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

Contents

Editorial

Eliminating hepatitis from the Eastern Mediterranean Region...... 459 Research articles

Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East...... 461 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011...... 469 Eastern Mediterranean Implementation of a peer-mediated health education model in the United Arab Emirates: Health Journal addressing risky behaviours among expatriate adolescents...... 480 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan...... 486 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015...... 492 La Revue de Santé de Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Volume 23 Number 7 Islamic Republic of Iran...... 500 la Méditerranée orientale Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012...... 507

Short communication July 2017

Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals...... 514

WHO events addressing public health priorities The Eastern Mediterranean Region presents the highest prevalence of hepatitis C in the world, Prevention of re-establishment of local malaria transmission in malaria-free countries...... 520 while gaps in hepatitis B birth-dose vaccination remain higher than the global average. “Eliminate Hepatitis” is the theme of World Hepatitis Day 2017, and reflects the priority the World Health Organization has given to eliminating hepatitis B and C in the Region and globally.

املجلد الثالث والعرشون / عدد Volume 23 / No. 7 7 يوليو/متوز July/Juillet 2017

Cover 23-07.indd 5-7 8/22/2017 12:16:09 PM Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري Republic . Tunisia . United Arab Emirates . Yemen ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه.

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

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

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

Editor-in-chief Eastern Mediterranean Health Journal © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence WHO Regional Office for the Eastern Mediterranean (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). P.O. Box 7608 Nasr City, Cairo 11371 Disclaimer. Egypt The designations employed and the presentation of the material in this publication do not imply the expression of any opinion Tel: (+202) 2276 5000 whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning Fax: (+202) 2670 2492/(+202) 2670 2494 the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which Email: [email protected] there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the Subscriptions and Permissions interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Publications of the World Health Organization can be obtained from Knowledge Sharing The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, and Production, World Health Organization, Regional Office for the Eastern Mediterranean, decisions or policies of the institutions with which they are affiliated. PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected]). Requests for permission to reproduce, in part or in whole, or to If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this translate publications of WHO Regional Office for the Eastern Mediterranean – whether for publication and do not necessarily represent the decisions, policy or views of the World Health Organization. sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: [email protected].

ISSN 1020-3397

Cover 23-07.indd 8-10 8/22/2017 12:16:09 PM Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale

املجلد الثالث والعرشون عدد Vol. 23 No. 7 • 2017 • 7 Contents

Editorial Eliminating hepatitis from the Eastern Mediterranean Region Mahmoud Fikri...... 459 Research articles Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East Tamer Hifnawy, Samer Kobrosly, Hillary Edwards, Manal Anwar, Dalia Zahran and Henry Silverman...... 461 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 Zahra Khorrami, Koorosh Etemad, Shahin Yarahmadi, Soheila Khodakarim, Mohammadesmail Kameli, Alireza Mahdavi Hezaveh and Ebrahim Rahimi...... 469 Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents Zachary D. Stanley, Leena W. Asfour, Michael Weitzman and Scott E. Sherman...... 480 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan Manar Al Azzam, Mohammed Al Bashtawy, Ahmad Tubaishat, Abdul-Monim Batiha and Loai Tawalbeh...... 486 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 Salem Al Wahabi, Fayssal Farahat and Ahmed Y. Bahloul...... 492 Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran Naim S. Kia, Farhad Malek, Elaheh Ghods and Mona Fathi...... 500 Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 Seyed Morteza Shamshirgaran, Hamid Barzkar, Saber Ghaffari-Fam, Ahmad Kosha, Parvin Sarbakhsh and Pari Ghasemzadeh...... 507 Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals Rehab H. El-Sokkary, Ahmed A. Wegdan, Ahmed A. Mosaad, Rasha H. Bassyouni and Wael M. Awad...... 514 WHO events addressing public health priorities Prevention of re-establishment of local malaria transmission in malaria-free countries...... 520

Book 23-07.indb 457 8/23/2017 8:01:55 AM Mahmoud Fikri, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics) Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy, Dalya Mostafa

Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean

Book 23-07.indb 458 8/23/2017 8:01:55 AM املجلة الصحية لرشق املتوسط املجلد الثالث و العرشون العدد السابع

Editorial Eliminating hepatitis from the Eastern Mediterranean Region Mahmoud Fikri1

As we mark World Hepatitis Day on to high-risk sexual practices or shared treatment of chronic hepatitis infection, 28 July, our attention naturally focuses syringes and paraphernalia by people are essential to achieve the elimination on the relentless battle to eliminate viral who inject drugs. of viral hepatitis B and C (9). hepatitis from populations suffering The World Health Organization In this respect, it is important to under the heavy toll of this commu- (WHO) has given special priority to acknowledge the efforts of Member nicable disease. The theme for World hepatitis B and C prevention, diagnosis States in the Region. Within the span Hepatitis Day this year is “Eliminate and treatment, both at the regional and of around 2 years, over 1 million people Hepatitis”. Currently an estimated 325 global levels. Following a resolution in Egypt have been treated with direct- million people worldwide are living with adopted at the 67th session of the World acting antivirals for hepatitis C. In addi- chronic hepatitis B or hepatitis C virus Health Assembly (3). WHO developed tion, a number of other countries with infection. In 2015 alone, viral hepatitis the Global Health Sector Strategy for varied endemicity levels have set up caused 1.34 million deaths, while 1.75 Viral Hepatitis. This strategy is rooted in their multi-sectoral strategies to address million people were newly infected with the global commitment to the Sustain- viral hepatitis aiming at eliminating viral hepatitis C (1). It would appear on the able Development Goals (SDGs) and hepatitis B and C by 2030. face of it that eliminating hepatitis is to universal health coverage, and sets Furthermore, the successful price an insurmountable task, but substan- out a vision towards eliminating viral negotiation and generic licensing tial attention and resources have been hepatitis globally by 2030, and poten- agreements between the ministries of directed to promoting hepatitis preven- tially avert 7.1 million deaths (4,5). To health and the pharmaceutical indus- tion and treatment, and with heartening guide implementation of the Global try resulted in major price reductions results. Health Sector Strategy within the East- making medicines more affordable. For The Eastern Mediterranean Region ern Mediterranean Region, a Regional example, in Egypt the price for a 28-day (EMR) continues to have the highest Action Plan for the hepatitis response supply of generic sofosbuvir was as low prevalence of viral hepatitis C globally. was developed as part the EMR Road- as US$ 51 in 2016. In Morocco, the WHO estimates that more than 15 mil- map 2017–2021 (6,7). Resolution price for a 28-day supply of a generic lion people in the Region are currently EM/RC63/R.1 urges EMR Member formulation of daclatasvir dropped to chronically infected with hepatitis C, States to develop or update national US$ 120, and down to US$ 7 in Egypt and 21 million with hepatitis B (1). plans of action in line with the regional in 2016 (9). Similarly in Pakistan, the 80% of the regional burden of these action plan (8). price of 28-day supply of sofosbuvir infections lies in Egypt and Pakistan The vision, goal and targets of the through generic companies has reached (1). Unfortunately, many people in Regional Action Plan are aligned with as low as US$ 15 (9). These prices the Region acquire hepatitis B and C those of the Global Strategy. Accord- are substantially below the originator in the place where they least expect ingly, the vision is “An Eastern Medi- prices in low-income countries and the it, namely health care settings due to terranean Region free of new hepatitis price in high and upper-middle income sub-optimal infection control and pre- infections and where people living with countries that fall outside the generic vention, unsafe injection practices and chronic hepatitis have access to afford- licensing agreements. inadequately screened blood transfu- able and effective prevention, care and Nevertheless, weaknesses remain in sions. Mother-to-child transmission is treatment” (6). Five core viral hepatitis the hepatitis responses of several region- the primary cause of hepatitis B among interventions, i.e. hepatitis B vaccina- al Member States. Blood transfusion children (2). Furthermore, many peo- tion (including birth dose); injection safety, infection control and prevention ple who are at risk of HIV are also at safety; blood safety; harm reduction ser- as well as injection safety continue to risk of hepatitis B and C infections, due vices for people who inject drugs; and face many challenges in countries like

1Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

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Somalia, Yemen, and Pakistan (1). In very low scale in most countries of the enhancing prevention strategies and several countries, birth-dose vaccina- Region (1). ensuring equitable access to quality di- tion against hepatitis B is either not WHO continues to support and agnosis and treatment, until hepatitis is adopted or implemented at a low cov- work closely with Member States and eliminated from the Region. As we ob- erage level. Although harm reduction other partners to implement and scale serve World Hepatitis Day, it is reassur- services for people who inject drugs are up all interventions for viral hepatitis ing to know that real progress is being well established in the Islamic Republic control. This includes providing birth- made to prevent and control hepatitis of Iran, such services still remain at a dose vaccination against hepatitis B, and that many lives can be saved.

References

1. World Health Organization. New hepatitis data highlight need 6. World Health Organization. Eliminating hepatitis: WHO. Ge- for urgent global response. Geneva: World Health Organiza- neva: World Health Organization; 2017 (http://www.who.int/ tion; 2017 (http://www.who.int/mediacentre/news/releas- mediacentre/news/releases/2017/eliminate-hepatitis/en/, es/2017/global-hepatitis-report/en/, accessed 31 July 2017). accessed 31 July 2017). 2. World Health Organization. Hepatitis B. Geneva: World 7. WHO Regional Office for the Eastern Mediterranean. Regional Health Organization; 2017 (http://www.who.int/mediacen- action plan for the implementation of the global strategy for tre/factsheets/fs204/en/, accessed 2017). viral hepatitis 2017–2021. Cairo: WHO Regional Office for the 3. World Health Organization. Sixty-seventh World Health As- Eastern Mediterranean; 2016 (http://www.emro.who.int/im- sembly. Geneva: World Health Organization; 2014 (http:// ages/stories/hepatitis/hepatitis_action_plan_2017_2021_for_ www.who.int/mediacentre/events/2014/wha67/en/, ac- consulation.pdf?ua=1, accessed 31 July 2017). cessed 31 July 2017). 8. World Health Organization. Resolution EM/RC63/R.1. Geneva: 4. World Health Organization. Global health sector strategy on World Health Organization; 2016 (http://applications.emro. viral hepatitis 2016–2021. Geneva: World Health Organization; who.int/docs/RC63_Resolutions_2016_R3_19120_EN.pdf, ac- 2016 (http://www.who.int/hepatitis/strategy2016-2021/ghss- cessed 10 August 2017). hep/en/, accessed 31 July 2017). 9. World Health Organization. Key facts on hepatitis C treatment. 5. Imperial College Applied Modelling Group. Global invest- Geneva: World Health Organization; 2016 (http://www.who. ment case document. Unpublished report commissioned by int/medicines/areas/access/hepCtreat_key_facts/en/, ac- WHO´s Global Hepatitis Programme. cessed 31 July 2017).

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Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East Tamer Hifnawy, 1,2 Samer Kobrosly, 3 Hillary Edwards, 4 Manal Anwar, 2 Dalia Zahran 1,5 and Henry Silverman 4

اجتاهات وتصورات املرىض إزاء البحوث وحقوقهم: دراسة استقصائية جتريبية من الرشق األوسط تامر حفناوي، سامر قربصيل، هيالري إدواردز، منال أنور، داليا زهران، هنري سيلفرمان اخلالصــة:قــد تكــون الرقابــة األخالقيــة والتنظيميــة عــى البحــوث دون املســتوى األمثــل يف البلــدان املنخفضــة واملتوســطة الدخــل. ولتحديــد اجتاهــات وتصــورات املــرىض جتــاه املشــاركة يف البحــوث وتصوراهتــم بشــأن حقوقهــم، طلبنــا مــن 202 ًمريضــا مــن املستشــفيات يف مــر ولبنــان واململكــة العربيــة الســعودية والســودان اســتكامل اســتبيان لتقييــم االجتاهــات والتصــورات. وأعــرب نحــو 20 % منهــم عــن اعتقادهــم بــأن األطبــاءيف بعــضاألحيــان جيــرون ً بحوثــاعــى املــرىض دون علمهــم، يف حــن أعــرب 35 % منهــم عــن اعتقادهــم بأنــه يف حالــة انســحاب املشــاركي مــن البحــوث فإهنــم ال يتلقــون رعايــة طبيــة جيــدة. ورأى مــا يزيــد عــى 85 % أنــه ينبغــي أن يكــون هلــم حقــوق فيــام يتعلــق برسيــة البيانــات واحلصــول عــى الرعايــة الطبيــة ً يفجمانــا حالــة إصابتهــم أثنــاء إجــراء البحــث وطــرح األســئلة. وأعــرب نحــو نصفهــم عــن رأهيــم 75 بأنــه حيــق هلــم االنســحاب دون عقوبــة، وأعــرب حــوايل % عــن رضورة ّمتكنهــم مــن تقديــم الشــكاوى دون خــوف مــن ُّالتعــرض لــأذى. ولقــد َّ تبــنأن األشــخاص ّاألميــون أو غــر العاملــن أقــل ً تقديــراحلقوقهــم مقارنــة بنظرائهــم.

ABSTRACT Ethical and regulatory oversight of research may be suboptimal in low- and middle-income countries. To determine patients’ attitudes and perceptions toward research participation and perceptions of their rights, we recruited 202 participants from hospitals in Egypt, Lebanon, Saudi Arabia and Sudan and asked them to complete a questionnaire assessing attitudes and perceptions. Around 20% believed that doctors sometimes perform research on patients without their knowledge and 35% believed that if participants withdrew from the research they would not receive good medical care. Over 85% believed that they should have rights regarding confidentiality of data, free medical care if injured during the research and asking questions. Almost half believed they have a right to withdraw without penalty and around 75% believed they could make complaints without fear of harm. Those who were illiterate or unemployed were less likely to appreciate their rights compared with their counterparts.

Attitudes et perceptions des patients à l’égard de la recherche et de leurs droits : étude pilote au Moyen-Orient

RESUME La surveillance éthique et réglementaire de la recherche peut ne pas être optimale dans les pays à revenu faible et intermédiaire. Afin de déterminer les attitudes et les perceptions des patients à l’égard de la participation à la recherche et des perceptions de leurs droits, nous avons recruté 202 participants dans des hôpitaux en Arabie saoudite, en Égypte, au Liban et au Soudan, et leur avons demandé de compléter un questionnaire évaluant leurs attitudes et perceptions à ce sujet. Environ 20 % croyaient qu’il arrivait que des médecins mènent des recherches sur des patients sans leur consentement, et 35 % pensaient que si les participants se retiraient du processus de recherche, ils ne bénéficieraient pas de soins médicaux de qualité. Plus de 85 % pensaient qu’ils devaient avoir droit à la confidentialité de leurs données, à des soins médicaux gratuits en cas d’incident durant la recherche et qu’ils devaient pouvoir poser des questions. Près de la moitié étaient d’avis qu’ils avaient le droit de se retirer de la recherche sans être pénalisés, et environ 75 % pensaient qu’ils pouvaient adresser des plaintes sans craindre de subir des préjudices. Les participants illettrés ou sans emploi étaient moins susceptibles d’évaluer leurs droits que les autres participants.

1Department of Public Health and Community Medicine, College of Dentistry, Taibah University, Saudi Arabia (Correspondence to: Tamer Hifnawy: [email protected]). 2Faculty of Medicine, Beni Suef University, Beni Suef, Egypt. 3Makassed General Hospital, Beirut. Lebanon. 4University of Maryland School of Medicine, Baltimore, Maryland, United States of America. 5Faculty of Dentistry, Tanta University, Tanta, Egypt. Received: 15/3/16; accepted: 16/11/16

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Introduction to protect their interests and prevent measures to enhance confidentiality potential exploitation. protections, and the requirement to ob- The number of clinical trials conducted The concept of rights in research tain indemnity insurance for research- in low- and middle-income countries first developed after World War II in related injuries. has increased worldwide (1), including response to the practices of Nazi physi- Several studies have investigated the the Middle East (2). Despite growing cians who had experimented on un- awareness of patients regarding their political volatility, the Middle East is willing subjects. The first international rights in clinical care in non-Western poised for an escalation in the num- instrument on the ethics of medical countries (25–34), but there are lim- bers of clinical trials as pharmaceutical research, the Nuremberg Code of 1947, ited data regarding the perceptions of companies continue their search for was a direct outcome of these unethical research participants regarding their regions with large, treatment naïve practices, and it emphasized that the rights (13). Accordingly, this study populations (3). Since medical research voluntary consent is “absolutely essen- aimed to identify attitudes and percep- involves human subjects, knowledge tial” and that “the human subject should tions towards research participation regarding their attitudes and percep- be at liberty to bring the experiment and awareness and understanding of tions vis-à-vis research would help with to an end”, i.e. a right to withdraw (20, the rights of potential participants from understanding and addressing their 21). Since the Nuremberg Code, other several countries in the Middle East: concerns, which would enhance the international instruments have empha- Egypt, Lebanon, Saudi Arabia and Su- overall trust between the public and sized either directly or indirectly the dan. the scientific community. Studies elicit- existence of human rights in biomedical ing the views of patients on medical research, e.g. the Declaration of Helsinki research have been performed in the in 1964, which has since undergone Methods United States, Denmark, Australia, and multiple revisions (17), the United Na- Survey tool Japan (4–7), however these results tions’ International Covenant on Civil might not be generalizable to low- and and Political Rights (1966) (22) the We developed a survey which contained middle-income countries that may have Council of Europe’s “The Convention the following sections: demographic different cultures, religions and eco- for the Protection of Human Rights information that included age, sex, education level, employment type and nomic backgrounds. Currently, there and Dignity of the Human Being with hospital type; attitudes and perceptions is limited empirical research involving regard to the Application of Biology toward aspects of research participa- the perspectives of patients from the and Medicine: Convention on Human tion; the extent of agreement to receive Middle East (8–13). Additional stud- Rights and Biomedicine” (1997) (23) certain types of information necessary ies would help with clarifying further and in 2005, the “Additional Protocol to decide upon participation in research; the underlying assumptions of patients to the Convention on Human Rights and the extent of agreement with certain regarding their participation in research. and Biomedicine, concerning Biomedi- rights in research. Questions required cal Research” (24). These documents Another issue that warrants further either a single/multiple response or make clear that the rights in research investigation is the extent to which po- were in the form of a 5-point Likert ethics are linked to ethics guidelines and tential research participants are aware scale (strongly agree, agree, uncertain, governmental regulations, and emanate of and understand their rights in the disagree, strongly disagree). research process. Although adherence from fundamental ethical principles. Participants were also asked to re- to research ethics principles and guide- The use of “rights” language can help spond to the following case study: lines help protect the welfare and the apply the general ethical principles in Rebekah comes to the clinic to have rights of research participants and their research. For example, to secure au- her blood drawn for routine labora- communities (14–16), commentators tonomy investigators need to disclose tory examination. The investigator have expressed concerns regarding the adequate information to potential withdraws a little more than usual for regulatory framework (17), the func- research participants and ensure their research purposes. Which of the follow- tionality of research ethics committees understanding (i.e. the doctrine of in- ing are true? (18), and the training of the research formed consent). Other rights include team regarding responsible research the right to privacy and confidentiality • The investigator does not have to tell conduct (19) in low- and middle-in- and the right to medical treatment for Rebekah the purpose of taking more come countries, including the Middle any trial-related injury. The correspond- blood. East. Such concerns make clear that ing obligations on investigators and • The investigator does not have to tell research participants’ realization of their sponsors that help secure these rights Rebekah whether the blood will be rights provides them with a mechanism include mechanisms to respect privacy, used in research.

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• The investigator should have asked participants per site. The only inclusion To improve the power, we collapsed for permission and informed consent criterion was age above 18 years. Par- the Likert scale responses of “strongly from Rebekah ticipants were recruited during January agree” and “agree” into one category; and June 2014. The questionnaire was • It is expected that patients participate and the combination of “uncertain”, self-administered, however, for those in research without patients’ knowl- “disagree” and “strongly disagree” into who could not read or write, a study edge another category. If Rebekah suspects that the blood team member helped these individuals will be used in research, she can do by reading and explaining each ques- Ethics review tions and the possible answers. which of the following: We received ethics approval from the • Ask the investigator to withdraw this Statistical analysis research ethics committees at: Univer- sample We entered the data into a Microsoft sity of Maryland School of Medicine, • Complain to the hospital director Excel coded file and transformed the Baltimore (United States); College of Dentistry, Taibah University (Saudi • Submit a complaint to the medical data to SPSS, version 22. We used Arabia); Faculty of Medicine, Beni Suef syndicate or the organization giving descriptive analysis and chi-squared University (Egypt); Makassed General the license analysis to determine the strength of the association of each of the independ- Hospital (Lebanon); and the Univer- • Call the police ent variables (sex, education levels, and sity of Medical Sciences and Technol- • Go to court employment type) with each of the ogy (Sudan). • Tell her family members, colleagues responses. Statistical differences within and friends not to go to this doctor the sex, education and employment Results • Tell the media in order to warn the subgroups were determined using the public from dealing with this doctor Fisher’s exact test. We set the significance level at P-value < 0.05. We enrolled 202 participants, 51 each and this clinic from Egypt and Sudan and 50 each To enhance our analyses, we col- • Do nothing as nothing will be done from Saudi Arabia and Lebanon. Re- lapsed the independent variables into about it sults were not significantly different the following subgroups. The survey was developed in Eng- between these countries and therefore, lish and then translated into Arabic fol- • Education: illiterate, high school or we aggregated the data into a single lowed by a back-translation into English less, greater than high school group. The mean age of the participants to ensure accuracy of the Arabic transla- • Employment status: unemployed, was 42.1 [standard deviation (SD) tion. We pilot tested the survey among manual worker/merchant, profes- 15.6] years. Twenty-eight respondents several lay persons to assess readabil- sional. (13.9%) had participated in medical ity and understanding. Several changes were made in response to this assessment. Reliability of the questionnaire Table 1 Demographic characteristics of the respondents of respondents from 4 was calculated using the Cronbach α Middle Eastern countries (n = 202) test for internal consistency. Reliability Characteristic No. % of the questionnaire was judged by the Sex internal consistency coefficient (Cron- Male 94 46.5 bach α) of the 29 items using a 5 point Female 108 53.5 Likert scale; this was 0.901, indicative of Education a good degree of internal consistency. Illiterate 19 9.4 Participants High school or less 119 58.9 Greater than high school (university-level) 64 31.7 Trained coordinators recruited partici- Employment pants from several sites at university and Unemployed 67 33.2 private-affiliated hospital outpatient Manual worker/merchant 88 43.6 clinics at the following locations: Beni Professional 47 23.3 Suef, Egypt; Beirut, Lebanon; Medina, Saudi Arabia; and Khartoum, Sudan. Hospital type We used a convenience sampling tech- Private 50 24.8 nique with a target recruitment of 50 University 152 75.2

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research, of whom 17 were currently physician withdraws additional blood At least 85% of the respondents enrolled in research. Responses from for research purposes, 80.5% believed believed that they should be told that those with and those without experi- that the investigator should have asked enrolment in research is voluntary and ence in research were not significantly for the patient’s informed consent for that they have the right to have data kept different and hence we only present the the additional blood (Table 2). Those confidential; have the right to receive results of the entire study sample. who were unemployed were significant- free medical care if injured from the Table 1 shows the respondents’ ly less likely to believe that physicians research; and have the right to ask ques- demographic data. There were an al- should ask for consent from the pa- tions about the study (Table 4). How- most equal number of men and women tient compared with manual workers/ ever, only 49% thought they should participants (46.5% and 54.5% respec- merchants and professionals (68.2% have a right to withdraw from the study. tively). Sixty-four (31.7%) participants vs 85.24% and 89.1%, respectively; P < Respondents who were unem- had an education level above high 0.01). ployed were significantly less likely to school. Approximately one-third were When asked what the patient could believe that they should be told that unemployed. The ratio of patients at- do about the additional sample of blood enrolment is voluntary compared with tending private and university hospital that was withdrawn, the top choices manual workers/merchants and profes- outpatient clinics was 1:3. included: ask the physician to withdraw sionals (80.0% vs. 92.0% and 97.9%, Table 2 shows respondents’ atti- the sample (51.0%); complain to the respectively; P < 0.01). Individuals tudes toward medical research. Overall, hospital director (25.7%); and one who were illiterate were significantly 92.6% believed that medical research should do nothing as nothing would less likely to believe they could file a was necessary to improve health within be done (22.3%) (Table 2). Those who complaint compared with the other a society. Respondents held decreas- were illiterate were more likely to believe 2 education levels (57.9% vs. 70.1% ing preferences for participation in the that “one should do nothing as nothing and 87.5%, respectively, P < 0.01); they following types of research: question- would be done” compared with those were significantly less likely to believe naire studies, blood sampling studies at a higher educational levels; (36.8% that research data should be kept se- and drug trials (87.1%, 64.4%, and vs. 25.2% and 12.5%, respectively; P < cret from individuals not involved in 44.6%; respectively). The top 3 reasons 0.05). Similarly, those who were un- research compared with the other 2 for enrolling in research were: to help employed were more likely to believe education levels (52.6% vs. 87.2% and other patients (50.0%), the belief that this compared with manual workers/ 90.6%, respectively); and they were patients in research get better treatment merchants and professionals (31.3% also significantly less likely to believe (41.6%) and the chance to get better vs. 20.5% and 12.8%, respectively; P < they should have an opportunity to ask care (41.1%). 0.05). Those who were unemployed questions compared with the other two groups (78.9% vs. 93.2% and 98.4%, Around 20% of respondents be- were significantly less likely to ask the respectively, P < 0.01). lieved that doctors sometimes perform physician to withdraw the sample research on patients without their compared with those who were manual knowledge; individuals who were illiter- workers/merchants and professionals Discussion ate were more likely to hold this opinion (37.3% vs. 53.4% and 66.0%, respective- compared with those in the 2 other ly; P < 0.01). However, those who were This study reveals certain attitudes education groups (42.1% vs. 22.7% and unemployed or were manual workers/ and perceptions of patients from the 10.9%, respectively; P < 0.01) (Table 2). merchants were more likely to com- Middle East regarding research as well A little over a third of the respondents plain to the hospital director compared as their perceptions of their rights as (35.0%) believed that if research partici- with professionals (32.8% and 28.4% vs. research participants. In general, most pants withdrew from the research they 10.6%, respectively, P < 0.05). of our participants expressed favourable would not receive good medical care More than 75% of the respondents attitudes towards research. For example, from their doctors. believed that, prior to enrolment in more than 90% believed that research Actions that respondents would a study, research participants should was necessary to improve the health take if they had have a complaint about be provided with all the information of society; similar findings regarding the research included: complain to the described in the questions (Table 3). the importance of research have been investigators (41.0%) and complain to More than 95% agreed that participants reported in other studies from the Mid- the hospital director (28.8%) (Table 2). should be informed about the risks and dle East (9,13). We found that 50.0% In response to the case study re- side-effects and the anticipated benefits of participants cited a desire to help garding a clinic patient from whom a of the research. others as a reason to enrol in research.

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Table 2 Attitudes and perceptions of respondents in 4 Middle Eastern countries towards medical research (n = 202) Question Responsea No. % Medical research is necessary to improve the health of society 187 92.6 I would most likely volunteer to participate in the following types of trials a: Questionnaire studies 176 8 7. 1 Blood sampling studies 130 64.4 Drug trialst 90 44.6 Why would you volunteer to participate in research? b Help other patients 101 50.0 Patients in research receive better treatment than those not in researcha 84 41.6 Chance to get better care 83 41.1 Participants who withdraw from the research will not receive good medical care from their 70 35.0 doctorsa Get extra attention 62 30.7 My doctor sometimes performs research on me without my knowledgea 42 20.8 Only way to get hospital care 18 8.9 Monetary incentives 15 7. 4 Actions that participants could take if they have complaints about the researchc (n = 156) Complain to the investigators 64 41.0 Complain to the hospital director 45 28.8 No need to complain, nothing will be done 37 25.4 Put a paper in the complaint box 24 15.4 Complain to the research ethics committee 14 9.0 Case of patient from whom physician withdraws additional blood sample for research c Which of the following is true? Physicians should ask for consent from the patient 161 80.5 Physicians do not need to reveal the purpose of the additional blood sample 19 9.4 Other response 20 9.9 What can the patient do if she suspects that the additional blood will be used in research? Ask the physician to withdraw the sample 103 51.0 Complain to the hospital director 52 25.7 Do nothing as nothing will be done 45 22.3 Tell others not to see this doctor/tell the media 28 13.9 Complain to the physician’s board 15 7. 4 Call the police or go to court 8 4.0

aPercentage of those who strongly agreed or agreed. bCheck all that apply. cChoose one best answer.

This, however, contrasts with other trials (13), and in an Egyptian study blood sampling and questionnaire stud- studies showing that more than 90% 100% of the participants who were en- ies; this might explain why fewer of our stated a similar reason (9,12,13). Also, rolled in clinical trials were motivated participants cited better treatment/care the chance to get better treatment was to receive a “chance to get better treat- as a motivation. cited by only 41.1% of our respondents ment” (9). These 2 studies were focused Most respondents said they would as a reason to participate in research. In on motivations for enrolling in clinical participate in questionnaire studies, contrast, a recent study in Saudi Arabia trials, which have potential direct ben- while significantly fewer would partici- reported that 80.4% of their respondents efits to participants, whereas our survey pate in studies involving blood sampling stated that “receiving best medical care” asked respondents for their reasons for and drugs. Khalil et al. observed similar was a motivation to enrol in clinical enrolling in research that also included findings in their qualitative, in-depth

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Table 3 Participants’ agreement with the type of information they should receive prior to enrolment in research (n = 202) Item Responsea No. No. Participants should know the risks and side-effects of the research 197 98.5 Participants should be given an explanation of anticipated benefits from the research 191 95.5 Participants should be given an explanation of the procedures and any drugs that will be used 181 90.0 Participants should be told that enrolment in research is voluntary 179 89.5 Participants should know the purpose of the research 177 88.1 Patients should be provided with contact information if questions, concerns, or complaints about the 176 88.0 research were to occur Participants should know the alternatives of medical treatment they can receive outside of the study 157 78.9

aPercentage of those who strongly agreed or agreed.

interview study in Egypt regarding complaint in the case study we used in that only 59.5% of the respondents were preferences for participation in types of the questionnaire. This concern that aware of their right to withdraw from a research, and attributed their findings no-one would respond to their com- clinical trial at any time without conse- to the increasing risk associated with plaints harmonizes with our finding that quences (13). questionnaire, blood sample and drug 74.5% of our respondents believed that Our data showed that individuals trials respectively (8). research participants should have a right who might be vulnerable in research, Our respondents held several to make a complaint against any mem- e.g. those who are illiterate or unem- problematic perceptions. For example, ber of the research team without a fear ployed, were less sure of their rights. For around one-fifth believed that research of retribution. example, compared with individuals at is performed on them without their Many of our participants also ex- a higher level of education, those who knowledge and more than a third that pressed awareness in regard to other were illiterate were significantly less they would not get good medical care if research rights. For example, over 85% likely to believe that research partici- they withdrew from the study. In a study believed that there should be protection pants should have rights regarding con- involving Saudi Arabian patients and for confidentiality, compensation for fidentiality, filing a complaint against their companions from the outpatient research-related injury, the ability to the research team and having the op- clinics of a tertiary hospital, Al-Tannir ask questions about the research study portunity to ask questions. Those who et al. reported that only 48.7% of their and that they should be told that par- were unemployed were significantly less respondents believed that research ticipation was voluntary. Indirectly, our likely to believe that physicians should was conducted in a responsible and respondents also believed in the right obtain informed consent for obtaining ethical manner, which led the authors to informed consent as, when respond- an additional blood sample for research to conclude that potential participants ing to the case study, a large majority purposes, and less likely to believe that held “conditional” attitudes towards believed that there was a requirement they should be told that participation in participating in clinical trials and that for the physician to obtain informed research was voluntary. These findings investigators need to provide assur- consent from the patient for the ad- regarding vulnerable individuals (i.e. ances to potential research participants ditional blood sample being obtained those less able to protect their interests) that all necessary procedures would be for research. may be a result of their being unaware of used to enhance their welfare and rights In contrast, just under half of our their rights and less optimistic that such (13). Our findings also support this respondents believed they had a right to rights can be realized, or a concern that proposition. withdraw from the study without giving retribution would occur if they insist on Our study also demonstrated that any reason. This perception might be their rights. a significant minority of respondents due to potential concerns with retribu- Although studies investigating per- had a sense of futility if they had a com- tion after withdrawal, as 35% also be- ceptions of potential research partici- plaint about a research study as 25.4% lieved that participants who withdrew pants’ regarding their rights are limited, believed that nothing would be done if from the research would not receive several studies from low- and middle- they complained. A similar proportion good medical care from their doctors. In income countries have explored the (22.3%) held a comparable attitude a study involving Saudi Arabian patients awareness of patients regarding their regarding the uselessness of filing a and their companions, it was reported rights in medical care. These studies

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Table 4 Participants’ perceptions regarding their rights regarding participation in research (n = 202) Item Responsea No. % Participants should be given the opportunity to ask questions about the study 187 93.5 If participants become injured, then they should receive free medical care 182 91.0 Participants should be told that enrolment in research is voluntary 179 89.5 The data obtained from participants should be kept secret from individuals not involved in the research 170 85.0 Participants should be given a copy of the informed consent form 153 76.5 Participants should be able to make a complaint against any member of the research team without fear of 149 74.5 being harmed Participants should be provided with monies to reimburse for the costs of travel 116 58.6 Participants in clinical research should be allowed to withdraw from the study without giving any reason 98 49.0 Participants should be able to receive money for their efforts that is above reimbursements 92 46.2

aPercentage of those who strongly agreed or agreed.

demonstrate a wide range of variabil- sampling method for recruitment and validate our findings and to further ity. For example, studies demonstrating our site coordinators reported that explore in-depth the potential role of that patients have a low awareness of some potential respondents did not independent factors (e.g. education, their rights included those from Tur- want to participate due to their uncer- poverty) that might be associated with key (23%) (25), Greece (15.7%) (26), tainty regarding the informed consent potential research participants’ aware- Egypt (23.3%) (31), and Saudi Arabia process. This selection bias might have (25%) (29). In contrast, higher rates of affected the validity of our results. Also, ness of rights and the likelihood that awareness were demonstrated among our sample size might not have been they will make a claim on their rights. patients in Lithuania (56%) (27), Po- large enough to detect other significant Such studies should also include those land (80%) (30), Malaysia (90%) (28), findings. Future studies should employ currently enrolled in research studies. and Nigeria (94.2%) (33). a larger sample size and enrol individu- Furthermore, we recommend the use In a study involving patients in als from additional centres in the region of qualitative studies (semi-structured Greece, 25.7% would do nothing if their to enhance the generalizability of our interviews, focus groups) to further ex- rights were being violated (26) and in results. Finally, the conduct of research plore the explanatory mechanisms that another study involving patients attend- in the Middle East is limited compared ing outpatient clinics in Nigeria, 25% with other regions in the world (3), and promote awareness and realization of would not seek redress if their rights hence, several of the troubling percep- rights. were violated (33). These results are tions expressed by our study population Regarding best practices, we recom- similar to our data showing that ap- might not reflect how research is actual- mend that members of the research proximately 25% of respondents would ly conducted and the level of safeguards team take affirmative action to provide associated with research that provide not file a complaint as they thought that assurances to potential participants nothing would be done in response. protection of their welfare and rights that all necessary steps will be taken However, in the study in Egypt, a higher in research. Consequently, percep- proportion of the patients or their com- tions might differ from those who have to protect their rights and welfare. In- panions (approximately 60%) would participated in research (9). Nonethe- vestigators and other members of the “do nothing” when facing problems or less, the perceptions held by our study research staff should also serve as the harm in the hospital (31). This higher sample may represent major limiting critical link to informing participants in result might be due to their sample factors for recruitment for research and research about their rights. Optimizing population, almost half of whom were impair trust in the research endeavour practices regarding rights in research illiterate, as opposed to only 9% in our and hence, need to be addressed. can help enhance and maintain trust in sample, indicating that illiteracy might Regarding a research agenda, we the research endeavour. be a surrogate marker for vulnerability. recommend additional studies regard- There were several limitations to ing perception of rights in research in Funding: None. our study. First, we used a convenience other countries in the Middle East to Competing interests: None declared.

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Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 Zahra Khorrami,1 Koorosh Etemad,1 Shahin Yarahmadi,2 Soheila Khodakarim,1 Mohammadesmail Kameli,3 Alireza Mahdavi Hezaveh 4 and Ebrahim Rahimi 1,5

ُّ التحــروعوامــل اخلطــر املتعلقــة باألمراض غــر الســارية: ترصد عوامــل اخلطر املتعلقــة باألمراض غــرالســارية يف إيــران يف 2011 ًوفقــاللنهــج ّ رجاملتــد ملنظمة الصحــة العاملية زهرا خرمى، كورش اعتامد، شهي يارا أمحدي، سهيال خداكريم، حممد إسامعيل كاميل ، عليضا مهدودي هزاوه، ابراهيم رحيمي

اخلالصــة: أجريــت هــذه الدراســة للنظــر يف العالقــة بــن التحــر وعوامــل اخلطــر املرتبطــة باألمــراض غــر الســارية ًوفقــا للنهــج ّاملتــدرج ملنظمــة الصحــة العامليــة ملراقبــة األمــراض غــر الســارية. وتــأيت هــذه الدراســة ضمــن عمليــة ترصــد عوامــل اخلطــر املرتبطــة باألمــراض غــر الســارية ملــا جمموعــه 10,069 ًشــخصايف مجيــع حمافظــات مجهوريــة إيــران اإلســالمية، يف الفئــة العمريــة فــوق 20 ًعامــا، خــالل عــام 2011. وباســتخدام بيانــات التعــداد الســكاين لعــام 2011، حــددت مســتويات التحــر يف مجيــع املحافظــات واســتخدم االنحــدار اللوجســتي لدراســة العالقــة بــن التحــر وعوامــل اخلطــر. ويف صفــوف الذكــور، ظهــر ارتبــاط موجــب بــن التحــر وانخفــاض النشــاط البــدين )OR=1.7,،) CI %95 = 1.42 – 2.09 وانخفــاض معــدل اســتهالك الفاكهــة واخلــر )OR=1.8, CI %95 = 1.09 – 2.96(، وارتفــاع مؤرش كتلة اجلســم )OR=1.4;a OR=1.2; CI = %95 = 1.08 – CI %95 = 1.20 – 1.70 (. أمــا يف صفــوف اإلنــاث، ُفس ِّــجل ارتبــاط موجــب وذو داللــة بــن التحــر وانخفــاض النشــاط البــدين ) (،1.49 وانخفــاض معــدل اســتهالك الفاكهــة واخلــر )OR=1.3; CI %95 = 1.14 – 1.53(، وارتفاع مؤرش كتلــة اجلســم )OR=1.22; CI %95 = 0.78 – 1.91(. ومن َّثــم، يتضــح أن التحــر يرتبــط ًارتباطــاذا داللــة مــع زيــادة عوامل اخلطــر املرتبطة باألمــراض غي الســارية يف مجهوريــة إيران اإلســالمية.

ABSTRACT This study was conducted to examine the relationship between urbanization and risk factors of noncommunicable diseases (NCDs) according to the World Health Organization stepwise approach to surveillance of NCDs. This study is part of a NCD risk factor surveillance of 10 069 individuals in all provinces of the Islamic Republic of Iran, aged over 20 years, during 2011. By utilizing 2011 census data, urbanization levels were determined in all provinces and logistics regression was used to examine the relationship between urbanization and risk factors. Among males, urbanization had a positive correlation with low physical activity (OR=1.7; 95% CI: 1.42-2.09), low fruit and vegetable consumption (OR=1.8; 95% CI: 1.09-2.96), and high BMI (OR=1.4; 95% CI: 1.20-1.70). Among females there was a positive and significant correlation with low physical activity (OR=1.2; 95% CI: 1.08-1.49), low fruit and vegetable consumption (OR=1.22; 95% CI: 0.78-1.91) and high BMI (OR=1.3; 95% CI: 1.14-1.53). Thus, urbanization has a significant correlation with increases in NCD factors in the Islamic Republic of Iran.

Urbanisation et facteurs de risque de maladies non transmissibles (MNT) : approche STEPwise de l’OMS pour la surveillance des facteurs de risque de MNT en République islamique d’Iran en 2011

RÉSUMÉ La présente étude a été menée afin d’examiner la relation entre l’urbanisation et les facteurs de risque de MNT, selon le modèle de l’approche STEPwise de l’OMS pour la surveillance des maladies non transmissibles. L’étude s’inscrit dans la surveillance des facteurs de risque de MNT opérée sur 10 069 personnes âgées de plus de 20 ans dans l’ensemble des provinces de la République islamique d’Iran en 2011. À l’aide de données du recensement de 2011, les niveaux d’urbanisation ont pu être déterminés pour toutes les provinces, et la régression logistique a été utilisée afin d’examiner la relation entre l’urbanisation et les facteurs de risque. Parmi les hommes, l’urbanisation avait une corrélation positive avec une faible activité physique (OR = 1,7, IC à 95 % : 1,42-2,09), une faible consommation de fruits et légumes (OR = 1,8, IC à 95 % : 1,09-2,96) et un indice de masse corporelle élevé (OR = 1,4, IC à 95 % : 1,20-1,70). Parmi les femmes, il existait une corrélation positive et significative avec une faible activité physique (OR = 1,2, IC à 95 % : 1,08-1,49), une faible consommation de fruits et légumes (OR = 1,22, IC à 95 % : 0,78-1,91) et un indice de masse corporelle élevé (OR = 1,3, IC à 95 % : 1,14-1,53). L’urbanisation a donc une corrélation significative avec l’augmentation des facteurs de MNT en République islamique d’Iran.

1Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: Koorosh Etemad: [email protected]). 2Endocrine and Metabolic Office;3 Office of Hospital Management and Clinical Service Excellence; 4Diabetes Control and Prevention Program, Center for Noncommunicable Diseases Control, Ministry of Health & Medical Education, Tehran, Islamic Republic of Iran; 5Department of Epidemiology, Mamasani Higher Education Complex for Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. Received: 13/01/16; accepted: 16/11/16 469

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Introduction community due to the escalation in constructs. The principal components urbanization and industrialization. The analysis-based index is a simple and It has been predicted that over 60% aim of this study was to investigate the robust measure whose values and of the world population in low- and association between urbanization and groupings can only be moderately af- middle-income countries will be living the risk factors for NCDs, which may fected by changes in the urbanization in cities by 2030 (1). Certain lifestyle lead to the identification of new, more landscapes. This multivariate statistical and environmental factors related to effective interventions in the prevention technique is used to reduce the number urbanization have a significant effect of chronic diseases. of variables in a data set into a smaller on health and noncommunicable dis- number of “dimensions” that are linear eases (NCDs). Urbanization is one of combinations of the original variables. the main socioenvironmental factors Method Principal components analysis provides which has a relationship with chang- an objective way of aggregating the in- Study population and ing lifestyles as an important risk fac- sampling dicators so that variation in the data tor for NCDs (2). Previous research can be accounted for as concisely as in low- and middle-income countries We assessed the association between possible .The urbanization index for has indicated that NCD risk factors are urbanization and NCD risk factors us- all 31 provinces was calculated using more common in urban than in rural ing the data from the 2011 survey of this method and every province was areas (3). In recent years, the increase in NCD risk factor surveillance (STEPS) classified into 3 urbanization levels. NCDs has been a common concern as conducted by the Ministry of Health Variables such as average household a major cause of morbidity and mortal- and Medical Education in the 31 prov- size, population density, urbanization ity worldwide (4). It has been estimated inces of the Islamic Republic of Iran rate, average floor area of the dwell- that 33 million deaths in 2008 were (14). The study population was 10 069 ing unit per family member, economic due to NCDs, and this is predicted to people aged 20–70 years. A multistage participation rate, unemployment rate, reach 52 million by 2030 (5). Urbaniza- random cluster sampling method with employment in agriculture and indus- tion has an association with lifestyle probability proportional to size sam- try, internet penetration, telephone and and behavioural risk factors such as pling was used. mobile penetration rate, percentage of unhealthy diet and low physical activ- Measuring urbanization villages with telephone communication, ity (6–8). Evidence from South-East gas and electricity energy use per 1000 Asia has indicated that urbanization has Principal component analysis is a multi- population, percentage of cities and a is associated with NCD risk factors variate statistical method to reduce the rural areas with gas facilities, propor- such as low physical activity, unhealthy number of variables (15). This method tion of physicians per 1000 population, diet, overweight and high blood pres- was used to create the urbanization vari- proportion of nurses per 1000 popula- sure (9,10). In the past few decades, able; overall score is based on the score tion, proportion of specialist physicians traditional communities in low- and obtained using the xtile quint command per 1000 population, and the human middle-income countries have experi- in SPSS (percentiles of 33.3 and 66.7) in development index for each province enced rapid, unplanned urbanization, 3 categories low, medium and high. were included in the analysis. which changed lifestyles and resulted in There is no global standard indica- unhealthy diets, a sedentary lifestyle and tor to measure urbanization because Risk factors smoking (11). In the past, urban and the factors associated with urbanization The data from the first and second rural environments were significantly in one region of a country are different stages of the 6th survey of risk factors for different; however, the distinction is less from those of others countries. From NCDs in 2011 in the Islamic Republic clear now due to recent advances (12). analysis of previous studies, the indices of Iran were used in this study (14). The Many definitions of urbanization only that had the greatest effect on urbani- NCD risk factors suggested by WHO use the simple dichotomous variable zation were identified and included such as demographic (residential of urban and rural, making it difficult to in this study (13,16,17). Data on 24 location, age, gender, education, and understand the specific changes within variables measuring multiple aspects of job), nutrition (fruit and vegetable con- the urbanization process that have led urbanization (e.g. demographic and so- sumption), behavioural (smoking and to changes in the main risk factors for cioeconomic indices, human resources, physical activity), and anthropometric NCDs (13). communication, energy, the human and blood pressure measurements were In recent years, there has been a rap- development index for the province, used in this survey. Anthropometric id change in lifestyle and demographic and health and treatment indicators) measurements include height, weight and socioeconomic status in the Iranian were used to extract their underlying and body mass index (BMI) as an

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indicator of obesity. Blood pressure was Results human development index achieved measured 3 times at 3 minute intervals the greatest weight in comparison with in a sitting position using an Omron Urbanization index other variables related to urbanization. electronic sphygmomanometer with Urbanization scores ranged from Demographic characteristics an accuracy of 1 mmHg. Smoking was –1.34 to 3.83 (Table 1). These were defined as daily cigarette and/or water- divided based on the scores obtained The study population was aged 20–70 [overall mean 43.00 (standard devia- pipe consumption, low fruit and vegeta- from xtile quint command (percentile tion 15.34)] years (Table 2). Individual ble consumption as < 5 units per day, of 33.3 and 66.7) into 3 categories: low, medium and high. Table 1 shows the education levels were higher with great- and low physical activity as < 150 min er urbanization: 35.7% of those living in of moderate intensity physical activity distribution of provinces according to urbanization index. In the principal areas of low urbanization were illiterate per week. The Global Physical Activity components analysis, variables such while only 20.2% of those living in ar- Questionnaire was used in this survey as internet penetration and provincial eas of high urbanization were illiterate. (18). High BMI was defined as 25≥ kg/ m2, and high blood pressure as systolic

blood pressure > 140 mmHg and/or Table 1 Urbanization index score of each province (each province to the new diastolic blood pressure > 90 mmHg index score of urbanization) (16). Province Urbanization score Urbanization level Sistan and Baluchestan –1.348 Low Outcome variable North Khorasan –0.931 We calculated the risk factor preva- Ardebil –0.889 lence for each outcome within each Chaharmahal and Bakhtiari –0.829 level of urbanization. In addition, we Kordestan –0.794 investigated the relationship between Lorestan –0.783 risk factor and level of urbanization. Ilam –0.695 Following WHO guidelines (19), we Western Azarbayjan –0.690 calculated the average consumption SouthKhorasan –0.655 unit of fruits and vegetables a day, BMI, Hamedan –0.521 systolic and diastolic blood pressure, Kohgiloyeh and Boyerahmad –0.931 Medium and age of starting smoking. Kerman –0.351 East Azarbayjan –0.436 Statistical methods Golestan –0.344 The principal components analysis Kermanshah –0.342 method was used to calculate the ur- Markazi –0.306 banization variable. Descriptive analysis Gilan –0.004 was reported using descriptive statistics Qazvin 0.012 for every level of urbanization. The Kol- Fars 0.013 mogorov–Smirnov test was utilized to Khuzestan 0.127 assess the normality of variables. The Hormozgan 0.149 2-way Kruskal–Wallis test was used to Yazd 0.156 assess the association between every Mazandaran 0.157 continuous exposure variable and level Khorasan Razavi 0.259 High of urbanization. Binary logistic regres- Zanjan 0.434 sion analysis was used to explore the Booshehr 0.543 association between NCD risk factors Semnan 0.594 and urbanization level. P-value < 0.05 Esfahan 0.757 was considered significant, andSPSS , Qom 1.000 version 21, was used for all computa- Alborz 2.208 tions. Tehran 3.837

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Table 2 Demographic characteristics of participants in the study of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Characteristic Urbanization level Total Low Medium High Participants, no. )%( 2025 (20.1) 4071 (40.4) 3973 (39.5) 10 069 Mean (SD) age (years) 42.70 (15.57) 43.03 (15.18) 43.14 (15.38) 43.00 (15.34) Age range (years) 20–70 20–70 20–70 20–70 Sex, no. )%(* Male 786 (38.8) 1712 (42.1) 1637 (41.2) 4135 (41.1) Female 1239 (61.2) 2359 (57.9) 2335 (58.8) 5933 (58.9) Education status, no.)%( Illiterate 722 (35.7) 1060 (26) 801 (20.2) 2583 (25.7) Elementary 387 (19.1) 884 (21.7) 923 (23.2) 2194 (21.8) Junior high school 270 (13.3) 663 (16.3) 583 (14.7) 1516 (15.1) Diploma 406 (20.0) 928 (22.8) 960 (24.2) 2294 (22.8) Higher education 237 (11.7) 535 (13.1) 701 (17.6) 1473 (14.6) Work status, no. )%(* Public sector employee 92 (4.5) 257 (6.3) 271 (6.8) 620 (6.2) Private sector employee 93 (4.6) 265 (6.5) 296 (7.5) 654 (6.5) Employed, self-employed 412 (20.3) 819 (20.1) 688 (17.3) 1919 (19.1) Student, soldier 129 (6.4) 237 (5.8) 292 (7.3) 658 (6.5) Housewife, retired, unpaid work, 1275 (63.0) 2490 (61.2) 2415 (60.8) 6180 (61.4) unemployed, disabled

Values are expressed as mean and standard deviation (SD) for normally distributed data and % for non-normally distribute data. *Significance defined as P < 0.05.

There was also a significant difference in levels (Table 3). In univariate logistic 95% CI: 0.61–1.19 for high versus low terms of employment among different regression analysis, there was no sig- levels of urbanization) (Table 4). In urbanization levels (P < 0.05) (Table 2). nificant association between smoking multiple logistic regression analysis after Urbanization and and urbanization among men (OR = adjustment for age, there was still no sig- noncommunicable disease 1.02, 95% CI: 0.84–1.24 for medium nificant association between smoking risk factors and OR = 0.90, 95% CI: 0.74–1.10 and urbanization in men and women. Tobacco for high versus low levels of urbaniza- Among those living in higher levels of The prevalence of smoking among tion) or women (OR = 0.70, 95% CI: urbanization, the average age of starting men was similar in all 3 urbanization 0.50–0.99 for medium and OR = 0.85, smoking was lower in both sexes, and

Mean age of starting smoking (year)

All Female Male 25 35 24

24 23 23 30

22 22 Age (year) Age (year) Age (year) 25 21 21

20 20 20 Low Medium High Low Medium High Low Medium High Urbanization level Urbanization level Urbanization level

Figure 1A Mean of noncommunicable disease risk factor variables in urbanicity groups, Islamic Republic of Iran, 2011

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Table 3 Prevalence of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Risk factor Urbanization Males Females All level No. % 95% CI No. % 95% CI No. % 95% CI Daily tobacco Low 208 26.5 23.42–29.58 59 4.8 3.63–5.97 267 13.2 11.73–14.67 use Medium 471 27.5 25.39–29.61 80 3.4 2.67–4.13 551 13.5 12.46–14.54

High 414 25.3 23.20–27.40 96 4.1 3.30–4.90 510 12.8 11.77–13.83

Low physical Low 252 32.1 30.44–33.76 536 43.3 40.56–46.04 788 38.9 36.78–41.02 activitya* Medium 666 38.9 36.61–41.19 999 42.3 40.32–44.28 1665 40.9 39.40–42.41

High 690 42.2 39.81–44.59 1103 47.2 45.19–49.21 1793 45.1 43.56–46.64

Low fruit & Low 609 77.5 74.59–80.41 1012 81.7 79.56–83.14 1621 80.0 78.26–81.74 vegetable intakeb* Medium 1455 85.0 83.31–86.96 2042 86.6 85.23–87.97 3497 85.9 84.84–86.96 High 1370 83.7 81.92–85.57 1959 83.9 82.41–85.39 3330 83.8 82.66–84.94

High BMIc* Low 356 45.3 41.83–48.77 711 5 7. 4 54.65–60.15 1067 52.7 50.53–54.87

Medium 866 50.6 48.24–52.96 1461 61.9 59.95–63.85 2327 57.2 55.69–58.71

High 910 55.6 53.20–58.00 1488 63.7 61.75–65.65 2399 60.4 58.88–61.92

High blood Low 125 15.9 13.35–18.45 210 16.9 14.82–18.98 335 16.5 14.89–18.11 Pressured* Medium 335 19.6 17.73–21.47 489 20.7 19.07–22.33 824 20.2 18.97–21.43

High 237 14.5 12.81–16.20 310 13.3 11.93–14.67 547 13.8 12.73–14.87

Low fruit & vegetable intake significant only for men. CI = confidence interval. BMI = body mass index. a< 150 min of moderate or intense physical activity per week. b< 5 servings of fruit and vegetables per day. cBMI ≥ 25 kg/m. dSystolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. *Kruskall–Wallace test, significant at P < 0.05.

smoking was more prevalent among the prevalence of low physical activity physical activity and urbanization in women (Figure 1A). increased significantly with increased men (OR = 1.58, 95% CI: 1.30–1.91 urbanization (Table 3). In multiple for medium and OR = 1.72, 95% CI: Low physical activity logistic regression analysis after adjust- 1.42–2.09 for high versus low levels Urbanization had an inverse associa- ment for age, there was a statistically of urbanization) and women (OR = tion with physical activity in both sexes: significant association between low 1.36, 95% CI: 1.15–1.60 for medium

Mean fruits and vegetables intake per day (servings)

All Female Male 4.00 4.10 4.00

4.00 3.90 3.90 3.90

3.80 3.80 3.80 Servings Servings Servings 3.70 3.70 3.70 3.60

3.60 3.50 3.60 Low Medium High Low Medium High Low Medium High Urbanization level Urbanization level Urbanization level

Figure 1B

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Mean BMI (kg/m2)

All Female Male 28.00 29.00 27.00

27.50 26.50 28.00

27.00 26.00 27.00

kg/m2 26.50 kg/m2 kg/m2 25.50

26.00 26.00 25.00

25.50 25.00 24.50 Low Medium High Low Medium High Low Medium High Urbanization level Urbanization level Urbanization level

Figure 1C

and OR = 1.26, 95% CI: 1.08–1.49 for those living in areas with a low level of and 1.44 (crude OR = 1.44, 95% CI: high versus low levels of urbanization) urbanization. This association did not 1.21–1.71) in comparison with lower (Table 4). change after adjustment for age in mul- levels of urbanization (Table 4). There Low fruit and vegetable consumption tiple logistic regression. This positive re- was also a significant association be- lationship was also seen in women, but tween high BMI and urbanization in In both sexes, the prevalence of low fruit it was not statistically significant (Table women (OR = 1.21, 95% CI: 1.05–1.29 and vegetable consumption increased 4). We also found a small difference for medium and OR = 1.30, 95% CI: with increased urbanization, but this between the mean servings of fruits and 1.13–1.50 for high versus low levels of was significant only for men (Table vegetables consumed per day for both urbanization). These associations did 3). With increasing urbanization, the sexes at different levels of urbanization not change after adjustment for age in odds of low consumption of fruits and (P < 0.05) (Table 5 and Figure 1B). multiple logistic regressions. Moreover, vegetables increased. Men who were a statistically significant association was living in provinces with a medium level High body mass index observed between urbanization and of urbanization were 2.10 times more The prevalence of higher BMI levels mean BMI in both sexes as a continu- likely (crude OR = 2.10, 95%CI: 1.26– (obese and overweight) in both sexes ous variable (P < 0.001) (Table 5 and 3.48) and those living in provinces with was positively related to increased ur- Figure 1C). a high level of urbanization 1.81 times banization (Table 3). The odds of men more likely (crude OR = 1.81, 95%CI: having high BMI levels in medium and High blood pressure 1.10–2.98) to have low fruit and veg- high levels of urbanization were 1.18 A higher prevalence of high blood pres- etable consumption in comparison with (crude OR = 1.18, 95% CI: 0.99–1.40) sure was observed in areas with medium

Mean systolic blood pressure (mmHg)

All Female Male 128.00 128.00 129.00

128.00 126.00 126.00 127.00

124.00 126.00 mmHg mmHg mmHg 124.00 125.00 122.00 124.00

122.00 120.00 123.00 Low Medium High Low Medium High Low Medium High Urbanization level Urbanization level Urbanization level

Figure 1D

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Mean diastolic blood pressure (mmHg)

All Female Male 80.50 81.00 80.00

80.00 80.50 79.50

79.50 80.00 79.00

79.00 79.50 78.50 mmHg mmHg mmHg 78.50 79.00 78.00

78.00 78.50 77.50

78.00 77.50 77.00 Low Medium High Low Medium High Low Medium High Urbanization level Urbanization level Urbanization level

Figure 1E

levels compared with areas with low that prevalence of NCD risk factors of urbanization before and after age- levels of urbanization for both sexes increased with increasing urbanization, adjusted analyses. In a study conducted (Table 3). The same observation was consistent with our findings (20). A in Greenland, no relationship was found not seen for areas with high levels of study conducted in India indicated that between unhealthy dietary patterns and urbanization. In univariate logistic re- there was a relationship between smok- urbanization or socioeconomic status gression analysis, there was a significant ing and urbanization in men (21). In (25). In a study in 100 countries, Ez- association between high blood pres- our study, however, no such significant zati et al. found that BMI increased sure and urbanization in men (OR = association was observed. Nevertheless, with increasing urbanization (26). Our 1.25, 95% CI: 1.00–1.57) for medium the results showed that with increasing findings indicate that with increasing versus low levels of urbanization and urbanization the age of starting smok- urbanization, average BMI, high blood women for medium (OR = 1.29, 95% ing decreased; this relationship was pressure, and low physical activity in- CI: 1.08–1.54) and for high (OR = 0.78, more evident in women, suggesting that creased, consistent with previous studies 95% CI: 0.64–0.94) versus low levels preventive measures should be taken (27–29). We found the prevalence of of urbanization. This association did along with education about the dangers physical activity was higher in areas with not change after adjustment for age in and side-effects of smoking in high-risk low urbanization than in areas with high multiple logistic regression (Table 4). groups. In Qingdao, China, researchers urbanization, consistent with the results In addition, using the Kruskal–Wallis found that urbanization was related to of other studies (30,31). In a study in Sri test, mean systolic and diastolic blood a number of risk factors such as low Lanka, men and women in areas with pressure had a significant association physical activity, unhealthy diet and high urbanization had respectively 3 with level of urbanization in both sexes obesity (21), consistent with the results and 2 times lower physical activity than (P < 0.001) (Table 5 and Figures 1D of this study. Liu et al. found that urban those living in other urban areas, which and 1E). development significantly reduced was significant after age adjustment daily physical activity and increased the (32). Monda et al. also found that low consumption of high calorie foods (fast physical activity increased with increas- Discussion food) (22). It has consequently led to a ing urbanization (33). Our findings are rapid increase in obesity and overweight consistent with those of other studies in Our findings support the hypothesis due to changes in diet and lifestyle which that as a result of office jobs in the city that there is a relationship between ur- significantly affect health12,23,24 ( ). A and the use of technology, physical ac- banization and NCD risk factors: ur- study from India showed no significant tivity is reduced and the city population banization had a positive association relationship between the prevalence of has a sedentary rather than an active with low physical activity, low intake of low fruit and vegetable consumption lifestyle. Therefore, it is suggested that fruit and vegetables, BMI and hyperten- and different levels of urbanization in in areas with high levels of urbanization, sion in both sexes. In 2009, a study con- either sex (16). Unlike the Indian study, the focus should be on environmental ducted in the Islamic Republic of Iran we found significant differences in the characteristics and providing facilities reported a relationship between urbani- prevalence of low fruit and vegetable such as trails, parks, swimming pools, zation and risk factors of NCD, such consumption among different levels and gyms. Walking teams, teams for

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Table 4. Crude odds ratios and age-adjusted odds ratios for noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Risk factor Urbanization level Crude OR Age-adjusted OR OR 95% CI P-value OR 95% CI P-value Males Daily tobacco use Low 1.00 – – 1.00 – – Medium 1.02 0.84–1.24 0.805 1.01 0.83–1.22 0.885 High 0.90 0.74–1.10 0.330 0.90 0.74–1.09 0.299 Low physical Low 1.00 – – 1.00 – – activitya Medium 1.60 1.33–1.94 < 0.001 1.58 1.30–1.91 < 0.001 High 1.72 1.42–2.08 < 0.001 1.72 1.42–2.09 < 0.001 Low fruit & vegetable Low 1.00 – – 1.00 – – intakeb Medium 2.10 1.26–3.48 0.004 2.08 1.25–3.46 0.005 High 1.81 1.10–2.98 0.019 1.80 1.09–2.96 0.021 High BMIc Low 1.00 – – 1.00 – – Medium 1.18 0.99–1.40 0.056 1.15 0.97–1.37 0.107 High 1.44 1.21–1.71 < 0.001 1.43 1.20–1.70 < 0.001 High blood Low 1.00 – – 1.00 – – pressured Medium 1.25 1.00–1.57 0.046 1.22 0.96–1.55 0.099 High 0.90 0.71–1.14 0.386 0.85 0.66–1.09 0.214 Females Daily tobacco use Low 1.00 – – 1.00 – – Medium 0.70 0.50–0.99 0.046 0.70 0.50–1.00 0.050 High 0.85 0.61–1.19 0.370 0.85 0.61–1.19 0.360 Low physical Low 1.00 – – 1.00 – – activitya Medium 1.36 1.15–1.60 < 0.001 1.36 1.15–1.60 < 0.001 High 1.26 1.08–1.49 0.004 1.26 1.08–1.49 0.004 Low fruit & vegetable Low 1.00 – – 1.00 – – intakeb Medium 1.44 0.92–2.27 0.110 1.44 0.92–2.28 0.109 High 1.22 0.78–1.91 0.362 1.22 0.78–1.90 0.367 High BMIc Low 1.00 – – 1.00 – – Medium 1.21 1.05–1.39 0.006 1.25 1.08–1.44 0.003 High 1.30 1.13–1.50 < 0.001 1.32 1.14–1.53 < 0.001 High blood Low 1.00 – – 1.00 – – pressured Medium 1.29 1.08–1.54 0.005 1.44 1.18–1.76 < 0.001 High 0.78 0.64–0.94 0.011 0.72 0.59–0.89 0.003

OR = odds ratio. CI = confidence interval. BMI = body mass index. a< 150 min of moderate or intense physical activity per week. b< 5 servings of fruit and vegetables per day. cBMI ≥ 25 kg/m. dSystolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg.

beautifying green spaces, and increasing adjustment (26,29,30,34). Mathenge impact on systolic and diastolic blood street lighting are effective in increas- et al. found that likelihood of having pressure (35). Increased prevalence of ing physical activity (32,33). In some hypertension was greater in urban high blood pressure can be attributed studies, the likelihood of having high residents than in rural residents after blood pressure was greater for residents age and sex adjustment (27). A 2015 to increased environmental risk factors of areas with high urbanization than Chinese study concluded that envi- parallel to increased urbanization, while for residents of other areas, after age ronmental changes have a potential globally, high blood pressure is one of

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Table 5. Distribution of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Outcome Urbanization No. of people Mean SD 95% CI P-value level in group Males No. of servings of fruit and Low 638 3.79 2.31 3.60–3.97 0.007 vegetables per day Medium 1488 3.84 1.84 3.75–3.94 High 1406 3.82 2.04 3.71–3.93 BMI (kg/m*2) Low 763 25.08 0.71 24.58–25.59 0.0001 Medium 1704 25.88 1.13 25.34–26.42 High 1632 26.28 1.28 25.65–26.90 Systolic blood pressure (mmHg) Low 763 124.57 19.12 123.21–125.92 0.0001 Medium 1693 128.06 17.36 127.23–128.89 High 1580 125.69 16.85 124.86–126.52 Diastolic blood pressure (mmHg) Low 763 78.63 12.49 77.74–79.51 0.0001 Medium 1693 77.67 11.48 77.12–78.22 High 1580 79.37 11.67 78.79–79.94 Females No. of servings of fruit and Low 1045 3.66 2.07 3.53–3.79 0.0001 vegetables per day Medium 2088 3.83 1.88 3.75–3.91 High 2011 3.95 2.39 3.84–4.05 BMI (kg/m*2) Low 1235 26.83 1.67 25.89–27.76 0.0001 Medium 2347 27.79 1.30 27.26–28.32 High 2330 28.15 2.06 27.32–28.99 Systolic blood pressure (mmHg) Low 1234 122.45 21.68 121.23–123.66 0.0001 Medium 2334 126.93 20.82 126.08–127.77 High 2247 120.85 19.96 120.03–121.66 Diastolic blood pressure (mmHg) Low 1232 80.12 13.14 79.39–80.86 0.004 Medium 2334 78.74 12.15 78.24–79.23 High 2247 78.66 12.31 78.15–79.17

Means were compared using the Kruskal–Wallis test when assumptions for analysis of variance were not met. SD = standard deviation. CI = confidence interval. BMI = body mass index. *P-value for Kruskal–Wallis test.

the risk factors associated with number measure for NCDs. Moreover, possible (smoking and physical activity), there is of deaths (36). differences in factors probably caused the possibility that information bias may Our study has a cross-sectional na- by urbanization, such as stress levels and have affected the results. ture, and thus no causality association environmental factors, were not investigated; these could be considered valid Our findings indicate that increasing can be deduced from it. In terms of the for future population studies. Further urbanization is related to the increased scale of urbanization, 2 provinces can development is required to understand prevalence of several modifiable NCD have the same urbanization level, but the relative contribution of internet risk factors that couldn serve as a basis may differ in other environmental di- penetration, human development infor future studies, planning in order to mensions that are likely to differentially dex, and each scale element for risk of manage health problems, determining affect health. Thus, more environmen- chronic diseases. As self-reported infor- tal research is needed to understand mation was received from participants the distribution of financial resources the implications of urbanizing the regarding nutrition (fruit and vegetable and human resources, and coordinating environment to develop an exposure consumption) and behavioural factors prevention and intervention strategies

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for NCDs based on different levels of factors instead of the known rural/ur- which requires an intersectoral agree- urbanization. ban dichotomy, and a clear association ment and cooperation with other aca- was observed between different levels demic and administrative sectors. of urbanization and NCD risk factors. Funding: This study was part of the MSc Conclusion Increasing urbanization and its conse- thesis of Zahra Khorrami, supported by quent complications requires policies Shahid Beheshti University of Medical In this study, urbanization was de- and preparations by local governments Sciences (grant No.: /A/9294/36). scribed and classified using different to meet the needs of the community, Competing interests: None declared.

References

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29. Addo J, Smeeth L, Leon D. Hypertension in sub-Saharan Af- pational physical activity. Soc Sci Med. 2007;64(4):858–70. rica: a systematic review. Hypertension. 2007;50(6):1012–8. PMID:17125897 PMID:17954720 34. Kamadjeu RM, Edwards R, Atanga JS, Kiawi EC, Unwin N, 30. Reis JP, Bowles HR, Ainsworth BE, Dubose KD, Smith S, La- Mbanya JC. Anthropometry measures and prevalence of obe- ditka JN. Nonoccupational physical activity by degree of sity in the urban adult population of Cameroon: an update urbanization and US geographic region. Med Sci Sports Exerc. from the Cameroon Burden of Diabetes Baseline Survey. BMC 2004;36(12):2093–8. PMID:15570145 Public Health. 2006;6:228. PMID:16970806 31. Parks S, Housemann R, Brownson RC. Differential correlates of 35. Attard SM, Herring AH, Zhang B, Du S, Popkin BM, Gordon- physical activity in urban and rural adults of various socioeco- Larsen P. Associations between age, cohort, and urbanization nomic backgrounds in the United States. J Epidemiol Commu- with SBP and DBP in China: a population-based study across 18 nity Health. 2003;57(1):29–35. PMID:12490645 years. J Hypertens. 2015;33(5):948–56. PMID:25668349 32. Allender S, Wickramasinghe K, Goldacre M, Matthews D, 36. Choh AC, Nahhas RW, Lee M, Choi YS, Chumlea WC, Duren Katulanda P. Quantifying urbanization as a risk factor for non- DL, et al. Secular trends in blood pressure during early-to- communicable disease. J Urban Health. 2011;88(5):906–18. middle adulthood: the Fels Longitudinal Study. J Hypertens. PMID:21638117 2011;29(5):838-45. PMID:21430562 33. Monda KL, Gordon-Larsen P, Stevens J, Popkin BM. China's transition: the effect of rapid urbanization on adult occu-

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Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents Zachary D. Stanley 1*, Leena W. Asfour 2*, Michael Weitzman 3,5,6 and Scott E. Sherman 4,5

تنفيــذ نمــوذج التعليــم الصحــي عــن طريــق األقــران يف اإلمــارات العربيــة املتحــدة: ِّ ي التصــدللســلوكيات اخلطــرة يف صفــوف املراهقــن املغرتبــن زاكري ستانيل، لينا عصفور، مايكل وايتزمان، سكوت رشمان بــدأ اخلالصــة:اســتخدام التبــغ يف التزايــد يف صفــوف الشــباب يف دولــة اإلمــارات العربيــة املتحــدة، وحيتــل البلــد املرتبــة اخلامســة عــرشة عــى مســتوى العــامل النتشــار النــوع الثــاين مــن داء ّالســكري. ّل ويشــكاملغرتبــون أغلبيــة الســكان، ممــا جيعلهــم جمموعــة فرعيــة مهمــة للدراســة. واســتهدفنا يف هــذه الدراســة اختبــار مــدى فعاليــة التدخــالت التعليميــة يف هــذا اإلطــار الثقــايف. فقمنــا بتصميــم َحلقت ْــي عمــل للقــران يف 18 املجــال الصحــي حــول: اســتخدام التبــغ، والتغذية/النشــاط البــدين. ُوخصصــت إحــدى َحلقت ْ ــيالعمــل بصــورة عشــوائية إىل ًصفــا ًدراســيا يف مدينــة أبــو ظبــي. وأجريــت مســوح قبــل وبعــد َحلقت ْــي العمــل لتقييــم فعاليــة ُّالتدخــل. َّومتكنــت حلقــة العمــل املعنيــة بالتبــغ مــن حتســن االســتجابات عــى نحــو ملحــوظ )p.) < 0.05 وأســفرت حلقــة العمــل املعنيــة بالتغذيــة والنشــاط البــدين عــن انخفــاض مســتوى الرضــا عــن مســتويات النشــاط الشــخيص. ِّوتوفــر هــذه الدراســة الدليــل لدعــم اعتــامد نمــوذج التعليــم الصحــي بــن األقــران عــى املســتوى الوطنــي باعتبــاره تدخــ ً الملواجهــة اســتخدام التبــغ ولكــن ليــس ألغــراض التغذيــة واالختيــارات اخلاصــة بالنشــاط البــدين.

ABSTRACT Tobacco use among young people is increasing in the United Arab Emirates, and the country is ranked 15th in the world for prevalence of type II diabetes. Expatriates comprise a majority of the population, making them an important subset to study. We aimed to test whether an educational intervention would be effective in this cultural setting. We designed 2 peer-to-peer health workshops: tobacco use and nutrition/physical activity. One workshop was randomly assigned to 18 classrooms in private schools in Abu Dhabi. Surveys were administered before and after the workshops to assess intervention effectiveness. The tobacco workshop significantly improved responses (P < 0.05). The nutrition and physical activity workshop resulted in decreased satisfaction with personal activity levels. This study provides evidence to support the national adoption of a peer-to-peer health education model as an intervention for tobacco use but not for nutrition and physical activity choices.

Mise en œuvre d’un modèle d’éducation en santé axé sur l'intervention des pairs aux Émirats arabes unis : lutter contre les comportements à risque des adolescents expatriés

RÉSUMÉ La consommation de tabac parmi les jeunes est en augmentation aux Émirats arabes unis, et le pays se classe au quinzième rang mondial pour la prévalence du diabète de type 2. Les expatriés constituent une majorité de la population, ce qui fait d’eux un sous-ensemble important à étudier. Notre objectif consistait à déterminer si une intervention éducative serait efficace dans ce contexte culturel. Nous avons mis au point deux ateliers de santé organisés par des pairs et portant sur le tabagisme d’une part, et sur la nutrition et l’activité physique d’autre part. Dix-huit classes d’établissements privés à Abou Dhabi se sont vues attribuées l’un des deux ateliers thématiques susmentionnés. Des sondages ont été menés avant et après les ateliers afin d’évaluer l’efficacité de l’intervention. L’atelier sur le tabagisme a conduit à une amélioration significative des modifications de comportement (p < 0,05). L’atelier sur la nutrition et l’activité physique a permis une baisse de la satisfaction des participants concernant leurs niveaux personnels d’activité. Cette étude fournit des arguments en faveur de l’adoption d’un modèle d’éducation par les pairs comme intervention de lutte contre le tabagisme, mais pas pour les choix liés à la nutrition et l’activité physique.

1University of Oklahoma School of Community Medicine, Tulsa, United States of America; 2New York University School of Medicine, New York, United States of America (Correspondence to: Leena W. Asfour: [email protected]). 3Departments of Pediatrics and Environmental Medicine; 4Department of Population Health, New York University School of Medicine; 6Public Health Research Center, Global Institute of Public Health, New York University, New York, United States of America. *Authors contributed equally. Received: 11/9/15; accepted: 20/11/16 480

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Introduction tobacco and 7% had tried dokha at an in improving knowledge, attitudes and average age of 11–12 years (5). perceptions of the condition (15). We As the prevalence of noncommunica- With 18.8% of the population liv- decided to use this model in designing ble diseases continues to rise, health ing with type II diabetes, the United our school-based intervention. To sup- care providers and policy-makers have Arab Emirates is ranked 15th in the plement our study of intervention effec- begun to seek preventive measures. world for prevalence of this condition tiveness on the health topics specifically, Prevention can be as simple as healthy (8). The rise in obesity and sedentary we also decided to elicit feedback from lifestyle choices regarding tobacco use, lifestyles along with increasing access to the students about the peer-to-peer diet and physical activity (1). However, unhealthy food options has contributed model. No other studies to date have these choices are heavily influenced by to the increased prevalence (9). Even tested a health education intervention habits formed at very young ages (2). By with government mandated initiatives for tobacco use, nutrition and physical targeting teenagers and educating them to fight the increase in childhood obe- activity in the United Arab Emirates at about the consequences of their lifestyle sity, the dramatic change in lifestyle over the high school level. choices, we may be able to combat the past 40 years has developed a cul- major behavioural contributors to the ture of poor eating habits and physical Methods most burdensome health conditions. inactivity that are strongly embedded in the daily routine of the average resi- To date, however, school-based health Study design education has not been established as dent (10). While our study focuses on A pre-workshop survey was admin- a global norm. School systems in many expatriate youth, these data are relevant istered to our cohort to establish a Gulf Cooperation Council countries as the culture and environment of the baseline for knowledge, attitudes and have yet to incorporate comprehensive United Arab Emirates influence the behaviours regarding tobacco use, nu- health curricula as part of students’ lifestyle decisions of the large expatriate community. Moreover it has been trition and physical activity. The cohort academic experience (3). In the United reported that our cohort of teens con- was split and given either a nutrition and Arab Emirates, high schools are not sumed a large amount of sugary drinks physical activity workshop or a tobacco mandated to provide any sort of health each day and are not physically active workshop. A post-workshop survey was education to their students (4). In an- on a daily basis. Many students also administered. We evaluated the efficacy other study using the same cohort stud- self-reported eating too much or too of each workshop by comparing the ied here, we identified not only a gap in little and going to extreme measures to pre- and post-survey questions perti- health education but also an inefficacy lose weight (5). nent to each workshop (i.e. tobacco or of anti-tobacco laws and campaigns (5). The purpose of this study was to nutrition and physical activity) and us- In light of these findings, health educa- evaluate the efficacy of peer-mediated ing the responses of the other workshop tion has unexplored potential. health education in schools with pre- group as a control. We chose the focus of our health dominantly expatriate youth in Abu We focused on 9th graders because workshops to be topics that are the Dhabi, United Arab Emirates. Accord- the literature suggested that smoking most salient to the population of the ing to the last census information avail- tobacco becomes a highly relevant topic United Arab Emirates, namely tobacco able, just over 89% of the population around this age. As noted earlier, 39% of use, physical activity and nutrition. were identified as non-nationals 11( ). males and 19% of females of this cohort Although tobacco consumption in As this is such a large majority of the had already tried cigarette smoking 5( ). high- and middle-income countries has population, it is an important subset for recently decreased, the Middle East has us to study and understand, especially if Data collection and workshop an increasing prevalence of tobacco use, current migration trends continue (12). implementation especially among youth (6,7). In this Research in other countries has shown The cohort consisted of 9th grade cohort, 39% of males had already tried that peer-to-peer education models students from 5 private high schools cigarette smoking, at an average age of which train young people to teach distributed throughout the city of Abu 12–13 years (5). Furthermore, 39% of students are highly effective (13). As a Dhabi. Schools whose curricula were males report using waterpipe tobacco result, peer-mediated models have seen not taught in English were excluded (shisha) and 7% report using dokha, a increased utilization for topics in health in order to ensure the students had type of tobacco common around the education (14). A study conducted in sufficient English reading and writing Persian Gulf (5). Amongst females in the United Arab Emirates with 12th skills to complete the surveys accurately this cohort, 19% had tried cigarette grade students found that a peer-to-peer (all 36 public schools in Abu Dhabi smoking, 37% had tried waterpipe workshop on HIV/AIDS was effective with a 9th grade teach in Arabic and

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were not included). According to the the region, influences on teen smoking, activity, the statistical softwareSTATA Abu Dhabi Education Council website and the benefits of tobacco cessation. was used to calculate ordinal logistic re- there are 80 private schools in the Abu An analogous nutrition and physical gressions (proportional odds models) Dhabi Emirate that have a 9th grade. Of activity workshop was also implement- on responses for 29 questions. There these, 18 teach their curricula in Arabic, ed, following the same curriculum pat- were 22 questions mapped to the to- leaving 62 that do not teach in Arabic. tern as listed above. The focus of each bacco workshop and 7 to the nutrition We called these schools at random. The workshop was to provide accurate and and physical activity workshop. The pre- first 5 that answered our phone calls useful information that students could workshop data acted as the baseline for and did not have health curricula were use to make healthy decisions and to the regression, and the post-workshop included in the study. After calling 11 complete exercises that improved at- data were monitored for change using schools we had found the appropriate titudes towards healthy lifestyles. The this baseline. Each dependent variable number of classes meeting our criteria workshop materials consisted of a brief (survey question) was controlled for and willing to work our study into their workbook and several props to make by several independent variables – age, class schedule. We would like to point the workshop more interactive. Power- sex and school attended. Because the out that only 2 of the 11 schools we Point presentation was not used. Two post-workshop surveys were identical contacted already had health curricula. of the authors (LWA and ZDS), both for each workshop group, the post- Each school had a student body primar- university students who were trained workshop data for one workshop group ily composed of students from a Middle and had experience as health educators acted as the control for the other. For Eastern or North African (MENA) ori- and curriculum designers, designed and example, we could examine changes in gin. Upon reaching an agreement with taught the workshops. Each workshop a certain attitude on tobacco use in the each partner school, both parental and lasted the duration of 1 class period, nutrition and physical activity group minor consent forms were distributed generally 45 minutes. and the tobacco group. The comparison and returned before scheduling the pre- We taught the workshops to a total identifies whether the information in workshop survey. Of the possible study of 18 segregated classrooms (10 female, the tobacco workshop was indepen- cohort, 99% of the students agreed to 8 male). Each classroom was randomly dently associated with the change or participate in the study. Those who did assigned either the tobacco or the nutri- whether another factor was responsible. not return the consent forms were al- tion and physical activity workshop (5 Odds ratios and 95% confidence inter- lowed to study in a separate classroom female tobacco workshops, 5 female vals were calculated to interpret the coef- during the lesson and surveys. nutrition and physical activity work- ficient of the ordinal logistic regression. The pre- and post-workshop sur- shops, 4 male tobacco workshops, and For the 4 yes or no questions as- veys were completely anonymous and 4 male nutrition and physical activity sessing the efficacy of the peer-to-peer comprised questions from the World workshops). The post-workshop survey model, which were only included in Health Organization (WHO) Global was administered approximately 2–3 the post-workshop survey, the statisti- Youth Tobacco Survey (GYTS) and weeks after the workshop. cal software R was used for perform- ing simple binomial tests on response the Centers for Disease Control Youth The Institutional Review Board of frequencies. Risk Behavior Surveillance System. The New York University Abu Dhabi ap- WHO had previously administered the proved all steps of the methodology. GYTS in the United Arab Emirates in Results 2001 and 2005, yet failed to address Statistical analysis of survey research more-regional varieties of tobacco that Description of intervention students might readily encounter. All survey data were compiled into a cohort After administration of the pre- database, and letter choices were con- The sample consisted of 439 respond- workshop survey, a peer-mediated to- verted according to our survey code- ents: 46.5% male and 53.5% female. The bacco or nutrition and physical activity book using Python. Where relevant, average age was 13.9 years (σ = 0.76). workshop was conducted. The tobacco letter choices were ranked based on The average weekly disposable income workshop was organized into subsec- which responses had the best health of the students was AED 94.41 ($US tions that focus on the following: the outcomes with the best response start- 25.70). importance of talking about tobacco ing at zero. No sample size calculations as a teenager, what tobacco is, long and were performed. Analyses of workshop short term effects of tobacco smoking To assess the impact of the work- effectiveness on the human body, different types of shops on the participants’ beliefs on We analysed 439 completed pre-sur- tobacco smoking that are common in tobacco use or nutrition and physical veys and 394 completed post-surveys,

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with missing data accounted for by We did not evaluate our data for questions that did not show significant absence from school on the date of the differences between male and female changes may be attributed to the fact workshop or survey. Compared to the responses. that they did not have many undesirable cohort’s baseline responses in the pre- potential responses or to a weakness in workshop survey, the tobacco work- the workshop content. shop effected change in 12 questions Discussion The 4 questions that probed the related to attitudes and perceptions of students’ opinions on the model we Overall, the tobacco workshop was tobacco use. The specific questions, used confirmed that the peer-to-peer effective in improving knowledge, at- ordinal logit coefficients and odds ratios model was popular and effective in this titudes and perceptions about tobacco are outlined in Table 1. The answer cultural setting. An overwhelming ma- use, resulting in improvement on 12 jority of students stated that they plan choices within a question were ranked questions. The nutrition and physical from healthiest to least healthy. The on using something they learned in their activity workshop was not effective in workshop to make a future decision healthiest response was scored as 0, improving knowledge, attitudes and and the score increased by 1 for the regarding their health, which hits at the perceptions of nutrition and physical crux of the goals for health education for answer choices based on their health activity; it only resulted in a decrease in adolescents: prevention of participation ranking within a question. As a result of the teenagers’ level of satisfaction with in risky behaviours that increase the risk this ranking method, a negative ordinal their physical activity. The success of the for noncommunicable diseases later in logit coefficient demonstrates change tobacco workshop may be attributed life. Engagement in the health education towards a healthier perception, attitude to the fact that tobacco use is a more workshop is crucial to its success and or knowledge base. The tobacco work- salient topic at this stage in life than it is encouraging that the majority of shop was also significantly associated nutrition and physical fitness. It may students would not only recommend with changes in 2 nutrition and physical also be because the gap in knowledge a similar workshop to friends or fam- activity-related questions in bivariate about tobacco use is greater than it is for ily but would also share something that analyses. The changes in all cases were in eating healthily and exercising regularly. they have learned, further increasing the the desired direction, namely a healthier Many students were shocked to learn audience and power of the workshop. outcome. that shisha and dokha presented health Evaluation and improvements When compared with the baseline, risks just as serious as those of cigarette the nutrition and physical activity work- smoking. On the other hand, only 3 out Because self-reporting was the method shop was associated with a change in of 10 students had not received advice used to collect data, the results are sub- response to 1 of the 7 nutrition and about leading a healthy lifestyle (5). ject to social desirability bias. Despite physical activity-related questions, but This suggests that another workshop assuring our participants of the con- did not affect any of the tobacco re- or another method of disseminating fidentiality of their survey responses, information should be developed as lated questions. Table 1 includes the 1 the cultural setting of the United Arab the cohort did reveal unhealthy lifestyle Emirates may have prevented some nutrition and physical activity question habits. from reporting honestly. It should be affected along with the ordinal logistic noted that the surveys used were not regression coefficient and correspond- An examination of the questions that were not significantly impacted tested for reliability or validity in this ing odds ratio. by the workshops reveals a number of cultural context. Finally, we found that overall the important findings. The questions “If There may also be some spillover cohort felt that the peer-to-peer work- one of your best friends offered you effects between the workshops. The to- shop model was informative, relatable, shisha, would you smoke it?” and “Do bacco workshop, for example, was able worth sharing with family and friends, you agree or disagree with the follow- to affect 2 nutrition and physical activity and recommendable to friends. The ing: I think I might enjoy smoking questions which were not addressed in majority of students in both the tobacco shisha?” were significantly impacted by that workshop. We hypothesize that and the nutrition groups responded the tobacco workshop while the same learning about how tobacco use impacts positively to 4 questions that evaluate questions about “tobacco products” human health led to students thinking how the cohort felt about the peer-to- and “dokha” were not. This appears to about healthier behaviours in general. peer model (Table 2). For the 2-sided confirm that shisha was thought of as a Our cohort (exclusively 9th graders binomial tests P < 0.01, meaning that harmless social activity and that the to- in private schools in Abu Dhabi whose the respondents significantly chose bacco workshop successfully corrected language of instruction is English) lim- “yes” to each of the 4 questions. this common misconception. Other its the scope of the study. Differences

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with public schools, schools with Arabic Future studies model and tested to see if they are also as the language of instruction, other The sample in this study did not take effective in this environment. grade levels, and schools in different into account the Emirati perspective, parts of the United Arab Emirates may since we included schools predomi- be notable. Additionally, our study did Conclusion nantly for expatriates rather than local not assess changes in behaviour owing to the short time between the baseline public schools. Future studies on the By creating, implementing and evaluat- and post-workshop surveys. Due to the effectiveness of peer-mediated health ing a peer-mediated health education relatively small sample size, we recog- workshops should target local popula- model among expatriate students in the nize that our attempts to randomize tions in their native language. Moreo- United Arab Emirates, we have shown may have had limited effectiveness in ver, workshops on other health topics that simple, cost–effective interventions balancing the 2 workshop groups. should be created using the peer-to-peer can have a significant impact. Tobacco

Table 1. Logistic regression of knowledge, attitudes and beliefs regarding tobacco, nutrition and physical activity Question Workshop Ordinal logit coefficient Odds ratio (SE) (SE) Do you agree or disagree with the following: “I think I N/PA 0.200 (0.165) 1.220 (0.201) might enjoy smoking shisha.” Tobacco –0.525 (0.168)*** 0.592 (0.099)*** Do you think smoking shisha helps people feel more N/PA 0.126 (0.166) 1.130 (0.189) comfortable or less comfortable at celebrations, parties, Tobacco –0.336 (0.163)** 0.715 (0.117)** or in other social gatherings? Do you think smoking dokha helps people feel more N/PA –0.066 (0.167) 0.936 (0.156) comfortable or less comfortable at celebrations, parties, Tobacco –0.345 (0.166)** 0.708 (0.118)** or in other social gatherings? Once someone has started smoking tobacco, do you N/PA 0.019 (0.172) 1.020 (0.175) think it would be difficult for him or her to quit? Tobacco –0.347 (0.172)** 0.707 (0.121)** Once someone has started smoking shisha, do you think N/PA 0.199 (0.166) 1.220 (0.203) it would be difficult for him or her to quit? Tobacco –0.594 (0.167)*** 0.655 (0.134)*** Once someone has started smoking dokha, do you think N/PA 0.168 (0.170) 1.183 (0.201) it would be difficult for them to quit? Tobacco –0.284 (0.165)* 0.752 (0.124)* Do you think the smoke from other people’s tobacco N/PA –0.072 (0.171) 0.930 (0.159) smoking is harmful to you? Tobacco –0.813 (0.183)*** 0.440 (0.081)*** Do you think the smoke from other people’s shisha N/PA –0.028 (0.164) 0.972 (0.159) smoking is harmful to you? Tobacco –0.695 (0.168)*** 0.499 (0.084)*** Do you think the smoke from other people’s dokha N/PA 0.031 (0.170) 1.030 (0.175) smoking is harmful to you? Tobacco –0.516 (0.174)*** 0.597 (0.104)*** At any time during the next 12 months do you think you N/PA –0.124 (0.188) 0.884 (0.167) will use any form of tobacco? Tobacco –0.384 (0.194)** 0.681 (0.132)** If one of your best friends offered you shisha, would you N/PA 0.111 (0.169) 1.110 (0.189) smoke it? Tobacco –0.433 (0.177)** 0.648 (0.115)** Do you think smoking tobacco is harmful to your health? N/PA 0.008 (0.194) 1.010 (0.196) Tobacco –0.595 (0.217)*** 0.551 (0.119)*** How important do you think nutrition is to maintaining a N/PA 0.139 (0.179) 1.150 (0.206) healthy lifestyle? Tobacco –0.554 (0.192)*** 0.575 (0.111)*** On an average school day, how many hours do you N/PA –0.069 (0.161) 0.933 (0.150) watch TV? Tobacco –0.314 (0.160)** 0.730 (0.117)** Are you currently satisfied with your level of physical N/PA 0.332 (0.163)** 1.390 (0.228)** activity? Tobacco 0.157 (0.163) 1.17 (0.190)

The n values used in the logistic ordinal regressions were s: pre-N/PA = 230, pre-tobacco = 209, post-N/PA = 196, post-tobacco = 198. SE = standard error. N/PA = nutrition and physical activity. *P < 0.1. **P <.05. ***P < 0.01. 484

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Table 2. A breakdown of cohort feedback concerning the workshop experience Question Tobacco N/PA (n = 198) (n = 196) Yes Yes No. % No. % Do you think that college students are more relatable (to yourself) than adults or 125 63 118 60 medical professionals? Would you recommend this type of workshop to your friends? 164 83 129 66 Do you plan on sharing anything you learned in the workshop with friends and/or 154 78 125 64 family? Do you think that you will use any of the information you learned in the workshop 164 83 137 70 to make future decisions about your health? N/PA = nutrition and physical activity.

use is a serious issue for young adults continue into adulthood, directly ad- Peer education not only equips the high in the Middle East and even minimal dressing the behaviours that increase school students with the knowledge education can have an impact on their the risk for cancer, heart disease, stroke, they need to make healthy decisions perceptions of this life threatening habit. diabetes, etc. It is our hope that these about their life but also empowers stu- We believe that such an approach is a types of grass roots initiatives can be dent teachers to be agents of change in used to enhance the efficacy of legisla- promising method for producing posi- their own communities and gain excel- tive changes in lifestyle decisions among tion and enforcement of laws designed lent communication skills. the youth in Abu Dhabi, and possibly to promote a healthier lifestyle. elsewhere in the United Arab Emir- This type of model is also self-sus- Funding: This study was funded by ates. Moreover, one might anticipate taining in that university students can New York University Abu Dhabi. that healthy habits formed early on will teach high school students at no cost. Competing interests: None declared.

References

1. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria 9. Musaiger AO. Diet and prevention of coronary heart disease in P, et al. Priority actions for the non-communicable disease the Arab Middle East countries. Med Princ Pract. 2002;11(Sup- crisis. Lancet. 2011;377(9775):1438–47. PMID: 21474174 pl. 2):9–16. PMID:12444306 2. Jones AM. Health, addiction, social interaction and the deci- 10. Jayakumary M, Jayadevan S, Ranade AV, Mathew E. Prevalence sion to quit smoking. J Health Economics. 1994;13(1):93–110. and pattern of dokha use among medical and allied health 3. Buente M, Hashemi AA, Moujaes CN, Samman, H. GCC school students in Ajman, United Arab Emirates. Asian Pac J Cancer health programs. Health and wellness through early interven- Prev. 2010;11:1547–9. PMID:21338195 tion. Booz and Company; 2010. 11. Methodology of estimating the population in UAE. Abu 4. Godwin SM. Globalization, education, and Emiratisation: a Dhabi: United Arab Emirates National Bureau of Statistics; 2011 study of the United Arab Emirates. Electronic J Information (http://www.uaestatistics.gov.ae/ReportPDF/Population Es- Systems in Developing Countries. 2006;27(1):1–14. timates 2006 - 2010.pdf, accessed 15 Nov, 2014). 5. Asfour LW, Stanley ZD, Weitzman M, Sherman SE. Uncover- 12. Shah NM. Arab migration patterns in the Gulf. In: Arab migra- ing risky behaviors of expatriate teenagers in the United Arab tion in a globalized world. Geneva: International Organization Emirates: a survey of tobacco use, nutrition and physical activ- for Migration and League of Arab States; 2004:91–113 (http:// ity habits. BMC Public Health. 2015;15:944. PMID: 2639975 publications.iom.int/system/files/pdf/arab_migration_glo- 6. Jha P, Chaloupka FJ, Moore J, et al. Tobacco addiction. In: balized_world.pdf, accessed 19 April 2017). Jamison DT, Breman JG, Measham AR, eds. Disease control 13. Damon W. Peer education: the untapped potential. J Appl priorities in developing countries. Washington DC: World Dev Psychol. 1984;5(4):331–43. Bank, 2006: Chapter 46. 7. Tamim H, Al-Sahab B, Akkary G, Ghanem M, Tamim N, El 14. Backett-Milburn K. Understanding peer education: insights Roueiheb Z, et al. Cigarette and nargileh smoking practices from a process evaluation. Health Educ Res. 2000;15(1):85–96. among school students in Beirut, Lebanon. Am J Health Behav. PMID:10788205 2007;31:56–63. PMID:17181462 15. Barss P, Grivna M, Ganczak M, Bernsen R, Al-Maskari F, El Agab 8. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes H, et al. Effects of a rapid peer-based HIV/AIDS educational in- atlas: global estimates of the prevalence of diabetes for tervention on knowledge and attitudes of high school students 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311–21. in a high-income Arab country. J Acquir Immune Defic Syndr. PMID:22079683 2009;52.1:86–98. PMID:19590431

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Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan Manar Al Azzam 1, Mohammed Al Bashtawy 1, Ahmad Tubaishat 2, Abdul-Monim Batiha 3 and Loai Tawalbeh 2

انتشار اضطراب قصور االنتباه املقرتن بفرط النشاط بي األطفال يف سن املدرسة يف األردن منار العزام، حممد البشتاوي، أمحد طبيشات، عبد املنعم بطيحة، لؤي طوالبة اخلالصــة: الغــرض مــن هــذه الدراســة هــو حتديــد مــدى انتشــار اضطــراب قصــور االنتبــاه املقــرتن بفــرط النشــاط بــن أطفــال املــدارس يف األردن، وعوامــل اخلطــر املحتملــة املرتبطــة بــه. ُواســتخدمت دراســة وصفيــة مقطعيــة وعينــه عشــوائية بســيطة الختيــار 480 ًطالبــا، تــرتاوح أعامرهــم بــن 6 ســنوات و 12ســنة، مــن املــدارس االبتدائيــة احلكوميــة يف مدينــة املفــرق بــاألردن. و ُمجعــت بيانــات الدراســة باســتخدام النســخة العربيــة ّلــة املعدمــن اإلصــدار املــدريس ملقيــاس تقييــم اضطــراب قصــور االنتبــاه واســتبيان أوليــاء األمــر. وأظهــرت النتائــج أن معــدالت 9.58 10.83 االنتشــار يف النــوع الفرعــي ُّت »تشــتاالنتبــاه« والنــوع الفرعــي »فــرط احلركة/االندفــاع«، والنــوع الفرعــي ّاملجمــع بلغــت %، %، 20.21 % عــى التــوايل. وترتبــط زيــادة حجــم األرسة والذكــورة بزيــادة انتشــار أعــراض هــذا االضطــراب. وكشــفت الدراســة انتشــار اضطــراب قصــور االنتبــاه املقــرتن بفــرط النشــاط يف صفــوف طــالب املــدارس األردنيــة. وينبغــي للحكومــة وضــع برامــج تعليميــة لزيــادة الوعــي بجوانــب اضطــراب قصــور االنتبــاه املقــرتن بفــرط النشــاط.

ABSTRACT The purpose of this study was to determine the prevalence of attention deficit hyperactivity disorder (ADHD) symptoms among school children in Jordan and the probable associated risk factors. This was a cross- sectional descriptive study and simple random sampling was used to select 480 students, aged 6–12 years, from government primary schools in Mafraq City, Jordan. Data were collected using the modified Arabic version of the Attention Deficit Disorder Evaluation Scale (ADDES) school version and parental questionnaire. Prevalence rates within the inattentive, hyperactive–impulsive and combined subtypes were 10.83, 9.58 and 20.21%, respectively. Increased family size and being male were both associated with increased prevalence of ADHD symptoms. The study revealed that ADHD is common among Jordanian school children. The government should establish education programmes to increase awareness of ADHD.

Prévalence du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants d’âge scolaire en Jordanie

RÉSUMÉ La présente étude a pour objectif de déterminer la prévalence des symptômes du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants scolarisés en Jordanie, ainsi que les probables facteurs de risque associés. Une étude descriptive transversale ainsi qu’un sondage aléatoire simple ont été utilisés afin de sélectionner 480 élèves, âgés de 6 à 12 ans, dans des écoles primaires gouvernementales de la ville de Mafraq, en Jordanie. Les données de l’étude ont été collectées en utilisant la version scolaire modifiée de l'échelle d'évaluation du trouble de déficit de l’attention (ADDES) en langue arabe et un questionnaire destiné aux parents. Les résultats ont montré que les taux de prévalence du sous-type inattentif, du sous-type hyperactif/ impulsif, et du sous-type combiné étaient de 10,83 %, 9,58 %, et 20,21 % respectivement. Le fait d'être une famille nombreuse et d’être de sexe masculin était associé à une prévalence accrue des symptômes de TDAH. L’étude a révélé que le TDAH était répandu parmi les élèves scolarisés en Jordanie. Le gouvernement devrait mettre en place des programmes éducatifs afin de sensibiliser sur les aspects du TDAH.

1Department of Community and Mental Health Nursing, Faculty of Nursing, Al al-Bayt University, Al-Mafraq, Jordan (Correspondence to: M. Al Azzam: [email protected]). 2Department of Adult Health Nursing, Al al-Bayt University, Al-Mafraq, Jordan. 3Department of Adult Health Nursing, Faculty of Nursing, Philadelphia University, Amman, Jordan. Received: 01/05/16; accepted: 23/11/16

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Introduction ADHD is one of the most com- study that might help to develop aware- mon neurodevelopmental disorders of ness and intervention programmes to Attention deficit hyperactivity disorder childhood, with a worldwide prevalence deal with affected individuals and their (ADHD) is a neurodevelopmental dis- ranging from 2.2 to 17.8% (10). The families. order characterized by core symptoms variability in prevalence might be due to of hyperactivity, inattention and impul- several factors, such as study method- sivity, affecting children across all socio- ology, diagnostic criteria, populations Methods economic strata and ethnic and regional studied, sample size, cultural percep- groups (1,2). Forty to sixty percent of tions, and informants (e.g., respondents Research design children with ADHD have comorbidity to questionnaires) (1,6,9,10). Moreo- This was a cross-sectional descriptive such as anxiety, depression and learning ver, the literature indicates that the re- study to assess the prevalence of ADHD disabilities (1). Fifty percent of ADHD ported rates might vary depending on among school children in Jordan, to- cases are associated with disruptive and the source of the information (1,3,11). gether with the associated risk factors. aggressive behavioural characteristics In Arab countries there has been The study was conducted at schools as seen in oppositional defiant disorder a shortage of studies addressing chil- in Mafraq City, Jordan from February and conduct disorder (3). ADHD may dren’s behavioural problems in general to April 2014. Mafraq is located 80 serve as a developmental precursor and ADHD in particular (8). The prev- to increasingly problematic behav- alence of ADHD symptoms in Arab km north of the capital Amman. It has ioural outcomes, because children with countries varies considerably between nearly 127 830 residents. There are 30 ADHD are at significantly higher risk 1.3 and 16% (8,12–14), although these governmental schools listed in the city, of being involved with substance abuse, rates were based on a limited number with a total of 19 000 students (15). The delinquency and persistent problems of studies that used different methods. study was approved by the Institutional with social relationships, as well as aca- For example, Richa and colleagues (14) Review Board of Al al-Bayt University, demic and job performance difficulties conducted a study of 1000 Lebanese Mafraq. (1,4–6). school children aged 6–10 years using Study population The emotional and behavioural the ADHD Rating Scale – IV School The target population was school problems associated with ADHD may Version. They found prevalence of 3% children aged 6–12 years. A list of the interfere with nearly every aspect of a for ADHD inattentive subtype, 12% primary schools in Mafraq City was child’s life, including family and sib- for hyperactive–impulsive subtype and obtained from the Ministry of Educa- ling relationships, peer relationships, 17% for ADHD combined subtype. tion. A random sample of 6 schools academic performance, planning, and Jenahi and colleagues (13) used the was chosen. Six classes, 1 from each task completion (1,3,7). ADHD has a Attention Deficit Disorders Evalu- grade in each school, were chosen using significant lifelong impact on a person’s ation Scale (ADDES) to investigate systematic random sampling to ensure emotional, social and cognitive func- the prevalence of ADHD among 1009 representativeness of all classes of the tioning. Saudi students aged 6–15 years. They same grade. Proportional allocation of Factors that contribute to the aetiol- found prevalence of 2.1% for ADHD the sample was used when choosing the ogy of ADHD are still under investiga- inattentive subtype and 5.6% for hyper- children so that the sampling fractions tion (1,8). Various approaches have active–impulsive subtype. were equal. been used to try to explain the aetiology, The main purpose of the current including biological, neuro-psychobio- study was to determine the prevalence The sample size was determined logical, trauma-based, and environmen- of ADHD symptoms among school using the following formula: 2 2 tally based models, or a combination of children in Jordan. We also aimed to N = Z 1 –α/2 × P (1 – P) / d these. It is reported that several child, identify possible risk factors related to where N is minimum sample size; family and environmental risk factors the symptoms associated with ADHD. Z2 1 − α/2 is the confidence level at might increase the severity of ADHD It is hoped that the current study will 95%; P is the expected prevalence of symptoms (3). These factors include provide baseline information that may ADHD symptoms among school-aged low socioeconomic status, living in eco- help teachers, parents, healthcare pro- children (0.5%); and d is the margin nomically stressed neighbourhoods, fessionals and policy-makers to design of error at 0.05% (4). The minimum poor family functioning, family size, age, comprehensive strategies to enhance sample size needed was 400 students, and gender. ADHD is a complex disor- awareness of ADHD. Also, the study but, to allow for non-responses and under, with genetic and environmental risk may be a preliminary step toward completed questionnaires, we increased factors contributing to its onset (1,9). launching a large community-based the sample size to 500 students.

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Exclusion criteria number of siblings, parents’ educational head teachers were instructed to fill out All students in the selected classes level, family mental health history, and the modified Arabic school version of were eligible to participate in the study, consanguinity. ADDES after they had received appro- except for children who were not Jorda- priate training. Parents were instructed Data collection and to fill out the demographic data ques- nian. This was because non-Jordanian procedures children may have been refugees with tionnaire. After obtaining IRB approval, 2 research other diagnoses that could have inter- team members visited the schools and Data analysis fered with ADHD symptoms. We also explained the aims and methods of The completeness and accuracy of excluded children with chronic physical the study to the head teacher, in order the study data were checked and then illness and those attending special edu- to obtain permission to distribute the coded, entered and analysed using SPSS cational classes to compensate for learn- study forms. A letter of invitation to version 22. Descriptive statistics were ing disabilities, because the diagnosis of participate in the study was sent to the used to describe the sample character- ADHD is often comorbid with other children’s parents and the head teach- istics and to assess the prevalence of diagnoses such as learning disabilities. ers. The letter explained the aims and ADHD symptoms. The 2χ test was used Study instruments methods of the study, name and contact to assess whether there was a significant information of the chief researcher, and association between ADHD symptoms Two instruments were used to assess that participation was voluntary. All and demographic data. P < 0.05 was the main variables. The modified Arabic participants’ rights about anonymity considered statistically significant. Bi- School Version of ADDES was used and confidentiality were protected. The nary logistic regression was performed to measure the prevalence of ADHD symptoms (Appendix 1). Permission to use the instrument was obtained from Hawthorne Educational Service (Co- Table 1 Sociodemographic characteristics of study population (n = 480) lombia, MO, USA). The questionnaire Sociodemographic characteristics No. (%) Child’s age, yr contained two parts: Part I consisted of 6–9 210 (43.75) 29 questions that measured inattention; 10–12 270 (56.25) and Part II comprised 31 questions that Child’s gender measured hyperactivity–impulsivity. Male 250 (52.08) All 60 questions were used to diagnose Female 230 (47.92) combined ADHD. The same scoring Birth order 1–3 250 (52.08) procedure, as outlined in the original 4–6 170 (35.42) manual, was used by the authors. 7–9 38 (7.92) ≥ 10 22 (4.58) The Arabic version of the instru- No. of siblings ment was established by translation and 1–3 154 (32.08) back translation and the content validity 4–6 209 (43.54) was checked by a panel of experts who > 6 117 (24.38) were interested in the research topic. Maternal education Illiterate 31 (6.46) The instrument was piloted with 30 stu- Secondary 98 (20.42) dents who were not included within the High school 244 (50.83) main sample, before the data collection Undergraduate 87 (18.13) Postgraduate 20 (4.17) process began, to assess the clarity and appropriateness of items and to test the Paternal education Illiterate 6 (1.25) readability of the instrument among a Secondary 24 (5) Jordanian sample. The results indicated High school 163 (33.96) that the instruments were clear and Undergraduate 257 (53.54) readable. The findings also showed that Postgraduate 30 (6.25) Cronbach’s α was 0.93. Consanguinity Yes 231 (48.13) An Arabic questionnaire was de- No 249 (51.87) vised to collect relevant sociodemo- Family mental health problems graphic data for the present study, Yes 15 (3.13) No 465 (96.87) including children’s age, birth order,

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Table 2 Prevalence of ADHD subtypes by age group (n = 480) ADHD type Total no. with Overall Prevalence by age group disorder prevalence 6–9 yr 10–12 yr n = 210 n = 270 No. % No. % Combined 97 20.21% 68 32.38 29 10.74 Hyperactivity–impulsivity 46 9.58% 32 15.24 14 5.19 Inattention 52 10.83% 35 16.67 17 6.30

P value (χ2 test) = 0.008. ADHD = attention deficit hyperactivity disorder.

to identify the factors that may have ADHD prevalence Discussion contributed to the prevalence rate of The prevalence of ADHD in Mafraq ADHD. To assess the predictors of the City among school-age children was The purpose of the current study was to prevalence rate of ADHD, the follow- 40.62%, and the percentage of each assess the prevalence of ADHD symp- ing predictors were entered into the subtype is shown in Table 2. There toms among school children in Mafraq City, Jordan and to identify the potential regression equation: age, gender, birth was a significant association between associated risk factors. We found high the children’s age and prevalence of order, number of siblings, maternal prevalence rates of combined ADHD ADHD symptoms [P value (χ2 test) = educational level, paternal educational of 20.21%, hyperactivity–impulsivity of 0.008] (Table 2). The prevalence of the level, consanguinity, and family mental 9.58% and inattention of 10.83%. These 3 subtypes of ADHD decreased with health problems. rates were higher than those reported in increasing age. There was a significant other studies (6,13,14,16). For example, association between the number of sib- in Turkey, a study of 1508 schoolchil- Results lings and prevalence of ADHD [P value 2 dren aged 6–14 years showed a preva- (χ test) < 0.004], as demonstrated by lence of 8% for combined ADHD, 20% Demographic characteristics the increasing rate of ADHD with num- for inattentive subtype and 14.3% for Four hundred and eighty out ber of siblings among the 3 ADHD hyperactive–impulsive subtype (6). In of the 500 questionnaires were com- subtypes (Table 3). Table 4 shows another cross-sectional study of ADHD the association between gender and pleted and available for analysis, yielding in Nigeria among 487 school children, prevalence estimates of ADHD. The a response rate of 96%, representing there was a prevalence of 3.08% for com- prevalence estimate of all 3 subtypes of 250 (52.08%) boys and 230 (47.92%) bined ADHD and inattentive subtype ADHD was significantly higher among and 2.05% for hyperactive–impulsive girls. Demographic characteristics are 2 boys [P value (χ test) < 0.001]. Of the subtype (15). These differences could shown in Table 1. There were 2 age 250 male students, 54% had ADHD be because estimates of the prevalence groups of 6–9 and 10–12 years, with distributed among the 3 subtypes. Ac- of ADHD worldwide vary, depending a mean (standard deviation; SD) of 9 cording to Wald statistics, age, gender on the study methodology, diagnostic (1.9) years. The number of siblings were and family size were associated with criteria, populations studied, sample grouped into 1–3, 4–6 and > 6, with a higher prevalence of ADHD among size, cultural perceptions, informants, mean of 4.6 (3.2) and median of 5. school children in Jordan (Table 5). and instruments used. In the current

Table 3 Prevalence of ADHD subtypes by number of siblings (n = 480) No. of siblings Total no. of ADHD subtype children Combined Hyperactivity–impulsivity Inattention No. % No. % No. % 1–3 154 19 12.34 9 5.84 17 11.04 4–6 209 47 22.49 27 12.92 22 10.53 > 6 117 31 26.50 10 8.55 13 11.11

P value (χ2 test) < 0.004 ADHD = attention deficit hyperactivity disorder.

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Table 4 Prevalence of ADHD subtypes by child gender (n = 480) Child gender Total no. of children ADHD subtype Combined Hyperactivity– Inattention impulsivity No. % No. % No. % Male 250 60 24 32 12.8 43 17.2 Female 230 37 16.09 14 6.09 9 3.91

P value (χ2 test) < 0.001. ADHD = attention deficit hyperactivity disorder.

study, the only source of behavioural as- Our results are comparable to those 9:1 (8,11–13,17,18). One commonly sessment was the teachers, which could of other studies conducted in Arab coun- accepted explanation for the observed explain the high prevalence of ADHD tries, which have shown that ADHD is difference is that, in general, boys are symptoms. If we had had multiple more noticeable among children aged more likely to exhibit aggressive and an- sources of assessment (e.g., teachers, 6–9 years and the symptoms start to tisocial behaviour compared to girls (1). parents and health professionals), the regress after 11 years 8( ,12,13,17). The present research was a prelimi- prevalence might well have been lower. The current study indicated a signifi- nary study that indicated that ADHD Our results revealed that the rate of cant association between the number might be a problem among school chil- ADHD symptoms decreased with age, of siblings and the prevalence estimates dren in Jordan. Our findings could be of the 3 subtypes of ADHD, for which used as a guide for further investigations and the symptoms were mostly notice- lower rates have been reported among of ADHD in Jordan since there has able among children aged 6–9 years. children in small families compared to been a dearth of related studies to date. For many children, ADHD behaviour is children in large families. These results Future studies should involve large ran- not noticed until they enter elementary are in line with the findings of studies domized samples from all areas of the school. Experts have tried to explain this conducted in Saudi Arabia, Kuwait and country to enable generalization of the by stating that almost all toddlers and Qatar (8,12,13,17,18), and could be results. Moreover, such findings should preschool children exhibit behaviour explained by the fact that children in help to create health programmes to or symptoms that exemplify ADHD as large families receives less care, which increase awareness of parents, teach- part of their normal development. In results in behavioural problems being ers, policy-makers, school nurses and order to diagnose a child with ADHD, observed more often among these chil- healthcare professionals about ADHD, the symptoms should be present before dren. particularly with regard to the signs, the age of 12 years, and the child must We found a significant gender differ- symptoms, causes and consequences. show evidence of several symptoms ence in the prevalence of the 3 subtypes The present study had some limita- in ≥ 2 settings (e.g., at home, school or of ADHD, with a higher prevalence in tions, which means that the results must work; with friends or relatives; or in boys, which is consistent with the lit- be considered with caution. First, the other activities) (1,3). erature, with ratios ranging from 2:1 to study sample was not representative

Table 5 Logistic regression analysis to identify significant predictors of ADHD symptoms n( = 480) Predictor B Wald Significance Odds ratio Age (yr) −0.85 06.73 0.008** 0.48 Gender −0.10 10.21 0.001** 0.95 Birth order 0.01 0.35 0.55 1.01 No. of siblings 1.50 8.34 0.004** 4.45 Maternal educational level −0.21 0.38 0.53 0.80 Paternal educational level 0.11 0.14 0.71 1.12 Consanguinity −0.17 0.09 0.75 0.84 Family mental health problems 1.09 4.87 0. 27 2.99

*P significant at ≤ 0.01. **P significant at ≤ 0.001. ADHD = attention deficit hyperactivity disorder.

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of the population of school children parents and health professionals to con- children’s age and gender, and family in Jordan as a whole. Second, we used firm the diagnosis of ADHD. size. a screening tool and no attempt was In conclusion, this study is one of the made to establish a clinical diagnosis earliest efforts to assess ADHD among Acknowledgements among the study sample. Future studies school children in Jordan. The preva- should involve screening and diagnosis lence reported suggests that ADHD is The authors thank all who facilitated in order to identify the symptoms of more common in school children in the conduct of this study. Additionally, ADHD among school children. Third, Jordan than in other parts of the world. many thanks are owed to the parents the prevalence of ADHD was based Furthermore, the current study showed and teachers who participated in the on information that was obtained from that a variety of sociodemographic fac- study. a single source (school teachers). Fu- tors were significantly associated with Funding: None. ture research should involve teachers, development of ADHD, including Competing interests: None declared.

References

1. Barkley RA. Attention deficit hyperactivity disorder: a hand- 10. Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. book for diagnosis and treatment. 4th edition. New York: The ADHD prevalence estimates across three decades: an up- Guilford Press; 2014. dated systematic review and meta-regression analysis. Int J 2. Vaziri S, Kashani FL, Sorati M. Effectiveness of family training Epidemiol. 2014 Apr;43(2):434–42. PMID:24464188 in reduced symptoms of the children with attention deficit 11. Ramtekkar UP, Reiersen AM, Todorov AA, Todd RD. Sex and hyperactivity disorder. Procedia Soc Behav Sci. 2014;128:337– age differences in attention-deficit/hyperactivity disorder 42 (http://www.sciencedirect.com/science/article/pii/ symptoms and diagnoses: Implications for DSM-V and ICD-11. S1877042814022587?via%3Dihub) J Am Acad Child Adolesc Psychiatry. 2010 Mar;49(3):217–28. 3. Diagnostic and codes. In: Diagnostic and statistical manual of e1-3. PMID:20410711 mental disorders. 5th edition. Arlington, VA: American Psychi- 12. Aboul-Ata MA, Amin FA. The prevalence of ADHD in Fay- atric Association; 2013. oum City (Egypt) among school-age children: depending 4. Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, Nedjat on a DSM-5-based rating scale. J Atten Disord.2015 Mar 26; S, Mohammadi E. Alcohol and drug use prevalence and fac- pii:1087054715576917 [Epub ahead of print]. PMID:25814429 tors associated with the experience of alcohol use in Iranian 13. Jenahi E, Khalil M, Bella H. Prevalence of attention deficit hy- adolescents. Iran Red Crescent Med J. 2013 Mar;15(3):212–7. peractivity symptoms in female schoolchildren in Saudi Arabia. PMID:23984000 Ann Saudi Med. 2012 Sep-Oct;32(5):462–8. PMID:22871613 5. Michielsen M1. Comijs HC, Semeijn EJ, Beekman AT, Deeg 14. Richa S, Rohayem J, Chammai R, Haddad R, Hleis S, Alamed- DJ, Sandra JJ. The comorbidity of anxiety and depressive dine A, et al. ADHD prevalence in Lebanese school-age popu- symptoms in older adults with attention-deficit/hyperactivity lation. J Atten Disord. 2014 Apr;18(3):242–6. PMID:22628148 disorder: a longitudinal study. J Affect Disord. 2013 Jun;148(2- 15. Ministry of education. Annual statistical book. Amman, Jordan: 3):220–7. PMID:23267726 Ministry of Education; 2014 (http://www.moe.gov.jo/MOE/ 6. Zurlo A, Unlu G, Cakaloz B, Zencir M, Buber A, Isildar Y. Files/Publication/report2014_2.pdf). The prevalence and comorbidity rates of ADHD among 16. Umar MU, Obindo JT, Omigbodun OO. Prevalence and cor- school-age children in Turkey. J Atten Disord. 2015 Apr 6; pii: relates of ADHD among adolescent students in Nigeria. J Atten 1087054715577991 [Epub ahead of print] PMID:25846229 Disord. 2015; Jul 28. pii:1087054715594456 [Epub ahead of 7. Larson K, Russ A, Kahn S, Halfon N. Patterns of comorbidity, print]. PMID:26220786 functioning, and service use for US children with ADHD. J 17. Homidi M, Obaidat Y, Hamaidi D. Prevalence of attention Pediatr. 2011 Mar;127(3):462–70. PMID:21300675 deficit and hyperactivity disorder among primary school 8. Alhraiwil NJ, Ali A, Househ MS, Al-Shehri AM, El-Metwally students in Jeddah city, KSA. Life Sci J. 2013;10(3):280–5 AA. Systematic review of the epidemiology of attention deficit (http://www.lifesciencesite.com/lsj/life1003/044_19518li hyperactivity disorder in Arab countries. Neurosciences. 2015 fe1003_280_285.pdf) Apr;20(2):137–44. PMID:25864066 18. Rucklidge JJ. Gender differences in attention-deficit/hyperac- 9. Parens E, Johnston J. Facts, values, and attention-deficit hy- tivity disorder. Psychiatr Clin North Am. 2010 Jun;33(2):357–73. peractivity disorder (ADHD): An update on the controversies. PMID:20385342 Child Adolesc Psychiatry Ment Health. 2009 Jan 19;3(1):1. PMID:19152690

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Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 Salem Al Wahabi 1, Fayssal Farahat 2 and Ahmed Y. Bahloul 1

انتشار األحداث اخلافرة وإمكانية الوقاية منها يف اململكة العربية السعودية: حتليل التقارير من 2012 إىل 2015 سامل الوهايب، فيصل فرحات، أمحد هبلول اخلالصــة: ّــل متثاهلــدف مــن هــذه الدراســة يف تقييــم نمــط األحــداث اخلافــرة التــي ُأبلــغ عنهــا لــدى وزارة الصحــة الســعودية منــذ ينايــر/ كانــون الثــاين 2012 إىل يونيو/حزيــران . 2015وقــد تــم فحــص تقاريــر األحــداث اخلافــرة ملعرفــة خصائــص املــرىض ونــوع األحــداث ونتائجهــا وأســباهبا وإمكانيــة الوقايــة منهــا. وبلــغ عــدد األحــداث اخلافــرة 433 ًحدثــا: 58.2 % وفــاة، و14.8 % أحــداث غــر متوقعــة لفقــدان طــرف أو وظيفــة حيويــة، و%7.4 أخطــاء تــداوي جســيمة، و 4 .7 % أحــداث نامجــة عــن نســيان أدوات أو اســفنجات داخــل اجلســم. وارتبــط %44 مــن األحــداث املبلــغ عنهــا بالتدخــالت اجلراحيــة وصنّــف معظمهــا حتــت فئــة األمــراض القابلــة للوقايــة )91.6 %(. وثبــت ارتبــاط الفئــة العمريــة 19 - 64 ًعامــا، ً ارتباطــاذا داللــة بالوفــاة باعتبارهــا نتيجــة )p.) = 0.02 وســجلت األحــداث اخلافــرة غــر القابلــة للوقايــة مســتوى احتــامل أكــرب بكثــر يف صفــوف النســاء ًمقارنــة بالرجــال )p = 0.01(. َّومتثلــت األســباب الرئيســية للحــداث الســلبية يف عــدم تطبيــق سياســات وإجــراءات و/أو الفشــل يف تنفيذهــا )55 %(، واالفتقــار إىل االتصــال املالئــم )35 %(، ونقــص التدريــب )33 %(. وينبغــي تركيــز اجلهــود عــى تعزيــز "النظــام الوطنــي لإلبــالغ عــن األحــداث اخلافــرة"، باعتــامد معايــر فعالــة لإلبــالغ وضــامن توفــر وتنفيــذ السياســات واإلجــراءات.

ABSTRACT This study aimed to assess the pattern of sentinel events reported to Ministry of Health of Saudi Arabia from January 2012 to June 2015. Sentinel event reports were examined for patient characteristics, type of event, outcome, cause and preventability. There were 433 sentinel events: 58.2% were deaths, 14.8% were unexpected loss of a limb or a function, 7.4% major medication errors and 7.4% retained instruments or sponges. Among the reported events, 44% were associated with surgical interventions and most were classified as preventable (91.6%). Age 19-64 years was significantly associated with death as an outcome (P = 0.02). Non-preventable sentinel events were significantly more likely among women than men (P = 0.01). Unavailability of policy and procedures and/ or failure to implement them (55%), and lack of proper communication (35%) and training (33%) were the main causes for the adverse events. Efforts should focus on enhancing the National Sentinel Events Reporting System, adopting criteria for effective reporting and ensuring availability and implementation of policies and procedures.

Prévalence et possibilités de prévention des événements sentinelles en Arabie saoudite : analyse de rapports publiés entre 2012 et 2015

RÉSUMÉ La présente étude avait pour objectif d’évaluer le profil des événements sentinelles rapportés au ministère de la Santé saoudien entre janvier 2012 et juin 2015. Les caractéristiques des patients, les types d’événements, les issues, les causes et les possibilités de prévention détaillés dans les rapports sur les événements sentinelles ont fait l’objet d’un examen. Nous avons répertorié 433 événements sentinelles : 58,2 % étaient des décès, 14,8% concernaient la perte accidentelle d’un membre ou d’une fonction, 7,4 % des erreurs médicamenteuses majeures et 7,4% un oubli d’instruments ou d’éponges. Parmi les événements rapportés, 44 % étaient associés à des interventions chirurgicales et la majorité étaient classifiés comme évitables (91,6 %). Un âge compris entre 19 et 64 ans était fortement associé au risque de décéder des suites de l’événement (p = 0,02). Les événement sentinelles non évitables étaient significativement plus susceptibles de toucher les femmes que les hommes (p = 0,01). Le manque de politiques et de procédures et/ou l’inaptitude à les appliquer (55 %), ainsi que le manque de communication (35 %) et de formation (33 %) constituaient les causes principales d’événements indésirables. Les efforts devraient se concentrer sur l’amélioration du Système national de notification des événements sentinelles, en adoptant des critères en vue d’une notification efficace et en garantissant la disponibilité et la mise en œuvre de politiques et de procédures.

1Saudi Central Board for Accreditation of Healthcare Institutions, Riyadh, Saudi Arabia (Correspondence to: Salem Al Wahabi: salwahabi@cbahi. gov.sa). 2King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul Aziz Medical City, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia; and Department of Public Health and Community Medicine, Menoufia University, Menoufia, Egypt. Received: 10/12/15; accepted: 23/11/16 492

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Introduction sentinel events within the 3rd edition the root cause analysis reported by the of the national hospital standards in the hospitals for each event. A checklist A sentinel event is the most serious form form of 10 sentinel events. The Board’s was used to record data on patient of adverse event that can occur in health policy urges the hospitals to report the characteristics, type of intervention and care. The Joint Commission’s Sentinel sentinel event within 5 days of its occur- hospital, outcome and preventability. Event Policy and Procedures defines a rence and then to report a root cause The independent variables included sentinel event as any unexpected event analysis and the risk reduction plan in this study were: age, sex, type of in- that reaches the patient and harms the within 30 days (6). tervention (surgical, non-surgical, de- patient seriously, either physically or The 10 reportable events are: un- livery) and type of hospital reporting psychologically, such as causing death, expected death, maternal death, wrong the event (government, private). The permanent harm or disability, or severe patient, procedure or site, retained independent variables were patient out- temporary harm requiring an interven- strument or sponge, medication error come as a result of the event (died, sur- tion to sustain life. Sentinel events can leading to death or major morbidity, vived) and preventability of the event. be as a result of medical errors or any infant abduction or infant discharge to Preventability was judged by the inves- other risks or hazards, e.g. a fire. They the wrong family, unexpected loss of a tigators based on the available clinical require immediate investigation and limb or a function, haemolytic blood information that either supported the response (1). transfusion reaction, inpatient suicide, presence of an identifiable and modifi- Despite increased awareness and gas embolism (6). able cause of harm or the lack of adher- and identification of strategies to To date, there have been no pub- ence to guidelines. address patient safety in the past lished studies on sentinel event surveil- Statistical analysis few years, medical errors and sen- lance in Saudi Arabia. Therefore, the aim tinel events continue to occur (1). of this study was to review and assess the Data were analysed using SPSS, version The reporting of incidents, includ- patterns and root causes of the sentinel 20). Descriptive statistics (e.g. numbers ing sentinel events, is essential in order events reported to the Saudi Ministry of and percentages) were used. The chi- to improve and maintain the quality Health (MoH) over 3.5 years (January squared test was used for categorical of health care systems (2). The major- 2012–June 2015). This study also as- variables. Univariable logistic regression ity of adverse medical events are man- sessed the preventability of the reported analysis was performed to determine agement-related and preventable (3). events. The findings of the study could the likelihood of death or non-prevent- This finding is consistent with Edward encourage managers in health care to able sentinel event. Odds ratios (OR) Deming’s rule, which attributes 85% systematically tackle such events in and 95% confidence intervals (CI) were of problems to the system and its pro- their facilities and help policy-makers calculated. A P-value less than 0.05 was cesses (the majority of which are related to take actions that could lead to a safer considered statistically significant. to the complexity and nature of the sys- health care system in Saudi Arabia. Fur- tem itself) and only 15% to individuals thermore, the lessons learned could be Results (4). This means major improvement useful to all health care professionals in can be made by changing systems and the country. A total of 433 sentinel events were re- standardizing processes with policies ported from January 2012 to June 2015. and procedures, protocols and clinical Figure 1 shows types of sentinel events practice guidelines (5). According to Methods reported. The main types of events the Joint Commission, failing to pre- reported were death (unexpected and pare a thorough and credible root cause This was a retrospective review of all maternal deaths) (58.2%), unexpected analysis and implement an action plan events reported to the MoH from loss of a limb or a function (14.8%), following the occurrence of a sentinel January 2012 to June 2015 which were major medication errors (7.4%) and re- event may affect a hospital’s accredita- given to the Saudi Central Board for tained instruments or sponges (7.4%). tion (5). Accreditation of Healthcare Institu- tions. The study is an analysis of data Figure 2 shows the outcomes of the The Ministry of Health (MoH) in that are routinely collected as part of different types of sentinel events (died Saudi Arabia requires 12 sentinel events the surveillance programme, no per- or survived). Death as an outcome of to be reported by public and private sonal identifiers were reported and no the sentinel event was reported in 100% hospitals. The Saudi Central Board for institutional review board approval was of suicide in the inpatient departments Accreditation of Healthcare Institutions required. The reports were reviewed and intravascular gas embolism, 40.6% integrated the MoH’s list of reportable by the study investigators, including of major medication errors, and 6.8%

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40 37.4 35 30

25 20.8

% 20 14.8 15 10 7.4 7.4 3.9 2.8 2.5 1.6 5 0.7 0.5 0.2 0 ) ) ) ) 7 ) 3 ) 2 ) 11 32 90 162 ======n n n = = n n n n ) ) 17 64 1 ) = = n ) ) n = n 12 32 = = n n ( ( Wrong patient( family( reaction ( function ( function Maternaldeath ( Wrong site surgery surgery ( site Wrong Unexpecteddeath ( Haemolytic blood transfusion blood Haemolytic Unexpectedloss of a orlimb a Major medication error ( error medication Major Deadbody discharged to wrong Infantdischarged to wrong family Retained instrumentsor a sponge Intravascular gas embolism ( Suicide in an inpatient unit ( unit in an inpatient Suicide

Figure 1 Type sentinel events reported to Saudi Ministry of Health, January 2012–June 2015

60 55 Died Survived

% 30 27 19 20 15 13 11 6 10 4 3 2 0 1 0 1 0 0 0 ) ) 7 ) 2 ) 3 ) 11 32 ======n n n n n ) 64 = n ) 17 = 32 ) n ( = Wrong patient( n ( function ( function Wrong site surgery surgery ( site Wrong Unexpectedloss of a orlimb a Major medication error ( error medication Major Retained instrumentsor a sponge Intravascular gas embolism ( Suicide in an inpatient unit ( unit in an inpatient Suicide Haemolytic blood transfusion reaction transfusion blood Haemolytic

Figure 2 Outcome of primary sentinel events (excluding death as a primary event) reported to Saudi Ministry of Health, January 2012–June 2015

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of unexpected loss of limb or function. other age group. In addition, there was The likelihood of a non-preventable One patient each died of haemolytic no statistically significant association sentinel event was significantly higher blood transfusion reaction and wrong between death and sex, kind of inter- among women than men: OR: 9.06; site surgery events. vention or type of hospital (P > 0.05) 95%CI: 1.59–194.90 (P = 0.01). How- Half of the reported cases were (Table 1). ever, none of the other variables were women; however, data on sex were The majority of the reported senti- significantly associated with sentinel event preventability (P > 0.05) (Table missing for 115 (26.6%) patients. Most nel events were classified as preventable 2). of the reported cases were adults (19– (91.6%). Preventable causes were iden- 64 years) (61.7%), followed by infants tified in 95.3% of unexpected deaths, Embolism occurred in 22.8% and 31.11% of cases of maternal deaths and < 1 year (16.6%), children and adoles- 78.3% of maternal deaths, 93.0% of cents (1–18 years) (11.7%) and elderly unexpected deaths, respectively. unexpected loss of a limb or a function patients ≥ 65 years (9.9%) (Table 1). Figure 4 shows the causes of the and 84.6% of retained instruments or Among the reported sentinel events, sentinel events as reported in the root sponges. Retained instruments would 47.9% were non-surgical interventions, cause analysis. An event was not nec- be 100% preventable; however, a mal- 44.0% were surgical interventions and essarily a result of a single cause and 8.2% were vaginal delivery. Most of the function of intravenous cannulas in more than one cause (e.g. availability of reported events were in government some hospitals, which resulted in a bro- policy and procedures, communication, hospitals (82.4%). ken tip on application, were reported as equipment) may contribute to occur- Table 1 shows the characteristics of non-preventable and the manufacturers rence of one event. Hence the overall the cases, and type of intervention and were notified n( = 4). Other reported percentage of the identified causes was hospital by outcome (died, survived). sentinel events (major medication er- more than 100%. Age 19–64 years was significantly as- ror, infant discharged to wrong family, Unavailability of policy and proce- sociated with death as an outcome of suicide in an inpatient unit, wrong site dures and/or failure to implement them sentinel events compared with infants < surgery, wrong patient, intravascular gas was the most common cause of sen- 1 year: OR: 2.17; 95% CI: 1.15–4.08 (P embolism and dead body discharged to tinel events (55.0%), followed by lack = 0.02). However, there was no signifi- wrong family) were identified as 100% of proper communication and train- cant association between death and any preventable (Figure 3). ing (35.3% and 33.0% respectively).

Table 1 Factors associated with death as an outcome of the sentinel events reported to the Saudi Ministry of Health, January 2012–June 2015 Variable Patient outcome Odds ratio (95% confidence P-value Died Survived interval) No. (%) No. (%) Sex Female (n = 215) 150 (69.8) 65 (30.2) Reference Male (n = 98) 71 (72.4) 27 (27.6 ) 1.14 (0.67, 1.96) 0.64 Age group (years) < 1 (n = 55) 33 (60.0) 22 (40.0) Reference 1−5 (n = 13) 9 (69.2) 4 (30.8) 1.49 (0.41, 6.19) 0.78 6−18 (n = 26) 17 (65.4) 9 (34.6) 1.26 (0.47, 3.44) 0.66 19−64 (n = 205) 157 (76.6) 48 (23.4) 2.17 (1.15, 4.08) 0.02 ≥ 65 (n =33) 26 (78.8) 7 (21.2) 2.45 (0.92, 7.04) 0.07 Intervention Non-surgery (n = 198) 136 (68.7) 62 (31.3) Reference Surgery (n = 183) 118 (64.5) 65 (35.5) 0.83 (0.55, 1.27) 0.38 Delivery (n = 34) 27 (79.4) 7 (20.6) 1.75 (0.74, 4.56) 0.21 Hospital Government (n = 347) 235 (67.7) 112 (32.3) Reference Private (n = 75) 52 (69.3) 23 (30.7) 1.08 (0.63, 1.87) 0.80

Data were missing for some variables.

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Preventable Not preventable 120 101 100

% 60 47 40 40 24 22 15 12 10 7 3 1 1 13 20 5 4 3 0 1 0 0 0 0 0 0 0 ) ) 1 ) 3 ) 7 ) 10 24 ) 60 ) = = 106 = = = n = n = = n = = n = n ) ) n n 16 43 1 ) = = n n = n n = 12 ) n = 26 ) n ( ( Wrong patient( family( reaction ( function ( function Maternaldeath ( Wrong site surgery surgery ( site Wrong Unexpecteddeath ( Haemolytic blood transfusion blood Haemolytic Unexpectedloss of a orlimb a Major medication error ( error medication Major Deadbody discharged to wrong Intravascular gas embolism ( Infantdischarged to wrong family Retained instrumentsor a sponge Suicide in an inpatient unit ( unit in an inpatient Suicide

Figure 3 Distribution of the reported sentinel events according to preventability based on reports to Saudi Ministry of Health, January 2012−June 2015

About 25% of the causes were attributed than half of the events), unexpected loss delay in treatment, wrong patient, to equipment/supplies and 22.2% to of a limb or a function, major medica- wrong site, wrong procedure, op- staffing (shortage/misallocation and/ tion errors and retained instruments or erative/post-operative complication, or work overload). Other causes rep- sponges. criminal event and perinatal death or resented about 10% each (delay in The incidence of adverse and sen- injury (8). treatment, non-adherence to clinical tinel events reported in studies varies In a systematic review of 8 retrospec- practice guidelines and hospital system considerably. Variations are related to tive chart review studies from the USA, malfunction). study setting, methodology and un- Canada, the United Kingdom (UK), derlying definitions. The problem of Australia and New Zealand, permanent under-reporting has a major effect disability and death were found in 7.0% Discussion on the estimated incidence as well (inter quartile range 6.1–11.0%) and (7). Therefore, comparison with other 7.4% (inter quartile range 4.7–14.2%) of Our study is an analysis of sentinel studies may not be always possible giv- patients respectively who experienced events in Saudi Arabia. It relied on en the differences in the methodologi- an adverse event [the median incidence reports sent to the MOH and our cal designs and the reporting culture. of adverse events was 9.2% (inter quar- conclusions are dependent on the In hospitals in the United States of tile range 4.6–12.4%)]. The median quality of documentation. It could America (USA), the total number of proportion of adverse events associ- be assumed that some of the actual sentinel events reported to the Joint ated with surgical procedures was 58.4% events are not reported (6). There- Commission increased from 449 (inter quartile range 54.5–70.9%) (9). fore, conclusions about the relative cases in 2000 to a peak of 1243 cases This was higher than another study frequency of events or trends in events in 2011. In the following years from which reported that 44.9% of the ad- over time should be drawn with cau- 2012 to mid-2015, the number of cas- verse events were related to surgical tion. es decreased (901, 887, 764 and 474 interventions (10). When it comes to There were 433 reported sentinel respectively). The most commonly critical areas (e.g. intensive care units), events; most commonly reported reported events were unintended re- the magnitude of the problem could be events were deaths (representing more tention of a foreign body, fall, suicide, underestimated, although as estimated

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Table 2 Factors associated with preventability of the sentinel events reported to the Saudi Ministry of Health, January 2012– June 2015 Variable Preventability Odds ratio (95% P-value Not preventable Preventable confidence interval) No. (%) No. (%) Sex Male (n = 75) 1 (1.3) 74 (98.7) Reference Female (n = 155) 17 (11.0) 138 (89.0) 9.06 (1.59, 194.9) 0.01 Age group (years) < 1 (n = 47) 1 (2.1) 46 (97.9) Reference 1−5 (n = 9) 0 (0.0) 9 (100.0) − 6−18 (n = 19) 1 (5.3) 18 (94.7) 2.51 (0.06, 101.6) 0.58 19−64 (n = 151) 16 (10.6) 135 (89.4) 5.42 (0.93, 117.8) 0.11 ≥ 65 (n =20) 0 (0.0) 20 (100.0) − Intervention Non-surgery (n =146) 9 (6.2) 137 (93.8) Reference Surgery (n =137) 13 (9.5) 124 (90.5) 1.59 (0.65, 4.01) 0.30 Delivery (n =23) 4 (17.4) 19 (82.6) 3.17 (0.78, 11.25) 0.16 Hospital Government (n = 275) 21 (7.6) 254 (92.4) Reference 0.28 Private (n = 34) 5 (14.7) 29 (85.3) 2.08 (0.65, 5.73)

by Cullen et al., the incidence of adverse We judged the preventability of an 42.8% of the adverse events could have events in intensive care units was nearly event based on the investigation of each been prevented (12). De Vries et al. twice the rate of other units (11) case and assessment of the information reported a similar rate in their system- Our findings showed that elderly available on the presence of a modifiable atic review, where 43.5% of the adverse people (≥ 65 years) and adults were at cause of harm or a lack of adherence to events were judged preventable (inter higher risk of death as an outcome of guidelines. We found a high frequency of quartile range 39.4–49.6%) (9). A wor- sentinel events than newborns and chil- preventable events (range 78.3–100%). rying number of patients experienced dren. In a national study in Spain, elderly Negligence of people and system errors permanent disability or death as a result people (≥ 65 years) were at a 2.5 greater that could be prevented at the time of of these events (9). In addition, events the event were difficult to identify. In due to negligence, defined as adverse risk of adverse events than younger a study in the Eastern Mediterranean events caused by a failure to meet stand- age groups (12), while in a Moroccan and African regions, 83% of adverse ards reasonably expected of the average study, adverse events occurred more events were considered preventable physician or institution, were not con- frequently in younger patients, which (13). Differences in study design and sidered in the preventability calculation the authors attributed to the increased types of sentinel events should be taken (9). In the Harvard Medical Practice self-medication among younger people into consideration when comparing Study I, one third of the adverse events (7). the findings with our study. We also were attributed to negligence 16( ). Our study showed that embolism found that non-preventable events were A lack of policies and procedures, caused 23–31% of the maternal and higher among women, which could be inappropriate communication, lack of unexpected deaths. Attention should be attributed to adverse effects of labour staff training, and issues of equipment given to this finding with further review and delivery interventions. and supplies and staffing (whether of medical practices, including identi- The incidence of preventable ad- because of shortages or allocation or fication of patients at risk of embolism verse events differs in various studies. It scheduling) were all important causes and implementation of evidence-based ranged from 18.7% to 73.2% in a review of sentinel events; together they repre- prevention interventions. The Saudi of the literature by Kanjanarat et al. sented 80% of the causes. These issues Arabian MoH has published guidelines (14), and it was estimated that 28% of clearly need to be tackled in order to on the prevention of post-surgical pul- adverse events in hospitals in the USA improve the health care and patient monary embolism; however, adherence were preventable (15). The report of safety in the reporting hospitals. The to these guidelines is not known. a national study in Spain showed that root cause analysis of the sentinel events

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60.0 55.0

50.0

40.0 35.3 33.0

% 30.0 23.6 22.2 20.0 11.6 11.1 10.6 10.0

0.0

Figure 4 Cause of the sentinel events based on reports to Saudi Ministry of Health, January 2012−June 2015

in our study showed consistency with national system for adverse events of sentinel events with sanctions in cases the patient safety study conducted the reporting and investigation lead to an of non-reporting. Eastern Mediterranean and African increased burden on the health care In conclusion, this study is the first regions (13) with some variations, pri- system (18,19). report of sentinel events in Saudi Ara- marily due to study design differences. Classen et al. found that voluntary bia. It alerts the health care system in The ultimate value of sentinel events reporting in hospitals in the USA and Saudi Arabia to the magnitude of sentinel events and the need for immediate reporting is communication of lessons measuring patient safety indicators did learned to the stakeholders and the pub- intervention. Ensuring availability and not reflect the real incidence of adverse lic. Examples are the National Patient implementation of policies and proce- events within the hospitals. Using the Safety Agency which is the UK national dures, fixing the flaws in the organiza- reporting system (17) and standards/ global trigger tool of the Institute for tional system and training of health care resources by the Joint Commission Healthcare Improvement, at least 10 workers are central to improving patient for sentinel events reporting, aggrega- times more adverse events were found safety in health care facilities. Efforts tion, analysis, and communication. The (20). Increasing incident reporting should focus on enhancing the National Saudi Central Board for Accreditation does not mean increasing events, rather Sentinel Events Reporting System, con- of Healthcare Institutions in combina- dissemination of non-punitive report- ducting expert analysis of the incidents tion with the MoH aims to make health ing (21). reported and building a patient safety care facilities better equipped to actively The main limitations of this study culture that is system-oriented, non- eliminate the risk of sentinel events or at are related to its retrospective design. It punitive, confidential and responsive. least to reduce the risk. The Saudi Arabia may be difficult to generalize the current MoH adopted an electronic portal for findings because of underreporting and reporting sentinel events which is cur- Acknowledgement because most of the reported data were rently active; however, the effect of this portal could be improved if further ana- from MoH hospitals with only a small Abdulrahman Albawardi, MD, Minis- lytical features were included (e.g. root number from private hospitals. Health try of Health, Information and Com- cause analysis, corrective or preventive care workers tend to be suspicious about munication Technology Department, action plan and communicating lessons the consequences of reporting and this Riyadh, Saudi Arabia: for providing the to the health care community). It has may result in underreporting. However, data reported to the MoH portal. been shown that reliance on voluntary the MoH leadership has placed a strong Funding: None reporting and the lack of an effective emphasis on the mandatory reporting Competing interests: None declared. 498

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References

1. The Joint Commission. Sentinel Event Policy and Procedures. 12. National Study on Hospitalisation-Related Adverse Events (http://www.jointcommission.org/Sentinel_Event_Policy_ (ENEAS). Report. Madrid: Ministry of Health and Consumer and_Procedures/default.aspx, accessed 27 March 2017). Affairs; 2006 (http://www.who.int/patientsafety/informa- 2. Lawtonr R, Parker D. Barriers to incident reporting in a health- tion_centre/reports/ENEAS-EnglishVersion-SPAIN.pdf, ac- care system. Qual Saf Health Care. 2002 Mar;11(1):15–8. cessed 27 March 2017). 3. Leapel LL, Brennan TA, Laird N, Lawthers AG, Localio AR, 13. Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El- Barnes BA, et al. The nature of adverse events in hospitalized Assady R, et al. Patient safety in developing countries: retro- patients: Results of the Harvard Medical Practice Study II. N spective estimation of scale and nature of harm to patients in Engl J Med. 1991;324:377–84. hospital. BMJ. 2012 Mar 13;344:e832. 4. Lynn ML, Osborn DP. Deming’s quality principles: a health care 14. Kanjanarat P, Winterstein AG, Johns TE, Hatton RC, Gonzalez- application. Hosp Health Serv Adm. 1991 Spring;36(1):111–20. Rothi R, Segal R. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm. 2003 5. The Joint Commission. Comprehensive accreditation manual Sep 1;60(17):1750–9. for hospitals. January 2013 (http://www.jointcommission.org/ assets/1/6/CAMH_2012_Update2_24_SE.pdf, accessed 27 15. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, March 2017). et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention 6. National hospital standards. 3rd ed. Jeddah: Saudi Central Study Group. JAMA. 1995 Jul 5;274(1):29–34. Board for Accreditation of Healthcare Institutions (CBAHI); 2014. 16. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Law- thers AG, et al. Incidence of adverse events and negligence in 7. Benkirane R, Pariente A, Achour S, Ouammi L, Azzouzi A, hospitalized patients: results of the Harvard Medical Practice Soulaymani R. Prevalence and preventability of adverse drug Study I. N Engl J Med. 1991 Feb 7;324(6):370–6. events in a teaching hospital: a cross-sectional study. East Mediterr Health J. 2009 Sep-Oct;15(5):1145–55. 17. Vincent C. Incident reporting and patient safety: Emphasis is needed on measurement and safety improvement pro- 8. The Joint Commission. Sentinel event data. General grammes. BMJ. 2007;(334):51. Information,1995–2Q 2015 (http://www.jointcommission. org/assets/1/18/General-Information_19952Q-2015.pdf, 18. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental accessed: 27 March 2017). deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405–9. 9. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital 19. Milgate K, Hackbarth G. Quality in Medicare: from measure- adverse events: a systematic review. Qual Saf Health Care. ment to payment and provider to patient. Health Care Financ 2008;17:216–23. 10.1136/qshc.2007.023622 Rev. 2005/06;27(2):91–101. 10. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams 20. Classen DC1. Resar R, Griffin F, Federico F, Frankel T, Kimmel EJ, et al. Incidence and types of adverse events and negligent N, Whittington JC, Frankel A, Seger A, James BC. ‘Global trigger care in Utah and Colorado. Med Care. 2000 Mar;38(3):261–71. tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011 11. Cullen DJ1. Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Apr;30(4):581–9. 10.1377/hlthaff.2011.0190. Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care 21. Beyea SC. Learning from sentinel event statistics. AORN J. units. Crit Care Med. 1997 Aug;25(8):1289–97. 2004 Aug;80(2):315–8.

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Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran Naim S. Kia 1, Farhad Malek 2, Elaheh Ghods 1 and Mona Fathi 3

جودة احلياة الصحية ملرىض الربو: دراسة مقطعية يف سيمنان، مجهورية إيران اإلسالمية نعيم السادات كيا، فرهاد ملك، اهله قدس، منا فتحي اخلالصــة: يمكــن أن يؤثــر الربــو ًتأثــرا ًعــى عميقــاجــودة حيــاة األفــراد املصابــن هبــذا املــرض. وال تتوفــر يف مجهوريــة إيــران اإلســالمية ســوى بيانــات حمــدودة عــن جــودة حيــاة املصابــن بالربــو. وهدفــت هــذه الدراســة املقطعيــة إىل تقييــم جــودة احليــاة لــدى البالغــن املصابــن بالربــو يف حمافظــة ســمنان باســتخدام املســح الصحــي القصــر املكــون مــن 36 ًبنــدا ) (. SF-36وتــم فحــص تأثــر اخلصائــص االجتامعيــة الســكانية عــى جــودة حيــاة العــرشات مــن األفــراد. وشــملت الدراســة عينــة "ســهولة ")غــر عشــوائية( ملــا جمموعــه 385 ً مريضــامــن املــرىض اخلارجيــن املصابــن بالربــو الذيــن ارتــادوا عيــادات للمــراض الرئويــة يف الفــرتة مــن يونيو/حزيــران إىل ديســمرب/كانون األول 2013. وجــاء متوســط درجــات املكونــن البــدين والعقــيل 58.8 )بانحــراف معيــاري 183( و57.3 )بانحــراف معيــاري (170 عــى التــوايل. وجــاءت درجــات p < 0.05 جــودة احليــاة يف عينــة الدراســة يف مجيــع املجــاالت أقــل مــن درجــات جمموعــة الســكان املرجعيــة ) (. يف حــن ُســجلت درجــات أقــل عــى مســتوى جــودة احليــاة يف صفــوف املــرىض ذوي مســتوى التعليــم املنخفــض، وســكان املناطــق احلضيــة، ّواألرامل/املطلقــن، والعــامل اليدويــن )p < 0.05(. ويلــزم بــذل جهــود لتحســن جــودة احليــاة للشــخاص املصابــن بالربــو بالتــوازي مــع إعــداد خطــط إداريــة دقيقــة.

ABSTRACT Asthma can profoundly affect the quality of life of individuals with the disease. There are limited data on the quality of life of people with asthma in the Islamic Republic of Iran. This cross-sectional study aimed to evaluate quality of life in adults with asthma in Semnan using the 36-item short form health survey (SF-36). The effect of sociodemographic characteristics on quality of life scores was examined. The study included a convenience sample of 385 outpatients with asthma attending a pulmonary clinic from June to December 2013. The mean physical and mental component scores were 58.8 (SD 18.3) and 57.3 (SD 17.0) respectively. The study sample had lower quality of life scores in all the fields than the reference population (P < 0.05). Patients with lower education, urban residents, widowed/divorced patients and manual workers had lower quality of life scores (P < 0.05). Efforts are needed to improve the quality of life of people with asthma in parallel with precise management plans.

Qualité de vie liée à la santé de patients asthmatiques : étude transversale à Semnan, République islamique d’Iran

RÉSUMÉ L’asthme peut affecter gravement la qualité de vie des personnes qui en souffrent. Les données sur la qualité de vie des personnes vivant avec l’asthme en République islamique d’Iran sont en nombre limité. La présente étude transversale avait pour objectif d’évaluer la qualité de vie des adultes asthmatiques à Semnan sur la base du SF-36, un questionnaire court d’enquête sur la santé comprenant 36 items. L’effet des caractéristiques socio-démographiques sur les scores de la qualité de vie a été examiné. L’étude incluait un échantillon de commodité de 385 patients externes souffrant d’asthme et s’étant rendus dans une clinique spécialisée pour les maladies pulmonaires entre juin et décembre 2013. Les scores moyens des composantes physiques et mentales étaient de 58,8 (ET 18,3) et 57,3 (ET 17,0) respectivement. L’échantillon de l’étude affichait des scores inférieurs pour la qualité de vie dans tous les domaines par rapport à la population de référence (p < 0,05). Les patients ayant un niveau d’instruction moindre, les habitants urbains, les patients veufs/divorcés et les travailleurs manuels obtenaient des scores de la qualité de vie plus faibles (p < 0,05). Des efforts sont requis pour améliorer la qualité de vie des patients asthmatiques parallèlement à la mise en place de plans précis pour leur prise en charge.

1Department of Community Medicine, Research Centre for Social Determinants of Health, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran (Correspondence to: ElahehGhods: [email protected]; [email protected]). 2Department of Internal Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran. 3Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran. Received: 07/10/15; accepted: 20/11/16 500

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Introduction Asthma Quality of Life Questionnaire administration of 400 mg (2-3 puffs) discriminate poorly between subscales of albuterol or equivalent (8). Asthma According to the latest report of the (8,10). The Short Form Health Survey patients who were affected by other Global Initiative for Asthma (GINA), (SF-36) is the most common validated, serious chronic physical or psychologi- about 334 million people in the world rapid, self-rated assessment tool for cal diseases, such as cancer and major have asthma (1). Although the data adult disease, despite lower inter-class depression, based on self-report, were about adults over 45 years are not pre- correlation and minor responsive index excluded from the study. cise, the number of asthma patients has compared with disease-specific scales Ethical considerations increased considerably in the past 30 such as the Asthma Quality of Life years. It is estimated that by 2025, 100 Questionnaire. It has allowed compari- The study was approved by the Semnan million people will have asthma glob- son of QoL in different disease states University Ethics Committee. Informed ally, an approximate 50% increase in and can be useful to evaluate patient- consent was obtained from all the par- every decade (1,2). reported outcome measures (11−13). ticipants before data collection. All of these instruments have shown The estimated global prevalence of Data collection asthma is 4.5% (3). In Asia, which is lower QoL scores in people with asthma Demographic data, including age, the most changing population in the compared with those without the dis- marital status, occupation and educa- world, less than 5% of adults are diag- ease (7,10). Several factors could affect tion were collected by interview at the nosed with clinical asthma (4) and in QoL of people with asthma, such as age, pulmonary clinic. The Persian version of the Eastern Mediterranean region this socioeconomic status, education level SF-36 questionnaire was used to evalu- is between 2.74% and 3.12% (3). Based and marital status. These factors could ate QoL (11,15). on the latest report, the prevalence of modify classification, diagnosis and asthma in the Islamic Republic of Iran treatment of asthma (14). Despite the SF-36 has 8 domains and 36 was higher than the global rate of dis- importance of assessing QoL in chronic questions and includes a physical ease and is estimated between 5.1% and respiratory diseases such as asthma, component score (PCS) and mental component score (MCS), selected 7.5% (5,6). there has been limited research on QoL in people with asthma in the Islamic from the medical outcomes study in The global burden of asthma is Republic of Iran. This study therefore 1992 (16). PCS has 4 scales: Physical high because of its high prevalence, the aimed to evaluate the QoL in adults Functioning, Physical Role, Bodily Pain prolonged duration of the disease and with asthma and the sociodemographic and General Health. MCS has 4 scales: because it affects a considerable propor- characteristics associated with it. Vitality, Social Functioning, Emotional tion of the population of working age. Role and Mental Health (17). Par- Asthma affects various aspects of life, ticipants are scored individually in each including lifestyle, well-being, health, Methods area (0 = worst to 100 = best); the lower personal satisfaction, occupation and the score the lower the QoL. Study setting and sample education (7,8). Quality of life (QoL) The reliability and internal consistency is a subjective and multidimensional in- This was cross-sectional study of adult of this tool has determined (18). It can dex of well-being from a patient’s point asthma patients referred to the pulmo- be used in different countries and for of view. It is defined as physical, emo- nary clinic of the University of Semnan different diseases or even for compari- tional, social, material well-being and from June to December 2013. son between groups with a disease and development, activity functional ability A convenience sample was selected healthy groups (17).Validation of the (9). It has become more important with of 385 asthma patients aged 18 years SF-36 for measurement of QoL in increased life expectancy and changes or older. All patients were approached people with asthma has been done and in the pattern of disease as a result of during their routine follow-up care in its suitability for this group established advancements in medical sciences in or- the pulmonary clinic and asked for their (19). The Farsi version of the SF-36 der to evaluate cost−utility and cost−ef- participation in the study. All those ap- questionnaire has been validated (20) fectiveness of health care programs (4). proached agreed to participate. and used in different studies in our There are different instruments Asthma was diagnosed by a pul- country (20−23). for assessment of QoL in adults (9). monary subspecialist based on chronic However, none of them can evaluate persistent inflammation with acute Statistical analysis the effect of asthma on all of the key episodic exacerbations and reduced The data were entered into SPSS, version dimensions of QoL and none is able lung function confirmed by spirom- 16. The QoL scores of the participants to provide a core assessment. Even the etry, forced expiratory volume per sec- are presented as medians and ranges most disease-specific tools such as the ond (FEV1) before and 15 min after or as means and standard deviations

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(SD) according to sociodemographic patients, manual workers had lower concern, particularly for chronic non- characteristics. Analysis was done by QoL in all domains. Compared with communicable diseases. one-way ANOVA, one-sample t-test urban residents, those living in rural Our study showed found lower and independent t-test when necessary. areas had higher QoL scores in the areas QoL scores in asthma patients than in of Physical Functioning, Bodily Pain, the general population, which concurs General Health and Emotional Role. with the results of other studies in this Results Patients who had shorter duration of field which used different scales10,11 ( ). the disease also had higher QoL scores The results of our study showed that A total of 385 patients with asthma in all domains, except for Emotional the mean PCS and MCS of individuals [177 (45.5%) females; 208 (53.5%) with asthma were 58.8 (SD 18.3) and males] were enrolled in the study. The Role. Single patients had significantly 57.3 (SD 17.0) respectively. As expect- mean age of the patients was 48.7 (SD higher scores in all the areas of PCS but ed, the mean score of the asthma group 15.2) years. Of all the participants, 263 the association was significant only for Vitality. was significantly lower than that of the (68.6%) were married, 46 (11.9%) were general Iranian adult population (15). Table 3 shows the correlation be- widowed/divorced and 76 (19.5%) Patients with asthma have also been tween the different variables based on were single. Older patients with had reported to have lower General Health lower QoL in all domains except for the results obtained from the SF 36 but higher Emotional Role scores com- Mental Health (P < 0.001). questionnaire. The lowest PCS and pared with pregnant women experi- Mean physical functioning and MCS were among those in lowest in- encing domestic violence (20), lower mental health scores of the patients with come category (P = 0.001 for both) and Physical Functioning, Physical Role, asthma were 58.8 (SD 18.3) and 57.3 manual workers (P = 0.001 for both). General Health and Mental Health (SD 17.0) respectively. The PCS score Patients with a disease duration of scores than adolescents with premen- of the study group was significantly bet- more than 15 years (P = 0.001), urban strual disorder (21), lower scores in ter than the MCS score (P < 0.001). residence (P = 0.001) and widowed or Emotional Role, Physical Role and Table 1 shows the mean scores of all divorced (P = 0.001) had significantly Physical Functioning compared with PCS and MCS scales in the patients lower physical scores. Higher physi- patients with diabetes (22), and lower with asthma and the general population. cal score were found in patients with a scores in all subdomains except General The association between the patient master’s degree or higher (P < 0.001). Health than patients with thalassemia demographic and socioeconomic char- There were no differences in MCS and major (23). acteristics and their QoL is shown in PCS by sex. Based on results of a large epide- Table 2. The participants with lower miological study, mean PCS and MCS education levels had significantly lower score in asthma patients was 45.6 and scores in all domains except for Physical Discussion 48.1 respectively (11). In another study Role and Emotional Role. Higher in- in France, the General Health QoL come was associated with higher scores The assessment of disease outcomes score was 65−88 for mild to moderate in all the domains. Among employed based on QoL score is an important asthma and 63−78 for severe asthma

Table 1 Mean scores of health-related quality of life as measured by SF-36 in patients with asthma and the general Iranian population Domain Asthma patients Reference population (15) P-value Mean (SD)a Mean (SD)a Physical functioning 58.4 (27.6) 85.3 (20.8) < 0.001 Physical role 49.5 (33.1)b 70.0 (38.0) < 0.001 Bodily pain 72.1 (21.2) 79.4 (25.1) < 0.001 General health 55.2 (16.7) 67.5 (20.4) < 0.001 Vitality 55.9 (17.5) 65.8 (17.3) < 0.001 Social functioning 66.6 (20.3) 76.0 (24.4) < 0.001 Emotional role 49.3 (36.1)b 65.6 (41.4) < 0.001 Mental health 57.3 (17.7) 67.0 (18.0) < 0.001

aAnalysis by one-sample t-test bMedian (IQR). SD = standard deviation.

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Book 23-07.indb 502 8/23/2017 8:02:00 AM املجلة الصحية لرشق املتوسط املجلد الثالث و العرشون العدد السابع MH 57.8 (17.6) 57.8 (19.3) 57.0 61.8 (15.1) 61.8 53.9 (16.1) 53.9 55.2 (5.2) 55.2 (20.3) 55.8 (18.1) 55.9 (15.3) 55.0 52.9 (12.2) 52.1(19.7) 63.9 (19.4) 63.9 58.9 (13.0) 56.8 (19.3) (14.0) 58.4 56.5 (19.4) 58.7 (19.7) (20.3) 56.4 56.0 (18.1) 58.2 (13.1) 49.7 (14.5) 49.7 (9.8) 49.7 62.5 (17.1) 68.4 (20.7) 68.4 Mean (SD) Mean 60. 8 (17.6) (18.8) 60.1 60.5 (17.4) 59 (10.92) ER 51.2 (36.7) 51.2 (36.3) 51.5 37.9 (32.4) 37.9 57.2 (40.7) 57.2 41.2(34.3) (35.9) 41.8 53.3 (37.7) 53.3 55.5 (45.4) 55.5 (36.0) 55.8 73.3 (26.3) 73.3 43.1 (31.8) 43.1 52.9 (36.9) 39.8 (34.0) 39.8 (38.1) 39.3 63.2(36.5) 59.7 (38.6) 59.7 44.7 (32.2) 44.2 (35.8) 36.0 (37.8) 48.0 (32.2) 48.6 (34.4) 48.3 (36.6) 50.4 (37.0) 50.4 50.6 (32.5) 50.9(37.3) 50.2(38.3) 50.2 (32.2) Median (IQR) SF 71.8 (18.5) 71.8 (23.1) 71.4 71.5(20.9) (25.5) 71.0 57.8 (20.4) 57.8 Mean (SD) Mean 61.3 (17.2) 61.3 67.12 (22.7) 67.12 (21.2) 67.6 (20.3) 67.3 67.3(20.6) 63.7 (18.5) 63.7 65.9 (18.9) 65.9 (12.2) 65.9 65.4(20.4) (17.6) 65.5 59.1(18.3) 76.8 (24.2) 62.9 (14.7) 92.5 (6.45) 64.2 (19.3) 66.0 (20.2) 66.0 (19.9) (19.9) 68.4 68.6 (19.3) 68.8 (20.7) 68.7 (17.8) 60.5 (20.3) VI 51.67 (15.6) 51.67 (7.5) 51.7 (20.1) 51.7 57.0 (9.2) 57.0 (12.8) 57.9 (18.6) 57.8 Mean (SD) Mean 67.5 (16.8) 67.5 53.9 (16.9) 53.9 53.6(12.2) 55.5 (17.8) 55.5 (17.2) 55.3 55.3(23.3) (18.9) 55.4 54.2 (15.1) 54.7 (14.0) 54.5 (17.3) 54.1(20.3) 65.6 (15.5) 65.6 (17.8) 65.5 65.5(17.6) 56.1(18.2) 56.5 (18.1) 58.2(9.1) 49.31(16.3) 62.4 (16.5) 62.4 64.9 (18.1) 50.7 (16.7)

GH 51.0 (19.6) 51.0 51.7(16.8) 57.6 (14.1) 57.6 (22.9) 57.0 61.5 (12.8) 61.5 Mean (SD) Mean 55.0 (16.4) 55.0 73.5 (3.4) 73.5 52.2 (15.8) 52.5 (18.8) 63.3 (15.0) 63.3 (12.8) 63.2 59.7 (16.3) 59.7 56.5 (8.0) 56.5 (15.3) 56.0 (15.3) 56.7(15.4) (14.3) 56.1 49.0 (19.0) 49.0 62.6 (14.5) 48.5 (14.5) 48.2 (18.3) 46.8 (16.4) 48.8 (16.6) 50.6 (14.3) 66.9 (16.3) 60.2 (15.4) (15.0) 60.4 BP 71.7 (16.4) 71.7 (23.1) 71.9 77.3 (21.2) 77.3 81.0 (21.7) 81.0 73.1 (22.6) 73.1 (21.6) 73.4 73.2(23.1) 75.7 (19.2) 75.7 (20.9) 75.0 74.4 (21.6) 74.4 (21.73) 74.6 59.4 (16.9) 59.4 (5.3) 95.0 (19.9) 65.7 (19.7) 65.0 (20.6) 65.2 79.2 (17.0) 79.2 78.5 (18.4) 69.1 (23.6) 69.1 (19.5) 69.4 (19.4) 69.9 (19.8) 69.7 68.3 (22.5) 66.2 (19.1) 68.9 (17.0) (20.0) 66.1 Mean (SD) Mean 80.3 (22.2) PR 51.0 (19.6) 51.0 51.3(15.4) 47.5 (35.2) 47.5 61.7 (33.4) 61.7 67.5(30.2) 33.9 (36.6) 33.9 (24.8) 33.2 55.4 (31.2) 55.4 73.6 (28.1) 73.6 45.9 (33.7) 45.9 52.5 (33.1) (35.8) 52.4 34.0 (25.9) 34.7 (22.2) 54.8 (32.9) 54.30(33.4) 39.0 (33.0) 39.0 59.9(28.8) 44.5(31.0) 44.6 (34.8) 76.2 (14.9) 49.8 (33.2) 49.8 (29.7) 49.4 48.2(33.5) 40.7 (31.2) 60.0 (3.9) 60.3 (34.1) Median (IQR) PF 51.3 (26.3) 51.3 77.5 (23.2) 77.5 61.7 (26.7) 61.7 Mean (SD) Mean 55.3 (27.3) 55.3 75.9 (17.6) 75.9 43.6 (27.3) 43.6 52.0 (22.4) 72.6 (21.1) 54.9 (26.4) 63.8 (23.1) 63.8 59.8 (27.0) 59.8 59.8(28.3) 44.8 (28.1) 58.7 (30.6) (20.6) 58.4 62.5 (25.6) 64.9 (22.4) 46.7 (27.6) 69.1 (22.6) 69.1 (20.4) 69.1 66.2 (27.2) 40.5 (23.5) 40.8 (26.2) 60.3 (27.5) 90.5 (6.8) 60.6 (31.3) 60.9(27.6) No. (%) No. 51 (13.2) 71 (18.4) 21 (5.5) 12 (3.1) 10 (2.6) 77 (20.0) 74 (19.2) 74 72 (18.7) 39 (10.1) 39 (10.1) 85 (22.1) 65 (16.9) 76 (19.7) 62 (16.1) 46 (11.9) 46 (11.9) 48 (12.5) 50 (13.0) 89 (23.2) 88 (22.8) 125 (32.5) 136 (35.4) 120 (31.2) 160 (41.5) 100 (26.0) 263 (68.4) 285 (74.0) Health-related quality of by SF-36 as measured the life scores asthma patients characteristics to socio-demographic according Single Married Widowed, divorced Illiterate years < 9. 9- Diploma BSc University, ≥ MSc University, Manual worker Government employee worker Office Retired Self-employed Housewife Other Urban Rural < 5 5-9 10-14 > 15 < 500 500-999 1000-1499 1500-1999 > 2000 Variable Marital status Education level Occupation Residence Duration (years) of disease Monthly (× 10 000 rials) income PF: Physical functioning,PF: Physical SF: Social Functioning, health, ER: Emotional Role, BP: Bodily pain, GH: General PR: Physical VT Vitality, Role, MH: Mental Health. deviation;SD = standard IQR = interquartile range. Table 2 Table

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Table 3 Mean physical and mental component scores (PCS and MCS) of the asthma patients according to demographic and socioeconomic characteristics Variable PCS P-level MCS P-level Mean (SD) Mean (SD) Marital status Single 73.9 (13.8) 61.2 (14.0) Married 59.9 (18.1) 0.001a 57.6 (18.5) 0.07a Widowed, divorced 45.9 (12.8) 54.0 (12.6) Education level Illiterate 50.5 (18.9) 49.9 (16.4) < 9. years 52.7 (15.7) 57.7 (15.1) 9- 62.4 (17.1) 65.8 (18.3) 0.001a 0.1a Diploma 60.7 (19.2) 56.9 (17.5) University, BSc 63.8 (15.0) 57.6 (16.4) University, ≥ MSc 83.8 (5.7) 69.5 (7.4) Occupation Manual worker 51.4 (19.6) 50.4 (13.1) Government employee 64.6 (15.1) 51.8 (16.9) Office worker 55.3 (17.9) 57.0 (19.1) Retired 49.2 (16.4) 0.001a 54.5 (13.8) 0.001a Self-employed 65.8 (18.0) 63.8 (17.9) House-wife 54.3 (16.4) 56.2 (18.0) other 74.4 (15.5) 62.6 (8.9) Residence Urban 52.9 (18.3) 54.9 (15.9) 0.001b 0.1a Rural 60.9 (18.0) 58.1 (17.4) Duration of disease (years) < 5 61.8 (17.9) 56.5 (13.6) 5- 58.7 (18.9) 58.5 (17.5) 0.001a 0.65a 10- 59.9 (17.9) 56.6 (21.4) > 15 50.1 (17.5) 59.1 (18.3) Income (× 10 000 rials) < 500 55.5 (17.4) 56.7 (16.8) 500- 62.3 (21.9) 57.6 (15.6) 1000- 50.3 (14.4) 0.001a 51.6 (14.6) 0.001a 1500- 65.8 (16.9) 59.1 (17.1) > 2000 70.2 (17.2) 66.4 (18.5) Sex Male 57.9 (18.5) 56.2 (18.3) 0.32b 0.18b Female 59.8 (18.2) 58.8 (15.4)

aOne-way ANOVA; bIndependent t-test. SD = standard deviation.

(14). Comparing different assessment time, in spite of the strength of SF 36 Therefore, QoL assessment with SF scales for health-related QoL (SF 36, in detecting burden of illness overall 36 could be applicable for this case and Asthma Quality of Life Questionnaire and measuring non-specific situation even better for comparative studies. and modified shortened Living With that affect quality of life 12,15( ). On the In our study, the highest score was Asthma Questionnaire), there was only other hand, recent research has shown a observed in Physical Pain domain modest correlation between physical good sensitivity of SF 36 for treatment and the lowest score in Emotional score SF 36 and asthma control over efficacy of different disease states (24). Role functioning. Due to the type of 504

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disease pathogenesis, it is expected that college education in suburban and rural In our study, widowed and divorced asthma results in little or no pain and areas (29−32). individuals had lower QoL scores than moderately good social functioning, Lower PCS and MCS scores in single and married individuals. Previous however dyspnea and wheezing lead our study were associated with lower studies suggest widows have a lower to disability and subsequent negative education, lower level of job and lower QoL than the general population, main- feelings (12,20). Reid et al. reported the income. A significant correlation was ly because of their lower incomes (34). lowest score in Vitality (12) which is in observed between higher socioeco- Psychological disorders are also more contrast to our results. nomic status and better QoL in indi- common in this group of people (35). Our findings showed lower MSC viduals with asthma (29). Moreira et The better QoL for younger patients scores compared with the PSC scores, al. in a retrospective cohort study with with asthma could be explained by a which is in agreement with the results a large sample of 40 000 found a lower short duration of the disease and fewer of previous research (20). Although incidence of asthma in the subgroup complications. the mental score of SF 36 concentrates with higher income (31). Several stud- There was no significant sex differ- more on depression, anxiety is a main ies are in agreement with the results ence in QoL scores in our study. In factor in asthma attacks 19( ). It has of our study of a lower QoL among contrast, the results of several studies in- been reported that there is a cyclical those with lower socioeconomic status dicate that female patients with asthma interaction between respiratory symp- (2,29,30). A higher level of education, are likely to have a greater perception toms in asthma and the likelihood of a stable job and health insurance also of dyspnea, report a poorer control and mood disorders, which limits physical improve the QoL of individuals with have a poorer QoL compared with and emotional functioning in people asthma (30,31). with asthma (25,26). Mental health has males and they recommended sex- These relationships could be inter- a strong role in the control of asthma specific management protocols 11( ). preted in different ways. Patients with (27). Mood disorders decrease the ef- higher education and those with higher A limitation of our study was the ficacy of treatment and increase the re- incomes are more likely to schedule lack of response by some participants currence of acute attacks, which further regular follow-up visits and show better on some of the variables evaluated, reduces QoL (28). adherence to treatments. Lower educa- such as monthly income and severity In our study, PCS was significantly tion increases the likelihood of underes- of asthma. In addition, we did not have higher in rural residents with asthma. timating the significance of control and access to validated Farsi version of the The higher incidence of asthma in recent treatment plans (32). Asthma Quality of Life Questionnaire years could be explained by changes in Similar to the results of our study, to use in parallel with the SF-36 health environmental and geographical factors survey, which would have strengthened (29). Actually the prevalence and mor- a European study found significantly our assessment and allowed us to evalu- bidity of asthma is lower in rural areas lower PCS scores in manual workers ate intra-class correlation. than urban areas (29,30). This difference (11). Manual workers are more likely could be explained by differences in a to be exposed to allergens than office workers (3). However, different job number of environmental and lifestyle Conclusion factors between urban and rural areas: classifications between countries make the interpretation of contradictory re- for example air pollution, diet, energy The results of this study indicate that sults difficult11,30,31 ( ). sources, biomass fuel, farming, livestock low QoL was common among our We found some evidence of an in- and occupational exposures, dust mites, sample of asthma patients. Efforts are vehicle emissions, respiratory infection verse relationship between duration needed to improve the QoL of patients and a westernized lifestyle (12,29). The of disease and QoL. Rajanandh et al. with asthma in parallel with precise conflicting reports of higher morbid- found a similar relationship in patients management plans. The increase in ity from asthma in rural areas could who had had asthma for more than 5 the incidence of this chronic disease in be explained by a higher proportion of years (33). Another study also showed those aged 55 years or older (i.e. longer lower PCS score in older patients, who recent decades makes this a priority. duration of disease too), low income, had likely had the disease for a long Funding: None. lack of health insurance coverage and period (11). Competing interests: None declared.

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References

1. The Global Asthma Report 2014. Auckland: Global Asthma Net- ity, scaling assumptions, and reliability across diverse patient work, 2014 (http://www.globalasthmareport.org/resources/ groups.Med Care. 1994;32(1):40–66. Global_Asthma_Report_2014.pdf, accessed 20 March 2017). 19. Bousquet J, Knani J, Dhivert H, Richard AL, Chicoye AN, Ware 2. Braman SS. The global burden of asthma.Chest. 2006 Jul JE Jr, et al. Quality of life in asthma. I. Internal consistency and 1;130(1_suppl):4S-12S. validity of the SF-36 questionnaire. Am J RespirCrit Care Med. 3. To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz 1994 Feb;149(2):371–5. AA, et al. Global asthma prevalence in adults: findings from the 20. Tavoli Z, Tavoli A, Amirpour R, Hosseini R, Montazeri A. Quality cross-sectional world health survey. BMC Public Health. 2012 of life in women who were exposed to domestic violence dur- Mar 19;12(1):1. ing pregnancy. BMC Pregnancy Childbirth. 2016 Jan 26;16:19. 4. Song WJ, Kang MG, Chang YS, Cho SH. Epidemiology of adult 21. Delara M, Ghofranipour F, Azadfallah P, Tavafian SS, Kazemne- asthma in Asia: toward a better understanding. Asia Pac Allergy. jad A, Montazeri A. Health related quality of life among ado- 2014 Apr 1;4(2):75–85. lescents with premenstrual disorders: a cross sectional study. 5. Varmaghani M, Rashidian A, Kebriaeezadeh A, Moradi-Lakeh Health Qual Life Outcomes. 2012 Jan 1;10(1):1. M, Moin M, Ghasemian A, et al. National and sub-national 22. Darvish poor Kakhki A, Abed Saeedi Z. Health-related quality prevalence, trend, and burden of asthma in Iran from 1990 to of life of diabetic patients in Tehran. Int J Endocrinol Metab. 2013; the study protocol. Arch Iran Med. 2014 Dec;17(12):804-9. 2013;11(4):e7945 6. Heidarnia MA, Entezari A, Moein M, Mehrabi Y, Pourpak Z. 23. Haghpanah S, Nasirabadi S, Ghaffarpasand F, Karami R, [Prevalence of asthma symptom in Iran: a meta-analysis]. Pe- Mahmoodi M, Parand S, et al. Quality of life among Iranian jouhesh. 2007 Oct 1;31(3):217–25 [in Farsi]. patients with beta-thalassemia major using the SF-36 question- 7. Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, naire. Sao Paulo Med J. 2013;131(3):166–72. Busse WW, et al. An official American Thoracic Society/Eu- 24. Atabakhsh M, Mazaheri M. Responsiveness of the SF-36 ques- ropean Respiratory Society statement: asthma control and tionnaire to the treatment outcome: a comparison of the mental exacerbations: standardizing endpoints for clinical asthma and the physical patients. Modern Applied Science. 2016 Apr trials and clinical practice. Am J RespirCrit Care Med. 2009 Jul 10;10(6):183-7. 1;180(1):59–99. 25. Wong KO, Hunter Rowe B, Douwes J, Senthilselvan A. Asthma 8. Wilson SR, Rand CS, Cabana MD, Foggs MB, Halterman JS, and wheezing are associated with depression and anxiety in Olson L, et al. Asthma outcomes: quality of life. J Allergy ClinIm- adults: an analysis from 54 countries. Pulm Med. 2013 Mar munol. 2012 Mar 31;129(3):S88–123. 17;2013. 9. Felce D, Perry J. Quality of life: Its definition and measurement. 26. Sundberg R, Palmqvist M, Tunsäter A, Torén K. Health-related Res DevDisabil. 1995 Feb 28;16(1):51–74. quality of life in young adults with asthma. Respir Med. 2009 10. Huss K, Naumann PL, Mason PJ, Nanda JP, Huss RW, Smith CM, Oct 31;103(10):1580–5. et al. Asthma severity, atopic status, allergen exposure, and 27. Schatz M, Mosen D, Apter AJ, Zeiger RS, Vollmer WM, Stibolt quality of life in elderly persons. Ann Allergy Asthma Immunol. TB, et al. Relationships among quality of life, severity, and con- 2001 May 31;86(5):524–30. trol measures in asthma: an evaluation using factor analysis. J 11. Voll-Aanerud M, Eagan TM, Plana E, Omenaas ER, Bakke PS, Allergy ClinImmunol. 2005 May 31;115(5):1049–55. Svanes C, et al. Respiratory symptoms in adults are related to 28. Oraka E, King ME, Callahan DB. Asthma and serious psychologi- impaired quality of life, regardless of asthma and COPD: results cal distress: prevalence and risk factors among US adults, 2001- from the European community respiratory health survey. Health Qual Life Outcomes. 2010 Sep 27;8(1):1. 2007. Chest. 2010;137(3):609–16. 12. Ried LD, Nau DP, Grainger-Rousseau TJ. Evaluation of patient’s 29. Jie Y, Isa ZM, Jie X, Ju ZL, Ismail NH. Urban vs. rural factors that af- health-related quality of life using a modified and shortened fect adult asthma. Rev Environ ContamToxicol. 2013;226:33–63. version of the living with asthma questionnaire (ms-LWAQ) and 30. Moreira P, Moreira A, Padrão P, Delgado L. The role of econom- the medical outcomes study, short-form 36 (SF-36). Qual Life ic and educational factors in asthma: evidence from the Portu- Res. 1999 Sep 1;8(6):491–9. guese Health Survey. Public Health. 2008 Apr 30;122(4):434–9. 13. Juniper EF, Norman GR, Cox FM, Roberts JN. Comparison of the 31. Curtis LM, Wolf MS, Weiss KB, Grammer LC. The impact of standard gamble, rating scale, AQLQ and SF-36 for measuring health literacy and socioeconomic status on asthma disparities.J quality of life in asthma.EurRespir J. 2001 Jul 1;18(1):38–44. Asthma. 2012 Mar 1;49(2):178–83. 14. Doz M, Chouaid C, Com-Ruelle L, Calvo E, Brosa M, Robert J, et 32. Pappa E, Kontodimopoulos N, Papadopoulos AA, Niakas D. al. The association between asthma control, health care costs, Assessing the socioeconomic and demographic impact on and quality of life in France and Spain. BMC Pulm Med. 2013 health-related quality of life: Evidence from Greece. Int J Public Mar 22;13:15. Health. 2009;54:241–9. 15. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short 33. Rajanandh MG, Nageswari AD, Ilango K. Influence of demo- Form Health Survey (SF-36): translation and validation study of graphic status on pulmonary function, quality of life, and symp- the Iranian version. Qual Life Res. 2005 Apr 1;14(3):875–82. tom scores in patients with mild to moderate persistent asthma. 16. Stewart AL. Measuring functioning and well-being: the medi- J ExpClin Med. 2014 Jun 30;6(3):102–4. cal outcomes study approach. Durham (NC): Duke University 34. Wheaton AG, Ford ES, Thompson WW, Greenlund KJ, Presley- Press; 1992. Cantrell LR, Croft JB. Pulmonary function, chronic respiratory 17. Ware JE, Snow KK, Kosinski M, Gandek B. New England Medical symptoms, and health-related quality of life among adults in Center Hospital. Health Institute. SF-36 health survey: Manual the United States–National Health and Nutrition Examination and interpretation guide. Boston (MA): The Health Institute, Survey 2007–2010.BMC Public Health. 2013 Sep 17;13:854. New England Medical Center; 1993. 35. Lavoie KL, Bacon SL, Barone S, Cartier A, Ditto B, Labrecque M. 18. McHorney CA, Ware JE Jr, Lu JR, Sherbourne CD. The MOS What is worse for asthma control and quality of life: Depressive 36-item Short-Form Health Survey (SF-36): III. Tests of data qual- disorders, anxiety disorders, or both? Chest. 2006;130:1039–47.

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Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 Seyed Morteza Shamshirgaran 1,2, Hamid Barzkar 1, Saber Ghaffari-Fam 3, Ahmad Kosha 4, Parvin Sarbakhsh 1 and Pari Ghasemzadeh 5

2012 - 2003 اخلصائص واالجتاهات الوبائية يف حالة اإلصابة بعضات احليوانات يف مقاطعة ماكو، مجهورية إيران اإلسالمية، مرتىض شمشيكران، محيد برزكار، صابر غفاري فام، أمحد كوشا، بروين رسبخش، بري قاسم زاده اخلالصــة: تناولــت هــذه الدراســةاخلصائــص الوبائيــة لعضــات احليوانــات ّالتومعــد اإلصابــة هبــا عــرب الزمــن يف مقاطعــة ماكــو. ُواســت ِمدت 2012 2003 البيانــات مــن ســجالت املركــز الصحــي للعضــات احليوانيــة للفــرتة مــن إىل . ُوس ِّــجلت املعلومــات املتعلقــة باخلصائــص الســكانية 2232 والعوامــل املتصلــة بالعضــات. وبلــغ جممــوع األشــخاص الذيــن تعرضــوا لعضــات ًشــخصا؛ ّوســجل الذكــور أعــى معــدل لإلصابــة بالعضــات )75.4 %(، ثــم ســكان الريــف )72.3 %( ومــن هــم فــوق ســن العرشيــن )47.3 %(. وجــاءت معظــم العضــات يف الســاق والقــدم 25 92 65 ) %( ّوشــكلت عضــات الــكالب % مــن هــذه العضــات. ّوتبــن ُّتأخــر أكثــر مــن % مــن املصابــن بتلــك العضــات يف احلصــول عــى 100 000 250 الرعايــة الالزمــة ألكثــر مــن يــوم، ال ســيام ســكان الريــف. وبلــغ متوســط اإلصابــة حالــة لــكل نســمة، ُوســجلت زيــادة ذات داللــة إحصائيــة خــالل فــرتة العــ رشســنوات. وهنــاك حاجــة لزيــادة الوعــي العــام، ال ســيام بــنســكان املناطــق الريفيــة، بشــأن أمهيــة العــالج املبكــر. ويف ضــوء االجتــاه املتزايــد يف عضــات احليوانــات، هنــاك حاجــة لوضــع سياســة صحيــة ملعاجلــة هــذه املشــكلة.

ABSTRACT This study examined the epidemiological characteristics and incidence over time of animal bites in Maku County. Data were obtained from health centre records of animal bites from 2003 to 2012. Information on demographic characteristics and bite-related factors were recorded. A total of 2232 people were bitten; the frequency of bites was highest among males (75.4%), rural residents (72.3%) and those < 20 years (47.3%). Most bites were to the legs and feet (65%) and dogs were responsible for 92% of bites. Over 25% of those bitten delayed seeking care for more than a day, particularly rural residents. The mean incidence was 250 per 100 000 population and there was a statistically significant increasing linear trend over the 10-year period. There is a need to raise public awareness, especially among rural residents, of the importance of early treatment. Given the increasing trend in animal bites, a health policy to tackle this problem is needed.

Caractéristiques et tendances épidémiologiques de l’incidence des morsures d’animaux dans la préfecture de Makou (République islamique d’Iran), 2003-2012

RÉSUMÉ La présente étude a examiné les caractéristiques et l’incidence épidémiologiques dans le temps des morsures d’animaux dans la préfecture de Makou. Les données ont été obtenues à partir des registres de centres de santé portant sur les morsures d’animaux entre 2003 et 2012. Des informations sur les caractéristiques démographiques et les facteurs associés aux morsures d’animaux ont été enregistrées. Un total de 2232 personnes avaient été mordues. La fréquence des morsures était plus élevée parmi les hommes (75,4 %), les habitants ruraux (72,3 %) et les individus de moins de 20 ans (47,3 %). La plupart des morsures se situaient au niveau des jambes et des pieds (65 %) et les chiens étaient responsables de 92 % des morsures. Plus de 25 % des personnes mordues mettaient plus d’une journée à recourir à des soins, en particulier les habitants ruraux. L’incidence moyenne était de 250 pour 100 000 habitants, et on observait une tendance linéaire en hausse statistiquement significative sur la période de 10 ans. Il est nécessaire de sensibiliser le public, et particulièrement les habitants ruraux, à l’importance d’un traitement rapide. Eu égard à la tendance croissante des morsures d’animaux, une politique sanitaire pour s’attaquer à ce problème est requise.

1Department of Statistics and Epidemiology, 2Road Traffic Injury Research Centre, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 3School of Nursing of Miandoab, Urmia University of Medical Sciences, Urmia, Islamic Republic of Iran. 4Department of Health Education, School of Health Sciences Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 5Maku Health Centre, Maku, West Azerbaijan, Islamic Republic of Iran. (Correspondence to: Morteza Shamshirgaran: [email protected]). Received: 24/11/15; accepted: 28/11/16

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Introduction years (12–14). Recent reports from including hour, day and season of the different parts of the Islamic Republic bite; 4) Characteristics of the animals Animal bites are a major cause of mor- of Iran have indicated that animal bites such as the type and species of the ani- bidity and mortality around the world, are increasing. For instance, a study con- mal and whether it was alive 10 days af- and are among the most important pub- ducted in Rafsanjan city among 1542 ter the bite; 5) Location characteristics lic health problems in some countries, patients referred to a health centre for of bites including injury site, size of the such as in southern and eastern Medi- animal bites from 2003 to 2005 esti- wound, lesion type (superficial or deep) terranean countries as well as in Middle mated the incidence of animal bites in and whether the bite was covered by a Eastern countries with approximately the area to be 180, 195 and 241 per cloth or not; 6) Health care received 2% of the population being bitten an- 100 000 persons in 2003, 2004 and after the bite, e.g. number of vaccina- nually (1,2). 2005 respectively (14). tions, tetanus vaccine received or not, Numerous animal species can cause Maku County is located in West infusion of rabies serum received, delay bites, however, most bites are from dogs, Azerbaijan province, north-west of the in receiving medicine after the bite and snakes, cats and monkeys. For example, Islamic Republic of Iran. It has a popula- previous history of animal bites. snake bites are more frequent in Africa tion of about 90 000 and an area size of and South-East Asia. Evidence shows 5 000 square kilometres. This study was Data analysis that dogs account for 76–94% of animal conducted to investigate the epidemiol- The crude incidence rate was deter- bite injuries in low- and middle-income ogy and the time trend of animal bites mined on the basis of the total number in this county between 2003 and 2012. countries (3). of people bitten. To calculate the crude In the Middle East, dogs are the main incidence rate, the population of the cause of animal bites followed by cats, Methods county by age group was obtained from cattle, sheep, goats, camels, donkeys and the health centres of Maku. wild animals (1). Animal bites are an Study design and population Descriptive statistics were used to important health concern because of This was a cross-sectional study con- summarize the data. Mean and standard the risk of secondary infections and also ducted among 15 health centres in deviation (SD) were determined to the possibility of contracting rabies. The Maku County which serve all of the show distribution of the data. For cat- populations most at risk include young population of the county. egorical variables, frequency was used. children and men ( ). Animal bites can 4 According to the Iran Health Age was categorized into 6 age groups: < have a significant health impact; this Network, people who are bitten by an 10 years, 10–19, 20–29, 30–39, 40–49 depends on many factors including the animal are referred to the local health and ≥ 50 years. The chi-squared test was type, size and location of the bite, health centre. A form is completed by trained used to assess the association of cat- of the animal, health of the person bit- staff for all referral cases of animal bites egorical variables; if 20% of the expected ten, and the health care received by the in each health centre. Therefore, the frequencies were ≤ 5, the Fisher exact person bitten. Surveillance of animal- data of animal bites were compiled by test was used. To compare the mean related injuries can help determine the the trained staff working in the Maku age of victims according to sex and place extent and scope of animal bites in order health centres. The study population in- of residence, the Mann–Whitney test to provide useful information for im- cluded all the people who were bitten by plementation and evaluation of public was used because the data were not animals and were referred to the health normally distributed. health prevention interventions (5). centres of Maku in the 10-year period The chi-squared test for linear trend Animal bites are public health con- from 20 March 2003 to 20 March 2012. cern in the Islamic Republic of Iran and was used to test whether there was a the pattern and frequency vary in differ- Data collection statistically significant time trend in the ent areas (6–10). Golestan province Data were collected from the medi- incidence of animal bites. in the north of the country has a high cal records of animal bites at the health A P-value of less than 0.05 was con- incidence of animal bites (11) and the centres in the study period. The vari- sidered statistically significant. highest rate of animal bites has, recently, ables of interest were: 1) Demographic Ethical considerations been reported from Aq Qala, Golestan variables including age, sex, occupation province – 1 222 bites per 100 000 per- and education of the victims, 2) Place The study protocol was reviewed and sons (12). Additionally, some studies variables including place of residence approved by the institutional Ethics have shown a change in the pattern and of the person bitten and place where Committee of Tabriz University of frequency of animal bites in the past 10 the bite occurred; 3) Time patterns Medical Sciences.

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Results were from rural areas. About one-third The majority of the bites (34.9%) of the people bitten (33%) were stu- occurred between 12:00–18:00. Sat- A total of 2 232 victims of animal bites dents, 15% were self-employed and 15% urday and Sunday, the first two days were included in this study from 2003 were housewives (Table 1). of the week in the official calendar of to 2012. The majority of the people In the univariate analysis in all age the country, had the most reported bitten had only 1 bite from the animal bites—16.1% and 15.7% respectively groups, the number of people bitten (96.1%). The mean age of the victims (data not shown in tables). from rural areas was significantly higher was 25.11 (SD 17.47) years, ranging than from urban areas (P < 0.001). The Dogs accounted for 92.8% of the from 6 months to 89 years. The highest bites, with cats 5.2% and others 2.0%. difference in mean age of the people percentage of animal bites occurred in The highest percentage of animal bites bitten #by the area of residence was the age group of 10–19 years (28.7%). (29.2%) occurred in the summer and statistically significant; those from rural The majority of cases were men the lowest in the autumn (19.5%). (75.4%). The mean age of the males was areas were younger than victims from Among all the victims, 72.6% were re- 24.11 (SD 16.56) years and of females urban areas [24.65 (SD 17.75) versus ferred to the health centre on the same was 28.17 (SD 19.72) years, which 26.30 (SD 16.71) years] (Mann–Whit- day of the bite and 5.2% were referred was a statistically significant difference ney test, P = 0.001). Furthermore, there 3 or more days after the bite (Table (Mann–Whitney test, P = 0.002). More was a statistically significant association 2). There was a statistically significant than half of those bitten (57.7%) were between place of residence and educa- association between place of residence illiterate or had received primary school tion level and occupation (P < 0.001) and the type of animal that inflicted education and the majority (72.3%) (Table 1). the bite (P < 0.001). There was also

Table 1 Demographic characteristics of victims of animal bites according to place of residence, Maku County, Islamic Republic of Iran, 2003-2012 (n = 2232) Characteristic Total Rural Urban P-value1 No. % No. % No. % Age group (years) < 0.001 < 10 416 18.6 324 20.1 92 14.9 10−19 640 28.7 487 30.2 153 24.8 20−29 441 19.8 270 16.7 171 27.7 30−39 262 11.7 187 11.6 75 12.1 40−49 191 8.6 140 8.7 51 8.3 ≥ 50 282 12.6 206 12.8 76 12.3 Sex < 0.001 Male 1683 75.4 1158 71.7 525 85.0 Female 549 24.6 456 28.3 93 15.0 Education < 0.001 Illiterate 578 25.9 474 29.4 104 16.9 Primary school 709 31.8 546 33.9 163 26.5 Secondary school 512 23.0 368 22.8 144 23.4 High school and higher 429 19.3 224 13.9 205 33.3 Occupation < 0.001 Student 739 33.1 571 35.4 168 27.2 Not working + child 282 12.6 217 13.5 65 10.5 Farmer/sheep keeper 210 9.4 187 11.6 23 3.7 Paid employment 249 11.2 115 7. 1 134 21.7 Self-employed 338 15.2 201 12.5 137 22.2 Housewife 334 15.0 290 18.0 44 7. 1 Other 78 3.5 31 1.9 47 7. 6

1Chi-squared test. Some data were missing for education and occupation.

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Table 2 Characteristics of the animal bite according to place of residence, Maku County, Islamic Republic of Iran, 2003–2012 Characteristic Total Rural Urban P-value1 No. % No. % No. % Animal type < 0.001 Dog 2072 92.8 1558 96.5 514 83.2 Cat 125 5.6 41 2.6 84 13.6 Other 35 1.6 15 0.9 20 3.2 Season 0.41 Spring 602 27.0 439 27.2 163 26.4 Summer 652 29.2 465 28.8 187 30.4 Autumn 435 19.5 305 18.9 130 21.0 Winter 543 24.3 405 25.1 138 22.3 Injury site 0.02 Head and neck 67 3.1 50 3.2 17 2.8 Pelvis, abdomen 231 10.8 185 12.0 46 7. 6 Shoulder, upper limbs 387 18.1 217 14.2 170 28.2 Lower limbs 1457 68.0 1087 70.6 370 61.4 Post-exposure treatment delay < 0.001 Immediate 1616 72.6 1141 70.9 475 77.0 1 day 338 15.2 258 16.0 80 13.0 2 days 154 6.9 115 7. 2 39 6.3 ≥ 3 days 118 5.2 95 5.9 23 3.7

1Chi-squared test. Some data were missing for injury site and post-exposure treatment time.

a statistically significant difference in no sex difference in wound location; studies conducted in the Islamic Re- delay time according to place of resi- both in males and females, the highest public of Iran: in Kerman 73.48% of dence (P = 0.02). proportion of injuries was on the leg(s) people bitten were men 13( ), in Tabriz In addition, 93.1% of the animal (data not shown in tables). 84.68% (15), in Ardabil 75% (16), in bites were caused by a domestic animal Table 3 shows the frequency of ani- Khuzestan 62% (17), in the East of the and 94% of the animals were alive 10 mal bites over time based on place of Islamic Republic of Iran 78.3% (18), days after the bite. Only 13.2% of the residence (urban/rural). The average in Tehran 79.16% (19), in Illam prov- victims received serum therapy and incidence rate over the 10 years was ince 68.3% (10), in the Shush County 99.4% received tetanus vaccine on the 250 per 100 000 persons. The high- 77.6% (20), and in Islamabad-Gharb first visit. Few of the victims reported a est incidence of animal bites was 295 County 72.5% (21). The higher rate of previous history of animal bites (3%). per 100 000 persons in 2010 and the animal bites in men may be due to their The rabies vaccination was given once lowest was 208 per 100 000 in 2005. job and outdoor activities. for 4.7% of the victims, twice for 14.9% The trend of incidence of animal bites In our study, animal bites were and three times for 77.2%. fluctuated with time; it increased from more common in rural areas and Superficial lesions were seen in 2005 to 2008 and decreased from among individuals with lower educa- 86.4% of the injuries. In 83.6% of the 2011 to 2013. Overall, a significant tion levels, and in students, housewives bites, the bite was on clothes. The increasing linear trend of animal bites and self-employed people. This is simi- depth and extent of the wound was was observed (chi-squared test for lar to findings of other studies in the low in 85.7% of the injuries. Most of trend 7.21, P = 0.007) (Figure 1). the injuries were on the lower extrem- Islamic Republic of Iran (12,13,17,22). ity (68%), followed by shoulder and The majority of animal bites in our upper limbs (Table 1). There was a Discussion study were among people in the age statistically significant association be- group of 10–19 years in both genders, tween wound location and the type of In the present study, the majority of which is in line with many studies that animal inflicting the bite and also place the people bitten were men, which have been conducted in the Islamic of residence (P < 0.001). There was agrees with the results of some other Republic of Iran (16,20,21). This might

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Table 3 Year of animal bite by residence, Maku County, Islamic Republic of Iran, 2003−2012 Year Urban Rural Total No. % No. % No. 2003 84 38.5 134 61.5 218 2004 82 32.4 171 67.6 253 2005 74 27.6 194 72.4 268 2006 56 24.2 175 75.8 231 2007 70 26.3 196 73.7 266 2008 57 25.6 166 74.4 223 2009 33 18.4 146 81.6 179 2010 64 30.9 143 69.1 207 2011 32 17.2 154 82.8 186 2012 66 32.8 135 67.2 201 Total 618 27.7 1614 72.3 2232

be because this age group spends more and in the north-west of the country studies in the Islamic Republic of Iran time in outdoor activities. where dogs were responsible for 72.4% have reported a high frequency of Most of the bites were inflicted by of animal bites (15). An explanation animal bite injuries to the lower limbs: dogs. This is similar to the results of for this finding might be the key role 75.8% of injuries were to the leg in Kas- some other studies such as a study from played by dogs in rural life and the close- siri (Islamabad-Gharb, Kermanshah Illam province where dogs accounted ness of human beings with dogs in such province) (21), 81.4% were to the feet for 89.2% of the incidence of animal places. The vast majority of the animal in Kassiri (Shush, Khuzestan province) bites (10), in Northern Iran where dog bites were caused by a domestic animal (20), 71.8% were also to feet in Sab- bites were reported by 84.87% of the (93.1%). The lower frequency of animal ouri Ghannad (Illam province) (10), people bitten (23), in a study from Teh- bites from dogs in urban areas such as 52.93% were to the lower limbs in Na- ran where dogs were responsible for Tehran (19) also lends support to this jafi (northern Islamic Republic of Iran 65.9% of animal bites (19), in the East hypothesis. Iran) (23), 53.8% were also to the lower of the Islamic Republic of Iran where We found that the majority of bites limbs in Eslamifar (Tehran) (19) and dogs caused 80.3% of animal bites (18), were to the lower limbs. Numerous 70.89% were to the legs in Majidpour

350

300

250

200

Incidence per 100 000 people 100 per Incidence 150

100 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year

Figure 1 Trend in the incidence of animal bites, Maku County, Islamic Republic of Iran, 2003−2012

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(Ardabil) (16).This might be explained The linear time trend in the inci- by the people bitten, which indicates a by the type of animal, i.e. dogs, as well as dence of animal bites was statistically need to raise awareness of the public, by the victim’s body posture while being significant. Overall, incidence rates of especially those who live in rural areas, bitten by a dog and also by the fact that animal bites increased during the study of the health risks of animal bites and the lower limbs are an easy place for a period (2003–2012). Some studies in the importance of early treatment. Fur- dog to reach, especially for small dogs. the Islamic Republic of Iran have also thermore, bites by domestic dogs to the reported an increase in the incidence of The highest proportions of the ani- lower limbs are an important problem animal bites in the past decades (14). mal bites were in the summer and spring which should be tackled. The significant This might be explained by an increase increasing linear trend of animal bites seasons, and on Saturdays and Sundays, in awareness of people of the need to which is in line with some studies in the points to the need for a comprehensive visit a health centre after a bite or it may health policy to prevent and control this Islamic Republic of Iran (7,14). How- reflect a true increase in animal bites. ever, a study from a southern part of the problem. Surveillance of animal bites in However, the incidence of animal bites different areas is recommended so as to country reported a higher frequency decreased in the last 2 years examined gather evidence to implement preven- in autumn (20). This might be due to in our study, so further study of more tion strategies. the longer day time and working hours recent years is needed. spent on farms among people in rural A limitation of our study is that the areas in these regions. data were taken from medical records Acknowledgements Most of the people who were bit- of the people who were bitten. It is prob- ten in our study were referred for care able that there were bite victims who The authors gratefully thank the person- immediately after the biting incident. did not seek care, especially those with nel of the Maku health centres for their However, over a quarter of them delayed minor injuries, and no registered data kind cooperation and the Epidemiology seeking care for more than a day. There were available for them. Our finding and Traffic Injury Prevention Research was an association between place of may therefore be an underestimate of Centre of Tabriz University of Medical the incidence of animal bites in Maku. residence and delay in seeking care, with Sciences for their financial support. a greater delay among rural residents. A Funding: This study was funded by lack of frequent public transportation in Conclusion the Epidemiology and Traffic Injury the rural areas and a lack of knowledge Prevention Research Centre of Tabriz about the dangers of animal bites might Based on the results of our study, there University of Medical Sciences. be the reasons for this difference. was a delay in the treatment received Competing interests: None declared.

References

1. Seimenis A. The rabies situation in the Middle East. Dev Biol pediatric animal bites and post exposure prophylaxis in Isfa- (Basel). 2008;131:43–53. han Province-Iran, 2015. Int J Ped. 2016;4(6):1977–82. 2. Wunner WH, Briggs DJ. Rabies in the 21 century. PLoS Negl 9. Ansari-Moghaddam A, Martiniuk AL, Mohammadi M, Rad Trop Dis. 2010;4(3):e591. M, Sargazi F, Sheykhzadeh K, et al. The pattern of injury and 3. World Health Organization. Animal bites. Fact sheet no. 373, poisoning in South East Iran. BMC Int Health Hum Rights. February 2013 http://www.who.int/mediacentre/factsheets/ 2012;12:17. fs373/en/, accessed 20 March 2017). 10. Ghannad MS, Roshanaei G, Alikhani MY, Alijani P, Sardari MG. 4. Dendle C, Looke D. Review article: Animal bites: an update for Animal bites in Borujerd: an overview of animal bites in Iran. management with a focus on infections. Emerg Med Australas. Avicenna J Clin Microbiol Infect. 2014;1(1):e19568. 2008;20(6):458–67. 11. Zeinali A, Tajik P, Rad M. [Wild life diseases]. Donyaye 5. Emet M, Beyhun NE, Kosan Z, Aslan S, Uzkeser M, Cakir ZG. andisheh. 2002;4:53 [In Farsi]. Animal-related injuries: epidemiological and meteorological 12. Charkazi A, Behnampour N, Fathi M, Esmaeili A, Shahnazi features. Ann Agric Environ Med. 2009;16(1):87–92. H, Heshmati H. Epidemiology of animal bite in Aq Qala city, 6. Moini M, Peyvandi AA, Rasouli MR, Khajei A, Kakavand M, northen of Iran. J Educ Health Promot. 2013;2:13. Eghbal P, et al. Pattern of animal-related injuries in Iran. Acta 13. Rezaeinasab M, Rad I, Bahonar A, Rashidi H, Fayaz A, Simani Med Iran. 2011;49(3):163–8. S, et al. The prevalence of rabies and animal bites during 1994 7. Ghaffari-Fam S, Hosseini SR, Daemi A, Heydari H, Malekzade to 2003 in Kerman province, southeast of Iran. Iran J Vet Res. R, Ayubi E, et al. Epidemiological patterns of animal bites in 2007;8(4):343–50. the Babol County, North of Iran. J Acute Dis. 2016;5(2):126–30. 14. Sheikholeslami NZ, Rezaeian M, Salem Z. Epidemiology of 8. Khazaei S, Ayubi E, Nematollahi S, Mansouri K, Ahmadi- animal bites in Rafsanjan, southeast of Islamic Republic of Iran, Pishkuhi M, Mohammadian-Hafshejani A, et al. Pattern of 2003-05. East Mediterr Health J. 2009;15(2):455–7.

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15. Vahdati SS, Mesbahi N, Anvarian M, Habibollahi P, Babapour S. 20. Kassiri H, Kassiri A, Lotfi M, Shahkarami B, Hosseini S-S. Ani- Demographics of rabies exposure in north-west of Iran: 5 years mal bite incidence in the County of Shush, Iran. J Acute Dis. experience. J Anal Res Clin Med. 2013;1(1):18–21. 2014;3(1):26–30. 16. Majidpour A, Sadeghi-Bazargani H, Habibzadeh S. Injuries due 21. Kassiri H, Kassiri A, Pourpolad-Fard M, Lotfi M. The prevalence to animal bites: a descriptive study. J Clin Res Gov. 2012;1(1):22– of animal bite during 2004–2008 in Islamabad-Gharb County, 4. Kermanshah Province, Western Iran. Asian Pac J Trop Dis. 17. Alavi SM, Alavi L. Epidemiology of animal bites and stings in 2014;4:S342–6. Khuzestan, Iran, 1997-2006. J Infect Public Health. 2008;1(1):51– 22. Majidpour A, Arshi S, Sadeghi H, Shamshirgaran S, Habibzadeh 5. S. Animal bites: epidemiological considerations in Ardabil 18. Bijari B, Sharifzade GR, Abbasi A, Salehi S. Epidemiological Province, 2000. ARUMS. 2003;3(4):39–43. survey of animal bites in east of Iran. Arch Clin Infect Dis. 23. Najafi N, Ghasemian R. Animal bites and rabies in northern 2011;6(2):90–2. Iran; 2001–2005. Arch Clin Infect Dis. 2009;4(4):224–7. 19. Eslamifar A, Ramezani A, Razzaghi-Abyaneh M, Fallahian V, Mashayekhi P, Hazrati M, et al. Animal bites in Tehran, Iran. Arch Iran Med. 2008;11(2):200–2.

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Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals Rehab H. El-Sokkary 1, Ahmed A. Wegdan 2, Ahmed A. Mosaad 1, Rasha H. Bassyouni 2 and Wael M. Awad 3

ممارسات إعادة معاجلة مناظي اجلهاز اهلضمي: دراسة ِّمتعددة املراكز يف مستشفيات جامعية مرصية رحاب ّالسكري، أمحد وجدان، أمحد مسعد، رشا بسيوين، وائل عوض اخلالصــة: ّــل متثاهلــدف مــن هــذه الدراســة يف تقييــم ممارســات العاملــن يف جمــال الرعايــة الصحيــة أثنــاء إعــادة معاجلــة مناظــر اجلهــاز اهلضمــي،وتقييــم معلوماهتــمبشــأن إعــادة املعاجلــة، ُّوالتحقــق مــن االمتثــال يف املختــربات واالختبــارات امليكروبيولوجيــة يف وحــدات املناظــر يف مستشــفيات جامعتــي الزقازيــق والفيــوم. ُوأدرج مجيــع أفــراد هيئــة التمريــض املناوبــن مــن 10 وحــدات للمناظــر حتتــوي عــى مناظــر 19 7.5 مرنــة. ُوق ّمــتي املعلومــات واملامرســات بواســطة اســتبيان وقائمــة مرجعيــة. وجــاء متوســط درجــة املعرفــة )بانحــراف معيــاري (. يف حــن ســجل االمتثــال 90 % بالنســبة للتعقيــم و74 % لتجهيــز املنظــار بعــد التطهــر. وقبــل إعــادة اســتخدام املناظــر بعــد تنظيفهــا، مل تكتشــف 8 أي كائنــات حيــة يف مخســة مناظــر، يف حــن ُاكتشــفت وحــدات ّمكونــة ملســتعمرات يف منظاريــن. وكانــت الزائفــة ّالز ّنجاريــة الكائــن األكثــر ً شــيوعاالــذي تــم عزلــه. خلصــت الدراســة إىل وجــود حاجــة ماســة لتطبيــق املعايــر اخلاصــة بإعــادة معاجلــة املناظــر بشــكل صــارم، ال ســيام يف مرحلــة مــا قبــل التنظيــف ويف اختبــار الترسيــب. وجيــب تكــرار التطهــر عــايل املســتوى بعــد التخزيــن وقبــل االســتخدام.

ABSTRACT The aim of this study was to assess the practices of health care workers during gasterointestinal endoscope reprocessing, evaluate their knowledge about reprocessing, and verify their compliance with laboratory and microbiological tests in endoscopy units at Zagazig University and Fayoum University hospitals. All nursing staff on duty from 10 endoscopy units, with 16 flexible endoscopes, were included. Knowledge and practice were assessed by a questionnaire and a checklist. The mean knowledge score was 7.5 (SD 1.9), which was poor. Compliance was 90% for disinfection and 74% for endoscope processing after disinfection. Before reuse after cleaning, no organisms were detected in 5 endoscopes, while 8 colony forming units were found in 2. Pseudomonas aeruginosa was the most common organism isolated. Strict implementation of the reprocessing guidelines are needed, especially the pre-cleaning stage and leak testing. Repeating high level disinfection after storage and before use must be followed.

Pratiques de traitement des endoscopes gastro-intestinaux : étude multicentrique dans des hôpitaux universitaires en Égypte

RÉSUMÉ La présente étude avait pour objectif d’évaluer les pratiques des agents de soins de santé lors du traitement des endoscopes gastro-intestinaux, de mesurer leur connaissance du traitement, et de vérifier leur bonne exécution des tests de laboratoire et des tests microbiologiques dans les unités d’endoscopie des hôpitaux universitaires de Zagazig et de Fayoum. Toutes les équipes de personnels infirmiers issues de 10 unités d’endoscopie, avec 16 endoscopes souples, ont été incluses dans l’étude. Les connaissances et les pratiques ont été évaluées par un questionnaire et une liste de contrôle. Le score de connaissance moyen était de 7,5 (ET 1,9). La conformité était de 90 % pour la désinfection, et de 74 % pour le traitement des endoscopes après désinfection. Après nettoyage et avant réutilisation, aucun organisme n’a été détecté pour cinq endoscopes, et huit unités formant des colonies ont été trouvées dans deux autres endoscopes. Pseudomonas aeruginosa était l’organisme le plus couramment isolé. Une application stricte des directives de traitement est requise, notamment à l’étape du pré-nettoyage et des essais d'étanchéité. Il est important d’effectuer une désinfection de haut niveau répétée après entreposage et avant utilisation.

1Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt (Correspondence to: Rehab H. El-Sokkary: [email protected]). 2Department of Medical Microbiology and Immunology, Faculty of Medicine, Fayoum University, Fayoum, Egypt. 3Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Received: 15/09/16; accepted: 23/11/16

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Introduction were assessed and in phase two, labora- than 6.4 µg/mL protein as described in tory and microbiological verification of a previous study (7). Appropriate reprocessing of endo- compliance was determined. Microbiological examination of scopes and their accessories is essential Knowledge of the health care endoscopes was done after storage and to safeguard patients and staff. Repro- workers was assessed by a 21-question before being used again. Using aseptic cessing flexible endoscopes involves questionnaire (4,5) in Arabic. It was technique, 10 mL of rinse solution were multiple steps (cleaning, disinfection prepared in Arabic for better under- collected (7) from reprocessed endo- and sterilization) and adherence to the standing and to get more reliable results. scopes and a culture was done. Colony guidelines on reprocessing is essential The questionnaire was pilot tested on count and identification to species level (1). In Egypt, rules for this process have a sample of 15 nurses to determine was performed (8). been figured out in the national guide its acceptability and the clarity of the After bacterial culture and isolation, for infection prevention and control (2), questions, and to confirm its face valid- the bioburden level was estimated as which is the standard for the country. ity; it was then modified accordingly. follows: counts were reported as the Information about staff practices in These staff were excluded from the final number of colony forming units (cfu) endoscopy units regarding reprocess- analysis. The questionnaire included per mL (9). Quantification of bacterial ing and their adherence to guidelines 7 questions about personal and job- growth was done: no growth = 0 cfu, is needed to support the development related variables (age, sex, place of work, sparse growth = <5 cfu/mL, moder- of effective performance improvement duration of work in general, duration of ate growth = 5–20 cfu/mL and heavy (3). To our knowledge there have been work in endoscopy units, and training growth = ˃ 20 cfu/mL (10). no previous studies that have assessed on endoscope reprocessing and aware- Statistical analysis was done using these practices. Therefore, the objec- ness of reprocessing guidelines) and 13 SPSS, version 15. Quantitative data tives of this study were to: evaluate the scored questions about the reprocess- are presented as ranges, means and practices of nursing staff during gas- ing procedures at the facility. A correct standard deviations (SD). For quali- trointestinal endoscope reprocessing, answer was assigned a score of 1, an tative data, numbers and percentages assess their knowledge about repro- incorrect answer was assigned a score are presented. The Pearson correlation cessing, and verify their compliance by of 0. The total knowledge score was coefficientr ( ) was used to assess the laboratory and microbiological tests. calculated by adding the number of significance of association between pro- correct answers. A mean score equal to tein and bioburden levels. A P-value less and above the median was considered than 0.05 was considered statistically Methods satisfactory knowledge, and a score significant. below the median was considered un- A cross-sectional multicentre study was satisfactory knowledge. The survey was carried out at the endoscopy units of distributed to and self-completed by Results Zagazig University Hospitals and Fay- all participants. All surveys were anony- oum University Hospitals from March mous. A total of 46 health care workers were 2015 to September 2015. The study Evaluation of the compliance of present at the time of the study and was approved by the institutional re- health care workers was done using were enrolled: 43 were women. Their view boards of the Zagazig and Fayoum another 49-point self-completed ques- ages ranged from 25 to 53 years with a universities. tionnaire, adapted from the national mean of 35.3 (SD 5.6) years. Duration All functioning endoscopes were guidelines (2), which were grouped of work in endoscopy units ranged from included—16 flexible endoscopes under 7 areas. All criteria were marked 3 months to 30 years. Most of the staff from 10 endoscopy units. A total of as: compliant, not compliant or not ap- (78%) were aware that there were re- 59 nursing staff in the units, who were plicable, and the percentage of compli- processing instructions available in the responsible for cleaning and storage ance was calculated (6). unit and 44% had had training courses of the endoscopes, were enrolled. We Laboratory verification of cleaning on endoscope reprocessing (Table 1). excluded staff members who were on processes by protein assay was done as The knowledge and compliance leave during the study period. No staff follows: 10 mL of rinse solution were of health care workers are shown in declined to participate and all gave their collected after cleaning of the endo- Tables 2 and 3. The mean knowledge written consent. scope and before high level disinfection. score about all reprocessing steps was The study was conducted in 2 Protein assay was done by the biuret 7.5 (SD 1.9), with a maximum of 13. phases: in phase one, the knowledge method. The permissible level for or- The median score was 8.3. The mean and compliance of health care workers ganic and bioburden residuals is less score for cleaning processes was 2.9

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Table 1 Personal and job-related variables (SD 0.75). All participants thought that Variable Values after mechanical cleaning, immersible Sex (No.) equipment should be thoroughly rinsed Male 3 with water. On the other hand, only Female 43 47% of participants thought that endo- Age (years) scope should be checked by inspection Range 25−53 and a leak test. The mean score for dis- Mean (SD) 35.3 (5.6) infection steps was 2.1 (SD 0.08): 98% Duration of work in nursing (years) of the participants knew that repeated Range 10−35 entry into any chemical disinfectant and Mean (SD) 17.5 (6.3) retained water on equipment can lower Duration of work in endoscopy units (range) 3 months−30 years the concentration over time. On the Previous experience in an endoscopy unit [(No. (%)] other hand, 67% of participants knew Only one unit 2 (4.3) that internal and external surfaces of the More than one unit 44 (95.7) endoscope should be in contact with Aware of available instructions about reprocessing? [(No. (%)] disinfectant for 20 minutes. The mean Yes 35 (77.8) score for storage processes was 1.5 (SD No 10 (22.2) 0.08). Only 6% of participants knew Had training courses on endoscope reprocessing [(No. (%)] that control valves, distal hoods, caps, Yes 20 (43.5) etc. should be removed prior to storage No 25 (54.3) of the endoscope.

Table 2 Knowledge of endoscope reprocessing among health care workers Reprocessing step Percentage who answered the question correctly Cleaning The cleaning brushes should be disposable/thoroughly cleaned and receive a high-level 49 disinfection or sterilization after each use All channels should be brushed and irrigated with large amounts of enzymatic presoak 50 solution or detergent and tap water After mechanical cleaning, immersible equipment should be thoroughly rinsed with water 100 The endoscope should be checked by inspection and leak test 47 All detachable parts should be removed and soaked in an enzymatic presoak solution 67 Disinfection Internal and external surfaces and channels must be in contact with the disinfecting agent 67 for at least 20 minutes Repeated dipping into any chemical disinfectant and retained water on equipment can 98 lower the concentration over time All containers with glutaraldehyde solutions should be sealed or covered 85 Treatment after disinfection Rinsing should be done with sterile water. If sterile water is not available, then potable tap 62 water should be used with a rinse of the internal lumens with alcohol Drying with alcohol and compressed air should be done between each patient when tap 67 water is being used to rinse the endoscope channels Drying with alcohol and compressed air should be done before storage whether tap water 79 or sterile water is used Endoscopes should be stored vertically in a cabinet 72 Control valves, distal hoods, caps, etc. should be removed before storage of the endoscope 6

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Table 3 Compliance with specific policies, procedures and practices Reprocessing step Rate1 (%) Cleaning of endoscope 67 Disinfection of endoscope 90 Treatment of the endoscope after disinfection 74 Processing endoscopic accessory equipment 44 Hazardous materials’ management 0 Endoscopy personnel occupational health issues2 61 Environmental factors (storage) and design issues for the endoscopy unit 58

1Minimal compliance = ≤ 75%, partial compliance = 76–84% and satisfactory compliance = ≥ 85% (7). 2Such as thorough hand hygiene before and after each procedure, use of personal protective equipment as needed, accessible personal protective equipment, vaccination against hepatitis B.

The results of the laboratory and Discussion (12), while Seoane-Vazquez and col- microbiological verification of com- leagues reported that the primary cause pliance are shown in Table 4. Protein In the current study, more than three of endoscopy-related infections was levels ranged from 4.6 to 32.8 µg/mL quarters of the staff were familiar with poor reprocessing practices (13). with a mean of 14.8 (SD 8.9) µg/mL. existing reprocessing policies. A study in Despite the importance of the clean- The highest level of protein (32.8 µg/ the United States of America (USA) re- ing process, minimal compliance was mL) was detected from endoscope ported that only 35% of bronchoscopists reported for this area in the current and 45% of medical directors in bron- numbers 5 and 15. Three endoscopes study. Inadequate cleaning can leave choscope units were familiar with any showed protein levels below the permis- excess biomaterial on the surface of an national reprocessing rules (4). Only sible level (i.e.< 6.4 µg/mL), indicating endoscope, even after multiple repro- about half of our study participants had cessing. Appropriate cleaning reduces the cleaning process was effective. The received training on endoscope repro- the amount of organic debris (14) that number of cfu ranged from 0 to 8, with cessing. Continuous medical education can interfere with high level disinfection. a mean of 2 (SD 5.8). Endoscope num- is important for all staff members and Missing or rushing through key steps is bers 5 and 15 had the highest number should be considered in the planning of a common problem (15). In the present of cfu (8 each), while no growth was training programmes in the units stud- study, nearly half of the study partici- detected from endoscope numbers 4, ied. Guidelines might be valuable for pants knew that leak testing is a required 7, 8, 13 and 14. There was a statistically detailing proper practices, however they step; this is much lower than a previous significant positive correlation between are not necessarily effective in changing study (77%) (3). The failure to per- protein and bioburden levels (r = 0.589, behaviour (11). form a proper leak test could also have P = 0.03). The participants in the current study serious implications. This test detects While, endoscope numbers 4 and had a poor mean knowledge score of 7.5 any physical breaks to the exterior or 14 showed no bacterial growth, the (SD 1.9). Similar results have been re- interior of the endoscope. These physi- protein level was higher than the per- ported previously (4). A similar knowl- cal breaks compromise the integrity missible level (< 6.4 µg/mL). Only en- edge score about cleaning procedures of the endoscope and will damage the internal structures (i.e. electrical wires, doscopes numbers 7, 8 and 13 showed was recorded in a study in the USA (3), except for the leak test step; 90% of staff light bundle, manipulation cables) of no bacterial growth and permissible in their study (3) versus 47% in our study the endoscope, which are not designed protein levels. knew the endoscope should be checked to be in contact with fluids. These breaks Pseudomonas aeruginosa was the most by inspection and leak test. Compliance may also create a reservoir for micro- common isolated organism (30.8%), with national guidelines was achieved organisms to grow. Continuing to use followed by micrococcus (15.4%), for disinfection steps with partial com- a damaged endoscope could result in Serratia spp. (7.7%), Staphylococcus pliance for treatment of the endoscope further damage and be costly (3). saprophyticus (7.7%) and diphtheroids after disinfection. Another study found The rates of compliance with guide- (7.7%). No growth was detected in that most practitioners complied with lines for reprocessing were 27% and 50% 30.7% of samples. the established disinfection guidelines in 2 separate studies (16). The present

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Table 4 Results of the microbiological and protein assays1 Endoscope no. Bioburden Protein level (µg/mL)2 P-value r estimation (cfu) 1 5 16.3 0.03 0.58 2 3 15.6 3 2 28.6 4 0 10 5 8 32.8 6 4 12.3 7 0 4.9 8 0 5.1 9 5 22.2 10 2 8.1 11 3 12 12 1 15.6 13 0 4.6 14 0 9.1 15 8 32.8 16 3 28.6 Total level Range 0−8 4.6−32.8 Mean (SD) 2 (5.8) 14.8 (8.9)

1Results are the average of 3 repeated experiments. 2The proposed standard for permissible level is 6.4 µg/mL. P < 0.05 was considered as statistically significant. r = Pearson correlation coefficient; cfu = colony forming units.

study results showed that there was majority (78%) did not wear protective cleaning steps. This is supported by the minimal compliance for processing of eyewear (17). low compliance rate for this step (67%). endoscopic accessory equipment. This Unfortunately, no responses were According to the national guide- agrees with the results of another study recorded for dealing with hazardous lines, repeating high level disinfection which found that a third of respondents materials. This suggests that occupa- after storage and before use is highly reported that they reused disposable tional safety programmes are not recommended, yet it is often not done. accessories (12). Reuse of disposable properly implemented in the hospitals Checking for storage efficacy by mi- accessories should be avoided so as to studied. crobiological testing of the endoscope limit the likelihood of cross-infection Visual inspection could be used to fluid wash was performed to confirm between patients and staff (17). A lack check for adequate cleaning. However, the importance of conducting this step. of financial resources may lead to reuse compliance with cleaning of flexible Our study showed that, on 4 out of so it is essential that an adequate budget endoscope channels cannot be con- 16 occasions, the reprocessing steps is allocated to prevent reuse. firmed using visual inspection (7). and storage conditions were sufficient In the current study, there was Therefore, in our study, verification of to avoid bacterial contamination. In minimal compliance with endoscopy efficient cleaning was done by estimat- contrast, on 2 out of 16 occasions, the personnel occupational health issues, ing protein levels on the endoscope. A process was inadequate with moderate including thorough hand hygiene be- considerable amount of residual protein growth (8 cfu/mL) and in 10 out of 16 fore and after each procedure, use of was detected, which exceeded a pro- occasions there was sparse growth. personal protective equipment, acces- posed standard for permissible levels Given the sparse growth and the sible personal protective equipment (6.4 µg/mL) (7). A much lower result nature of the organisms, most probably and vaccination against hepatitis B. A was obtained in a previous study, 0.1 the cleaning protocols were not fol- study in Korea found that although and 0.22 µg/mL after total cleaning 7( ). lowed and/or monitored on a regular most respondents reported having ex- This could be explained by poor adher- basis (18). Our laboratory and micro- perienced occupational hazards, the ence of the health care workers to the biological findings confirmed the results

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about knowledge and compliance from non-fermenting rods indicates insuf- after storage and before use should be the questionnaire, which showed de- ficient final rinsing and incomplete dry- strictly followed. An occupational safety ficiencies in the cleaning process. On ing of the endoscope or contaminated programme is needed for staff working the other hand, the moderate bacterial flushing equipment for the air/water- in endoscope units. Efforts are needed growth found and the organisms isolat- channel (19). ed indicate breaches in the reprocessing to overcome knowledge barriers and steps and/or storage conditions in some financial constraints so as to ensure cases. This is an alarming sign which Conclusion proper reprocessing of endoscopes and needs close monitoring to ensure that avoid adverse health effects on patients Strict regulations are still needed for the the reprocessing guidelines are imple- and staff. mented and closely adhered to. In the endoscope cleaning process, especially current study, detection of Pseudomonas the pre-cleaning stage and leak test- Funding: None. spp. (especially P. aeruginosa) and other ing. Repeating high level disinfection Competing interests: None declared.

References

1. Kovaleva J, Meessen NE, Peters FT, Been MH, Arends JP, Borg- 10. Riley R, Beanland C, Bos H. Establishing the shelf life of flexible ers RP, et al. Is bacteriologic surveillance in endoscope repro- colonoscopes. Gastroenterol Nurs. 2002;25(3):114–20. cessing stringent enough? Endoscopy. 2009;41:913–6. 11. Measuring hand hygiene adherence: overcoming the chal- 2. [Egyptian National guide for infection control. Part 2: Infec- lenges [Monograph]: Oakbrook Terrace (IL): The Joint tion control in specialized units: Endoscopy unit. 3rd ed]. Commission;2009 (https://www.jointcommission.org/as- Arab Republic of Egypt: Ministry of Health and Population; sets/1/18/hh_monograph.pdf, accessed 22 March 2017) 2016:40–50 [In Arabic]. 12. Park S, Jang JY, Koo JS, Park JB, Lim YJ, Hong SJ, et al. A review 3. Ofstead CL, Wetzler HP, Snyder AK, Horton RA. Endoscope of current disinfectants for gastrointestinal endoscopic repro- reprocessing methods: a prospective study on the impact cessing. Clin Endosc. 2013;46:337–41. of human factors and automation. Gastroenterol Nurs. 13. Seoane-Vazquez E, Rodriguez-Monguio R, Visaria J, Carlson A. 2010;33(4):304–11. Exogenous endoscopy-related infections, pseudoinfections, 4. Srinivasan A, Wolfenden L, Song X, Perl T, Haponik F. Pre- and toxic reactions: Clinical and economic burden. Curr Med vention and control: bronchoscope reprocessing and infec- Res Opin. 2006;22(10):2007–21. tion: bronchoscopy-specific guidelines are needed. Chest. 14. Burdick JS, Hambrick D. Endoscope reprocessing and repair 2004;125:307–14. costs. Gastrointest Endosc Clin N Am. 2004;14:717–24. 5. Mortada EM, Zalat MM. Assessment of compliance to stand- 15. Rutala WA, Weber DJ. How to assess risk of disease transmis- ard precautions among surgeons in Zagazig University Hospi- sion to patients when there is a failure to follow recommended tals, Egypt, using the Health Belief Model. J Arab Soc Med Res. disinfection and sterilization guidelines. Infect Control Hosp 2014;9:6–14. Epidemiol. 2007;28:146–55. 6. Infection Control Nurses Association. Audit tools for monitor- 16. Seol SY, Moon JS, Kae SH. Result report of endoscope repro- ing infection control guidelines within the community setting. cessing survey: 2002 and 2004. Korean J Gastrointest Endosc. 2005 (file:///C:/Users/Fiona/Downloads/AuditTools2005. 2005;30 S1:109S–18S. pdf, accessed 22 March 2017). 17. Cho Y. Current Status of Endoscope Reprocessing in Korea. 7. Alfa M, Fatima I, Nancy Olson N. Validation of adenosine Clin Endosc. 2015;48:1–3. triphosphate to audit manual cleaning of flexible endoscope 18. Riley R, Beanland C, Bos H: Establishing the Shelf Life of Flex- channels. Am J Infect Control. 2013;41:245–8. ible Colonoscopes. Gastroent nursing. 2001; 25(3): 114-119. 8. Forbes BA, Sahm DF, Weissfeld AS. Bailey and Scott’s diagnos- 19. Hamed MMA, Shamseya MM. Dafa Alah IDAN, El Sawaf G. tic microbiology. 12th ed. St. Louis: Mosby; 2007. Estimation of average bioburden values on flexible gastroin- 9. Gillespie EE, Kotsanas D, Stuart RL. Microbiological monitor- testinal endoscopes after clinical use and cleaning: Assess- ing of endoscopes: 5-year review. J Gastroenterol Hepatol. ment of the efficiency of cleaning processes. Alex J Med. 2008;23:1069–74. 2015;51:95–103.

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WHO events addressing public health priorities

Prevention of re-establishment of local malaria transmission in malaria-free countries1

The battle to eliminate the scourge of malaria in the Eastern from endemic countries and preventing re-establishment of Mediterranean Region (EMR) continues unabated. To local transmission in malaria-free areas. date there have been notable successes in this fight, with 14 countries so far having succeeded in eliminating malaria (1). Situation in malaria-free countries in WHO Their main priority now is to prevent re-establishment of local Eastern Mediterranean Region malaria transmission in receptive and vulnerable areas. How- The situation in malaria-free EMR countries was discussed ever, local malaria outbreaks have been reported recently during the workshop. It was noted that in North African from some malaria-free countries in the Region (such as countries, imported malarial cases are mainly from sub- Egypt and Oman), as well as countries in other regions Saharan Africa, where the majority of cases are due to Plas- (such as Greece) from 2010 to 2014 (2). Such examples modium falciparum. However, the number of imported highlight the need for vigilance, continuous assessment of the cases is increasing, mainly due to recent immigration trends to eco-epidemiological situation, and readiness for prompt and European countries through North Africa (1,2). In Morocco, appropriate interventions. cases of imported P. ovale have increased in recent years. Thus, a workshop was requested by these malaria-free Delay in seeking care by patients and late diagnosis by health countries in order to update, harmonize strategies and to plan staff have resulted in some deaths due to malaria in Egypt, for more efficient and coordinated participation of malaria- Libya and Morocco in the past 3 years (1,2). Malaria cases free countries in the global efforts for malaria elimination. The in Gulf Cooperation Council (GCC) countries were mainly World Health Organization Regional Office for the Eastern imported from India and Pakistan; the majority of cases due Mediterranean (WHO/EMRO), in collaboration with the to P. vivax (2). Oman reported only four introduced cases Government of Morocco, conducted a regional workshop in 2015, while the last year with transmission of indigenous on updating national strategic plans for the prevention of malaria was 2010. During the past 3 years, the number of re-establishment of local malaria transmission in malaria- imported cases in GCC countries has started to decrease due free countries from 18–20 October 2016, in Casablanca, to changes in immigration policies and/or changes of burden Morocco (3). in countries of origin (1,2). The objectives of the workshop were to: Iraq reported only two imported P. vivax cases in 2014; one P. falciparum and one P. vivax in 2015. In Jordan, the • review the progress and challenges in sustaining the malaria- majority of cases were from sub-Saharan Africa and mainly free status in EMR countries and agree on key priority due to P. falciparum (70%). More than 90% of malaria cases actions; in Lebanon were due to P. falciparum, mainly from African • develop updated national strategic plans for prevention of countries. In 2015, due to problems in confirmation and re-establishment of local malaria transmission in all malaria- reporting from the private sector, 13 cases were not classified free countries of the Region. by species. In 2015, the Syrian Arab Republic reported no In 2015, all countries globally committed to the targets local cases and all 12 reported imported cases were due to of the Sustainable Development Goals (SDGs) including P. falciparum. Four deaths were reported in 2014, and zero target 3.3 for ending the epidemic of malaria (4). Countries deaths were reported in 2015 (1,2). also adopted the WHO Global technical strategy for malaria 2016–2030 with the final goal of a malaria-free world 5( ). The Discussion global technical strategy provides a guide to Member States Participants were provided with new and updated information in the fight against malaria, with the aim of eliminating malaria on the different aspects of malaria control and elimination,

1 This report is extracted from the Summary report on the Regional workshop on updating national strategic plans for the prevention of re-establishment of local malaria transmission in malaria-free countries, Casablanca, Morocco, 20–18 October 2016 (http:// applications.emro.who.int/docs/IC_Meet_Rep_2017_EN_19349.pdf?ua=1, accessed 13 June 2017).

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including: the WHO “Malaria microscopy quality assurance 2. Develop/update existing national strategies/plans to pre- manual” (2016) (6) and availability of malaria microscopy vent re-establishment of indigenous malaria transmission; standard operating procedures (SOPs); WHO criteria for 3. Maintain a core expert group at national level for develop- procurement of quality rapid diagnostic tests;; raising aware- ment of malaria policies and strategies, case management, ness about malaria among travellers and health staff; provid- surveillance and integrated vector management; ing quality antimalarial medicine for both uncomplicated and severe malaria; use of primaquine for radical treatment of P. 4. In collaboration with WHO/EMRO, establish sub-regional vivax and as gametocidal medicine for P. falciparum cases; networks for malaria-free countries (GCC countries, North artemisinin resistance; status of malaria vaccine; develop- African countries (Morocco, Libya, Egypt, Tunisia), and Iraq, ment of a new Global Vector Control Response; and the Jordan, Lebanon, Palestine and the Syrian Arab Republic) to importance of integrated vector management strategy, noting exchange relevant information for improving intercountry a new trend of vector-borne diseases at global and regional collaboration. levels (1–3). Participants were also informed that WHO has estab- To World Health Organization lished a Strategic Advisory Group on malaria eradication to 1. Support malaria-free countries both inside and outside the prepare an analysis of future malaria trends and advise WHO Region, in their efforts to develop/update national strate- on the feasibility, expected cost and potential strategies for gies/plans for prevention of re-establishment of indigenous malaria eradication over the coming years (7). malaria transmission. Recommendations 2. Support countries in strengthening their capacities in surveillance, vector control and malaria case management. To Member States 3. Assist in establishing an effective and sustainable mechanism 1. Reaffirm previous commitments to prevent re-establish- for procurement and supply of antimalarial drugs for countries ment of indigenous malaria transmission; in need.

References

1. World Health Organization. Eliminating malaria. Geneva: 4. United Nations. Sustainable development goal 3. New York: World Health Organization; 2016 (http://www.who.int/ma- United Nations; 2015 (https://sustainabledevelopment. laria/publications/atoz/eliminating-malaria.pdf, accessed 13 un.org/sdg3, accessed 13 June 2017). June 2017). 5. World Health Organization. Global technical strategy for malaria 2016–2030. Geneva: World Health Organization; 2016 2. World Health Organization. World malaria report 2015. Ge- (http://www.who.int/malaria/areas/global_technical_strat- neva: World Health Organization; 2015 (http://www.who.int/ egy/en/, accessed 13 June 2017). malaria/publications/world-malaria-report-2015/wmr2015- 6. World Health Organization. Malaria microscopy qual- profiles.pdf, accessed 13 June 2017). ity assurance manual – ver. 2. Geneva: World Health Or- ganization; 2016 (http://www.who.int/malaria/publications/ 3. WHO Regional Office for the Eastern Mediterranean. Re- atoz/9789241549394/en/, accessed 13 June 2017). gional workshop on updating national strategic plans for the 7. World Health Organization. Strategic advisory group on prevention of re-establishment of local malaria transmission malaria eradication. Geneva: World Health Organization; in malaria-free countries, Casablanca, Morocco, 18–20 Octo- 2016 (http://www.who.int/malaria/mpac/mpac-mar2016- ber 2015 (http://applications.emro.who.int/docs/IC_Meet_ strategic-advisory-group-presentation.pdf?ua=1, accessed 13 Rep_2017_EN_19349.pdf?ua=1, accessed 13 June 2017). June 2016).

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Book 23-07.indb 521 8/23/2017 8:02:02 AM Members of the WHO Regional Committee for the Eastern Mediterranean املجلة الصحية لرشق املتوسط Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية. وهى منرب لتقديم السياسات Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab واملبادرات اجلديدة ىف اخلدمات الصحية والرتويج هلا، ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري Republic . Tunisia . United Arab Emirates . Yemen ذلك من املعلومات، وخاصة ما يتعلق منها بإقليم رشق املتوسط. وهى موجهة إىل كل أعضاء املهن الصحية، والكليات الطبية وسائر املعاهد التعليمية، وكذا املنظامت غري احلكومية املعنية، واملراكز املتعاونة مع منظمة الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه.

ISSN 1020-3397

Cover 23-07.indd 8-10 8/22/2017 12:16:09 PM Contents

Editorial

Eliminating hepatitis from the Eastern Mediterranean Region...... 459 Research articles

Short communication July 2017

Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals...... 514

املجلد الثالث والعرشون / عدد Volume 23 / No. 7 7 يوليو/متوز July/Juillet 2017

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