EMHJ – Vol. 24 No. 5 – 2018 Eastern Mediterranean La Revue de Santé de la Editorial Health Journal Méditerranée orientale World No Tobacco Day 2018: towards a sustainable campaign involving the cardiovascular community Fatimah El-Awa, Nizal Sarrafzadegan, Slim Slama and Asmus Hammerich...... 409 Research articles Smoking behaviour among male students in a Saudi University Guoping Jiang, Shafi Aldamer and Ahmed Bendania...... 411 Tobacco cessation: attitude and practice of dentists in Northern United Arab Emirates Danavanthi Bangera, Mohamed Takana and Jayakumary Muttappallymyalil...... 419 Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region Hedieh Mehrtash, Richard Laing and Veronika J. Wirtz...... 427 Hypertension and associated cardiovascular risk factors among urban slum dwellers in Egypt: a population-based survey Mohsen Gadallah, Soad Abdel Megid, Amira Mohsen and Sahar Kandil...... 435

Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan Eastern Mediterranean Health Journal Muhammad Fazal Zeeshan, Ahmad Al Ibad, Abdul Aziz, Aftab Subhani, Asif Shah, Tahir Khan, Hidayat Ullah and Umair Qazi...... 443 Parental vaccine knowledge and behaviours: a survey of Turkish families Soner Sertan Kara, Meltem Polat, Burcu Ceylan Yayla, Tugba Bedir Demirdag, Anil Tapisiz, Hasan Tezer and Aysu Duyan Camurdan...... 451 Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children Hoshiar Sangawi, John Adams and Nadja Reissland...... 459 Population and mortality profile in the Islamic Republic of Iran, 2006–2035 Saeide Aghamohamadi, Kamran Hajinabi, Katayoun Jahangiri, Iravan Masoudi Asl and Reza Dehnavieh...... 469

Vol. 24 No. 5 Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region Dalia Samhouri, Arash Rashidian, Stella Chungong, Antione Flahault, Suzanne Babich and Jaouad Mahjour...... 477 Reviews –

Seroprevalence of Toxoplasma gondii infection among Iranian pregnant women: a systematic review and meta- 2018 analysis Mina Malary, Zeinab Hamzehgardeshi, Mahmood Moosazadeh, Mahdi Afshari, Imaneh Ahmadi, Iman Moghaddasifar and Motahareh Kheradmand...... 488 WHO events addressing public health priorities Annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control...... 488 News Important notes for clinical trials funded or sponsored by WHO...... 500

Cardiovascular disease is still the main cause of death in almost all countries in the Eastern Mediterranean Region, where tobacco use ranks one of the highest globally. To help tackle the tobacco use epidemic, the World Health Organization Framework Convention on Tobacco Control rallies countries to the cause of reducing tobacco use, as highlighted by World No Tobacco Day on 31 May.

املجلد الرابع والعرشون / عدد Volume 24 / No. 5 2018 5 مايو/أيار May/Mai

Cover 24-05.indd 1-3 7/8/2018 2:08:32 PM Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.

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

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Cover 24-05.indd 4-6 7/8/2018 2:08:32 PM Vol. 24.05 – 2018

Editorial World No Tobacco Day 2018: towards a sustainable campaign involving the cardiovascular community Fatimah El-Awa, Nizal Sarrafzadegan, Slim Slama and Asmus Hammerich...... 409 Research articles Smoking behaviour among male students in a Saudi University Guoping Jiang, Shafi Aldamer and Ahmed Bendania...... 411 Tobacco cessation: attitude and practice of dentists in Northern United Arab Emirates Danavanthi Bangera, Mohamed Takana and Jayakumary Muttappallymyalil...... 419 Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region Hedieh Mehrtash, Richard Laing and Veronika J. Wirtz...... 427 Hypertension and associated cardiovascular risk factors among urban slum dwellers in Egypt: a population-based survey Mohsen Gadallah, Soad Abdel Megid, Amira Mohsen and Sahar Kandil...... 435 Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan Muhammad Fazal Zeeshan, Ahmad Al Ibad, Abdul Aziz, Aftab Subhani, Asif Shah, Tahir Khan, Hidayat Ullah and Umair Qazi...... 443 Parental vaccine knowledge and behaviours: a survey of Turkish families Soner Sertan Kara, Meltem Polat, Burcu Ceylan Yayla, Tugba Bedir Demirdag, Anil Tapisiz, Hasan Tezer and Aysu Duyan Camurdan...... 451 Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children Hoshiar Sangawi, John Adams and Nadja Reissland...... 459 Population and mortality profile in the Islamic Republic of Iran, 2006–2035 Saeide Aghamohamadi, Kamran Hajinabi, Katayoun Jahangiri, Iravan Masoudi Asl and Reza Dehnavieh...... 469 Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region Dalia Samhouri, Kashef Ijaz, Arash Rashidian, Stella Chungong, Antoine Flahault, Suzanne Babich and Jaouad Mahjour...... 477 Reviews Seroprevalence of Toxoplasma gondii infection among Iranian pregnant women: a systematic review and meta- analysis Mina Malary, Zeinab Hamzehgardeshi, Mahmood Moosazadeh, Mahdi Afshari, Imaneh Ahmadi, Iman Moghaddasifar and Motahareh Kheradmand...... 488 WHO events addressing public health priorities Annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control...... 488 News Important notes for clinical trials funded or sponsored by WHO...... 500

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

Book 24-05.indb 407 7/19/2018 1:23:14 PM Jaouad Mahjour Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor Phillip Dingwall Managing Editor

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

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

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

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

Administration Iman Fawzy, Sarah El Shawarby

Web publishing Nahed El Shazly, Ihab Fouad, Hazem Sakr

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

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

Book 24-05.indb 408 7/19/2018 1:23:14 PM Editorial EMHJ – Vol. 24 No. 5 – 2018

World No Tobacco Day 2018: towards a sustainable campaign involving the cardiovascular community

Fatimah El-Awa 1, Nizal Sarrafzadegan 2, Slim Slama 1 and Asmus Hammerich 1

1Department of Noncommunicable Diseases and Mental Health, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Isfahan Cardiovascular Research Center, Cardiovascular Research institute, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran. Citation: El-Awa F; Sarrafzadegan N; Slama S; Hammerich A. World No Tobacco Day 2018: towards a sustainable campaign involving the cardiovascular community. East Mediterr Health J. 2018;24(5):409-410. https://doi.org/10.26719/2018.24.5.409 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

The movement to reduce tobacco use has been gathering that cardiovascular disease (CVD) is still the main cause pace in the Eastern Mediterranean Region (EMR), of death in almost all EMR countries, and the fact that the as governments aim at implementing legislation to Region is expected to face a dramatic rise in CVD in the encourage populations to turn away from tobacco next decade. Their role is needed at many levels including consumption and avoid the associated health risks. clinical, public health and policy, and the promotion of Indeed, within the Region it was in 2007 that Egyptian existing international packages in their work, such as cardiologist Prof. Hamdi El Sayed, former member of the WHO Global HEARTS initiative (6); highlighting the parliament and former head of the Medical Syndicate, role of tobacco as a major risk factor for CVD; including successfully proposed legislation for the implementation combatting tobacco use in clinical guidelines of every of graphic health warnings on tobacco packets covering CVD type; supporting scientific research on new tobacco 50% of visible packaging (1). In 2011, cardiologist Dr products; confronting misleading information from the George Saade, former focal point of tobacco control in the tobacco industry; advice on tobacco use prevention and Lebanese Ministry of Health, proposed banning tobacco cessation; and networking with civil society entities to use in all public places in Lebanon – a country coined a prioritize tobacco control. “paradise for smokers” in local media – and witnessed When the RJ Reynolds Tobacco Company launched its the implementation of this ground-breaking legislation “More Doctors” campaign in 1946, they knew that doctors’ (2). Meanwhile, in 2013, cardiologist Dr Sania Nishtar, preferences and choices would influence the public, and Pakistan, stood strongly in support of the tobacco control was a blatant attempt to manipulate the element of trust movement with regard to the adoption of legislation between physicians and the public (7). On 31 May 2018, comprehensively banning tobacco advertising in World No Tobacco Day (WNTD) focuses on the heart and Pakistan (3). is a chance for renewed commitment for the participation These examples and many others have been of cardiologists in the tobacco control movement. This instrumental in advancing the tobacco control agenda movement has, since the entry into force of the WHO at all levels (4). The statements of the World Congress Framework Convention on Tobacco Control (FCTC) in of Cardiology and Cardiovascular Health of the World 2005 (8), benefited greatly from the inclusion of many Heart Federation have, repeatedly, cited examples of the other disciplines. Sustaining the efforts of cardiologists work of cardiologists in tobacco control and underlined and the cardiology community is essential. This can the importance of continued efforts in this regard (5). only be achieved through continued partnership with The influence of cardiologists and the cardiovascular the global tobacco control movement, and establishment community on the tobacco control movement leaves no of sustained networks between national, regional and doubt that they have a remarkable and impactful role to global cardiovascular communities in the area of tobacco play. control. This year, WNTD is a great opportunity to In the changing world of tobacco control there are commence a new phase of stronger solidarity among many emerging challenges, including the introduction all tobacco control workers, to move forward towards of new tobacco products. Thus, the role of cardiologists meeting new challenges, and to end altogether the and the cardiovascular community is essential, noting tobacco use epidemic.

References 1. World Health Organization Regional Office for the Eastern Mediterranean (EMRO). New pictorial health warnings on tobacco products. Cairo: EMRO; 2012 (http://www.emro.who.int/egy/egypt-news/tobacco-pictorial-warnings.html). 2. Agence France Press. No butts about it, Lebanon a smoker’s paradise. The Daily Star. 30 May 2009 (http://www.dailystar.com.lb/ News/Lebanon-News/2009/May-30/54987-no-butts-about-it-lebanon-a-smokers-paradise.ash, accessed 16 April 2018). 3. World health Organization. WHO to establish high-level commission on noncommunicable diseases. Geneva: World Health Organization; 2017 (http://www.who.int/mediacentre/news/statements/2017/ncd-commission/en/). 4. European Society of Cardiology. Position paper on the “tobacco products directive”. Biot: European Society of Cardiology; 2013 (https://www.escardio.org/static_file/Escardio/EU-Affairs/tobacco-products-directive-position-paper.pdf).

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5. World Heart Federation. World Congress of Cardiology & Cardiovascular Health, Mexico City, Mexico, 4–7 June 2016 (https:// www.world-heart-federation.org/global-experts-call-stronger-tobacco-control-laws-save-millions-lives-per-year/). 6. World Health Organization. Global hearts initiative. Geneva: World Health Organization; 2017 (http://www.who.int/ cardiovascular_diseases/global-hearts/en/). 7. Gardner M, Brandt AB. “The doctors’ choice is America’s choice” – the physician in US cigarette advertisements, 1930–1953. Am J Public Health. 2006 Feb;96(2):222–232. doi: 10.2105/AJPH.2005.066654. PMID:16434689 8. World Health Organization. WHO framework convention on tobacco control (FCTC). Geneva: World Health Organization; 2005 (http://apps.who.int/iris/bitstream/handle/10665/42811/9241591013.pdf?sequence=1).

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Smoking behaviour among male students in a Saudi University

Guoping Jiang 1, Shafi Aldamer 2 and Ahmed Bendania 2

1Department of Sociology, Nanchang University, Nanchang, China (Correspondence to: G. Jiang: [email protected], [email protected]). 2Department of General Studies, King Fahd University of Petroleum and Minerals, Dhahran, Saudi Arabia.

Abstract Background: Smoking among university students is a social and public health problem worldwide. There is a high prevalence of smoking in Saudi Arabia. Aims: To investigate the factors associated with the onset and cessation of smoking behaviour among university students in Saudi Arabia, and establish what contributes to changes of students’ smoking behaviour. Methods: A sample of 340 students from a national university in Saudi Arabia was randomly recruited and surveyed twice at a 5-month interval. Multiple ordinal logistic regression was run to compare changes in social, psychological and political factors and their impact on students’ smoking behaviour. Results: We found that beliefs supporting nonsmoking (e.g., religious prohibition of smoking) correlated with changes in smoking behaviour among university students [adjusted odds ratio (AOR) = 1.89, 95% confidence interval (CI) = 1.23– 2.91]. There was a significant positive correlation between government policy and changes in male university students’ smoking behaviour (AOR = 0.46, 95% CI = 0.29–0.072). The psychological effect of smoking, such as releasing psychological pressures, was also correlated with changes in smoking behaviour (AOR = 0.31, 95% CI = 0.21–0.47). Conclusions: Our study suggests that the government can play a significant role in curbing smoking by strengthening beliefs promoting antismoking among university students, by developing corresponding policies against smoking, and by providing psychological consultation for them. Keywords: Smoking, tobacco, cessation, ordinary logit analysis, Saudi Arabia, Citation: Jiang G; Aldamer S; Bendania A. Smoking behaviour among male students in a Saudi University. East Mediterr Health J. 2018;24(5):411-418. https://doi.org/10.26719/2018.24.5.411 Received: 05/04/16; accepted: 16/02/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction workplace, government offices, factories, banks and all public transportation facilities (5). Unfortunately, there Tobacco smoking remains an important threat to pub- have been no empirical studies on the impact of such lic health. Almost 5 million deaths per year are related changes on Saudis’ smoking behaviour. The limited to smoking worldwide and the figure is expected to rise number of previous studies were based on a cross-sectional to 10 million by 2030 (1). Although such risky behaviour design, therefore, it was not possible to track changes in is denounced religiously in Saudi Arabia because of the smoking behaviour and the impact of environmental self-destructiveness and financial waste attributed to changes on smoking behaviour. They also focused on the smoking, smoking is common among Saudi citizens. onset of smoking while ignoring its cessation (6). Social Saudi Arabia is ranked 8th in the world for tobacco con- environments that influence male college students’ sumption, although it only involves a small percentage of smoking behaviour have not received much attention the population (2). either. Students move from a strictly controlled family/ There has only been a limited number of studies high school environment to a less strictly controlled on Saudis’ smoking behaviour; therefore, a more university environment. Such a new social environment comprehensive study is needed for the following can give rise to some factors that are more or less reasons. Social, government and psychological factors associated with smoking, such as “attachment to society were ignored in previous studies. For instance, via social connections”, “commitment to be a good social the Saudi Government ratified the World Health member”, “involvement in work or study”, “association Organization (WHO) Framework Convention on Tobacco with smoking or nonsmoking people”, “differential Control (FCTC) in 2005 (3), and they banned tobacco reinforcement by surrounding people”, “imitation of advertisements in local media. Sponsorship of sport by smoking behaviour”, and “awareness of health risk”. tobacco companies was banned and tobacco tax was However, despite the social environment becoming increased in the late 1990s (4). Recently, King Salman freer, it has become more regulated to control smoking issued the strictest royal decree against smoking, which behaviour. Since 2000, smoking has been forbidden in banned smoking in the vicinity of religious, educational, government buildings, educational institutions and health, sport and cultural institutions, as well as, social healthcare facilities, and new regulations in 2013 banned and charity institutions; the ban is also enforced in the smoking in all public areas (7). Therefore, we conducted

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a timely comprehensive study using a panel design of mean age was 22.08 with a standard deviation of 1.26. Saudi university students’ smoking behaviour. We aimed Measurement scales to explain changes in Saudis’ smoking behaviour from social, psychological and institutional perspectives. The questionnaire was based on 5 factors following the theoretical framework based on social learning theory, Saudi university students live in a dynamic social control theory, institutional efforts, awareness of environment from which they receive influence, common health risks, and common psychological func- information, encouragement, support, pressure and tions of smoking. The questionnaire assumed that stu- constraints. Changes in smoking behaviour (either dents lived in a social environment within which they re- from being a nonsmoker to a smoker or from being a ceived influence, information, encouragement, support, smoker to quitting) are embedded in such influences pressure and constraints. Various studies have dealt with from social pressure and conditioned by constraints. the factors in the theoretical framework and the reported Hence, the present study considered the following alternative hypotheses: (Hypothesis 1) attachment, tools were found to be valid and reliable (9). Scales were commitment, involvement and beliefs as mechanisms composed referring to those studies. of social control have a significant impact on Saudi Social control, one of the main independent variables, male university students’ smoking onset or cessation; was assessed with 4 scales that were borrowed from (Hypothesis 2) the process of social learning, including Hirschi (10); namely, attachment (attached to society association with, attitudes towards, and imitation of or not; e.g., I have a lot of close friends); commitment smokers, may change Saudi male university students’ (committed to a good social member or not; e.g., I behave smoking behaviour; (Hypothesis 3) increased awareness well; therefore, my teachers think I am a good student); regarding health risks of smoking is associated with involvement (occupied with various activities or not, e.g.; a higher likelihood of quitting smoking among Saudi I have not much time to have fun like smoking cigarettes); university students, while decreased awareness is and belief (having a belief in nonsmoking or not; e.g., associated with a lower likelihood of quitting or a higher smoking in my culture is considered to be self-harming). likelihood of smoking onset; (Hypothesis 4) government Social learning, the second independent variable, was as- policy on tobacco control prompts changes in Saudi male sessed with 3 scales that were developed from the study university students’ smoking behaviour, which means of Petraitis et al. (11); namely, scale of differential associ- that, while strict policies trigger quitting, loose policies ation (close friends or family members’ attitude towards may facilitate smoking initiation; and (Hypothesis 5) smoking; e.g., my friends around me smoke); differential positive psychological functions of smoking, including reinforcement (close friends or family members’ attitude stress relief, increase in confidence and feeling of pride, towards smoking; e.g., my image looks bad in people’s influence the change in Saudi male university students’ eyes if I smoke); and imitation (see people smoking or smoking behaviour. not; e.g., I see my friends smoking). The last 3 independent variables had only 1 scale each, Methods with a varying number of questions, ranging between 3 Study design and 5. They were awareness of health risk (e.g., smoking- The panel study design benefits from longitudinal as related diseases are difficult to be cured); government well as cross-sectional elements and compares a cohort at policy on tobacco control (e.g., I have seen many 2 different points in time (8). In this study, it was adopted antismoking advertisements recently); and psychological to establish which factors changed for each Saudi male function of smoking (e.g., smoking relieves me from university student, and how the changed factor influ- stress). enced his smoking behaviour. Data were collected at the The above scales were Likert-type questions, with “1” beginning (week 2; Time 1) and end (week 15; Time 2) of representing “strongly disagree” and “7” representing an academic semester with the same questionnaire. Data “strongly agree”. Questionnaire reliability was tested were processed with Stata version 13. with Cronbach’s α (Table 1), and was found to be in the Study sample acceptable range (12). Study samples were randomly drawn with cluster sam- The dependent variable was ordinal reported smoking pling methods from a male-only Saudi university that re- status. Answers were coded in order with 0 representing cruits students from across the nation. Fourteen classes “smoking”, 1 “smoked but quit”, and 2 “never smoked”. (380 students) were randomly drawn from the registrar Ordinal panel data logistic regression was used to list of all classes of the semester at which the study took find the impacts that social environmental changes place. Three hundred and forty responses to the question- had on changes in students’ smoking behaviour. Given naire were valid and matched for Time 1 and Time 2, and the imprecise estimation of stepwise regression and then processed for data analysis. The class breakdown of unavailability of logistic regression for panel data in respondents were: sophomore (66 students, 19.41%), jun- Stata, backward logistic regression was adopted in data ior (162 students, 47.65%) and senior (98 students, 28.82%). analysis to find a parsimonious model that could explain Age of respondents ranged from 18 to 26 years, with the Saudi male university students’ smoking behaviour with majority (272 students, 80%) between 21 and 23 years. The the least number of predictor variables.

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Table 1 Spearman’s ρ between predictor variables and changes in ly correlated with dependent variable smoking status at smoking behaviour among male Saudi university students Time 1 and Time 2, plus variable age and grade. Model 3 Predictor variable Spearman’s ρ Cronbach’s α only embraced independent variables that were signifi- cant in Model 2. Model 4 was tested with independent Time 1 Time 2 variables that were significant in Model 3. All models Social control were tested on proportional odds assumption and found Attachment −0.09 0.01 0.591 to have met the assumption (Table 2). Commitment 0.33* 0.20* 0.810 Model 1 was statistically significant [log likelihood Involvement 0.11 0.14 0.599 (l(θ|x) = 199.44, likelihood ratio (LR) χ2 (12) = 70.33, Belief 0.48* 0.26* 0.661 P < 0.001]. Predictor variables age, grade, belief in nonsmoking (Hypothesis 2), differential association with Social learning surrounding people (Hypothesis 3), government policy Differential association −0.21* −0.05 0.565 (Hypothesis 4) and psychological function (Hypothesis 5) Differential reinforcement −0.06 −0.01 0.641 had a significant influence on changes in Saudi university Imitation −0.23* −0.23* 0.553 students’ smoking behaviour. Model 2 was also found to Awareness of health risk −0.21* −0.35* 0.617 be statistically significant (l(θ|x) = −203.35, LR χ2 (12) = 62.51, P < 0.001). Tested with likelihood ratio test statistic, Governmental policy −0.30* −0.18* 0.625 Model 2 was proved to fit better than Model 1 P( = 0.0985). Psychological functions −0.51* −0.51* 0.630 In the same manner, Model 3 was statistically significant *P < 0.05. (LR χ2 = 57.26, P < 0.001), and fitted better than Model 2. Model 4 nested in Model 3 was statistically significant (l(θ|x = −206.70371; LR χ2 (3) = 55.81; P < 0.001) and superior Results to Model 3 (χ2 = 1.44978, P = 0.229). Therefore, it was regarded as the parsimonious model that explained best Smoking status the impact of social environmental changes on Saudi Among all respondents, 72 (21.18%) students reported male university students’ smoking behaviour, with the smoking at Time 1. This number increased to 106 (31.18%) least number of predictor variables. Hypotheses 4 and at Time 2. At Time 1, 244 (71.76%) students never smoked, 5 were supported; Hypothesis 1 was partially supported but this was reduced to 206 (60.58%) at Time 2. At Time because only the mechanism of control via belief had a 1, 24 (7.06%) students smoked but quit, and this number significant influence on smoking; while Hypotheses 2 increased to 28 (8.24%) at Time 2. The changes in Saudi and 3 were rejected because Saudi university students did students’ smoking behaviour between the 2 surveys were not initiate or quit smoking because of social influences tested with the χ2 test, and were found to be significant and awareness of health risks. (Pearson 2 = 5.0276, P = 0.081). χ In Model 4, for a 1-unit increase in independent Correlations between independent and dependent variable belief, the odds of smoking versus the combined variables category of never smoked and smoked but quit were 1.89 Correlation between independent variables and depend- times greater, given that all other variables in the model ent variable smoking status was tested with Spearman’s ρ. were held constant. Likewise, the odds of the combined At Time 1, independent variables commitment and belief category of smoking and smoked but quit versus never (Hypothesis 1), differential association and imitation (Hy- smoked were 1.89 times greater, given that all other pothesis 2), health risk (Hypothesis 3), government policy variables in the model were held constant. For a 1-unit (Hypothesis 4) and psychological function (Hypothesis 5) increase in independent variable government policy, were significantly correlated with smoking status (Table the odds of smoking versus the combined category of 1). At Time 2, independent variables commitment and be- never smoked and smoked but quit were 0.46 times lief (Hypothesis 1), imitation (Hypothesis 2), health risk greater, given that all other variables in the model were (Hypothesis 3), government interference (Hypothesis 4) held constant. Because of the satisfaction of proportional and psychological function (Hypothesis 5) were signifi- odds assumption, the same increase was also found cantly correlated with smoking status. These independ- between never smoked and the combined category of ent variables were therefore significantly associated with smoking and smoked but quit. For a 1-unit increase in Saudi male university students’ smoking behaviour. independent variable psychological function, the odds of smoking versus the combined category of never smoked Ordered logit models and smoked but quit were 0.31 times greater, given that Four ordinal logit models were tested with the longitudi- all other variables in the model were held constant. nal panel data to find the parsimonious one. Model 1 was Likewise, the odds of the combined category of smoking fully loaded with all independent variables plus variable and smoked but quit versus never smoked were 0.31 age and grade. Model 2 included independent variables greater, given that all other variables in the model were (commitment, belief, imitation, health risk, government held constant. The parsimonious model is illustrated in policy and psychological function) that were significant- Figure 1.

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Table 2 Ordinal logistic models predicting change in smoking status between Time 1 and Time 2 (n = 340 pairs) Variable Model 1 Model 2 Model 3 Model 4 AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI Age 0.48* 0.26–0.89 0.53* 0.29–0.97 0.77 0.49–1.19 — — Grade 2.77* 1.14–6.70 2.33 0.96–5.67 — — — — Social control Attachment 0.87 0.53–1.42 — — — — — — Commitment 1.12 0.67–1.85 1.03 0.64–1.68 — — — — Involvement 1.08 0.68–1.72 — — — — — — Belief 1.97* 1.21–3.19 1.71* 1.07 – 2.74 1.90* 1.24–2.92 1.89* 1.23–2.91 Social learning Differential association 1.95* 1.15–3.33 — — — — — — Differential reinforcement 1.39 0.75–2.58 — — Imitation 0.68 0.42–1.12 0.82 0.51–1.33 — — — — Health risk 0.72 0.40–1.31 0.74 0.41–1.36 — — — — Governmental policy 0.42* 0.26–0.68 0.46* 0.29–0.73 0.46* 0.29–0.72 0.46* 0.29–0.72 Psychological function 0.31* 0.20–0.48 0.34* 0.22–0.52 0.32* 0.21–0.48 0.31* 0.21–0.47 Test of prop. odds ASM χ2 = 12.49 (P = 0.41) χ2 = 6.06 (P = 0.64) χ2 = 2.89 (P = 0.58) χ2 = 2.20 (P = 0.53) Test of ordinal vs nonordinal χ2 = 20.13** χ2 = 23.98** χ2 = 26.97** χ2 = 26.68** regression Likelihood ratio χ2 70.33** 62.51** 57.26** 55.81** Log likelihood −199.44** −203.35** −205.98** −206.70** *P < 0.05; **P < 0.001. prop. odds ASM = proportional odds assumption.

Discussion impact on changing smoking behaviour. Those who held a weak attitude towards nonsmoking from an Islamic Smoking behaviour is influenced by various factors. Our perspective might have smoked, while those whose panel study demonstrated that belief in nonsmoking, attitude was strong might have quit smoking. It should government policy on tobacco control, and psychologi- be noted that antismoking attitude in Saudi Arabia differs cal function of smoking were significant predictors for from that in other countries because, it is forbidden changes in smoking behaviour among Saudi male uni- religiously. Therefore, antismoking attitudes are stronger versity students. On the contrary, attachment to society and imbued with meaning for Muslims, which may not via social connections, commitment to be a good social be the case for non-Muslims. member, involvement in work or study, association with Our findings are consistent with studies from other smoking or nonsmoking people, differential reinforce- countries regarding government role in curbing smoking ment by surrounding people, imitation of smoking, and (17). However, in comparison to western countries, the awareness of health risk did not contribute to under- Saudi government has not taken systematic punitive standing changes in Saudi university students’ smoking measures against smoking. The Saudi Government has behaviour. Hence, social control theory was partially sup- had some sporadic policies, such as ratification of the ported, while social learning theory was not. WHO FCTC in 2005, ban on tobacco advertisements Antismoking attitude was found to have the most in local media, smoking ban in health and education important influence on tobacco use in some western facilities and public transportation areas (18), ban on and eastern countries, such as Hungary (13), Korea (14) sponsorship of sport by tobacco companies (18), and and the United States of America (15). However, Islam tobacco tax increase in the 1990s (4). The present study does not approve of smoking for health and financial shows that such controls may reduce tobacco use among reasons. Saudi Arabia has a deeply rooted religious Saudi male university students. If the Saudi Government culture. Islam is internalized in its practitioners, were to put more effort into developing systematic therefore, antismoking attitude is ideally supposed to antismoking policies, smoking prevalence would be be part of Saudi consciousness. Religious conviction reduced significantly. has been the most important reason for not or quitting The present study showed that Saudi male university smoking in some Saudi studies (16). Such a finding students have low awareness of the health risks of was also demonstrated in the present study. Belief in smoking. This is consistent with a finding on water-pipe nonsmoking is 1 of 3 variables that had a significant smoking from a sample of Eastern Saudi secondary school

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Figure 1 Parsimonious model of impact of social environments on changes in Saudi male university students’ smoking behaviour

Belief in non-smoking 1.89*

Governmental policy on tobacco 0.46* Changes of Saudi university control male students’ smoking behaviour

0.31* Psychological function of smoking *P < 0.05.

adolescents (19), but differs from the results from western pride or confidence, while not having any indications of studies (20). Social and school education on antismoking psychological distress. without detailed knowledge about the relationship In studies of non-Muslim societies, tobacco use was of mortality to smoking in Saudi Arabia might not associated with other risky behaviours, such as alcohol produce an effective outcome. It has been demonstrated use, hazardous driving, relational abuse, fighting, dislike in European studies that a person who is aware of the of school, and illicit drug use (28,32), which were not tested mortality consequences of smoking smokes less than in our study. It could be assumed that alcohol use is not a person who believes that the effect is reversible (21), related to tobacco use in Saudi Arabia because alcohol is but such a conclusion was not confirmed in the present not legally available in the country. However, it is possible study. It is possible that Saudi male university students that smoking is related to hazardous driving in Saudi use some explanations such as moderate use is not Arabia because Saudis are known for their recklessness harmful, counter-evidence, and compensatory behaviour behind the wheel (33). to justify their smoking and to protect themselves from The present study shows that smoking can be curbed self-blame as well as blame from others, as discovered in in Saudi Arabia. Specifically, the Saudi Government can a Finnish study (22). reduce prevalence of smoking by strengthening religious Smoking has been found to start via behavioural education on nonsmoking; developing systematic mechanisms such as differential association, differential measures for tobacco control, including education, reinforcement, and imitation of western and Asian communication, training and public awareness in line populations (23). However, these mechanisms had no with the FCTC Article 12 (34); and providing cessation significant impact on changing smoking behaviour in services including psychological consultation as well as the present study, in contrast to 2 studies on medical social services. students in Saudi Arabia, in which peer influence was There were some limitations to the present study. significantly associated with smoking onset (24). In First, as the sample was drawn from students of a male contrast to some western societies in which there are university, the conclusion may not be generalized to social climates encouraging smoking at a young age (25), the whole adolescent Saudi population. A study of there is no cultural reward or expectation for smoking in adolescence with less education could help draw a more an Islamic social environment. Therefore, even if they are general conclusion and help understand the impact of surrounded by smokers, Saudi male university students education on smoking behaviour. It has been discovered do not feel pressure from them for smoking is denounced that there is a greater likelihood of smoking among culturally in the Kingdom. individuals with low education level (4). Second, the As a result of recent rapid urbanization and migration, time gap between the 2 rounds of data collection might psychological problems have started to become an issue not have been long enough to discover changes in social in Saudi Arabia (26). Although recognition and treatment settings. It could be more revealing to extend the period of mental health disorders have made marked progress as attitudes on smoking may be affected temporally. in Saudi Arabia (27), some Saudis release stress and Third, the current study only collected data from male anxiety through tobacco use (18). Our study confirmed Saudi university students, therefore the conclusion may that psychological problems such as depression play a not be generalized to female students. A follow-up study significant role in changes in smoking behaviour, which on female university students’ smoking behaviour could is consistent with findings from western and East Asian help to show the impact of gender on smoking behaviour, countries (28–31). In contrast to the above findings, in the given that it is common for Saudi women to smoke present study, Saudi male university students smoked to shisha or cigarettes, especially when shisha is somehow improve their psychological wellbeing, such as gaining acceptable in Saudi Arabia (35).

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Study at university is an important period in which ad- sion analysis revealed that belief in nonsmoking, govern- olescents start or stop smoking. Prior studies from the mental policy, and positive psychological effects of smok- Middle East have tackled the causes from a medical per- ing are the most important predictors of smoking onset spective with multivariate regression, but little is known and cessation. Smoking prevalence can be reduced by from a sociological perspective. The present study helped strengthening nonsmoking beliefs, restricting smoking to establish the causes of changes in smoking behaviour in public areas, raising tobacco tax, and providing psy- among Saudi male students. Our ordinal logistic regres- chological consultations for people under pressure.

Funding: The study was funded by King Fahd University of Petroleum and Minerals. Grant ID: IN111055. Competing interests: None declared.

Comportements tabagiques chez des étudiants de sexe masculin dans une université en Arabie saoudite Résumé Contexte : Le tabagisme chez les étudiants à l’université constitue un problème social et de santé publique partout dans le monde. La prévalence du tabagisme est élevée en Arabie saoudite. Objectif : La présente étude avait pour objectif d’étudier les facteurs associés à la mise en route ou l’arrêt du tabagisme parmi les étudiants à l’université en Arabie saoudite, ainsi que de déterminer ce qui contribue à modifier leurs comportements tabagiques. Méthodes : Un échantillon de 340 étudiants issus d’une université nationale en Arabie saoudite a été sélectionné au hasard et étudié à deux reprises à cinq mois d’intervalle. Une régression logistique ordinale multiple a été menée afin de comparer les changements en termes de facteurs sociaux, psychologiques et politiques, ainsi que leur impact sur les comportements tabagiques des étudiants. Résultats : Nous avons constaté une corrélation entre les croyances antitabac (telles que l’interdiction religieuse de fumer) et les changements des comportements tabagiques chez les étudiants à l’université (odds ratio ajusté = 1,89, intervalle de confiance [IC] à 95 % = 1,23-2,91). Il existait une corrélation positive significative entre les politiques gouvernementales et les changements de comportements tabagiques chez les étudiants de sexe masculin à l’université (odds ratio ajusté = 0,46, IC à 95 % = 0,29-0,072). L’effet psychologique du tabagisme, tel que soulager la pression psychologique, était également corrélé aux changements de comportements tabagiques (odds ratio ajusté = 0,31, IC à 95 % = 0,21-0,47). Conclusion : Cette étude suggère que le rôle du gouvernement pour infléchir le tabagisme peut être significatif s’il permet de renforcer les croyances de promotion antitabac parmi les étudiants à l’université, de mettre au point des politiques de lutte antitabac correspondantes et de mettre à leur disposition un système de consultations psychologiques.

سلوك التدخني بني طالب اجلامعات الذكور يف اململكة العربية السعودية جوبنج جيانج، شايف الدامر، أمحد بن دانية اخلالصة اخللفية:يمثل التدخني مشكلة اجتامعية وصحية بني الطالب اجلامعيني. هناك معدالت انتشار عالية للتدخني يف اململكة العربية السعودية. هدفتهذه األهداف:الدراسة إىل التعرف عىل عوامل بداية ممارسة التدخني واإلقالع عنه بني الطالب اجلامعيني يف اململكة العربية السعودية، وكذلك ما يساهم يف تغيري أنامط التدخني بني الطالب. طرق البحث: تم اختيار عينة عشوائية تتكون من340 ًطالبامن جامعة حكومية يف اململكة العربية السعودية. استجاب أفراد املجموعة مرتني لنفس الستبانة تفصل بينهام مدة مخسة أشهر. تم استخدام أسلوب االنحدار اللوجستي املرتب ملقارنة التغريات يف العوامل االجتامعية والنفسية والسياسية خالل فرتة الدراسة ملعرفة تأثرياهتا عىل سلوكيات تدخني الطالب. النتائج:بينت النتائج أن اإليامن بعدم التدخني )املتمثل يف االعتقاد بأن التدخني غري مقبول، أو أنه عىل سبيل املثال حمرم ً(دينيا يرتبط بتغريات سلوك التدخني لدى طلبة اجلامعة السعوديني )CI %95 ،1.89 = AOR = 1.23- (؛ 2.91كام تبني وجود عالقة ارتباطية موجبة ذات داللة إحصائية بني السياسات احلكومية حول التدخني والتغريات يف سلوك التدخني لدى طالب اجلامعات السعوديني )CI %95 ،0.46 = AOR = 0.29- (؛كام 0.072تبني أن الوظيفة النفسية للتدخني ترتتبط بتغريات سلوكيات التدخني بني الطالب السعوديني باجلامعة )AOR = 0.31، .)0.47-0.21 = CI %95 االستنتاجات: يستخلص من الدراسة أنه يمكن للحكومة أن تلعب ً دورا ًكبريايف احلد من التدخني من خالل تقوية قناعاهتم يف عدم التدخني، وتطوير سياسات مكافحة التدخني، وتقديم االستشارات النفسية للشباب.

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Tobacco cessation: attitude and practice of dentists in Northern United Arab Emirates

Danavanthi Bangera1, Mohamed Takana2 and Jayakumary Muttappallymyalil 3

1Gulf Medical Hospital & Research Centre, Ajman, United Arab Emirates (Correspondence to: D.S. Bangera: [email protected]). 2Al Madina Primary Health Care Centre, Ajman, United Arab Emirates. 3Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates.

Abstract Background: Tobacco use has profound health consequences globally. Dentists with positive attitudes towards tobacco cessation counselling show minimal involvement in practice. Aims: To assess the attitude and practice of dentists in the Northern United Arab Emirates towards tobacco cessation advice. Methods: An interviewer-administered, questionnaire-based study was conducted among 250 dentists practicing in the Northern Emirates in 2015. Statistical analysis was performed with the χ2 test and multivariate analysis. Results: Around 88% of dentists exhibited good attitudes but only 37% had good practice of providing tobacco cessation advice to their patients. Nationality, level of education, total duration of practice and personal use of tobacco were signif- icantly associated with attitude towards tobacco cessation. Nonusers of tobacco showed an odds ratio of 3.12 (95% confi- dence interval: 1.18–8.20) towards good attitude. Conclusions: Most of the surveyed dentists had a good attitude towards provision of tobacco cessation advice, but com- paratively suboptimal practice was observed. We recommend providing training to the dentists on the methods and tech- niques of tobacco cessation. Keywords: Dentists, smoking, tobacco, cessation, United Arab Emirates, Citation: Bangera D; Takana M; Muttappallymyalil J. Tobacco cessation: attitude and practice of dentists in Northern United Arab Emirates. East Mediterr Health J. 2018;24(5):419-426. https://doi.org/10.26719/2018.24.5.419 Received: 16/07/16; accepted: 01/03/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction and 94.7% reported that they were confident in providing tobacco cessation advice to their patients (7–12). A study Globally, tobacco use has profound health consequenc- among dentists in Kelantan, Malaysia showed that 72.7% es not only for the smokers but also for those who are were confident in giving such counselling. However, only exposed to second- and thirdhand smoking (1). There are 4.8% of the dentists viewed that their advice would be different forms of tobacco available and consumed world- wide but cigarettes are predominant and account for 96% effective and only 2.4% were positive about their patients’ of global sales (1,2). In the Middle East, cigarette smoking ability to stop tobacco use (13). Attitude of dentists in has emerged as a serious public health problem (3). providing tobacco use cessation advice also depends on many background factors such as past experiences with Tobacco smoke and smokeless tobacco cause a variety counselling, and interest and rewards in practice and of oral mucosal changes due to the irritants and toxins training (13,14). In a study among Hong Kong dentists, present in tobacco. In an effort to reduce mortality and 89% strongly agreed that dentists play an important role morbidity associated with tobacco use, African and in delivering tobacco cessation advice (15). Likewise, 80.6% Middle Eastern countries have developed guidelines on the utilization of appropriate tobacco control policies of dentists in Saudi Arabia agreed about the importance initiated by the World Health Organization (WHO) of providing tobacco cessation counselling and only 9% Framework Convention on Tobacco Control (FCTC) (4,5). of them disagreed (16). This policy also includes strategies such as the 5As (Ask, Despite this encouraging and favourable attitude, Advise, Assess, Assist and Arrange) and the ABC algorithm involvement of dentists in tobacco cessation advice has Ask about the smoking status, provide Brief advice to been minimal. In India, 45% of dentists did not provide stop smoking to all smokers, and assist in Cessation those tobacco cessation pamphlets, although 81.5% did have who are willing to quit (4–6). posters about this in the waiting room (7). In Malaysia, Generally, dentists have a favourable and encouraging although 82.1% dentists offered tobacco cessation advice attitude towards smoking cessation counselling. Most to their patients, only 17.9% were really involved in dentists believe it to be their responsibility to help their cessation advice; 20.2% provided an explanation on the patients with tobacco cessation or to prevent tobacco use. health implications of tobacco use; and 21.4% offered A study in India showed that 98.7% of dentists felt that they motivation to their patients in relation to tobacco were responsible for providing tobacco cessation advice, cessation (13).

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A study in Hong Kong showed that dentists practicing to them. Written consent was obtained prior to in government sectors and those who have undergone administration of the questionnaire and participants training in tobacco cessation were more likely to enquire were recruited conveniently till the required sample size about their patients’ smoking status. Thus, appropriately was achieved. A total of 250 dentists participated in the trained dentists were 14 times more familiar with study with a response rate of 89.3%. contacting local smoking cessation agencies and 8 times The data were fed into an Excel spreadsheet and more likely to provide advice for smoking cessation to analysed using SPSS version 22 software. Results are their patients (15). This study reflected the need for both presented as frequencies and percentages. Attitude of the didactic and clinical training in counselling skills in the dentists towards tobacco cessation advice was assessed undergraduate curriculum. Moreover, dentists should by grading on a 0–4 Likert scale that was rated as strongly also undergo ongoing tobacco cessation training that disagree, disagree, neutral, agree and strongly agree. will help them to acquire better knowledge and updated Each statement was assessed as good attitude if the score techniques (15). was > 2 and poor attitude if the score was ≤ 2. Tobacco Dentists are healthcare providers and play a vital role cessation advice in practice was assessed by grading on a in educating the community about the effects of tobacco 0–2 Likert scale that was rated as never, occasionally and use on oral health and general health (17–19). Engagement always. Each statement was assessed as good practice if of dentists in smoking cessation programmes will allow the score was > 1 and poor practice if the score was ≤ 1. 2 them to become involved in this significant area of The χ test was used to assess the association between prevention. The present study was conducted to assess the dependent and independent variables. The variables attitude and practice of dentists in the Northern United with a level of significance of P ≤ 0.1 were included in Arab Emirates towards providing tobacco cessation the 2nd level of simple binary logistic regression. The advice to their patients. We also assessed the association variables showing a significant level were included in a between attitude and practice in providing tobacco multiple binary logistic regression model to estimate the cessation advice and sociodemographic characteristics, net effect of each variable on tobacco cessation practice. years of practice, areas of specialization and tobacco use The variables that gave adjusted odds ratio with a level of of dentists. significance of P ≤ 0.05 were concluded to be factors that influenced tobacco cessation advice. Methods Results In 2015, we used a cross-sectional study to assess the at- titude and practice of dentists in the Northern Emirates Table 1 illustrates the association between participants’ towards giving tobacco cessation advice to their patients. sociodemographic characteristics and their attitude to- The study population included dentists practicing in hos- wards tobacco cessation intervention. We found that fe- male participants, those < 40 years of age and those with pitals, dental clinics, polyclinics, dental clinics in medical postgraduate and higher education had higher scores centres, and dental centres in primary healthcare centres for good attitude compared to male participants, those in the Northern Emirates. We included general dental aged ≥ 40 years of age and those with graduate educa- practitioners and specialists in dentistry. Dentists who tion. None of these differences was significant. In con- were not willing to participate and those who were exclu- trast, participants from other regions had a significantly sively academics were excluded. higher score for good attitude compared to those from A minimum sample size of 245 was calculated based the World Health Organization Eastern Mediterranean on the formula for cross-sectional studies. The sampling Region. frame was obtained from the lists of Marketing Division, Table 2 shows the association between details of Gulf Medical College Hospital and Research Centre, clinical practice and the participants’ total attitude and Health Communication Division, Gulf Medical score towards tobacco cessation advice. Specialists, University, Ajman. participants practicing in government settings, those An interviewer-administered questionnaire was who consulted < 60 patients per week and those who content and face validated by 3 experts from the field of attended training programmes had higher good attitude tobacco research and 2 from the field of dentistry. Twenty- scores for all the domains (Ask, Advise, Assess, Assist two questions were included each on attitude and practice and Arrange) as compared to general practitioners, towards giving smoking cessation advice. The questions those practicing in private setting, those who consulted were revised based on suggestions received from the ≥ 60 patients per week and those who had not attended experts. Pilot testing of the questions was carried out any training programme. None of these differences among 5 dentists to assess the comprehensiveness, was significant. Good attitude was significantly higher feasibility and time needed to complete the questionnaire. among the participants with ≤ 10 years of clinical practice Ethical approval was obtained from Ethics and as compared to those with > 10 years of clinical practice. Research Committee of Gulf Medical University, Ajman Around 22 (71.0%) current tobacco users had a good and the Ethics Committee of the Ministry of Health, attitude (score > 44) and only 9 (29.0%) had a poor attitude United Arab Emirates. Participants were approached (score ≤ 44) towards all the domains. Among the non- personally and the purpose of the study was explained tobacco users, 199 (90.9%) had a good attitude (score >

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Table 1 Association between participants’ socio-demographic characteristics and their total attitude score towards tobacco cessation advice (n = 250) Sociodemographic Groups Total attitude score P characteristics Good (score > 44) Poor (score ≤ 44) No. % No. % Age groups (yr) < 40 135 90.0 15 10.0 0.33 ≥ 40 86 86.0 14 14.0 Gender Male 94 87.0 14 13.0 0.56 Female 127 89.4 15 10.6 Nationality EMR 94 83.2 19 16.8 ≤ 0.05 Other Regions 127 92.7 10 7.3 Education Graduate 132 85.7 22 14.3 0.09 Postgraduate and higher 89 92.7 7 7.3 EMR = World Health Organization Eastern Mediterranean Region.

Table 2 Association between participants’ details of clinical practice and their total attitude score towards tobacco cessation advice (n = 250) Details of clinical practice Groups Total attitude score P Good (score > 44) Poor (score ≤ 44) No. % No. % Type of practice General 137 86.2 22 13.8 0.14 Specialist 84 92.3 7 7.7 Total duration of practice ≤ 10 years 92 93.9 6 6.1 ≤ 0.05 > 10 years 129 84.9 23 15.1 Type of settings Government 47 90.4 5 9.6 0.62 Private 174 87.9 24 12.1 No. of patients seen/wk < 60 152 88.9 19 11.1 0.72 ≥ 60 69 87.3 10 12.7

Training programme attended Yes 22 95.7 1 4.3 0.49a No 199 87.7 28 12.3 aBy Fisher’s exact test.

44) and 20 (9.1%) had a poor attitude (score ≤ 44) towards Nonusers of tobacco were 3.12 times more likely to have all the domains. Good attitude was significantly higher a good attitude towards tobacco cessation advice as among non-tobacco users compared to current tobacco compared to tobacco users. users (P ≤ 0.01) Table 4 shows the association between socio- Table 3 shows the predictors of good attitude demographic characteristics and participants’ total towards tobacco cessation advice. The χ2 test showed practice score for all domains toward tobacco cessation that nationality, level of education, total duration of advice. Female dentists, those aged ≥ 40 years, those practice and personal use of tobacco were significantly with graduate education, and those from other regions associated with attitude towards tobacco cessation at P had higher good practice scores for all the domains as ≤ 0.1. After adjustment of the confounding factors, these compared to male participants, those aged < 40 years, factors were subjected to multiple logistic regression. those with postgraduate and higher education, and those Participants from other regions were 2.38 times from the Eastern Mediterranean Region. None of these more likely to have a good attitude towards tobacco differences was significant. cessation advice as compared to those from the Eastern Table 5 shows the association between the dentists’ Mediterranean Region. Participants with postgraduate details of clinical practice and the total practice score and higher education were 2.79 times more likely to have towards tobacco cessation advice. Good practice scores a good attitude towards tobacco cessation advice than for all domains were higher for general practitioners, those with graduate education were. Participants with ≤ dentists with > 10 years clinical practice, those seeing ≥ 10 years of clinical practice were 3.61 times more likely 60 patients per week, those practicing in private settings, to have a good attitude towards tobacco cessation advice and those who attended a training programme compared as compared to those with > 10 years clinical practice. to specialists, dentists with ≤ 10 years clinical practice,

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Table 3 Predictors for good attitude of the dentists towards tobacco cessation advice Factors Good attitude Crude Adjusted OR 95% CI OR 95% CI Nationality Other Regions 2.57 (≤ 0.05) 1.14–5.78 2.38 (≤ 0.05) 1.01–5.62 EMR (Ref) 1 – 1 – Education Postgraduates and higher 2.12 (≤ 0.1) 0.87–5.17 2.79 (≤ 0.05) 1.07–7.23 Graduates (Ref) 1 – 1 – Total duration of practice ≤ 10 years 2.73 (≤ 0.05) 1.07–6.98 3.61 (≤ 0.05) 1.33–9.76 > 10 years (Ref) 1 – 1 – Personal use of tobacco No 4.07 (≤ 0.01) 1.65–10.03 3.12 (≤ 0.05) 1.18–8.20 Yes (Ref) 1 – 1 – EMR = World Health Organization Eastern Mediterranean Region.

Table 4 Association between participants’ sociodemographic characteristics and their practice on tobacco cessation advice (n = 250) Sociodemographic Groups Total practice score P characteristics Good (score > 22) Poor (score ≤ 22) No. % No. % Age groups (yr) < 40 53 35.3 97 64.7 0.46 ≥ 40 40 40.0 60 60.0 Gender Male 38 35.2 70 64.8 0.57 Female 55 38.7 87 61.3 Nationality EMR 39 34.5 74 65.5 0.43 Other Regions 54 39.4 83 60.6 Education Graduate 59 38.3 95 61.7 0.65 Postgraduate and higher 34 35.4 62 64.6

EMR = World Health Organization Eastern Mediterranean Region.

those seeing < 60 patients per week, those practicing in Discussion government settings, and those who did not attend any The current tobacco epidemic is one of the greatest training programme. None of these differences was threats to global health. Tobacco use has a detrimental significant. impact on oral as well as general health (16,20). It is im- Among current tobacco users, 23 (74.2%) had poor perative that dentists recognize the need to include inter- practice (score ≤ 22) and only 8 (25.8%) had good practice vention for tobacco use prevention and cessation along (score > 22) towards all the domains. Among the nonusers with dental treatment. Our study aimed to determine the of tobacco, 134 (61.2%) had poor practice (score ≤ 22) and attitude and practice regarding tobacco cessation inter- 85 (38.8%) had good practice (score > 22) towards all the vention among dentists practicing in the Northern Unit- domains. None of these differences was significant. ed Arab Emirates. Among all the variables, good attitude of the dentists Most dentists had a good attitude towards the domains was significantly associated with good practice towards Ask (81.2%), Advise (89.6%), Assess (66.8%), Assist (79.2%) tobacco cessation advice (P ≤ 0.05). When this factor and Arrange (69.2%). Studies in Malaysia, India, Hong was included in the simple binary logistic regression Kong, Saudi Arabia and Islamic Republic of Iran reported model, dentists with a good attitude were 3.18 times (95% that most dentists had an encouraging attitude towards confidence interval: 1.17–8.64) more likely to have good providing tobacco cessation advice to their patients (7, 8, practice towards tobacco cessation advice as compared to 13, 15, 16, 21). In contrast, a similar study conducted in the those with poor attitude. United States of America (USA) reported that only 58%

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Table 5 Association between participants’ details of clinical practice and their practice on tobacco cessation advice (n = 250) Details of clinical practice Groups Total practice score P Good (score > 22) Poor (score ≤ 22) No. % No. % Type of practice General 61 38.4 98 61.6 0.61 Specialist 32 35.2 59 64.8 Total duration of practice ≤ 10 years 36 36.7 62 63.3 0.90 > 10 years 57 37.5 95 62.5 No. of patients seen/wk < 60 62 36.3 109 63.7 0.65 ≥ 60 31 39.2 48 60.8 Type of settings Government 15 28.8 37 71.2 0.16 Private 78 39.4 120 60.6 Training programme attended Yes 11 47.8 12 52.2 0.27 No 82 36.1 145 63.9

of dentists had a positive attitude (22). Attitude depends dentists despite an encouraging attitude towards them. on many factors such as knowledge and interest in This indicates dentists’ perceived lack of skill for their practicing tobacco cessation intervention, which were actual involvement in tobacco cessation interventions. not explored in this study. However, this varying attitude Good practice towards all the domains was observed may be attributable to differences in interest in and to be higher among female dentists, dentists aged ≥ 40 knowledge of the perceived duties of dentists among the years and general practitioners as compared to their dental community. counterparts but this association was not significant. Total attitude score of female dentists and dentists Also, no significant association of total practice was aged < 40 years was higher than in other groups but was observed with regard to nationality, duration of practice not significantly associated. This observation was in and number of patients treated per week. Dentists who conformity with that of Binnal et al., who reported that attended an intervention training programme had better younger dentists had a better attitude towards tobacco good practice than those who had not but this difference cessation interventions than their older counterparts (23). was not significant. This finding is in line with a study One possible reason is that younger dentists are perceived done in Hong Kong that stated that government dentists to have more interest in such intervention compared to and those who received training were significantly older dentists. Dentists who had attended intervention more likely to have good practice towards tobacco training had a better attitude than those who had not cessation than their counterparts (15). Similar findings but the difference was not significant. This finding is in have been reported in the USA and Ontario, Canada accordance with a study in the USA that reported that (14,31). A Cochrane review concluded that healthcare dentists who received training had a significantly more professionals who were trained were better in offering positive attitude towards tobacco cessation counselling tobacco cessation interventions (32). Good practice was (14). This indicates that training in tobacco cessation observed more among nonusers of tobacco as compared programmes has the potential to increase awareness to current tobacco users but the difference was not among dentists and make them more involved in the significant. This is in accordance with other studies provision of tobacco cessation counselling to their (24,33,34). By comparison, a study in Ontario showed that patients. Dentists who have never consumed tobacco had former smokers and never smokers were significantly a significantly higher good attitude score than those that more likely to have good practice than current smokers had ever been tobacco users. This finding is consistent have (31). This indicates increased awareness among with studies in Kuwait, Kenya and Finland that reported nonsmokers about the adverse effects of tobacco use on a negative attitude towards patient counselling about oral as well as general health. Thus, effectiveness of any smoking among healthcare professionals who smoke intervention may increase if the counselling is done by compared to those who are nonsmokers (24–26). This dentists who do not consume tobacco. provides insight into the fact that dentists hold strong Dentists with a good attitude towards the domains beliefs that they serve as a role model to their patients Ask, Advise, Assess, Assist and Arrange were significantly (11,12). more likely to have good practice in all the domains In the present survey, actual involvement of the towards the provision of tobacco cessation interventions. dentists in tobacco cessation interventions were reported This was similar to previous studies (22,25,35,36). This as follows: Ask (39.6%), Advise (68.4%), Assess (24%), indicates that efforts to improve the attitude of dentists Assist (19.2%) and Arrange (18.8%). This is consistent towards tobacco cessation interventions would increase with previous studies (22,27–30). Assisting, assessing the actual involvement of the dentists in provision of and arranging were the least-often-delivered services by such interventions to their patients.

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This study had some limitations. The cross-sectional titude towards tobacco cessation advice were nationality, design of the study allowed us only to provide a snapshot level of education, total duration of practice and tobacco of the situation. However, the study assessed the consumption of the dentists. Good attitude of the den- attitude and practice of the dentists towards tobacco tists towards tobacco cessation advice was significantly cessation advice, which were less likely to change over associated with good practice of the dentists in provision time. Dentists were recruited by convenience sampling, of advice. which may have contributed to selection bias. This limits the generalization of the results as the sample may not Recommendations have been truly representative of the wider population. We recommend training dentists at the individual and However, participants were recruited from a large community level on the methods and techniques of to- geographical area and most dentists were able to respond bacco cessation strategies. Training programmes should to the survey. be planned and implemented by healthcare management teams and concerned authorities for all dental profes- Conclusion sionals at regular intervals. Skill-based approaches may The majority of the surveyed dentists had a good atti- be required to enhance the confidence and competence tude towards provision of tobacco cessation services. of the dentists in offering tobacco cessation intervention. However, despite this encouraging attitude, few dentists Moreover, it would be advisable to arrange cessation in- provided tobacco cessation intervention to their patients. tervention for healthcare workers, including dentists, as Factors that were significantly associated with a good at- they are role models, especially to adolescents.

Funding: None. Competing interests: None declared.

Sevrage tabagique : attitude et pratique des dentistes au nord des Émirats arabes unis Résumé Contexte : Le tabagisme a de profondes répercussions sur la santé au niveau mondial. Les dentistes qui ont une attitude favorable au regard du conseil en matière de sevrage tabagique se montrent peu impliqués dans la pratique. Objectif : Évaluer l’attitude et la pratique des dentistes du nord des Émirats arabes unis au regard de la dispensation de conseils en vue du sevrage tabagique. Méthodes : Une étude basée sur un questionnaire et administrée par un enquêteur a été menée en 2015 auprès de 250 dentistes exerçant dans le nord des Émirats. Des analyses statistiques ont été effectuées à l’aide du test du χ2 et de l’analyse multivariée. Résultats : Environ 88 % des dentistes affichaient une attitude positive mais seuls 37 % faisaient preuve d’une bonne pratique de dispensation de conseils en faveur du sevrage tabagique auprès de leurs patients. La nationalité, le niveau d’éducation, la durée totale de l’exercice et le tabagisme personnel étaient associés de façon significative à l’attitude adoptée face au sevrage tabagique. Chez les non-fumeurs, l’odds ratio pour l’attitude favorable était de 3,12 (IC à 95 % : 1,18- 8,20). Conclusion : La plupart des dentistes interrogés affichaient une attitude positive quant à la dispensation de conseils en matière de sevrage tabagique, alors que la pratique observée était comparativement insuffisante. Nous recommandons de proposer une formation aux dentistes au regard des méthodes et techniques du sevrage tabagique.

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اإلقالععن استهالك التبغ: اجتاهات وممارسات أطباء األسنان يف اإلمارات الشاملية من دولة اإلمارات العربية املتحدة دانافانتي بانجريا، حممد تاكانا، جاكوماري موتابيل ميالل اخلالصة ينطوي اخللفية:استهالك التبغ عىل آثار صحية وخيمة عىل املستوى العاملي. ويف املامرسة العملية، يعد تدخل أطباء األسنان الذين لدهيم مواقف إجيابية إزاء تقديم املشورة بشأن اإلقالع عن تعاطي التبغ ًتدخال ًضئيال. تقييم اهلدف:اجتاهات وممارسات أطباء األسنان يف اإلمارات الشاملية من دولة اإلمارات العربية املتحدة إزاء تقديم املشورة بشأن اإلقالع عن تعاطي التبغ. طرق البحث: ُأجريت دراسة قائمة عىل استبيان أداره حماورون ملا جمموعه 250 ً طبيبا ًلطب ممارسااألسنان يف اإلمارات الشاملية من دولة اإلمارات يف عام 2015. ُوأجري حتليل إحصائي باستخدام اختبار املقارنة بني متوسطني والتحليل املتعدد املتغريات. النتائج: أظهر نحو 88% من أطباء األسنان سلوكيات جيدة يف حني تب ّني أن 37% فقط منهم يعتمدون ممارسة جيدة تتعلق بإسداء املشورة ملرضاهم بشأن اإلقالع عن استهالك التبغ. وتب ّنيوجود ارتباط وثيق بني اجلنسية ومستوى التعليم واملدة الكلية ملامرسة املهنة واستهالك التبغ عىل املستوى الشخيص بموقف الطبيب إزاء اإلقالع عن استهالك التبغ. وجاءت نسبة احتامل املواقف اجليدة يف أوساط األطباء غري املتعاطني للتبغ 3.12 )فاصل ثقة بنسبة %95: 8.20-1.18(. االستنتاج: أبدى معظم أطباء األسنان الذين خضعوا للمسح سلوكيات جيدة إزاء إسداء املشورة بشأن اإلقالع عن استهالك التبغ، وإن لوحظت ممارسات أقل من املنتظر ً. نسبياونويص بتدريب أطباء األسنان عىل طرق وأساليب اإلقالع عن استهالك التبغ.

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15. Li KW, Chao DV. Current practices, attitudes, and perceived barriers for treating smokers by Hong Kong dentists. Hong Kong Med J. 2014 Apr;20(2):94–101. PMID:24625385 16. Al-Moberiek A. Al-Qhatani D, Al-Otibi O, Al-Qhatni M. Dentists’ Attitudes and practice towards smoking cessation and interven- tion in Riyadh, Saudi Arabia. J Dent. 2013;1(1):1–7. http://dx.doi.org/10.12974/2311-8695.2013.01.01.1 17. Vanka A, Roshan NM, Ravi KS, Shashikiran ND. A review of tobacco cessation services for youth in the dental clinic. J Indian Soc Pedod Prev Dent. 2009 Apr–Jun;27(2):78–84. http://dx.doi.org/10.4103/0970-4388.55326 PMID:19736499 18. Oberoi SS, Sharma G, Nagpal A, Oberoi A. Tobacco cessation in India: how can oral health professionals contribute? Asian Pac J Cancer Prev. 2014;15(5):2383–91. http://dx.doi.org/10.7314/APJCP.2014.15.5.2383 PMID:24716989 19. Mohanty VR, Rajesh GR, Aruna DS. Role of dental institutions in tobacco cessation in India: current status and future prospects. Asian Pac J Cancer Prev. 2013;14(4):2673–80. http://dx.doi.org/10.7314/APJCP.2013.14.4.2673 PMID:23725194 20. FDI World Dental Federation, World Health Organization. Tobacco or oral health: an advocacy guide for oral health profes- sionals. Lowestoft, UK: FDI World Dental Federation; 2005 (www.who.int/oral_health/media/orh_tobacco_fdi_book.pdf?ua=1, accessed 18 December 2017). 21. Razavi SM, Zolfaghari B, Doost ME, Tahani B. Attitude and practices among dentists and senior dental students in iran toward tobacco cessation as an effort to prevent oral cancer. Asian Pac J Cancer Prev. 2015;16(1):333–8. http://dx.doi.org/10.7314/AP- JCP.2015.16.1.333 PMID:25640375 22. Prakash P, Belek MG, Grimes B, Silverstein S, Meckstroth R, Heckman B, et al. Dentists’ attitudes, behaviors, and barriers related to tobacco-use cessation in the dental setting. J Public Health Dent. 2013 Spring;73(2):94–102. http://dx.doi.org/10.1111/j.1752- 7325.2012.00347.x PMID:22731618 23. Binnal A, Rajesh G, Denny C, Ahmed J. Insights into the tobacco cessation scenario among dental graduates: an Indian perspec- tive. Asian Pac J Cancer Prev. 2012;13(6):2611–7. http://dx.doi.org/10.7314/APJCP.2012.13.6.2611 PMID:22938429 24. Waheedi M, Al-Tmimy AM, Enlund H. Preparedness for the smoking cessation role among health sciences students in Kuwait. Med Princ Pract. 2011;20(3):237–43. http://dx.doi.org/10.1159/000321273 PMID:21454993 25. Watiri G. Health care providers knowledge, attitude and practice of smoking cessation interventions in public health facilities in Kiambu County, Kenya [thesis]. University of Nairobi; 2014. 26. Toriola A, Myllykangas M, Barengo N. Smoking behavior and attitudes regarding the role of physicians in tobacco control among medical students in Kuopio, Finland, in 2006. CVD Prev Control. 2008;3(2):53–60. http://dx.doi.org/10.1016/j.pre- con.2007.10.001 27. Uti OG, Sofola OO. Smoking cessation counseling in dentistry: attitudes of Nigerian dentists and dental students. J Dent Educ. 2011 Mar;75(3):406–12. PMID:21368264 28. Chandrashekar J, Manjunath BC, Unnikrishnan M. Addressing tobacco control in dental practice: a survey of dentists’ knowl- edge, attitudes and behaviours in India. Oral Health Prev Dent. 2011;9(3):243–9. PMID:22068180 29. Rajasundaram P, Sequeira PS, Jain J. Perceptions of dental students in India about smoking cessation counseling. J Dent Educ. 2011 Dec;75(12):1603–10. PMID:22184600 30. Brothwell D, Gelskey S. Tobacco use cessation services provided by dentists and dental hygienists in Manitoba: part 1. Influence of practitioner demographics and psychosocial factors. J Can Dent Assoc. 2008 Dec;74(10):905. PMID:19126359 31. Babayan A, Dubray J, Haji F, Schwartz R. Provision of smoking cessation by Ontario dental health professionals. Ontario Tobacco Research Unit; 2012:1–59. 32. Ebbert J, Montori VM, Erwin PJ, Stead LF. Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD004306. http://dx.doi.org/10.1002/14651858.CD004306.pub4 PMID:21328266 33. Ferrante M, Saulle R, Ledda C, Pappalardo R, Fallico R, La Torre G et al. Prevalence of smoking habits, attitudes, knowledge and beliefs among health professional school students: a cross-sectional study. Ann Ist Super Sanita. 2013;49(2):143–9. http://dx.doi. org/10.4415/ANN_13_02_06 PMID:23771259 34. Asfar T, Al-Ali R, Ward KD, Vander Weg MW, Maziak W. Are primary health care providers prepared to implement an anti-smok- ing program in Syria? Patient Educ Couns. 2011 Nov;85(2):201–5. http://dx.doi.org/10.1016/j.pec.2010.11.011 PMID:21168300 35. Abdullah AS, Rahman AS, Suen CW, Wing LS, Ling LW, Mei LY, et al. Investigation of Hong Kong doctors’ current knowledge, beliefs, attitudes, confidence and practices: implications for the treatment of tobacco dependency. J Chin Med Assoc. 2006 Oct;69(10):461–71. http://dx.doi.org/10.1016/S1726-4901(09)70310-7 PMID:17098670 36. Meredith LS, Yano EM, Hickey SC, Sherman SE. Primary care provider attitudes are associated with smoking cessation coun- seling and referral. Med Care. 2005 Sep;43(9):929–34. http://dx.doi.org/10.1097/01.mlr.0000173566.01877.ac PMID:16116358

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Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region Hedieh Mehrtash 1, Richard Laing 1,2 and Veronika J. Wirtz 1

1Department of Global Health, School of Public Health, Boston University, Boston, United States of America. (Correspondence to: Hedieh Mehrtash: [email protected]). 2School of Public Health, Faculty of Community and Health Sciences, University of Western Cape, Cape Town, South Africa. Abstract Background: Adequate access to essential medicines for cardiovascular disease is necessary to address the high cardiovascular disease burden in countries of the Eastern Mediterranean Region of the World Health Organization (WHO). Aims: This study compared the cardiovascular disease medicines included in the WHO Model Essential Medicines List with those in the national essential medicines lists of 19 countries of the Region. Methods: Data were extracted on the number of cardiovascular medicines and dosage forms in the national lists and compared with those on the WHO Model List (24 medicines in total and 48 dosage forms). Factors associated with the number of essential cardiovascular medicines on the national lists (burden of cardiovascular diseases and health expenditure per capita) were assessed. The number of medicines from 6 therapeutic groups of cardiovascular medicines listed in the national lists but not in the core WHO Model List were evaluated. Results: Countries with the lowest percentage of medicines from the WHO Model List out of the total cardiovascular disease medicines in the national lists were Djibouti (21%), Tunisia (22%), Saudi Arabia and Iraq (31% each), and Bahrain and Libya (32% each). The most common medicine dosage form in the national lists was tablets while some that needed oral liquid forms were not listed by any country. Tunisia (8%), Jordan (14%), Bahrain and Saudi Arabia (15% each) had the lowest alignment of dosage forms from the WHO model list. Conclusions: Countries should improve the selection of essential medicines for cardiovascular diseases to promote access to therapy. Keywords: Drugs, Essential, Cardiovascular diseases; World Health Organization, Eastern Mediterranean region Citation: Mehrtash H; Laing R; Wirtz VJ. Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region. East Mediterr Health J. 2018;24(5):427-434. https://doi.org/10.26719/2018.24.5.427 Received: 29/06/15; accepted: 05/03/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction Essential medicines are intended to be available in the context of functioning national health systems in In 2011, the United Nations (UN) launched a global adequate amounts, in the appropriate dosage forms, with campaign to reduce deaths from noncommunicable assured quality and adequate information, and at a price diseases (NCDs) (1). The summit declaration highlighted the individual and the community can afford” (4). that about 9 million deaths caused by NCDs occur before the age of 60 years, with nearly 80% of those in low- and The WHO Model Essential Medicines List plays a middle-income countries. To tackle the burden of NCDs, key role in defining the criteria for medicines, including the UN recommended strengthening national policies public-health relevance, efficacy, safety and cost– and health systems through a multisectoral approach to effectiveness, and it is an important tool for promoting implement policies and plans, taking into account the health equity (5). The list is a guide for countries in World Health Organization (WHO) global strategy for developing their national essential medicine lists, the prevention and control of NCDs (2). and most countries around the world have developed WHO released a briefing document following their own lists in order to best meet the needs of their the 2011 UN meeting which stated that the burden of communities (6). disease related to NCDs could not be reduced without In order to achieve good health outcomes, access to equitable access to essential medicines (3). While primary medicines needs to be combined with the provision of prevention of NCDs is a key objective, treatment of quality care and services. One critical step to achieving existing cases (secondary prevention) is also needed. better access to medicines at the national level is defining Medicines are an essential component of the treatment those medicines required to tackle the burden of NCDs of NCDs such as cardiovascular diseases, diabetes, in the country. The WHO Model List can help guide chronic obstructive pulmonary disease including asthma, countries in their priority setting exercise. many cancers (including palliative pain treatment) and The Eastern Mediterranean Region (EMR) of WHO depression (3). has one of the highest burdens of disease, and NCDs have WHO defines essential medicines as, “medicines that been among the top causes of death since 1997 (7). It is satisfy the priority health care needs of the population. estimated that 54% of deaths from NCDs in the Region are

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caused by cardiovascular diseases (8). Deaths attributed example of one out of a class of medicines are denoted by a to cardiovascular diseases (of total deaths) range from 512 square box symbol (11). Any other medicine from the same per 100 000 in Afghanistan to 157 in Qatar (9). pharmacological class, which has similar clinical effects, The objective of this study was to compare the WHO can replace medicines with this symbol with a medicine Model Essential Medicines List for cardiovascular of the appropriate anatomical therapeutic classification disease medicines with available national essential code (10). These can be substituted by medicines that medicines lists of EMR countries. Three countries were are recommended in the WHO Technical Series Reports omitted because their lists were unavailable online. The (http://www.who.int/biologicals/technical_report_series/ study aimed to identify differences between countries en/). of different economic and developmental status, and WHO indicates substituted medicines for the highlight the need for EMR countries to prioritize the following 6 groups: thiazides and sulfonamides selection of medicines for NCDs given their great burden (diuretics), selective beta blockers and alpha blockers, in the Region. dihydropyridil derivatives, angiotensin-converting enzyme inhibitors, HMG CoA reductase inhibitors, and Methods organic nitrates (vasodilators). All 22 EMR countries were eligible for inclusion, 19 of A matrix was used to identify those countries with which had a national essential medicines lists available either no medicine listed in each of the 6 therapeutic online. The countries were classified according to groups or more than 2. No medicine listed would indicate the World Bank income levels (Table 1). We used the a gap in the selection, while more than 2 would indicate most recent WHO Model Essential Medicines List that selection is not restricted to the most essential at the time of our study (2015) (10) and the national medicines. essential medicines lists available online. The section Statistical analysis on cardiovascular medicines (section 12) of the WHO Univariable linear regression analysis was used to Model Essential Medicines List has 24 medicines in its examine the associations between continuous variables core list and 4 medicines (amiodarone, streptokinase, dopamine and sodium nitroprusside) as complementary. (burden of cardiovascular disease and overall health Complementary essential medicines are for diseases for expenditure per capita of the countries) and the total which specialized diagnostic or monitoring facilities, number of essential medicines for cardiovascular and/or specialist medical care, and/or specialist training medicines on the national lists of the studied countries. are needed. Core essential medicines satisfy the basic The burden of disease for cardiovascular disease (age- needs of a health care system, and consist of safe and standardized mortality rates) was obtained for each cost-effective medicines for priority conditions. country from the WHO Global Health Observatory (11). World Bank data on health expenditure per capita for the Cardiovascular medicines and dosage forms countries were used (12). We extracted data on the following for each country: SAS software was used for all statistical analyses. A • number of cardiovascular medicines in the national P-value ≤ 0.05 was considered statistically significant. list that are listed in the WHO Model List (24 Ethics statement medicines in total). This study did not need Ethics Review Board approval/ • total number of cardiovascular medicines listed in review as it used publicly available data which did not the national list. The percentage of WHO medicines involve people or animals. out of the total number of cardiovascular medicines listed in the national list was calculated. Results • number of WHO cardiovascular medicine dosage Table 1 shows the national essential medicines lists forms (48 product forms) listed in the national list. available in EMR countries by income group. Nineteen • total number of cardiovascular medicine dosage countries had national list or formulary guides accessible forms listed in the national lists. The percentage of online, which included information on the medicine, or WHO cardiovascular medicine dosage forms out the medicine and the dosage form. For 3 countries (Kuwait, of the total number of cardiovascular dosage forms Qatar, United Arab Emirates), no national essential listed in the national list was calculated. medicines list was publicly available electronically (Table The dosage form is relevant because solid forms 1). None of the 19 countries only included medicines from of medicines (e.g. tablets, pills, capsules) may not be the WHO Model List. appropriate and other forms (e.g. syrups, injections, Comparison of medicines on the WHO Model List sublingual dosage forms) may be needed to ensure and national lists treatment access for patients of different age groups (e.g. the elderly) or different disease severities. Table 2 shows the number of medicines from the WHO Model List for cardiovascular diseases included in the Medicines not listed in the WHO Model List national lists for the 19 EMR countries. Bahrain had all Medicines for which the WHO Model List selects an 24 medicines in the WHO Model List in their national

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Table 1 National essential medicines lists (NEML) available in countries of the Eastern Mediterranean region by income group Low income Lower-middle income Upper-middle income High income NEML medicine + product • Afghanistan (2014) • Djibouti (2007) • Islamic Republic of Iran • Saudi Arabia (2012) presentation listed • Somalia (2003) • Egypt (2012) (2014) • Oman (2009) • Morocco (2012) • Iraq (2010) • Pakistan (2007) • Lebanon (2014) • Sudan (2014) • Libya (2005) • West Bank & Gaza (2012) • Yemen (2009) • Syrian Arab Republic (2014) NEML derived from • Jordan (2011) • Bahrain (2009) formulary guide • Tunisia (2008) No NEML available online – – – • United Arab Emirates • Qatar • Kuwait

In brackets is the year of the edition of the NEML that was used for analysis in this study.

Table 2 Cardiovascular medicines in the national essential disease medicines in its national list (74 medicines), medicines lists (NEML) from the WHO Model Essential followed by Saudi Arabia with 72 medicines, Libya Medicines List and in total in Eastern Mediterranean countries with 66, Iraq with 64, and Tunisia and Djibouti each Country Cardiovascular medicines % of WHO with 63 medicines listed. The countries with the lowest in the NEML cardiovascular percentage of medicines from the WHO Model List out No. from the Total no. medicines in of the total cardiovascular medicines in the national lists the NEML WHO Model were Djibouti (21%), Tunisia (22%), Saudi Arabia and Iraq List (n = 24) (each 31%), and Bahrain and Libya (each 32%). Bahrain 24 74 32 Comparison of dosage forms on the WHO Model Sudan 23 23 100 List and national lists Oman 22 62 35 The WHO Model List gives 48 dosages forms for the Saudi Arabia 22 72 31 cardiovascular medicines listed. Table 3 shows the Libya 21 66 32 dosage forms included in the national lists of the EMR Pakistan 20 24 83 countries. The average number of medicine dosage Islamic Republic 20 58 forms for cardiovascular diseases from the WHO Model of Iran 34 List was 19. Sudan with 33 dosage forms included the Palestine 20 32 63 highest number of WHO dosage forms in its national list, Iraq 20 64 31 Pakistan had 32 WHO dosage forms, Islamic Republic of Syrian Arab Iran had 25, and Lebanon and Iraq each included 24 WHO 20 28 Republic 71 dosage forms. Somalia with 7 WHO dosage forms, Yemen Lebanon 19 20 95 with 8, Djibouti with 10 and Tunisia with 11 included the fewest WHO dosage forms in their national lists. Jordan 19 42 45 Egypt 18 31 58 The countries with the lowest percentage of dosage forms from the WHO Model List out of the total dosage Morocco 16 34 47 forms for cardiovascular diseases medicines in the Afghanistan 15 16 94 national lists were Tunisia (8%), Jordan (14%), and Bahrain Tunisia 14 63 22 and Saudi Arabia (each 15%). Yemen 12 20 60 Factors associated with the selection of essential Djibouti 9 63 14 medicines Somalia 9 10 90 Table 4 shows the association between the burden of cardiovascular disease and per capita health expenditure list, Sudan had 23, Oman and Saudi Arabia each had and the number of cardiovascular medicines in a national 22, and Libya had 21. Dijbouti and Somalia, each with 9 list. Per capita health expenditure was significantly medicines, and Yemen with 12 had the fewest number of associated with the number of medicines on the national list (beta = 0.00456, P = 0.00463). The data suggest that the medicines for cardiovascular diseases from the WHO an increase in health expenditure per capita of US$ 100 Model List. would on average result in the addition of 5 medicines for Many countries had considerably more medicines for cardiovascular diseases on the national list. The relative cardiovascular diseases in their national lists than the burden of cardiovascular diseases, based on deaths from WHO Model List. Bahrain had the most cardiovascular cardiovascular diseases, was not associated with the total

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number of essential medicines for cardiovascular disease than the 1 WHO-recommended model list medicine listed on the national list (beta = –0.0352, P = 0.571). for all 6 therapeutic groups in their national lists. Pakistan Complementary groups of medicines and Sudan were most aligned with only 1 medicine per therapeutic category. Yemen, Somalia, Afghanistan and Table 5 shows the number of medicines from the 6 Djibouti had the biggest gaps in their national lists with therapeutic groups of cardiovascular medicines listed no medicines listed for some therapeutic groups. in the core WHO Model List and others that are not on the WHO Model List but which are in the national Discussion essential medicine lists of the different countries. Most Our results indicate that there is room for improvement of the countries listed more than 2 medicines from each in the selection of essential medicines for cardiovascular therapeutic group in their national lists, one of which diseases in EMR countries. Several countries (e.g. Yemen, was usually a medicine on the WHO Model List. Other Somalia, Afghanistan and Djibouti) have no medicines countries such as Bahrain, Iraq, Islamic Republic of Iran, listed in certain therapeutic areas which are necessary Jordan, Saudi Arabia and Syrian Arab Republic had more to treat cardiovascular diseases. Moreover, in some other countries such as Tunisia and Saudi Arabia, the percentage of cardiovascular medicines and corresponding dosage Table 3 Cardiovascular medicines dosage forms in the national forms from the WHO Model List in their national lists essential medicines lists (NEML) from the WHO Model Essential Medicines List and in total in Eastern Mediterranean countries is low, which could limit access for certain populations. Country Dosage forms in the NEML % of WHO Previous studies that compared national lists for cancer and diabetes treatment in countries also found several No. from the Total no. dosage forms WHO Model in the NEML areas needing improvement (13–15). List (n = 48) A higher burden of cardiovascular diseases was not Sudan 33 67 49 associated with a more essential cardiovascular disease Pakistan 32 79 41 medicines in the national list, which suggests a more Islamic Republic rational selection procedure is needed in EMR countries 25 139 of Iran 18 (Table 4). Each country should develop its national list, Lebanon 24 37 65 not only according to the WHO Model List, but taking account of the country’s specific political, social, financial, Iraq 24 128 19 economic and epidemiological context. The listing of Syrian Arab 23 37 Republic 62 medicines should be in line with the burden of disease (16). National essential medicines lists are the foundation Oman 22 105 21 to ensure public health delivery of essential medicines, Libya 21 99 21 including consistent supply and management (17). Egypt 20 73 27 In the past few years, EMR countries have experienced Saudi Arabia 20 130 15 a growing number of conflicts. These include Afghanistan, Bahrain 19 128 15 Iraq, Somalia, Yemen, Syrian Arab Republic and Libya. Morocco 19 73 26 After communicable diseases, cardiovascular diseases Palestine 19 46 41 are the second most common cause of death in the Syrian Jordan 17 124 14 Arab Republic (28%), Yemen (21%) and Libya (43%) (11). Afghanistan 15 21 71 Countries with very limited resources need to ensure that the selection of medicines is guided by the disease Tunisia 11 140 8 burden and standard treatment guidelines, among other Djibouti 10 19 53 factors (18). Yemen 8 19 42 Somalia had the lowest number of cardiovascular Somalia 7 12 58 medicines from the WHO Model List and also the

Table 4 Association between relative burden of cardiovascular diseases and health expenditure per capita, and the total number of essential cardiovascular disease medicines in national essential medicines lists Factor Regression coefficient P-value* (95% confidence interval) Health expenditure (US$) Per capita– intercept 15.9 (16.0 to 42.3) 0.00027 Per capita 0.00456 (0.0164 to 0.0749) 0.00463 Cardiovascular diseases mortality Age-standardized death rate per 100 000 population, both sexes, 2012 – intercept 53.9 (11.6 to 96.3) 0.0159 Age-standardized death rate per 100 000 population, both sexes, 2012 –0.0352 (–0.164 to 0.0939) 0.571

*Significant at P ≤ 0.05.

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lowest number in total cardiovascular medicines in its help countries, both in conflict and with limited income, national list. However, the list we found was old and did use their resources to procure and make available the not include a specific cardiovascular medicine section. most appropriate treatments in relation to their burden There is a need therefore to update the current list. In of disease (17). the current edition of Somalia’s national health strategic Jordan and Tunisia selected many medicines out of plan, the country’s service provision ranked “less than the same therapeutic group, including ACE inhibitors, adequate” (19) and the supply of essential medicines dihydropyridil derivatives and HMG CoA reductase to the country relies on diseases kits provided by the inhibitors. For better efficiency, a maximum of 2 of UN and nongovernmental organizations (20). Capacity each class should be selected. WHO has highlighted building is a key component of WHO’s intervention for that “careful selection of a limited range of essential essential medicines (20). Updating the national essential medicines” will improve the quality of care, management medicines list and addressing gaps in the selection of of medicines and cost-effective use of resources (18). cardiovascular medicines should form part of Somalia’s Jordan’s national formulary guide (national list) includes health systems strengthening activities. medicines specified by international nonproprietary Although the current Syrian crisis has limited many names or specific brands of generic medicines. This of the country’s public health activities, WHO prioritized influences the public sector market to procure from a the provision of essential medicines for primary care and particular manufacturer (24). It is recommended that chronic illness, and the country’s 2014 national essential Jordan follows best practices to procure medicines by medicines list incorporated priority medicines, including generic names and specify quality standards, not specific those for cardiovascular diseases (21,22). brands, for its products (24). Collective action to deliver health services in Medicines that had been on the WHO Model List countries affected by conflict is needed, which includes for longer (e.g. digoxin, isosorbide dinitrate and glyceryl the provision of essential medicines, in order to increase trinitrate) were more likely to be in the national lists, the resilience of the health systems in the face of including medicines that may have been removed from emergencies, and ensure effective public health responses the Model List. The April 2015 WHO Model Essential during crises (23). A national essential medicines list can Medicines List was used for comparison with the national

Table 5 Cardiovascular medicines in the national essential medicines listsa for the complementary categories in the WHO Model Essential Medicines List in Eastern Mediterranean Region countries HMG CoA Selective Dihydropyridil Country Diuretics Vasodilators ACE inhibitors reductase alpha and beta derivatives inhibitors blockers No. No. No. No. No. No. Afghanistan 1 2 2 0 0 1 Bahrain 2 2 3 4 4 2 Djibouti 1 2 1 1 0 0 Egypt 1 2 3 3 1 1 Iran (IR) 3 2 2 3 2 2 Iraq 3 3 3 4 3 3 Jordan 4 3 2 6 4 2 Lebanon 1 2 1 3 1 0 Libya 2 2 3 2 2 1 Morocco 3 2 1 3 1 2 Oman 3 2 2 3 3 1 Pakistan 1 2 2 1 1 0 Palestine 1 2 3 1 1 2 Saudi Arabia 3 2 2 5 2 3 Somalia 0 0 0 0 0 0 Sudan 1 2 2 1 1 1 Syrian Arab Republic 3 3 3 7 4 3 Tunisia 5 2 1 6 4 2 Yemen 1 0 2 2 0 0

aThese include both medicines in the WHO Model list and medicines that are not. Red: potential therapeutic gap; Green: efficient selection; Orange: potential duplication in selection. ACE = angiotensin-converting-enzyme; HMG CoA = 3-hydroxy-3-methyl-glutaryl-coenzyme A.

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essential medicines lists while most of the national lists formulary guide. It is unclear, therefore, whether they were last updated and notified to WHO 3–6 years ago. had used the WHO Model List or formulary guide to Countries need to update their lists every 2 years as is select their medicines. done with the WHO Model List (18). However, there The relatively small sample size (19 countries) could are some medicines, such as sodium nitroprossuide, have affected the analyses on the association between that have been on the WHO Model List for over 25 per capita health expenditure and burden of disease and years but only 6 countries had this medicine in their the number of essential cardiovascular medicines; the national list. Even though there is strong evidence about statistical power might have been too low to detect small the effectiveness of sodium nitroprossuide, countries differences. may avoid its use because of its potential toxicity and Finally, we did not look at the procedures for treatment management compared with other medicines. procurement and reimbursement which would highlight Non-solid dosage forms, such as liquids, suspensions, the actual availability of medicines. As previously noted, suppositories and injection forms of medicines, are national lists serve as the first step to achieving access to important for certain patient groups (e.g. geriatric or medicines (26). paediatric patients) (25). Children and the elderly may have difficulty in swallowing solid dosage forms for oral Conclusion use. In both patient groups, small tablets or liquid dosage forms are more appropriate. We found that the most EMR countries need to keep up-to-date with the WHO frequently listed medicine dosage forms in the national Model List which is revised every 2 years, so that they lists were tablet form. Furosemide oral liquid solution can keep track of the addition and deletion of medicines and hydrochlorothiazide oral liquid solution 50 mg were on the Model List and link their disease burden to the medicine selection process (26). Countries that have not not listed by any country as a form of drug intake. This provided WHO with their national lists need to make creates access barriers for patient groups who need to them publicly available to be transparent about selection take the required medicines in a liquid form. of medicines and increase accountability (18). In addition, Limitations a pricing and availability study, similar to a previous study We did not examine the budget allocation for medicines in the EMR, would complement our study and provide and standard treatment guidelines. The WHO formulary the health system perspective on access to medicines (10). guide was last updated in 2008 (19). There is a disparity It is important for countries, especially those with between the medicines listed for cardiovascular diseases limited resources, to select medicines efficiently. This in the formulary guide compared with the WHO Model can be done by reducing the number of medicines in List that is updated frequently. For 3 of the countries therapeutic groups and limiting numerous dosage (Bahrain, Jordan, Tunisia) we retrieved the cardiovascular forms, and by linking public sector procurement with the essential medicines selection from their national national essential medicines list.

Funding: None. Competing interests: None declared.

Analyse comparative des médicaments essentiels pour le traitement des maladies cardio-vasculaires dans les pays de la Région OMS de la Méditerranée orientale

Résumé Contexte : Un accès suffisant aux médicaments essentiels pour le traitement des maladies cardio-vasculaires est nécessaire afin de s’attaquer au problème de la charge de morbidité élevée due à ce type de maladies dans la Région OMS de la Méditerranée orientale. Objectifs : La présente étude a comparé les médicaments pour le traitement des maladies cardio-vasculaires de la liste modèle OMS des médicaments essentiels avec ceux des listes nationales de médicaments essentiels de 19 pays de la Région de la Méditerranée orientale. Méthodes : Des données ont été extraites sur le nombre de médicaments cardio-vasculaires et les formes galéniques inclus aux listes nationales, et ces données ont été comparées avec celles de la liste modèle OMS (24 médicaments au total et 48 formes galéniques). Les facteurs associés au nombre de médicaments essentiels pour le traitement des maladies cardio-vasculaires inclus dans les listes nationales (charge des maladies cardio-vasculaires et dépenses de santé par habitant) ont été étudiés. Le nombre de médicaments issus de six groupes thérapeutiques de médicaments cardio- vasculaires et inclus aux listes nationales, mais absents de la liste modèle OMS principale, a été évalué. Résultats : Djibouti (21 %), la Tunisie (22 %), l’Arabie saoudite et l’Iraq (31 % chacun), et Bahreïn et la Libye (32 % chacun) étaient les pays qui avaient le plus faible pourcentage de médicaments figurant sur la liste modèle de l’OMS par rapport au nombre total de médicaments cardio-vasculaires sur leurs listes nationales. La forme galénique la plus répandue sur les

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listes nationales était les comprimés, tandis que certains liquides administrables par voie orale n’étaient listés par aucun pays. La Tunisie (8 %), la Jordanie (14 %), Bahreïn et l’Arabie saoudite (15 % chacun) étaient les pays qui alignaient le moins leurs formes galéniques sur la liste modèle de l’OMS. Conclusions : Les pays peuvent améliorer leur sélection de médicaments cardio-vasculaires essentiels afin de promouvoir l’accès au traitement.

حتليل مقارن لألدوية األساسية لألمراض الوعائية القلبية يف بلدان إقليم رشق املتوسط ملنظمة الصحة العاملية هدية مهرتاش، ريتشارد الينج، فريونيكا ورتز اخلالصة يمثل اخللفية:الوصول إىل األدوية األساسية لألمراض الوعائية القلبية بصورة كافية رضورة للتصدي الرتفاع عبء األمراض الوعائية القلبية يف بلدان إقليم رشق املتوسط ملنظمة الصحة العاملية. األهداف:عمدت هذه الدراسة إىل مقارنة أدوية األمراض الوعائية القلبية املدرجة يف قائمة منظمة الصحة العاملية النموذجية لألدوية األساسية وقائمة األدوية األساسية الوطنية ملا جمموعه 19 ً بلدامن بلدان إقليم رشق املتوسط. طرق البحث: ُقت اشتبيانات متعلقة بعدد األدوية الوعائية القلبية وأشكال اجلرعات يف القوائم الوطنية ومقارنتها بتلك الواردة يف قائمة منظمة الصحة العاملية النموذجية )ما جمموعه 24 دواء و48 ًمن شكالأشكال اجلرعات(. وتم تقييم العوامل املرتبطة بعدد األدوية األساسية لألمراض الوعائية القلبية والواردة يف القوائم الوطنية )عبء داء السكري والنفقات الصحية للفرد(. وتم تقييم عدد األدوية من 6جمموعات عالجية من األدوية الوعائية القلبية املدرجة يف القوائم الوطنية ولكنها ليست يف قائمة منظمة الصحة العاملية النموذجية األساسية. كانت النتائج:البلدان التي لدهيا أدنى نسبة من األدوية املوصوفة يف القائمة النموذجية ملنظمة الصحة العاملية من بني جمموع أدوية املرض القلبي الوعائي املوجودة يف قوائمها الوطنية هي جيبويت )21%(، وتونس )22%(، واململكة العربية السعودية والعراق ) %31 لكل منهام(، والبحرين وليبيا )32% لكل منهام(. ومثلت األقراص أكثر أشكال جرعات األدوية ًيف شيوعاالقوائم الوطنية، بينام مل يدرج أي بلد بعض السوائل الفموية الالزمة يف قوائمها. وكانت لدى تونس )8%(، واألردن )14%(، والبحرين واململكة العربية السعودية )15% لكل منهام( أدنى أشكال اجلرعات املتوافقة مع القائمة النموذجية ملنظمة الصحة العاملية. االستنتاجات:يمكن للبلدان حتسني اختيار األدوية األساسية لألمراض الوعائية القلبية لتحسني احلصول عىل العالج. References 1. General Assembly of the United Nations. President of the 65th Session. High-level meeting on non-communicable diseases (www.un.org/en/ga/president/65/issues/ncdiseases.shtml, accessed 30 January 2018). 2. UN High-level meeting on NCDs (New York, 19–20 September 2011). Summary report of the discussions at the round tables (www.who.int/nmh/events/moscow_ncds_2011/round_tables_summary.pdf?ua=1, accessed 30 January 2018). 3. Briefing document. Essential medicines for non-communicable diseases (NCDs). World Health Organization. April 2011 www.( who.int/medicines/areas/policy/access_noncommunicable/NCDbriefingdocument.pdf?ua=1, accessed 30 January 2018). 4. World Health Organization. Health topics. Essential medicines (www.who.int/topics/essential_medicines/en/, accessed 30 January 2018). 5. Laing R, Waning B, Gray A, Ford N, ’t Hoen E. 25 years of the WHO essential medicines lists: progress and challenges. Lancet. 2003 May 17;361(9370):1723–9. https://doi.org/10.1016/S0140-6736(03)13375-2 PMID:12767751 6. Tejani AH, Wertheimer A. International variations in Essential Medication Lists. Innovations in pharmacy. 2014;5(1) (https:// conservancy.umn.edu/bitstream/handle/11299/171719/cop_article_474923.pdf?sequence=1&isAllowed=y, accessed 30 January 2018). 7. Rahim HFA, Sibai A, Khader Y, Hwalla N, Fadhil I, Alsiyabi H, et al. Non-communicable diseases in the Arab world. Lancet. 2014 Jan 25;383(9914):356–67. https://doi.org/10.1016/S0140-6736(13)62383-1 PMID:24452044 8. World Health Organization Regional Office for the Eastern Mediterranean. Cardiovascular diseases www.emro.who.int/health-( topics/cardiovascular-diseases/index.html, accessed 30 January 2018). 9. World Health Organization. Media centre. Cardiovascular diseases (CVDs). Fact sheet. Updated May 2017 (www.who.int/ mediacentre/factsheets/fs317/en/, accessed 30 January 2018). 10. WHO Model List of Essential Medicines. 19th List (April 2015). (Amended August 2015). World Health Organization. (www.who. int/selection_medicines/committees/expert/20/EML_2015_FINAL_amended_AUG2015.pdf?ua=1, accessed 30 January 2018). 11. World Health Organization. Cardiovascular diseases mortality: age-standardized death rate per 100 000 population, 2000–2012 [Internet]. [cited 2016 Jan 16]. Available from: , accessed 16 January 2016).http://apps.who.int/gho/data/view.wrapper.NCD02v 12. World Bank. Data. Health expenditure per capita (current US$). Tables (http://data.worldbank.org/indicator/SH.XPD.PCAP, accessed 30 January 2018).

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13. Bazargani YT, de Boer A, Schellens JHM, Leufkens HGM, Mantel-Teeuwisse AK. Essential medicines for breast cancer in low and middle income countries BMC Cancer. 2015 Aug 18;15:591. https://doi.org/10.1186/s12885-015-1583-4 PMID:26283654 14. Bazargani YT, de Boer A, Schellens JHM, Leufkens HGM, Mantel-Teeuwisse AK. Selection of oncology medicines in low- and middle-income countries. Ann Oncol. 2014 Jan;25(1):270–6. https://doi.org/10.1093/annonc/mdt514 PMID:24356638 15. Kirby J, Ojha RP, Johnson KM, Bittner EC, Caniza MA. Challenges in managing infections among pediatric cancer patients: Suboptimal national essential medicines lists for low and middle income countries. Pediatr Blood Cancer. 2015 Feb;62(2):204–7. https://doi.org/10.1002/pbc.25273 PMID:25307693 16. The world medicines situation 2011 – Global health trends: global burden of disease and pharmaceutical needs (http://apps.who. int/medicinedocs/en/m/abstract/Js20036en/, accessed 30 January 2018). 17. van den Ham R, Bero L, Laing. The world medicine situation 2011. Selection of essential medicines. Geneva: World Health Organization: 2011 (http://apps.who.int/medicinedocs/documents/s18770en/s18770en.pdf, accessed 30 January 2018). 18. WHO Policy Perspectives on Medicines – The selection of essential medicines. World Health Organization. June 2002 (http:// apps.who.int/medicinedocs/pdf/s2296e/s2296e.pdf, accessed 30 January 2018). 19. The Federal Government of Somalia Republic, Ministry of Human Development and Public Services, Directorate of Health. Health Sector Strategic Plan January 2013–December 2016 (www.nationalplanningcycles.org/sites/default/files/country_docs/ Somalia/the_federal_government_of_somali_republic_health_sector_strategic_plan_2013-2016.pdf, accessed 30 January 2018). 20. World Health Organization. Somalia Report 2012 (www.emro.who.int/images/stories/somalia/documents/who_-_somalia_ annual_report_design_lores.pdf?ua=1, accessed 30 January 2018). 21. Health response to the crisis in Syrian Arab Republic and neighbouring countries. World Health Organization. January 2013 (www.who.int/hac/donorinfo/donor_alert_syria_and_neighbouring_Jan2013.pdf, accessed 30 January 2018). 22. Syria Essential Drug List. 2014 (www.emro.who.int/images/stories/syria/documents/SYRIA_EDL_2014_Priority_FINAL.pdf, accessed 30 January 2018). 23. El-Zein A, Jabbour S, Tekce B, Zurayk H, Nuwayhid I, Khawaja M, et al. Health and ecological sustainability in the Arab world: a matter of survival. Lancet. 2014 Feb 1;383(9915):458–76. https://doi.org/10.1016/S0140-6736(13)62338-7 PMID:24452051 24. Management Sciences for Health. Managing procurement. (MDS-3: Managing access to medicines and health technologies, Chapter 18). (www.msh.org/sites/msh.org/files/mds3-ch20-quantifying-mar2012.pdf, accessed 30 January 2018). 25. Howard NJ, Laing RO. Changes in the World Health Organisation essential drug list. Lancet. 1991 Sep 21;338(8769):743–5. https:// doi.org/10.1016/0140-6736(91)91455-4 PMID:1679879 26. Wirtz VJ, Kaplan WA, Kwan GF, Laing RO. Response by Wirtz et al to Letter Regarding Article, “Access to medications for cardiovascular diseases in low- and middle-income countries”. Circulation. 2016 Oct 4;134(14):e305–6. https://doi.org/10.1161/ CIRCULATIONAHA.116.024527 PMID:27698055

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Hypertension and associated cardiovascular risk factors among urban slum dwellers in Egypt: a population-based survey

Mohsen Gadallah 1, Soad Abdel Megid 2, Amira Mohsen3 and Sahar Kandil 1

1Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt (Correspondence to: Sahar Kandil: [email protected], [email protected]). 2Ministry of Health and Population, Cairo, Egypt. 3National Research Centre, Cairo, Egypt.

Abstract Background: The economic deprivation of most slum inhabitants, and the lack of services and facilities may increase their vulnerability to unhealthy lifestyles and cardiovascular diseases. Aims: This study aimed to determine the prevalence of modifiable risk factors for cardiovascular diseases in slum residents in Cairo, Egypt and evaluate their association with hypertension. Methods: A household cluster survey was conducted in Mansheiet Nasser, a large slum area in Cairo. The study included 984 adult participants. The World Health Organization STEPS instrument for noncommunicable disease risk factor surveillance was used to determine the prevalence of smoking, fruit/vegetable consumption, overweight/obesity, physical activity, diabetes and hypertension. Results: Smoking, insufficient fruit/vegetable consumption, low physical activity and diabetes were reported by 43.4%, 92.2%, 98.4% and 8.7% of the sample respectively. The prevalence of hypertension and overweight/obesity were 31.2% and 73.0% respectively. Most of the participants (83.8%) had ≥ 3 cardiovascular risk factors. A significantly higher proportion of men smoked, engaged in less physical activity, had diabetes and had multiple risk factors. Hypertension was significantly associated with age 30–< 50 years (OR = 3.04, 95% CI: 1.66–5.58), age ≥ 50 years (OR = 12.5, 95% CI: 6.71–23.26), overweight (OR = 1.58, 95% CI: 1.0–62.35), obesity (OR = 2.23, 95% CI: 1.49–3.35), low fruit/vegetable consumption (OR = 1.88, 95% CI: 1.02–3.48), and diabetes (OR = 1.77, 95% CI: 1.08–2.92). Conclusions: Urban slum dwellers in Mansheiet Nasser have an increased vulnerability to cardiovascular diseases compared with the Egyptian population. Measures are needed to improve their lifestyles and reduce their risk of cardiovascular diseases. Keywords: Cardiovascular disease, risk factors, hypertension, lifestyle, poverty areas, Egypt Citation: Gadallah M; Abdel Megid S; Mohsen A; Kandil S. Hypertension and associated cardiovascular risk factors among urban slum dwellers in Egypt: a population-based survey. East Mediterr Health J. 2018;24(5):435-442. https://doi.org/10.26719/2018.24.5.435 Received: 20/08/16; accepted: 05/03/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction diseases, especially cardiovascular disease, is increasingly evident in low- and middle-income countries (4). Cardiovascular disease (CVD) is the leading cause of death, representing 30% of all global deaths. Over 80% of The prevalence of cardiovascular risk factors is deaths from cardiovascular disease take place in low- and reported to be higher among urban slum dwellers (5–9). middle-income countries (1). Among the 10 leading risk Egypt has experienced considerable socioeconomic change with increasing urbanization in the past 60 factors for global mortality from cardiovascular disease years and migration to urban areas, especially to Cairo, with their relative contribution are high blood pressure the capital city. This migration has led to the emergence (12.8%), tobacco use (8.7%), high blood glucose (5.8%), of many slum areas in Cairo, which are characterized physical inactivity (5.5%), overweight and obesity (4.8%), by a limited supply of many of the essential services. high cholesterol (4.5%), alcohol use (3.8%), and low fruit Although electricity is supplied to all houses, many areas and vegetable intake (2.9%). Fortunately, they can be lack water and sanitation services. Parks, sidewalks, controlled, treated or modified 2( ). sports or recreational facilities are also lacking. These The Egyptian national survey conducted in 2012 conditions, along with the economic deprivation of showed a higher prevalence of various cardiovascular most of slum inhabitants, may enhance the adoption risk factors than the global and regional figures, of an unhealthy lifestyle. The increasing vulnerability especially increased body weight, physical inactivity, and of this deprived population to cardiovascular disease low fruit and vegetable consumption. The prevalence of needs to be investigated. This study aimed to measure hypertension and tobacco use were also high, 39.7% and the prevalence of risk factors for cardiovascular disease 24.4% respectively (3). The association of urbanization among slum residents in Cairo, Egypt, and to determine with the increased prevalence of noncommunicable their association with hypertension.

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Methods using a calibrated mercury sphygmomanometer (Riester; Jungingen Germany). The average of the 2 readings Study design and site was recorded. American Heart Association guidelines This study was a household cluster survey conducted for blood pressure measurements were followed (12). in Mansheiet Nasser, one of the biggest slum areas Participants were informed about their blood pressure in Cairo. It developed as an unplanned area and has readings and referred to the health unit if it was high. considerable variation in building quality, ranging from Assessment of the validity of the weighing scales, one-story makeshift houses to good quality brick houses tape measures and sphygmomanometers was performed (10). Mansheiet Nasser is divided into 8 administrative weekly by taking the measurements of one person on districts and has an estimated population of about each of the instruments to ensure their standardization. 300 000 people. The active field survey was conducted between June and December 2014. The household crowding index was calculated as the total number of residents (excluding the newborns) Study sample divided by the total number of rooms, excluding kitchen The sample size was calculated assuming: a design effect and bathrooms. of 1.5, 10% anticipated non-response rate, 30% prevalence The duration of a visit ranged from 15 to 22 minutes. of hypertension, average family size of 6 persons, No names were recorded on the questionnaires to ensure 50% of the population ≥ 18 years, and 95% confidence anonymity. level. A sample of 493 households was needed and was selected from each of the 8 districts, proportionate to its Definitions of risk factors population size. • Smoking status: a smoker was anyone who reported For the selection of households within each district, currently smoking cigarettes, shisha or both. a mosque, a church, or a school was taken as the starting • Diabetes was recorded as positive when participants point from which we walked in a clockwise direction reported a diagnosis of diabetes by a doctor or were and selected the houses in a systematic random way. Of receiving treatment for diabetes—insulin or oral the 493 households selected, 481 agreed to participate hypoglycaemic therapy. (97.6% response rate). Data were collected from all adults ≥ 18 years (excluding pregnant women) available at the • Low fruit/vegetable consumption: < 5 per portions of time of the survey who consented to participate and had fresh and/or cooked fruits/vegetables a day (11). been resident in the area for ≥ 12 months. Within the • Low physical activity: < 150 minutes of moderate households that agreed to participate, none of the adults intensity, or 75 minutes of vigorous intensity declined to participate. A total of 984 participants were exercise per week or equivalent combination of both, interviewed with an average of 2 adults per household. or < 10 minutes of any type of physical activities per Data collection day, including activities at work, travel, leisure time and at home. Examples and show cards were used for The survey was conducted by 2 teams, each consisting of illustration (11). a trained interviewer and a medical assistant from staff of one Mansheiet Nasser health centre. • Overweight: BMI > 25 to 29.9 kg/m2; obesity: BMI ≥ 2 An interview questionnaire was designed based on the 30 kg/m (11). World Health Organization (WHO) STEPS instrument • Hypertension: systolic blood pressure ≥ 140 mmHg for stepwise surveillance of noncommunicable disease and/or diastolic blood pressure ≥ 90 mmHg (11). risk factors (11). It included sociodemographic data and Data management and analysis questions about smoking, daily amount of fruit and vegetable eaten, physical activity level, and prior diagnosis Questionnaires were reviewed for completeness and of diabetes by a doctor or treatment for diabetes. Each precision. Data coding, entry and cleaning through item of the questionnaire was reviewed for both face and exploratory analysis and appropriate cross-classification content validity by experts in epidemiology and public were done. health. After considering their comments, they agreed SPSS, version 17 was used for the analyses (13). the final form was valid for measuring cardiovascular Descriptive and analytical statistics were used. The disease risk factors and that the questionnaire items were chi-squared test was used to test differences between relevant, readable and comprehensive. The questionnaire proportions. Binary logistic regression analysis was final form was pilot-tested on 36 households, not included done to identify potential risk factors associated with in the study sample. Internal consistency was assessed hypertension. The regression analysis included variables by the Cronbach alpha coefficient (0.721). that were either significant in the bivariate analysis or Measurements of body weight to the nearest 0.5 kg were previously known to be independently associated and height to the nearest 1.0 cm were taken. Body mass with hypertension. Crude and adjusted odds ratios (OR) index (BMI) was calculated as weight (kg)/height2 (m2). were calculated with their corresponding 95% confidence After filling the questionnaire, 2 blood pressure readings interval (CI). A P-value ≤ 0.05 was considered statistically were taken on the right arm with the participant seated significant.

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Ethical considerations University (Approval number: FWA00017585. 2014). Informed written consent was obtained from each participant after explanation of the study purpose. For Results illiterate participants we explained the details of the The study included 984 participants, 428 (43.50%) of study and took their verbal consent as there was no/low whom were women. The ages ranged from 18 to 82 years risk to the participants and potential harm to them was with a mean (SD) of 42.56 (12.70) years. unlikely. Table 1 shows that just over half the participants The study was approved by the Research Ethics (51.1%) had no education and 59.8% were in low-income Committee of the Faculty of Medicine, Ain Shams families (< 1000 EGP per month). The mean (SD) crowding

Table 1 Demographic characteristics of the study sample and their cardiovascular risk factors overall by sex Characteristic Overall Men Women P-value a (n = 984) (n = 556) (n = 428) No. (%) No. (%) No. (%) Age group (years) < 30 years 161 (16.4) 78 (14.0) 83 (19.4) 30 to < 50 528 (53.7) 305 (54.9) 223 (52.1) 0.076 ≥ 50 295 (30.0) 173 (31.1) 122 (28.5) Education Illiterate/informal education 503 (51.1) 283 (50.9) 220 (51.4) 0.876 Primary school & above 481 (48.9) 273 (49.1) 208 (48.6) Family income per month (EGP)b < 250 39 (4.0) 16 (2.9) 23 (5.4) 250–499 153 (15.6) 83 (14.9) 70 (16.4) 500–749 239 (24.3) 147 (26.4) 92 (21.5) 0.127 750–999 157 (16.0) 92 (16.4) 65 (15.2) ≥ 1000 396 (40.2) 218 (39.2) 178 (41.6) Fruit/vegetable consumption Low (< 5 daily portions) 907 (92.2) 517 (93.0) 390 (91.1) 0.280 Adequate (≥ 5 daily portions) 77 (7.8) 39 (7.0) 38 (8.9) Physical activity Low (< 150 min/wk) 968 (98.4) 552 (99.3) 416 (97.2) 0.021 Healthy (≥ 150 min/wk) 16 (1.6) 4 (0.7) 12 (2.8) Current tobacco smoking < 0.001 Smokers 427 (43.4) 407 (73.2) 20 (4.7) Non-smokers 557 (56.6) 149 (26.8) 408 (95.3) Weight Normal 266 (27.0) 155 (27.9) 111 (25.9) Overweight 389 (39.5) 218 (39.2) 171 (40.0) 0.788 Obese 329 (33.4) 183 (32.9) 146 (34.1) Diabetes Yes 86 (8.7) 63 (11.3) 23 (5.4) < 0.001 No 898 (91.3) 493 (88.7) 405 (94.6) Hypertension Yes 307 (31.2) 175 (31.5) 132 (30.8) 0.832 No 677 (68.8) 381 (68.5) 296 (69.2) Number of risk factors ≥ 3 825 (83.8) 511 (91.9) 314 (73.4) < 0.001 < 3 159 (16.2) 45 (8.1) 114 (26.6)

aChi-squared test; statistically significant at P < 0.05. b1 US$ = 6.1 EGP at the time of the study (2014). Min/wk = minutes per week, EGP = Egyptian pounds.

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index for the 481 households was 2.09 (SD 1.24); over 80% 11.3% in men compared with 5.4% in women (P < 0.001). of households had crowding index >1. Both men and Hypertension was diagnosed in 307 (31.2%) participants women had a similar age distribution, educational level with no significant sex difference. The majority of our and family income. Low fruit and vegetable consumption sample (83.8%), had 3 or more of the modifiable risk was reported by 907 (92.2%) participants with no observed factors (low fruit/vegetable consumption, low physical difference between men and women. Low physical activity, tobacco smoking, above normal body weight, activity was reported by 968 (98.4%) participants, with diabetes and hypertension) with men being significantly women being significantly more active than men P( = more affected. 0.021). Tobacco smoking was reported by 427 (43.4%) Risk factors for hypertension are shown in Table 2. In participants and was significantly more prevalent among the bivariate analysis, the prevalence of hypertension was men; 73.2% of men smoked compared with 4.7% of women significantly higher in those who were older, uneducated, (P < 0.001). The median BMI was 27.8 (IQ: 24.8 – 31.2) kg/ had a family income below the median (800 EGP per m2and 73.0% of the total sample was overweight or obese month), had diabetes and were overweight or obese. After but no significant difference was observed between men adjustment for potential confounders, 4 variables were and women. Diabetes history was reported by 86 (8.7%) significantly associated with hypertension in the logistic respondents and it was significantly higher among men; regression model: age, body weight, fruit and vegetable

Table 2 Risk factors for hypertension: logistic regression analysis Risk factor Hypertension P-value Crude OR Adjusted OR (95% CI) (95% CI) No. (%) Sex Women 132 (30.8) 0.443 0.97 (0.74–1.28) 1.17 (0.77–1.78) Men (ref) 175 (31.5) Age group (years) < 30 (ref) 13 (8.1) < 0.001 30 to < 50 123 (23.3) 3.46 (1.89–6.31) 3.04 (1.66–5.58)* ≥ 50 171 (58.0) 15.70 (8.51–28.96) 12.50 (6.71–23.26)* Education Illiterate/informal education 184 (36.6) < 0.001 1.68 (1.28–2.21) 1.07 (0.76–1.50) Primary school & above (ref) 123 (25.6) Family income per month (EGP)a < median value 101 (36.9) 0.017 1.43 (1.06–1.92) 1.13 (0.79–1.62) ≥ median value (ref) 206 (29.0) Fruit/vegetable consumption Low (< 5 daily portions) 290 (32.0) 0.072 1.66 (0.95–2.89) 1.88 (1.02–3.48)* Adequate (≥ 5 daily) (ref) 17 (22.1) Exercise Low (< 150 min/wk) 301 (31.1) 0.583 1.33 (0.48–3.69) 1.52 (0.74–4.85) Healthy (≥ 150 min/wk) (ref) 6 (37.5) Tobacco smoking Smoker 134 (31.4) 0.914 1.02 (0.77–1.33) 1.04 (0.77–1.40) Non-smoker (ref) 173 (31.1) Diabetes Yes 49 (57.0) < 0.001 3.05 (1.93–4.81) 1.77 (1.08–2.92)* No (ref) 258 (28.7) Weight Obese 140 (42.6) < 0.001 2.98 (2.05–3.32) 2.23 (1.49–3.35)* Overweight 114 (29.3) 1.67 (1.15–2.42) 1.58 (1.06–2.35)* Normal (ref) 53 (19.9)

aMedian income = 800 EGP/month: 1 US$ = 6.1 EGP (2014). *Significant at P ≤ 0.05. OR = odds ratio, CI = confidence interval. ref = reference category, EGP = Egyptian pound, min/wk = minutes per week.

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consumption and history of diabetes. Compared to those countries and communities, however, it was generally under 30 years of age, the risk of hypertension was 3 times less common than we found among our participants. For higher in the age group 30 to < 50 years (OR= 3.04, 95% CI: example, in Kenya and in Nepal, overweight/obesity was 1.66–5.58) and 12 times higher in the age group ≥ 50 years 58% and 30% respectively and in India, it ranged between (OR = 12.50, 95% CI: 6.71–23.26). The risk of hypertension 32% in Patna and 75% in Hyderabad (5,6,8,9). The high was about double in those who consumed < 5 portions of prevalence of overweight/obesity in our participants fruits/vegetables daily (OR = 1.88, 95% CI: 1.02–3.48), had cannot be explained solely by the low physical activity. We diabetes (OR = 1.77, 95% CI: 1.08–2.92) and were obese (OR: did not enquire about eating habits, body size preference 2.23, 95% CI: 1.49–3.35). and perception of body image, which may affect people’s weight. Statistical modelling of BMI along with disease Discussion incidence, mortality and survival data from national and subnational datasets in the Middle East showed that a The current study was conducted as a cross-sectional small reduction, as low as 1%, in the obesity level would household survey in one of the largest slum areas in Cairo reduce the number of cases per 100 000 population of Governorate with the participation of 984 individuals. diabetes by about 1200 and coronary heart disease and Our results reveal alarmingly high prevalence rates of stoke by about 800 (17). This finding highlights the need some important modifiable cardiovascular risk factors. to target multi-morbidity and take preventive action on Adequate daily fruit and vegetable intake was rarely obesity-associated diseases. met: low intake seems to be common among Egyptians Diabetes was more prevalent in our study participants as seen from our results (92.2%) and from the nationally than in the national survey of 2015 (8.4% versus 4.8%) reported rates in 2012 (95.6%) (3). Among slum dwellers, (15). In fact, previous studies have shown that a higher low intake of fruit and vegetables varies in different prevalence of diabetes in deprived areas could be countries: it has been reported as only 8% in Nepal but attributed to factors such as low physical activity, around 50% in Kenya (6,7). cigarette smoking, dietary patterns, and overweight and The vast majority of our participants (98.4%) did obesity (18,19). Our data show a high prevalence of such not reach the minimum level of physical activity factors, and 2 of them (smoking and low physical activity) recommended for health by WHO (14). This figure is were higher than the national rates. 3 times higher than the national figure for insufficient The prevalence of hypertension in our study (31.2%) physical activity reported in the 2012 survey (32.1%) (3). was much higher than the national rate reported in 2015 Among residents of urban slums in other countries, (17.2%) and the rate reported from a screening survey in the prevalence of insufficient physical activity was urban Cairo (16.5%) (15,20). The prevalence of hypertension much lower than in our study: 15% to 20% in Kenya and among urban slum populations varies, ranging between about 30% in both Nepal and India (5–8). Many factors 25% and 34% in India and Nepal and about 23% in Kenya associated with urbanization that are frequently found (5,6,8,9). in our urban slums tend to discourage engagement in physical activity, for example violence, high-density Of concern, 83.8% of our participants had 3 or more traffic, pollution and low air quality, and the lack of parks, of the 6 studied risk factors for cardiovascular disease. sidewalks and recreational or sport facilities. This rate far exceeds the reported national figure in 2012, which was 51.1% with 3 or more risk factors (3). Having Tobacco smoking was more prevalent in our multiple risk factors for noncommunicable diseases is participants (43.4%) than either of the national rates closely associated with the social determinants of health, reported in 2012 and 2015, 18% and 20.9% respectively with factors such as low level of education, low income, (3,15). Again, smoking was more common in our study unemployment and deprived living conditions being compared with studies among slum dwellers elsewhere: implicated (21). Therefore, living in an urban slum where in both Kenya and India, smoking prevalence was about all these factors are evident could increase vulnerability 10–12% and in Nepal, it was 35.6% (5–8). The health risk of to noncommunicable diseases in Egypt. tobacco smoking is not only from its direct consumption but also from second-hand smoke. Unfortunately, most of Our results confirm the well-known association our study participants lived in crowded homes (crowding between hypertension and advancing age. The likelihood index ≥ 1 in more than 80% of the households). Thus, the of suffering from hypertension at age 30 to < 50 years was probability of indoor exposure to second-hand smoke 3 times higher than at age < 30 years, and 12 times higher is high, which highlights the importance of smoking at the age of ≥ 50 years. cessation in people living in such conditions. Diabetes was also associated with hypertension The prevalence of overweight and obesity in our with the likelihood of hypertension being nearly double participants (72.9%) was not greatly different from among those with diabetes than those without. A strong the national figures for Egypt reported in 2012 and association between diabetes and hypertension was 2015 (66.0% and 76.0% respectively) (3,15). Studies previously confirmed with strong evidence of sharing indicate that overweight and obesity are prevalent in common pathways (22). all socioeconomic strata in Egypt (15,16). Among slum The significantly higher prevalence of hypertension residents, overweight and obesity varied in different in obese and overweight individuals that we observed

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has been previously reported in other studies (20,22,23). recently published critical review that reported no gender The alarmingly high prevalence of overweight and difference in the overall prevalence of hypertension, but obesity, especially in this less privileged population, did report differences between age groups (29). might increase the risk of hypertension. Incorporating The level of physical activity had no significant weight reduction programmes in primary health care relationship with hypertension in our participants. could help control obesity-associated diseases including Other studies have reported an association of high and diabetes and hypertension. moderate levels of recreational physical activity with Hypertension was significantly more prevalent lower risk of hypertension (30). This protective effect among participants who had a low fruit and vegetable could not be seen in our group, probably because of the intake. Our results concur with other observational and very small proportion (1.6%) who achieved the healthy intervention studies which reported convincing evidence level of physical activity. that high consumption of fruit and vegetable can lower blood pressure (24). Conclusion Tobacco smoking was not significantly associated The population living in the Egyptian urban slum was with hypertension in our participants. This finding at increased cardiovascular risk, with higher rates of contradicts other studies (5,8). However, a large nationally behavioural risk factors and multi-morbidity than representative study in England also failed to find any the corresponding national rates, namely insufficient consistent independent clinically significant difference physical activity, smoking, diabetes, hypertension, and in blood pressure values between smokers and non- the simultaneous presence of 3 or more cardiovascular smokers, which concurs with our findings 25( ). This lack risk factors. The vast majority consumed less than the of association could be partially attributed to the transient daily recommended amount of fruits and vegetables, and effect of smoking on blood pressure, through stimulation three quarters were overweight or obese. Hypertension of the sympathetic system, which would be lost within was significantly associated with older age, low fruit half an hour of the last smoke. This period is usually and vegetable consumption, diabetes, and overweight/ missed when blood pressure is measured both in research obesity. Behavioural risk factors can be changed but studies and in clinical practice (26). More importantly, people living in disadvantaged areas are at increased however, is the evidence that smoking produces arterial vulnerability to unhealthy lifestyles and hence risk stiffness and this predominantly affects central aortic factors for cardiovascular disease because of low levels of blood pressure and damages key organs (kidneys and income, education and employment, and deprived living heart) rather than brachial blood pressure (27,28). conditions. Initiatives are urgently needed to tackle the Our study did not find any relationship between problem and help slum residents adopt more healthy gender and hypertension. This finding is supported by a lifestyles and reduce their risk of cardiovascular disease. Acknowledgements We thank the residents of Mansheiet Nasser for their cooperation, the health authority in Cairo Governorate and the data collection teams for facilitating the fieldwork. Funding: None. Competing interests: None declared.

Hypertension et facteurs de risque cardio-vasculaires associés parmi les habitants de taudis urbains en Égypte : étude populationnelle

Résumé Contexte : Le dénuement économique dans lequel vivent la plupart des habitants de taudis urbains, ainsi que le manque de services et d’établissements à leur disposition peut les rendre davantage vulnérables à des modes de vie malsains et aux maladies cardio-vasculaires. Objectifs : La présente étude avait pour objectif de déterminer la prévalence des facteurs de risque modifiables des maladies cardio-vasculaires chez les habitants de taudis urbains du Caire (Égypte), ainsi que d’évaluer leur association avec l’hypertension. Méthodes : Un sondage par grappes auprès des ménages a été réalisé dans le quartier de Mansheiet Nasser, une importante zone de logements insalubres au Caire. L’étude incluait 984 participants adultes. L’enquête STEPS de l’Organisation mondiale de la Santé pour la surveillance des facteurs de risque des maladies non transmissibles a été utilisée afin de déterminer la prévalence du tabagisme, de la consommation de fruits et légumes, de la surcharge pondérale/de l'obésité, de l’activité physique, du diabète et de l’hypertension. Résultats : Le tabagisme, une consommation insuffisante de fruits et légumes, une faible activité physique et le diabète étaient notifiés par 43,4 %, 92,2 %, 98,4 % et 8,7 % des personnes respectivement dans l’échantillon étudié. La prévalence

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de l’hypertension et de la surcharge pondérale/de l'obésité était de 31,2 % et de 73,0 % respectivement. La plupart des participants (83,8 %) présentaient trois facteurs de risque cardio-vasculaires ou plus. Une proportion significativement plus élevée d’hommes fumait, avait une activité physique moindre, souffrait de diabète et présentait des facteurs de risque multiples. L’hypertension était associée de façon significative au fait d’être âgé de 30 à 49 ans (OR = 3,04, IC de 95 % : 1,66- 5,58), d’avoir 50 ans ou plus (OR = 12,5, IC de 95 % : 6,71-23,26), à une surcharge pondérale (OR = 1,58, IC de 95 % : 1,0-62,35), à l’obésité (OR = 2,23, IC de 95 % : 1,49-3,35), à une faible consommation de fruits et légumes (OR = 1,88, IC de 95 % : 1,02- 3,48), et au diabète (OR = 1,77, IC de 95 % : 1,08-2,92). Conclusions : Les habitants du taudis urbain de Mansheiet Nasser sont davantage exposés aux maladies cardio- vasculaires comparés au reste de la population égyptienne. Des mesures sont nécessaires afin d’améliorer leurs modes de vie et réduire le risque de maladies cardio-vasculaires.

ارتفاع ضغط الدم وما يرتبط به من عوامل خطر لألمراض القلبية الوعائية بني سكان العشوائيات احلرضية يف مرص: مسح سكاين حمسن جاد اهلل، سعاد عبد املجيد، أمرية حمسن، سحر قنديل اخلالصة يمكن اخللفية:أن يؤدي احلرمان االقتصادي الذي يعاين منه معظم قاطني العشوائيات، ونقص اخلدمات واملرافق، إىل زيادة تعرضهم ملخاطر األنامط احلياتية غري الصحية واألمراض الوعائية القلبية. هدفتاألهداف: هذه الدراسة إىل حتديد مستوى انتشار عوامل اخلطر القابلة للتعديل لألمراض الوعائية القلبية بني قاطني العشوائيات بمدينة القاهرة، مرص، وتقييم ارتباطها بارتفاع ضغط الدم. طرق البحث: ُجري أمسح عنقودي سكني يف منطقة منشية نارص، إحدى املناطق العشوائية الضخمة يف القاهرة. وضمت الدراسة 984 ًمشاركا من البالغني. ُواستخدمت أداة STEPS ملنظمة الصحة العاملية يف ترصد عوامل خطر األمراض غري السارية لتحديد مستوى انتشار التدخني، واستهالك الفاكهة/اخلرض، وزيادة الوزن/البدانة، والنشاط البدين، واإلصابة بداء السكري، وارتفاع ضغط الدم. النتائج: ُأفاد 43.4% و92.2% و98.4% و8.7%من أفراد العينة بالتدخني، وعدم استهالك الفاكهة/اخلرض، وقلة النشاط البدين، واإلصابة بالسكري عىل الرتتيب. وبلغ مستوى انتشار ارتفاع ضغط الدم وزيادة الوزن/البدانة 31.2% و % 73.0عىل الرتتيب. وأبدى معظم املشاركني )83.8%( 3عوامل خطر أو أكثر لألمراض الوعائية القلبية. وتب ّني أن نسبة مرتفعة للغاية من الرجال يدخنون، ويبذلون ًنشاطا ًبدنيا ًمنخفضا، ومصابون بالسكري، ومعرضون لعوامل خطر متعددة. وارتبط ارتفاع ضغط الدم ً ارتباطاذو داللة إحصائية بكل من: التقدم بالسن يف الفئة العمرية 30-50 سنة )CI %95 ،3.04 = OR: 1.66-5.58(، و≥ 50 سنة )CI %95 ،12.5 = OR: 6.71-23.26(، وزيادة الوزن )OR = CI %95 ،1.58: 1.0-62.35(، والبدانة )CI %95 ،2.23 = OR: 1.49- (، 3.35وانخفاض استهالك الفاكهة/اخلرض )OR = 1.88، CI %95: 1.02-3.48(، وداء السكري )CI %95 ،1.77 = OR: 2.92-1.08(. يعاين االستنتاجات:قاطنو العشوائيات احلرضية يف منشية نارص مع ارتفاع مستوى تعرضهم ملخاطر األمراض الوعائية القلبية مقارنة بغريهم من السكانيف مرص. ويلزم اختاذ تدابري من أجل حتسني أنامط حياهتم واحلد من خماطر إصابتهم باألمراض الوعائية القلبية.

References 1. Global status report on noncommunicable diseases 2010. Geneva: World Health Organization; 2011. 2. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization; 2009. 3. WHO STEPS chronic disease risk factor surveillance. Egypt STEPS Survey 2011–2012. Fact Sheet 6-3C-1 (www.who.int/chp/ steps/2011-2012_Egypt_FactSheet.pdf, accessed 30 January 2018). 4. Hernández AV, Pasupuleti V, Deshpande A, Bernabé-Ortiz A, Miranda JJ. Effect of rural-to-urban within-country migration on cardiovascular risk factors in low- and middle-income countries: a systematic review. Heart. 2012 Feb;98(3):185–94. https://doi. org/10.1136/heartjnl-2011-300599 PMID:21917659 5. Joshi MD, Ayah R, Njau EK, Wanjiru R, Kayima JK, Njeru EK, et al. Prevalence of hypertension and associated cardiovascular risk factors in an urban slum in Nairobi, Kenya: a population-based survey. BMC Public Health. 2014 11 18;14(1):1177. https://doi. org/10.1186/1471-2458-14-1177 PMID:25407513 6. Oli N, Vaidya A, Thapa G. Behavioural risk factors of noncommunicable diseases among Nepalese urban poor: a descriptive study from a slum area of Kathmandu. Epidemiol Res Int. 2013; 2013. https://doi.org/10.1155/2013/329156 7. Haregu TN, Oti S, Egondi T, Kyobutungi C. Co-occurrence of behavioral risk factors of common non-communicable diseases among urban slum dwellers in Nairobi, Kenya. Glob Health Action. 2015 09 16;8(1):28697. https://doi.org/10.3402/gha.v8.28697 PMID:26385542

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8. Singh R, Mukherjee M, Kumar R, Singh R, Pa R. Study of risk factors of coronary heart disease in urban slums of Patna. Nepal J Epidemiol. 2012;2:205–12. 9. Lavanya KM, Thomas V, Rao N. Usha Rani.K.M. Cardiovascular risk factors among adults: a cross-sectional study in urban slums of Hyderabad, Andhra Pradesh, India. Int J Med Health Sci. 2014;4(3):272–7. 10. Piffero E. Beyond rules and regulations: the growth of informal Cairo. In: Kipper R, Fischer M, Eds. Cairo’s informal areas between urban challenges and hidden potentials. Cairo: GTZ Egypt; 2009 (www.citiesalliance.org/sites/citiesalliance.org/files/ CA_Docs/resources/Cairo's%20Informal%20Areas%20Between%20Urban%20Challenges%20and%20Hidden%20Potentials/ CairosInformalAreas_fulltext.pdf, accessed 30 January 2018). 11. World Health Organization. Noncommunicable diseases and their risk factors. The STEPS Instrument and Support Materials. THE STEPS INSTRUMENT. (www.who.int/chp/steps/instrument/en/, accessed 30 January 2018). 12. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005 Jan;45(1):142–61. https://doi.org/10.1161/01.HYP.0000150859.47929.8e PMID:15611362 13. SPSS statistics for Windows, version 17.0. Chicago: SPSS Inc.; 2008. 14. Global recommendations on physical activity for health. Geneva: World Health Organization; 2010. 15. Ministry of Health and Population (Egypt), El-Zanaty and Associates (Egypt), and ICF International. Egypt Health Issues Survey 2015. Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International; 2015. 16. Mowafi M, Khadr Z, Kawachi I, Subramanian SV, Hill A, Bennett GG. Socioeconomic status and obesity in Cairo, Egypt: a heavy burden for all. J Epidemiol Glob Health. 2014 Mar;4(1):13–21. https://doi.org/10.1016/j.jegh.2013.09.001 PMID:24534331 17. Kilpi F, Webber L, Musaigner A, Aitsi-Selmi A, Marsh T, Rtveladze K, et al. Alarming predictions for obesity and non-communicable diseases in the Middle East. Public Health Nutr. 2014 May;17(5):1078–86. https://doi.org/10.1017/ S1368980013000840 PMID:23642403 18. Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W. Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health. 2000 Mar;54(3):173– 7. https://doi.org/10.1136/jech.54.3.173 PMID:10746110 19. Ezeamama AE, Viali S, Tuitele J, McGarvey ST. The influence of socioeconomic factors on cardiovascular disease risk factors in the context of economic development in the Samoan archipelago. Soc Sci Med. 2006 Nov;63(10):2533–45. https://doi.org/10.1016/j. socscimed.2006.06.023 PMID:16876925 20. Abd Elaziz KM, Dewedar SA, Sabbour S, El Gafaary MM, Marzouk DM, Aboul Fotouh A, et al. Screening for hypertension among adults: community outreach in Cairo, Egypt. J Public Health (Oxf). 2015 Dec;37(4):701–6. PMID:25355687 21. Boutayeb A, Boutayeb S, Boutayeb W. Multi-morbidity of noncommunicable diseases and equity in WHO Eastern Mediterranean countries. Int J Equity Health. 2013 08 20;12(1):60. https://doi.org/10.1186/1475-9276-12-60 PMID:23961989 22. Cheung BM, Li C. Diabetes and hypertension: is there a common metabolic pathway? Curr Atheroscler Rep. 2012 Apr;14(2):160–6. https://doi.org/10.1007/s11883-012-0227-2 PMID:22281657 23. American Heart Association. Know your risk for high blood pressure. (heart.org/HEARTORG/Conditions/HighBloodPressure/ Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp, accessed 30 January 2018). 24. Boeing H, Bechthold A, Bub A, Ellinger S, Haller D, Kroke A, et al. Critical review: vegetables and fruit in the prevention of chronic diseases. Eur J Nutr. 2012 Sep;51(6):637–63. https://doi.org/10.1007/s00394-012-0380-y PMID:22684631 25. Primatesta P, Falaschetti E, Gupta S, Marmot MG, Poulter NR. Association between smoking and blood pressure: evidence from the health survey for England. Hypertension. 2001 Feb;37(2):187–93. https://doi.org/10.1161/01.HYP.37.2.187 PMID:11230269 26. Kaplan NM. Smoking and hypertension. UpToDate; 2015 (www.uptodate.com/contents/smoking-and-hypertension, accessed 30 January 2018). 27. Mahmud A, Feely J. Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension. 2003 Jan;41(1):183–7. https://doi.org/10.1161/01.HYP.0000047464.66901.60 PMID:12511550 28. Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Curr Pharm Des. 2010;16(23):2518– 25. https://doi.org/10.2174/138161210792062920 PMID:20550499 29. Doumas M, Papademetriou V, Faselis C, Kokkinos P. Gender differences in hypertension: myths and reality. Curr Hypertens Rep. 2013 Aug;15(4):321–30. https://doi.org/10.1007/s11906-013-0359-y PMID:23749317 30. Huai P, Xun H, Reilly KH, Wang Y, Ma W, Xi B. Physical activity and risk of hypertension: a meta-analysis of prospective cohort studies. Hypertension. 2013 Dec;62(6):1021–6. https://doi.org/10.1161/HYPERTENSIONAHA.113.01965 PMID:24082054

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Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan

Muhammad Fazal Zeeshan 1,2, Ahmad Al Ibad 1,2, Abdul Aziz 1,2, Aftab Subhani 1,2, Asif Shah 1,2, Tahir Khan 1,2, Hidayat Ullah 1,2 and Umair Qazi 1,2

1Riphah International University, Islamabad, Pakistan. 2Peshawar Medical College, Peshawar, Pakistan (Correspondence to: M.F. Zeeshan: mzeeshan@ piph.prime.edu.pk). Abstract Background: Hospital waste management (HWM) rules in Pakistan were issued in 2005. Despite a decade of enactment, adherence to HWM 2005 rules has been inconsistent and systematic assessment of adherence using a World Health Organization (WHO)-recommended questionnaire has not been done in all teaching hospitals of Peshawar District. Aims: This study assessed the adherence to HWM 2005 rules by tertiary care teaching hospitals of Peshawar District with respect to HWM personnel, policy and practices. Methods: Pretested structured questionnaires based on WHO recommendations were used to survey all teaching hospitals of Peshawar District from January to March 2015. Data were also collected on HWM infrastructure and processes from 1 randomly selected medical, surgical, paediatric, and obstetrics/gynaecology unit in each hospital. Besides descriptive statistics, public and private hospitals were compared using Fisher’s exact and Wilcoxon rank-sum tests. Results: Most surveyed hospitals lacked formal HWM plans (70%), written procedures (80%), related job descriptions (80%) or records (90%). Many hospitals neither had trained HWM supervisors (56%) nor did they organize formal HWM trainings for new staff (40%). None of the hospitals followed waste segregation and colour coding. When compared to national HWM 2005 rules, multiple gaps in appropriate transportation, storage and disposal were found with no statistically significant difference between public and private hospitals. Conclusions: Serious gaps in adherence to HWM 2005 rules exist in surveyed hospitals. With recent devolution of environmental function, the Government of Khyber Pakhtunkhwa should enact provincial HWM rules (and ensure their implementation) to facilitate effective HWM practice across provincial healthcare facilities. Keywords: Waste management, hospitals, environmental health, World Health Organization, Pakistan Citation: Zeeshan MF; Al Ibad A; Aziz A; Subhani A; Shah A; Khan T; et al. Practice and enforcement of national hospital waste management 2005 rules in Pakistan. East Mediterr Health J. 2018;24(5):443-450. https://doi.org/10.26719/2018.24.5.443 Received: 22/12/16; accepted: 28/05/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction Environmental Protection Act (PEPA) of 1997 (12). This was the first comprehensive legislation that aimed to Hospital waste is generated during patient care and has the achieve sustainable improvements in HWM practices. potential to cause health and environmental damage (1). The HWM 2005 rules reflected the World Health Depending upon the spectrum of hospital services, waste Organization guidelines from establishment of a facility- includes 10–25% biohazardous material (such as sharps based waste management plan (detailing the assignment and chemical, infectious, pharmaceutical, radioactive and of responsibilities, management structure, and duties) genotoxic waste) and 75–90% nonbiohazardous waste to effective regulation of onsite collection, segregation, (such as food waste, cardboard and packaging) (2). It is handling, labelling, storage, transportation and disposal of not surprising that hospital waste, if poorly managed, healthcare waste (12,13). In addition, the HWM 2005 rules poses a serious threat to neighbouring communities as specified the constitution of an HWM Team and roles well as healthcare providers, patients and visitors (3). of its members, along with outlining a supervisory and In Pakistan, like other developing countries, prior advisory mechanism in the form of a Hospital Complaint studies have reported poor hospital waste management Scrutiny Committee for each district, and an HWM (HWM) practices (4–6). Studies conducted in major Advisory Committee at federal and provincial levels (12). cities in Pakistan (i.e., Karachi, Lahore, Rawalpindi and After devolution of health, education, environment and Islamabad) have consistently reported mismanagement other social sectors from the federal to provincial tiers in of hospital waste with respect to following segregation July 2011, Khyber Pakhtunkhwa Province enacted its own techniques and appropriate disposal procedures (7–10). Environmental Protection Act (KPEPA) in December 2014. This is alarming as ~0.8 million tonnes of waste is The HWM rules on the basis of KPEPA 2014 are yet to be produced daily from hospitals in Pakistan (11). developed. However, despite a decade of federal HWM To improve HWM, the Government of Pakistan 2005 rules enactment (2005–2014), adherence has been enacted the HWM 2005 rules based on the Pakistan inconsistent (6,7,9) and a systematic formal inspection for

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adherence to HWM 2005 rules by the relevant authorities of cleaning staff, incinerator supervisors and other staff has not yet been conducted. relevant to HWM processes. The legal and regulatory frameworks for solid The HWM-related infrastructure and processes in waste management are based on the federal and (now) each hospital were observed by trained data collection provincial Environment Protection Acts. Apart from staff for 1 medical, surgical, paediatric and obstetrics/ constituting the Environmental Protection Agency, the gynaecology unit. Among hospitals with > 1 unit in Acts established Environmental Improvement a specialty, the observed unit was randomly selected Funds and Environmental Protection Tribunals, through a simple draw. Descriptive statistics were listing the relevant functions, powers, penalties and other reported as relevant frequencies, proportions, means and procedures. The enforcement of HWM 2005 rules within standard deviations. Proportional comparisons between health facilities is under the domain of the Department of public and private sector tertiary care teaching hospitals Health, and if hazardous waste is found outside a health for HWM policies, personnel, and practice-related facility, the Regional Chapter of the Environmental variables were tested for similarity using Fisher’s exact tests. The assumption of normality was assessed for Protection Agency takes action. HWM staffing levels using the Shapiro–Wilk test. The Peshawar is the provincial capital of Khyber HWM staffing levels were compared between public and Pakhtunkhwa, with an estimated population of 3.7 private teaching hospitals using the Wilcoxon rank-sum million and 10 tertiary care teaching hospitals (14). The (Mann–Whitney U) test. The level of significance used HWM practices among these hospitals have not been for all statistical analyses was 0.05. All analyses were reported as a whole. More specifically, to the best of our performed using SPSS version 19 software. The study was knowledge, no recent study has assessed adherence to approved by the Institutional Review Board of the Prime the HWM 2005 rules after a decade of enactment among Foundation, Peshawar, Pakistan. all tertiary care teaching hospitals of Peshawar District. The present study included all tertiary care teaching Results hospitals (both public and private) of Peshawar District All 10 surveyed hospitals were general hospitals providing to document their adherence to HWM 2005 rules. We a range of emergency and nonemergency medical and also aimed to identify the existing human resources and surgical services to adult and paediatric patients. Overall, infrastructure dedicated to waste management functions when compared to private sector tertiary care teaching within each hospital. hospitals, public sectors hospitals of Peshawar District had significantly higher average bed capacity (1367 vs. 272 Methods for private sector hospitals, P = 0.01), average daily new This cross-sectional study included all 10 (7 private and admissions (288 vs. 47, P = 0.02), outdoor patients (1804 3 public) tertiary care teaching hospitals in Peshawar vs. 247, P = 0.03), and daily major surgical procedures (69 District, Khyber Pakhtunkhwa Province, Pakistan. Data vs. 11, P = 0.05). The summary characteristics of surveyed were collected from January to March 2015 by direct hospitals are given in Table 1. observation using a checklist and a pretested structured HWM policy questionnaire. The structured questionnaire was based This study determined adherence of surveyed hospitals on recommendations by the World Health Organization to HWM rules 2005 in general but more specifically (13) for evaluation of HWM in developing countries. Data regarding HWM polices, personnel and practice. For were collected about 3 main domains. 1) HWM-related HWM polices, the HWM rules 2005 stipulate constitution policy: awareness about HWM 2005 rules, existence of of a waste management team, development of a waste HWM plan, dedicated team, written procedures, record management plan and written procedures, and weekly maintenance and HWM-related tasks in job descriptions. record maintenance for quantities of generated waste 2) HWM-related personnel: dedicated formally trained (12). We found that 40% of those in charge of HWM in personnel, and trainings for new and existing HWM the surveyed hospitals were not aware of the HWM rules staff. 3) HWM-related practices: waste segregation, 2005 (Table 2). While there was a formal HWM team in colour coding, waste handling, use of personal protective 70% of hospitals, only 30% of the surveyed hospitals had an equipment (PPE), separate transport for infectious and HWM plan. Twenty percent of the hospitals had written noninfectious waste, presence of temporary waste HWM procedures. Similarly, only 20% of the surveyed storage area, use of internal transport containers and hospitals mentioned HWM-related duties in the job vehicles/media and waste disposal and incinerators. descriptions of the relevant personnel. Ninety percent Functionality of the incinerators was assessed among of the surveyed hospitals had no formal records of the the hospitals where the incinerators were present. The quantity and type of waste that they produced. Most of incinerators were considered functional if used regularly the hospitals (60%) did not allocate a dedicated budget to by the hospital for waste destruction. HWM practices. The study compared the HWM policy- In addition, questionnaires were completed by related indicators among private and public hospitals interviewing management staff, including medical or and found no significant difference (Fisher’s exact test, deputy medical superintendents, and nurses in charge P > 0.05). It is worth mentioning that none of the public

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Table 1 Characteristics of tertiary care teaching hospitals in Peshawar Districta,b All surveyed Private hospitals Public hospitals P Wilcoxon rank- hospitals (n = 7) (n = 3) sum (Mann– (n = 10) Whitney) test Mean (SD) 601 (549) 272 (105) 1367 (255) Bed capacity 0.01 Median (IQR) 330 (950) 260 (210) 1240 (461) Mean (SD) 766 (1000) 247 (132) 1804 (±1240) Outdoor patients per day 0.03 Median (IQR) 353 (150) 275 (243) 2263 (2348) Mean (SD) 127 (133) 47 (33) 288 (101) New hospital admissions per day 0.02 Median (IQR) 70 (189) 44 (50) 250 (191) Mean (SD) 15 (19) 5 (2) 40 (18) Operating theatre tables 0.02 Median (IQR) 7 (21) 4 (4) 37 (36) Mean (SD) 29 (43) 11 (6) 69 (67) Major operations conducted per day 0.05 Median (IQR) 13 (12) 10 (12) 48 (128)

aMedian and IQR are also reported, as data do not follow normal distribution. bEven though caution should be used to interpret the P values due to small sample size, the significant P values indicate statistically significant differences between public and private tertiary care teaching hospitals of Peshawar district in terms of basic hospital attributes. IQR = interquartile range; SD = standard deviation.

Table 2 Study findings related to HWM policies Overall, % Private hospitals Public hospitals P* (Fisher’s exact (n = 10) (n = 7), % (n = 3), % test) HWM supervisors’ awareness about HWM 2005 Rules 60.0 57.1 66.7 1.00 Existence of HWM plan 30.0 28.6 33.3 1.00 Presence of formal HWM team 70.0 71.4 66.7 1.00 Presence of written HWM procedures 20.0 28.6 0.0 1.00 Record maintenance of hospital waste produced 10.0 14.3 0.0 1.00 Presence of dedicated HWM budget 40.0 28.6 66.7 0.50 Documentation of HWM related tasks in job descriptions 20.0 28.7 0.0 1.00

*Even though caution should be used to interpret the P values due to small sample size, the nonsignificant 2-sided Fisher’s exact test P values for HWM policy-related variables indicate that nonadherence to HWM 2005 rules is statistically similar in both public and private teaching hospitals of Peshawar District. HWM = hospital waste management.

hospitals had written HWM procedures, maintained HWM practices records of hospital waste, or documented HWM-related HWM-related practices from waste generation to disposal tasks in job descriptions. The detailed breakdown of within hospital premises were observed (Table 5). None of HWM policy-related indicators are given in Table 2. the tertiary care teaching hospitals of Peshawar District HWM personnel practiced the prescribed segregation and colour-coding Overall, on average, 28 dedicated staff members were techniques for hospital waste handling. Despite this, 40% responsible for HWM-related activities in each surveyed of the hospitals internally transported hazardous waste hospital (Table 3). The number of dedicated HWM staff separately on the basis of waste bin location (i.e., mixed was significantly greater in public (47) as compared waste from patient wards was considered hazardous, to private (20) hospitals (Wilcoxon rank-sum P < 0.05). while that from doctors’ lounges and other administrative When the number of total beds per hospital was taken offices was deemed nonhazardous). Since there was no into account, public hospitals had fewer dedicated HWM segregation or colour coding, separate internal transport staff members (not significant,P = 0.14). Most (55.6%) of in its true technical sense was also not performed in any the HWM supervisors in the surveyed hospitals had no of the surveyed hospitals. formal training in HWM (Table 4). In 60% of the surveyed Most (80%) of the tertiary care hospitals had HWM hospitals, newly hired, lower-grade staff were informally staff wearing protective gloves. Among those wearing trained about HWM practices by their immediate protecting gloves (not shown in Table 5), 66% wore masks supervisors. Most of such hospitals (71.5%) were private or protective shoes, while half wore aprons. Only 30% tertiary care teaching hospitals. There was no formal of the tertiary care teaching hospitals had HWM staff refresher HWM training in public sector hospitals, while wearing all four types of PPE. In public sector hospitals, 28.6% of the private hospitals arranged refresher training none of the observed HWM staff wore masks, aprons or at monthly to bimonthly intervals. protective shoes (Table 5).

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Table 3 Comparison of dedicated HWM staffing among private and public hospitals (n = 10) Overall, mean (SD) Private hospitals, Public hospitals, P (Wilcoxon rank- mean (SD) mean (SD) sum test) Dedicated HWM personnela 28.1 (18.2) 20.1 (10.2) 46.7 (20.8) 0.03 HWM personnel per 100 beds 6.7 (4.2) 8.1 (4.2) 3.3 (0.9) 0.14

aWhile the number of dedicated HWM personnel is reported here, it is the HWM personnel per 100 beds that reflect the status of HWM staffing in the surveyed hospitals. HWM = hospital waste management; SD = standard deviation.

Table 4 Study findings related to HWM personnel HWM personnel variables Overall, % Private hospitals, % Public hospitals, % P* (Fisher’s exact (n = 10) (n = 7) (n = 3) test) Formally trained HWM supervisors 44.4 28.6 100.0 0.17 Formal HWM trainings to new staff 60.0 71.5 33.3 0.50 Formal HWM refresher trainings to staff 20.0 28.6 0.0 1.00

*Caution should be used to interpret the P values due to small sample size. HWM = hospital waste management.

Table 5 Study findings related to HWM practices HWM practices Overall, % Private hospitals, Public hospitals, P* (n = 10) % % (Fisher’s exact (n = 7) (n = 3) test) Waste segregation 0.0 0.0 0.0 – Colour coding 0.0 0.0 0.0 – Waste handling, storage and transport Use of personal protective equipment Gloves (surgical or thick) 80.0 85.7 66.7 1.00 Face masks 40.0 57.1 0.0 0.20 Plastic aprons 30.0 42.9 0.0 0.48 Protective shoes/long boots 40.0 57.1 0.0 0.20 Presence of temporary waste storage area 90.0 85.7 100.0 1.00 Restricted access to temporary storage area 20.0 28.6 0.0 1.00 At least once monthly disinfection of temporary storage area 40.0 57.1 0.0 0.20 Internal transport containers Plastic bags 20.0 28.6 0.0 1.00 Containers with lids 40.0 42.9 33.3 1.00 Containers without lids 50.0 42.9 66.7 1.00 Internal transport vehicles/medium Trolley (3 or 4 wheels) 20.0 14.3 33.3 1.00 Carts/wheelbarrows (1 or 2 wheels) 60.0 57.1 66.7 1.00 Manually carrying bags/by hand 60.0 71.4 33.3 0.50 Waste disposal Incinerators Present 70.0 57.1 100.0 0.48 Functional (n = 7) 71.4 100.0 33.3 0.14

*Caution should be used to interpret the P values due to small sample size. HWM = hospital waste management.

A temporary waste storage area was present in 90% the designated waste storage facility should be totally of the surveyed hospitals (Table 5). Overall, only 40% enclosed and secure from unauthorized access). regularly disinfected the storage area (frequency ranged Regarding containers for internal transportation from daily to once monthly). Eighty percent of the of hospital waste, 20% of the surveyed hospitals were temporary waste storage areas were open to anyone and using plastic bags, 40% were using containers with had no restricted access (HWM 2005 rules specify that lids, while 50% had containers without lids (Table 5).

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The proportions were not mutually exclusive as some for compliance, and lack of a minimum dedicated HWM hospitals were using multiple types of internal transport budget, may explain the limited capacity of the public containers. For internal transportation media or vehicles, hospitals to follow the HWM 2005 rules. 20% of hospitals were only using a 3- or 4-wheel trolley, We identified absence of formal HWM training 20% had only 1- or 2-wheel carts or wheelbarrows, while sessions for healthcare workers in many surveyed in 20% hospital waste was transported only by hand (i.e., hospitals. Most of the newly hired workers in such manually lifted by HWM staff). It is important to note hospitals were informally coached by their immediate that some hospitals were using more than one means of supervisors and peers over a period of time. The lack of internal transportation of hospital waste. For instance, formal HWM training has also been reported previously 40% of the hospitals were using both 1- or 2-wheel in other cities in Pakistan (8,9,18). Besides the overall carts/wheelbarrows and manual lifting for internal limited commitment to HWM, the lack of institutional transportation. training mechanisms is expected to result from an absence Eighty percent of the tertiary care teaching hospitals of a comprehensive HWM plan, written procedures, and/ (100% public vs. 57.1% private) had incinerators and 71.4% or sufficient budget allocation (and expense) to HWM of them were functional (Table 5). The nonfunctional practices. The HWM training of all healthcare workers incinerators belonged to public sector tertiary care in general, and hospital waste handlers in particular, has teaching hospitals. The incinerators were considered been shown to be an important prerequisite for better functional if they were used regularly by the hospital waste management practices (19,20). We believe that for waste destruction. Assessment of the technical and HWM training should be standardized and repeated procedural details of the incineration process, including at regular intervals across the provincial healthcare recording the exact temperatures and discharged gases, facilities. To improve HWM practices, training must was considered beyond the scope of the present study. accompany senior management’s explicit commitment, Autoclaves were neither present nor used for waste with adequate structural and financial support. treatment by any of the surveyed hospitals. We found major gaps at every step of HWM systems, starting from waste segregation and colour coding at Discussion the point of care, to handling, storage, transportation This study assessed HWM-related policies, personnel and disposal. HWM staff in the surveyed hospitals and practice of all tertiary care teaching hospitals in did not use all the required PPE during waste handling Peshawar District for adherence to national HWM 2005 and transport. Similar results have been reported from rules. There was an alarming gap between HWM at elsewhere in Pakistan (8, 9). Studies have also frequently surveyed hospitals and the requirements prescribed in shown the link between lack of PPE use and the risk HWM 2005 rules. of exposure to blood and blood-contaminated body To align HWM policy and practice, the HWM 2005 fluids and disease contraction among HWM staff (15, rules in Pakistan specify constitution and responsibilities 21–23). The likelihood of an accidental prick is higher of HWM teams, along with the development of an HWM if the waste transport is mostly done manually, using plan (12). We found that while most of the surveyed open containers or plastic bags, and especially with hospitals had formal HWM teams, most did not have unsegregated waste in which an empty juice box may lie HWM plans, written HWM procedures, or records of next to a used infected sharp, as was found in our study. hospital waste produced. An alarming finding was that Weak oversight on the part of hospital management, none of the public hospitals had written HWM procedures, and lack of regulatory commitment from government maintained records of hospital waste produced, or institutions (departments of health and environmental had any documentation of HWM-related tasks in protection, and city administrations) and patients’ and job descriptions. Similar findings have been reported healthcare workers’ rights activists are reflected through previously by studies performed elsewhere in Pakistan the use of varying types of containers or vehicles/media and other developing countries (7,8,15,16,17). This may for internal transport of waste, inconsistent use of PPE reflect the poor HWM training of senior and mid-level among HWM staff members, and unrestricted access to hospital management, lack of managerial commitment temporary waste storage sites along with their infrequent towards an organized and documented HWM system, disinfection. and/or poor regulatory role of government, especially Most of the surveyed hospitals were located in in public hospitals. Our study also found that the overall densely populated neighbourhoods. Using incinerators number of dedicated HWM staff per 100 beds was about for hospital waste disposal risks environmental pollution 7 in surveyed hospitals, which is especially low if waste in neighbouring residential areas (24). However, despite handling and transportation is mostly done manually, the controversies regarding the use of incinerators or using small carts/wheelbarrows. The number of (24,25), when assessed for adherence to HWM 2005 HWM staff per 100 beds was even lower for public rules, the surveyed hospitals had either no incinerator sector hospitals (3 vs. 8 in private hospitals). This, along present or a nonfunctioning incinerator. In both cases, with higher inpatient flow and number of daily surgical it meant that the hospital waste was either treated as procedures, lack of proper means for waste handling domestic waste and disposed by the city waste disposal and transportation, absence of regulating inspections company, or sent for recycling. Hospitals and other health

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institutions producing potentially biohazardous waste 1. Establish a centralized district-wide integrated HWM remain responsible for any hazards that their waste may mechanism. The advantages of a central mechanism may cause in the community. Earlier studies have reported include the following. local hospitals’ practices related to selling used sharps, a. Cost savings on establishing, running and injection syringes and other plastic waste (8,26,27). In maintenance of the hospital waste disposal equipment our study, one large public sector hospital attributed its and staff. incinerator nonfunction to the inadequate gas supply b. Appropriate waste disposal in locations far from from the city gas department. Other hospitals with residential areas. Over the past 2 decades, most of the nonfunctional incinerators had equipment maintenance health facilities have clustered in few areas of Peshawar issues. It is worth mentioning that the final disposal of District and are located close to residential areas. Any the hospital waste from all the surveyed hospitals (with incinerator-based disposal of hospital waste risks or without functional incinerators) was carried out using deteriorating the air quality for the nearby residential the municipal solid waste disposal services. The fact that areas. The centralized HWM mechanism will ensure none of the surveyed hospitals treated their healthcare that the disposal is done far from residential areas. waste using autoclaves exacerbated the management challenge for the municipal waste disposal staff. The lack c. Installation of well-functioning high-temperature of adhering to proper disposal protocols in our study was incinerators with adequate capacity that can efficiently similar across both public and private hospitals. cater for all the HWM needs of the district. Our study had some limitations. The study only 2. Allocation of a predetermined percentage of total included tertiary care teaching hospitals in Peshawar hospital funds on practices related to HWM, especially District. The study did not include other nontertiary for public sector hospitals. public and private hospitals of varying bed size. 3. Training and capacity building of HWM-related Conclusion staff should be led by the Department of Health. The Department should develop and implement uniform This is believed to be the first study in Khyber HWM training programmes, followed by third party Pakhtunkhwa Province to evaluate adherence to HWM evaluations to identify the level of adherence in health 2005 rules implemented nationally more than a decade facilities. The Department should also provide guidance ago. This study highlights the lack of adherence to related to PPE, transport equipment, containers, national HWM 2005 rules by all the tertiary care teaching disinfection and sterilization materials, and training hospitals in Peshawar District. There is an urgent need manuals. Lastly, the management of the individual health for the implementation of the HWM 2005 rules by the facilities should be held accountable for implementing hospitals and other healthcare facilities. The government regular effective HWM trainings of their staff. authorities should play a leading role by supporting healthcare providers with development of HWM teams 4. A functional health inspection mechanism should and plans, creation of standardized HWM training be created that facilitates regular inspections and modules, and establishment of frequent monitoring of evaluations, and provides feedback for legal and their HWM practices. An integrated city-wide medical regulatory compliance to respective health facilities. This waste disposal mechanism may prove useful to reduce may require a supplementary provincial legal framework in the form of provincial HWM rules based on KPEPA the current waste burden on large hospitals. Services 2014 and/or amending the existing healthcare regulatory of such integrated medical waste disposal procedures mechanisms (e.g., Provincial Health Care Commission should also be extended to other small hospitals, clinics that regulates all healthcare services) with appropriate and laboratories. HWM-related requirements. The hospital management must have a regular internal inspection and evaluation Recommendations mechanism as they hold the primary responsibility In view of multiple gaps in the HWM practices highlighted towards implementation of all internal and external by this study, we make the following recommendations. regulatory requirements. Funding: None. Competing interests: None declared. Pratiques et application des réglementations nationales en matière de gestion des déchets hospitaliers 2005 : étude de cas au Pakistan Résumé Contexte : Les réglementations en matière de gestion des déchets hospitaliers au Pakistan ont été publiées en 2005. Dix ans après leur adoption, l’observation des réglementations de 2005 en matière de gestion des déchets hospitaliers demeure incohérente, et une évaluation systématique de la conformité à l’aide d’un questionnaire recommandé par l'Organistation

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mondiale de la Santé (OMS) n’a pas été effectuée dans tous les hôpitaux universitaires du district de Peshawar (Khyber Pakhtunkhwa). Objectif : La présente étude a évalué l’observation des réglementations de 2005 en matière de gestion des déchets hospitaliers par les hôpitaux universitaires de soins tertiaires dans le district de Peshawar eu égard au personnel, aux politiques et aux pratiques de gestion des déchets hospitaliers. Méthodes : Des questionnaires structurés prétestés reposant sur les recommandations de l’OMS ont été utilisés pour enquêter dans tous les hôpitaux universitaires du district de Peshawar entre janvier et mars 2015. Des données ont également été recueillies sur les infrastructures et les processus de gestion des déchets hospitaliers auprès de départements de médecine, de chirurgie, de pédiatrie, de gynécologie/d’obstétrique sélectionnés de façon aléatoire dans chaque hôpital. Outre les statistiques descriptives, les hôpitaux publics et privés ont été comparés à l’aide du test exact de Fisher et du test des rangs signés de Wilcoxon. Résultats : La plupart des hôpitaux enquêtés n'avaient pas de plans officiels (70 %), de procédures écrites (80 %), de descriptifs de postes associés (80 %) ou de dossiers (90 %) pour la gestion des déchets hospitaliers. De nombreux hôpitaux n’avaient pas formé de responsables en gestion des déchets hospitaliers (56 %), ou organisé de formations officielles dans le domaine pour les nouveaux membres du personnel (40 %). Aucun des hôpitaux ne procédait à un tri des déchets ou n’appliquait le code couleurs. Eu égard aux réglementations nationales en matière de gestion des déchets hospitaliers, des lacunes multiples en matière de transports, d’entreposage et d’élimination appropriés ont été révélées, sans différences significatives entre les hôpitaux publics et privés. Conclusions : Il existe de sérieuses lacunes concernant le respect des réglementations de 2005 en matière de gestion des déchets hospitaliers dans les hôpitaux ayant fait l’objet de l’enquête. Au vu de la décentralisation récente de la gestion environnementale, le gouvernement de Khyber Pakhtunkhwa devrait adopter des réglementations en matière de gestion des déchets hospitaliers à l’échelle de la province (et garantir leur application) afin de faciliter la mise en place de pratiques efficaces de gestion des déchets hospitaliers au sein des établissements de soins de santé dans la province.

ممارسات وتنفيذ القواعد الوطنية إلدارة نفاقات املستشفيات لعام 2005 يف باكستان حممد فضل ذيشان، أمحد العباد، عبد العزيز، افتاب سبحاين، آصف شاه، طاهر خان، هداية اهلل، عمري قايض اخلالصة اخللفية: صدرت قواعد إدارة نفايات املستشفيات يف باكستان يف عام . 2005وعىل الرغم من مرور عقد عىل سن هذه القواعد، ظل االمتثال هلا يفتقر إىل االتساق، ومل ُجيرأي تقييم منهجي لالمتثال باستخدام استبيان موىص به من منظمة الصحة العاملية يف مجيع املستشفيات التعليمية يف منطقة بيشاور. اهلدف: عمدت هذه الدراسة إىل تقييم االمتثال لقواعد إدارة نفايات املستشفيات لعام يف2005 مستشفيات الرعاية الثالثية التعليمية يف منطقة بيشاور بالنسبة للمختصني بإدارة نفايات املستشفيات وسياساهتا وممارساهتا. طرق البحث: ُاستخدمت استبيانات ّ ةمنظم ّوجمربة ًسلفا ًاستناداإىل توصيات منظمة الصحة العاملية ملسح مجيع املستشفيات التعليمية يف منطقة بيشاور يف الفرتة من يناير إىل مارس . 2015ومجعت بيانات أيضا بشأن البنية التحتية إلدارة نفايات املستشفيات وعملياهتا من وحدة واحدة من كل من أقسام الباطنة، اجلراحة، طب األطفال، النساء والوالدة اختريت ًيف عشوائياكل مستشفى. وباإلضافة إىل اإلحصاءات الوصفية، أجريت مقارنة بني مستشفيات عامة وخاصة باستخدام اختبار فيرش الدقيق واختبار ويلكوكسون حلساب جمموع الرتب. النتائج: افتقرت معظم املستشفيات اخلاضعة لالستقصاء ألي خطط رسمية إلدارة نفايات املستشفيات )70%( أو إجراءات مكتوبة )80%( أو توصيف للوظائف ذات الصلة )80%( أو سجالت ) %(. 90ومل يقدم كثري من املستشفيات أي تدريب للمرشفني )56%( وال تنظيم دورات تدريبية رسمية بشأن إدارة نفايات املستشفيات للموظفني اجلدد ) %(. 40ومل تلتزم أي من املستشفيات بفصل النفايات والرتميز اللوين. وعند مقارنة هذه القواعد بالقواعد الوطنية إلدارة نفايات املستشفيات لعام 2005، ظهرت عدة فجوات تتصل بالنقل والتخزين والتخلص املالئم مع عدم ظهور أي فرق ذي داللة إحصائية بني املستشفيات العامة واخلاصة. االستنتاج: توجد فجوات خطرية يف االمتثال لقواعد إدارة نفايات املستشفيات لعام يف2005 املستشفيات اخلاضعة للمسح. وبعد إلغاء الوظيفة البيئية ً،ينبغي مؤخراحلكومة خيرب باختونخوا سن قواعد إلدارة نفايات املستشفيات عىل مستوى املقاطعات )وكفالة تنفيذها( لتيسري ممارسة إدارة نفايات املستشفيات بفعالية يف مجيع مرافق الرعاية الصحية عىل مستوى املقاطعات.

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3. Gupta S, Boojh R. Report: biomedical waste management practices at Balrampur Hospital, Lucknow, India. Waste Manag Res. 2006 Dec;24(6):584–91. http://dx.doi.org/10.1177/0734242X06068342 PMID:17253005 4. Farzadkia M, Moradi A, Mohammadi MS, Jorfi S. Hospital waste management status in Iran: a case study in the teaching hospitals of Iran University of Medical Sciences. Waste Manag Res. 2009 Jun;27(4):384–9. http://dx.doi. org/10.1177/0734242X09335703 PMID:19487312 5. Hageman JP. Handling, storage, treatment, and disposal of mixed wastes at medical facilities and academic institutions. Health Phys. 2002 May;82(5) Suppl:S66–76. http://dx.doi.org/10.1097/00004032-200205001-00007 PMID:12003031 6. Ali S, Mahmood U, Malik AU, Aziz F, Naghman RB, Ahmed I. Current hospital waste management practices in Pakistan: case study and curative measures. Public Health Prevent Med. 2015 Aug;1(3):125–9. http://files.aiscience.org/journal/article/ html/70260042.html 7. Khattak FH. Hospital waste management in Pakistan. Pak J Med Res. 2009 Jan–Mar;48(1):19–23. 8. Rasheed S, Iqbal S, Baig LA, Mufti K. Hospital waste management in the teaching hospitals of Karachi. J Pak Med Assoc. 2005 May;55(5):192–5. PMID:15960283 9. Kumar R, Khan EA, Ahmed J, Khan Z, Magan M, Nousheen A, et al. Healthcare waste management (HCWM) in Pakistan: current situation and training options. J Ayub Med Coll Abbottabad. 2010 Oct-Dec;22(4):101–5. PMID:22455273 10. Rohra DK, Jawaid A, Rehman T, Sukkurwala AQ, Palanpurwala AS, Gangwani R, et al. Waste disposal of government health-care facilities in urban area of Karachi-A KAP Survey. Pak J Med Res. 2007;46(1):5–10. 11. Khan JA. Hospital waste management issues and steps taken by the Government of Pakistan Oct 2006 (http://www.env.go.jp/ recycle/3r/en/asia/02_03-2/04.pdf, accessed 16 January 2018). 12. Hospital Waste Management Rules, 2005. Ministry of Environment, Government of Pakistan; 2005 (http://www.environment. gov.pk/act-rules/rHWMRules2005.PDF, accessed 16 Jaunary 2018). 13. Prüss A, Giroult E, Rushbrook P (editors). Safe management of wastes from health-care activities. Geneva: World Health Organization; 1999 (http://apps.who.int/iris/bitstream/10665/42175/1/9241545259.pdf, accessed 16 January 2018). 14. Khyber Pakhtunkhwa in Figures 2015. Bureau of Statistics, Government of Khyber Pakhtunkhwa; 2015 (http://kpbos.gov.pk/ files/1456999405.pdf, accessed 16 January 2018) 15. Camacho-Ortiz A, Díaz-Rodríguez X, Rodríguez-López JM, Martínez-Palomares M, Palomares-De la Rosa A, Garza-Gonzalez E. A 5-year surveillance of occupational exposure to bloodborne pathogens in a university teaching hospital in Monterrey, Mexico. Am J Infect Control. 2013 Sep;41(9):e85–8. http://dx.doi.org/10.1016/j.ajic.2013.01.008 PMID:23523519 16. Abdulla F, Qdais HA, Rabi A. Site investigation on medical waste management practices in northern Jordan. Waste Manage. 2008;28(2):450–8. 17. Patil AD, Shekdar AV. Health-care waste management in India. J Environ Manage. 2001 Oct;63(2):211–20. http://dx.doi.org/10.1006/ jema.2001.0453 PMID:11721600 18. Imdad S, Anwar S, Shoukat MS. Healthcare waste: evaluation of its generation rate and management practices in tertiary care hospitals of Lahore. Ann King Edward Med Univ. 2013 Oct–Dec;19(4):274–81 (https://doi.org/10.21649/akemu.v19i4.527, accessed 16 January 2018). 19. Kumar R, Somrongthong R, Shaikh BT. Effectiveness of intensive healthcare waste management training model among health professionals at teaching hospitals of Pakistan: a quasi-experimental study. BMC Health Serv Res. 2015 02 28;15(1):81. http:// dx.doi.org/10.1186/s12913-015-0758-7 PMID:25889451 20. Sapkota B, Gupta GK, Mainali D. Impact of intervention on healthcare waste management practices in a tertiary care governmental hospital of Nepal. BMC Public Health. 2014 Sep 26;14(1):1005. http://dx.doi.org/10.1186/1471-2458-14-1005 PMID:25261099 21. Mol MP, Gonçalves JP, Silva EA, Scarponi CF, Greco DB, Cairncross S, et al. Seroprevalence of hepatitis B and C among domestic and healthcare waste handlers in Belo Horizonte, Brazil. Waste Manage Res. 2016 Sep;34(9):875–83. http://dx.doi. org/10.1177/0734242X16649686 PMID:27207769 22. Ream PSF, Tipple AFV, Barros DX, Souza ACS, Pereira MS. Biological risk among hospital housekeepers. Arch Environ Occup Health. 2016;71(2):59–65. http://dx.doi.org/10.1080/19338244.2014.927347 PMID:25136771 23. Shiferaw Y, Abebe T, Mihret A. Sharps injuries and exposure to blood and bloodstained body fluids involving medical waste handlers. Waste Manag Res. 2012 Dec;30(12):1299–305. http://dx.doi.org/10.1177/0734242X12459550 PMID:22964471 24. Thornton J, McCally M, Orris P, Weinberg J. Hospitals and plastics. Dioxin prevention and medical waste incinerators. Public Health Rep. 1996 Jul–Aug;111(4):298–313. PMID:8711095 25. Chaerul M, Tanaka M, Shekdar AV. A system dynamics approach for hospital waste management. Waste Manage. 2008;28(2):442–9. 26. Mahmood SS, Malik R, Azim W. A study of waste generation, collection and disposal in a tertiary hospital in Pakistan. Pak J Med Res. 2001;40(1):13–7. 27. Abdul Mujeeb S, Adil MM, Altaf A, Hutin Y, Luby S. Recycling of injection equipment in Pakistan. Infect Control Hosp Epidemiol. 2003 Feb;24(2):145–6. http://dx.doi.org/10.1086/502175 PMID:12602701

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Parental vaccine knowledge and behaviours: a survey of Turkish families

Soner Sertan Kara,1 Meltem Polat,1 Burcu Ceylan Yayla,1 Tugba Bedir Demirdag,1 Anil Tapisiz,1 Hasan Tezer1 and Aysu Duyan Camurdan2

1Department of Paediatric Infectious Diseases; 2Department of Social Paediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey (Correspondence to: Soner S. Kara: [email protected]).

Abstract Background Personal and herd immunity require durability in high vaccination coverage rates, and this mainly depends on the interaction between parental and service/provider factors. Aims: The aim of this study was to assess Turkish parents' knowledge and behaviours concerning childhood vaccination and their association with familial sociodemographic characteristics. Methods: A cross-sectional survey, including a questionnaire, was conducted with parents of children aged between 1 day and 120 months. Results: Of the 903 index children, 881 (97.6%) were up to date for all vaccinations by age. Demographic variables were not related to belief in protection through vaccination or rejection of obligatory vaccines. Mean age, education level, occupation of mother (P = 0.006, P < 0.001, and P = 0.01, respectively) and father (P = 0.002, P < 0.001, and P = 0.006, respectively), average monthly household income (P < 0.001), and experience of vaccine side-effects (P = 0.02) were associated with knowledge about optional childhood vaccines. Father’s education level was independently associated with knowledge about optional childhood vaccines. Conclusions: Having any experience of vaccine side-effects and parental sociodemographic characteristics, especially father’s education level, affect Turkish parents' knowledge of childhood optional vaccines. Keywords: Childhood, vaccine, immunization, parental knowledge, Turkey Citation: Kara SS; Polat M; Cura Yayla B; Bedir Demirdag T; Tapisiz A; Tezer H; et al. Parental vacccine knowledge and behaviours: a survey of Turkish families. East Mediterr Health J. 2018;24(5):451-458. https://doi.org/10.26719/2018.24.5.451 Received: 07/04/16; accepted: 15/05/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction parents the choice of accepting one or more optional vaccines (5). The coverage for optional vaccines may vary Vaccination is one of the main preventive measures in in different populations for various reasons, such as low national public health policies. Over the last few decades, awareness and the perceived costs of obtaining these newer vaccines have been rapidly added to the Turkish vaccines (6). national immunization programme and are provided Turkey’s geographical position, its close proximity free and without obligation by the Ministry of Health (1). to countries in a state of war and with low vaccination Except for optional vaccines [rotavirus, meningococcal, coverage, and receiving extensive immigration always human papillomavirus (HPV), and influenza virus], raises the possibility of a reintroduction of formerly the Turkish national immunization programme offers eradicated vaccine-preventable diseases such as polio vaccines that protect against most of the vaccine- (7). In addition to these epidemiological risks, parents’ preventable diseases typically addressed by equivalent negative perceptions and attitudes and lack of knowledge programmes in developed countries (2,3). regarding immunization may gradually lower the According to Ministry of Health data, very high high vaccination rates achieved so far. In different vaccination coverage rates of 96–97% were reported for populations, under-vaccination has been shown to be the vaccines in the national immunization programme in related to inadequate immunization services and parental 2012 [for diphtheria, tetanus, acellular pertussis vaccines knowledge, attitudes and concerns (8,9). (DTaP)-1-2-3, measles, mumps, rubella (MMR), 7-valent In order to sustain high vaccination coverage rates pneumococcal conjugate vaccine (PCV7) and hepatitis and to maintain positive family attitudes towards B (HBV)-1-2-3] (4), enough to achieve herd immunity vaccination, vaccination interventions must be targeted for these diseases, and thus protect even unvaccinated on the basis of areas of interest, such as parents’ children. knowledge, attitudes and beliefs or levels of hesitancy, in Recommending optional vaccines is considered an addition to how parents assess vaccination (10). integral part of the health services provided in paediatric The aim of this study was to assess the current clinics. While ensuring that all babies are up to date with knowledge and behaviours of Turkish parents their compulsory immunizations, counselling can give concerning childhood vaccines and vaccination, and

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to demonstrate the associations between vaccination Children’s vaccination status was defined as status, belief in the protective effects of vaccination, completely immunized if they had been immunized up parental thinking regarding rejected childhood vaccines, to age and partially immunized if they had missed at knowledge concerning childhood optional vaccines and least 1 of the vaccines in the programme. Children in our sociodemographic characteristics. study who had not received either hepatitis A or varicella- zoster vaccines were nonetheless regarded as completely Methods immunized because the majority of the children were older than the recommended age for these vaccines. This cross-sectional survey of a non-randomized sample Verbal informed consent was obtained from all of 903 parents (57% of 1560 eligible parents) was carried parents. Approval was granted for the study from out at paediatric outpatient clinics (paediatrics, paediatric the Institutional Ethical Committee of the Faculty of infectious diseases, and well-child care) in Gazi University Medicine, Gazi University. The patient’s identity and Hospital between 1 January and 31 December 2014. Data other personal information were kept confidential at data for the study were based on interviews with parents of analysis by using unique codes for each patient. index children aged between 1 day and 120 months at the time of the study, and who consented to participate while Data were analysed using SPSS, version 16.0. The attending for various medical reasons. The interviews Kolmogorov–Smirnov test was used to verify that were conducted by 2 specialists in paediatric infectious continuous variables were normally distributed. diseases, who also explained the medical terms involved. Continuous variables were expressed as mean and The vaccination status of the index children was standard deviation (SD) or median (minimum– determined by checking written vaccination records or maximum), and categorical variables were expressed on the basis of parental declarations if no such a card was as percentages. The independent samples t-test was available, and this was later compared with the digital used for continuous variables and the chi-squared test records of the hospital. for categorical variables. Those variables identified as significant for possession of knowledge of optional The study questionnaire included open and closed childhood vaccines at univariate analysis (sex of child questions. Some items in the survey were drafted by and parent, education level of mother and father, and modifying similar, previously published surveys (11–14). presence of any experience of vaccine side-effects) were In addition to general demographic variables (age and sex included in binary logistic regression analysis in order of index children; age, level of education and occupation to explore independent associations with knowledge of of both parents; average monthly household income) and these vaccines (the answers to the parental knowledge underlying disease of index children, the questionnaire of optional childhood vaccines on the 5-point Likert-type also enquired into parents’ knowledge and behaviours scale were grouped into 2 in this analysis: “yes, I certainly concerning vaccines (whether vaccines were thought agree” and “ yes I agree” were included in 1 group and to be protective, whether any vaccines in the national the rest were included in the other group). Statistical immunization programme were unacceptable, whether significance was set atP < 0.05. the optional vaccines were known, which optional vaccines had been administered, whether any adverse Results reactions related to vaccines had been experienced, and from which person/setting the caregivers first seek Participants assistance in the event of adverse reactions during We surveyed 903 parents for this study. Most were from vaccination). the Paediatric Infectious Diseases clinic (n = 567, 62.8%) In order to assess belief in the protective effects of and were mothers (n = 651, 72.1%). vaccination, caregivers were asked if they thought the Personal characteristics of the children investigated vaccines were protective or not, and their answers were Characteristics of the index children and parents are scored on a 5-point Likert-type scale. Answers ranged shown in Table 1. The median age was 36 months (range from “yes, certainly” to “no, certainly not”. 6 days to 120 months). There were 470 male children In order to assess attitudes to routine vaccines, (52.0%) and 433 females (48.0%), a male to female ratio caregivers were asked whether there were any of 1.08. We found that 135 children (14.9%) had a chronic unacceptable vaccines for their child in the national disease, the most common being immunodeficiency (n immunization programme. Answers on a 5-point Likert- = 23, 2.5%). Most of the caregivers involved in the child’s type scale ranged from “There is no routine vaccine that vaccination were mothers (n = 507, 56.1%). The mean ages I refuse to use for my child(ren)” to “I refuse to vaccinate of mothers and fathers was 32.2 (SD 6.2) and 35.7 (SD 6.4) my child(ren) with any of the routine vaccines”. In order years, respectively. The majority of mothers and fathers to assess knowledge of optional vaccines, caregivers had graduated from secondary or high school (n = 450, were asked whether there were any optional vaccines 49.8% and n = 477, 52.8%, respectively). Average monthly not included in the national immunization programme household incomes mostly fell into the highest category that they could pay for and have their children vaccinated (> 4000 TL/month) (n = 274, 30.3%). Nearly half (54.2%) with. Answers ranged from “Yes, I certainly agree” to “No, of the families had average monthly incomes above I certainly do not agree” on a 5-point Likert-type scale. the rural poverty threshold, while 30.3% were over the

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poverty threshold for whole of Turkey determined by the There were no unvaccinated children, but 22 (2.4%) Turkish Statistical Institute (15). were only partially immunized. Reasons cited for partial immunization were wishing the child to acquire immunity through natural infections (n = 8, 36.3%), lack Table 1. Characteristics of the index children and parents of interest (n = 6, 27.2%), thinking that vaccination causes Characteristic No. % serious side-effects (n = 4, 18.1%), believing vaccination Median age of children (months) (range) 36 (0.2–120) to be useless (n = 3, 13.6%), and thinking that vaccination Sex of index child causes illness (n = 1, 4.5%). No statistically significant association was observed between the immunization Male 470 52.0 status of the index children and the characteristics of Female 433 48.0 the study population (age of the index children and their Principal caregiver involved in child’s vaccination parents, gender and underlying diseases of the index Mother 507 56.1 children, education level and occupation of both parents, Father 17 1.9 and average monthly household income of the family). Mother & father 372 41.2 Knowledge and beliefs of parents regarding Other (grandmother, uncle, etc.) 7 0.8 childhood vaccines and vaccination Maternal education level Most parents (n = 859, 95.1%) reported believing in Elementary school 84 9.3 the protective effects of vaccination. No statistically Secondary/high school 450 49.8 significant association was determined between belief in University 369 40.9 vaccination’s protective effects and the characteristics of the study population (P > 0.05). Maternal occupation Housewife 558 61.8 In our study population, 2.7% (n = 25) of parents considered one or more vaccines in the childhood Public official 260 28.7 national immunization programme unacceptable. Self employed 41 4.5 Levels of rejection of hepatitis B (n = 13, 52.0%), Bacillus Doctor/nurse 44 4.8 Calmette–Guérin vaccine (BCG) (n = 10, 40.0%), hepatitis Paternal education level A (n = 10, 40.0%), diphtheria, tetanus, acellular pertussis, Elementary school 71 7.8 inactivated polio, Haemophilus influenza type B vaccine Secondary/high school 477 52.8 (DTaP-IPV-Hib) (n = 10, 40.0%), MMR (n = 9, 36.0%), University 355 39.3 varicella (n = 8, 32.0%), and oral polio vaccine (OPV) (n = 7, 28.0%) were all similar. No association was determined Paternal occupation between the characteristics of the study population and Manual 245 27.1 parental thinking regarding unacceptable childhood Public official 349 38.6 vaccine(s) (P > 0.05). Self employed 297 32.8 Two-thirds of parents (n = 602, 66.6%) knew about Doctor 12 1.3 optional vaccines. Of these, 33.4% (n=302) had their Average monthly household income (TL)α children inoculated with optional vaccines. Influenza (n < 1000 171 18.9 = 97, 32.1%) and rotavirus (n = 94, 31.1%) were the mostly 1000–3000 242 26.8 popular and implemented vaccines. Three hundred one (33.3%) parents were completely uninformed about 3001–4000 216 23.9 optional vaccines, and 78.7% (n = 237) of these felt that > 4000 274 30.3 health-care professionals, especially doctors, should have Immunization status of index children informed them about optional vaccines. The relationship Completely immunized 881 97.5 between the characteristics of the study population and Partially immunized 22 2.4 parental knowledge of the optional vaccines is shown Unimmunized 0 0 in Table 2. While the median age of the index children Underlying diseases of the index children was not associated with knowledge of optional childhood vaccine(s), the mean ages of the mothers and fathers were Immunodeficiency 23 2.5 statistically significantly correlated with such knowledge Chronic heart disease 8 0.9 (P = 0.006 and P = 0.002, respectively). Parents’ education Chronic lung disease 17 1.9 level, occupation of mothers and fathers, average monthly Renal disease 10 1.1 household income and any experience of vaccine side- Diabetes mellitus 3 0.3 effects were also statistically significantly correlated Otherb 74 8.2 with knowledge of optional childhood vaccines (Table 2). None 768 85.0 Regression analysis showed that the father’s education

a1 US$ 2.6 Turkish lira (TL). level was independently associated with knowledge of bIncludes congenital metabolic/neurometabolic disorders, other endocrinopathies, optional childhood vaccines (Table 3). Fathers who had ≅ neurological disorders, etc. graduated from secondary/high school had a 1.8-fold

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Table 2. Relations between the characteristics of the study population and parental knowledge of optional childhood vaccines Characteristic Optional childhood vaccines known Yes No P-value Median age of index children (years) mean (SD) 3.5 (2.8) 3.4 (3.0) 0.81 Mean (SD) age of fathers 36.2 (6.3) 34.8 (6.5) 0.002* Mean (SD) age of mother 32.6 (6.1) 31.4 (6.4) 0.006* No. % No. % Male sex in index children 310 66.0 160 34.0 0.63 Chronic diseases in children 0.84 Present 89 14.8 46 15.2 Not present 513 85.2 255 84.7 Education level of mother < 0.001* Elementary school 2 0.3 2 0.6 Secondary/high school 314 52.1 216 71.7 University 286 47.5 83 27.5 Occupation of mother 0.01* Housewife 346 57.4 212 70.4 Government official 196 32.5 64 21.2 Self-employed 26 4.3 15 4.9 Doctor/nurse 34 5.6 10 3.3 Education level of father < 0.001* Elementary school 1 0.1 1 0.2 Secondary/high school 316 52.4 230 76.4 University 285 47.3 70 23.2 Occupation of father 0.006* Manual 143 23.7 102 33.8 Public official 249 41.3 100 33.2 Self employed 200 33.2 97 32.2 Doctor 10 1.6 2 0.6 Average monthly household income (TL)a < 0.001* < 1000 85 14.1 86 28.5 1000–3000 161 26.7 81 26.9 3001–4000 137 22.7 79 26.2 > 4000 219 36.3 55 18.2 Rejection of any childhood vaccine 0.77 Yes 16 64.0 9 36.0 No 586 66.7 292 33.3 Experience of vaccine side-effects 0.02* Present 550 91.3 261 86.7 Not present 52 8.6 40 13.2

SD = standard deviation. a1 US$ 2.6 Turkish liras (TL). *Statistically significant (P < 0.05). ≅

Table 3. Regression analysis of associations between population greater knowledge of optional childhood vaccines and characteristics and parental knowledge of optional childhood university graduate fathers a 4.1-fold greater knowledge vaccines compared to fathers who had graduated from elementary Independent Odds ratio 95% confidence P school. parameter interval Adverse events and medical information Education level of fathers 0.03 Elementary school Reference Adverse events caused by any vaccine were reported by 811 (89.8%) parents. The most common adverse event Secondary/high school 1.8 1.050–3.138 was fever (n = 670; 74.1%), followed by local reactions (n = University 4.1 2.185–7.809 456, 50.4%) and irritability n = 257; 28.4%). The first place

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where caregivers sought information about vaccinations for seasonal influenza vaccine was 15%, lower than and adverse reactions when these occurred during in our study (3). In the present study, parents with no vaccination were the paediatrician (n = 456, 50.4%), knowledge about optional vaccines felt that health care followed by the family physician (n = 296, 32.7%), the nurse professionals should have informed them. Similarly, who administered the vaccine (n = 112, 12.4%), the internet Bardenheier et al. reported that not having received a (n = 21, 2.3%), and finally parents of other children who doctor’s or health department recommendation for the may have experienced similar side-effects (n = 3, 0.3%). Hep A vaccine was cited as the factor most strongly associated with not receiving that vaccination (18). In a Discussion previous Turkish study (16), parents of children who did not receive the influenza vaccine tended to believe that This study represents an evaluation of Turkish vaccination was not essential, rather than citing a lack of parental beliefs, knowledge, attitude, and behaviours recommendation. toward childhood vaccines and vaccination. The study population exhibited a slightly higher percentage of Most of the index children (97.6%) in this study immunization than the Turkish national data reported were up-to-date for all vaccinations. Only 2.7% of the by the Ministry of Health for each vaccine (4). This may respondents declared an unwillingness to vaccinate be associated with the city, Ankara, where the study was their children with one or more of the routine vaccines performed. Ankara is the capital of Turkey, and health in the national immunization programme. These low care services are more available and caregivers’ education percentages made it impossible to determine statistically levels are higher than the average national values. The significant associations with familial sociodemographic parents in the study population were generally young characteristics. In contrast, nearly 12% of American parents adults, and most were educated to secondary/high school have been reported to refuse at least one recommended level or above. Occupation of both parents, and older childhood vaccine (14). The American Academy of parental age, education level and family income were Pediatrics advises physicians to respond to vaccine associated with parental knowledge of optional vaccines. refusal by respectfully listening to parents’ concerns We believe that a certain level of economic status and and discussing the risks associated with nonvaccination knowledge and understanding of vaccines and their (19). For partially immunized children, although routine benefits are important if a vaccine involving additional vaccines are provided free of charge by the government, costs is to attract the interest of parents. Data concerning other costs such as transportation may account for optional vaccines are scarce in the Turkish-language children not being up-to-date for all vaccinations. Parental literature, and the results of this study are particularly uncertainty regarding the importance of immunization significant from that perspective. Logistic regression may have resulted in undervaccination, and such anxiety analysis showed that levels of paternal knowledge of also needs to be alleviated with adequate information optional vaccines increased in line with education level. (20). Providing better information for parents (9), mass However, that association did not apply to mothers. immunization campaigns and proper vaccine delivery In Turkey it is mostly mothers who are responsible for systems all play an important role in vaccination uptake child care. Similarly, among the caregivers in this study in other countries (21). Parents may prefer disease- it was predominantly mothers who were involved in induced immunity to vaccination (22). In our study, no the children’s vaccinations. Strikingly, however, fathers specific vaccine was the subject of particular reluctance, still desired to receive information about vaccination. while some vaccines, e.g. measles, HBV and influenza, This may be attributed to the sociocultural structure have been unpopular owing to safety concerns in some in Turkey, which may impact on vaccination coverage parts of the world (23,24). because of fathers’ roles in decision-making on behalf Most of the index children in this study were healthy. of all family members. Previous experience with any No association was determined with immunization vaccine side-effects was also associated with knowledge status. Excepting cases of valid medical contraindications concerning optional childhood vaccines. It is likely that for immunization, as well as children who are too young such experience may have resulted in hypervigilance on to be vaccinated or whose vaccinations could not reach the part of caregivers, so they were anxious to learn more adequate efficacy and effectiveness, unvaccinated about the subject. children are not only more prone to vaccine-preventable Influenza and rotavirus vaccines were the most diseases but may also transmit these diseases to other frequently administered optional vaccines in this study. individuals (13). Children with chronic diseases therefore Although no nationwide data are available, similar need to be carefully evaluated in terms of vaccination. coverage rates to those in our study have been reported The parents in this study generally agreed that vaccines in previous research. Gunduz et al. (16) reported levels protected their children against vaccine-preventable of 8.8% for influenza and 37% for rotavirus vaccinations diseases; nevertheless, family sociodemographic among a Turkish study population. Camurdan et al. characteristics were not associated with the decision to reported an influenza vaccination rate of 50% among vaccinate. Gust et al. observed that their study population diabetic children (17). In a 2014 study from Hong Kong, generally believed in the protective effect of vaccines, but which has immunization coverage rates for mandated parents in the lowest income category and parents with vaccines similar to those in Turkey, the coverage rate lower levels of education exhibited a significantly lower

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level of belief in the protective value of vaccines than The findings of this study should be interpreted parents in other categories (12). Characteristics such as in the light of a number of limitations. The findings parental age, education and family income have been may not represent all Turkish parents: this was a cross- associated with belief in the protective properties of sectional study and the study population was sampled vaccination in other studies (19,20,22,23,25,26). from health clinics. The study population therefore A history of vaccine-related adverse events was consisted of caregivers who were least able to travel to a hospital. The study was not designed to evaluate the reported by almost 90% of parents. Such events may reason(s) for partial immunization, or which measures be expected to occur more frequently as vaccination might be taken to resolve problems identified in it. It also coverage levels increase (12). An increased frequency did not evaluate the presence of any underlying parental of vaccine-related adverse events may result in the disease, the characteristics of siblings or parental attitude global perception that vaccines are hazardous, despite towards combination vaccines, all of which may influence continued improvements in vaccine safety (11). Incorrect parental decisions, perceptions and attitudes concerning information given by, or a mistrust of, health professionals vaccination. The age range of the children was also may lead to refusal of immunization (27). Nevertheless, very wide. This may have resulted in inconsistencies paediatricians and family physicians were reported to in recalling vaccine-related experiences, especially be the most trusted sources of information regarding among the parents of older children. Additionally, vaccines and vaccinations in this study. Unfriendly or nonsignificant associations were determined between disrespectful attitudes and behaviour toward mothers on children’s immunization status, parents’ beliefs in the the part of health workers in developing countries have protective effects of vaccinations and the demographic frequently been cited as discouraging the vaccination of characteristics of the study population due to the children (8). Physicians are a most important source of disproportional distribution of the groups. A larger study reliable information regarding vaccines and vaccination, population and a multicentre design may have elicited and good communication with concerned parents to more homogeneous population characteristics. provide them with the information required is therefore In conclusion, this study may represent a useful particularly important (28). Some populations may place source of information concerning Turkish parental greater trust in other individuals or systems than in health beliefs, knowledge, attitudes and behaviours toward care professionals (29). Some people obtain information childhood vaccination. Vaccination coverage in this study from other sources such as family, friends and the was similar to national levels, although some important internet (11), which may result in the dissemination of demographic variables differed somewhat from national uncontrolled information without editorial control or averages. Parents’ sociodemographic characteristics, peer review (12). Our study population reported resorting and particularly paternal education level, were shown less to the media and internet for information, in to affect knowledge of optional vaccines in the Turkish agreement with Serpell et al. (9). population.

Funding: None. Competing interests: None declared.

Connaissance parentale des vaccins et comportements à cet égard : étude de familles turques

Résumé Contexte : L’établissement d’une immunité personnelle et collective nécessite que les taux de couverture vaccinale demeurent durablement élevés, ce qui dépend grandement de l’interaction entre les parents et les services/prestataires de vaccination. Objectifs : La présente étude avait pour objectif d’évaluer les connaissances et les comportements des parents turcs en termes de vaccination durant l’enfance, ainsi que leur association avec les caractéristiques socio-démographiques familiales. Méthodes : Une étude transversale, incluant un questionnaire, a été menée auprès des parents d’enfants dont l'âge était compris entre 1 jour et 120 mois. Résultats : Sur les 903 enfants index, 881 (97,6 %) étaient à jour pour toutes les vaccinations par groupe d’âge. Les variables démographiques n’étaient pas liées au fait de croire à une protection induite par la vaccination ou à un rejet des vaccins obligatoires. L’âge moyen, le niveau d’éducation, la profession de la mère (p = 0,006, p < 0,001, et p = 0,01, respectivement) et du père (p = 0,002, p < 0,001, et p = 0,006, respectivement), le revenu mensuel moyen du foyer (p < 0,001), et des antécédents d’effets secondaires des vaccins (p = 0,02) étaient associés à une connaissance des vaccins facultatifs pour les enfants. Le niveau d’éducation du père avait une association indépendante avec la connaissance des vaccins facultatifs pour les enfants.

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Conclusions : Les antécédents d’effets secondaires liés aux vaccins ainsi que les caractéristiques socio-démographiques parentales, notamment le niveau d’éducation du père, influencent les connaissances des parents turcs en termes de vaccins facultatifs pour les enfants.

معلومات أولياء األمور بالتطعيامت وسلوكياهتم جتاهها: دراسة استقصائية لألرس الرتكية صونر سريتان قارا، ملتم بوالد، برجو سيالن يايال، طوبى بدير دمريداغ، انيل طابسز، حسن ته زر، ايصو دويان جاموردان اخلالصة اخللفية:تستلزم املناعة الشخصية ومناعة القطيع استمرارية احلفاظ عىل معدالت تغطية مرتفعة للتطعيامت، وهو ما يعتمد ًأساسا عىل التفاعل بني أولياء األمور ومقدمي اخلدمة. هدفت األهداف:هذه الدراسة إىل تقييم معلومات أولياء األمور األتراك وسلوكياهتم إزاء تطعيم األطفال وارتباط ذلك بالسامت االجتامعية السكانية لألرسة. طرق البحث: أجري مسح مقطعي شمل إجراء استبيان، ألولياء أمور أطفال ترتاوح أعامرهم بني يوم واحد و120 ًشهرا. من النتائج:بني األطفال األساسيني البالغ عددهم 903 ً، طفالبلغ عدد األطفال الذين تلقوا أحدث التطعيامت ًوفقا لسنهم 881 ًطفال )%97.6(. وتبنيأن املتغريات السكانية ال ترتبط باإليامن باحلامية التي توفرها التطعيامت أو رفض التطعيامت اإللزامية. وتبني ارتباط متوسط عمر األم ومستوى تعليمها ومهنتها )P = 0.006، وP > 0.001، و P = عىل0.01 الرتتيب( ومتوسط عمر األب ومستوى تعليمه ومهنته )P = 0.002، وP > 0.001، وP = 0.006 عىل الرتتيب(، والتعرض السابق آلثار جانبية للتطعيم )P = ( 0.02بمعلومات التطعيامت االختيارية لألطفال. وتبني وجود ارتباط مستقل بني مستوى تعليم األب ومعلومات تطعيامت األطفال االختيارية. إنوجود االستنتاجات:خربة سابقة باآلثار اجلانبية للتطعيامت وسامت الوالدين االجتامعية السكانية، ال سيام مستوى تعليم األب، له تأثري عىل معلومات أولياء األمور األتراك بالتطعيامت االختيارية يف مرحلة الطفولة. References 1. Arisoy ES, Ceyhan M, Ciftci E, Hacimustafaoglu M, Kara A, Kuyucu N, et al. The national vaccination schedule in previously healthy children: the practical recommendations about additional vaccines. Çocuk Enfeksiyon Dergisi [J Pediatr Inf]. 2014;8:1–6. 2. Recommended immunization schedule for persons aged 0 through 18 years – United States. Atlanta: Centers for Disease Control and Prevention; 2015 (https://www.cdc.gov/vaccines/schedules/downloads/past/2015-child.pdf, accessed 01 December 2015). 3. Wang LD, Lam WW, Wu JT, Liao Q, Fielding R. Chinese immigrant parents’ vaccination decision making for children: a qualitative analysis. BMC Public Health. 2014;14:133. PMID:24507384 4. Turkish Ministry Health Annual of health statistics. Ankara: General Directorate of Health Research; 2013 (in Turkish). 5. Kannan Kutty P, Pathmanathan G, Salleh NM. Analysis of factors in response to rotavirus vaccination counselling in a private paediatric clinic. Med J Malaysia. 2010;65(2):127–32. PMID:23756797 6. Manthiram K, Blood EA, Kuppuswamy V, Martins Y, Narayan A, Burmeister K, et al. Predictors of optional immunization uptake in an urbansouth Indian population. Vaccine. 2014;32(27):3417–23. PMID: 24736005 7. Vancelik S, Guraksin A, Ayyildiz A, Beyhun NE. Seroepidemiology of poliovirus antibody among the children in Eastern Turkey. Indian J Med Res. 2007;126(6):528–33. PMID:18219079 8. Favin M, Steinglass R, Fields R, Banerjee K, Sawhney M. Why children are not vaccinated: a review of the grey literature. Int Health. 2012;4(4):229–38. PMID:24029668 9. Serpell L, Green J. Parental decision-making in childhood vaccination. Vaccine. 2006;24(19):4041–6. PMID:16530892 10. Brunson EK. How parents make decisions about their children’s vaccinations. Vaccine. 2013;31(46):5466–70. PMID:24076175 11. Downs JS, de Bruin WB, Fischhoff B. Parents’ vaccination comprehension and decisions. Vaccine. 2008;26(12):1595–607. PMID:18295940 12. Gust DA, Woodruff R, Kennedy A, Brown C, Sheedy K, Hibbs B. Parental perceptions surrounding risks and benefits of immunization. Semin Pediatr Infect Dis. 2003;14(3):207–12. PMID:12913833 13. Kennedy AM, Brown CJ, Gust DA. Vaccine beliefs of parents who oppose compulsory vaccination. Public Health Rep. 2005;120(3):252–8. PMID:16134564 14. Opel DJ, Taylor JA, Mangione-Smith R, Solomon C, Zhao C, Catz S, et al. Validity and reliability of a survey to identify vaccine- hesitant parents. Vaccine. 2011;29(38):6598–605. PMID:21763384 15. Income distribution and Living Conditions Statistics 2011. Ankara: Turkish Statistical Institute; 2014 (TUIK website) (http://www. tuik.gov.tr/PreHaberBultenleri.do?id=16083, accessed 05 November 2015) [in Turkish]. 16. Gunduz S, Yuksel NC, Aktoprak HB, Canbal M, Kaya M. Attitudes towards influenza vaccination in high socioeconomic status Turkish parents. Turk J Med Sci. 2014;44(4):649–55. PMID: 25551937

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17. Camurdan MO, Camurdan AD, Beyazova U, Bideci A. The rate of seasonal influenza vaccination in diabetic children, the effect of recommendation and the factors influencing the acceptance of recommendation: an interventional study. Balkan Med J. 2012;29(4):434–9. PMID: 25207049 18. Bardenheier B, González IM, Washington ML, Bell BP, Averhoff F, Massoudi MS, et al. Parental knowledge, attitudes, and practices associated with not receiving hepatitis A vaccine in a demonstration project in Butte County, California. Pediatrics. 2003;112(4):e269. PMID: 14523210 19. Diekma DS; American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics. 2005;115(5):1428–31. PMID: 15867060 20. Tickner S, Leman PJ, Woodcock A. Factors underlying suboptimal childhood immunisation. Vaccine. 2006;24(49–50):7030–6. PMID:16890330 21. Barreto TV, Rodrigues LC. Factors influencing childhood immunisationin an urban area of Brazil. J Epidemiol Community Health. 1992;46(4):357–61. PMID:1431706 22. Streefland PH. Public doubts about vaccination safety and resistance against vaccination. Health Policy. 2001;55(3):159–72. PMID:11164965 23. Alfredsson R, Svensson E, Trollfors B, Borres MP. Why do parents hesitate to vaccinate their children against measles, mumps and rubella? Acta Paediatr. 2004;93(9):1232–7. PMID:15384890 24. Langer-Gould A, Qian L, Tartof SY, Brara SM, Jacobsen SJ, Beaber BE, et al. Vaccines and the risk of multiple sclerosis and other central nervous system demyelinating diseases. JAMA Neurol. 2014;71(12):1506–13. PMID:25329096 25. Gust DA, Strine TW, Maurice E, Smith P, Yusuf H, Wilkinson M, et al. Underimmunization among children: effects of vaccine safety concerns on immunization status. Pediatrics. 2004;114(1):e16–22. PMID:15231968 26. Smith PJ, Humiston SG, Marcuse EK, Zhao Z, Dorell CG, Howes C, et al. Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the health belief model. Public Health Rep. 2011;126(Suppl. 2):135–46. PMID:21812176 27. Ołpiński M. Anti-vaccination movement and parental refusals of immunization of children in USA. Pediatriapolska. 2012;87(4):381–5. 28. Taylor JA, Darden PM, Slora E, Hasemeier CM, Asmussen L, Wasserman R. The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from Pediatric Research in Office Settings.Pediatrics. 1997;99(2):209–15. PMID:9024448 29. Paulussen TG, Hoekstra F, Lanting CI, Buijs GB, Hirasing RA. Determinants of Dutch parents' decisions to vaccinate their child. Vaccine. 2006;24(5):644–51. PMID:16157423

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Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children

Hoshiar Sangawi 1, John Adams 1 and Nadja Reissland 1

1Department of Psychology, University of Durham, Durham, United Kingdom (Correspondence to: H. Sangawi: [email protected]; hoshiar. [email protected]).

Abstract Background: Parenting interventions are rarely offered in developing countries and there is an urgent need to include low-income countries. Aims: To examine the effectiveness of Systematic Training for Effective Parenting (STEP) among Kurdish parents and their children. Methods: This was a randomized control pilot trial using pre- and post-test scores of 17 mothers (mean age 35.25 years, standard deviation 4.3 years; range: 29.58–45.3 years) who agreed to participate in the intervention. We utilized the Alabama Parenting Questionnaire (APQ) to assess parenting style; Parental Stress Scale (PSS) to investigate parental stress; and Step Parenting Assessment Technique (SPAT) to identify whether participants in the treatment group had learned the material of the intervention. Results: There were significant differences between the groups on 3 subscales of the APQ: mother involvement subscale, 2 2 F(1.13) = 25.81, P < 0.001, η p = 0.67; inconsistent discipline subscale, F(1.13) = 25.46, P < 0.001, η p = 0.66; and corporal 2 punishment subscale F(1.13) = 17.3, P < 0.005, η p = 0.57. A significant difference between groups was also found on the PSS, 2 F(1.13) = 19.63, P < 0.001, η p = 0.60. The changes were sustained over a 3-month period. No significant differences were found in academic self-concept and behavioural problems between children whose mothers attended STEP and others whose mothers did not attend. Conclusions: The STEP programme appears to promote parenting style and reduce the level of parental stress in Kurdish mothers. Trial Registration: IRCT2016032527125N1 Keywords: Academic self concept, behavioural problems, intervention, parenting styles, parental stress. Citation: Sangawi H; Adams J; Reissland N. Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children. East Mediterr Health J. 2018;24(5):459-468. https://doi.org/10.26719/2018.24.5.459 Received: 13/01/16; accepted: 20/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction thereby improving child behaviour (6). Based on a review and critique of 16 major parental education programmes, There is widespread evidence that positive parenting STEP is considered to be one of the best programmes, styles play a significant role in decreasing behavioural using 3 review criteria: programme readiness, strength problems among children (1,2). Parenting training is of scientific base, and empirical evidence of programme considered to be an effective approach to improve relationships between children and their parents effectiveness (7). (3). Bunting (4) examined the findings from several There has been considerable empirical research systematic reviews that summarized the effect of a evaluating the effectiveness of the STEP programme variety of parenting programmes. Their results indicated on improving parenting styles and psychological that parenting programmes have a positive influence adjustments. For instance, in a quasiexperimental study on improving behavioural and psychological outcomes by Jonyniene et al. (8), the efficacy of the STEP programme for parents and children including child behaviour, was examined amongst Lithuanian parents. The findings parent–child interaction and knowledge, and maternal showed noteworthy improvements in the parenting self-esteem and stress. Furthermore, the results of a styles and parental negative perceptions of their child’s meta-analysis by Barlow et al. (5), found that parenting behaviour. Additionally, in a study by Larson (9), 56 family programmes can be effective in alleviating maternal dyads of parents and their target children (aged 12–15 depression, reducing stress, increasing self-esteem and years) participated in STEP intervention. There was a improving the mother’s relationship with her spouse. significant increase in authoritative (positive) parenting The Systematic Training for Effective Parenting and a significant decrease in authoritarian (negative) (STEP) is considered to be helpful in improving parent– parenting style. Pan and Wu (10) also carried out an child interaction and promoting parental experiences by intervention study of STEP with 11 Chinese parents that educating parents about effective parenting methods and showed improvement in parent–child relationships.

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Huebner (11) demonstrated the benefit of STEP among These findings indicate that parents in this region 199 parents and found an improvement in quality of the need significant support to improve their parenting skills. family environment alongside a significant decrease Currently, however, there is no empirical research on the in parenting stress, particularly that originating from efficacy of educational and counselling interventions parent–child interactions. with parents in Kurdish society. The current study These studies provide evidence for the impact examined whether participation in the STEP as a on parents; however, STEP has also been found to standardized, highly structured parental education substantially improve children’s behaviour. More intervention improved Kurdish parenting styles and specifically, in the study by Larson 9( ) parents reported decreased the level of parental stress. Based on previous that their teenage children’s externalizing behaviour research it was hypothesized that mothers participating was significantly reduced after participating in a STEP in STEP would significantly improve their parenting intervention. Wantz and Recor (12) also carried out a styles and decrease their level of stress compared to those study with 11 families who participated in a 6-week who did not attend STEP. STEP intervention. The results showed a noteworthy improvement in the children’s behaviour as a result of Methods their parent’s participation in the programme. Overall, Participants these results indicate that the STEP programme plays an important role in the psychological and developmental Seventeen mothers (mean age 35.25 years, standard deviation 4.3 years; age range: 29.58–45.3 years) agreed to wellbeing of both parents and their children. participate in the intervention. Mothers were randomly Parenting interventions have been widely carried out assigned (following a simple randomization procedure) in Europe and America. For instance, a systematic review to the treatment (n = 9) or control (n = 8) group. One by Thomas et al. (13) indicated that from 14 included mother in the treatment group could only attend 4 studies, 75% were conducted in the United States of sessions and her post-test data could not be collected at America, 17% in Canada and 8% in the United Kingdom of the end of the programme. A questionnaire filled out by Great Britain and Northern Ireland. The lack of research mothers provided information about their demographic in developing countries is a clear gap in the literature. background (Table 1). It has been argued that most parenting training programmes have been tested in high-income countries Procedure and that there is an urgent need to include low-income The sample derived from a group of mothers whose countries (14,15). Currently, there is no substantial body children (in 6th grade) had taken part in a previous of evidence to show that STEP has an effect on parents study (17). Based on the Strengths and Difficulties and their children in Middle Eastern countries, including Questionnaire (SDQ) (18) symptom scores, teachers low-income areas such the Kurdistan Region of Iraq. The reported that 37 of 199 children had a high score in ≥ 1 importance of such studies was highlighted in a cross- of the behavioural problems subscales (19). Of these, 32 sectional study of 275 Kurdish college students, reporting children were also found to have higher than cut-off that during childhood 20% of students had encountered scores for negative parental style. Consequently, the at least 1 negative treatment, including physical and mothers of these 32 children were asked to participate in emotional abuse (16). It has also been reported by mass the STEP programme. media and the police that, in 2014, Kurdish children Mothers rather than fathers were asked to participate aged 3–12 years were the victims of violent treatment because Kurdish children spend more time at home with by their parents, and in 1 instance, this lead to the death their mothers than their fathers as the latter are primarily of a 5-year-old child (http://archive.xendan.org/dreja. responsible for the financial needs of the family. aspx?=hewal&jmara=7273&Jor=1). Maternal rather than paternal involvement in parenting is a significant predictor of levels of Kurdish children’s academic self-concept and behavioural problems (17). Table 1 Demographic characteristics of mothers Although there is no doubt that fathers have a significant Variables % Treatment Control role in their children’s development (20), it has been group group established that mothers have a greater impact on Educational background children’s psychological outcomes (21). Another criterion Low 71% 7 5 High 29% 2 3 was that mothers had to have ≥ 1 child in 6th grade (age 11–12 years). Mothers had to be Kurdish speakers and Mean age 36.1 yr 34.5 yr SD (5.01) SD (3.6) they also had to be no older than 50 years. Employment status An invitation letter was sent to the 32 mothers via Employed 35% 3 3 their children’s schools outlining the purpose of the study Unemployed 65% 6 5 and a brief description of the STEP programme. In the Marital status parent’s consent form it was stated that their responses Married 94% 8 8 were confidential and would only be shared with the Divorced 6% 1 0 research team. Mothers were also informed that they SD = standard deviation. would be free to withdraw at any time without giving a

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reason. Seventeen mothers agreed to participate in the scale ranging from 1 (strongly disagree) to 5 (strongly programme. agree). The positive items 1, 2, 5–8, 17 and 18 should be The treatment (STEP) group was led by the researcher reverse scored giving 5 (strongly disagree) to 1 (strongly and his assistant in weekly workshops lasting 2 hours. agree). Parents are asked to agree or disagree with items Approximately 1 week before the initial treatment, in terms of their typical relationship with their children. baseline measures were collected through questionnaires An example of a positive item would be “I am happy in from the treatment and control groups. Participants in the my role as a parent” and “The behaviour of my child(ren) treatment group were asked to return the questionnaires is often embarrassing or stressful to me” is a negative before starting the training sessions. After the treatment item. The total score is obtained by summing up the procedure, lasting 7 weeks, post-test measures were values for each item. A higher score indicates a higher requested from both groups. level of parental stress, and overall possible scores on the scale range from 18 to 90. The scale can be used for the Three months after the intervention, the evaluation of parental stress for both parents of children questionnaires were sent to the mothers in both groups via with and without clinical problems (24). The reliability of their child’s school to follow up any changes in parenting the PSS has been described as adequate, as an α coefficient styles and parental stress during the intervening period. of 0.83 and test–retest reliability of 0.81 were found in We also examined whether any positive changes in the study of Berry & Jones (24). In the current study, an α children’s academic self-concept and behavioural coefficient of 0.79 was obtained. problems were observed after their mothers attended the STEP. The data obtained for the children previously SPAT (21) were used as the pretest baseline. To obtain post-test SPAT (6) is a questionnaire that was designed for data, the children (12 boys and 4 girls) were asked to fill use during the STEP programme to ensure that the in the Myself-as-a-Learner Scale (MALS) (22) to measure participants in the treatment group learn the material their academic self-concept. Teachers also completed the from the STEP programme. SPAT comprises 20 questions SDQ (18) to identify children’s behavioural problems for a and participants are asked to agree or disagree with second time (post-test). items in terms of their typical relationship with their Measures children. Each item can be rated on a 4-point scale: 1 (strongly disagree) to 4 (strongly agree). Higher scores on APQ: version 2: parental form the scale at the end of the programme demonstrate that The APQ version 2 parental form (23) was used to measure participants have greater knowledge and understanding parenting styles. The parental form of APQ consists of of the STEP programme concepts. The α coefficient was 42 items that require parents to respond on a 5-point 0.72 in the present study. Likert scale ranging from 1 (Never) to 5 (Always). The APQ All questionnaires used in this study were translated covers 5 dimensions or subscales: parental involvement and back-translated to Kurdish by 3 professionals; 2 of (10 items; e.g., “You have a friendly talk with your child”) whom were fluent in both English and Kurdish and and positive parenting (6 items; e.g., “You let your child an English native speaker who evaluated the content know when he/she is doing a good job with something”). equivalence of each item. These 2 dimensions can be considered as a positive composite. The following dimensions are considered as a Study design negative composite, including poor parental monitoring, We used a randomized controlled design using pre- inconsistent discipline and corporal punishment. Poor and post-test scores in this pilot trial. The intervention parental monitoring comprises 10 items, such as “You tested was a 7-week structured parent educational group don’t tell your child where you are going”; inconsistent programme. Mothers assigned to the control group discipline includes 6 items, such as, “You threaten to did not receive any intervention, but completed the punish your child and then do not actually punish him/ questionnaires at the same time as the treatment groups. her”; and corporal punishment comprises 3 items, such This was a proof of principle study of whether STEP was as “You slap your child when he/she has done something effective for Kurdish mothers. wrong”. The 7 remaining items have not been assigned to Study setting a specific style, but they also assess discipline practices other than corporal punishment. These items have been The programme was held at Kankawa Primary School in included in the APQ to avoid an implicit negative bias for Sulaymaniyah City. Some parents used transportation the corporal punishment items (23). The measure of each (via buses or taxis) when attending the sessions. Thus, APQ subscale was obtained by summing the scores of for each session 7500 Iraqi dinar (US$ 6.5) was given to its items. In terms of the reliability, apart from corporal the parents as reimbursement. punishment, adequate coefficients (> 0.70) were reported Intervention (treatment) for the APQ subscales. The age-appropriate STEP programme can be typically PSS taught through 7–9 weeks and is presented in a group The PSS (24) was used to measure the level of parental workshop format with an optimal class size consisting stress. The PSS is a self-reporting scale that consists of of 6–14 parents. In terms of the lessons, each workshop 18 positive and negative items rated on a 5-point Likert takes ~2 hours. The workshops include information about

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parental behaviour and style, exploring alternative ways positive parenting, t (15) = 0.66, d = 0.32; inconsistent for parental behaviour and expressing different ideas discipline, t (15) = _0.14, d = _0.07; poor parental monitoring, and feelings, understanding the reasons for children’s t (15) = 0.43, d = 0.20; corporal punishment, t (15) = 0.22, d = misbehaviour, and developing children’s responsibilities 0.08. No significant difference was found in PSS scores,t and confidence. The programme also includes videos (15) = _0.84, d = _0.41) between the treatment and control that demonstrate examples of effective and ineffective groups. family interactions. Analysis 2: after training session In the current study 7 sessions of ~2 hours were After completion of the intervention, the data from taught. The leader reviewed the purpose of STEP and 16 mothers were entered into the analyses. To test outlined the topics that centred around the following the hypothesis that mothers participating in STEP 7 topics based on the STEP parent handbook: (A) would significantly improve their parenting style understanding yourself, your child and the reason behind and have significantly lowered stress levels compared the child’s misbehaviour; (B) understanding children’s to the controls, ANCOVA (with pretest scores as the misbehaviour and choosing an effective response for covariate) was performed. ANCOVA showed significant this behaviour; (C) encouraging your child to promote differences between groups for 3 subscales of the APQ: positive behaviour; (D) communication: how to listen to mother involvement, F(1,13) = 25.81, P < 0.001, η2 = 0.67; your child’s feelings and talk to your child; (E) helping p inconsistent discipline, F(1,13) = 25.46, P < 0.001, η2 = children cooperate; (F) discipline that makes sense; and p 0.66; and corporal punishment , F(1,13) = 17.3, P < 0.005, (G) choosing your approach (6). 2 η p = 0.57. A significant difference between groups was Data analysis 2 also found for the PSS, F(1,13) = 19.63, P < 0.001, η p = 0.60. SPSS version 21 was used for all data analyses. Frequencies No significant results were found for positive parenting were calculated for the demographic characteristics of F(1,13) = 0.77 (not significant), and poor parental styles the study population. Descriptive statistics (means and F(1,13) = 1.51 (not significant). standard deviations) were also used. Independent sample To examine the differences in more detail, pairwise t test analyses were performed to examine differences comparisons of the estimated marginal means with between groups before starting the intervention. Bonferroni adjusted levels showed a significant mean Hypotheses were tested by analysis of covariance difference between the groups. This suggested that the (ANCOVA) to investigate whether the adjusted group mothers in the treatment group achieved more positive means differed significantly from each other. ANCOVA improvements in parenting style (mother involvement, has been shown to have benefits over repeated measures, inconsistent discipline and corporal punishment) and a such as a higher power (larger F ratios) and smaller noteworthy decrease in parental stress as a result of their standard errors (25). Therefore, the assumptions of participation in the STEP programme. ANCOVA were checked to make sure that the data were To test whether the mothers in the treatment group suitable. learned the material from the STEP programme, a paired Skewness and kurtosis values for each variable were t test compared the pretest and post-test scores of the assessed based on Kline’s recommendation (26) proposing SPAT questionnaire. The sample distributions were that the skewness value for a variable should be < 3 and adequate and a high association between the 2 conditions kurtosis should be < 8. No skewness or kurtosis values (r = 0.81, P < 0.05) was found, suggesting that the paired for any variables in the current study were above those t test was suitable in this case. Consequently, the result recommended cut-offs and no significant deviations showed that the mothers’ post-test mean score in SPAT from normality were detected. With regard to the effect was significantly higher than the pretest mean, t 7( ) = size, Cohen’s d value (as assessed by Becker’s effect-size −3.28, P < 0.05, d = −0.70. 2 calculator) and partial eta-squared (η p) were used to Although the findings overall indicate that there were determine the effect size. According to Cohen’s d (1992) some improvements in the parenting style and parental guidelines, 0.2 is a small effect, 0.5 is a moderate effect stress for the treatment group, it was unclear whether the 2 and ≥ 0.8 is a large effect. Suggested norms for η p have changes would be sustained over time. In addition, it was been shown to be: small = 0.01; medium = 0.06 and large not clear whether the STEP mothers improved parenting = 0.14 (27). would affect their children’s academic self-concept and behavioural problems. Therefore, we followed up the Results mothers and their respective children after 3 months. Analysis 1: before the training session Analysis 3: differences in parenting styles and Prior to the STEP programme, an independent samples parental stress (pretest to follow-up) t test was performed to test for differences between the In this analysis we aimed to address the following treatment and control groups for the pretest scores of questions. First, did the improvements after attending the APQ and PPS. There were no significant differences STEP in parenting style and parental stress persist over a in pretest scores between the groups in each of the APQ period of time? Second, were there any positive changes subscales: mother involvement, t (15) = 0.20, d = 0.11; in children’s academic self-concept and behavioural

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problems observed after their mothers attended the Discussion STEP? The main aim of this study was to examine whether Descriptive statistics from pretest to follow-up are STEP is an effective intervention to improve parenting shown in Table 2. To find group differences from pretest style and decrease parental stress among Kurdish to follow-up, ANCOVA showed significant differences mothers. A secondary objective was follow-up 3 months between the groups for 3 subscales of the APQ (mother after intervention to measure academic self-concept 2 involvement, F(1,13) = 13.2, P < 0.005, η p = 0.50; inconsistent and behavioural problems for those children whose 2 discipline, F(1,13) = 16.3, P < 0.001, η p = 0.56; and corporal mothers attended the programme. In common with 2 punishment , F(1,13) = 24.1, P < 0.0005, η p = 0.65. No other previous findings (9,11,28) our results showed significant significant differences were found for the remaining improvements in parenting style and parental stress in APQ scales. Significant differences between groups were the treatment group. Specifically, there were significant 2 also found for the PSS, F(1,13) = 5.1, P < 0.05, η p = 0.28. differences between the groups for 3 of the subscales of Pairwise comparisons of the estimated marginal the APQ (i.e., mother involvement, inconsistent discipline means with Bonferroni adjusted levels showed that and corporal punishment) and the PSS. Mothers in mothers in the treatment group had a significantly the treatment group scored higher on the mother higher mean score for mother involvement (P < 0.005) involvement subscale and lower scores for inconsistent and lower scores for inconsistent discipline (P < 0.001), discipline, corporal punishment and PSS. Mothers corporal punishment (P < 0.0005) and PSS (P < 0.05) reported through the SPAT questionnaire that they had a than the control group had. It should be noted that the better understanding of the STEP programme materials significant group differences from pretest to follow- after intervention. up for mother involvement, inconsistent discipline The other two APQ subscales (positive parenting and and PSS were maintained, and that a larger drop for poor parental monitoring) also showed improvements, corporal punishment was noticed in the treatment group although the difference was not found to be significant. (Figure 1). There was no clear explanation for this; however, a possible reason for this result is that mothers might be Group differences in academic self-concept and more motivated to deal with inconsistent discipline and behavioural problems of children corporal punishment because STEP centres around topics The descriptive statistics for the children’s data from related to this, for example, discipline that makes sense, baseline to post-test are shown in Table 3. ANCOVA (with understanding children’s misbehaviour and choosing an baseline scores as the covariate) was performed to observe effective response for this behaviour. group differences in children’s academic self-concept At 3 months after intervention, questionnaires were and behavioural problems for children whose mothers completed by both groups. The positive changes achieved attended the intervention compared to children whose from pre- to post-test were sustained at 3 months by the mothers were in the control group. The assumptions of treatment group. Furthermore, there was a significant ANCOVA were tested. ANCOVA showed no significant and sustained continuing decrease in the use of corporal differences in academic self-concept and behavioural punishment in this group. These findings are consistent problems between children whose mothers attended with previous studies (8,29,30) in which improvements in STEP and others whose mothers did not attend (Table 4). parenting style and parental stress as a result of parenting

Table 2 Descriptive and analytical statistics from pretest to follow-up time point on the APQ and PPS Pretest scores Post-test scores Follow-up scores Treatment Control group Treatment Control group Treatment Control group Variables group (n = 8) group (n = 8) group (n = 8) (n = 9) (n = 8) (n = 8) M SD M SD P M SD M SD P M SD M SD P APQ Mother involvement 33.2 2.4 32.8 4.8 ns 37.6 2.9 33.1 4.3 0.001 38.0 3.8 33.3 3.2 0.005 Positive parenting 25.3 3.8 24.1 3.6 ns 26.1 3.0 24.5 3.7 ns 27.0 3.1 25.1 3.5 ns Inconsistent discipline 18.8 5.2 19.2 5.39 ns 13.7 3.9 18.3 3.8 0.001 14.4 2.5 18.6 4.1 0.001 Poor parental monitoring 19.3 2.7 18.5 5.1 ns 17.8 2.6 18.0 4.3 ns 17.6 2.7 17.1 4.3 ns Corporal punishment 8.2 2.3 8.0 2.3 ns 5.2 1.4 7.8 1.7 0.005 4.8 1.4 8.1 1.4 0.0005 PSS 50.5 7.1 53.3 6.5 ns 45.7 7.1 52.8 5.0 0.001 46.1 6.8 52.2 4.0 0.05

One mother in the treatment group could only attend 4 sessions and her post-test and follow-up data could not be collected at the end of the programme. The differences between groups in pretest score were analysed using a t test. The group differences in post-test and follow-up were analysed using analysis of covariance (with pretest scores as the covariate). APQ = Alabama Parenting Questionnaire; M = mean; ns = not significant; PSS = Parental Stress Scale; SD = standard deviation.

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Mother involvement Positive parenting 38 27

37 26.5 Group 36 26 Treatment Control Group 35 Treatment 25.5 Control

34 25 Estimated marginal means marginal Estimated means marginal Estimated 33 24.5

32 24

1 2 3 1 2 3 pre post Follow-up pre post Follow-up

Inconsistent discipline Poor parental monitoring 20 19.5

19 18

Group 18.5 Group Treatment Treatment 16 Control Control 18 Estimated marginal means marginal Estimated Estimated marginal means marginal Estimated 17.5 14

17

1 2 3 1 2 3 pre post Follow-up pre post Follow-up

Corporal punishment Parental stress scale 9 54

8 52

7 50 Group Group Treatment Treatment Control Control 6 48

Estimated marginal means marginal Estimated 5 means marginal Estimated 46

4 44

1 2 3 1 2 3 pre post Follow-up pre post Follow-up

Figure 1 Changes in parenting styles and parental stress between groups

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Table 3 Descriptive statistics from baseline to post-test for children Children whose mother attended Children whose mother did not attend (n = 8) (n = 8) Variables Base line Post-test Base line Post-test M SD M SD M SD M SD P Academic self-concept 74.5 12.3 78.5 11.4 76.5 8.6 77.0 10.3 0.13 SDQ Prosocial behaviour 5.4 1.06 7.0 0.84 6.4 2.4 6.7 1.67 0.12 Hyperactivity 6.0 1.2 4.2 1.04 5.0 1.8 3.6 1.2 0.48 Emotional problems 5.5 1.9 4.0 1.3 4.8 0.89 3.9 0.84 0.38 Conduct problems 3.4 1.8 3.5 0.93 3.2 2.3 3.6 0.74 0.65 Peer problems 3.4 1.1 3.6 0.92 4.4 1.4 4.6 0.73 0.13 Total difficulties 18.2 2.0 15.3 2.9 17.0 1.9 15.8 1.8 0.30 Internalizing problems 9.3 2.1 7.8 1.4 8.3 1.5 7.2 1.04 0.17 Externalizing problems 8.9 2.2 7.6 2.0 9.13 1.3 8.5 1.1 0.59

M = mean; SD = standard deviation; SDQ = Strengths and Difficulties Questionnaire.

of these children need to be studied further to reach any Table 4 ANCOVA of academic self-concept and behavioural problems among children firm conclusions. Tests of between-subjects effects Nevertheless, our results suggest that the STEP 2 programme improved parenting style and reduced Dependent variables df F P η p parental stress, which ultimately may be a key mechanism Academic self-concept 1 2.57 0.13 0.16 for change in their children’s long-term psychological SDQ and behavioural outcomes. These findings are promising Prosocial behaviour 1 2.71 0.12 0.17 because it has previously been concluded that there Hyperactivity 1 0.54 0.48 0.04 is a strong relationship between parenting style and Emotional problems 1 0.83 0.38 0.06 academic self-concept and behavioural problems (17). Conduct problems 1 0.21 0.65 0.02 STEP offers strategies for parents with which they can Peer problems 1 2.56 0.13 0.16 engage with their children more effectively; therefore, using STEP strategies over a longer period of time Total difficulties 1 1.2 0.30 0.08 may have an increasingly positive impact on reducing Internalizing problems 1 2.1 0.17 0.14 children’s behavioural problems (34). Externalizing problems 1 0.30 0.59 0.02 Our findings suggest that for Kurdish mothers the ANCOVA = analysis of covariance; df = degrees of freedom; SDQ = Strengths and STEP programme is an effective intervention for the Difficulties Questionnaire. promotion of positive parenting style and a decline in parental stress. Our proof of concept study suggests interventions were found to be sustained over a period of that such a programme is accepted by Kurdish parents time (3 months to 3 years). as a positive measure to improve their parenting skills, However, there were no significant improvements and that STEP can be used in low-income countries, in academic self-concept and behavioural problems particularly those with high prevalence rates of domestic for those children whose mothers attended the STEP violence and psychological and physical abuse. In programme compared with those that did not. These addition, this intervention can be considered as a suitable findings are similar to the results of Davis 31( ) who found training programme for parents. Mothers gave positive no significant improvement in child behaviour after feedback after the intervention and confirmed that they parents attended 4 sessions of STEP. The findings are would participate in the programme again in the future. also supported by a study by Clarkson (32) who found They suggested that participation in STEP increased no significant differences in classroom performance their motivation to read more information concerning and self-concept subscales (i.e., peer, school, family and parenting practice. general) between children whose parents attended a The current study had some strengths. The programme STEP programme and those whose parents did not. One was tested in a developing country and it is believed reason for this finding may be that the children did not to be the first study to evaluate the STEP intervention simultaneously attend STEP sessions with their mothers. with mothers rather than fathers in a Muslim society Another reason may be related to the short duration of the where fathers normally take a leading role in the family. intervention, during which time children did not show a The study also indicates to concerned authorities in direct benefit. It has also been argued that children who the Kurdistan Region that parenting interventions are are vulnerable to harsh rearing practices are less affected effective for the Kurdish population. A further strength by a positive rearing style (33); thus, the characteristics is that we recruited both treatment and control groups.

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This was not the case in most other studies of this topic. it might have been useful to detect negative behaviours For example, from a systematic review by Smith (35), only in > 1 setting; therefore, multi-informant reporting by 4 of 17 studies had a control group for comparison at teachers and parents may help to overcome some of follow-up, and the lack of a control group has been cited the bias involved in single-informant studies. Future as a significant limitation of many studies. research needs to obtain data from a larger sample, collect Our study also had some limitations. First, although data from multiple informants, recruit both parents, and a STEP class size of 6–14 parents is considered optimal, could potentially include specific groups, for example, the STEP programme needs to be repeated with several parents with children with learning disabilities. groups to increase the sample size and statistical power. Implications for practice Given the small sample size in our study, the findings The results of this study are consistent with most studies should be interpreted with caution, and it was not in the literature that emphasize the effectiveness of STEP possible to control all confounding variables. Second, programmes in improving a range of parental behaviours. the participants were all Kurdish; hence, the results may Our results indicate that STEP can be implemented not be generalized to other ethnic groups. The sample in low-income and developing countries, particularly was mothers rather than fathers, which again affects those that have high rates of domestic violence and generalization. Third, this study focused only on parental psychological and physical abuse. The findings of the self-reports and did not include any parental interviews or study also indicate that experts such as primary care observational data on maternal behaviour. Fourth, follow- professionals, educators and psychologists could have an up was short term (3 months). Fifth, child behaviour important role to play in supporting parents to improve profile on the SDQ was reported by teachers. However, parenting style and decrease levels of parental stress.

Funding: Ministry of Higher Education – KRG; Department of Psychology, University of Durham, United Kingdom. Competing interests: None declared.

Effets des interventions parentales sur les comportements et l'état psychologique pour les parents et les enfants kurdes Résumé Contexte : Les interventions parentales sont rarement proposées dans les pays en développement et il existe un besoin urgent qu’elles le soient également dans les pays à revenu faible. Objectifs : Examiner l’efficacité du programme éducatif appelé Approche systématique pour une parentalité efficace (STEP) parmi les parents et les enfants kurdes. Méthodes : Il s’agissait d’un essai pilote contrôlé randomisé utilisant les résultats avant et après la formation menée auprès de 17 mères (âge moyen de 35,25 ans, ET 4,3 ans, compris entre 29,58 et 45,3 ans) qui avaient accepté de participer à cette intervention. Nous avons utilisé le Questionnaire parental d’Alabama afin d’évaluer le style parental, l’Échelle de stress parental afin d’examiner le stress lié à la parentalité, et la Technique d’évaluation de la parentalité selon l’approche STEP afin de déterminer si les participants du groupe témoin avaient pris connaissance de la documentation de l’intervention. Résultats : Nous avons observé des différences significatives entre les groupes sur trois sous-échelles du Questionnaire 2 parental d’Alabama : la sous-échelle de l’engagement maternel (F(1,13) = 25,81, p < 0,001, η p = 0,67); la sous-échelle de 2 la discipline inconsistante (F(1,13) = 25,46, p < 0,001, η p = 0,66) ; et la sous-échelle des punitions corporelles (F(1,13) = 2 17,3, p < 0,005, η p = 0,57). Il y avait également une différence significative entre les groupes selon l’Échelle de stress 2 parental (F(1,13) = 19,63, p < 0,001, η p = 0,60). Ces différences se maintenaient sur une période de trois mois. Aucune différence notable n’a été trouvée dans l'auto-perception scolaire et les problèmes comportementaux des enfants dont les mères avaient participé à l’approche STEP et ceux dont les mères n’y avaient pas participé. Conclusion : Il semblerait que l’approche STEP permette d'améliorer le style de parentalité et réduise le niveau de stress parental chez les mères kurdes.

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آثار تدخالت األهل عىل املخرجات السلوكية والنفسية للوالدين األكراد وأبنائهم هوشيار سنكاوي، جون آدامز، ناديا رايسالند اخلالصة اخللفية: لقد وجد أن التدخالت اخلاصة بتنشئة األطفال ًنادرا ما ُتقدم يف البلدان النامية، وثمة حاجة ملحة إلرشاك البلدان املنخفضة الدخل. األهداف:دراسة فعالية التدريب املنهجي للتنشئة الفعالة ) ( STEPبني الوالدين األكراد وأبنائهم. طرق البحث: ُأجريت دراسة جتريبية ضابطة عشوائية باستخدام القياسات املسجلة قبل وبعد االختبار ملا جمموعه 17 ًأما )متوسط العمر 35.25 سنة، بانحراف معياري مقداره 4.3 سنوات؛ النطاق: 29.58- 45.3سنة( وافقن عىل املشاركة يف النشاط. واستخدمنا استبيان أالباما للتنشئة ) (APQ لتقييم نمط تنشئة األطفال؛ واستخدمنا مقياس إجهاد الوالدين ) ( PSSلتحري اإلجهاد يف صفوف الوالدين؛ واألسلوب التدرجيي لتقييم التنشئة )SPAT( لتحديد ما إذا كان املشاركون يف املجموعة التجريبية قد تعلموا املواد املستخدمة يف النشاط. النتائج: تب ّني وجود اختالفات كبرية بني املجموعات عىل 3 مقاييس فرعية الستبيان أالباما للتنشئة، وهي: املقياس الفرعي إلرشاك األم، F)1.13( 2η < P F 2η < P = p ،0.001 ،25.81 = ؛0.67 واملقياس الفرعي لعدم اتساق النظام التأديبي، )p ،0.001 ،25.46 = )1.13 = 0.66؛ < P F 2η واملقياس الفرعي للعقاب البدين p = 0.57 )1.13( = 17.3، 0.005، وتبني وجود اختالف كبري كذلك بني املجموعات عىل مقياس F 2η < P إجهاد الوالدين، p ،0.001 = 0.60 )1.13( = . 19.63واستمرت التغيريات عىل مدى ثالثة أشهر. ومل تظهر أي اختالفات كبرية عىل مستوى فكرة الطفل عن نفسه من الناحية التعليمية واملشكالت السلوكية بني األطفال الذين شاركت أمهاهتم يف التدريب املنهجي للتنشئة الفعالة ) ( STEPوالذين مل تشارك أمهاهتن فيه. االستنتاج:يبدو أن برنامج التدريب املنهجي للتنشئة الفعالة يعمل عىل حتسني أسلوب تنشئة األطفال وخفض مستوى اإلجهاد املرتبط بالتنشئة لدى األمهات الكرديات.

References 1. Chan TW, Koo A. Parenting style and youth outcomes in the UK. Eur Sociol Rev. 2011 Jun;27(3):385–99. https://doi.org/10.1093/esr/ jcq013 2. Sangawi HS, Adams J, Reissland N. The effects of parenting styles on behavioral problems in primary school children: a cross- cultural review. Asian Soc Sci. 2015;11(22):171–86. http://dx.doi.org/10.5539/ass.v11n22p171 3. Preventing violence through the development of safe, stable and nurturing relationships between children and their parents and caregivers. Geneva: World Health Organization; 2009 (http://www.who.int/iris/handle/10665/44088, accessed 20 January 2018). 4. Bunting L. Parenting programmes: the best available evidence. Child Care Pract. 2004;10(4):327–43. https://doi. org/10.1080/1357527042000285510 5. Barlow J, Coren E, Stewart-Brown S. Meta-analysis of the effectiveness of parenting programmes in improving maternal psychosocial health. Br J Gen Pract. 2002 Mar;52(476):223–33. PMID:12030667 6. Dinkmeyer D. McKay GD. The parent’s handbook: systematic training for effective parenting. Fredericksburg, VA: STEP Publishers; 1997. 7. Collins CL, Fetsch RJ. A review and critique of 16 major parent education programs. J Extension. 2012 Aug;50(4):4FEA8. https://joe. org/joe/2012august/a8.php 8. Jonyniene J, Kern R, Gfroerer K. Efficacy of Lithuanian Systematic Training for Effective Parenting (STEP) on parenting style and perception of child behavior. Fam J. 2015;23(4):392–406. https://doi.org/10.1177/1066480715574473 9. Larson BJ. Systematic training for effective parenting of teens (STEP/Teen): parental authority, adolescent externalizing behavior, and parent-child relationships [thesis]. Almeda (CA): California School of Professional Psychology; 2000. 10. Pan Z, Wu X. A study on the effect of systematic training for effective parenting on improving the parent–child relation. Chin J Clin Psychol. 2008;16(4):446–7 (in Chinese). 11. Huebner CE. Evaluation of a clinic-based parent education program to reduce the risk of infant and toddler maltreatment. Public Health Nurs. 2002 Sep–Oct;19(5):377–89. https://doi.org/10.1046/j.1525-1446.2002.19507.x PMID:12182697 12. Wantz RA , Recor R D. Simultaneous parent-child group intervention. Elem Sch Guid Couns. 1984;19(2):126–31. 13. Thomas H, Camiletti Y, Cava M, Feldman R, Underwood J, Wade K. Effectiveness of parenting groups with professional involvement in improving parent and child outcomes. Effective Public Health Practice Project;1999. (http://bit.ly/1OqNNLl, accessed 20 January 2018). 14. Knerr W, Gardner F, Cluver L. Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle- income countries: a systematic review. Prev Sci. 2013 Aug;14(4):352–63. https://doi.org/10.1007/s11121-012-0314-1 PMID:23315023 15. Mejia A, Calam R, Sanders MR. A review of parenting programs in developing countries: opportunities and challenges for preventing emotional and behavioral difficulties in children. Clin Child Fam Psychol Rev. 2012 Jun;15(2):163–75. https://doi.

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org/10.1007/s10567-012-0116-9 PMID:22427004 16. Saed BA, Talat LA, Saed BA. Prevalence of childhood maltreatment among college students in Erbil, Iraq. East Mediterr Health J. 2013 May;19(5):441–6. PMID:24617122 17. Sangawi H, Adams J, Reissland N. The impact of parenting styles on children developmental outcome: The role of academic self- concept as a mediator. Int J Psychol. 2016 Aug 23; https://doi.org/10.1002/ijop.12380 PMID:27554170 18. Goodman R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry. 1997 Jul;38(5):581–6. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x PMID:9255702 19. Australian Mental Health Outcomes and Classification Network. Strengths and Difficulties Questionnaire training manual. NSW Institute of Psychiatry; 2005 (http://www.amhocn.org/sites/default/files/publication_files/sdq_manual_0.pdf, accessed 20 January 2018). 20. Lamb ME, Lewis C. The development and significance of father-child relationships in two-parent families. In: Lamb ME, editor. The role of the father in child development. Hoboken (NJ): Wiley; 2004:272–307. 21. Grolnick WS, Ryan RM. Parent styles associated with children’s self-regulation and competence in school. J Educ Psychol. 1989;81(2):143–54. https://doi.org/10.1037/0022-0663.81.2.143 22. Burden R. Assessing children’s perceptions of themselves as learners and problem-solvers: the construction of the Myself-as- Learner Scale (MALS). School Psychol Int. 1998;19(4):291–305. https://doi.org/10.1177/0143034398194002 23. Shelton KK, Frick PJ, Wootton J. Assessment of parenting practices in families of elementary school-age children. J Clin Child Psychol. 1996;25(3):317–29. https://doi.org/10.1207/s15374424jccp2503_8 24. Berry JO, Jones WH. The Parental Stress Scale: initial psychometric evidence. J Soc Pers Relat. 1995;12(3):463–72. https://doi. org/10.1177/0265407595123009 25. Huitema B. Analysis of covariance (ANCOVA). In: Salkind NJ, Rasmussen K, editors. Encyclopedia of measurement and statistics. Thousand Oaks (CA): Sage; 2007:30–3. 26. Kline RB. Principles and practice of structural equation modeling. 3rd edition. New York: Guilford Press; 2011. 27. Statistics & Methods Centre - (M)AN(C)OVA models (http://bit.ly/1Kd3dkH, accessed 20 January 2018). 28. Sharpley CF, Poiner AM. An exploratory evaluation of the Systematic Training for Effective Parenting (STEP) programme. Aust Psychol. 1980;15(1):103–9. 29. Hautmann C, Hoijtink H, Eichelberger I, Hanisch C, Plück J, Walter D, et al. One-year follow-up of a parent management training for children with externalizing behaviour problems in the real world. Behav Cogn Psychother. 2009 Jul;37(4):379–96. https://doi. org/10.1017/S135246580999021X PMID:19619384 30. Webster-Stratton C, Hollinsworth T, Kolpacoff M. The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. J Consult Clin Psychol. 1989 Aug;57(4):550–3. https://doi. org/10.1037/0022-006X.57.4.550 PMID:2504794 31. Davis LAJ. The effect of parent involvement training on the achievement of Hispanic students [thesis]. University of North Texas; 1994. 32. Clarkson PJ. Effects of parent training and group counseling on children’s functioning in elementary school. Diss Abstr Int. 1979;39(8-A):4726–7. 33. Jarrett C. Some children are extra sensitive to parenting styles, bad and good. British Psychological Society Research Digest. 12 October 2016 (http://bit.ly/2lAGgCC, accessed 20 January 2018). 34. Spence JA. Changes in perception of family environment and self-reported symptom status in adolescents whose parents participate in an Adlerian parent-training intervention. Proquest, UMI Dissertation Publishing; 2011. 35. Smith R. An evaluation of parenting groups for children with behavioural difficulties [thesis]. University of Birmingham; 2013.

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Population and mortality profile in the Islamic Republic of Iran, 2006–2035

Saeide Aghamohamadi,1 Kamran Hajinabi,2 Katayoun Jahangiri,3 Iravan Masoudi Asl 4 and Reza Dehnavieh 5

1Department of Health Services Administration, Science and Research Branch, Islamic Azad University, Tehran, Islamic Republic of Iran. 2Department of Health Services Administration, Science and Research Branch, Islamic Azad University, Tehran, Islamic Republic of Iran (Correspondence to: Kamran Hajinabi: [email protected]). 3Department of Health in Disasters and Emergencies, School of Health, Safety & Environment (HSE), Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Islamic Parliament Research Center, Tehran, Islamic Republic of Iran. 5Department of Health Service Management. Institute for Future Studies in Health, Kerman, Islamic Republic of Iran. Abstract Background: The Islamic Republic of Iran has encountered demographic and epidemiological changes as a result of the transformation of health measures. Aims: This study aimed to calculate the population and mortality in the Islamic Republic of Iran during the years 2006 to 2035. Methods: We carried out a cross-sectional analytical–descriptive account. We calculated the age and sex structure of the Iranian population using census data as well as mathematical methods. The crude and causal death rates were calculated and their 20-year trend was predicted using the Lee–Carter model. Results: In 2035, the age group 60 years and over will reach 17.6% of the total population. Endocrine, nutritional and metabolic diseases will be the biggest causes of an increase in the rate of death in the general population. The largest decline in cause of death is for unintentional injuries. Conclusions: Noncommunicable diseases will increase as the aging population grows. Identification of their primary causal and risk factors can, therefore, contribute to prevention and control. Keywords: profile, prediction, population, cause of death, Iran Citation: Aghamohamadi S; Hajinabi K; Jahangiri K; Masoudi Asl I; Dehnavieh R. Population and mortality profile in the Islamic Republic of Iran, 2006–2035. East Mediterr Health J. 2018;24(5):469-476. https://doi.org/10.26719/2018.24.5.469 Received: 18/12/16; accepted: 13/04/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction as a serious threat, and in many cases causes irreparable damage to public safety (3). One of the most important variables to be calculated regarding social planning is the size and characteristics The country is in the third epidemiological transition of the population and its transformation process in the (4), where it is assumed the rate of death from infectious past, present and future (1). After the Second World War, diseases decreases, while the rate of death from chronic diseases increases (5). Recognizing these changes allows many countries and international organizations became for providing different manifestations of public health concerned about the increasing population. Their in the present and future and, thus, involves managers concern was not just about the population explosion, in social development planning, the training of health but also the continuation of the process of demographic care workers, shaping the structure of health care service change and the phenomenon of demographic transition. provision and, eventually, improving the community (4). Other demographic challenges began to stand out, such that age transition, age structure, demographic Considering the importance of recognizing the window, population aging and other factors began health transition transformation, this study deals with to enter the literature. The population explosion has investigating and predicting the age and sex structure of the population, as well as the causes of death in the drawn the attention of planners and experts, while the Islamic Republic of Iran from 2006 to 2035. implementation of birth control and renewing generation policies had an unprecedented effect on the changing age structure of the population (2). Methods Today, this change can be seen in the structure and Data collection and analysis composition of the population of the Islamic Republic This was a cross-sectional descriptive–analytic study of Iran and has had a number of negative consequences conducted in 2 phases. In the first phase, the age and sex for the economic, social and political system of the structure of the population was predicted in 3 steps. In country. So, adverse changes, even natural changes, in the first step, using data from the General Population the structure of the population (age structure) and the and Housing Census in 2006 and 2011, the population lack of planning to manage these developments is seen data were extracted (6–8). In the second step, a prediction

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of the population of the country was estimated up to the (mortality) rates observed for age x and in year t; year 2035 with 4 fertility assumptions published by the • a , b k and ε are age and time dependent parameters: Statistical Center of Iran (9) and using a mathematical x x t x,t – a indicate the average time logarithm of death method. The mathematical method is one of the ways of x rates at age x; predicting population growth, and is expressed through

the following relationship (10): – kt is the mortality index in year t, which indicates the main trend in the natural logarithm of P + n = P (1 + r)n t t mortality rates for all ages over time; Where, P + n is the population in the second census, P t t – b shows the rate of change in the mortality rate is the population at the first census, n is the gap between x logarithm at age x to (per) changes in the mortality the 2 censuses, and r is the annual growth rate of the index over time; population, which is the basis for the calculations (in this

study, to estimate the population in 2016, 2021, 2026, 2031 • component εx,t is equal to the component error at age x and time (15). and 2035 as Pt + n, Pt was considered, respectively, the population in 2011, 2016, 2021, 2026 and 2031). The Lee–Carter model, as a generalization method, In the third step, given the calculated populations is a combination of a rich demographic model (without for the whole country, and by using the United Nations the least parameters) and time series methods (16). In population prediction information for the next 150 years short, this method predicts death by age and period (11), the population was estimated in 5-year age and sex duration for a single population (15). One of the strengths groups. of the Lee–Carter method, as well as other generalizing In the second phase, the value of the general groups methods is its use in conditions where there is a linear for cause of death in the country was assessed, calculated trend of death rates in different age groups (17). However, and predicted during the indicated years. In this phase, due the existence of the linear trend in death rates, and the study population comprised total deaths registered introducing the Lee–Carter method as a leading method in the system and classification of cause of death by the for the prediction of mortality (16), this method was Ministry of Health and Medical Education for the years utilized to predict crude death rate and cause of death 2006–2015, grouped by cause of death, sex and age. These groups in this study. data were collected from various sources, including It should be noted that, in this model, the International hospitals, clinics, surgeries, legal medicine organizations, Classification of Diseases was used to predict the trend health centres, health care centres and cemeteries during for cause of death (12–14). Of the total of 21 main disease the investigation. Data collection instruments included groups in this classification, the diseases that cannot be death certificates, burial permits and information forms. considered as the underlying cause of death (e.g. diseases It should be noted that this study is not based on of the eye and adnexa, diseases of the ear and mastoid individual information and medical intervention and so process and factors influencing health status and contact there was no need for ethical approval, however, formal with health services) were excluded from the study permission from the Ministry of Health and Medical because, according to the International Classification of Education, number D308/22604, was issued to use of Diseases, the underlying cause has been defined as “(a) mortality data. the disease or injury which initiated the train of morbid events leading directly to death, or (b) circumstances of After data collection, cause of death was determined, the accident or violence which produced the fatal injury” coded and recorded based on the International Statistical (13) and these diseases are not included in this definition. Classification of Diseases 12–14( ) and numbers of deaths Also disease groups such as diseases of the skin and in terms of cause of death, sex and age group were subcutaneous tissue, diseases of the musculoskeletal calculated. The death rate was computed per 100 000 system and connective tissue; pregnancy, childbirth population. Population estimates between 2 censuses and the puerperium; and conditions originating in the were employed for the years 2007–2010 and 2012–2015. perinatal period with negligible or zero value in age and For the years 2006 and 2011, the census information for sex groups were excluded from the study because their each year was used (7,8). trend was not predictable by this model. Ultimately, Predicting crude rates and the main group rate doe a forecast for 13 major groups for cause of death was cause of death conducted. After calculating the crude and causal rates of death in Data analysis tools: 5-year age groups during the study period, the 20-year The demography package (18.1) of the Lee–Carter model trend was predicted using the Lee–Carter model (15). in the R software, version 3.3.1, was utilized to predict The structure of the proposed Lee–Carter model is mortality rates in the main groups for cause of death. presented as follows: Ln (m ) = a + b k + x,t x x t εx,t Results Where: In the census year 2006, the population of the Islamic

• Ln (mx,t) indicates the natural logarithm of death Republic of Iran was 70 495 782 (34 629 420 females and

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Book 24-05.indb 470 7/19/2018 1:23:22 PM Research articles EMHJ – Vol. 24 No. 5 – 2018 4,850,858 4,532,769 3,737,546 3,260,413 3,260,413 3,260,413 4,811,930 4,448,765 2,703,757 2,544,712 2,544,712 2,360,569 3,631,645 3,359,272 2,067,579 1,906,614 3,177,689 3,177,689 1,908,534 795,223 1,543,449 2,905,316 Female Female 1,590,445 477,134 2,632,943 357,850 1,089,494 1,351,878 318,089 2,451,360 2,451,360 998,702 2,178,987 2,178,987 2016 2035 1,272,356 357,850 397,611 556,656 Male Male 1,590,445 795,223 1,988,057 817,120 2,269,778 2,269,778 2,385,668 1,089,494 2,542,152 2,723,734 2,814,525 2,703,757 1,543,449 2,783,279 2,862,801 3,086,898 3,268,481 3,268,481 3,359,272 3,450,063 2,088,196 3,339,935 3,419,457 3,419,457 3,419,457 2,542,152 4,176,392 4,267,183 4,294,202 4,373,724 5–9 5–9 80+ 80+ 0–4 0–4

15–19 15–19 10–14 10–14

35–39 35–39 75–79 75–79 55–59 55–59 25–29 25–29 30–34 30–34

70–74 70–74 65–69 65–69 50–54 50–54 45–49 45–49 20–24 20–24 60–64 60–64 40–44 40–44

Age (years) Age (years) Age 4,499,571 4,750,573 4,283,860 4,491,451 3,564,785 3,627,710 3,267,349 3,282,214 3,195,840 3,109,466 2,715,562 2,688,533 2,662,410 2,936,718 2,677,596 2,409,579 2,504,848 2,504,848 2,418,474 964,445 1,122,863 Female Female 2,007,479 738,003 2,072,977 1,730,280 575,080 521,087 1,813,855 604,618 321,552 310,488 1,369,357 431,870 1,468,359 2026 2006 335,113 1,386,063 372,570 Male Male 598,231 1,468,359 518,244 518,244 622,470 1,792,481 726,449 923,536 1,900,229 2,081,679 1,036,489 2,511,545 2,332,100 2,504,848 2,591,222 2,801,568 2,837,969 2,820,524 2,763,970 2,850,344 3,023,092 3,282,214 3,282,214 3,441,245 3,368,588 3,454,962 3,660,167 4,232,329 4,442,901 4,511,851 4,318,703 Demographic transition in the Islamic Republic of Iran, 2006–2035 in the Islamic Republic transition Iran, of Demographic 5–9 5–9 80+ 80+ 0–4 0–4

15–19 15–19 10–14 10–14

35–39 35–39 75–79 75–79 55–59 55–59 25–29 25–29 30–34 30–34

70–74 70–74 65–69 65–69 50–54 50–54 45–49 45–49 20–24 20–24 60–64 60–64 40–44 40–44

Age (years) Age (years) Age Figure 1.Figure

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Table 1. Total population estimates (millions) for the Islamic Republic of Iran, 2016–2035, according to four assumptions of fertility Year Rate of decline (1.3) Stabilization rate (1.8) Increase rate up to Increase rate above replacement level (2.1) replacement level (2.5) Female Male Total Female Male Total Female Male Total Female Male Total 2016 39.48 39.88 79.37 39.60 39.92 79.53 39.61 40.04 79.64 39.66 40.06 79.72 2021 41.36 41.69 83.04 41.52 41.85 83.38 41.63 41.96 83.58 41.77 42.10 83.87 2026 42.806 43.23 86.03 43.01 43.45 86.47 43.19 43.62 86.80 43.38 43.81 87.20 2031 43.930 44.37 88.30 44.21 44.65 88.87 44.43 44.88 89.31 44.67 45.12 89.80 2035 44.92 45.193 90.12 45.30 45.58 90.89 45.60 45.88 91.47 45.92 46.19 92.11

35 866 362 males). In the 2011 census, the population of the blood and blood-forming organs, intentional reached 75 103 347 (37 226 196 females and 37 877 151 injuries, and mental and behavioural disorders (5.83, 3.42 males). The population by the year 2035 was estimated and 0.52 per 100 000 population respectively) will show based on the 4 fertility assumptions (Table 1). the lowest rates for cause of death (Table 3). In 2006, the population comprised the following age groups: ≤ 5 years 7.75%, 5–14 years 17.33%, 15–49 years Discussion 61.06%, 50–69 years 10.36%, and ≥ 70 years 3.49%. We In the 20th century, improving health, decreasing number estimated that in 2035 the population will be: 5 years and of deaths, increasing life expectancy and declining under 4.9%, 5–14 years 10.4%, 15–49 years 49.6%, 50–69 fertility have caused a rapid unprecedented demographic years 27.4%, and ≥70 years 7.8%. The process of change in transition (18). According to the United Nations, in recent the age and sex structure of the population during 2006– years the growth rate of the world's elderly population, 2035 is shown in age pyramids in Figure 1. 19%, is considerably higher than the growth rate of the According to the data available, the crude death rate in total world population, 12%. Predictions show that in the 2006 in the total population is calculated at 4.36 per 1000 period 2025–2030, the elderly population will grow 35 population (female 3.65, male 5.04). It is estimated that, in times faster than the total population (19). The results of 2035, the crude death rate for the whole population will the biological study of the population also show that the reach 4.05 per 1000 population (female 3.74, male 4.47). demographic characteristics of today's world are heading The trend for crude death rates is shown in Figure 2. towards further aging. Globally, the elderly population In 2006, the top 3 causes of death in females were is rapidly increasing, with the number of people aged 60 diseases of the circulatory system, neoplasms and years and above having doubled over the last 3 decades. unintentional injuries (193.63, 42.38 and 30.49 per It is expected that, from 2010 to 2050, their numbers will 100 000 population respectively). Mental and behavioural have risen from 795 million to 2 billion (20). Based on the disorders, infectious and parasitic diseases and diseases results of our study, from 2006 to 2035 the growth of the of the blood and blood-forming organs showed the lowest elderly population in the Islamic Republic of Iran will rates for cause of death (4.67, 3.41 and 1.75 per 100 000 increase in a similar fashion: in 2006 the population aged population respectively). However, it is predicted that over 60 years made up 7.3% of the total population; it is in 2035 the rate for endocrine, nutritional and metabolic estimated that in 2016 it will reach 8.4%, in 2026 12.6% and diseases will be 202.97, diseases of the circulatory system in 2035 it is expected to reach 17.6%. will be 132.66, and neoplasms will be 113.68 per 100 000 It is predicted that, in 2035, the Islamic Republic population, and these will be the main groups among of Iran will be beyond the epidemiological transition. the major causes of death in females. Diseases of the During this time, chronic diseases will emerge, most blood and blood-forming organs, mental and behaviour of which will be diseases of aging (21). The death rate disorders and intentional injuries (2.70, 0.80 and 0.51 per from the endocrine, nutritional and metabolic diseases 100 000 population respectively) will have the lowest shows a substantial increasing trend. It is predicted rates for cause of death (Table 2). that from 10.19 per 100 000 population in 2006, the rate Additionally, in 2006 diseases of the circulatory will reach 78.78 per 100 000 population in 2026 and system, unintentional injuries and neoplasms (211.52, 197.71 per 100 000 population in 2035. In this regard, the 99.03 and 62.84 per 100 000 population respectively) prediction for global death rates and burden of disease were the 3 major causes of death in males. Diseases of the shows that the more advanced a country becomes, with nervous system, infectious and parasitic diseases, and higher incomes, the more noncontagious diseases will diseases of the blood and blood-forming organs (6.36, 5.64 comprise the dominant sector for cause of death and and 1.9 per 100 000 population respectively) showed the burden of disease (22). It is predicted that diabetes will be lowest rates for cause of death. It is predicted that in 2035 the fourth leading cause of death in developed countries, diseases of the circulatory system, endocrine, nutritional the sixth in middle-income countries and the ninth in and metabolic diseases, and neoplasms (211.41, 188.99 and developing countries by 2030 (23,24). According to the 134.84 per 100 000 population respectively) will be the World Health Organization (WHO), diabetes will be the major groups among causes of death for males. Diseases fifth leading cause of death worldwide by 2030 with a

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.

.

.

. Crude death rate Crude .

.

.

                                    

Year Total Female Male

Figure 2. The trend of crude death rate from 2006 to 2035 (per 1000 population) according to sex

Table 2. Female death rates (per 100 000 population) in the Islamic Republic of Iran for the main groups of disease, 2006–2035 Year Death rate for each disease group Diseases of the circulatory the circulatory Diseases of system Neoplasms injuries Unintentional the respiratory Diseases of system nutritional and Endocrine, metabolic diseases the digestive Diseases of system the Diseases of system genitourinary malformations, Congenital & chromosomal deformities abnormalities the nervous Diseases of system injuries Intentional and behavioural Mental disorders and parasitic Infectious diseases blood & blood– Diseases of organs forming

2006 193.63 42.38 30.49 24.46 11.40 8.23 8.17 8.10 5.50 4.78 4.67 3.41 1.75 2016 170.91 59.14 18.00 25.65 30.75 9.93 10.40 7.77 9.94 2.20 2.56 5.55 2.09 2026 149.58 83.42 10.59 26.56 83.02 12.81 13.12 7.06 17.85 1.02 1.39 8.84 2.39 2035 132.66 113.68 6.57 27.41 202.97 16.09 16.17 6.48 30.25 0.51 0.80 13.44 2.70

Table 3. Male death rates (per 100 000 population) in the Islamic Republic of Iran for the main groups of disease, 2006–2035 Year Death rate for each disease group Diseases of the circulatory the circulatory Diseases of system injuries Unintentional Neoplasms the respiratory Diseases of system injuries Intentional the digestive Diseases of system and behavioural Mental disorders the Diseases of system genitourinary nutritional & Endocrine, metabolic diseases malformations, Congenital & chromosomal deformities abnormalities the nervous Diseases of system and parasitic Infectious diseases blood and Diseases of organs. blood– forming

2006 211.52 99.03 62.84 31.28 12.62 11.45 10.61 10.31 9.21 8.97 6.36 5.64 1.90 2016 211.68 54.96 81.58 34.81 8.09 13.02 3.78 14.04 26.10 8.72 11.62 8.72 2.81 2026 211.54 30.37 106.28 38.79 5.14 14.76 1.33 19.40 73.99 7.97 21.14 13.29 4.13 2035 211.41 17.81 134.84 42.76 3.42 16.53 0.52 25.95 188.99 7.35 36.22 19.42 5.83

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rate of 30 per 100 000 population (25) and comprise 1.4% (28). The prevalence of cancers in different areas of the of cause of death for females and about 3.0% for males. In world is on the rise (25). An increase in cancer ratio by the Eastern Mediterranean Region, diabetes in females 2030 compared with 2008 has been estimated at 82% will account for 3.1% of deaths and males will account for for low-income countries, 70% for average–low-income 2.5% of deaths in 2015. Based on the registration system countries, 58% for countries with above average income for data and classification of cause of death used in this and 40% for high-income countries. study, in 2015 diabetes accounted for 5.2% of deaths in In the Islamic Republic of Iran, the deaths from the total population, 6.6% females and 4.11% males. This unintentional and intentional injuries have reduced indicates a higher incidence of this disease in the Region, considerably in both men and women and, according to and it is expected that in the future the rate of diabetes our findings, it is predicted that unintentional injuries in our country will exceed that of the overall rate for the in 2035 compared to 2006 will be reduced by a rate of countries of the Region. 24 in men and by 88 in women per 100 000 population. Our findings also show that, with the aging population, Since the major proportion of unintentional injuries is diseases of the circulatory system will be the main cause related to traffic accidents, various reports, including of death in males in the Islamic Republic of Iran in mortality profile reports in 30 provinces (29) and reports 2035, and the second leading cause of death in females. of the Legal Medicine Organization of Iran (30), show a According to WHO, diseases of the circulatory system, decreasing trend in these events and these numbers are the leading cause of death in the world, have a high expected to decline significantly. prevalence in old age, i.e. people aged 70+ years; in 2030, ischemic heart disease will be the leading cause of death Noncommunicable diseases account for more than in the world, and will constitute 33.4% of cause death for 53% of the total burden of disease worldwide (4). It is females and 30.6% for men in the Eastern Mediterranean expected that, by 2020, they will be responsible for 60% Region (25). A study carried out between 2010 and 2040 of the total burden of disease and 73% of all deaths, 80% on the effect of an increase in the aging population on of which occur in developing countries. In the Islamic cardiovascular disease in the United States of America Republic of Iran, noncommunicable diseases account for predicted that the rate of death due to coronary artery more than 76% of the total burden of disease (4). disease is strongly influenced by an aging population In the Islamic Republic of Iran the rise in the aging with a 56% increase (26). populations is one of the fastest in the world. An aging Neoplasms are another major cause of death in the population is not important in itself, but its consequences Islamic Republic of Iran. In general, cancers are one of and effects on socioeconomic and health care aspects the major problems in different areas of the world (27). doubles its importance. Increasing age will lead to a According to our findings, it will be the third leading decline in health and a rise in chronic diseases, and will cause of death in the Islamic Republic of Iran in 2035. increase the burden of disease. The basis for prevention is Also, according to cancer statistics in 2013, about 60% to identify the primary risk factors, especially among the of the total cancers are seen in people aged 65+ years elderly population. Acknowledgements The authors wish to thank Dr Ardeshir Khosravi and Dr Elahe Kazemi of the Information and Statistical System Group in the Ministry of Health and Medical Education Network system, who cooperated on this study. Funding: None. Competing interests: None declared.

Profil démographique et de la mortalité en République islamique d’Iran entre 2006 et 2035 Résumé Contexte : La République islamique d’Iran connaît des changements démographiques et épidémiologiques qui découlent d’une modification des mesures sanitaires. Objectifs : La présente étude avait pour objectif d’estimer la population et la mortalité en République islamique d’Iran entre 2006 et 2035. Méthodes : Il s’agissait d’un compte-rendu analytique et descriptif transversal. Nous avons calculé la structure par âge et par sexe de la population iranienne en utilisant les données de recensement et à l'aide de méthodes mathématiques. Le taux brut de mortalité et les taux de mortalité par cause ont été calculés et leur tendance sur 20 ans a été prédite à selon le modèle de Lee-Carter.

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Résultats : En 2035, le groupe d’âge des 60 ans et plus comptera pour 17,6 % de la population totale. Les maladies endocriniennes, nutritionnelles et métaboliques seront les causes principales à l’origine d’une augmentation du taux de décès dans la population générale, et la baisse de décès la plus importante concernera les traumatismes non intentionnels. Conclusion : Les maladies non transmissibles connaîtront une augmentation dans la population vieillissante dont le nombre croît en République islamique d’Iran. L’identification de leurs principaux facteurs de risque et causes peut donc contribuer à la prévention et la maîtrise de ces maladies.

مرتسم تعداد السكان ومعدل الوفيات يف مجهورية إيران اإلسالمية يف الفرتة من 2006 إىل 2035 سعيدة أقا حممدي، كامران حاجي نبي، كتايون جهانگريي، إيروان مسعودي اصل، رضا دهنوية اخلالصة اخللفية:تشهد مجهورية إيران اإلسالمية يف الوقت احلايل تغريات سكانية ووبائية نامجة عن تغري التدابري الصحية. األهداف:هدفت هذه الدراسة إىل حساب تعداد السكان ومعدل الوفيات يف مجهورية إيران اإلسالمية يف الفرتة من 2006 إىل 2035. طرق البحث: أجرينا دراسة وصفية حتليلية مقطعية حلساب بنية العمر والنوع للسكان اإليرانيني باستخدام بيانات مستمدة من إحصاء السكان. وقمنا بحساب معديل الوفيات اخلام والسبـبي والتنبؤ باجتاههام عىل مدى 20عاما باستخدام نموذج يل-كارتر. النتائج: من املتوقع أن تصل نسبة السكان يف عام 2035 يف الفئة العمرية 60عاما وأكثر إىل % 17.6من جمموع السكان. ومن املتوقع أن تشكل أمراض الغدد الصامء والتغذية واالستقالب أكرب أسباب الزيادة يف معدل الوفيات بني عموم السكان، ومن املتوقع أن تسجل اإلصابات غري املتعمدة أكرب انخفاض يف العوامل املسببة للوفاة. االستنتاج:مناملتوقع أن تزداد األمراض غري السارية مع زيادة السكان املسنني يف مجهورية إيران اإلسالمية. وبالتايل، فإن حتديد عواملها األساسية وعوامل خطرها من شأنه أن يسهم يف الوقاية واحلد منها.

References 1. Kinsella KG, Phillips DR. Global aging: the challenge of success. Population Bull. 2005;60(1):5–43. 2. Saraei H. The crowd valve Iran. Planning, Social Welfare and Development J. 2010;1(1):33–45 [in Farsi]. 3. Khosravi Vashmgir H. Pathological changes in the Iran population structure by economic security approach. Tehran: Research Institute, Fiscal Strategies; 2009 [in Farsi]. 4. Naghavi M. Health transition in Iran. Iran J Epidemiol. 2006;2(2):45–57 ()http://irje.tums.ac.ir/article-1-185-fa.pdf, accessed 8 March 2018 [in Farsi]. 5. Hatami H. Comprehensive public health. Tehran: Ministry of Health and Medical Education; 2012 [in Farsi]. 6. General census of population and housing. Tehran: Statistical Center of Iran; 1996 (https://amar.sci.org.ir/PlanList.aspx, accessed 8 September 2015) [in Farsi]. 7. General census of population and housing. Tehran: Statistical Center of Iran; 2006 (https://www.amar.org.ir/Portals/0/ sarshomari90/n_sarshomari90_2.pdf, accessed 15 September 2015) [in Farsi]. 8. General census of population and housing Tehran: Statistical Center of Iran; 2011 (https://www.amar.org.ir/Portals/0/ sarshomari90/n_sarshomari90_2.pdf, accessed 23 September 2015) [in Farsi]. 9. Growth forecast for the country's population in the five-year period until 1430 solar year. Tehran: Statistical Center of Iran; 2012 (http://www.amar.org.ir/Portals/0/SlideShow_Photos/files/baravord_1420_r2.xlsx, accessed 10 Feb 2016) [in Farsi]. 10. Kazemi Pour Sh. Basics of demography. Tehran: Center for Population Studies and Research of Asia and Oceania; 2004 [in Farsi]. 11. World population prospects. United Nations, Department of Economic and Social Affairs, Population Division 2015 (https://www. populationpyramid.net/iran-islamic-republic-of/2017/, accessed 5 Nov 2016). 12. International statistical classification of diseases & related health problems. Volume 1. 10th rev ed. Geneva: World Health Organization; 1992. 13. International statistical classification of diseases & related health problems. Volume 2. 10th rev. ed. Geneva: World Health Organization; 1992. 14. International Statistical Classification of Diseases & Related Health Problems. Volume 3. 10th rev. ed. Geneva: World Health Organization; 1992. 15. Lee RD, Carter LR. Modelling and forecasting U.S. mortality. American Statistical Association J. 1992;87(419):659–71. 16. Deaton A, Pakson CP. Mortality, income, and income inequality over time in the Britain and the United States. Cambridge, Massachusetts: National Bureau of Economic Research; 2004 (Technical Report 8534).

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17. Booth H, Hyndman RJ, Tickle L, De Jong P. Lee–Carter mortality forecasting: a multi-country comparison of variants and extensions. Demographic Res. 2006;15(9):289–310. 18. Aging and health: a shift in the paradigm. Washington, DC: Pan American Health Organization; 1998 (CE12213). 19. World population aging 1950–2050. World Health Organization; 2002. 20. Christense K. Human biodemography: some challenges and possibilities for aging research. Demographic Res. 2008;19(43):1575– 86. 21. Pour Reza A. Khabiri Nemati R. Economics of health and ageing. Iran J Ageing. 2206;1(2):80–8 [in Farsi]. 22. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442. https://doi.org/10.1371/journal.pmed.0030442 PMID:17132052 23. Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from: an assessment of the global status of cause of death data. Bull World Health Organ. 2005 Mar;83(3):171–7. PMID:15798840 24. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047–53. https://doi.org/10.2337/diacare.27.5.1047 PMID:15111519 25. Projections of mortality and causes of death, 2015 and 2030. Geneva: World Health Organization; 2015 (http://www.who.int/ healthinfo/global_burden_disease/projections/en/, accessed 1 March 2018). 26. Odden MC. Coxson PG. Moran A. Lightwood JM. Goldman L. Bibbins-Domingo K. The impact of the aging population on coronary heart disease in the United States. Am J Med. 2011;124(9):827–33. PMID:21722862 27. Poston PL, Micklin M. Handbook of population. New York: Kluwer Academic/Plenum Publishers; 2005. 28. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11–30. doi: 10.3322/caac.21166 PMID:23335087 29. Khosravi A, Aghamohamadi S, Kazemi E. Mortality profile in Iran (30 provinces) in 2011. Tehran: Ministry of Health and Medical Education; 2015 [in Farsi]. 30. Annual statistical report. Tehran: Legal Medicine Organization; 2015 [in Farsi].

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Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region

Dalia Samhouri 1,5, Kashef Ijaz 2, Arash Rashidian 3, Stella Chungong 4, Antoine Flahault 5, Suzanne M. Babich 6 and Jaouad Mahjour 7

1WHO Health Emergency Programme (WHE), WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Centers for Disease Control and Prevention, Atlanta, United States of America. 3Division of Information, Evidence & Research, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4WHO Health Emergency Programme (WHE), WHO headquarters, Geneva, Switzerland. 5Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland. 6Department of Health Policy and Management at Indiana University, Richard M. Fairbanks School of Public Health, Indianapolis, United States of America. 7Programme Management, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Dalia Samhouri: [email protected]). Abstract Background: Joint External Evaluation (JEE) was developed as a new model of peer-to-peer expert external evaluations of IHR capacities using standardized approaches. Aims: This study aimed to consolidate findings of these assessments in the Eastern Mediterranean Region and assess their significance. Methods: Analysis of the data were conducted for 14 countries completing JEE in the Region. Mean JEE score for each of the 19 technical areas and for the overall technical areas were calculated. Bivariate and multivariate analyses were done to assess correlations with key health, socio-economic and health system indicators. Results: Mean JEE scores varied substantially across technical areas. The cumulative mean JEE (mean of indicator scores related to that technical area) was 3 (range: 1–4). Antimicrobial resistance, Biosecurity and Biosafety indicators obtained the lowest scores. Medical countermeasures, personnel deployment and linking public health with security capacities had the highest cumulative mean score of 4 (range: 2–5). JEE scores correlated with most of the key indicators examined. Countries with better health financing system, health service coverage and health status generally had higher JEE scores. Adolescent fertility rate, neonatal mortality ratio and net primary school enrollment ratio were primary factors within a country's overall JEE score. Conclusions: An integrated multisectoral approach, including well-planned cross-cutting health financing system and coverage, are critical to address the key gaps identified by JEEs in order to ensure regional and global health security. Keywords: Eastern Mediterranean Region, joint external evaluation, communicable diseases, international health regulations, health finance. Citation: Samhouri D; Ijaz K; Rashidian A; Chungong S; Flahault A; Babich SM; et al. Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region. East Mediterr Health J. 2018;24(5):477–487. https://doi.org/10.26719/2018.24.5.477 Received: 10/06/18; accepted: 03/07/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction the shorter- and longer-term assessment and development of IHR core capacities and the [WHO] Secretariat should The revised International Health Regulations (2005) develop options to move from exclusive self-evaluation (IHR 2005) requires Member States to develop and to approaches that combine self-evaluation, peer review maintain core public health capacities for surveillance and voluntary external evaluations (9–11). To address this and response at points of entry, including early detection, recommendation, WHO developed the IHR Monitoring assessment, notification and reporting to WHO about and Evaluation Framework (IHRMEF) comprising events covered by their provisions, laid out in Annex 1 of four components, notably the mandatory Annual A and B of IHR (1). The Ebola epidemic in West Africa of Reporting, and the voluntary joint external evaluation 2014–2015 demonstrated that the world was ill-prepared (JEE), simulation exercises and After Action Reviews to detect, prevent and respond to emerging infectious (AAR) (12–14). disease outbreaks (2–6). It also demonstrated that IHR The JEE was developed as a new model of peer-to-peer (2005) mandated self-reporting by countries may not be expert external evaluations of IHR capacities, carried out truly reflective of the country’s public health capacity by a multidisciplinary external team of experts jointly to prevent, detect and respond to major public health with a multi-sectoral team of national experts, using threats (7,8). The 2016 Zika virus outbreak once again put a standardized score-based indicator data collection the IHR (2005) capacities under scrutiny, highlighting the instrument (JEE Tool) (15–17). importance of their implementation. As of July 2018, 78 countries, including 14 countries The IHR Review Committee on Second Extensions for in the WHO Eastern Mediterranean Region (EMR), had Establishing National Public Health Capacities and on IHR carried out JEEs (18). The experience of in-country focal Implementation convened in 2014. It recommended that points during JEEs in these countries has been described the Director General consider a variety of approaches for (19). However, this paper provides a detailed descriptive

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analysis of outcomes of JEEs in the first 14 countries assessing health system response were developed. The completing JEEs in the EMR. It also analyses groups EMR Member States have been annually reporting on of objectively selected demographic, socio-economic, these indicators since 2014 (23,24). mortality, morbidity, health financing, health workforce, Of these 68 core indicators, 32 indicators were selected service delivery, service provision and political stability to assess the correlation with the JEE indicators, as indicators in these countries, and their correlation possible predictors of JEE scores. A descriptive overview with JEE scores to assess for potential predictors. It of these 32 demographics, socioeconomic status, provides suggested actions that countries, WHO and mortality, morbidity, health finance, health workforce, the international community could take to increase service delivery, service coverage and political stability their effectiveness in increasing JEE scores to meet IHR indicators for the 14 EMR countries completing JEEs obligations and ensuring global health security. shows the wide range of countries in terms of population, resources and political challenges facing these Member Methods States in the Region (Appendix 1). The remaining 36 The study is based on analyses of data collected indicators were excluded either due to incomplete data, through the JEE processes for the first 14 EMR countries (e.g. population with catastrophic expenditure) or were completing JEEs (Afghanistan, Bahrain, Jordan, Kuwait, not directly related to any of the 19 technical areas of Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, JEE tool (e.g. physical activity). Additionally, based on Somalia, Sudan, Tunisia and United Arab Emirates) published data showing the impact of political stability between April 2016 and December 2017, as well as other on health systems strengthening (25–27), two political key indicators, as described below. stability indicators were selected for inclusion from the WHO’s list of Global indicators and from the World Bank JEE tool development indicators (28,29). The JEE tool consists of 19 technical areas organized by four main groups (i.e., prevent, detect, respond and points Statistical analysis of entry (PoE) and IHR-related hazards). The 19 technical For each of the 19 technical areas, the mean JEE score was areas consist of 48 indicators1 that are measured by calculated for the 14 countries based on mean score of incremental 5-step definitive scoring criteria. The score indicators related to that technical area. An overall JEE for each indicator ranges on a Likert scale from 1 to 5 as score was also calculated based on mean JEE scores across follows: 1) no capacity; 2) limited capacity; 3) developed all 19 technical areas. We used the existing categorization capacity; 4) demonstrated capacity; and 5) sustainable of the countries of the Region into three groups (Group capacity. JEE scores of 3 and above were defined as high 1, Group 2 and Group 3)2 for comparative purposes (30). JEE scores and below 3 as low JEE scores. Only integer Only integer scores were allowed both for cumulative scores for indicators and technical areas are allowed (20). score and overall JEE score. To assess the distribution A standardized JEE process was followed in the 14 of scores across technical areas, measures of centrality EMR countries (18). The JEE tool was applied through in- (mean, median, and range) were calculated. Correlational country missions (external evaluation phase) to validate analyses were conducted in pairwise comparisons to the information collected through the self-evaluation obtain Spearman rank correlation coefficient between phase and background documents. Field visits to settings JEE major groups, between JEE indicator on coordination such as hospitals, primary health care centres, public and the response related indicators, and between overall health laboratories, veterinary laboratories, poison JEE mean score and the selected health system core centres, emergency operating centres, airports, ports and indicators. Logistic regression analysis was conducted to ground crossings were also conducted when feasible and find potential associations between the overall JEE mean varied by country (21). score and the key indicators. A stepwise selection process Selection of health system indicators was followed using the 32 indicators with the overall JEE score until all remaining explanatory variables in The EMR consists of 22 countries with an estimated the model showed statistically significant P( < 0.05) population of 644 million (8.6% of global population associations with the outcome variable. in 2017) (22). The WHO Regional Office for the Eastern Mediterranean (WHO/EMRO) has developed a clear framework for health systems with 68 core indicators Results that focus on three main components: 1) monitoring The overall mean JEE score across 19 technical areas in the health determinants and risks; 2) assessing health status, 14 EMR countries was 3 (median 3, range: 1–4). The mean including morbidity and cause-specific mortality; and 3) JEE score for the four main groups of technical areas was

1 First edition of the JEE tool can be viewed at: (http://apps.who.int/iris/bitstream/handle/10665/204368/9789241510172_eng.pdf?sequence=1). An updated version was developed (49 indicators) with an additional indicator related to finance. This second can be viewed at: (http://apps.who.int/iris/ bitstream/handle/10665/259961/9789241550222-eng.pdf;jsessionid=ECC519F17F2B1134C8294AFEB5200807?sequence=1). 2 Country grouping is done based on country income level and political instability level. Group 1: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates; Group 2: Jordan, Lebanon, Morocco, Tunisia; Group 3: Afghanistan, Pakistan, Somalia and Sudan.

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3 (Median: 3, Range: 1–5). In reviewing the range, Prevent indicators (31) was 3, while the mean score of 6 indicators and Points of entry and other IHR related hazards had was 2 and for 11 indicators was 4. Five of the 6 indicators the lowest minimum score of 1; while respond and Points with the lowest mean score of 2 related to AMR and of entry and other IHR related hazards had the highest biosafety biosecurity, while one related to workforce maximum score of 5. The overall mean JEE scores and strategy specifically (Table 2). mean JEE scores for the four main groups analysed by Using Spearman rank correlation coefficients, the three country groups showed that countries in Group countries’ JEE scores for prevent, detect and respond were 1 had an overall mean score of 4 (Median:, Range: 3–5). correlated (P < 0.01). In addition, correlation was found The countries in Group 2 had an overall mean score of between PoE and other IHR hazards and prevent, detect 3 (Median:3, Range: 2–3), while the countries in Group 3 and respond. The JEE coordination indicator (defined had an overall mean score of 2 (Median:2, Range: 1–3). Functional mechanism is established for the coordination Examining each of 19 technical areas in the 14 EMR and integration of relevant sectors in the implementation countries demonstrated that the cumulative mean score of IHR) and other response related indicators for zoonosis, of IHR implementation varied across the 19 technical food safety, chemical and radiation and emergency areas. The cumulative mean JEE score was 3 (median: response operations were also found correlated (P < 3; range: 2–4). Antimicrobial resistance (AMR) and 0.01). The overall JEE score was correlated with the listed biosecurity and biosafety had the lowest mean score demographic and socioeconomic determinants and of 2- limited capacity. Medical countermeasures and health risks set of variables except for total population, personnel deployment, and linking public health with annual growth rate and adolescent fertility rate. Among security, had the highest mean scores of 4- demonstrated health status indicators, the overall JEE score correlated capacity (Table 1). The mean score for the majority of the with life expectancy rate and inversely correlated with

Table 1. Summary of the JEE score per technical areas per group3 of countries in the 14 countries, 2016–2017 Group 1 Group 2 Group 3 All 14 countries Technical Area Mean Med (Range) Mean Med (Range) Mean Med (Range) Mean Med (Range) Overall Score 4 4( 3–5) 3 3 (3–3) 2 2 (1–3) 3 3 (1–4) Prevent 4 4 (3–4) 3 3 (3–3) 2 2 (1–3) 3 3 (1–4) National Legislation 4 4 (2–5) 3 3 (2–4) 2 1 (1–3) 3 3 (1, 5) National IHR Focal point 5 5 (3–5) 3 3 (2–4) 2 1 (1–3) 3 3 (1–5) Coordination Anti–microbial resistance 3 3 (3–4) 2 2 (1–2) 1 1 (1–2) 2 2 (1–4) Zoonoses 4 4 (3–5) 3 3 (3–4) 3 3 (2–4) 3 3 (1–5) Food Safety 4 4 (3–5) 3 3 (2–4) 1 1 (1–2) 3 3 (1–5) Biosafety and Biosecurity 3 3 (3–4) 2 2 (2–3) 1 1 (1–2) 2 2 (1–4) Immunization 5 5 (4–5) 4 5 (3–5) 3 3 (2–4) 4 5 (1–5) Detect 4 4 (4–4) 3 3 (3–3) 3 3 (2–3) 3 3 (2–4) National laboratory system 4 4 (3–5) 3 3 (3–4) 2 2 (2–3) 3 4 (2–5) Real time surveillance 4 4 (4–4) 3 3 (3–4) 3 3 (2–4) 3 3 (2–4) Reporting 4 4 (4–5) 3 3 (2–4) 2 2 (2–3) 3 3 (2–5) Workforce development 3 3 (2–4) 3 3 (2–3) 2 2 (2–2) 3 3 (1–5) Respond 4 4 (4–5) 3 3 (3–4) 2 2 (2–3) 3 3 (2–5) Preparedness 4 4 (4–5) 2 2 (1–4) 2 2 (1–4) 3 4 (1–5) Response Operations 5 5 (3–5) 3 3 (2–4) 2 2 (2–3) 3 4 (1–5) Linking Public health with 5 5 (4–5) 4 4 (3–4) 4 4 (2–5) 4 4 (2–5) security Medical countermeasures and 5 5 (4–5) 4 4 (4–5) 3 2 (2–5) 4 5 (2–5) Personnel Deployment Risk Communications 4 4 (3–5) 2 2 (2–3) 2 2 (2–3) 3 3 (1–5) PoE and other IHR Hazards 4 4 (3–5) 3 3 (2–3) 2 2 (1–3) 3 3 (1–5) Points of entry 4 4 (3–5) 2 3 (2–3) 2 1 (1–3) 3 3 (1, 5) Chemical events 4 4 (3–4) 3 3 (2–3) 1 1 (1–2) 3 3 (1, 4) Radiation emergencies 4 4 (3–5) 3 3 (2–5) 2 1 (1–3) 3 3 (1, 5)

3 Group 1: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates; Group 2: Jordan, Lebanon, Morocco, Tunisia; Group 3: Afghanistan, Pakistan, Somalia and Sudan.

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Table 2. Status of the 48 indicator in the 14 EMR countries, 2016–2017 Low Mean score (2) Intermediate Mean score (3) High Mean score (4) Total: 6 Indicators Total: 31 Indicators Total: 11 Indicators P.1.1 Legislation, laws, regulations, administrative requirements, policies or P.4.1 Surveillance systems in other government instruments in place are sufficient for implementation of place for priority zoonotic IHR. diseases/pathogens. P.1.2 The state can demonstrate that it has adjusted and aligned its domestic P.7.1 Vaccine coverage (measles) legislation, policies and administrative arrangements to enable compliance as part of national program. with the IHR (2005). P.7.2 National vaccine access and P.2.1 A functional mechanism is established for the coordination and delivery. integration of relevant sectors in the implementation of IHR. D.1.1 Laboratory testing for P.3.3 Healthcare associated infection (HCAI) prevention and control programs. detection of priority diseases. P.4.2 Veterinary or Animal Health Workforce D.1.2 Specimen referral and P.4.3 Mechanisms for responding to infectious zoonoses and potential transport system. zoonoses are established and functional. D.2.3 Analysis of surveillance P.5.1 Mechanisms are established and functioning for detecting and data. responding to foodborne disease and food contamination. D.2.4 Syndromic surveillance D.1.3 Effective modern point of care and laboratory based diagnostics. systems. P.3.1 Antimicrobial resistance D.1.4 Laboratory Quality System. R.2.3 Emergency Operations (AMR) detection. D.2.1 Indicator and event based surveillance systems. Program. P.3.2 Surveillance of infections D.2.2 Inter-operable, interconnected, electronic real-time reporting system. R.3.1 Public Health and caused by AMR pathogens. D.3.1 System for efficient reporting to WHO, FAO and OIE. Security Authorities, (e.g. Law P.3.4 Antimicrobial stewardship D.3.2 Reporting network and protocols in country. Enforcement, Border Control, activities. D.4.1 Human resources are available to implement IHR core capacity Customs) are linked during a P.6.1 Whole-of-Government requirements. suspect or confirmed biological biosafety and biosecurity D.4.2 Applied epidemiology training program in place such as FETP. event. system is in place for human, R.1.1 Multi-hazard National Public Health Emergency Preparedness and R.4.1 System is in place for animal, and agriculture Response Plan is developed and implemented. sending and receiving medical facilities. R.1.2 Priority public health risks and resources are mapped and utilized. countermeasures during a P.6.2 Biosafety and biosecurity R.2.1 Capacity to Activate Emergency Operations. public health emergency. training and practices. R.2.2 Emergency Operations Center Operating Procedures and Plans. R.4.2 System is in place for D.4.3 Workforce strategy. R.2.4 Case management procedures are implemented for IHR relevant sending and receiving health hazards. personnel during a public health R.5.1 Risk Communication Systems (plans, mechanisms, etc.). emergency. R.5.2 Internal and Partner Communication and Coordination. R.5.3 Public Communication. R.5.4 Communication Engagement with Affected Communities. R.5.5 Dynamic Listening and Rumour Management. PoE.1 Routine capacities are established at PoE. PoE.2 Effective Public Health Response at Points of Entry. CE.1 Mechanisms are established and functioning for detecting and responding to chemical events or emergencies. CE.2 Enabling environment is in place for management of chemical Events. RE.1 Mechanisms are established and functioning for detecting and responding to radiological and nuclear emergencies RE.2 Enabling environment is in place for management of Radiation Emergencies.

all mortality indicators except with the communicable score. On average, net primary school enrollment above diseases mortality. No correlation was found with the 80 increased the odds of countries receiving high JEE morbidity indicators except with incidence rate of scores (OR 19.54, 95% CI: 5.24–72.82; P < 0.01) (Table 4). Hepatitis B. For health system response indicators, it also strongly correlated with all health finance indicators, Discussion except with general government expenditure on health Countries in EMR seem to be doing well in technical areas as percentage of general government expenditure. The such as immunizations, indicator based surveillance, overall JEE score was also found inversely correlated with diagnostics for priority pathogens, referral of laboratory listed political instability indicators (Table 3). samples, multisectoral response to public health Regression analysis showed that adolescent fertility emergencies and medical countermeasures. However, rate, neonatal mortality ratio and net primary school common gaps and recommendations identified by the enrollment ratio influenced the odds of a country scoring countries during JEEs suggest that innovative ways and high on JEE. Countries with adolescent fertility rate of efforts need to be identified and enhanced to improve above 20; on average, received higher JEE scores. Holding capacities such as antimicrobial resistance (AMR), all other variables constant, compared with countries biosafety and biosecurity, surveillance data analysis with neonatal mortality ratio ≤ 8, countries with neonatal and interpretation, enhancement of laboratory quality mortality ratio of > 8 were 4.65 times (OR 4.65, 95% CI: management system, risk communication, and public 1.42–15.19; P = 0.01) more likely to receive a lower JEE health preparedness to all hazards, including at points of

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Table 3. Correlation of JEE scores percentage and demographic, socioeconomic, mortality, universal health coverage and political instability indicators in the 14 EMR countries Spearman rank correlation Indicator list Indicator coefficient with JEE Overall mean score Health determinant and risks Total population (000s) -0.49 Annual popuation growth (%) 0.08 Demographic and Total fertility rate -0.58* socioeconomic determinants Adolescent fertility rate (15-19 years) -0.30 Net primary school enrollment ration per 100 school- age children 0.60* Literacy rate (15-24 years), both sexes (%) 0.71* Access to improved drinking water (%) 0.66** Health Risks Access to improved sanitation facilities (%) 0.77*** Health Status Life expectancy at birth, both sexes 0.71*** neonatal mortality rate (per 1000 live births), 2015 -0.83*** Infant mortality rate (per 1000 live births), 2015 -0.80*** Under-five mortality rate (per 1000 live births), 2015 -0.77*** Life expectancy and Maternal mortality ratio (per 100 000 live births) -0.84*** Mortality CD mortality (%) -0.51 NCD mortality (%) -0.58* Mortality rate attributed to exposure to unsafe WASH services (per 100 000 population) -0.77*** Mortality rate attributed to household and ambient air pollution (per 10 000 population) -0.81*** Tuberculosis, case notification rate per 100 000, 2015 -0.64** Morbidity HIV, number of newly reported cases, -0.47 Hepatitis B, incidence rate per 100 000 -0.75*** Health System Response Health expenditure per capita (USD) 0.87** Health Finance General government expenditure on health as % of general government expenditure -0.14 Out of pocket expenditure as % of total health expenditure -0.66** Hospital bed density (per 1000 population) 0.52 Service delivery Primary health care facilities (per 1000 population) -0.45 Annual outpatient visit per capita, Ratio 0.18 Proportion of births attended by skilled health personnel 0.72** Tuberculosis success rate of new bacteriology confirmed cases, 2015 -0.26 Service coverage Suspected malaria cases that have had a diagnostic test 0.75*** Adults and children currently receiving ARV therapy among all living with HIV estimates 0.66** Estimated direct deaths from major conflicts/100000s 0.56* Political instability Global Peace Index 0.62**

*P < 0.05 **P < 0.01 ***P < 0.001

entry. Additionally, in the majority of countries, the human This requires developing a strategy for targeted health and animal sectors are not at par, which negatively affects workforce development along with a career structure and the overall JEE scores for the aforementioned technical a monitoring and evaluation component. areas from a multisectoral standpoint. This suggests a The analysis has shown that there is developed critical need to improve capacities for the animal sector, capacity of having a fully functioning Emergency such as targeted interventions in specific technical areas Operating Centres (EOC) among the 14 countries (3). to help accelerate IHR (2005) implementation. However, these EOCs are primarily managed by non- Most countries already have multiple governmental health sectors, such as defense for response to disasters training programmes. However, the need to strengthen and humanitarian emergencies. Inclusion of ministries the number and distribution of sufficiently skilled human of health as part of the management structure of these resources at all levels of the health system is critical. EOCs, or coordination among various EOCs in-country if

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Table 4. Results of the multivariate analysis of explanatory variables’ associated with JEE indicator Variable Coefficient (SE) Odd Ratio (95% CI) P value Adolescent fertility rate (15–19 years) ≤ 20 Reference > 20 1.53 (0.60) 4.65 (1.42 – 15.19) 0.01 Neonatal mortality ratio (per 100 000 live births) ≤ 8 Reference > 8 -1.97 (0.52) 0.14 (0.05 – 0.39) <0.01 Net primary school enrollment ration per 100 school- age children ≤ 80 Reference > 80 2.97 (0.67) 19.54 (5.24 – 72.82) <0.01 Random Effect (Variance) Intercept (SE) 95% CI Country 0.27 (0.20) 0.06 – 1.13 JEE technical area 0.46 (0.22) 0.18 – 1.16

managed by multiple sectors like defense and health, is Compared with Groups 2 and 3 countries in the critical to coordinate the effective public health response Region, Group 1 countries tend to score higher on JEE. during outbreak or humanitarian emergencies. However, the overall lack of a significant correlation A detailed review of national legislation is important between JEE scores and government expenditure on to improve governance and facilitate the implementation health may be due to sample size. Another possible reason of IHR (2005) capacities including cross border could be flaws in resources allocation and mobilization collaboration for surveillance and response to public within the health system. For the latter, resources in the health events (31). Many countries benefit from public developing countries might be received but are targeting health-related legislation that dates back a few decades categorical vertical programmes such as maternal and and has not been updated with the requirements of the child health and tuberculosis, but not for cross-cutting IHR and the development in public health systems in public health and multisectoral programmes. As such, development of IHR systems are more of a function of the specified countries. Additionally, mechanisms to focused attentions to the requirements of such systems, enhance the public health management of foodborne while being affected by the general economic capabilities diseases and food contamination, chemical, nuclear and of the countries. Attention to health financing situation of radiological events appeared to be common gaps among the country is also important in order to develop feasible the 14 countries. Therefore, mechanisms to enhance financing options to increase allocation of domestic public health surveillance and response to chemical, resources to priority areas of health system development nuclear and radiological events need further attention. and response. The strong correlations found between some The paper has also shown that politically stable indicators suggest that targeted interventions in specific countries tend to score higher than less politically stable technical areas may also accelerate the implementation countries. However, a country can still develop its public of other technical areas under IHR (2005). For example, health functions. Related plans of action need to be multisectoral coordination and regular information flexible enough to accommodate the changing situation sharing between sectors may not only improve the and respond to the needs but manages to maintain public development of IHR capacities, but also may improve health capacities. notification of notifiable events under IHR as part of the overall enhancement of health information system. Such Limitations developments in the health information systems should Our analysis had limitations that include a small aim for solutions that bring together vertical modalities sample size, which could have resulted in identifying of data collection under a systematic and comprehensive additional correlations that may have been significant approach. Additionally, the strong correlation between and can provide additional information to improving the JEE scores and the burden of mortality indicators and JEE scores. Also, the sample included data analysis from health system related variables – and their determination 14 of the 22 countries in the Region, which may limit the by key developmental indicators – suggest that generalizability. However, the results of the analysis do developing and implementing plans of action to meet the have face validity from a programmatic standpoint. There IHR (2005) capacities is critically needed as an integral may also be other factors, untested here, that empirically part of the essential public health functions of national play a predictive role in JEE scoring, including additional health systems. A recent systematic review of the analysis and methods that could be utlized for future JEE- building blocks’ relevance to the Ebola outbreak related programmatic research and decision-making. underlines their importance in practice and as an Implementation of the JEE process is a work in evaluative framework (32). progress in the WHO EMR. This paper helps to fill an

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important evidence gap in our understanding of JEEs and the poorest and most vulnerable populations through their relevance to countries. Throughout the process of public funds. Harmonizing the planning with the conducting the JEE, countries have shown commitment annual national budgeting processes, and increasing of their national authorities to improve their IHR (2005) and appropriate allocation of the health sector portion capacities. They have also found the JEEs to be valuable in the national budget, is critical for implementation and for multisectoral engagement and generating evidence for their policy-makers (19). This commitment may sustainability of NAPHS. Support for countries could best be further reflected in the coming months as these be directed to improving measures of cooperation and countries finalize the development of their national organization in specific technical areas. In implementing action plans for health security based on the JEE the JEE and the other components of the IHR MEF, it is outcomes. Also, as JEE scores tend to differ between hoped that improved compliance in the application and countries based on their category, it may be important implementation of the IHR (2005) will be achieved. to take into account the other components of the IHR monitoring and evaluation framework (IHRMEF), such as simulation exercises and after action reviews. This Conclusion would provide a comprehensive view of the countries’ In conclusion, to effectively promote health and build capacities and functionality, and consider prioritizing the capacity to prevent, detect and respond to diseases, a focus of IHR implementation while developing National country needs to have in place a number of essential public Action Plans for Health Security (NAPHS). This is not to health functions (33). The IHR (2005) core capacities, imply that the other technical areas are less important, as represented in the JEE tool by the 19 technical areas, but given the challenges and reality check associated with implementation at country-level, it is important to are a subset of such essential public health functions. prioritize and tailor implementation activities based on Lessons from the JEE missions and these analyses show country needs, context and future plans for development. that compliance with the IHR (2005) appears to be within Inclusive of universal health coverage needs to be reach for most countries, thereby ensuring not only considered so that the implementation of a plan covers health security at the country level but globally. Acknowledgements The authors wish to acknowledge the leadership of its Member States in the Eastern Mediterranean Region for volunteering for JEEs and their commitment to implement and address gaps identified through their own resources as well as partners with international agencies and public and private donors. We also recognize the guidance and support received by the WHO JEE secretariat as well as from the US Department of Health and Human Services, the US Centers for Disease Control and Prevention, the US Department of Agriculture, the Food and Agricultural Organization of the United Nations, the Organization for Animal Health, and the Government of Finland; and express our appreciation to the National IHR focal points in WHO Regional Office for the Eastern Mediterranean (WHO/EMRO), as well as to the subject matter experts that participated and contributed to JEEs in WHO/EMRO. Funding: None. Competing interests: None declared. Analyse des évaluations externes conjointes dans la Région OMS de la Méditerranée orientale Résumé Contexte : L’évaluation externe conjointe est un nouveau modèle d’examen externe par les pairs des capacités requises au titre du RSI utilisant des approches normalisées. Objectifs : La présente étude avait pour objectif de consolider les résultats de ces évaluations dans la Région de la Méditerranée orientale et d’évaluer leur pertinence. Méthodes : Une analyse des données a été menée dans 14 pays ayant conduit une évaluation externe conjointe dans la Région. Le score moyen des évaluations externes conjointes pour chacun des 19 domaines techniques, ainsi que celui des domaines techniques dans leur ensemble, ont été calculés. Des analyses bivariées et multivariées ont été menées afin d’évaluer les corrélations avec les indicateurs clés en matière de santé, de statut socio-économique et de systèmes de santé. Résultats : Les scores moyens des évaluations externes conjointes variaient considérablement entre les domaines techniques. La moyenne cumulative des évaluations externes conjointes (moyenne des scores des indicateurs d’un domaine technique donné) était de 3 (fourchette comprise entre 1 et 4). Les indicateurs liés à la résistance aux antimicrobiens, à la sécurité et la sûreté biologiques affichaient les scores les plus bas. Les contre-mesures médicales, et les capacités liées au déploiement de personnel et au lien entre la santé publique et la sécurité obtenaient la moyenne cumulative la plus haute de 4 (fourchette comprise entre 2 et 5). Les scores des évaluations externes conjointes liés à la plupart des indicateurs clés ont été examinés. Les pays dotés d’un meilleur système de financement de la santé, ayant une meilleure couverture

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des services de santé, et dont la situation sanitaire était meilleure avaient généralement des scores d’évaluations externes conjointes plus élevés. Les taux de fécondité des adolescents, le ratio de mortalité néonatale et le ratio net d’inscription en école primaire constituaient des facteurs essentiels dans le score d’évaluation externe conjointe d’un pays. Conclusion : Une approche multisectorielle intégrée, incluant un système de financement de la santé et une couverture transversaux et bien planifiés, est cruciale pour combler les lacunes principales identifiées par les évaluations externes conjointes et ainsi garantir la sécurité sanitaire régionale et mondiale.

حتليل التقييامت اخلارجية املشرتكة يف إقليم منظمة الصحة العاملية لرشق املتوسط داليا سمهوري، كاشف أجياز، آرش رشيديان، ستيال شونغونغ، أنتوان فالهو، سوزان بابتش، جواد املحجور اخلالصة اخللفية: لقد ُطـ ِّو َر التقييم اخلارجي املشرتك كنموذج جديد للتقييامت اخلارجية ملراجعة القرناء بشأن القدرات اخلاصة باللوائح الصحية الدولية وذلك باستخدام ُ ُنج معيارية. اهلدف:هدفت هذه الدراسة إىل جتميع النتائج التي توصلت إليها هذه التقييامت يف إقليم رشق املتوسط، وتقييم أمهيتها. ُ ِ طرق البحث: أ ْجـ ِر َي حتليل لبيانات التقييامت اخلارجية املشرتكة لعدد 14 ًبلدا الذين أكملوا هذه التقييامت يف اإلقليم. ُوحس َب متوسط درجات التقييامت اخلارجية املشرتكة لكل جمال من 19 ًجماال ً تقنياوملجمل املجاالت التقنية. ُوأجريت حتليالت ثنائية املتغري ومتعددة املتغريات لتقييم العالقات املتبادلة مع املؤرشات الرئيسية الصحية، واالجتامعية-االقتصادية، ومؤرشات النظام الصحي. النتائج: تباين متوسط درجات التقييم اخلارجي املشرتك ً تبيانا ًكبريايف املجاالت التقنية. كان املتوسط الرتاكمي للتقييم اخلارجي املشرتك )متوسط درجات املؤرش املتصل باملجال التقني( قد بلغ 3 درجات )النطاق: 1- ( 4وحصلت مؤرشات مقاومة مضادات امليكروبات، ومؤرشات السالمة البيولوجية واألمن البيولوجي عىل أدنى الدرجات. وقد حصلت التدابري الطبية، ونرش املوظفني، وربط الصحة العامة مع األمن عىل أعىل درجة للمتوسط الرتاكمي وبلغت 4 درجات )النطاق: 2- ( 5ارتبطت درجات التقييم اخلارجي املشرتك مع أغلب املؤرشات الرئيسية التي ُف ِح َصت. وحصلت البلدان التي لدهيا مستوى أفضل من التمويل الصحي والتغطية باخلدمات الصحية واحلالة الصحية ًعموما عىل درجات أعىل يف التقييم اخلارجي املشرتك. وارتبط معدل خصوبة املراهقني، ونسبة وفيات الولدان، ونسبة االلتحاق باملدارس االبتدائية مع درجة التقييم اخلارجي اإلمجايل للبلد. االستنتاجات: إن اتباع نج متكامل ِّمتعدد القطاعات، ويشمل ً نظاما ً شامال ًوخمططا له ً جيداللتمويل الصحي والتغطية الصحية، أمر بالغ األمهية ملعاجلة الثغرات الرئيسية التي حددها التقييم اخلارجي املشرتك لضامن األمن الصحي العاملي واإلقليمي. References 1. World Health Organization. World Health Assembly resolution WHA58.3. May, 2005. http://www.who.int/csr/ihr/WHA58-en.pdf, accessed May 2017. 2. Hoffman JJ. Making the international health regulations matter: promoting universal compliance through effective dispute resolution. In: Rushton S, Youde J, editors. Routledge handbook on global health security. Oxford: Routledge; 2014. pp. 239–51. 3. World Health Organization. Sixty-Eighth World Health Assembly. First report of the Ebola Interim Assessment Panel. Geneva. 2015, A68/25. Last seen World Health Organization: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_25-en.pdf 4. Commission on a Global Health Risk Framework for the Future. The neglected dimension of global security: a framework to counter infectious disease crises. Geneva, 2016. Last seen 15 February, 2018. http://www.nap.edu/catalog/21891/the-neglected- dimension-of-global-security-a-framework-tocounter 5. World Health Organization. Report of the Ebola Interim Assessment Panel. July 2015. (http://www.who.int/csr/resources/ publications/ebola/report-by-panel.pdf). 6. Moon S, Sridhar D, Pate MA, Jha AK, Clinton C, Delaunay S, et al. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. Lancet. 2015 Nov 28;386(10009):2204–21. https://doi.org/10.1016/S0140-6736(15)00946-0 PMID:26615326 7. World Health Organization. Sixty second Regional Committee for the Eastern Mediterranean. Assessment and monitoring of the implementation of the International Health Regulations (2005). Cairo, 2015; EM/RC62/R.3. (http://applications.emro.who.int/ docs/RC62_Resolutions_2015_R3_16576_EN.pdf). 8. Gostin LO, Katz R. The International Health Regulations: The Governing Framework for Global Health Security. Milbank Q. 2016 06;94(2):264–313. https://doi.org/10.1111/1468-0009.12186 (http://scholarship.law.georgetown.edu/facpub/1770 PMID:27166578). 9. World Health Organization. Checklist and indicators for monitoring progress in the development of IHR core capacities in States Parties. Geneva, 2013. (http://apps.who.int/iris/bitstream/handle/10665/84933/WHO_HSE_GCR_2013.2_eng.pdf?sequence=1). 10. World Health Organization. Sixty-ninth World Health Assembly. Annual report on the Implementation of the International Health Regulations (2005). Annex to document A69.20; Geneva. 2016. Last seen (http://apps.who.int/gb/ebwha/pdf_files/WHA69/ A69_20-en.pdf).

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11. World Health Organization. Sixty-eighth World Health Assembly. Report of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation. Geneva, 2015; A68/22 Add.1: (http://apps.who.int/gb/ ebwha/pdf_files/WHA68/A68_22Add1-en.pdf). 12. World Health Organization. Fifty-eight World Health Assembly. International Health Regulations (2005). Geneva. 2005; WHA58.3. last seen 15 February 2018 (http://apps.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/A58_2005_REC1-en.pdf). 13. World Health Organization. Sixty second Regional Committee for the Eastern Mediterranean. Assessment and Monitoring of implementation of the International Health Regulations (2005): meeting the 2016 target. Cairo. 2015; EM/RC62/8. Last seen 10 January 208: (http://applications.emro.who.int/docs/RC_technical_papers_2015_8_16537_EN.pdf?ua=1). 14. Moon S, Leigh J, Woskie L, Checchi F, Dzau V, Fallah M, et al. Post-Ebola reforms: ample analysis, inadequate action. BMJ. 2017 01 23;356:j280. https://doi.org/10.1136/bmj.j280 PMID:28115316 15. Bell E. at Al. Joint External Evaluation—Development and Scale-Up of Global Multisectoral Health Capacity Evaluation Process, Emerging Infectious Disease, December 2017. Volume 23, Globalhealth security supplement. (http://wwwnc.cdc.gov/eid/not- found.html?aspxerrorpath=/eid/article/23/13/17-0949_article). 16. World Health Organization. Sixty-ninth World Health Assembly. Annual report on the Implementation of the International Health Regulations (2005). Annex to document A69.20; Geneva. 2016 (http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_20-en. pdf). 17. World Health Organization. Sixty-eighth World Health Assembly. Report of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation. Geneva, 2015; A68/22 Add.1: (http://apps.who.int/gb/ ebwha/pdf_files/WHA68/A68_22Add1-en.pdf). 18. World Health Organization. Strategic Partnership Portal, building stronger health systems for sustainable health security. Geneva. 2016. Last seen 14, February, 2018: (https://extranet.who.int/sph/). 19. Samhouri D, Ijaz K, Thieren M, Flahault A, Babich SM, Jafari H, et al. World Health Organization Joint External Evaluations in the Eastern Mediterranean Region, 2016-17. Health Secur. 2018 Jan/Feb;16(1):69–76. https://doi.org/10.1089/hs.2017.0066 PMID:29406822 20. World Health Organization. Joint External Evaluation Tool. Last seen 14, February, 2018 http://apps.who.int/iris/bitstream/ handle/10665/204368/9789241510172_eng.pdf?sequence=1). 21. Samhouri D, Ijaz K, Thieren M, Flahault A, Babich SM, Jafari H, et al. World Health Organization Joint External Evaluations in the Eastern Mediterranean Region, 2016-17. Health Secur. 2018 Jan/Feb;16(1):69–76. https://doi.org/10.1089/hs.2017.0066 PMID:29406822 22. World Health Organization. Eastern Mediterranean Region Framework for health information systems and core indicators for monitoring health situation and health system performance 2017. Cairo, 2017. Available at: http://applications.emro.who.int/docs/ EMROPUB_2017_EN_16766.pdf?ua=1&ua=1. Accessed May, 2018 23. Alwan A, Ali M, Aly E, Badr A, Doctor H, Mandil A, et al. Strengthening national health information systems: challenges and response. East Mediterr Health J. 2016 02 1;22(11):840–49. https://doi.org/10.26719/2016.22.11.840 PMID:28177115 24. World Health organization. Eastern Mediterranean Region Framework for health information systems and core indicators for monitoring health situation and health system performance, Cairo, 201 (http://applications.emro.who.int/docs/EMROPUB_2017_ EN_16766.pdf?ua=1). 25. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004 Sep 4-10;364(9437):900–6. https://doi.org/10.1016/S0140-6736(04)16987-0 (https:// www.sciencedirect.com/science/article/pii/S0140673604169870) PMID:15351199 26. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet. 2004 Nov 27;364(9449):1984–90. https://doi.org/10.1016/S0140-6736(04)17482-5 (https://www.sciencedirect.com/science/article/pii/ S0140673604174825) PMID:15567015 27. World Health Organization. Working together for health. The world health report, 2006. Policy Briefs. Geneva, 2006 (http://apps. who.int/iris/bitstream/10665/43471/1/9241594241_eng.pdf). 28. World Bank Group. World development indicators. Washington DC, 2017 (https://data.worldbank.org/indicator). 29. World Health Organization. Global Health Observatory (GHO) data, World Health Statistics 2017: Monitoring health for the SDGs. Geneva, 2017. (http://www.who.int/gho/publications/world_health_statistics/2017/en/). 30. World Health organization. Demographic, social and health indicators for countries of the eastern Mediterranean region, 2013 (http://applications.emro.who.int/dsaf/EMROPUB_2013_EN_1537.pdf). 31. World Health Organization. International Health Regulations. Review of National Legislation (http://www.who.int/ihr/legal_ issues/legislation/en/) 32. Shoman H, Karafillakis E, Rawaf S. The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review. Global Health. 2017 01 4;13(1):1. https://doi.org/10.1186/s12992-016-0224-2 PMID:28049495 33. Bettcher DW, Sapirie S, Goon EHT. Essential public health functions: results of the international Delphi study. World Health Stat Q. 1998;51(1):44–54. PMID:9675808

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Book 24-05.indb 485 7/19/2018 1:23:23 PM Research articles EMHJ – Vol. 24 No. 5 – 2018 7 4 - 7.1 95 99 1.8 3.2 2.9 8.6 9.0 100 100 74.7 74.7 18.0 0.09 3892 KUW -- 17 - 10 93 97 96 5.2 5.2 0.4 4.0 11.6 17.8 13.5 12.0 76.6 76.6 4491 OMN 6 6 -- - 91 1.3 98 1.8 7.0 3.5 0.3 6.8 77.1 77.1 100 17.4 67.0 9157 UAE 13 - 12 97 99 98 7.9 2.3 2.4 100 17.6 14.5 16.4 12.0 74.5 74.5 0.09 KSA 31540 31 57 55 32 66 2.7 5.3 91.1 396 51.9 31.0 35.5 35.8 34.6 39.0 60.5 60.5 AFG 32527 (23,27,28) 12 14 1.1 97 62 92 99 98 7.0 2.4 8.2 8.0 0.8 15.5 16.8 75.3 75.3 11254 TUN 17 31 - 23 85 2.9 6.4 732 39.7 55.0 55.0 20.2 64.0 98.8 68.0 136.8 SOM 10787 55 76 24 60 48 311 5.2 2.4 25.7 70.1 64.1 64.1 87.0 34.6 46.5 36.0 29.8 SUD 40235 - 5 - 15 1.1 99 2.1 0.1 - -- 3.8 6.2 100 17.0 15.5 13.8 76.9 76.9 1377 BAH 15 97 58 96 99 98 1.0 3.2 3.4 17.9 74.1 74.1 19.6 12.0 14.4 10.6 26.0 JOR 7595 Health Status Health - 7 - - 15 81 93 99 1.5 8.3 2.6 4.8 0.4 4.0 18.4 74.9 74.9 LEB 5851 Health determinant and risks determinant Health 77 85 24 99 88 1.4 121 2.2 3.4 8.9 16.7 17.6 15.0 27.6 74.3 74.3 32.0 34378 MOR 7 8 13 - 91 98 98 3.5 3.8 2.0 6.0 100 13.4 14.2 78.2 78.2 0.09 2235 QAT 91 67 56 58 64 3.8 2.0 178 81.1 21.0 24.7 20.7 35.0 45.5 66.4 66.4 44.0 PAK 188925 Total population (000s) Total expectancy at birth, both Life sexes Indicator (%) Annual popuation growth rate fertility Total rate (15-19 Adolescent fertility years) primary school enrollment Net ration per 100 school- age children the below Population lines (%) international poverty expectancy at birth, both Life sexes both years), Literacy rate (15-24 (%) sexes drinking Access to improved (%) water sanitation Access to improved (%) facilities rate (per neonatal mortality 2015 births), 1000 live 1000 rate (per mortality Infant 2015 births), live (per rate mortality Under-five 2015 births), 1000 live ratio (per Maternal mortality births) 100 000 live (%) CD mortality (%) NCD mortality rate attributed Mortality to unsafe to exposure services 100 000 (per WASH population) Selected demographic, socioeconomic, mortality, universal health coverage and political stability Indicators in the 14 studied countries in the 14 studied Indicators stability and political health coverage universal mortality, socioeconomic, demographic, Selected Indicator list Indicator and Demographic socioeconomic determinants RisksHealth expectancy Life and Mortality Appendix 1.

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Book 24-05.indb 486 7/19/2018 1:23:24 PM Research articles EMHJ – Vol. 24 No. 5 – 2018 35 87 20 80 0.1 0.7 5.8 0.2 100 100 12.7 14.2 99.9 2.00 1,386 1.842 KUW 8 88 1.2 6.1 5.8 6.8 135 0.0 100 675 14.5 400 1.80 99.0 2.016 OMN 1 - 87 49 7.3 8.7 2.2 0.2 100 100 17.8 1.50 1,611 0.09 1.931 UAE 2 72 60 0.7 8.2 4.4 100 2.17 434 14.3 300 27.5 98.0 0.09 1,147 KSA 2.338 7 81 88 1.9 1.9 147 204 500 51.0 12.0 57.0 63.9 0.43 114.8 AFG 3.538 40.90 (23,27,28) (concluded) (23,27,28) 31 91 29 0.4 164 100 305 37.3 14.2 800 74.0 42.6 0.30 2.08 1.949 TUN 11 - - - - 85 24 84 1.9 9.0 116.9 1084 3.414 35.80 SOM 10500 10 79 36 0.5 130 11.6 15.6 0.73 75.5 7.00 64.5 78.0 4309 2900 SUD 3.269 -- 11 42 44 5.4 0.2 11.1 100 1.93 200 10.5 23.3 2.00 1,243 BAH 100.0 2.398 4 35 55 85 6.9 13.7 100 395 21.2 1.80 0.01 20.9 0.04 JOR 1000 2.127 100.0 Health System Response System Health - 15 51 83 2.5 6.2 108 100 10.7 569 29.1 200 3.50 36.4 3.80 LEB 2.752 Health determinant and risks determinant Health 94 88 48 0.1 6.0 0.8 190 100 25.1 500 1.00 0.01 1167 74.0 58.4 2.086 MOR 0 16 70 86 0.1 4.3 6.9 5.8 8.9 100 1.27 200 1.716 0.00 QAT 2,106 100.0 7 93 36 76 4.7 0.5 4.6 193 87.2 56.3 52.0 4.20 0.60 5156 PAK 3.145 2800 General government General government as on health expenditure government general % of expenditure as % expenditure pocket Out of expenditure total health of 1000 (per bed density Hospital population) facilities care health Primary 1000 population) (per Annual outpatient visit per Ratiocapita, births attended by of Proportion personnel skilled health rate of success Tuberculosis new bacteriology confirmed 2015 cases, malaria cases that Suspected test had a diagnostic have Adults currently and children among therapy ARV receiving all living with HIV estimates from deaths direct Estimated major conflicts/100000s Index Global Peace Health expenditure per capita per capita expenditure Health (USD) Indicator rate attributed Mortality to household and ambient 10 000 air pollution (per population) case notification Tuberculosis, 2015 rate per 100 000, newly reported number of HIV, cases, incidence rate per B, Hepatitis 100 000 Selected demographic, socioeconomic, mortality, universal health coverage and political stability Indicators in the 14 studied countries in the 14 studied Indicators stability and political health coverage universal mortality, socioeconomic, demographic, Selected Service delivery Service coverage Political instability Indicator list Indicator Morbidity Finance Health Appendix 1.

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Seroprevalence of Toxoplasma gondii infection among Iranian pregnant women: a systematic review and meta-analysis

Mina Malary,1 Zeinab Hamzehgardeshi,2 Mahmood Moosazadeh,3 Mahdi Afshari,4 Imaneh Ahmadi,5 Iman Moghaddasifar1 and Motahareh Kheradmand3

1Student Research Committee; 2Department of Reproductive Health and Midwifery, School of Nursing and Midwifery; 3Health Sciences Research Centre, Faculty of Health; 5Department of Obstetrics & Gynaecology, Emam Hospital, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran (Correspondence to: Mahmood Moosazadeh: [email protected]). 4Department of Community Medicine, School of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran. Abstract Background: Toxoplasmosis is a great public health concern due to its capacity for prenatal transmission. Serologic studies have reported various estimates for seroprevalence of toxoplasmosis among Iranian pregnant women. Estimation of the pooled prevalence of this infection is necessary for policy-making. Aims: The aim of this study was to estimate the prevalence of Toxoplasma gondii infection in Iranian pregnant women using systematic review and meta-analysis. Methods: We searched national and international databases to identify relevant studies. To enhance the search sensitivity, we evaluated all references and interviewed relevant researchers and research centres. The final studies for meta-analysis were selected according to the quality assessment as well as inclusion/exclusion criteria. Because of the heterogeneity of the primary results, random effects models were used to estimate the pooled prevalence of T. gondii. We included 43 studies with a total sample size of 22 644 in the meta-analysis. Results: The pooled seroprevalence of overall toxoplasma infection, IgG antibody and IgM antibody was estimated at 41.3% (95% CI: 35.8–46.8), 39.2% (95% CI: 33.3–45.1) and 4.0% (95% CI: 3.1–4.9) respectively. Conclusions: Our study showed that a considerable proportion of Iranian pregnant women are at high risk for toxoplasmosis. Keywords: Toxoplasmosis, Toxoplasma gondii, infection, pregnancy, Iran Citation: Malary M; Hamzehgardeshi Z; Moosazadeh M; Afshari M; Ahmadi I; Moghaddasifar I; et al. Seroprevalence of Toxoplasma gondii infection among Iranian pregnant women: a systematic review and meta-analysis. East Mediterr Health J. 2018;24(5):488-496. https://doi. org/10.26719/2018.24.5.488 Received: 09/09/15; accepted: 23/04/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction gondii in pregnant women. However, ELISA is the most commonly used diagnostic technique (7,9). Toxoplasma gondii is an obligate intracellular protozoa with a complicated life cycle. This agent causes Previous research has shown that toxoplasmosis toxoplasmosis among humans and animals and is one infection was more common among those with history of the most prevalent chronic infections, infecting one- of close contact with cats, raw meat and vegetable consumption, and low education level (3). The most third of the world population (1–5). Three main modes important benefit in the serology of toxoplasma is to are responsible for fetal: consumption of including raw detect whether the pregnant woman has acute infection or semi-cooked meat, eating the oocytes defecated by or not, and if so, whether it occurred before pregnancy cats and vertical transmission from an infected pregnant (10). The main problem in diagnosis among pregnant mother to her fetus (6–7). Consideration of toxoplasmosis women is long-term antibody IgM, but T. gondii-specific among pregnant women (owing to the risk of maternal antibody (IgM) does not necessarily indicate acute transmission) and immunocompromised patients is infection (11). In many cases, laboratory diagnosis of of great importance for control programmes because latent and acute T. gondii is based on detecting T. gondii- infection can lead to serious pathologic outcomes among specific IgM and IgG antibodies 7( ). There are several neonates with congenital toxoplasmosis and patients serologic tests for anti-toxoplasma IgM and IgG, among with immunodeficiency status (8–9). Knowing the which ELISA has maximum sensitivity and specificity burden of this infection will help health systems focus on (2). Chronic infection before pregnancy cannot be prevention of risk factors. transmitted to the fetus, but acute untreated infection A number of serological tests, such as the latex during pregnancy may lead to congenital toxoplasmosis agglutination test, enzyme-linked immunosorbent with neonatal complications (6). The risk of transmission assay (ELISA) and indirect fluorescence antibody test, and the severity of fetal disease is based on gestational have been used in the detection of antibodies against T. age and progressive antibody titration (8), so this risk

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varies between 0–9% (congenital infection during the search strategy was carried out applying “AND” to select first trimester) and 35–59% (congenital infection during studies with all of the required keywords. To provide the third trimester) (12). Although the infection is usually more relevant keywords and studies leading to increased asymptomatic or mild and self-limiting (fever, agitation, search sensitivity, we investigated all references used in lymphadenopathy), infection occurring during pregnancy these papers. One of the researchers randomly evaluated causes vertical transmission to the fetus (3) leading to the search action and found that all required studies had pathologic complications such as hydrocephaly (2,3), been entered in the systematic review. Moreover, to find microcephaly, chorioretinitis (12), blindness (2,3), mental unpublished studies, we asked some well-known Iranian retardation (2,12), epilepsy (12), jaundice (12), abortion parasitologists working in the medical universities and (2,3,12) and fetal death (2,3,12). These complications can be infectious diseases research centres to introduce any accompanied by disabilities, reduced quality of life and a relevant manuscripts which had not been published. high socioeconomic burden (8). However, we did not find any evidence during this phase Prevention of toxoplasmosis by screening is of the search. All stages of the search as well as the follow- mandatory in some countries and is recommended in up actions were performed by 2 independent researchers. some others such as the United States of America and Any disagreement was settled by a third researcher. Canada (12). There is no routine screening programme Selection of studies for toxoplasmosis in the Islamic Republic of Iran (8) and We extracted the full texts or abstracts of all documents there is no agreement on the best strategy for control collected during our search. During primary screening, of congenital toxoplasmosis (11) although treatment is repeated studies were excluded by investigation of the very important, especially among immunocompromised title and abstract. Secondary screening was conducted patients and pregnant women (1). among studies selected during the primary phase to Seroprevalence of toxoplasmosis has been reported select more relevant studies with evaluation of the full as 30–60% in developed and developing countries (3). In text. In this stage, abstracts and full texts of the papers an Iranian study, the incidence of congenital infection were investigated to exclude irrelevant and duplicated during pregnancy was reported to vary from 1 to 8 per studies. 1000 pregnancies (8). According to a systematic review, the global annual incidence of congenital toxoplasmosis Inclusion criteria was estimated at 190 100, equivalent to a burden of 1.20 All studies published in Farsi or English that achieved an million disability-adjusted life years. This burden was adequate quality score (> 8 of 12) during the assessment greater in South America, some Eastern Mediterranean process and also those estimating seroprevalence of countries and other low-income countries (13). toxoplasmosis, IgG and IgM titration among Iranian Various primary studies have been published pregnant women were selected. These titrations were estimating the prevalence of toxoplasmosis among categorized according to the standards defined by the pregnant women in the Islamic Republic of Iran. companies manufacturing the relevant substances (in Combining the results of these studies using systematic most studies, antibody titration > 1.1 IU/mL for indirect and meta-analytic methods will be of great importance. fluorescence antibody test and ELISA was considered Therefore, in this study, we used the methods outlined positive). above to estimate the pooled seroprevalence of Exclusion criteria toxoplasma antibodies among Iranian pregnant women. Studies without estimations of IgG or IgM seroprevalence, studies without sample size reporting, Methods abstracts submitted in congresses whose full texts were Data sources and search strategy not available and case–control studies which could not The current study is a systematic review and meta- report prevalence estimations were excluded from the analysis of estimation of the seroprevalence of study. toxoplasmosis among Iranian pregnant women. Quality assessment All electronic papers published in national and After selecting relevant studies based on titles and international databases including SID, Iranmedex, contents, to select the documents of satisfactory quality, Magiran, Irandoc, Pubmed, Google Scholar, Scopus we applied the STROBE checklist (14). This checklist and Science Direct from 1990 until 10 March 2015 includes 22 items covering various components of were enrolled in this study. The search strategy was the methodology such as sample size estimation and performed using the following keywords as well as their selection, study population, data collection methods, Farsi equivalents: “toxoplasmosis”, “Toxoplasma gondii”, instrument for data collection, statistical analysis, “toxoplasma infection”, “T. gondii”, “Iran”, “pregnant”, geographical distribution of the study, aims of the study “seroepidemiology”, “seroprevalence”, “IgG antibody”, “ and appropriate illustration of the results based on the IgM antibody”, “prevalence” . study objectives. Scores were determined from 0 to 44. Searching was done from 11 to 20 March 2015. We Based on the STROBE checklist assessment, documents used “OR” to identify studies with any of the keywords were divided into to 3 groups: low quality, score < 15.5; in their titles, abstracts and full texts. Limiting the moderate quality, score 15.5– 29.5; and high quality, score

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30.0– 44.0. Studies with score < 15.5 were excluded from the meta-regression method. We illustrated the point the meta-analysis. prevalence in forest plots, including the study weights Data extraction (size of each box) and 95% confidence interval (CI) (lines crossing the boxes). Title of the study, first author’s name, date and area of the study, total sample size, type of study, serologic method used, mean age of participants, seroprevalence Results of toxoplasmosis, prevalence of positive IgG and IgM We found 12 545 documents from national and (according to the cut-off points defined by the companies international databanks using relevant keywords (12 541) who manufactured the kits) were extracted from each and reviewing the references (4 papers). After limiting of the selected studies. Extracted data were entered into the search strategy and excluding duplicated papers, the Microsoft Excel for descriptive data analysis. number of relevant articles decreased to 1885. Reviewing Analysis the titles and abstracts, 1696 irrelevant records were removed. Out of the remaining papers, 146 were excluded All extracted data were entered into Stata, version after full text review and according to other exclusion 11 software. The standard error of toxoplasma and inclusion criteria. Finally, 43 papers (6,7,9,12,16–54) seroprevalence for each study was calculated based on binomial distribution. The heterogeneity of the study were considered eligible for inclusion in the systematic results was determined using the Cochrane (Q) test and review and meta-analysis (Table 1; Figure 1). I-squared (15). The random effects model was used to The final selection of papers was published from 1990 estimate the combined seroprevalence of toxoplasmosis to 2015 (Table 1), 15 articles in English and 28 in Farsi. Type as well as IgG/IgM seropositivity rates. The effects of of study was explained in 34 papers, including 1 cohort potential factors in heterogeneity were assessed using and 33 descriptive and cross-sectional studies. The age of

Table 1 Baseline characteristics of included studies in meta-analysis of seroprevalence of Toxoplasma gondii in Iranian pregnant women of Reference Publication Publication Type of study Quality Sample Serological Prevalence of women with year language score size method positive antibody (%) IgG IgM IgM + IgG Abdi (34) 2008 English Cross-sectional 26 553 IFA 44.8 – 44.8 Akhlaghi (48) 2014 English – 32 400 ELISA 29.0 1.0 30.0 Akhlaghi (13) 2013 English Cross-sectional 27 200 IFA & ELISA 39.6 5.7 45.3 Alleyassin (51) 1990 English – 29 320 IFA 77.2 – 77.2 Anvaritafti (39) 2012 Farsi Cross-sectional 28 181 ELISA 32.0 – 32.0 Arbabi (54) 2001 Farsi descriptive 27 340 IFA % ELISA – – 66.7 Athari (45) 1994 English – 26 495 IFA – – 32.7 Cheragipour (44) 2010 Farsi Cross-sectional 30 390 ELISA 23.6 7.4 31.0 Cheragipour (43) 2009 Farsi Cross-sectional 31 331 ELISA 28.7 10.5 39.2 Dalimiasl (40) 2011 Farsi Cross-sectional 31 300 ELISA 26.3 0.3 26.6 Ebrahimzadeh (52) 2013 Farsi – 30 221 ELISA 30.8 1.4 30.8 Eskandareian (37) 2009 Farsi – 29 255 IFA 62.7 – 62.7 Fallah (9) 2008 English Cross-sectional 32 576 IFA – – 33.5 Firozivand (41) 2014 English Cross-sectional 30 200 ELISA 39.5 2.5 41.0 Gasemi (35) 2011 Farsi – 27 127 IFA 47.2 – 47.2 Ghorvi (42) 2002 Farsi – 34 4120 IFA 67.6 0.4 68.0 Ghasemloo (47) 2014 English Cross-sectional 31 785 ELISA 31.1 0.0 31.1 Javadi (49) 2014 English Cross-sectional 29 195 ELISA 58.9 5.1 60.5 Hajsoleimani (7) 2012 English – 28 500 ELISA 37.2 1.4 38.6 Hamidi (50) 2015 English Descriptive 33 2523 ELISA 27.0 2.0 29.0 Sotudehjahromi (30) 2002 Farsi Cross-sectional 31 418 ELISA 34.2 7.9 39.7 Tabatabaei (31) 2015 English Cross-sectional 27 200 ELISA 29.0 2.0 31.0 Talari (32) 2003 Farsi Descriptive 28 270 IFA 26.7 5.5 32.2 Talari (33) 2001 Farsi Descriptive 31 562 IFA 33.8 7.8 41.6 Fooladvand (46) 1998 Farsi Cross-sectional 29 365 ELISA 37.8 5.7 43.6 Yad (6) 2014 English Cross-sectional 33 501 ELISA 27.8 1.3 29.1

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Table 1 Baseline characteristics of included studies in meta-analysis of seroprevalence of Toxoplasma gondii in Iranian pregnant women of (concluded) Reference Publication Publication Type of study Quality Sample Serological Prevalence of women with year language score size method positive antibody (%) IgG IgM IgM + IgG Jalai (16) 2013 Farsi Cross-sectional 34 211 ELISA 30.8 1.4 30.8 Babaie (36) 2013 English – 35 419 ELISA 34.4 18.8 34.4 Jamshidi (12) 2012 English Cross-sectional 35 600 ELISA 41.9 0.0 41.9 Kalantari (17) 2013 Farsi Cross-sectional 29 175 ELISA 60.6 0.0 60.6 Magsood (18) 2013 Farsi Cross-sectional 33 350 ELISA 30.0 2.9 32.9 Manoochehrinaeini 2004 Farsi Cross-sectional 32 394 IFA 27.4 0.0 27.4 (19) Manoochehrinaeini 2006 Farsi Cross-sectional 30 384 IFA – – 27.6 (20) Mardani (21) 2004 Farsi Cross-sectional 31 600 ELISA 41.0 – 41.0 Moosavi (22) 2014 Farsi Cross-sectional 28 185 ELISA 10.3 0.6 10.3 Parvizpoor (23) 2010 Farsi Cross-sectional 27 201 ELISA 43.2 28.3 55.0 Rasti (24) 2014 English Cohort 34 798 ELISA 42.7 0.6 43.3 Rostaminejad (53) 2012 Farsi Descriptive 32 496 ELISA 31.0 7.0 38.0 Saffar (25) 1997 Farsi Descriptive 33 612 ELISA 71.0 – 71.0 Sharbatkhori (26) 2014 English Cross-sectional 33 555 ELISA 39.8 3.4 40.4 Sharifi-mood (27) 1998 Farsi Cross-sectional 32 200 IFA 27.0 1.3 27.0 Siyadat Panah (28) 2013 English Cross-sectional 36 1057 ELISA 69.9 5.3 75.0 Sohrabi (29) 2007 Farsi Cross-sectional 31 79 ELISA 35.4 – 35.4

IFA = indirect fluorescence antibody test. ELISA = enzyme-linked immunosorbent assay.

Records identified through Additional records identified database searching through other sources (n = 2639) (n = 9906)

After duplicate records removed and after limiting search (n = 10660)

Records screened Records excluded (n =1885) (n = 1696)

Full-text articles Full-text articles assessed for eligibility excluded, (n = 189) (n = 146)

Studies included in qualitative synthesis (n = 43 )

Studies included in quantitative synthesis (meta-analysis) (n = 43 )

Figure 1 Selection process of studies

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the participants was stated in 14 records, varying between Table 2 Seroprevalence of Toxoplasma gondii in the Iranian 21.0 and 29.9 years. Serologic methods used for diagnosis population group based on other meta-analyses of toxoplasma infection were indirect fluorescence Reference Population Sample Pooled antibody test (12 studies), ELISA (29 studies) and both (2 group size (No.) estimate based studies). on random This meta-analysis involved 22 644 pregnant women effect (%) from different areas in the Islamic Republic of Iran. Daryani (3) General 52 294 39.3 Minimum and maximum sample sizes were 72 and 4120 population respectively. Raised IgG titration ranged between 10.3% Borna (8) Women of 13 480 39.9 (23) and 77.2% (51) (10.8% and 76.6% respectively adjusting childbearing age by Bayesian analysis). In addition, the prevalence of raised IgM varied from 0.0% (12,17,19,47) to 28.3% (23) (Bayesian Ahmadpour HIV/AIDS 1 032 50.1 (55) patients adjusted values 0.4% and 11.9%). Ahmadpour Cancer patients 1 071 45.1 The pooled prevalence of toxoplasmosis among (55) Iranian pregnant women was estimated at 41.3% using Ahmadpour Transplant 702 55.1 the random effects model (I-squared: 98.7%, Q = 3279.2; (55) patients P < 0.0001) and 45.4% using the fixed model. According to the heterogeneity between the included studies, the results provided by the first model are acceptable. Values for the seroprevalence of raised IgG and IgM using the lower than the rates estimated in our meta-analysis. That random effects model were 39.2% (I-squared: 98.7%, Q = was also the case for a study carried out in Norway which 3178; P < 0.0001) and 4.0% (I-squared: 94.3%, Q = 453.8; estimated the IgG seroprevalence as 9.3% (57). Out of 760 P < 0.0001) respectively. These high I-squares indicate pregnant women investigated in a study in Thailand, 25% considerable heterogeneity between the results. were seropositive for toxoplasmosis (22% IgG positive Excluding the extreme results of some studies and 3% IgG+IgM positive) (58). Two different studies, (23,28,51,53), the total prevalence of toxoplasmosis, reported the seroprevalence of Korean pregnant women raised IgG prevalence and raised IgM prevalence were as 3.7% (59) and 0.8% (60). estimated at 40.3% (I-squared: 98.3%, Q = 2322; P < 0.0001), Seroprevalence of IgG and IgM among Indian 38.9% (I-squared: 98.7%, Q = 2751.3; P < 0.0001) and 3.1% pregnant women was 45% and 3.3% respectively (61) (I-squared: 91.8%, Q = 293; P < 0.0001) respectively. Also, corresponding values for 1149 Turkish pregnant women according to the meta-regression analysis, publication were 60.4% and 3.0% respectively (62). A systematic year had no significant effect in heterogeneity among review conducted in Brazil indicated that more than 50% primary studies. of primary school children as well as 50–80% of women during the reproductive period were seropositive for Discussion toxoplasmosis (63). The variability was due to multiple Our systematic review and meta-analysis showed factors such as contact with faeces of infected cats, adult that more than 41% of Iranian pregnant women are oocyte consumption, nutritional behaviours and climate. seropositive for T. gondii antibodies. Congenital toxoplasmosis is one of the most important According to the results of the other systematic reviews fetal diseases and is also a major factor for developing and meta-analyses, Seroprevalence of toxoplasmosis mental retardation. Infection during pregnancy can among Iranian pregnant women is similar to that in the facilitate the development of such pathologies. During the general population in the Islamic Republic of Iran, but is first months of pregnancy particularly,T. gondii infection lower than the prevalence of toxoplasmosis in other high can cause abortion and even stillbirth (64). Incidence of risk groups, e.g. immunocompromised groups such as the congenital infection during pregnancy was estimated patients with HIV/AIDS, or cancer and kidney transplant as 1–8 per 1000 pregnancies in a 2013 Iranian review patients (3,8,55) (Table 2). These differences are related (8). Therefore, in IgM-seropositive pregnant women, a to the different characteristics of the studies (general treatment regimen for acute infection is necessary to populations, immunocompromised groups, different prevent the development of congenital toxoplasmosis and nutritional behaviours, geographical conditions and its complications. Diagnosis of T. gondii infection among various diagnostic serologic methods). pregnant women in populations with low prevalence Some research has shown that prevalence of is critical, however, it is not possible for all pregnant toxoplasmosis is higher in temperate climate regions women and is restricted to suspected cases. Therefore, and lower in cold and hot and dry areas. Inappropriate routine screening among low-risk pregnant women is conditions for growth and development of oocytes in the not recommended; it is only suggested for those with a areas with hot and dry climates may be an explanation higher risk of infection (65). for low prevalence of toxoplasmosis in such areas (9,22). Unfortunately, we could not perform a meta-analysis Prevalence of toxoplasmosis among pregnant women based on the different climatic areas of the Islamic in a Chinese study was less than 10% (56), which was Republic of Iran because of the low number of studies

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conducted in temperate and cold regions. Variations This systematic review and meta-analysis provides a in the primary studies due to factors such as different comprehensive understanding of the seroepidemiology cut-off points for positive IgG, sampling methods, of T. gondii among Iranian pregnant women. Such background evidence can provide important guidelines questionnaires used, situations for data collection, for policy-makers to implement screening and sample sizes and date of studies are other limitations of educational programmes for high-risk populations in the our study. Islamic Republic of Iran. Acknowledgments The authors thank the Student Research Committee and Deputy for Research of Mazandaran University of Medical Sciences for their kind cooperation. Funding: This study was financially supported by Mazandaran University of Medical Sciences. Competing interests: None declared.

Séroprévalence de l’infection à Toxoplasma gondii chez les femmes enceintes iraniennes : examen systématique et méta-analyse

Résumé Contexte : La toxoplasmose est une importante préoccupation de santé publique du fait de sa capacité de transmission prénatale. Différentes études sérologiques ont fait état de séroprévalences de la toxoplasmose variées chez les femmes enceintes iraniennes. L’estimation de la prévalence globale de cette infection est nécessaire en vue de l’élaboration de politiques. Objectif : Le but de la présente étude est d’estimer la prévalence de l’infection à Toxoplasma gondii en République islamique d’Iran au moyen de l’examen systématique et des méthodes de méta-analyse. Méthodes : Nous avons effectué des recherches dans différentes bases de données nationales et internationales pour identifier les études pertinentes. Afin de renforcer la sensibilité de la recherche, nous avons évalué toutes les références et interrogé les chercheurs et centres de recherche concernés. Les études finales requises pour la méta-analyse ont été sélectionnées en fonction des résultats de l'évaluation de la qualité ainsi que des critères d'inclusion/exclusion. En raison de l'hétérogénéité des résultats primaires, des modèles à effets aléatoires ont été utilisés pour estimer la prévalence globale de Toxoplasma gondii. Nous avons recruté 43 études, la taille totale de l'échantillon étant de 22 644 dans la méta-analyse. Résultats : Les séroprévalences globales de l’infection à Toxoplasma globale, des anticorps IgG et des anticorps IgM ont été estimées à 41,3 % (IC à 95 % : 35,8-46,8), 39,2 % (IC à 95 % : 33,3-45,1) et 4,0 % (IC à 95 % : 3,1-4,9) respectivement. Conclusion : Notre étude a montré qu'une proportion considérable de femmes enceintes iraniennes courent un risque élevé de toxoplasmose.

مستوى االنتشار املصيل لعدوى املقوسة العوندية بني النساء احلوامل اإليرانيات: استعراض منهجي وحتليل وصفي مينا ماالري، زينب محزة كرديش، حممود موسى زاده، مهدي افصهاري، إيامنه أمحدي، إيامن مقديس فر، مطهرة خريادمند اخلالصة اخللفية:يمثل داء املقوسات ًشاغال خطرية للصحة العامة بسبب إمكانية انتقاله للجنني أثناء احلمل. وأفادت دراسات مصلية خمتلفة وجود مستويات انتشار مصيل خمتلفة لداء املقوسات يف صفوف النساء احلوامل اإليرانيات. اهلدف:يعد تقدير مستوى االنتشار املجمع هلذه العدوى ًأمرا ًرضوريا لرسم السياسات. ومن ثم، فقد متثل اهلدف من هذه الدراسة يف تقدير مستوى انتشار عدوى املقوسة العوندية يف إيران باستخدام استعراض منهجي وأساليب التحليل الوصفي. طرق البحث: عمدنا إىل البحث يف قواعد بيانات وطنية ودولية خمتلفة لتحديد الدراسات ذات الصلة. ولتحسني احلساسية البحثية، قمنا بتحليل مجيع املراجع، كام أجرينا مقابالت مع الباحثني واملراكز البحثية املعنية. واختريت الدراسات النهائية املطلوبة ألغراض التحليل الوصفي ًوفقا لنتائج تقييم اجلودة إىل جانب معايري الشمول/االستبعاد. ًونظرا لتنافر النتائج األولية، ُاستخدمت نامذج اآلثار العشوائية لتقدير مستوى االنتشار املجمع لعدوى املقوسة العوندية. وأجريت حتاليل إحصائية باستخدام برجمية STATA SE V.11. ولقد ضم التحليل الوصفي 43دراسة منشورة، بعينة إمجالية بلغت 22.644. النتائج: ُدرت قمستويات االنتشار املصيل املجمعة لعدوى املقوسة العوندية وأضداد اجللوبولني املناعي Gوأضداد اجللوبولني املناعي M بمقدار CI %95[ %41.3: 35.8-46.8[، وCI %95[ %39.2: 33.3-45.1[ وCI %95[ %4: 3.1- [ 4.9عىل الرتتيب. االستنتاج: أظهرت دراستنا أن نسبة كبرية من النساء احلوامل اإليرانيات تواجهن خماطر مرتفعة لإلصابة بعدوى املقوسة العوندية.

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References 1. Galvan-Ramirez ML, Troyo R, Roman S, Calvillo-Sanchez C, Bernal-Redondo R. A systematic review and meta-analysis of Toxoplasma gondii infection among the Mexican population. Parasit Vectors. 2012 11 26;5(1):271. https://doi.org/10.1186/1756-3305- 5-271 PMID:23181616 2. Saki J, Mohammadpour N, Moramezi F, Khademvatan S. Seroprevalence of Toxoplasma gondii in women who have aborted in comparison with the women with normal delivery in Ahvaz, southwest of Iran. Sci World J. 2015;2015:764369. https://doi. org/10.1155/2015/764369 PMID:25699288 3. Daryani A, Sarvi S, Aarabi M, Mizani A, Ahmadpour E, Shokri A, et al. Seroprevalence of Toxoplasma gondii in the Iranian general population: a systematic review and meta-analysis. Acta Trop. 2014 Sep;137:185–94. https://doi.org/10.1016/j. actatropica.2014.05.015 PMID:24887263 4. Dubey JP, Hotea I, Olariu TR, Jones JL, Dărăbuş G. Epidemiological review of toxoplasmosis in humans and animals in Romania. 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26. Sharbatkhori M, Dadi Moghaddam Y, Pagheh AS, Mohammadi R, Hedayat Mofidi H, Shojaee S. Seroprevalence ofToxoplasma gondii infections in pregnant women in Gorgan City, Golestan Province, Northern Iran-2012. Iran J Parasitol. 2014 Apr- Jun;9(2):181–7. PMID:25848383 27. Sharifi-Mood B, Hashemi-Shahri M, Naderi M. Investigation of the prevalence of toxoplasma antibodies in women during pregnancy in child and mother’s clinic in zahedan. Iranian J Obst,Gynecol Infertil. 2000–2001;3(5&6):72–5. 28. Siyadatpanah A, Soufiani KB, Barzegar G, Gharachorlou A, Zeydi AE. Seroprevalence ofToxoplasma gondii infection among pregnant women in Amol, Northern Iran. Life Sci J. 2013;10(2s):164–8. 29. Sohrabi A, Samarbafzadeh A, Makvandi M, Maraghi S, Razi T, Darban D. Seroepidemiological study of Parvovirus B19, Toxoplasma gondii and Chlamydia trachomatis in pregnant women visiting the maternity ward of Imam Khomeini Hospital in Ahwaz. J Reprod Infertil. 2007;4(3):171–5. 30. Sotudeh Jahromi A, Safa O, Zare S, Davoudian P, Farshidfar G. Anti–toxoplasmosis antibodies prevalence among pregnant women admitted to hospital in Bandar Abbas. J Hormozgan Univ Med Sci. 2002;6(4):25–30. 31. Tabatabaie F, Mafi M, Golestani M, Shahmohammad N, Mafi H, Maleki F. Seroprevalence of and risk factors forToxoplasma gondii among pregnant women in Abyek township of Qazvin Province, Iran (2013). Asian J Pharmaceut Clin Res. 2015;8(1):1–3. 32. Talari SA, Hejazi SH, Rasti S, Shadzi S. Seroepidemiology of Toxoplasma gondii in pregnant females referring to Ashrafi Isfahani Hospital in Khomeinishahr, 1998–2000. KAUMS J (FEYZ). 2003;6(4):32–7. 33. Talari S, Namaki S, Khorshidi Mal Ahmadi A. Seroepidemiology of toxoplasmosis in pregnant women admitted to hospital in Kashan Shabihkhani, 1990–1993. J Faculty of Med. 2001;25(4):243–8. 34. Abdi J, Shojaee S, Mirzaee A, Keshavarz H. Seroprevalence of toxoplasmosis in pregnant women in Ilam province, Iran. Iran J Parasitol. 2008;3(2):34–7. 35. Ghasemi A, Razaghi Manesh M, Alidusti H, Bahavarnia R, Baradaran H. Seroprevalence of antibodies against Toxoplasma in pregnant women in Esfahan with emphasis on cats on transmission of the disease. J Modern Vet Res. 2011;3(9):23–7. 36. Babaie J, Amiri S, Mostafavi E, Hassan N, Lotfi P, Esmaeili Rastaghi AR, et al. Seroprevalence and risk factors forToxoplasma gondii infection among pregnant women in Northeast Iran. Clin Vaccine Immunol. 2013 Nov;20(11):1771–3. https://doi.org/10.1128/ CVI.00125-13 PMID:24006138 37. Eskandarian A. Seroepidemiology of toxoplasmosis in admitted pregnant women in maternity ward of Kowsar teaching and cure center in Qazvin-2006. Iran. J. Med. Microbiol. 2009;3(2):73–9. 38. Akhlaghi L, Shirbazou S, Maleki F, Keyghobadi A, Tabaraei Y, Tabatabaie F. Seroepidemiology of toxoplasma infection in pregnant women in Qom Province, Iran (2010). Life Sci J. 2013;10(7s):322–5. 39. Anvaritafti M, Ghafourzadeh M. Seroepidemiology of Toxoplasma infection in pregnant women in Yazd in 2012. Tolue Behdasht. 2014;13(3):116–25. 40. Dalimiasl A, Arshad M. Sero-epidemiology of toxoplasma infection in pregnant women referred to Al Zahra Hospital in Tabriz. Sci J Ilam Univ Med Sci. 2011;20(3):55–62. 41. Firozivand Y, Garedaghi Y. Seroprevalence of Toxoplasma gondii infection in pregnant women in Miandoab city, Iran. Indian J Fundamental Appl Life Sci. 2014;4(3):449–54. 42. Gharavi M. Seroepidemiological survey of toxoplasmosis in pregnant women in Tehran. Hakim Res J. 2002;5(2):91–8. 43. Cheraghipour K, Sheikhian A, Maghsood A, Hejazi Z, Rostaminezhad M, Moradpour K. Prevalence of toxoplasmosis in pregnant women in urban and rural health centers in Aleshtar in 2008. J Lorestan Univ Med Sci. 2009;11(4):65–73. 44. Cheraghipour K, Taherkhani H, Falah Mohammad S, Sardarian K, Rostamnezhad M, et al. Seroprevalence of toxoplasmosis in pregnant women admitted to the health centers of Khorram-Abad City, Iran. Hamadan Univ Med Sci. 2010;17(3):46–51. 45. Athari A, Shojaeian S, ELIASI O, Delfani K. Seroprevalence of toxoplasma antibodies among pregnant women in Kerman Shah. Med J Islamic Republic of Iran (MJIRI). 1994;8(2):93–5. 46. Foladvand M, Jaafary S. Seroprevalence of anti-toxoplasma antibodies in pregnant women in Bushehr. Iran J Parasitol. 1998;3(2):113–6. 47. Ghasemloo H, Ghomashlooyan M, Hooshyar H. Seroprevalence of Toxoplasma gondii infection among pregnant women admitted at Shahid Akbar Abadi hospital, Tehran, Iran, 2010–2013. J Med Microbiol Infec Dis. 2014;1(2):16–9. 48. Akhlaghi L, Ghasemi A, Hadighi R, Tabatabaie F. Study of seroprevalence and risk factors for Toxoplasma gondii among pregnant women in Karaj township of Alborz province [2013]. J Entomol Zool Stud. 2014;2(6):217–9. 49. Javadi EHS, Haghdoost M, Taghizadeh S, Oweysee H. Toxoplasma infection in pregnancy: Diagnosis and treatment. Int J Curr Res Acad Rev. 2014;2(8):274–80. 50. Hamidi M, Khulojini M, Azizian R, Bashiri H, Ahanchian A, Babanejad M, et al. Seroprevalence of toxoplasmosis among women referring to Shahid Beheshti Hospital, Hamadan, Iran. Novelty in Biomed. 2015;3(1):1–5. 51. Alleyassin F, Moatari A, Zare F. The prevalence of Toxoplasma gondii antibodies in pregnant women in Shiraz. Iran J Med Sci. 1990;1(15):17–3. 52. Ebrahimzadeh A, Mohammadi S, Davoodi T, Salimi Khorashad A, Jamshidi A. Seroepidemiology of toxoplasmosis among pregnant women referring to the reference laboratory of Zahedan, Iran (2011). Med Laboratory J. 2013;7(3):61–8.

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53. Rostami Nejad M, Fazeli Z, Nazemalhosseini Mojarad E, Cheraghipour K, Pourhoseingholi M, Rostami K, et al. Prevalence of celiac disease and toxoplasmosis during pregnancy. Med Sci J Islamic Azad Univ. 2013; 22 (4):288–293. 54. Arbabi M, Talari S. Seroprevalence of toxoplasma infection in pregnant women in Kashan Iran. Feiz J. 2001;22:28–38. 55. Ahmadpour E, Daryani A, Sharif M, Sarvi S, Aarabi M, Mizani A, et al. Toxoplasmosis in immunocompromised patients in Iran: a systematic review and meta-analysis. J Infect Dev Ctries. 2014 12 15;8(12):1503–10. https://doi.org/10.3855/jidc.4796 PMID:25500647 56. Gao XJ, Zhao ZJ, He ZH, Wang T, Yang TB, Chen XG, et al. Toxoplasma gondii infection in pregnant women in China. Parasitology. 2012 Feb;139(2):139–47. https://doi.org/10.1017/S0031182011001880 PMID:22054357 57. Findal G, Barlinn R, Sandven I, Stray-Pedersen B, Nordbø SA, Samdal HH, et al. Toxoplasma prevalence among pregnant women in Norway: a cross-sectional study. APMIS. 2015 Apr;123(4):321–5. https://doi.org/10.1111/apm.12354 PMID:25628065 58. Andiappan H, Nissapatorn V, Sawangjaroen N, Chemoh W, Lau YL, Kumar T, et al. Toxoplasma infection in pregnant women: a current status in Songklanagarind hospital, southern Thailand. Parasit Vectors. 2014 05 22;7(1):239. https://doi.org/10.1186/1756- 3305-7-239 PMID:24886651 59. Han K, Shin DW, Lee TY, Lee YH. Seroprevalence of Toxoplasma gondii infection and risk factors associated with seropositivity of pregnant women in Korea. J Parasitol. 2008 Aug;94(4):963–5. https://doi.org/10.1645/GE-1435.1 PMID:18576787 60. Song KJ, Shin JC, Shin HJ, Nam HW. Seroprevalence of toxoplasmosis in Korean pregnant women. Korean J Parasitol. 2005 Jun;43(2):69–71. https://doi.org/10.3347/kjp.2005.43.2.69 PMID:15951643 61. Singh S, Pandit AJ. Incidence and prevalence of toxoplasmosis in Indian pregnant women: a prospective study. Am J Reprod Immunol. 2004 Oct;52(4):276–83. https://doi.org/10.1111/j.1600-0897.2004.00222.x PMID:15494049 62. Harma M, Harma M, Gungen N, Demir N. Toxoplasmosis in pregnant women in Sanliurfa, Southeastern Anatolia City, Turkey. J Egypt Soc Parasitol. 2004 Aug;34(2):519–25. PMID:15287175 63. Dubey JP, Lago EG, Gennari SM, Su C, Jones JL. Toxoplasmosis in humans and animals in Brazil: high prevalence, high burden of disease, and epidemiology. Parasitology. 2012 Sep;139(11):1375–424. https://doi.org/10.1017/S0031182012000765 PMID:22776427. 64. Saki J, Mohammadpour N, Moramezi F, Khademvatan S. Seroprevalence of Toxoplasma gondii in women who have aborted in comparison with the women with normal delivery in Ahvaz, Southwest of Iran. Scientific World J. 2015;2015:1–4. 65. Paquet C, Yudin MH, Yudin MH, Allen VM, Bouchard C, Boucher M, et al.; Society of Obstetricians and Gynaecologists of Canada. Toxoplasmosis in pregnancy: prevention, screening, and treatment. J Obstet Gynaecol Can. 2013 Jan;35(1):78–81. https:// doi.org/10.1016/S1701-2163(15)31053-7 PMID:23343802

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Annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control

Citation: Annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control. East Mediterr Health J. 2018;24(5):497- 499. https://doi.org/10.26719/2018.24.5.497 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

Tobacco use is one of the biggest public health threats Dr Yves Souteyrand, WHO Representative to Tunisia, globally, killing more than 7 million people each year (1). delivered opening remarks on behalf of Dr Jaouad Around 80% of the 1.1 billion tobacco users worldwide Mahjour, acting Regional Director, WHO/EMRO, and live in low- and middle-income countries, where the emphasized the alarming picture presented by the WHO burden of tobacco-related illness and death is heaviest Report on the Global Tobacco Epidemic 2017 (5), noting (1). As part of the World Health Organization’s continuing that the Region had the second-highest average tobacco support to reduce tobacco use globally, the Organization’s use prevalence among men and was one of only two Regional Office for the Eastern Mediterranean (WHO/ WHO regions that did not report a decline in tobacco EMRO) organized the 2017 Annual Regional Meeting on use prevalence between 2000 and 2012 (5). He called for the Implementation of the WHO Framework Convention countries to implement the WHO FCTC through a holistic on Tobacco Control (FCTC), 6–7 December, 2017, in Tunis, approach, fully mindful of tobacco industry interference. Tunisia (2). The meeting was attended by representatives Dr Asmus Hammerich, Director, Noncommunicable of 15 Member States from the Region: 12 Parties to Diseases and Mental Health, WHO/EMRO, noted that the Framework Convention and 3 non-Parties. The tobacco control was an essential part of the Regional participants included representatives from ministries of Framework for Action to Implement the United Nations health and agriculture in addition to faculties of national Political Declaration on Noncommunicable Diseases (6), universities. In addition, there were representatives from and that the global target to reduce noncommunicable the Framework Convention Alliance for Tobacco Control, diseases by 25% by 2025 is closely bound to the global the League of Arab States, WHO headquarters, WHO/ target to reduce tobacco use by 30% by 2025 (5,6). EMRO, the Framework Convention Secretariat, WHO Dr Nicolás Guerrero Peniche, Senior Legal Officer temporary advisers from India, the Tanzania Tobacco for the Framework Convention Secretariat, noted that Control Forum, and the Southeast Asia Tobacco Control the Framework Convention Protocol to Eliminate Illicit Alliance. The meeting was chaired by two representatives Trade in Tobacco Products (7) would likely enter into force of the Ministry of Health of Tunisia, i.e. Dr Rafla Dallagi, during 2018, and that this would represent a watershed and Dr Faycal Samaali, on a rotatory basis. moment for tobacco control. The challenge for Parties to the Protocol would be to ensure effective implementation, The core area of the 2017 meeting was the while the challenge for non-Parties would be to continue implementation of Framework Convention Articles the domestic process to ratify the Protocol. 17 and 18 (3) on tobacco growing, namely support for economically viable alternative activities and the Summary of discussions protection of the environment and the health of persons An overview of tobacco control in the Region emphasized involved in tobacco cultivation. The meeting’s specific that the WHO FCTC articles aiming to reduce the supply objectives were to: of tobacco (Articles 15–18) (3) must be complemented by 1. discuss the status of WHO FCTC implementation those which address tobacco–demand reduction (Articles nationally and globally; 6, 8, and 11–14 (3) – broadly speaking, the MPOWER package). However, many Member States in the Region 2. enhance Member States’ understanding of the cur- only reach the middle level of achievement for MPOWER rent WHO FCTC guidelines and strengthen their policies, take a selective approach to the policies they implementation at national level; adopt, and struggle to maintain the highest level of 3. present key seventh session of the Conference of the achievement. These three weaknesses lead to minimal Parties’ (COP7) (4) decisions related to tobacco use impact. Instead, the following MPOWER best practices topics such as the water-pipe, electronic cigarettes must be adopted for each policy (8): and tobacco growing; Monitor – surveys should be conducted at least once 4. debate the different technical needs for the imple- every 5 years and be nationally representative. mentation of COP7 decisions; and Protect – 100% smoke-free indoor public places including 5. discuss the status of the WHO FCTC Protocol to Elim- e-cigarettes; no designated smoking rooms; and strong inate Illicit Trade in Tobacco Products and look into enforcement. possible ways of activating the ratification process at Offer help to quit – integrate cessation services into national level. primary health care; provide nicotine replacement

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therapy for free; insert contact information on how to 5. Ensure that WHO FCTC Assessed Contributions are quit on tobacco packages; and appropriate training for paid on time and that national reports of WHO FCTC health professionals. implementation are submitted on time. Warn – apply graphic health warnings on all tobacco 6. Develop full national profiles on tobacco growing and products, including water-pipes, and implement a plain tobacco trade in order to generate new regional data, packaging policy. in line with the WHO/United Nations Conference for Trade and Development Status of tobacco production Enforce a direct and indirect tobacco advertising, and trade in Africa factsheets. promotion and sponsorship ban. 7. Develop national plans for the implementation of Raise tobacco taxes – implement frequent increases to Framework Convention Articles 17 and 18. account for inflation, and have taxes comprising at least 75% of tobacco retail price. 8. Explore, document and disseminate information on tobacco growing, including its occupational and The WHO report on the global tobacco epidemic environmental hazards, among regional Parties and 2017 shows that good progress was made in the Region non-Parties. between 2007 and 2012, as the number of countries with at least 1 MPOWER measure at the highest level 9. Prioritize the needs of the most vulnerable members of achievement increased from five to 13. Discussions of the tobacco-growing workforce. Children who highlighted that progress slowed between 2012 and 2016, work in tobacco growing are exposed to the health with the number of countries with at least 1 MPOWER hazards of tobacco growing and denied educational measure at the highest level of achievement only rising opportunities. to 14. Attention was drawn to the fact that while the 10. Raise awareness among decision-makers and tobacco main areas of regional progress were the organization farmers about obligations related to WHO FCTC Arti- of anti-tobacco mass media campaigns and tobacco cles 17 and 18. advertising, promotion and sponsorship bans, the Eastern 11. Work with national and international partners to Mediterranean Region is estimated to see tobacco counter and undermine tobacco industry efforts to smoking prevalence increase between 2000 and 2025. weaken the implementation of the WHO FCTC. Therefore, without urgent action, the noncommunicable 12. Acknowledge the compatibility between anti-corrup- disease target of a 30% relative reduction in tobacco use tion laws and WHO FCTC Article 5.3, and utilize these by 2025 (5,6) would not expected to be achieved. anti-corruption laws in relation to tobacco industry Recommendations activities. To Member States To WHO 1. Continue to monitor the tobacco epidemic at nation- 1. Continue holding annual meetings that focus on the al level, for both adults and youth. Data should be multi-sectoral implementation of the WHO FCTC. recent, representative, and periodic (collected a mini- 2. Continue to offer technical and, where possible, fi- mum of once every 5 years). nancial support for WHO FCTC Parties and non-Par- 2. Maintain the progress already achieved in national ties to help bring about full implementation of WHO tobacco control and protect this progress from to- FCTC. bacco industry interference. This is possible through 3. Identify, in coordination with the WHO Study Group close adherence to WHO FCTC Article 5.3 (9) and by on Tobacco Product Regulation (TobReg) and the using the expertise of WHO/EMRO, the WHO FCTC WHO Tobacco Laboratory Network (TobLabNet), a Secretariat’s Tobacco Industry Monitoring Centres set of laboratories that can perform reliable testing (Observatories), and Article 5.3 Knowledge Hub (10). for tobacco products. 3. Promote multi-sectoral collaboration in order to in- 4. Develop policy and advocacy briefs on the Protocol crease the number of Parties to the Protocol to Elimi- to Eliminate Illicit Trade in Tobacco Products to nate Illicit Trade in Tobacco Products. persuade national decision-makers of the benefits of 4. Explore the most effective ways to regulate new to- ratification. bacco products, and extend national tobacco control 5. Conduct reviews following the ratification of the Pro- laws to cover new products including, but not limited tocol to Eliminate Illicit Trade in Tobacco Products to to, electronic cigarettes and heated tobacco products. ensure its effective implementation.

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References 1. World Health Organization. Tobacco, key facts. Geneva: World Health Organization; 2018 (http://www.who.int/news-room/fact- sheets/detail/tobacco). 2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control. Cairo: WHO/EMRO; 2017 (http:// applications.emro.who.int/docs/IC_Meet_Rep_2018_EN_16771.pdf?ua=1). 3. World Health Organization. WHO framework convention on tobacco control. Geneva: World Health Organization; 2005 (http:// www.who.int/tobacco/framework/WHO_FCTC_english.pdf). 4. World Health Organization. Report of the seventh session of the conference of the parties to the WHO framework convention on tobacco control. Geneva: World Health Organization; 2016 (http://www.who.int/fctc/cop/cop7/FINAL_COP7_REPORT_EN.pdf). 5. World Health Organization. WHO report on the global tobacco epidemic, 2017. Geneva: World Health Organization; 2017 (http:// apps.who.int/iris/bitstream/handle/10665/255874/9789241512824-eng.pdf;jsessionid=9D9208CB3FB000F71777DEE44835F96C?se- quence=1). 6. United Nations. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases (66/2). New York: United Nations; 2011 (http://www.who.int/nmh/events/un_ncd_summit2011/politi- cal_declaration_en.pdf). 7. World Health Organization. Protocol to eliminate illicit trade in tobacco products. Geneva: World Health Organization; 2013 (http://www.who.int/fctc/protocol/illicit_trade/protocol-publication/en/). 8. World Health Organization. Tobacco free initiative (TFI): MPOWER brochures and other resources. Geneva: World Health Or- ganization; 2017 (http://www.who.int/tobacco/mpower/publications/en/). 9. World Health Organization. Guidelines for implementation of Article 5.3 of the WHO framework convention on tobacco control. Geneva: World Health Organization; 2018 (http://www.who.int/fctc/guidelines/article_5_3.pdf). 10. World Health Organization. The WHO FCTC Secretariat’s knowledge hubs and the tobacco industry monitoring centres (obser- vatories). Geneva: World Health Organization; 2017 (http://www.who.int/fctc/implementation/knowledge-management/en/).

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Important notes for clinical trials funded or sponsored by WHO

Citation: World Health Organization. Important notes for clinical trials funded or sponsored by WHO. East Mediterr Health J. 2018;24(5):489. https:// doi.org/10.26719/2018.24.5.500 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).

access, publicly available, searchable institutional Registration with clinical trial registry website, such as the WHO website. Before the clinical trial is initiated (at any Phase), its The clinical trial protocol is to be made publicly details are to be registered in a publically available, free to available no later than the time at which the summary access, searchable clinical trial registry complying with results are posted on the results section of the clinical trial WHO’s international agreed standards (see www.who.int/ registry. This includes amendments approved by ethics ictrp). The clinical trial registry entry is to be made before committees/institutional review boards. The protocol the first subject receives the first medical intervention in and amendments are to be either uploaded in electronic the trial. It is preferable that a registry is chosen with a document formats such as PDFs, or provided as a link to functional results section. electronic document formats. Study completion means the date on which the final participant in the clinical Publication of results trial was examined or received an intervention for the purposes of final collection of data for the primary Without prejudice to the confidentiality of proprietary outcome, whether the study concluded according to the information, clinical trial results are to be reported as set pre-specified protocol or was terminated earlier. forth below. In the case of results that may be capable of industrial or commercial exploitation, confidentiality Where negative or inconclusive results are not shall be maintained for a period of twelve months in expected for publication in a peer review journal, order to enable patent rights to be safeguarded or to disclosure requirements will be met by point 2 above, allow alternative forms of legal protection to be explored. and a final study report including all protocol specified Unless it is mutually agreed that confidentiality beyond a analyses is to be developed and retained by the WHO responsible staff member for WHO sponsored clinical period of twelve months is necessary and consistent with trials and the Principal investigator for WHO funded the public interest, the parties shall not be bound by any clinical trials. obligation to keep the results confidential. The Trial ID or registry identifier code/number is 1. The clinical trial results (main findings) are to be to be included in all publications of clinical trials, and submitted for publication in a peer reviewed journal provided as a part of the abstract to PubMed and other within 12 months of study completion, and are to bibliographic search databases for easy linking of trial be published through an open access mechanism in related publications with clinical trial registry site accordance with WHO’s open access policy within 24 records. This is essential for linking journal publications months of study completion; and with registry records. 2. Summary results of clinical trials are to be posted on Compliance (or failure to comply) with the above the results section of the primary clinical trial registry mentioned requirements within the above mentioned within 12 months from primary study completion. deadlines or any extensions thereof agreed by WHO Where a registry is used without a results database in writing, will be monitored by WHO and the details available, the results is to be posted on a free-to- thereof may publicly be disclosed on the WHO website.

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Book 24-05.indb 500 7/19/2018 1:23:25 PM Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses Tunisia . United Arab Emirates . Yemen all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط املجلة الصحية لرشق املتوسط األردن . أفغانستان . اإلمارات العربية املتحدة . باكستان . البحرين . تونس . ليبيا . مجهورية إيران اإلسالمية هىاملجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة ...... اجلمهورية العربية السورية جيبويت السودان الصومال العراق عُ امن فلسطني قطر الكويت لبنان مرص املغرب واخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق اململكة العربية السعودية . اليمن املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه. Membres du Comité régional de l’OMS pour la Méditerranée orientale La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région.

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Cover 24-05.indd 4-6 7/8/2018 2:08:32 PM EMHJ – Vol. 24 No. 5 – 2018 Eastern Mediterranean La Revue de Santé de la Editorial Health Journal Méditerranée orientale World No Tobacco Day 2018: towards a sustainable campaign involving the cardiovascular community Fatimah El-Awa, Nizal Sarrafzadegan, Slim Slama and Asmus Hammerich...... 409 Research articles Smoking behaviour among male students in a Saudi University Guoping Jiang, Shafi Aldamer and Ahmed Bendania...... 411 Tobacco cessation: attitude and practice of dentists in Northern United Arab Emirates Danavanthi Bangera, Mohamed Takana and Jayakumary Muttappallymyalil...... 419 Comparative analysis of essential medicines for cardiovascular diseases in countries of the WHO Eastern Mediterranean Region Hedieh Mehrtash, Richard Laing and Veronika J. Wirtz...... 427 Hypertension and associated cardiovascular risk factors among urban slum dwellers in Egypt: a population-based survey Mohsen Gadallah, Soad Abdel Megid, Amira Mohsen and Sahar Kandil...... 435

Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan Eastern Mediterranean Health Journal Muhammad Fazal Zeeshan, Ahmad Al Ibad, Abdul Aziz, Aftab Subhani, Asif Shah, Tahir Khan, Hidayat Ullah and Umair Qazi...... 443 Parental vaccine knowledge and behaviours: a survey of Turkish families Soner Sertan Kara, Meltem Polat, Burcu Ceylan Yayla, Tugba Bedir Demirdag, Anil Tapisiz, Hasan Tezer and Aysu Duyan Camurdan...... 451 Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children Hoshiar Sangawi, John Adams and Nadja Reissland...... 459 Population and mortality profile in the Islamic Republic of Iran, 2006–2035 Saeide Aghamohamadi, Kamran Hajinabi, Katayoun Jahangiri, Iravan Masoudi Asl and Reza Dehnavieh...... 469

Vol. 24 No. 5 Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region Dalia Samhouri, Arash Rashidian, Stella Chungong, Antione Flahault, Suzanne Babich and Jaouad Mahjour...... 477 Reviews –

Seroprevalence of Toxoplasma gondii infection among Iranian pregnant women: a systematic review and meta- 2018 analysis Mina Malary, Zeinab Hamzehgardeshi, Mahmood Moosazadeh, Mahdi Afshari, Imaneh Ahmadi, Iman Moghaddasifar and Motahareh Kheradmand...... 488 WHO events addressing public health priorities Annual regional meeting on implementation of the WHO Framework Convention on Tobacco Control...... 488 News Important notes for clinical trials funded or sponsored by WHO...... 500

Cardiovascular disease is still the main cause of death in almost all countries in the Eastern Mediterranean Region, where tobacco use ranks one of the highest globally. To help tackle the tobacco use epidemic, the World Health Organization Framework Convention on Tobacco Control rallies countries to the cause of reducing tobacco use, as highlighted by World No Tobacco Day on 31 May.

املجلد الرابع والعرشون / عدد Volume 24 / No. 5 2018 5 مايو/أيار May/Mai

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