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Hagar was a mother who struggled alone in to their illnesses, distributed household the desert to ensure the survival and nour- medications, determined their nutritional ishment of her infant son Ismail. Khadija needs, and taught them hygienic practices? single-handedly developed and ran a suc- &an anyone deny the mother¶s compre- cessful business. The queen of Sheba was a hensive need for education to successfully powerful leader who ruled by consultation, accomplish these tasks, which have lifelong consensus and reason, as mentioned in the consequences on the well-being and health Quran. These are but a few well-known of boys as well as girls? In fact, educational examples in the Eastern Mediterranean Re- attainment of women has been found to be gion of courageous, innovative and strong the single most influential factor in reducing women who overcame obstacles and left child morbidity [1]. Education for women rich legacies for the communities to which results in their greater capacities in directing they belonged. Yet many of their inheritors, family matters, less fatalistic attitudes in the women of the Region today, have far responding to children¶s illness, and greater less opportunity to contribute to their own awareness of health risks and behaviours communities. This is especially true for that reinforce health. women at lower socioeconomic levels, who Women directly impact the productivity have less social space, fewer options and of the population through their promotive less access to resources with which to navi- and preventative health care roles and yet gate their lives. Without their contributions, are insufficiently recognized for this crucial however, sustainable human development contribution. An unhealthy population can- cannot be achieved. not be productive. Macroeconomic calcula- Men and women are partners in life and tions rarely consider the reproductive sector enter and leave this world on equal terms. in the growth equation of economies and yet Accordingly, they must be equally nour- populations are maintained by the reproduc- ished and provided with resources to build tive sector. The interaction that the mother and protect their communities. Assump- has within society, the resources that are tions have sometimes been made that result available for her use, and the roles that are in greater opportunities for boys in access- expected of her form the background for ing education, employment and leadership her parenting abilities and influence the out- opportunities, in part because it is reasoned comes of her children¶s health and social, they will carry the economic burden in their educational and economic development. adulthood. And yet, who has nurtured these And yet we must be cautious not to boys throughout their childhood, tended assign women only to the reproductive

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S role. This denies and suppresses their other Women must be given the resources talents and contributions to society. It also necessary to navigate through life and to be amounts to an injustice to women who do equally prepared alongside their male part- not marry or who marry but for various ners for the challenges which life brings. reasons do not, or cannot, have children. By To ensure successful and sustainable linking the woman¶s role only to mother- development, women must be involved hood, we condemn those women not filling as decision-makers in community devel- this role to a social vacuum, vulnerable to opment committees and must be equal social exclusion by their communities. This recipients of social sector projects and is especially true in societies where women income-generation projects, including vo- are valued only for the number of children, cational training and micro credit support. especially boys, that they can successfully Vocational skills for women should not be give birth to. limited to gender stereotypical skills such as Consigning and providing resources handicrafts, which are often not sustainable for women only in fulfilling the reproduc- and provide limited market opportunities. tive role in society ignores the economic Women and men must be equal recipients reality many communities face, and fails to of capacity-building, including both health account for the economic productivity that and academic literacy, and both men and women can contribute to societies. Limiting women should have the responsibility to access to resources for women based solely volunteer and contribute to the health of the on their assignment in the reproductive role community. leaves women with a life-long dependency To deny women the skills and capacities on others for their income and unable to take to face life properly equipped is to deny care of themselves should their support for them their human rights. The denial of equal any reason fail. For example, many women resources and opportunities for women find themselves the heads of household be- impedes the success of any sustainable hu- cause of the unemployment of their spouses, man development programme. The needs death of their spouses, or abandonment by and contexts of both men and women are their spouses. Lack of education, lack of essential components of any development capacity in management skills, and lack measure and both voices must be heard of experience in the formal labour market from the conception to the planning, imple- means female heads of households have few mentation and monitoring of development viable employment options. While juggling programmes. household responsibilities, they must often Governments must recognize the neces- turn for economic support to the informal sity of building human capacity to ensure labour market, where they are vulnerable to economic growth and must not limit capacity- exploitation, receive insufficient compensa- building to only half their populations. To tion, and are not entitled to social protection do so is to deny the contributions women measures such as health insurance because make to their communities and to deny the the informal market is not regulated. rich heritage of their cultures.

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The interplay between health, poverty and America (USA), Japan and other countries development is well known and has been belonging to the Organisation for Economic studied by public health professionals, so- Co-operation and Development (OECD) cial scientists and development specialists is considered the main cause of increasing and also by international agencies includ- life expectancy and decreasing mortality. ing the United Nations Development Pro- Economic growth leads to an increase in gramme (UNDP), the World Bank and the income for individuals and communities World Health Organization (WHO). and to improvement of housing and nutri- The Millennium Development Goals tional status, which are major determinants (MDGs), to which all countries of the world of health. However, ill planned and non- are committed, emphasize the linkages and environmentally sensitive economic devel- synergies between health, poverty and de- opment projects may have negative impacts velopment. These Goals put health at the on health because of exposure of people to centre of social and economic development hazards resulting from the projects. Some by focusing on tackling the social determi- major agricultural and industrial projects, nants, including literacy, poverty reduction including dams and plants, are known to and environmental protection, and by scal- have had an adverse effect on the environ- ing up public health programmes and im- ment where people live and hence on their proving access to quality health services. health and development. As part of the studies on the social de- The economic growth experienced by terminants of health initiated by WHO since developed economies later allowed greater Alma Ata [1] evidence has been collected investment in modern health care systems on the positive impact of economic de- after the Second World War, which led velopment, improved access to safe water to improved infrastructure, trained health and sanitation on health development [2]. workforce and access to biomedical tech- Indeed, that these are important factors nology. Furthermore, developed economies is clear from the fact that the decrease in have invested in education which has a general mortality and increase in life ex- positive impact on health in terms of en- pectancy during the last century and half couraging health protection and promotion. occurred long before the development of Recognizing the importance of eco- health systems and the important break- nomic and social conditions, UNDP, since throughs in medical technology. the 1960s, has promoted the concept of The improvement of living conditions securing the basic minimum needs for de- facilitated by economic growth and development. Such an approach was also used velopment in Europe, the United States of in the field of health development and led

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S to its implementation in Thailand and other development which thus does not allow Asian countries after Alma Ata. Similar health systems to fund health programmes, approaches have been implemented in the to secure necessary health and biomedical Eastern Mediterranean Region of WHO technology and to develop a motivated as part of its commitment to health for all personnel. As a consequence, effective through primary health care. The concept coverage by health interventions and pro- evolved from initially simply meeting the grammes is limited which results in poor basic needs to a more proactive and com- health outcomes. prehensive developmental approach owned But funding is not the only issue; the way by the communities. health systems are organized can also have While economic improvement contrib- a direct impact on poverty and develop- utes to better health, health also contributes ment. Inequities in health care financing, for to economic growth and development by example the financial vulnerability caused increasing the social capital in terms of: a by high levels of out-of-pocket spending healthy and productive workforce, reduced on health care services, constitute a major absenteeism, savings resulting from the barrier to access to health care by the poor prevention of occupational hazards, and in many low- and middle-income countries increased number of disability-free years worldwide, including the Eastern Mediter- of life. Models of the contribution of health ranean Region. Poor patients, in the absence development to economic growth have been of social health protection mechanisms, described by developmental economists often face catastrophic medical care expen- worldwide and this concept was behind ditures when they become sick which may the focus of the 1993 World Development impoverish them and their families. Report: investing in health [3]. The contri- Studies implemented by WHO in 42 bution of major public health programmes, countries including in 2 in the Eastern including malaria and river blindness con- Mediterranean WHO regional office have trol in Africa and Asia, to freeing more land shown that 2±3 of households face cata- for housing and agricultural development, strophic health care expenditures and that was clearly evident in economic terms. 1±2 are pushed into poverty when they In recent works, developmental econo- become sick. Translating this into figures, mists, including Nobel prize-winner health systems in the Eastern Mediterranean Amartya Sen and Nicholas Stern, have Region are producing an additional 10 mil- highlighted the importance of social en- lion poor people every year. gagement and empowerment. Without em- Public health professionals through- powerment, argues Stern, economic growth out history have been keenly aware of the will not bring improvement in health and need to fight against poverty in order to education or relief from poverty. The active achieve better health outcomes. Health pro- involvement of individuals, and communi- fessionals, dealing with poor and deprived ties, in decisions that affect their lives is populations, are often frustrated by the crucial. lack of response to their health and medical Health systems play an important role in interventions as patients again become sick securing access to health care provided that when they return to their home environ- they are adequately financed, governed and ment which lacks appropriate nutrition, managed at the various levels. Countries safe water and sanitation. In dealing with with low incomes spend less on health patients, physicians have the obligation to

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Traditional medicine Many countries use traditional medicine to help meet some of their primary health care needs: in Africa, up to 80% of the population uses traditional medicine for primary health care. In China, traditional herbal preparations account for 0%²0% of total medicinal consumption and in Germany, 90% of the population have used a natural remedy at some point in their life. The World Health Organization (WHO) launched its first ever comprehensive traditional medicine strategy in 2002. The strategy is designed to assist countries to: develop national policies on the evaluation and regulation of traditional/complementary practices; create a stronger evidence base on the safety, efficacy and quality of the products and practices; ensure availability and affordability, including essential herbal medicines; document traditional medicines and remedies. At present, WHO is supporting clinical studies on antimalarials in 3 African countries. Collaboration is also taking place with a number of countries, including Burkina Faso, Mali, Nigeria and Kenya in the research and evaluation of herbal treatments for HIV/AIDS, malaria, sickle cell anaemia and diabetes mellitus. In Tanzania, WHO, in collaboration with China, is providing technical support to the government for the production of antimalarials derived from the Chinese herb Artemisia annua. Local production will bring the price of one dose down from 8S ² to a more affordable 8S 2.

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-RXVSHYGXMSR Earlier, the Universal Declaration of Human Rights adopted by United Nations Human development does not depend sim- General Assembly Resolution 217A (III) of ply on national income; it goes far beyond December 10, 1948 stipulated that all the that. It is ³about creating an environment individuals in society are equally entitled in which people can develop their full po- to the right of access to public services, tential and lead productive, creative lives social security, work, and free choice of in accord with their needs and interests« employment. It is also said, ³Everyone has Development is thus about expanding the the right to a standard of living adequate for choices people have to lead lives that they the health and well-being of himself and of value´ [1]. In order to have more choices re- his family, including food, clothing, hous- quires building human capabilities, i.e. the ing and medical care and necessary social things that people can do or be in life. ³The services´ [3]. In poor countries, fulfilment most basic capabilities for human develop- of these rights remains a great challenge. ment are to lead long and healthy lives, to Poverty is a multidimensional concept: be knowledgeable, to have access to the the most popular definitions relate poverty resources needed for a decent standard of to income or to the provision of the basic living and to be able to participate in the life needs. An often used definition of the pov- of the community´ [1]. erty line is an income of US$ 1 per day per The United Nations Conference on En- person. Poverty can also be viewed from the vironment and Development held in Rio basic needs perspective where poor families de Janeiro, Brazil, in June 1992, led to the are characterized by frequent illness, low famous Rio declaration stating as principle birth weight, low education, social or po- 1 that ³Human beings are at the centre of litical marginalization, and discrimination concerns for sustainable development. They based on gender or age or other [4]. are entitled to a healthy and productive life It has been shown that health and de- in harmony with nature´[2]. velopment go hand in hand; they have a

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S reciprocal influence on each other and each motion, triggering appropriate initiatives enhances the effects of the other. Health de- for improving health and quality of life of teriorates with poor socioeconomic condi- communities. This effort was promoted tions and is generally poor in circumstances within the WHO Eastern Mediterranean where development is lagging. The poor Region (EMR) through community-based health conditions associated with under- initiatives (CBI) composed of basic de- development and poverty reduce productiv- velopment needs (BDN), healthy villages ity and worsen other aspects of life. On the programme, healthy cities programme, and other hand, holistic development improves women in health and development, which health which further enhances levels of have provided opportunities to integrate development. health interventions in local development Poverty remains one of the main causes processes. These initiatives have imple- of ill-health because poor people are less mented flexible strategies at the local level likely to have access to good quality health- in different cultures and societies by ac- care services, proper education, safe water tively involving communities and the re- and sanitation and other basic needs. Ac- lated sectors. The CBI approach addresses cording to the World Health Organization the major socioeconomic determinants of (WHO), approximately 1.2 billion people health within a broad perspective of devel- in the world live in extreme poverty. Those opment and creates access to the essential people are five times more likely to die social services to provide optimum equity before reaching the age of 5 years, and two at the grass-roots level. The outcomes of and half times more likely to die between these initiatives provide clear evidence that the ages of 15 and 59 years, compared health is a human capital and investment to those living in higher-income groups. to promote comprehensive development Moreover, the gap between the rich and results in the improved quality of life and poor is growing with serious implications well-being of the communities [6]. for health [5]. This paper discusses how WHO/EMRO A less recognized reality is that im- has advocated the importance of alleviat- proved health status can alleviate vulner- ing poverty in order to improve the health ability and offer a route out of poverty. Both of individuals and their communities and macro- and microeconomic studies indicate fulfil other socioeconomic needs through that better health translates into greater and community ownership and intersectoral more equitably distributed wealth because it collaboration. builds human capital and increases productivity. Indeed, healthy children are better able to learn, while healthy breadwinner 'SRGITXSJGSQQYRMX]FEWIH adults are more able to work and care for MRMXMEXMZIW their families. The health sector has thus sufficient incentives to justify engaging in The concept of CBI is a continuum of poverty reduction initiatives, and needs to WHO¶s definition of health that encom- develop both the skills and infrastructures passes a holistic approach to health with necessary to work in partnership with other as much significance ascribed to the social sectors and the community. well-being of the individual as to physical In the past few decades, the health sector and mental health. In fact, CBI can be seen has proved its catalytic role in health pro- as an extension of primary health care that

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S libraries and community-based information tegral part of the responsibilities of the vil- centres, supporting agriculture and livestock lage/community development committees projects, and tree planting. The provision of who manage this revolving fund. The CBI microcredit schemes for income generation intersectoral team reviews the feasibility also falls within the purview of CBI. All of the proposals prior to finalization. The these activities are, however, preceded by loans are repaid on instalment to the village an elaborate exercise aimed at organizing development committee once the project and mobilizing the community with an is operational so that the money can be emphasis on their enhanced awareness of redistributed to other needy members of the health issues, active participation, gender community. mainstreaming and self-reliance. Local The CBI interventions assume added cluster representatives (CRs), district au- relevance for the countries of the Eastern thorities and public sector line departments Mediterranean in the light of a recent WHO contribute and complement each other in initiative, the Commission for the Social programme implementation. Determinants of Health (CSDH). The so- Representatives from various line de- cial determinants of health refer to both partments constitute the CBI intersectoral specific features and pathways by which teams, which are instrumental in providing societal conditions affect health and which the requisite guidance in building local can potentially be altered by informed ac- organizations to enhance community in- tion. Many of the inequalities in health, volvement. The teams offer technical as- both within and between countries, can be sistance in priority areas for community understood in terms of inequalities in the action related to social development and social conditions in which people live and poverty reduction. These teams vigilantly work, such as literacy, housing, employ- support the implementation process of care- ment, etc. These social determinants of fully selected social and income-generating daily life have a major impact on health ventures and develop an interactive work- status and on general well-being. Tackling ing relationship with village/community such underlying causes of poor health can development committees. They also con- contribute to improving health and health stitute the bridge that conveys community equity. CBI is thus seen as an appropri- concerns and perceived needs and priorities ate grass-roots intervention to address key to the relevant line departments of the dis- social determinants of health in EMR and trict government. CBI teams are thus help- beyond [8]. ful in generating the trust and confidence necessary for building a solid partnership between the government and civil society '&-WXEXYWMRXLI)EWXIVR organizations. Furthermore, in most of the 1IHMXIVVERIER6IKMSR villages within the CBI area of operation, women¶s organizations are established to The basic development needs programme, spearhead women¶s development activities the healthy villages programme, the healthy at the community level. cities programme and the women in health Provision of interest-free loans for and development programme are being income-generating schemes targets the implemented in 17 countries in EMR. Cur- poorest members of the community with rently, these interventions cover a popula- defined criteria. This is included as an in- tion of 17 503 841 people.

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EMRO is advocating the sustainabil- and international nongovernmental organi- ity of CBI interventions as a vital strategy zations. Djibouti, with the consent of 5 during the programme expansion in the other ministries as well as the Ministry of member countries. This is achieved through Health, has included basic development community involvement in programme needs as part of the national health and management, partnership approaches and development strategy. This is a promising institutionalization of the programme as an action paving the way for more programme integral part of the system. Member States expansion. Other countries implementing have demonstrated different degrees of CBI are in the process of integrating the institutionalizing CBI within the national community-based approach within their development policy. For instance, Bah- health and development plans. rain, Islamic Republic of Iran, Iraq, Jordan, The Regional Office assists countries Morocco, Oman, Pakistan, Saudi Arabia, in developing model areas to implement Sudan, Syrian Arab Republic and Yemen CBI. These model areas can serve as the have established a unit responsible for CBI operational research projects and the basis within the Ministry of Health. Jordan, Pa- for subsequent expansion to a national pro- kistan and Syrian Arab Republic have also gramme. allocated an annual budget for maintenance Figure 2 shows the improvement in and expansion of the programme. Jordan, health and in other social indicators in coun- Pakistan, Sudan and Syrian Arab Republic tries where the CBI programme has been have linked the programme with national evaluated.

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8S[EVHWWYWXEMREFPI by the end of 2007. Another key interven- GSQQYRMX]FEWIHMRMXMEXMZIW tion is the preparation of a plan to expand community-based health insurance schemes Commitment of the national and local gov- in Pakistan, Sudan and Yemen in 2008. ernments, collaboration with civil society The experience in countries of the EMR and some form of external financial support with CBI, where health is central to the are essential to meet the challenge of sus- development process, provides a useful tainability and scaling up of CBI. Monitor- model for other regions for providing inter- ing, evaluation and documentation need to ventions at the grass-roots level that address be improved, but at the same time care is the social determinants of health. CBI is needed not to compromise the participa- especially effective in overcoming gender tion of community members in the process discrimination and in providing a social of data collection and management, as this environment that supports women¶s devel- is essential to the local feeling of project opment. Despite the effectiveness of CBI, ³ownership´. Nor must the emerging lead- the major challenge is its full ownership by ership roles of local women be undermined the community and its institutionalization if work through formal government chan- within national health and development nels ignores the community voice. policies and programmes. WHO continues Plans for future interventions build on its technical support to Member States to current CBI experiences. Thus there are overcome these challenges and make CBI plans to expand community-based strate- a part of the national health and develop- gies to control malaria, tuberculosis and ment plans. This will eventually improve HIV/AIDS, applying the lessons learned the quality of life of the people, particularly from CBI. One objective is to make DOTS the poor and most vulnerable groups of the available in all BDN areas of the Region community.

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El Niño and malaria The term El Niño is nowadays used to refer to periods of strong and prolonged warm weather in the eastern Pacific which influence the climate worldwide. Events occur every 2² years and last around 2²8 months. They begin with the weakening of the prevailing winds in the Pacific and a shift in rainfall patterns; the warm waters are accompanied by changes of air pressure in the Pacific. The whole cycle is now referred to as El Niño Southern Oscillation (ENSO). The regions where El Niño has a strong effect on climate are those with the least resources: southern Africa, parts of South America, South-East Asia. The El Niño phenomenon provides good opportunities to study effects of climate variability on human health. Research is centred on the ability to predict El Niño events: seasonal forecasts are used to predict major climate trends for anything from several months to a few seasons ahead and are much more reliable during El Niño. WHO is a member of the United Nations Inter-Agency Task Force on El Niño, which aims to develop strategies towards prevention, prepared- ness and mitigation as regards El Niño-induced disasters. ENSO is associated with increased risks of some of the diseases transmitted by mosquitoes, such as malaria, dengue and Rift Valley fever. Malaria transmission is particularly sensitive to weather conditions. In some highland regions of the world, higher temperatures possibly linked to El Niño may increase transmission. This has been shown to occur in higher latitude parts of Asia such as northern Pakistan. A pilot study on the application of seasonal forecasting to malaria control has been undertaken in southern Africa. WHO·s ´Roll Back Malariaµ initiative targets control efforts to years when there is a high-risk of El Niño, increasing the cost-effectiveness of malaria control; the judicious use of insecticides can also delay the development of resistance. Source: WHO Fact sheet N°192

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S

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-RXVSHYGXMSR Even in the most affluent countries, people who are less well off have substantially Debate around poverty and health has been shorter life expectancies and more illnesses going on for decades. More central to this than the rich. Not only are these differences debate in recent times is the argument in health an important social injustice, they whether poverty leads to ill-health, or poor have also drawn scientific attention to some health is a precursor of poverty. Although of the most powerful determinants of health ample scientific evidence currently sup- standards in modern societies [3]. ports both arguments, the fact remains the This paper frames a debate around the same: poverty and ill-health almost always nexus between ill-health and poverty and co-exist. articulates the various dimensions of health In recent years, governments and devel- promotion, viz. exploring the dynamics of opment partners have placed greater focus how health promotion interventions can on addressing the determinants of health. be relevant in poverty reduction, and thus Health promotion, as defined in the Ottawa improving the health of the population. Charter in 1986, has been shown to be an important element of public health [1]. By virtue of this phenomenon, health promo- *VEQMRKXLIHIFEXI tion has been shown to address the ³causes of the causes´ of health, thereby improving The definition of health promotion as out- the health of the population. The nexus of lined in the Ottawa Charter is ³Health pro- health and poverty has also been reinforced motion is the process of enabling people in the United Nations Millennium Devel- to increase control over, and to improve, opment Goals. The importance of these their health´. To reach a state of complete goals in health is, in one sense, self-evident. physical, mental and social well-being, an Improving the health and longevity of the individual or group must be able to identify poor is an end in itself² a fundamental goal and to realize aspirations, to satisfy needs, of economic development. But it is also a and to change or cope with the environment. meansto achieving the other development Health is, therefore, seen as a resource for goals relating to poverty reduction [2]. The everyday life, not the objective of living. linkages of health to poverty reduction and Health is a positive concept emphasizing to long-term economic growth are powerful, social and personal resources, as well as much stronger than is generally understood. physical capacities. Therefore, health pro-

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S motion is not just the responsibility of the health outcomes would improve. This has, health sector, but goes beyond healthy life- however, proven not to be an automatic styles to well-being [1]. This definition has process [7]. Moreover, studies in recent been amplified in practice and has been the years have shown that improvements in subject of 6 global conferences. To many, health contribute significantly to economic the Ottawa charter for health promotion growth. became the gospel and foundation stone of Health is a continuum that ranges from a new public health movement [4]. the healthy, unexposed population through In many parts of the world, health pro- to the population that suffers from specific motion goals and processes are firmly em- diseases and their consequences. Health bedded in national and multinational health promotion incorporates both upstream ap- policies, objectives and targets. The focus proaches (aiming to improve the contexts of health promotion on the prerequisites for health generation, improving social for health and equity in health is recog- capital and community capacity to act on nized nationally and globally through the health) as well as downstream actions (risk Millennium Development Goals and other reduction through behaviour change com- policies to address social and economic munication, promotion of self-help in dis- determinants of health and inequalities in ease and coping with the consequences of health. The Ottawa Charter¶s call to work disease). in partnership with other sectors to develop The focus is on upstream approaches, healthier public policy has been widely with the Bangkok charter for health promo- adopted and implemented. This has taken tion in a globalized world [8] identifying shape in various ways, reflecting social, actions and commitments in 4 areas: cultural and economic contexts and the the global development agenda stage of development of health promotion whole-of-government approaches practice [5]. action by communities and civil society The number of people living in absolute poverty and despair is growing stead- health promotion as an integral part of ily despite unprecedented wealth creation good corporate practice. worldwide in the past 2 decades. Today nearly 1300 million people live in absolute poverty [6]. Poverty is a major cause of 8LIRI\YWFIX[IIRTSZIVX]ERH ill-health; it contributes to the spread of LIEPXL disease, undermines the effectiveness of health services and slows population con- Health is unevenly distributed among so- trol. Morbidity and disability among poor cial groups in the population. We have to and disadvantaged groups lead to a vicious acknowledge that we live in a stratified spiral of marginalization, to their remain- society, where the most privileged people, ing in poverty, and in turn, to increased in economic terms, have the best health. ill-health. In the past, spending on health These inequalities in health are socially and health programmes was considered determined, unfair and modifiable. At the to be expenditure on welfare and welfare same time there has been a paradigm shift programmes. It was thought that economic in the perception and vocabulary of de- growth would make more resources avail- velopment in recent years. Where once able to health systems and that as a result development was equated with economic

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S growth, which was seen as the ultimate social services, productive employment goal, now poverty reduction is seen as the opportunities and better governance, not as overarching achievement of development. an end in itself. Where the route to economic growth was As Williamson says, ³povert\ is« a once seen as running through investment in complex phenomenon rooted in an array physical capital, it is now recognised that of factors and conditions, many of which many forms of capital, including human extend beyond the control of the health and social capital, contribute to the growth sector´ [10]. Poverty reduction is not a of output [9]. Poverty itself is recognised as feature that can be accomplished by any one a multifaceted concept, not simply a matter person in any one sector because poverty is of insufficient income, but also a matter of multi-faceted and deeply rooted in many insufficient or inappropriate earning capaci- socioenvironmental conditions. It calls for a ties in relation to ill health, ignorance, and community-based, multisectoral approach. lack of power and voice. Where once it The nexus between poverty and health is was assumed that the benefits of economic best articulated in Figure 1. growth would eventually ³trickle down´ to At a purely material level, income has an the poor, the delivery of welfare to the poor obvious impact on health insofar as it pro- in the forms of improved livelihoods, social vides the means of obtaining the fundamen- services, and benevolent governance is now tal prerequisites for health such as shelter, seen as both a direct assault on those multi- food, warmth and the ability to participate ple deprivations and as an investment in the in society. Low income, therefore, increases capacities of the poor to lift themselves out individuals¶ exposure to harmful environ- of poverty. ments, e.g. inadequate housing, and reduces Economic growth is still perceived as a family¶s ability to purchase necessities desirable, but it is for its instrumental value such as a healthy diet. Poverty also rein- in enhancing the resource base to deliver forces health-damaging behaviours [11].

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8LITPEGISJLIEPXLTVSQSXMSR reinforcement and extension of health MRTSZIVX]VIHYGXMSR systems to provide better management of poor communities by increasing the Health promotion is a basic building block budget of ministries of health and using of public health. Together with popula- their resources more effectively; tion health assessment, health surveillance, strengthening inter-sectoral collabora- disease and injury prevention, and health tion for the benefit of the poor in order protection, health promotion is a central to have a positive impact on the key public health function that furthers allpublic determinants (education, employment, health work. Health promotion and disease nutrition, participation of the poor in and injury prevention can be approached by decision-making). addressing individual risk factors for spe- Priority interventions aimed at reducing cific health outcomes (e.g. poor nutrition, poverty must be based on certain major prin- physical inactivity, excessive sun exposure) ciples such as equity and ethics, relevance or by addressing the underlying societal of health interventions to the needs of the risk conditions (e.g. poverty and socioeco- poor, accessibility, quality, efficiency and nomic-related linked inequities) [12]. For sustainability, participation of communities many years, the international health com- concerned, and the taking into account of munity has been pointing to the large gaps gender specificity. in health outcomes between rich and poor Interventions may comprise actions countries. Extensive scientific evidence is aimed at improving health through the in- now available on the factors that contribute tensification of the fight against practices to good health outcomes in childhood, the harmful to health, tuberculosis, maternal and reproductive period and adulthood. For ex- child mortality, tobacco use, malnutrition ample, much is known about preventive and and HIV/AIDS, and also through immuni- curative health services that promote good zation, education, environmental health and health among small children, sound dietary clean water supply. and sanitary practices and the importance of A common claim that is incessantly stimulation for young children [13]. reiterated in health promotion is lack of Health² along with education² is seen resources. There is a broadly held belief as one of the key ultimate goals of develop- that economically poor countries have far ment. Indeed, increasingly health is seen fewer resources than others with which to as a dimensionof poverty in its own right. engage in interventions to promote health. This is reflected in the fact that no less than Moreover, this issue of resources seems to 4 of the 7 Millennium Development Goals be a feature that distinguishes the practice relate to health broadly defined. The role of health promotion in the economically- that health promotion can play in combating developed world from that carried out in poverty is based on 3 essential components, the economically-poor world. This may namely: not, however, accurately represent the situ- definition and implementation of prior- ation. The argument can surely be made that ity interventions and health services, resources are more than purely financial, taking into account the major causes and that communities throughout the world of morbidity and mortality among the have many different kinds of resources with poor; which to support and carry out interventions

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S that are health promoting. In fact, an entire to managing and improving health at in- area of research and practice has arisen on dividual, community, national and global how to recognize, foster and benefit from levels [15]. The commonplace of arguing assets for health promotion. Nonetheless, for the place of health promotion in poverty in terms of visibility of health-promoting reduction clearly has convergent theoreti- interventions, financial resources seem to cal foundations. They refer to the need to be the cornerstone for subsistence and dis- work ³upstream´, to address the ³causes semination. It is, however, the case that of the causes´. They are founded on strong quite often there are important and critical ideology and have complementary evidence interventions occurring in the less eco- bases. They recognize the need to operate nomically developed world that are indeed on social structures, to involve non-health effective, but these are not seen because the sectors and indeed to base the emphasis of financial issues associated with evaluation, their work on ³whole-of-government´ com- publication, diffusion, etc. are not available. mitment. Together, these areas demonstrate The assumption that there are noteworthy the scope, breadth and depth of actions that and vital effective interventions occurring governments and society as a whole must in the developing world has come to be an undertake in order to achieve better health accepted belief among many in the field of outcomes. Indeed, a key challenge for a health promotion [14]. unified approach to these areas would be to demonstrate what it would take for public health to navigate complex social and po- (MWGYWWMSRERHGSRGPYWMSR litical processes that are driving the way in which health and resources for health are Many factors play a part in creating and per- distributed. petuating social inequalities in health. The Convergence, though, is not identity. situation is complex, but we can neverthe- The juxtaposition of the work of these fields less state that it is generally social circum- raises a number of areas of difference such stances that affect health and not the other as those outlined below (World Health Or- way round. Although in many cases serious ganization, unpublished report, 2007). The health problems lead to loss of income and following scenarios are simplified versions work and difficulties completing education, of actual situations that demonstrate the social status still has a bigger impact on different contributions to be made within health than health does on social status. a unified structure that addresses all the The Ottawa Charter formally recog- determinants of health: nized that health services should incor- porate health promotion concepts such as Burden versus gradient² How are poli- community development, empowerment cy-makers to reconcile efforts to improve and advocacy, and called upon the health the public health situation of the popula- sector to move in this direction. The charter tion generally (e.g. broad improvements states that ³... the health sector must move in nutritional status) with the observa- increasingly in a health promotion direction that this may be associated with tion, beyond its responsibility for providing worsening inequity (as better-off social clinical and curative services´. The charter classes get proportionally greater im- provides logic and order to health promo- provement)? Broad improvements, the tion. It also discusses normative approaches population approach to prevention, may

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S

need to be balanced against high-risk ap- smaller portion of the burden is caused proaches (intensive targeted prevention by indoor air pollution which is con- for the poorest classes). But how are we centrated in the poorest segments of to develop an investment framework for the population. Clearly, both are issues such activities? that need addressing, but capacity is Conflict of interest² A soft drinks com- limited and local public health officials pany mini-sizes its products (sells it in need guidance on whether to primarily small bottles priced at a level affordable invest in tobacco control (the traditional by poorer families) and uses micro- public health approach) or in promotion finance strategies to ensure a distri- of safer fuels (a primarily equity-based bution mechanism that extends to the strategy). farthest reaches of the poorest shanty That being said, fair distribution of re- towns. Is this an example of a pro-poor sources is a good public health policy [17]. initiative offering a way out of poverty The primary goal of future public health and generation of small businesses? Or work is not to further improve the health of is it an example of cynical marketing de- the people who already enjoy good health: signed to maximize sales while diverting the challenge now is to bring the rest of the poor families¶ incomes into the purchase population up to the same level as the peo- of ³empty´ nutrients? ple who have the best health² levelling up. Side-effects of structural interven- In conclusion, it may be argued that tions² Raising people out of poverty health promotion has an in-built survival has an energy cost. If poorer countries kit since it deals not only with disease pre- develop via the use of environmentally vention, but the changing or promotion of unsound technologies, then the net ef- conditions within which health can thrive fect of massive poverty alleviation pro- [18]. Health promotion seeks to promote grammes could contribute to intolerable conditions supportive of health improve- global warming. For instance, biofuels, ment, and for this reason both the developed which supposedly have a neutral effect and developing countries must cooperate on the environment and promote income to ensure that the discipline is well estab- for poorer countries that export the raw lished in the latter. All policymakers and materials (e.g. palm oil), have recently programme managers are keen to see better been documented as causing widespread health outcomes for the populations they environmental degradation as slash and serve. Better health outcomes are achieved burn agricultural techniques and clear- through well-functioning health systems, ance of peat areas are adopted to make characterized by good governance, adequate way for increased palm oil production and fair financing, optimal distribution of [16]. resources and accessible services, priority Priority setting² Consider this scenario health programmes targeting problems that for a community which has a significant are responsible for the major burden of burden of chronic respiratory diseases. diseases, and promotional components that Most of the burden is due to tobac- tackle the upstream health determinants co smoking, concentrated in the richer [19]. parts of this middle-income country. A

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-RXVSHYGXMSR required for any national hepatitis vaccination programme [6]. Viral hepatitis, which causes various forms In Egypt, which is considered an area of of acute and chronic liver disease, presents a high endemicity for HAV infection, marked public health problem worldwide. Hepatitis economic, hygiene, and sanitary improve- A virus (HAV) is an enterically transmitted ments have taken place in recent years, viral infection, endemic in many develop- especially in urban areas [7]. Improvements ing countries, where the prevalence can in living conditions may lead to changes in approach 100% in children by 5 years of the epidemiology of HAV infection, with age [1]. Most infections in children younger a decrease in antibody prevalence among than this are asymptomatic or have mild, children; consequently a significant propor- nonspecific manifestations (e.g. fever) that tion of the adolescent and adult population are indistinguishable from other viral infec- will be at risk of infection [8]. tions. With increasing age symptomatic The aim of the present study was to as- acute infection is more common; chronic sess the difference in the seroprevalence of HAV infection does not occur [2]. anti-HAV antibodies and the age of symp- Seroprevalence of HAV infection var- tomatic HAV infection among children of ies from one country to another according different socioeconomic status in Cairo, to socioeconomic factors and standard of Egypt. We also aimed to identify potential living. In the developing countries, HAV risk factors for seropositivity for anti-HAV is acquired very early in life and nearly antibodies. 100% of adults have detectable levels of anti-HAV and are therefore immune to infection. In such countries, epidemics of 1IXLSHW HAV are uncommon [3]. In the more developed countries, where there is good This was a cross-sectional study carried out sanitation and hygiene, most people reach in the Health Insurance Clinic at El Abas- adulthood without experiencing infection. It seya, Cairo during the 6 month period Oc- is characterized by a low prevalence among tober 2003±March 2004. The clinic serves children (10%), and a large susceptible several areas, mainly of low SES. Approval pool of adults being negative for anti-HAV from the General Institute of Health Insur- (about 63%) [4]. ance was taken to allow the researchers In the United States of America, because to conduct the study and to collect blood children account for at least one third of from the participants. All students referred cases and are also a potential source of to the health insurance services for further infection for others, routine vaccination of examination for minor medical problems children is an effective way of reducing (school accidents, falls, cuts, headache, hepatitis A incidence [5]. Highly effec- pallor, problems in visual acuity, etc.) were tive vaccines against hepatitis A have been asked to participate in this study. The clinic available since the mid 1990s, but vaccina- is one of the paediatric clinics of the Gen- tion is expensive and there are numerous eral Institute of Health Insurance (Ministry reports worldwide on the changing epide- of Health and Population). It serves school- miology of hepatitis A and its prevalence. children referred from public schools in the Therefore, information on the prevalence area. Therefore the participants are repre- of immunity in each population would be sentative of the school population in urban

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S and semi-urban areas. For younger children, infection, 142 children of high SES, chil- parent¶s consent for taking a blood sample dren of physicians working in the National was taken; for those aged 11 years and over, Research Centre, of comparable age and sex consent was obtained from both the parent were also studied. and the child. There were 10 refusals to Blood was drawn aseptically by participate and 2 children who had already venepuncture by a physician in the outpa- been vaccinated against hepatitis A were tients¶ laboratory (clinical and chemical excluded. pathology) at the General Institute of Health All children aged 3±18 years, consecu- Insurance. The serum was separated by tively attending the Health Insurance Clinic centrifugation at 2000 rpm for 20 minutes; during the study period were invited to serum was stored at ±20 C until examined participate in the study without any selec- for determination of antibodies to HAV us- tion. Children who attended more than ing competitive enzyme immunoassay com- once during the study period were included mercial kits (Dia.Pro Diagnostic Bioprobes only once. Parents of young children were Srl, Milan, Italy). This is a solid phase interviewed by a member of the research sandwich enzyme (linked immunosorbent team, while adolescents were personally assay) [10]. Liver enzyme alanine ami- interviewed, in the presence of their par- notransferase (ALT) level was evaluated ents, to complete a questionnaire to collect to assess liver function by a kinetic method demographic data (age, sex, residence, level (ELITech Diagnostic Kit, SEPPIM, Sees, of education, number of family members, France) [11]. SES, etc.), home sanitary conditions (source Data entry and analysis were done us- of drinking water, sewage disposal, etc.) and ing SPSS, version 9. Statistical analysis of previous history of symptomatic hepatitis A the results was made by applying the chi- (history of jaundice, confirmed by elevated squared test of significance. liver enzymes and positive antibody test). The association between potential risk Socioeconomic status (SES) was de- factors and past infection with HAV was termined according to the scale of Fahmy evaluated using backward logistic regres- and El-Sherbiny [9]; 7 items were assessed sion analysis. Goodness-of-fit statistics to categorize SES of the children into very were examined to determine appropriate- low, low, middle and high. These items ness of the final models. Risk factors en- were: mother¶s education, father¶s educa- tered in the logistic analysis included age, tion, family income, family size, water sex, housing conditions and socioeconomic supply, refuse disposal and sewage disposal variables to detect the most significant pre- [9]. dictive risk factors associated with HAV Residence was divided into 4 regions seropositivity. based on level of environmental sanitation and source of water supply: region 1: Hadaek El Kobbah and surrounding areas; region 2: 6IWYPXW Misr El Kademah and El Moneib; region 3: Among the children who participated from Mansheyet Nasser and El Duekah; region 4: the Health Insurance Clinic, seroprevalence Ain Shams and surrounding areas. of anti-HAV antibodies was 86.2% overall, To compare between the children of low 85.3% among males and 86.9% females SES and children of high SES as regards the with no statistically significant difference prevalence and age symptomatic of HAV

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(P > 0.05). In the high SES group (children < 0.05). There was also a statistically sig- of physicians), overall prevalence of anti- nificant association between HAV seroposi- HAV antibodies was 50.2%, also with no tivity and socioeconomic status (P < 0.01). significant difference between males and A higher proportion of children from the females. very low social level were HAV positive A significantly higher prevalence of (91.7%) compared to the other social levels anti-HAV in relation to age was observed in (Table 2). A higher prevalence of anti-HAV the low SES children, 64.3% among those (90.0%) was also found among children liv- 6 years, 85.3% among those aged 6±10 ing in slum areas (areas with non-hygienic years, and 90.0% among older children water supply, sewage disposal and refuse ( 11 years) (P < 0.05). disposal) compared to areas with a safe The relations between prevalence of water supply and basic sanitation (77.6%) anti-HAV antibodies and socioeconomic (P < 0.01). There was a significant regional characteristics and sanitary housing con- (based on sanitation and water supply) vari- ditions among the participants from the ation in the anti-HAV prevalence, it was Health Insurance Clinic are shown in Table lowest (73.2%) in region 1 and highest 2. There was a statistically significant as- (95.8%) in region 4 (P < 0.001). sociation with education of parents: sero- Among the 367 HAV-seropositive chil- prevalence of anti-HAV antibodies was dren participating from the Health Insurance higher for children whose parents were Clinic, 33 had had symptomatic disease. At educated to preparatory level or below (P the time of the study, 6 children had acute hepatitis with elevated serum ALT (range 74±422 U/L). Table 3 shows no significant 8E FP I 7IVSTVIZEPIRGISJERXMLITEXMXMW% statistical difference in the seroprevalence ZMVYW ,%: ERXMFSHMIWEQSRKEKVSYTSJ of HAV antibodies between children with GLMPHVIRJVSQPS[WSGMSIGSRSQMGEVIEWMR a history of jaundice or contact with a jaun- 'EMVS diced patient and those without (P > 0.05). :EVMEFPI 2S %RXM,%:ZI 4 Excluding the 6 cases with acute infection, 2S there was no significant difference in mean 7I\ALT levels among children positive for (9.7 1EPI U/L; standard deviation 4.5) and negative *IQEPI for (9.5 U/L; standard deviation 5.5) HAV %KI ]IEVW IgG antibodies (P > 0.05). From multiple logistic analysis, wa- z ter supply and sewage disposal were the z most important risk factors for prediction of " HAV seropositivity among the participants )HYGEXMSRE from the Health Insurance Clinic. The risk /MRHIVKEVXIR of infection with HAV was 3 times higher 4VMQEV] among children using a public water supply 4VITEVEXSV] compared to those with piped water inside 7IGSRHEV] the home. Using non-hygienic sewage dis- 8S X E P posal increased the risk of HAV infection EGLMPHVIR ]IEVWSPH[IVIRSXVIKMWXIVIHMR 2.6-fold compared to using a private toilet OMRHIVKEVXIRERHWXE]IHLSQI[MXLXLIMVQSXLIVW with flush (Table 4).

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Table 5 shows the comparison between HAV infection contracted at 10 years of the children of very low and low SES (from age or older was significantly higher among the Health Insurance Clinic) and those from children of high SES than among those of high SES (142 children of physicians from very low and low SES (P < 0.05). They the National Research Centre). Seropreva- also reported having more severe symptoms lence of HAV antibodies was significantly compared to younger children lower among children of high SES (50.7%) than among those of very low and low SES (87.7%) (P < 0.01). The proportion (MWGYWWMSR of children with history of symptomatic Results of the present study were compared with previous HAV seroprevalence studies done in Egypt [12±16]. Direct comparison 8E FP I 1YPXMTPIPSKMWXMGEREP]WMWMHIRXMJ]MRK between these studies is difficult because VMWOJEGXSVWWMKRMJMGERXP]TVIHMGXMZISJ different age strata and geographical distri- LITEXMXMW%ZMVYWWIVSTSWMXMZMX] bution were studied. However, the overall 4VIHMGXMZIZEVMEFPI %HNYWXIH '- seroprevalence of hepatitis A in all the 36 previous studies ranges between 89.4% ;EXIVWYTTP] (in Alexandria) and 100% (in rural areas). -RWMHILSYWI 6 In the present study, although the overall 3YXWMHILSYWI z prevalence of anti-HAV was still very high 7I[EKI (86.2%) it was slightly lower than in the 4VMZEXIXSMPIX[MXLJPYWL 6 previous studies. A similar high prevalence 2SRL]KMIRMGHMWTSWEP z has been reported from Palestine (93.3%) 4 and Syria (89%) [17,18]. Intermediate prev- 4 36!SHHWVEXMS '-!GSRJMHIRGIMRXIVZEP alence of 52.4% has been recorded in Saudi 6!VIJIVIRGIKVSYT Arabia [19].

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A higher prevalence of anti-HAV anti- SES [26]. In the present study the majority bodies was noted with greater family size but of low SES children who gave a history of it was not statistically significant. However, symptomatic HAV infection were under 10 Fix et al. found a significant association years of age while for children of high SES between the prevalence of anti-HAV anti- the majority who gave history of symp- bodies and crowded living situations [24]. tomatic infection were aged 10 years. The present study as well as other studies Children who got symptomatic infection revealed that lower levels of maternal or above age of 10 years reported severe form paternal education were significantly as- of symptoms compared to younger children. sociated with a higher seroprevalence [24]. Similarly, Arguedas and Fallon reported A history of hepatitis or of contact with that the severity of HAV illness increases a case of hepatitis has been shown to be with age [27]. associated with anti-HAV seropositivity To sum up, despite improvements in [19]. In the present study no statistically sig- gross national products and in socioeco- nificant association was found. Regarding nomic standards [28], Egypt is still highly children who had history of symptomatic endemic for HAV infection, especially HAV infection, most contracted the infec- among those living in a low SES with poor tion before 10 years of age but more than 20% housing conditions. While, nearly half contracted the infection at age 10 years. of the studied children of high SES were While more than 80% of cases of hepatitis A susceptible to hepatitis A infection (non- occurring in children under 5 years of age immune). Raising the socioeconomic stand- are asymptomatic, infected children without ard of the population, improving housing jaundice can still shed the virus and serve conditions and improving sanitary condi- as a source of infection for others [25]. tions are needed for these low SES regions. Tosun et al. reported a shift of seropositiv- Further studies are needed for high SES ity from children to adolescents in Turkey, children to assess their need for HAV vac- especially in families with average or high cination.

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-RXVSHYGXMSR This case±control study was undertaken to investigate this subject and the inconsist- Similar to other human cancers, breast can- ency between the results of the studies in cer arises from a multifactorial process. northern and central parts of the Islamic Re- Recent attention has focused on genetic public of Iran and populations elsewhere. predisposition to breast cancer [1,2] and on its association with factors relating to modern affluence, including diet and al- 1IXLSHW cohol consumption [3±5]. Furthermore, the effect of reproductive factors strongly A case±control study was conducted from supports a hormonal role in its etiology in April 2000 to March 2002 in Bandar Abbas some industrialized countries [6,7]. Earlier city, Hormozgan, Islamic Republic of Iran. age at menarche [8±10] and later age at first Hormozgan province is the southernmost full-term pregnancy [9±12] are associated province of the country located along the with a significant increase in the risk of the Straits of Hormoz. disease, whereas the few studies that have The eligible cases were all incident (i.e. been conducted in northern and central diagnosed within 2 years before the inter- parts of the Islamic Republic of Iran have view) breast cancer patients living in the not confirmed a significant effect of these city during the study period. We approached factors [13±15]. 173 women with primary breast cancer who While numerous studies have been con- were eligible for our study but only 168 ducted in industrialized countries to assess agreed to participate, giving a participation the epidemiology of breast cancer, there rate for cases of 97.1%. have been few studies in Eastern Mediter- Women were entered into the study if ranean Region populations. Such studies they had a confirmed pathological primary are of interest because their different risk breast cancer diagnosis from the pathology profiles may help to explain the different department of Bandar Abbas Shahid Mo- occurrence of the disease in different popu- hammadi Hospital, the leading university- lations. Although breast cancer is the most based hospital in the region. For each case, common form of cancer in Iranian women 3 age-matched (to within 3 years) women [16], few epidemiological studies have been were recruited from patients without any conducted on its risk factors, especially in history of breast problems or neoplastic the south of the country. The age-adjusted diseases who attended the outpatient oph- incidence of the disease is estimated to be thalmology or dermatology clinic in the 22.4 per 100 000 [16]. Epidemiological same hospital. Women with a history of studies have revealed a lower age of Iranian hysterectomy or artificial menopause were patients compared with their counterparts in excluded from the study. industrialized countries [14,17] and a mod- After taking informed consent from the erately rapid increase in the incidence of the women, a structured questionnaire was disease in recent years [16]. The question administered was completed at the time therefore arises as to whether or not breast of recruitment including the following: cancer in the south of the Islamic Republic demographic characteristics, family history of Iran is influenced by some of the risk of breast cancer in a first-degree relative, factors previously established in studies of age at menarche, marital status, parity, age high or moderate incidence areas. at first full-term pregnancy, number of chil-

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(OR 7.79, 95% CI: 4.25±9.12 ) (Table 2 ). accepted or suspected risk factors in the Furthermore, it was shown that > 5 full-term Islamic Republic of Iran. pregnancies would be expected to correlate As in industrialized countries, we found with an increase in the risk of breast cancer that a family history of breast cancer was ( ² = 111.12, P < 0.05). an important factor contributing to breast In forward multivariate logistic regres- cancer in the south of the Islamic Republic sion analysis, in addition to those factors of Iran. This observed familial association which were significantly associated with is likely to imply a genetic predisposition. breast cancer, parity and breastfeeding were Therefore, it is of interest to determine included in the model because of their rela- whether known breast cancer susceptibil- tively high but not statistically significant ity genes, such as BRCA1 [18] and BRCA2 OR. The final model revealed that in addi- [19], responsible for a proportion of breast tion to those factors which were significant cancers in other countries [8,9,20], also play in univariate logistic regression analysis, a role in breast cancer in Islamic Republic negative history of breastfeeding was a of Iran. significant factor in increasing risk of breast The relation between women¶s risk of cancer (OR 1.55, 95% CI: 1.08±2.90), but breast cancer and reproductive history has nulliparity remained not significant. been the subject of many investigations [5±17,21±31]. Despite the large number of studies, the findings for reproductive risk (MWGYWWMSR factors have been inconsistent. Our findings suggest an inverse relationship between age The purpose of the present study was to at menarche and breast cancer risk, which characterize breast cancer epidemiology, is consistent with findings in some studies especially in determining the generally

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[8±10], although it was not a significant The results of the few studies in northern risk factor for breast cancer in some other and central parts of Islamic Republic of Iran populations [5,11,13±15,17]. The basis of do not indicate a significant relationship this difference in different populations is between history of breastfeeding and breast not clear and warrants further study. cancer rate [13±15], but according to the The findings of our study show that results of the present study, the protective never married women were at higher risk effect of breastfeeding was clear on multi- for breast cancer. However, results of multivariate analysis. This finding is consistent variate logistic regression analysis revealed with a large collaborative study [26] and that nulliparity was not a statistical sig- some other studies in different populations nificant risk factor for breast cancer. These [5,8,9,11,23,27±29] showing breastfeeding results are in agreement with the results to be protective for breast cancer through of another study on the Iranian population hormonal or other mechanisms. [17]. In some studies, single and nullipa- Recent reviews reach conflicting con- rous married women were found to have a clusions on breast cancer risk after spon- similar increased risk for breast cancer as taneous or induced abortion [13,15,30,31]. compared with parous women of the same In our study, history of abortion, either age [21]. Thus one possible explanation for spontaneous or induced, was not found to these results is that marital status or nul- be correlated to breast cancer. liparity by itself is not a determining factor Disagreement remains in the literature for increased or decreased beast cancer risk, on the direction and magnitude of effect, and rather the main effect is due to age at if any, of oral contraceptive use on breast first full-term pregnancy or parity number. cancer risk [5,8,9,17,28,32±34]. Despite Our findings clearly suggest that older large studies designed to address such dif- age at first full-term pregnancy increased ferences, chance, selection factors, changes the risk of breast cancer. Although this in formulations, pattern of use and different result is consistent with some studies in background risk for breast cancer might ac- different nations and ethnic groups [9±12], count for some of the variation in findings. it is inconsistent with findings from some No association was found between the use other studies and particularly from studies of oral contraceptives and breast cancer risk in northern and central parts of the Islamic in our study participants. Republic of Iran [5,8,13±15,17]. Our results show that there was no large Although on the basis of a suggested difference in ever-use of HRT among cases influence of full-term pregnancy on breast and controls, which was similar to some re- cells [22] an increase in full-term pregnan- cent case±control studies [5,35]. However, cies would be expected to correlate with a small increased risk has been observed in a decreased risk of breast cancer in some larger studies [36,37], which might be ac- women [8,11,23], evidence suggest that counted for by the specific questions about there is a dual effect of parity on breast types of HRT and the small sample size of cancer risk with pregnancy [11,24,25]. our study; future studies may need to exam- Our findings showed that more than 5 full- ine the detail of different HRT regimens and term pregnancies would be expected to duration or age of use. correlate with an increase in the risk of Smoking history was not associated breast cancer. with breast cancer risk. This result is in

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S agreement with the results of some other of breast cancer risk factors in developing studies [5,8]. countries might reveal other important risk A number of limitations such as the factors in these populations. small sample size and the selection of case and controls may affect the interpretation of our results. Although the results cannot %GORS[PIHKIQIRXW be generalized, the findings suggest that the We thank Sepideh Ebrahimi and Maria Re- associations between some known risk fac- zazadeh for interviewing and study assist- tors for breast cancer may differ in the south ance. We are also grateful for the time and of the Islamic Republic of Iran as compared commitment of the study participants. with other populations. Intensive studies

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Global age-friendly cities: a guide Population ageing and urbanization comprise major forces shaping the 21st century. At the same time as cities are growing, their share of residents aged 60 years and over is increasing. Older people are a resource for their families, communities and economies. The World Health Organization (WHO) regards active ageing as a lifelong process shaped by several factors that favour health, participation and security in older adult life. The purpose of this Guide is to engage cities to become more age-friendly so as to tap the potential that older people represent for humanity. WHO asked older people, caregivers and service providers living in 33 cities in all WHO regions to describe the advantages and barriers they experience in eight areas of city living. The results led to the development of a set of age-friendly city checklists. The challenge facing cities and the ´active ageingµ concept are outlined. Issues and concerns voiced by older people and those who serve older people are highlighted. The principal traits of the ´idealµ age-friendly city are listed and the Guide shows how changing one aspect of the city can have positive effects on the lives of older people in other areas. WHO collaborators are now undertaking initiatives to translate the research into local action, to expand the scope beyond cities, and to spread it to more communities. An age-friendly community movement is growing, for which this Guide is the starting point. It can be downloaded from: http://www.who.int/ageing/publications/Global_ age_friendly_cities_Guide_English.pdf

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-RXVSHYGXMSR (CHA), l¶h{pital général Peltier (HGP), le centre d¶Einguela, le Centre des Forces La Rppublique de Djibouti, d¶une superficie Nationales de Police (FNP), le Centre de de 23 000 km2, compte 690 000 habitants. l¶Armée Nationale Djiboutienne et le Cen- La séroprévalence du VIH est de 2,9 % et tre Paul Faure (CPF). Il s¶agit d¶une analyse l¶on estime j 9100 le nombre de personnes en intention de traiter. vivant avec le VIH dans le pays [1]. La mise Cette enqurte a eu l¶autorisation du mi- à disposition du traitement antirétroviral a nistère de la Santé et du Programme de lutte démarré en mars 2004. Est éligible au trai- contre le SIDA. Le patient était informé tement antirétroviral tout patient séropositif de l¶enqurte et son consentement libre et au stade IV de la classification SIDA de éclairé a été obtenu avant l¶examen. Tout au l¶Organisation mondiale de la Santé (OMS) long de cette enquête, le respect rigoureux ou ayant des CD4 (Lymphocytes T Clus- et strict de la confidentialité et du secret ter of Differenciation 4) 200/mm3. Les médical a été observé. schémas thérapeutiques prescrits sont, pour le traitement de première ligne, 2 inhibi- 'SPPIGXIHIWHSRRÍIW teurs nucléosidiques de la transcriptase Le recueil des données a été réalisé à l¶aide inverse (INTI) + 1 inhibiteur non nucléosi- d¶un formulaire. La variable dépendante est dique de la transcriptase inverse (INNTI) ou la charge virale (CV). Les variables indé- 3 inhibiteurs nucléosidiques de la transcrip- pendantes sont au plan des renseignements tase inverse (INTI), et pour le traitement généraux (la date d¶inclusion, la date de de 2e ligne, 2 INTI + 1 IP (inhibiteur de la l¶enquête, l¶âge, le sexe, l¶état matrimonial, protéase). le district d¶origine, le centre de traitement, Il importe, après une année de mise en la catégorie socio-professionnelle), au plan route du projet pilote, d¶évaluer son effica- clinique (le poids, la taille, l¶état général cité et sa tolérance. Pour ce faire, nous nous coté grâce à l¶indice de Karnofsky [IK], les sommes fixés comme objectifs d¶évaluer affections opportunistes, le stade clinique l¶efficacité et la tolérance clinique et biolo- selon la classification OMS du SIDA au gique du traitement, de vérifier la corréla- début du traitement, les troubles digestifs, tion entre les CD4 et les lymphocytes totaux neurologiques et lipidiques), au plan théra- (LT) et d¶identifier les facteurs influenoant peutique (les associations d¶antirétroviraux le succès thérapeutique. prescrits), au plan biologique (le taux de CD4, le taux d¶hémoglobine, le nombre de globules blancs, le taux de plaquettes, 1ÍXLSHIW le taux des lymphocytes totaux, la créa- 7GLÍQEHvÍXYHI tininémie, les transaminases glutamique Il s¶agit d¶une enqurte transversale mul- oxalo-acétique [TGO] et glutamique-pyru- ticentrique couvrant la période d¶octobre vique [TGP], la triglycéridémie). L¶outil de 2004 à mars 2005, soit une durée de 6 mois, collecte est un questionnaire. Les données qui regroupe l¶ensemble des séropositifs cliniques sont recueillies lors des consulta- âgés de plus de 15 ans, traités depuis au tions et les prélèvements sanguins réalisés moins 3 mois, quel que soit le protocole au moment de l¶enquête. prescrit sur l¶un des 9 sites : le Centre Yo- nis Toussaint (CYT), les deux centres de 1ÍXLSHIHvÍZEPYEXMSR santé de l¶Organisme de Protection So- L¶efficacité virologique est appréhendée ciale (OPS), le Centre Hospitalier Bouffard à travers la charge virale. Au delà de trois

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S mois de traitement, on considère qu¶il y a 400 copies après trois mois de traitement. un échec virologique si la charge virale est La charge virale est mesurée sur une échelle supérieure ou égale à 400 copies/mL et un logarithmique décimale (log10). Les tests de succès virologique si la charge virale est 2, de Fischer et de Mac Nemar sont utilisés inférieure à 400 copies/mL. On considère pour la comparaison des variables qualitati- qu¶il y a un succès immunologique si on a ves. La comparaison des différences des va- une augmentation de plus de 20 % du taux riables quantitatives clinique et biologique de CD4 initial et un échec si on a moins de est réalisée à l¶aide du test T de Wilcoxon. 20 %. Un taux d¶hémoglobine < 12 g/dL La comparaison d¶une variable continue correspond à une anémie, des leucocytes entre deux groupes est réalisée à l¶aide des < 4 G/L correspondent à une leucopénie tests de Mann-Whitney et entre plusieurs et des plaquettes < 150 G/L à une throm- groupes à l¶aide du test de Kruskall-Wallis. bopénie. L¶association d¶une anémie + Pour vérifier la corrélation entre le taux leucopénie ou thrombopénie + anémie ou de CD4 et le taux de lymphocytes, le test leucopénie + thrombopénie correspond à du coefficient de corrélation de Spearman une bicytopénie et une pancytopénie cor- et une représentation graphique selon un respond à anémie + leucopénie + thrombo- modèle de régression linéaire sont utilisés. pénie. L¶indice de masse corporelle (IMC) Une analyse multivariée est réalisée à correspond au rapport poids / (taille)². l¶aide d¶un modèle de régression logistique. La procédure de sélection pas à pas des- 8IGLRMUYIWHIPEFSVEXSMVI cendante est utilisée pour obtenir le modèle Pour le suivi, le dosage des CD4 est réalisé final contenant uniquement les variables grâce à deux appareils FACS-Count (Fluo- significatives et les variables de confusion. rescent Activated Cell Sorter) de Becton Tous les tests ont été interprétés avec un Dickinson. La technique NASBA (Nucleic seuil de significativité de 5 %, et les inter- Acid Sequence-Based Amplification) déve- valles de confiance ont été calculés à 95 %. loppée par bioMérieux permet la réalisation de la charge virale. Sa sensibilité est à partir de 25 UI/mL. La numération formule 6ÍWYPXEXW sanguine (NFS) + plaquette est obtenue à (IWGVMTXMSRHIPETSTYPEXMSRHvÍXYHI l¶aide de l¶appareil Micros développé par Pour l¶enquête, 112 patients sont retenus. Abis ; cet appareil ne donne pas la formule La durée médiane sous traitement antirétro- leucocytaire. Ces bilans sont réalisés au viral des patients est de 196 jours (écart in- niveau du laboratoire de l¶h{pital général terquartile [EIQ] : 132-252). L¶âge médian Peltier, vers lequel tous les prélèvements est de 36 ans (EIQ : 30-41). L¶âge moyen convergeaient. des hommes est de 38 ans (IC 95 % : 35,9- 40,3) et celui des femmes de 34,7 ans (IC %REP]WIWXEXMWXMUYI 95 % : 32,6-36,9). Les femmes sont Les données, saisies à l¶aide du logiciel plus jeunes que les hommes (p = 0,03). Epidata 3.02 (Centers for Disease Control Le sex ratio est de 1,04. Les patients vi- and Prevention [CDC], Atlanta, États-Unis) vant ou ayant vécu en couple sont sont analysées dans le logiciel Stata 8.1, majoritaires (82,14 %). Les sans-emploi re- (Stata Corporation, College Station, Texas, présentent 54,46 %. Les patients des districts Ét a t s - U n i s ) . (15 %) s¶approvisionnent en antirétroviraux Le critère principal de jugement de l¶ef- (ARV) à Djibouti-ville ; 52 % des patients ficacité est une charge virale inférieure à

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S de Balbala (arrondissements 4 & 5) suivent leucoplasie (4,5 %), la salmonellose leur traitement à l¶h{pital général Peltier. (3,6 %), la toxoplasmose (2,7 %), la maladie Les patients sont suivis à l¶h{pital général de Kaposi (0,9 %) et une tumeur oculaire Peltier (36 %), le centre Yonis Toussaint (0,9 %). Selon la classification du CDC (27 %), le centre hospitalier des armées d¶Atlanta, 7 % sont au stade A, 26 % au françaises Bouffard (21 %), le centre Paul stade B et 67 % au stade C. Au niveau des Faure (8 %), les deux centres de santé de LT CD4 (Lymphocytes T Cluster of Diffe- l¶Organisme de Protection Sociale (7 %) et renciation 4), 4,5 % ont plus de 500/mm3, le centre communautaire d¶Einguela (1 %). 16,1 % entre 500 et 200/mm3 et 67 % ont au Les caractéristiques socio-démographiques plus 200/mm3. ¬ l¶inclusion, le taux médian sont présentées au Tableau 1. de CD4 est de 118/mm3 (EIQ : 52-186). Les principales affections opportunis- Quatre-vingt-dix pour cent (90 %) des tes présentées à l¶initiation du traitement patients sont au stade SIDA selon la défi- sont les candidoses (51 %), la tuberculose nition du CDC d¶Atlanta de 1993. Il existe (39 %), les lymphadénopathies (37,5 %), une différence dans la distribution des CD4 les diarrhées (12,5 %), les broncho- entre les trois stades cliniques (p = 0,009). pneumonies (11,7 %), le pru- Les taux moyens de CD4 pour les stades rigo (11,6 %), le syndrome cachec- A, B, et C sont respectivement de 89, 59 et tique (10,7 %), le zona (7,1 %) et la 52 cellules/mm3. La description clinique, biologique et thérapeutique de la population d¶étude est résumée dans le Tableau 2. Quant au profil virologique, le VIH 1 est 8EFPIEY6ÍTEVXMXMSRHIPETSTYPEXMSR prédominant avec 97,32 %. La moitié des HvÍXYHIWIPSRPIWGEVEGXÍVMWXMUYIWWSGMS patients ont reçu une trithérapie associant HÍQSKVETLMUYIW 2 INTI +1 INNTI (51 %). Les différentes 'EVEGXÍVMWXMUYIW 2FVI combinaisons antirétrovirales sont présen- tées au Tableau 3. ¦KI ERW " )JJMGEGMXÍHYXVEMXIQIRXERXMVÍXVSZMVEP Pour l¶ensemble des patients, le gain mé- 7I\I dian de CD4 est de 82 cellules/mm3. La *ÍQMRMR 1EWGYPMR charge virale médiane est de 1,4 log10 (EIQ : 1,4-2,9). Toutefois, 18 patients (16 %) pré- XEXQEXVMQSRMEP sentent un rebond virologique. Selon notre 1EVMÍ I 'ÍPMFEXEMVI définition de l¶efficacité, le traitement est :IYJ ZI efficace respectivement au plan virologique (MZSVGÍ I chez 83 patients (74 %) et au plan immuno- 'EXÍKSVMIWSGMSTVSJIWWMSRRIPPI logique chez 80 (71 %) ; 72 (64 %) présen- %HQMRMWXVEXMSR tent un succès immuno-virologique contre 'SQQIVËERX 18 (16 %) en échec (Tableaux 4 et 5). On 8VERWTSVX note une discordance immuno-virologique PÌZIÍXYHMERX chez 20 %. %VXMWER L¶efficacité ne diffère pas selon le pro- 7ERWIQTPSM tocole prescrit (2 INTI + 1 INNTI, 2 INTI + %YXVIW 1IP ou 3 INTI ; p = 0,21) et le profil clinico-

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8EFPIEY(IWGVMTXMSRGPMRMUYIFMSPSKMUYIIX immunologique initial (stades selon le CDC XLÍVETIYXMUYIHIPETSTYPEXMSRHvÍXYHI d¶Atlanta, p = 0,065). L¶amélioration des indicateurs cliniques 'EVEGXÍVMWXMUYIW -RMXMEXMSR est statistiquement significative (Tableau -/ 5). En effet, les gains médians en IK sont de 1ÍHMERI )-5 20 %, en IMC de 2,1 kg/m². Une réduction -1' OKQ de 62,2 % des affections opportunistes est 1ÍHMERI )-5 retrouvée. Si l¶on compare les patients en %JJIGXMSRWSTTSVXYRMWXIW succès et ceux en échec virologique, les ?2FVI A patients en succès ont moins d¶affections 7XEHIGPMRMUYIÄPvMRGPYWMSR opportunistes (p = 0,002), une meilleure ?2FVI A amélioration de l¶état général (gain en IK 7XEHI% de 4 %, p = 0,04) mais l¶IMC n¶est pas 7XEHI& distribué différemment parmi les patients en 7XEHI' succès et ceux en échec (p = 0,33). 8EY\HI'( QQ 1ÍHMERI )-5 'SVVÍPEXMSRIRXVIPIWP]QTLSG]XIW 0MKRIWXLÍVETIYXMUYIW XSXEY\IXPIW08'(ÄPvMRMXMEXMSRHY ?2FVI A XVEMXIQIRX -28--228- La Figure 1 permet de déceler que les deux -28- variables évoluent dans le même sens dans -28--4 une relation linéaire directement propor- -/MRHMGIHI/EVRSJWO] tionnelle. -1'MRHMGIHIQEWWIGSVTSVIPPI )-5ÍGEVXMRXIVUYEVXMPI

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8EFPIEY)JJMGEGMXÍMQQYRSPSKMUYIIX abdominales (9,1 %), de troubles du som- ZMVSPSKMUYI meil (18,2 %), de neuropathie périphérique (18,2 %) et d¶éruption cutanée (9,1 %). Les 2FVI troubles digestifs (54,6 %) (nausées, vomis- 2MZIEYZMVSPSKMUYI GSTMIWQ0 sements, diarrhées, douleurs abdominales) ': sont en tête des effets indésirables, suivis ': des troubles neuropsychiques (36,4 %) puis 2MZIEYMQQYRSPSKMUYIGSIJJMGMIRX de la toxicité cutanée (9 %). Il est important HvEWGIRWMSRHYXEY\HI'(MRMXMEP de noter que 15 patients (13,39 %) ont eu un changement de traitement. ¬ l¶initiation, une grande partie des ':GLEVKIZMVEPI patients soit 87 (78 %) présentent une anémie, 37 (33 %) une leucopénie et 26 (23 %) une thrombopénie. Au moment Le coefficient de Spearman (r = 0,51 ; de l¶enquête, 78 (69,6 %) présentent une p < 0,0001) montre une forte corrélation anémie, 6 (5,4 %) une thrombopénie et 34 entre les deux variables. Les lymphocytes (30,4 %) une leucopénie. Sous traitement, permettent d¶expliquer au début plus de on retrouve un gain médian de plaquettes de 50 % de la variance observée des LT CD4. 53 G/L et de 0,35 g/dL d¶hémoglobine ; Pour déterminer le seuil de lymphocytes 36 patients présentaient une bicytopénie et totaux correspondant au taux de CD4 200/ 4 une pancytopénie contre 30 bicytopénies mm3, nous avons stratifié le taux de lym- et 4 pancytopénies à l¶initiation du trai- phocytes totaux selon le taux de LT CD4 tement. La distribution de l¶anémie (p = de mise sous antirétroviraux retenu dans les 0,06), de la lymphopénie (p = 0,42), de la pays en développement ( 200/mm3). En se thrombopénie (p = 0,14) et de la leucopénie basant uniquement sur la recommandation (p = 0,93) ne diffère pas chez les patients en de l¶OMS qui est le seuil de 1,2 G/L de lym- échec et ceux en succès. phocytes totaux, on retrouve que seulement Le dosage des transaminases retrouve 33 % des patients nécessitant un traitement 19 % des patients ayant des TGO et des auraient été mis sous antirétroviraux. TGP élevées mais une créatininémie et Si l¶on prend la valeur 1,7 G/L comme une triglycéridémie normales. Les valeurs seuil de lymphocytes totaux pour la mise retrouvées des paramètres biochimiques sous traitement, seuls 6 % des patients sont résumées dans le Tableau 5. seraient mis sous traitement par erreur et En analyse multivariée, on retrouve deux 53 % des patients nécessitant le traitement facteurs associés au succès thérapeutique : l¶auraient reçu. Si l¶on élève le taux de CD4 un bon état général (IK > 70 %) et la qualité pour la mise sous traitement à 350/mm3, des soins. Les patients ayant un stade clini- seuls 3 patients auraient été mis par erreur que avancé à l¶inclusion sont prédisposés à sous traitement. l¶échec (Tableau 6).

8SPÍVERGIGPMRMUYIIXFMSPSKMUYI La prévalence des effets indésirables sous (MWGYWWMSR ARV est de 84 % ; 44 % des patients étaient 9RITSTYPEXMSRGMFPITIYHMZIVWMJMÍI à trois mois de traitement. Les patients ÄYRWXEHIEZERGÍHIPEQEPEHMI se plaignent de nausées-vomissements À Djibouti, la couverture du traitement an- (27,3 %), de diarrhées (18,2 %), de douleurs tirétroviral est de 3 % jusqu¶à fin décembre

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2004 contre 1 % en Afrique [2]. Le jeune en charge tardive. Une assistance finan- âge des femmes indique leur entrée précoce cière s¶avère utile pour permettre à ces en sexualité. En effet, elles se marient plus patients d¶avoir un niveau de vie décent et jeunes que les hommes. La majorité des de poursuivre les soins. Les données socio- contaminations se produisent au sein des démographiques rejoignent celles retrou- couples hétérosexuels. La prédominance vées en Afrique [3-5]. des sans-emploi s¶explique par le taux de La découverte du VIH chez les patients ch{mage élevé ainsi que l¶incapacité phy- était le plus souvent à la suite de la survenue sique des séropositifs d¶exercer, vu la prise d¶affections opportunistes. Un travail anté-

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rieur à Djibouti classait la tuberculose en tête leur utilisation s¶explique par la précocité des affections opportunistes [6]. Les mêmes du traitement et la proportion élevée de tu- proportions d¶affections opportunistes sont berculeux empêchant l¶association avec retrouvées au Gabon [7] au Bénin [8] et en la rifampicine. Toutefois, cet acquis est à Afrique du Sud [9]. En outre, le VIH 1, plus conserver par un renforcement de l¶obser- transmissible que le VIH 2 et entraînant une vance afin d¶éviter l¶émergence de souches progression plus rapide vers les stades de résistantes sachant que le développement SIDA-maladie, représente la majorité des des résistances aux INNTI est très rapide identifications réalisées contre 95,2 % au [11]. Bénin [5] et 95,8 % au Sénégal [3]. À l¶initiation, le poids et l¶indice de masse corporelle médians sont plus faibles que 9REGUYMWGPMRMUYIWXEFPIIXYRI ceux des cohortes sénégalaise et béninoise VÍTSRWIMQQYRSZMVSPSKMUYI [3,5]. Toutefois, au moment de l¶enquête, WSYXIRYI les niveaux atteints par nos patients sont L¶usage des inhibiteurs de la protéase pré- importants. Cette nette amélioration des domine au Sénégal [3] et au Bénin [5] par paramètres cliniques s¶explique par la prise rapport à Djibouti. Les inhibiteurs de la en charge des affections opportunistes mais protéase sont reconnus pour la révolution aussi l¶hygiène de vie. de la thérapie antirétrovirale dans les essais À l¶inclusion, le taux médian de CD4 cliniques [10,11]. La faible proportion de est de 118/mm³ contre 117 au Bénin [5]

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S et 124 au Sénégal [3]. L¶efficacité théra- autres cohortes africaines est probablement peutique rejoint celle observée au Bénin due à la zidovudine. [4], au Sénégal [3], en Europe [12] et aux Cependant, l¶importance des bicyto- Ét a t s - U n i s d ¶Amérique [13,14]. Cepen- pénies et des pancytopénies est liée aux dant, on retrouve une discordance immuno- stades avancés de l¶infection. Parmi les virologique chez nos patients [12]. patients ayant les transaminases élevées, Le dosage des lymphocytes totaux n¶est la recherche de l¶antigène Australia (HBs) pas spécifique aux LT CD4 puisqu¶ils re- est positive chez deux. Par contre, il n¶y a groupent, en plus des LT CD4, les lympho- pas d¶atteintes rénales, ni de troubles du cytes B et les lymphocytes Natural Killer. métabolisme lipidique ou de la répartition Pourtant à l¶initiation du traitement, on des graisses [23]. En outre, deux facteurs retrouve une corrélation entre les LT CD4 peuvent influencer le succès thérapeutique : et les lymphocytes totaux aussi bien dans la qualité des soins et un bon état général notre étude (r = 0,50) que dans les études à l¶initiation du traitement. Cette analyse béninoise [3] (r = 0,37), sud-africaine [9] confirme que le traitement antirétroviral (r = 0,61), américaine [15] (r = 0,69) et n¶est pas une urgence et qu¶au lieu d¶instau- éthiopienne [16]. Ces études montrent in- rer rapidement le traitement antirétroviral, directement aussi que des patients ont été il est préférable de prendre en charge les af- mis inutilement sous traitement (27 % à fections opportunistes et d¶améliorer l¶état San Francisco Hospital [17]). Le rebond général. L¶analyse multivariée corrobore viral constaté est plus lié à un relâchement les résultats des études réalisées en Europe de l¶observance qu¶à une sélection de virus [12] et aux États-Unis d¶Amérique [13,14]. mutant. Par contre, il n¶est pas exclu de rechercher une résistance éventuelle, d¶o &MEMWIXZEPMHMXÍ l¶intérêt du test génotypique de résistance Une grande partie des patients n¶avait pas [18-21]. Il est important de juguler précoce- eu leur bilan de contrôle selon le calendrier ment une situation d¶échec. de suivi. La peur de la stigmatisation et les longues files d¶attente les dissuadent de se 9RXVEMXIQIRXFMIRXSPÍVÍIXYR présenter au centre et des intermédiaires les EZIRMVTVSQIXXIYV ravitaillent en antirétroviraux. Les assis- La prévalence des patients présentant des tants psychosociaux et les accompagnateurs effets indésirables est de 84 % ; elle est de thérapeutiques les ont convaincus de se pré- 75,4 % au Bénin [22] et de 49 % au Sénégal senter pour les prélèvements. La population [3]. La majorité de ces événements sont d¶étude est représentative de la population d¶ordre digestif et neuropsychique comme sous traitement antirétroviral à Djibouti au Bénin [22] et au Sénégal [3]. La toxi- puisque tous les patients éligibles ont été cité hématologique est surtout marquée par retenus. Les résultats obtenus ne peuvent l¶anémie. Cette dernière est fréquemment être généralisés du fait du faible nombre associée à la prise de la zidovudine et de l¶in- de patients sous traitement au moment de dinavir. Plusieurs patients sous zidovudine l¶enquête. Par contre, on peut avoir un biais ont été transfusés. En effet, la zidovudine d¶information lié à l¶enregistrement des provoque une anémie centrale macrocytaire. données. Le biais de classement des patients Toutefois, la proportion d¶anémie élevée au en succès ou en échec est possible. sein de notre cohorte comparativement aux

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-RXVSHYGXMSR afin de limiter l¶émergence de souches résistantes et de prévenir l¶échec thérapeu- Dans les pays du Sud, seuls 12 % des per- tique [11-13]. sonnes ont accès au traitement antirétroviral Nous nous sommes fixés comme objec- fin 2004 [1]. Les régimes thérapeutiques tif de déterminer le taux d¶observance au prescrits sont, pour le traitement de pre- traitement antirétroviral et d¶identifier les mière ligne, 2 inhibiteurs nucléosidiques facteurs prédictifs d¶une mauvaise obser- de la transcriptase inverse (INTI) + 1 inhi- vance. biteur non nucléosidique de la transcriptase inverse (INNTI) ou 3 inhibiteurs nucléosi- diques de la transcriptase inverse (INTI), et 1ÍXLSHIW pour le traitement de 2e ligne, 2 INTI + 1 IP (inhibiteur de la protéase). Les pays ayant 8]TIHvÍXYHI développé des programmes d¶accès aux Il s¶agit d¶une enquête transversale sur une antirétroviraux sont confrontés à l¶organisa- population qui regroupe l¶ensemble des tion de l¶observance. En effet, l¶observance personnes vivant avec le VIH, âgées de plus est la capacité du malade à respecter les de 15 ans, sous antirétroviraux, présentes prises du traitement qui lui a été prescrit. dans le district de Djibouti du 31 janvier au Elle a été souvent considérée comme un 1er mai 2005. objectif irréalisable dans les pays africains. L¶évaluation des programmes d¶accès aux 4STYPEXMSRHvÍXYHI antirétroviraux (ARV) au Sénégal [2], en Les patients sélectionnés pour l¶enquête Côte d¶Ivoire [3,4] et au Burkina Faso [5] sont les personnes vivant avec le VIH âgées montre qu¶il n¶y a pas de difficulté spécifi- de plus de 15 ans, sous antirétroviraux de- que mais que le principal obstacle au suivi puis au moins trois mois, suivies dans l¶un du traitement est d¶ordre économique (dif- des neuf centres de santé, figurant dans le ficulté financière des patients, approvision- registre du projet d¶accès au traitement, nement discontinu en antirétroviraux) et résidant dans le district de Djibouti durant géographique (nécessité de déplacement). la période de l¶enquête, quels que soient le La valeur moyenne de l¶observance est pas- sexe, la nationalité, la situation familiale et sée de 83 % en 1999 à 90 % en 2000, suite à le protocole prescrit. Les exclus sont les re- une réduction de la participation financière fus motivés après information et les absents [2,6,7]. du district au moment de l¶enquête. À Djibouti, le traitement antirétroviral et les bilans biologiques nécessaires au suivi 'SPPIGXIHIWHSRRÍIW sont gratuits. Une grande partie des patients Le dispositif de recueil des informations vit dans la capitale Djibouti, qui regroupe les est un questionnaire anonyme avec des neuf centres de traitement. Dans ce contexte questions fermées qui a fait l¶objet d¶un pré- de gratuité et de proximité des soins, quels test. Chaque patient vient avec sa dernière sont les autres aléas de l¶observance ? ordonnance et avec les antirétroviraux qui Du fait de la corrélation forte entre restent. Puis, on lui remet le questionnaire l¶observance et l¶évolution de l¶infection qu¶il aura à remplir seul. Les patients illet- à VIH [8-10], il est opportun d¶évaluer dès trés sont interrogés. Ont été combinées les à présent le niveau d¶observance dans cette méthodes de l¶entretien pour les illettrés, cohorte avant l¶extension du programme de l¶autoquestionnaire pour les autres et du

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S dénombrement des comprimés pour tous a été utilisée pour le dosage au niveau du les patients [14]. Les autres variables explo- Centre National de Transfusion Sanguine rent quatre composantes : et de l¶Unité de Biologie-SIDA de l¶hôpital la composante socio-démographique : général Peltier. Le seuil de détection de la âge, sexe, état matrimonial, niveau charge virale plasmatique est de 25 copies/ d¶étude, revenu, adhésion à une asso- mL. L¶efficacité virologique est appréhen- ciation, aide communautaire, soutien de dée à travers la charge virale à au moins l¶entourage ; trois mois de traitement. On considère qu¶il la composante comportementale : durée y a : du traitement, khat, tabac, motifs de échec virologique si la charge virale est prise manquée (financier, judiciaire, supérieure à 400 copies/mL ; survenue d¶autres affections, effets gê- succès virologique si la charge virale est nants, oubli, conflits familiaux, durée inférieure ou égale à 400 copies/mL. longue, rupture de stock, prise simul- tanée d¶autres médicaments, sommeil, 8IGLRMUYIHvEREP]WI médecine traditionnelle, consomma- La variable dépendante est l¶observance. tion de khat), participation financière, Les données sont analysées avec le logiciel conservation des produits, attitude ; Stata 8.1. La comparaison des variables la perception des soins : qualité de vie qualitatives est réalisée avec le test de 2 (échelle visuelle de qualité de vie), ou le test exact de Fischer et les variables confidentialité, disponibilité du person- quantitatives à l¶aide du test de Mann- nel, conseil, distance du centre, relation Whitney. La corrélation entre la charge de confiance ; virale et le taux d¶observance est testée la composante biologique : charge vi- à l¶aide du coefficient de Spearman. Le rale. modèle de régression linéaire a permis un aperçu visuel de cette corrélation. La charge virale est analysée sur une échelle logarith- 'VMXÌVIWHvÍZEPYEXMSR mique décimale (log ). Tous les tests ont Le critère principal d¶évaluation de l¶obser- 10 vance a été le dénombrement des comprimés été interprétés avec un seuil de significati- restants. Le ratio d¶observance est calculé à vité de 5 % et les intervalles de confiance partir du rapport entre le nombre de doses calculés à 95 %. prises et le nombre de doses prescrites. Il est Pour identifier les facteurs prédictifs exprimé en pourcentage. Le nombre de do- de la non-observance, on a effectué une ses concerne l¶ensemble des antirétroviraux analyse multivariée à l¶aide d¶un modèle prescrits. On considère un patient observant de régression logistique. La procédure de si le ratio d¶observance est 90 % et non sélection pas à pas descendante a été utilisée observant si ce ratio est < 90 %. pour obtenir le modèle final contenant uni- À la fin de l¶interrogatoire, pour les quement les variables significatives dont le patients n¶ayant pas eu de contrôle biologi- p < 0,05 et les variables de confusion. que dans les 15 jours précédant l¶enquête, un prélèvement sanguin pour le dosage de 'SRWMHÍVEXMSRWÍXLMUYIW la charge virale est réalisé. La technique Le ministère de la Santé et le Programme NASBA (Nucleic Acid Sequenced Based de lutte contre le SIDA ont donné leur aval Amplification) développée par bioMérieux à cette étude. Les patients ont été informés

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S et leur consentement libre et éclairé a été 8EFPIEY'EVEGXÍVMWXMUYIWWSGMS obtenu avant l¶enquête. Tout au long de HÍQSKVETLMUYIWHIWTEXMIRXW R! cette étude, le secret médical a été respecté de manière stricte et rigoureuse. 'EVEGXÍVMWXMUYI )JJIGXMJW ¦KIQÍHMERI?)-5A 7I\I 6ÍWYPXEXW ,SQQIW *IQQIW (IWGVMTXMSRHIPETSTYPEXMSRHvÍXYHI Participation XEXQEXVMQSRMEP 1EVMÍ I Fin janvier 2005, 200 patients ont été mis 'ÍPMFEXEMVI sous traitement antirétroviral. Dans une :IYJ ZI période allant de mars 2004 à janvier 2005, (MZSVGÍ I 145 recevaient ce traitement depuis au 2MZIEYHvÍXYHI moins trois mois, 8 patients sont décédés, 7ERWRMZIEY 7 perdus de vue et 10 absents du district 7GSPEMVI de Djibouti. Entre janvier et avril 2005, le 7IGSRHEMVI questionnaire a été présenté à 110 patients. 9RMZIVWMXEMVI Sept patients n¶ont pas répondu, 6 ont refusé 1IQFVIHvYRIEWWSGMEXMSR de participer par peur de discrimination et %MHIGSQQYREYXEMVI 4 par insatisfaction de l¶appui social, 7 'SRWSQQEXMSRHIOLEX n¶ont pas eu de dosage de la charge virale suite à une rupture des réactifs. Au total, 'SRWSQQEXMSRHIXEFEG 86 patients ont été retenus pour l¶analyse. )-5ÍGEVXMRXIVUYEVXMPI Les 86 patients étaient naïfs de traitement antirétroviral. Aucun des patients n¶a béné- ficié de consultations d¶éducation thérapeu- tique. Les patients ont reçu un traitement Françaises Bouffard, 4 (5 %) à l¶Organisme associant 2 INTI + 1 INNTI (52 %), 3 INTI de Protection Sociale et 3 (3 %) au Centre (40 %), 2 INTI + 1 IP (8 %). Les proportions de pneumo-phtisiologie Paul Faure. Seuls des associations en un comprimé prescri- 28 % sont salariés et 8 % ont une activité tes sont à 86 % zidovudine/lamivudine, à génératrice de revenus mais 64 % sont sans 5 % lopinavir/ritonavir et à 8 % en généri- emploi avec 27 % soutenus par un tiers et que zidovudine/lamivudine/névirapine. En 37 % sans ressources. outre, 34 patients prennent l¶éfavirenz, 34 Tolérance l¶abacavir, 4 la névirapine, 4 la lamivudine, Une très grande partie des patients (n = 74, 4 la stavudine, 3 le nelfinavir, 2 la didano- 86 %) ont déclaré avoir ressenti durant le sine et 1 la zidovudine. La médiane de suivi mois précédant l¶interrogatoire des effets des patients dans la cohorte est de 258 jours indésirables. Trente-six (42,1 %) signalent (écart interquartile [EIQ] : 151-336). Leurs plus de quatre effets indésirables. Les trou- caractéristiques socio-démographiques sont bles digestifs viennent en tête (30 %), suivis présentées dans le tableau 1. des troubles neuropsychiques (29 %), des Trente-sept patients (43 %) suivent effets généraux (21 %), dermatologiques leur thérapie au Centre Yonis Toussaint, (7 %) et articulaires (7 %). 30 (35 %) à l¶hôpital général Peltier, 12 (14 %) au Centre Hospitalier des Armées

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Observance degré de confidentialité ont un risque 4 fois Quatre-vingt-deux patients (95 %) sont plus grand d¶être non observants (Tableau observants si l¶on se tient aux déclarations 4). contre 66 (77 %) en se basant sur le dé- nombrement des comprimés (Tableau 2). Les deux mesures ne sont pas concordantes. (MWGYWWMSR Selon notre critère principal de jugement, Cette étude a permis de mettre en éviden- 66 patients (77 %) sont observants au trai- ce des déterminants spécifiques à la non- tement antirétroviral. Parmi les 20 patients observance dans un contexte de gratuité non observants, 2 (10 %) ont totalement ar- et de proximité géographique du centre de rêté leur traitement et 18 (90 %) ont manqué soins d¶un pays du Sud. des prises. Le ratio moyen d¶observance de notre *EGXIYVWHÍXIVQMRERXWHIPERSR population d¶étude est de 92 % (EIQ : 90- SFWIVZERGI 100]. Le rôle prédictif de la composante socio- En outre, 46 patients (53,4 %) déclarent économique sur la non-observance est mi- avoir manqué au moins une prise depuis le noré par l¶aide communautaire et l¶aide début de leur traitement. Les raisons les plus des associations. Nous avons montré que fréquemment évoquées sont : l¶oubli 12 la gêne de prendre les médicaments en (25 %), le sommeil 7 (15 %), le voyage 5 présence de l¶entourage conduit le patient (11 %), la durée longue 5 (11 %), le doute non seulement au non-respect des horaires sur l¶efficacité 4 (9 %), la rupture de stock 3 de prise mais surtout à l¶oubli. Les patients (6 %) et les effets indésirables 3 (6 %). observants sont plus nombreux à être membres d¶une association par rapport aux non- (ÍXIVQMRERXWPMÍWÄPvSFWIVZERGI observants (p = 0,001). L¶aide commu- Le tableau 3 résume l¶ensemble des varia- nautaire n¶est pas liée à l¶observance (p = bles étudiées. 0,13). La durée sous traitement (p = 0,25) et En analyse multivariée, l¶aide commu- le coût du transport (p = 0,46) au centre de nautaire et un niveau d¶étude sont protec- soins ne diffèrent pas chez les observants et teurs de la non-observance. Les patients qui les non-observants. disent avoir manqué des prises avant notre enquête et ceux qui ne sont pas satisfaits du

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En effet, chez les patients sous antiré- dires du soignant (p = 0,11). Par contre, troviraux, les traits socio-démographiques, l¶observance est significativement liée psychologiques, cliniques, la qualité de la au degré de confidentialité du centre de relation médecin-patient et le type de soins (p = 0,006). En effet, 35 % des non- protocole prescrit sont associés à la non- observants qualifient le degré de confidenti- observance. Cependant, 88 % des pa- alité comme « assez bien » ou « mal » contre tients reconnaissent être bien écoutés par 8 % des observants. Mais l¶observance n¶est le personnel soignant et déclareront une pas influencée par le protocole prescrit inobservance éventuelle au soignant, 9 ne (p = 0,60). La consommation des substances le déclareront pas de peur de reproches telles que le khat qui est une drogue douce et 1 d¶être moins bien soigné ; 90 % ont (p = 0,22) et le tabac (p = 0,41) n¶est pas confiance dans les dires de leur médecin. associée à la non-observance. Aucune différence significative n¶a été Dans la littérature, l¶âge jeune [15-18], trouvée entre les patients observants et le sexe féminin, les conditions de vie défa- non observants pour l¶éc o u t e d u s o i g n a n t vorables [19-21] et l¶absence de perception (p = 0,23), les déclarations d¶inobservance de soutien de l¶entourage [18,19,22] sont au médecin (p = 0,79) et la confiance aux des facteurs prédictifs de la non-observance

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[23,24]. Dans notre étude, on ne retrouve pas vie est la même dans les deux groupes (p = d¶association significative de l¶observance 0,49). Chez tous nos patients observants ou avec le sexe (p = 0,57), l¶âge (p = 0,74), non observants, 46 (53,4 %) déclarent avoir l¶état matrimonial (p = 0,72), le revenu (p = manqué au moins une prise depuis le début 0,91) et le niveau d¶étude (p = 0,39). de leur traitement. Si l¶on s¶intéresse aux L¶étude retrouve la relation entre les motifs ayant amené les patients à manquer effets indésirables et la non-observance des prises depuis le début du traitement, citée dans la majorité des études [18-20]. nous retrouvons une relation statistique- Une très grande partie des patients (n = 74, ment significative entre la non-observance 86 %) ont déclaré avoir ressenti durant le et un saut de prise pour rupture de stock ou mois précédant l¶interrogatoire des effets à l¶occasion d¶un voyage (p = 0,02). Aucun indésirables. La non-observance est signi- des groupes de motifs de prise manquée que ficativement reliée à la survenue des effets nous avons classés en facteur personnel indésirables (100 % des non-observants (doute de l¶efficacité + durée longue + contre 82 % chez les observants) (p = 0,03). médecine traditionnelle + oubli + sommeil, Mais les effets indésirables ne sont pas p = 0,78), facteur socio-économique (finan- distribués différemment dans les deux grou- cier + judiciaire + conflit familial + prise pes. En effet, après regroupement, on ne de khat, p = 0,80), facteur médical (effets retrouve pas de relation significative entre gênants + survenue d¶autres affections + la non-observance et les troubles digestifs prise d¶autres médicaments, p = 0,11) n¶est (p = 0,23), les troubles neurologiques (p = cité avec une fréquence significativement 0,06), les effets généraux (p = 0,18) et les différente entre les patients observants et autres effets (p = 0,29). non observants. En outre, les patients ayant déjà manqué Cependant, les diverses origines eth- une prise donc ayant déjà eu, même avant niques des patients et l¶oubli justifient notre enquête, un problème d¶observance l¶incrimination des voyages associés à la sont susceptibles d¶être non observants rupture de stock dans la non-observance. La [17]. perception négative du personnel soignant À l¶opposé, les patients bénéficiant d¶une favorise la non-observance. Cette liaison aide communautaire sont plus observants. est d¶autant plus forte que la confidentia- En effet, la proportion élevée de chômeurs lité n¶est pas bonne. La préoccupation des confirme cette situation de dépendance du patients concerne surtout leur statut sérolo- sujet vis-à-vis de la famille élargie et de la gique et l¶attente du médecin. société. Ainsi, parmi les patients observants, La thérapie antirétrovirale est la seule nombreux sont membres d¶une association exigeant un niveau d¶observance excellent (94 % contre 65 %, p = 0,001). pour son efficacité. Notre étude montre une Le niveau d¶étude joue un rôle protecteur relation significative entre l¶observance [15,16]. En revanche, nous n¶avons pas pu et l¶efficacité thérapeutique comme dans confirmer certaines caractéristiques de non- les autres études [2,8-10,18,19]. Le taux observance comme le coût du déplacement d¶observance est corrélé à la charge vi- [2], l¶utilisation de la médecine tradition- rale (rho = -0,61, p < 0,001). Toutefois, la nelle [18,19], la difficulté financière [2-4], proportion de 77 % d¶observants rejoint l¶absence de connaissance du traitement celle des autres pays africains au cours de [18,19]. L¶amélioration de la qualité de leur première année de traitement (Sénégal

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[2], Côte d¶Ivoire [4], Burkina Faso [5], ficacité virologique. Le taux d¶observance Mozambique [10]) mais aussi celle des pays est corrélé à la charge virale (rho = -0,61, du Nord [14]. Ceci témoigne de la capacité p < 0,001). En effet, cette association est des patients à être observants et donc la d¶autant plus forte que le taux d¶observance faisabilité de la trithérapie au Sud [6,7]. est élevé : à 90 % (p = 0,25), à 97 % (p = 0,02), à 100 % (p < 0,001). 9RIETTVSGLIWERXÍTYFPMUYIHI La méthode d¶évaluation de l¶observan- PvSFWIVZERGI ce utilisée est peu coûteuse, bien adaptée à Tout d¶abord, il est important de réévaluer notre contexte et surtout crédible [14]. En l¶observance au cours du traitement. Chez effet, l¶indicateur d¶observance basé sur la les patients prédisposés à être non obser- déclaration du patient surestime l¶observants, nous préconisons de les mettre sous vance effective. L¶observance perçue par inhibiteurs de la protéase puisque le risque les patients reflète l¶observance mesurée de développement de résistance est limité (p = 0,007). Toutefois, 70 % des patients en cas d¶interruption [25]. non observants estiment être observants Ensuite, le suivi médical est à renforcer au traitement tandis que 4 % des patients par la mise en place d¶une consultation observants ont des doutes et pensent qu¶ils d¶éducation thérapeutique qui va s¶inscrire ne sont pas assez observants. Ceci montre dans un cadre bien défini et rigoureux pour une surestimation de l¶observance effective ne pas aboutir à l¶effet contraire [26,27]. chez les patients non observants. Puis la fréquence élevée de l¶oubli et Toutefois, la faible proportion de pa- l¶extrême mobilité de notre population nous tients sous antirétroviraux (ARV) dans amènent à préconiser respectivement la pré- notre pays est une limite. Par ailleurs, nos férence des antirétroviraux combinés avec résultats montrent également les limites de le moins de prises possible et de remettre l¶approche transversale pour l¶évaluation au patient une quantité suffisante pour la de l¶observance qui est dynamique. Le biais période d¶absence du lieu de résidence. de mémorisation est relatif dans les enquê- En effet, les régimes succincts favorisent tes rétrospectives. Nous ne retrouvons pas l¶observance [28,29]. Les entretiens de mo- certains facteurs de l¶inobservance trouvés tivation lors des rencontres avec le patient dans les études du Sud du fait des différen- et la thérapie comportementale et cognitive ces entre les populations étudiées. Ainsi, on améliorent l¶adhérence au traitement [30]. évitera de généraliser les résultats de notre En début de traitement et lors du renou- étude à des contextes différents du nôtre. vellement de chaque ordonnance, la contribution des pharmaciens à l¶amélioration de l¶observance s¶est avérée efficace [31]. Les 'SRGPYWMSR stratégies de la thérapie sous surveillance Cette étude montre que la préoccupation directe, les groupes de paroles, le Telephon principale des patients concerne l¶accepta- Line Computer, les piluliers électroniques tion de la maladie VIH/SIDA et le vécu sous sont inadaptés à notre contexte. traitement antirétroviral. En pratique, il fau- drait dès le début aider les patients à penser &MEMWIXZEPMHMXÍHIPvÍXYHI Il n¶existe pas de gold standard pour éva- à l¶avance au traitement et leur assurer un luer l¶observance. Cette étude est validée soutien personnalisé. par la corrélation entre l¶observance et l¶ef-

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6IQIVGMIQIRXW tous les médecins référents, les assistants psychosociaux et les accompagnateurs thé- Les auteurs tiennent à remercier le ministère rapeutiques pour leur soutien à ce travail. de la Santé de Djibouti, le Programme de lutte contre le SIDA, le Secrétariat Exécutif,

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-RXVSHYGXMSR guide health planners and also to bring to their attention the full picture of the devas- In addition to the health burden, malaria tating effect of malaria. places an enormous economic burden on The objectives of the study therefore households in endemic regions [1]. The bur- were to estimate the direct and indirect den includes the direct cost (medical con- costs associated with malaria episodes at the sultation, laboratory investigation, drugs household level in Khartoum State, and to and hospitalization) [2] and the indirect identify the possible effects of care-seeking cost due to work days lost through morbid- behaviour and occupation of malaria cases ity and mortality for both malaria cases and on these costs. individuals looking after them [3,4]. As in many other parts of Sudan, malaria represents a major public health problem 1IXLSHW in Khartoum State. In Khartoum, malaria accounts for 24% of all patients seen at 7XYH]HIWMKRERHWIXXMRK outpatient departments and 13.4% of hos- This was a descriptive cross-sectional pital admissions [5]. In terms of the health community-based study. It was conducted burden of malaria on the community, these in Khartoum State in 2004, the capital of Sudan; the state is the smallest state of figures mean that malaria not only con- 2 sumes the greater share of the treatment-re- Sudan with an area of 28 000 km . The lated expenditure of households than other total population is estimated as 7 million. diseseses, but is also the cause of the highest Khatroum state consists of central urban loss of working days. areas, peripheral rural areas and camps Although the exact economic burden established to accommodate the internally that falls on households in Khartoum is not displaced populations (IDPs) coming from known, it is expected to vary from one sub- other states of the country. It is considered group of the population to another. There as an area of unstable malaria transmission with high peaks of incidence during, and are a large number of possible determinants immediately after, the rainy season, and that may affect the level of economic loss during the winter months [8]. by households [6]. For instance, as regards direct cost, the level of treatment-related expenditure is affected by the care-seeking 7EQTPMRK The primary sampling unit was the house- behaviour of the patient [7]. During malaria hold. To be included in the study a house- episodes patients can chose from a wide hold had to have resided for at least 12 range of health care providers or they may months in Khartoum State. For the sample resort to self-treatment. As drug and service size calculation it was assumed that the prices differ from one health care provider proportion treated for malaria during the to another, the level of expenditure will vary previous month would be 25% based on the according to the provider chosen. results of a previous study [9]. Thus a sam- The indirect cost, on the other hand, ple of 1200 households was required. depends on the economic activity and type Using the probability proportional to of job of the malaria cases and the family size method, 25 geographically defined member looking after him/her. clusters were selected from a sampling Estimating the total and differential eco- frame provided by the Central Bureau of nomic cost in Khartoum State is vital to

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Statistics. The frame was stratified by rural Questionnaire 2 was used with all ma- area, urban area and IDP camp. Systematic laria cases to collect the following data: sampling was used to select 48 households background information on malaria cases, from each cluster to give the total of 1200 care-seeking behaviour, working days lost households (in total 1203 household were and expenditure on malaria treatment. included). The reliability and validity of the data Data were collected in 3 phases to cover were tested by reliability analysis using the period of the rainy transmission season SPSS and the analysis yielded an alpha of 2004. The rainy season usually extends value of 0.0009. from July to October. The first phase of the study was conducted during the second half (EXEGSPPIGXMSR of August 2004, the second phase during Data were collected by 5 teams each com- the first half of October 2004 and the last posed of 1 field supervisor and 3 inter- phase during the second half of November viewers. The field supervisors were social 2004. Thus 400 households were visited in science graduates who were previously each phase. trained on data collection methods and field The inclusion criteria of malaria cases supervision, and they had received further were: training on the field-work and the tools Malaria confirmed by positive blood of the this study. The interviewers were film or other blood tests. university graduates, previously trained on Malaria diagnosed on a clinical basis by data collection methods and had received a health care provider. training on the tools of this study. The training in both instances was conducted by the For non-confirmed cases the diagnosis principal investigator and included lectures was verified by asking about the pres- and role play. ence of the following symptoms: fever, headache, sweating and vomiting. These (EXEEREP]WMW were found to be associated with a posi- Data were analysed with SPSS, version tive blood film for malaria using binary 11.5. The analysis included descriptive sta- logistic regression in a previous study tistics for frequencies and averages [mean [10]. and standard deviation (SD)], and com- An individual was considered to have parison between subgroups using the chi- 2 or more malaria episodes if a minimum squared test for proportions, and one-way period of 2 weeks had elapsed between the analysis of variance and t-test for means of 2 episodes. In this study all episodes where independent samples. A P-value less than included. 0.05 at 95% confidence interval was considered significant. 5YIWXMSRREMVIW Cost calculations included treatment-re- Two questionnaires were used for data lated expenditure (direct cost) and indirect collection; both were adapted from the costs. Average treatment-related expendi- questionnaires used for estimating the ture was estimated first for the household malaria-related costs in Sri Lanka [1]. and then per fully cured malaria case. The Questionnaire 1 was used with all se- measurement of indirect costs was based on lected households to collect background an output-related approach. The estimates information.

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S included only days lost by malaria cases lation (> 14 years). In only 18.7% of the and their caretakers who were involved episodes was the individual who contracted in productive work. Productive work was malaria covered by health insurance. broadly defined as involvement in any eco- In only 18.0% of malaria episodes was nomic activity with the potential to add to the individual involved in economic activi- the disposable income of the household. ties. Of the economically active individuals, This output-related method excluded time 44.1% worked in the formal sector and had loss of economically inactive patients [1]. regular salaries, i.e. government and private The total number of working days lost sector employees and public sector work- by both patients and their caretakers was ers. The remaining 55.9% belonged to the recorded. The indirect cost was calculated informal sector (self-employed, farmers and for the level of both households and fully casual labourers) and their earnings were cured malaria cases. irregular. The average monthly income per malaria case was US$ 127.9 (SD 72.9) (Table 2). 6IWYPXW 'EVIWIIOMRKFILEZMSYV 7SGMSHIQSKVETLMGHEXE The majority of reported malaria episodes The 1203 households included 6836 peo- (78.9%) were diagnosed by a positive blood ple. The majority (72%) of the households film, while 14.4% were clinically diagnosed participating in the survey resided in urban at a health facility. Self-diagnosis was ob- areas, 20% in rural areas, while only 8% served in only 6.7% of the episodes. resided in IDP camps. The majority of the In 89.3% of episodes, the individual heads of the households were involved in went to a health facility to seek care in some income-earning activity (95.2%). The the first instance; only 5.8% resorted to average monthly income per household was self-treatment. For the remaining 4.9%, equivalent to US$ 216.8 (SD 430.8).

1EPEVMEMRGMHIRGI Only 25.2% of the households reported at least 1 malaria episode during the month 8E FP I 'LEVEGXIVMWXMGWSJQEPEVMEITMWSHIW preceding the survey. A total of 327 malaria /LEVXSYQ7XEXI episodes occurred during the 3 phases of 'LEVEGXIVMWXMG 2S R! data collection and no individual reported having malaria more than once during the 7I\ 1EPI study period. The incidence of malaria *IQEPI episodes was 51/1000 in the first phase, %KIKVSYT ]IEVW 42.5/1000 in the second phase and 51/1000 z in the third phase giving an overall inci- " dence of 48.2/1000 per month during the ,IEXLMRWYVERGIGSZIVEKI whole period of the survey. 'SZIVIH Table 1 shows the characteristics of the 2SXGSZIVIH individuals who suffered a malaria episode. %ZIVEKIMRGSQITIV More than half of the malaria episodes QEPEVMEGEWI?1IER 7( A97 (57.2%) occurred among females. About 7(!WXERHEVHHIZMEXMSR two-thirds occurred among the adult popu-

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8E FP I (MWXVMFYXMSRSJITMWSHIWEGGSVHMRKXS 0SWX[SVOMRKHE]W IGSRSQMGEGXMZMX]/LEVXSYQ7XEXI The average number of working days lost by malaria cases was 6.2 (SD 6) days. Only )GSRSQMGEGXMZMX] 2S R! 26 (8%) of the malaria cases needed another )GSRSQMGEPP]EGXMZI family member to absent him/herself from *SVQEPWIGXSV VIKYPEVWEPEV] work or school to take care of them. Of +SZIVRQIRXIQTPS]II these co-patients, 19 (73.1%) were involved 4VMZEXIWIGXSVIQTPS]II in economic activities (employees, self- 4YFPMGWIGXSV[SVOIVW employed regular and casual labourers), -RJSVQEPWIGXSV MVVIKYPEVIEVRMRKW *EVQIV while 7 (26.9%) were students. The average 7IPJIQTPS]IHE number of working days lost by co-patients 'EWYEPPEFSYVIVF was 3.1 (SD 1.6) days. The study showed )GSRSQMGEPP]MREGXMZI that 35.1% of the economically active ma- ,SYWI[MJI laria cases and 47.6% of the economically 9RIQTPS]IH active co-patients had obtained paid sick- 7XYHIRX leave for the period of absence from work. 4VIWGLSSPGLMPH These were mainly employed in the formal 6IXMVIH sector. 8SXEP E7IPJIQTPS]IHHIRSXIWER]MRHMZMHYEP[LSS[RW 8VIEXQIRXVIPEXIHI\TIRHMXYVI LMWLIVFYWMRIWWERH[SVOWJSVLMQWIPJLIVWIPJMRWXIEH SJEWERIQTPS]IISJERSXLIVTIVWSRSVSVKERM^EXMSR The average monthly expenditure on ma- HVE[MRKMRGSQIJVSQEXVEHISVFYWMRIWW,IWLI laria treatment per household was equiva- YWYEPP]S[RWSVWLEVIWXLIGETMXEPSJXLIFYWMRIWW lent to US$ 1.7 (SD 4.1); this reduced the F'EWYEPPEFSYVIVEVIYRWOMPPIHSVWIQMWOMPPIHPEFSYVIVW [LS[SVOMREVIEWWYGLEWGSRWXVYGXMSRERHHSQIWXMG average monthly income per household by WIVZMGIXLI]YWYEPP][SVOJSVZIV]WLSVXHYVEXMSRSJ 0.8% (Table 3). XMQIJSVERIQTPS]IVERHEVIYWYEPP]TEMHJSVXLIMV At the individual level, the average ex- PEFSYVSREHEMP]FEWMW8LIMVIEVRMRKWEVIMVVIKYPEVERH HITIRHSRXLIEZEMPEFMPMX]SJENSF penditure per fully cured malaria case was found to be US$ 6.3 (SD 5.9) and the median was US$ 6.6. This reduced the average the individual made blood investigations monthly income per malaria case by 5.3% without consulting a health care provider, (Table 3). Table 3 also shows that seeking consulted a traditional healer or ignored the treatment from a health facility was associ- illness. The governmental health centres ated with significantly higher expenditure were the facilities most commonly used, by per fully cured malaria case than resorting 46% of those seeking care from a facility. to self-treatment [health facility = US$ 6.4 Private health facilities (clinics or hospitals) (SD 5.6), self-treatment = US$ 2.5 (2.2); P were the least used facilities, used by only < 0.05]. Taking more than one action was 1% of the cases. After taking all the actions, associated the highest treatment-related 97.2% of the malaria cases were fully cured expenditure (P < 0.05). of the illness (as reported by the individual As shown in Table 3, private clinics and or his/her family), while in 2.8% the person hospitals were associated with significantly was still taking treatment. The 318 fully higher treatment expenditure per fully cured cured cases were further analysed to esti- malaria case than all the other facilities mate the costs. [(private clinic = US$ 16.2 (SD10.1), gov-

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ernmental health centre = US$ 5.0 (SD case (co-patient days) was US$ 0.5 (SD 2.7), nongovernmental organization (NGO) 3.4). The overall average indirect cost per centre = US$ 5.0 (SD 1.7); P < 0.05)]. fully cured malaria case (both patient and When breaking down the treatment-related co-patient days) was US$ 3.2 (SD 9.2). expenditure, it was found that the highest Individuals who were self-employed proportion of treatment expenditure (42%) and casual labourers had significantly went for purchasing drugs. This was fol- higher average indirect costs per fully cured lowed by doctor¶s fees which constituted malaria case than employees and public 30.4% of the expenditure. sector workers: self-employed = US$ 22.1 (SD 17.2), casual labourers = US$ 13.5 (SD -RHMVIGXGSWXW 10.9), employees US$ 7.6 (14.7), public Table 4 shows that the average indirect cost sector workers = US$ 9.0 (SD 14.3); P < of malaria per household per month was 0.0001. US$ 0.8 (SD 4.9), reducing the average monthly income of households by 0.4%. The average indirect cost per fully cured (MWGYWWMSR malaria case (patient days only) was US$ 2.6 (SD 8.7) reducing the average monthly Information on the economic consequences income of malaria cases by 2%. The aver- of malaria on households is an important age indirect cost per fully cured malaria complementary tool needed for successful

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formulation of policies in areas such as cines [11,12]. Thus where chloroquine, health financing, introduction of new thera- the cheapest drug, is still effective, the pies, and regulation of the private sector. average expenditure per case is expected to be relatively low. However, in Khartoum (MVIGXGSWXSJQEPEVME State, chloroquine was replaced with the In Khartoum State, patients seeking care for more expensive artesunate plus sulfadox- malaria illness from governmental, NGOs, ine±pyrimethamine combination therapy and private sector facilities ± unless covered during the year 2004, and the complete by health insurance ± pay directly out of establishment of this replacement is ex- pocket for medical consultation, laboratory pected to increase the treatment-related investigations and purchase of medicines. expenditure even further. This user charge system, augmented by The difference in the pattern of care- the limited coverage by health insurance, seeking behaviour was also behind the in- was most probably behind the high average consistency in treatment costs. Unlike the treatment expenditure per fully cured case trend in other malaria-endemic countries when compared with values from other [1,3,13], there was high use rate of health countries. For instance, in Sri Lanka, At- facilities and low rate of self-treatment tanayake and colleagues reported a value during malaria episodes in Khartoum State. equivalent to US$ 1.1 for malaria cases vis- This practice is probably motivated by the iting public health facilities where services high coverage of health facilities provided are provided free of charge [1]. by both the public and private sectors [14]. Our study and many others have shown As reported by studies from other endemic that the highest proportion of treatment countries [6,11,2,14], the treatment-related expenditure for malaria goes on medi- expenditure was found to be significantly

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S higher for those using health facilities than [1], i.e. excluding economically inactive for those who self-treat. It is worth men- individuals and those who obtained paid tioning that self-treatment is resorted to sick leave. This leads to cost estimates that by malaria cases to cut down the treatment are less than the estimates generated by cost. However, the self-treatment can have other methods that use some estimate of the serious repercussions. For example, it can average wage that includes all individuals result in under-dosing which will lead to above a certain age irrespective of whether drug resistance and increase the cost of they are economically active or not or if treatment in the long run through the neces- they actually lose any output or income due sary introduction of expensive drugs. to malaria [1]. The output-related method Our findings agree with many other was earlier used to estimate the indirect cost studies in that seeking care from private related to malaria in Sri Lanka [1]. health facilities was associated with the The average indirect cost per fully cured highest expenditure per fully cured case malaria case of US$ 3.2 (SD 9.2) found in [1,15,16]. The variations in treatment costs our study lies towards the lower limit of the between the public and private sectors are range of US$ 0.68 to US$ 25 reported by due to the higher fees charged by the private Chima et al. [2]. The choice of method to sector for malaria management. measure and value time loss is potentially an important explanatory factor of the vari- -RHMVIGXGSWXSJQEPEVME ations in household costs reported to date The indirect cost of malaria depends on [1]. both the amount of time lost due to illness The indirect costs estimated by our study and the value of that time in financial terms. were less than the direct costs and this con- In Khartoum State Plasmodium falciparum curs with most studies estimating malaria is responsible for around 90% of all malaria costs [2]. cases [5]. This species is associated with a Occupation of the malaria case was more severe disease that is followed by a found to considerably affect the indirect prolonged period of weakness and disabil- cost; those working within the formal sector ity [16,17]. In addition to that, Khartoum is (government and private employees and considered an area of unstable transmission public sector workers) had significantly of malaria where the intensity of transmis- lower indirect costs compared with those sion varies across the years [8]. Conditions working within the informal sector (casual of unstable malaria transmission are as- labourers and the self-employed). The rea- sociated with low immunity levels, longer son behind this was that the majority of periods of disability, and a high degree of employees and public sector workers were clinical illness in adults [16±19]. able to obtain paid sick leave for the period Both these factors would imply a high of their illness thus avoiding salary cuts. On average indirect cost in Khartoum State. the other hand, casual labourers, who work However, we used an output-related method in construction and domestic service are in this study to estimate the indirect cost so paid on a daily basis and any loss of activity as to avoid over-emphasizing the burden. is associated with loss of earnings. More- The output-related method takes into con- over these individuals do not usually enjoy sideration only time lost by economically the benefits of health insurance, which is active individuals and specifically those restricted mostly to the formal sector; this who actually suffered income or output loss exacerbates the economic burden that falls

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S on them. However, although employees and provision of free malaria curative services public sector workers may not bear the di- should be considered. Regulation of prices rect effect of this indirect cost, the economy of malaria services in the private sector of a country suffers from the effect of these should also be considered. absences and, in the long run, this can have an impact on the individual. %GORS[PIHKIQIRXW 'SRGPYWMSR Funding for this study was provided by the Research Policy and Cooperation Unit of Malaria places a great economic burden World Health Organization Regional Office on households of Khartoum State in terms for the Eastern Mediterranean. of direct and indirect costs. The indirect We are very grateful to Dr Nimal At- cost burden was especially tremendous on tanayake, Health Economics Study Pro- individuals belonging to the informal sec- gramme, University of Colombo, Sri Lanka tor. High use rate of health facilities and the for providing the questionnaires that were limited coverage by health insurance con- of great help to us. We are also very grate- tributed to the high treatment cost. Reduc- ful to the team of data collectors and field ing this burden requires strategies such as supervisors. Our thanks also extend to the increasing coverage by health insurance to households who participated in this study include all employees in the formal sector. for their patience and cooperation. For those belonging to the informal sector,

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-RXVSHYGXMSR this problem is not available in the majority of these countries. For instance, a study on Hypothermia is an important determinant of 50 Iraqi children with hypothermia showed the survival of newborns, especially among that the majority of infants had evidence low-birth-weight (LBW) babies [1]. An in- of infection, particularly septicaemia [5]. fant loses heat by evaporation, convection, The overall mortality rate in that study was radiation and conduction. If hypothermia 26% (42% in LBW infants) and the most persists, there is a risk of neonatal cold common finding was a high incidence of injury, in which case the infant usually aspiration pneumonia in infants over 3 days becomes lethargic, with slow, shallow and old. The results from another study on 36 irregular respiration and a slow heart rate cases of neonatal intestinal obstruction in corresponding to decreased body tempera- Iraq revealed that hypothermia was one of ture. Prolonged cold injury leads to oedema, the main causes of death [6]. In a survey scleroderma, general haemorrhage (espe- of paediatric mortality in Lebanon, the cially pulmonary haemorrhage), jaundice researchers recommended that prevention and death [2]. of 5 risk factors² acidosis, hypoxaemia, In many parts of the world, health per- hypoglycaemia, hypotension and hypo- sonnel are not aware of the importance of thermia² was important for reducing the keeping babies warm by simple methods death rate [7]. Neonatal hypothermia is also such as drying and wrapping immediately prevalent in Israel [8]. Different studies in after birth, avoiding harmful traditional that country have shown that mortality and practices, encouraging early breastfeeding morbidity in hypothermic infants are mainly and keeping newborns in close contact with related to the presence or absence of an as- their mothers [3]. A study on 160 medical sociated septicaemia [9±11]. In Turkey, and paramedical staff dealing with neonatal a study on 66 babies who had undergone care in India showed that only 47.8% of surgery because of peritonitis showed 100% the subjects defined neonatal hypothermia mortality in hypothermic neonates [12]. correctly. In addition, only 18.6% of the In our country, Islamic Republic of interviewees had knowledge about the cor- Iran, previous reports about the prevalence rect method of recording the temperature and risk factors of neonatal hypothermia in a newborn [4]. Previous reports from are confined to unpublished studies, small different Asian and African developing sample sizes or local surveys. Regarding countries show that most of the neonates this variable information, we believe that became hypothermic soon after birth [3]. In neonatal hypothermia is a serious health developed countries, however, awareness of problem in our country, even among those the problem has resulted in improved care, born at university teaching hospitals. There- and the incidence of neonatal hypothermia fore, we decided to design an epidemiologic was mostly confined to outborn, premature survey to obtain more accurate information and LBW infants. about the incidence rate and risk factors of In previous decades, most of the studies this problem at referral university teaching from countries of the Eastern Mediterranean hospitals of Tehran, which are expected to Region focused on the prevention of neona- have better trained staff as well as higher tal hypothermia or its related complications level of medical resources compared to among newborn infants. Therefore, ad- small or local centres in other cities of the equate information about the prevalence of Islamic Republic of Iran.

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Here, it should be noted that while other > 38 °C), outborn babies (because of inad- surveys in the area of neonatal hypothermia equate sample size) and those with diagnos- have generally focused on its incidence, our able anomalies at birth, 900 neonates were study gives more attention to the severity of recruited to the study. hypothermia through a longitudinal study. This repeated measures study helps us to 6ITIEXIHQIEWYVIQIRXW assess the trend of improvement among After obtaining consent from the parents, hypothermic infants after recommended the neonate¶s rectal temperature was meas- treatments. The results would provide a ured using a calibrated digital low-reading baseline for future health programmes in thermometer at 5 time periods: immediately these hospitals. after birth in the operating room, several minutes after admission to the neonatal unit (levels I, II, III of nursery care), and 1, 2, 1IXLSHW and 4 hours after admission to the neonatal unit. If a newborn was hypothermic, she/ 7EQTPMRKXIGLRMUYI he was rewarmed according to the World This study of neonatal hypothermia was an Health Organization recommendations [3]. epidemiologic longitudinal survey at refer- The outcome variable for each newborn was ral university hospitals in Tehran, Islamic the severity of hypothermia, graded as fol- Republic of Iran. Since one of the most lows: normal body temperature (rectal tem- important objectives of the study was to perature 36.5±38.0 °C); mild hypothermia estimate the prevalence of neonatal hypo- (rectal temperature 35±36.5 °C); moderate thermia at these hospitals, the sample size hypothermia (rectal temperature 32±35 °C); formula for the prevalence studies (n = or severe hypothermia (rectal temperature Z2P(1±P)/d2), with = 0.02, d = 0.04 and < 32 °C). P = 0.5 (which yields the maximum sample At each hospital, body temperatures of size), was used to estimate the required the neonates were measured by 2 trained sample size. Using simple calculation, it nurses. Since the body temperature for each was found that the study sample should baby was considered an ordinal outcome consist of at least 845 newborns. (severity of hypothermia according to the There are 15 referral university teaching classification), the inter-observer and intra- hospitals with a neonatal intensive care observer reliability were assessed via a pilot unit (NICU) in Tehran. To select the study study using generalized Kappa index [13]. sample, the city was divided into 5 districts All the obtained inter- and intra-observer (north, south, east, west and centre), each Kappa statistics were about 100% for these with 3 referral hospitals. Then 1 hospital nurses. These findings indicated perfect was randomly selected in each district. In inter- and intra-observer reliability in this the next stage, 100 days were randomly study. chosen between February and November 2004 (to include 4 seasons with air tem- 6MWOJEGXSVW perature ranging from ±5 C to 40 C). After preliminary analyses, the following Finally, for each selected day, 2 newborn explanatory variables were considered po- infants were selected at each hospital using tential risk factors for neonatal hypothermia a random numbers table. After excluding in the regression analysis: sex (0 = male, 1 hyperthermic neonates (rectal temperature

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= female), birth weight (0 = 2500 g, 1 = 6IWYPXW < 2500 g), gestational age (0 = 37 weeks, 1 = < 37 weeks), environmental tempera- (IWGVMTXMSRSJXLIHEXE ture (temperature of the operating room The study sample consisted of 900 neonates and neonatal unit), Apgar score (0 = 8, 1 (452 males and 448 females). Of these, = < 8), pregnancy type (0 = singleton, 1 = 298 (33.1%) had birth weight < 2500 g, multiple) and cardiopulmonary resuscita- and 323 (35.9%) were preterm (gestational tion (CPR) (0 = not received, 1 = received). age < 37 weeks). The mean temperature of Note that, sex, birth weight, gestational the operating rooms and neonatal units at age, pregnancy type and CPR variables are these hospitals was about 28.5 °C (standard time-stationary factors (which are constant deviation = 1.7). In addition, 174 neonates at different time points of the study), but (19.3%) had Apgar score < 8 on at least one environmental temperature and Apgar score occasion. In this sample, the rate of multiple are time-dependent variables (which may pregnancy was about 3.5%. Additionally, vary at different time points). 104 neonates (11.6%) received CPR during the study. 7XEXMWXMGEPEREP]WMW Table 1 shows the severity of hypother- The descriptive part of the statistical analy- mia among these babies at different time sis was carried out using rates and fre- points. Summing the data for mild, moder- quency tables. For analytical purposes, ate and severe hypothermia shows that a multivariate logistic regression model 53.3% were hypothermic immediately after (marginal model) was utilized. The general- birth, 13.6% on admission to the NICU, ized estimating equations methodology was 2.7% 1 hour after admission, 0.5% 2 hours also used for estimating the regression pa- after admission and 0.3% 4 hours after rameters and accounting for the correlation admission. between repeated outcomes. The analysis was performed using the Genmod proce- %REP]WMWSJVMWOJEGXSVWERHHIEXL dure in SAS software, version 8. P-values VEXI less than 0.05 were considered statistically A multivariate logistic regression model significant. was utilized to identify some of the most

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S effect (±0.213) tells us that a 1 °C increase Apgar score, from multiple pregnancies in the operating room or neonatal unit tem- and received CPR were significantly more perature decreases the odds of neonatal prevalent compared with infants who were hypothermia by exp (±0.213) = 0.81. not LBW, term, of normal Apgar, singleton In order to provide more detailed in- and those not received CPR. For instance, formation about the relationship between the prevalence of mild, moderate and severe severity of hypothermia and the significant hypothermia in low Apgar score infants factors, we classified the severity of hy- were respectively 35.2%, 3.7% and 5.5%, pothermia immediately after admission while these rates were 11.2%, 0.4% and to the neonatal unit in terms of weight, 0.0% in normal Apgar score babies. gestational age, environmental temperature, Finally, it is important to note that total Apgar score, type of pregnancy and CPR. mortality rate was 6% (54 neonates) during Table 3 shows the results. It is clear that this study and the death rate in hypothermic the mild, moderate and severe hypothermia babies was considerably higher than in nor- in infants who were LBW, preterm, of low mothermic ones. Table 4 shows the death

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S mon practice in labour rooms. A study on neonates [15]. In a retrospective study in 227 randomly selected normal-term infants USA, it was revealed that 45% of outborn in this country revealed that this traditional VLBW infants were hypothermic (body method of cleaning is significantly associ- temperature < 36.3 °C) on admission [17]. ated with hypothermia [21]. The researchers Another study, in Australia, showed that concluded that the labour room temperature 17% of infants born during transport were should be set at a higher level and cleaning hypothermic (axillary temperature less than infants using this method should be discour- 36 °C) [24]. In the United Kingdom, a aged. In the Himalayan state of north India, study on 4004 infants born before 26 weeks a warm heated room for delivery and lying- of gestation showed that among those ad- in, early rooming in, oil massage and layers mitted for intensive care, 66.7%, 80.0%, of warm clothing are traditional means for 58.3%, 42.7% and 29.6% were hypothermic thermo-regulation [22]. In Turkey, Sarman at weeks 21, 22, 23, 24 and 25 of gestational et al. randomly assigned 60 LBW hypo- age respectively [25]. thermic newborns admitted to a neonatal In developing countries, however, this care unit for treatment either in a cot on a problem is more prevalent even in healthy heated, water-filled mattress kept at 37 °C full term and normal-birth-weight (NBW) or in an air-heated incubator with a mean infants. In Nepal, a study on 500 inborns temperature of 35 °C. They demonstrated revealed that 85% of neonates were hypo- that normal temperatures were achieved thermic (body temperature < 36 °C) 2 hours within the first day and remained within after delivery [26]. In north India, research this range during the subsequent days after on 189 term healthy neonates delivered at admission in all the infants treated on the home showed hypothermia in 19.1% and mattress, whereas they were not achieved 3.1% respectively in winter and summer, until 3 days later in the incubator group. The 24 hours after delivery (axillary tempera- neonatal mortality among those treated on a ture < 35.6 °C) [27]. In our study, 7.8% of mattress was 21% and among those treated NBWs and 9.4% of full-term babies were in the incubator 34%. They concluded that hypothermic after admission to the neonatal a heated, water-filled mattress provides a unit. Hypothermia is a serious health prob- good alternative to skin-to-skin contact with lem, even in tropical developing countries, the mother, and to the use of a complex and despite warm environmental conditions, and expensive incubator for rapidly attaining it contributes to a high neonatal morbidity and maintaining normal temperatures in the and mortality. A study on neonates admitted LBW newborn [23]. to a neonatal care unit in Tanzania revealed In developed countries, the incidence that 22.4% were hypothermic (axillary tem- of neonatal hypothermia is mostly con- perature < 35.6 °C). Severe hypothermia fined to LBW and small-for-gestational- was found in 13% of these neonates (axil- age neonates. Therefore, the majority of lary temperature < 32 °C) and hypothermic studies have been focused on LBW, pre- infants had a 3-fold higher mortality and mature and other high-risk neonates. For morbidity [28]. In another study on 313 instance, a study on very-low-birth-weight consecutive newborn infants admitted to a (VLBW) infants in Canada showed that neonatal unit in Harare, Zimbabwe, it was the overall incidence of moderate to severe found that the prevalence of hypothermia on hypothermia (body temperature < 35 °C) admission was 85%, with a mean axillary on admission was 11.5%±12.5% among temperature of 34.3 °C [29]. In Zambia, a

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S prospective study at a university teaching air temperature and neonatal temperature hospital among 261 infants aged 0±7 days among home-delivered newborns in north admitted to the paediatric unit during the India [27]. In addition, Cheah and Boo warm season revealed that 44% were hy- found that lower labour room temperature pothermic (body temperature < 36 °C) on was a significant risk factor for being hypo- admission [30]. thermic [21]. In the present study, 33.1% of infants The above mentioned findings help us were of LBW, 35.9% were premature and to sensitize and educate all levels of staff 19.3% had low Apgar scores. It should be dealing with neonates about the risk fac- noted that the selected hospitals are refer- tors of neonatal hypothermia in developing ral tertiary care centres, so a considerable countries. Proper management of LBW and proportion of high-risk pregnant women are preterm neonates is of great importance referred to these centres from different parts to reduce the prevalence of hypothermia of the country. This is the possible reason and subsequent problems among newborn for the high rate of LBW, low Apgar score infants. Recently, major studies have been and preterm neonates. undertaken about the management and out- The results of logistic regression analy- comes of extremely preterm neonates in sis showed that infants who were LBW, Sweden and the United Kingdom [25,33± premature, with low Apgar score, from a 36]. multiple pregnancy and had received CPR In conclusion, it should be stated that the had higher risk of being hypothermic. Our effect of hypothermia on neonatal mortality study did not show any relation between hy- and morbidity is undeniable [7,14,30,37]. pothermia and sex of neonate. Kambarami The results from the present study showed and Chidede did not find any significant that more than 50% of the infants suffered relationship between need for resuscitation, from hypothermia soon after birth at refer- birth weight, sex and neonatal hypothermia ral university teaching hospitals of Tehran. [29]. However, recent studies from dif- This concerning result shows that the extent ferent parts of the world have shown a and significance of neonatal hypothermia significant association between neonatal are not fully realized in our country. Here it hypothermia and LBW, prematurity, low should be emphasized that the nursing staff Apgar sore, deliveries from outside hospi- play a vital role for controlling this health tal, inadequate clothing after delivery, low problem in developing countries such as the socioeconomic status of the mother and air Islamic Republic of Iran. Therefore, there is temperature [8,28,30±32]. Additionally, our an urgent need to increase awareness about study showed a strong correlation between the consequences of hypothermia and train environmental temperature and neonatal mothers and all levels of neonatal care staff hypothermia. Kumar and Aggarwal report- to control this health problem in developing ed a significant correlation between room countries.

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-RXVSHYGXMSR semesters). Its main aim is to provide practical field training for students in rural com- Basic development needs (BDN) is a communities. The organization of the module prehensive approach to community devel- is as follows. Groups of 15±18 students are opment that aims at improving the quality posted to a village (with a population of at of life of communities through their full least a few hundred to few thousand) where involvement, self-management and self- they conduct field activities, supervised by reliance, supported by intersectoral collabo- a group of university staff members. The ration. Local management of BDN projects students are responsible for the develop- focuses on community organization, mobi- ment of their assigned village. The module lization, capacity-building and needs-based consists of 3 phases: bottom-up planning that supports inter- Phase 1: Students collect basic socio- sectoral collaboration in the attainment of demographic information and other data overall community development. to identity priority developmental prob- A BDN programme was first set up in lems and to plan and design projects to Sudan in 1980 as a pilot programme. In investigate the causes of these problems 1997 the World Health Organization, in with a view to identifying solutions. coordination with the Federal Ministry of Health, started an organized, structured Phase 2: Students analyse data, draw implementation. In Gezira state, the pro- conclusions and implement a project- gramme has been implemented since 2001 targeted solution for the selected in a model area (Um-Alghora locality, 1 of problem(s), with the full involvement 7 areas in Gezira state) and later in 2 other of the community and through mobiliza- areas (South Gezira and Almanagil). tion of necessary resources from differ- The Faculty of Medicine, University ent sectors. of Gezira, was established in Wad Medani Phase 3: Students follow up their projects town, the capital of Gezira state in 1975. It and make an evaluation of the outcomes adopts the philosophy of community orien- and impact of their project and other tation aiming at solving community prob- related activities. lems. Thus, it implements an innovative During their stay in the village in the problem-solving, integrated, student-centred 3 phases of the module, students usually community-based educational programme. conduct different activities aiming at the Community-based courses comprise 22% improvement of community health. Such of the total credit hours of its curriculum. activities include: 1-day clinics, sessions The Faculty has actively participated in dif- addressing prevailing health problems, ferent programme activities throughout all cleaning campaigns, planting of trees and phases of the evolution of BDN in Gezira, health education on issues such as immu- such as: training of technical support teams, nization, breastfeeding, use of insecticide- village development committees and cluster treated bednets, correct nutritional practices representatives; community mobilization; and so on. They also engage the community and supervision of community surveys. in many cultural, sports and recreational The interdisciplinary field training re- activities. search and rural development (IDFTRRD) The objective of this study was to inves- programme is a community-based course tigate the effect of students of the Faculty offered to medical students at the end of the of Medicine, University of Gezira on vari- summer semester (in the 2nd, 4th and 6th ous indicators of community development

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S in Um-Alghora. A comparison was made volunteers prepared by the Federal Ministry between areas where BDN had been imple- of Health was utilized for this purpose. The mented before the University¶s IDFTRRD trained cluster representatives conducted programme and areas where the students training of community members within implemented the IDFTRRD programme their clusters. For this they used the training alone to investigate the effect of BDN on module for community volunteers on key various indicators of community develop- family and community practices, which is ment, the participation of local communi- part of the IMCI community component ties in students¶ activities and on students¶ (also prepared by the Federal Ministry of access to and quality of data collected at Health), as the IMCI programme was intro- community level. duced into the area in 2001. Group 2 comprised 3 villages (Almaiaa, Ghifar and Ki¶wirra) that also hosted the 1IXLSHW students¶ IDFTRRD programme, but where 7XYH]HIWMKR the BDN project was not implemented. A cross-sectional study design was adopted Villages were selected by stratified random where the study population was students sampling from the 3 administrative units in from the Faculty of Medicine, University the Um-Alghora area. The total population of Gezira, implementing the IDFTRRD in the 3 villages was 15 000. programme in 2 groups of villages of Um- Pre- and postintervention surveys were Alghora area. Data collected as part of this conducted in the 2 groups of villages in study followed a prospective interventional phase 1 and 3 of the students¶ training, longitudinal study design where the study utilizing a standardized questionnaire that population was families in the study area is routinely used by the students during the with children aged under 5 years. IDFTRRD programme. From each group of villages, 100 fami- 7XYH]EVIEW lies with children aged under 5 years were The study areas were 2 groups of villages in included in the study. The families were Um-Alghora area. selected by simple random sampling. The Group 1 comprised 4 villages (Ragwa questionnaire was designed to assess the Bakir, Ragwa Ahmed, Dahawi Bakir and knowledge, attitudes and practices of the Dahawi Karor), with a total population family (mainly mothers of children aged of 5000. This area hosted the students¶ under 5 years) that affect the health of their IDFTRRD programme, and was also an children, and the morbidity rate due to diar- area where the BDN community-based ini- rhoea, cough and fever among those under 5 tiative had been introduced in the year 2001. years. The study variables included: As part of the BDN initiative, 86 income- Socioeconomic characteristics of the generating projects (mainly breeding of study population. cows and goats) were owned by local fami- Improvements in the health practices lies. Cluster representatives also received of families. These were assessed by training on family and community practices students through the utilization of the according to the integrated management Sudanese adapted IMCI mother card. of childhood illnesses (IMCI) approach Improvements were identified by com- plus vocational training on food processing paring results of pre- and postinterven- and handicrafts. A training package for tion surveys regarding a number of

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indicators: % of under 5s not vaccinated the Z-test, to find out if there were signifi- at all, % of under 5s up-to-date with cant differences. their vaccination, % of families utilizing regular growth monitoring services, % of pregnant women utilizing antenatal 6IWYPXW services, % of married women using oral contraceptives for family planning, 7SGMSHIQSKVETLMGGLEVEGXIVMWXMGW % of under 5s up-to-date taking vitamin There were no statistically significant dif- A supplements, % of under 5s sleeping ferences in the distribution of age, edu- under insecticide-treated bednets. cational status and occupation among the Improvement in the health status of the parents and caretakers of children aged under 5s. A comparison was made pre- under 5 years in the 2 groups of villages and postintervention of % of families (data not shown). seeking care from a professional health worker for an under 5 with an episode of Improvements in family and community diarrhoea, cough or fever during the past practices 2 weeks. In group 1 villages most of the preinterven- Assessment of community participation tion indicators for students¶ interventions in the students¶ programme. were better than those of group 2 villages, Data were also collected from all stu- a situation that could be attributed to the dent groups who were posted as part of previous implementation of BDN in the the IDFTRRD programme in group 1 and group 1 villages. Furthermore, the effect of group 2 villages. The data collection was student¶s interventions on improving family done immediately after students returned practices was more marked in BDN villages from the villages to the university campus. in comparison with their effect in villages A structured pretested questionnaire was not implementing BDN (Table 1). used to assess: The students¶ impact was higher in BDN Participation of community members in villages with regard to the following objec- the students¶ activities and interventions tives of their interventions: such as the survey, project, cleaning Reduction of percentage of families with campaign, 1-day clinic and tree planting. children under 5 years who were not Students¶ access to and quality of the vaccinated at all. data collected by them at the village lev- Increase in percentage of families with el. Student¶s assessment of community children under 5 years who were up-to- participation and data were indicated on date with their immunizations. a 3-point scale (0±2), where 0 indicated Increase in percentage of families utiliz- poor and 2 indicated good. ing regular monthly growth monitoring services. (EXEEREP]WMW Data was entered and analysed using SPSS, Increase in percentage of married wom- version 10. All percentages were obtained en utilizing antenatal care services. through the program. The difference be- Increase in percentage of married wom- tween percentages was tested using non- en in childbearing age using oral contra- parametric tests, mainly binomial based on ceptives for family planning.

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Increase in percentage of families with Community participation in students¶ their children under 5 years sleeping interventions under insecticide-treated bednets. Table 2 presents a comparison between Increase in percentage of families seek- the number of community members (both ing care from a professional health sexes) who participated in different student worker for their children under 5 years activities in group 1and 2 villages. No specific denominator was identified to transfer who had fever. the frequencies of participating community Increase in percentage of families seek- members into percentage indicators. How- ing care from a professional health ever, in view of the total population in each worker for their children under 5 years of the 2 groups of villages (5000 in group 1 who had diarrhoea. and 15 000 in group 2 and the almost equal Increase in percentage of families able to numbers of participating individuals we can perform correct nutritional practices for conclude that, overall, the community par- feeding their children under 5 years. ticipation of group 1 villages was far greater The effects of students¶ interventions than that of group 2 villages. in non-BDN villages was only higher with The most notable difference between the regard to the following objectives: 2 groups of villages was the participation of women in group 1 villages. The number Increase in percentage of families whose of women participants in the 2 groups was children under 5 years were up-to-date almost equal in activities such as the stu- with supplementary doses of vitamin A. dents¶ survey, tree planting and cleaning Increase in percentage of families who campaigns. The women in group 1 villages seek care from a professional health were organized and active as cluster repre- worker for their children under 5 years sentatives. They came out to welcome the with cough. students on their arrival to the villages and participated with the students in different Health status of under-5-year-olds parts of their project. Students described The reduction in the occurrence of diar- women from group 1 as ³active and com- rhoea and cough among the under 5s was mitted to developing their villages´. more marked in group 1 villages, whereas Regarding the students¶ access to and the reduction in the occurrence of fever quality of data collected, families and community members in both groups of villages was more marked in group 2 villages. In were very ready to provide students with the group 1 villages the incidence of diarrhoea required sociodemographic data. Students in the pre-intervention period (17.2%) was commented that community members in even lower than the postintervention levels group 1 villages were more cooperative observed in group 2 villages (21.2%), an and could understand students¶ requests effect that could be attributed to the BDN more easily. The data of group 1 villages programme. Although the reduction in the was more organized and complete than that occurrence of fever among under 5s was of group 2 villages. Village information larger in group 2 villages, the postinterven- centres had been established in group 1 tion level was still lower in group 1 villages villages as part of BDN implementation and (11.2%) compared with group 2 (16.1%) some trained cluster representatives assisted (Figure 1). students in their surveys.

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(MWGYWWMSR and commitment to organizing communities in a similar way to BDN villages in any As community-based interventions, both future community-based projects. the BDN and students¶ activities of the uni- Capacity-building of local communities. versity IDFTRRD programme, are based on similar principles as follows: Both BDN and the university IDFTRRD Organizing the community for promot- programmes aim to achieve sustainable ing partnership for self-development. BDN development and not only the provision of works through organization of the com- transient urgent services. Training of vil- munity into clusters and formation of village development committees and cluster lage development committees. Students in representatives in the BDN programme the IDFTRRD programme also mobilize contributes effectively to raising social and work in the community through its awareness of the community, enhancing existing organizations such as peoples¶ self-reliance and thus ensuring sustain- committees, students¶ unions, etc. They ability of developmental activities. The also address community leaders (traditional and religious) whose status and role in their involvement of communities by students communities cannot be overlooked. How- throughout all phases of their programme ever, students working in non-BDN villages has also contributed to raising the social and noted that villages expressed a willingness health awareness of villages.

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Improving the behaviours and health Although behaviour change usually status of local communities. Health educa- takes a long time to be established, the re- tion was provided by trained cluster rep- sults of the study showed a significant im- resentatives to communities in group 1 provement, with varying degrees, in all the villages. The community members in both measured behavioural and health indicators groups of villages received organized edu- in the 2 groups of villages. Evaluation of cation and training by the medical students BDN programmes in many countries has who were formerly trained in IMCI fam- demonstrated similar effects. In Yemen ily and community practices as part of the [1], where the tetanus toxoid coverage Faculty of Medicine curriculum. It is to be was previously low, the BDN intervention noted that house-to-house distribution of improved the situation considerably and vitamin A doses had stopped in Gezira state resulted in a slight increase in the status of in the period 2000±02. Students have thus immunization and a slight decrease in the promoted community-based distribution of percentage of deaths in infants. In Djibouti vitamin A capsules. [2], the principal effect of the BDN pro- Emphasis of comprehensiveness and gramme in the field of health has been the multidisciplinary development. The impor- prevention of diseases through community tant role of government and other sectors in health volunteers who educate communities different stages of developmental projects is about school health, immunization, nutri- addressed in BDN through involvement of tion, environmental health, prevention of trained technical support teams. Students¶ malaria and HIV/AIDS. As a result, infant analysis of community problems has also mortality, immunization coverage among infants (1 month to 1 year), percentage of enabled community members to realize the children under 5 years followed for growth different determinants of health and illness monitoring and percentage of women im- and to identify the roles of relevant sectors munized against tetanus showed vast im- in the solutions to their problems.

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S provements against the national averages. have the opportunity to learn, in real-life In Jordon, the quality of life project villages situations, about different community- also demonstrated improved utilization of based programmes such as BDN and the family planning, antenatal care coverage IMCI community component. Students (almost 100%), together with an increase in group 1 villages appreciated the role in the expanded programme of immuniza- of BDN in community organization and tion coverage, through health awareness awareness. sessions and motivation of mothers through During their posting, students deliver community representatives [3]. health education sessions and discuss The community-based training pro- the results of the health surveys with the gramme of the Faculty of Medicine, Uni- community, including analysis of the versity of Gezira, sets a good model for how causes and impacts of different com- to adjust health manpower development to munity problems and needs. All these the real health needs and demands of the opportunities can enhance students¶ population and the national health system, learning, as information is better un- which was formerly identified as the ³health derstood, processed and retrieved if stu- manpower development concept´ [4]. dents have opportunities to elaborate on Community-oriented medical education that information [5]. was first defined in the first meeting of the Students posted in Um-Alghora have network of community-oriented educational contributed to the availability of health institutions for health sciences in 1979 as ³a type of training of health personnel that services in the villages, ranging from focuses on both population groups and indi- curative services (1-day clinics) to pro- viduals and that takes into account the health motion and preventive services such as needs of the community concerned´ [4]. health education, cleaning campaigns, The community-based education that is tree planting and distribution of vitamin adopted by the Faculty of Medicine, Univer- A capsules. This should be considered sity of Gezira, represents a tool to achieve as an active contribution from our stu- the faculty objectives through students¶ dents to solving the problems of service postings in the community. Community-based delivery in those rural areas and to the education in itself is thus a means of achiev- improvement of the health system, as it ing educational relevance to community works towards resolving priority health needs and, consequently, a way of imple- problems of the population [7]. menting the faculty¶s community-oriented During their posting in villages or as- educational programme [5]. signments in rural health facilities, stu- The IDFTRRD programme implemented dents have had opportunities to practice in Um-Alghora has satisfied the rationale of a multidisciplinary and holistic approach community-based education for the follow- to health care [8]. ing reasons: This educational programme of the Fac- Education of students during their resi- ulty of Medicine, University of Gezira, thus dence in the community is an estab- provides an excellent model for partnership lished approach to training doctors who between the community, the university and are willing and able to work in under- the government, being an advanced step in served areas, particularly rural com- collaboration between the 3 parties, a goal munities [6]. In addition, our students that BDN aims to achieve in creating part-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S nerships between communities and relevant regarding medical practice at individual, sectors. family and community levels. Faculty of Medicine staff (from the 'SQQYRMX]TEVXMGMTEXMSR Department of Community Medicine) Important determinants, which constitute have participated as part of Gezira state preconditions, for community participation, BDN steering committee and core of include: trainers in the planning and implementa- Commitment of the professionals who tion of all the project activities: train- engage in the process. ing of technical support teams, village Competences in areas such as commu- development committees and cluster nication and facilitating and managing representatives; community mobiliza- change, to ensure effective work with tion; and monitoring and follow-up of and between decision-makers, middle the project activities. This role puts the managers, community leaders and com- Faculty of Medicine more in touch with munity members. the community and its leaders in BDN Both preconditions were ensured by the (group 1) villages. BDN approach, through the commitment All these factors provide a favourable of higher-level and local authorities (by the environment for community participation commitment of technical support teams and in students¶ activities in Um-Alghora, es- training in BDN strategies and methods). pecially in BDN villages. It is well rec- As for student activities, the following fac- ognized that involving communities in tors and conditions coexisted: assessing their own needs and assets is Commitment of the top administrators in a key component of the overall planning the University of Gezira who conducted process, often providing a starting point for field visits and meetings with commu- community participation by increasing the nity leaders to express the university understanding of both professionals and commitment to supporting students¶ ac- the community and enabling more respon- tivities. sive and participatory policy-making and Faculty of Medicine staff conducted service delivery [9]. Such involvement in preliminary visits to all the concerned the implementation, monitoring and evalu- villages prior to each phase of the ation stages were ensured by both the BDN IDFTRRD programme to seek the per- project and the students¶ project in group mission of the community and to orient 1 villages. The population of group 1 vil- community leaders with the course ob- lages, exposed to the experience with the jectives and the students¶ tasks. BDN project, were already organized and Field visits by Faculty of Medicine staff enabled in issues concerning quality of life to supervise students¶ activities. and comprehensive development. Faculty of Medicine students usually receive training in communication skills 'SRGPYWMSR as part of the faculty curriculum programme. In addition, students also learn The study revealed that the collective imple- about legal aspects of the medical profes- mentation of community-based programmes sion and professional ethical principles such as BDN and students¶ interventions

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S brought about marked improvements in Introduction of BDN concepts and strat- family and community practices and greater egies in the curricula of medical schools reductions in the incidence of all assessed and other health professional training major childhood illnesses (diarrhoea, cough institutes. and fever) than with the students¶ pro- Adoption of community-based education gramme alone. It also demonstrated that as an educational strategy in different BDN implementation resulted in an organ- training institutes for health profession- ized and ready-to-mobilize community in als. addition to the availability of easily re- Medical students in phase 1 of their trieved and good quality community-based IDFTRRD programme should organ- data. ize communities according to the BDN strategy, in order to facilitate positive interaction and community participation. 6IGSQQIRHEXMSRW Continuous research to measure the BDN areas should be the focus of all effect of BDN and medical students community-based health activities or- in promoting family and community ganized by different sectors (including practices and assess the different factors academic institutions). influencing these practices.

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-RXVSHYGXMSR of nutrition among children cause serious long- and short-term consequences in their Over the past 35 years, Egyptian demo- physical and mental growth. Studies report graphic and survival indicators have shown high levels of mortality among malnour- marked improvement. For example, from ished children [3]. Further, malnourished 1970 to 2005 life expectancy increased children are more likely to have functional from 52.1 years to 68.8 years, infant mortal- impairment in adult life [4] leading to a ity dropped from 157 to 35 deaths per 1000 reduction in productive life and thus af- live births, and under-5 mortality dropped fecting the overall economic productivity from 235 to 41 deaths per 1000 live births of the society [5]. For example, it is widely [1]. Despite these improvements in health accepted that adults who survive malnutri- conditions there are still important impedi- tion as children are more likely to suffer ments to survival and development, espe- from higher levels of chronic illness and cially for children. One of the most serious disability [6,7]. health concerns is under-nutrition. Figure 1 Studies on the nutritional status of chil- presents the trends in under-nutrition levels dren often accept the notion that it is deter- in children in Egypt from 1992±2000 [1]. mined by a multiplicity of factors [7±9]. In While there are decreases in levels of child this regard, several theoretical explanations under-nutrition, approximately 1 in 10 chil- of malnutrition among children are found dren (11%) under the age of 5 years was in the literature [10]. These include fam- under-weight and approximately 1 in 5 chil- ily planning approaches [11,12], socioeco- dren (21%) was under-height for age [2]. nomic approaches [9,13] and the framework The nutritional level in children is a recommended by UNICEF [14]. The former vital component to their survival and de- 2 approaches emphasize a set of factors to velopment in their early years. Low levels the exclusion of factors important to the

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10% of the households were selected for This program transforms the international re-interview [1]. growth reference curves into a Z-score rep- resentation. These growth reference curves (EXEEREP]WMW have been used worldwide since 1978 to To assess the nutritional status of indi- assess the nutritional status of children in vidual children, WHO recommends the cross-sectional surveys. Smoothed nor- use of Z-score indicators of weight-for- malized curves are fitted by polynomial age (WAZ) (under-weight), height-for-age regression and cubic spline techniques and (HAZ) (stunting) and weight-for-height these curves are used to calculate all other (WHZ) (wasting). To compute the anthro- normalized Z-score values. The standard pometric indices, information on each in- deviations are defined separately for the up- dividual¶s gender, age, weight, and height per and lower half of the skewed reference are needed. WHZ and HAZ are the most distributions. It has been argued that the use commonly used indices for determining of Z-score cut-off points provides interpre- nutritional status. The former is an indica- tative guidance in that a known proportion tor of wasting (i.e. thinness indicating acute of the reference population would be ex- malnourishment) and the latter is an indi- pected to be below the cut-off point at any cator of stunting (i.e. shortness indicating given age or height and for all indicators chronic malnourishment). The third index, [19,20]. The commonly used conservative WAZ, is primarily a composite of WHZ and cut-off value of Z-score less than ±2 SD is HAZ and is considered to represent acute followed in our analysis. and chronic malnourishment. These indices Once the measures of malnutrition present the long- and short-term prevalence were calculated for each of the 3 indices, of malnutrition in children. In the ADHS measures of parental and socioeconomic 2000 survey, ³heights for children younger conditions were identified. The basic causes than 24 months were measured lying on a at the societal level can be divided into measuring board and standing height was 2 types: potential resources and quantity measured for older children. Weight data and quality of actual resources. Potential were obtained using digital scales with resources are understood in terms of po- an accuracy of 100 g´ [1]. For measuring litical, cultural, religious, economic and child¶s age a series of techniques were ap- social subsystems present in the society and plied in order to maintain accuracy. In ad- include conditions such as women¶s status dition to asking mothers in what month and in the society [23]. The potential resources, year the child was born, the mothers were in turn, influence the quantity and quality also asked, ³How old was your child at his/ of actual resources. The quantity and qual- her last birthday?´ In addition, interviewers ity of the resources available is shaped by asked the mothers for birth cards or certifi- the human, economic, and organizational cates in cases where one was available and manner in which they are controlled [23]. cross checked the responses. For the purposes of this paper, the basic The procedure for the computation of causes at the societal level were measured these measures and their interpretation are in terms of place of residence, consanguin- well documented [19±22]. In our study, ity between parents, parents¶ level of educa- the values of WAZ, WHZ and HAZ were tion, mother¶s employment status, mother¶s calculated using the Epi-Nut program pro- height, and child¶s sex. vided along with the Epi-Info, version 6.03.

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Place of residence was identified as variable, Xij: individual control variables, rural or urban. Consanguinity between the Pj: variables at the community (PSU) level, parents was measured as: no relation, first mj: error of unobserved community vari- degree, second degree, or other blood rela- ables and ejj: error of unobserved individual tive. Father¶s education was measured as no variables. The basic assumption is that mj formal education, primary school, second- is uncorrelated with the regressors; in other ary school, or higher education. Mother¶s words, the above model considers the sam- education was measured as no formal edu- ple design as well. Specifically, the model cation, primary school, secondary school, predicting the probability that the Z-score or higher education. Mother¶s employment value will fall below ±2 SD (i.e. malnour- was identified as working outside the home ished) takes the form: p(z = 1) = eY/(1 + or not working outside the home. Mother¶s eY). height was measured in centimetres as: The predictor variables entered in the < 150 cm, 150±160 cm, or >160 cm. The regression equation are sets of dummy sex of the child was measured as male or variables. Thus, the results obtained were female. compared with the reference category. The The second level identified in the predictor variables used in the logistic re- UNICEF model considers underlying caus- gression model were: current place of resi- es at the household/family level [6]. Central dence, sex of the child, mother¶s education, to these underlying causes are the maternal father¶s education, birth spacing between and child care practices and include many the child and the previous birth, birth order, factors linked to family planning activi- age of mother at the time of the child¶s ties. In this paper, mother¶s age at birth delivery and age of the child at the time of her last child, child¶s age, birth order of survey. The reference categories for the and birth interval were included. The age different variables mentioned above were: of mother at birth was measured as < 19 living in a rural area, female child, maternal years of age, 19±24 years, 25±34 years or illiteracy, paternal illiteracy, birth spacing < 35 years. The age of the child at the time 24 months, birth order of 5, mother¶s age of data collection was measured in months at child¶s birth < 19 years and age of child as 0±11 months, 12±23 months, 24±35 < 12 months old respectively. All outliers months, 36±47 months or 48±59 months. in anthropometric measures were deleted The birth order was identified as 1, 2, 3, 4 or prior to data analysis. The Epi-Nut program 5 and higher. Birth intervals were first born, flagged 32 cases as outliers by default and 0±23 months, 24±35 months, 36±47 months further investigation of data did not show or 48 months. any additional outliers. The statistical anal- A logistic regression technique was used ysis was performed using SAS 9.1 statistical to estimate the odds of being malnourished. software for windows. This technique permits control of the parental and socioeconomic variables. To create the dependent variable, the children whose 6IWYPXW Z-scores were less than 2 SD were coded as Table 1 presents the percentage distribu- 1 and the children with Z-scores of ±2 SD or tion of children below ±2 SD units for the higher were coded as 0. The following was 3 anthropometric measures (wasting, stunt- the basic model used in the analysis: Y = a ij ing and underweight) according to selected + bXij+ cPj + mj+ eij; where: Yij: outcome

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S parental and socioeconomic characteristics. born to mothers in other age groups, 19.53% Based on a theoretical distribution, it would and 21.35% respectively. Just over 15% of be expected that 2.2% of children would be children aged 0±11 months at the time of below ±2 SD. On this basis, the 3 measures the survey were stunted as were 23.44% of of under-nutrition were greater than would children aged 12±23 months. be expected. Among children under 5 years While lower than the prevalence of of age in Egypt, 18.67% were stunted (low stunting, at 2.52% wasting was still greater height-for-age), 2.52% were wasted (low than the expected 2.2%. There were no gen- weight-for-height) and 4.06% were under- erally clear patterns seen for stunting with weight (low weight-for-age). the different variables (Table 1). As regards The prevalence of stunting was higher under-nutrition, 4.06% of children under 5 among rural children (21.79%) as compared years were under-nourished. The patterns to urban children (13.79%). The proportion seen were generally fairly similar to those of children with stunting fell as parents of stunting (Table 1). education increased. For example, among Although all 3 measures of under-nutri- mothers and fathers with no education, tion were higher than would be expected, 22.56% and 23.26% respectively of the the highest prevalence was found in stunt- children were stunted compared to 13.81% ing (chronic malnourishment) (HAZ); and 12.53% respectively among mothers 18.67% of the children under age 5 years and fathers with higher than secondary edu- were stunted. As this was the most preva- cation. A sharp decline in stunting was ob- lent form of under-nutrition in Egypt, the served with an increase in mother¶s height. subsequent analysis focused on stunting Among mothers < 150 cm tall, 30.89% of only. Multivariate analysis was carried out the children were stunted; the percentage de- to find the odds of stunting among children creased to 13.61% of children with mothers (Table 2). Since the birth interval variable > 160 cm tall. Children of mothers working was calculated only for births of second outside the home had a lower prevalence and higher orders, the multivariate analysis of stunting (17.76%) than those whose excluded the first order births. mothers who did not (18.82%). Stunting Several variables were found to have was higher among children born to mothers a significant influence on the prevalence married to close relatives; approximately of stunting in Egypt. The odds of children 22% of children born to mothers married to being stunted in urban areas were 0.71 times their first cousins (father¶s or mother¶s side) lower than for children in rural areas. While were stunted compared to those born to not all categories of mother¶s education mothers with no blood relation to their hus- were statistically significant, they were bands. Stunting was higher in male children in the expected direction. That is, as the (19.85%) than female children (17.42%). maternal educational level increased, the Higher levels of stunting were found in odds of children being stunted decreased. children of higher birth order (24.31% for While no clear and significant pattern was birth order 5 vs 17.26% birth order 1) observed with father¶s education on stunt- and shorter birth intervals (23.44% for birth ing, the odds of stunting were 0.76 times interval < 23 months vs 16.7% birth interval lower among children whose fathers had at 48 months). Children born to mothers least higher secondary education as com- aged < 19 years and 35 years showed a pared to children born to fathers with no higher prevalence of stunting than children education. Mother¶s height was found to

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S the past 10 years in the nutritional status gests the need for age-specific interventions of children but much work remains to be to address the nutritional needs of children. done. In order to further decrease levels Additionally, family planning conditions of childhood malnutrition in Egypt, policy such as birth interval, which was found to frameworks must be established that incor- be very important in our study, need to be porate short-term, medium-term and long- considered. This finding supports the idea term strategies to solve nutritional problems that rearing children requires a large amount [24]. The intervention strategies should be of resources and attention. When children comprehensive, culturally sensitive and, as are born closely together, the demands on malnutrition is a public health concern, ad- resources such as mother¶s time, food, and dressed at various levels of government. other resources may be greater than the Based on the findings of this research, family can provide. Our findings therefore policy development must take into consid- suggest that greater spacing of children eration the rural±urban divide in malnutri- could help to address under-nutrition by tion. It is clear that children raised in rural relieving competition and exhaustion of areas are at greater risk for under-nutrition. available resources. Our results support the findings of prior While socioeconomic conditions cer- studies that have also described the urban± tainly have an effect on the nutritional status rural differences in health in Egypt. People of children, there is growing recognition living in urban areas are provided with that genetic factors must be considered better access to health services, education as well. There have been calls for the in- and other social support systems which are clusion of genetic characteristics in the either not available or not easily accessible study of child health and nutrition [27,28] to residents in rural areas. For example, but genetic components have not been ad- studies have shown that immunization rates equately examined in many studies [29]. are higher in urban areas as compared to ru- The inclusion of 2 genetic factors in this ral areas of Egypt [25]. Programmes should study is an important contribution to the thus be developed to analyse and implement literature on childhood nutritional status. appropriate strategies to address rural and The 2 genetic characteristics (mother¶s urban child malnutrition. For example, in height and parental consanguinity) emerged Egypt most nutritionists are based in urban as significant factors influencing stunting hospitals while cases of malnutrition in of children in Egypt. Consanguinity in a rural areas are unlikely to seek care in such population depends on several factors such hospitals [26]. Improvements in access to as demographic, social and religious norms care in rural areas together with the intro- and values. Many studies have shown conduction of awareness programmes will have flicting results on the impact of consan- a significant impact on ameliorating the guineous marriages on childhood health existing nutritional conditions in children. [30±32]. Children born to consanguineous Programmes should be developed that parents are at an increased risk of autosomal target higher risk groups such as young recessive disorders, multifactorial diseases children and higher birth order children. [30] and early postnatal mortality [33,34]. Further research and needs assessments are These disease processes can produce disor- required to examine this situation in order to ders similar to nutrient deficiency and may design intervention programmes. The fact result in the appearance of stunting [24]. that risks are different at different ages sug- Although there are conflicting opinions,

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S nutritional studies have seldom included as inclusion of immediate causes such as this phenomenon. More studies are thus the presence of disease and dietary intake needed in this area to explore further the in the child. influence of genetic characteristics on early These factors should be considered in childhood nutrition in Egypt and elsewhere. the development of any policies or pro- From a policy implementation perspective, grammes aimed at alleviating the problem the issue of consanguinity will require cul- of under-nutrition. Among all factors, pa- tural sensitivity to the issue [24]. To address rental characteristics, mother¶s character- consanguinity, educational programmes istics in particular, were found to have a could be instigated to create awareness, significant impact on determining the nu- particularly among young unmarried males tritional status of children. Empowerment and females, about the potential risks as- of women through increasing educational sociated with consanguineous marriage. levels, choice in marriage, family planning, Additionally, genetic counselling and risk and other activities that improve the status assessment for consanguineous couples of women in society must be a priority in would assist families in making family programme and policy development aimed planning decisions that could have an im- at addressing the factors associated with pact on the nutritional and health status of under-nutrition in children in Egypt. their children. Hameida and Billot argue that ³to meas- The results of our study show the impor- ure the weight and height of a child is to tance of the UNICEF model incorporating measure his or her health´ [35]. In the parental and socioeconomic characteristics present study we assessed the factors that in understanding the prevalence of under- contribute to the health condition of the nutrition, especially stunting, in Egypt. child. More specifically, we considered The framework classifies the causes of basic and underlying conditions that affect malnutrition to account for the complexity the nutritional status of children in Egypt. of the nutritional status of children. At the The study results further strengthen our basic level, rural conditions and the status understanding about the nutritional status of of women in society have an important con- children in Egypt. Although, at the national tribution to the nutritional status of children. level, the prevalence of under-weight and Specifically, children in rural areas are at wasting has decreased since 1995, these greater risk of stunting. Regarding women¶s estimates are still higher than would be de- status in society, education and the practice sired. Most alarmingly, the high prevalence of consanguinity contributed to the child- of stunting signifies a public health prob- hood malnutrition. Family planning factors lem; the anthropometric measures show as underlying causes at the household/fam- estimates of stunting above international ily level were also found to be important standards. Stunting is so prevalent that al- aspects of the UNICEF model. Specifically, most one child in every five children under birth order and birth interval were important the age of 5 years in Egypt is stunted. The factors and relate to inadequate maternal documented decrease in childhood stunting and childcare practices. Further research in Egypt is promising but more work must is needed to explore the influence of ad- be done to address the issues of childhood ditional basic level causes and underlying malnutrition if the gains are to be sustained causes at the family/household level as well and further progress achieved.

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-RXVSHYGXMSR cially beneficial to identify factors that are modifiable among this group of women. Low birth weight (LBW) is a potentially The objective of the study was to iden- preventable public health problem par- tify the maternal risk factors associated with ticularly prevalent in developing countries LBW among women aged 1535 years in [1]. It contributes substantially to neonatal, hospital births in Karachi. infant and childhood mortality as well as to morbidity [2]. In addition, the weight of an infant at birth is an important indicator of 1IXLSHW maternal health and nutrition prior to and during pregnancy. We carried out a hospital-based case Striking variation exists in LBW preva- control study on LBW in Karachi in the lence within Asia: the highest rates are in maternity wards of 3 hospitals that provide South Asia and the lowest in East Asia [3]. health services to the lower socioeconomic In East Asia, the proportion of LBW ranges strata, to study risk factors of LBW among from 5% to 10%, with the exception of Thai- those of underprivileged social status. Each land, where an estimated 36% of all infants of these hospitals hosts about 3500 deliver- are LBW [4]. In South Asia, the problem is ies per year. Patients are drawn from urban, most acute with up to 50% of all neonates suburban and rural areas, and about 75% having LBW [3]. Up to 25% of neonates in of users are classified as living in poverty. Pakistan are classed as LBW [5]. Civil Hospital, a 1400 bed hospital, is a gen- Infants with LBW have higher rates of eral hospital working under the Sind gov- morbidity and mortality from infectious ernment. This hospital is attached to Dow disease, malnutrition and growth failure and Medical College, Karachi. Jinnah Postgrad- are also more likely to have abnormal cogni- uate Medical Centre is a federal government tive development, neurological impairment general hospital attached to Sind Medical and poor school performance [6,7]. These College, Karachi. Lady Dufferin Hospital is babies are at greater risk of cardiovascular a charity hospital for women and children, disease, hypertension and diabetes in adult mainly catering to the needs of low-income life [±11]. families living in nearby Lyari, Shershah There are numerous factors contribut- and other places in the Old City area. It ing to LBW, both maternal and fetal. The began with 25 beds and it now has over 200 maternal risk factors are biologically and beds. In 2003 over 4000 deliveries were car- socially interrelated; most are, however, ried out there. modifiable. The high uptake of services at these In Pakistan, statistics are available, na- hospitals is probably owing to their low tional nutrition surveys are carried out and cost. After admission, the majority of births the prevalence of LBW has been estimated take place within 2 days. The hospital stay at 12%25% [5]. There has, however, been is usually 1 day after delivery unless the very little research done on risk factors of mother or infant experience problems. LBW among women aged 1535 years. The study data were collected between This group is not biologically at high risk, July 2003 and September 2003 by trained but as most childbearing occurs in this age interviewers by interviews with the moth- range, preventable risk factors among this ers, abstraction of medical records and group need to be assessed. It would be espe- anthropometry.

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Birth weight 2.5 kg was defined as control. Mothers were enrolled on a daily LBW in this study. Cases were defined as basis. The response rate was almost 99%. mothers of LBW neonates while controls Only 3 mothers refused to participate (did were mothers of neonates weighing > 2.5 kg not give consent) in the study. The reason at the time of birth. This modification in the for this was that they had delivered by cae- definition of LBW (birth weight < 2.5kg) sarean section and at the time of interview was adopted to avoid digit preference, i.e. a they were in pain. Out of these 3 mothers, 1 tendency in the observers to record a weight had delivered a LBW baby. of 2.4 kg as 2.5 kg [12]. Controls were iden- Study information included demographic tified from birth records as the next eligible data, socioeconomic status, previous preg- delivery of a non-LBW baby after a woman nancies, ANC during current pregnancy, delivered an LBW baby. morbidity during pregnancy, maternal nu- Sample size was calculated using the tritional status, strenuous physical activity method of Schlesselman for an unmatched and smoking. Socioeconomic status was casecontrol study [13] to detect the odds assessed by employment of the mother and ratio (OR) of 2.0, power of 90%, specify- her spouse, mean household size, monthly ing alpha at 5% with 22% prevalence of household income and house type. In Pa- antenatal care (ANC) [14] and estimating kistan house types are pucca (cemented), the non-responders at 10%. kutcha (mud houses) and kutcha pucca A total of 262 cases (vaginal delivery or (made with asbestos sheets). The pucca caesarean section) and 262 controls of age houses are a sign of higher socioeconomic 1535 years with no known medical illness status. Maternal age was recorded as a con- who delivered a live-born singleton baby tinuous variable as completed years. Age through without congenital malformation was confirmed from the mother through and with gestational age 3742 weeks were interview, from her national identity card enrolled from hospital records within 1 day as well as from the hospital records. In of delivery. Mothers with a known chronic case of disparity, the national identity card illness (hypertension, tuberculosis, diabetes was used. Education status of both parents mellitus), or who had multiple births or was coded to distinguish between parents delivered babies with congenital abnormali- who had received no school education ties were excluded. Only 10 women were (illiterate), had primary school education excluded: 3 had twin pregnancies, 2 were (< 6 years) or had completed secondary > 35 years, 3 did not give consent, 1 had school ( 6 years). Parity was analysed tuberculosis and 1 was 14 years old. as a continuous variable. History of abor- A pre-coded questionnaire was devel- tion was classified as ever/never had abor- oped in English, translated into Urdu and tion. Birth interval between the current and then back-translated into English to check last pregnancy was taken as a continuous the phrasing to ensure that that the sense of variable. Total numbers of ANC visits for the questions was not changed. Information the current pregnancy were categorized was taken from interviews with mothers, as 4 visits and < 4 visits, based on the medical records and post-partum maternal World Health Organization (WHO) and examination. Hospital records were used UNICEF criteria that women should have to identify cases. For every case selected, 4 ANC visits with an appropriate health the next woman who delivered a non-LBW care provider [15]. Information given by baby on the same date was selected as a the ANC provider was considered adequate

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S if the provider discussed the importance of by computing frequencies. Crude odds ratio healthy food and breastfeeding, weight gain (OR) and 95% confidence interval (CI) for during pregnancy, early labour and future each variable of interest were calculated. family planning with the mother. P-values were calculated by likelihood Maternal nutritional status was assessed ratio test for the significance of the beta by postpartum weight, haemoglobin level coefficients; P 0.05 was considered sig- before delivery, and food consumption nificant for all the independent variables before and during pregnancy. Maternal in the model. Multiple logistic regression haemoglobin was analysed as a continuous analysis was performed to identify factors variable. associated with LBW, while adjusting for Use of iron and calcium supplements other variables. during pregnancy was dichotomized into Data gathered from the study were daily and not daily. An account of a typical analysed according to WHO definition of day spent by the mother was taken. This LBW (< 2.5 kg) as well as 2.5 kg and included travelling on foot, washing clothes it was found that the results were similar. by hand, sweeping floors and midday rest. Therefore, the original definition of 2.5 These variables were categorized into every kg was used because the power of the study day, ~ 3 times a week and once a week. would have been reduced if the definition Information about maternal haemoglob- was changed. All analyses discussed were in, gestational age and morbidity during based on 2.5 kg. pregnancy was taken from the hospital records. Gestational age was calculated from the menstrual history or an ultrasound 6IWYPXW result if available.The expected date of each With regard to demographic and socio- delivery was calculated from the menstrual economic characteristics controls appeared history provided the dates were sure and to have better housing conditions while the menstrual cycles regular and there was household income was similar among the 2 no history of use of oral contraceptives in groups (Table 1). Cases and their husbands the 3 months before conception. If any of were less educated than the controls (Table the above criteria were not met then the 1) but the difference was only significant results of the ultrasound scan, if available, for the mothers (P = 0.007). were used to calculate the expected date of During the current pregnancy, a high per- delivery. centage of both cases (96.9%) and controls Ethical approval for the study was taken (90.5%) received appropriate ANC (Table from the Aga Khan University Ethical Re- 2). The ANC experience of the mothers in view Committee. the control group was slightly better than that of cases. Mean number of ANC visits 7XEXMWXMGEPEREP]WMW was 4.3 [standard deviation (SD) 1.4] for Logistic regression was used to identify the cases and 3.8 (SD 1.8) for controls (P = factors associated with LBW using SPSS, 0.002). version 10. Descriptive statistics were com- Although both cases and controls were puted for all variables according to type. physically active during pregnancy, a great- Frequency, mean and standard deviation er proportion of women in the control group were obtained for continuous variables had a daily midday rest (P = 0.044) (Table while the categorical variable was assessed

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3). Mean duration of the midday rest was maternal post-partum weight and maternal 142 (SD 90) minutes for mothers of LBW age. After adjusting for the effect of other babies and 148 (SD 103) minutes for the variables in the model it was found that control group (P = 0.493). maternal haemoglobin level (measured be- The haemoglobin status and daily intake fore delivery) was independently associated of iron supplements was significantly bet- with LBW (Table 4). Odds of delivering ter among the control group (P < 0.001) an LBW baby decreased with increase in (Tables 2 and 4). maternal haemoglobin (OR: 0.70; 95% The final logistic regression model in- CI: 0.630.79). Mothers who did not take cluded maternal haemoglobin before de- iron supplements during pregnancy had in- livery, iron supplement intake of mother, creased odds of having an LBW baby (OR:

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2.88; 95% CI: 1.834.54). With increase pregnant women carried out in Pakistan in maternal post-partum weight, odds de- [17,18] and Syria [19]. Women can develop creased (OR: 0.97; 95% CI: 0.950.99). iron deficiency anaemia from the loss of blood during menstruation and from repeated pregnancies; it can also be caused by (MWGYWWMSR a lack of iron in the diet. During pregnancy, women may develop anaemia because the In the present study the relationships be- growing fetus draws upon the mothers iron tween LBW and maternal haemoglobin sta- for the development of red blood cells and tus, iron supplement intake and post-partum other tissues. weight were found to be statistically signifi- Due to the natural decrease in haemo- cant. All these factors are interrelated. globin level during pregnancy, the haema- A strong relationship was found between tocrit measurement should be carried out anaemia and LBW [16]. The findings were prior to pregnancy. In the present study, in agreement with other studies of anaemic

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S since the pre-pregnancy haemoglobin lev- last menstrual period and ANC were de- els were not available, the haemoglobin termined from the mother, these variables levels were taken from the hospital records may have been subject to recall bias. Due to which measured the maternal haemoglobin logistic constraints maternal pre-pregnancy at the time of admission for delivery. It was, weight, weight gain during pregnancy and thus, not possible to conclude whether the haemoglobin level before pregnancy could mothers became anaemic at some stage in not be measured. This was a hospital-based pregnancy or they were already anaemic study, while in Pakistan a large number of before getting pregnant. deliveries are conducted at home and only Intake of iron supplements during preg- those neonates that are born in hospital are nancy was also found to have a protective weighed, a small proportion of all births. effect with respect to LBW. This is consist- Information regarding smoking status of ent with the findings of some other studies the mother could not be analysed because on iron supplementation and pregnancy altogether only 6 mothers admitted that they outcome [2±22]. Iron supplementation were smokers. during pregnancy protects a woman from becoming anaemic because the required amounts may not be supplied from dietary 'SRGPYWMSR intake during this period. In view of the fact that for the present An important measure that can be taken to study the pre-pregnancy weight and weight reduce anaemia in pregnancy is to determine gain during pregnancy were not available, whether a woman is anaemic before preg- the post-partum weights were taken. The nancy. Haemoglobin assessments should maternal post-partum weight was also found be done in the early stages of pregnancy. In to be associated with the birth weight of the order to prevent anaemia during pregnancy, baby. This is in accordance with a study mothers should be advised to take iron conducted in Cleveland, Ohio [23]. supplements during pregnancy. For appro- Our results showed that the risk of LBW priate weight gain during pregnancy, preg- increased to some extent with increasing nant women need to be counselled about maternal age. This was consistent with a healthy diet. Weight before pregnancy results from a number of other studies as well as weight gain during pregnancy [24±27]. In Pakistan women generally get should be carefully monitored to promote married early and begin childbearing soon optimal outcomes for mother and infant. after marriage. They are expected to have The problem of LBW in Pakistan needs a high total fertility rate. Due to repeated focused attention, and research requires pregnancies and short pregnancy intervals, innovative strategies to attempt to identify the risk of having an LBW baby increases in protective factors among women who are older, grand multiparous women [28]. at high risk.

0MQMXEXMSRWSJXLIWXYH] There were a number of limitations to this %GORS[PIHKIQIRXW study. The international definition of LBW was not used. This criterion was adopted We wish to acknowledge the Internation- in order to resolve the problem of digit al Maternal and Child Health Research preference. Since maternal age, date of Training Programme (FIC, NIH # 5 D43

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TW05497-03) of the Aga Khan University ham for providing technical support in the and the University of Alabama at Birming- development of this manuscript.

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-RXVSHYGXMSR Along with under-nutrition, maternal health is affected by manual labour (getting water Initiatives were taken in the year 2000 to and fuel for their households) [11±14]. work towards achieving the Millennium Moreover the fertility rates among such Development Goals (MDG) by the year women are high. The high energy demands 2015. The specific objectives of MDGs are on poor women from their combined pro- to eradicate extreme poverty and hunger, ductive and reproductive roles together achieve universal primary education, pro- with under-nutrition thus have a substantial mote gender equity and empower women, impact on their health. This is further com- reduce child mortality, improve maternal pounded by poor health care. health, control infectious diseases, ensure Children born to underweight and stunt- environmental sustainability, and develop ed women are also likely to be underweight a global partnership for development [1]. and stunted which will affect their future Womens empowerment and improvement potential at the individual and community in womens health are linked to the issue of level, thus establishing a vicious cycle [4]. poverty. The World Bank report of 2003 on Overall 19% of the children born in Pakistan poverty in Pakistan indicated that poverty are of low birth weight (LBW) [15] (birth exists in various forms in Pakistan and will weight < 2500 g), which leads to high infant continue to exist if various dimensions of morbidity and mortality [16±18]. LBW var- poverty are not addressed as increase in ies within subgroups of a population and is income alone will not help to reduce or reported to be associated with low socioeco- eliminate it. nomic status, parity, poor nutritional status, It is known that poverty is a feature anaemia, maternal infections, smoking, of rural and semi-rural areas in Pakistan, hypertension, inadequate antenatal care and compared to urban areas. Furthermore, pov- rural settings [8±1,14,19,2]. erty affects women in Pakistan through low The serious implications for maternal income and vulnerability to gender-related and child health have been studied and non-income factors [2±5]. Women usually reported on but there is less information do not earn direct income and household on the maternal dimensions of poverty. To income is low in rural and semi-rural areas address the specific nature of such poverty, and is associated with poor health status. In it is important to evaluate maternal charac- developing countries like Pakistan, human teristics related to poverty. Thus the main development indices are in fact largely objective of this study was to evaluate the dependent on womens health and socio- relationship of monthly household income economic status [6] and the intrahousehold with gravidity status and demographic, nu- status of women is related to food security, tritional and social characteristics in women particularly for children [7]. living in a semi-rural location in Pakistan Low educational status of women is the with at least 1 child under 5 years of age. strongest predictor of poverty and women in rural and semi-rural locations are not literate [8]. Poverty and socioeconomic dis- 1IXLSHW advantage to women leads to environmental 7XYH]WIXXMRK exposures that may increase their risk of The study was conducted in a semi-ru- nutritional deficiencies, adverse reproduc- ral area of District Malir, Rehri Goth and tive outcomes and poor health status [8±1].

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S adjoining communities located about 25 of the study area was done from January to miles from the city of Karachi, Pakistan. September 2005 to obtain complete house The area is spread over 3 km and has a listings in order to assemble the cohort, population of 35 000. It lacks basic utilities, whereby a map of the area was used to transportation and health services [21,22]. identify ever-married women with at least 1 It has a rural health centre, and general clin- child less than 5 years of age. In this survey ics run by nongovernmental organizations participation was high. (NGOs). The Departments of Pediatrics & Child Health and Community Health -RXIVZMI[W Sciences have centre-based and outreach The survey and consent form were ap- programmes for child health; in addition proved by the Institutional Review Board of the Department of Community Health Sci- the University of California (UC) at Davis ences is involved in community-based de- and the Ethics Review Committee of the velopmental activities. These programmes Aga Khan University, Pakistan. The author are conducted with the support of a local with a study team supervised the conduct of community-based health management the survey. The study team consisted of 3 group. In this setting, participation from field supervisors and 7 field workers. Field community residents is 100% as long as supervisors were graduates and received there has been mutual agreement with the training from the author about the manuals, community management group. key documents for the questionnaire, and anthropometric measurements. The author 7EQTPIWM^I and field supervisors were certified to ob- Sample size was calculated using a cor- tain consent after taking an online tutorial relation coefficient of at least 0.1 between and quiz on the National Institute of Health monthly income and maternal gravidity website for research with human subject (number of pregnancies), two-sided alpha participation. Field workers were recruited of 0.05 and beta of 0.10; thus 1050 partici- from the area with the help of the local pants were required. The survey identified community management team and were 1111 married women living in the study trained for consent taking, conducting pi- area with at least 1 child less than 5 years lot and modified questionnaire interviews, of age; hence data for all of them were ana- and measuring participants weight, height, lysed to determine the relationship between mid-arm circumference and skin-fold thick- maternal characteristics and household (nu- ness. After reading aloud the consent form, clear family) reported monthly income. the women either signed the form or provided a thumb print if they were wiling to 7XYH]TEVXMGMTERXW participate. Field workers conducted the in- All married women aged 15 to 45 years who terviews and measurements. Quality checks delivered a singleton live birth during the for missing values were made on a daily ba- years 2000 to 2002 were included; pregnan- sis by field supervisors and corrected. The cies were identified historically by house- questionnaire was pilot tested on a sample to-house surveys in 20002002. This study of 30 women living in the area who had at was the first part of a study that was done to least 1 child less than 5 years of age. The establish a historical cohort of women who final questionnaire obtained information delivered a singleton live infants during the on demographic, socioeconomic, lifestyle, years 20002002. This initial full survey anthropometric and reproductive factors,

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S namely: participants age, address, marital grams using a calibrated bathroom scale. A status, number of family members, number Lange skin caliper was used to measure left of persons living in the house, number of arm triceps skin-fold thickness. Standard rooms in the house, and number of nuclear measurement tapes were used by trained family members and rooms in use by them. workers to measure participants height, Monthly household income was recorded in mid-arm, and mid-calf circumference in Pakistani rupees (Rs) (US$ 1 = Rs 60 at the centimetres. Two measurements were taken time of survey). Literacy was categorized as for weight, height, skin-fold thickness, and ability to read and/or write and completed mid-arm and mid-calf circumference. The years of schooling. This variable was di- first 50 measurements taken by health work- chotomized as totally illiterate and literate. ers were standardized to those taken by the Husbands occupation was categorized as field supervisor and significant differences skilled (fisherman, tailor, driver and electri- were not found. cian) and unskilled (labourer and daily casual worker). Information was also obtained 7XEXMWXMGEPQIXLSHW for the number of animals owned. Continuous and ordinal variables were sum- Information on smoking history and marized first with descriptive statistics to current use inside and outside the house was check for distributions, and measures of sought for the participant, spouse and other central tendency were calculated. The Stu- household members, including daily number dent t-test was used for comparing means of cigarettes smoked (local or available on for continuous variables. The chi-squared the market) and duration of smoking. For test for significance was used for comparing participants, any use for cigarettes, beedi (a categorical covariates. locally made cigarette from fragmented to- Self-reported household income was bacco leaves rolled in dried tobacco leaves), the dependent variable. Relationship with and or huqqa (a traditional water pipe) was monthly income was determined for demo- ascertained. Participants use of chewing graphic, nutritional (anthropometric), re- tobacco, including duration, frequency, and productive, and non-income socioeconomic use with other substances, such as areca characteristics. The variable for income was nuts and betel leaf, was also ascertained dichotomized at the median level for com- for current use and use during the past parison purposes. An index of crowding pregnancy. Tobacco use was dichotomized was calculated as the number of persons in as tobacco user (cigarette, beeri, huqqa or the house divided by the number of rooms chewing tobacco) and non-user. Tobacco in the house; a similar index was calculated use (as defined above) in the most recent for the number of nuclear family members past pregnancy was also recorded. Informa- by number of rooms in use by the nuclear tion was also sought on type of cooking fuel family. Gravidity was defined as the total used, duration of cooking daily and amount number of pregnancies experienced by the of daytime rest per day. A structured grid woman irrespective of outcome; parity was was used to record history of all pregnan- the number of live births she had had. In cies by the year, and gravidity and parity multiple linear regression models, monthly were calculated for each participant. income was regressed on demographic, Trained health workers used calibrated nutritional (anthropometric), reproductive, weighing scales to measure the womens and non-income socioeconomic variables weight in light clothing and bare feet in kilo- that were associated with monthly income in

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S the bivariate analyses. The distribution and Smoking in past pregnancy was greater linear association of continuous variables in women in the higher income group (Ta- were checked prior to its inclusion in the ble 1) but did not differ for reported cur- multiple regression models; when required rent smoking status (P = 0.68). Current transformation or addition of a quadratic to spousal smoking was greater in the higher achieve linear association was done. income group (21.6%) compared to the Data were double-entered and validated lower income group (15.2%) (P = 0.007); in Epi-Info, version 6 and analyses were reported use by other family members was conducted using SPSS, version 12.00. The also greater in the higher income group level of significance was taken as P < 0.05. (11%) than the lower income group (7.5%) (P = 0.06). More participants in the higher income group lived in houses made of a mix 6IWYPXW of straw and bricks and those made only with bricks than participants from the lower A total of 1111 mothers living in the area income group who lived in houses made of who had at least 1 child less than 5 years straw and a mix of straw and bricks (Ta- of age consented to participate in this ble 1). The majority of the husbands were interview-based survey. The median month- fisherman (77.7%) which was included as a ly income was Rs 3000. Table 1 shows de- skilled profession; there were more fisher- scriptive characteristics of the participants men in the lower income group (80.7%) and comparison of these with the median than the higher income group (75.4%) (P = income variable. Mean age of the partici- 0.04). Participants were asked about their pants was 29.28 [standard deviation (SD) current and past occupation, whether they 5.4] years, with a significant difference by were working in 2005 or had worked for income (Table 1). Mean crowding index for money during the past pregnancy. Reported participants nuclear family was 5.0 (SD duration of daytime rest by the women 2.0) in the higher income group which was ranged from none to 3 hours; women in the not significantly different from the lower high income group had significantly longer income group [4.9 (SD 1.9)] (P = 0.10). daytime rest than the low income group. Mean gravidity and parity were signifi- Maternal age and gravidity were significantly greater for the higher income group cantly correlated (Pearson correlation coef- compared to the lower income group (Table ficient = 0.73, P < 0.01). Figure 1 shows the 1). Anthropometric indicators showed a bet- relationship between increasing maternal ter nutritional status for the higher income age and mean gravidity status by median group compared to the lower income group, income level; with consistently higher mean as expected (Table 1). Most of the women number of pregnancies in the high income (53.4%) in the higher income group used group. In the linear regression model, age natural gas for cooking and most (62.2%) was positively associated with income; but in the lower income group uses wood (P < after inclusion of gravidity the association 0.001). In addition, frequency of cooking was inverse. The self-reported monthly was also greater in the high income group income was earned mainly by spouses, as (P = 0.048). A significantly greater number women generally did not work other than do of households possessed animals in the high the housework. Monthly income was taken income group (36%) than the lower income as a dependent variable in the linear regres- group (30%) (P = 0.03). sion model and was positively associated

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(MWGYWWMSR which women and children are likely to be more exposed to. The MDGs for environ- This study provides valuable information mental sustainability consider ambient air on the relationship between income and pollution, and rural families are vulnerable non-income aspects of maternal poverty in to indoor pollution if not to outside air pol- a semi-rural and poor community. These lution [1,11]. non-income factors rely on income [2], and Housing structure was not significantly the purchasing capacity of participants is associated with income in the final model. dependent on spousal earnings. Womens However, the crowding index (occupants use of wood as a cooking fuel for example per room) was, and this was independent of had a strong relationship with lower income wood use and other variables. and higher frequency of cooking per day Higher income was associated with in- with higher income. This is relevant to creased gravidity; hence it is likely that MDGs related to reducing hunger and eat- increasing income could lead to larger fami- ing the appropriate number of calories per lies. This observation suggests strategic day. In Pakistan about 53% of the popula- planning is needed to address this factor. tion uses wood as a cooking fuel, and when Rural parts of Pakistan have higher fertility combined with use of crop residues and rates [5] and this setting is comparable to biomass, this figure rises to 70% [12,13]. rural areas, and in spite of it being near to In addition to being a correlate of poverty, a large city, it has limited accessibility to fuel also contributes to indoor air pollution civic amenities [22].

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It is well known that education is the helps prevent the family from falling further strongest predictor of reduction in pov- into poverty. Achieved networking is devel- erty, especially female education. Our study oping networks at the individual level; this found a positive association between the is largely done by males and is known to education of both the woman and her hus- move the household out of poverty [8]. band and monthly income. It is reported that In the current study, higher-income par- improvement in maternal education from ticipants had a greater number of people none or less than primary level to com- living in the house. There is a cultural norm pleted primary level has led to a reduction for families to live together and it is possible in extreme poverty [8]; furthermore it is not that some economic gains occur in this situ- only the female financial contribution that is ation. However, the higher crowding index, important but networking with other people indicating less space per person, had a nega- also has positive effects. Two types of net- tive relationship with income as expected. working namely bound and achieved were Skilled occupation of the spouse was as- reported. Bound networking is with close sociated with decreasing income in the final relatives, mainly developed by females, that model. This is perplexing and the data do

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S not provide a logical reason for this associa- checked and hence is not the most valid of tion. However, there are reports that many measurements. The relationship of skilled fishermen (defined as a skilled occupation) occupation with lower income is perhaps in this locality are in debt to the boat owner unusual but it is possible that it exists in and this may be a possible explanation [21]. some population groups. Hence economic Alternatively, fishing may currently be growth schemes must consider this in their facing problems whereby general unskilled strategies and evaluation. Similarly does labour can earn more than fishing. This the frequency of cooking reflect how often could be associated with breeding season, a family eats? Perhaps, but as conditions for environmental pollution, reasons related storing cooked food are poor in the com- to net income for services and many other munity, this cannot be concluded without factors. further evaluation. Maternal weight, body mass index and Income is dependent on non-income mid upper-arm circumference were associ- factors such as literacy, and the nutritional ated with income; surprisingly, maternal and reproductive health status of women height was not. Mid upper-arm circumfer- and these must be addressed to achieve ence is a good indicator of protein reserves the MDGs for health. However, reduction of a body and body mass index is a better in poverty by increasing income may not indicator of obesity [23]. Among the nu- directly lead to improvement in non-income tritional indicators (weight, height, body indicators and relevant concurrent strategies mass index, mid upper-arm circumference) need to be formulated for social problems of participants, increasing mid upper-arm that may arise, such as increasing gravid- circumference was included in the model ity (with consequent maternal morbidity and was positively related to increasing and mortality), tobacco use, and the age income. However, the mean mid upper-arm cohort effects related to those who have low circumference of participants in this study literacy levels but contribute to indicators of was at the lower end (10th percentile of the human development index. standard values for age). The final model of income in this study also showed nearly significant associations %GORS[PIHKIQIRXW with maternal use of tobacco in the past I am thankful to Dr Zulfiqar Bhutta, Depart- pregnancy. This points towards increasing ment of Paediatrics and Child Health, Aga tobacco use in women, which was recently Khan University, Dr Kenneth H. Brown, reported for rural areas of Pakistan [24]. Programme in International Nutrition, Uni- Health education and other measures are versity of California at Davis and Dr Ellen required for its control. B. Gold, Department of Public Health Sci- The strength of this study lies in the ences, University of California at Davis large sample and evaluation of non-income for their review of the design of the survey dimensions of maternal poverty. Poverty is instrument. The financial support of the Na- a complex condition and we found strong tional Institute of Health, USA is gratefully and at times unexpected relationships with acknowledged (NIH Grant number 5R03 income. One of the limitations of the study ES13159-2). is that self-reported income cannot be

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World Health Report 2006 The World Health Report 2006 - working together for health, available in English, French, Spanish and Portuguese, contains an expert assessment of the current crisis in the global health workforce and ambitious proposals to tackle it over the next ten years, starting immediately. The report reveals an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide. The shortage is most severe in the poorest countries, especially in sub- Saharan Africa, where health workers are most needed. Focusing on all stages of the health workers· career lifespan from entry to health training, to job recruitment through to retirement, the report lays out a ten-year action plan in which countries can build their health work- forces, with the support of global partners. The report can be downloaded at: http://www.who.int/whr/2006/en/

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-RXVSHYGXMSR a relationship between fertility and degree of religiosity, regardless of the persons The number of children per household is Muslim sect, Sunni or Shiite [3]. Marriage decreasing in Kuwait. In 1970 the birth rate type can also affect fertility. More closely was about 45/1000 population and the total related couples appear to desire more chil- fertility rate was about 7. In 1987, the total dren [6,7]. fertility rate had dropped to 4.4, with 34 As a result of the declining fertility in births/1000 population [1]. Kuwait, the Kuwaiti government, like some Several factors have been associated other governments of the area such as Iraq with this decline in the fertility in the Ku- (during Saddam Hussains regime), Israel, waiti society. One such is the factor in the and Cyprus, have provided incentives to age at marriage among Kuwaitis, especially Kuwaiti females in an effort to raise the among females. For example, the age at fertility rates [8]. The Kuwaiti government marriage was estimated to be 22.4 years for provides cash child allowances (at present Kuwaiti females in 1985 versus 20.9 years in 50 Kuwaiti dinars per child up to a maxi- 1975 [1]. Another factor that can affect the mum of 7 children) and maternity benefits fertility rate and age at marriage is female (2 months paid leave and another 6 months education. Kohli and Al-Omaim found that off at half salary). illiterate women at marriage were younger It is clear that the speed of economic than university educated females by about growth in Kuwait has had many social 5 years [2]. They also found that there consequences. Family structure is one of the was clear evidence of declining fertility in main social aspects that has been affected. younger Kuwaitis but not in the older age Ideas and thoughts regarding family size, groups. Abdal found that female university spouse selection, and fertility have changed students had a stronger desire to limit fertil- markedly in Kuwaiti families. There are ity than male students, which emphasizes few recent studies on fertility and its rela- the effect of education on fertility [3]. The tionship with other sociocultural factors in National Health Survey of 1984/5 revealed Kuwait. For this reason, the main aim of this that 39% of married women in Kuwait were study was to examine this relationship and using contraception [3]. Shah reviewed to see how certain sociocultural variables the data of a labour survey between 1965 act as determinants in the fertility rate in and 1993 and showed that female illiteracy Kuwaiti society today. declined as the number of females getting This paper will try to answer the follow- a higher education and going into the work ing questions: is there a significant differ- force increased [4]. ence in the fertility rate between Kuwaitis Another factor reported to affect fertility from Bedouin versus non-Bedouin roots? Is is ethnicity. Al-Gallaf et al. found differ- there a significant difference in the fertility ences between 2 major ethnic groups in rate between the Sunni and Shiite sects? Is Kuwait, Bedouin and non-Bedouin, with there a significant difference in the fertil- regard to their use of contraception; 42% of ity rate between consanguineous and non- the Bedouin women and 65% of the non- consanguineous couples? Is there a signifi- Bedouin women were using contraceptives cant relationship between the fertility rate [5]. It has also been reported that there is and some other sociocultural factors?

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1IXLSHW According to their suggestions and remarks, the questionnaire was modified. A pilot 7EQTPI study was conducted in which the modified The sample was 8000 married Kuwaiti version of the questionnaire was given to 70 women aged 1578 years. In order to ap- married Kuwaiti women. The results of this proach this target, we distributed 8100 pilot study indicated the questionnaire was a questionnaires to eligible women. Some reliable tool to assess data related to fertility were incomplete and final sample size was among Kuwaiti women. 7749. The sample represents about 1.7% of The questionnaire included some de- the total Kuwaiti female population aged mographic questions. Fertility, number of 15 years and older [9]. The reason for us- births per woman, was the dependent vari- ing such wide age sample was to ensure able. The respondents were asked directly better representatives of Kuwaiti females at about the number of children they had. age of marriage and reproduction. Another Education was divided into 8 categories reason was to make sure of the experiences (from read and write and below = 1 to and opinions of older women concerning doctoral degree = 8). Annual family income fertility and related variables, especially the was also divided into 8 categories. Work impact of age on fertility. position had 6 categories (not working = 1 The women were selected randomly to professional = 6). Socioeconomic status from the records of 10 different primary (SES) was measured by using these 3 vari- health care (PHC) centres in Kuwait; 10 ables, i.e. annual income, educational level, clinics were selected to ensure all ethnic and occupational position and was coded groups in Kuwait were represented. Many according to the Social Science Research areas in the Kuwait governorates are known Council [10]. The respondents were asked to be representative of certain ethnic groups. about their age at marriage and their kin The 10 PHC centres were selected using relationship with their spouse, and the de- a cluster random sample method. These gree of the spousal relationship. Types of clinics are attended by individuals of all so- marriage were grouped into 9 categories: ciocultural backgrounds and ethnicities and double-cousin marriage (2 categories), this thus ensured that all population groups first-cousin marriage (cousins on the fa- were involved in the study. No other places thers and the mothers side, 4 categories), in Kuwait can represent all the general second-cousin marriage, third-cousin mar- population. The sample was drawn from all riage and non-consanguineous marriage. females attending the PHC clinics for minor The respondents were asked directly about health problems, after they were asked if their Muslim sect, Sunni or Shiite, and their they were married or not. ethnicity, Bedouin and non-Bedouin.

7XYH]XSSP (EXEGSPPIGXMSR Data on the respondents opinions about Data collection took about 6 months from and attitudes toward fertility and the related January to June 2002. The questionnaire variables were collected by a questionnaire was distributed by 10 trained research as- developed locally by the author. In order to sistants. The respondents answered the ensure validity of the questionnaire, 5 pro- questionnaire voluntarily after an explana- fessors at the Department of Sociology and tion of the aim of study by the research as- Social Work, Kuwait University reviewed it. sistants. The research assistants helped any

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S respondents who were illiterate to complete guineous and non-consanguineous marriage the questionnaire. and by the degree of relation between the Because of the direct contact between spouses (4 categories) beginning with the research assistants and the respondents, the double-cousin marriage and first-cousin response rate was high (96%). Most of the marriage, second-cousin marriage, third- non-responders were excluded because they cousin marriage, and non-consanguineous did not complete all parts of the question- marriage. naire.

7XEXMWXMGEPEREP]WMW 6IWYPXW SPSS, version 11.0 was used for the data The average fertility for the entire sample analysis. The data were analysed using (n = 7749) was 3.58 (SD 2.45). Table 1 both descriptive and inferential statistics. shows the difference between some so- Descriptive statistics such as mean and ciocultural variables and fertility, namely standard deviation (SD) were used. To ex- ethnicity, type of marriage and sect. There amine the differences between sect, origin, were significant differences between all 3 and marriage type, the Student t-test was variables in relation to fertility. Bedouin used. Pearson correlation was used to assess respondents had a higher mean fertility the degree and nature of the relationship than non-Bedouin [3.71 (SD 2.67) versus between fertility and some sociocultural 3.43 (SD 2.18) respectively, P < 0.001]. variables. Finally a multivariate regression Respondents married to a relative had a model was used to predict the outcome. higher mean fertility than those married to For statistical analysis purposes, type a non-relative [3.51 (SD 2.19) versus 3.34 of marriage was dichotomized as consan-

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(SD 2.15) respectively, P < 0.001]. Sunni To predict the effect of selected socio- respondents had higher mean fertility than cultural variables on fertility, multivariate Shiites [3.64 (SD 2.53) versus 3.38 (SD regression was used. Independent variables 2.15) respectively, P < 0.001]. were respondents age, education level, Shiites are considered a minority in age at marriage, sect, ethnicity, SES, and Kuwait. They show a lower mean fertility. marriage type (Table 3). The analysis shows They come mostly from non-Bedouin so- that Shiite respondents would be expected ciety while those who come from Bedouin to have 0.17 fewer children than Sunnis, origins are Sunni. Even when comparing and non-Bedouin respondents 0.33 fewer Sunnis (excluding Bedouins) with Shiites children than the Bedouins. In addition, (Table 1) there was also a significant dif- high education level, high age at marriage, ference between the 2 groups. The non- and lesser degree of consanguinity of the Bedouin Sunni respondents had a higher respondents predicted lower fertility. An mean fertility rate than the Shiites [3.51 (SD increase of 1 SD in the educational level 2.19) versus 3.34 (SD 2.15) respectively, of the respondents was associated with a P < 0.001]. 0.10 SD decrease in the family size. As Table 2 illustrates this correlation be- expected also, an increase in 1 SD in the tween the fertility rate and selected so- respondents age at marriage was associated ciocultural variables. The data show that with a 0.26 SD decrease in the number of there were significant relationships between children. Also, an increase in 1 SD in the fertility and all of the selected sociocultural marriage type was associated with 0.02 SD variables. There was a negative relationship decrease in the family size. In contrast, high between fertility and the respondents edu- family income of the respondents predicted cational level, job position, age at marriage, an increase in the number of children. A SES and type of marriage (P < 0.01). On the 1 SD increase in the family income of the other hand, there was a positive relationship respondents was associated with a 0.10 between fertility and the respondents age SD increase in the number of children. As and family income (P < 0.01).

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S expected, the high age of the respondents The changing attitudes regarding the age predicted higher family size. at marriage are related to education for both genders but especially for females. Univer- sity education and also higher education (MWGYWWMSR for females is increasing in Kuwait. Jobs have also become an important aspect of Fertility is affected by sociocultural chang- womens lives. As stated by Shah, female es. In some societies, a decline in fertility illiteracy has declined and the proportion has been related to a decline in polygyny of females with a degree in higher educa- [11]. In others there is a connection between tion and involved in the labour force has lower fertility and the raising of the age at increased [4]. marriage [12]. Current ways of thinking Another factor affecting age at marriage and attitudes regarding fertility are a direct is that both males and females are less result of modernization. financially dependent on their families and The current study confirms the general extended families compared with the past. decline in the fertility rate in Kuwait over For this reason, education and work have time. The fertility rate was 3.58, while in become more important for females. Fe- 1970, it was 7.0 and in 1987 it was reported male awareness and dependency on herself to be 4.4 [1]. One of the most probable are major changes in the family structure reasons for this is the increase in the age at in Kuwaiti society and this has led to an marriage for both male and female Kuwaitis. increase in the age at marriage. For a man, Recent studies show that the perceived ideal dependency on himself and establishing average age of marriage is 25.7 years for himself financially is important before mar- males and 21.4 years for females [6,7]. In riage and this can usually only be completed the past, these ages for getting married were after graduation from university. These considered to be very old for both males changes in the family structure have thus and females. The ideal age and time for affected the fertility rate. getting married for both males and females It has been shown that there is an in- appears to be almost immediately upon verse relationship between a households graduation from university for females and socioeconomic status and its fertility level around 2 to 3 years after graduation for [16]. In this study, fertility was negatively males. Modernization has played a major associated with the socioeconomic status role in changing the attitudes regarding of the respondents. On the other hand, the marriage and the age at marriage. data also showed that there was a positive Fertility is affected by many different relationship between fertility and family cultural, socioeconomic, and environmental income. This is expected since the govern- factors, as seen in many different cultures ment of Kuwait now encourages couples and societies. For example, fertility is in- to have children and provides cash child fluenced by society type, such as urban allowances for each family; around US$ and non-urban society [13,14]. Education 160 per month per child, which increases and occupation, especially for women, are the family income. However, the general other important factors that influence fertil- socioeconomic status was negatively corre- ity. Educated and employed women are lated with fertility, although family income more likely to use contraception than those was one dimension of the socioeconomic who have little education and who are not measure. employed [15].

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Ethnicity is another factor affecting fer- tion of Kuwaiti nationals. The data in the tility. It is reported in the United States, for current study show that this group had a example, that the differences in fertility lower fertility rate than the whole Kuwaiti rates for American Indians, Hispanics, and population, even when ethnicity was con- Asian or Pacific Island Americans were trolled for. More studies are needed for a considerable [17]. The findings in this study clear explanation of the low rate of fertility show that fertility was affected by ethnicity. in this group. The respondents who came originally from Consanguinity plays a major role in fer- Bedouin society had a higher fertility rate tility. It has been reported that consanguin- compared with non-Bedouins. Children, ity is related to high fertility rates in many especially males, in Bedouin life and fam- different cultures [20]. In contrast, another ily structure are very important. They are study showed that women in consanguine- called ezwa or sanad which mean sup- ous marriages had a lower mean number porter. Bedouins have now all settled in of conceptions [21]. The data in the cur- cities in modern Kuwait, but their ideas rent study show that non-consanguineous about the importance of children in the fam- couples had lower fertility rates than related ily still differ from non-Bedouins. This may couples. There are 2 possible explanations explain why Bedouins have a higher fertil- for this: first, most consanguineous mar- ity rate. Al-Gallaf et al. in 1995 reported riages occur among the Bedouins for whom that there was a significant difference in the children are very important; second, the age level of contraception use between Bedouin of marriage in consanguineous marriages and non-Bedouin women [5]. They found is earlier than in non-consanguineous mar- that the use of a contraceptive method was riages. This has been also reported in other 42% for Bedouin women and 65% for non- recent studies [6,7]. Bedouin women. It would appear that some traditional There are differences in results of stud- attitudes that affect fertility are in decline ies about the fertility of minorities com- in Kuwait as a result of modernity. Many pared with the whole population. Some sociocultural factors play a major role in studies have concluded that minorities have determining family size. This suggests there a higher fertility rate and others showed the may be an increase in some subgroups of opposite [18,19]. Muslim Shiites comprise the population compared with others. around 20% to 30% of the total popula-

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-RXVSHYGXMSR contraceptive use and consequent declines in fertility [6]. Oral contraceptives and Countries with a large population and high condoms are the base of many programmes, density relative to available resources suffer but some earlier programmes relied, and tremendously from high fertility rates. High continue to rely heavily, on methods such fertility rates are strongly associated with as the intrauterine device (IUD), that are inadequate spacing between births, which less prominent in programmes that started in turn is associated with high maternal and later. Over time newer methods such as in- infant mortality. jectables and implants have found their own An estimated 600 000 maternal deaths niches. The main trend has been towards occur worldwide each year, 99% of them permanent methods; sterilization, which in developing countries. The World Health has become simpler and more demanded, Organization estimates that 13% of these now accounts for half of all contraceptive are due to unsafe abortions. Worldwide, use [6]. approximately 50 million women resort Family planning services were intro- to induced abortion each year, frequently duced in Sudan in 1965 with the foundation resulting in mortality and adverse health of the Sudan Family Planning Association, consequences [1,2]. Other causes of high which provides services throughout the maternal death rates in developing countries country (Federal Ministry of Health, Sudan, include complications of pregnancy and unpublished report, 1992). The total fertility complications of childbirth. rate for the age group 1549 years suggests In Sudan, maternal and infant mortal- a sharp fall in fertility level in recent years. ity and fertility indicators are among the Total fertility was 6.5 births per woman highest in the Region. Maternal mortality is during the 1014 years before the 1999 safe estimated at 600 per 100 000 live births and motherhood survey, 6.2 births per woman infant mortality at 70 per 1000 live births; 59 years before the survey, and 4.9 births the fertility rate is estimated at 4.6 children per woman 04 years before the survey [7]. per woman [3]. The total fertility rate of a In January 2002 the government drafted nation is directly related to the prevalence a national population policy. This sup- of contraceptive use. On average, for every ports efforts to empower married couples 15 percentage points increase in contracep- to receive information about a range of tive use in the community there is a reduc- contraceptive methods and access to the tion of 1 birth per woman [4]. This suggests methods of their choice. However, avail- that countries with high total fertility rates ability and accessibility to services still vary tend to have low contraceptive use and vice greatly, especially between urban and rural versa. Unintended pregnancies have signifi- areas. While many Sudanese women have cant consequences and occur most frequent- heard of family planning, research indicates ly in adolescents, low-income groups and significant unmet needs. Although nearly women from minority groups. Improving 20% of married women in Sudan reported contraceptive compliance among high-risk adolescents is a key to reducing the rates of not wanting another child, contraceptive use unintended pregnancy in this group of the is still low [8]. The proportion of women population [5]. using modern methods of contraception National family planning programmes in Northern Sudan increased slightly from and services in developing countries have 4% in 19771978 to 6% in 1989 and 7% in been associated with notable increases in 19921993 [8,9].

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Family planning practice is determined 1IXLSHW by many factors that can be considered obstacles to the use of family planning serv- 7XYH]HIWMKR ices. Caldwell and Caldwell emphasized the The study was a cross-sectional survey cultural imperatives of African communities among a representative sample of married that are important in maintaining high levels women aged 1549 years from both urban of fertility [10]. In many African cultures it and rural localities in Khartoum State in is taboo to be childless: high fertility, there- Sudan. The women were from varying socio- fore, enjoys both community and divine economic, educational, employment and approval [10,11]. A womans age, residence cultural backgrounds. (urban or rural), education and income may have substantial effects on contraceptive 'SRGITXYEPJVEQI[SVO use and are likely to affect how women The model applied in this study was an choose family planning services [12]. extension of Duttons access and utilization Behaviour regarding contraception is model for health services [13], which, in known to vary widely according to educa- turn, builds upon Andersen and Newmans tion, which is likely to be positively corre- predisposing-enabling-need (PEN) explan- lated with the use of private sector services. atory model for health services utilization Significant ruralurban difference exists in [14]. fertility levels in Sudan. On average, age The dependent variable in this study specific fertility rates are lower in urban was the utilization of modern family plan- than in rural areas, which suggests greater ning techniques. The independent variables use of contraception by urban women [7]. were the demographic and socioeconomic variables of age, residence, socioeconomic status, and education level, and also the 3FNIGXMZIW This study describes the current family plan- predisposing factor of knowledge about ning situation in Khartoum State, Sudan. family planning. Place from which services The information gathered will be useful are obtained (location) and knowledge are in designing programmes which will con- variables affected by government policy on tribute in making family planning services family planning. more available and accessible to Sudanese Utilization was defined as the respond- women. ents state of using or having used 1 Specific objectives of the study were to: modern family planning techniques [contraceptive pill, intrauterine device, injection, examine the differences in utilization male condom, diaphragm (known locally as between urban and rural areas in Khar- female condom), male sterilization, and toum State; female sterilization]. Traditional methods describe the family planning methods used were breastfeeding, rhythm method that are used; and withdrawal. No use was scored 0 and assess the impact of socioeconomic defined as never used; use of 1 modern status, womens level of education, age, methods was scored 1 and defined as using. area of residence and knowledge on the Education was defined as completed edu- utilization of family planning services; cational status. It was scored 1 (no school- examine the effect of government policy ing), 2 (primary education), 3 (intermediate and providers on services distribution. education), 4 (secondary education) and 5

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(university and higher education). Age was that differed in socioeconomic status and defined as respondents age at the time of living conditions. The total population in interview. It was recoded as younger age Khartoum State was 5 548 784 (Khartoum (1529 years) and older age (3045 years). State Ministry of Health, Department of Location and distribution of services were Statistics, unpublished data, 2004). The defined as place from which respondents state comprises 3 provinces, Khartoum, got access to techniques when they decided Omdurman and Bahri, with heterogeneous to use them, and was scored 0 for local urban and rural societies in each province. health centre, 1 for other health centre, 2 Khartoum province contains 1 rural locality for public hospital, 3 for family planning and 6 urban localities; Omdurman province clinic, 4 for motherchild centre, 5 for pri- contains 2 rural and 7 urban localities while vate hospital/clinic, 6 for nongovernmental Bahri province contains 6 rural and 4 urban organization clinic, 7 for pharmacy, 8 for localities. The ratio of the total rural locali- friends and relatives, 9 for other and 10 for ties to the total locality number in the state is not applicable. Knowledge about family 9/26 = 0.346, and the ratio of the total urban planning methods was defined as the re- localities to the total state localities is 17/26 spondent status of having heard about the 10 = 0.654. Applying the above ratios within different traditional (breastfeeding; rhythm; each province (owing to the heterogeneous withdrawal) and modern techniques of fam- nature of the population in the state), the ily planning: heard about 07 methods and single rural locality in Khartoum province techniques was defined as poor knowledge was selected; the urban localities were se- and heard about 810 was defined as good lected using the equation: 0.654 × 6 = 4. knowledge. From the 2 rural localities in Omdurman Data about reasons for not using family province, 1 was selected by applying the planning services were collected from the equation: 2 × 0.346 = 1, while from the 7 ur- non-users; answers included unavailability ban localities, 5 were selected applying the of services and services available only at equation: 7 × 0.654 = 5. In Bahri province, full price. 2 out of the 6 rural localities were selected The collection of data on socioeconomic by the equation: 6 × 0.346 = 2, while 3 out status was guided by the methods used in of the 4 urban localities were selected by the safe motherhood survey of 1999 [7]. the equation: 4 × 0.654 = 3. So, a total of Data collected covered ownership of du- 16 localities were selected for the research rable goods (TV, refrigerator, car etc.) and throughout the state, 12 urban and 4 rural. standard of living (fuel used for cooking, Then within each province, the localities source of water, etc.) were also considered were randomly selected. as indicators. Using factor analysis, a new A sample size of 601 married women variable on socioeconomic status of indi- from the target population was used for the viduals was derived and was scored 1 (low), study. The sampling frame was the 2002 2 (medium) or 3 (high). total women targeted for family planning in Khartoum State, Ministry of Health and the 7IPIGXMSRSJXLIWXYH]EVIEERH total households baseline data for the 2003 WEQTPMRK population census of the Central Bureau Utilization of family planning services of Statistics (Khartoum State Ministry of were studied in Khartoum State by compar- Health, unpublished data, 2003). The ratio ing urban and rural localities of the state of women aged 1549 years to the total

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S population of the state for the year 2002 was SPSS, version 11. Factor analysis was ap- considered the population frame. The total plied to construct an indicator for socio- sample for the study group in all the state economic status. Logistic regression analy- was derived using the formula: sis was used to measure the relative impact of the selected independent variables on n = ( 2 × × Q × d e f f ) / d 2 utilization of family planning service. Logistic regression analysis was used Where n is the projected number of the to identify the determinants of modern targeted study population (women 1549 contraceptive use. The dependent variable years old), Z is the Z-score, which is a contraceptive use was coded 1 if the standard (1.96 2); P is the expected preva- respondent was categorised as user, and lence of the study group population (tar- 0 if not. The statistical model was estimated geted population ratio), 25.04% (0.2504); with a range of independent variables and Q = 1P; deff is the design effect (1.52) assessed the effect of changing one of the 2; and d is the marginal error (degree of independent variables on the odds of the precision). Alpha error = 0.05. respondent being a user of family plan- So: ning methods). One category of each of the independent variables was chosen as the n = (22 × 0.2504 × 0.7496 × 2)/0.052 = 601 reference category. Age was considered a continuous independent variable. The coef- The total sample size was divided be- ficient [Exp (B)] for the reference category tween the localities according to the ratio was set at 1.0, and the coefficients for other of number of households in each locality values of the variable were interpreted rela- to the total number of households (482 854 tive to this reference category. A coefficient households). In each locality, the every > 1.0 means that the value of the variable in other household rule was applied for inter- question increases the odds of the individual viewing respondents. In all the localities, using family planning compared with the reference category; a coefficient < 1.0 all selected households were covered. The means that the odds are reduced compared overall response rate for the household with the reference category. questionnaire was 100%. The major factor explaining this high response rate was that the data collectors were females, who could easily get access to women; males would 6IWYPXW find it difficult to interview women due 9XMPM^EXMSRSJJEQMP]TPERRMRK to the cultural and religious values in the WIVZMGIW country. After excluding traditional methods of family planning, about half (51.4%) the women (EXEGSPPIGXMSRERHEREP]WMW in the entire sample used modern family The data were collected in the period Au- planning methods (Table 1). Women from gust 2002December 2002 after collectors urban and rural settings had almost the were trained and questionnaires were tested. same level of use. Women with high socio- Bivariate (cross-tabulation and chi-squared economic status (73.1%) reported using tests, independent sample t-tests), factor modern family planning methods more analysis and logistic regression analysis often than those with medium (51.1%) and were used for the analysis of data using low (28.0%) socioeconomic status. Signifi-

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Rural women reported using public out- ly more likely to report a high level of using let agencies as sources of family planning the modern methods (P < 0.001) (Table 3). services much more than urban women Education level also had a statistically (44.7% and 29.9% respectively; P = 0.025), significant influence on the odds of the whereas urban women reported using the respondents using modern methods of private sector much more than rural women contraception. Compared with those with (21.2% and 10.7% respectively; P = 0.063). no schooling; those with education were For women in rural areas, local health cen- significantly more likely to report using tres were the core source of services com- contraception (P = 0.003). Socioeconomic pared to women from urban areas (37.5% status also appeared to play a significant and 19.9% respectively; P = 0.002). role: women with a higher socioeconomic Child spacing was the main reason en- status were more likely than their coun- couraging women to use family planning terparts to use modern methods of family services (58.4%), whereas the desire for planning. Area of residence and age did not more children was the main reason for appear to be associated with use of modern not using these services. Very few women methods of family planning. (0.8%) reported that the use of contraception was against religious or cultural beliefs. (MWGYWWMSRERHGSRGPYWMSRW (IXIVQMRERXWSJGSRXVEGITXMZIYWI In the present study 51.4% of all women Compared with respondents who had poor surveyed in the state of Khartoum used knowledge about family planning, those modern family planning methods. Compar- who had good knowledge were significant-

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8E FP I 1YPXMZEVMEXIPSKMWXMGVIKVIWWMSREREP]WMWJSVHITIRHIRX ZEVMEFPISJYXMPM^EXMSRSJQSHIVRJEQMP]TPERRMRKQIXLSHW[MXL SXLIVTVIHMGXSVW :EVMEFPI )\T & 4ZEPYI '- JSV)\T & /RS[PIHKI TSSV!KSSH! z )HYGEXMSR RSRI! 4VMQEV] z -RXIVQIHMEXI z 7IGSRHEV] z 9RMZIVWMX] z %KI z 6IWMHIRGI VYVEP!YVFER! z 7SGMSIGSRSQMGPIZIP PS[! 1IHMYQ z ,MKL z 'SRWXERX '-!GSRJMHIRGIMRXIVZEP ing with recent studies in the northern states by the fact that these methods are perceived of Sudan, the utilization rate in Khartoum as being in conflict with traditional culture, State is far greater. The level of use of patriarchal norms, native notions of male- any method of contraception varies from ness and religious doctrine [16]. < 1.0% in Western Darfur State to 21.0% The study identified public outlet agen- in Khartoum State [7]. This could be attrib- cies as being particularly important sources uted to the fact that Khartoum is the capital of family planning services for women from of the country and socioeconomic status, urban as well as from rural areas. Contrary education level, availability and capacity of to what was expected for Sudan, an Islamic health care services as well as supplies of country in the developing world, very few available modern family planning methods women reported that the use of contracep- are considerably better compared with other tive methods was against religion or cultural states of the country. beliefs. The 2 types of location, urban and rural, The principal predisposing and enabling used modern methods of family planning factors affecting utilization of modern fam- almost equally. Only very few women use ily planning methods by women were socio- methods such as injection or male and fe- economic status, knowledge, and education male sterilization. Although international of the mother. This leads to the conclusion family planning efforts have successfully that the main limiting factors to the utiliza- integrated male methods [15] such as con- tion of modern family planning methods doms and sterilization into their various in the state are poverty, ignorance, and programmes, our findings demonstrated illiteracy. The study has clearly evidenced that use of these methods by males was ex- that knowledge of family planning among tremely low. This might partly be explained

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S married Sudanese women is far from being Apart from the development and imple- universal. mentation of programmes targeting women, Although education was associated with planners might also attempt to overcome re- increase in the use of modern family plan- sistance of men to family planning methods. ning methods, a drop was noticed in women As a first step, research would be needed with university and higher education. This to analyse the psychosocial and cultural might partly be explained by the fact that determinants of non-use and barriers to the these women start their family life after use of modern family planning methods by their education, i.e. at a later age, and try men. Based on such research, concerted to have the number of children they wish programmes could be developed to encour- before their menopause begins. age men to participate in family planning The findings of this study evidenced the and use modern male methods. need to empower the population through There were some limitations and short- income-generation and improving stand- comings to our study that may qualify our ards of living. Increasing education might results. The first was the exclusion of un- help in solving the income problem as well married women from the sample, in spite and would increase knowledge about mod- of the fact that local religious values and ern family planning methods and hence, norms prohibit sexual activities outside increase predisposition to their use. Basic marriage, some unmarried women still get education programmes must be effectively pregnant and seek induced abortions. The run for people who are illiterate. Specific most important limitation of our study was programmes about family planning should that data about men on family planning be developed and implemented. Such pro- was collected from their wives and not di- grammes need to target urban as well as rectly. Specially designed family planning rural communities as in both areas women research involving men would be needed to were found in conditions predisposing them explore their role in family planning and in for non-use of family planning. In order using male methods. Last, overlapping of to satisfy the needs for family planning some urbanrural localities of the countrys services, expansion of existing family plan- capital city and similarities in standards of ning services to cover all urban as well as living in some of them may have affected rural areas is essential. Policy makers may the accuracy of the results regarding differ- introduce legislation that would make it ences in utilization according to residence. easier for states to extend family planning services to reach more low-income women. Other efforts to provide coverage through %GORS[PIHKIQIRXW establishing new family planning centres This study was supported by grants from the and clinics and providing existing ones with Government of Sudan and the University of modern services are needed. Implementing Maastricht. efficient reproductive health programmes would also make a difference.

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-RXVSHYGXMSR 1IXLSHW Family planning implies the ability of indi- 7XYH]EVIE viduals and couples to anticipate and attain Dohuk district is a semi-mountainous area their desired number of children through the that is located in upper northern Iraq. Its spacing and timing of their births, achieved population, about 350 000, are mostly Mos- through the use of contraceptive methods lem Kurds, plus some other ethnic and reli- and the treatment of involuntary infertility gious minorities, living mainly in 28 urban [1]. A planned family is the best environ- areas (Dohuk city) and 9 periurban areas. ment for a childs overall development [2]. Large families and rapidly growing 7EQTPI populations hold back development at both The current survey was conducted from 9 the household and national level [3]. High June 2003 to 30 September 2003. parity and close child spacing are related to A sample size of 800 currently married increased maternal and childhood morbid- women in the reproductive ages of 1549 ity and mortality [4]. Worldwide, millions years was estimated from: N = (PQZ²D)/E², of women desire to have longer spaces where N = sample size, P = estimated preva- between births or to limit the total number lence of unmet need = 0.50, Q = 100 P, Z of births, but, especially in the developing = 95% confidence level = 1.96, D = design world, they have unmet needs for contra- effect = 2, E = accepted standard error = ception [5,6]. 0.05 [7]. Dohuk governorate is composed of 6 Multi-stage sampling was used. In stage districts with a population of 850 000. It is 1, the 37 areas of Dohuk district were stratified into 4 socioeconomic strata: high (n = currently one of the 3 main governorates 6), medium (n = 8), low (n = 14) and very comprising Kurdistan region in northern low (n = 9), using a scoring system based Iraq, and its centre, Dohuk district, is the on the type of building, sanitation, furniture 3rd large district in this region. Apart from and educational attainment (husband and private services, the current family planning wife) [8]. To facilitate sampling, this was programme in Dohuk governorate is limited done prior to the survey by visiting each to 2 government clinics; one opened in 1997 area, all of them well-known to the authors. at the main general hospital in the centre Areas within each stratum were randomly of the governorate and the other opened in sequenced. In stage 2 the proportion of 2002 in Zakho district. areas for each stratum was multiplied by The aim of this study was to help inform the total sample size to obtain the number the development of family planning services of women to be interviewed in that stratum. in the area by estimation of the prevalence In stage 3, areas were surveyed by random of contraceptive use and of unmet need sequence, selecting every 5th household for contraception among currently married until the required number of women for women aged 1549 years in Dohuk district. each stratum was achieved. The study included an investigation of the sociodemographic factors associated with (EXEGSPPIGXMSR unmet need and of knowledge, attitudes and Selected women were interviewed by a practices (KAP) about family planning. female doctor in their homes using a pre-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S tested questionnaire designed for this fam- for any contraception. For countries with ily planning KAP survey. Probing was used a high prevalence of traditional methods, to encourage mothers to answer sensitive an expanded formulation from the Johns questions. When an eligible woman was Hopkins Reproductive Health Survey added absent, the interviewer returned to her home traditional methods to the standard for- later. The questionnaire form collected the mulation [5], and in the current study this following information about each woman: addition was regarded as unmet need for Personal particulars: socioeconomic modern contraception. The sum of both stratum (as described above), age, mari- types was regarded as all current unmet tal age, educational attainment and em- need for contraception. To estimate the ployment outside the home, if any. size of the problem over the last 3 decades Fertility experience: including gravid- (period prevalence), any respondent who ity, abortions, number of live births and had current unmet need or gave a history of deaths of children aged under 5 years. induced abortion or unwanted or mistimed Family planning: all respondents were pregnancy(ies) at any time during her repro- asked about their knowledge of the socio- ductive life, was classified as ever having economic benefits of family planning, unmet need. contraceptive methods and the main Continuous variables were categorized, source of such information. They were ordinally when applicable, and described asked if they ever used contraception by frequency distributions. Associations of and which type. Currently non-pregnant sociodemographic and KAP variables with women were asked about any contracep- current family planning use and unmet need tion they were using at the time of the were analysed by chi-squared tests using survey, its type and source. Non-users SPSS, version 12. ates continuity correc- were asked about the reasons for not tion was used in the case of 2 × 2 tables, and using a contraceptive. Pregnant women adjacent cells were combined as necessary were asked whether their pregnancy was in other cases. planned, due to failure of contraception or due to non-use of contraception (unmet need). All respondents (except 6IWYPXW nulligravidas) were then asked about All the women selected for the study agreed any history of successful or attempted to be interviewed, although 61 (7.8%) need- induced abortion, and about their history ed a 2nd or 3rd visit. of unwanted or mistimed pregnancies. Table 1 shows the characteristics of all All respondents were asked about their respondents (pregnant and non-pregnant). preferred family size. About one-quarter of all respondents were The definition of current unmet need living in periurban squatter areas and were (point prevalence) was either: current non- classified as very low socioeconomic stra- use of contraception when more children tum. Nearly two thirds (62.4%) of all wom- were not wanted, now or ever, usually en had married before the age of 20 years. with a statement of reasons for non-use; The ages of more than two thirds (71.8%) or current pregnancy due to non-use. This of respondents were between 2040 years is the Demographic Health Survey (DHS) at the time of the survey. Half of the re- formulation of unmet need [5,9,10] and in spondents were incapable of reading and the current study it was regarded as unmet writing. Two fifths of all women had at least

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1 abortion, spontaneous or induced. About (attempted) induced abortion, and around three fifths had 4 or more offspring and 13% two thirds had experienced unwanted or had experienced the death of a child aged mistimed pregnancy(ies). The median fer- under 5 years. tility preference for all respondents was 4 Knowledge about family planning and children. its benefits was very good as almost every Among pregnant women (n = 132), preg- respondent knew what family planning was, nancies were planned for 61 (46.2%), due to 82.4% knew some of its benefits and two failure of used contraception for 24 (18.2%) thirds knew at least 46 methods. Most of and due to unmet need for contraception the women (85%) obtained their informa- (non-use) for 47 (35.6%). Three quarters tion from acquaintances; only 10.7% got (74.0%) of all respondents had ever-used information from health practitioners (Table 1). family planning in a similar pattern to that One fifth of respondents had a history of of non-pregnant women alone shown later.

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Table 2 shows current sources of family of death of a child aged under 5 years. Use planning and reasons for non-use among of withdrawal and all traditional methods the 668 non-pregnant women. Non-pub- increased as the socioeconomic and edu- lic sources, in form of private clinics and cational standard improved. Female steri- pharmacies, represented 73.8% of fam- lization was most common among grand ily planning services used by non-pregnant multiparas, particularly those who were respondents. It also shows that about half illiterate. of non-users stated the desire to have more Of all respondents, 80.8% ever had un- children as the reason for non-use, while met need for contraception throughout their the other half stated reasons associated with fertile life (period prevalence). unmet need. Table 4 shows that current unmet need Table 3 shows that among non-pregnant for contraception was 29.3% by the standard respondents (n = 668) current use of family DHS definition (unmet need for any contra- planning by any method was 60.6%; 26.5% ception). However, another 28.5% also had were using modern methods and 34.1% current unmet need by the expanded Repro- were using traditional methods, namely ductive Health Survey formulation which withdrawal, lactation amenorrhea and peri- adds traditional contraceptive users to the odic abstinence. Overall lower contraceptive standard definition. This makes the total use was associated with low socioeconomic current unmet need 57.8%. Table 4 also and educational status, increasing maternal shows the distribution of all respondents by age and number of live-births and a history type of current unmet need according to important characteristics. Low socioeconomic and educational status, increasing maternal age and live births and a history of child 8E FP I 'YVVIRXWSYVGIWSJJEQMP]TPERRMRK ERHVIEWSRWJSVRSRYWIEQSRKRSR death were all associated with high unmet TVIKRERX[SQIR R! need for any contraception and all current 'LEVEGXIVMWXMG 2SSJ unmet need. Unmet need for modern con- [SQIR traception increased as the socioeconomic and educational standard improved and 7SYVGIWSJJEQMP]TPERRMRK decreased with high fertility and a history WIVZMGIEQSRKYWIVW of a child death. 4VMZEXIGPMRMGW 4VMZEXITLEVQEGMIW +SZIVRQIRXEPGPMRMG 8SXEP (MWGYWWMSR 6IEWSRWJSVRSXYWMRK As in some other developing countries, GSRXVEGITXMSR people in Kurdish northern Iraq still value 3RISVFSXLTEVXRIVW[ERX early marriage, large families and a role for QSVIGLMPHVIR woman inside the house. Additionally, the 6IPMKMSYWFIPMIJW previous Iraqi government, particularly in 1SVIXLERSRIVIEWSR 1SXLIVMRPE[SFNIGXMSR the 1980s, encouraged high fertility to com- ,MKLTVMGISJGSRXVEGITXMSR pensate for human loss during its wars. Un- -RWYJJMGMIRXORS[PIHKI til the middle of the last decade, therefore, 'SRXVEGITXMSRRSXVIUYMVIH the Iraqi Ministry of Health neglected fam- JSVQIHMGEPVIEWSRW ily planning in the country. This explains 8SXEP why Iraqs crude birth rate was among the

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7SGMSIGSRSQMGWXVEXYQ :IV]PS[ 0S[ 1IHMYQ ,MKL 4VIWIRXEKI ]IEVW z z z z )HYGEXMSR -PPMXIVEXI 4VMQEV]WGLSSP 7IGSRHEV]WGLSSP ,MKLIVIHYGEXMSR 8SXEPRSSJPMZIFMVXLW z z z 2SSJYRHIVGLMPHHIEXLW 8S X E P E%GGSVHMRKXSXLII\TERHIHVITVSHYGXMZILIEPXLWYVZI]JSVQYPEXMSR?A highest in the world in the late 1980s and about family planning was good, but infor- early 1990s [11]. At the time of the survey, mation was mainly derived from acquaint- health services in northern Iraq, including ances rather than from health practitioners. family planning, were almost free of charge For many mothers, sources of family at government clinics, when these were ac- planning services were private clinics and cessible, but expensive at private clinics and pharmacies, due to the limited and cen- pharmacies. tralized nature of related public services. The sociodemographic and fertility Apart from the desire to have more children, characteristics of our study population are non-use of contraception among the studied consistent with the above. The notable fea- population reflected local norms and reli- tures include high teenage marriage, high gious beliefs. illiteracy and fertility rates and a very low Current use of modern contraception employment rate of mothers. Knowledge in this study (26.5%) was low compared

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S with countries such as the United States there are an estimated 87 million unintended of America and Canada (70%), Hungary pregnancies and 46 million induced abor- (68%), the Islamic Republic of Iran (56%) tions per year [19]. As abortion is generally and Egypt (53.9%), but was higher than that illegal in Iraq, most induced abortions in for Yemen (9.8%), Azerbaijan (11.9%) and this study were failed self-attempts, using Sudan (7%) [3,12]. However, in the study heavy exercise or local herbs. However it population, more women were using tra- is powerful evidence that women want to ditional methods than in any other country control their fertility when they have not in the Eastern Mediterranean Region [12]. been able to use effective contraception. Worldwide, levels of use of traditional Current unmet need for contraception in contraception are generally much lower the studied population by the standard DHS than that of modern methods [10], but a high formulation (29.3%), may be compared prevalence of traditional contraception, in with countries such as Pakistan (32%), particular withdrawal, has been reported in Bangladesh (15%), Egypt and Jordan (11%) neighbouring Turkey [13] and in Azerbai- and Morocco (20%) [10]. However, be- jan [10]. cause many women were using traditional The high rate of female sterilization methods, the expanded RHS formulation (tubectomy) among grand multiparas, es- was applied to give an estimated prevalence pecially illiterate women, is probably due of all current unmet need of 57.8%, and this to its being performed during caesarean would be higher than in any other region. section to deliver the last child. High rates Whether unmet need was for spacing or lim- of caesarean section have been reported in iting births was not considered in this study, Iraq [14]. but based on the almost equal prevalence The relatively high rate of male condom of history of unwanted and of mistimed use compared with neighbouring countries pregnancy(ies), it may be assumed that an [12] may be due to availability of condoms equal distribution of unmet need for spacing free of charge, as for the intrauterine device and for limiting births exists in the area. and oral contraceptives, at the governmental Low socioeconomic and educational sta- family planning clinic in Dohuk. However, tus, long fertile life, high parity and history similar rates of male condom use have been of child death were associated with a high reported for Iraq [14], Islamic Republic of current unmet need for contraception (but Iran [12] and among Palestinian refugees not unmet need for modern contraception) [15]. in the present study as well as in other KAP A high prevalence of history of unin- and DHS studies locally, regionally and glo- tended (mistimed or unwanted) pregnancies bally [20±23]. In particular, we can predict and (attempted) induced abortion reflects that mothers with a history of child death the magnitude of the unmet need for contra- would be more likely to disregard family ception in this area over the past 3 decades. planning. Globally, DHS demonstrated this This is shown by a prevalence of ever-un- as a cause for continued high fertility in the met need of 80.8%. Unintended pregnancy, less-developed countries [24]. as an expression of unmet need, has always In the current study the women with been a problem when women do not use high socioeconomic and educational stratus contraception, or use traditional methods, had low unmet need for any contracep- for example in Egypt [16], Japan [17] and tion and all unmet need, but a high unmet other developing countries [18]. Worldwide need for modern contraception. Among this

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S group, family planning use was high, but families, is in fact currently almost 4, but for because of local traditions and difficulties mothers above 40 years, average family size with access to family planning services, is almost double that. they were relying on traditional contraception. Increasing rate of contraceptive use has been found to be accompanied, over 'SRGPYWMSRWERH time, by shifts toward use of more effective VIGSQQIRHEXMSRW methods [25] and it is hoped this can occur among the studied population. Levels of In the studied population, the women with unmet need have been found to rise as more low socioeconomic/educational status have and more women want to control their fer- high unmet need for any contraception; tility and then fall as more and more women those with high socioeconomic/education- use contraception to do so [9]. That is why it al status had high unmet need for mod- is important to make modern contraception ern contraception. Both situations lead to available to all couples. high unwanted fertility. There is a need to It seems that in the study population, provide comprehensive, accessible, client- there has been a vicious cycle of low, or high sensitive and modern family planning serv- but ineffective, contraceptive use resulting ices through all primary health care services in many unwanted or mistimed pregnancies in all districts of Dohuk. The community, and even attempts at induced abortion. This in particular womens groups such as the unmet need for contraception leads to high Womens Union, should participate in plan- use but ineffective family planning and high ning (e.g. selecting the types of contracep- fertility. However, a sign of change in the tives to be made available), implementation study population is apparent from a fertility (e.g. distributing contraceptives and educat- preference of 4 children. Average family ing the community in their use) and evalu- size for all women, including many young ating the services (e.g. by contributing to mothers who have not yet completed their annual KAP surveys).

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-RXVSHYGXMSR used contraception, and unintended pregnancy was more prevalent in this category The most common cause of reproduc- compared to those who had ever used [11]. tive mortality is pregnancy and its related In Harare, a significant association was problems [1]. At the time of conception, found between unintended pregnancy and pregnancy may be intended or unintended. age, with women aged 19 years and below Unintended pregnancies can be defined as or 35 years and above having a higher risk pregnancies reported to have been either of unintended pregnancy [12]. Moreover, unwanted (i.e. occurring when no children, women with more than 5 children, and or no more children, were desired) or mis- women who were unemployed, nulliparous timed (i.e. occurring earlier than desired) and with low income, were significantly [2]. Unintended pregnancy is an important more likely to present with unplanned preg- issue to address because the risk factors of nancy [3]. unintended pregnancies are similar to those The objectives of this study were: of maternal mortality, and unintended preg- To estimate the prevalence of unin- nancy is often an indicator of the presence tended pregnancies that ended in birth of risk factors for maternal mortality [3]. in 1999 among ever-married Egyptian One of the common results of unintend- women. ed pregnancy is abortion [1], an outcome To assess the sociodemographic, re- for which there are few, if any, data in productive and nonreproductive health developing countries as it is not generally correlates of unintended pregnancy, in reported. In addition, unintended pregnancy particular contraceptive use. is associated with an array of risky health To explore some health-related outcomes behaviours, such as domestic violence [4], of unintended pregnancy in Egypt. decreased likelihood of breastfeeding initiation or continuation [5,6], and poor antenatal care [7]. In Egypt, poor antenatal care is considered the second most important 1IXLSHW preventable factor in maternal mortality 7XYH]WEQTPI after substandard obstetric care [8]. Data were obtained from the most recent The results of studies looking at the Egypt Demographic and Health Survey relationship between low birth weight and 2000 (EDHS 2000), which was a cross- unintended pregnancy are inconsistent. A sectional survey conducted in the first half study using data from the National Lon- of the year 2000 by the Ministry of Health gitudinal Study of Youth found little as- and Population and the National Popula- sociation between unwanted pregnancy tion Council in Egypt [13]. The EDHS and low birth weight [9], whereas another 2000 sample included 15 573 women from study conducted in Ecuador indicated that 16 357 households from all governorates unwanted, but not mistimed, pregnancies of Egypt. A total of 2352 respondents were were associated with a higher odds of low ever-married women aged 15 to 49 years birth weight [10]. who had given birth in 1999. Out of these, Concerning the determinants of unin- 3 did not provide information about their tended pregnancy, a recent prospective pregnancy intention, thus making the sam- study in 2 governorates of Upper Egypt ple size in the current study 2349. revealed that the majority of women never

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3YXGSQIW of ANC visits according to the World Health Pregnancy intention was the main variable Organization [14]. of interest for this study. Pregnancies were Data on all the above-mentioned vari- classified as those that were wanted at the ables were obtained from the womens time of conception (intended pregnancy) answers. or mistimed or unwanted (unintended pregnancies) at the time of conception. 7XEXMWXMGEPEREP]WMW Bivariate associations between unintended 1IEWYVIW pregnancy and each of the determinants and Selected reproductive health determinants outcomes were checked. These associations for each woman were: previous terminated were described by computing odds ratios pregnancy (yes/no), family planning history (OR) with 95% confidence intervals (CI) (never used contraceptives, used just before and P values, where P 0.05 indicated a the last pregnancy, ever-used), age of wom- significant association. Only variables that an at first birth (< 18, 1825, 25 years), were significant at the bivariate level were birth order of the child (1st, 2nd, 3rd, 4th or entered into a multivariable logistic regres- more), knowledge about the ovulatory cycle sion model to estimate adjusted odds ratios (woman knows/does not know), difference (AOR) of unintended pregnancy and the between achieved and desired family size corresponding 95% CI and P values. All (have ideal number, have more than ideal, analyses were conducted using SPSS for have less than ideal) and couple agreement Windows, version 12.0. on the reproductive desire (agree, disagree, woman does not know). Sociodemographic variables included 6IWYPXW were: age of woman (< 18, 1834, 35 7SGMSHIQSKVETLMGGLEVEGXIVMWXMGW years) and her education (no education, The mean age of the sample of women was primary, secondary, higher education). 26.4 years, standard deviation (SD) 6.03. Because of the high percentage of unem- The study respondents were similar to the ployed women, the husbands occupation overall EDHS respondents regarding region was used and classified into 3 categories of residence, education, husbands occu- (professional, managerial, clerical and pation and contraceptive use. There were sales; agriculture workers; service persons observed differences in the age of women and manual workers). In addition, place of and family size (measured as number of residence was studied according to type of live children at the time of the survey). The governorate [urban, frontier, Upper Egypt proportion of the study sample aged 35 (rural and urban) and Lower Egypt (rural years was lower than the overall EDHS re- and urban)]. spondents (10.4% and 40.6% respectively) The selected outcome measures for un- and most of the study respondents had 1 or intended pregnancy were: child size at birth 2 children, while most of the overall EDHS as reported by the mother (average, large, respondents had 4 children (Table 1). small); 2nd dose of polio vaccination status However, these differences were not statis- (yes/no), child status in 2000 (alive/dead) tically significant and the study sample was and antenatal care (ANC), measured by the representative of EDHS 2000 participants numbers of ANC visits (0, < 4, 4 visits) and all Egypt governorates. where 4 is the adequate minimum number

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4VIZEPIRGIERHHIXIVQMRERXWSJ and sociodemographic variables the follow- YRMRXIRHIHTVIKRERG] ing variables were significantly associated Unintended pregnancy that ended in birth in with unintended pregnancy: age, place of 1999 was reported by 431 women (18.4%): residence, education and husbands occupa- mistimed pregnancies were 137 (5.8%) and tion. Thus unintended pregnancy was more unwanted pregnancies were 294 (12.5%). In prevalent among older age groups, women the bivariate analysis of pregnancy intention living in Upper (rural and urban) Egypt,

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3.026.48) more likely to report their preg- to be unintended in 1995 [15]. This rate is nancy as unintended compared with those lower than that reported in the United States who had 1 or 2 children (Table 4). (US), where almost half of the pregnancies in 1994 were unintended [16], and in Japan, 3YXGSQISJYRMRXIRHIHTVIKRERG] where the rate of unintended pregnancy Among the selected pregnancy outcomes, according to a 2002 survey was 46% [17]. only the size of the newborn, as reported However, the US and the Japan rates were by mothers, and the number of ANC visits calculated among all females, while the were significantly associated with unin- Egypt rate is only among ever-married fe- tended pregnancy. Women who reported males. On the other hand, the Egyptian rate unintended pregnancy were more likely to of unintended pregnancy is closer to that report the child size at birth to be smaller found in the Islamic Republic of Iran, where or larger than average size compared with the rate was 35% [18]. It is much higher women who did not report unintended preg- however than other African countries such nancy (OR = 1.34, 95% CI: 1.021.76; OR as Nigeria, where the rate was 14% in 2003 = 2.25, 95% CI: 1.483.44, respectively). [19]. In addition, women who reported unin- Almost 1 in 5 women in the 1999 survey tended pregnancy were significantly more in Egypt reported an unintended pregnancy, likely to receive no ANC or < 4 ANC visits mostly unwanted. This prevalence does compared to those who did not report un- not reflect the true magnitude of the prob- intended pregnancy (OR = 1.56, 95% CI: lem, but can rather be considered as an 1.241.96; OR = 1.41, 95% CI: 1.031.93 underestimate since it was only calculated respectively) (Table 5). among ever-married women, and those whose pregnancies ended in birth. How- ever, it is lower than the prevalence of (MWGYWWMSR unintended pregnancy that ended in birth With an annual population growth rate of in 1995 (36.0%) [15]. This decline could 1.8 and a total fertility rate of 3.3, unplanned be due to the effect of various intervention pregnancy in Egypt the most populous programmes in the area of maternal health Arab country is an important reproductive that were implemented in Egypt in the issue to address, especially given that over 1990s. In 1984, the National Population one-third of all pregnancies were reported Council was established and headed by the

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President of Egypt because political leaders tion. However, the direction of the relation were concerned about the population de- between these 2 variables is inconsistent mography in Egypt and government efforts within the literature. In the present study, were directed toward increasing the aware- women who had tried contraceptive meth- ness and prevalence of family planning ods prior to the last pregnancy which ended [20]. Effective policies were in place after in birth in 1999 were more likely to have the International Conference on Population unintended pregnancy than those who never and Development (ICPD) in 1994 where the tried these methods. Casterline et al. studied role of nongovernmental organizations was unintended fertility in 2 governorates in strengthened. The number of family plan- Upper Egypt in 1997 and reported that the ning units rose from 3764 in 1980 to 4356 majority of women were nonusers of contra- in 1990 [20]. Prevalence of contraceptive ceptives (73.6%) and had higher unintended use increased from 24.2% for any method pregnancy rates compared with those who and 22.8% for modern methods in 1990 to have ever-used contraceptive methods [11]. 47.9% for any method and 45.5% for mod- Casterline et al. encouraged family planning ern methods in 1995. Furthermore, the total programmes to address nonuser groups fertility rate dropped from 5.28 in 1980, to [11]. The findings of this study shed light on 4.41 in 1988, then to 3.63 in 1995 [20]. the important issues of contraceptive failure One important determinant of unin- and the quality of contraceptive services. tended pregnancy is the use of contracep-

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The selection of a suitable contraceptive Overall, our study findings were consist- method, its quality and efficiency, knowl- ent with the published literature regard- edge about its utilization and the womans ing the sociodemographic determinants of compliance are important factors to be as- unintended pregnancy. Analysis of the data sessed and addressed in Egypt. The present at the bivariate level showed a significant national study offers evidence that provid- relationship between pregnancy intention ing family planning methods to target more and womens age, education and area of women is not enough to prevent unintended residence. Women aged 35 years were pregnancies, and that this provision should more likely to have unintended pregnancy be associated with high quality service. In compared with those aged 1834 years. In other words, it might be time to address the contrast, those aged < 18 years were less qualitative aspects of reproductive health likely to report unintended pregnancy. The programmes rather than only their quantita- most obvious interpretation of this finding tive aspects. Looking at the components of is that the former group, as opposed to reproductive health services and the way the latter, could have achieved their de- they are delivered are important challenges sired family size. Unintended pregnancy to improving the quality aspects. In addition, in the < 18 years group is a high figure and other comprehensive and holistic social considered a serious problem [3]. Educa- and economical services and programmes tion was also an important determinant of should be taken into consideration. Fur- unintended pregnancy at the bivariate level thermore, our study revealed that nonusers as women with secondary or higher educa- of contraceptives comprised 55.1% of the tion had lower odds of having unintended sample and they had the lowest unintended pregnancies. This could be explained by the pregnancy rates, which further emphasizes potentially higher ability of the educated contraceptive failure, rather than nonuse, women to receive and understand the family as a predictor of unintended pregnancies. planning messages, and their use of effec- Consequently, higher programme priority tive contraceptive methods. Concerning the should entail providing contraceptive users residence, Upper Egypt governorates, both with good quality services and information urban and rural, had the highest proportion to avoid unintended pregnancy [21,22]. of unintended pregnancies. Upper Egypt The current study also showed a strong governorates are remote areas characterized association between unintended pregnancy by a high prevalence of illiteracy, poor and deficient knowledge about the ovu- housing conditions, higher rates of fertil- latory cycle. This relationship should be ity and limited provision and utilization of interpreted with caution, as the information social services [11]. about knowledge of the ovulatory cycle With respect to health outcomes, only was obtained by only 1 yes/no question. child size and ANC were associated with However, this finding highlights the need unintended pregnancy. On the other hand, for health education regarding family plan- the results regarding child status should ning and for further investigation of this be interpreted cautiously as the numbers issue. Obviously, a deficient knowledge of of live children were 2081 (88.5%), dead the ovulatory cycle for this group of women children 50 (2.1%) and unknown status might lead to contraceptive failure and thus 220 (9.4%). Taking the last 2 categories unintended pregnancies. into consideration could have influenced

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S our estimates. The absence of a significant will lead to improvements in efforts to association between unintended pregnancy avoid such pregnancies, and improve the and the polio vaccination status of the child well-being of women and children [7]. The could be due to the compulsory vaccination study of unintended pregnancy offers public and the availability of free medical services health practitioners and demographers the for children. chance to understand fertility patterns and to plan and implement more efficient and 7XYH]PMQMXEXMSRW successful interventions regarding mater- The EDHS Egypt 2000 was a cross- nal and child health. Moreover, this study sectional survey that looked retrospectively targets Egyptian women of different so- at womens pregnancy intention and its re- ciodemographic status and with different lated determinants and outcomes. Our study reproductive health behaviours than their results should be cautiously interpreted in peers in developed countries. In Egypt, due view of the limitations of the cross-sectional to the high population density, looking at design. unintended pregnancy and its determinants Women with unintended pregnancy are provides valuable information for policy- usually at a higher risk of abortion. Because makers and public health professionals to of the unavailability of data on abortion address maternal and child health policies in Egypt, the current study only addressed and implement interventions. Addressing women who had pregnancies that ended in this issue is timely and should be linked childbirth. Furthermore, this study only sur- with the important reproductive health pro- veyed ever-married women. These 2 factors grammes and interventions addressing ma- together mean that a key limitation of the ternal and child health, which took place study was underestimating the prevalence during the last decade in Egypt [8]. Unin- of unintended pregnancy. tended pregnancy may be a major outcome Unintended pregnancy in this study re- measure for such programmes and under- fers to unwanted and mistimed pregnancies. standing and addressing its determinants It has been suggested in the literature that could improve these programmes. unwanted and mistimed pregnancies dif- Based on the findings of the study, we fer with respect to their determinants and recommend more interventions concern- outcomes [23], which necessitates further ing reproductive health programmes and studies to examine these differences. services, whereby qualitative aspects of the The prevalence of contraceptive use programmes should be taken into consid- might have been underestimated due to eration and more care given to promoting recall bias. The variables child size and reproductive health awareness of women in knowledge of the ovulatory cycle are Upper Egypt. Since pregnancy intention is based solely on the mothers response, thus not recognized as an individual product, making these measures subjective. but as a multidimensional product of social, cultural and economical power [7], other social and economical interventions should 'SRGPYWMSR be implemented in Upper Egypt. Further There is no doubt that understanding of prospective cohort studies on pregnant the determinants of unintended pregnancy women are also required.

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Note from the Editor We wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements of the EMHJ when preparing their manuscripts for submission for publication. These pro- visions can be seen in the Guidelines for authors, which are published at the end of every issue of the Journal. We regret that we are unable to accept papers that do not conform to the editorial requirements.

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-RXVSHYGXMSR ily planning. However, few were using a condom although more than 18% of married Men play a powerful role in reproductive men surveyed reported having used a male decisions. Their actions can have unhealthy method of contraception in the past includ- and even dangerous results. Mens partici- ing condoms [8]. Another study on the male pation is a promising strategy for addressing role in reproductive health in Egypt showed some of the worlds pressing reproductive that 64.7% of husbands did not wish to use health problems. With HIV infection now male contraceptives including condoms spreading faster among women than among [9]. A study in Pakistan, a country in the men, the AIDS epidemic has focused atten- same region, showed low knowledge levels tion on the health consequences of mens regarding the appropriate use and efficacy sexual behaviour. At the same time surveys, of condoms even among contraceptive us- mostly in Africa, have found that a considers [10]. erable per cent of men (about 70% in some While perceived unreliability is often a countries) favour and are concerned about problem, many other issues present greater family planning. Such findings suggest barriers to overall acceptability of condoms. that mens reproductive health behaviour is Many people do not believe they are at risk ready to change [1] of STIs/AIDS. Others do not like the feeling Since the 1930s, latex condoms have of condoms or worry about their partners been available to prevent both pregnancy reactions to suggesting condom use. Some and sexually transmitted disease, but in are embarrassed by the buying and using of most parts of the world they have never condoms or lack the skills to add their use been widely used [2]. Estimated pregnancy to sexual activity [11]. rates during perfect use of condoms is 3% at In the era of HIV/AIDS, it is essential 12 months [3]. Numerous studies have been to study the pattern of condom use which is conducted on the risk of sexually transmitted now not only important for family planning infections (STIs) in condom users. Virtu- and reducing fertility indices but is also a ally all clinical and epidemiological studies live saver by preventing HIV infection. have found substantial reductions in the risk This study aimed to study: of disease among condom users [4,5]. A multi-country European collaborative study the pattern of condom use among adult enrolled 378 seronegative regular partners Egyptian males in Lower Egypt; of HIV-infected men or women. About the pattern of risky behaviour of Egyp- one-half of the couples used condoms at tian adult males necessitating condom every intercourse, and no seroconversions use as a protective measure; occurred among these couples. About 10% the knowledge and attitudes of Egyptian of the couples who used condoms inconsist- adult males towards condom use and ently or not at all seroconverted with an barriers to use. incidence rate of 4.8% [6]. In Egypt, results of the 2003 Demo- graphic and Health Survey showed that 1IXLSHW male methods of contraception are still less widely recognized than female methods [7]. 7XYH]WIXXMRKERHWYFNIGXW In another study, it was found that 87% of This was a cross-sectional study conducted Egyptian men were agreeable to using fam- during 2004 in 4 governorates randomly

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S selected from the 13 governorates of low- ing to expected percentages of each in the er Egypt. They were Gharbia, Damietta, community as estimated by the researchers Dakahlia and Menoufiya. Two randomly because exact figures were not available. selected localities in each governorate (1 urban and 1 rural) were selected for data 7EQTPMRKXIGLRMUYI collection. The sampling frame for urban Random sample selection was done from localities was based on the list of cities in strata representing different educations and each Governorate from which 1 city was occupations. The identified strata included: chosen randomly. For the rural locality, a government employees, taxi and minibus list of related villages to the chosen city was drivers, industrial workers and university obtained from which 1 village was chosen and secondary-school students. randomly. Full lists of the available places of gath- The target population of this study was ering of the target population of each stratum adult males aged 1549 years representing were obtained from the Governorate office a sexually active group of the population. and multiple places were chosen randomly. They were chosen from different educa- The total population of the chosen places tional levels and occupational groups; in- were divided into clusters and 1 or 2 clusters dustrial workers, taxi and minibus drivers, were randomly chosen from each place to university and secondary school students reach the required sample size. Clustering and government employees. was based on the circumstances of each place; number of offices in governmental 7EQTPIWM^I premises, different student sections in the Gharbia governorate, with a population faculties, workplace divisions. Drivers were of 3 735 700, lies in the centre of the Nile all taken from the station of the chosen Delta. Damietta governorate, with a popula- locality which was always one station for tion of 1 005 243, lies on the northern coast. internal and another for external transporta- In Gharbia governorate, the population of tion (between governorates). Refusal rate males aged 1549 years was 997 859 while to participate ranged between 2% (among that of Damietta was 270 198. The esti- students) and 7% (among drivers). mated sample size in these 2 governorates was 1270 individuals (1000 in Gharbia and (EXEGSPPIGXMSR 270 in Damietta). A pre-designed questionnaire sheet (avail- Dakahlia governorate is located in the able on request from the corresponding east of the Nile Delta and has a population author) was used for data collection. This of 4 825 882. Menoufiya is located in the questionnaire included the following data: south of the Nile Delta and has a popula- Sociodemographic data (name not in- tion of 3 058 362. The population of males cluded) aged 1549 years in the 2 governorates was Perception of condoms as a method of estimated to be 2 275 493. The sample size protection against STIs and as a contra- represented 1/1000 of the target population ceptive method based on the CAPMAS census 1996 and Pattern of condom use and barriers to estimated increase by end of 2003 [12]. use Thus the total sample size in this study was 2304. Practice of risky behaviours necessitat- The sample size was drawn proportion- ing condom use as a protective measure ally from the different study groups accord- against STIs.

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S

Content validity of the questionnaire 6IWYPXW was tested by 3 experts. A pilot study including 30 individuals, not included in Table 1 shows the characteristics of the the study sample, was performed to en- 4 occupation groups. The study included sure the suitability of the questionnaire 2304 males aged 1549 years. These com- for data collection relevant to the study prised 590 industrial workers (25.6%), 382 design and objectives. Results of the pilot drivers (16.6%), 627 government employ- study showed that direct enquiry about ees (27.2%) and 705 students (30.6%). The sexual behaviour was not acceptable to majority of industrial workers and driv- respondents. Therefore, the questions relat- ers had received primary and secondary ed to personal sexual activity were replaced education (98.0% and 95.0% respectively) by questions enquiring about friends with while 45.1% of government employees extramarital relations. This was found to had received a higher education. Regarding be more acceptable and allowed projection students, 12.9% were secondary-school stu- of the prevalence of unsafe sexual relations dents while 87.1% were university students. in the studied community. Testretest reli- Of the entire sample, 44.1% were urban ability was conducted to ensure intra-rater residents and 42.2% were unmarried. The reliability. Inter-rater bias was not likely majority of industrial workers, drivers and because the questionnaire was designed to employees were married (79.0%, 67.8% be self-administered. Only those who could and 84.1% respectively) while the majority hardly read were helped in completing the of students were single (98.2%). questionnaire by the interviewers (about Table 2 presents the knowledge and 5%7% depending on the locality). attitude of the sample towards condom Data collection was done through direct use. In all, 60.5% perceived condoms as interviewing by members of the research an effective method of contraception. The team who were trained on communication highest percentage was reported by indus- interviewing skills by senior experts in a trial workers and drivers (63.6% and 63.1% 2-day workshop before starting data col- respectively) while the lowest percentage lection activities. Group interviewing was was that of government employees (56.5%). arranged with the study subjects before Condoms were reported as an effective distribution of the study questionnaire to measure for prevention of sexually trans- explain the importance of proper and committed infections (STIs) by 60.0% of the plete filling of the questionnaire. Only fully respondents; drivers (61.8%) and industrial completed sheets of those aged 1549 years workers (65.8%) reported the highest per- were included in the study (6%7% were centage. excluded of the total distributed). About 27% accepted the possibility of using condoms in the future with the high- (EXEQEREKIQIRXERHWXEXMWXMGEP est percentage reported by drivers (34.0%) EREP]WMW and the lowest by employees (22.2%). Re- The collected data were organized and sta- garding knowledge about the proper use tistically analysed using SPSS, version 12. of condoms 25.3% claimed to have this The number and per cent distribution were with the highest percentage being industrial calculated and the chi-squared test was used workers (32.7%). About 32% thought that for statistical analysis. The 5% level of sig- condom use may be associated with harm- nificance was used for interpretation of the ful effects and about 58% believed that the chi-squared results. partner might possibly reject condom use.

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More than two-thirds of the sample (69.6%) them for both contraception and prevention reported availability of condoms in their of STIs. Only 3.3% reported using condom neighbourhood; 53.1% reported that they during menses. The main reasons for not would be embarrassed to buy condoms in using condom were: no need being single or the presence of somebody known to them. married but wanting children (75.7%) and There were statistically significant differ- condoms decrease sexual pleasure (18.3%) ences between the 4 groups in their attitudes (Table 3). There were statistically signifi- and knowledge (Table 2). cant differences between the groups. Only 23.9% had ever used condoms The majority of the studied population with the highest percentage reported by reported having knowledge about HIV/ industrial workers (33.9%) and the low- AIDS (90.8%). Less than one-fifth reported est by students (10.4%). Among single that their behaviour put them at risk for males 11.6% reported using condoms while STIs and HIV infection (11.2% and 10.3% 32.9% of married males had used condoms. respectively). On the other hand, 28.9% Among the 552 participants who reported reported having friends who engaged in using condoms, the main reasons for con- extramarital sexual relations; drivers and dom use were for contraception (56.2%) and students reported the highest percentages for prevention of STIs (35.0%); 5.6% used (33.2% and 37.7% respectively). Differences

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S between the 4 groups were statistically prevent infection with HIV. In addition, significant in relation to risk perception for some are too embarrassed by their lack of STIs and HIV infection and having friends skills to add condom use to sexual activity engaging in extramarital sexual relations. [15]. Therefore, with more information and The participants reported that these unsafe encouragement more men would be willing sexual relations of their friends happened to use condoms [16]. frequently (44.5%) and with multiple part- Although condoms were reported by the ners (66.6%). Regarding condom use in majority of the participants in the present the extramarital relations of their friends, study to be easily available, only around a 53.5% said condoms were never used while quarter had ever used condoms and or said 18.4% said condoms were always used. they might be potential users in the future. The majority of the respondents who had Among all married persons only a third had friends engaged in extramarital relations ever used condoms. This figure is different (73.1%) believed their friends were at risk from that reported by the Egypt Demo- for HIV/AIDS (Table 4). graphic and Health Survey (3.2%) which gave the per cent of married couples using condoms only for family planning. Our (MWGYWWMSR study included all those in the community as a whole who had ever used condoms for Men play a powerful and even dominant any reason [2]. role in reproductive decisions sometimes The low level of condom use in this regardless of their partners wishes or the study should be considered in relation to health consequences to themselves or their partners. For these reasons, it is important the observation that only about a quarter to direct the action of health programmes to of the studied population reported having healthy male sexual behaviour [13] enough information about proper condom This study shows that slightly about use and that just over half were in need of 60% of the studied sample believed in the more information. The main reasons for not effectiveness of condom as a contraceptive using condoms in the present study were: method and for the prevention of STIs. Gov- not needing it (being single or married but ernment employees had the lowest level of wanting children) and decreased sensation confidence in condoms in this regard. Prop- during sexual relations. In addition, about erly used, male condoms are a proven and 30% believed that there may be harmful ef- effective means of family planning and for fects associated with condom use. Rejection preventing transmission of HIV/AIDS and by partner was another reason for non-use. other STIs [14]. Laboratory tests showed Despite the importance of condoms for that no STI organism, including HIV, can protection against both pregnancy and STIs pass through an intact synthetic condom. In and HIV/AIDS, use of male condoms for fact, a condom protects against any STI that family planning is rare, especially in de- is transmitted through bodily fluids [15]. veloping countries [17]. While perceived Many people, especially young men, unreliability is often a problem, many other may not be adequately informed about the issues present greater barriers to overall ac- protective effect of condoms against STIs ceptability of condoms and may explain this and AIDS. In some countries, only a minor- wide gap between awareness and use. Insuf- ity of never married men who had heard of ficient knowledge about the proper method AIDS knew that the use of condoms could of condom use and the places to obtain

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S them has also been reported to be a cause tices between different groups [22]. Risky for under-utilization [15,18]. Among other sexual behaviour includes unprotected sex, obstacles are social disapproval that stigma- irregular use of condoms, multiple partners tizes condom buying and use, difficulties in and relationships, and particular sexual ini- obtaining condoms due to restricted avail- tiation rituals [23]. Risky sexual behaviour ability, high price, and lack of privacy at is accompanied by increased risk of con- the point of sale or distribution. Fear, lack tracting STIs especially HIV [24]. Despite of trust in their partners, personal reluctance the AIDS epidemic, and even when men due to decreased sensitivity and unpleasant know that unprotected sex is risky, many odour, inhibition of sexual gratification and still take the risk and engage in risky sexual the possible irritation of the partners sexual behaviour [15]. organs that may interfere with intercourse The majority of the sample (90.8%) knew are other reasons for non-use of condoms about HIV/AIDS. While the participants [19,20]. In a study among adolescents, were not asked about their own sexual be- barriers to condom use among adolescents haviour, their knowledge of friends engaged engaged in risky behaviour were:, sud- in extramarital relations clearly shows that denness of the sexual event (21%), lack unsafe, risky behaviour is present in the of awareness of the nature of the risk and population. Furthermore, in spite of the the role of condoms as a protective method low condom use observed by this study, (16%), reduction in pleasure (15%), not 11.6% of single males had previous experi- knowing how to use (8%), partner is mar- ence with condom use, suggesting they had ried and it is her responsibility, too shy to extramarital sexual relations. Again among buy (6%), condoms not available (5%), students, only 2.1% were married but 10.4% partners insistence not to use (2%), and no reported previous experience with condoms. response (23%) [21]. Furthermore, many While 73.1% of those with friends engaging people do not believe they are at risk of STIs in unsafe sex believed that these friends or AIDS and may think they do not need were at risk of contracting HIV/AIDS, the protection. perception of the respondents of their own Among the 4 groups in our study, in- risk of STIs and HIV infection was low dustrial workers and drivers were the group (11.2% and 10.3% respectively). with the highest confidence in condom use and the highest frequency of ever use. They were also the groups that were most 'SRGPYWMSRERH willing to consider using condoms in the VIGSQQIRHEXMSRW future and were the least likely to believe that condom use has harmful effects (30.2% Condom use is still low among Egyptians. and 17.0% respectively). However, fewer Reasons for non-use include low confidence, drivers (59.2%) reported knowing where low perception of risk, lack of information, to obtain condoms than the other groups. perceived harmful effects, decreased sensa- These observations should be considered tion during intercourse and social stigma of on trials to encourage condom use among buying condoms. The presence of unsafe these groups. sexual behaviour necessitates increasing the Sexual behaviour patterns vary widely level of condom use in Egypt through: between countries and there may be large Family planning, communication and differences in the sexual norms and prac- social marketing campaigns to promote

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S

the dual role of condoms in preventing mental organizations. This will help pregnancy and transmission of STIs. meet condom needs and disseminate Sexual education with more information information about condom use. about condoms to encourage more men to play a positive role in reproductive health. Sex education for unmarried %GORS[PIHKIQIRX young people should stress on sexual This study received technical and financial abstinence before marriage and use of support from the joint WHO Eastern Medi- condoms for protection from STIs and terranean Regional Office (EMRO), Divi- HIV/AIDS. sion of Communicable Diseases (DCD) and Voluntary counselling and testing to ex- the WHO Special Programme for Research plore unsafe behaviours associated with and Training in Tropical Diseases (TDR): STIs including HIV/AIDS, to promote The EMRO/TDR Small Grants Scheme for condom use and to disseminate more in- Operational Research in Tropical Medicine formation concerning their proper use. and other Communicable Diseases. Cooperation of governmental sectors, the commercial sector and nongovern-

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-RXVSHYGXMSR conditions [12±14], while emotional abuse can have severe long-term effects [15]. Violence against women in developing In developing countries, women are countries is emerging as a growing con- more susceptible to domestic violence. For cern for public health practitioners as it example, one study in Karachi in 2000 re- is well known that women are vulnerable ported that all husbands surveyed admitted to many forms of violence, and domestic that they shouted at their wife, even when violence represents the commonest form she was pregnant [16]; 32.8% admitted to [1]. Domestic violence, or intimate partner having slapped their wives and 77.1% ad- violence (IPV), is defined by the American mitted to having engaged in non-consen- Medical Association as a pattern of physi- sual sex with their wives. Another study cal, sexual and/or psychological abuse by conducted in Karachi in 1999 reported a person with whom the victim has had an that 34% of the women had been physi- intimate relationship [2]. The World Health cally abused by their husbands and 15% Organization (WHO) defines domestic vio- had been abused even while pregnant. As lence as any act of gender-based violence a result, 72% of physically abused women that results in, or is likely to result in, physi- were anxious/depressed [17]. Another study cal, sexual or mental harm or suffering in 2005 on 176 married men showed that to women, including threats of such acts, 94.9% had ever used verbal abuse during coercion or arbitrary deprivation of liberty, their marital life and 49.4% had used physi- whether occurring in public or in private cal abuse [18]. life. [3]. Domestic violence is an important According to our recent study, it is not cause of morbidity and mortality for women only the husband but also the in-laws who in every country where these associations commit violence against women [19]. In have been studied [3]. In a literature review Pakistan a joint or extended family system of population-based studies, Krug et al. is the common practice where the husband found that 10%69% of women reported and his wife live with his parents, sisters that they had experienced physical abuse and brothers in one household. The wife is from a male partner [4]. There have been placed in a submissive position where she numerous studies in other communities in faces harassment from the whole family which women have reported experiencing [19,20]. domestic violence: 34% (n = 6566) in an The situation of domestic violence Egyptian study [5], 17% in Canada [6], against women in Pakistan is far from clear 16.4% in Haiti [7]. The reported reasons but what is clear is that it is an issue and for abuse included non-compliance with not much is being done to prevent it either female contraception, talking to strangers, by the government or nongovernmental jealousy; abuse has also been found to be organizations (NGOs). To be able to ad- associated with low income [5±8]. dress the issue properly it is important to There are many forms of violence against have baseline data about its prevalence and women. These includes psychological (e.g. reasons behind violence against women controlling behaviour, economic abuse, [21]. Although some studies have been con- social isolation), physical and sexual abuse ducted in Pakistan, none has been entirely [1,9±11]. Physical violence can often result community based. Therefore we conducted in multiple injuries and may lead to chronic a community-based study in a low socio-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S economic area with the following research experiencing violence was estimated at objectives. approximately 30% [17]. Using Epi-Info To estimate the prevalence of domestic for sample size calculation at the 95% con- violence among a selected sample of fidence level with 5% error, sample size women from low socioeconomic com- was estimated as 333. To be able to capture munities in Karachi, Pakistan. variability of the reasons for violence iden- To identify the reasons for domestic tified in our study we finally enrolled 400 violence among the women. currently married women using purposive sampling. The participants were identified by community health workers of the 1IXLSHW programmes and projects present in the selected communities based on the following 7IXXMRK inclusion criteria. This was a cross-sectional descriptive study Informed consent to participate in this conducted from March to August 2003 in study given 5 low socioeconomic communities where Resident of the community for more populations of mixed ethnicity live: Kor- than 3 years angi, Sohrab Goath, Orangi town, Mohajir Married camp and Layree. The inhabitants were the Mohajir (people who migrated from India Age between 15 and 45 years (reproduc- at the time of partition), and urban migrants tive age) from Punjab (Punjabi) and Balouchistan Having at least 2 children. (Baluchi). There are 3 types of dwelling: Registered for at least 2 years with the pucca which have cement walls, floors and community health worker of the NGO roofs; katcha-pucca which have cement or the national health programme of the walls with roofs of asbestos/tin/wood; and government of Pakistan. kutcha which have walls and floor made of mud/tin/wood and roof made of asbestos/ (EXEGSPPIGXMSR tin. Public utilities, such as water, electricity The data collection instrument (question- and health care centres, are very limited in naire) was based on the main objectives these areas. The 5 communities were select- of the study. Five focus group discussions ed based on the presence of a household sur- (FGD) were held with currently married veillance system. At Korangi, Orangi town women in the selected communities. Data and Mohajir camp a national health workers gathered from the FGD were used to de- programme is present working for maternal velop the questionnaire. The questionnaire and child heath. At Sohrab Goth there was was originally developed in English and no such programme present. At Layree the then translated into Urdu. Two rounds of Layree Community Development Project is pre-testing were run. Sociodemographic doing developmental work. data of the participants were collected, including age of respondent/husband, age at 7XYH]WEQTPI marriage, duration of marriage, number of Sample size was calculated to assess the pregnancies, occupation (respondent and prevalence of violence against women of husband), education (respondent and hus- low socioeconomic areas in Karachi, Pa- band), monthly household income, type of kistan. The proportion of urban women house and ownership of the house. Using

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S a closed-ended pre-coded questionnaire, returned to the interviewers to complete by information was also collected on verbal revisiting the women in their homes. Sur- and physical abuse experienced by the re- prise reinterviews were done by either the spondent from the husband and/or in-laws. principal investigator or the co-investigator The reasons for violence were also elicited so as to recheck various variables of the from the respondents with closed-ended questionnaire. questions. The data were collected by 5 interview- (IJMRMXMSRW ers who were selected by the investigators, The definition of domestic violence was 1 for each study site. All the interviewers developed from the literature review prior held masters degrees in Sociology, had to the study. taken some health-related training and had Conceptual definition (domestic vio- at least 2 years of data collection experi- lence): a pattern of physical, sexual, and ence. All spoke Urdu and at least 1 other psychological abuse by a person with regional language. The interviewers were whom the victim has had an intimate given 4 days of theoretical and practical relationship [2]. training including explanation of the study Operational definitions (domestic vio- objectives, sampling strategy, communica- lence): violence as perceived by the tion skills, questioning techniques, ethical women under study. considerations and completing the ques- The following forms were seen as types tionnaire. The training sessions included of violence. demonstration of communication skills, role-playing, lectures and case studies. Each Verbal violence (conflict): taunting, data collector had to demonstrate their ac- blaming, criticizing and shouting. quired skills until their performance was Physical violence: beating, pushing, found to be satisfactory. Field supervisors, shoving, using any means such as hands, who were also sociologists with 10 years legs, sticks. of field supervision, were involved in the Emotional violence: feeling anxious, training and conducted the qualitative work depressed or upset due to conflicts with to develop the questionnaire. husband and/or in-laws. The interviews were conducted during the day at the homes of the women, when )XLMGEPGSRWMHIVEXMSRW the husbands were not around. The families The Ethics Review Committee of our in- were already comfortable with the health stitution approved the study. Before data workers so it was not difficult to come into collection, verbal informed consent was the house and collect data in private. None- taken from all the women and they were as- theless, the data were collected with other sured that all the information would be kept information, to avoid any problems for the confidential. There were 30 women who women. The women gave verbal consent refused to participate and were replaced by easily and they were open in their answers. women residing in the next neighbourhood The field supervisor was responsible for who fulfilled the criteria. checking the data quality. The questionnaires were edited by the field supervisor (EXEQEREKIQIRX on a daily basis both in the field and in Data were double entered into Epi-Info, the office. Incomplete questionnaires were version 6. For analysis, the data were trans-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S ferred in to SPSS, version 10. Descriptive 8E FPI 7SGMSHIQSKVETLMGGLEVEGXIVMWXMGWSJ statistics were computed at The Aga Khan XLI[SQIRMRYVFER/EVEGLM University by the principal investigator. 'LEVEGXIVMWXMG 1IER 7( 6IWTSRHIRXvWEKI ]IEVW 6IWYPXW (YVEXMSRSJQEVVMEKI ]IEVW 7SGMSHIQSKVETLMGGLEVEGXIVMWXMGW %KIEXQEVVMEKI ]IEVW The mean age of the women was 29.0 [stand- 2YQFIVSJTVIKRERGMIW ard deviation (SD) 4.6] years (range 1939 1SRXLP]MRGSQISJLSYWILSPH years). The mean duration of marriage was MR4EOMWXERMVYTIIWE 10.5 (SD 5.0) years and age at the time of 2S marriage was 18.8 (SD 3.3) years. A total of R! 1661 pregnancies were reported by the 400 =IEVWSJWGLSSPMRKSJVIWTSRHIRX women with a mean of 4.1 (SD 1.7) preg- 2SRI MPPMXIVEXI nancies. Of the 400 women, 33.8% were z illiterate and 25.5% of the husbands were z illiterate. Only 24.0% of the women were z employed, whereas the majority (94.7%) of 9RMZIVWMX] the husbands were employed. Most of the =IEVWSJWGLSSPMRKSJ women lived in katcha pucca dwellings; VIWTSRHIRXvWLYWFERH only 69% owned their homes (Table 1). 2SRIMPPMXIVEXI z z 4VIZEPIRGISJHSQIWXMGZMSPIRGI z The majority of women (97.5%) reported 9RMZIVWMX] that they had experienced verbal abuse (conflict) from their husbands and 97.0% 3GGYTEXMSRSJVIWTSRHIRX ,SYWI[MJI experienced such abuse from their in-laws. )QTPS]IHSYXWMHIXLILSQI As regards physical violence, 80.0% reported receiving beatings by their husbands and 3GGYTEXMSRSJVIWTSRHIRXvW LYWFERH 57.5% experienced such violence from their 9RIQTPS]IH in-laws. The majority of women reported )QTPS]IH feeling stressed by the conflict with their 8]TISJH[IPPMRKF husbands (98.5% of the women) and with /EXGLE their in-laws (97.3%). 4YGGE /EXGLETYGGE 6IEWSRWJSVGSRJPMGXW[MXLLYWFERH 3[RIHXLILSYWI ERHMRPE[W =IW The main reasons for conflicts with hus- 2STE]VIRXJSVMX bands were reported as: financial causes 4VSZMHIHF]IQTPS]IV (65.0%), infertility (33.3%), not having a E97!4EOMWXERMVYTIIWEXXLIXMQISJXLIWXYH] son (32.0%), husband beating or hitting the F4YGGELEZIGIQIRX[EPPWJPSSVWERHVSSJW OEXGLETYGGELEZIGIQIRX[EPPW[MXLVSSJWSJ children (21.3%) and husband being ad- EWFIWXSWXMR[SSH OYXGLELEZIQYHXMR[SSH[EPPW dicted to drugs (15.8%) (Table 2). ERHJPSSVW[MXLVSSJWSJXMREWFIWXSW The main reasons for conflicts with 7(!WXERHEVHHIZMEXMSR in-laws were reported as: household chores

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(80.3%), infertility (33.8%), not having a ity (22.8%), financial reasons (19.8%), not son (28.5%) and financial reasons (20.8%) having a son (18.8%) and husband being (Table 2). addicted to drugs (15.8%) (Table 2). The main reasons reported for beating by 6IEWSRWJSVTL]WMGEPZMSPIRGIJVSQ in-laws included: household chores (28.8%), LYWFERHERHMRPE[W husband addicted to drugs (20.5%), not hav- The main reasons reported for physical vio- ing a son (19.3%), dowry issues (13.0%), lence by the husband included: disobeying and disobeying and arguing with in-laws and arguing with in-laws (38.8%), infertil- (7.5%) (Table 2).

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(MWGYWWMSR the balance of power between husband and wife can lead to violence. Violence affects the lives of millions of A predisposing factor for our partici- women worldwide, of all socioeconomic pants perception of domestic violence is and educational classes. However, a study the power bestowed upon males which conducted in medical clinics in Sudan in subjugates women and makes them submis- 2001 reported that women with low edu- sive to men. In Pakistan, the bride generally cational status and unemployed women lives with her in-laws and looks upon them and newly married women were more fre- as the ultimate authority figure in the house- quently abused [22]. Domestic violence hold. This gives power to the in-laws. The cuts across cultural and religious barriers, brides parents are not supposed to interfere undermining the right of women to partici- with the life of their daughter once she is pate fully in society [23]. married. Any attempt on the part of the Our community-based study found that brides parents to influence her may lead to the prevalence of conflict with the husband conflicts with the husband and the in-laws. as perceived by the wife was about 98% and It may even go as far as the husband and in- with in-laws about 97%. The prevalence of laws beating the wife to show their power. physical abuse by husbands reported by the Financial issues were an important rea- women was 80% and by the in-laws 58%. son for domestic violence in our study. This Our findings support those of previous finding has been reported by many other studies done in Egypt (34%) [5], Canada studies. For example, studies on Haitian (17%) [6], Haiti (16.4%) [7], Bangladesh and Native American women showed that (42%) [24], India (30%) and some squatter because of their lack of financial contribu- settlements of Pakistan (34%) [8,16±18], tion they perceived themselves as power- but our figures are much higher. The high less [7,8]. In Pakistan, a number of NGOs prevalence of perceived violence against are working to raise the economic status women in this study could be attributed to of women by offering them microcredit. the fact that 50% of our participants were However, these programmes are providing either not educated or had had only limited protection only to a very few because many schooling. It has been reported generally women are not aware of the schemes or may that a womans ability to make decisions is not be allowed by the husband/the family acquired when she has had at least 10 years to go to a bank or NGO to learn about the of schooling [7]. As reported by one study, system. many women perceived that education im- Infertility and not giving birth to a son proved womens status and increased their were 2 other reasons for violence found in contribution to their households, thereby our study. In the communities studied, it is awarding them more freedom and less de- believed that the woman alone is respon- pendency [24]. In the womens view, edu- sible for the sex of a child. The concept cation has both a direct effect on womens of male involvement in providing X and status and an indirect effect that operates Y chromosomes to the female is either through increased earning potential. On the unknown, unclear or completely ignored. other hand, the study identified that a hus- In addition, such families are not aware of bands violence against his wife was associ- how much the male can contribute to the ated with the woman being more financially cause of infertility. It is the woman who is independent. This indicates that a shift in held responsible for infertility, becomes so-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S cially stigmatized and possibly the victim of tend not to wish to discuss it especially verbal and physical abuse too [20]. In China with strangers. Therefore, the health care and India, some women choose to terminate workers were used to collect the data as they their pregnancies when expecting daughters were known to the women and her family but carry their pregnancies to term when and had a rapport with them. We collected expecting sons [25,26]. Further an Egyptian information only about physical (beating), study identified that women are not aware and verbal (conflict) violence. Due to the of their reproductive rights [27]. sensitivity of the topic, we did not collect Another perceived reason for the abuse information on sexual violence, which is suffered by our participants was the drug another limitation of our study. The find- addiction of the husband. Other studies ings of this study should be taken in the light have reported on the association between of these limitations. Despite this, we believe domestic violence and drug and alcohol use the study contributes to our understanding [25,28]. of the prevalence of and possible reasons Domestic chores are one of the reasons for domestic violence among urban women reported by women in our study particu- of low socioeconomic status in Karachi, larly in relation to the in-laws. The wife will Pakistan. work for 24 hours without recognition and We conclude that the prevalence of rest because little social value is given to domestic violence among such women is her by her husband and in-laws. This may high and this violence puts the women un- result in the woman becoming stressed and der considerable stress. The main reported irritable which then often gives the husband reasons for the violence are public health and in-laws the opportunity to physically issues which should be addressed by health abuse her. Many men and in-laws have false professionals. There is therefore a need for socioreligious belief that women have lower womens empowerment through increased intellects than men and are thus not able to schooling and improved financial capacity understand what is right for them and make so that they are able to participate in the proper decisions. Therefore, they are over- decision-making process of a household. protective of the woman and completely The media could play a leading role in limit her mobility and contact with others persuading society to be more supportive of [16]. In addition in our culture womens women and their role in society. Awareness exposure to men other than the husband is the first step towards a more supportive tends to be restricted. The women in our and tolerant society. study reported that their husbands were jealous if they talked to other men. This result is supported by the qualitative study %GORS[PIHKIQIRXW we conducted to develop the questionnaire We would like to thank the Aga Khan Uni- that found that when women talk to another versity, Karachi, Pakistan for providing the man, it is viewed almost as an extramarital grant for conducting this study. We would affair. also like thank all the participants and staff The major limitation in this study was of this project without whose help the study the non-random purposive sampling tech- would not have been possible. In addition, nique used whereby only women of low we would like to thank Dr Sanah Baig for socioeconomic level were recruited. This editing the paper. Finally, we thank Dr was done because domestic violence in our Neelofar Sami, the principal investigator of culture is a very sensitive issue and people the larger project.

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Violence and injury prevention: road traffic injuries http://www.emro.who.int/vip/roadtrafficinjuries-regionaldata.htm In 2002 there were an estimated 132 207 road traffic deaths in the WHO Eastern Mediterranean Region (362 deaths/day). The Region has the highest rate of road traffic deaths among males. In low- and middle-income countries, the annual road traffic death rate for males (117.0/100 000) is more than double the rate for low- and middle-income countries across the world (53.3/100 000). For males aged 45²5, the rate in low- and middle-income countries in the Region (63.9/100 000) is 50% higher than that in low- and middle- income countries across the world (43.2/100 000). Similarly, the annual road traffic death rate for females aged 60 and over in the Eastern Mediterranean Region as a whole (46.0/100 000) is 241% higher than the rate for females in this age group across the world (19.1/100 000).

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-RXVSHYGXMSR The objective of the present study therefore was to assess the quality of different Omeprazole, a proton pump inhibitor which brands of omeprazole capsules available has greater anti-secretory activity than H2 on the Egyptian market and the efficiency antagonists, has been widely used in the of the national regulatory system to ensure treatment of reflux oesophagitis, Zollinger the pharmaceutical quality of multisource Ellison syndrome and peptic ulcer disease products or product components. [1]. Being unstable in acidic pH [2], omeprazole is marketed as enteric-coated pellets encased in hard gelatin capsules. Pellets 1IXLSHW may undergo changes upon storage involving mainly enteric performance and release Omeprazole standard was obtained from characteristics [3]. After encasing into cap- Astra Hässle AB, Sweden. Seven commer- sules, additional storage-induced changes in cial generic brands of omeprazole capsule the capsule shell may take place [4,5]. Thus, products (20 mg) marketed in Egypt (Table 1) were purchased from local pharmacies post-marketing follow-up is necessary to and compared to the original innovator monitor probable changes which may affect product (Losec®) manufactured by Astra. the performance of omeprazole capsules. Variations in manufacturingexpiry date Omeprazole is currently marketed in ranges were small. Acetonitrile (Fisher Egypt by a number of pharmaceutical com- Scientific, United Kingdom) and metha- panies using coated microgranules from nol (Riedel-de Häen, Germany) were of different origins and using different types high performance liquid chromatography of packaging (Table 1). Differences in the (HPLC) grade. Other chemicals were of quality of granules coating may be a source analytical grade. of variability in the in vitro and consequently in vivo availability of omeprazole (IXIVQMREXMSRSJSQITVE^SPI [1]. Packaging types have been reported to GSRXIRX be an additional factor significantly influ- The omeprazole content of the products encing formulae stability and performance was determined using the HPLC method re- [6]. Moreover, there are wide variations in ported by Storpirtis and Rodrigues [8] with price in the marketed omeprazole products, slight modification. The HPLC system used particularly between generic products and (Perkin Elmer series 200, United States) the proprietary one. The price per capsule was equipped with a pump, vacuum degas- ranges from Egyptian pounds (LE) 1.5 ser, ultraviolet/visible detector, autosampler to 7 (US$1 = LE 6.8 at the time of the and a chromatography interface 600 series study) (Table 1). Recurring gastrointestinal link operated by a software system version tract (GIT) conditions necessitate long-term 6.2. A reserved phase column, Spheri-5, therapy with long-term cost implications. RP-18, 5μ, 220 × 4.6 mm (Perkin Elmer, Remak et al. suggested an economic model Brownlee columns) was used. The mobile to compare the cost and effectiveness of 7 phase consisted of 40% (v/v) acetonitrile proton pump inhibitors (PPIs) in patients and 60% (v/v) phosphate buffer solution suffering from gastro-oesophageal reflux pH 7.6 flowing at a rate of 1 mL/minute; the disease (GERD) [7]. Accordingly, there ap- detection wavelength was 302 nm. Analysis pear to be many sources of variation in the was performed at room temperature with an pharmaceutical performance of omeprazole injection volume of 20 μL. capsules.

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An amount of the pellets equivalent to 20 under these conditions it is expected to be mg of omeprazole was accurately weighted stable for 3 days [8]. Before analysis, the and sonicated with 60 mL of 0.1 N NaOH filtrate was diluted with water/acetonitrile (ultrasonic bath) for 10 minutes. Methanol mixture (60:40) to a final concentration of (20 mL) was added and the mixture soni- 5 μg/mL. cated for 5 minutes. The volume was com- A standard solution was prepared by pleted with 0.1 N NaOH to 100 mL, and the dissolving 20 mg of omeprazole standard mixture filtered through a Millipore nylon powder in 20 mL methanol (HPLC grade). filter (0.45 μm × 25 mm). The filtrate was The volume was completed to 100 mL kept in the refrigerator protected from light; with 0.1 N NaOH and the solution filtered

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S through a Millipore nylon filter (0.45 μm × Modified release method 25 mm). The filtrate was kept in a refrig- The pH of the release medium used in erator protected from light. Concentrations the initial acid stage of the standard USP used for the calibration graph ranged from method was changed from pH 1 to pH 4 ±

0.125 to 15 μg/mL. 0.5 [9] by adding Na2HPO4. Three capsules per brand were tested. 'SRXIRXYRMJSVQMX]XIWXMRK Ten capsules were assayed individually and 7XEFMPMX]XIWXMRK the content was expressed as a percentage All products were subjected to the accel- of the label claim. The mean and relative erated stability testing conditions recom- standard deviation (SD) were calculated mended by the International Conference and compared as directed by United States on Harmonization (ICH) guideline [10]. Pharmacopeia (USP) 28. Samples of omeprazole capsules in their original packages were stored in an incuba- (VYKVIPIEWIXIWXMRK tor at temperature of 40 ± 2 °C and relative The evaluation of the biopharmaceutical humidity (RH) of 75 ± 5%. The capsules quality of omeprazole capsules, regard- were monitored over the 3-month study ing its dissolution characteristics, is not period for changes in the appearance of the specifically regulated in the commonest pellets, drug content and drug release using pharmacopeias (USP28 includes a general the official USP release test. monograph for enteric-coated products).The in vitro release from the studied capsules (EXEEREP]WMWERHWXEXMWXMGW was thus assessed using the official method Interbrand variation was evaluated using and compared to a modified method. the one-way analysis of variance (ANOVA) followed by the Dunnett multiple compari- Standard USP method son post-test to compare each of the local Drug-release studies were performed ac- brands with the innovators. P < 0.05 was cording to the USP 28 procedure for de- considered significant. layed-release (enteric-coated) articles. In each study, 6 capsules were tested using dissolution apparatus type 2. Initially, the cap- 6IWYPXW sules were exposed to a simulated gastric Among the 7 brands tested, only brand C fluid (750 mL 0.1 N HCl, pH 1) maintained failed to conform with the USP require- at 37 ± 0.5 °C and rotated at 100 rpm for 2 ments for content and content uniformity; hours. After withdrawal of a 2 mL sample, its initial assay value was 121.02% and its 250 mL of 0.2 M Na PO solution equili- 3 4 content uniformity ranged from 118.17% to brated at 37 ºC were added to the acidic 127.44%. medium and the pH was adjusted to 6.8 ± Figure 1A and B show the release pro- 0.5. Two mL samples were withdrawn at 5, files of the different brands of omeprazole 10, 20, 30 and 45 minutes and transferred to capsules using the official method and the tubes containing 1 mL 0.3 N NaOH. Sam- modified one respectively. Pre-exposure ples were then filtered through a 0.45 μm to pH 1 (Figure 1A) did not result in drug cellulose nitrate membrane filter and kept in release; this was only initiated by switching a refrigerator protected from light pending the release medium pH to 6.8. Significant analysis. The analysis followed the same differences were observed in omeprazole HPLC procedure described above.

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S release time between the innovator product Stability of the studied brands was moni- and the tested brands for up to 10 minutes, tored over a 3-month period at 40 °C/75% except for brand D which had a release RH using changes in pellet appearance, profile similar to that of the innovator. Ac- drug content and release stability as pa- cording to USP 28, not less than 75% of the rameters (Table 2, Figure 2). At zero time, labeled omeprazole must be released, from the majority of the observed pellets were a 20 mg capsule, in 45 minutes; all tested white, except for brand B and D. Brand A brands exceeded 90% release (Figure 1A). It and F showed progressive stickiness and is worth noting that brand C achieved 120% darkening of the pellets (Table 2). The drug release at 45 minutes, which is consistent content of the tested brands was within the with its higher drug content (121.02%). acceptable range (90%110%) at the end of Figure 1B shows obvious interbrand vari- 2 months storage, except for brand B which ations concerning both rate and extent of showed a drastic decrease to 1.79% (Figure drug release after pre-exposure to pH 4. 2A). After 3 months, 3 other brands, A, D In addition, brands A and F released 7.1% and F, in addition to brand B, failed to main- and 3.7% of their drug content at zero-time tain omeprazole content above 90%. The respectively. This may point to loss of coat initial omeprazole content of brand C was integrity during the acidic stage (pH 4). higher than the upper limit of the acceptable Statistical evaluation of the release data range (121.02%); this decreased after 2 and indicated significant interbrand variability 3 months storage to 103.6% and 102.33% in the first 10 minutes of the release test, respectively (Figure 2A). as well as significant differences between Percentage drug release at 45 minutes the innovator and each of brands A, B, C over the 3 months storage is shown in Fig- and E2. In addition, the innovator showed ure 2B. Brands A and B showed a signifi- statistically significant differences regard- cant decrease in omeprazole release at 45 ing the extent of omeprazole release (% minutes at 2 and 3 months; after 3 months released at 45 minutes) when compared to omeprazole release at 45 minutes for brands brands A, B and C. D and F was also significantly lower.

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Release stability of omeprazole capsules (MWGYWWMSR upon storage was also studied using per cent dissolution efficiency (% DE) (Figure 2C). Inspection of the in vitro performance of Again, for brands A, B, D and F, the %DE omeprazole capsules produced by Egyp- decreased significantly at 3 months. tian companies revealed remarkable inter- Regarding the influence of packaging brand variations and significant differences materials on capsule stability (Tables 1 between some of the local brands and the and 2), the results show the superiority of innovator. the innovator packaging. The PVC/PVdC- Omeprazole, being a proton pump inhibi- aluminium blister of brand B proved to be tor (PPI), induces an increase in stomach pH the least protective. Amber glass bottles up to 4 upon repeated administration [11]. were the most protective of the locally used Accordingly, performing the release test at packaging materials. this pH provides more realistic conditions Figure 3 shows the influence of pre- for drug release from capsules [9].The pro- exposure of omeprazole capsules to pH 1 tective capacity of the enteric coat has been or pH 4 on the % omeprazole released at 45 reported to be threatened at elevated gastric minutes. There was a decrease in % released pH [12]. Our results showed a decrease in % at 45 minutes for brands A, B and C after released at 45 minutes for brand A, B and C pre-exposure to pH 4 compared to pH 1. after pre-exposure to pH 4 compared to pH The insert shows an extra peak in a chroma- 1. This could be explained by the probable togram of a release sample at pH 4. loss of gastric resistance of the enteric coat-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S ing polymers with consequent omeprazole during the acid stage of the dissolution test. degradation at pH 4. The appearance of a The appearance of new peaks in the dis- new peak, in addition to the omeprazole solution samples analysed of the 4 brands peak, in the release samples analysed con- confirmed this degradation. The loss of the firmed this degradation. gastroresistance of enteric-coated formulae Mathew et al. mentioned the appearance with ageing has been previously reported of 4 extra peaks when omeprazole was [14,15]. Moreover, the polymer structure subjected to drastic acidic conditions [2]. may influence omeprazole stability [16]; One of the degradation products (H 238/85- the acid structure of the enteric coating Astra) was identified by Storpiritis and polymers as well as the acidic by-products Rodrigues [8]. In addition to its capability induced degradation of omeprazole. to evaluate the protective capacity of the The results revealed that colour change coating, the modified release method is in pellets may be indicative of alteration in more discriminative and can reveal differ- the coating polymer which in turn may in- ences in pharmaceutical quality of different fluence drug release [8] and content stability omeprazole capsule brands, which might be [17]. Moreover, the influence of packaging obscured under the conventional USP test. materials on product stability was obvious Elkoshi et al. showed that pre-exposure of when comparing brands E1 and E2; both omeprazole capsules to pH 3 or 4 was more were from the same source but with dif- discriminative and resulted in release data ferent packaging. The packaging material that could correlate well with in vivo avail- was most probably responsible for the dif- ability, while the official test results did not ferences in stability observed between the reflect the actual in vivo behaviour [12]. 2 brands. The stability of the tested capsule brands Release stability of omeprazole capsules was monitored over 3 months of storage; the upon storage was further assessed using per results revealed that the tested brands could cent dissolution efficiency (% DE). The be classified in 3 categories (Figure 2). The % decrease in DE after 3 months storage first one includes the innovator and brands was statistically significant between the in- C and E2, which showed drug content and novator and each of the tested brands except % release at 45 minutes above the USP brand E2. This parameter is more realistic limits throughout the 3-month study pe- for comparison of release data as it takes riod. The second category comprised brand into consideration all release data points E1, which maintained omeprazole content rather than a single point [18]. above 90% but failed to maintain drug release above 75%. The observed decrease in drug release was not merely due to drug 'SRGPYWMSR degradation, but rather may be attributed to Wide variations in the in vitro performance changes in coating polymer properties [13]. of omeprazole capsule products marketed The third category included products that in Egypt were observed and the modified suffered decrease in both omeprazole con- release method proved to be more dis- tent (< 90%) and drug release (< 75%); this criminative than the conventional USP one. included brands A, B, D and F. These prod- The nature of the packaging materials had ucts showed a more pronounced decrease a clear influence on the performance of in release when compared to the decrease omeprazole capsules when stored: amber in content, indicating probable degradation

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S glass bottles ensured higher protection than effective for long-term therapy compared to blisters, strips or plastic bottles. The pro- the innovator. gressive darkening of the pellets indicated, The data obtained in this study strongly qualitatively, the level of degradation of point to the need for assessment of the the product. The innovator was the brand performance of drug products post- most resistant to changes followed by brand marketing and for strengthening the role of E2. In addition, brand E2 is less expensive the national regulatory system to ensure the and thus could be considered more cost- quality of multisource products.

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6afety of children·s medicines The lack of thorough and reliable clinical data on the way medicines affect children requires strengthened safety monitoring and vigilance of medicinal products. This is the fundamental message of Promoting safety of medicines for children. Intended for policy-makers, manufacturers, medicines control bodies and researchers, the publication gives an overview of the problem and offers solutions on how best to address side effects from medicines in children. It is part of a broad effort WHO is initiating to expand children·s access to quality-assured, safe and effective medicines. For instance, countries should establish national and regional monitoring systems for the detection of serious adverse medicine reactions and medical errors in children; regulatory authorities need to make an effort to refine the science of clinical trials in children, create an active post-marketing surveillance programme and develop public databases of up-to-date information about efficacy and safety in paediatric medicines. In addition, regulatory authorities need to make an effort to refine the science of clinical trials in children, create an active post-marketing surveillance programme and develop public databases of up to date information about efficacy and safety in paediatric medicines. This publication can be ordered from the WHO bookshop (contact: [email protected]) or can be downloaded as a PDF file at: http:// www.who.int/entity/medicines/publications/essentialmedicines/Pro- motion_safe_med_childrens.pdf.

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-RXVSHYGXMSR developing countries: poverty. Most street children go onto the street to look for a The phenomenon of street children today better way of living, to earn money for has become an important subject of inter- themselves and support their families and national concern. A street child has been to find shelter [2,3,9]. In general, street chil- defined as: any girl or boy who has not dren share common problems which may be reached adulthood (318 years) for whom social, physical, psychological and mental the street has become his/her habitual abode [2,3,9]. Social problems include poverty and/or source of livelihood and who is inad- and illiteracy, discrimination and lack of equately protected, supervised or directed accessible resources, a violent environment by responsible adults [1]. In industrial and stigmatization. Physical problems in- countries, this definition may be extended clude lack of adequate nutrition, intentional to include those who spend all day in the and unintentional injuries, sexual and repro- street unsupervised [1±4]. The United Na- ductive health problems and some common tions has estimated the population of street diseases such as skin diseases, parasitic children worldwide at 150 million, and the diseases, tuberculosis and dental problems. number is rising daily; 40% of those are Psychological and mental problems can be homeless and the other 60% work on the precipitated by a stressful past, transitory streets to support their families [5]. lifestyle, psychoactive substance use and In Africa, the problem of street chil- include mental health problems such as dren is poorly documented [4]. Most street emotional aggression, psychiatric disorders children are boys. The percentage of girls and learning difficulties [2,3,9]. among street children in various developing An earlier cross-sectional descriptive countries ranges from only 3% to 29% [6]. study was conducted on 100 street children Miserable living conditions and domestic attending rehabilitation institutions in order violence are major reasons why these young to define their problems and needs. The people leave home or are sent out to the results of this preliminary study are reported streets in order to make money to support in an earlier paper [10] and showed that their families. Very often women aban- street children are disproportionately vic- doned by the father of their children are left tims of family breakdown, and sexual and to support the house alone. As a result, fam- physical abuse. They suffer from malnutri- ily ties are broken and these children move tion, health problems and lack of educa- away from their communities and form tion and they tend to display aggressive alliances with other street children in order and violent behaviour. They are extremely to survive [7,8]. Research indicates that vulnerable to communicable diseases such families with single mothers and children as tuberculosis. They are thus a potential make up the largest group of people who hazard to themselves and the public at large. are homeless in rural areas [8]. Increasingly A behavioural modification intervention these children are defenceless victims of was therefore designed to address the needs, violence, sexual exploitation, neglect and psychological issues and problems of street criminal activities [5,8]. children in Alexandria via a programme to The reasons why children live on the improve their environmental behaviour and street vary. However, there is one explana- raise their self-esteem. This paper reports an tion that holds true for both developed and evaluation of the intervention programme.

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1IXLSHW (EXEGSPPIGXMSR Data on the children were collected using a 7EQTPI specially designed questionnaire. The ques- The original sample of 100 street chil- tionnaire was structured according to the dren was a non-random, purposive sample, handbook of the World Health Organiza- chosen from 3 central districts of Alexan- tion [2]. It assessed the family background, dria (Middle, East and West districts) that education status of the children and their have a high concentration of street children parents, reasons for being on the street, du- (although all children attended the same ration of street life, presence of responsible rehabilitation institution) [10]. Children adults, activities performed to earn money eligible for the study were those who met and history of police arrest. The interview the definition of street child adopted by was repeated twice to ensure the reliability UNICEF [8]. of the data. A representative sample from the origi- Each child was given the Arabic version nal 100 street children was chosen to take of the Weksler IQ test for intelligence [11] part in the environmental behavioural modi- and was observed using an observational fication programme. A total of 42 street sheet for adaptive behaviour, as previously boys aged between 7 and 15 years were described [12]. The IQ test was performed selected from the El-Horreya Institute for for every child in order to ensure that the community development in Alexandria chosen sample was within the normal range (an institution that only provides shelter). of IQ. Boys were included in the programme if All children were medically examined they had more than 1 behavioural prob- at the clinic of the rehabilitation institution lem, had not been exposed to a previous and interviewed in more than one setting. environmental behavioural modification An observation sheet was used in order programme, remained in the Institute during to monitor the adaptive behaviours for each the programme, did not try to leave and had child through conversation sessions. Data an IQ within the normal range. Most of the were collected through conversation ses- boys had been on the streets since before the sions recorded on videotape, to identify the age of 6 years. Behavioural problem include main environmental behavioural problems. aggression and violence, stealing, begging, Priorities were settled and a strategic plan scavenging, commercial sex, illicit drug was developed to fulfil their needs. trafficking or substance use. The invention programme was planned From the initial sample 7 children were and adapted from several publications con- excluded: 2 brothers returned to their fam- cerning behaviour modification [12±19] ily; 4 children had jobs outside the institute and the researchers supervised its activities during the day and could not attend the for the different age groups of children. programme activities and 1 child left the Pre- and postprogramme tests using institute due to family problems. Thus, the observational sheets were performed the final sample for the intervention was approximately 12 weeks before the in- 35 boys: 28 aged 711 years and 7 aged tervention and after application of all the 1215 years. All gave their full consent to programme units. participate in the programme.

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8LITVSKVEQQI such as accidents, sexual abuse, violence The behavioural modification programme and substance use [20,21]. ran from October 2001 to April 2003. The The 3rd unit of heritage and museum ed- programme was designed in 7 main units: ucation aimed to help children acquire new outdoors and recreational education; urban skills related to national history; increase and health education; heritage and museum their awareness of their environment; de- education; moral and religious education; velop feelings of respecting and belonging human rights and peace education; eco- to society and its culture, values, thoughts nomic and civic education; and future and and traditions; help them to change their sustainable education. The programme was attitudes towards historic places; and un- applied through several activities, includ- derstand how the past can affect the present ing: camping and field trips, recreational positively. The activities of heritage and activities and games, role play and theatre, museum education can also help children to positive actions and experiences, story- find jobs such as selling small things they telling, life-skill activities and gardening have made or plan small income-generating and animal care. projects [20]. The 1st unit of the programme concerned The 4th and the 5th units were concerned with outdoors and recreational education with moral and religious education, and was conducted through trips and camping. human rights and peace education, respec- The unit aimed to provide opportunities tively, and were considered complementary to encourage enjoyment, appreciation and to other programme units. Religious and awareness of the environment so as to help moral values were encouraged through change attitudes by exposing children to certain activities such as religious stories, new and relevant experiences that would prayer and guidance conversations to help lead to better understanding of themselves the children to have real internal change, as well as their environment [13,14,16]. understand their rights and be peace seek- The 2nd unit included urban and health ers. Street children all over the world have education. The urban education part aimed common problems, one of which is aggres- to create understanding of the social, physi- sion [1,4], so they need peace and human cal and natural characteristics of the urban rights education which can help them to environment and their interrelationships respect themselves, others and others pos- so as to help children deal with their ur- sessions. ban environment [15,17,18]. The health The 6th unit of economic and civic edu- education unit was designed to give the cation was concerned with understanding boys basic information about the changes the developmental processes within and be- that take place in their bodies during the tween countries and rich and poor people, in different ages, teaching them skills to help order to give the children an understanding them adopt positive attitudes for sustain- of the economic and political system. It was ing healthy lifestyles and avoiding risk designed to be learned through activities to behaviours. The major items covered by the help children know their rights and duties, health education were nutrition and dietary acquire new skills to find jobs and to make practices, personal health, correct lifestyles plans for their future. for health promotion and disease preven- Finally, the 7th unit of future and sus- tion, and first-aid skills in order to help them tainable education was designed to help the survive street life, as they face problems children learn suitable ways to develop their

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S skills and personality in order to find jobs 8EFPI(IWGVMTXMZIHEXESJXLIWIPIGXIH and plan for their future. WEQTPISJWXVIIXGLMPHVIRFIJSVIXLI MRXIVZIRXMSR R! (EXEEREP]WMW :EVMEFPI The data were analysed by SPSS, version 10. They were checked for accuracy and *EQMP]FEGOKVSYRH normality using the KolmogorovSmirnov 4EVIRXWWXMPPQEVVMIH and ShapiroWilk tests. The data were 4EVIRXWHMZSVGIHSVWITEVEXIH (IEXLSJSVFSXLTEVIRXW found to be not normally distributed and 7XITTEVIRXW were presented as means and standard deviations (SD). The Wilcoxon signed rank 'LMPHvWVIPEXMSR[MXLLMWJEQMP] +SSH test was used as a non-parametric test for 1SHIVEXI comparison between the results before and &EH after the intervention (paired comparison of 2SRI the 13 items). Percentage change was calcu- %KISJKSMRKSRXLIWXVIIXW ]IEVW lated for each item and for total scores of the programme before and after the interven- z tion. The MannWhitney test was used for " comparison between the 2 subgroups while 6IEWSRWJSVKSMRKSRXLIWXVIIXW the KruskalWallis test was used for com- )EVRQSRI] parison between more than 2 subgroups. )WGETIJEQMP]GSRJPMGXW Spearman rank correlation coefficient was *MRHWLIPXIV calculated to measure the mutual corre- )WGETITL]WMGEPEFYWIEXLSQI spondence between 2 variables. P 0.05 )WGETIJVSQGLMPHVIRvWMRWXMXYXMSR was the level of significance. 0MZIXLI[E]LI[ERXWXSPMZI )HYGEXMSREPWXEXYWSJXLIGLMPH 7XYHIRX 6IWYPXW 'ERVIEHERHSV[VMXI -PPMXIVEXI In the current study a behavioural modi- 4PEGISJWPIITMRKEXRMKLX fication intervention was designed for a -RXLIWXVIIX sample of 35 street children in order to %XLSQI raise their self-esteem and ameliorate their 7XVIIXEGXMZMXMIW behaviour. The characteristics of the sample 7IPPMRKWQEPPMXIQW of street children selected for the interven- ;EWLMRKGEVW tion are presented in Tables 1 and 2. In the 7GEZIRKMRK present study the observation sheet that 7XIEPMRK was designed to characterize the children &IKKMRK preintervention showed the main behav- 7YVZMZEPWI\ ioural factors were: antisocial behaviour (VYKXVEJJMGOMRK (46%), aggressive behaviour (43%), sub- *EZSYVMXIEGXMZMX] stance use (43%), helper (one who offers *MWLMRK help to others and tries to provide help to ']GPMRK others if required) (42%), destructive be- +EQIW haviour (37%) and paranoia (31%). Street (ERGMRK activities performed to earn money were:

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8EFPI(IWGVMTXMZIHEXESJXLIWIPIGXIH 8EFPI &ILEZMSYVEPTVSJMPISJXLIWIPIGXIH WEQTPISJWXVIIXGLMPHVIRFIJSVIXLI WEQTPISJWXVIIXGLMPHVIRFIJSVIXLI MRXIVZIRXMSR R! GSRGPYHIH MRXIVZIRXMSR R! :EVMEFPI :EVMEFPI

%VXW 'LMPHEFYWIWYJJIVIH +EVHIRMRK :IVFEP ,ERHMGVEJXW 4L]WMGEP 7MRKMRK 7I\YEP 6IEHMRK )QSXMSREP 8]TISJTIIVVIPEXMSRW 7QSOMRKERHWYFWXERGIYWI *I[ 7QSOMRK 1ER] %P[E]WYWIWYFWXERGIW *I[ERHWYTIVJMGMEP 7SQIXMQIWYWIWYFWXERGIW 1ER]ERHHIIT 2IZIVYWIWYFWXERGIW 1ER]ERHJSVETYVTSWI &ILEZMSYVEPMWWYIW *I[ERHHIIT %RXMWSGMEPFILEZMSYV *I[ERHJSVETYVTSWI %KKVIWWMZIFILEZMSYV *I[WYTIVJMGMEPERHJSVETYVTSWI ,IPTIV (IWXVYGXMZIFILEZMSYV 4EVERSME ,SQSWI\YEPMX] selling small items (40%), washing cars .IEPSYW] (31%), begging (9%), scavenging (9%), 2EVGMWWMWQ stealing (6%) and drug trafficking (3%); 3% 2EMPFMXMRK engaged in survival sex (i.e. sex for rewards %ZSMHERGI but not money) but none reported being 0]MRK involved in commercial sex. Favourite ac- 2SGXYVREPIRYVIWMW tivities were fishing (100%), cycling (46%), 7GLM^SMHFILEZMSYV games (46%) and dancing (37%). (ITIRHIRGI 2YXVMXMSRHMWSVHIVW From the results of the preliminary study 7TIIGLHMWSVHIVW the intervention programme was designed 4LSFME to target and modify the behaviour problems 7XIEPMRK identified. Table 3 shows the results of each 8IQTIVXERXVYQW behavioural item and the items combined, 7PIITHMWSVHIVW before and after the intervention. The Z- (ITVIWWMZIHMWSVHIVW test values, the percentage change values and the correlation coefficients showed improvements in the targeted behaviours ence were helper personality, narcissistic and suggest that the programme had been personality and passive aggressive person- successful. ality (P 0.05, between children displaying The percentage change of total scores the behaviour and those not). No other on behavioural items before and after the behaviours were significant. Other items intervention were used to compare children of behaviour that showed a significant de- who had a behavioural disorder and those crease were speech disorders, homosexual- who did not (Table 4). The only behaviours ity and substance use (P 0.05), suggesting disorders that showed a significant differ- an effect of the programme.

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(MWGYWWMSR highly disadvantaged and forgotten. They represent a hazardous environmental prob- Street children constitute a considerable lem in all societies due to the behaviours part of the homeless population, who are they acquire from street life and the psycho-

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The present study was designed to define to physical and psychological danger, and the psychological profile of a sample of 35 exploitation of their basic rights [24]. The street children before and after participation NCCM introduce in March 2003 a national in a behavioural modification interven- strategy to define, characterize, protect, tion in order to establish how effective the integrate and rehabilitate street children in programme was in raising their self-esteem Egypt [25]. The NCCM introduced a pro- and ameliorating their behaviour. The protection and caring project for street children gramme was based on training the children involved with drugs in collaboration with to behave in a more appropriate and socially NGOs and police stations in Cairo, Giza acceptable manner [20]. The programme and Alexandria [26]. The project aims to included different units, which contained support the health, nutritional, social and variable activities that were chosen care- cultural care services for street children fully to be appropriate with the nature and through reception centres for arrested chil- ages of the studied sample. The intervention dren to ensure care and safety for them. The was applied to help children to change their NCCM arranged a workshop to discuss and behaviour, fulfil their needs through activi- verify the working guidelines for the dealers ties, discover their abilities and develop and with street children (part of the project was acquire new skills. The results of the inter- funded by the NCCM, the United Nations vention showed a significant improvement Office on Drugs and Crime and the Danish in some aspects of the childrens behaviour Embassy in Cairo) in order to raise the after attending the programme compared to performance of those who deal with street before, using statistical analysis of scores children (psychiatrists, sociologists, police for each behavioural item. The programme officers, caring institutes, NGO staff, etc.) activities seemed to be successful in modi- to protect and prevent street children from fying the street childrens behaviour. smoking and substance abuse [27]. In Egypt, there are currently a number of Egyptian NGOs such as the Hope Vil- projects sponsored by the President of the lage Society in Cairo and El-Horriya Insti- country and other governmental and non- tute in Alexandria provide some services for governmental organizations (NGOs) to sup- street children. The Hope Village Society in port street children through the declaration Egypt is the best model of NGOs that deal of the second decade for the protection and with street children. It is a private volun- welfare of the Egyptian child (200010). tary association established by a group of This declaration has signified that childhood businessmen and women and is dedicated issues should occupy a place at the centre of to providing attention, care, education and future plans for the community and will training to children in difficult circum- focus on guaranteeing health and educa- stances, with an emphasis on street children. tion in cultural and social areas, backed The Society has successfully expanded up by strict legislation to protect mothers from caring for a few boys in one shelter to and children and to guarantee their safety a number of separate sites around Cairo us- and stability [23]. The National Council of ing a mobile unit, reception day care centres Childhood and Motherhood (NCCM) uses and short-term and long-term shelters [28]. the term homeless child instead of street The Society provides care and shelter and child, which reflects similar concepts, and rehabilitation and training and facilitates defines them as children who lack any kind government education for street children, of care and protection, and are vulnerable runs training projects to sustain continuity

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S and stability of society, carries out scien- called the Center for Habilitating and Inte- tific research on the phenomenon of street grating Young Street Mothers, introduces children, provides small loans to families special care for young mothers who are of street children and re-integrates them victims of sexual and physical abuse [28]. with the community. It also provides sub- The current programme for environ- donations and technical help and training mental behavioural modification of street to other NGOs that work in the same field children is the first programme to be applied and it networks and exchanges experiences in Egypt and needs to be further applied in with other associations and organizations different institutions and localities. Also, [28]. The Society targets training the chil- further studies are required for long-term dren through several vocational programme behavioural modification programme to ful- workshops on handicrafts, and electrical, fil the needs of street children. Knowing the carpentry or plumbing products. It offers risk factors, efforts on a wider scale should religious, cultural and recreational pro- be addressed at an earlier level of interven- grammes through monthly trips, fun parties tion to the target population to prevent the and summer camping. A new programme phenomenon of street children.

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-RXVSHYGXMSR compared with high-school students in Bel- fast [15], Syria [16] and Egypt [17]. Tobacco use is one of the chief preventable In spite of the many studies carried out risk factors of some 25 noncommunicable in the EMR on tobacco consumption among diseases, many of which are eventually fa- secondary/high-school students, only a few tal. The World Health Organization (WHO) have focused on university students, such attributes some 4 million deaths annually to as studies performed in Saudi Arabia [18], tobacco consumption, and this is expected Jordan [19], Egypt [20], Lebanon [21] and to rise to 8.4 million by 2020 [1±3]. A report Bahrain [22]. Hence, there was a great need by WHO Regional Office for the Eastern to bridge the gap in the literature for UAE Mediterranean indicates that the prevalence students. This study aimed to estimate the of tobacco consumption among adult males prevalence, patterns and risk factors of in the countries of the Eastern Mediter- tobacco consumption among students at- ranean Region (EMR) ranges from 24% tending the University of Sharjah (UoS). to 70% among adult males and 3% to 22% among adult females, and that these are among the highest in the world, especially 1IXLSHW for males [4]. The study was cross-sectional, conducted A few studies have estimated tobacco during the academic year 2004/05. prevalence among young people aged less than 18 years of age in the United Arab 7IXXMRK Emirates (UAE). The UAE has recently Founded in 1997, the UoS is one of the participated in the Global Youth Tobacco leading higher education establishments in Survey (GYTS) which reported that among the UAE, with 4 health-related colleges, 4178 surveyed schoolchildren aged 1315 namely: health sciences, medicine, phar- years, 14.3% of boys and 2.9% of girls were macy and dentistry, with an overall student current smokers, while 25% of students had population of about 6000, of whom 66% first tried smoking at under 10 years of age, (3755) are females, and 34% (1949) males, more than 70% had seen a tobacco advertise- with 9.4% health-related students in 4 col- ment, 20% had been offered free cigarettes leges (2004/05 data). from a tobacco company representative and 50% had bought their cigarettes from stores, 7EQTPI 80% of whom were not refused purchase A stratified proportionate random sampling because of their age [5]. Another study by technique was used to select 1290 students the UAE University in 1999 found that 30% for the study, representing the 13 differ- of surveyed 1519-year-old schoolboys ent colleges of the UoS. The sample size were smokers [6]. A family health survey estimate was based on an estimated 20% in 1995, covering 45 830 UAE citizens, re- prevalence of smoking. Table 1 shows the vealed that 18.3% of adult males and 0.4% distribution of the 1290 students in the sur- of adult females were current smokers [7]. vey by college. Other studies on tobacco use and its risk factors among secondary-school students 5YIWXMSRREMVI were carried out in other Gulf nations, in- The data collection tool used in the study cluding Bahrain [8], Saudi Arabia [9±12], was a modified version of the standard Kuwait [13] and Yemen [14], and can be WHO questionnaire and the GYTS ques-

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8E FP I (MWXVMFYXMSRF]GSPPIKISJXLIWEQTPISJ 9RMZIVWMX]SJ7LEVNELWXYHIRXW 'SPPIKI 8SXEPRS 2S SJWXYHIRXW WIPIGXIH %VXWERHWGMIRGIW &YWMRIWWERHQEREKIQIRX 'SQQYRMGEXMSR ,IEPXLERHQIHMGEPWGMIRGIWE -RXIRWMZI)RKPMWLTVSKVEQQI )RKMRIIVMRK *MRIEVXW 0E[ 7LEVMEERH-WPEQMGWXYHMIW 'EVIIVHIZIPSTQIRX 8SXEP E,IEPXLWGMIRGIWQIHMGMRITLEVQEG]ERHHIRXMWXV] tionnaires, which have previously been study tool. To facilitate data collection, the validated for use in both their English and purpose and operation of the study were Arabic versions [23,24]. It was developed adequately explained to the deans of stu- as an anonymous self-administered ques- dents affairs (men and women) as well as tionnaire by the investigators (all bilingual), the deans of different UoS colleges in per- revised, piloted and edited several times sonal letters from the principal investigator. before it was finally utilized in its English Deans then asked their faculty to cooperate and Arabic versions. in data collection before/after lectures. The The study proposal and instrument were data collectors explained the purpose of the approved by the College of Health Sciences study to the students, asking for their verbal Institutional Review Board. consent, and emphasized the voluntary and The questionnaire enquired about demo- anonymous nature of the study. graphic information (age, sex, marital status, nationality, field of study, residence, work 7XEXMWXMGEPEREP]WMW status, pocket money, mothers and fathers Data were coded, entered, cleaned and ana- education, years in university) and tobacco lysed using SPSS, version 14.0. Analysis consumption (status, type, frequency, dura- included univariate, bivariate as well as tion, age at first attempt, family members multivariate analytical techniques. This and peers smoking status, etc.). Five data collectors (3 women and 2 included calculation of odds ratios (OR) men), with a social sciences background with 95% confidence intervals (CI) and and experience in supervising student ac- corresponding P-values, while multiple tivities in UoS and carrying out surveys logistic regression was carried out to iden- among university students were trained by tify variables most predictive of taking up the investigators on how to administer the the habit of smoking among the surveyed

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S students. P < 0.05 was used as the level of 8E FP I 'LEVEGXIVMWXMGWSJXLIWXYH]WEQTPI significance. SJ9RMZIVWMX]SJ7LEVNELWXYHIRXW :EVMEFPI 2SSJ 6IWYPXW WXYHIRXW 7I\ Table 2 shows the characteristics of the 1EPI study population. The total sample was *IQEPI 1057 students, with a response rate of 82%. 2EXMSREPMX] The age range was 1737 years, mean 20.9 9%) [standard deviation (SD) 2.6] years. About 2SR9%) two-thirds of participants in the survey 1EVMXEPWXEXYW were females (60.7%), more than half were 7MRKPI UAE nationals (57.2%) and lived with their 1EVVMIH parents (53.9%). Most students were single 6IWMHIRGI (87.9%) and were from colleges other than ;MXLTEVIRXW health and medical sciences (84.0%). About ;MXLJEQMP] (SVQMXSV] two-thirds of students (63.1%) in the sam- 3XLIV ple were in their junior (3rd) or senior (4th) 1SXLIVvWIHYGEXMSR years. More of the students fathers had -PPMXIVEXIVIEHERH[VMXI university or higher education (44.5%) than )PIQIRXEV]MRXIVQIHMEXI did the mothers (27.3%). 7IGSRHEV] A total of 163 students reported smok- 9RMZIVWMX]LMKLIV ing, giving an overall smoking prevalence *EXLIVvWIHYGEXMSR (cigarettes and waterpipe) of 15.1%; this -PPMXIVEXIVIEHERH[VMXI was 33.0% among males, 3.9% among )PIQIRXEV]MRXIVQIHMEXI females (Table 3). The mean age of smok- 7IGSRHEV] 9RMZIVWMX]LMKLIV ers was 22.3 (SD 2.9) years, slightly older 'SPPIKI than the whole sample. Smokers in the ,IEPXLERHQIHMGEP sample were mostly single (81.0%), males WGMIRGIW (84.6%), non-UAE nationals (62.7%), non- 3XLIVW health majors (89.3%) and living with their 7XYH]PIZIP parents or relatives (64.5%). Table 3 shows -)4 the characteristics of the student smokers, *VIWLQER comparing cigarette smokers (prevalence 7STLSQSVI of 9.4%) with waterpipe smokers (5.6%). .YRMSV 7IRMSVLMKL While most smokers had 1 or more friends who smoked (86.7%), less than one-quarter 1IER 7( (24.5%) had fathers who smoked. %KI ]IEVW XSXEPWEQTPI =IEVWMRYRMZIVWMX] &MZEVMEXIEREP]WIW %KI ]IEVW XSXEPWQSOIVW The results of bivariate analyses showed =IEVWMRYRMZIVWMX] that the most important predictors of smok- 8LIXSXEPRYQFIVSJVIWTSRWIWQE]HMJJIVJSVHMJJIVIRX ing among UoS students in our sample were: ZEVMEFPIW 9%)!9RMXIH%VEF)QMVEXIW -)4!MRXIRWMZI)RKPMWL male sex (OR = 12.2; CI: 7.819.0), having TVSKVEQQI a smoking friend (OR = 9.8; CI: 6.115.8), 7(!WXERHEVHHIZMEXMSR

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8E FP I 'LEVEGXIVMWXMGWSJVITSVXIH WQSOIVWEQSRK9RMZIVWMX]SJ 7LEVNELWXYHIRXW GSRGPYHIH :EVMEFPI 'MKEVIXXI ;EXIVTMTI 8SXEP WQSOIVW WQSOIVW WQSOIVW 2S 2S 2S

7QSOMRKWXEXYWSJJVMIRHW 2SRI 7SQIQSWXSJXLIQ %PPSJXLIQ 8LIXSXEPRYQFIVSJVIWTSRWIWQE]HMJJIVJSVHMJJIVIRXZEVMEFPIW 9%)!9RMXIH%VEF)QMVEXIW -)4!MRXIRWMZI)RKPMWLTVSKVEQQI working (OR = 4.0; CI: 2.66.2), non-UAE Nevertheless, smoking still remains nationality (OR = 2.6; CI: 1.83.7), higher prevalent among young people in the UAE. education of father (OR = 2.1; CI: 1.53.0), This study showed that 15.1% of surveyed having pocket money of > 500 Arab Emir- students reported smoking, with a much ate dirhams (OR = 2; CI: 1.42.9), single higher prevalence among males (33.0%) status (OR = 1.95; CI: 1.253.0), having than females (3.9%). Such figures seem a smoking family member (father/mother/ to be comparable to other studies in the both) (OR = 1.9; CI: 1.32.8), and mothers EMR among university students [18±22] education (OR = 1.76; CI: 1.22.6) (Table 4). or high-school students [8±17]. The smoking prevalence ranged from 11.8% among 1YPXMTPIPSKMWXMGVIKVIWWMSREREP]WIW Cairo University students, Egypt [20] (22% Results of multiple logistic regression among males; 1.7% among females) and analysis showed that the most important 28.6% among Jordan University of Sci- predictors for smoking among students in ence and Technology students [19] (50% our sample were: male sex (OR = 6.1; CI: among males; 6.5% among females). A 3.211.7), having a smoking friend (OR = study of Aga Khan University medical 3.3; CI: 1.76.4), having a smoking family students, Pakistan [26], also reported a member (father/mother/both) (OR = 2.1; considerable sex difference (17% among CI: 1.23.5) and older age group (OR = 1.2; males; 4% among females). Reported fig- CI: 1.01.3) (Table 5). ures among high-school males in the EMR ranged from 16% to 22% in different studies [6,8,11,12,14,16]. (MWGYWWMSR The gender difference is explainable, given the local traditions in the EMR, but The UAE Ministry of Health (MoH) has it should be noted that figures here are been implementing important measures reported ones, and females, despite the to combat smoking, whether through ant- anonymity of the questionnaire, are less ismoking campaigns with special emphasis likely to report a habit which may be seen as on primary prevention of smoking among a social stigma. It has also been observed adolescents, or establishment of antismok- that smoking prevalence is on the rise ing clinics during the past 8 years across among women in the EMR in recent years, the 9 districts of the MoH in the 7 Emirates especially waterpipe consumption [personal [25].

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S observation]. In our study, it was shown that serious complications ensue. Both ciga- while only 8.9% of cigarette smokers in rettes and the waterpipe still attract young our study were females, 26.2% of reported people, including females, not only in the waterpipe smokers were females. UAE, but also in many other countries of Being a male with a smoking friend or the EMR. In fact, one-third of the smokers family member was shown by multiple rein our study were waterpipe smokers, and it gression analysis in our study to be the most was the most common habit among female predictive factor for being a smoker. In fact, smokers. This points to the need for effec- having a smoking friend (peer pressure) has tive outreach health education programmes, been shown by this study and many others targeting young schoolchildren, in primary to be consistently linked with smoking of education, before they take up the habit of youngsters. A Bahraini study reported that smoking. Teachers and parents should be 43% of smokers reported that their best involved, and the mass and mini media all friend was a smoker, compared with 15.4% brought into action. among non-smokers [19]. Similar results The message emerging from the role of were reported from other Gulf country stud- peer pressure in smoking is for role models ies in Saudi Arabia [9,10], Kuwait [13] and in the community, for example parents, Yemen [14]. teachers (in basic and university education), community and religious leaders. The health community is no exception here, and 'SRGPYWMSRERH there is no value of preaching the harmful 6IGSQQIRHEXMSRW effects of smoking and asking the public to avoid or quit the habit, when many health We conclude, based on the findings in this professionals themselves are smokers. We study, that an intensification of efforts is are a long way from reducing the incidence needed to prevent young people taking up as well prevalence of tobacco consumption the habit of smoking and to help those who among students, but combined multisectoral consume tobacco to swiftly quit before efforts are called for without delay.

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Workshop on the Framework Convention on Tobacco Control implementation and reporting The World Health Organization is organizing a workshop on the Frame- work Convention on Tobacco Control (FCTC) implementation and reporting in Alexandria from 18 to 20 November 2007. The objectives of the workshop are to: discuss the status of the FCTC implementation at the national level; start the needed work for reporting; take the needed steps to involve other sectors in the reporting mechanism. Experts from Canada, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libyan Arab Jamahiriya, Oman, Pakistan, Qatar, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen as well as WHO concerned staff will be participating in this workshop.

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)QTS[IVQIRXHIJMRMRKXLI This paper highlights the factors that RSXMSR contribute to gender inequities, that create barriers to womens empowerment and Researchers and reform activists have that compromise their health status in de- always advocated for gender equity and veloping countries. These factors will be womens empowerment as prerequisites of discussed within the framework of 4 insti- social reform. These notions have been most tutions of power, i.e. family, community, strongly stressed by advocates of health re- health care systems and the state [5]. The forms. Empowerment by definition is a impact of womens low status in some de- process by which the powerless get greater veloping countries and its repercussions on control over circumstances in terms of both their health will be discussed, with special ideology and resources [1]. reference to Pakistan. Furthermore, the pa- It is not so easy to apply this principle per highlights the potential for active input in practice, as embedded within communi- by women in promoting the health of their ties are strong social and cultural values, families and the wider community. norms and beliefs which, if challenged, may become a source of discord within the community. The values of a culture %WGIREVMSSJHIZIPSTMRK determine the role of women in its society GSYRXVMIW and this phenomenon is global [2]. World- wide, women play a pivotal role in raising The factors determining womens health children, caring for household members status have frequently been analysed for and running the home, in addition to their solutions to the problem of poor health, par- roles in the world outside the home. Hence, ticularly in developing countries. Though they may suffer an even greater physical, much effort has been invested in research- social and mental burden, and are especially ing womens health problems, macro-issues deserving of appropriate health care. pertaining to the society they live in have Womens right to health has time and often been ignored. again been advocated. However, a multitude The 4 institutions of power family, of social and cultural barriers have directly community, health care systems and the or indirectly hindered empowerment, rein- state [5] play an important role in deter- forcing the negative impact on their health mining the health status of women. Family status [3]. Health systems, therefore, must traditions and customs govern the lives of develop an understanding of womens role women. A lack of formal education and and status within this complex sociocul- poor nutrition for girls, early marriage and tural environment. Having acknowledged multiparity are some of the determinants of this, strategic health reforms need to be ill-health and discomfort for women, [6]. translated into actions for the enhancement On the part of the community, lack of social of the lives of women. This is not just for support networks, religious barriers and their own sakes: there is evidence that the restrictions on womens mobility outside health systems in a country function more the home affect the process of seeking effectively if women are acknowledged as health and hinder womens health status the crucial link between health services and [7]. The health care system is also important the home [4]. in determining womens health, including

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S factors such as the low availability and poor ailments because they lack knowledge and quality of health care services, particularly awareness of health problems [16]. Besides obstetric care [8]. Finally, the states lack of the sociocultural barriers to womens role in responsiveness to womens development is health promotion, there is often negligence reflected in terms of inadequate provision on the part of the health care providers and of female health care providers in primary government organizations [17]. Negligence health care facilities, insufficient allocation on the part of health care providers is seen of resources for girls education and lack in their attitudes towards female patients, of awareness of gender issues in all sectors the quality of health care services and af- [9]. fordability of medicines prescribed. On Most developing countries have been the part of the government, it is seen in the unable to devise any health reforms to work lack of concrete policies, the lack of inter- towards improving womens economic and sectoral collaboration and unwillingness to social role in society. As the dismal health empower women. indicators show, we are faced with the challenges of consistently high rates of fertility, maternal mortality and morbidity ;SQIRvWIQTS[IVQIRXERH and infant mortality [10,11]. The reasons LIEPXLMR4EOMWXERXLIFEVVMIVW are clear, as the World Health Organization XLIGSRWXVEMRXW definition of healtha complete state of physical, social, mental and emotional As in other south Asian countries, the situa- wellbeing is never reflected in womens tion of womens health is grim in Pakistan. life experiences. From the beginning of her Estimates of the maternal mortality rate life, a girl child is given lower priority than (500/10 000 live births), infant mortality a male child [12]. Owing to limited family rate (86/1000 live births) and total fertility income, girls have limited opportunities for rate (5 children/woman) are still high [11]. formal education and are fed the least and In terms of the United Nations Develop- the last, with malnourishment leading to a ment Programmes (UNDP) gender em- weakly-developed immune system and a powerment measurement (GEM), Pakistan greater chance of ill health [13]. lies 100th out of 102 countries [18]. As Compounding the biological vulnerabil- mentioned before, all the 4 key institutions ity of girls are many social realities reflect- of power in society are accountable. ing womens lower social status, such as Traditions in a family play a fundamental limited educational opportunities, unequal role in developing a girls physical, social gender relations, inability to contribute to and mental health status. Cultural values are family decisions, domination of the hus- embedded deeply in the family traditions, bands family and lack of control over their making her access to health care limited and own lives and bodies [14]. most of the time dependent on the familys Women are always considered subor- decision [19]. In terms of seeking health for dinate to men, therefore they have a mini- herself, a woman has no control over deci- mal say in matters related to marriage, sion-making, difficulty in accessing health pregnancy and family size [15]. Ironically, centres and discomfort with communicating despite being the primary care providers of with male physicians. With a patriarchal the family, women in developing countries system dominating, women are not allowed are poorly equipped to deal with family much liberty in terms of education and

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S freedom of any kind, including freedom of ever, the urban and formal setting of these movement [20]. clinics makes these health services difficult Another factor inhibiting womens em- and costly to access for rural women [26]. powerment and better health status is lack Furthermore, male practitioners are neither of support from the husbands family [21]. gender-sensitized nor well trained to handle In Pakistani society, the role of women womens health problems; this brings a as prescribed in Islam is often cited as a great deal of uneasiness among women determinant of womens status. However, clients [27]. religious doctrine is often misinterpreted, In the state-owned health sector, there leading to an unjustified restriction on are also inadequate numbers of female womens mobility on the grounds that it is health care practitioners employed in the a threat to social and religious values and a government sector, a fact which restricts the distraction from household duties [22]. female clients access to health care [28]. Barriers imposed by the community Village elders or community leaders often play a primary role in opposing womens impede the activities of women practition- empowerment, resulting in poor health ers and health professionals for various indicators. Disregarding girls education, reasons, which may be political or incorrect restricting the decision-making power and interpretations of religious laws for exam- the mobility of women and misinterpreting ple, services may be seen as socioculturally religious teachings are some of the many inappropriate, there may be mistrust of the community-instituted barriers. For exam- health workers and services or there may ple, a woman in labour who suffers from be myths and misperceptions about the complications may be unable to seek help services. In the public sector, primary health if a male member of the family is absent. care centres are underutilized [29]. Support from the community is minimal Another factor is short working hours or absent, and social support systems are so that health providers are often unavail- lacking. Such a situation can lead to the able in the facilities. The ability to deliver death of the mother or the child or to future quality health services also remains a big morbidity [23]. challenge in the Pakistani health sector As for health care providers, the situa- because of the dearth of sound policies tion is no different. As women do not have and poor implementation of public health any economic autonomy, the cost of health programmes [30]. care is definitely a barrier to appropriate and quality health care seeking. Even if care is accessed, there is a communication gap be- ;LEXRIIHWXSFIHSRI# tween male physicians and female clients, When proposing what needs to be done, we whose problems are considered to be of must first look at the role of family. Family lesser importance than males [24]. Due to a heads should be sensitized to issues such dearth of female health care providers, only as malnourishment among girls, the impor- 16% of women seek proper antenatal care tance of girls education, the appropriate and as few as 17% deliver in health facilities age for marriage, greater child spacing, [11]. Most of the health care in Pakistan safe motherhood, etc. Private sector and is sought from the private sector. Private nongovernmental organizations (NGOs) practitioners thus have a crucial role to play can play a key role in bringing this infor- in promoting womens health [25]. How-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S mation to the communities they work in. A Social Development and all others con- successful example of a community-based cerned is needed, to invest in developmental project run by civil society organizations programmes that lead to womens empow- with funding from the state is that of Tawa- erment in society. na Pakistan, an endeavour to increase girls More schools for formal and non-formal school enrolment and provide them with a education for girls could be one possible healthy diet at school. Such programmes initiative. Better womens education has need to be carried out with consistency and been associated with success in reducing be sustained so that they lead to improved infant and maternal mortality rates in the health status [20]. past decade [19,25,32]. With respect to communityissues, es- As for health, more female physicians pecially in rural areas of Pakistan, there is need to be trained and employed in the a need to listen to the communitys views public sector, and working hours need to on social and health-related issues. Holding be expanded so as to improve accessibility. group discussions with all members of the Better status of women health care workers, community in order to highlight their issues better pay and working conditions and bet- would be a practical approach. Then ses- ter incentives in the form of benefits to the sions can be held to discuss the myths and family are essential. taboos held in the community and address There is a need to invest in skills de- misinterpretations of religious teachings velopment of women, for example by ena- with the community leaders and clergy- bling them to set up small-scale businesses, men. Community meetings could be held thereby supplementing the family income to encourage mothers-in-law and husbands and fostering financial independence. to take a role in promoting womens health The micro-credit scheme in Kerala and [31]. They need to be sensitized to their the Grameen Banks initiative in Bangla- responsibility to look after a womans needs desh are some of the lessons to be learned and wants, and to give due regard to the [19,33]. rights to which she is entitled on both social Empowering women and improving and religious grounds. their health status requires concerted efforts The health care providers also need by the state, external donors, NGOs and to be sensitized to womens health issues. womens health groups. The gender-based Issues such as quality of services, long institutional rules need to be changed. The waiting hours, lack of female practitioners hierarchies of power should be transformed and apathy of physicians towards women to work towards gender equality and to clients ought to be addressed mutually by initiate the process of womens empow- the state, NGOs, health care providers and erment. The United Nations Millennium the community. Monitoring of initiatives Declaration clearly acknowledges womens to support and promote womens health is empowerment and gender equality as pil- imperative. lars of social justice in any society [34]. In The state needs to contribute to the response to this call and to join the efforts to promotion of girls education and other achieve the Millennium Goals, the process womens empowerment programmes. An needs to be initiated within communities not inter-ministerial collaboration involving the only for gender rights but also for the well- Ministries of Health, Population Welfare, being and health of women, family and the Education, Womens Development and entire community.

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-RXVSHYGXMSR ductivity was declining and poverty and Many countries in western and central Asia landlessness expanding. When the elements suffer from rural underdevelopment and of the Islamic Republic were starting to take poor health indicators among rural popula- shape in 1976, almost 18 million people tions. Conventionally, greater economic lived in 66 000 villages and settlements with development of a country ultimately leads less than 5000 people [6]. About 80% of the to improvements in the health status of the rural population aged 10 years and older population. However, there is a significant worked in agriculture. The majority were lag between initiating development efforts family farmers working small plots of land. and the time it takes for them to impact on Landless workers were the poorest sector health status. Hence there is an urgent need of the population and in some areas 15% of for implementation of inexpensive and ef- the families were landless and surviving in fective programmes to improve the health extreme poverty and debt [7,8]. status of rural populations in the short run. An outcome of persistent ruralurban These may in fact also contribute to the inequality and extreme rural poverty was success of rural economic development the low health status of rural populations. projects. After the success of the revolution, a major Even after almost 50 years (192177) of issue for the government was improvement modernization and economic development of the health and life chances of the rural by the oil-rich state of the Islamic Republic population. In this paper we describe the of Iran, after the Islamic Revolution in fast-paced, low cost, health devlopment 1979, rural areas were still extremely poor programme that the revolutionary gov- and underdeveloped, with very low health ernment implemented to reduce the deep indicators. The modernization and eco- ruralurban health disparities and attempt to nomic development efforts which started illustrate its impact with data from various in the 1920s and intensified through the sources. 1960s and 1970s were not balanced across social classes, regions and economic sectors, resulting in rural underdevelopment 6YVEPLIEPXLMRXIVZIRXMSR and a decline in agriculture [1±2]. Despite TVSKVEQQI the rapid and heavy industrial investment Faced with the situation of major underde- and strong modernization effort of the Ira- velopment and low levels for health indica- nian state, poverty and underdevelopment tors for over 50% of the population living remained persistent in rural communities in rural areas, the Islamic government set and villages at the dawn of the Revolution in about improving the situation with rural de- 197879. The land reforms by the state had velopment projects which are convention- not prevented the rural population falling ally considered as the precursor to improved deeper into poverty and underdevelopment health of the community [9,10]. However, [3±5]. it was clear that the existing extremely low Iranian economic development of the health status could not wait for the impact 1960s and 1970s was industrial and ur- of rural development to take effect and that ban-based, and concentrated mainly in the rapid action was needed to improve the national capital and a few large provincial health and wellbeing of the disadvantaged capitals. In rural areas, agricultural pro- population who ought to be equal benefici-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S aries of the revolution. To this end the main PHC network. As a result, the behvarz often innovation of the government was a strong knows every mother, child and family who push to establish an inexpensive community- seeks health care at the health house. Such based primary health care (PHC) system in a close relationship between the behvarz the early 1980s and oversee its wide expan- and his/her community facilitates the ac- sion in the 1990s. curate collection of health information, The focus of the programme on pri- among other things. According to the latest mary care and prevention rather than on available statistics, there were 16 340 rural the capital-intensive tertiary sector made it health houses scattered among the 66 000 relatively inexpensive. The main element villages and settlements, covering about of the programme was establishing a strong 85% of the rural population [12]. network of rural health centres (RHCs) The rest of the rural population is covered and smaller centres called health houses by mobile teams. Each team is composed to deliver low-technology PHC through of doctor from the RHC, a health techni- indigenous health care providers at village cian for basic laboratory tasks and 1 or 2 level. Hence, training and utilization of lo- behvarz. The team visits their designated cal personnel was a key part of the system. remote villages each month and provides Based on the results of a few small- PHC support. If there are any patients that scale experimental studies carried out in the need to be referred to larger health centres 1970s, the Ministry of Health and Medical in rural or urban areas the team provides Education launched in the early 1980s a support and referrals. large-scale PHC system with a focus on The main function of a health house is rural areas and small towns [11]. The focal to offer PHC services to the community it point of activity for this programme was the serves including: establishment of the health houses (khane annual census of the population cov- behdasht). Each health house is designed ered, to cover a target population of about 1500. collection, recording and storage of Since most Iranian villages have fewer health information and regular reports, than 1500 residents, each health house also public health education and promotion serves several satellite villages. Such of community participation, villages are carefully grouped according to a realistic consideration of their cultural provision of family health care, and social compatibility. The distance be- antenatal, prenatal and postnatal care, tween the main and satellite villages is also care of children under 5 years, pragmatically defined to be no more than care of school-age children, 1-hours walk (rather than a certain number family planning services, of kilometres). immunizations, Each health house is staffed by 1 or more female and 1 male community health work- disease control services, ers who are known as behvarz. The behvarz environmental health activities. comes from the same village where he/she Each health house is supported by an is to be stationed in the future. Choosing RHC, which is a village-based facility. behvarz from among the local population It supervises the health house in its own has been a key policy decision, closely village, and a few more health houses in observed throughout the expansion of the neighbouring villages. Each RHC covers

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S about 7500 people on average. Apart from a workers serving their villages and satellite physician, the RHC includes the at least 1 of villages. The female behvarz is generally each of the following staff specialties: fam- responsible for the tasks that are performed ily health, disease control, environmental within a health house. The male behvarz, on health, oral health, laboratory technician, the other hand, is predominantly concerned nurse-aid(s) and administrative staff. All with activities outside the health house (i.e. staff members function under the doctors follow-up of cases with communicable leadership. About 3000 RHCs support the disease, case-finding, immunization, envi- network of rural health houses. The chief ronmental health activities and routine care responsibilities are to support health houses in satellite villages). This partial division and supervise their activities; accept re- of duties does not mean that either behvarz ferred cases; and maintain proper contact cannot perform all the duties on his/her own with the higher levels of the health system. if required. Other major functions include carrying out Behvarz have strong community ties basic laboratory tests, participation in hu- with their villages. The behvarz is nearly man resources training, taking samples of always chosen from the main village where food products, monitoring environmental the health house will be stationed. How- health in schools and workplaces, carrying ever, if this is not feasible, a candidate is out statistical studies and preparation of recruited from one of the satellite villages. reports. In the area of reproductive health, The behvarz are selected from among 16- to providers at RHCs are authorized to insert 24-year-old female candidates, and 20- to intrauterine devices (IUDs). 28-year-old males with direct participation Specifically, the RHCs support the from village authorities, such as the village health house by: council, local clergy and other influential providing outpatient care and case- figures of the community. finding among referred patients, The process of training the behvarz pro- advising on monitoring and follow-up vides a good example of the use of appropri- of the treatment schedule of established ate technology at the village level. Given cases, the low rural literacy rate, candidates are required to have 8 years of formal schooling supervising family health, disease con- (nowadays frequently a high-school di- trol and environmental health activities ploma). Candidates must successfully com- of health houses, plete a written examination and interview offering oral health services, before enrolment in the training course. monitoring basic environmental sanita- Their studies, which span 2 years, are a tion (water sampling where required), contrast with traditional pedagogy. Memo- supporting health houses in the procure- rization of large amounts of written material ment of necessary drugs and equip- has been eliminated. Training is effected ment. through group discussion, role-playing ex- While RHCs provide the infrastructure ercises and working at the health houses of support for providers, the soul of the rural alongside a carefully selected qualified health network has been its most outlying behvarz. Students receive free training and facility, the health house, which is run by financial support throughout the 2-year the behvarz. There are now almost 26 000 period of the programme. In return, they of these male and female community health are formally obliged to remain and serve at

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S the village health house for a minimum of years of exposure during the 2-year period 4 years after completing their study. Each (averaged to obtain an annual figure). These students progress is assessed by instruc- data represent the preintervention mortality tors at monthly intervals. Students who and fertility level for the Islamic Republic successfully complete all the courses, pass of Iran at the peak of pre-Revolution devel- the examination at the end of each block, opment and modernization in 1976. and pass the final examination, receive the The data for the postintervention impact Certificate for Completion of Behvarz analysis come from the demographic and Training. Then they are ready to start health survey (DHSI-2000) [14]. This is providing PHC in a friendly environment the first effort to apply a locally adapted to their home villages and nearby villages, version of the internationally recognized where they usually have relatives and fam- demographic and health survey instruments ily acquaintances. to a large sample of households representative of the urban and rural populations in all provinces of the country. The DHSI-2000 (EXEGSPPIGXMSR is probably unique both for its reliance on national expertise for advice in design and In order to document the impact of the rural implementation of the survey and for its health intervention programme on health coverage of a huge sample (close to 114 000 indicators for Islamic Republic of Iran we households with a total population of about compared data from a number of different 475 000), selected so that it is possible to sources in the period before the intervention carry out separate analyses for the urban (1976) with the period after the interven- and rural areas of each of the 28 provinces tion had been in place for over 2 decades of the Islamic Republic of Iran as well as (2000). the Tehran metropolitan area. The financial The Iran Statistical Centre compiles support of the project by the United Nations official data from various ministries and Population Fund and Childrens Fund (UN- provincial offices annually and publishes FPA and UNICEF) and their participation in the Annual statistical abstract of Iran. Two the various stages of the survey contributed major sections of this publication are related significantly to the quality of the project to population and health. A national census implementation. of population and housing has been con- The DHSI-2000 was developed over a ducted in the Islamic Republic of Iran since 3-year period. The Population and Family 1956. The published reports from these Health Department of the Ministry of Health censuses provide key demographic and and Medical Education was assigned over- housing data by rural and urban residence. all responsibility for the design and imple- The survey of population growth provided mentation of the survey [14]. To ensure the reliable mortality data for the period 1975 technical quality of the survey and make its through 1976 [13]. results acceptable to academic researchers The data for our survey were gathered as well as specialized agencies, a steering through dual record systems where both committee consisting of academic demog- survey methods and a registration system raphers, staff members from the Statistical were used to record the changes in the sam- Centre of Iran, staff members from the Civil ple households due to birth, death, incoming Registration Organization and researchers and outgoing migration and marriage. The with long track-records of research and rates were then calculated based on person-

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S teaching on population and reproductive household access to sanitary facilities health oversaw the implementation of the and ownership of modern household project at various stages. comforts, communications and transpor- The sampling frame for the survey was tation. based on the 1996 census. The availability Questionnaire for ever-married women of data for the provincial level estimation of aged 1049 years, focussing on pregnan- various indicators was carefully considered cies, births and family planning knowl- in the sampling process. The sample design edge and practices. was to select 400 primary sampling units Questionnaire about nutrition and health (200 urban and 200 rural) from each of of children aged under 5 years. the 28 provinces of the country. In Tehran province, 400 primary sampling units were selected from urban and rural areas outside 3YXGSQIW the Tehran metropolitan area. Tehran metropolitan area was treated as a separate urban 4VIMRXIVZIRXMSRWXEXYWSJLIEPXL province represented by an independently GEVIMR selected sample of 2000 households. An es- Data on the status of health care in 1979 timated total sample of 114 000 households is limited to the official data reported in (58 000 urban and 56 000 rural households) the Statistical abstract of Iran [15]. From was expected to be covered by the study. these data it is obvious that the numbers of The actual sample size achieved included health care providers were minimal in rural 113 957 households (57 968 urban and areas. Of the 10 000 Iranian general medical 55 989 rural). The response rate was 97.5% practitioners in 1979, 54% were living in in urban areas and 99.0% in rural areas. Tehran, the capital city and 5 other large cit- In addition to the heads of households (or ies, leaving 46% for other urban areas and other adult member of the household) who almost none for rural areas. Of almost 6000 provided the household level information, medical specialists, 87% practiced in Te- a total of 91 604 ever-married women of hran and 5 other large cities. Out of nearly reproductive age were interviewed (46 916 2400 dentists, 65% worked in Tehran and urban and 44 688 rural). These women 5 other large cities and practically none in provided data on reproductive health and rural areas. At the time, some 700 medical other issues concerning women and young doctors graduated from the medical schools children. every year, half of whom would leave the The data collection instrument was a country sooner or later because they were 213-item questionnaire adapted from the dissatisfied with their situation and could standard interview schedules used in de- easily find work in developed countries. mographic and health surveys. The ques- About 2.5%3.5% of the total government tionnaire consisted of the following major budget was allocated to the health sector. sections: Most of these resources were focused on General household questionnaire, fo- expensive endeavours of building hospitals cusing on household members data, in big cities, to which access by the rural including economic activity, migration population was limited by economic, geo- status over the previous 5 years for all graphic and cultural factors. ages, loss of parents for those aged under Table 1 summarizes data from the 15 years, accidents, disability, deaths, population growth survey of 197576 [13].

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The adverse health service infrastructure ing urbanrural disparities in terms of other and strong health disparities between rural variables correlated with health status at the and urban populations are reflected in the macro-level. Among these were access to mortality rates. The crude death rate for such basic facilities as safe drinking water, rural areas was 72% higher than the rate for electricity, and bathing facilities. By 1979, urban areas. Overall infant mortality was for instance, only 19.9% of rural households high. However, the infant mortality rate of (compared with 90.1% of urban ones) had rural areas was one of the highest rates in access to piped water while only 27.7% of 1976 and was 105% higher than the urban them versus 97.8% of their urban counter- areas. The worst situation was observed for parts had access to electricity. Similarly, rural female infants whose mortality was only 2.8% of rural households, as compared 112% higher than the rate for urban female with 45.7% of the urban, had a hot water infants. bath/shower inside their dwellings. Similar disparities can be found in the measure of life expectancy. The difference 4SWXMRXIVZIRXMSRMQTEGXSJXLI in the life expectancy of rural and urban TVSKVEQQI men was 10 years in favour of urban men. The PHC network has drastically improved The life expectancy of rural women in 1976 the health status of rural communities over was barely 52 years, which was 10 years a relatively short period of time. Data from less than urban men. These differences DHSI-2000 reported in Table 2 provides were not surprising in view of the prevail- a number of indicators for rural and urban

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ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S areas in the year 2000. In most cases the in- rural difference of only 3 units was observed dicators in rural areas were as good as urban in favour of urban areas. The difference be- areas or only slightly lower. For example, tween rural and urban areas in mortality of regarding neonatal mortality, an urban children aged 1 to 4 years was not large.

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Infant mortality for rural and urban com- had visited a rural health house. Moreover, munities has declined greatly but the most the ability of the PHC system to support the important observation is the sharp rate of health messages by providing easy access decline in rural areas, which brought the to the tools needed (e.g. vaccines, oral rehy- level of infant mortality to almost the same dration therapy, essential drugs, etc.) where level as in urban areas. and when they were required contributed to Other indicators of health of children bridging the traditional gap between knowl- and mothers, reported in Table 2, showed edge, attitudes and practices. a similar pattern of ruralurban equality. The health and social returns of the PHC The efficient delivery of family planning programme in rural areas of the Islamic services by rural health workers definitely Republic of Iran has been much higher than contributed to the effectiveness of the ex- the cost of the programme. The Iranian pansion of PHC and prevention. government could not have made such gains in health outcomes by waiting for general economic development efforts to have an 'SRGPYWMSRW effect on population health and could not This report has described and analysed the have continued to rely on investing in an impact of a rural health programme deliv- extensive curative health infrastructure. ered to communities suffering poverty and A number of countries neighbour- underdevelopment. The rural heath pro- ing the Islamic Republic of Iran such as gramme developed and implemented in the Afghanistan and central Asian countries Islamic Republic of Iran was a very effective such as Tajikistan, could benefit from our and inexpensive way to improve the heath experience and success in implementing of the population, especially children and PHC in rural areas. These countries have mothers. By all indications this programme a significant portion of their population has accelerated the decline of infant mortal- in rural areas with high levels of poverty ity, child mortality and maternal mortality. and underdevelopment. Using inexpensive It has improved the level of prenatal and programmes to promote PHC can in fact postnatal care and increased the use of support the rural economic development contraceptives as a way of reducing the efforts. The major factor in designing such future mortality of mothers and children. It programmes, however, should be a firm and has contributed to the promotion of healthy rational basis for service delivery and the attitudes and behaviours, universal immu- distribution of facilities guided by a mas- nization of children, and correct treatment ter plan and continuous evaluation of the of children suffering from diarrhoea and programme at each step in expansion. The acute respiratory infection. The presence of plan should allow for assured, easy access the friendly behvarz in the village and their to health service facilities, effective and ap- constant interaction with the community and propriate training, availability and produc- proactive interventions has enabled them to tion of relevant statistics, selection of rural ensure that health education messages are health care providers from the community effective. For example, according to the and creation of a respected network, sup- DHSI-2000, among the rural women who ported through the urbanrural hierarchy. were pregnant during 19982000, 77.5%

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%GORS[PIHKIQIRX grant P20 MD001089 from the Department of Health and Human Services while work- Akbar Aghajanian acknowledges the re- ing on this manuscript. search release support received through

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&EGOKVSYRH 102 health centres, 18 hospitals and 18 community pharmacies. To run these it has Drugs are a critical component of any health 74 pharmacists, 202 pharmacy technicians care system, and since the 1980s there have and 297 support staff. been a variety of experiments in develop- In 2004, an evaluation was commissioned ing countries with different approaches to to focus on how the RDF was functioning cost recovery which aim to increase access as an independent organi]ation² whether to drugs. Some, such as the Bamako Ini- it was still fulfilling its original mandate tiative, use the willingness to pay for drugs to supply quality drugs at below-market to increase resources in the health sector prices² and to examine which groups were generally [1,2]. Others operate strict cost benefiting from the RDF and how access recovery, using payments to purchase new could be extended to any groups found to drug supplies, but without any leakage of be excluded. The team was also asked to revenue for other purposes. One of the main draw out lessons for roll-out in other states features of many of these experiments is of Sudan. that they have been small-scale, and often This paper presents the findings of the not very long-lasting, due to a variety of evaluation, in terms of financial sustain- managerial problems which lead to deple- ability, quality of drug supply and access, tion of the original capital. and the lessons for drug funds in other The importance of financing strate- developing country contexts. gies for drug supplies is underlined by the fact that, generally speaking, developing countries spend a much higher proportion ,MWXSV]SJXLI/LEVXSYQ6(* of their total health spending on drugs, ±, compared with ±0 for The RDF was jointly initiated by the Khar- developed countries [3]. In addition, the toum Ministry of Health (MoH) and Save public spending on drugs as a proportion the Children (UK) in the mid-1980s, though of total drug expenditure is typically much it took until 1989 for the first drugs to lower in developing countries ±0 be supplied to health centres. It arose in compared with developed countries 0± response to the weakness of the primary 90%), leaving a heavy financial burden on care system in the state and the increasing households. Despite being costly, though, number of common childhood illnesses be- drugs are highly valued; studies in Sudan ing brought to the Children¶s (mergency and elsewhere confirm that the availability Hospital. The RDF was developed as part of of drugs is often seen as the key indicator of a wider project² the Khartoum Comprehen- quality of health care by households [4]. sive Child Care 3roject (KCCC3)² which The revolving drug fund (RDF) in Khar- aimed to revitalize primary health care serv- toum State, Sudan, is worth studying for 2 ices through improved drug supplies, equip- reasons: first, it is the largest single revolv- ment, staff training, refurbishment of health ing drug fund in the world, with an annual centres, and improving primary health care turnover of £2 million and currently provid- (PHC) systems. ing drugs to 3 million patients per year. The aims of the RDF component were to Secondly, it has been in existence for nearly increase access to essential drugs at afford- 2 decades now, and has been growing in able prices and to encourage the rational scale and scope. The RDF now supplies use of drugs. The first was to be achieved

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S by setting up a sustainable drug revolving ³was able to improve the supply system and fund, with full cost recovery (but no subsidy avail a range of essential drugs at affordable to external activities, as was practised by prices´ [7]. It also noted improvements in the Bamako Initiative). The second was to rational prescribing, though ³efforts are be achieved by investment in infrastructure, still needed for further improvements in training and operational research. this area´. It found that 8% of patients were The RDF imports drugs from non-profit unable to pay the prescription cost (this was suppliers abroad, or from local sources, based on the proportion of prescriptions where these are available. A committee where the drugs were available, but were made up of RDF management and PHC not dispensed). It noted that the RDF policy representatives selects the drugs from the of cost recovery had since become a key Sudan Essential Drugs List. These are then government policy in health throughout the sold on at cost, plus a mark-up to cover over- country, and recommended that the RDF all running costs (including reserves against model be expanded nationwide. currency devaluation, etc.). Cross-subsidies During the next phase, 1996±2002, the are operated from the common, cheaper RDF became an independent project within drugs to some of the more expensive ones. the Khartoum MoH. Changes over this Prices for patients are uniform across the period included the following: State: there is therefore some cross-subsidy Financial incentives were introduced to from the closer facilities to the more remote retain staff. ones, which are more expensive to supply Training programmes were organized and supervise. for all members of staff. Drugs are delivered to RDF-supported A new employment contract was signed pharmacies in the health facilities, based on with pharmaceutical staff, whereby they previous consumption patterns. Funds are would have to pay for stock losses. This collected monthly, against sales records. reduced the leakage of drugs. (For a more detailed description of the operation of the RDF, see [5]). An important Management improvements included point is that the RDF does not sell to the a system for reconciling cash with the health centres to sell on (which would place value of sales made, as well as ABC the financial risk on the health centre), but analysis of sales (investigating the pro- sells directly to the patients, via pharmacies portion of revenue generated by differ- in health centres and hospitals. ent products). Starting with 13 health centres in 1989, A policy of selling through the newly the RDF expanded to 77 outlets (65 health established ³people¶s pharmacies´ in- centres and 12 rural hospitals) by 1996. The creased the number of outlets of the list of essential drugs also expanded from RDF, as did the expansion to a number 70 to 90 items. A total of US$ 1.8 million of national hospitals. was invested in capitalizing these outlets. The RDF took responsibility for deliver- Save the Children (UK) also provided training free drugs for the first 24 hours of ing, refurbished pharmacies and provided emergency treatment in public hospi- transport until the programme was handed tals. over in 1996 to the Khartoum MoH [6]. One study noted an increase in utiliza- An evaluation of the overall KCCCP tion of health facilities during this period carried out in 1996 concluded that the RDF that was attributed to the RDF and also to

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S the new health insurance system introduced care, coping strategies and perceptions in 1997 [8]. of health facilities and the RDF [11]. In 2002, the Wali (Governor) of Khar- Focus group discussions, which looked toum State signed a constitutional decree at the same questions as the house- on the establishment of the RDF as an hold survey, but using qualitative tech- independent foundation, responsible for niques. the medical supply in Khartoum State. An A health facility survey, which looked at independent administrative board was es- prescribing practices, financial manage- tablished, chaired by the State Minister for ment and pricing structures, and some Health. At the same time, 7 RDFs were indicators of quality of care within RDF set up in other states, financed by the Cen- outlets [12]. tral Medical Supplies Public Organization A financial analysis of the RDF, to focus (CMSPO). on profitability, operating costs, financial management and probity. )ZEPYEXMSRGSQTSRIRXW A pharmaceutical study, to look at issues of quality, pricing, procurement, man- The study was designed and approved by a agement and the range of drugs which steering committee, which included repre- the RDF supplies. sentatives of the Federal MoH, the Khartoum A management study, focussing on the MoH, the RDF, World Health Organization structure of the RDF, its human resource (WHO), United 1ation¶s Children¶s Fund policies, management issues and legal (UNICEF) and Save the Children (UK) status. [9]. Ethical approval for the research design, tools and sites was obtained from the Khartoum MoH and the Humanitarian Aid Commission. %REP]WMW There were 9 different components to *MRERGMEPWYWXEMREFMPMX] this study: Financial sustainability was measured in a A literature review, to examine the number of ways, including by examining: RDF¶s history and also to fit the study the change in profit margins over time findings into the context of wider devel- and from different revenue streams, opments in Sudan and internationally. the proportion of revenue expended on Interviews with key informants in Khar- overheads (including staffing), toum, to assess the policy context and various efficiency measures, such as to identify concerns and suggestions for working capital efficiency ratios. potential improvements to the RDF. risks and liabilities to future sustain- A household economy approach study ability. of different areas within the state, fo- The evaluation found that the RDF has cussing on household livelihoods and continued to grow, in terms of its volume coping strategies, and ability to afford of sales and assets, and remains in good health care and other basic goods [10]. financial health. However, concerns were A household survey of 700 households raised that increases in sales value, profit (5111 individuals) looking at health- margins and salary costs could indicate that seeking behaviour, expenditure on health the primary ethos of the RDF was shifting

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S from a public health to a more commercial Ministry¶s investment in the health care and one. pharmacy infrastructure. The initial agree- In addition, some trends were noted ment between Save the Children (UK) and towards less efficient management, such as the MoH stated that 6% of the RDF sales increasing stocks (which increase the risk of should be transferred to the MoH to finance losses), longer turnaround periods for stock, other PHC investments. The proportion of and the lack of some important information RDF sales revenue that is being transferred in financial reports. has increased, and the amount of money One of the ways in which the RDF has received by the MoH has doubled, in the expanded its business beyond the initial net- light of the growth in RDF business and work of public health centres and hospitals the addition of the income stream from the (which are supplied with essential drugs) is people¶s pharmacies (which did not exist by growing a semi-commercial wing, which when the original agreement was drawn supplies essential and non-essential drugs to up). It is also not entirely clear how the the people¶s pharmacies. The high volumes money is being used, and whether it is being and low overheads associated with this side invested in primary care or one of the terti- of the business make it profitable, despite a ary institutions. lower mark-up. The removal of the people¶s The RDF is also subject to a complex pharmacies side of the business would pose array of pharmaceutical regulations and tax a threat to the core business of the RDF. concessions, which, if altered in a way that There are a number of other threats to increased operating costs, could diminish the long-term future of the RDF, which are its ability to continue to ³revolve´ success- common to funds of this kind. One is de- fully. faulting by debtors. The RDF supplies most of the public facilities in Khartoum State, 5YEPMX]SJHVYKWWYTTP] including some tertiary referral centres. Un- Quality of drugs supply was examined in 4 like the health centres and hospitals (where main ways: the RDF sells direct to patients), the referral by looking at changes in prescriptions hospitals (which are federal institutions, in relation to WHO rational prescribing not state) buy drugs themselves and some indicators, have not been paying promptly. They have by comparing drug prices at RDF outlets considerable clout and it has taken delicate with market alternatives, negotiations to reach a deal on payment of by checking availability of essential outstanding debts owed to the RDF. These drugs at RDF outlets, issues, if unresolved, could threaten the RDF¶s credit rating with its creditors² the by investigating whether RDF supervi- European not-for-profit suppliers which sion and quality control systems are still provide most of its imported drugs. operating effectively. Financial independence has been crucial The evaluation found that many of the to the survival and success of the RDF. High systems² for procurement, quality assur- level political support has helped to ensure ance, distribution and stock control² con- that to date its funds have not been diverted tinued to operate effectively. In addition, to other uses. The RDF has traditionally the market survey confirmed that the RDF paid a proportion of its profits to the Khar- continued to offer lower prices to its cli- toum MoH, originally to compensate for the ents, compared with alternative outlets (it

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S is 40% cheaper, on average across its list, What is the level of community partici- compared to the CMSPO and 100% cheaper pation in health services generally? than private sector outlets). In terms of overall access, utilization However, there were some areas of trends were impressive (the RDF reached concern. One was that the availability of 3 million patients, some three-fifths of the essential drugs, while remaining good, had total population of Khartoum State in 2002) deteriorated since the last evaluation: the but may have declined slightly in the last proportion of available stock in the facility few years. Changes in reporting by the RDF had reduced from a reported 100% in health and lack of a recent population census made centres in 1996 and 2000 to 95.6% in 2004. it hard to track some of these issues. Some indicators of rational drugs use had Geographic coverage is good and there also deteriorated (in particular, there had was no evidence that distance to facilities been an increase in prescription of anti- was a major barrier (it takes on average 15 biotics). This suggests that renewed atten- minutes to reach a health centre and just tion to prescriber training and public educa- over half an hour to reach a public hospital, tion is required. Systems for stock-keeping according to the household survey). Quality also appeared to be relatively poor in many indicators examined in the health facility of the RDF facilities² the number of health survey suggested that quality did not vary facilities stocking expired drugs had risen systematically by location or rural/urban from 16% in 1996 to 28%. These raised status, with the exception of supervision questions about the quality and robustness by the Khartoum MoH, which was more of the supervision which is being under- frequent in urban areas. taken. The household survey also reinforced The RDF applies a cross-subsidy from the importance of the public services: the cheaper to more expensive drugs, which main treatment strategy was to go to a increases access to costly items such as in- health centre (36% overall), followed by sulin. The equity effects of that are unclear, public hospitals (29% overall). Moreover, but it does mean that its prices, while lower these facilities are more important for the on average for the full list than all its rivals, poor: use of health centres is concentrated are higher compared with the CMSPO for in the bottom 3 quintiles, while hospitals the 15 most common drugs. are important to the bottom 4 quintiles, but not the richest. %GGIWW Financial access is the main issue of Access was measured through 5 questions: concern, with the health sector charging How many people are being served by for almost the entire range of health serv- the RDF: what are the trends in utiliza- ices and also, of course, the drugs. The tion? household economy component of the study Geographical access: are RDF services suggested that 17% of the population of within reach? Khartoum State were unable to afford basic How many households, and what kinds health care costs, and 24% could meet basic of households, cannot afford to access costs but were unable to meet ³emergency´ RDF drugs and health services? costs, if they arose. These households are mainly composed of internally displaced How much awareness is there in the people (60%±75% of whom were estimated community of the RDF?

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S to be unable to meet their basic health care the sample had been exempted from paying costs)1, plus the poorest 5%±10% of the for health care; 3% had had assistance from urban and rural households. the Zakat Fund (an official charitable fund, The household survey results are broad- based on mandatory payroll deductions), ly consistent with the household economy while a further 3% had had assistance from approach results. It found that 51% of the Takaful (a voluntary fund set up to assist overall sample were living in absolute with hospital costs). In addition, just under poverty, but that the areas with internally 5% had benefited from insurance coverage displaced people were most affected (66% (though this did not reduce the members¶ ex- of whom are under the poverty line), as well penditure, rather it increased the proportion as being most disadvantaged in terms of able to treat, especially at more expensive infrastructure, which is also linked to higher facilities). Informal channels appeared to be rates of communicable disease. It found the most prolific and supportive² 57% of that 6% of the sick did not have treatment those who could not pay relied on borrow- (largely for economic reasons), and that ing to cover their bills² though these often 29% of those who do treat cannot afford create debts and future obligations. to pay for their treatment, resorting largely Community awareness of the RDF was to borrowing or reduced treatment. For the low: only 10% of household survey re- internally displaced people areas, this was spondents had heard of it. Given that the much higher (46%), as it was when results RDF works through regular health service were analysed by income quintile (37% outlets, this low awareness is not surpris- of the bottom quintile could not afford to ing. In terms of community participation pay). Moreover, the poorest quintile was 5 in those health services, the health facility times more likely not to treat sick members, survey found that 73% of the health centres compared with the top quintile. and 50% of the hospitals reported having a These results related to overall health functioning community health committee care costs, not just drug costs; however, (CHC), but only 33% and 20% respectively drugs form the bulk of health care expendi- had minutes of the meetings, which sug- ture, according to the household survey, gests that this may be a more realistic figure accounting for 58% of total costs. Overall, for active CHCs. For the health centres with household expenditure on health care ab- active committees, some 70% held monthly sorbs 1%±5% of total household income meetings, and the other 30% met weekly. and averages US$ 57 per person per year, These figures on availability of CHCs much higher than previous estimates. Given showed some improvement by comparison that public spending on health averages with the evaluation of 1996, though the US$ 4 per person per year, these figures proportion of health centres with an active suggest that public sources are contributing committee remains less than a third. a mere 7% of total health expenditure, at least within Khartoum State. There are various formal mechanisms 0IWWSRWPIEVRIH for protecting households against health There are a number of general lessons that care costs, but the survey suggests that they emerge from the RDF evaluation. are only playing a small role. Only 1% of

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One is that there is an inherent tension drug funds, where they were set up, have in revolving drug funds between being either ceased to function or have become business-minded (ensuring financial sus- the private businesses of individual health tainability) and being philanthropic (ensur- workers, seeking to supplement meagre ing access). The RDF originally managed salaries [14]. The importance of context has the tension by coexisting with a project been emphasized by other studies which which focused on training and investments evaluated cost recovery programmes, for in the primary care network. Since 1996, example McPake et al. [15]. when the project was handed over, and In addition to the economic base in even more since 2002, when it became an Khartoum, a number of other factors for the independent organization, the temptation is success of the RDF have been identified, there to focus on the business side, with less which are of wider applicability. One is emphasis on looking for ways of increasing the large-scale and long-term investment coverage for excluded groups. There is no which was made in establishing the RDF. trend data for exclusion, as it was not meas- The start-up took 7 years, with considerable ured accurately in the past, but current data technical and training inputs from Save the suggest that some 20% overall are either Children (UK), as well as a capital infusion denied treatment or are having to resort to of US$ 1.8 million. Strong systems were strategies which may threaten their future established, and local technical competence ability to cope. Although the RDF provides and leadership built. The commitment of the drugs at prices below those of competitors political leadership of Khartoum to preserv- (thus improving relative affordability), it ing the independence of the RDF, especially is unable to tackle issues of absolute af- after handover, has also been crucial. In fordability without endangering its own addition, the development of the national financial security. health insurance system has allowed the The interaction with the health financing RDF to expand beyond what was previ- context is all-important. The RDF has been ously affordable by the local population. A developed in the context of a health system synergy has developed with the Khartoum which has increasingly been passing costs Health Insurance Corporation, which is now on to households. Since the 1990s, Sudan its main purchaser. In 2003 it paid for 52% has been following the familiar path of of the sales through people¶s pharmacies health sector reform, including an increas- and 43% of the sales through RDF outlets ing role for cost recovery (user fees), de- in health centres and hospitals. centralization and encouraging the growth Threats to financial sustainability need of the private sector [13]. This increases continued management, however. In par- the willingness to pay for drugs (especially ticular, there is a temptation to change the if they are accessible, of high quality and purpose of a successful RDF, by extracting relatively cheap), while at the same time re- revenue for other purposes (making it more ducing the ability to pay, as households are akin to a Bamako Initiative scheme, fund- already absorbing the full range of health ing health care through drugs sales). If the care (and other) costs. In Khartoum, this funds are used to subsidise primary care tension has been manageable because of and reduce user costs, then the effect could the buoyancy of the economy. In more be cost-neutral on the users. However, in remote parts of Sudan, evidence from what the case of the Khartoum RDF, this does few reports exist suggests that revolving not appear to have happened, in which

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ 0E6IZYIHI7ERXÍHIPE1ÍHMXIVVERÍISVMIRXEPI:SP2S case it is preferable to channel profits back has no built-in exemptions for those who into price reductions for drugs, or set the are unable to pay. It is unable to square the ³excess profits´ aside to fund exemptions circle of low incomes and high burden of ill- for indigents. Other potential threats include ness, which lead to exclusion and financial political interference, poor leadership and hardship for around one fifth of the popula- weak management systems which allow tion. Drug funds, at their best, can improve overhead costs, losses and fraud to grow. availability and relative affordability, but in areas with high levels of absolute poverty, they cannot ensure access for all without 'SRGPYWMSR external support. This is particularly true where cost recovery is applied not just to The RDF provides a useful model for other drugs, but to all health care services, as is countries. It has survived for nearly 2 dec- the case in Sudan. ades now and is continuing to fulfil its origi- In Sudan, where the government pro- nal mandate to supply high-quality essential vides one of the lowest proportions of total drugs at below-market prices to a state of health expenditure in the whole of Africa more than 5 million people. Most revolv- (19%, according to World Bank estimates), ing drug funds fail due to problems such as there is a strong case for increased public under-capitalization, prices set below re- expenditure targeted at specific deprived replacement costs, delays in cash flow, rapid gions and groups. This could be channelled programme expansion without sufficient through the health budget or through the additional capital, losses due to theft and growing health insurance system. In other deterioration, unanticipated price increases countries which have developed revolv- due to inflation and changes in parity rates ing drug funds, other methods of reducing or foreign exchange restrictions [16]. The exclusion will need to be developed to RDF, however, has gone from strength to complement their RDFs. strength, expanding its network, expanding coverage and range of products, and maintaining its price advantage over alternative sources. %GORS[PIHKIQIRXW The benefits are most marked in rural The author would like to acknowledge the areas, which suffered from greater drug inputs of the whole evaluation team, includ- supply problems in the past (the private ing Nichola Cadge, Lesley Adams, Muneef sector was less developed there) and which Babiker, K.E. Vaidyanathan, Ibtisam Ibra- now benefit from the ³one price´ policy of him, Mohammed Awad al Karim, Nilesh the RDF (drugs cost the same throughout Patwa, Yousif Abaker and Malony Tong, the RDF network, no matter how remote and of Save the Children (UK) for funding the facility). In ensuring a reliable and rela- and managing this evaluation, with assist- tively affordable drug supply, the RDF has ance from WHO and UNICEF. Thanks are contributed to revitalizing the primary care also due to all key informants, including in system and has supported the growth since the Ministry of Health and the RDF, and 1997 of a new national insurance scheme. to those who commented on draft reports, At the same time, the RDF is based on including Regina Keith, Geraldine McCul- a strict cost-recovery mechanism, which lough, and Gamal Kalafalla Mohammed.

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-RXVSHYGXMSR factors, contributes to the increased cancer morbidity. The EMR is expected to see the Cancer is the second most common killer greatest increase in cancer incidence in the in the world today, after cardiovascular next 15 years, with an increase between disease [1]. According to the World Health 100% and 180% according to projection Organization (WHO), 13% of all deaths modelling (Figure 2) [13]. worldwide are currently caused by cancer The considerable magnitude of the can- [2]. Cancer is and will become an increas- cer burden in the EMR was recognized at ingly important factor in the global burden the 43rd Session of the WHO Regional of disease in the decades to come. The Committee for the Eastern Mediterranean estimated number of new cases each year in 1996, at which a resolution for cancer is expected to rise from 11 million in 2002 control and prevention was adopted. In the to 27 million by 2030 [1±4] (Table 1). Ap- last 15 years, the WHO Cancer Control proximately 60% (about 6.5 million) of all Programme has fostered the development these new cases are expected to occur in less of national cancer control programmes as a developed countries. primary intervention strategy for a compre- In the Eastern Mediterranean Region hensive and cost-effective approach at the (EMR) of WHO, cancer is the fourth most country level. common killer and is increasingly recog- This paper presents an overview of the nized as a major heath problem (Figure 1, current cancer situation in the Region and Table 1) [1±12]. The main factors contribut- the actions needed to tackle the growing ing to the projected increase are the growing burden. Data for this report were obtained proportion of elderly people and the overall from the following sources. National popu- reduction in deaths from communicable lation-based registries [7,14±17], regional diseases. Changes in lifestyle have resulted population-based registries [18,19,20±24], in more exposure to cancer-promoting sub- GLOBOCAN ± 2002 IARC for countries stances. This, together with the increased with hospital-based registries (Morocco, prevalence of tobacco use, changes in social Sudan and Yemen) or those lacking any and dietary habits, decreased physical activ- form of cancer registry (Somalia, Djibouti ity, and exposure to other environmental risk and Afghanistan) [25].

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[33] at the 58th World Health Assembly ;,3WXIT[MWIETTVSEGLJSVGERGIV in May 2005, the Director-General has re- TVIZIRXMSRERHGEVI cently approved the development of various WHO has outlined a stepwise framework activities for cancer prevention and control. that ministries of health can use to cre- The aim of the WHO cancer control ate a policy and regulatory environment strategy is to ³strengthen and accelerate the in which other sectors can operate suc- translation of cancer control knowledge into cessfully [1,2,27]. The guidance and republic health action. The focus is placed on commendations provided may be used by countries to ensure the reduction of cancer policy-makers and planners at the national cases and the improvement of the quality of and sub-national levels. This approach in- life of patients and their families´ [34]. cludes the following elements.

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Promotion of intersectoral interaction to reduce such burdens. The World Health at all stages of policy formulation and Report 2002 [9] identified 8 risk factors that implementation because major determi- contribute the most to mortality and mor- nants of the cancer burden lie outside the bidity that can be changed through primary health sector. intervention and that can be easily measured Establishment of locally relevant and in populations. These are tobacco, alcohol explicit milestones for each step and at use, physical inactivity, low fruit/vegetable each level of intervention, with particu- intake, obesity, raised blood pressure, raised lar focus on reducing health inequali- cholesterol and diabetes. ties. (IZIPSTREXMSREPTYFPMGLIEPXL TSPMGMIWWXVEXIKMIWERHTPERWJSV 7XVEXIKMIWJSV)16GSYRXVMIW GERGIVTVIZIRXMSRERHGEVIERH GETEGMX]FYMPHMRK More than 30% of cancers can be prevented As 30% of cancer can be prevented and and controlled by using available knowl- controlled using available knowledge, a edge. However, without national strategic comprehensive and integrated approach action, deaths from cancer are expected to is required at the country level, led by the increase globally by 17% between 2005 and government, and with the full participation 2015 [1,2,26,27]. of the community. The population-wide There are several problems facing approach aims to reduce the risks in the countries of the Region which include: entire population. Cancer can be reduced by lack of national cancer surveillance and small reductions in the average population harmonization of monitoring and surveil- levels of several known risk factors, such lance methodologies; absence of linkage of as tobacco consumption and unhealthy diet. cancer mortality data with NCD prevention Population-wide and individual approaches and control, and lack of availability of an in- are complementary and together provide a tegrated care model for NCD prevention in continuum of interventions. Countries of general and cancer in particular; inadequate the Region need to set strategies for devel- national capacity-building; and a lack of oping a model of integrated care for cancer programme sustainability. prevention and national capacity-building. EMR states thus need to develop and Seventy per cent of EMR countries are adopt the following strategies and activities low-resource countries and they need to to tackle effectively and efficiently cancer focus on areas where the needs are greatest prevention and care in their countries. and there is potential for success. National strategies need to consider priority status )WXMQEXITSTYPEXMSRRIIHERH for cancer prevention strategies and direct EHZSGEXIJSVEGXMSR special attention to combat infections that Many countries of the Region do not have a may promote cancer development, such as surveillance system for cancer. Knowledge schistosomiasis and hepatitis B. In areas of cancer risk factors is important for pre- of endemicity for liver cancer, hepatitis B dicting the burden of cancer in populations vaccination should be integrated with other and for identifying potential interventions vaccination programmes.

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-RXVSHYGXMSR bile workshops in Peshawar, Pakistan, their reasons for working and the adverse health Pakistan¶s exports have suffered heavy effects experienced, in order to add to the losses due to its denunciation for use of voice against the child labour. children in industry on the premise that it destroys their childhood and desire for betterment. The children in this area are de- 1IXLSHW prived and are trapped between working for the family and the desire to live the life of a This study was conducted in automobile child with hopes, dreams and aspiration for workshops located on the university road, a better future. However, it has been argued ring road, hajj camp and bazaar area in Pe- that making them jobless may only aggra- shawar from June to November 2005. The vate their health and financial problems and sample comprised only boys, which reflects will not improve their social and economic the Pashtun culture that requires men to status [1]. work and earn for the whole family without According to unofficial estimates, during any or very little contribution from women. 2004±05, 8±10 million children in Pakistan A total of 200 boys with ages ranging were employed in various sectors. Official- from 6 to15 years were randomly selected ly, 3.5 million children were acknowledged from 32 randomly selected automobile to be a part of the labour force. It has been workshops of Peshawar. The inclusion cri- reported that child labour among 10±14- teria were that the individuals: were 5±15 years-olds increased to 2.0 million during years old, could be identified unambiguous- 1992±93 from 1.8 million during 1990±91 ly as being within that age range, and were [2]. The growth in the number of girl work- working only in the automobile workshop ers is higher than that in boys. In urban rather than any other type of labour. areas, the services sector employs 52% of Respondents were interviewed during all children, followed by the manufacturing their work time after prior permission from sector, which employs 38%. Moreover, it the head of the workshop. They were inter- has been reported that about 70% of the viewed using a predesigned questionnaire children work longer than normal working prepared in accordance with the objectives hours (35 hours/week) [2]. of the study. Our medical interviewers vis- Child labour and corporal punishment ited the workshops with stethoscope and are believed to be the major causes of a sphygmomanometer and carried out some Sindh school drop-out rate of over 50%, clinical examinations of the children to while similar reasons are also responsible confirm the systems involved in a particular for children leaving school in other prov- disease the boys were complaining of. inces [3]. The questionnaire sought information In the city of Peshawar, there are hun- about age, nature of work (assigned to them dreds of motor vehicle repair workshops, in the workshop), monthly wage, expo- where huge numbers of children work with- sure to dangerous environment at work and out any safety measures. A considerable chronic symptoms that children were suf- number of children work in these workshops fering from. It also included information out of financial necessity because of the low about the father¶s profession, family size socioeconomic status of their families [4]. and income. Major accident/injury was This study aimed to determine the char- defined as any permanent loss to an organ, acteristics of children working in automo- or loss of hearing, or fracture of bones, or

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S a permanent physical disability and injury and being sent by parents (26.5%) (Table that caused anatomical distortion. 2). The largest proportion was involved in mechanical work (42.5%). Table 3 shows the family background 6IWYPXW of the boys. Just over half of the fathers of the boys had had no schooling and were Table 1 shows selected characteristics of the illiterate; only 11% had high school or boys working in automobile workshops. A higher education. As regards profession, large proportion (34%) had never been to 20% of the fathers were farmers, 16.5% school while 41.5% had dropped out before were unskilled labourers, 15.0% were un- class five (age 10 years). For 66% of the re- employed and 10% were dead. About 85% spondents, the average monthly income was of the boys came from large families (5 or 700 rupees. The age of starting work was more children). Father¶s monthly income < 10 years for 76.5% of the children. was less than 3000 rupees/month for 33.3% The reasons for starting work and leav- of cases. ing school were: to help the family finan- The symptoms recorded in the 200 boys cially, either going on own accord (40%) were: watery eyes (31.0%), chronic cough (29.0%), diarrhoea (22.0%), runny nose (18.0%), skin lesions and fatigue (each 8E FP I 'LEVEGXIVMWXMGWSJXLIFS]W[SVOMRK 17.5%), chronic backache (16.5%), breath- MREYXSQSFMPI[SVOWLSTWMR4IWLE[EV lessness (13.5%) and no symptoms in 23.0% cases. Some suffered from more than 1 'LEVEGXIVMWXMG 2SSJFS]W R! symptom. Of the 200 boys, 76 (38%) had

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8E FP I *EQMP]FEGOKVSYRHSJXLIFS]W had a major accident, the commonest being [SVOMRKMREYXSQSFMPI[SVOWLSTWMR severe cuts (60%) (Table 4). 4IWLE[EV :EVMEFPI 2SSJFS]W R! (MWGYWWMSR *EQMP]WM^I RSSJGLMPHVIR In Pakistan it is estimated that 10%±19% z of children are working. The estimate for z Egypt was 6.5% of children 6±14 years in " 1980 [2,4]. The present study aimed to raise *EXLIVvWTVSJIWWMSR awareness of the problem of child labour in *EVQIV our city, and to explore some of the charac- 7LSTOIITIV teristics of the boys related to their working. 'MZMPWIVZERX Although the number of boys included was 7OMPPIH[SVOIV small, the study still provides useful infor- 9RWOMPPIHPEFSYVIV mation regarding child labour in the area. 9RIQTPS]IH 4VMZEXIWIGXSV[SVOIV Children ranging in age from 6 to 15 years (IEH were selected. This is the age that children 3XLIV need to be in school but many factors force *EXLIVvWIHYGEXMSR R! them to drop out and join the labour force, 2SWGLSSPMRK usually earning only low wages. Helping to 4VMQEV]WGLSSP support the family is a main reason for this. 1MHHPIWGLSSP Indeed, 13% of the population of Pakistan ,MKLWGLSSPERHEFSZI earn less than US$ 1 per day so there is tremendous pressure to supplement income however possible [3]. The father¶s profession can directly affect the life of a child and a father¶s inability to support his family can lead to children being forced to go out to 8E FP I ,MWXSV]SJQENSVMRNYVMIWVIGSVHIHMR work. In the present study, the fathers of the XLIFS]W[SVOMRKMREYXSQSFMPI[SVOWLSTW boys working in the automobile workshops MR4IWLE[EV were mainly in low level jobs that did not ,MWXSV]SJMRNYV] 2SSJFS]W pay adequate salaries; for about a third of ,MWXSV]SJQENSVMRNYV] the boys their father¶s monthly income was VIGSVHIH R! less than 3000 rupees/month. Furthermore, =IW 15% of the fathers were unemployed and 2S 10% were dead, situations that can further -J]IWREXYVISJMRNYV] R! put pressure on children to work in order to 7IZIVIGYX[SYRHW help provide for the family. The low level &PYRXMRNYV] of jobs of the fathers may be a result of the &YVR low level of education that they had. The *VEGXYVI majority of the fathers were illiterate. Our 3XLIV study correlates with other studies showing

ÏÍÍÔ Ó ƽƾǠǳơ ǂǌǟ ƮǳƢưǳơ ƾǴƴŭơ ƨȈŭƢǠǳơ ƨƸǐǳơ ƨǸǜǼǷ ǖǇȂƬŭơ ǩǂǌǳ ƨȈƸǐǳơ ƨǴƴŭơ )EWXIVR1IHMXIVVERIER,IEPXL.SYVREP:SP2S that the parents of children working in fac- and clearly show a considerable proportion tories had low educational levels and were of boys suffered from respiratory problems. either unemployed or employed in unskilled Major injuries were recorded in 38% of the occupations [5]. boys in our study and clearly show the real Symptoms recorded in the boys were: risks children face when working in unsafe watery eyes, chronic cough, diarrhoea, run- environments, such as car repair workshops. ny nose, skin lesions, fatigue and chronic Other studies also show that mild traumatic backache. These are indicative of possible brain injury is frequently encountered in exposure to polluted, hazardous environ- working children [10]. ments and hard labour. Ravikumara and The children in our study are trapped and Sandhu reported that bowel diseases were deprived of their childhood and the chance common in working children and accounted to aspire for a better future. Such children for nearly 30% of total cases [6]. Another are caught in a vicious cycle; they need study showed an increased prevalence of to work to help provide for their families childhood dermatosis especially in work- and as a result are unable to attend school ing children [7]. Diarrhoeal diseases are a and get an education which could provide leading cause of mortality and morbidity, them with the skills to better themselves especially among children in developing and break out of the poverty trap. Not only countries. Many of the infectious agents as- are they deprived of the means (education) sociated with diarrhoeal disease are water- to achieve a better life, but by working, borne [8]. Regarding asthma/dyspnoea in particularly in unsafe environments, their working children, a study from Puerto Rico health is being endangered, and they may revealed that 25% of child workers were also be subject to abuse and exploitation affected by this chronic condition [9]. In [11]. This may further limit their ability to our study, 29% of the boys had a chronic escape the poverty trap. Poverty is clearly a cough and 13% reported breathlessness, key factor and is the issue that must be ad- both of which could be indicative of asthma dressed to try and eliminate child labour.

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7KHVWDWHRIWKHZRUOG·VFKLOGUHQZRPHQDQGFKLOGUHQWKH double dividend of gender equality This UNICEF report, which can be downloaded at: http://www.unicef. org.uk/publications/pub_detail.asp?pub_id=111, intends to provide a road map to accelerate progress towards gender equality and empowering women. It describes the lives of women around the world. Gender equality and the well-being of children go hand in hand: when women are empowered to live full and productive lives, children prosper; when women are denied equal opportunity within a society, children suffer. 'espite substantial gains in women·s empowerment since the Con- vention on the Elimination of All Forms of Discrimination against Women was adopted by the UN General Assembly in 1979, gender discrimination remains pervasive in every region of the world. It appears in the preference for sons over daughters, limited opportunities in education and work, and gender-based physical and sexual violence. Other, less obvious, forms of gender discrimination can be equally destructive. Institutional discrimination is hard to identify and rectify. Cultural traditions can perpetuate discrimination as gender stere- otypes remain widely accepted and go unchallenged. Eliminating gender discrimination requires enhancing women·s influence in the decisions that shape their lives and those of children in three distinct arenas: the household, the workplace and the political sphere. A change for the better in any one of these influences women·s equality in the others and has a positive impact on children everywhere.

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