and contributing risk factors towards MetS differed by gender, with family history other risk factors and prevalence of concurred with other studies from the of obesity and diabetes, and lower edu- MetS in the region. Additionally, free region. Obesity rates in Arab countries cation level reaching significant levels trade policy has triggered the entry and are high, with alarming rates already among women. The link between edu- demonstrated in Kuwait (31.4%) and promotion of foreign tobacco products, cation and MetS has been investigated Bahrain (21.2% and 47.1% among men reflecting strongly on smoking rates in in several studies in western countries, and women, respectively) (22,23). Hy- Aleppo, notably among men (73.4%) developing countries and neighbour- pertension rates are also high in the (17), which may have increased certain ing Gulf states; all revealing an inverse components of MetS such as hyper- region, notably in Morocco (70.4%), with undiagnosed hypertension be- strong relationship (4,14,30–33). tension. Such factors constituting the coming a pressing public health issue Education has been linked to health “causes of causes” have been similarly (24,25). We also found that women in 3 different ways: educated people established in recent studies from the had more central obesity than men, are less likely to adopt risky health region, showing alarmingly high preva- whereas a higher proportion of men had behaviours; they are more likely to be lence rates of MetS approaching 64% in reduced levels of HDL-C and increased cushioned by enhanced sociopsycho- certain urbanized high socioeconomic levels of TG. Gender disparities in the logical resources; and they may have strata (11). association of several metabolic disor- more rewarding jobs, higher incomes In this study, the prevalence of MetS ders with MetS have been suggested in and better economic conditions; all was similar between genders (male-to- the international literature (26). Also, of which are significantly associated female ratio = 0.92). Comparable ratios genetic polymorphism contributing to with better health 34( ). Moreover, the were obtained from the USA (1.03), dyslipidaemia has been previously iden- strength of the association with fam- Europe (1.15) and the West Bank (1.0) tified in men but not in women 27( ). ily history of obesity in our study (OR (18–20). However, studies conducted Furthermore, the higher smoking rates = 1.60) was close to that obtained in in Turkey, Russia and Oman showed in men than women (73.4% vs 25.2%) studies in other countries including the

672 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع 95% CI 1.16–2.51 1.09–2.34 3.57–9.13 4.16–15.88 0.60–1.48 0.28–0.99 0.36–2.54 0.42–3.70 0.33–1.19 0.81–1.92 0.35–1.52 Adjusted OR* 1.0 1.0 1.0 1.25 1.0 1.0 1.25 1.0 1.0 1.71 1.0 1.60 OR 5.71 8.13 0.94 0.53 0.96 0.63 0.73 95% CI 1.12–6.09 1.14–2.23 1.27–2.50 3.83–9.07 2.25–14.60 4.77–15.08 0.35–0.75 0.16–0.42 0.24–0.65 0.79–1.68 0.29–1.05 Women OR Unadjusted OR 1.0 1.0 1.0 1.0 1.0 1.15 1.0 1.0 1.6 1.0 1.78 5.89 5.73 2.61 8.48 0.51 0.25 0.4 0.55 % 37.3 41.3 61.7 19.4 16.0 53.8 35.0 23.5 43.7 52.9 34.4 22.8 39.3 42.7 38.7 58.0 28.0 46.3 48.3 Prevalence 7 14 n 35 47 24 29 64 50 90 117 114 116 124 179 219 148 169 109 209 95% CI 1.48–6.50 2.09–5.15 0.40–1.06 0.63–1.81 0.61–4.50 0.29–8.38 0.34–1.08 0.62–1.43 0.56–1.81 0.85–1.84 0.96–2.05 Adjusted OR* OR 1.0 1.0 1.07 1.0 1.66 1.55 1.0 1.0 1.0 1.01 1.0 1.25 1.0 1.40 3.28 3.10 0.65 0.6 0.94 95% CI 1.33–7.98 1.06–22.09 2.44–5.65 2.70–7.99 0.31–0.74 0.46–1.15 0.28–0.65 0.56–1.20 0.49–1.42 0.78–1.56 0.97–1.95 Men OR Unadjusted OR 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.01 1.0 1.38 3.72 3.25 4.64 4.83 0.48 0.73 0.43 0.82 0.84 % 1 7. 1 37.7 41.6 35.3 35.9 55.3 43.5 32.0 34.7 54.0 39.5 42.5 38.3 49.6 48.5 50.0 20.2 40.2 40.6 Prevalence 5 6 41 n 61 72 47 24 63 97 82 62 88 191 118 153 152 127 127 204

Prevalence ofPrevalence MetS and associations with baseline covariates by gender 25–39 40–59 ≥ 60 < 6 6–11 ≥ 12 Single Married Divorced/widowed Not working Working Never Ever No Yes No Yes No Yes Age, years Education, years Marital status Employment status Smoking activityPhysical history of obesity Family history of diabetes Family *Adjusted for all the in the variables table. ratio. OR = odds interval; CI = confidence Table 3 Table

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United Kingdom of Great Britain and education and MetS among men may populations and refugees within the Northern Ireland (2.0 for men and 2.7 have been limited by the use of a single Syrian Arab Republic and its neigh- for women), Sweden (2.7 for women) indicator to represent socioeconomic bouring countries. Unfortunately, relief and Republic of Korea (1.22–2.64, for status. This might have failed to capture agencies in the region continue to focus various female birth cohorts between the complexity of the social gradient in their humanitarian efforts on maternal 1904–45 and 1963–76) (31–33). This health outcomes, including the poten- and child health, infectious diseases and association was not fully explained by tial role of wealth as an effect modifier sanitation, and have until today over- baseline socioeconomic characteristics interacting with education on the casual looked the needs of older adults and and behavioural risk factors, suggest- pathway to MetS (35). In spite of the the burden of pre-existing NCDs on ing the existence of other unstudied above limitations, this study is one of the individuals and families struggling with genetic-related mediators (32). few in the region in which the covariates mundane livelihood and security con- The findings of our study need to relied on objective biochemical and an- cerns. Health professionals need to raise be considered in light of some limita- thropometric measures, yielding more awareness and direct attention of relief tions and offsetting strengths. The cross- valid estimates than surveys relying on agencies to create a system of screening reported morbidity. sectional nature of the study means that for CVD risk factors and management the temporality of certain associations In conclusion, our findings point of CVDs within their humanitarian cannot be established with confidence. to the high levels of hypertension and response. However, this should not be regarded as obesity and consequently of MetS in Funding: The Syrian Center for To- a limitation for the association between pre-crisis Aleppo. They also shed light bacco Studies is supported by grants education or family history and MetS on the less visible NCD-related health because such exposures had certainly needs of the Syrian adult population, from the National Institute on Drug occurred prior to the outcome of inter- when access to health care and chronic Abuse (NIDA; R01DA024876–01) est. Although the study was conducted disease medication is becoming in- and Fogarty International Center in a largely urbanized city and it may not creasingly scarce. The currently over- (TW05962). The original field work be possible to generalize the findings burdened healthcare system, political was further supported by ASIA Phar- to the rural population in the Syrian insecurity and ongoing fighting will maceuticals (Aleppo, Syria), Medichem Arab Republic, the study did include limit potential interventions in the near Middle East Company (Aleppo, Syria), the informal neighbourhoods that were future. Nevertheless, our survey under- and the University of Aleppo (Aleppo, formed by many of the rural settlers. Fi- lines the importance of screening for Syria). nally, the lack of an association between CVD risk factors among the displaced Competing interests: None declared.

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Trends in outpatient cataract surgery in the Islamic Republic of Iran, 2006–2010 H. Hashemi 1, A. Fotouhi 2, F. Rezvan 3, H. Gilasi 4, S. Asgari 3, S. Mohazzab-Torabi 1, K. Etemad 5, A. Yekta 6, M. Khabazkhoob 7

االجتاهات السائدة يف جراحة الكتاركت يف العيادات اخلارجية يف مجهورية إيران اإلسالمية، 2010-2006 حســن هاشــمي، أكــر فتوحــي، فرهــاد رضــوان، محيــد رضــا جيــ يس،ال ســهيال عســغري، ســامان مهــذب - تــرايب، كــوروش اعتــاد، عبــاس عــي يكتــا، مهــدي خبــاز خوب اخلالصــة:هدفــت هــذه الدراســة إىل حتديــد االجتاهــات الســائدة يف جراحــة الكتاركــت )امليــاه البيضــاء( يف العيــادات اخلارجيــة ِّوحمدداهتــا يف مجهوريــة إيــران اإلســالمية بــن عامــي 2006 و2010. ُفانت ْ قيــتيف هــذه الدراســة املقطعيــة 106مراكــز جلراحــة الكتاركــت يف مجيــع املحافظــات عن طريــق اختيــار العينــة العنقــودي العشــوائي متعــدد املراحــل ُوح ِّد ــدعــدد مــن املراكــز يف كل حمافظــة مــن خــالل عــدد عمليــات الكتاركــت، وكان عــدد خمططــاتاملــرىض التــي فحصــت يف كل مركــز ً متناســبامــع عــدد عمليــات الكتاركــتيف ذلــك املركــز. لقــد ازداد انتشــار جراحــة العيــادات اخلارجيــة مــن (CI 35.3–56.8 %95) % 46.0% يف عــام 2006 إىل CI 40.2-62.7) %51.4 %95) يف عــام p = 0.549( 2010(. ومكــث املــرىض يف املستشــفى أكثــر مــن ليلــة واحــدة بعــد CI 6.9-14.1) 10.5% %95) مــنالعمليــات. ولقــد أدى اســتخدام اســتحالب العدســة والتخديــر املوضعــي إىل زيــادة انتشــار جراحــة العيــادات اخلارجيــة وإىل التقليــل مــن حــدوث املضاعفــات أثنــاء العمليــة. عــى الرغــم مــن أن جراحــة الكتاركــت يف العيــادات اخلارجيــة ازدادت بنســبة %11.7 فــإن اســتخدام بعــض الطــرق - مثــل اســتحالب العدســة – ليــس ًمنتــرا عــى نطــاق واســع، وينبغــي إيــالء املزيــد مــن االهتــام بالعوائــق التــي حتــول دون إجــراء جراحــة الكتاركــت يف العيــادات اخلارجيــة يف مجهوريــة إيــران اإلســالمية.

ABSTRACT This study aimed to determine the trends in outpatient cataract surgery and its determinants in the Islamic Republic of Iran between 2006 and 2010. In this cross-sectional study, 106 cataract surgery centres were selected in all provinces by multistage randomized cluster sampling. The number of centres in each province was determined from the number of cataract operations and the number of patient charts examined in each centre was proportionate to the number of cataract operations in that centre. The prevalence of outpatient surgery increased from 46.0% (95% CI, 35.3–56.8) in 2006 to 51.4% (95% CI, 40.2-62.7) in 2010 (P = 0.549). Patients stayed in hospital for more than one night after 10.5% (95% CI, 6.9-14.1) of operations. Use of phacoemulsification and topical anaesthesia increased the prevalence of outpatient surgery and decreased intraoperative complications. Although outpatient cataract surgery increased by 11.7%, use of methods such as phacoemulsification is not widespread, and more attention should be paid to the barriers to outpatient cataract surgery in the Islamic Republic of Iran.

Tendances de la chirurgie ambulatoire de la cataracte en République islamique d’Iran, 2006-2010

RÉSUMÉ La présente étude avait pour objectif de déterminer les tendances de la chirurgie de la cataracte en ambulatoire et ses déterminants en République islamique d’Iran entre 2006 et 2010. Dans cette étude transversale, 106 centres de chirurgie de la cataracte ont été sélectionnés dans toutes les provinces par échantillonnage aléatoire en grappes à plusieurs degrés. Le nombre de centres dans chaque province a été déterminé sur la base du nombre d’opérations de la cataracte et le nombre de dossiers de patients examinés dans chaque centre était proportionnel au nombre de chirurgies de la cataracte pratiquées dans ce centre. La prévalence des chirurgies de la cataracte est passée de 46 % (IC à 95 %, 35,3-56,8) en 2006 à 51,4 % (IC à 95 %, 40-62,7) en 2010 (p = 0,549). Les patients sont restés plus d’une nuit à l’hôpital après 10,5 % (IC à 95 %, 6,9-14,1) des opérations. Le recours à la phaco-émulsification et l’anesthésie topique faisait augmenter la prévalence de la chirurgie ambulatoire et réduisait les complications intra-opératoires. Bien que la chirurgie de la cataracte en ambulatoire ait augmenté de 11,7 %, l’utilisation de méthodes telles que la phaco-émusification n’est pas répandue, et davantage d’attention devrait être apportée aux obstacles qui s’opposent à la chirurgie de la cataracte en ambulatoire en République islamique d’Iran.

1Noor Research Centre for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Islamic Republic of Iran. 2Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 3Noor Ophthalmology Research Centre, Noor Eye Hospital, Tehran, Islamic Republic of Iran. 4Department of Public Health and Biostatistics, Faculty of Health, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran. 5Department of Epidemiology, Faculty of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 6Department of Optometry, School of Sciences, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. 7Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: [email protected]). Received: 25/11/15; accepted: 03/07/16 676 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Introduction patients who underwent cataract sur- logistic regression models. All analyses gery in centres in Iran between 2006 were done with STATA software ver- The latest report from WHO 1( ) in- and 2010. sion 11. dicated that about 20 million people Sampling worldwide are blind as a result of cata- ract, corresponding to half of all cases The methods used have been described Results of blindness (2). The high prevalence in detail elsewhere (12); a summary of cataracts in people over the age of 50 is given here. According to the Iranian We evaluated 26 727 charts from 106 makes their removal one of the most Ministry of Health, there are 272 cata- centres. After exclusion of charts that prevalent operations, imposing heavy ract surgery centres in the country, of were incomplete, 23 020 charts were costs on countries (3), due mainly to which 35 were not included in the study analysed. Males represented 48.1% of the type of lens and surgical and hospi- because fewer than 100 cataract opera- the patients; 0.4% of the patients were talization costs (4). Outpatient cataract tions are performed per year. Of the re- aged ≤ 10 years, 3.7% were aged 11–40 surgery in many centres around the maining 237 centres, 106 were selected years, 7.6% were aged 41–50 years, world has resulted in an increase in the by multistage randomized cluster sam- 17.9% were aged 51–60 years, 28.3% rate of surgery for this condition, and, pling. The number of centres in each were aged 61–70 years, 30.8% were because there is no hospitalization, the province was determined according to aged 71–80 years, and 11.2% were aged waiting time has decreased (5). Thus, the number of cataract operations in > 80 years. Of all the cataract opera- outpatient cataract surgery reduces the that province, and the number of charts tions, 49.9% (95% CI, 39.5–60.4) were cost of the operation by 20% (6,7). It of patients who underwent cataract sur- performed in an outpatient setting. has been shown that US$ 33.6 million gery was proportionate to the number The prevalence of outpatient cataract could be saved annually in Spain and of operations in the centre. surgery increased by 11.7% between US$ 270 per surgery in England if 80% Ten data collectors were trained 2006 and 2010, from 46.0% (95% CI, of cataract operations were performed to sample patient charts after they had 35.3–56.8) in 2006 to 51.4% (95% CI, on an outpatient basis (7,8). Although established the necessary coordination 40.2-62.7) in 2010. No significant dif- ference in the prevalence of outpatient the cost of cataract surgery differs by with the archiving department. They ex- 2 country, eliminating hospitalization tracted information on the underlying cataract surgery was found by year (χ after surgery has many advantages for disease, the type of cataract, the method = 31.27, P = 0.549), and no significant difference was found between males governments and patients. Identifica- of surgery and the type of lens and also 2 tion of the factors that contribute to an identified intraoperative complications. (50.3%) and females (49.6%) (χ = increase in outpatient cataract surgery They collected information on the age 0.977, P = 0.594). Table 1 shows that could increase its use. One of the most and sex of the patient, date of surgery, the prevalence of outpatient cataract surgery differed significantly according important factors is use of the phaco- discharge date and the name of the sur- 2 emulsification method 9( ,10). geon. The duration of hospitalization to age (χ = 38.46, P < 0.001). The low- est percentage was observed in patients A recent report by our group was calculated as the interval between aged < 10 years. showed a substantial increase in the admission and discharge. To ensure cataract surgery rate in our country over consistency, five charts were given to The prevalence of outpatient cata- 10 data collectors to evaluate; in cases ract surgery did not differ significantly 10 years (11). Therefore, the costs of 2 hospitalization, ophthalmologists’ fees, of disagreement, the opinion of an oph- by season (χ = 6.79, P = 0.499) (Table consumables and indirect costs have thalmologist was sought. 1). Most outpatient operations were also increased. We performed the pre- performed by the phacoemulsification Statistical analysis method (52.5%; 41.8–63.2) and the sent study to evaluate the prevalence 2 of and trends in outpatient cataract The prevalence of outpatient surgery fewest by the extracapsular method (χ surgery and its determinants, in order to and hospitalization for more than one = 5.3.72; P < 0.001). find ways to reduce the costs. night is given as a percentage with 95% Intraoperative complications oc- confidence intervals (CIs) and standard curred in 31.6% (95% CI, 18.6–44.6) errors, with account taken of the effect of operations, and 50.7% (95% CI, Methods of cluster sampling. The χ2 test was used 40.1–61.3) were complication-free. to examine the effects of variables. The The odds for complications were 2.22 This cross-sectional study was per- relation between outpatient surgery and (95% CI, 1.39–3.54) times higher in formed between March 2011 and hospitalization for more than one night inpatient surgery (P < 0.001). Most of May 2012. The target population was was examined in simple and multiple the outpatient operations (75.9%) were

677 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Table 1. Prevalence of outpatient and more than one night of hospitalization for cataract surgery in the Islamic Republic of Iran, 2006–2010 Outpatient Hospitalization > 1 night % (95% CI) % (95% CI) Total 49.9 (39.5–60.4) 10.5 (6.9–14.1) Year 2006 46.0 (35.3–56.8) 11.0 (6.0–15.9) 2007 50.4 (38.3–62.5) 10.0 (6.0–14.0) 2008 49.9 (38.5–61.3) 12.2 (7.0–17.5) 2009 51.2 (39.6–62.7) 10.0 (5.7–14.3) 2010 51.4 (40.2–62.7) 9.3 (5.3–13.4) Gender Male 50.3 (39.9–60.7) 10.4 (6.8–14.1) Female 49.6 (39.0–60.3) 10.4 (6.8–14.0) Age ≤ 10 44.7 (32.3–57.1) 21.3 (8.0–34.6) 11–40 47.0 (35.4–58.5) 13.8 (9.2–18.4) 41–50 53.9 (38.0–69.9) 9.6 (6.4–12.8) 51–60 46.7 (36.0–57.4) 9.0 (5.9–12.0) 61–70 50.7 (40.0–61.4) 9.5 (6.0–12.9) 71–80 51.0 (40.3–61.7) 11.2 (6.9–15.4) > 80 48.8 (37.3–60.3) 12.8 (7.6–18.0) Season Spring 50.8 (40.0–61.7) 10.8 (6.8–14.9) Summer 49.6 (38.9–60.2) 10.0 (6.5–13.6) Autumn 48.7 (38.2–59.1) 11.1 (7.3–14.9) Winter 50.6 (40.0–61.2) 10.1 (6.5–13.7) Type of surgery Intracapsular 43.4 (7.5–79.2) 26.5 (8.3–44.7) Extracapsular 23.0 (8.8–37.3) 27.1 (12.9–41.3) Phacoemulsification 52.5 (41.8–63.2) 8.5 (5.4–11.6) Lensectomy 37.4 (16.3–58.5) 39.8 (19.5–60.2)

CI = confidence interval.

performed under topical anaesthesia hospitalized for more than one night, models were used to evaluate the rela- and 40.7% of inpatient operations un- the difference being significantP ( < tions between outpatient surgery, hos- der general anaesthesia (P < 0.001). 0.001). Of the patients hospitalized for pitalization for more than one night and The duration of hospital stay was more than one night, 41.3% (95% CI, other variables (Table 2). more than one night after 10.5% (95% 26.3–56.2) had intraoperative compli- cations and 9.3% (95% CI, 6.0–12.5) CI, 6.9–14.1) of operations. A hospital had no complications. The odds ratio Discussion stay of more than one night showed a for hospitalization was significantly U-shaped relation with age, with the higher after cataract surgery with in- About half of all cataract operations highest prevalence for patients aged < traoperative complications (1.93; 95% were performed in an outpatient setting 10 years, followed by a decrease and CI, 3.9–12.0). More than one night of during the 5 years of the study, with then an increase after the age of 70 years. hospitalization was required for 14.7% no significant change, the prevalence As shown in Table 1, 39.8% (95% CI, of operations performed by residents increasing by only 11.7%. Few studies 19.5–60.2) of patients who underwent and 10.4% of operations performed have been conducted in other countries; lensectomy and 8.5% of patients who by surgeons other than residents (P < Mojon-Azzi et al. (13) reported a wide underwent phacoemulsification were 0.001). Two multiple logistic regression range in the prevalence of outpatient

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cataract surgery in 10 countries, from Use of the phacoemulsification and leads to fewer post-surgical com- 0% in Australia to 100% in Denmark; method has increased over the past plications (21), and previous studies however, apart from Australia, where all 10 years in many countries, including have described the efficacy of topical operations are performed in hospital, ours, because it is faster, leads to fewer anaesthesia in outpatient operations, and Greece, where only 41% of cataract complications (5,16,17), and satisfies even when performed by residents operations are performed in an outpa- patients (17). In a previous study, we (22–24). Koolwijk et al. (25) reported tient setting, the rate was > 50%. In the found that the rate of phacoemulsifica- that outpatient cataract surgery is easy Netherlands and Sweden, more than tion surgery had increased from 7% in and safe with topical anaesthesia, with 90% of operations were performed in 2000 to 57% in 2005, while the rate of minimal complications. In a 2-year an outpatient setting. We had expected extracapsular cataract extraction sur- evaluation of 4347 patients, they found that more than 80% of the operations gery decreased from 91% to 41% over that only 0.04% required intervention in the Islamic Republic of Iran would the same period (18) and from 89.1% to during the operation and none required be performed in an outpatient setting 92% between 2006 and 2010. Despite a hospitalization. The risk for endophthal- in view of the recent increase in use of difference in cost of US$ 245 between mitis increases with topical anaesthesia phacoemulsification and intracapsular phacoemulsification and the strong cor- and the phacoemulsification method cataract extraction, phacoemulsification relation between use of this method and (26), however, as seen in 8.7 per 1000 is recommended because of its short- outpatient surgery. This study shows operations versus 1.3 per 1000 opera- and long-term benefits, including fewer that a number of factors other than the tions with retrobulbar anaesthesia (27), complications and shorter hospital type of surgery decrease the duration of a complication that requires hospi- stays (19). The rapid increase in cataract hospitalization. surgery has been associated with a de- talization. Castelle et al. (7) evaluated The duration of hospitalization crease in the duration of hospital stays. 1103 patients and found that, despite affects waiting time and costs. The In Canada, 50–55 cataract patients a significantly higher incidence of com- Government of China has decreased were hospitalized per 10 000 patients in plications in outpatient surgery, the the rate of blindness due to cataract 1991 and only 1–2 per 10 000 in 2002, long-term complications were similar dramatically by increasing outpatient at a time when the rate of phacoemulsi- after outpatient and inpatient surgery. cataract surgery, and not only surgeons fication surgery increased by 100 times In a study in Spain, Cortinas et al. (28) but also governments are interested in (8). Factors such as reduced costs and observed that 499 of 11 187 (4.46%) greater use of outpatient cataract sur- faster procedures have decreased the outpatients operated by phacoemul- gery to reduce costs (14,15). Leong duration of hospital stays (20). sification required hospitalization, of et al. (8) showed that hospitalization Thus, use of the phacoemulsifica- whom 460 were hospitalized immedi- for cataract surgery was significantly tion model and topical anaesthesia has ately after surgery. Other studies have higher in spring and autumn, whereas increased the rate of outpatient cataract reported longer hospitalization after we found no significant difference in surgery, and the rate of intraoperative general anaesthesia (29). We found that the rate of outpatient cataract surgery complications has decreased. Neverthe- the rate of hospitalization after surgery by season, perhaps due to the distribu- less, it is important that all conditions was significantly higher when opera- tion of facilities in the Islamic Republic be evaluated prior to operation in older tions were performed by residents, per- of Iran, which has made the operation individuals with risk factors. Topical haps due to a higher prevalence of more available throughout the year. anaesthesia is very useful for outpatients severe complications.

Table 2. Associations between outpatient and hospitalization for more than one night for cataract surgery according to five variables Variable Outpatient Hospitalization for > 1 night OR (95% CI) P OR (95% CI) P Age (years) 1.00 0.824 1.00 0.204 Gender (male:female) 1.02 (0.91–1.14) 0.757 0.98 (0.88–1.09) 0.735 Complications (yes/no) 5.68 (3.24–9.95) < 0.001 0.52 (0.36–0.75) 0.001 Phacoemulsification (no/yes) 0.33 (0.16–0.67) 0.003 2.60 (1.3–5.23) 0.008 Topical anaesthesia (no/yes) 0.57 (0.29–1.12) 0.102 4.02 (1.87–8.60) < 0.001

CI = confidence interval; OR = odds ratio.

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Although it has been shown that their families, distance to the eye care of complications of surgery and use the quality of operations by residents, facility (access), feedback on willing- of phacoemulsification shortened the especially phacoemulsification surgery, ness and satisfaction, ophthalmologists’ duration of hospital stay. Other impor- is acceptable (29,30), complications views, incentives and disincentives for tant factors might play a role, and we such as vitreous loss (31–33) are more surgeons and facilities was a limitation suggest that larger studies be conducted common; therefore, all patients should of this study. We were therefore un- on economical hospitalization, patient undergo a complete evaluation before able to identify barriers efficiently. We and physician satisfaction and access to surgery to prevent or reduce the inci- suggest that researchers use the results services. dence of complications (34,35). of this study to evaluate the indexes of Funding: This project was funded by The most important strength of the hospitalization after cataract surgery. study was the large sample size obtained In conclusion, this study shows the the noncommunicable disease unit of by cluster sampling in many centres. trends in hospitalization after cataract the Ministry of Health, Treatment and Lack of evaluation of factors such as the surgery over 5 years. In general, the Medical Education, Tehran, Islamic patients’ socio-economic status, out- percentage of outpatient cataract sur- Republic of Iran. of-pocket expenditure by patients and gery was relatively low. The absence Competing interests: None declared.

References

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30. Briszi A, Prahs P, Hillenkamp J, Helbig H, Herrmann W. Com- 33. Kothari M, Thomas R, Parikh R, Braganza A, Kuriakose T, Muliyil plication rate and risk factors for intraoperative complications J. The incidence of vitreous loss and visual outcome in patients in resident-performed phacoemulsification surgery. Graefes undergoing cataract surgery in a teaching hospital. Indian J Arch Clin Exp Ophthalmol. 2012;250:1315–20. Ophthalmol. 2003;51:45. 31. Hashemi H, Mohammadpour M, Jabbarvand M, Nezamdoost 34. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative com- Z, Ghadimi H. Incidence of and risk factors for vitreous loss in plications in resident-performed phacoemulsification surgery. resident-performed phacoemulsification surgery. J Cataract Ophthalmology. 2009;116:431–6. Refract Surg. 2013;39:1377–82. 35. Woodfield AS, Gower EW, Cassard SD, Ramanthan S. Intraop- 32. Blomquist PH, Morales ME, Tong L, Ahn C. Risk factors for vitre- erative phacoemulsification complication rates of second-and ous complications in resident-performed phacoemulsification third-year ophthalmology residents: a 5-year comparison. surgery. J Cataract Refract Surg. 2012;38:208–14. Ophthalmology. 2011;118:954–8.

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The status of serum vitamin D in the population of the United Arab Emirates K. Yammine 1 and H. Al Adham 2

احلالة املصلية لفيتامني )د( لدى سكان اإلمارات العربية املتحدة قيرص يامني، محدي األدهم اخلالصــة: ُتظهــر األبحــاث املعنيــة باستكشــاف حالــة "املســتويات املصليــة لفيتامــني د "عنــد ســكان البلــدان املطلــة عــى اخلليــج ًانتشــارا ًواســعا لنقــص الفيتامــني )د( أو عــدم كفايتــه. وكانــت هــذه التقاريــر َتســتخلص - عــادة - مــن عينــات صغــرة ُيســتبعد أن تكــون ِّممثلــة للســكان. فقمنــابالتحــري عــناملســتوى املصــي لفيتامــني )د( لــدى عينــة كبــرة ) ( 7924مــن املــرىض الذيــن أجــري هلــمحتليــل دم ملعرفــة حالــة الفيتامــني )د( لدهيــم يف أول استشــارة هلــم يف أحــد مستشــفيات جراحــة اليــوم الواحــد يف ديب. فــكان املســتوى الوســطي اإلمجــايل لـــ OH) D) 25 قرابــة 20 نانوجرام/مليليـتر. و ُوجــد أن هناــك ً نقصــالــدى مجيــع الفئــات العمريــة مــنكال اجلنســني بــني الســكان املحليــني وغــر املحليــني عــى حــد ســواء: فباإلمجــال كان % 85.4مــن الســكان لدهيــم نقــص يف الفيتامــني )د(، بينــا كان لــدى % 12.5عــدم كفايــة يف املســتوى املصــي لفيتامــني )د(، كــا كان املســتوى ًمالئــا لــدى % 2.1 فقــط. ويف نمــوذج متعــدد املتغــرات كانــت هنــاك عالقــة طرديــة بــني التكيــزات املصليــة لفيتامــني )د( يف املصــل وبــني الذكــورة والســكان املحليــني والفئــة العمريــة 31−17 ســنة.

ABSTRACT Research exploring the status of serum vitamin D levels in the populations of countries bordering the Arabian Gulf shows a high prevalence of vitamin D deficiency/insufficiency. These reports were usually drawn from small samples unlikely to be representative of the population. We explored serum vitamin D level in a large sample (7924) of patients who were given a blood test to check their vitamin D status on their first consultation at a day surgery hospital in Dubai. The overall mean level of 25(OH) D was ~ 20 ng/mL Deficiency was found among all age groups, in both sexes and in both local and non-local populations: overall 85.4% were vitamin D deficient, 12.5% showed insufficient serum vitamin D level, and only 2.1% had an appropriate level. In the multivariate model, serum vitamin D concentrations were positively correlated with male sex, local population and the 17−31 years age group.

Statut en vitamine D sérique de la population des Émirats arabes unis

RÉSUMÉ Les travaux de recherche se penchant sur le statut des concentrations sériques de vitamine D dans les populations des pays bordant le Golfe arabique montrent une forte prévalence de la carence/l’insuffisance en vitamine D. Ces rapports s’appuyaient habituellement sur de petits échantillons qui n’étaient certainement pas représentatifs de la population. Nous avons étudié la concentration en vitamine D dans un grand échantillon de patients (7924) qui ont été soumis à un examen sanguin pour vérifier leur statut en vitamine D lors de leur première consultation dans un hôpital chirurgical de jour de Dubaï. La concentration moyenne globale de 25(OH) D était d’environ 20 ng/mL. Une carence a été observée dans tous les groupes d’âge, pour les deux sexes et dans les populations locales et non locales. Globalement, 85,4 % d’entre eux avaient une carence en vitamine D, 12,5 % montraient une concentration sérique en vitamine D insuffisante, et seulement 2,1 % avaient une concentration adéquate. Dans le modèle multivarié, les concentrations sériques de vitamine D avaient une corrélation positive avec le sexe masculin, la population locale et le groupe d’âge des 17-31 ans.

1Foot and Hand Clinic, Center for Evidence-Based Anatomy, Sport and Orthopaedic Research, Beirut, Lebanon (Correspondence to: K. Yammine: [email protected]). 2Administration Department, Emirates Hospital, Dubai, United Arab Emirates. Received: 29/03/15; accepted:03/08/16

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Introduction population and the residents of Dubai insufficiency 30–50 ng/mL; and suf- from a very large sample. ficiency > 50 ng/mL. The role of vitamin D (25(OH) D) in maintaining optimal health has been Outcomes well documented and deficiency has Methods The overall vitamin D mean value in been linked to a spectrum of conditions our sample was set as the first primary Setting such as autoimmune disorders, cancer, outcome. Other primary outcomes osteoporosis, cardiovascular disease This cross-sectional retrospective study were the mean values related to age, and obesity (1). Epidemic low levels was conducted at Emirates Hospital, nationality and sex. We defined 2 na- are reported from around the globe, a day surgery hospital in Dubai where tionality groups: the local group, which regardless of sex and age (2−4). Besides almost all surgeries are elective. In ad- comprised patients with United Arab a suboptimal consumption of foods dition to surgical specialties, medical Emirates nationality and the non-local containing vitamin D such as fish and expertise such endocrinology, internal group comprising all other nationali- fortified milk, limited sun exposure is medicine, dermatology and cardiology ties. We divided our sample into 4 age considered the major cause of vitamin are available. The hospital is located in categories (1–16 years, 17–31 years, D deficiency (4). Populations at risk an urban community and patients’ na- 32–46 years and 47–92 years). are mainly those having minimal out- tionalities reflect the wide diversity of We did not include body mass index door activities such as indoor workers the Dubai population. (BMI) as a variable because weight is and students. Extensive clothing or The study was approved by the ethi- not documented in the system. extensive sunscreen application are also cal committee of the institution. considered major risk factors (2,5,6). As a secondary outcome, we Reports of prevalence of vitamin D Sample and data extraction searched for any correlation between insufficiency/deficiency in countries Data values for 25(OH) D level tested vitamin D serum levels and each of our bordering the Persian Gulf are indica- at the first medical consultation were 3 predefined variables. tive of a serious health issue (7−9). collected retrospectively from the hos- Data analysis Vitamin D insufficiency (30−50 ng/ pital laboratory’s information system mL) has been reported in up to 80% of between February 2012 and January The overall mean values for 25(OH) D Saudi Arabian girls and women (10) 2014. Blood results at follow-up con- for each variable were first computed. and Kuwaiti women (11), and in up to sultations were excluded. The clinical Then the Pearson test was used to 90% of the population of Qatar (12) rationale for the blood test was not investigate any correlation. We used and the female population in the United retrieved, nor was the specialty of the simple and multiple linear regression Arab Emirates (13). The United Arab treating doctor. tests to look for possible relationships. Emirates has an average of 10 hours Two-tailed P-values were recorded and of sunshine per day, which should fa- Blood testing and P-value < 0.05 was considered statisti- vour vitamin D synthesis all year round measurement cally significant. Statistical operations (2,14). We used serum 25(OH) D level as were done using StatsDirect, version Many studies on vitamin D status an indicator of vitamin D status (22). 2.7.8 (Altrincham, United Kingdom). have been published from universities Blood specimen collection and analysis and research centres in the United Arab are done systematically at the hospital Emirates (14−21). In all those studies, and follow rigorous protocols. Blood Results sample size was generally too small for samples were sent to the laboratory Demographic characteristics an accurate estimation of the prevalence within 30 minutes of drawing, where of vitamin D insufficiency/deficiency in they underwent standardized (quality Vitamin D results were retrieved from the population. controlled) analyses, blood clotting for a total of 7924 patients attending their Population-based data on the status 30 minutes followed by centrifugation first consultation at the hospital (Table of vitamin D in the United Arab Emir- for 20 minutes. Serum 25(OH) D 1). A large proportion of the patients in ates are lacking. Therefore, the aim of concentrations were measured by im- our sample, 6787 (85.8%), were non- this retrospective study was to gener- munofluorescence (Liaison XL) with a local, i.e. of various nationalities. Patients ate overall, sex-based, age-based and cut-off level for 25(OH) D of < 30 ng/ aged 32−46 years made up largest age nationality-based prevalence estimates mL (1). Vitamin D status was defined group, 4097 (51.7%). Overall mean age of vitamin D status among the local as: deficiency 25(OH) D < 30 ng/mL; was 37 years

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Overall and variable-based Correlation with gender, Discussion mean values of vitamin D ancestry and age The overall mean serum vitamin D Correlation with sex of the patient Summary and interpretation level was 19.9 [standard deviation (SD) yielded a significant difference between of main results 11.3] ng/mL (Table 1). The lower males and females: males had lower To our knowledge, it is the first study quartile was 11.9 ng/mL and the upper serum vitamin D levels than females (r = carried out in the United Arab Emir- ates with such a large size sample. The quartile was 25.2 ng/mL. The youngest 0.028, CI: 0.006−0.050, P = 0.01). Cor- majority of the population in this study and oldest age groups had the high- relation with nationality yielded a highly were vitamin D deficient (overall mean est mean vitamin D values (Table 1). significant difference between local and ≈ 20 ng/mL), and this was seen in Vitamin D level was ≥30 ng/mL among non-local populations: the local popula- all age groups and in both sexes. The 13.7% of the males in our sample and tion showed lower serum vitamin D results indicate an alarming serum vi- 15.2% of the females. levels than the non-local (r = 0.11, CI: tamin D level among the population when compared with other Emirati 0.093−0.136, P = < 0.0001). Correlation We found that 1384 (17.5%) pa- reports (13−21), with just around 2% tients had vitamin levels ≤ 10 ng/mL, with age also yielded highly significant of patients attending their first consulta- 3176 (40%) having 10 < 25(OH) D ≤ differences in relation to age group r( = tion showing an appropriate level. For 20, 2207 (27.8%) patients having 20 < 0.08, CI: 0.057−0.101, P < 0.0001). The instance, the mean level of vitamin D 25(OH) D ≤ 30, 757 (9.6%) patients mean level of serum vitamin D in our in our paediatric population, where the majority were above the age of 8 years, youngest age group, where the majority having 30 < 25(OH) D ≤ 40, 239 (3%) was 22.3 ng/mL, reflecting a deficiency patients having 40 < 25(OH) D ≤ 50, were above the age of 8 years, was 22.3 when compared with the insufficient 96 (1.2%) patients having 50 < 25(OH) ng/mL value of 35.3 ng/mL reported by Rajah D ≤ 60, and 64 (0.9%) patients having A multiple regression test including et al. among 48 children in the same 25(OH) D > 60. Thus, 6767 (85.4%) all 3 variables yielded r2 = 2% (r = 0.14, age group living in Abu Dhabi (20). Furthermore, out of a sample of 315 were vitamin D deficient, 996 (12.5%) P < 0.0001). Age group of 17–31, males healthy adolescents residing in Al Ain had an insufficient level of vitamin D, and locals yielded positive correlation in city, Muhairi et al. reported vitamin D and only 160 (2.1%) had an appropriate the model. A summary of the regression concentration of less than 25 ng/mL in serum vitamin D level (Table 1). analysis results are given in Table 2. 65% (23).

Table 1. Characteristics of the sample and low serum vitamin D prevalence/correlation values, United Arab Emirates, 2012–2014 Variable No. (%) 25(OH) D mean (SD) Correlation ng/mL r value CI P Total 7924 (100) 19.9 (11.3) NA NA NA Males 2418 (30.5) 20.6 (11.3) 0.028 0.006−0.050 0.01 Females 5506 (69.5) 19.8 (11.29) Locals 1137 (14.3) 19.1 (11.1) 0.11 0 0.093−0.136 0.0001 Non-locals 6787 (85.7) 20.07 (11.3) Age (years) 0−16 425 (5.3) 22.3 (0.1) 17−31 1944 (24.5) 17.8 (11.4) 0.080 0.057−0.101 < 0.0001 32−46 4097 (51.7) 19.8 (11.0) > 47 1458 (18.4) 22.1 (11.5) 25(OH) D (ng/mL) < 30 6767 (85.4) NA NA NA NA 30–50 996 (12.5) NA NA NA NA > 50 161 (2.1) NA NA NA NA

NA = not appropriate

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Table 2. Summary of simple and multiple regression analyses for serum vitamin D level, United Arab Emirates, 2012–2014 Variable Equation Two-sided P Notes Age Result = 0.07094 age + 17.283366 < 0.0001 NA Sex Result = 0.691757 sex + 19.454921 0.01 Male = 0 Female = 1 Nationality Result = 3.717087 local + 16.747169 < 0.0001 Non-local = 1 Local = 0 Age + sex + nationality Result = 13.465351 +0.900458 sex +3.745023 Local < 0.0001 NA +0.070404 age

NA = not appropriate.

Our results showed that vitamin D exposure is the main source of vitamin results indicate that vitamin D deficien- deficiency was significantly associated D, countermeasures for preventing de- cy among males is at least as prevalent with the 17−31 years age group, males ficiency and maintaining an appropriate as in females. and Emirati nationality. None of the serum level among residents should be Due to its predefined limited scope, variables was found to be a confounder; within reach in this sunny country. this study did not check for other the coefficient associated with each vari- potential risk factors such as diet and able in simple linear regression tests did Limitations not change significantly from that found A possible limitation in this study is the sun exposure. We could not verify the in the multiple linear regression tests for lack of information regarding the clinical nationalities of the non-local popula- each variable. The number of females presentation of the patients. However, tion to look for any differences within in our study sample was significantly the correlation between the clinical that group. Additionally, the study was higher than males (70% female, 30% presentation and serum 25(OH) D conducted in a private hospital in Dubai male); we found that deficiency was level was not within the scope of the where mostly insured patients access associated with male sex, emphasizing study. In fact, our findings indicate that the medical care. On the other hand, the epidemic aspect of the deficiency. for whatever clinical reason, a great due to the settings of our institution, our In this part of the world where osteo- majority of patients who seek medical relatively young patients, 82% under porosis and vitamin D deficiency are advice for the first time are 25(OH) 46 years, very seldom have severely im- mostly investigated among women, this D deficient; the upper quartile of the paired health conditions such as chronic study should encourage physicians to overall mean value was 25.2. Moreover, renal or liver failure, which could result consider this issue as highly prevalent in it is very likely that a number of these pa- in decreased conversion to the active men, and our findings provide a ration- tients were examined and treated some form of vitamin D (24). Checking for ale for mass screening among the male time in their life in other health care population as well as females. facilities. Therefore, the mean values vitamin D level is very commonly re- Although we found a significant cor- generated in our study could be even quested by both patients and doctors in relation between each of those variable lower if data on such patients were not our hospital. Furthermore, it is difficult and mean 25(OH) D level, the multiple included. This fact should alert health to distinguish between healthy people linear regression test yielded an r2 of care professionals of the seriousness of and patients in regard to this condition; only 2%, meaning that only 2% of the issues such as non-compliance or lack as mentioned above, previous studies variations in 25(OH) D values is ex- of awareness of the role of vitamin D in have reported frequencies of up to 90% plained by this model. This result is in maintaining optimal health by patients vitamin D deficiency/insufficiency in accordance with current knowledge, i.e. in this region of the world. “healthy” subjects (12,13). that the most important variable for an Since a statistical estimate drawn Nevertheless, although our results appropriate vitamin D blood level is sun from a larger sample will reflect more may not be generalizable to the whole exposure (20). accurately the true estimate in a popula- population of the United Arab Emirates, It is hoped the results of this study tion, the difference between sex-based the large sample size should reduce the will encourage decision-makers to prevalence values found in this study impact of this limitation to a minimum. tackle this treatable medical condition, could be biased since the number and efforts should be coordinated at of females in the sample was double Funding: None. the highest national level. While sun the number of males. However, the Competing interests: None declared

685 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

References

1. Holick MF. Vitamin D status: measurement, interpretation 14. Dawodu A, Absood G, Patel M, Agarwal M, Ezimokhai M, and clinical application. Ann Epidemiol. 2009 Feb;19(2):73−8. Abdulrazzaq Y et al. Biosocial factors affecting vitamin D status PMID:18329892 of women of childbearing age in the United Arab Emirates. J 2. Holick MF. Sunlight and vitamin D for bone health and pre- Biosoc Sci. 1998 Oct;30(4):431−7. PMID:9818552 vention of autoimmune diseases, cancers, and cardiovascular 15. Dawodu A, Dawson KP, Amirlak I, Kochiyil J, Agarwal M, Badri- disease. Amer J Clin Nutr. 2004 Dec;80(6 Suppl.):1678S−88S. nath P. Diet, clothing, sunshine exposure and micronutrient PMID:15585788 status of Arab infants and young children. Ann Trop Paediatr. 3. Holick MF. The vitamin D epidemic and its health conse- 2001 Mar;21(1):39−44. PMID:11284245 quences. J Nutr. 2005 Nov;135(11):2739S−48S. PMID:16251641 16. Dawodu A, Agarwal M, Hossain M, Kochiyil J, Zayed R. Hypo- 4. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, vitaminosis D and vitamin D deficiency in exclusively breast- Hanley DA, Heaney RP, et al. Evaluation, treatment, and feeding infants and their mothers in summer: a justification for prevention of vitamin D deficiency: an Endocrine Society vitamin D supplementation of breast-feeding infants. J Pediatr. Clinical Practice Guideline. J Clin Endocrinol Metab. 2011 Jul; 2003 Feb;142(2):169−73. PMID:12584539 96(7):1911−30. PMID:21646368 17. Saadi HF, Nagelkerke N, Benedict S, Qazaq HS, Zilahi E, 5. Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Thom- Mohamadiyeh MK, et al. Predictors and relationships of sen J, et al. Commonly recommended daily intake of vitamin D serum 25 hydroxyvitamin D concentration with bone turno- is not sufficient if sunlight exposure is limited. J Int Med. 2000 ver markers, bone mineral density, and vitamin D receptor Feb; 247(2):260−8. PMID:10692090 genotype in Emirati women. Bone. 2006 Nov;39(5):1136−43. PMID:16814623 6. Grant WB. In defense of the sun: An estimate of changes in mortality rates in the United States if mean serum 25-hy- 18. Dawodu A, Kochiyil J, Altaye N. Pilot study of sunlight expo- droxyvitamin D levels were raised to 45 ng/mL by solar ultra- sure and vitamin D status in Arab women of childbearing age. violet-B irradiance. Dermato-Endocrinol. 2009 Jul; 1:207−14. East Mediterr Health J. 2011 Jul;17(7):570−4. PMID:21972479 PMID:20592792 19. Laleye LC, Kerkadi AH, Wasesa AA, Rao MV, Aboubacar A. As- 7. Lips P. Vitamin D status and nutrition in Europe and Asia. sessment of vitamin D and vitamin A intake by female students J Steroid Biochem Mol Biol. 2007 Mar;103(3−5):620−5. at the United Arab Emirates University based on self-reported PMID:17287117 dietary and selected fortified food consumption. Int J Food Sci Nutr. 2011 Jun;62(4):370−6. PMID:21126211 8. Fields J, Trivedi NJ, Horton E, Mechanick JI. Vitamin D in the Persian Gulf: integrative physiology and socioeconomic fac- 20. Rajah J, Haq A, Pettifor JM. Vitamin D and calcium status tors. Curr Osteoporos Rep. 2011;9(4):243−50. PMID:21901427 in urban children attending an ambulatory clinic service in the United Arab Emirates. Dermato-endocrinol. 2012 9. Fahed AC, El-Hage-Sleiman A-KM, Farhat TI, Nemer GM. Jan;4(1):39−43. PMID:22870351 Diet, genetics, and disease: a focus on the Middle East and North Africa region. J Nutr Metab. 2012;2012:109037. 21. Al-Anouti F, Al-Ameri S, Thomas J, Abdel-Wareth L, Devkaran doi:10.1155/2012/109037. S, Rajah J, et al. Sun avoidance among indoor employees lead- ing to vitamin D deficiency and depression in the United Arab 10. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes Emirates. Int J Med Med Sci. 2013 Dec;5:503−9. B, Eisman JA, et al and IOF Committee of Scientific Advisors (CSA) Nutrition Working Group. Global vitamin D status and 22. Haq A, Rajah J, Abdel-Wareth LO. Vitamin D: measurement, determinants of hypovitaminosis D. Osteoporos Int. 2009 deficiency, and its health consequences. Middle East Lab. Nov;20(11):1807−20. PMID:19543765 2009 12(1):6−10. 11. El-Sonbaty MR, Abdul-Ghaffar NU. Vitamin D deficiency in 23. Muhairi SJ, Mehairi AE, Khouri AA, Naqbi MM, Maskari FA, Al veiled Kuwait women. Eur J Clin Nutr. 1996 May;50(5):315−8. Kaabi J, et al. Vitamin D deficiency among healthy adolescents PMID:8735313 in Al Ain, United Arab Emirates. BMC Public Health. 2013 Jan 14;13:33. PMID:23311702 12. Badawi A, Arora P, Sadoun E, Al-Thani A, Al Thani MH. Preva- lence of vitamin D insufficiency in Qatar: a systematic review. 24. Kennel KA, Drake MT, Hurley DL. Vitamin D deficiency in J Public Health Res. 2012 Dec;1(3): 229–35. PMID:25170469 adults: when to test and how to treat. Mayo Clin Proc. 2010 Aug;85(8):752−7. PMID:20675513 13. Al Attia HM, Ibrahim MA. The high prevalence of vitamin D inadequacy and dress style of women in the sunny UAE. Arch Osteoporos. 2012;7(1−2):307−10. PMID:23150183

686 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Association between body mass index, diet and dental caries in Grade 6 boys in Medina, Saudi Arabia A. Bhayat 1,2, M.S. Ahmad 2, H.T. Fadel 2

العالقة بني مقياس كتلة اجلسم والنظام الغذائي وتسوس األسنان عند التالميذ الذكور بالصف السادس يف املدينة املنورة باململكة العربية السعودية أمحد هبايات، حممد سامي أمحد، هاين طالل فاضل

اخلالصة: يتزايد انتشار السمنة يف اململكة العربية السعودية، وعىل الرغم من أن التسوس يرتبط مع السمنة فإن هذه العالقة مل ُت ْس َقىص تيف املدينة املنورة. ولقد هدفت هذه الدراسة إىل حتديد العالقة بني تسوس األسنان ومقياس كتلة اجلسم والعادات الغذائية لدى ذكور أعامرهم إثني عرش ًعاما من أربع مدارس من مناطق جغرافية خمتلفة يف املدينة املنورة. فكان متوسط مقياس كتلة اجلسم للعينة 22.17 )5.15 ±( من بينهم %14 كان مقياس كتلة اجلسم )± 2.04( 1.46 30 25 لدهيم ًطبيعيا، و% كان لدهيم زيادة وزن، و% كانوا يعانون من السمنة. وكان متوسط مقياس األسنان املسوسة واملفقودة واملحشوة . وكان انتشار التسوس % 57ومقياس األسنان املسوسة واملفقودة واملحشوة ) ( 1.92عند أولئك الذين مقياس كتلة اجلسم لدهيم ضمن املجال الطبيعي أعىل بكثري مقارنة مع فئتي زيادة الوزن والسمنة. وظلت هذه الفروق ذات داللة إحصائية التحكم بالعوامل اخلارجية املحتملة عن طريق ُّالتحوف اخلطي. وكان متوسط مقياس كتلة اجلسم أقل بكثري عند الذكور الذين لدهيم تسوس شديد مقارنة مع الذين كان التسوس لدهيم ًخفيفا أو ًمعدوما. وكان خطر ظهور التسوس لدى املشاركني طبيعيي وناقيص الوزن أعىل بضعفني ًتقريبا مما هو عليه لدى نظرائهم الذين يعانون زيادة الوزن والسمنة. وكان لدى األطفال عادات غذائية سيئة، ومل يكن هناك ارتباط يعتد به بني املتغريات الغذائية وبني التسوس.

ABSTRACT The prevalence of obesity is increasing in Saudi Arabia and although caries is associated with obesity, this association has not been investigated in Medina. This study aimed to determine the association between dental caries, body mass index (BMI) and dietary habits of 12-year-old boys from four geographically distinct schools in Medina. Mean BMI was 22.17 kg/m² (± 5.15); 41% had normal BMI, 25% were overweight and 30% were obese. The mean Decayed, Missing and Filled Teeth (DMFT) score was 1.46 (± 2.04). Those in the normal BMI range had a significantly higher prevalence of caries (57%) and DMFT score (1.92) compared with the overweight and obese groups (P < 0.05). These differences remained significant after controlling for possible confounders via linear regression. Mean BMI was significantly lower in boys with severe compared with mild or no caries. Normal and underweight participants had an almost 2 times greater risk of developing caries compared with their overweight and obese counterparts. The children had poor dietary habits and there were no significant associations between dietary variables and caries.

Association entre l’indice de masse corporelle, le régime alimentaire et les caries dentaires chez des garçons en dernière année de primaire à Médine (Arabie saoudite)

RÉSUMÉ La prévalence de l’obésité augmente en Arabie saoudite et malgré le lien qui existe entre la carie et l’obésité, cette association n’a pas été étudiée à Médine. La présente étude avait pour objectif de déterminer l’association entre les caries dentaires, l’indice de masse corporelle (IMC) et les habitudes alimentaires de garçons âgés de 12 ans venant de quatre écoles géographiquement distinctes à Médine. L’IMC moyen était de 22,17 kg/m² (± 5,15) ; 41 % avaient un IMC normal, 25 % étaient en surcharge pondérale et 30 % étaient obèses. Le score moyen de l’indice CAO (dent cariée, absente ou obturée) s’élevait à 1,46 (± 2,04). Les garçons dont l’IMC se situait dans les valeurs normales avaient un prévalence de la carie (57 %) et un indice CAO supérieurs (1,92) à ceux du groupe des enfants en surcharge pondérale et souffrant d’obésité (p < 0,05). Ces différences demeuraient significatives après avoir contrôlé d’autres facteurs de confusion potentiels grâce à la régression linéaire. L’IMC moyen était considérablement plus faible chez les garçons ayant des caries sévères par rapport à ceux qui avaient des caries bénignes ou qui n’en avaient pas. Les participants de poids normal ou présentant une insuffisance pondérale avaient un risque deux fois plus important de développer des caries que ceux qui étaient en surcharge pondérale ou obèses. Les enfants avaient de mauvaises habitudes alimentaires et il n’y avait aucune association entre les variables alimentaires et les caries.

1Department of Community Dentistry, University of Pretoria, Pretoria, South Africa (Correspondence to: A Bhayat [email protected]). 2Department of Preventive Dental Sciences, Taibah University Dental College & Hospital, Medina, Saudi Arabia. Received: 28/10/15; accepted: 03/08/16

687 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Introduction The aim of the study was to determine extracted because of caries were re- the relationship between dental caries, corded as missing, while teeth removed There is a strong association between BMI and dietary intake of 12-year-old due to trauma or orthodontic treatment nutritional status and dental caries, schoolchildren in Medina. were recorded as healthy according to and a direct link between caries, sugar the WHO criteria (9). Two dentists consumption and obesity (1,2). Some who had been trained in the diagnosis studies have reported a positive cor- Methods of dental caries using the DMFT index index completed the oral examinations. relation between caries and obesity, Study design whereas others have shown that under- Calibration was done using slides and weight children tend to have a higher This was a cross-sectional analytical mounted extracted teeth and κ scores prevalence of caries compared to their study of Grade 6 schoolboys carried out of 0.90 and 0.80 were obtained for intra- overweight counterparts (1,2). between February and April 2014. The and inter-examiner reliability, respec- sample size was calculated by estimating Dental caries is a worldwide epi- tively. For simplicity, the DMFT score the population of 12 year-old boys in was divided into 3 categories at the time demic affecting children of all ages 3( ,4). Medina to be 10 000 (7). Assuming of data presentation: 0, no caries; 1–3, Its aetiology is multifactorial and in- the prevalence of obesity to be 23% (8) mild caries; and ≥ 4, severe caries. cludes plaque accumulation, poor oral with a confidence level of 95% and mar- hygiene and consumption of ferment- A standardized dietary question- ginal error of ~0.05, a minimum sample able carbohydrates (2). Obesity is also naire (10,11) was used to determine size of 370 participants was required. multifactorial and its risk factors include the nutritional intake and physical activ- There were 194 male primary schools poor eating habits, lack of physical activ- ity of the participants. A pilot study, to in Medina and these were divided into ity, genetics and increased consumption validate the questionnaire, was carried 4 geographical areas as follows: North, of carbohydrates (3). out on 45 boys at the first school. Minor 40 schools; South, 51 schools; West, changes were made to the question- Children with caries may present 52 schools and East, 51 schools. One naire and the modified version was used with pain and ultimately tooth loss. This school was selected from each cluster at the remaining schools. Data from could result in a reduction in food in- using a convenience sampling strategy. the first school was included in the final take, which in turn may lead to stunting All grade 6 students from each of the analysis because there was sufficient of growth (3). In contrast, increased four schools were invited to participate overlap between the initial and latter consumption of fermentable carbo- in the study. A total of 419 participants information that was collected. The hydrates can result in increased body received consent forms for their parents questionnaire was self-administered weight and prevalence of dental caries to sign; this ensured that the minimum and consisted of 12 closed and 1 open- (4). sample size would be achieved. ended questions. The questions were re- Body mass index (BMI) is currently lated to the consumption of junk foods Data collection used as the gold standard to determine such as burgers, pizzas and sweets, soft anthropometric score and classifies in- The data collection consisted of 3 parts: drinks, milk, water, fruit and vegetables, dividuals into four groups; underweight, a clinical oral examination; completion and the frequency of physical activities. normal weight, overweight and obese of a dietary questionnaire; and measur- Trained dental students, using (3). Although there have been conflict- ing body height and weight. a medical scale to the nearest 100 g ing results regarding the association be- The oral examinations were per- and a standardized height measuring tween caries and BMI, this association formed in classrooms under fluorescent tape in meters to the nearest centime- has not been studied in grade 6 children lighting with the participant sitting on tre, recorded the weight and height in Medina. Saudi Arabia has one of a school chair according to the World respectively. The participants removed the highest obesity levels in the world, Health Organization (WHO) criteria their shoes and heavy garments before which could be due to its rapid growth (9). The Decayed, Missing and Filled their height and weight were recorded. and economic development over the Teeth (DMFT) index was used to re- The BMI was calculated by dividing past few years and the widespread intro- cord the caries status of the permanent the weight in kilograms by the square duction and consumption of fast foods dentition. The primary dentition was of the height in metres (kg/m2) (12). and soft drinks 5( ,6). excluded. Only teeth with frank caries The recorded height and weight were This study was carried out in the city were diagnosed as decayed while those classified according to the WHO BMI of Medina, which is located in North with early white spot lesions, uncon- categories using age-related guidelines West Saudi Arabia. It is the second holi- firmed caries or fissure sealants were into underweight, normal, overweight est site in the Islamic world after Mecca. recorded as sound. Teeth that were or obese (12).

688 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Oral hygiene achieve the best model fit. Confound- a response rate of 96%. Those who were The participants received a 15-minute ers were entered initially in a stepwise not included either did not have signed presentation regarding oral hygiene manner to observe the change in the consent forms or were absent on the day 2 practices and healthy eating habits. They R value, which increased from 3% to of the clinical examination. The mean were shown how to brush and floss 11% at most, possibly inferring a poor age of the participants was 12.6 years their teeth and all participants received model fit. However, the standard error (± 0.62; range 12–14 years) and mean a toothbrush, toothpaste and pamphlets of the regression was lowered from 6 to DMFT score was 1.46 (± 2.04; range containing information on brushing 5, inferring a prediction interval of up 0–9) (Table 1). The median DMFT and oral hygiene practices. A referral to 90%. A probability plot was used for score was 0.0 and the decayed, missing form was issued to those who were in regression model diagnostics to detect and filled components contributed 86, need of dental treatment and they were any possible nonlinearity or non-nor- 3 and 11% of the total DMFT score, advised to visit the Taibah University mality of the model. The results of the respectively. Dental College & Hospital for further model diagnostics turned out negative. The mean BMI was 22.17 (± 5.15) assessment and management. Logistic regression was also done using kg/m2. Sixteen (4%) of the schoolboys caries as the binary dependent variable were underweight, 165 (41%) were Statistical analyses and BMI, age, school, sport activities within the normal range, 100 (25%) Descriptive statistics including the and dietary intake as independent vari- were overweight and 121 (30%) were percentages, means and standard devia- ables. The crude and adjusted odds obese (Table 1). Boys in the normal and tions (SDs) were obtained. The χ2 test ratios (ORs) were calculated to assess underweight groups had a significantly was used to test the significance of the the odds of developing caries in the higher prevalence of caries (P < 0.05) categorical data in the different BMI different BMI groups. In all instances, and DMFT score (P < 0.01) compared and DMFT groups. Analysis of vari- the significance level was set at P < 0.05. to the overweight and obese groups ance (ANOVA) and Kruskal–Wallis Data were analysed using SPSS Statis- (Table 1). Because there were only 16 tests were used when comparing the tics for Windows, version 17.0, released (4%) boys classified as underweight, continuous data, mean DMFT and in 2008 (Chicago, IL, USA). they were combined with the normal mean BMI scores. Linear regression category for ease of analysis and referred analysis was used to assess whether sig- Ethical clearance to as the normal weight group. The dif- nificance levels remained after control- Ethical clearance was obtained from ferences among the 3 BMI groups in ling for possible confounding variables. the Taibah Dental Ethics Committee terms of DMFT score remained signifi- BMI was considered the dependent (TUCDREC/20130512/Bhayat) and cant after controlling for possible con- variable and DMFT score was con- all information was strictly confidential founders by means of linear regression sidered the independent variable. Age, and anonymous. analysis (P < 0.01) (Table 2). When school, freque ncy of snacks between calculating the unadjusted OR, normal meals, consumption of soft drinks, milk, weight children were 1.3 times more fruit and vegetables, and daily sports Results likely to develop caries compared to activities were all considered as possible overweight and obese children (P < confounders and were eventually en- The parents of 402 of the 419 partici- 0.05) (Table 3). Furthermore, when tered into the model simultaneously to pants provided signed consent, yielding adjusting for age, school, sport activities

Table 1 Mean number of DMFT and caries prevalence in the total sample and in different BMI groups Total BMI groups (n = 402) Underweight Normal Overweight Obese P value (n = 16; 4%) (n = 165; 41%) (n = 100; 25%) (n = 121; 30%)

Mean D (SD) 1.26 (1.87) 2.00 (2.78) 1.67 (2.16) 0.92 (1.60) 1.01 (1.56) 0.002* Mean M (SD) 0.04 (0.30) 0.25 (0.68) 0.06 (0.39) 0.05 (0.30) 0.01 (0.09) 0.022* Mean F (SD) 0.16 (0.50) 0.38 (0.72) 0.20 (0.58) 0.19 (0.48) 0.09 (0.37) 0.119 Mean DMFT (SD) 1.46 (2.04) 2.63 (3.34) 1.92 (2.35) 1.16 (1.85) 1.11 (1.62) 0.001* Prevalence of caries (%) 49 63 57 42 43 0.031**

*Statistically significant at the 0.01 level using Kruskal–Wallis test. **Statistically significant at the 0.05 level usingχ 2 test. BMI = body mass index; DMFT = decayed, missing and filled teeth.

689 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Table 2 Comparison between 319 participantsa according to BMI with regard to mean DMFT score after controlling for possible confounders by means of linear regression Independent variable Regression Coefficient of Standard error of regression P value coefficient determination (S) (R) (R2) DMFT 0.327 0.107 5.0 P < 0.01

Adjustments for possible confounders were made by entering age; school; frequency of eating snacks between meals; consuming soft drinks, milk, fruit and vegetables; and daily sports activities into the linear regression model, all at once. P values in bold are statistically significant. aRegression analysis was performed on only 319 participants who answered all items/variables that were selected as possible confounders. BMI = body mass index; DMFT = decayed, missing and filled teeth.

and dietary intake variables, the normal and chips (5%). Only 3% ate fruit at to fear, geographic location, high costs, weight children were almost 1.8 times school and 2% reported drinking milk lack of oral hygiene practices and poor more likely to develop caries compared daily. There were no significant associa- oral hygiene education (15,16). The to those who were overweight and tions between any of the age, school and heterogeneous distribution of dental obese (P < 0.05). dietary habits and the DMFT score and caries, with pockets of severe caries, em- The participants were also divided these were therefore excluded from the phasizes the need for regular dental visits into 3 groups based on their DMFT analysis. and school oral health programmes that score (13). There were significant differ- could prevent the onset and subsequent ences in the mean BMI scores among Discussion progression of dental caries. the 3 caries severity groups (P < 0.01) More than half of the sample (55%) (Table 4). Those who were caries free The aim of this study was to determine was either overweight or obese, and (DMFT = 0) had the highest mean the association between dental car- many of them could grow into obese BMI (22.69 kg/m2), while those with ies, BMI and dietary habits of Grade adults and possibly suffer from meta- severe caries (DMFT ≥ 4) had the low- 6 schoolboys in Medina. The mean est mean BMI (20.26 kg/m2). bolic diseases (17). The high prevalence DMFT score was 1.46, which was with- of overweight and obesity is consistent Regarding the dietary intake, less in the target set by the WHO and the with previous studies of adolescents than half of the participants reported range (1.31–1.53) reported by previous in the Middle East (6). Possible rea- eating fruit and vegetables daily (Figure studies in Medina (13,14). Although 1). The majority (97%) reported drink- the mean DMFT score was low, 49% sons for this high prevalence include ing up to 4 glasses of soft drinks per day, of the sample were diagnosed with car- the increased consumption of fried while 72% reported drinking < 5 glasses ies, of which, 15% had severe caries. foods, foods with a high fat content and of water daily. At school, almost 20% In addition, 86% of the decayed teeth a lack of physical activity (6). This calls reported eating junk foods, of which, were untreated. This shows the skewed for immediate actions to be taken by the most common were hamburgers distribution of caries and may be a result school administrations with regards to (38%), desserts (8%), chocolates (6%) of poor utilization of dental services due the type of food products being offered

Table 3 Crude and adjusted OR for developing caries among the different BMI groups BMI group comparisons Unadjusted (crude) OR Adjusted OR OR 95% CI P value OR 95% CI P value Underweight vs normal, overweight & obese 1.30 0.88–1.93 0.253 — — — Normal vs overweight & obese 1.30 1.06–1.59 0.012 1.77 1.11–2.82 0.016 Overweight vs normal & obese 0.80 0.62–1.04 0.085 0.94 0.56–1.59 0.822 Obese vs normal & overweight 0.88 0.70–1.11 0.281 0.75 0.47–1.05 0.11

For adjusted OR, adjustments were made for age, school, sport activities and dietary intake variables. P values in bold are statistically significant. Normal weight refers to all individuals who were classified as having normal BMI according to World Health Organization criteria. BMI = body mass index; CI = confidence interval; OR = odds ratio.

690 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Table 4 Mean BMI in relation to caries severity using DMFT score (n = 402) Caries severity using n (%) Mean (SD) BMI, kg/m2 95% confidence interval P value DMFT categories Lower limit Upper limit 0 (caries free) 207 (51) 22.69 (5.03) 22.0 23.38 1–3 (mild caries) 137 (34) 22.18 (5.50) 21.26 23.11 0.006* ≥ 4 (severe caries) 58 (15) 20.26 (4.31) 19.13 21.39 Total 402 (100) 22.17 (5.15) 21.66 22.67

*Statistically significant at the 0.01 level using analysis of variance. BMI = body mass index; DMFT = decayed, missing and filled teeth; SD = standard deviation.

and, more importantly, by the parents severity decrease (18,19). The cause of ANOVA to associate each of the three at home. this inverse relationship is not clearly groups of dental caries with mean BMI. There was a significant inverse as- understood, but it may be attributed to Therefore, mean BMI and BMI catego- sociation between the DMFT and BMI the unique dietary patterns found in this ries were associated with DMFT scores scores. Normal weight children had a region. The common diet comprises to identify any significant associations. significantly higher mean DMFT score fried foods that are loaded with fat but Mean BMI scores and categories both and prevalence of caries compared to have low amounts of refined carbohy- yielded significant results when associ- the overweight and obese participants. drates. This could increase the BMI and ated with DMFT scores. Those with a This significant inverse association not necessarily have a direct effect on higher DMFT tended to have a lower remained significant even after con- dental caries. mean BMI. This could be due to their trolling for possible confounders by We used an additional statistical poor diet, or as others have suggested, means of linear regression. This result test to confirm the inverse relationship the increased caries could have resulted confirmed previous studies and high- between caries and BMI. Previous stud- in dental pain, which had a negative lights an unusual trend in the Middle ies have shown that if continuous data, impact on eating and chewing (18,19). East (18,19). Sugar is one of the risk fac- like BMI, are categorized into groups, This could have reduced their nutri- tors for the development of caries and such as normal weight, overweight and tional intake and resulted in stunting obesity. Hence, it can be assumed that if obese, insignificant statistical associa- of growth (18,19). In addition, severe the sugar consumption increases, dental tions could be interpreted as significant, caries is associated with iron deficiency caries and BMI should also increase. which could result in insignificant asso- anaemia, which could contribute to However, these studies have shown that ciations being interpreted as significant poor growth and reduced BMI in these as BMI increases, caries prevalence and ones (20). To prevent this, we used children (21). Children with normal BMI were ~1.8 times more likely to have caries 100% compared to those who were over- weight or obese. This contradicts the

75% accepted hypothesis that increased sugar consumption results in obesity and dental caries. It is probable that this 50% sample consumes large volumes of fatty fried foods and unrefined carbohydrates 25% that increase BMI but not necessarily caries. This could not be confirmed in 0% our study as the dietary questionnaire Snacks Fruits Vegetables Milk Sports did not specify the type or amount of between activities meals food that was consumed. Future stud- ies are being planned with a modified < Once/week Twice or thrice/week Daily dietary questionnaire that addresses these shortfalls in order to identify any Figure 1 Percentage of the total sample (n = 402) with regards to frequency of confounders that may have influenced sports activities and consumption of certain dietary products. the results.

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The protective effect of obesity on may have influenced their responses Conclusion dental caries could also be explained and contributed to the weak correla- Within the limits of the study, we ob- by an increase in saliva production due tions between caries and the supposed served a significant inverse relationship to increased food consumption (22). diet that they were consuming. This between dental caries and BMI among This increase in saliva could act as a was confirmed by the poor responses grade 6 students in Medina. Those mechanical cleanser, buffering the low obtained regarding the diet consumed in the underweight and normal BMI pH produced by bacteria, and hence at schools. Many respondents reported groups had the highest prevalence of reducing the incidence of dental caries. eating junk food regularly while few caries and were almost 2 times greater Although some studies have re- admitted that they consumed fruit and at risk of developing caries compared ported that children with a high DMFT milk. This has severe implications for to the overweight and obese groups. score were more likely to be overweight oral health, systemic health and intel- Although the prevalence of caries was or obese, these studies compared the lectual development (10,25). School low, the decayed component contrib- BMI categories and not the mean BMI management should regulate the types uted most to the DMFT index, which with the DMFT score, which may have of foods being sold in the cafeteria and emphasized the unmet dental burden affected the results (23,24). In addi- the types of lunch and snacks being of these participants. In general, they tion, the dietary habits were different brought from home. This could ensure had poor dietary habits and there were from those in the current study. In the that children are directed towards eat- no significant associations between previous studies, overweight and obese ing a healthier diet. any of the dietary variables and caries. children consumed more sweetened We recommend: (1) regulation of the Limitations junk foods compared to children in the type of food being sold and brought normal weight range. This increased The sample comprised only boys be- into school; (2) implementation of both the BMI and DMFT scores (24). cause of accessibility limitations. Fur- oral hygiene education in schools; and Another reason for the contradictory ther studies are required to determine (3) stressing the importance of regular results could be that some studies ana- whether these results are common to dental check-ups, which would iden- lysed the caries status of both the pri- both genders. Moreover, this study was tify, treat and subsequently reduce oral mary and permanent dentitions, while conducted on a convenience sample, health disorders such as dental caries. the current study was limited to the inferring that the results should be permanent dentition. The inclusion of interpreted with caution. The dietary both dentitions at different ages could questionnaire did not include the vol- Acknowledgements have skewed the caries prevalence and ume of food consumed, specific types affected the association between caries of food and beverages consumed, oral The authors would like to thank Dr and BMI. hygiene practices and socioeconomic Ahmed Marghalani and Dr Moham- There were no significant associa- status. Future studies should include med Sarhan from the Department of tions between dietary habits and DMFT these variables. It must be noted that Preventive Dental Sciences at Taibah scores. This could be due to response ac- students could have answered based University for their invaluable assistance quiescence. The students may have an- on their knowledge and not on their in helping collect the data. In addition, swered the questionnaire based on their actual dietary intake, which could have special thanks must be given to the 2014 knowledge rather than on their actual skewed the results. Lastly, caries was final year dental students of the Taibah eating habits. Saudi Arabia has launched scored using the DMFT index. This University Dental College & Hospital many educational campaigns focusing index classifies only frank caries as for assisting with the data collection on healthy lifestyle to try and reduce decayed; early caries and white spot and entry. the prevalence of overweight and obe- lesions are classified as healthy. This Funding: Funding was obtained from sity among school children. This could often results in an underestimation of the Deanship of Scientific Research, have improved the students’ knowledge the true disease burden. Future studies Taibah University. The research grant on healthy versus unhealthy foods and should use a more sensitive index that number is 6121/1435. their effects on health. Therefore, this can detect early caries. Competing interests: None declared.

References

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3. Mohammadi TM, Hossienian Z. The association between 15. Al-Hussyeen AJ. Factors affecting utilization of dental health body mass index with dental caries in an Iranian sample. J Oral services and satisfaction among adolescent females in Riyadh Health Oral Epidemiol. 2012;1(1):29–35 (http://johoe.kmu. City. Saudi Dent J. 2010 Jan;22(1):19–25. PMID:23960475 ac.ir/index.php/johoe/article/view/9). 16. Al Agili DE, Alaki SM. Can Socioeconomic status indicators 4. Parkar SM, Chokshi M. Exploring the association between predict caries risk in schoolchildren in Saudi Arabia? a cross- dental caries and body mass index in public school children sectional study. Oral Health Prev Dent. 2014;12(3):277–88. of Ahmadabad city, Gujarat. SRM J Res Dent Sci. 2013;4:101–5. PMID:24624395 5. Mirmiran P, Sherafat-Kazemzadeh R, Jalali-Farahani S, Azizi F. 17. Ekelund U, Ong KK, Linné Y, Neovius M, Brage S, Dunger DB, Childhood obesity in the Middle East: a review. East Mediterr et al. Association of weight gain in infancy and early childhood Health J. 2010 Sep;16(9):1009–17. PMID:21218730 with metabolic risk in young adults. J Clin Endocrinol Metab. 6. Al-Rethaiaa AS, Fahmy AE, Al-Shwaiyat NM. Obesity and eat- 2007 Jan;92(1):98–103. PMID:17032722 ing habits among college students in Saudi Arabia: a cross 18. Alkarimi HA, Watt RG, Pikhart H, Sheiham A, Tsakos G. Dental sectional study. Nutr J. 2010 09 19;9:39–45. PMID:20849655 caries and growth in school-age children. Pediatrics. 2014 7. Al-Qahtani A, Al-Ghamdi RA, Al-Ghamdi KS. Childhood Mar;133(3):e616–23. PMID:24534405 obesity: Prevalence, risk factors and lifestyle behavior among 19. Goodson JM, Tavares M, Wang X, et al. Obesity and dental primary school male children in Al-Madinah Al- Munawarah, decay: inference on the role of dietary sugar. PLoS One. 2013 Saudi Arabia. Int J Med Sci Public Health. 2013;2(4):1085–89 Oct 10; 8(10):e74461. PMID:24130667 (http://www.scopemed.org/fulltextpdf.php?mno=43964). 20. Owen SV, Froman RD. Why carve up your continuous data? 8. Al Shehri A, Al Fattani A, Al Alwan I. Obesity among Saudi chil- Res Nurs Health. 2005 Dec;28(6):496–503. PMID:16287057 dren. Saudi J Obes. 2013;1:3–9. 21. Tang RS, Huang MC, Huang ST. Relationship between dental 9. Oral health survey: basic methods. Geneva: World Health caries status and anemia in children with severe early child- Organization; 1997. hood caries. Kaohsiung J Med Sci. 2013 Jun;29(6):330–6. 10. Al-Muammar MN, El-Shafie M, Feroze S. Association between PMID:23684139 dietary habits and body mass index of adolescent females in 22. Lenander-Lumikari M, Loimaranta V. Saliva and dental caries. intermediate schools in Riyadh, Saudi Arabia. East Mediterr Adv Dent Res. 2000 Dec;14:40–7. PMID:11842922 Health J. 2014 Feb 11;20(1):39–45. PMID:24932932 23. Sharma A, Hegde AM. Relationship between body mass index, 11. Yahia N, Achkar A, Abdallah A, Rizk S. Eating habits and obesity caries experience and dietary preferences in children. J Clin among Lebanese university students. Nutr J. 2008 Oct 30;7:32. Pediatr Dent. 2009 Fall;34(1):49–52. PMID:19953809 PMID:18973661 24. Alm A, Isaksson H, Fåhraeus C, Koch G, Andersson-Gäre B, Nils- 12. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siek- son M, et al. BMI status in Swedish children and young adults mann J. Development of a WHO growth reference for school- in relation to caries prevalence. Swed Dent J. 2011;35(1):1–8. aged children and adolescents. Bull World Health Organ. 2007 PMID:21591594 Sep;85(9):660–7. PMID:18026621 25. Kumar S, Kroon J, Lalloo R. A systematic review of the impact 13. Bhayat A, Ahmad MS, Hifnawy T, Mahrous MS, Al-Shorman H, of parental socio-economic status and home environment Abu-Naba’a L, et al. Correlating dental caries with oral bacteria characteristics on children’s oral health related quality of life. and the buffering capacity of saliva in children in Madinah, Sau- Health Qual Life Outcomes. 2014 Mar 21;12:41. PMID:24650192 di Arabia. J Int Soc Prev Community Dent. 2013 Jan;3(1):38–43. PMID:24478979 14. Bhayat A, Ahmad MS. Oral health status of 12-year-old male schoolchildren in Medina, Saudi Arabia. East Mediterr Health J. 2014 12 17;20(11):732–7. PMID:25601812

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Report Essential public health functions: the experience of the Eastern Mediterranean Region Ala Alwan 1, Olla Shideed 1 and Sameen Siddiqi 2

Introduction Mediterranean Region: Reinforcing the in public health within ministries of role of WHO 2012–2016” (2, 3). health during this period. It was clear Early 2012, the WHO Regional Office In addition to the pre-existing chal- in 2012 that competencies in public for the Eastern Mediterranean (EMR) lenges in the five priorities, the past five health are insufficient in tackling the worked with Member States to reach years witnessed major developments health priorities in many countries of consensus on the key health challenges that had a considerable impact on the the Region. Thus, strengthening public that would be the focus of joint work public health landscape in the Region. health capacity was established as a spe- over the course of the next five years. Political changes, social and economic cial initiative of the Regional Director Five strategic priorities were identified crises, civil unrest and emergencies, as and was given a high priority during and were subsequently endorsed by the well as rapid demographic changes, have his five-year term. This was translated World Health Organization (WHO) had a significant impact on health of the through a number of regional initiatives Regional Committee for the Eastern Eastern Mediterranean populations. launched since 2012, including: the Mediterranean, which is the WHO The same period has also experienced Leadership for Health programme, governing body at the regional level, at the unfolding crises in Iraq, Libya, Syria, health diplomacy initiative, refocusing its 59th session in October 2012 (1). and Yemen, in addition to the ongoing the Eastern Mediterranean Health Jour- These were: health system strengthen- protracted emergencies in countries nal as a regional public health journal, ing, maternal and child health, preven- like Afghanistan, Pakistan, Somalia and and reinforcing national public health tion and control of noncommunicable parts of Sudan. Today, almost two- institutes and associations. One key diseases, health security and the un- thirds of Member States in the Eastern component of this initiative focused on the assessment of Essential Public finished agenda of communicable Mediterranean Region are directly or Health Functions (EPHFs) (8). diseases, and emergency preparedness indirectly significantly affected by cri- and response. ses resulting in unprecedented massive In close coordination with Member population movements (4-6). Purpose and objectives States, WHO undertook a comprehen- A common gap that was identified sive situation analysis for each priority for all five priority areas is the limited The overall purpose of this initiative is area, in terms of the nature and char- availability of public health capacity (7). to provide evidence-informed recom- acteristics of the challenges encoun- Although there has been some progress mendations for improving public health tered, gaps and barriers to action, as in public health capacity in the Region capacity and performance in Member well as opportunities for intervention. over the last two decades, this has not States. This is achieved through 1) This was followed by identifying what matched the overwhelming public providing a baseline assessment of had to be done to address these gaps. health challenges the Region faces. In public health services and capacities at This is summarized in the report “Shap- fact, some countries did not appear to the national level; 2) identifying areas ing the future for health in the Eastern have made a significant improvement of strength as well as areas for further

Definition of essential public health functions

Essential Public Health Functions (EPHFs) have been defined as the indispensable set of actions, under the primary responsibility of the state, that are fundamental for achieving the goal of public health which is to improve, promote, protect, and restore the health of the population through collective action (9).

1WHO Regional office for the Eastern Mediterranean, Cairo, Egypt.2 WHO Representative, Tehran, Islamic Republic of Iran.

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development and actions needed at countries led by their ministries of WHO staff and international experts, country level to strengthen EPHF; 3) health are able to identify the strengths conducted between 2013 and 2014. convening a national policy dialogue and weaknesses in the public health The framework identifies eight inter- that brings together different stakehold- system and based on the results develop related functions, four core and four ers to reach consensus on strategic interventions designed to sustain good enabling functions, which are neces- directions and develop an action plan practices and bridge gaps. sary for a comprehensive public health to address priorities; and 4) developing The uniqueness of the EMRO system (Figure 1). According to the institutional capacity within the Region initiative is that 1) it has built on existing conceptual framework of essential to undertake an assessment of EPHF. initiatives to develop a framework that public health functions for the EMR, The process of assessing EPHFs is is relevant to the context of the Region operational definitions have been de- not new. There are several assessment and considers latest developments in veloped for each term. This has further frameworks, developed as early as the global health; 2) the basis for the as- been the basis for development of a 1990s (Table 1), with a common aim sessment tool is topic-specific WHO comprehensive assessment tools and – to identify areas of strength as well guidelines, assessment tools and policy accompanying glossary of terms. The as areas that require strengthening in recommendations, in order to foster eight functions are further broken down into a detailed list of sub-headings and national public health systems. The as- a coherent, evidence-based approach sub-functions, which together consti- sessment of EPHFs in the Eastern Med- to public health challenges; 3) it stems tute a comprehensive package of public iterranean Region provides a renewed from the request of Member States and health services that all Member States in opportunity to refine and update the is not intended to be an “external audit” the EMR should aim to provide to their methodology and develop a regional of the health system; and 4) it combines populations. framework that practical, feasible, and a mixed approach of self-assessment meets the needs and addresses the chal- followed by a joint external assessment lenges of the different Member States in to validate the findings. Approach and process the region. Several Member States in the East- The scope of assessment of essential ern Mediterranean Region were engag- Essential public health public health functions is country-wide ing in a process of health sector reform functions in the EMR and follows a multi-sectoral approach. and development of national health It is done in close collaboration with strategies and were therefore open to an The conceptual framework for essential the ministry of health, as its owner, but objective approach to evaluating their public health functions for the Region ensures the involvement of relevant own health systems and the response has been developed through a review of stakeholders. The assessment is a col- to their key health challenges. Through experiences from other WHO regions laborative effort between WHO and the the EPHF performance assessment, and a series of technical meetings of Member State, with full ownership of the project by the national authorities. The scope of the assessment of EPHF will be country-wide, country-owned and will follow a multi-sectoral ap- proach. The assessment tool provides a brief list of criteria for each item, which na- Enabling functions tional public health officials and external experts can use to evaluate the adequa- Core cy, quality and comprehensiveness of functions the service. These criteria have generally been synthesized from topic-specific WHO guidelines, assessment tools and policy recommendations, in order to foster a coherent, evidence-based ap- proach to public health.

Figure 1 Essential Public Health Functions in the Eastern Mediterranean Region. The tool is unique in that it has been conceived to facilitate a broad,

695 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale EMRO 1. Surveillance and monitoring 1. of health determinants, risks, morbidity and mortality and public health 2. Preparedness outbreaks, to disease response disasters and othernatural emergencies Health protection3. including management of environmental, and food, toxicological occupational safety 4. Health promotion and disease prevention through population and personalized interventions, social including action to address determinants and health inequity effective health Assuring 5. governance, public health legislation, financing and institutional (stewardship structures function) and a sufficient 6. Assuring for effective competent workforce public health delivery Communication and social 7. mobilization for health 8. Advancing public health research to inform and influence policy practice ) 13 EURO ( • EPHO1: Surveillance of population health and wellbeing • EPHO2: Monitoring and to health and response hazards emergencies • EPHO3: Health protection including environmental occupational, food safety and others • EPHO4: Health Promotion social including action to address determinants and health inequity prevention,• EPHO5: Disease detectionincluding early of illness governance for • EPHO6: Assuring health and wellbeing a sufficient • EPHO7: Assuring and competent public health workforce sustainable • EPHO8: Assuring organisational and structures financing • EPHO9: Advocacy communication and social mobilisation for health • EPH10: Advancing public health to inform policy and research practice ) 12 WPRO ( 1. Health situation monitoring and 1. analysis 2. Epidemiological surveillance/ preventiondisease and control Development of3. policies and planning in public health management of 4. Strategic health systems and services for population health gain Regulation to and enforcement 5. public healthprotect development 6. Human resources and planning in public health Health promotion, social 7. participation and empowerment 8. Ensuring the quality of personal and population-based health services development and Research, 9. implementation of innovative public health solutions ) 11

CDC, CLAISS and PAHO ( CDC, CLAISS and PAHO EPHF 1. Monitoring,EPHF 1. evaluation, and analysis of health status and EPHF 2. Surveillance, research, ofcontrol the and threats to risks public health Health promotionEPHF 3. EPHF 4. Social participation in health Development ofEPHF 5. policies and institutional capacity for public health planning and management EPHF 6. Strengthening of public health regulation and enforcement capacity Evaluation and promotion EPHF 7. of to necessary equitable access health services EPHF 8. Human resources in development and training public health in Quality assurance EPHF 9. personal and population-based health services in public health EPHF 10. Research Reduction ofEPHF 11. the impact of and disasters on emergencies health

) 10 Building on other - Identifying frameworks EPHFs of to the relevance Region Eastern Mediterranean EPHFs ( to Delphi study) (according Immunization D-EPHF 1. D-EPHF 2. Monitoring morbidity and mortality outbreak Disease D-EPHF 3. control surveillance D-EPHF 4. Disease of Promotion D-EPHF 5. community involvement in health D-EPHF 6. Monitoring determinants of health and Production D-EPHF 7. protection of safe water ofD-EPHF 8. Control food quality and safety health Provide D-EPHF 9. information and education theD-EPHF 10. Evaluate ofeffectiveness health programs and services Table 1: Table and prevention control for disease CDC Centre Latino Centro CLAISS de Investigaciones Americano en Sistemas de Salud EPHFs Essential Health Public Functions Regional Office EMRO Eastern Mediterranean for Europe EURO Regional Office Health American Organization Pan PAHO Regional Office Pacific WPRO Western

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system-wide assessment of public • Reviewing the sections correspond- in the country, based on the respons- health functions in Member States ing to the eight EPHFs in an integrat- es to the tool, the presentations, site and to identify gaps and areas where ed way, by the national steering group visits and parallel meetings. to avoid any duplications/conflicting improvement is needed. The pathways • Share the report with the national information. for assessment include three different authorities for their review and feed- dimensions (Box 1). • Sharing the completed tool and re- back. In the self-assessment (stage 2), lated documentation with WHO well Once the assessment is complete a national public health authorities take in advance of the planned external follow-up workshop is jointly organized assessment mission to the country. the responsibility of completing the as- (by WHO and the country) to discuss In the joint external assessment sessment tool, in advance of the joint the findings of the assessment and de- (stage 3), a WHO-led team of experts external assessment. The assessment velop a plan of action for strengthening will conduct a country mission, meet- the areas covered under the essential tool is a comprehensive document that ing with officials from the Ministry of public health functions. The workshop is not meant to be completed by one Health (or equivalent), unit directors, brings together the relevant stakehold- person or even by one unit within the and other key stakeholders. The role of ers at country level, under the leadership Ministry of Health, but rather through the WHO-led team during the third a multi-sectoral involvement and a stage can be summarized as follows: of the Ministry of Health to outline the national meeting produce their own steps that need to be taken to strengthen conclusions on their capacity and areas • Review documents shared by the public health capacity and performance country and the filled in assessment requiring further development. Stage 2 in the country. tool, prior to the country mission. will involve the following steps: It is important to emphasize that • Attend presentations prepared by the the success of the initiative relies heav- • Assembling a national steering group national team, summarizing the situa- ily on partnerships between different to oversee the assessment process at tion in the country in relation to each stakeholders. At national level, the as- national level. Ideally, the group may of the eight EPHFs. consist of directors of different sec- sessment is a joint initiative of different • Conduct in-depth face-to-face in- partners, including: tors/departments/units in the Minis- terviews and meetings with relevant try of Health and related entities. ministry of health staff, stakeholders • Ministry of Health (or its equivalent) • Completing each of the eight sections and partners in the country (follow- – as the principal steward of the pub- of the assessment tool by the depart- ing the structure of the tool), to un- lic health system in the country; ment/sector/unit that corresponds derstand the interplay of contextual • Other relevant sectors of the govern- to it. The process requires reviewing factors in the delivery of EPHFs. ment, parliament and partners in the available documents, reports, strate- • Draft an assessment report that in- country (with responsibilities influ- gies, and publications in support of cludes the outcome of the assessment encing the wider social determinants the information needed while filling as well as a set of recommendations of health) – environment, food and the assessment tool. for improving public health services agriculture, industry, transport, etc.;

Box 1: Pathways for the assessment process 1. Stage 1 is a desk review carried out by WHO, based on the experience accumulating as a result of the long-standing technical collaboration between WHO and the Member State. The different WHO programme managers and tech- nical staff provide their evaluation of the current status of capacity in implementing public health functions in their own areas of work. This also entails review of global, regional and national documentation and reports, to provide an evidence-base for the assessment. 2. Stage 2 is a national self-assessment conducted inside the country by the national technical staff, coordinated by the national health authority using the WHO assessment tool. National public health authorities take the responsibility of completing the WHO assessment tool, in advance of the independent assessment. 3. Stage 3 is a joint external assessment conducted by a team of WHO experts, working closely with national public health officials. The team reviews the outcome of stages 1 and 2 and develops their own assessment based on inter- views with health and relevant non health stakeholders.

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• Leading academic institutions and other countries. The lessons learned are • Multisectoral involvement is key, think tanks in order to build capacity elaborated across three headings: bringing together different sectors within the country and Region; and at national level, to discuss and ana- Approach lyze the challenges, gaps in action and • Public health experts of international roles in addressing them. eminence with diverse expertise and • The current format of a combined experience in leading health systems approach of self-assessment followed • Structure of the national assessment team is key to ensure that individuals and public health programs in their by an external review has proved very with knowledge are identified and own countries. useful and contributes to ensuring an included early on in the assessment unbiased and a more objective final In conclusion, Figure 2 summarizes process. the steps recommended to conduct the product. assessment of essential public health • WHO preparatory work in conduct- Assessment tools functions: ing a desk review of public health • The current tools are very compre- functions provide background infor- hensive and cover many areas. Con- mation and important input on the sideration of an “abridged” version Lessons from the situation in the country prior to the may be useful in contexts where a country experiences visit. thorough assessment is not possible. • The joint external assessment is un- • Some questions are not obviously Using the regional framework, WHO dertaken through a five-day mission, clear and in some cases it is not a yes/ has supported two countries in con- which is only sufficient to adequately no answer. There is need for clarifica- ducting an assessment of essential assess the whole situation on the tion and restructuring of some sec- public health functions, Qatar being the ground if a thorough national assess- tions to avoid misunderstanding. pilot country in the Region, followed ment is conducted prior. • Some areas need to be updated to by Morocco. A number of requests cover recent developments and new from other Member States have been Assessment process public health innovations. received, expressing interest to conduct • Timing of the assessment during the • The “norm” for each function needs an assessment of EPHF. A review of country’s planning cycle is vital. The to be explained, in terms of “what an the initiative was conducted to reflect assessment can be an effective ad- ideal system looks like”. on what was achieved and reflect on vocacy tool and contributes to plac- • Within each function, there is need the lessons learned to further enhance ing “public health” high on the policy to identify issues that are “core” and the initiative before expanding to agenda. others that are “optimal”.

Team of international Preliminary report Member State experts undertakes express interest drafted and shared mission to country with national team

National team uses Discussion and National team WHO tools to consensus on results is assembled conduct a national and recommendations assessment

WHO desk review to National workshop WHO shares tools collate all relevant to develop action and methodology information, reports plan based on and documents recommendations

Figure 2 EPHF assessment process in the Eastern Mediterranean Region

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Conclusion and international and regional organizations or review of the regional framework way forward working the health field. Sustainability and/or participated in the country pilot will also depend on the full engagement assessments. Their contribution and of regional public health institutions. It is imperative to acknowledge the dedicated support was essential for the work of the two countries that under- WHO will continue to act as secretariat for the assessment and for supporting success of this initiative (in alphabetical took an EPHF assessment (Qatar and order): Walid Ammar, Ezra Barzilay, Morocco) and the countries that have and monitoring implementation of Timothy Evans, David Heymann, Did- expressed their interest to undertake an recommendations. Needless to say, the assessment. The leadership of Member initiative will also benefit from broaden- ier Houssin, Jose Martin-Moreno, Rob ing and expanding the expert group, to States in this area is vital to sustain and Moodie, José Pereira-Miguel, Pekka include more regional experts and those build on this initiative. From the lessons Puska, Peter Salama, Suwit Wibulpol- who have been leading EPHF assess- learned in the two countries, specific prasert, the National Team in Qatar led ments at national level. actions are recommended to continue by the Ministry of Public Health, and to improve the process. Developing a the National Team in Morocco led by road-map for implementation of the Acknowledgements the Ministry of Health. Regional experts recommendations is of critical impor- who participated in one of the meetings tance (Box 2). The WHO Regional Office for the also include (in alphabetical order): Sustainability of the initiative will Eastern Mediterranean expresses require further inclusion of other great appreciation for the following Homoud Algarni, Assad Hafeez, Naser partners in the initiative like other UN international and regional experts Kalantari, Reza Majdzadeh, Fauziah agencies, World Bank and other key who participated in the development Rabbani, and Arash Rashidian.

Box 2: In summary, the key good practices which characterize the Eastern Mediterranean Region’s experience include: 1. The request for an assessment is made by a Member State on a voluntary basis, providing funding for the assessment to ensure ownership. 2. The development of a “Glossary of terms” to ensure terminology is clear and consistent. 3. Following three pathways for the assessment, to ensure adequate sources of information; including the two-tier assess- ment process, self-assessment followed by a joint external assessment. 4. The involvement of a national team from the early stages and throughout the process contributes to strengthening national capacity in this area and ensuring sustainability. 5. Within the WHO Regional Office, the initiative has involved all technical departments allowing an all-inclusive -ap proach to the inter-related functions. 6. The assessment tools build on existing WHO tools and references, thereby serving as a compilation of existing WHO guidance and documents on the subject.

References

1. Regional Committee for the Eastern Mediterranean. Annual Regional Office of the Eastern Mediterranean, 2016. (http:// report of the Regional Director for 2011 and progress reports. applications.emro.who.int/dsaf/EMROPUB_2016_EN_18776. Cairo: WHO Regional Office of the Eastern Mediterranean; pdf?ua=1). 2012 (EM/RC59/R.1). (http://applications.emro.who.int/ 4. Health Emergencies WHO. Countries in crisis. Cairo: World docs/RC_Resolutions_2012_1_14690_EN.pdf?ua=1 EP). Health Organization Regional Office of the Eastern Mediter- 2. World Health Organization. Shaping the future of health in the ranean; 2016. (http://www.emro.who.int/eha/countries-in- WHO Eastern Mediterranean Region: reinforcing the role of crisis/index.html). WHO 2012-2016. Cairo: WHO Regional Office of the Eastern 5. Humanitarian Health Action WHO. WHO Grade 3 and Grade Mediterranean, 2012. (http://applications.emro.who.int/ 2 emergencies. Geneva: World Health Organization; 2016. dsaf/EMROPUB_2012_EN_742.pdf?ua=1). (http://www.who.int/hac/donorinfo/g3_contributions). 3. World Health Organization. Shaping the future of health in 6. United Nations High Commissioner for Refugees. Global the Eastern Mediterranean Region: reinforcing the role of Trends: Forced displacement in 2015. Geneva: UNHCR; 2016. WHO 2012-2016: progress report May 2016. Cairo: WHO (http://www.unhcr.org/576408cd7.pdf).

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7. Regional Committee for the Eastern Mediterranean. Report of 11. Centers for Disease Control and Prevention, Centro Latino the first meeting of the Technical Advisory Committee to the Americano de Investigaciones en Sistemas de Salud, Pan Regional Director, 15–17 April 2013. Cairo: WHO; 2013 (EM/ American Health Organization/World Health Organization. RC60/INF.DOC.9). (http://applications.emro.who.int/docs/ Public health in the Americas: national level instrument for RC_Techn_paper_2013_inf_doc_9_14998_EN.pdf?ua=1). measuring essential public health functions. Washington DC, 8. Regional Director - Assessment of essential public health func- Pan American Health Organization, 2000. Pilot test version, tions in countries of the Eastern Mediterranean Region. Cairo: May 2000. (http://www1.paho.org/english/dpm/shd/hp/ World Health Organization Regional Office of the Eastern EPHF.htm). Mediterranean; 2016. (http://www.emro.who.int/about- 12. Regional Office for the Western Pacific. 2003. World Health who/public-health-functions/assessment-public-health-func- Organization. Essential public health functions: a three-coun- tions.html). try study in the Western Pacific Region. (http://www.wpro. 9. Pan American Health Organization/World Health Organiza- who.int/publications/docs/Essential_public_health_func- tion (PAHO/WHO). Public Health in the Americas: Concep- tions.pdf). tual Renewal, Performance Assessment, and Bases for Action. 13. Regional Office for Europe, World Health Organization. The Washington (DC): PAHO/WHO; 2002. 10 Essential Public Health Operations. (http://www.euro.who. 10. Bettcher D, Sapirie S, Goon EHT. Essential public health func- int/en/what-we-do/health-topics/Health-systems/public- tions: results of the international Delphi study. World Health health-services/policy/the-10-essential-public-health-oper- Stat Q. 1998;51:44–55. ations).

700 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Invited commentary The growing threat of antibiotic resistance in the Eastern Mediterranean Region – what does it take to control it? R. Hajjeh 1 and A. Mafi 1

For decades, antibiotics represented Development Goals, and subsequently, in order to understand the root causes an essential component of modern achieving the Sustainable Development of AMR and the measures needed to medicine. Not only were they respon- Goals, are at great risk. Multiple factors control it, including more cautious use sible for saving millions of lives from are responsible for the rise of antibiotic of antibiotics, better hygiene and infec- previously deadly infections, but also resistance, with the main driving fac- tion control, and better prevention of made it possible to perform complex tor being the widespread overuse and infection through the use of vaccines. surgeries and better manage complica- misuse of antibiotics in both the health In 2015, WHO launched a global tions of chemotherapy and diabetes, and agriculture sectors. campaign to increase awareness of among others. However, these miracle antibiotic resistance and to encourage drugs are quickly losing their power Global response to antibiotic resistance best practices among the general public, and becoming ineffective, as bacteria health workers and policy makers to have increasingly become resistant to In order to address the growing threat of avoid the further emergence and spread them. The global rates of antimicrobial antibiotic resistance, a global coordinat- of antibiotic resistance. The theme of resistance (AMR) have become alarm- ed effort involving all countries and key the campaign, “Antibiotics: Handle ingly high with dire consequences: over stakeholders has been initiated. In May with Care”, reflects the overarching 700 000 deaths worldwide attributable 2015, a Global Action Plan on AMR (2) message that antibiotics are a precious to antibiotic resistant bacteria (1). In was adopted by countries at the World resource and should be preserved. They Health Assembly and supported by the the Eastern Mediterranean Region should be used to treat bacterial infec- governing bodies of the Food and Ag- (EMR), reported rates of resistance tions, only when prescribed by a certi- riculture Organization (FAO) and the have reached dangerous levels both in fied health professional. This campaign World Organisation for Animal Health healthcare settings and the commu- continues this year and the week of (OIE). Furthermore, recognizing the nity, threatening the hard-won gains 14–18 November, 2016 is the second catastrophic consequences of failing to in health and development, and the global Antibiotics Awareness Week. tackle AMR, world leaders gathered at sustainability of public health response WHO is encouraging all countries, the United Nations General Assembly to many communicable diseases, in- health partners, and the public to join (UNGA) in New York in September cluding pneumonia, diarrhoea, tuber- this campaign and help raise awareness 2016 and committed to taking a broad culosis, malaria, HIV/AIDS, sexually of antibiotic resistance. transmitted infections and healthcare coordinated approach to address the acquired infections. root causes of AMR across multiple Developing national AMR A systematic review on the burden sectors (3). Countries are expected to plans of AMR in the EMR conducted in report on their progress to the UNGA Resolution WHA 68.7 of the World 2015 (WHO /EMRO, unpublished in 2018. Health Assembly urged all countries data) revealed significant gaps in stud- Taking Action in the EMR to develop and have in place by 2017 ies representative of national burden national action plans on AMR that are of antimicrobial disease, particularly Raising awareness aligned with the objectives of the global from lower and middle-income coun- One of the key objectives of the global action plan. These plans are important tries (LMICs), where the impact of action plan is to improve awareness as they serve as road maps for countries AMR is more detrimental. In par- and understanding of AMR through ef- to guide their efforts to curb antibiotic ticular, the viability of achievements fective communication, education and resistance. So far, 12 countries in the through the health-related Millennium training. Increasing awareness is critical Region have started developing their

1Department of Communicable Diseases Control and Prevention, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt

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national action plans, with technical as- Antimicrobial Resistance Surveillance other partners to enact effective public sistance provided by WHO, as needed. System (GLASS), which supports a policies, legislations, multisectoral col- standardized approach to the collec- laboration, and to encourage new drugs Surveillance of resistance tion, analysis and sharing of data on and diagnostics development. Antibi- Although data on AMR are increas- AMR at a global level (7). Countries in otic resistance affects all of us—from ingly being generated from the region the EMR are increasingly recognizing healthcare facilities to communities, (4–6), there are still significant gaps in the importance of GLASS, and have families and individuals the world over. the information available on antibiotic initiated the process needed to establish It demands immediate and aggressive resistance. To understand better and this surveillance system. GLASS will action by everyone. Without political help generate more data from the region respond to antibiotic resistance patterns commitment at all levels: community, that are comparable across countries, and key drivers, standardized informa- healthcare workers, animal health, in- and will make it possible to monitor the tion about AMR incidence, prevalence, dustry and others, we are headed for a impact of various interventions that aim and trends must be gathered. at reducing rates of AMR. post-antibiotic era where minor infec- Surveillance is the cornerstone for tions once again kill, and the benefits of assessing the burden of AMR and for Call to action modern medicine infectious diseases providing the necessary information The adoption of the Global Action Plan will disappear. Our region in particu- for action in support of local, national on AMR through resolution WHA 68.7 lar has suffered from many wars and and global strategies. In order to in- and the UNGA political declarations conflicts recently that have led to a re- form decision-making and provide on AMR are important milestones, but emergence of many infectious diseases the evidence base for action and ad- this is just the beginning. Real change (8). We cannot afford losing war against vocacy, WHO launched the Global depends on the governments and antibiotic resistance.

References

1. Jim O’Neill. Tackling Drug-Resistant Infections Globally: Final 5. Saied T, Elkholy A, Hafez SF, Basim H, Wasfy MO, El-Soubary Report and Recommendations. The Review on Antimicrobial W, et al. Antimicrobial resistance in pathogens causing noso- Resistance. London: the UK Government and the Wellcome comial bloodstream infections in university hospitals in Egypt. Trust, May 2016 (ttps://amr-review.org/Publications). Am J Infect Control. 2011;39:e61–5. 2. Global Action Plan on AMR. Geneva: World Health Organiza- 6. Aly M, Balkhy HH. The prevalence of antimicrobial resistance tion, 2015 (ISBN: 9789241509763) (http://www.who.int/anti- in clinical isolates from Gulf Corporation Council countries. microbial-resistance/ publications/ global-action-plan/en/). Antimicrob Resist Infect Control. 2012;1:26. 3. PRESS RELEASE. High-Level Meeting on Antimicrobial Re- 7. Global Antimicrobial Resistance Surveillance System, Manual sistance. New York: UN Headquarters, 2016 (http://www. for Early Implementation. Geneva: World Health Organiza- un.org/pga/71/2016/09/21/press-release-hl-meeting-on- tion, 2015 (ISBN 978 92 4 154940 0) (http://www.who.int/ antimicrobial-resistance/, accessed 8 November 2016). antimicrobial-resistance/global-action-plan/surveillance/ 4. El-Herte RI, Kanj SS, Matar GM, Araj GF. The threat of carbap- glass/en/). enem-resistant Enterobacteriaceae in Lebanon: an update on 8. Alwan A. The cost of war. Newsweek Nov. 5, 2015. http:// the regional and local epidemiology. J Infect Public Health. newsweekme.com/the-cost-of-war). 2012;5:233–43.

702 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

Short communication Primary oral health care: a missing link in public health in Pakistan S.Basharat 1, B.T. Shaikh 1

الرعاية األولية لصحة الفم: حلقة مفقودة يف الصحة العامة يف باكستان سارة بشارت، بابر تسنيم شيخ

اخلالصــة:إن قلــة توافــر الرعايــة الصحيــة للفــم يف باكســتان َوكثــرة احتياجاهتــا غــر امللبــاة أمــر موثــق ًمتامــا. فاالنتشــار َّاملســجل لتســوس 70-50 األســنان يبلــغ % ، وانتشــار رسطــان الفــم ُعــد يمــن بــن أعــى املعــدالت يف العــامل. وعــى الرغــم مــن اإلعــان عــن جعــل الرعايــة الصحيــة للفــم ًمــن جــزءانظــام الرعايــة الصحيــة األوليــة فــإن الفــوارق املوجــودة بــن األغنيــاء والفقــراء يف جمــال صحــة الفــم َواملشــاكل الناشــئة عــن إمكانيــة الوصــول إىل الرعايــة املناســبة واإلفــادة منهــا مل تعالــج ًأبــدا، ممــايعكــس قلــة الوعــيلــدى كل مــناملــرىض وصنــاع القــرار يف النظــام الصحــي. إن التحــري عــن رسطــان الفــم واملعاجلــة الرتميميــة غــر الراضحــة لتســوس األســنان يمكــن إدراجهــا ضمــن احلزمــة األساســية للعنايــة بالفــم التــي ال تتطلــب جراحــي أســنان ذوي مؤهــات عاليــة. إن هــذا املقــال يقــدم ًبرهانــا - يســتند إىل مراجعــة األدبيــات وإىل حتليــل النظــام الصحــي يف باكســتان - عــى الكيفيــة التــي ِّمتكــن ً برناجمــالصحــة الفــم األساســية مــن أن يكــون ِّمكو ًنــا ًمتاحــا وميســور التكلفــة ومقبــوالً مــن ِّمكونــات نظــام الرعايــة الصحيــة األوليــة.

ABSTRACT In Pakistan, the limited availability of oral health care and the high level of unmet oral health care needs are well documented. The recorded prevalence of dental caries is 50–70% and that of oral cancer is among the highest in the world. Although oral health care has been declared to be part of the primary health care system, oral health disparities between rich and poor, and emerging problems of access to and use of appropriate care have never been addressed, reflecting a lack of awareness among both patients and health system decision- makers. Oral cancer screening and atraumatic restorative treatment for tooth decay could be included in a basic package of oral care that does not require qualified dental surgeons. This article develops an argument, based on literature review and an analysis of the health system in Pakistan, for how a basic oral health programme could be an accessible, affordable and acceptable component of the primary health care system.

Soins de santé bucco-dentaire primaires : le chaînon manquant de la santé publique au Pakistan

RÉSUMÉ Au Pakistan, la disponibilité limitée des soins de santé bucco-dentaire et le niveau élevé des besoins non satisfaits dans ce domaine sont bien documentés. La prévalence enregistrée pour les caries dentaires est de 50 à 70 % et celle du cancer de la cavité buccale compte parmi les plus élevées au monde. Bien que les soins de santé bucco-dentaire aient été déclarés comme faisant partie du système de soins de santé primaires, les disparités en matière de santé bucco-dentaire entre riches et pauvres, et les nouveaux problèmes d’accès et de recours aux soins appropriés n’ont jamais été traités, ce qui démontre un manque de prise de conscience des patients et des décideurs du domaine des systèmes de santé. Le dépistage du cancer de la cavité buccale et le traitement restaurateur atraumatique pour les caries dentaires pourraient être inclus à un ensemble de base de soins bucco-dentaires ne requérant pas de chirurgien dentaire qualifié. L’article développe un argument, reposant sur une analyse documentaire et sur l’analyse du système de santé du Pakistan, qui présente la façon dont un programme de santé bucco-dentaire de base pourrait constituer une composante accessible, abordable et acceptable du système de soins de santé primaires.

1 Health Systems and Policy Department, Health Services Academy, Islamabad, Pakistan (Correspondence to: B.T. Shaikh: shaikh.babar@gmail. com) Received: 15/12/15; accepted: 21/07/16

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Introduction Affordability and access to oral by oral health care services. There are health care are major problems, which several similarities between Pakistan and Oral health is a state of freedom from are more pronounced in rural than ur- India: for example, oral cancer is the chronic mouth and facial pain, oral ban areas (11). The more delayed the most prevalent form of cancer among and throat cancer, oral sores, birth diagnosis of cancer, the worse the prog- men in the country (8,9); and dental defects such as cleft lip and cleft pal- nosis, the lower the chances of survival caries in both India and Pakistan are ate, periodontal (gum) disease, tooth and the greater the cost. The treatment said to be prevalent among 60–65% of decay and tooth loss, and other diseases of tooth decay is also more successful the population (5,7,14). Pakistan faces and disorders that affect the oral cav- with early detection and a conservative an acute shortage of health workers, ity. Risk factors for oral diseases include approach to cavity restoration (12). Ef- including dentists; this, combined with unhealthy diet, tobacco use, harmful fective public health interventions are rapid population growth, is bound to alcohol use, and poor oral hygiene (1). therefore needed to improve awareness, lead to a need for higher numbers of Like other noncommunicable diseases, knowledge, acceptability, and above all dental surgeons and auxiliary staff 16( ). the global burden of oral diseases has access to oral health care at a cost that In 1999, India launched a national oral greatly increased in recent years (2), is affordable to the general public (13). health care programme to address the which is of serious concern for both This is a situation faced by most develop- burden of oral health problems, with developed and developing countries, ing and even some developed countries. a strong focus on prevention, through as these disorders are the fourth most raising awareness in the community expensive to treat and monitor (3). The (17). In Pakistan, information about Methods situation is exacerbated by the fact that, the burden of oral diseases is scarce; in most developing countries, basic oral however, the issue of limited availability An online literature search was con- health care is often not as well designed of care and unmet oral health needs is ducted on PubMed. This database well documented ( ). Curative dental as other essential components of the 18 was chosen because it includes only services are available at primary health primary health care system. This paper reputable, peer-reviewed journals. We care level in Pakistan in only a few places argues for the development of a basic accessed the most relevant papers from (19), and cannot deal with the burden package of oral health care at primary Pakistan and other developing countries of oral cancer and tooth decay. There health care level in Pakistan, based on (Bangladesh, India, United Republic of is thus a need to introduce oral health evidence about oral health disorders, Tanzania, Zimbabwe and Latin Ameri- promotion, screening, restorative treat- including tooth decay and oral cancers. can countries) on orodental care, public ment, and referral services into existing Globally, tooth decay is the most health, and primary health care using primary care facilities. common chronic disease (4). In Paki- the MeSH terms primary health care, stan, very little up-to-date information is oral hygiene, dental atraumatic restora- Oral cancers available on the prevalence of dental car- tive treatment, and health system. The A timely diagnosis of oral cancer could ies (which are largely preventable) and full texts of articles were retrieved from mean the difference between life and other oral health problems. However, Medline/PubMed. Publications of the death. The diagnostic delay comprises research in two large cosmopolitan areas World Health Organization were also a “patient delay” – the time between the of Pakistan, Karachi and Lahore, found used as basic references. patient first noticing a symptom and the a 50–70% prevalence of tooth decay in first consultation with a health profes- the study population (5–7). Further- Findings sional – and a “professional delay” – the more, according to WHO, cancer of the Oral health care has been neglected at time between the first consultation and oropharynx is the sixth most common primary health care level in most of the a definitive diagnosis. According to a cancer worldwide; in Pakistan it is the developing countries included in our study conducted in Pakistan, nearly 75% second most common cancer in women review, and even in some developed of oral cancer patients first present when and the third most common in men (8). countries, such as the United States of the cancer is at T3 or T4 level (20). Still, This is of serious concern because no America. Although oral health care is merely informing the community about formal programme or basic package of part of primary health care in Bangla- suspicious oral lesions will probably oral care to prevent this cancer exists in desh, India, Indonesia, the Islamic not be sufficient to significantly reduce the primary health care system (9). The Republic of Iran and Nepal (14,15), patient delay. The availability of an ap- integration of oral health into primary oral health disparities between rich and propriate health care provider at a facil- health care has given rise to the idea of poor have not been reduced, and there ity that is both accessible and affordable “essential oral health” (10). is inadequate coverage of the population could be greatly beneficial in ensuring

704 املجلة الصحية لرشق املتوسط املجلد الثاين و العرشون العدد التاسع

timely diagnosis and referral (21). care in Pakistan. Training of community for primary health care workers on Dental auxiliaries have been successfully volunteers or informal dental health care primary oral care in Pakistan, and to trained in India to carry out oral cancer providers in dental health promotion determine the impact and effectiveness screening and dental health promotion and information-sharing with vulnerable of such a programme in improving (21). Qualified dentists are not required communities, and deployment of den- to identify suspicious and potentially tal auxiliaries for screening of patients, awareness about caries prevention and malignant lesions. Oral cancer screening detection and referral of suspicious modification of risky behaviour for oral could be made available and accessible oral lesions and provision of basic oral cancer prevention, and in improving to high-risk groups in Pakistan, through health care could be an efficient and access to and affordability of oral health the introduction of a cadre of dental effective way of reducing the burden of care services in rural areas of Pakistan. auxiliaries at primary level. oral diseases in Pakistan. The dentist- It would also be worthwhile to provide to-population ratio in Pakistan is low Tooth decay (1:10 850) compared with the WHO- refresher training to physicians, to sen- Atraumatic restorative treatment recommended level of 1:7500 (1). sitize them about the importance of oral (ART) is a minimally invasive proce- In some developed countries with health for general health. In outreach dure used to prevent and treat dental a shortage of human resources in oral services, lady health workers could be caries and is specifically designed for use health, local health workers are being trained to help women understand the in developing countries. It requires no trained as dental therapists to meet the need for a clean and healthy mouth. special electrically driven instruments needs of underprivileged and under- or professional set-up. Furthermore, the served populations (24). Dental hygien- procedure is simple enough to be per- ists are also being trained to work as formed by dental auxiliaries using hand Conclusion primary oral health care providers (10). excavation instruments (22). ART was Training these auxiliary staff to detect developed to preserve infected teeth, ART is a tried and tested technique, and and refer suspicious oral lesions would particularly in communities with limited oral cancer screening can be effectively bring considerable added advantage financial resources, little or no provision with little or no added cost in terms carried out by dental auxiliaries as part of of piped water or electricity, and limited of time or financial resources. Such an the primary health care system. Because access to and availability of oral health intervention could have a positive im- of the significant burden of oral diseases care (23). It is expected to be practical pact on the oral health and quality of and useful in Pakistan. in Pakistan, it is becoming critical to de- life of communities where there are no sign a model of community-based, self- dentists, hence helping to reduce the sustaining, locally supported, effective disparities in health care provision and Discussion and basic oral health care in the country. oral health status. There is an obvious lack of availability of Simultaneously, it would be impor- Funding: None. and accessibility to oral and dental health tant to introduce a training programme Competing interests: None declared.

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10. Monajem S. Integration of oral health into primary health care: loads/documents/MSDS%20_Health_%20Final.pdf, accessed the role of dental hygienists and the WHO stewardship. Int J 12 June 2015). Dent Hyg. 2006;4(1):47–51. 20. Shah I, Sefvan O, Luqman U, Ibrahim W, Mehmood S, Alamgir 11. Wilson K, Wilson I, Holmes R. Oral urgent treatment (OUT) – a W. Clinical stage of oral cancer patients at the time of initial volunteer led training programme in North West Tanzania. Br diagnosis. J Ayub Med Coll. 2010;22(3):61–3. Dent J. 2012;212(9):443–8. 21. Mathew B, Sankaranarayanan R, Sunilkumar K, Kuruvila B, 12. Brostek A, Walsh L. Minimal intervention dentistry in general Pisani P, Nair M. Reproducibility and validity of oral visual practice. Oral Health Dent Manag. 2014;13(2):285–94. inspection by trained health workers in the detection of oral 13. Larson TD. Prevention of dental disease versus surgical treat- precancer and cancer. Br J Cancer. 1997;76:390–4. ment. Northwest Dent. 2014;93(2):35–8. 22. Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P. Atraumatic 14. Gambhir R, Brar P, Singh G, Sofat A, Kakar H. Utilization of den- restorative treatment (ART): rationale, technique, and devel- tal care: an Indian outlook. J Nat Sci Biol Med. 2013;4(2):292–7. opment. J Public Health Dent. 1996;56(3 Spec No):135-40; discussion 61-3. 15. van Palenstein Helderman W, Mikx F, Begum A, Adyatmaka A, Bajracharya M, Kikwilu E, et al. Integrating oral health into 23. Estupinan-Day S, Tellez M, Kaur S, Milner T, Solari A. Managing primary health care – experiences in Bangladesh, Indonesia, dental caries with atraumatic restorative treatment in children: Nepal and Tanzania. Int Dent J. 1999;49(4):240–8. successful experience in three Latin American countries. Rev Panam Salud Publica. 2013;33(4):237–43. 16. Abdullah A, Mukhtar F, Wazir S, Gilani I, Gorar Z, Shaikh BT. The health workforce crisis in Pakistan: a critical review and the 24. Friedman JW, Mathu-Muju KR. Dental therapists: improving way forward. World Health Popul. 2014;15(3):4–12. access to oral health care for underserved children. Am J Public Health. 2014;104(6):1005–9. 17. Parkash H. National Oral Health Care Program. Indian Pediatr. 2002;39:1001–5. 18. Shah M, Darby M, Bauman D. Improving oral health in Pakistan using dental hygienists. Int J Dent Hyg. 2011;9(1):43–52. 19. Punjab Devolved Social Services Programme. Minimum ser- vice delivery standards for primary and secondary health care in Punjab. Lahore: 2010 (http://www.pdssp.gop.pk/down-

706 املجلة الصحية لرشق املتوسط املجلد الثاين والعرشون العدد التاسع

WHO events addressing public health priorities

Detection and screening of priority cancers in the Eastern Mediterranean Region1

In its drive to address the importance of early cancer diagnosis, Cancer control was an integral component to each of the WHO Regional Office for the Eastern Mediterranean these four areas and thus critical for a range of stakeholders. organized a consultative meeting on early detection of prior- Furthermore, it was most relevant to policy-makers within ity cancers in the Eastern Mediterranean Region (EMR) on the context of the overarching Sustainable Development 14–15 January 2016 in Cairo, Egypt. This expert consultation Goals adopted by the UN in September 2015, specifically was based on previous regional meetings that identified breast, considering the global push towards universal health coverage. colorectal, cervical, prostate and oral cavity cancers as the most As such, the consultation discussed a very specific component common cancers in the Region that are amenable to early of cancer control—early detection. He closed by highlighting detection/screening. two subjects: using cost-effective measures and the best avail- Participants included international experts, regional ex- able evidence, including economic evaluation approaches, perts, and members of the WHO Secretariat, with significant in light of the health system; and implementation challenges input and engagement from the International Agency for each country faces. Research on Cancer (IARC), the U.S. National Institutes In October 2013, WHO in collaboration with the IARC of Health and National Cancer Institute (NIH/NCI) and organized a regional meeting on cancer control and research other relevant international partners. Professor Anthony B. priorities in Doha, Qatar, which had the following recom- Miller, Professor Emeritus in the Dalla Lana School of Public mendations: strengthening cancer registration and surveil- Health at the University of Toronto, was selected as Chair of lance; carrying out priority research on cancer causation in the meeting. collaboration with IARC; and strengthening screening and early detection of priority cancers. It was concluded that The objectives of the expert consultative meeting included: the most common cancers in the Region that are amenable 1) reviewing the draft documents and collecting feedback with to early detection are breast, colorectal, cervix, prostate and respect to their content and comprehensiveness; 2) reviewing oral cavity cancers. Furthermore, a preparatory meeting for the evidence on screening of the five priority cancers for early the high-level ministerial meeting to scale up cancer control, detection in the Region; 3) discussing the proposed strategic held in Cairo in July 2014, identified early detection as a high approach for early cancer detection in the Region, including a priority intervention in the Region, where almost half of all matrix of key components of an early detection programme; cancers are amenable to early detection and potential cure 4) discussing policy options as applied to the three groups of with adequate treatment and follow-up. Member States also countries in the Region; and 5) agreeing on the way forward indicated the need for strengthening cancer screening pro- and next steps for implementing evidence-based recommen- grammes and improving technical capacity for early detection dations to strengthen early detection of priority cancers. of priority cancers. Dr Asmus Hammerich, Acting Director of Noncom- municable Diseases and Mental Health, opened the meeting Summary of discussions by welcoming all participants. In his opening statement, Dr For this consultation, several documents were presented and Ala Alwan, WHO Regional Director for the Eastern Mediter- discussed, i.e. a working paper on early detection of five prior- ranean, reviewed previous WHO initiatives relevant to cancer ity cancers in the Region; a draft policy statement on breast control. Cancer control programmes that had been launched cancer early detection; and a desk review on early detection of in the 1990s later became integrated components of WHO’s breast cancer in the Region. noncommunicable disease agenda, for which a regional frame- Dr Anthony B. Miller, Professor Emeritus, Dalla Lana work of action was launched in 2012. This regional framework School of Public Health University of Toronto, introduced set four priority actions, i.e. governance; prevention and reduc- two principles for early detection of cancers, i.e. early diag- tion of risk factors; surveillance, research and monitoring; and nosis targeting people with early symptoms and signs; and health care. population-based cancer screening programmes targeting

1 This report is extracted from the Summary report on the Consultative meeting on early detection and screening of priority cancers in the Eastern Mediterranean Region, Cairo, Egypt 15–14 January 2016 (https://extranet.who.int/iris/restricted/ bitstream/1/204645/10665/IC_Meet_Rep_2016_EN_16607.pdf)

707 EMHJ • Vol. 22 No. 9 • 2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

asymptomatic people. Both approaches need improved recommendations. As such, early diagnosis recommendations public awareness and professional education, efficient and based on best international evidence and existing regional well-developed health services and appropriate health care experience must take into account the existing resources, chal- financing mechanisms. lenges and opportunities for each group of countries. Dr Sankar Rengaswamy, International Agency for Re- Participants also discussed the importance of clearly search on Cancer (IARC), briefly reviewed the burden and distinguishing between screening tools and diagnostic tools pattern of cancers the Region with emphasis on trends in within the context of early detection. For example, mam- age-specific and age-standardized incidence rates and the mography is best used as a diagnostic tool, not as a screening projected burden in 2030. The presentation and subsequent tool, so breast cancer control programmes must distinguish discussions focused on the five most common cancers in the its use. There was also general consensus that mammography EMR, i.e. breast, colorectal and prostate cancers, with high risk screening is not feasible recommended in Group Three (low in all or most countries, with moderate to high risk of cervix income) countries. The group agreed that all existing screen- and oral cancer in certain countries/subregions within the ing programmes in the Region be reviewed. Group One (high Region. He also introduced the contents of the early detection income) countries may consider pilot programmes before document that emphasized the different early detection tests national scale-up with quality assurance as an important available for screening and early diagnosis of these cancers and component of all screening programmes. Mammography reviewed important regional experiences. screening may be feasible in some Group Two countries but Considering this background, the consultation empha- national scale-up should be preceded by pilot programmes sized three major issues, with reference to national perspec- and review of ongoing screening programmes. Monitoring tives and experiences. First, participants agreed on definition and evaluation is also a key component of such programmes and components of early detection. Second, they considered and must be included. the categorization of countries and how best to present recom- Furthermore, the interventions and age specificity for mendations accordingly. Third, specific concerns regarding screening and diagnosis were most controversial regarding screening, especially for breast, cervix and prostate cancer, and mammography for breast cancer, human papillomavirus subsequent recommendations were debated. vaccination for cervical cancer and prostate-specific antigen For the first issue, early detection is split into two major (PSA) screening for prostate cancer. For prostate cancer, there parts: 1) early diagnosis of symptomatic individuals; and 2) was general consensus that PSA screening for prostate cancer screening of asymptomatic individuals. Early diagnosis is is not recommended. based on awareness (among the public and among health professionals through continued education) of early signs and Finally, all participants agreed that early diagnosis of breast, symptoms of cancer in order to facilitate more effective and colorectal, cervix, prostate and oral cavity cancers among simpler therapy. Screening is the presumptive identification symptomatic persons is a core early detection intervention in an apparently asymptomatic population of unrecognized and relevant to all countries of the Region. disease or defects by means of tests, examinations or other The experts concluded that population awareness and procedures that can be applied rapidly and easily to the target health provider training with skilled physical examination is population followed by effective treatment of cancers detected. critical. Awareness among people and primary care physicians In terms of categorization, EMR countries are commonly is vital and prompt referral and investigations are crucial for categorized into three health system groups based on popula- success of early detection programmes. tion health outcomes, health system performance and the level Next steps of health expenditure.2 Some participants expressed concerns over the categoriza- The following regional documents were considered during the tion of countries, particularly the categorization of Group Two expert discussions and group work. countries (as it does not accurately reflect the health service ca- • Statements on early detection of: breast cancer, colorectal pabilities and development and their readiness to implement cancer, and cervical cancerStatement on early detection of screening programmes). This Group is most heterogeneous oral cancer and present a challenge to experts on how best to fit the • Steps for early detection of prostate cancer 2 Group 1: high income countries (Bahrain, Kuwait, Oman, • Scope of early detection interventions for priority cancers by Qatar, Saudi Arabia and the United Arab Emirates); Group three groups of countries of the Region 2: middle income countries (Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Palestine, Syrian These will be revised in the light of the meeting’s discus- Arab Republic and Tunisia); Group 3: low income countries sions and circulated to participants for comments, before (Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen) being finalized.

708 Members of the WHO Regional Committee for the Eastern Mediterranean

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Membres du Comité régional de l’OMS pour la Méditerranée orientale

Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen

Correspondence

Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: [email protected]

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