EMHJ - 24 - 3 - 2018 Iraq

EMHJ – Vol. 24 No.
3 – 2018 Eastern Mediterranean La Revue de Santé de la

Editorial
Health Journal Méditerranée orientale
The role of access to affordable and quality assured blood and blood products for achieving Universal Health
Coverage
Yetmgeta Abdella, Ali Akbar Pourfathollah, Hmida Slama and May Raouf.................................................................................................235
Research articles
Adherence to antiretroviral therapy in HIV-positive, male intravenous drug users in Pakistan
Bakht Ali, Nighat Nisar and Faryal Nawab.............................................................................................................................................................237
Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees
and health care providers
Tala Al-Rousan, Zaker Schwabkey, Lara Jirmanus and Brett D. Nelson........................................................................................................243
Screening for dysglycaemia using anthropometric indices in an adult population in Oman
Shyam Sundar Ganguly, Kamalesh Sarkar, Samir Al-Adawi and Abdul Aziz Al-Mahrezi.......................................................................254
Burnout among primary school teachers in Iraq: prevalence and risk factors
Jasim Al-Asadi, Shukrya Khalaf, Aqeel Al-Waaly, Alaa Abed and Sabah Shami...........................................................................................262
Relationship between lean practices, soft total quality management and innovation skills in Lebanese hospitals
Eastern Mediterranean Health Journal Vol. 24 No. 3 – 2018

Malak Aoun, Norlena Hasnan and Hassan Al-Aaraj............................................................................................................................................269
Prevalence of and attitudes to waterpipe smoking among Saudi Arabian physicians
Mohammed Al Ghobain, Anwar Ahmed, Zynab Abdrabalnabi, Wjdan Mutairi and Ali Al Khathaami.............................................277
Sociodemographic predictors of tobacco smoking among expatriate and national adolescents in the United Arab
Emirates
Ayesha Siddiqua, Rania Dghaim and Caroline Barakat-Haddad.....................................................................................................................283
Seroprevalence and social determinants of varicella in Turkey
Can Hekimoğlu, Özgen Ozbek, Mestan Emek, Mehmet Öktem, Galip Köroğlu, Mustafa Sertel, Sevin Özdeniz, Ali Ceylan,
Ayla Açikgöz and Belgin Ünal......................................................................................................................................................................................295
Growth patterns of Palestinian children from birth to 24 months
Ali Albelbeisi, Zalilah Mohd Shariff, Chan Yoke Mun, Hejar Abdul-Rahman and Yehia Abed..............................................................302
Reviews
Factors affecting empathetic patient care behaviour among medical doctors and nurses: an integrative literature
review
Muntaha Elayyan, Janet Rankin and MW Chaarani...........................................................................................................................................311
WHO events addressing public health priorities
Meeting of the Eastern Mediterranean Research Ethics Review Committee............................................................................319
The World Health Organization has been at the forefront of the movement to improve access to affordable and quality assured blood and
blood products as mandated by successive World Health Assembly resolutions.
Volume 24 / No. 3 3 ‫ عدد‬/ ‫املجلد الرابع والعرشون‬

March/Mars 2018 ‫آذار‬/‫مارس‬
Cover 24-03.indd 1-3 6/6/2018 3:36:28 PM

Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean
IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon
the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic
epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses
Tunisia . United Arab Emirates . Yemen
all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and
individuals within and outside the Region.
‫البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط‬
‫املجلة الصحية لرشق املتوسط‬
‫ مجهورية إيران اإلسالمية‬. ‫ ليبيا‬. ‫ تونس‬. ‫ البحرين‬. ‫ باكستان‬. ‫ اإلمارات العربية املتحدة‬. ‫ أفغانستان‬. ‫األردن‬
‫ وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة‬.‫هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية‬
‫ وخاصة ما يتعلق منها بإقليم رشق‬،‫ ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات‬،‫واخلدمات الصحية والرتويج هلا‬ ‫ املغرب‬. ‫ مرص‬. ‫ لبنان‬. ‫ الكويت‬. ‫ قطر‬. ‫ فلسطني‬. ‫ عُ امن‬. ‫ العراق‬. ‫ الصومال‬. ‫ السودان‬. ‫ جيبويت‬. ‫اجلمهورية العربية السورية‬
‫ واملراكز املتعاونة مع منظمة‬،‫ وكذا املنظامت غري احلكومية املعنية‬،‫ والكليات الطبية وسائر املعاهد التعليمية‬،‫ وهى موجهة إىل كل أعضاء املهن الصحية‬.‫املتوسط‬ ‫ اليمن‬. ‫اململكة العربية السعودية‬
.‫الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه‬
Membres du Comité régional de l’OMS pour la Méditerranée orientale
La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran
EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne
offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen
services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa-
tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux
membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes
concernés au sein et hors de la Région.
EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website:
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Editor-in-chief
Medicus for the WHO Eastern Mediterranean Region (IMEMR).
Eastern Mediterranean Health Journal
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Cover 24-03.indd 4-6 6/6/2018 3:36:28 PM

Vol. 24.03 – 2018
Editorial
Coverage
Yetmgeta Abdella, Ali Akbar Pourfathollah, Hmida Slama and May Raouf....................................................................................................235
Research articles
Bakht Ali, Nighat Nisar and Faryal Nawab................................................................................................................................................................237
Tala Al-Rousan, Zaker Schwabkey, Lara Jirmanus and Brett D. Nelson...........................................................................................................243
Shyam Sundar Ganguly, Kamalesh Sarkar, Samir Al-Adawi and Abdul Aziz Al-Mahrezi..........................................................................254
Jasim Al-Asadi, Shukrya Khalaf, Aqeel Al-Waaly, Alaa Abed and Sabah Shami..............................................................................................262
Malak Aoun, Norlena Hasnan and Hassan Al-Aaraj...............................................................................................................................................269
Mohammed Al Ghobain, Anwar Ahmed, Zynab Abdrabalnabi, Wjdan Mutairi and Ali Al Khathaami.................................................277
Emirates
Ayesha Siddiqua, Rania Dghaim and Caroline Barakat-Haddad........................................................................................................................283
Ayla Açikgöz and Belgin Ünal.........................................................................................................................................................................................295
Ali Albelbeisi, Zalilah Mohd Shariff, Chan Yoke Mun, Hejar Abdul-Rahman and Yehia Abed.................................................................302
Reviews
review
Muntaha Elayyan, Janet Rankin and MW Chaarani..............................................................................................................................................311
Meeting of the Eastern Mediterranean Research Ethics Review Committee...............................................................................319
Eastern Mediterranean La Revue de Santé de la

Book 24-03.indb 233 13/06/2018 09:44:03

Jaouad Mahjour Editor-in-Chief
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Book 24-03.indb 234 13/06/2018 09:44:03

Editorial EMHJ – Vol. 24 No. 3 – 2018
The role of access to affordable and quality assured blood and blood
products for achieving Universal Health Coverage
Yetmgeta Abdella, 1 Ali Akbar Pourfathollah, 2 Hmida Slama 3 and May Raouf 4
Medical Officer, Department of Communicable Diseases, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt 2Director, High Institute
1
of Research and Education in Transfusion Medicine, Iranian Blood Transfusion Organization, (WHO Collaborating Centre for Research & Training on
Blood Safety), Tehran, Islamic Republic of Iran 3Director, National Blood Transfusion Centre (WHO Collaborating Centre for Transfusion Medicine),
Tunis, Tunisia 4Head & Medical Director, Dubai Blood Donation Center, Dubai, United Arab Emirates (Former Director, WHO Collaborating Centre for
Training and Research in Blood Transfusion, Sharjah, United Arab Emirates).
Citation: Abdella Y; Akbar Pourfathollah A; Slama H; Raouf M. The role of access to affordable and quality assured blood and blood products for
achieving Universal Health Coverage. East Mediterr Health J. 2018;24(3):235-236. https://doi.org/10.26719/2018.24.3.235.
Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://
creativecommons.org/licenses/by-nc-sa/3.0/igo).
The theme of World Health Day 2018 is ‘Universal health Six countries have inadequate supply of blood, with blood
coverage: everyone, everywhere’ under the slogan ‘Health donation rates less than 10 units per 1000 population.
for All’. Universal Health Coverage (UHC), as pertains Only half of the total collection in the Region comes
to blood and blood products, means that all individuals from voluntary, non-remunerated blood donors. Many
and communities have access to affordable and timely countries still depend on family/replacement donations,
supplies of safe and quality-assured blood and blood as requested by some healthcare delivery institutions
products (1,2). Blood and blood products are essential that are short of blood supplies, which compromise
components in the proper management of women safety and sustainability of blood supply. Moreover, the
suffering from bleeding associated with pregnancy and quality and effectiveness of screening tools for detection
childbirth; children suffering from severe anaemia due to of transfusion-transmitted infections, covering known
malaria and malnutrition; patients with blood and bone and newly emerging pathogens, remain a concern.
marrow disorders and immune deficiency conditions; In addition, the majority of patients with blood, bone
victims of trauma, emergencies, disasters and accidents; marrow disorders and immune deficiency conditions do
and patients undergoing advanced medical and surgical not have access to life-saving plasma-derived medicinal
procedures (3). products, which are often imported at huge cost to
Globally, the World Health Organization (WHO) has governments (8). Out of pocket payments and insufficient
been at the forefront of the movement to improve access public financing of blood and blood products are also
to affordable and quality assured blood and blood products main barriers to access in most EMR Member States (9).
as mandated by successive World Health Assembly At the national level, blood systems are in place in
(WHA) resolutions, namely WHA28.72 ‘Utilization and all EMR Member States and have a vital role to play in
supply of human blood and blood products’ (4), WHA58.13 the delivery on UHC. However, despite previous efforts,
‘Blood safety: proposal to establish World Blood Donor inadequate attention has been given to address challenges
Day’ (5), and WHA63.12 ‘Availability, safety and quality of in meeting the increasing clinical needs of patients for
blood products’ (6). In line with these resolutions, blood blood and blood products through the establishment
and blood products (whole blood, red blood cells, platelets, of an appropriately regulated, effective national blood
frozen fresh plasma and plasma-derived medicinal supply and transfusion service, as part of the national
products) were also added to the core list of the WHO health system. In some countries, the development of
Model List of Essential Medicines from 1979 to 2013 (7), blood systems has been largely restricted to major cities
and which is still currently valid. and access is still not guaranteed for those in most critical
At the regional level, the WHO Regional Committee need for these products.
for the Eastern Mediterranean, in its 63rd session in In January 2016, the global development community
2016, adopted resolution EM/RC63/R.5 that endorsed committed to the 2030 Agenda for Sustainable
the Regional Strategic Framework for blood safety and Development Goals (SDGs). Those health targets for
availability 2016–2025. The Framework acts as a guide SDG 3 that pertain to blood and blood products challenge
for countries to develop and strengthen national blood governments and partners to achieve UHC, reduce the
systems; improve access to affordable and timely supplies global maternal mortality, end preventable deaths of
of safe and quality-assured blood and blood products to newborns and children under 5 years of age, and end
meet patients’ needs; and contributing to achieving UHC the epidemics of AIDS and hepatitis (10). The increasing
(3). global attention on the SDGs and the set targets provide
About seven million units of blood are collected much needed impetus to focus on proven interventions
annually in the Eastern Mediterranean Region (EMR), to achieve UHC and other health targets for SDG 3. These
with blood donation rates ranging widely among cannot be ensured without significant investment in
Member States, from 0.7 to 29 units per 1000 population. access to affordable and quality assured blood and blood
235
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Editorial EMHJ – Vol. 24 No. 3 – 2018
products. the blood system; strategic partnerships and collaboration

Ministries of health are responsible for meeting the between concerned partners (blood donor organizations,
clinical needs of patients for blood and blood products. patients’ associations, academic institutions, among
These responsibilities include ensuring the quality, others); provision of safe blood and blood products;
appropriate and evidence-based use of safe blood, blood
safety, availability and equitable distribution of these
products and patient blood management; and quality
products through the establishment of an appropriately
system management throughout the blood transfusion
regulated and effectively managed national blood supply
chain (3).
and transfusion services, with financial protection. This
requires identifying gaps through in-depth analysis of In conclusion, national governments and relevant
partners must provide the necessary financial resources
factors affecting access to affordable and timely supplies
to address gaps in the blood regulatory, supply and
of safe and quality-assured blood and blood products
transfusion systems. This is imperative in order to
and implementing evidence-based interventions, in line
improve supply of blood and blood products that comply
with the priority interventions identified in the Regional
with quality standards, as well as ensure good practices
Strategic Framework for blood safety and availability from the vein of the blood donor to the vein of the patient
2016–2025 (3). (vein-to-vein). Member States need to make the long-
The five priority interventions guiding countries term investments and structural changes required to
to address gaps in the blood regulatory, supply and build stronger national blood systems that can contribute
transfusion systems are, leadership and governance of towards meeting UHC and SDG commitments.
References
11. World Health Organization. World Health Day 2018: universal health coverage: everyone, everywhere. Geneva: World Health
Organization; 2018 (http://www.emro.who.int/media/news/world-health-day-2018-universal-health-coverage-everyone-
everywhere.html).
22. World Health Organization. Draft thirteenth general programme of work 2023–2019. Geneva: World Health Organization; 2018
(http://apps.who.int/gb/ebwha/pdf_files/EB142/B3_142Rev-2en.pdf).
33. World Health Organization Regional Office for the Eastern Mediterranean (EMRO). Strategic framework for blood safety and
availability 2025–2016. Cairo: EMRO; 2017 (http://applications.emro.who.int/dsaf/EMROPub_2017_EN_19608.pdf?ua=1).
44. World Health Organization. WHA28.72. Utilization and supply of human blood and blood products. Geneva: World Health
Organization; 1975 (http://www.who.int/bloodsafety/en/WHA28.72.pdf).
55. World Health Organization. WHA58.13. Blood safety: proposal to establish World Blood Donor Day. Geneva: World Health
Organization; 2005 (http://apps.who.int/iris/bitstream/handle/20363/10665/WHA-13_58en.pdf?sequence=1).
66. World Health Organization. WHA63.12. Availability, safety and quality of blood products. Geneva: World Health Organization;
2010 (http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R-12en.pdf).
77. World Health Organization. WHO Model Lists of Essential Medicines. Geneva: World Health Organization; 2017 (http://www.
who.int/medicines/publications/essentialmedicines/en/).
88. World Health Organization Regional Office for the Eastern Mediterranean (EMRO). Regional Status Report on Blood Safety and
Availability 2016. Cairo: EMRO; 2017 (http://applications.emro.who.int/docs/EMROPub_2017_EN_18907.pdf?ua=1).
99. World Health Organization Regional Office for the Eastern Mediterranean (EMRO). Framework for action on advancing
universal health coverage in the Eastern Mediterranean Region. Cairo: EMRO; 2016 (http://applications.emro.who.int/docs/
Technical_Notes_EN_16287.pdf).
1010 United Nations. Sustainable Development Goals. New York: United Nations; 2015. (https://sustainabledevelopment.
un.org/?menu=1300).
236
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Research article EMHJ – Vol. 24 No. 3 – 2018
Adherence to antiretroviral therapy in HIV-positive, male

intravenous drug users in Pakistan
Bakht Ali 1, Nighat Nisar 2 and Faryal Nawab 2
School of Public Health, Dow University of Health Sciences, Karachi, Pakistan 2Deparment of Community Medicine, Dow University of Health
1
Sciences, Karachi, Pakistan (Correspondence to: Nighat Nisar: [email protected])
Abstract
Background: Human immunodeficiency virus (HIV) is fifth leading cause of mortality and disability among infectious
diseases worldwide. HIV burden is increasing annually and compliance with antiretroviral therapy (ART) is low among
intravenous drug users, especially in developing countries.
Aim: To determine the adherence level to ART among HIV-positive intravenous drug users in Karachi Pakistan.
Methods: A cross-sectional study was conducted in 2015. A pretested questionnaire was administered to 375 of 3000
people who inject drugs, registered at the Civil Hospital in Karachi, Pakistan.
Results: The mean age was 30 years, 181 were married, 179 were illiterate and 287 had income < 5000 rupees per month.
Only 63 patients were adherent to ART and 343 were alcoholics. Nonadherence was greater in patients who were single
and did not have children. The most common reason for missing ART was that they simply forgot to take the tablets.
Conclusion: We conclude that adherence to ART among intravenous drug users was low. Family cohesion and support
were essential to maintain adherence to ART.
Keywords: HIV, ART adherence, IV drug users, Patient who use drugs (PWIDS), Nation AIDS Control Program
Citation: Bakht A; Nisar N; Nawab F. Adherence to antiretroviral therapy in HIV-positive, male intravenous drug users in Pakistan. East Mediterr
Health J. 2018;24(3):237-242. https://doi.org/10.26719/2018.24.3.237
Received: 20/07/16; accepted: 01/03/17
Introduction adherence to ART was 70–89% among HIV patients who

were receiving health services from Johns Hopkins AIDS
People who inject drugs (PWIDs) are at high risk of
Service Center (10). A study from India found that 73%
human immunodeficiency virus (HIV) infection. It was
and 77% of HIV patients were > 95% and > 90% adherent,
estimated in 2016 that there were 11.7 million PWIDs
respectively (11).
worldwide, and 14% of them were infected with HIV (1).
Approximately 78% of HIV-positive PWIDs were living Active drug use has been associated with poor
in low- and middle-income countries. The burden of ART adherence. There are several factors, including
HIV among PWIDs is 3.4 million in Eastern Europe and sociodemographics, psychosocial factors, patients’
Central Asia; 3.3 million in South Asia and Southeast Asia; experience during treatment, treatment-related issues
and 2.3 million in East Asia and the Pacific Region (2). The (regimen, pill burden, dosing frequency, dietary
overall global prevalence of HIV among PWIDs ranges instructions and adverse effects) and opioid substitution
between 20 and 40% (3). Mortality among HIV-positive treatment (12,13). A cohort study found that lack of stable
PWIDs is higher than among HIV patients who do not relationships, depression, and drug injection were strong
inject drugs (4). predictors of adherence failure (14).
In Pakistan, the prevalence of HIV was < 0.1% in 2001 Noncompliance with ART among HIV-positive
and it had increased to 0.2% in 2012 (5). The number of patients is a major issue in Central Asia and Eastern
patients registered with HIV infection was 130 000; Europe, and the situation is worst among HIV-positive
of whom, 8900 were receiving antiretroviral therapy PWIDs (15). Achievement of uniformity in prevention
(ART) in 2016 (6). According to the Pakistan Global Aids and treatment in PWIDs remains a challenge for
Response Progress Report, prevalence of HIV among healthcare systems and policy makers. The identification
PWIDs increased from 10.8% in 2005 to 37.8% in 2011 (7). of predictors of adherence among PWIDs is crucial for
HIV medication adherence is a vital component in healthcare providers and communities in Pakistan. There
viral suppression and decreasing the risk of developing has been a lack of research on this important aspect of
drug resistance. It has been demonstrated that 95% adherence to ART in HIV-positive patients, and especially
adherence is necessary to maintain viral suppression and among PWIDs in Pakistan. The objective of the present
halt disease progression (8). An international systematic study was to determine the adherence level of ART
review of several studies from 7 countries revealed among HIV-positive intravenous drug users in Karachi,
that adherence levels were 33–97% (9). The cumulative Pakistan.
237
Book 24-03.indb 237 13/06/2018 09:44:03

Methods for the quantitative data. Frequencies and percentages

were calculated for categorical data. Univariate analysis
A cross-sectional study was conducted from January to
was performed to determine the association between
June 2015 at the ART Unit of the Civil Hospital, Karachi.
dependent and independent variables, and variables
Approximately 3000 HIV-positive PWIDs are currently
with P < 0.10 were further analysed by multiple logistic
enrolled at the unit and its outpatient clinic caters for > 50
regression model. In multiple logistic regression analysis,
patients daily. About 375 HIV-positive patients aged ≥ 18
variables with P < 0.05 were considered significant.
years, who had injected drugs at least once in the previous
12 months, were included in the study through purposive
sampling after obtaining informed consent. Patients Results
who had multiorgan failure or other complications Sociodemographic characteristics
were excluded. The sample size of 375 was calculated Mean age of the respondents was 30.32 (SD, 9.59) years
using the World Health Organization (WHO) Calculator (Table 1). Most of the participants were aged 18–30 years
software; the frequency of ART adherence was taken as (192, 51.2%) and had a monthly income < 5000 Pakistani
40% with 95% confidence interval and 5% margin of error. rupees (287, 76.5%).
The study was approved by the Research Committee of
Dow University of Health Sciences, Karachi, Pakistan, Adherence to ART among HIV-positive patients
and written permission was obtained from the Sind Seventy (18.7%) participants missed up to 3 doses during
AIDS Control Program Director. Full confidentiality and the past month and were classified as the adherent
privacy were maintained throughout the study. group, and 305 (81.3%) participants missed > 3 doses of
Information regarding sociodemographics, ART during the last month and were classified as the
psychosocial factors and adherence to treatment nonadherent group.
was obtained using a pretested questionnaire that Reasons for missing ART
was adapted from AIDS Control Trial Group (ACTG)
Adherence Baseline Questionnaire (16). Adherence to ART Three hundred and sixty (96%) respondents reported that
was a dependent variable, while sociodemographics and they simply forgot to take their medication; 338 (90.2%)
psychosocial factors such as age, marital status, education, missed ART due to lack of family support; 145 (38.6%)
monthly income, alcohol dependency and history of missed ART to avoid the adverse effects; and 58 (15.5%)
unsafe sex practices were independent variables. Patients missed ART for other reasons, including feeling that they
who missed ≤ 3 doses during the previous month were had too many pills, and feeling sick after taking ART. All
considered to be the > 95% adherence group (adherent patients reported that they never ran out of pills.
group). However, those who missed > 3 doses were Factors associated with adherence to ART
considered to be the < 95% adherence group (nonadherent Seventy patients were adherent to ART: 51 (72.9%) were
group). aged > 40 years; 47 (67.1%) were married; 51 (72.9%) had
Data were entered and analysed using SPSS version monthly income < 5000 rupees; 49 (5.7%) reported having
21.0. Mean and standard deviation (SD) were calculated intercourse with an HIV-positive man in the past month;
6 (8.6%) reported having intercourse with an HIV-positive
Table 1 Distribution of sociodemographic characteristics among women in the past month; and 11 (15.7%) had full family
HIV-positive PWIDs (n = 375) support for treatment and medication (Table 2). In
Sociodemographic Frequency Percentage univariate analysis HIV patients who were aged > 40
characteristics years, were married, had children and had full family
Age (yr) support in taking ART had higher odds of being adherent
18–30 192 51.2 to ART compared to those who were single, were aged <
31–40 112 29.8 40 years, did not have children and did not have complete
> 40 71 19 family support. In multiple logistic regression patients
Marital status who forgot to take ART > 3 times during the last month
Single 175 46.7 were significantly nonadherent to ART while age, marital
Married 181 48.3 status, education, income, number of children and
Divorced 19 5.1 family support did not show significant association with
Educational attainment adherence to ART.
Illiterate 179 47.7
5 yr 113 30.1 Discussion
10 yr 64 17.1
> 10 yr 19 5.1 We found low adherence to ART among HIV patients
Monthly income (rupees) who were injectable drug users. Seventy (18.7%) of the
study participants had missed ART > 3 times during the
< 5000 287 76.5
5000–10 000 69 18.4 previous month. Most of the patients simply forgot to
11 000–15 000 18 4.8 take ART.
> 15 000 1 0.2 In this study, adherence to ART was alarmingly
HIV = human immunodeficiency virus; PWIDs = people who inject drugs. low. Similar results have been reported in studies from
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Book 24-03.indb 238 13/06/2018 09:44:04

Table 2 Factors associated with adherence to ART drugs among study participants
Variables Frequency Adherent Nonadherent Univariate analysis Multiple logistic regression
n = 375 n = 70 n = 305
COR P AOR P
(95% CI) (95% CI)
Age (yr)
> 40 71 (18.9%) 19 (27.1%) 52 (17%) 1.813 (0.989–3.321) 0.054 1.606 (0.849–3.037) 0.967
< 40 304 (81.1%) 51(72.9%) 253 (83%) Ref
Marital status
Single 175 (46.6%) 23 (32.9%) 152 (49.8%) 2.030 (1.175–3.508) 0.010 1.862 (0.829–4.181) 0.145
Married 200 (53.4%) 47 (67.1%) 153 (50.2%) Ref
Educational attainment (yr)
<5 292 (77.9%) 53 (75.7%) 239 (78.3%) 1.162 (0.631–2.139) 0.631 —
>5 83 (22.1%) 17 (24.3%) 66 (17.7%) Ref
Total monthly income in Pakistani rupees
<5000 287 (76.5%) 51 (72.9%) 236 (77.4%) 1.274 (0.706–2.301) 0.421 —
> 5000 88 (23.5%) 19 (27.1%) 69 (22.6%) Ref
Have children
Yes 182 (48.5%) 29 (41.4%) 164 (53.8%) 1.644 (0.972–2.783) 0.064 1.862 (0.829–4.18) 0.132
No 193 (51.4%) 41 (58.6%) 141 (46.2%) Ref
Family supports treatment
Yes 37 (9.8%) 11 (15.7%) 26 (8.5%) 2.001 (0.937–4.273) 0.069 1.486 (0.633–3.487) 0.363
No 338 (90.2%) 59 (84.3%) 279 (91.5%) Ref
Had intercourse with HIV-positive man during last month
Yes 16 (4.3%) 49 (5.7%) 12 (3.9%) 0.676 (0.211–2.161) 0.506 —
No 359 (95.7%) 66 (94.3%) 293 (96.1%) Ref
Had intercourse with HIV-positive woman during last month
Yes 30 (8.5%) 6 (8.6%) 279 (92.1%) 0.918 (0.360–2.337) 0.851 —
No 343 (91.5%) 64 (91.4%) 24 (7.9%) Ref
Forgot to take medication during last month > 3 times
Yes 360 (96%) 63 (90%) 297 (93.4%) 4.125 (1.443–11.79) 0.005 3.46 (1.086–11.04) 0.036
No 15 (4%) 7 (10%) 8 (2.6%) Ref
AOR = adjusted odds ratio; ART = antiretroviral therapy; CI = confidence interval; COR = crude odds ratio; HIV = human immunodeficiency virus; Ref = reference value.
Rwanda (17) and Hanoi (18) in which adherence to ART important for healthcare utilization and conduciveness
was significantly lower among PWIDs. This low level and adherence to ART among HIV patients (25). These
of adherence is lower than that in other developing findings highlight the importance of family support in
countries such as India (19) and Thailand (20). A study treatment and adherence to ART. HIV patients who are
conducted in California reported that 11% of the patients living with their families receive better moral, emotional
missed 1 dose of ART prior to the day of interview, and and financial support, which helps them to be more
the most common reason for missing ART was that they adherent to ART. It is noteworthy that family relationships
simply forgot (21), which is consistent with the finding are a strong predictor for better adherence to ART, hence
of our study. Studies from Canada and United States of family involvement is needed throughout the medication
America (USA) reported that PWIDs who were on opioid process. Low levels of family support can be attributed to
substitution showed improved adherence to ART (22, stigmatization of HIV and PWIDs in our society.
23). The low adherence in our study can be attributed A study conducted in Taiwan reported that PWIDs
to poor utilization of healthcare facilities or lack of new who were illiterate and of low socioeconomic status
strategies such as opioid substitution therapy or directly were less adherent to ART (26). In contrast, we did
assisted ART. not report a significant association of education and
Our univariate model showed that HIV-positive income with adherence to ART, which could be because
PWIDs who were married and had children were more most of the patients were illiterate and had low income.
likely to be adherent to ART. However, these factors Similar findings have been reported from other studies
remained insignificant in our multivariate model. conducted in Columbia and India (27,28). Education
A previous review has shown that adequate support has a positive impact on ART adherence by facilitating
services for PWIDs are the most important factor communication with healthcare providers. Low literacy
in ART adherence (24). A previous meta-analysis has rate is a major obstacle to taking ART correctly. Another
indicated that social support and family coherence are study conducted in Nepal reported that literate patients
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Book 24-03.indb 239 13/06/2018 09:44:04

were more adherent to ART compared to illiterate that major barriers to adherence were the religious
patients, which shows that education plays a significant festivals of Ramadan among Muslims and Teej among
role in adherence to ART (29). It was further observed Hindus, and fasting made it difficult to take ART (34).
that knowledge, expectation and belief of participants There were several limitations to our study. First, this
regarding ART depend on health education and was a cross-sectional study, so a temporal association
awareness. Another study from India did not find any
between the independent variables and outcome could
significant association between literacy and adherence
not be established. Second, we relied on self-reports
to ART, and it was reported that psychosocial factors
for adherence so the results may have been subject to
influence adherence to ART (30).
reporting bias.
We found that most of the respondents missed ART
In conclusion, this study showed that adherence to
during last month and the most common reason was
that they simply forgot to take their medication, and ART among HIV-positive PWIDs was alarmingly low.
no patients ran out of pills. In contrast, in a study from Forgetting to take medication was the most common
Mississippi, USA, in which most of the patients missed reason for nonadherence to ART. Measures should be
ART over the last 3 days, the major reason was running taken to provide social support and acceptance of HIV-
out of pills (31). Another study conducted in Uganda positive PWIDs in their families and society to make ART
showed that similar numbers of participants forgot to programmes successful. Further interventional studies
take their medication, ran out of pills and felt sick after are recommended to integrate opioid substitution therapy
taking medication (32). Another study from Uganda and directly observed therapy for PWIDs, which may
suggested that willingness for treatment and compliance improve adherence to ART. It is further recommended
were major factors affecting adherence to ART (33). In that an e-reminder network system can be developed that
contrast to our findings, a study from Tanzania showed could help patients to remember their medication timing.
Funding: None.
Competing interests: None declared.
Observance du traitement antirétroviral chez les consommateurs de drogue par voie

intraveineuse séropositifs au VIH au Pakistan
Résumé
Contexte : L’infection par le virus de l’immunodéficience humaine (VIH) est la cinquième cause principale de mortalité
et d’incapacité dues à des maladies infectieuses dans le monde entier. La charge de VIH augmente chaque année et
l’observance du traitement antirétroviral (TAR) est faible chez les consommateurs de drogues par voie intraveineuse, en
particulier dans les pays en développement.
Objectif : Déterminer le niveau d’observance du TAR chez les consommateurs de drogue par voie intraveineuse
séropositifs au VIH à Karachi (Pakistan)
Méthodes : Une étude transversale a été conduite en 2015. Un questionnaire préalablement testé a été administré à 375
des 3000 consommateurs de drogues par injection enregistrés au Civil Hospital de Karachi (Pakistan).
Résultats : L’âge moyen était 30 ans, 181 étaient mariés, 179 étaient analphabètes et 287 avaient des revenus inférieurs
à 5000 roupies par mois. Seuls 63 patients observaient leur traitement antirétroviral et 343 étaient alcooliques. La non-
observance était supérieure chez les patients célibataires et sans enfants. La raison la plus courante justifiant le fait de ne
pas prendre le TAR était tout simplement l’oubli de la prise des comprimés.
Conclusion : Nous concluons que l’observance du TAR chez les consommateurs de drogues par voie intraveineuse est
faible. La cohésion familiale et le soutien des proches sont essentiels pour maintenir l’observance du TAR.
‫االلتزام بالعالج املضاد للفريوسات القهقرية يف صفوف الذكور املصابني بفريوس العوز املناعي البرشي املتعاطني‬
‫للمخدرات باستخدام احلقن يف باكستان‬
‫ فريال نواب‬،‫ نغهت نثار‬،‫بخت عيل‬
‫اخلالصة‬
‫ ويتزايد عبء‬.‫ يمثل فريوس العوز املناعي البرشي خامس سبب رئييس للوفيات واإلعاقة من بني األمراض املعدية يف مجيع أنحاء العامل‬:‫اخللفية‬
‫ ال‬،‫فريوس العوز املناعي البرشي سنوي ًا مع انخفاض مستوى االلتزام بالعالج املضاد للفريوسات القهقرية يف صفوف متعاطي املخدرات باحلقن‬
.‫سيام يف البلدان النامية‬
‫ حتديد مستوى االلتزام بالعالج املضاد للفريوسات القهقرية يف صفوف متعاطي املخدرات باحلقن املصابني بفريوس العوز املناعي البرشي‬:‫اهلدف‬
.‫يف كراتيش بباكستان‬
240
Book 24-03.indb 240 13/06/2018 09:44:04

‫ شخص يتعاطون‬3000 ‫ شخص ًا من أصل‬375 ‫جمرب مسبق ًا الستجواب‬ ِ ‫ وإست‬.2015 ‫ ُأجريت دراسة مقطعية يف عام‬:‫طرق البحث‬
ّ ‫ُخدم استبيان‬
.‫ومسجلني يف املستشفى املدين يف كراتيش بباكستان‬
ّ ،‫املخدرات باحلقن‬
‫ مريض ًا فقط من‬63 ‫ والتزم‬،‫ وجد أن االلتزام بالعالج املضاد للفريوسات القهقرية بني متعاطي املخدرات باحلقن الوريدي كان منخفض ًا‬:‫النتائج‬
‫ وتبني أن املرىض غري املتزوجني وليس لدهيم‬.‫ مريض ًا) من املدمنني عىل الكحوليات‬343( ‫ وكانت غالبية املرىض‬.‫ مريض ًا بالعالج‬375 ‫أصل‬
‫ وكان نسيان تناول‬.‫ وذلك باملقارنة مع املرىض املتزوجني ولدهيم أطفال‬،‫أطفال كانوا أقل التزاما بتناول العالج بسبب افتقارهم إىل الدعم األرسي‬
.‫األقراص هو السبب األكثر شيوع ًا لعدم االلتزام بالعالج املضاد للفريوسات القهقرية‬
‫ ويعد التامسك‬.‫ توصلنا إىل استنتاج مفاده انخفاض مستوى االلتزام بالعالج املضاد للفريوسات القهقرية بني متعاطي املخدرات باحلقن‬:‫االستنتاج‬
.‫والدعم األرسي عاملني أساسيني لالستمرار يف االلتزام بالعالج باألدوية املضادة للفريوسات القهقرية‬
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28. Cohn SE, Jiang H, McCutchan JA, Koletar SL, Murphy RL, Robertson KR, et al. Association of ongoing drug and alcohol use
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29. Shah B, Walshe L, Saple DG, Mehta SH, Ramnani JP, Kharkar RD, et al. Adherence to antiretroviral therapy and virologic suppres-
sion among HIV-infected persons receiving care in private clinics in Mumbai, India. Clin Infect Dis. 2007 May 1;44(9):1235–44.
PMID:17407045
30. Anuradha S, Joshi A, Negi M, Nischal N, Rajeshwari K, Dewan R. Factors influencing adherence to ART: new insights from a
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31. Amico KR, Konkle-Parker DJ, Cornman DH, Barta WD, Ferrer R, Norton WE, et al. Reasons for ART non-adherence in the Deep
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adult patients in Uganda. ISRN AIDS. 2013 Jan 14;2013:270914. PMID:24052886
33. Kamarulzaman A, Altice FL. Challenges in managing HIV in people who use drugs. Curr Opin Infect Dis. 2015 Feb;28(1):10–6.
PMID:25490106
34. Tomori C, Kennedy CE, Brahmbhatt H, Wagman JA, Mbwambo JK, Likindikoki S, et al. Barriers and facilitators of retention in
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242
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Health needs and priorities of Syrian refugees in camps and urban

settings in Jordan: perspectives of refugees and health care providers
Tala Al-Rousan 1, Zaker Schwabkey 2, Lara Jirmanus 3 and Brett D. Nelson 4,5
Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America (Correspondence to: Tala Al-Rousan: talarousan@
1
gmail.com). 2King Abdullah University Hospital, Amman, Jordan. 3Connor’s Center for Global Women’s Health, Brigham and Women’s Hospital,
Boston, Massachusetts, United States of America. 4Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston,
Massachusetts, United States of America. 5Harvard Medical School, Boston, Massachusetts, United States of America.
Abstract
Background: The United Nations has declared the Syrian refugee crisis to be the biggest humanitarian emergency of our
era. Neighbouring countries, such as Jordan, strain to meet the health needs of Syrian refugees in addition to their own
citizens given limited resources.
Objectives: This study aimed to determine the perspectives of Syrian refugees in Jordan, Jordanian health care providers
and other stakeholders in addressing the public health issues of the refugee crisis.
Methods: Qualitative and quantitative methodologies were used to explore Syrian refugee health needs and services in
camp and urban settings in Jordan. Focus group discussions and key informant interviews were used to identify needs,
challenges and potential solutions to providing quality health care to refugees. By-person factor analysis divided refugee
participants into 4 unique respondent types and compared priorities for interventions.
Results: Focus group discussions and key informant interviews revealed a many different problems. Cost, limited
resources, changing policies, livelihoods and poor health literacy impeded delivery of public and clinical health services.
Respondent Type 1 emphasized the importance of policy changes to improve Syrian refugee health. Type 2 highlighted
access to fresh foods and recreational activities for children. For Type 3, poor quality drinking-water was the primary
concern, and Type 4 believed the lack of good, free education for Syrian children exacerbated their mental health problems.
Conclusions: Syrian refugees identified cost as the main barrier to health care access. Both refugees and health care
providers emphasized the importance of directing more resources to chronic diseases and mental health.
Keywords: Refugee Health, Health Care Services, Syria, Jordan, Syrian Refugees
Citation: Al-Rousan T; Schwabkey Z; Jirmanus L; Nelson BD. Health needs and priorities of Syrian refugees in camps and urban settings in Jordan:
perspectives of refugees and health care providers. East Mediterr Health J. 2018;24(3):243–253. https://doi.org/10.26719/2018.24.3.243
Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license )https://
Introduction urban areas of Jordan (5) and must now pay foreigner’s
fee at government clinics (6). According to UNHCR, mean
The United Nations has declared the Syrian crisis to be the
monthly household out-of-pocket health care spending
worst refugee crisis since the Second World War (1). The for Syrian refugees was approximately US$ 80 in 2014, a
vast majority of displaced Syrians, some 5 million people, large sum for an average Syrian family with a monthly
live in Jordan, Lebanon, and Turkey, whose economies household income of US$ 322 (7). Refugees living outside
and social safety nets strain to serve a growing refugee of camps are more vulnerable to these costs, as only a few
population, in addition to their own citizens. hospitals and clinics offer subsidized services for Syrian
According to the Jordanian government, Jordan refugees in urban settings.
currently hosts 1 million Syrian refugees, the vast majority Research has focused on isolated issues that have
of whom live on less than US$ 2 a day (2). Jordan offers affected the health of Syrian refugees in neighbouring
free universal health coverage to its citizens, which was countries, such as health service access and utilization
available to Syrian refugees until 2014. Between 2012 and (8,9), the prevalence of chronic conditions among certain
2013, the number of physicians per 10 000 people in Jordan refugee age groups (10), the prevalence of infectious
declined from 27.1 to 20.2, due to the influx of 600 000 diseases among refugees, and the psychosocial and
Syrian refugees (3). Citing untenable health care costs, mental health care shortcomings. However, research
the Jordanian Ministry of Health ended full coverage on how refugees prioritize these issues that affect their
of health care for Syrian refugees in September 2014 (4). health is scarce.
The United Nations High Commissioner for Refugees Little is known about the perspectives of Syrian
(UNHCR) now covers 100% of the cost of primary and refugees themselves, Jordanian health care providers
secondary health services for refugees who are referred and other important stakeholders, such as policy-makers
from camps. However, 80% of Syrian refugees live in and aid workers, when it comes to addressing the
243
Book 24-03.indb 243 13/06/2018 09:44:04

growing clinical and public health burden. This will be Interviews and focus groups were led by the primary
critical in refining programmes to serve the displaced investigator (TA) and conducted in Arabic (and audio
Syrian population now and in years to come. This study recorded with permission) by the trained study authors
introduces the unheard voices of both refugees and the using a semi-structured questionnaire (Box 1). Audio
host population to delineate health needs and prioritize recordings were then transcribed into English, and
allocation of health care spending 5 years after the start the immersion/crystallization method was used (11).
of the Syrian conflict. This involved 2 authors who independently read each
transcript, while taking notes on emerging themes. Next,
Methods the authors met several times as a group to discuss data
interpretation, potential biases and application of the
This study used a mixed-methods approach to identify findings to refugee health needs.
the needs of Syrian refugees living in camp and
community settings in Jordan. A total of 230 Syrian By-person factor analysis
refugees participated in the study. Convenience sampling By-person factor analysis was used to identify, evaluate
was used to recruit Syrian refugees and Jordanian health and prioritize the views of Syrian refugees living outside
care workers. Key informants and health care providers refugee camps (12). This method has been successfully
were recruited from the Jordanian Ministry of Health used to study perceptions of refugees on health issues in
and UNHCR. other parts of the world (13). Qualitative and quantitative
Community development centres in Irbid and Kafrein methods are combined to identify groups called
“respondent types” within a study population, to evaluate
were used to recruit participants in urban settings
the degree of agreement among participants and identify
because they are located in the areas with the largest
conflicting opinions.
concentration of Syrian refugees and serve as gathering
places which offer recreational, psychosocial and public We first developed a collection of perceptions
health services. Al Zaatari participants were recruited regarding the health of Syrian refugees through
through the public health office at the UNHCR. Data literature review and using our focus group discussions
were collected from October to December 2015. and key informant interviews. From this, we developed
45 statements representing the spectrum of ideas on the
Triangulation of the data was sought by using
study topic. After refining and reducing these statements
different data sources (multiple stakeholders) and mixed through processes of piloting, the final number of Q set
methodologies. Large focus group discussions were used statements was 23. Nine participants from Irbid and
to identify the leading themes on the topic, followed up Kafrein were recruited for the pilot study to confirm
with one-on-one key informant interviews to verify that
the themes identified matched. The Q-method brought
in an additional group of participants to help in the
interpretation and prioritization of the qualitative data Box 1 Guide for focus group discussions (n = 8 interviews)
gathered in the initial interviews. • What are the main health problems that Syrian refugees suffer
Focus group discussion were organized and conducted from? What are the needs that are not addressed well?
until thematic saturation was reached. • What are the sources of health care provided to Syrian
refugees?
Key informant interviews and focus group
• What do you think of health care provided to Syrian refugees?
discussions
• Can you describe the health care provided to Syrian refugees in
A total of 8 key informant interviews and 17 focus group comparison to care provided for Jordanians?
discussions were conducted to explore the health needs • What are the strengths of the current Jordanian health care
of Syrian refugees and the barriers facing them in system in responding to the Syrian refugee crisis?
obtaining health care, and to collect a variety of opinions • What are the obstacles to providing health care to Syrian
and perceptions for subsequent by-person factor analysis. patients?
The average length of interviews was about 45 minutes. • What do you think are the solutions to alleviate the impact of
the Syrian refugee crisis?
Key informant interviews involved key officials in the
• What are the priorities in the improvement of health care
Jordanian Ministry of Health, the UNHCR main and
services provided for Syrian refugees?
camp-based offices, Jordan University for Science and
• What do you think would be the reaction of the health care
Technology School of Medicine and Public Health, and community (physicians, nurses, administrators) to health
international organizations such as the International care development? And the response of the public and the
Medical Corps. government?
Focus group participants included: 1) local Jordanian • What types of training could be offered for the development of
the refugee health care system?
health care providers caring for Syrian refugees in
• What can the global community do better to help with the
Mafraq and Ramtha, 2) Syrian refugees in camps and
Syrian refugee crisis?
3) Syrian refugees in urban settings. Focus groups with
• What strategies do you think are working well and what are
Syrian refugees were stratified by gender, while groups not?
with health care providers were mixed gender.
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the accurate representation of the 23 statements. primary reason for reduced access to perinatal care was
These statements were representative of the original the lack of female physicians. Chronic conditions were
perceptions and views about health needs provided by common among older adults, including hypertension,
the members of the key informants interviews and focus cardiovascular disease, diabetes, chronic respiratory
groups discussions. disease, arthritis and cataracts. Both key informants and
Respondents from community-dwelling Syrian health care providers identified cardiovascular disease as
refugees living in Irbid and Kafrein (2 governorates in the main cause of mortality, and high rates of smoking
Jordan with the largest Syrian refugee concentration) were noted.
were recruited through a community-based organization Jordanian health care providers caring for Syrian
that offers social activities (skills training, rehabilitation refugees reported feeling overworked, and were
and recreational activities) for Syrian refugees living struggling to care for the growing numbers of Syrian
in the north of Jordan. Informed written consent was refugee patients in understaffed and under-resourced
obtained from each participant. They were given the list clinics. These challenges contributed to staff burn-out.
of the 23 statements and asked to sort them into a semi- Providers also indicated that Syrian refugees preferred
Gaussian, Q-sort grid, with the instruction, “Please sort injections to oral medications and often questioned the
these statements with respect to your opinion of the quality of care received if a physician did not prescribe
current health situation of Syrian refugees in Jordan.” an injection.
Each respondent ranked each of the 23 statements from Syrian refugees living in established refugee camps
–3 (strong disagreement) to +3 (strong agreement) and
wrote each statement’s corresponding number in an Four focus group discussions were conducted with
empty box in the grid. Syrian refugees in the largest refugee camps in Jordan:
Zaatari Camp (2 focus groups, n = 60) and Azraq Camp
Factor analysis was then done by the investigators on
(2 focus groups, n = 15). Table 2 shows the demographics
all completed grids, followed by automatic factor rotation
of the participants. The results from the focus group
using PQMethod 2.35 (14). To define and characterize the
discussions with Syrian refugees in refugee camps are
respondent types, all respondents who loaded heavily
presented in Table 1.
on a respondent type (> 50% concordance) were selected
as respondent “loaders.” The respondents who loaded Participants identified the following obstacles to
heavily and specifically on a single respondent type (i.e. health and health care access: increased prevalence of
> 50% concordance on only a distinguishing position in smoking, unaffordable basic foods at unregulated local
a given factor) were designated respondent “definers” stores in the camps and lack of transportation from
and examined carefully to characterize each respondent the camp to nearby clinics. Exacerbation of respiratory
type. Individuals of the same respondent type expressed illness was attributed to living conditions in the desert.
similar ideas that most of the data were converged Early marriage and sexual abuse were also cited as
around. concerns and as consequences of poverty and insecurity
in the camps.
Ethical considerations
Recreational services for children, mental health
The study was approved by the Institutional Review clinics, vaccination awareness campaigns, and home
Board of Partners HealthCare (Massachusetts General visits by field officers to promote continuity of care
Hospital, Boston, USA) and the Jordanian Ministry for chronic diseases were described as health system
of Health. In addition, UNHCR granted approval for strengths. Refugees in both camps noted that essential
qualitative studies conducted in the refugee camps. medicines for chronic diseases were unavailable in camp
Confidentiality was protected through using study clinics and complained of long waiting times. Participants
codes, encryption of identifiable data, limiting access to also perceived discrimination and inhumane attitudes
data to only the study team and securely storing data. among health care providers and suggested that Syrian
physicians should be employed in the camps.
Results Syrian refugees living outside established refugee
Discussions with health care providers and key camps
informants A total of 13 focus group discussions with community-
Four focus group discussions, 2 in Irbid/Ramtha (n = 40) based Syrian refugees were conducted in Amman (n = 25),
and 2 in Marfaq (n = 40), and 4 key-informant interviews Ramtha (n = 22), Irbid (n = 45) and Mafraq (n = 18). Their
were conducted with health care providers, including demographics are presented in Table 2. The results from
physicians, nurses, and clinical social workers. The the focus group discussions with Syrian refugees living
results from the focus group discussions with health care in the community are presented in Table 1.
providers are presented in Table 1. Syrian refugee participants highlighted chronic
According to the health care providers and key conditions such as cardiovascular disease, diabetes,
informants, Syrian refugees primarily seek health care hypertension, cancer and kidney disease as important
for acute conditions, including respiratory illness, causes of illness, which they believed to be more prevalent
fever, diarrhoea and injuries. Providers noted that the since displacement. Poor housing conditions and poor
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Table 1 Summary of qualitative findings (n = 185)

Themes Concerns of health care Concerns of Syrian refugees in Concerns of Syrian refugees in urban
providers and key informants camps areas
Health problems • Syrian refugees primarily • Poor living conditions exacerbate • Limited health care access, especially
seek care for acute conditions respiratory illness secondary and tertiary care due to high
(respiratory illness, fever, • High costs of basic foods and costs and location
diarrhoea and injuries) unregulated stores in camps • Chronic conditions perceived to be
• High prevalence of chronic • Lack of transportation to health more prevalent since displacement,
conditions: e.g., hypertension, clinics inside the camp especially cardiovascular disease, diabetes,
cardiovascular disease, diabetes, • Insecurity in the camps hypertension, cancer and kidney diseases
chronic respiratory disease, • Mental illness, such as post-traumatic
• Sexual abuse
arthritis and cataracts. stress disorder and depression, are
• Child marriage as a response to
• High smoking prevalence increasing in young adults
poverty and lack of security
• Lack of health literacy • Lack of legal work opportunities and high
• Stigma around receiving mental costs of living and health care contribute
health care to psychological distress and domestic
• Lack of necessary documentation violence
such as marriage and birth • Poor housing conditions and poor water
certificates quality cause illness
Representative We do not see many differences in Some grocery shop owners know that I do not know a single Syrian refugee in Jordan
quotes the prevalence of chronic conditions baby formula is not always available who does not have someone in the family with a
between Syrian refugees and Jordanians. so they make sure to increase its price. I chronic condition and is struggling to see doctors
However, we see lower levels of health cannot afford it, and there is nobody to and buy medications. How can we afford all of this
literacy, bad health behaviours, lack complain to. If you complain, they would when we cannot work or do anything?
of trust and vulnerability for mental return you to Syria. – 42-year-old male engineer and refugee,
distress. There is a huge need for large- – 35-year-old female refugee, Zaatari Irbid
scale epidemiological studies. Camp We know that many Syrians have mental illness
– Jordanian physician All my kids have asthma. All of them due to what they have witnessed during the war
were born in Zaatari Camp which is but who would marry a daughter of someone who
located in the middle of the desert. When sees a mental health doctor or takes medications
a sandstorm hits, they cannot breathe, to stay sane?
and I see almost all kids of Zaatari in the – 33-year-old male, jobless ex-teacher and
emergency rooms of the 5 hospitals of the refugee, Kafrein
camp during sandstorm days. – 42-year-
old male refugee, Zaatari Camp
I have to marry off my daughters once they
hit puberty. How can I pay for their food if
I keep them in the same home with us?
– 46-year-old female refugee, Azraq
Camp
Strengths and Strengths: Strengths: Strengths:
weaknesses of the • Providing free/subsidized care to • Availability of primary health care • Iris scan technology is a convenient way to
Jordanian health Syrian refugees facilities and small hospitals inside access cash assistance
care system • Hospitality towards Syrian the camp Weaknesses
refugees • Recreational activities for children, • Cost is the primary barrier to health care
• Dedication to providing quality such as after-school sports and art access
health care to Syrian refugees programmes • High health care costs drive refugees to
and Jordanian citizens • Mental health clinics run by seek care in pharmacies instead of clinics
Weaknesses: International Medical Corps and • Discrimination in the health care setting
• Lack of electronic health other international organizations; and inhumane treatment from health care
information systems, especially vaccination awareness campaigns providers
in primary care • Home visits by field officers for • Physicians perform insufficient physical
• Limited mental health care chronic diseases examinations and do not spend enough
services Weaknesses: time with patients
• Insufficient health education • Periodic lack of essential medicines • Legal status makes access to health
programmes targeting chronic for chronic diseases, such as high services a challenge
disease prevention, smoking, blood pressure and diabetes • Lack of birth certificates and changing
domestic violence and mental • Long waiting times due to limited UNHCR policies complicate health care
health stigma staffing in camp clinics access
• Provider burn-out due to • Discrimination and inhumane • Lack of access to dental care
long work hours and staffing attitude of health care providers • Lack of female antenatal care providers
shortages
• Hospitals that provide 24/7 emergency
• Lack of community health care are located far away
outreach programmes
• Current policies do not allow donation of
blood among Syrians; thalassemia patients
cannot access blood transfusions
• Current policies do not allow Syrian health
care providers to work while in Jordan
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Table 1 Summary of qualitative findings (n = 185) (concluded)

Themes Concerns of health care Concerns of Syrian refugees in Concerns of Syrian refugees in urban
providers and key informants camps areas
Representative We do not discriminate against Syrian I wish they had more Syrian doctors to I have a bad type of cancer in my thyroid gland.
quotes refugees. In fact, we treat them better look after us instead of these Jordanian The hospital in Irbid covered the first session of my
since they are our guests and that is part health care providers that threaten to kick radiotherapy then they said I had to pay for the
of our traditions and culture. They are us out of the country. My neighbour in rest. I could not afford the rest of the treatment. My
more vulnerable and sensitive, and we the caravan next door is a talented Syrian brother has asked friends and philanthropists on
are overworked. surgeon, and I have gone to him when I social media to donate money for my treatment.
– Jordanian physician, Zaatari cut my finger. He sewed my skin with a – 59-year-old male refugee, Ramtha
Camp regular needle and thread.
– 55-year-old male refugee, Zaatari
Camp
Priorities and • Increase health education • Syrian physicians should be • Increase the quantity and quality of food
suggestions for programmes to address chronic employed in the camps coupons and ensure that they are accepted
change disease prevention and smoking • Provide transportation to hospitals at stores accessible to refugees
• Increase programmes to target and health clinics inside the camp • Revisit cash assistance criteria
mental health and mitigate • Regulate food and grocery stores • Train health care providers to care for the
stigma inside the camp vulnerable refugee population
• Increase health programmes to • Provide adequate care and health
address domestic violence education for chronic conditions
• Increase the number of female • Increase numbers of female physicians
antenatal providers to encourage caring for Syrian refugee women
use by Syrian refugees • Increase legal work opportunities, and
facilitate registration of marriage and
births in order to improve quality of life
and health care access for Syrian refugees
Table 2 Demographic information on refugee focus group participants (n = 185)

Area Amman Ramtha Irbid Mafraq Zaatari Camp Azraq Camp
No. of participants 25 22 45 18 60 15
Mean age (SD) (years) 42 (4) 36 (2) 27 (9) 25 (7) 38 (9) 21 (8)
Sex: No. (%)
Female 15 (60) 19 (86) 20 (44) 11 (61) 28 (47) 6 (40)
Male 10 (40) 3 (14) 25 (56) 7 (39) 32 (53) 9 (60)
Mean no. of years since 3.5 3.0 3.5 2.5 3.0 1.0
displacement
SD = standard deviation.
water quality were described as sources of illness. A lack services were far away from refugee homes. Refugees
of legal work opportunities and high costs of living and complained of discrimination in the health care setting
health care were intertwined with health problems and and inhumane treatment from health care providers, and
identified as a cause of psychological distress, which they perceived that physicians performed insufficient
reportedly contributed to domestic violence. physical examinations. Legal status and livelihoods were
UNHCR cash assistance programmes were the also described as barriers to health care, including a lack
most frequently raised topic in focus group discussions of birth certificates and changing UNHCR policies.
with Syrian refugees. Refugees approved of iris scan By-person factor analysis results
technology, which enables refugees to access cash Of the 44 Syrian refugees invited to participate in the
without a card or PIN. However, they questioned the factor analysis exercises, 34 completed them correctly
UNHCR beneficiary selection criteria for cash assistance, (77.3% response rate). Respondents were all community-
arguing that recipients were better off than the destitute dwelling Syrian refugees living in Irbid and Kafrein
majority who were denied it. areas. The mean age was 29.2 (standard deviation 9) years
Cost was the primary barrier to health care identified (range: 18–65), and 52.9% of the participants were females.
by Syrian refugees living outside refugee camps. Table 3 shows the Syrian respondents’ perceptions
This drove them to seek care in pharmacies and to of their health situation in Jordan in the by-person
ask pharmacists to diagnose diseases and prescribe factor analysis. The average level of agreement for all
medications, making pharmacies their primary source participants and the agreement levels by respondent
of health care. Medical facilities with 24-hour emergency type are given. In some cases, notable agreements or
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Table 3 Syrian refugees’ perceptions of their health situation in Jordan (n = 34)a

Statements for by-person factor analysis (listed from Averaged level of Agreement levels by respondent type
greatest consensus to least consensus) agreement for all
participants
Type 4 (9% of
participants)
participants)
participants)
participants)
(32% of
(14% of
(14% of
Type 2
Type 3
Type 1
Syrian refugees are open to the idea of receiving mental –0.05 –1 –1 –1 –2
health services
Not having female doctors is a reason why many female 0.82 1 0 1 1
Syrian refugees refuse to seek care
Health care would not improve if the ministry of health had 0.09 0 –1 0 1
better trained and qualified doctors
Cardiovascular disease is a major cause of death in Syrian –0.50 –1 0 1 1
refugees
I do not feel discrimination or inhumane attitude from the –1.27 –1 0 1 0
health care providers
Health would improve if refugees had more food 0.46 1 2 0 2
Training Jordanian doctors on humanitarian crises will not 0.18 0 –1 –2 0
improve health care services offered to refugees
Patients are adequately prescribed the medicine they need –0.09 0 1 –1 –1
The UNHCR needs to develop better standards for who gets 2.41 3 1 3 3
the iris scanb and this will improve health care access
Chronic diseases are well cared for at the governmental –0.68 –2 0 0 0
hospitals
Local pharmacies often have the medicines that doctors –0.59 –2 1 0 0
prescribe
Allowing Syrian doctors to practise medicine will not improve 0.23 2 1 2 –1
the health status of Syrians
If I have an emergency at night I can see the doctor quickly –1.78 –2 0 –1 –3
Giving injections is an important indicator of a good health –1.05 –3 –3 0 –1
care centre and good doctors
Patients with complicated conditions do not have to travel 0.64 1 –2 1 0
long distances to find the appropriate doctors
Smoking is very common among Syrian refugees, males and –0.68 0 –2 2 –2
females
Offering children fun programmes is important for their 0.64 2 2 –2 2
mental wellbeing
If Syrians were allowed to work legally, the health status of 1.73 3 3 3 –1
most of them would improve significantly
Free medical days offer great services –0.82 –3 2 –1 1
Domestic violence is a phenomenon that could benefit from –0.41 –1 –3 –2 2
community awareness programmes
The poor quality of the water causes many health problems –0.05 1 –1 2 –3
Quality school education is lacking and causes mental health 0.14 0 –2 –3 3
problems
Allowing Syrian refugees living in Jordan to visit their 0.91 2 3 –3 –2
families in Syria and return will significantly improve their
mental health
a
Participants were invited to sort 23 statements by level of agreement. Agreement levels were given from “I strongly disagree” (−3), “I feel ambivalent/neutral” (0), or “I strongly agree” (+3). The
responses were averaged and also analysed with by-person factor analysis to reveal 4 respondent types. Not all the participants matched sufficiently any of the 4 respondent types (they were
composites across the respondent types), and were therefore not classified.
b
The iris scan is a UNHCR needs-based cash assistance programme offered to only the most vulnerable refugees. It uses iris scan technology at certain banks in Jordan to enable refugees to access
their UNHCR funds without the need for a bank card or PIN code.
disagreements were found among the 4 respondent All respondent types agreed to some extent that
types. Table 4 shows the distinguishing statements for UNHCR should revisit beneficiary selection criteria for
each of the 4 respondent types. cash assistance (the iris scan cash programme). Almost
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Table 4 Distinguishing statements for each of the 4 respondent types and the differing levels of agreement of each respondent type (n = 34)
Statement Level of agreement
Type 1 Z-score Type 2 Z-score Type 3 Z-score Type 4 Z-score
Respondent type 1
Quality school education is lacking and 0 0.31* 2 –1.14 –3 –1.71 3 –1.71
causes mental health problems
Local pharmacies often have the medicines –2 –1.03 1 0.57 0 0 0 0
that doctors prescribe
Chronic diseases are well cared for at the –2 –1.27* 0 0 0 0 0 0
governmental hospital
Free medical days offer great services –3 –1.43* 2 1.14 –1 –0.57 1 0.57
Respondent type 2
The UNHCR needs to develop better 3 1.98 1 0.57 3 1.71 3 1.71
standards for who gets the iris scan and this
will improve health care access
The poor quality of the water causes many 1 0.67 –1 –0.57 2 1.14 –3 –1.71
health problems
Patients with complicated conditions do 1 0.64 –2 –1.14 1 0.57 0 0.00
not have to travel long distances to find the
appropriate doctors
Respondent type 3
Smoking is very common among Syrian 0 –0.32 –2 –1.14 2 1.14* –2 –1.14
refugees, males and females
Free medical days offer great services –3 –1.43 2 1.14 –1 –0.57 1 0.57
Offering children fun programmes is 2 1.01 2 1.14 –2 –1.14* 2 1.14
important for their mental wellbeing
Respondent type 4
Quality school education is lacking and 0 –0.31 –2 –1.14 –3 –1.71 3 1.17*
causes mental health problems
Domestic violence is a phenomenon that –1 –0.94 –3 –1.71 –2 –1.14 2 1.14*
could benefit from community awareness
programmes
If Syrians were allowed to work legally, 3 1.61 3 1.71 3 1.17 –1 –0.57*
the health status of most of them would
improve significantly
Allowing Syrian doctors to practise medicine 2 0.90 1 0.57 2 1.14 –1 –0.57
will not improve the health status of Syrians
The poor quality of the water causes many 1 0.67 –1 –0.57 2 1.14 –3 –1.71
health problems
*Significant at P < 0.01.
all the participants also agreed that increasing legal on refugee health issues, prescribing adequate drugs to
work opportunities for Syrian refugees would improve patients, smoking cessation efforts and providing good
their health. Participants tended to believe that stigma quality school education.
was a barrier to access of mental health resources. Most Individuals in respondent type 2 emphasized the
participants also complained that 24-hour emergency
importance of access to fresh foods and recreational
services were difficult to access.
activities for children. They also supported policies to
Respondent type 1 was heavily loaded by 21 increase legal work opportunities for Syrians and to
respondents (61.8% of participants) and defined by 11 permit Syrians to visit family in Syria and return to Jordan.
(32.4%), while each of the remaining 3 types included 2 This respondent type believed that Jordanian health care
loaders (5.9%) and 1 definer (2.9%). Respondent type 1
providers were qualified and felt that medicines were
generally emphasized the importance of policy changes
available and patients were prescribed the medicines
to improve Syrian refugee health, including increasing
they needed.
work opportunities, permitting refugees to visit
family members in Syria, and increasing recreational The poor quality drinking water that reportedly
programmes for children. Although according to this causes health problems was the primary concern that
respondent type most of these needs were not met, they characterized respondent type 3. The fourth respondent
were ambivalent about the need to train local doctors type believed that high quality, free education was lacking
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for Syrian children and this exacerbated their mental facilitate and allow for a larger number of refugees to
health problems. They supported expanding recreational work legally in Jordan.
programmes for youth and social interventions to Differences between refugees living inside versus
address domestic and sexual abuse. outside refugee camps
Refugees living outside of camps emphasized financial
Discussion constraints to health care access, attributing their limited
Health care providers and Syrian refugees highlighted financial resources to their inability to work legally.
the high burden of chronic disease in this population, This is consistent with findings from other studies
which is consistent with the World Health Organization in Jordan (27) and among refugees worldwide (29), as
data from Syria (15) and studies regarding Syrian refugees urban refugees must often make difficult decisions
(16–20). Participants also identified the high smoking between housing, health care and basic necessities.
prevalence among Syrian refugees as a major contributor Meanwhile, camp-based refugees emphasized living and
to the increase in chronic conditions. These findings security conditions in the camps as major concerns and
suggest relief efforts should increase emphasis on the mentioned domestic and sexual violence more than their
prevention and management of chronic diseases in order counterparts living in urban areas. Security concerns and
to tailor the response to the burden of disease in this poverty in the camps were cited as reasons for increased
population (21,22). rates of early marriage. Employment of Syrian doctors
Many of the Syrian refugee participants expressed to care for patients in the camps may simultaneously
that the lack of transportation was an issue when trying ease the burden on Jordanian physicians while providing
to access care, especially for after-hour emergencies. Also, employment opportunities for this specific group of
the changing policies about which clinics and hospitals Syrians (30).
offer subsidized care for Syrian refugees affected access During the focus group discussions, many Syrian
to care. refugee participants welcomed mental health services
Livelihoods and emphasized financial concerns as a primary source
Financial problems emerged as a central theme in focus of stress. Psychological stress was also identified as a
groups with refugees. Refugee participants questioned driver of domestic violence. Participants emphasized
the UNHCR beneficiary selection criteria through which recreational activities for children were important
only 23 000 Syrian families, a small percentage of the for their mental health. Health care providers and
Syrian population in Jordan, receive aid (23,24). As seen in participants in the Q-method felt that community
this study, access to food, medicines and free education education programmes were needed to combat mental
was a concern of the majority of the participating health stigma and develop more effective and acceptable
Syrian refugees in Jordan. As the Syrian crisis persists, interventions.
displaced Syrian families are exhausting their savings Jordanian health care providers
and becoming even more vulnerable (25). Employment Discussions with health care providers and key
for Syrian refugees in Jordan and across the region would informants from UNHCR, the Jordanian Ministry of
help them meet their own needs, as well as restore their Health and nongovernmental organizations underscored
dignity and mitigate some of the social tensions with the need for health education services targeting
host populations (25). smoking cessation, chronic disease risk prevention and
As reported in the focus group discussions, cost was management, and mitigating mental health care stigma.
the primary barrier to accessing care. This situation is In contrast to Syrian refugees who described experiences
similar to other neighbouring countries hosting Syrian of discrimination or inhumane treatment even at times
refugees such as Lebanon and Turkey (22,26). According to in health care settings, Jordanian health care providers
refugees in both camp and urban settings, it is particularly emphasized the hospitality with which Syrian refugees
difficult to access secondary or tertiary care, as previously were received in the health care system. A growing body
described in the literature (27). The limited ability to work of quality improvement literature demonstrates that
legally – due to the restricted number and high cost of patients are more likely to comply with treatment if their
work permits – is a great threat to livelihoods. Migrant interaction with a health care provider is positive (31).
families reported coping with this situation by working Thus, patient perceptions of clinician attitudes will likely
illegally, such as women cooking at home and selling have concrete public health consequences and should be
food or men working in construction. While limited prioritized.
resources necessitate prioritization, the policy to only
cover hospitalization or tertiary care for life-threatening Study limitations
illnesses may ultimately lead to increased future health All the participants were recruited by convenience
costs. High costs also prompt Syrian refugees to seek care sampling, which may limit the representativeness of the
from pharmacists, which may leave chronic conditions study sample and the generalizability of our findings.
uncontrolled and even promote antimicrobial resistance Locating and recruiting Syrian refugees living in urban
(28). All discussions with health care providers, key areas is a complex and lengthy process as they frequently
informants and refugees revolved around the need to migrate throughout the country searching for work.
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Individuals with strong opinions about health care identified cost as the most significant barrier to health
and with health needs may have been more likely to care access, seeing increased livelihood opportunities
participate. Nevertheless, our study sampled groups in as a potential solution to this problem. Perceived unfair
diverse geographical areas with the highest concentration aid distribution, discrimination and tensions with
of Syrian refugees in Jordan. host communities were common complaints of Syrian
refugees that reportedly adversely affected their health.
Conclusion Local and international policies concerned with
This study integrated qualitative and quantitative refugee health could benefit from these findings and from
methodologies to present the priorities of Syrian refugees, this multilayered approach to prioritizing needs. Future
key stakeholders and Jordanian health care providers research exploring refugee coping mechanisms could
related to the health of refugees in Jordan. All parties be conducted. This study may also lay the foundation
emphasized chronic disease and mental health as the for further research on approaches to most effectively
main problems facing this population. Syrian refugees address refugee social, clinical and public health needs.
Funding: None.
Besoins et priorités sanitaires des réfugiés syriens dans les camps et en milieu urbain
en Jordanie : perspectives des réfugiés et des prestataires de soins de santé
Résumé
Contexte : Les Nations Unies ont déclaré la crise des réfugiés syriens comme étant la plus importante situation d’urgence
humanitaire de notre ère. Les pays voisins, comme la Jordanie, s’efforcent péniblement de répondre aux besoins sanitaires
des réfugiés en plus de leurs propres citoyens, du fait des ressources limitées.
Objectifs : La présente étude visait à déterminer les perspectives des réfugiés syriens en Jordanie, des prestataires de
soins de santé jordaniens et d’autres parties prenantes en prenant en compte les questions de santé publique liées à la
crise des réfugiés.
Méthodes : Des méthodologies qualitatives et quantitatives ont été utilisées pour explorer les besoins sanitaires des
réfugiés syriens et les services de santé qui leur sont destinés dans les camps et en milieu urbain en Jordanie. Des groupes
de discussion et des entretiens auprès des principaux informateurs ont été utilisés pour identifier les besoins, les défis
et les solutions potentielles afin de fournir des soins de santé de qualité aux réfugiés. L’analyse factorielle par individu a
divisé les participants réfugiés en quatre types uniques de répondants et a comparé les priorités pour les interventions.
Résultats : Les discussions de groupes et les entretiens avec les principaux informateurs ont mis en évidence de nombreux
problèmes différents. Le coût, les ressources limitées, les changements de politiques, les moyens de subsistance et les
faibles connaissances en matière de santé venaient entraver la prestation de services de santé publique et clinique. Les
répondants de type 1 soulignaient l’importance des changements de politiques pour améliorer la santé des réfugiés
syriens. Ceux du type 2 ont mis en évidence l’accès à des aliments frais et aux activités récréatives pour les enfants. Pour
le type 3, la mauvaise qualité de l’eau de boisson était la principale préoccupation, et le type 4 pensait que l’absence de
bonne éducation, gratuite, pour les enfants syriens exacerbait leurs problèmes de santé mentale.
Conclusions : Les réfugiés syriens ont identifié le coût comme obstacle principal à l’accès aux soins de santé. Les réfugiés
tout comme les prestataires de soins de santé ont souligné l’importance d’attribuer davantage de ressources aux maladies
chroniques et à la santé mentale.
‫ وجهات نظر الالجئني‬:‫االحتياجات واألولويات الصحية لالجئني السوريني يف املخيامت واملناطق احلرضية يف األردن‬
‫ومقدمي الرعاية الصحية‬
‫ برت نيلسون‬،‫ الرا جريمانوس‬،‫ ذاكر الشوابكة‬،‫تاال الروسان‬
،‫ مثل األردن‬،‫ وتتحمل البلدان املجاورة‬.‫ أعلنت األمم املتحدة أن أزمة الالجئني السوريني تشكل أكرب حالة طوارئ إنسانية يف العرص احلايل‬:‫اخللفية‬
.‫ال عن مواطنيها يف ظل شح مواردها‬ ً ‫ضغوط ًا من أجل تلبية االحتياجات الصحية لالجئني السوريني فض‬
‫ وسائر أصحاب‬،‫ ومقدّ مي الرعاية الصحية األردنيني‬،‫ متثل اهلدف من هذه الدراسة يف حتديد وجهات نظر الالجئني السوريني يف األردن‬:‫األهداف‬
.‫املصلحة يف التصدي لقضايا الصحة العامة املرتبطة بأزمة الالجئني‬
251
Book 24-03.indb 251 13/06/2018 09:44:05

‫ استخدمت منهجيات بحث كمية وكيفية الستكشاف االحتياجات الصحية لالجئني السوريني واخلدمات الصحية املتاحة يف‬:‫طرق البحث‬
‫مركزة ومقابالت مع مستجيبني رئيسيني لتحديد االحتياجات والتحديات‬ ّ ‫وأجريت مناقشات مجاعية‬ ُ .‫املخيامت واملناطق احلرضية يف األردن‬
ُ .‫واحللول املحتملة لتوفري رعاية صحية ذات جودة لالجئني‬
‫ أنواع فريدة من‬4 ‫وأجري حتليل عوامل شخيص أدى إىل تقسيم املشاركني الالجئني إىل‬
.‫املستجيبني ومقارنة أولويات التدخل‬
‫وتبي أن ارتفاع التكلفة‬ ّ ‫ كشفت املناقشات اجلامعية‬:‫النتائج‬
ّ .‫املركزة واملقابالت التي أجريت مع املستجيبني الرئيسيني عن مشكالت كثرية وخمتلفة‬
‫ وأكد‬.‫ونقص املوارد وتغري السياسات وسبل العيش وضعف اإلملام بأساسيات املعرفة الصحية تعوق توفري اخلدمات الصحية العامة والرسيرية‬
‫ وأبرز النوع الثاين أمهية الوصول إىل األغذية الطازجة‬.‫النوع األول من املستجيبني أمهية تغيري السياسات لتحسني صحة الالجئني السوريني‬
‫ ورأى النوع الرابع أن االفتقار إىل‬،‫ يف حني أشار النوع الثالث إىل أن الشاغل األسايس هو ضعف جودة مياه الرشب‬.‫واألنشطة الرتفيهية لألطفال‬
.‫التعليم اجليد واملجاين لألطفال السوريني يؤدي إىل تفاقم مشكالت الصحة النفسية لدهيم‬
‫ وأكد الالجئون ومقدمو‬.‫ حدد الالجئون السوريون التكلفة باعتبارها العائق الرئييس الذي حيول دون الوصول إىل الرعاية الصحية‬:‫االستنتاجات‬
ٍ ‫الرعاية الصحية عىل‬
.‫حد سواء أمهية توجيه مزيد من املوارد لعالج األمراض املزمنة ومشكالت الصحة النفسية‬
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17. Gammouh OS, Al-Smadi AM, Tawalbeh LI, Khoury LS. Chronic diseases, lack of medications, and depression among Syrian refu-
gees in Jordan, 2013-2014. Prev Chronic Dis. 2015 01 29;12:E10. http://dx.doi.org/10.5888/pcd12.140424 PMID:25633485
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org/10.1016/S2213-8587(14)70196-2 PMID:25466522
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Confl Health. 2015 04 9;9(1):12. http://dx.doi.org/10.1186/s13031-014-0029-y PMID:26056531
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21. Krause S, Williams H, Onyango M, Sami S, Doedens W, Giga N, et al. Reproductive health services for Syrian refugees in Zaatri
Camp and Irbid City, Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package. Confl Health. 2015
Feb 2;9(Suppl 1 Taking Stock of Reproductive Health in Humanitarian):S4. doi: 10.1186/1752-1505-9-S1-S4 PMID: 25798190
22. Cousins S. Syrian crisis: health experts say more can be done. Lancet. 2015 Mar 14;385(9972):931–4. http://dx.doi.org/10.1016/
S0140-6736(15)60515-3 PMID:25784334
23. Balsari S, Abisaab J, Hamill K, Leaning J. Syrian refugee crisis: when aid is not enough. Lancet. 2015 Mar 14;385(9972):942–3.
http://dx.doi.org/10.1016/S0140-6736(15)60168-4 PMID:25748614
24. Sundelin G. Iris-scanning technology streamlines refugee registration process—UNHCR. Jordan Times. 21 July 2013.:21.
25. United Nations High Commissioner for Refugees, United Nations Development Program, United Nations Development Group.
3RP regional refugee and resilience plan in response to the Syria crisis. Regional Strategic Overview. 2015-2016 (http://www.3rp-
syriacrisis.org/wp-content/uploads/2015/01/3RP-Report-Overview.pdf, accessed 6 November 2017). .
26. Gornall J. Healthcare for Syrian refugees. BMJ. 2015 08 4;351:h4150. http://dx.doi.org/10.1136/bmj.h4150 PMID:26243793
27. Ay M, Arcos González P, Castro Delgado R. The Perceived Barriers of Access to Health Care Among a Group of Non-camp Syrian
Refugees in Jordan. Int J Health Serv. 2016 07;46(3):566–89. http://dx.doi.org/10.1177/0020731416636831 PMID:26962004
28. Byarugaba DK. A view on antimicrobial resistance in developing countries and responsible risk factors. Int J Antimicrob Agents.
2004 Aug;24(2):105–10. http://dx.doi.org/10.1016/j.ijantimicag.2004.02.015 PMID:15288307
29. Hynie M. Life on the edge. Science. 2016;351(6272):444–5. http://dx.doi.org/10.1126/science.aad8525
30. Arie S. Syrian doctors risk arrest and deportation for treating fellow refugees in Lebanon and Jordan. BMJ. 2015 03
23;350(8001):h1552–1552. http://dx.doi.org/10.1136/bmj.h1552 PMID:25801194
31. Bowling A. Research methods in health: investigating health and health services. UK: McGraw-Hill Education; 2014.
253
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Screening for dysglycaemia using anthropometric indices in an adult

population in Oman
Shyam Sundar Ganguly,1 Kamalesh Sarkar,2 Samir Al-Adawi3 and Abdul Aziz Al-Mahrezi1
Department of Family Medicine and Public Health; 3Department of Behavioural Medicine, College of Medicine & Health Sciences, Sultan Qaboos
1
University, Muscat, Oman (Correspondence to: Shyam Ganguly: [email protected]). 2Division of Epidemiology, National Institute of Cholera and
Enteric Diseases, Kolkata, India.
Abstract
Background: A previous community-based cross-sectional survey conducted in a semi-urban community revealed that
44% of people aged 18+ years manifest dysglycaemia, which appears to echo the national trend. There is lack of studies
examining the role of anthropometric indices in people with dysglycaemia.
Aim: We explored the screening ability of anthropometric indices, body mass index (BMI), waist circumference (WC),
waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) to detect dysglycaemia in the adult Omani population based
on a community-based survey conducted in 2005. The potential of anthropometric indices to detect the presence of
glycaemic disorder could aid in detection, prevention and health education.
Methods: A total of 480 male and 795 female subjects aged 18+ years were included in this study. The prevalence of
dysglycaemia was analysed using the American Diabetic Association criteria. Logistic regression approach and Receiver-
Operating Characteristic (ROC) curve analysis was performed.
Results: The analysis revealed that mean values of age, BMI, WC, WHR and WHtR increased significantly from
normoglycemic to pre-diabetic and further to diabetic in both sexes (P<0.0001). Dysglycemia showed an increasing
prevalence with age. WHtR showed the highest sensitivity for detecting dysglycemia in all age groups compared to other
anthropometric indices with sensitivity rate of 94.4% in ≥45 years, 88.6% in (25- 44) years and 45.6% in age group <25 years.
Conclusion: Among the anthropometric indices we investigated, WHtR was the best predictor of dysglycaemia among
Omani adults aged > 25 years.
Key words: Anthropometric measurements, Dysglycemia, Diabetes, ROC Curve
Citation: Ganguly SS; Sarkar K; Al-Adawi S; Al-Mahrezi A. Screening for disglycaemia using anthropometric indices in an adult population in Oman.
East Mediterr Health J. 2018;24(3):254–261. https://doi.org/10.26719/2018.24.3.254
Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license https://
creativecommons.org/licenses/by-nc-sa/3.0/igo
Introduction dysglycaemia. In the available literature, various

phenotypical indicators have been linked to the presence
Oman has been internationally praised for the fulfilment
of dysglycaemia. In Western population, body mass
of most of the Millennium Development Goals 2015 (1),
index (BMI) has been associated with the presence
however, along with the challenge of communicable
of dysglycaemia (11). The World Health Organization
diseases, there is an increasing challenge from
has provided guidelines for using BMI to assess
noncommunicable diseases, and diabetes appears to be
dysglycaemia with a cut off value of 25 kg/m2 (12). It
prominent, precipitated by rapid urbanisation and rising is not clear whether this is applicable to the Omani
standards of living (2,3). According to 2000 data from the population. Waist circumference (WC) and waist-to-hip
Ministry of Health, the prevalence of diabetes was 11.6%, ratio (WHR) have also been suggested as indicators of
rising to 12.3% in 2010 (4,5). Approximately 29% of the intra-abdominal fat. Some studies have suggested that
Omani population was classed as overweight and 9% as WC and WHR are better predictors of dysglycaemia than
obese (6). In a population-based national survey 22% of BMI (13–15). There is also a dissenting view suggesting
those surveyed were overweight or obese (7). Obesity and the relationship between WHR and dysglycaemia is poor.
overweight are recognised as independent risk factors Some preliminary data suggest that WHR correlates more
for the development of diabetes and dysglycaemia (8,9). weakly with glucose tolerance; sex is also a significant
In a 2010 community-based cross-sectional study, 35% confounding factor (16). A few studies have reported that
of the Omani men were prediabetic; advanced age and waist-to-height-ratio (WHtR) is a better screening tool
being overweight were identified as strong contributing than other anthropometric indices, with a cut off value
factors (10). of 0.5 (17,18). Against such a conflicting background, more
Within the emerging epidemic of dysglycaemia, studies are needed to determine the correlation between
more studies are needed to identify anthropometric anthropometric measures and dysglycaemia. This would
characteristic that would have a direct bearing on help to detect dysglycaemia cases early among apparently
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healthy people, and, in turn, mitigate morbidity and the laboratory of Sultan Qaboos University Hospital
mortality. This study aims to explore the screening according to the standard protocol. Height and weight
capacity of anthropometric indices to adequately detect were measured using a stature meter and high precision
dysglycaemia in adult Omani population. digital weighing machine with regular accuracy checks.
Weight/height was taken in a standing posture, wearing
Methods light clothing and without shoes. The BMI was calculated
as weight/height2 (kg/m2) and individuals with BMI ≥ 25
Survey
kg/m2 were considered overweight. Waist circumference
In this study, we used the data from a cross-sectional, was measured using a steel measuring tape with
community-based survey carried out on 1275 Omani measurements made half way between the lower border
adults, aged ≥ 18 years, residing in a semi-urban satellite of the ribs and the iliac crest in a horizontal plane. A value
town of Bidbid, which is situated 30 km west of the capital, of ≥ 94.0 cm for males and ≥ 80.0 cm for females (the
Muscat, during September 2004 to February 2005. cut-off values recommended for Eastern Mediterranean
The following exclusion criteria were used: and Middle Eastern Arab populations) was considered
participants with diabetics who were taking medication overweight (abnormal) (21). Similarly, hip circumference
or insulin for the disease; pregnant women or mothers was measured at the widest point over the buttocks and
within 3 months postpartum; and people with conditions the waist-to-hip ratio (WHR) was calculated; WHR ≥ 0.95
that were likely to interfere with research procedures, e.g. cm for males and ≥ 0.85 cm for females was considered
inability to communicate with staff or having a persistent abnormal (22,23). Waist-to-height ratio (WHtR) was also
and intransigent illnesses. calculated for each individual and if the ratio was ≥ 0.5,
Sample design and participants then the individual was considered as having abnormal
central obesity (24).
A sample size of 1500 subjects was determined based on
Dysglycaemia or glycaemic disorder is an age-
the estimated prevalence of prediabetes (36%) (10) and
dependent phenomenon and magnitude of problem
diabetes (12.3%) (4), a nonresponse rate of 10%, an error
usually remains low in young adult, medium in middle
margin of 5% with 95% confidence interval. We adopted
aged and high in older age group as observed in several
a 2-stage random cluster sampling design. The first stage
studies (25,26). On the other hand, sensitivity of a
was the random selection of census enumeration areas,
screening test is influenced by the prevalence of disease
where each area comprised 100 households as defined
under investigation in a community (27). Considering
by the Ministry of National Economy. Out of 100 census
the above, age-related prevalence of dysglycaemia
enumeration areas, 20 were randomly selected using a
random number allocation method. A sampling frame was analysed. Following this, sensitivity analysis of
of 6150 subjects was developed by conducting a census dysglycaemia using various anthropometric indices
among the 20 randomly selected areas. The name, family (BMI, WC, WHR and WHtR) was done for each age
name, sex, age, household and locality of all eligible group to obtain the sensitivity status. This was also
subjects was recorded on field maps. In the second stage, done to understand whether the anthropometric tool
1500 subjects were randomly selected from the sampling could be uniformly applicable to all age groups so far as
frame using computer generated random numbers. sensitivity was concerned. If not, a possible cut-off value
All persons aged ≥ 18 years in the selected households was expected to be explored based on sensitivity status.
were invited to participate in the study. Of these, 1275 Finally, the receiver operating characteristic curve was
completed the structured pre-tested questionnaire, an developed for the indices based on the findings of age
overall response rate of 85%. group sensitivity to obtain the test accuracy in subjects
with values below and above the cut-off (28). Receiver
Anthropometric and laboratory measurements operating characteristic curves were used to determine
Blood glucose (both fasting and post-prandial, 2 hours the predictive power of various anthropometric indices
following ingestion of 75 g glucose) was collected from for glycaemic status by comparing areas under the curve.
the venous blood at sodium fluoride potassium oxalate The Medical Research and Ethics Committee of the
tubes and tested at the laboratory after separating plasma College of Medicine and Health Sciences, Sultan Qaboos
on the same day, using Hitachi 911 automated clinical University, approved the study. All participants gave their
chemistry analysers (Boehringer–Mannheim). The written informed consents prior to participating in the
reagents used were supplied by the same manufacturer. study.
Glycaemic status according to the American Diabetes
Association (ADA) criteria was used: < 5.6 mmol/L fasting Statistical analysis
normal, 5.6–6.9 mmol/L impaired fasting glucose and Descriptive analysis for continuous variables was used to
≥ 7.0 mmol/L diabetes mellitus (19,20). Dysglycaemia was calculate mean values and standard deviation. Prevalence
defined as a subject having fasting plasma glucose ≥ 5.6 and frequencies were expressed as percentages. The
mmol/L (100 mg/dL) and/or impaired glucose tolerance differences in means of the anthropometric indices and
of ≥ 7.8 mmol/L (140 mg/dL) including prediabetes and age between the 3 glycaemic categories were assessed
diabetes. The fasting plasma glucose and oral glucose using 1-way analysis of variance (ANOVA). Where there
tolerance levels were estimated from venous blood at was a lack of homogeneity of variance, the Kruskal–Wallis
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Book 24-03.indb 255 13/06/2018 09:44:05

test was used to compare the distributions between the diabetes mellitus. An average male appears to have had
3 glycaemic categories. When ANOVA provided evidence a gap of 5 years prior to development of diabetes from
of significant difference between the groups, a post-hoc the prediabetic status, while females took about 7 years
test, Dunnett’s T3 test was used for pair-wise comparison to reach full-blown symptoms. A similar observation
of the means. was noted for developing impaired fasting glucose
To establish the relationship between anthropometric from normoglycaemic status: for males the average gap
indices of obesity and glycaemic status, odds ratios and was 4 years but for females it was about 7 years. This
their 95% confidence intervals were estimated using indicates that diabetes progresses more slowly and at an
logistic regression models, after adjusting for age (29). older age in females. These differences were statistically
The chi-squared trend test was used for trend analysis significant (P < 0.05). Mean values of BMI, WC, WHR and
for percentages of sensitivity and specificity across WHtR differed significantly from normoglycaemic to
the age groups. P-value (2-tailed) < 0.05 was considered impaired fasting glucose and further to diabetes in both
statistically significant. All data were analysed using sexes (Table 1).
SPSS, version 23. Overall prevalence of dysglycaemia was 44.1%
(combining all ages and both sexes) (Table 2). It is evident
Results that the prevalence of dysglycaemia increased in both
A total of 480 males and 795 females aged ≥ 18 years sexes with age. Prevalence in males was 49.4% and in
consented to participate in this study. Table 1 shows females 40.9%; prevalence was slightly lower in females
mean values for various anthropometric indices in each age group compared to their male counterparts
according to glycaemic status. The mean age for both except for the ≥ 45 years group. This indicates that
normoglycaemic males and females was similar, around diabetes is an age-dependent condition for both sexes.
29 years, but mean age of females was slightly older for It is evident that older age, BMI ≥ 25 kg/m2, WC
both types of dysglycaemia, impaired fasting glucose and ≥ 94.0 (male)/≥ 80.0 (female), WHR ≥ 0.95 (male)/≥ 0.85
Table 1. Anthropometric indices in relation to glycaemic status for male and female adults in Oman, 2004-2005
Index Normoglycaemic Dysglycaemic

Mean (SD) 95% CI IFG DM
Mean (SD) 95% CI Mean (SD) 95%CI
Males (No.) 258 – 195 – 27 –
Age (years) 29.20 (10.94) 27.86–30.55 33.84 (12.99) a
32.00–35.67 38.63 (11.25) b
34.18–43.08
BMI (kg/m2) 24.67 (4.50) 24.12–25.23 26.22 (4.74)a 25.55–26.88 28.77 (4.85)b 26.76–30.77
WC (cm) 85.33 (11.39) 83.92–86.73 90.14 (11.42) a
88.54–91.75 94.88 (10.95) b
90.46–99.31
WHR 0.88 (0.06) 0.87–0.89 0.91 (0.07)a 0.89–0.92 0.94 (0.05)b,c 0.92–0.96
WHtR 0.51 (0.07) 0.50–0.52 0.54 (0.07) a
0.53–0.55 0.58 (0.06) b,c
0.55–0.60
Females (No.) 504 – 258 – 33 –
Age (years) 29.17 (9.69) 28.32–30.02 36.26 (11.84) a
34.79–37.73 43.81 (13.01) b,c
39.12–48.50
BMI (kg/m2) 24.65 (5.20) 24.19–25.10 27.99 (6.16)a 27.23–28.74 29.98 (6.41)b 27.70–32.25
WC (cm) 78.80 (12.67) 77.70–79.91 88.58 (13.99) a
86.86–90.29 97.24 (13.89) b,c
92.32–102.17
WHR 0.82 (0.09) 0.81–0.82 0.88 (0.09)a 0.87–0.89 0.96 (0.08)b,c 0.93–0.99
WHtR 0.51 (0.08) 0.05–0.52 0.58 (0.09) a
0.57–0.59 0.64 (0.09) b,c
0.61–0.67
P-value (ANOVA) < 0.001 for all.
CI = confidence interval; IFG = impaired fasting glucose; DM = diabetes mellitus; SD = standard deviation; BMI = body mass index; WC = waist circumference; WHR = waist-to-hip-ratio; WHtR
= waist-to-height-ratio.
a
P < 0.01 for normoglycaemic versus IFG.
b
P < 0.01 for normoglycaemic versus DM.
c
P < 0.05 for IFG versus DM.
Table 2. Age and sex distribution of Omani adults with dysglycaemia, 2004-2005
Age (years) No. of males Dysglycaemia No. of females Dysglycaemia Total screened Dysglycaemia
screened No. (%) screened No. (%) No. (%)
< 25 164 58 (35.4) 245 59 (24.1) 409 117 (28.6)
25–44.9 250 135 (54) 461 202 (43.8) 711 337 (47.4)
≥ 45 66 44 (66.7) 89 64 (71.9) 155 108 (69.7)
Total 480 237 (49.4) 795 325 (40.9) 1275 562 (44.1)
256
Book 24-03.indb 256 13/06/2018 09:44:05

(female) and WHtR ≥ 0.5 are significantly associated with were calculated separately for each age group.
dysglycaemia (P < 0.001) (Table 3). For all 4 anthropometric Individually WHtR showed the highest sensitivity for
indices, females were at comparatively greater risk of detecting dysglycaemia for all age groups: 94.4% in
developing dysglycaemia compared with males. the oldest age group (≥ 45 years), 88.6% in the middle
The sensitivity and specificity for detecting age group (25.0–44.9 years) and 45.6% in the youngest
dysglycaemia using each anthropometric measurement age group (< 25 years) (Table 4). None of the measures
Table 3. Determinants of dysglycaemia in Omani adults, 2004-2005, based on logistic regression models adjusted for age
Index Males Females

OR 95% CI P-value OR 95% CI P-value
Age (years)
< 25 1 1
25–44 2.14 1.43–3.21 < 0.0001 2.26 1.74–3.47 < 0.0001
≥ 45 3.66 2.00–6.68 < 0.0001 8.07 4.67–13.94 < 0.0001
BMI (kg/m2)
< 25.0 1 1
≥ 25.0 2.11 1.43–3.10 < 0.0001 2.60 1.90–3.55 < 0.0001
WC (cm)
< 94.0 (M)/ < 80.0(F) 1 1
≥ 94.0 (M)/ ≥ 80.0 (F) 2.12 1.40–3.23 < 0.0001 3.11 2.22–4.37 < 0.0001
WHR
< 0.95(M)/ < 0.85 (F) 1 1
≥ 0.95(M)/ ≥ 0.85 (F) 1.90 1.19–3.02 0.007 3.78 2.68–5.33 < 0.0001
WHtR
< 0.5 1 1
≥ 0.5 2.43 1.54–3.81 < 0.0001 2.98 2.05–4.33 < 0.0001
M = male; F = female; BMI = body mass index; WC = waist circumference; WHR = waist-to-hip ratio; WHtR = waist-to-height ratio.
Table 4. Sensitivity and specificity of selected anthropometric indices for detecting dysglycaemia in three age groups in Omani adults
Index (cut-off) Age < 25 years Age 25–44 years Age ≥ 45 years
(n = 409) (n = 711) (n = 155)
Sensitivity
TP/ TP+FN Sensitivity % TP/ TP+FN Sensitivity % TP/ TP+FN Sensitivity %
BMI (≥ 25.0) 44/117 37.6 249/335 74.3 64/108 59.3
WC (cm) 30/117 25.6 234/335 69.8 75/108 69.4
(M ≥ 94/ F ≥ 80)
WHR 18/117 15.4 194/335 57.9 86/108 79.6
(M ≥ 0.95/ F ≥ 0.85)
WHtR (≥0.5) 52/114 45.6 288/325 88.6 101/107 94.4
BMI (≥ 25.0) and/or 54/114 47.5 291/324 89.8 101/107 94.4
WHtR (≥ 0.5)
Specificity
TN/ TN+FP* Specificity TN/ TN+FP Specificity TN/ TN+FP* Specificity
BMI (≥ 25.0) 207/289 71.6 189/373 50.6 30/47 63.8
WC (cm) 230/289 79.6 194/373 52.0 27/47 57.4
(M ≥ 94/ F ≥ 80)
WHR 261/289 90.3 239/373 64.1 23/47 48.9
(M ≥ 0.95/ F ≥ 0.85)
WHtR (≥ 0.5) 196/284 69.0 110/355 30.9 10/45 22.2
BMI (≥ 25.0) and/or 185/284 65.1 104/355 29.3 10/45 22.2
WHtR (≥ 0.5)
P-value < 0.001 for all.
TP = true positive; FN = false negative; M = male; F = female; BMI = body mass index; WC = waist circumference; WHR = waist-to-hip ratio; WHtR = waist-to-height ratio; TN = true negative;
FP = false positive.
257
Book 24-03.indb 257 13/06/2018 09:44:05

showed sensitivity ≥ 50% for detecting dysglycaemia in observations have been reported in other studies (32,33).
the age group < 25 years. Combining 2 sequential tests
It was observed that WHtR had the highest sensitivity
with BMI and WHtR to obtain a net gain in sensitivity
in the youngest age group, sensitivity increased to 47.5%, in all 3 age groups; BMI showed the second highest
1.9% above WHtR alone. sensitivity in the youngest age group and the lowest
Our analysis indicates that if dysglycaemia is sensitivity rate in the oldest age group as observed
screened for using WHtR, it would have a detecting in a similar study (34). In a study among Jordanian
ability of around 90% among those aged ≥ 25 years, but adult population, the comparison between the 4
less than 50% among those aged < 25 years. Specificity anthropometric indices was carried out for detecting
in the youngest age group was highest with WHR (90%),
metabolic abnormalities (35). The study revealed that the
followed by WC (79.6%) and BMI (71.6%). Specificity was
lower for all indices in the older age groups (Table 4). WHtR had a strong association and performed better
The areas under the receiver operating characteristic for the detection of high fasting blood glucose. The
curves for the 4 anthropometric indices at their respective estimated values of areas under the curve and odds ratios
cut-off values, i.e. are most likely to identify dysglycaemia, corresponding to WHtR were very close to the estimated
are shown in Table 5. The receiver operating characteristic values in our study.
area in those aged < 25 years are: BMI 0.551; WC 0.605;
WHR 0.640; WHtR 0.598 (Table 5). The area under the Sensitivity was 90% for WHtR in this study
ROC curve for each of the 4 anthropometric indices is population, when the 2 older age groups were combined
greater for the age group ≥ 25 years compared with < (i.e. age ≥ 25 years.). This means WHtR would detect 90%
25 years, indicating that the predictive power of each of of the dysglycaemia cases with a cut-off value of ≥ 0.5,
the 4 anthropometric indices to detect dysglycaemia is if used for community-based screening programmes
greater for the older age group.
for dysglycaemia (the cut off value for WHtR is the
same for all age groups). This means WHtR may be used
Discussion
as a screening tool for dysglycaemia in community-
Since noncommunicable diseases are on rise in almost
all countries in the region, including Oman, initiatives based screening among people aged ≥ 25 years. Other
were taken to identify some suitable anthropometric advantages of this tool are: this test is cheap and easy to
marker/s that would help in identifying the susceptible perform by health care workers once they are trained.
population at risk of developing dysglycaemia. Several Disadvantage include: lowering of sensitivity to < 50%
studies have been conducted to explore the possible role when applied to the subjects aged < 25 years. This age-
of anthropometric marker/s for dysglycaemia. Some
related change in sensitivity may be primarily due to the
indicated WHtR as a strong predictor compared to WC,
WHR and BMI (9,24,30,31). effect of increasing accumulation of visceral or intra-
As in other studies (25,26), we found the prevalence abdominal fat with older age. In an individual, height
of dysglycaemia to be significantly associated with the remains fixed but ratio between waist circumference
older age in both sexes. We attempted to highlight the and height changes. On the other hand, WC and WHR
screening ability of 4 anthropometric indices, BMI, WC, did not show a comparable sensitivity to WHtR. Thus, in
WHR and WHtR, in detecting dysglycaemia among 3
our study WHtR appears to be a better anthropometric
age groups. The study showed an association between
anthropometric measurements (BMI, WC, WHR, WHtR) predictor, which could be used for community-based
with their cut off values and dysglycaemia. Similar screening of dysglycaemia.
As indicated by the analysis of data, younger age group
(< 25 years) needs special attention as no anthropometric
Table 5. Area under the receiver operating characteristic
curves illustrating the power of the anthropometric indices in indicator showed a sensitivity ≥ 50%. In principle, if 2
predicting dysglycaemia for Omani adults in two age groups sequential screening tests are applied simultaneously,
Index Age (years) there is usually a net gain of sensitivity (36). Considering
< 25 (n = 409) ≥ 25 (n = 866) this principle, and since BMI showed the second highest
Area under 95% CI Area under 95% CI sensitivity in the youngest age group, BMI was combined
the curve the curve
with WHtR, resulting in a slight increase in sensitivity.
BMI 0.551 0.488–0.613 0.655* 0.618–0.691
This indicates that even if both tests are combined, this
WC 0.605* 0.544–0.666 0.685* 0.650–0.720
would not be able to detect even 50% of the individuals in
WHR 0.640* 0.580–0.701 0.694* 0.659–0.729
that age group with dysglycaemia. Consequently, finding
WHtR 0.598* 0.537–0.659 0.686* 0.651–0.721
a suitable screening tool for younger population poses a
*P < 0.01.
CI = confidence interval; BMI = body mass index; WC = waist circumference; WHR =
public health challenge and efforts must be continued to
waist-to-hip ratio; WHtR = waist-to-height ratio. find a suitable predictor.
258
Book 24-03.indb 258 13/06/2018 09:44:05

Acknowledgements
The authors would like to thank the participants as well as other research workers who contributed to the outcomes of
this study.
Funding: This study is a part of the AMAL Research Project supported by His Majesty Sultan Qaboos Strategic Research
Trust Fund (Grant SR/MED/FAMCO/03/01) from Sultan Qaboos University.
Dépistage de la dysglycémie au moyen d’indices anthropométriques dans une

population d’adultes à Oman
Résumé
Contexte : Une enquête transversale communautaire précédemment réalisée dans une communauté semi-urbaine a
révélé que 44 % des personnes de plus de 18 ans présentaient une dysglycémie, ce qui semble correspondre à la tendance
nationale. Il n’existe pas d’études permettant d’examiner le rôle des indices anthropométriques chez les sujets atteints de
dysglycémie.
Objectif : Nous avons exploré la capacité diagnostique des indices anthropométriques, de l’indice de masse corporelle  (IMC),
du tour de taille, du rapport tour de taille/tour de hanches, et du rapport tour de taille/taille pour détecter la dysglycémie
dans la population d’adultes à Oman sur la base d’une enquête communautaire réalisée en 2005. Le potentiel des indices
anthropométriques afin de détecter la présence de troubles de la glycémie pourrait contribuer au dépistage, à la prévention
et l’éducation sanitaire.
Méthodes : Au total, 480 sujets masculins et 795 sujets féminins de plus de 18 ans ont été inclus dans cette étude. La
prévalence de la dysglycémie a été analysée à l’aide des critères de l’Association américaine du diabète. On a recouru à
l’approche de régression logistique et à l’analyse de la courbe ROC (caractéristique du fonctionnement du récepteur).
Conclusion : Parmi les indices anthropométriques que nous avons étudiés, le rapport tour de taille/taille était le meilleur
prédicteur de la dysglycémie parmi les Omanais adultes âgés de plus de 25 ans.
‫فحص خلل سكر الدم لدى السكان البالغني يف ُعامن باستخدام مؤرشات أنثروبومرتية‬
‫ عبد العزيز املحرزي‬،‫ سمري العدوي‬،‫ كاماليش ساركار‬،‫شيام جانجويل‬
‫ يعانون‬،‫ فيام أكثر‬18 ‫ من السكان يف الفئة العمرية‬%44 ‫ كشف استقصاء مقطعي جمتمعي أجري يف وقت سابق يف جمتمع شبه حرضي أن‬:‫اخللفية‬
‫ وال توجد دراسات كافية لفحص دور املؤرشات األنثروبومرتية يف األشخاص‬.‫ وهو ما يعكس فيام يبدو املستوى الوطني‬،‫من خلل يف سكر الدم‬
.‫املصابني بخلل سكر الدم‬
‫ قمنا باستكشاف القدرة عىل التحري لكل من املؤرشات األنثروبومرتية ومؤرش كتلة اجلسم وحميط اخلرص و“نسبة اخلرص إىل الورك” و“نسبة‬:‫اهلدف‬
‫ ومن شأن ما تنطوي عليه‬.2005 ‫اخلرص إىل الطول” للكشف عن خلل سكر الدم لدى السكان العامنيني استناد ًا إىل استقصاء جمتمعي أجري يف عام‬
‫املؤرشات األنثروبومرتية من قدرات للكشف عن وجود اضطراب يف سكر الدم أن تساعد يف عملية الكشف عنه والوقاية منه والتثقيف الصحي‬
.‫بشأنه‬
‫ وتم حتليل انتشار خلل سكر الدم باستخدام معايري‬.18 ‫ مشاركة فوق سن‬795‫ مشارك ًا و‬480 ‫ ُأدرج يف هذه الدراسة ما جمموعه‬:‫طرق البحث‬
.‫ واستُخدم هنج االنحدار اللوجستي وحتليل منحنى خصائص التشغيل للمتلقي‬.‫مجعية داء السكري األمريكية‬
‫ ونسبة اخلرص إىل الطول قد زادت زيادة‬،‫ ونسبة اخلرص إىل الورك‬،‫ وحميط اخلرص‬،‫ ومؤرش كتلة اجلسم‬،‫ كشف التحليل أن متوسط قيم العمر‬:‫النتائج‬
‫ وظهر‬.)0.0001 < P( ‫كبرية من الرتكيز الطبيعي للجلوكوز يف الدم إىل مرحلة ما قبل السكري وإىل مزيد من املصابني بالسكري يف كال اجلنسني‬
‫ وأظهرت نسبة اخلرص إىل الطول حساسية أعىل يف الكشف عن اضطرابات‬.‫ازدياد يف انتشار اضطراب مستوى اجللوكوز يف الدم مع تقدم العمر‬
‫ يف من هم يف‬٪94.4 ‫ بمعدل حساسية بلغ‬،‫مستوى اجللوكوز يف الدم يف مجيع الفئات العمرية مقارنة بمؤرشات القياسات األنثروبومرتية األخرى‬
.‫ سنة‬25 ‫ يف الفئة العمرية دون عمر‬٪45.6‫ و‬،‫ سنة‬25-44 ‫ يف الفئة العمرية‬٪88.6‫ و‬،‫ سنة أو أقل‬45 ‫عمر‬
َّ ،‫ من بني املؤرشات األنثروبومرتية التي استقصيناها‬:‫االستنتاج‬
‫شكل مؤرش “نسبة اخلرص إىل الورك” أفضل منبئ خللل سكر الدم لدى البالغني‬
.‫ عام ًا وما أكثر‬25 ‫العامنيني يف الفئة العمرية‬
259
Book 24-03.indb 259 13/06/2018 09:44:06

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261
Book 24-03.indb 261 13/06/2018 09:44:06

Burnout among primary school teachers in Iraq: prevalence and risk

factors
Jasim Al-Asadi 1, Shukrya Khalaf 1, Aqeel Al-Waaly 2, Alaa Abed 3 and Sabah Shami 4
1
Community Medicine Department, College of Medicine, Basrah University, Basrah, Iraq (Correspondence to: Jasim N. Al-Asadi: [email protected]).
2
College of Medicine, Missan University, Amarah, Iraq. 3Community Medicine Department, College of Medicine, Thi-Qar University, Nasiriyah, Iraq.
4
Basrah General Health Directorate, Basrah, Iraq.
Abstract
Background: Studies from various parts of the world have shown that teachers are likely to suffer from burnout. So far,
there has been no research on burnout among primary school teachers in Basrah, Iraq.
Aim: We aimed to determine the prevalence and predisposing factors of self-reported burnout among primary school
teachers in Basrah.
Methods: This was a cross-sectional study in 32 governmental primary schools during November 2014–February 2015.
A self-administered questionnaire was used to collect sociodemographic and work-related data using the Oldenburg
Burnout Inventory.
Results: Of 800 questionnaires distributed, 706 (88.3%) were completed; 58.4% were from women. The prevalence of
burnout was 24.5% (95% CI: 21.5–27.8). A statistically significant association was found between burnout and age, sex
and marital status. Work-related factors that showed significant association with burnout were: work overload, problems
related to career advancement, high number of students per class and student misbehaviour.
Conclusion: Burnout is an important health problem among primary school teachers in Basrah. A number of risk factors,
particularly those related to work, are amenable to modification since they are related to the education policy.
Keywords: Basrah, burnout, prevalence, teachers
Citation: Al-Asadi J; Khalaf S; Al-Waaly A; Abed A; Shami S. Burnout among primary school teachers in Iraq: prevalence and risk factors. East Mediterr
Health J. 2018;24(3):262–268. https://doi.org/10.26719/2018.24.3.262
Introduction Therefore, it becomes extremely important to

investigate not only the sources or predictors of burnout
The concept of professional burnout was first described
but also their relationships. A considerable amount of
in the mid-1970s, referring to “emotions of depletion
information can be found on burnout and its related
and loss of motivation and commitment that social
factors among school teachers in many countries,
workers experience after prolonged and extensive stress
however, there is no known research on burnout among
conditions” (1,2). Shortly afterwards, it was characterized
primary school teachers in Basrah, Iraq. In this study, we
in detail by Maslach and Jackson (3) as a syndrome of
aimed to determine the level of self-reported burnout
excessive emotional load, or burnout, comprising a set of
and the main sources of burnout among primary school
emotional and physical responses to chronic work stress.
teachers in Basrah.
Teaching stress is a prevalent and well confirmed
problem (4). Job dissatisfaction and burnout among Methods
teachers can have personal implications such as
absenteeism and decline in performance and productivity, Study design
and a negative effect on students’ outcome (5). This was a cross-sectional study carried out in Basrah
Risk factors for burnout among teachers may City during the period November 2014–February 2015.
be organizational, such as work pressure, student The study was approved by the Research and Ethics
misbehaviour (6), role stress (7), lack of support from Committee of the College of Medicine, Basrah University.
peers and supervisors (8), school rules and type (private Participants
or governmental), school location (9) and financial
The study population included governmental primary
considerations (10), or personal factors such as age, sex,
school teachers of both sexes.
marital status, years of service and self efficacy (11,12).
Survey data have indicated that both in the Western Sampling and sample size
countries and in some Eastern European countries, about The sample size was calculated assuming a prevalence
10–40% of teachers suffer from burnout (13,14), while in rate of 50%, with a precision degree of 0.05 at the 95%
Asian countries it may reach 50–70% (11). confidence level, and a design effect of 1.8 (15). Taking into
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consideration a nonresponse rate of 15%, the sample size as mean and standard deviation (SD). Logistic regression
was calculated as 795. Eight hundred teachers (15.2% out analysis was used to determine the independent
of 5250 primary school teachers in Basrah City) received predictors of burnout. Pearson’s correlation coefficient
questionnaires. (r) was calculated to determine the relationship between
Participation in the study was voluntary and job satisfaction and burnout; P < 0.05 was considered
participants were assured of the confidentiality and statistically significant.
anonymity of the survey.
Data collection Results
A self-administered questionnaire especially designed A total of 800 questionnaires were distributed; 706
for the purposes of the study was used to collect completed questionnaires were returned, a response rate
data including sociodemographic and occupational of 88.3%.
information. The survey form also included questions The mean age of respondents was 36.6 (SD 8.9; range
about student misbehaviour, in-service training, career 20–63) years, 58.4% of them were women. The majority
advancement, salaries, distance from school to residence, (89.8%) were classroom teachers, and 36.7% had teaching
professional relationship, years of service, workload experience of > 15 years (Table 1).
and job satisfaction. Student misbehaviour was defined
The mean of the total burnout scores was 38.9 (SD 5.6),
as “those behaviours involving rule-breaking, violating
implicit norms or expectations, being inappropriate while the means for the exhaustion and disengagement
in the classroom settings and upsetting teaching and subscales scores were 23.3 (SD 4.4) and 15.6 (SD 4.2)
learning (talking out of turn, disrespecting teachers, respectively. Males showed significantly higher mean
habitual failure in submitting assignments, copying burnout scores than women for the total and both
homework, lateness to class, etc.” (16). Training was subscales. The prevalence of burnout among the teachers
defined as activities to increase the knowledge, skills and was 24.5% (95% confidence interval: 21.5–27.8).
positive beliefs of teachers.
Work overload has been defined as employees’
perception that they have more work than they can Table 1. Sociodemographic and work-related characteristics of
complete within a given time (17). Job satisfaction has primary school teachers (n = 706) in Basrah, 2014/2015
been defined as a perceived relationship between what Variable No. %
one wants from one’s job and what one perceives it as Age (years)
offering (18). The teachers were asked to indicate how 20–34 326 46.2
satisfied they felt with their job. The scale of answers
35–49 298 42.2
ranged from “very satisfied” to “not at all satisfied” (19). For
≥ 50 82 11.6
statistical purposes, job satisfaction was dichotomized
into satisfied and unsatisfied. Sex
The Oldenburg Burnout Inventory (20) has been Male 294 41.6
found to be valid in different populations and can be Female 412 58.4
applied to any occupational group (21). An English version Marital status
translated into Arabic was used to measure burnout in Married 474 76.1
this study. Two independent bilingual reviewers checked Unmarried 127 18.0
the Arabic translation to ensure consistency.
Divorced/widowed 105 14.9
The Oldenburg Burnout Inventory includes 2 No. of children
subscales: exhaustion and disengagement. It exhibits
0 139 19.7
good test–retest reliability and internal reliability (α
1–3 276 39.1
> 0.80) for both subscales (20). Each subscale includes 4
positively worded and 4 negatively worded items that are >3 291 41.2
scored on a 4-point Likert scale from 1 “strongly agree” Job responsibility
to 4 “strongly disagree”. After reverse scoring of the Classroom teacher 634 89.8
negatively worded items, the average was calculated for Administration 72 10.2
each subscale, with higher scores indicating higher level Years of service
of burnout. The cut-off score above the 75th percentile on
1–5 186 26.3
both subscales was considered as burnout.
6–10 170 24.1
Statistical analysis
11–15 91 12.9
The statistical analysis was made using SPSS, version > 15 259 36.7
19. Frequencies and percentages were calculated for the Training courses
categorical variables. Chi-squared test or Fisher’s exact
Yes 366 51.8
test were used to assess the differences between these
No 340 48.2
variables. Continuous numerical data were summarized
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Book 24-03.indb 263 13/06/2018 09:44:06

Burnout was found to be negatively related to age. problems related to career advancement, high number
It decreased with advancing age and the difference was of students per class and student misbehaviour were the
highly significant (P < 0.001). Sex was also significantly work-related independent risk factors (Table 4).
associated with burnout: men showed a higher Only 13.5% of the teachers in our sample were
prevalence of burnout than women. Married teachers dissatisfied with their job. Burnout was negatively and
showed a significantly lower level of burnout compared significantly correlated with job satisfaction (r = –0.131,
with their unmarried, widowed or divorced counterparts. P < 0.001).
No significant association was detected between number
of children and burnout. Number of years of service was Discussion
inversely and significantly related to burnout. Teachers
who had received training courses showed a significantly This study, which is the first to examine burnout among
teachers in Basrah, showed a high rate of burnout
lower level of burnout compared with those who had no
(24.5%) among the participants. Although comparing
training courses (Table 2).
our results with those of others is not straightforward
Table 3 shows the association between work-related due to variations in sociocultural factors, occupational
factors and burnout. Work overload (P = 0.001), students’ settings or using different measures of assessment,
misbehaviour (P = 0.002), high number of students our findings are in line with those of a number of other
per class (P = 0.024), and problems related to career studies. A similar prevalence of burnout among teachers
advancement (P = 0.021) were found to be significantly was reported in studies from a number of countries,
associated with burnout. e.g. 26% in Taiwan (22), 11.6% in Sri Lanka (23) and 21% in
The logistic regression analysis showed that age, Tunisia (24). Quality of education in Iraq is declining now
marital status and sex were the only sociodemographic due to poor preparation and weak training of teachers,
independent risk factors for burnout; work overload, lack of minimum standards of teaching materials, and
Table 2. Association of burnout with selected risk factors among primary school teachers (n = 706) in Basrah, 2014/2015
Variable Burnout No burnout χ2 P-value
No. % No. %
Age (years) 15.995 < 0.001
20–34 102 31.3 224 68.3
35–49 59 19.8 239 80.2
≥ 50 12 14.6 70 85.4
Sex 16.605 < 0.001
Male 95 32.3 199 67.7
Female 78 18.9 334 81.1
Marital status 13.364 0.001
Married 97 20.5 377 79.5
Unmarried 39 30.7 88 69.3
Divorced/Widowed 37 35.2 68 64.8
No. of children 4.534 0.104
0 42 30.2 97 69. 8
1–3 70 25.4 206 74.6
>3 61 21.0 230 79.0
Job responsibility 0.011 0.918
Classroom teacher 155 24.4 479 75.6
Administrative 18 25.0 54 75.0
Years of service
1–5 62 33.3 124 66.7 15.410 0.001
6–10 45 26.5 125 73.5
11–15 21 23.1 70 76.9
> 15 45 17.4 214 82.6
Training courses 4.435 0.026
Yes 77 21.0 289 79.0
No 96 28.2 244 71.8
Total 173 24.5 533 75.5
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Table 3. Association of burnout with work-related factors among primary school teachers (n = 706) in Basrah, 2014/2015
Variable Burnout No burnout χ2 P-value
No. % No. %
Work overload 14.589 0.001
Absent 108 21.1 405 78.9
Present 65 33.7 128 66.3
Low salary 0.860 0.354
No 49 23.3 171 77.7
Yes 124 25. 5 362 74.5
Students' misbehaviour 9.563 0.002
Absent 75 19.8 303 80.2
Present 98 29.9 230 70.1
Distance from residence to school (Km) 0.081 0.770
< 10 124 24.8 376 75.2
≥ 10 49 23.8 157 76.2
High no. of students per class 5.081 0.024
No 26 17.4 123 82.6
Yes 147 26.4 410 73.6
Problems related to career advancement 5.358 0.021
Absent 95 21.6 345 78.4
Present 78 29.3 188 70.7
Problems with colleagues 0.809 0.368
Absent 131 25.4 385 74.6
Present 42 22.1 148 77.9
Total 173 24.5 533 75.5
Table 4. Logistic regression analysis of independent predictors Studies on the role of sex in prevalence of burnout
of burnout among primary school teachers (n = 706) in Basrah, have shown inconsistent results. Some studies have
2014/2015 found that male teachers were more subject to burnout
Variable B P OR 95% CI than females (31,32) and this is in accordance with our
Age –0.030 0.006 0.97 0.95–0.91 own findings. However, other studies have reported that
Marital status 0.322 0.005 1.38 1.10–1.73 female teachers experienced burnout more than males
(27,33) or that there was no difference in burnout rates
Sex (male) 0.544 0.003 1.72 1.20–2.47
(34). In a 1992 study, it was reported that men and women
Work overload 0.500 0.009 1.85 1.14–2.40
suffered burnout in similar ways but they differed in
Problems related to career 0.376 0.045 1.46 1.01–2.10 what they experienced as stressors (35). Some researchers
advancement
have attributed sex differences in burnout to the different
High no. of students/class 0.252 0.032 1.29 1.15–2.12
career expectations resulting from differences in sex
Students' misbehaviour 0.299 0.035 1.49 1.03–2.16 role socialization or to differences in the ways men and
OR = odds ratio. women cope with stress (36). It has also been suggested
CI = confidence interval. that women may have a wider range of social relationship
and support than men that can help them in coping with
deteriorating infrastructure. Furthermore, teachers are burnout (37).
demoralized and unmotivated (25), these factors together We found that married teachers showed a lower
with that studied in this study could be the reasons for rate of burnout than single teachers. The findings of
such high prevalence rate of burnout among primary previous research on this aspect are not clear-cut: some
school teachers in Basrah. studies found that single people were more susceptible
We found that younger teachers and those with to burnout (26,38) while others found no significant
fewer years of service showed a significantly higher association (39,40).
rate of burnout than their older and more experienced In agreement with many studies, we found that
counterparts; this has also been reported in other studies work-related factors played a significant role in
(26–28). Younger teachers may be more idealistic and may burnout development. Work pressure or overload was
feel inadequate and undervalued if they fail to reach their significantly related to burnout, a finding that has been
students (29,30). reported by others (41,42). In line with the findings of a
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Book 24-03.indb 265 13/06/2018 09:44:06

French study (43), high number of students per class was inferences of causality among variables. Nonresponse
significantly associated with burnout. is a particular problem affecting cross-sectional studies
Other significant sources of burnout were and can result in bias of the measures of outcome. This
student misbehaviour and problems related to career is a particular problem when the characteristics of
advancement. Similarly, Hastings et al. found that nonrespondents differ from those of respondents. In
difficulties experienced with student behaviour were
our study, the response rate was good and there is no
associated with burnout (44) and according to a study in
Kenya, lack of promotion opportunities or slow progress reason to believe that those who declined to participate
in career advancement were found to be risk factors for were systematically different from those included in the
burnout (45). study in terms of their career characteristics. Despite the
In univariate analysis, we found that number of years limitations, the results of our study are comparable to
of service was negatively and significantly associated published findings.
with burnout, but the association disappeared in
In conclusion, burnout is an important health problem
multivariate analysis, possibly due to the confounding
among primary school teachers in Basrah, and many risk
effect of age: older teachers were found to be less burnt
out than younger teachers. factors, particularly those related to work, are amenable
In accordance with the results of a study in Namibia to modification since they are related to the national
(46), we found a significant negative correlation between education policy. Therefore, there is a need for periodic
job satisfaction and burnout in teachers. psychological assessment of teachers to early detect
This study had some limitations. It was a cross- burnout and for the introduction of an intervention
sectional study, and consequently this may preclude policy to prevent its effects on job performance.
Funding: None.
Épuisement professionnel chez les professeurs des écoles primaires en Iraq :

prévalence et facteurs de risque
Résumé
Contexte : Des études issues de différentes parties du monde ont révélé que les professeurs sont exposés au risque
d’épuisement professionnel (burnout). À ce jour, aucune recherche n’a été réalisée sur l’épuisement professionnel parmi
les professeurs des écoles primaires à Bassora, en Iraq.
Objectif : La présente étude avait pour objectif de déterminer la prévalence et les facteurs prédisposant à l’épuisement
professionnel perçu par les professeurs des écoles primaires à Bassora.
Méthodes : Une étude transversale a été conduite dans 32 écoles primaires gouvernementales entre novembre 2014 et
février 2015. Un questionnaire auto-administré a été utilisé afin de recueillir des données sociodémographiques et des
informations directement liées à la profession à l’aide de l’Inventaire du burnout d’Oldenberg (OLBI).
Résultats : Sur 800 questionnaires distribués, 706 (88,3 %) ont été remplis, dont 58,4 % par des femmes. La prévalence
de l’épuisement professionnel était de 24,5 % (IC à 95 % : 21,5-27,8). Une association statistiquement significative a été
trouvée entre l’épuisement professionnel et l’âge, le sexe, et le statut marital. Les facteurs directement liés à l’activité
professionnelle ont montré une association significative avec l’épuisement professionnel quand il y avait une surcharge
de travail, des problèmes liés à l’avancement de carrière, un grand nombre d’élèves par classe et des problèmes de
comportement chez ces derniers.
Conclusion : L’épuisement professionnel constitue un problème de santé important parmi les professeurs des écoles
primaires à Bassora. Un nombre de facteurs de risque, notamment ceux directement liés à l’activité professionnelle, sont
sujets à modification étant donné qu’ils sont inhérents à la politique d’éducation.
‫ معدل االنتشار وعوامل اخلطر‬:‫اإلهناك يف أوساط معلمي املدارس االبتدائية يف العراق‬

‫ صباح شامي‬،‫ عالء عبد‬،‫ عقيل الوائيل‬،‫ شكرية خلف‬،‫جاسم األسدي‬
‫ مل جير أي بحث بشأن اإلهناك بني‬،‫ وحتى اآلن‬.‫ أظهرت دراسات أجريت يف أنحاء خمتلفة من العامل أن املعلمني معرضون لإلصابة باإلهناك‬:‫اخللفية‬
.‫معلمي املدارس االبتدائية يف البرصة بالعراق‬
266
Book 24-03.indb 266 13/06/2018 09:44:06

‫ متثل هدفنا من هذه الدراسة يف حتديد مستوى انتشار اإلهناك حسب اإلفادات الذاتية والعوامل املؤدية إليه بني معلمي املدارس االبتدائية يف‬:‫اهلدف‬
.‫البرصة‬
.2015 ‫شباط‬/‫ حتى فرباير‬2014 ‫ترشين الثاين‬/‫ مدرسة ابتدائية حكومية خالل الفرتة من نوفمرب‬32 ‫ أجريت دراسة مقطعية يف‬:‫طرق البحث‬
.‫سكانية وبيانات متعلقة بالعمل باستخدام قائمة أولدنربج لإلهناك‬-‫واستخدم استبيان جياب عليه ذاتي ًا جلمع بيانات اجتامعية‬
:CI %95( %24.5 ‫ وبلغ مستوى انتشار اإلهناك‬.‫ من نساء‬%58.4 ‫) منها؛‬%88.3( 706 ‫ استكمل‬،‫ استبيان تم توزيعه‬800 ‫ من أصل‬:‫النتائج‬
‫ وجاء من بني العوامل املرتبطة بالعمل‬.‫وتبي وجود ارتباط ذي داللة إحصائية بني اإلهناك والعمر والنوع واحلالة االجتامعية‬
ّ .)27.8 – 21.5
‫ وسوء‬،‫ وارتفاع عدد األطفال يف الفصل الدرايس‬،‫ واملشكالت املتصلة باالرتقاء الوظيفي‬،‫ فرط عبء العمل‬:‫والتي أظهرت ارتباط ًا كبريا باإلهناك‬
ً
.‫سلوك الطالب‬
،‫ ال سيام تلك املرتبطة بالعمل‬،‫ وثمة عدد من عوامل اخلطر‬.‫يشكل اإلهناك مشكلة صحية مهمة بني معلمي املدارس االبتدائية يف البرصة‬ ّ :‫االستنتاج‬
.‫يمكن تعديلها نظر ًا الرتباطها بالسياسة التعليمية‬
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268
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Relationship between lean practices, soft total quality management

and innovation skills in Lebanese hospitals
Malak Aoun1, Norlena Hasnan2 and Hassan Al-Aaraj1
School of Technology Management & Logistics, University Utara Malaysia, Malaysia (Correspondence to: M. Aoun: [email protected]).
1
Deputy Director, University Utara Malaysia, Kuala Lumpur, Malaysia.

2
Abstract
Background: Lean practices are critical to eliminate waste and enhance the quality of healthcare services through
different improvement approaches of total quality management (TQM). In particular, the soft side of TQM is used to
develop the innovation skills of employees that are essential for the continuous improvement strategies of hospitals.
Aim: The main objective was to study the relationship between lean practices, soft TQM and innovation skills in Lebanese
hospitals.
Methods: A quantitative methodology was applied by surveying 352 employees from private and public hospitals in
Lebanon. The primary collected data were valid and reliable when analysed by SPSS and AMOS software as a part of
structural equation modelling.
Results: Lean practices significantly influenced the innovation skills; however, soft TQM did not mediate this relationship
because it was not well implemented, especially at the level of people-based management and continuous improvement.
Conclusion: This study has implications for healthcare practitioners to make greater efforts to implement lean practices
and soft TQM. Future studies are suggested to highlight different challenges facing quality improvement in the Region.
Keywords: Quality managament, Lebanon, hospitals, innovation
Citation: Aoun M; Hasnan N; Al-Aaraj H. Relationship between lean practices, soft total quality management and innovation skills in Lebanese
hospitals. East Mediterr Health J. 2018;24(3):269–276. https://doi.org/10.26719/2018.24.3.269
Introduction time and correct location, while jidoka is a series of

cultural and technical issues that combines machine
In response to the technological revolution in the
and manpower together. Poka-yoke is a Japanese term
healthcare industry and to meet the quality standards
for error proofing and kanban is related to inventory and
of accreditation systems, healthcare organizations have
material management. Andon or line stop is a notification
been struggling to find innovative ways to compete,
method used to show that a problem is detected in the
decrease costs and enhance the quality of their services.
process line. Hoshin kanri is a method by which strategic
Hospitals are complex organizations with many different
goals are derived from staff inputs and it relies on
departments and they are subject to work shifts and
policy development and benchmarking. In addition, 5S
high employee turnover. This leads to shortage of skilled
workplace discipline is a major lean practice initiative
human resources and limited employee participation,
especially when only a few people at the front line are for standardization of work within an organization.
engaged in the innovation process (1,2). Employees must It is defined as the system of rules and standards for
possess the necessary skills to help with the creation of organizing, cleaning, developing and sustaining a
innovative methods to meet the needs of the healthcare productive work environment (6–8).
sector (3,4). Therefore, hospitals have to focus more on Soft TQM focuses on human resource management
enhancing the innovation skills of their employees and that is based on leadership, teamwork, training and
invest appropriately to innovate successfully through employee involvement principles (9). However, these soft
adopting and implementing different improvement quality factors are intangible and difficult to be measured,
strategies such as lean practices and soft total quality such as top management commitment and involvement,
management (TQM). empowerment, effective communication, teamwork and
The main purpose of lean practices is to eliminate training education (10). Therefore, these soft skills can
waste and ensure the most advantageous utilization be discussed in the context of 2 major headings: people-
of existing resources in the organization (1,5). Some of based management and continuous improvement.
the lean practices that best fit the hospital environment For the present study, it was important to propose
are kaizen, quick changeover, poka-yoke, just in time a theoretical framework that filled the gaps that could
(JIT), jidoka, andon, kanban and hoshin kanri. JIT is the not be adequately covered in previous studies. This
technique of supplying the right quantity at the right study was based on 2 theories that have attracted wide
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academic and managerial attention in recent years: and innovation skills; and (10) soft TQM has a positive and
the theory of constraints and the resource-based view significant mediating influence between standardization
theory. The former has been defined as “a thinking and innovation skills.
process that enables people to invent simple solutions to Study design
seemingly complex problems” (11). The latter emphasizes
the significant role of resources, especially human, in This was a quantitative and cross-sectional study. The
the improvement strategies at any organization. The sample included 162 hospitals with contracts with the
theoretical framework of the study is presented in Lebanese Ministry of Public Health. The target population
Figure 1. was hospital employees, who were estimated to number
25 571 (12). The unit of analysis used was the individual,
including nursing, medical, administrative and technical
Methods staff of hospitals. The sample size was 400 (13,14).
Research objectives
Data collection
The foremost objective of this study was to determine
The survey was conducted using a self-administered
the mediating effect of soft TQM on the relationship
questionnaire. The measurement items were retrieved
between lean practices and innovation skills of
from the literature review and the content validity was
employees in hospitals in Lebanon. The concept of
approved through pretesting. A multistage sampling
this study was developed upon detecting a gap in the
technique was used. First, clusters of hospitals were
literature regarding the enhancement of innovation
chosen based on distribution by type, province and level
skills of employees in the healthcare sector. It seems
of accreditation. Then, each hospital allowed us to survey
to be difficult for employees integrated in an ordinary
a specific number of employees based on their own
culture of standards to innovate in solving problems and
policies. Finally, 400 questionnaires were distributed
reducing waste in the workplace, especially when there
randomly among the number of employees that was
is lack of staff empowerment and teamwork. Therefore,
recommended by the administration of each hospital. The
the aim of this research was to determine the ability of
6-point Likert rating scale was adopted (15) to measure
employees to enhance their innovation skills through the
the research variables. Thus, the respondents’ answers
implementation of lean practices as an effective means
ranged between 1, strongly disagree to 6, strongly agree.
for elimination of waste, while maintaining a culture of
The survey was limited to 11 private and 2 public hospitals.
quality through practicing soft TQM.
Most of the surveyed hospitals had a high accreditation
Ten hypotheses were developed based on the level that was appropriate for conducting the survey and
proposed theoretical research framework: (1) lean achieving the research objectives.
practices positively and significantly affect innovation
Statistical analysis
skills; (2) lean strategies positively and significantly
affect innovation skills; (3) standardization positively Survey data were analysed by SPSS and AMOS software.
and significantly affects innovation skills; (4) soft TQM Data were screened for missing values and outliers
positively and significantly affects innovation skills; were checked through a simple linear regression test
(5) lean practices positively and significantly affect soft based on comparing the Mahalanobis output with the
TQM; (6) lean strategies positively and significantly affect χ2 test (16,17). In addition, the assumptions of linearity
soft TQM; (7) standardization positively and significantly and homoscedasticity were approved using the normal
affects soft TQM; (8) soft TQM has a significant and P–P and scatter plots of the standardized residuals.
positive mediating influence between lean practices Assumptions of normality were also approved through
and innovation skills; (9) soft TQM has a positive and transformation of items using z scores. Goodness of
significant mediating influence between lean strategies measure was achieved through testing the reliability
and validity of the items. Data were analysed through
structural equation modelling (SEM). The measurement
model was assessed by checking the construct
Soft TQM validity through testing the convergent validity
• People-based management
• Continuous improvement
using confirmatory factor analysis, and construct
validity through discriminant validity, in addition to
measuring the composite reliability among the set of
items representing each construct. To test the research
hypotheses, the bias-corrected bootstrap method was
applied as it provides unbiased estimates of mediation
Lean practices Innovation skills effects and produces more accurate confidence intervals
• Lean strategies • Interpersonal,
(18).
• Standardization (5S) cognitive and
practical skills
Results
Figure 1 Research theoretical framework. TQM = total quality The usable response rate for this study was 95% and no
management. missing values were detected. In addition, 28 outliers
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among the respondents were checked and assumptions The first- and second-order structural models
of linearity, homoscedasticity and normality were also obtained by SEM analysis are presented in Figures 2 and
approved. 3, respectively. These models were obtained after deleting
Two hundred and fifty-seven (67.6%) respondents items with low standardized factor loadings (< 0.5) and
were female and 197 (51.8%) were aged 20–30 years. For high modification indices. Also, as suggested by Hair et
education level, 113 (29.7%) respondents had a Baccalaureate al. (17), the goodness of fit indices achieved the threshold
Technique or Superior Technician qualification. For measures, including comparative fit index (≥ 0.90),
work experience, 142 (37.4%) respondents had an average goodness of fit index (≥ 0.90), adjusted goodness of fit
of 5–10 years. Moreover, 169 (44.5%) respondents had index (≥ 0.90), root mean square error of approximation
worked at the surveyed hospital for < 5 years and 225 (≥ 0.08) and Tucker Lewis index (≥ 0.90). All the constructs
(59.2%) respondents were nurses. showed an acceptable level of composite reliability
with values ranging between 0.709 and 0.895 (Table 1),
Based on the descriptive statistics of research
indicating a high level of consistency among the items of
variables, the average mean values of all variables ranged
each latent construct.
between 4.36 and 5.11, indicating that employees had a
high level of agreement regarding the measured items of Finally, the hypotheses testing results showed that
the study: innovation skills (INS) 4.92; lean strategies (LS) 6 hypotheses were accepted with significant P values at
4.36; standardization (S) 4.99; people-based management 0.001 and 0.05 levels, while 4 hypotheses were rejected
(PBM) 4.93; and continuous improvement (CI) 5.11). with nonsignificant P values (Table 2).
Moreover, the results of the correlation matrix indicated
that there was no multicollinearity between the latent Discussion
variables of this study since all the correlations were We showed that lean practices, including lean strategies
significant at the 0.01 level and the Pearson correlation and standardization, had a significant and positive
coefficients were < 0.8. influence on the innovation skills of the employees.
For goodness of measure and based on the reliability These results are in line with previous studies (19,20).
test, all the items showed a good level of internal In contrast to the traditional perception that states that
consistency with Cronbach’s α > 0.7 (0.748 < α < 0.909). standardization limits innovation, this study proved the
Exploratory factor analysis confirmed the significance opposite, as also illustrated by Kovachevam (21). He found
of the validity where Kaiser–Meyer–Olkin measure of that standards promote innovation when the openness of
sampling adequacy values of all three constructs were > the standardization process is considered.
0.5 and Bartlett’s test of sphericity was significant with P The application of lean practices has been criticized
< 0.05 (16). for its lack of human integration or limited applicability
.47
.62
TCI7 .40 e2
e10 TPBM2 .76 .79 e34 e35 .69
.56 .63
1.07 TCI6 .34 e3
e11 TPBM3 .56 .87 .58
e12 TPBM4
PBM e36 CI .75 TCI5 .56 e4
.75 .11 1.04 .67 TCI4 .45
.75 e5
STQM TCI3 e6
.09 .11 .29

e37
.89 .55.54 TINS11.34 e23
e28 TLS5 .48 .94 .59
.70 LS .27 .15 .72
TINS7.52 e24
INS
e27 TLS6 .61 TINS6.37 e25
.61 TINS4 e26
Fit values
.51 S χ2 = 224.157
.72 .79 .84 .82 .60 Ratio = 1.546
.52 .62 .71 .68 .36
P = 0 .000
TS1 TS3 TS4 TS5 TS6 df = 145
GFI = 0.940
e33 e32 e31 e30 e29
AGFI = 0.921
TLI = 0.965
CFI = 0.970
REMSA = 0.039
Figure 2 First-order structural model.

AGFI = Adjusted Goodness of Fit Index; CFI = Comparative Fit Index; GFI = Goodness of Fit Index; RMSEA = root mean square error of approximation;
TLI = Tucker Lewis Index; STQM = soft total quality management; INS = innovation skills; S = standardization; CI = continuous improvement; LS =
lean strategies; PBM = people-based management; Transformed Items Using Z-Scores (TLS, TPBM, TS, TCI, TINS and TS)
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Book 24-03.indb 271 13/06/2018 09:44:07

.47
.62
TCI7 .40 e2
e10 TPBM2 .69
.76 .79
.56 1.07.63 TCI6 .34 e3
TPBM3 .87
e11 e36 .58
.56
.75 PBM TCI5 .56 e4
CI .75
e12 TPBM4 .75 .15 1.04 .67 TCI4 .45 e5
e20 STQM e19 TCI3 e6
Fit values
χ2 = 227.823
e34 .38 Ratio = 1.550 .02
.84 P = 0.000
.41 df = 147 e37
e28 TLS5 .91 GFI = 0.938
.29
.54
.74 LS AGFI = 0.920 TINS11.34 e23
e27 TLS6 .64 TLI = 0.965 .72 .53
CFI = 0.970 .59
.52 TINS7.52 e24
LP RMSEA = 0.040 INS .72
e33 TS1 .62 .72 e35 .61 TINS6.37 e25
.83 .84
.71 .78 .69
e32 TS3.84 TINS4 e26
.82.68
e31 TS4.56.32 S
e30 TS5
e29 TS6
Figure 3 Second-order structural model.

AGFI = Adjusted Goodness of Fit Index; CFI = Comparative Fit Index; GFI = Goodness of Fit Index; RMSEA = root mean square error of approximation;
TLI = Tucker Lewis Index; STQM = soft total quality management; INS = innovation skills; S = standardization; CI = continuous improvement; LS =
lean strategies; PBM = people-based management; Transformed Items Using Z-Scores (TLS, TPBM, TS, TCI, TINS and TS).
Table 1 Average variance extracted and composite reliability of constructs

Constructs Items L L2 VE AVE AVE SQRT A CR
Innovation skills TINS4 0.609 0.370 0.629 0.381 0.617 0.704 0.709
TINS6 0.722 0.521 0.478
TINS7 0.586 0.343 0.656
TINS11 0.537 0.288 0.711
STQM TPBM2 0.786 0.617 0.382 0.519 0.720 0.867 0.895
TPBM3 0.871 0.758 0.241
TPBM4 0.746 0.556 0.443
TCI3 0.668 0.446 0.553
TCI4 0.751 0.564 0.435
TCI5 0.58 0.336 0.663
TCI6 0.631 0.398 0.601
TCI7 0.689 0.474 0.525
Lean strategies TLS5 0.943 0.889 0.110 0.686 0.828 0.791 0.810
TLS6 0.695 0.483 0.516
Standardization TS1 0.723 0.522 0.477 0.578 0.760 0.867 0.871
TS3 0.787 0.619 0.380
TS4 0.842 0.708 0.291
TS5 0.824 0.678 0.321
TS6 0.6 0.36 0.64
A = Cronbach’s α; AVE; Average variance extracted; AVE SQRT = square root of every AVE value; CR = composite reliability; L = loading; STQM = soft total quality management; TCI =
transformed items for continuous improvement; TINS = transformed items for innovations skills; TLS = transformed items for lean strategies; TPBM = transformed items for people-based
management; TS = transformed items for S; VE = variance error.
in certain environments. Critics have suggested that innovation are required (22). The main criticism is at
problems arise when organizations try to apply lean the human level, where lean production is considered
practice strategies to areas in which creativity and to dehumanize and exploit the work force (23). It was
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Table 2 All hypotheses testing results with the dimensions of soft TQM compared to that of
Research hypotheses Result P
standardization. Furthermore, the results of hypotheses
testing indicated that in general, lean practices had a
H1 Lean practices positively and Accepted **
significant affect innovation skills
positive and significant influence on soft TQM, but
in particular, this influence was achieved through
H2 Lean strategies positively and Accepted 0.023*
significantly affect innovation skills
standardization and not through the lean strategies.
This is consistent with the culture of accreditation and
H3 Standardization positively and Accepted **
significantly affects innovation skills
assessment at hospitals that forces employees to be more
concerned and restricted to the standards and discipline
H4 Soft TQM positively and significantly Rejected 0.796
affects innovation skills
of work to maintain high quality of services. However,
lean strategies are more dependent on employees’
H5 Lean practices positively and Accepted **
significantly affect soft TQM voluntary actions such as being involved in teamwork
activities or their speed in detecting problems in the
H6 Lean strategies positively and Rejected 0.193
significantly affect soft TQM workplace and taking decisions to resolve them.
H7 Standardization positively and Accepted ** Previous studies have shown similar findings
significantly affects soft TQM regarding the positive relationship between lean practices
H8 Soft TQM has a significant and Rejected 0.812 and soft TQM (26–28). However, lean practices are
positive mediating influence between generally weaker on the human behaviour side. There is
lean practices and innovation skills still a concept that considers lean practices as an inhibitor
H9 Soft TQM has a positive and Rejected 0.200 of improvement, especially when related to reducing
significant mediating influence costs and setting limits, which can lead organizations
between lean strategies and to be narrow-minded and hinder the creativity of their
innovation skills
employees (28).
H10 Soft TQM has a positive and Accepted 0.029*
significant mediating influence In contrast to previous studies (7,29), we did not
between standardization and find a direct impact of soft TQM on innovation skills.
innovation skills Although TQM practices have been considered essential
*Significant at level of 0.05; **significant at level of 0.001. to develop the innovation skills of employees, they do not
appear to be an effective tool for improving the necessary
skills in healthcare organizations. Several studies have
claimed by Hines et al. (24) that the key aspects of this shown that TQM inhibits innovation in cases with poor
criticism are the “lack of contingency and ability to cope implementation (30,31); however, others have found that
with variability, the lack of consideration of human TQM has a positive impact on innovation capabilities
aspects and the narrow operational focus on the shop- (28,32). However, criticism has been raised that effective
floor”. Similarly, Seddon et al. (25) criticized lean practice TQM transformation is difficult because of weak change
programmes and standardization of work as demeaning management culture that is related to the employees’
and demoralizing, where workers have to do more resistance to change and innovation (33).
repetitive work.
Our results indicate that soft TQM mediates the
Hence, healthcare organizations in Lebanon are on relationship between standardization and innovation
the right track in promoting the innovation skills of skills. This is in line with previous studies (34) that have
their employees as they are implementing the quality shown that standardization can drive innovation and lead
standards and lean practices such as the 5S programme. to transformation, especially at the level of employees’
This tool helps organizations to eliminate inappropriate skills. However, soft TQM did not mediate the relationship
actions and sustain a productive work environment (7). between lean practice strategies and the innovation
Although lean practice principles are often associated skills of employees. The lack of skilled employees limits
with technical tools related to problem-solving methods, hospitals from generating and sustaining competitive
there is a soft side as well. Basically, this is the ability of advantages and consequently leads to failure of the lean
leadership to build a collaborative work environment practice strategies. Such challenges result from limited
that encourages other soft skills among employees, such employee participation and a shortage of skilled human
as communication skills and the ability to motivate and resources (1,2).
foster teamwork (3). These features are consistent with By developing the theoretical framework and
soft TQM methods that focus on training administrators, testing the relationships among lean practices, soft
managers and supervisors to be lean practice leaders. TQM and innovation skills, our research has made
Such improvements are achieved through implementing contributions to the academic and practical fields. It
rapid improvement teams of employees, applying a has several implications for healthcare practitioners
5S programme, standardizing work and maintaining and management to take into consideration as a part
continuous improvement. of the improvement strategies at hospitals in Lebanon.
The present study showed a significant direct In addition, it can serve as a theoretical background for
correlation between lean practices and soft TQM, but further research in the field of lean practice healthcare
in particular, lean strategies had a weak correlation and innovation at the hospital level.
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Although our research was conducted to fill in the survey among different Lebanese hospitals using a self-
gaps that were identified in the literature and previous administered questionnaire resulted in valid and reliable
empirical studies, there were still some limitations that data that were analysed through SEM that ensured that
could not be avoided, mainly at the methodological and the results could be generalized. Testing the research
geographical levels. Despite the wide participation of hypotheses has theoretically and practically added to
respondents to this survey, poor cooperation from most the previous literature. Some of our findings support
of the Lebanese hospitals was noted. Only 11 private and previous studies in which adoption of lean practices had a
2 public hospitals participated. The majority of hospitals significant influence on innovation skills. However, other
refused to participate because of their own policies results contrasted with previous studies in the positive
and considerations, while others were geographically relationship between soft TQM and lean practices and
unreachable because of the insecure situation in some innovation skills. Our results showed that soft TQM is
regions. Therefore, future studies may have better not well implemented, especially at the level of people-
opportunities to extend their sample geographically and based management and continuous improvement.
have a mix of more private and public hospitals to achieve
This does not support the successful application of lean
more reliable results. Another limitation faced while
practices because it is not able to enhance the innovation
preparing this research was the lack of conceptual and
skills of hospital employees.
empirical studies related to lean healthcare and soft TQM
implementation in the Lebanese context. This was also The main focus should be always at the level of human
observed empirically while conducting the survey where resources. Whatever efforts are made by management, if
lean healthcare was considered as a new concept for the the employees are not convinced by the concept of lean
Lebanese healthcare sector and still not as widespread practices and they are not developing their own skills to be
as other quality improvement tools. Therefore, efforts in line with the up-to-date quality and technological tools,
should be made to introduce lean healthcare principles any improvement strategy will not be successful. Policy
and study their implementation in hospitals in order to makers and top management at Lebanese hospitals must
use them as a database for future studies of quality and form priorities in their development strategies, especially
lean practices. at the level of employees because they are the dynamic
The research methods of this study were based on resource for the implementation and development of any
a quantitative approach through conducting a survey. strategy at the organization. It was clear from our survey
Therefore, future studies should extend the research and that employees are interested in lean practice tools and
use both quantitative and qualitative methods, mainly implementing quality standards that tend to eliminate
case studies, to obtain more accurate and practical waste and reduce the rate of errors in the workplace.
results, especially since lean healthcare, innovation and Still, the lack of engagement and weak empowerment of
quality are wide concepts that bear in-depth discussion employees lessened motivation towards the innovation
and interpretation. Moreover, different SEM-specific process, which negatively affected the innovation skills
software can be used to test the research hypotheses such of employees. Therefore, further studies are suggested
as partial least squares. to focus more on the means and approaches that would
In conclusion, this study achieved its objectives and develop the soft skills and enhance the implementation
illustrated the effect of lean practices and soft TQM on the of lean healthcare within a culture of innovation and
innovation skills of employees in Lebanese hospitals. The quality of services.
Funding: None.
Relation entre le lean management, la gestion totale de la qualité dite souple et les
capacités d’innovation dans les hôpitaux libanais
Résumé
Contexte : Le lean management est crucial pour éliminer le gaspillage et renforcer la qualité des services de soins de santé
au moyen de différentes approches améliorées de gestion totale de la qualité. La gestion totale de la qualité dite souple est
notamment utilisée pour développer les capacités d’innovation des employés qui sont considérées comme essentielles
aux stratégies d’amélioration continue des hôpitaux.
Objectif : La présente étude avait pour objectif principal d’étudier la relation entre le lean management, la gestion totale
de la qualité dite souple et les capacités d’innovation dans les hôpitaux libanais.
Méthodes : Une méthode quantitative a été appliquée en interrogeant 352 employés travaillant dans des hôpitaux privés
et publics au Liban. Les données primaires recueillies étaient valables et fiables à l’analyse réalisée à l’aide des logiciels
SPSS et AMOS dans le cadre d’une modélisation par équation structurelle.
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Résultats : Le lean management avait une influence considérable sur les capacités d’innovation. En revanche, la gestion
totale de la qualité dite souple n’intervenait pas dans cette relation du fait d’une mauvaise mise en œuvre, notamment au
niveau de la gestion du personnel et de l’amélioration continue.
Conclusion : Les résultats de cette étude doivent pousser les praticiens à déployer davantage d’efforts pour mettre en
œuvre le lean management et la gestion totale de la qualité dite souple. Enfin, les futures études devraient se concentrer
sur les différents défis s’opposant à l’amélioration de la qualité dans la région.
‫املبسطة وإدارة اجلودة الكاملة الناعمة ومهارات االبتكار يف املستشفيات اللبنانية‬

ّ ‫العالقة بني املامرسات‬
‫ حسن األعرج‬،‫ نورلينا حسنان‬،‫مالك عون‬
‫املبسطة عنرص ًا حيوي ًا للتخلص من النفايات وحتسني جودة خدمات الرعاية الصحية من خالل اعتامد ُنج حتسني خمتلفة‬ ّ ‫ متثل املامرسات‬:‫اخللفية‬
‫ يستخدم اجلانب الناعم من إدارة اجلودة الكاملة يف تنمية املهارات االبتكارية للموظفني الرضورية‬،‫ وعىل وجه التحديد‬.‫إزاء إدارة اجلودة الكاملة‬
.‫السرتاتيجيات التحسني املستمر للمستشفيات‬
ّ ‫ متثّل اهلدف الرئييس من هذا البحث يف دراسة العالقة بني املامرسات‬:‫اهلدف‬
.‫ وإدارة اجلودة الكاملة الناعمة ومهارات االبتكار يف لبنان‬،‫املبسطة‬
‫ وجاءت كل البيانات‬.‫ موظف ًا يعملون يف املستشفيات اخلاصة واحلكومية اللبنانية‬353 ‫كمية بإجراء مسح لـ‬ ّ ‫ استُخدمت منهجية‬:‫طرق البحث‬
‫) يف إطار‬AMOS( ‫) وبرجمية‬SPSS( ‫األولية التي تم جتميعها صحيحة وموثوقة عندما تم حتليلها بواسطة برجمية احلزمة اإلحصائية للعلوم االجتامعية‬
.‫النمذجة باملعادالت البنائية‬
‫املبسطة أثرت تأثري ًا كبري ًا عىل مهارات االبتكار؛ يف حني مل تتوسط إدارة اجلودة الكاملة الناعمة هذه العالقة نظر ًا لعدم‬ ّ :‫النتائج‬
ّ ‫تبي أن املامرسات‬
.‫ ال سيام عىل مستوى اإلدارة املتمحورة حول البرش والتحسني املستمر‬،‫تنفيذها بشكل مناسب‬
ّ ‫ تنطوي هذه الدراسة عىل اعتبارات للمامرسني يف جمال الرعاية الصحية من أجل بذل مزيد من اجلهود لتنفيذ املامرسات‬:‫االستنتاج‬
‫املبسطة وإدارة‬
.‫ وتقرتح يف النهاية إجراء دراسات لتسليط الضوء عىل خمتلف التحديات التي تواجه حتسني اجلودة يف اإلقليم‬.‫اجلودة الكاملة الناعمة‬
References
1. Jekiel C. Lean human resources: redesigning HR processes for a culture of continuous improvement. New York: Taylor and
Francis Group, Productivity Press; 2011.
2. Diab, S. Management of hospitals and healthcare centers. Amman: AL-Feker Publishers; 2009.
3. Evershed G. Innovation from Lean Six Sigma – Soft Skills. TRIZ Journal (http://www.triz-journal.com/content/c101018a.asp,
4. Putkonen A, Kairisto L, Penttilä T. Enhancing engineering students’ innovation skills through innovation pedagogy – Experienc-
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com/document/50450054/Theory-of-Constraints, accessed 5 December 2017.)
12. National News Agency. [Presentation of the reality of hospitals: a database prepared by the union. Press conference by Suliman
Harounon on 23 June 2013] (in Arabic) (http://www.nna-leb.gov.lb/ar/show-news/45997/, accessed 5 December 2017).
13. Vaske J, Needham M. Survey implementation, sampling, and weighting data. In: Survey research and analysis: applications in
parks, recreation, and human dimensions. 2008:173–222.
14. Dillman D. Mail and internet surveys: the tailored design. 2nd ed. New York: John Wiley and Sons; 2000.
15. Gwinner C. Infosurf White Paper. 5-point vs. 6-point Likert Scales. Atlanta: Infosurv; 2011 (http://www.infosurv.com/wp-content/
uploads/2011/01/Likert_Scale_Debate.pdf, accessed 27 November 2017).
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16. Sekaran U, Bougie R. Research methods for business: a skill building approach. 5th ed. London: Wiley; 2011.
17. Hair J, Black W, Rabin B, Anderson R. Multivariate data analysis: a global analysis. New Jersey: Pearson; 2010.
18. Danielsson J, de Haan L, Peng L, de Vries CG. Using a bootstrap method to choose the sample fraction in tail index estimation. J
Multivar Anal. 2001 Feb 1;76(2):226–48. http://dx.doi.org/10.1006/jmva.2000.1903
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Lincoln: University of Nebraska; 2012.
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performance. Procedia Soc Behav Sci. 2012;41:273–80. http://dx.doi.org/10.1016/j.sbspro.2012.04.031
29. Raphael, P. Maximizing innovation using Total Quality Management. [thesis]. Carson: California State University, Dominguez
Hills; 2010.
30. Hung R, Lien BY-H, Yang B, Wu C-M, Kuo Y-M, Lienb, B et al. Impact of TQM and organizational learning on innovation perfor-
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31. Moreno A. The influence of quality management on orientation to innovation in service firms. Afr J Bus Manag. 2011 Sep
4;5(17):8997–9006. http://www.academicjournals.org/article/article1380637133_Moreno%20et%20al.pdf
32. Ooi K, Lin B, Teh P, Chong AY-L. Does TQM support innovation performance in Malaysia’s manufacturing industry? J Bus Econ
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33. Bäckström I, Ingelsson P, Wiklund H. Learning from others to adapt quality management to the future. Total Qual Manage Bus
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com/1664682/5-ways-that-standardization-can-lead-to-innovation, accessed 27 November 2017).
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Prevalence of and attitudes to waterpipe smoking among Saudi

Arabian physicians
Mohammed Al Ghobain 1, Anwar Ahmed 2, Zynab Abdrabalnabi 3, Wjdan Mutairi 4 and Ali Al Khathaami 1
College of Medicine; 2College of Public Health and Health Informatics; 4College of Nursing, King Saud bin Abdulaziz University for Health Sciences,
1
Riyadh, Saudi Arabia (Correspondence to: Mohammed Al Ghobain: [email protected]). 3Department of Medicine, King Abdulaziz Medical City,
King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia.
Abstract
Background: Tobacco smoking kills more than 5 million people annually and it is the most important cause of preventable
death. Waterpipe smoking is common in the Middle East and is prevalent among young people. There is a misconception
that it is less harmful than cigarette smoking. Physicians are considered role models in the community and their behaviours
and attitudes towards smoking can have direct effects on cessation.
Aim: The aim of this study was to estimate current prevalence, attitudes and associated factors in regard to waterpipe
smoking among Saudi Arabian physicians.
Methods: Using a self-administered questionnaire, we conducted a cross-sectional study among 454 male and female
physicians from 3 specialties, and of various levels of training working in 4 hospitals in Riyadh.
Results: The prevalence of waterpipe smoking was 45%, greater in men than in women (58% vs 18%; P ≤ 0.001) and in
surgical than in medical specialists (58% vs 38%; P ≤ 0.001). More non-smokers than smokers believed that physicians
should serve as role models (79% vs 60%; P ≤ 0.001). Physicians who were waterpipe non-smokers had received more formal
training about cessation than smokers (50% vs 36%; P ≤ 0.001).
Conclusions: Waterpipe smoking among Saudi Arabian physicians is frequent and is associated with low exposure to
information about the hazards and cessation during medical education.
Keywords: Smoking, Water-pipe, Saudi Arabia, Physicians, Medical Education
Citation: Al Ghobain M; Ahmed AE; Abdrabalnabi Z; Mutairi W; Khathaami AA. Prevalence of and attitudes to waterpipe smoking among Saudi Arabian
physicians. East Mediterr Health J. 2018;24(3):277–282. https://doi.org/10.26719/2018.24.3.277
Introduction Saudi Arabia at 12.6% (4). Physicians are considered role

models in the community, and their behaviours and
Tobacco smoking in all forms kills more than 5 million
attitudes towards smoking can have direct effects on
people per year and it is the most important cause of
smoking cessation. Physicians (medical doctors) are
preventable death (1). According to the World Health
responsible for providing advice and education about
Organization, tobacco smoking is the second most
quitting and preventing smoking. Previous studies on
common cause of death and the fourth most common risk
waterpipe smoking among Saudi Arabian healthcare
factor for disease worldwide. If current trends continue,
professionals were limited to medical students in a single
smoking will cause 8 million deaths per year by 2030 (1).
college or centre, and limited information is available
Waterpipe smoking, also known as shisha, hubble- about knowledge and attitudes towards waterpipe
bubble, hookah, muassel or narghile, is another form of smoking in practising physicians. The objective of this
tobacco use which is common in restaurants and coffee study was to investigate the prevalence, attitudes and
shops in Middle East and many parts of the world in which associated factors of waterpipe smoking among Saudi
young people commonly use this method of smoking. Arabian physicians working in 4 hospitals in Riyadh,
There is a misconception that waterpipe smoking is Saudi Arabia.
less harmful than cigarette smoking because the smoke
passes through water and may be filtered by the water
before it is inhaled. The World Health Organization
Methods
issued a report in 2005 about waterpipe tobacco smoking Sample size
and called for research on methods to evaluate smoker Sample size was calculated using the Raosoft sample
exposure and tobacco-smoking surveys among health size calculator (www.raosoft.com). The sample size was
professionals (2). calculated by anticipating 30% prevalence of waterpipe
In Saudi Arabia, previous studies have reported smoking with z = 1.96 for a 95% confidence level, margin
the prevalence of waterpipe smoking in male medical of error of 5%. The minimum sample size required to
students in central Saudi Arabia at 13% (3) and in eastern estimate a population parameters was estimated ay 450.
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Book 24-03.indb 277 13/06/2018 09:44:08

Survey 38% and family medicine 10%) and different levels of

We used a specific structured questionnaire modified training and expertise (intern, resident, fellow, assistant
from the Global Health Professional Survey, an consultant and consultant) to complete the questionnaire
international standardized questionnaire developed by until we reached the target sample size.
the World Health Organization, the Centers for Disease The study protocol was approved by the Ethical
Control and Prevention and the Canadian Public Health Research Committee of King Abdullah International
Association to collect information on tobacco use and Medical Research Centre and all hospitals involved in the
cessation counselling among health professional students study.
about smoking prevalence, characteristics (including Data analysis
waterpipe smoking), attitudes, perception, and exposure
Data analysis was performed using SPSS statistical
to smoking cessation training (5). The questionnaire had
software. Sample characteristics were expressed as
been previously translated and validated for a number of
number (%) or mean and standard deviation. The
languages, including Arabic.
relations between waterpipe smoking and demographic
We carried out the survey during January and characteristics such as age, sex, medical profession level,
February 2015. Physicians were approached by data and medical specialty were evaluated with chi-square
collectors (medical students) and the objectives of the and t-test. Differences in attitudes and health education
study were explained. Physicians completed anonymous about waterpipe smoking across smoker status were
self-administered questionnaires during working hours evaluated using the t-test for independent samples.
in their workplace under the supervision of the medical Multivariate logistic regression analysis was used to
students. Completing the questionnaire took an average test for risk factors associated with waterpipe smoking.
of 15 minutes. The physicians were assured that the Statistical significance was defined as P ≤ 0.05.
information provided would remain confidential and
would be used only for the research purposes.
Results
A current waterpipe smoker was defined as a
physician who had smoked a waterpipe ≥ 1 time in the We approached around 600 Saudi Arabian physicians;
previous 30 days. 454 agreed to participate in the study an completed the
questionnaires, a 75% response rate (age range 22–56
Participants years). Characteristics of the participants, including
A cross-sectional, anonymous, self-administered speciality and training, are detailed in Table 1.
questionnaire was completed by Saudi Arabian physicians We found that 204 physicians (45%) were current
(medical doctors) who worked in 4 hospitals in Riyadh, waterpipe smokers (95% confidence interval 40–50). A
Saudi Arabia (King Abdulaziz Medical City, King Fahad significantly higher prevalence of waterpipe smoking
Medical City, King Khalid University Hospital, and Prince was found among males than females (58% vs 18%, P ≤
Sultan Military Medical City). We invited all male and 0.001). Waterpipe smoking was more common among
female Saudi Arabian physicians from the 4 hospitals, physicians who were surgical specialists 58% compared
covering 3 different specialties (medicine 52%, surgery with 38% among the medical specialists and 35% among
Table 1. Characteristics of the study population* and the relationship between waterpipe smoking and study population
Characteristic Total Waterpipe smokers Waterpipe non-smokers P-value
(n = 454) (n = 204) (n = 250)
No. % No. % No. %
Sex
Women 148 33 27 18 121 82 ≤ 0.001
Men 306 67 177 58 129 42
Training level
Intern 110 24 53 48 57 52 NS
Resident 199 44 97 49 102 51
Fellow, assistant 145 32 54 37 91 63
consultant, consultant
Medical specialty
Medical 218 52 83 38 135 62 ≤ 0.001
Surgical 160 38 93 58 67 42
Family medicine 43 10 15 35 28 65
Mean (SD)age (years) 31 (7) 30 (6) 31 (8) NS
NS = not significant (P > 0.05).
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Book 24-03.indb 278 13/06/2018 09:44:08

family medicine specialists (P = 0.001) (Table 1). Most smoking history as a part of a patient’s general medical
waterpipe smokers smoked at a coffee shop (41%), with history in comparison to waterpipe non-smokers (P ≤
some at home (27%) or in a restaurant (13%). Of the 204 0.001) (Table 2). Half (50%) of the non-smokers received
physicians who were waterpipe smokers, 157 (77%) started formal training on cessation approaches during their
smoking before age 24 years. medical school or residency training programmes
There were significant differences in attitudes and compared with 36% among waterpipe smokers, P ≤ 0.003
training between physicians who smoked and physicians (Table 2).
who did not smoke waterpipes (P ≤ 0.001) (Table 2). Multivariate analysis showed there was a higher risk
Compared with waterpipe smokers, a greater frequency of waterpipe smoking in men than women [odds ratio
of waterpipe non-smokers agreed that waterpipe sales (OR) = 4.6, P ≤ 0.001]; surgical than medical specialists
and advertising should be banned; waterpipes should (OR = 2.0, P ≤ 0.001); physicians who had negative than
be banned in restaurants, coffee shops, and all enclosed positive attitudes about banning waterpipe smoking in
public places; physicians should have specific training restaurants (OR = 3.9, P ≤ 0.001 ) and coffee shops (OR =
about techniques of cessation of waterpipe smoking; 7.6, P ≤ 0.001 ); and those who stated that physicians do
and physicians are role models who should advise and not have a role in giving information about smoking
give information to patients about quitting waterpipe cessation to patients (OR = 2.5, P ≤ 0.001) (Table 3).
smoking (Table 2).
In regard to education during training programmes, Discussion
waterpipe smokers received less education about the Our study provided insight about the prevalence and
dangers of waterpipe smoking, had less discussion attitudes in regard to waterpipe smoking in Saudi
about the reasons that people smoke waterpipe and less Arabian physicians from 4 hospitals and different
teaching about the importance of recording waterpipe specialties in Riyadh, Saudi Arabia. We identified a high
Table 2. Waterpipe smoking, attitudes, and training among (N = 454) Saudi physicians
Response Positive response P-value
Waterpipe smokers Waterpipe non-smokers
(n = 204) (n = 250)
No. % No. %
Attitude
Waterpipe sales should be banned 109 53 211 85 ≤ 0.001
Complete ban on the advertising of waterpipe products 141 70 225 90 ≤ 0.001
Waterpipes should be banned in restaurants 113 55 233 93 ≤ 0.001
Waterpipes should be banned in coffee shops 87 43 222 89 ≤ 0.001
Waterpipes should be banned in all enclosed public places 149 73 230 92 ≤ 0.001
Physicians should get specific training about techniques for 158 78 229 92 ≤ 0.001
cessation of waterpipe smoking
Physicians serve as role models for their patients and the 123 60 198 79 ≤ 0.001
public
Physicians should advise their patients who smoke 162 80 227 91 ≤ 0.001
waterpipes to quit
Physicians have a role in giving advice or information about 137 67 211 84 ≤ 0.001
waterpipe cessation
A patient’s chances of quitting waterpipe smoking are 155 76 218 87 ≤ 0.003
increased if physicians advise him or her to quit
Medical school curriculum or residency training
Were you taught in any of your classes about the dangers of 108 53 173 70 ≤ 0.001
waterpipe smoking?
Did you discuss in any of your classes the reasons why people 84 41 141 57 ≤ 0.001
smoke waterpipes?
Did you learn that it is important to record waterpipe 132 65 198 80 ≤ 0.001
smoking history as a part of the patient’s general medical
history?
Have you ever received any formal training in waterpipe 73 36 123 50 ≤ 0.003
smoking cessation approaches to use with patients?
Did you learn that it is important to provide educational 88 43 156 63 ≤ 0.001
materials to support waterpipe smoking cessation to patients
who want to quit waterpipe smoking?
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Table 3. Multivariate logistic regression analysis for risk factors The high prevalence of waterpipe smoking among
associated with waterpipe Saudi Arabian physicians (45%) is of concern because
Variable Odds ratio 95% physicians are considered role models for their patients
confidence
and the community in fighting tobacco consumption
interval
and promoting smoking cessation. There are several
Men vs women 4.6 2.59–8.25
potential explanations for the high prevalence, including
Surgical vs medical specialty 2.0 1.21–3.43
the high stress of a medical career and the misconception
Waterpipes should not be banned 3.9 1.61–3.43 that waterpipe smoking relieves stress. Moreover, there
in restaurants
is a belief that waterpipe smoking is less harmful than
Waterpipes should not be banned 7.6 3.28–3.43 cigarette smoking (16,17); other factors include curiosity
in coffee shops
and social trends as main reasons for waterpipe smoking
Waterpipes should not be banned 0.2 0.08–0.64
(18). However, the low exposure to education related to
in all enclosed public places
waterpipe hazards and cessation in medical school or
Physicians do not have a role 2.5 1.41–4.49
in giving information about
postgraduate training is probably the main contributing
waterpipe smoking cessation to factor for the high frequency of waterpipe smoking
patients among physicians. In our study, most physicians started
waterpipe smoking at age under 24 years, and this is
consistent with previous findings that most waterpipe
prevalence of waterpipe smoking among the physicians smokers start smoking in adolescence (19). Waterpipe
(45%). Predictors of waterpipe smoking in our study were smoking is more prevalent in junior physicians (interns
younger age, male sex and surgical specialty. Most of our and residents) because these physicians are under severe
participants started waterpipe smoking at high school or stress and have very busy schedules. Our study showed
medical school age. a significantly higher prevalence of waterpipe smoking
Although the data on waterpipe smoking in the Saudi among men than women; this may be true, however it
Arabian population are limited, a pilot study among may be a result of underreporting by women because
secondary school students in Al Hassa region showed there is a social stigma associated with waterpipe
a prevalence rate of 37% (6). The reported prevalence of smoking in women.
current cigarette smoking among adults in Saudi Arabia Limitations of the present study included the cross-
ranges from 11.6% to 52.3% (7). Cigarette smoking among sectional design, which may have introduced bias from
physicians and healthcare providers in Saudi Arabia has self-reporting. In addition, the study was limited to
been studied previously. More recently, in southwestern only one form of tobacco smoking. Nevertheless, the
Saudi Arabia 18.3% physicians were smokers, and the study had certain strengths: it was a multicentre study
highest prevalence of smoking was seen among hospital involving all levels of physicians with varying expertise
residents (25.3%), primary health care physicians (20.5%) and specialties.
and hospital consultants (18.6%) (8). In neighbouring
There is a need to implement strategies to reduce
countries, the frequency of tobacco smoking among
waterpipe smoking among physicians, which should
physicians was 11% in Oman (9), 56% in Jordan (10) and
have the additional benefit of reducing waterpipe
41% in Turkey (11). Waterpipe smoking is common in
smoking in the general population. These strategies
other Middle East countries: in a Syrian study, 25% of
could include classes, training and educational materials
male students used waterpipes (12). In Lebanon, 21%
about the health risks and cessation in medical schools
of university students reported current waterpipe
smoking (13). The introduction of flavoured tobacco, the and residency training programmes.
thriving coffee shop culture and the lack of regulations In conclusion, waterpipe smoking in Saudi Arabian
have been cited as the main factors contributing for the physicians has high prevalence, especially in men,
spread of waterpipe smoking globally (14). The Global junior physicians, surgeons and physicians who did not
Youth Tobacco Survey Collaborative Group estimated receive formal education about waterpipe smoking in
that 10–18% of adolescents aged 13–15 years use tobacco their training. This may result in a negative image of
products other than cigarettes, mostly in the Eastern physicians because patients regard their physician as a
Mediterranean region (15). model for health education and disease prevention.
Funding: None.
280
Book 24-03.indb 280 13/06/2018 09:44:08

Prévalence de la consommation de pipe à eau et attitudes à cet égard parmi les

médecins en Arabie saoudite
Résumé
Contexte : Le tabagisme tue plus de 5 millions de personnes par an et constitue la cause la plus importante de décès
évitables. La consommation de pipe à eau est courante au Moyen-Orient et elle est prévalente chez les jeunes. Selon
une idée reçue, elle serait moins dangereuse que la consommation de cigarettes. Les médecins sont considérés comme
des modèles à suivre dans la communauté et leurs comportements et attitudes vis-à-vis du tabagisme peuvent avoir un
impact direct sur le sevrage.
Objectif : La présente étude vise à estimer la prévalence actuelle, les attitudes et les facteurs associés à la consommation
de pipe à eau parmi les médecins en Arabie saoudite.
Méthodes : En recourant à un questionnaire auto-administré, nous avons réalisé une étude transversale auprès de
454 médecins hommes et femmes de trois spécialités et de différents niveaux de formation, travaillant dans quatre
hôpitaux de Riyadh.
Résultats : La prévalence de la pipe à eau s’élevait à 45 % ; elle était supérieure chez les hommes que chez les femmes (58 %
contre 18 % ; p ≤ 0,001) et chez les chirurgiens que chez les médecins (58 % contre 38 % ; p ≤ 0,001). Davantage de non-
fumeurs que de fumeurs pensaient que les médecins devaient jouer un rôle de modèle (79 % contre 60 % ; p ≤ 0,001). Les
médecins qui ne fumaient pas la pipe à eau avaient suivi une formation plus formelle sur le sevrage tabagique que ceux
qui la fumaient (50 % contre 36 % ; p ≤ 0,001).
Conclusions : La consommation de pipe à eau chez les médecins saoudiens est fréquente et elle est associée à une faible
exposition à l’information sur les risques et le sevrage tabagique durant la formation médicale.
‫انتشار تدخني الشيشة يف أوساط األطباء السعوديني ومواقفهم إزائه‬

‫ عيل اخلثعمي‬،‫ وجدان املطريي‬،‫ زينب عبد رب النبي‬،‫ أنور أمحد‬،‫حممد الغبني‬
‫ ويشيع تدخني الشيشة يف الرشق‬.‫ ماليني شخص سنوي ًا ويعد أهم سبب للوفاة التي يمكن الوقاية منها‬5 ‫ يودي تدخني التبغ بحياة أكثر من‬:‫اخللفية‬
‫ ويعترب األطباء قدوة يف جمتمعهم ومن‬.‫ وثمة تصور خاطئ بأن تدخني الشيشة أقل رضر ًا من تدخني السجائر‬.‫األوسط وينترش يف صفوف الشباب‬
.‫شأن سلوكياهتم ومواقفهم من التدخني أن تؤثر تأثري ًا مبارش ًا عىل اإلقالع عنه‬
‫ متثّل اهلدف من هذه الدراسة يف تقدير مستوى االنتشار احلايل لتدخني الشيشة بني أطباء اململكة العربية السعودية واملواقف املتخذة حياله‬:‫اهلدف‬
.‫والعوامل املرتبطة به‬
‫ لدهيم مستويات تدريب خمتلفة‬،‫ ختصصات‬3 ‫ طبيب ًا وطبيبة من‬454 ‫ لـ‬،‫ باستخدام استبيان جياب عليه ذاتي ًا‬،‫ أجرينا دراسة مقطعية‬:‫طرق البحث‬
.‫ مستشفيات يف الرياض‬4 ‫ويعملون يف‬
‫) ويف صفوف األطباء‬0.001 ≤ P ‫؛‬%18 ‫ مقابل‬%58( ‫ وسجل ارتفاع ًا يف صفوف الرجال مقارنة بالنساء‬،%45 ‫ بلغ انتشار تدخني الشيشة‬:‫النتائج‬
‫ وتبني ًأن عدد ًا أكرب من غري املدخنني مقارنة باملدخنني يرون أن األطباء ينبغي‬.)0.001 ≤ P ‫؛‬%38 ‫ مقابل‬%58( ‫اجلراحني أكثر من أطباء الباطنة‬
‫تبي أن األطباء غري املدخنني للشيشة سبق أن تلقوا تدريب ًا رسمي ًا بشأن اإلقالع عن التدخني‬
ّ ‫ كام‬.)0.001 ≤ P ‫؛‬%60 ‫ مقابل‬%79( ‫أن يكونوا قدوة‬
.)0.001 ≤ P ‫؛‬%36 ‫ مقابل‬%50( ‫مقارنة باألطباء املدخنني‬
‫ ينترش تدخني الشيشة يف صفوف األطباء السعوديني ويرتبط بانخفاض مستوى التعرض ملعلومات بشأن خماطره واإلقالع عنه أثناء‬:‫االستنتاجات‬
.‫التدريب الطبي الذي يتلقونه‬
References
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2. WHO Study Group on Tobacco Product Regulation. TobReg – advisory note, waterpipe tobacco smoking: health effects, research
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4. Taha AZ, Sabra AA, Al-Mustafa ZZ, Al-Awami HR, Al-Khalaf MA, Al-Momen MM. Water pipe (shisha) smoking among male stu-
dents of medical colleges in the eastern region of Saudi Arabia. Ann Saudi Med. 2010;30:222–6. PMID:20427939
5. Tobacco Free Initiative. WHO/CDC Global Health Professional Survey. Geneva: World Health Organization; 2004 (http://www.
who.int/tobacco/surveillance/ghps/en/, accessed 19 November 2017).
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6. Amin TT, Amr MA, Zaza BO, Kaliyadan F. Predictors of waterpipe smoking among secondary school adolescents in Al Hassa,
Saudi Arabia. Int J Behav Med. 2012 Sep;19(3):324–35. PMID:21643931
7. Bassiony MM. Smoking in Saudi Arabia. Saudi Med J. 2009;30(7):876–81. PMID:19617999
8. Mahfouz AA, Shatoor AS, Al-Ghamdi BR, Hassanein MA, Nahar S, Farheen A, et al. Tobacco use among health care workersin
southwestern Saudi Arabia. Biomed Res Int. 2013;2013:960292. PMID:24063018
9. Al-Lawati JA, Nooyi SC, Al-Lawati AM. Knowledge, attitudes and prevalence of tobacco use among physicians and dentists in
Oman. Ann Saudi Med. 2009;29(2):128–33. PMID:19318747
10. El-Khushman HM, Sharara AM, Al-Laham YM, Hijazi MA. Cigarette smoking among health care workers at King Hussein Medi-
cal Center. J Hosp Med. 2008;3(3):281–4. PMID:18571808
11. Poyrazoğlu S, Sarli S, Gencer Z, Günay O. Waterpipe (narghile) smoking among medicaland non-medical university students in
Turkey. Ups J Med Sci. 2010;115:210–6. PMID:20636256
12. Maziak W, Fouad FM, Asfar T, Hammal F, Bachir EM, Rastam S, et al. Prevalence and characteristics of narghile smoking among
university students in Syria. Int J Tuberc Lung Dis. 2004;8:882–9. PMID:15260281
13. Tamim H, Terro A, Kassem H, Ghazi A, Khamis TA, Hay MM, et al. Tobacco use by university students, Lebanon, 2001. Addiction.
2003;98:933–9. PMID:12814499
14. Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R, et al. The global epidemiology of waterpipe smoking. Tob Control. 2015
Mar;24(Suppl. 1):i3–12. PMID:25298368
15. Global Youth Tobacco Survey Collaborative Group. Tobacco use among youth: a cross-country comparison. Tob Control.
2002;11:252–70. PMID:12198280
16. Rezk-Hanna M, Macabasco-O’Connell A, Woo Ml. Hookah smoking among young adults in southern California. Nurs Res. 2014
Jul–Aug;63(4):300–6. PMID:24977727
17. Haroon M, Munir A, Mahmud W, Hyder O. Knowledge, attitude, and practice of water-pipe smoking among medical students in
Rawalpindi, Pakistan. J Pak Med Assoc. 2014 Feb;64(2):155–8. PMID:24640803
18. Alvur MT, Cinar N, Akduran F, Dede C. Fallacies about water pipe use in Turkish university students – what might be the conse-
quences? Asian Pac J Cancer Prev. 2014;15(5):1977–80. PMID: 24716921
19. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. Prevalence of waterpipe tobacco smoking among the gener-
al and specific populations: a systematic review. BMC Public Health. 2011;11:244. PMID:21504559
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Sociodemographic predictors of tobacco smoking among expatriate

and national adolescents in the United Arab Emirates
Ayesha Siddiqua1, Rania Dghaim2 and Caroline Barakat-Haddad3
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada (Correspondence to: A. Siddiqua: ayesha.
1
[email protected]). 2Department of Natural Science and Public Health, College of Sustainability Sciences and Humanities, Zayed University, Dubai,
United Arab Emirates. 3Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada.
Abstract
Background: Tobacco use among adolescents is an important public health concern as it causes various forms of smoking-
related health problems and can create a gateway for other substance abuse.
Aim: This study examined the prevalence, profile and predictors of tobacco use among expatriate and national adolescents
living in the United Arab Emirates (UAE).
Methods: Using a cross-sectional study design (2007–2009), we collected data on the prevalence of tobacco use in 6363
adolescents aged 13–20 years, including current smokers of cigarettes, midwakh, shisha and any other form of tobacco.
We also collected demographic, socioeconomic, residential and behavioural data.
Results: In the previous 30 days, 505 (8.9%) participants had smoked cigarettes, 355 (6.3%) had smoked midwakh, 421 (7.4%)
had smoked shisha and 380 (6.4%) had smoked any other form of tobacco. Overall, 818 (14.0%) adolescents were current
smokers, who reported occasional or daily use of at least one form of tobacco in the past 30 days. Results consistently
indicated that the prevalence of tobacco use was higher among men than women, regardless of age and tobacco form.
Among men, cigarette smoking was the most popular, whereas shisha was the most smoked form of tobacco among
women. Being male and ever having used illegal drugs consistently emerged as significant predictors of all forms of
tobacco use.
Conclusion: There is a need for continued public health strategies and education campaigns to discourage adolescents in
the UAE from using tobacco.
Key words: Adolescents, Tobacco-use, Smoking, Gender differences, United Arab Emirates
Citation: Siddiqua A; Dghaim R; Barakat-Haddad C. Sociodemographic predictors of tobacco smoking among expatriate and national adolescents in
the United Arab Emirates. East Mediterr Health J. 2018;24(3):283–294. https://doi.org/10.26719/2018.24.3.283
Introduction smoked cigarettes and 21.9% were current users of any

form of tobacco. Overall, 29.7% of men and 12.6% of women
Recent research suggests worldwide estimates of > 150
were current users of any form of tobacco. A repeat of the
million adolescents who use tobacco (1). Tobacco use
GYTS in 2005 indicated that these numbers remained
among adolescents is an important public health concern
as it causes various forms of smoking-related health high, with 22.6% of participants reporting having ever
problems and can create a gateway for other substance smoked cigarettes and 19.5% reporting current use of any
abuse (2). The younger an individual starts smoking, form of tobacco – 25.2% for men versus 13.2% for women.
the more difficult it is for them to quit later in life (3). Identification of the profile and potential predictors
Negative health consequences of smoking are a function of tobacco use among adolescents in the UAE is crucial for
of the duration (number of years smoking) and intensity delivering effective tobacco control measures and health
(number of cigarettes smoked) of use (4). Thus, there is an policies. Thus, the present study used the socioecological
increased risk of smoking-related health problems among model of health to: (1) determine the prevalence of
individuals who begin smoking during adolescence. tobacco use; (2) examine the profile of tobacco use; and
In the United Arab Emirates (UAE), tobacco (3) assess demographic, socioeconomic, residential and
consumption has increased drastically in recent years as behavioural predictors of tobacco use among the UAE
the number of cigarette factories has increased, and rapid adolescent population.
economic and social changes have led to an increase in
the popularity of tobacco (5,6). Despite acknowledgement Methods
by the UAE Ministry of Health that tobacco use is a
Data source and study design
growing problem among adolescents (7), few studies
have focused on this public health issue (8–10). In 2002, This study utilized data from the National Study of
the UAE participated in the Global Youth Tobacco Survey Population Health in the UAE (2007–2009) research
(GYTS) that focused on adolescents aged 13–15 years (11). programme that was undertaken in collaboration with
The survey showed that 20.9% of participants had ever the UAE Ministry of Education. A cross-sectional survey
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was developed and administered to 6363 adolescents aged participant was exposed to tobacco smoke at home or
13–20 years, who attended public and private schools in with friends, whether the participant was born in the
the 7 Emirates of the Federation. The developed survey UAE, parental marital status, and parental education level.
consisted of 2 main components: (1) data on smoking Nationality was grouped on the basis of similar cultures,
behaviour, type and frequency of tobacco use; data related traditions, ancestral linkages or geographical origins:
to other determinants of health; and demographic and UAE (local), GCC [included participants from GCC (Gulf
socioeconomic data (12); and (2) data related to residential Cooperation Council) countries or Greater Arab Free
mobility and location, and residential characteristics. Trade Area], Arab/Middle East, Arab/Africa, South East
Sampling procedure Asia, Western, no nationality, and others.
For socioeconomic profile, data on participants’
A stratified sampling strategy based on school enrolment
monthly family income included the following categories:
data from the UAE Ministry of Education identified
≤ 2000, 2001–5000, 5001–8000, 8001–10 000, 10 001–12
the need to select 147 private and public schools from
000, 12 001–15 000, 15 001–20 000 and > 20 000 UAE dirha.
10 educational zones. Schools were selected randomly
Data related to participants’ residential profiles included
by lottery using an updated (2005–2006) list of schools
location of residence, number of individuals who resided
provided by the Ministry of Education. For schools that
in the household, number of bedrooms in the residence,
had > 1 class per grade level, the fishbowl lottery method
and number of previous residences. A residential
was used to select 1 class from each of Grades 10–12 from
crowding variable was calculated using the ratio for the
each selected school.
number of individuals who resided in the household over
Ethics and administration the number of bedrooms in the residence.
Ethical approval was obtained from the UAE Ministry of Items related to behavioural lifestyle asked
Education and Ministry of Health. Detailed information participants if they had ever used illegal drugs such as
letters were sent to the parents or guardians of the marijuana, hashish or cocaine (yes/no/do not know). In
participants 2 days prior to survey administration. These relation to unconventional drug use, participants were
letters outlined the research objectives and methodology asked whether they had ever purposely inhaled gasoline
and requested participants’ consent. Social workers were fumes, glue, correction fluid, car exhaust or burning
trained to administer the 1st component of the survey to Black Ants (yes/no/do not know). These other forms of
participants from the 3 selected classes from each school, substance abuse are common knowledge among the UAE
during a spare period, in a classroom setting. The 2nd adolescent population and have been included in the UAE
component was sent home with the participant in order national health surveys. Recent United States Food and
to seek parental assistance with completion. Drug Administration laboratory analysis has confirmed
Outcome variables that Black Ants contain sildenafil, which is a current
ingredient used for sexual enhancement products (14).
Outcome variables were based on responses to 5 items
from the questionnaire. One item asked participants if Data analysis
they had ever smoked cigarettes or any form of tobacco Data were analysed using SPSS version 20. Descriptive
such as shisha (water pipe) or midwakh (dokha, small statistics were calculated for outcome and explanatory
tobacco pipe) (yes/no/do not know). In a series of 4 items, variables. To create binary outcome variables based on
and in relation to the past 30 days, participants were also the 4 items regarding different forms of tobacco use,
asked the following questions. How often did you smoke responses were categorized as daily/occasionally versus
cigarettes? How often did you smoke midwakh? How not at all. The χ2 test was used for bivariate analysis.
often did you smoke shisha? How often did you smoke All independent variables that were significant in the
any other form of tobacco? Participants were provided bivariate analysis were entered into logistic regression
the following choices: daily/occasionally, in which case models to predict tobacco-use outcomes. Six logistic
they were asked to circle the number of days between regression models were developed for smoking cigarettes,
1 and 30; not at all/do not know. In addition, 2 variables midwakh, shisha, other tobacco forms, current smoking,
were derived. The 1st variable categorized participants and smoking > 1 form of tobacco. For each of the modelled
as current smokers if they reported occasional or daily outcomes, forward stepwise entry of variables was
use of ≥ 1 form of tobacco in the past 30 days (namely conducted using P ≤ 0.05. For the independent variables,
cigarettes, shisha, midwakh or other). This categorization 1 category was chosen to be the reference category, with
is consistent with World Health Organization guidelines each category of the variable then compared to the
(13). The 2nd variable was derived to identify participants reference.
who reported occasional or daily use of > 1 tobacco
form (including combinations of any 2 of the following: Results
cigarettes, shisha, midwakh, or other form) in the past 30
days. Overall, 52 public and 44 private schools participated in the
study. Response rate ranged from 9% (2 private schools in
Explanatory variables Dubai) to 100% (5 public schools in Fujairah and 5 private
Data related to the participants’ demographic profiles and 3 public schools in Western Region), resulting in an
included sex, age, type of school attended, whether the overall response rate of 65% (4115 responses) (see 12 for
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details regarding response rate from public and private tobacco at home or with friends, GCC or Arab/Middle
schools in each emirate). Overall, 3101 (49%) participants Eastern or Arab/African nationality, parental marital
were of local national origin and 2785 (44%) were male. status identified as other, and location of residence.
The mean age of the sample was 16.2 (standard deviation Predictors of midwakh smoking also included daily or
1.22) years. occasional exposure to tobacco at home or with friends,
Among all participants, 1047 (17.0%) reported ever while those of shisha smoking included increasing age,
smoking any form of tobacco, with the majority smoking daily or occasional exposure to tobacco at home or with
cigarettes 505 (8.9%) followed by shisha 421 (7.4%), 380 friends, and Arab/Middle Eastern or western nationality.
(6.4%) other forms of tobacco, and 355 (6.3%) midwakh. For other forms of tobacco smoking, predictors included
Four hundred and forty (8.2%) reported using > 1 form of age, attending public school, daily or occasional exposure
tobacco, and 818 (14%) were current smokers. For every to tobacco at home or with friends, parental marital status
age group and tobacco form, the prevalence of tobacco use identified as other, and residential mobility (4 previous
was higher among men than women (Figure 1). For every residences). In relation to smoking > 1 form of tobacco,
age group, cigarette smoking was more popular among significant predictors were male sex, increasing age,
men: < 14 years: 6 (5.5%); 15 years: 77 (12.4%); 16 years: daily or occasional exposure to tobacco at home or with
99 (14.3%); 17 years: 139 (19.8%); 18 years: 40 (19.3%); > 19 friends, Arab/Middle Eastern Arab/African or western
years: 30 (25.4%). The highest proportion of male current nationality, parental marital status identified as other,
smokers was in the age group > 19 years: 57 (44.2%). In location of residence, and ever using illegal drugs.
contrast, shisha was the most smoked form of tobacco
among women in most age groups: < 14 years: 6 (3.1%); 15 Discussion
years: 20 (2.3%); 17 years: 24 (3.4%); 18 years: 5 (2.9%), except In this study, 1047 (17%) participants indicated that they
in the 16 and > 19 years age groups, in which cigarettes had ever smoked cigarettes or any form of tobacco,
were the most smoked form of tobacco: 32 (3.5%) and 3 while 818 (14%) were current smokers. The GYTS 2013,
(3.8%), respectively. The highest proportion of female administered to adolescents aged 13–15 years, reported
current smokers was in the age group 18 years: 15 (7.4%). higher prevalence rates for ever smoking (29.7%) and
Results showed that 5.5% of women and 24% of men lower prevalence rates for current smoking (10.5%) (15).
were current smokers (Table 1). There were significant Although this difference suggests a possible decrease
differences in the proportions of current smokers in current tobacco use, the prevalence of this health
and nonsmokers in relation to sex, age, type of school risk behaviour remains high and indicates the need for
attended, exposure to tobacco at home or with friends, continuous efforts to discourage UAE adolescents from
nationality, parental marital status, location of residence, using tobacco (15,16).
residential crowding, and illegal drug use. Overall, the The prevalence of current smoking among men in
highest prevalence of current smoking was in the age the present study (24%) was higher than that reported
groups 15–17 years for women and 16–17 years for men. in GYTS 2013 (14.6%) (15). In contrast, the prevalence of
Smoking prevalence was higher for men who attended current smoking among women in the present study
public schools (59.8%) compared to private schools (5.5%) was lower than that reported in GYTS 2013 (6.4%),
(40.2%), whereas the opposite trend was seen for women indicating that tobacco use is gaining popularity among
(34.5 vs 65.5%). For nationality, the highest proportion of women (15). While the GYTS 2013 focused on adolescents
male smokers was from the UAE (246; 42%). The highest aged 13–15 years, our study included participants from a
proportion of female smokers was from Arab/Middle larger age range and found that the highest prevalence
East group (60; 35.1%). Compared to their respective of current smoking was among men aged 19 years
counterparts, the highest prevalence of current smoking (44.2%) and women aged 18 years (7.4%). Furthermore,
was among those who reported parental marital status of our findings point to a positive association between age
other, those who resided in Ajman, those who were not and smoking cigarettes, > 1 form of tobacco and shisha.
exposed to residential crowding, and those who reported A recent study among school students aged 10–20 years
ever using illegal drugs. in Dubai reported prevalence rates of 11.2 and 2.2% for
Significant differences in all forms of tobacco use smoking cigarettes and shisha, respectively (10). This
were found in relation to sex, age, exposure to tobacco suggests higher prevalence rates of cigarette smoking and
smoke at home or with friends, and illegal drug use lower prevalence rates of shisha smoking compared to
(Table 2). The patterns of significant differences observed our study (8.8% and 6.2%, respectively). These differences
for each form of tobacco use in relation to the remaining are likely to become more pronounced with the recent
explanatory variables varied. enactment of the Federal Anti-Tobacco law in early 2013
Multivariate logistic regression modelling revealed (16), which specifies that shisha may not be served to
that male sex and ever using illegal drugs were significant individuals aged < 18 years.
predictors of all forms of tobacco use (Table 3). For Recently, several studies have highlighted an
current smoking, attending private school, nationality alarming increase in the use of unconventional forms
and location of residence also emerged as significant of tobacco, including shisha and midwakh, particularly
predictors. In addition, predictors of cigarette smoking in the Gulf Region (17). Earlier reports from the GYTS
included increasing age, daily or occasional exposure to suggest that the average rate of shisha smoking among
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(A) ≤ 14 years (B) 15 years

20
16
18
16 14
14 12
12 10
10 8
%
%
8
6
6
4
4
2 2
0 0
Cigarettes Midwakh Shisha Other Uses >1 Current Cigarettes Midwakh Shisha Other Uses >1 Current
tobacco product smokers tobacco product smokers
products products
Tobacco forms Tobacco forms
(C) 16 years 30 (D) 17 years

25
25
20
20
15
15
%
%
10
10
5 5
0 0
products products
50
35 (E) 18 years (F) ≥ 19 years
45
30 40
35
25
30
20
25
%
%
15 20
15
10
10
5
5
0 0
products products
Male Female Total
Figure 1 Distribution of tobacco use (%) in relation to age and gender, among adolescents who reside in the United Arab Emirates (n = 6363)
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Table 1 Demographic, socioeconomic, residential and behavioural profiles of study participants (n = 6363)
Prevalence of current smoking for:

Variable Classification Overall, n (%) Male, n (%) Female, n (%)
Current smoking 818 (14.0) 624 (100) 174 (100)
Sex, n = 798 ***
Female 174 (5.5)
Male 624 (24.0)
Age, yr, n = 746 ***
< 14 31 (10.2) 20 (3.5) 11 (6.8)
15 137 (8.8) 98 (17) 38 (23.5)
16 221 (13.4) 161 (28) 57 (35.2)
17 219 (14.7) 181 (31.4) 37 (22.8)
18 81 (20.8) 66 (11.5) 13 (8)
> 19 57 (28.8) 50 (8.7) 6 (3.7)
School, n = 818 **
Public 445 (12.8) 373 (59.8) 60 (34.5)
Private 373 (15.9) 251 (40.2) 114 (65.5)
Exposed to tobacco smoke at home or ***
with friends, n = 698 Not at all 272 (8.8) 198 (36.8) 69 (47.3)
Occasionally 237 (17.5) 189 (35.1) 44 (30.1)
Daily 189 (30.0) 44 (30.1) 33 (22.6)
UAE born, n = 789 No 209 (14.6) 138 (22.7) 69 (40.8)
Yes 580 (13.6) 471 (77.3) 100 (59.2)
Ethnicity, n = 792a ***
UAE 318 (11.3) 256 (42) 54 (31.6)
GCC 61 (19.2) 54 (8.9) 6 (3.5)
Arab/Middle East 215 (23.9) 155 (25.4) 60 (35.1)
Arab/Africa 93 (16.0) 83 (13.6) 10 (5.8)
South East Asia 66 (7.0) 44 (7.2) 21 (12.3)
Western 22 (27.5) 6 (1.0) 15 (8.8)
None/other 17 (23.0) 12 (2.0) 5 (2.9)
Parental marital status, n = 783 **
Married 687 (13.8) 535 (88.1) 150 (86.7)
Widowed 27 (12.4) 41 (6.8) 7 (4.0)
Separated/divorced 22 (9.8) 11 (1.8) 7 (4.0)
Other 47 (20.2) 20 (3.3) 9 (5.2)
Father graduated from high school, No 243 (12.5) 195 (42.1) 40 (30.5)
n = 605 Yes 362 (13.3) 268 (57.9) 91 (69.5)
Mother graduated from high school, No 291 (12.4) 235 (51.6) 50 (37.9)
n = 597 Yes 306 (13.1) 220 (48.4) 82 (62.1)
Monthly household income (AED), ≤2K 17 (11.8) 13 (3.4) 3 (3.2)
n = 479 > 2 and ≤ 5 K 100 (12.1) 88 (23.3) 12 (12.8)
> 5 and ≤ 8 K 81 (12.8) 63 (16.7) 15 (16.0)
> 8 and ≤ 10 K 52 (12.0) 41 (10.8) 10 (10.6)
> 10 and ≤ 12 K 42 (13.0) 34 (9.0) 8 (8.5)
> 12 and ≤ 15 K 44 (15.0) 33 (8.7) 10 (10.6)
> 15 and ≤ 20 K 38 (14.6) 29 (7.7) 9 (9.6)
> 20 K 105 (16.1) 77 (20.4) 27 (28.7)
Income divided (AED), n = 469b < 15 K 342 (12.9) 272 (74.3) 63 (65.6)
> 15 K 127 (13.9) 94 (25.7) 33 (34.4)
Location of residence, n = 818 ***
Abu Dhabi 411 (15.0) 331 (53.0) 71 (40.8)
Ajman 39 (17.9) 23 (3.7) 16 (9.2)
Dubai 75 (13.9) 64 (10.3) 11 (6.3)
Fujairah 62 (12.8) 37 (5.9) 22 (12.6)
RAK 51 (8.3) 38 (6.1) 10 (5.7)
Sharjah 170 (15.5) 125 (20.0) 41 (23.6)
UAQ 10 (7.6) 6 (1.0) 3 (1.7)
Residential *
Crowding, n = 234c No 106 (8.7) 74 (44.0) 30 (47.6)
Yes 128 (6.7) 94 (56.0) 33 (52.4)
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Table 1 Demographic, socioeconomic, residential and behavioural profiles of study participants (n = 6363) (concluded)
Prevalence of current smoking for:

Variable Classification Overall, n (%) Male, n (%) Female, n (%)
Number of previous residences, None 580 (14.5) 444 (71.2) 117 (67.2)
n = 818 1 160 (13.5) 120 (19.2) 40 (23.0)
2 41 (12.1) 30 (4.8) 10 (5.7)
3 18 (11.3) 16 (2.6) 2 (1.1)
4 19 (13.8) 14 (2.2) 5 (2.9)
Ever used illegal drugs, n = 800 ***
No 757 (13.8) 584 (94.8) 159 (95.8)
Yes 43 (47.8) 32 (5.2) 7 (4.2)
Unconventional drug use, n = 795 No 577 (14.8) 476 (77.8) 91 (54.8)
Yes 218 (13.2) 136 (22.2) 75 (45.2)
*P < 0.05; **P < 0.01; ***P < 0.001.
aUAE = local; GCC = Kuwait, Saudi Arabia, Oman, Qatar, Bahrain and Yemen; Arab/Middle East = Lebanon, Syria, Jordan, Palestine and Iraq; Arab/Africa = Egypt, Tunisia, Morocco, Algeria,
Libya, Sudan and Somalia; South East Asia = India, Pakistan, Bangladesh, Sri Lanka, Philippines and Indonesia; Western = Europe, United States of America, Australia, Canada; No nationality
and Others = all other nationalities.
aCutoff based on data from the UAE Ministry of Economy, indicating that the average monthly income for Emirati households is AED 36 438.10 and that for expatriate households is AED 15
074.30.
bCalculated using the ratio for the number of individuals that reside in the household over the number of bedrooms in the house.
AED = United Arab Emirates dirham; RAK = Ras al-Khaimah; UAQ = Umm al-Quwain.
Table 2 Demographic, socioeconomic, residential and behavioural profiles of study participants (n = 6363)
Variable Classification Cigarettes Midwakh Shisha Other Uses > 1 tobacco
(n = 505) (n = 355) (n = 421) (n = 380) form
(n = 440)
n (%) n (%) n (%) n (%) n (%)
Sex *** *** *** *** ***
Female 71 (2.4) 29 (1.0) 84 (2.8) 57 (1.8) 52 (1.8)
Male 416 (16.2) 310 (12.1) 320 (12.4) 303 (11.4) 371 (15.1)
Age, yr *** *** *** *** ***
< 14 8 (2.6) 8 (2.6) 12 (3.9) 11 (3.6) 6 (2.1)
15 94 (6.3) 66 (4.4) 72 (4.8) 67 (4.2) 74 (5.2)
16 135 (8.4) 92 (5.7) 106 (6.6) 94 (5.6) 108 (7.0)
17 158 (11.1) 109 (7.6) 134 (9.4) 122 (8.1) 148 (7.0)
18 43 (11.2) 21 (5.5) 37 (9.6) 32 (8.0) 40 (11.3)
> 19 33 (16.6) 28 (14.2) 25 (12.6) 21 (10.0) 29 (15.9)
School ** *** ** *
Public 303 (9.2) 235 (7.1) 211 (6.4) 253 (7.1) 274 (8.9)
Private 202 (8.5) 120 (5.1) 210 (8.9) 127 (5.3) 166 (7.3)
Exposed to tobacco *** *** *** *** ***
smoke at home or Not at all 92 (3.0) 52 (1.7) 84 (2.8) 68 (2.1) 60 (2.0)
with friends Occasionally 159 (12.3) 108 (8.3) 134 (10.3) 116 (8.3) 150 (12.2)
Daily 176 (29.4) 133 (22.1) 139 (23.0) 124 (19.3) 183 (28.7)
UAE born ** *
No 114 (8.0) 61 (4.3) 119 (8.4) 80 (5.4) 92 (6.7)
Yes 372 (9.0) 278 (6.7) 284 (6.9) 284 (6.5) 331 (8.6)
Ethnicitya *** *** ***
UAE 187 (6.9) 155 (5.7) 121 (4.5) 173 (6.1) 170 (6.7)
GCC 43 (13.6) 30 (9.5) 22 (6.9) 31 (9.1) 35 (11.6)
Arab/Middle East 137 (16.0) 84 (9.9) 165 (19.3) 75 (8.1) 128 (15.9)
Arab/Africa 70 (12.7) 41 (7.4) 42 (7.7) 49 (8.3) 51 (9.7)
South East Asia 33 (3.4) 19 (2.0) 29 (3.0) 22 (2.3) 20 (2.1)
Western 10 (12.3) 6 (7.5) 17 (21.0) 7 (8.8) 11 (13.9)
None/other 7 (10.0) 4 (5.7) 9 (13.0) 4 (5.1) 6 (9.0)
Parental marital * *** *** **
status Married 409 (8.4) 282 (5.8) 346 (7.2) 290 (5.7) 351 (7.7)
Widowed 16 (7.5) 10 (4.7) 13 (6.2) 15 (6.9) 13 (6.6)
Separated/ 19 (8.7) 12 (5.5) 13 (5.9) 18 (7.8) 18 (8.6)
Divorced 33 (14.8) 28 (12.6) 23 (10.3) 32 (14.0) 31 (14.8)
Other
Father graduated * *
from high school No 159 (8.5) 120 (6.4) 102 (5.5) 122 (6.1) 135 (7.7)
Yes 197 (7.4) 130 (4.9) 195 (7.3) 159 (5.7) 174 (6.9)
288
Book 24-03.indb 288 13/06/2018 09:44:09

Table 2 Demographic, socioeconomic, residential and behavioural profiles of study participants (n = 6363) (concluded)
Variable Classification Cigarettes Midwakh Shisha Other Uses > 1 tobacco
(n = 505) (n = 355) (n = 421) (n = 380) form
(n = 440)
n (%) n (%) n (%) n (%) n (%)
Mother graduated **
from high school No 179 (7.9) 132 (5.8) 124 (5.5) 147 (6.1) 149 (7.0)
Yes 175 (7.7) 115 (5.0) 172 (7.5) 134 (5.6) 158 (7.2)
Monthly <2K 10 (6.5) 9 (5.8) 10 (6.5) 11 (7.2) 9 (6.2)
household income > 2 and ≤ 5 K 70 (8.8) 44 (5.5) 43 (5.4) 50 (5.9) 59 (7.7)
(AED) > 5 and ≤ 8 K 44 (7.2) 32 (5.3) 35 (5.8) 33 (5.1) 44 (7.7)
> 8 and ≤ 10 K 34 (8.1) 22 (5.3) 32 (7.6) 28 (6.4) 28 (7.1)
> 10 and ≤ 12 K 38 (11.8) 23 (7.2) 30 (9.3) 23 (7.0) 26 (8.5)
> 12 and ≤ 15 K 18 (6.2) 15 (5.1) 26 (8.9) 20 (6.6) 18 (6.4)
> 15 and ≤ 20 K 18 (7.0) 12 (4.7) 18 (7.0) 16 (6.0) 18 (7.5)
> 20 K 48 (7.7) 39 (6.2) 46 (7.3) 43 (6.4) 49 (8.2)
Income divided < 15 K 222 (8.6) 153 (5.9) 181 (7.0) 169 (6.3) 198 (8.1)
(AED) > 15 K 73 (8.2) 54 (6.1) 74 (8.3) 63 (6.7) 71 (8.4)
Location of ** *** ***
residence Abu Dhabi 252 (10.3) 185 (7.6) 225 (9.2) 175 (6.2) 222 (9.6)
Ajman 24 (10.5) 20 (8.6) 21 (9.1) 23 (10.3) 23 (10.8)
Dubai 50 (8.8) 32 (5.7) 35 (6.2) 47 (8.4) 45 (8.4)
Fujairah 43 (8.5) 17 (3.4) 15 (3.0) 31 (6.4) 25 (5.3)
RAK 30 (4.7) 32 (5.0) 25 (3.9) 28 (4.5) 31 (5.1)
Sharjah 99 (8.7) 65 (5.7) 95 (8.3) 73 (6.6) 89 (8.2)
UAQ 7 (4.9) 4 (2.8) 5 (3.5) 3 (2.3) 5 (3.9)
Residential No 63 (5.2) 50 (4.2) 50 (4.2) 57 (4.6) 56 (5.0)
crowding Yes 86 (4.6) 62 (3.3) 79 (4.2) 77 (4.0) 75 (4.2)
No. of previous * ** ** **
residence None 384 (9.8) 281 (7.2) 308 (7.9) 292 (7.1) 336 (9.1)
1 72 (6.4) 44 (3.9) 62 (5.5) 55 (4.6) 63 (5.8)
2 25 (7.6) 14 (4.2) 27 (8.2) 12 (3.6) 19 (6.0)
3 14 (9.0) 9 (5.7) 14 (8.9) 12 (7.4) 14 (9.7)
4 10 (7.7) 7 (5.4) 10 (7.7) 9 (6.1) 8 (6.6)
Ever used illegal *** *** *** *** ***
drugs No 448 (8.4) 308 (5.8) 366 (6.9) 324 (5.7) 386 (7.5)
Yes 51 (55.4) 43 (47.3) 50 (55.6) 52 (56.5) 51 (57.3)
Unconventional No 364 (9.6) 255 (6.7) 291 (7.7) 258 (6.4) 318 (8.8)
drug use Yes 136 (8.3) 94 (5.8) 124 (7.6) 116 (6.9) 120 (7.7)
*P < 0.05; **P < 0.01; ***P < 0.001.
aUAE = local; GCC = Kuwait, Saudi Arabia, Oman, Qatar, Bahrain and Yemen; Arab/Middle East = Lebanon, Syria, Jordan, Palestine and Iraq; Arab/Africa = Egypt, Tunisia, Morocco, Algeria,
Libya, Sudan and Somalia; South East Asia = India, Pakistan, Bangladesh, Sri Lanka, Philippines and Indonesia; Western = Europe, United States of America, Australia, Canada; No nationality
and None/other = all other nationalities.
AED = United Arab Emirates dirham; RAK = Ras al-Khaimah; UAQ = Umm al-Quwain.
289
Book 24-03.indb 289 13/06/2018 09:44:09

Table 3 Predictors of different forms of tobacco use among adolescents who reside in UAE
290
Book 24-03.indb 290

Variable Reference Current smoking Cigarettes Midwakh Shisha Other Uses > 1 tobacco form
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Sex (Female) Male 4.34*** 2.95–6.38 5.77*** 4.24–7.85 11.50*** 6.68–19.81 3.68*** 2.57–5.27 3.10*** 2.34–4.11 7.21*** 5.00–10.39
Age (< 14 yr) 15 yr 1.08 0.48–2.46 3.43** 1.49–7.89 1.10 0.47–2.57 1.83 0.78–4.32 0.14*** 0.10–0.21 3.36* 1.34–8.43
Research article
16 yr 1.47 0.65–3.34 3.45** 1.51–7.86 0.79 0.34–1.87 2.18 0.93–5.10 0.13*** 0.09–0.19 3.34** 1.34–8.32
17 yr 1.53 0.66–3.55 4.45*** 1.96–10.12 1.25 0.54–2.92 3.65** 1.56–8.50 0.20*** 0.14–0.30 5.57*** 2.24–13.81
18 yr 1.33 0.48–3.72 4.90*** 2.00–11.97 0.79 0.29–2.18 5.56*** 2.18–14.20 0.23*** 0.14–0.39 6.35*** 2.38–16.96
> 19 yr 2.23 0.72–6.91 6.45*** 2.49–16.65 2.26 0.80–6.35 5.90** 2.08–16.79 0.24*** 0.13–0.46 7.99*** 2.79–22.92
School (public) Private 1.77* 1.06–2.94 0.77 0.51–1.17 1.47 0.98–2.20 0.54*** 0.41–0.70 1.05 0.73–1.50
Exposed to tobacco Occasionally 1.07 0.62–1.85 2.89*** 2.15–3.88 4.06*** 2.63–6.27 2.67*** 1.85–3.87 2.01*** 1.47–2.73 4.04*** 2.86–5.69
smoke (not at all)
Daily 0.46 0.16–1.36 8.09*** 5.90–11.11 12.78*** 8.17–19.99 4.81*** 3.22–7.17 5.54*** 4.04–7.59 10.67*** 7.43–15.34
UAE born (no) Yes 1.50 0.96–2.34 1.39 0.98–1.96
Ethnicity (South East GCC 2.77* 1.19–6.42 1.85* 1.01–3.41 1.40 0.58–3.37 1.88 0.85–4.17
Asia)a
Arab/Middle East 3.10*** 1.64–5.85 2.71*** 1.67–4.42 5.18*** 2.79–9.61 4.23*** 2.28–7.82
Arab/Africa 2.68** 1.31–547 2.42** 1.43–4.08 1.72 0.83–3.58 2.37* 1.20–4.70
Western 6.88** 2.01–23.61 2.13 0.79–5.79 7.98*** 3.04–20.92 3.49* 1.18–10.34
UAE 2.15* 1.10–4.22 1.24 0.77–1.98 1.39 0.69–2.78 1.60 0.81–3.13
None/other 4.91** 1.62–14.91 1.47 0.49–4.40 2.14 0.60–7.64 1.51 0.42–5.46
Parental marital Widowed 1.04 0.52–2.09 1.10 0.69–1.76 1.24 0.71–2.81 1.06 0.65–1.72 1.21 0.73–2.00
status (married)
Separated/divorced 0.51 0.12–2.23 0.97 0.48–1.96 0.70 0.23–2.11 1.31 0.67–2.54 1.10 0.52–2.32
Other 2.07 0.58–7.43 2.72** 1.28–5.77 1.92 0.51–7.29 3.30** 1.60–6.78 3.47** 1.60–7.68
Father graduated Yes 1.00 0.70–1.42 0.93 0.61–1.44
high school (no)
Mother graduated Yes 1.07 0.72–1.60
high school (no)
Location of residence Ajman 3.21** 1.36–7.53 2.61* 1.15–5.94 1.76 0.67–4.65 2.47* 1.04–5.86
(RAK)
Dubai 1.28 0.59–2.80 2.23* 1.17–4.26 2.07 0.96–4.47 1.85 0.94–3.64
Fujairah 1.09 0.45–2.67 2.90** 1.17–4.26 0.57 0.19–1.72 1.12 0.51–2.49
Sharjah 1.33 0.66–2.70 2.63** 1.45–4.78 1.97 0.96–4.04 2.30** 1.24–4.27
UAQ 1.57 0.33–7.49 0.64 0.067–6.05 1.69 0.28–10.15 0.83 0.08–8.50
Abu Dhabi 1.37 0.73–2.59 2.83*** 1.62–4.97 1.97* 1.01–3.83 2.41** 1.35–4.29
EMHJ – Vol. 24 No. 3 – 2018
13/06/2018 09:44:09
adolescents aged 13–15 years has increased from 15% in
4.28–16.80
0.41–3.50
0.32–1.84
0.52–2.79
0.33–2.35
Uses > 1 tobacco form
2002 to 28.2% in 2005. The GYTS findings raise concerns
95% CI
aUAE=local; GCC=Kuwait, Saudi Arabia, Oman, Qatar, Bahrain and Yemen; Arab/Middle East = Lebanon, Syria, Jordan, Palestine, and Iraq; Arab/Africa = Egypt, Tunisia, Morocco, Algeria, Libya, Sudan and Somalia; South East Asia = India, Pakistan, Bangladesh, Sri Lanka,
over shisha use by a group of students who have never
smoked (18). The overall prevalence of shisha smoking in
8.47
our sample is comparable to the prevalence of cigarette
smoking across all age groups. This highlights the need
8.48***
0.88
0.77
1.20
1.20
OR
for continued public health strategies and education

campaigns to discourage adolescents from smoking
6.55–21.69
other forms of tobacco, specifically shisha.
0.06–0.28
0.07–0.14
0.05–0.12
0.02–0.11
95% CI
We found that the prevalence of midwakh smoking

was 7.6, 5.5 and 14.2% for the 17, 18 and > 19 years age
Other
14.54
groups, respectively. According to Al-Houqani, midwakh
accounted for 15% of all tobacco smokers in Abu Dhabi,
11.92***
0.08***
0.05***
0.10***
0.13***
with a young age of onset (5). An alarming prevalence of

OR
midwakh smoking among medical students has been

reported in Ajman, with 30 and 5% prevalence among
male and female students, respectively (9). A more
4.91–22.23
95% CI
recent study conducted in 2015 for the same age group

in Ajman reported a dramatic increase in the prevalence
Shisha
5.13
rate of midwakh smoking (36% had ever smoked and 29%

currently smoked) (19). Similar to our results, prevalence
10.45***
OR
rates increased with age. This increase in the use of

other forms of tobacco could be due to the widespread
misconception that these forms are less harmful than
2.37–10.99
0.37–4.07
0.36–3.27
0.43–2.81
cigarettes.
0.25–1.77
95% CI
Our study suggests that cigarettes are the most

Midwakh
common form of tobacco among men, while shisha is the

5.26
most common among women. This observed difference

in smoking behaviour is not surprising given the social
5.11***
0.66
1.09
1.23
OR
1.10
context in the UAE, where social norms may be more

Table 3 Predictors of different forms of tobacco use among adolescents who reside in UAE (concluded)
accepting of men smoking cigarettes. This may urge

women to under-report their cigarette smoking habits,
Philippines and Indonesia; Western = Europe, United States of America, Australia and Canada; None/other = all other nationalities.
3.58–13.05
0.60–2.66
0.42–2.38
0.37–2.63
0.38–1.83
95% CI
and report their shisha smoking given that the latter may
be more socially accepted (20). Anti-tobacco education
Cigarettes
CI = confidence interval; OR = odds ratio; RAK = Ras Al Khaimah; UAE = United Arab Emirates; UAQ = Umm Al Quwain.
campaigns should address this social context, thus

6.02
emphasizing the health risks of all forms of tobacco to

6.83***
both male and female adolescents.

0.84
0.99
0.99
1.26
OR
There are policies to prevent adolescents aged < 18

years purchasing tobacco products in the UAE; however,
1.54–14.35
those attending private school may be more likely to

95% CI
Current smoking
purchase these products than their counterparts. Our

results also suggest that adolescents who attend private
10.61
schools are more likely to be current smokers. Possible

explanations focus on the issue of policy enforcement,
4.69**
OR
as well as the ability for these adolescents to purchase

tobacco products, as they are likely to have greater
material resources compared to those who attend public
schools. Moreover, it could be related to the demographic
composition in UAE public schools, where the majority
Hosmer and Lemeshow test (χ2)
of students are expatriates, and that tobacco smoking

Reference
may be more prevalent among expatriate adolescents

None
compared to nationals.
Yes
2
3
1
*P < 0.05; **P < 0.01; ***P < 0.001.
There is a well-established link between parental

smoking and adolescent initiation of smoking, regular
smoking, and persistence of smoking into adulthood
Ever used illegal
No. of previous
residences (4)
(21). Many prospective studies have also demonstrated

drugs (no)
positive associations between peer and adolescent

Variable
tobacco use (22). Similarly, our results suggest that

adolescents who are exposed to tobacco smoke at home
291
Book 24-03.indb 291 13/06/2018 09:44:09

or with friends are more likely to smoke. This highlights of tobacco use. It may be useful to incorporate tobacco-
the importance of supporting anti-tobacco education use prevention strategies in drug abuse treatment
campaigns and interventions that aim to alter social programmes (25). Although the prevalence of illegal drug
norms in peer/family settings (21,22). use is low in the UAE compared to international standards,
Our findings suggest that nationality is linked to it is imperative that public health programmes continue
tobacco smoking, which is consistent with previous to focus on strengthening their current educational
findings (2,23). Adolescents from western countries are
campaigns to prevent adolescents from using illegal
more likely to smoke shisha and use > 1 form of tobacco
drugs (26).
than adolescents from South East Asia. This may be
because shisha smoking is gaining steady popularity The present study had several limitations. Data were
among adolescents in western countries (24). Western self-reported and may have been subject to response bias.
adolescents who reside in the UAE also may be influenced Sampling led to lower representations of adolescents
by the social acceptance of smoking and feel inclined to who attended private schools in Dubai and among men
smoke a variety of tobacco forms that are available in this who resided in Umm al Quwain. This is relevant as
country.
the population of Dubai consists of a large proportion
Our results indicate that location of residence is of expatriates. Response to the survey may have been
linked to tobacco use. This can be explained by the
influenced by the presence of social workers, with
demographic and social differences among the different
the possibility of under-reporting tobacco use among
emirates. In particular, residents in Ras Al Khaimah have
fewer opportunities for shisha bars and social gatherings. women, given social norms, as well as under-reporting
Furthermore, there was a lower representation of men of illegal drug use among all participants. Despite these
from Umm al Quwain in this study, which is likely linked limitations, our findings present a detailed profile of
to the lower prevalence of smoking. tobacco use among UAE adolescents that is crucial
Our results show that adolescents who report ever for reducing the prevalence of tobacco use among
using illegal drugs are more likely to engage in all types adolescents and tobacco-related diseases.
Acknowledgements
This work was supported by a Zayed University Research Incentive Fund. We acknowledge Zayed University and the UAE
Ministry of Education for their contribution in the initial phase of this research.
Funding: None.
Conflict of interest: None.
Facteurs prédictifs sociodémographiques du tabagisme parmi les adolescents

expatriés et nationaux aux Émirats arabes unis
Résumé
Contexte : Les recherches récentes permettent de dégager des estimations qui montrent que plus de 150 millions
d’adolescents consomment du tabac dans le monde. Le tabagisme chez l’adolescent est une importante préoccupation de
santé publique du fait des risques pour la santé liés au fait de fumer. Par ailleurs, il peut mener à d’autres formes d’abus
de substances psychoactives.
Objectif : La présente étude examinait la prévalence, le profil et les facteurs prédictifs de la consommation de tabac chez
les adolescents expatriés et nationaux aux Émirats arabes unis.
Méthodes : À l’aide d’un plan d’étude transversale (2007-2009), nous avons collecté des données sur la prévalence du
tabagisme chez 6363 adolescents âgés de 13 à 20 ans, comprenant des fumeurs de cigarettes, de midwakh, de shisha et de
toute autre forme de tabac au moment de l’enquête. Nous avons par ailleurs recueilli des données démographiques, socio-
économiques, résidentielles et comportementales.
Résultats : Durant les 30 jours précédents, 505 (8,9 %) des participants avaient fumé des cigarettes, 355 (6,3 %) avaient fumé
la midwakh, 421 (7,4 %) avaient fumé la shisha et 380 (6,4 %) avaient consommé toute autre forme de tabac. Globalement,
14,0 % des adolescents étaient des fumeurs au moment de l’étude, notifiant l’utilisation occasionnelle ou quotidienne d’au
moins une forme de tabac au cours des 30 derniers jours. Les résultats ont généralement indiqué que la prévalence de la
consommation de tabac était plus forte chez les hommes que chez les femmes, indépendamment de l’âge et de la forme
de tabac consommée. Chez les hommes, la consommation de cigarettes était la plus populaire, tandis que la shisha était
la forme de tabac la plus utilisée chez les femmes. Le fait d’être un homme et d’avoir déjà consommé des drogues illégales
ressortait généralement comme facteur prédictif significatif de toutes formes de consommation de tabac.
Conclusion : Des stratégies de santé publique et des campagnes d’éducation permanentes sont nécessaires pour
décourager les adolescents de consommer du tabac au Émirats arabes unis.
292
Book 24-03.indb 292 13/06/2018 09:44:09

‫السكانية لتدخني التبغ يف صفوف اليافعني املغرتبني واملواطنني يف دولة اإلمارات العربية املتحدة‬-‫ا ُملنبئات االجتامعية‬
‫حداد‬-‫ كارولني بركات‬،‫ رانية دغيم‬،‫عائشة صدّ يقي‬
‫ وأن تعاطي التبغ بني اليافعني من األمور املثرية‬.‫ مليون‬150 ‫ تشري األبحاث احلديثة إىل تقديرات عاملية الستهالك التبغ بني اليافعني تزيد عىل‬:‫اخللفية‬
.‫ والذي يمكن أن يؤدي إىل أنامط أخرى من تعاطي املخدرات‬،‫للقلق يف جمال الصحة العامة بسبب املخاطر الصحية النامجة عن التدخني‬
‫ هدفت هذه الدراسة إىل تقييم انتشار تعاطي التبغ ومرتسمه ومنبئاته يف صفوف اليافعني من املغرتبني واملواطنني الذين يعيشون يف دولة‬:‫اهلدف‬
.‫اإلمارات العربية املتحدة‬
‫ يافع ًا يف الفئة العمرية‬6363 ‫ قمنا بجمع بيانات عن انتشار تعاطي التبغ يف صفوف‬،)2009-2007( ‫ باستخدام دراسة مقطعية‬:‫طرق البحث‬
‫ كام عمدنا إىل مجع بيانات‬.‫ بام يف ذلك املدخنون احلاليون للسجائر واملدواخ والشيشة وأي شكل آخر من أشكال إستهالك التبغ‬،‫ عام ًا‬20-13
.‫اقتصادية وسكنية وسلوكية‬-‫سكانية واجتامعية‬
.‫) دخنوا أشكاال أخرى من التبغ خالل فرتة الثالثني يوم ًا السابقة‬%6.3( 355‫) من املشاركني دخنوا السجائر و‬%8.9( 505 ‫تبي أن‬ ّ :‫النتائج‬
‫ وأفادوا باستهالك نوع واحد عىل األقل من أنواع التبغ سوا ًء بشكل عريض أو‬،‫ من املراهقني يدخنون يف الوقت احلايل‬%14 ‫تبي أن‬ ّ ،‫وبوجه عام‬
‫ بغض النظر‬،‫ وأشارت النتائج عىل نحو متسق إىل أن انتشار إستهالك التبغ يزيد يف صفوف الرجال عن النساء‬.‫يومي خالل السنوات الثالثني املاضية‬
.‫ يف حني جاءت الشيشة أكثر أنواع التبغ التي تدخنها النساء‬،‫ جاء تدخني السجائر النوع األكثر شيوع ًا‬،‫ ويف صفوف الرجال‬.‫عن العمر أو نوع التبغ‬
.‫وشكل عامال الذكورة وتعاطي املخدرات غري املرشوعة يف وقت سابق منبئني مهمني جلميع أشكال إستهالك التبع‬ّ
.‫ ثمة حاجة ملواصلة اسرتاتيجيات الصحة العامة وإجراء محالت التثقيف إلثناء اليافعني يف اإلمارات العربية املتحدة عن إستهالك التبغ‬:‫االستنتاج‬
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12. Barakat-Haddad C. Prevalence of high blood pressure, heart disease, thalassemia, sickle-cell anemia, and iron-deficiency anemia
among the UAE adolescent population. J Environ Public Health. 2013;2013:680631.
13. Guidelines for controlling and monitoring the tobacco epidemic. Geneva: World Health Organization; 1998.
14. Public Notification: "Black Ant” contains undeclared drug ingredient. Silver Spring, MD: U.S. Food and Drug Administration;
2011 (http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm247434.htm,
accessed 12 December 2017).
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15. Global Youth Tobacco Survey: United Arab Emirates 2013 fact sheet. World Health Organization; 2013 (http://apps.who.int/fctc/
implementation/database/sites/implementation/files/documents/reports/uae_annex2_gyts_2013.pdf, accessed 12 December
2017).
16. UAE Anti-tobacco law in effect: rules and fines... Emirates 24/7 News 21 January 2014 (http://www.emirates247.com/news/
emirates/uae-anti-tobacco-law-in-effect-rules-and-fines-2014-01-21-1.535551, accessed12 December 2017).
17. Vupputuri S, Hajat C, Al-Houqani M, Osman O, Sreedharan J, Ali R et al. Midwakh/dokha tobacco use in the Middle East: much to
learn. Tob Control. 2016 Mar;25(2):236–41. http://dx.doi.org/10.1136/tobaccocontrol-2013-051530 PMID:25342581
18. El-Awa F, Warren CW, Jones NR. Changes in tobacco use among 13-15-year-olds between 1999 and 2007: findings from the
Eastern Mediterranean Region. East Mediterr Health J. 2010 Mar;16(3):266–73. PMID:20795439
19. Al Shemmari N, Shaikh RB, Sreedharan J. Prevalence of dokha use among secondary school students in Ajman, United Arab
Emirates. Asian Pac J Cancer Prev. 2015;16(2):427–30. http://dx.doi.org/10.7314/APJCP.2015.16.2.427 PMID:25684466
20. El-Roueiheb Z, Tamim H, Kanj M, Jabbour S, Alayan I, Musharrafieh U. Cigarette and waterpipe smoking among
Lebanese adolescents, a cross-sectional study, 2003-2004. Nicotine Tob Res. 2008 Feb;10(2):309–14. http://dx.doi.
org/10.1080/14622200701825775 PMID:18236295
21. Turner L, Mermelstein R, Flay B. Individual and contextual influences on adolescent smoking. Ann N Y Acad Sci. 2004
Jun;1021(1):175–97. http://dx.doi.org/10.1196/annals.1308.023 PMID:15251888
22. Simons-Morton BG, Farhat T. Recent findings on peer group influences on adolescent smoking. J Prim Prev. 2010 Aug;31(4):191–
208. http://dx.doi.org/10.1007/s10935-010-0220-x PMID:20614184
23. Tobacco use: data by country. World Health Organization; 2009 (http://apps.who.int/gho/data/node.main.65, accessed 16 January
2018.
24. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the
general and specific populations: a systematic review. BMC Public Health. 2011 Apr 19;11(1):244. http://dx.doi.org/10.1186/1471-
2458-11-244 PMID:21504559
25. Richter KP, Ahluwalia HK, Mosier MC, Nazir N, Ahluwalia JS. A population-based study of cigarette smoking among illicit drug
users in the United States. Addiction. 2002 Jul;97(7):861–9. http://dx.doi.org/10.1046/j.1360-0443.2002.00162.x PMID:12133125
26. United Arab Emirates 2013 crime and safety report: Abu Dhabi: Overseas Security Advisory Council; 2013 (https://www.osac.gov/
Pages/ContentReportDetails.aspx?cid=13886, accessed12 December 2017).
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Can Hüseyin Hekimoğlu 1, Özgen Alpay Özbek 2, Mestan Emek 1, Mehmet Ali Öktem 2, Galip Köroğlu 3, Mustafa Sertel 3, Sevin Özdeniz 1, Ali Ceylan 1,
Ayla Açikgöz 1 and Belgin Ünal 1
Department of Public Health, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey (Correspondence to: C.H. Hekimoğlu: [email protected]).
1
Department of Medical Microbiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. 3Manisa Directorate of Public Health, Manisa,
2
Turkey.
Abstract
Background: In Turkey, varicella vaccine was introduced into routine childhood immunization in 2013, with a single
dose administered to children aged 12 months. However, there is limited information on the morbidity (incidence and
seroprevalence), mortality and burden of disease of varicella in the overall Turkish population.
Aim: To determine varicella seroprevalence and its social determinants in Manisa Province, Turkey in children aged > 2
years before single-dose varicella vaccination was introduced in 2013.
Methods: The presence of anti varicella-zoster virus IgG antibodies was determined using enzyme-linked immunosorbent
assay in serum samples collected from 1250 participants.
Results: The overall seroprevalence was 92.8% and the seroprevalence was > 90% among all age groups except 2–9 years
(55.7%). Seroprevalence was significantly associated with family size, annual per capita equivalent income, number of
people per room and education level. After adjusting by age, only education level remained significantly associated with
seroprevalence, reflecting the early age effect.
Conclusion: High seroprevalance depends on natural exposure to the infectious agent itself and is not associated with
social determinants. High vaccine coverage should be maintained for effective varicella control and switching to a 2-dose
schedule may also be considered to reduce the number and size of outbreaks in the Turkish population.
Keywords: seroprevalence, social factors, Turkey, vaccination, varicella
Citation: Hekimoğlu CH; Ozbek ÖA; Emek M; Öktem MA; Köroğlu G; Sertel M; et al. Seroprevalence and social determinants of varicella in Turkey.
East Mediterr Health J. 2018;24(3):295–301. https://doi.org/10.26719/2018.24.3.295
Introduction higher than that of varicella, introduction of varicella

vaccination into the national immunization programme
Varicella or chickenpox is distributed worldwide and is
is not a high priority. For these countries, a targeted
an acute highly contagious infectious disease caused
by varicella-zoster virus (VZV), which has no animal vaccination strategy may be an option (2,8).
reservoir (1,2). While varicella occurs predominantly In Turkey, varicella vaccine was introduced into the
in childhood in temperate climate regions, it is also routine childhood immunization programme in 2013, with
a disease of people aged 20–25 years in subtropical a single dose administered to children aged 12 months.
and tropical climate regions, with a lower overall However, there is limited information on the morbidity
incidence (2–4). Although varicella is often mild and (incidence and seroprevalence), mortality and disease
self-limiting in healthy children, some complications burden of varicella in the overall Turkish population
such as secondary bacterial infection of the skin, viral (11–22). Furthermore, varicella was only included in
or bacterial pneumonia, encephalitis and cerebellitis can the notifiable diseases list in Turkey in 2011. Therefore,
be life threatening especially in adolescents, adults and we aimed to determine varicella seroprevalence in the
immunosuppressive individuals (2,5–7). population aged > 2 years in Manisa Province and to
In 1998, the World Health Organization (WHO) examine some of the social determinants for varicella
recommended routine vaccination for countries where seroprevalence. This reflects the population before the
varicella is an important public health and socioeconomic introduction of varicella vaccination into the routine
problem, if high vaccine coverage could be provided and childhood immunization programme in Turkey in 2013.
it were economically viable (8). In some countries such
as the United States of America (USA), Greece, Republic
Methods
of Korea, Canada and Saudi Arabia, varicella is included
in the routine childhood immunization programme. This cross-sectional study was conducted as part of
In some countries such as England and Belgium, the the population survey titled “Determination of the
vaccine is administered to seronegative individuals seroprevalence of some vaccine preventable diseases in
after childhood and at high risk for varicella (9,10). In Manisa, 2014”. Manisa is located in Western Anatolia
developing countries, as the burden of other diseases is and has a population of ~1.3 million. In terms of
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socioeconomic development, Manisa was ranked 23rd Results

among 81 provinces of Turkey in 2011 (23).
The study group was 52.1% female and 47.9% male, with
The sampling frame consisted of all individuals aged a median age of 36 (2–89) years. Varicella seroprevalence
> 2 years who were registered under Manisa Province was 92.8% (95% CI: 91.2–94.1%) among all the participants.
Family Medicine Information System in October 2013 The seroprevalence changed between 92.6 and 100.0%
(n = 1 317 917). The minimum sample size required was in children aged > 9 years but it was 37.1 and 61.9% for
calculated as 1337 people within a 95% confidence level the 2–4- and 5–9-year age groups, respectively (P <
using the EpiInfo computer programme (Centers for 0.001) (Figure 1). There was no significant difference in
Disease Control and Prevention, Atlanta, USA), assuming seroprevalence according to gender (P = 0.37), area of
anticipated seronegativity of 2.0% and absolute precision residence (P = 0.57) and employment status (P = 0.83)
of 0.75%. The estimated sample size was then inflated (Table 1). Seroprevalence was significantly increased in
by 30% to reach 1740 to overcome nonresponse bias. The participants whose family size was ≤ 4 (OR = 1.75, 95%
sample was selected using a simple random sampling CI: 1.12–2.72); participants who had ≤ 1 person per room
method from the Manisa Province Family Medicine (OR = 2.32, 95% CI: 1.49–3.62); and participants in the
Information System. Individuals who were selected 3rd and 4th quartiles of annual per capita equivalent
for the study were invited to the family health centres income (OR = 1.94, 95% CI: 1.03–3.65 and OR = 2.21, 95%
by physicians or midwives. Data were collected from CI: 1.14–4.27). These associations disappeared after age
participants in family health centres between 18 March adjustment. There was also a significant difference in
and 22 June 2014. varicella seroprevalence according to education level.
Ten interviewers were trained and standardized Seroprevalence was > 95% for participants at all education
for data collection. Written informed consent was levels, apart from those who were not of school age (38.1%)
obtained from the participants, and questionnaires or attending primary school (74.2%) (P < 0.001). After
were completed by the interviewers during face-to-face adjusting by age, the only significant variable for varicella
interviews. Serum samples were collected in the family seroprevalence was education level. Age-adjusted OR for
health centres, transported to a centre in Manisa at 4–8°C varicella seroprevalence was 0.16 (95% Cl: 0.03–0.92) in
and stored at −20°C. Once weekly, samples were sent to participants who were not of school age.
the laboratory at −20°C to be stored at −80°C until they
were tested. The study protocol was approved by the Discussion
Dokuz Eylul University Clinical Research Ethics Board.
Varicella seroprevalence was 92.8% among people aged >
Among 1740 people who were sampled, 168 could 2 years in Manisa in 2014. The study population did not
not be reached in their place of residence, 312 refused to receive varicella vaccine in the national immunization
participate in the study and 10 participants’ blood samples programme since it was not introduced for children
were excluded from the analyses due to haemolysis or aged 12 months until 2013. Therefore, our findings reflect
insufficient quantity. We analysed data from 1250 people the seroepidemiology of varicella before the vaccine
(response rate: 71.8%). was introduced as part of the national immunization
The dependent variable of the study was varicella programme. The seroprevalence was > 90% among all age
seropositivity. The independent variables were gender, age groups except 2–9 years, which was 55.7%. This suggests
groups, area of residence, family size, number of people that varicella exists in the population and almost 90% of
per room, annual per capita equivalent income, education the population contract the virus by age 10 years.
level and employment status. The presence of specific In most temperate climates, > 90% of the population
varicella antibodies in serum samples was determined become seropositive for varicella before adolescence and
using Euroimmun (Medizinische Labordiagnostika AG, the incidence ranges from 13 to 16/1000 per year (2). In a
Lübeck, Germany) anti-VZV IgG ELISA test. Test results comparative seroepidemiology study in 11 countries in
with < 80 IU/ml were considered as negative and those Europe between 1996 and 2003, varicella seroprevalence
with ≥ 110 IU/ml were considered as positive. The results was > 90% in children aged 10–14 years, except in Italy
between these values were considered as uncertain. (81.7%) and England and Wales (89.7%) (24). There have
For the analysis, uncertain and negative results were been several previous epidemiological studies on varicella
interpreted as seronegative and positive results were in Turkey that included different age groups (11–22). In
interpreted as seropositive. 9 provinces of Turkey in 2002, the seroprevalence was
Categorical variables were summarized with count, 77.8% in the population aged < 30 years and this increased
percentage and 95% confidence interval (CI) and compared with age and reached 85% at 10 years (11). In eastern
using the χ2 test in univariate analysis. Continuous regions of the country the seroprevalence was 78% in
variables were summarized with median, minimum and people aged < 30 years in 2004 and 69% in those aged
maximum values. Crude and age-adjusted odds ratios and 1–16 years in 2006 (12,13). Varicella seroprevalence among
95% CIs for social determinants of varicella seropositivity school children aged 7–15 years residing in Manisa was
were calculated using logistic regression analysis. All 61.6% in 2009–2010 (14). In a 2010 study of people aged
statistical analyses were performed using SPSS version 1–80 years in Izmir, which is a neighbouring province
15.0 (SPSS Inc., Chicago, IL, USA). of Manisa, varicella seroprevalence was 71.5% (15). The
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100
90
80
70
Seroprevalence, %
60
50 97.4 98.9 99.0 97.8 100.0 97.9 98.9 98.5 98.4 100.0 97.6 100.0
92.8 92.6 93.8
40
30 61.9
20 37.1
10
0
2–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥ 80
Age groups
P < 0.001
Figure 1 Varicella seroprevalance and 95% confidence intervals by age groups, Manisa Province, Turkey, 2014.
Table 1 Varicella seroprevalance by social determinants of health in population aged > 2 years, Manisa province, Turkey, 2014
Variables (n) Seroprevalence, % P Crude OR Age adjusted OR
(95% CI) (95% CI) (95% CI)
Gender
Female (654) 93.4 (91.2–95.1) 0.370 Reference group
Male (596) 92.1 (89.6–94.0) 0.82 (0.53–1.26) 0.97 (0.61–1.55)
Living area
Surrounding counties (970) 92.6 (90.8–94.1) 0.571 Reference group
Central counties (280) 93.6 (90.2–96.0) 1.16 (0.68–1.19) 1.14 (0.61–2.03)
Family size
> 4 people in house (356) 89.9 (86.2–92.8) 0.012 Reference group
≤ 4 people in house (894) 94.0 (92.2–95.3) 1.75 (1.12–2.72) 0.92 (0.56–1.48)
No. of people per room
> 1 (551) 89.7 (86.9–92.0) < 0.001 Reference group
≤ 1 (698) 95.3 (93.5–96.6) 2.32 (1.49–3.62) 1.22 (0.75–1.99)
Quartiles of annual per capita equivalent income (Turkish Liraa)
1st quartile (<1814, n = 299) 90.3 (86.5–93.3) 0.030 Reference group
2nd quartile (1815–3265, n = 302) 91.1 (87.4-93.9) 1.09 (0.63–1.89) 0.93 (0.51–1.70)
3rd quartile (3266–5692, n = 305) 94.8 (91.8–96.8) 1.94 (1.03–3.65) 1.38 (0.70–2.73)
4th quartile (> 5692, n = 302) 95.4 (92.5–97.3) 2.21 (1.14–4.27) 1.33 (0.65–2.71)
Education level
Illiterate (102) 97.1 (92.2–99.2) < 0.001 Reference group
Literate (42) 95.2 (85.1–99.1) 0.62 (0.10–3.89) 1.12 (0.16–7.59)
Primary school (525) 98.3 (96.8–99.1) 1.75 (0.46–6.59) 3.89 (0.93–16.11)
Secondary school (182) 96.7 (92.8–98.7) 0.89 (0.21–3.67) 3.47 (0.69–17.39)
High school (152) 96.7 (92.8–98.7) 0.90 (0.21–3.85) 2.71 (0.55–13.23)
University (90) 97.8 (92.8–99.6) 1.34 (0.22–8.24) 3.59 (0.54–23.85)
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Table 1 Varicella seroprevalance by social determinants of health in population aged > 2 years, Manisa province, 2014 (concluded)
Variables (n) Seroprevalence, % P Crude OR Age adjusted OR
(95% CI) (95% CI) (95% CI)
Attending primary school (93) 74.2 (64.5–82.3) 0.08 (0.02–0.30) 0.64 (0.12–3.41)
Not of school age (63) 38.1 (26.7–50.5) 0.01 (0.0–0.06) 0.16 (0.03–0.92)
Employment status (> 18 years)
Employed (539) 98.5 (97.2–99.3) 0.826 Reference group
Unemployed (68) 98.5 (92.9–99.3) 1.00 (0.12–8.19) 1.05 (0.12–8.68)
Out of workforce/student (347) 98.0 (96.0–99.1) 0.73 (0.26–8.19) 0.73 (0.26–2.04)
a
1 Turkish lira was equal to average 2.14 US dollars between March and June 2014.
seroprevalence increased to 80.0% in the 10–14-year age and herd immunity thresholds varied from 70 to 94% (24).
group and to 88.3% among young adults. In another study This means that if the varicella-susceptible proportion
in Izmir in 2009–2010, the seroprevalence was 94.3% in in a population is over this threshold, an outbreak
the population aged > 15 years (16). Seroprevalence was is not expected to occur in that population (24–27).
reported to be 91.8% among Turkish immigrants in the However, we currently have no R0 and herd immunity
Amsterdam adult population in 2004 and 96% among the threshold estimation for the Turkish population.
21–25-year age group in the Turkish population of Cyprus WHO recommends that resources should be sufficient
in 2007 (17–25). According to these results, which are to ensure reaching and sustaining varicella vaccine
consistent with the current study, varicella is common in coverage for ≥ 80% of the population. If vaccine coverage
the Turkish population and the seroprevalence increases remains < 80% over the long term, it is expected to shift
with age, with a peak incidence in childhood. varicella infection to older age groups in some settings,
It is known that the most important risk factors and this may increase morbidity and mortality despite
associated with severity and mortality of varicella are a reduction in the total number of cases. The number
older age and a compromised immune system. Varicella of doses administered is determined by the goal of the
case fatality rates are about 1 per 100 000 people in vaccination programme. If the goal of the programme is
children and the risk of death is 4 times higher in infants to reduce mortality and severe morbidity from varicella,
than in children and 23–29 times higher in adults. Average 1 dose is sufficient. A 2-dose schedule increases vaccine
crude varicella mortality rates range from 0.3 to 0.5 per effectiveness. Therefore, 2 doses are recommended in
million people annually. It is estimated that varicella countries where the goal is to reduce the number of cases
leads to 4.2 million severe complications annually that and outbreaks as well as mortality and severe morbidity
require hospitalization and 4200 deaths globally (26). In (26).
developed countries, overall case fatality rates are 2–4 We found that varicella seroprevalence was not
per 100 000 cases compared to 1–3 per 1000 cases for associated with the social factors that were explored,
measles (2,26). Despite the routine use of measles and except for education level, which actually reflects the early
pertussis vaccination, the age-standardized death rate age effect. Our expectation was to demonstrate higher
per 100 000 cases in 2010 was lower for varicella (0.1) exposure to VZV and higher varicella seroprevalence in
than measles (1.7) and pertussis (1.1) (26). According to disadvantaged groups, for example, people with lower
WHO recommendations, varicella should be considered education, lower income per capita or crowded housing.
an important public health problem that requires routine However, only the group who was not of school age or
vaccination (8). A few studies in Turkey have evaluated at primary school had low varicella seroprevalence,
the financial burden and mortality of varicella in children suggesting that exposure to varicella increased with
and adults (18,19). In a multicentre study from 2008 to 2010 schooling. Some studies have reported that living in
that included 824 children aged < 15 years hospitalized urban areas, living in a large family (≥ 4 people) and
for varicella, total median length of hospital stay was children with more siblings are factors associated with
6 days and 0.36% of the children died of complications. higher varicella seroprevalence. Many studies have found
Approximately 26% of these varicella-related hospitalized no gender difference for varicella seroprevalence (2, 3, 16,
children had an immunosuppressive condition or chronic 17, 28–30). Consistent with the current study, varicella
underlying disease and death was 5 times higher in such seroprevalence was not associated with household size,
children than in previously healthy children (18). This income, occupation and education in a population-based
study was hospital based, and deaths from varicella were study in Izmir in 2009–2010 (16).
possibly overestimated. Therefore, varicella case fatality The current study had some strengths. First, the study
rate is expected to be < 0.36% in the population. group was randomly sampled from a general population
Varicella is one of the most contagious diseases. The and had a high response rate, hence it was representative
basic reproduction number (R0) estimates for varicella of all age groups > 2 years in Manisa Province. The
ranged between 3.3 and 16.9 in serum banks that were study reflected the epidemiology of varicella before the
collected between 1996 and 2003 in 11 European countries, introduction of routine varicella vaccination, which can
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provide invaluable baseline information for evaluating variables, the statistical power may have been lower to
the impact of the vaccination programme. Although some determine the difference in seroprevalence between
socioeconomic and primary healthcare quality variations those subcategories. For example, the literate group had
existed between the provinces, the findings may give only 42 participants and the unemployed group 68.
some indicators about the whole country since our study
In conclusion, since the study included age groups
group was a random sample from Manisa.
before starting routine varicella vaccination in Turkey,
Our study also had some limitations. First, vaccination the observed varicella seroprevalence depended on
histories were not taken from the participants, and some natural exposure to VZV and was not associated with
may have received varicella vaccine in private clinics
social determinants. For successful varicella control
before the vaccination programme started. However the
by routine vaccination programme, vaccine coverage
number of such people should not be a large proportion of
and effectiveness, burden of varicella and change in
the study participants. Second, the overall response rate
seroepidemiology in Turkey should carefully be followed
was 72% and we evaluated the age and gender structure of
responders and nonresponders. There was no significant up. High vaccine coverage should be targeted and
difference between the 2 groups by age but there were maintained. Otherwise, varicella outbreaks affecting
more female than male participants in the study. older age groups, with more severe clinical features, are
However, there was no significant gender difference in inevitable. To reduce the number and size of varicella
seroprevalence; therefore it can be considered that the outbreaks, as well as severe morbidity and mortality,
overall seroprevalence was not greatly affected by this switching to a 2-dose vaccination schedule may also be
limitation. Third, since there were fewer participants considered for the national immunization programme in
in the subcategories according to social determinant Turkey.
Acknowledgements
We thank the nurses in family health centres for collecting serum samples from the participants and the doctors in
community and family health centres for their support for the inclusion of participants in Manisa. We also thank the
students of the Department of Social Services of Celal Bayar University for data collection and Dokuz Eylül University
Scientific Research Projects Unit for financial support. We also thank Yucel Demiral, Sema Alp Cavus, Ziya Tay, Gonca
Atasoylu, Sanem Baykal, Ozgur Sekreter, Yasin Saglam, Duygu Islek, Nur Demirpence, Umran Kolukirik and Hilal Gorgel
for their contribution to the study.
Funding: This study was financially supported Dokuz Eylul University Scientific Research Projects Unit (grant number:
2014.KB.SAG.019).
Séroprévalence et déterminants sociaux de la varicelle en Turquie
Résumé
Contexte : En Turquie, le vaccin contre la varicelle a été introduit dans le programme de vaccination systématique
des enfants en 2013, avec une seule dose administrée aux enfants de 12 mois. Toutefois, les informations concernant
la morbidité (incidence et séroprévalence), la mortalité et la charge de morbidité de la varicelle dans l’ensemble de la
population turque sont limitées.
Objectif : Déterminer la séroprévalence de la varicelle et ses déterminants sociaux dans la province de Manisa (Turquie)
chez des enfants de plus de deux ans avant l’introduction de la vaccination en une seule dose en 2013.
Méthodes : La présence d’anticorps IgG dirigés contre le virus varicelle-zona (VZV) a été déterminée à l’aide de la méthode
immuno-enzymatique (ELISA) sur des échantillons de sérum collectés auprès de 1250 participants.
Résultats : La séroprévalence globale de la varicelle était de 92,8 % et la séroprévalence était supérieure à 90 % au sein
de tous les groupes d’âge, excepté chez les 2-9 ans (55,7 %). La séroprévalence de la varicelle était associée à la taille de la
famille, au revenu annuel équivalent par habitant, au nombre d’individus par classe et au niveau d’éducation (p < 0,05).
Après un ajustement par l’âge, seul le niveau d’éducation restait significativement associé à la séroprévalence de la
varicelle (p < 0,05), reflétant l’importance d’un jeune âge.
Conclusion : Une forte séroprévalence dépend de l’exposition naturelle à l’agent infectieux et n’est pas associée aux
déterminants sociaux. Une couverture vaccinale élevée devrait être maintenue si l’on veut que la lutte contre la varicelle
soit efficace et le passage à un schéma vaccinal à deux doses afin de réduire le nombre et l’ampleur des flambées de
varicelle dans la population turque.
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‫للحامق يف تركيا‬
ُ ‫االنتشار املصيل واملحددات االجتامعية‬
‫ بيلجن‬،‫ آيال أكيكجوز‬،‫ عيل سيالن‬،‫ سيفن أزديناز‬،‫ مصطفى سريتل‬،‫ غالب كوروجلو‬،‫ حممد أكتم‬،‫ ميستان إمك‬،‫ أوزقن أوزبك‬،‫جن حكم أولو‬
‫أنال‬
‫ من‬12 ‫ بإعطاء جرعة واحدة لألطفال عند الشهر‬2013 ‫ بدأ العمل بلقاح احلامق يف تركيا يف إطار برنامج تطعيم األطفال الروتيني يف عام‬:‫اخللفية‬
.2011 ‫ ومل يدرج احلامق يف قائمة األمراض واجبة التبليغ إال بدء ًا من عام‬،‫عمرهم‬
ُ ‫ هدفت هذه الدراسة القائمة عىل السكان قبل إطالق برنامج التطعيم الروتيني ضد‬:‫اهلدف‬
‫ إىل‬2013 ‫احلامق الذي بدأ العمل به يف تركيا يف عام‬
‫ ودراسة بعض املحددات االجتامعية لالنتشار املصيل‬،‫للحامق لدى السكان يف الفئة العمرية األكرب من سنتني يف مقاطعة مانيسا‬
ُ ‫حتديد االنتشار املصيل‬
.‫للحامق‬
ُ
‫املجمعة من‬
ّ ‫ يف العينات املصلية‬ELISA ‫ حتدّ د وجود األجسام املضادة للجلوبيولني املناعي «جيم» لفريوس فاريسال زوسرت باستخدام‬:‫طرق البحث‬
.‫ ومجعت البيانات باستخدام استبيانات أثناء إجراء مقابالت مبارشة‬.‫ مشارك ًا‬1250
‫ بني مجيع الفئات العمرية باستثناء الفئة‬%90 ‫ وجاء معدل االنتشار املصيل أعىل من‬%92.8 ‫للحامق‬ ُ ‫ بلغ املعدل الكيل لالنتشار املصيل‬:‫النتائج‬
،‫ وعدد األفراد يف كل غرفة‬،‫ والدخل السنوي املكافئ لكل فرد‬،‫ وارتبط االنتشار املصيل للحامق بحجم األرسة‬.)%55.7( ‫ أعوام‬9-2 ‫العمرية‬
‫) وهو ما يرجع إىل‬0.05 < P( ‫ ظل مستوى التعليم فقط مرتبط ًا باالنتشار املصيل للحامق‬،‫ وبعد حتييد عامل العمر‬.)0.05 < P( ‫ومستوى التعليم‬
‫ وحيث‬.‫ أعوام يف مانيسا‬10 ‫للحامق إىل املستوى احلدي للمناعة القطيعية عند بلوغ سن‬
ُ ‫ ويصل معدل االنتشار املصيل‬.‫أثر املراحل األوىل من العمر‬
ُ ً
‫ فإن االنتشار املصيل املشاهد يعتمد عىل التعرض الطبيعي للعامل‬،‫إن هذه الدراسة أدرجت الفئات العمرية قبل بداية التطعيم الروتيني ضد احلامق‬
.‫ا ُملعدي يف حد ذاته وال يرتبط باملحددات االجتامعية‬
ُ ‫ وإال سيتفيش‬،‫ ينبغي توجيه مستوى التغطية املرتفع للقاحات بصورة جيدة واحلفاظ عليه إلنجاح برنامج التطعيم‬:‫االستنتاج‬
‫احلامق حت ًام يف الفئات‬
.‫العمرية األكرب حمدث ًا آثار ًا رسيرية أكثر حدة‬
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11. Kanra G, Tezcan S, Badur S; Turkish National Study Team. Varicella seroprevalence in a random sample of the Turkish popula-
tion. Vaccine. 2002 Jan 31;20(9-10):1425–8. https://doi.org/10.1016/S0264-410X(01)00459-5 PMID:11818162
12. Alp H, Altinkaynak S, Ertekin V, Kiliçaslan B, Giiraksin A. Seroepidemiology of varicella-zoster virus infection in a cosmopol-
itan city (Erzurum) in the eastern Turkey. Health Policy. 2005 Apr;72(1):119–24. https://doi.org/10.1016/j.healthpol.2004.03.008
PMID:15760704
13. Gürgöze MK, Yilmaz E, Gödekmerdan A, Akça Z, Doğan Y, Akarsu S, et al. Seroprevalence of mumps, varicella and rubella anti-
bodies in children 1-16 years of age in eastern Turkey. Turk J Pediatr. 2006 Jul-Sep;48(3):185–8. PMID:17172059
14. Kose U, Ozguven AA, Ecemis T, Akçalı S, Lagarlı T, Onag A. Prevalence of chickenpox in children aged 7–15 years residing in Man-
isa. Ege J Med. 2011;50(3):187–91.
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15. Koturoglu G, Kurugol Z, Turkoglu E. Seroepidemiology of varicella-zoster virus and reliability of varicella history in Turkish
children, adolescents and adults. Paediatr Perinat Epidemiol. 2011 Jul;25(4):388–93. https://doi.org/10.1111/j.1365-3016.2010.01180.x
PMID:21649681
16. Kose S, Mandiracioglu A, Senger SS, Ulu Y, Cavdar G, Gol B, et al. Seroprevalence of varicella-zoster virus in the prevaccine era:
a population-based study in Izmir, Turkey. J Infect Public Health. 2013 Apr;6(2):115–9. https://doi.org/10.1016/j.jiph.2012.10.003
PMID:23537824
17. Kurugol Z, Koturoglu G, Aksit S, Ozacar T. Varicella seroprevalence in Turkish population in Cyprus. Acta Paediatr. 2007
Jun;96(6):861–3. https://doi.org/10.1111/j.1651-2227.2007.00289.x PMID:17465984
18. Dinleyici EC, Kurugol Z, Turel O, Hatipoglu N, Devrim I, Agin H, et al.; VARICOMP Study Group. The epidemiology and eco-
nomic impact of varicella-related hospitalizations in Turkey from 2008 to 2010: a nationwide survey during the pre-vaccine era
(VARICOMP study). Eur J Pediatr. 2012 May;171(5):817–25. https://doi.org/10.1007/s00431-011-1650-z PMID:22170238
19. Ozdemir H, Candir MO, Karbuz A, Belet N, Tapisiz A, Ciftçi E, et al. Chickenpox complications, incidence and financial burden
in previously healthy children and those with an underlying disease in Ankara in the pre-vaccination period. Turk J Pediatr. 2011
Nov–Dec;53(6):614–25. PMID:22389983
20. Savaş S, Dallar Y, Arikan I, Onde U. [Varicella-zoster virus seroprevalence in children between 0–15 years old]. Mikrobiyol Bul.
2004 Jan-Apr;38(1-2):69–75 (in Turkish). PMID:15293904
21. Dilli D, Dallar Y, Onde, U. Dogan F. Yagci. [Measles, rubella, mumps, and varicella seroprevalence among adolescents]. Cocuk
Dergisi. 2008;8(3):172–8 (in Turkish) https://www.journalagent.com/cocuk/pdfs/CD_8_3_172_178.pdf.
22. Ozkan S, Maral I, Ilhan F, Aycan S, Cirak MY, Beyazova U, et al. Varicella zoster seroprevalence in children less than 5 years old. J
Trop Pediatr. 2005 Jun;51(3):141–4. https://doi.org/10.1093/tropej/fmh102 PMID:15831668
23. The Ministry of Development of the Turkish Republic. [The socio-economic developmental ranking of provinces and regions
(SEGE-2011)] (in Turkish) (http://www.kalkinma.gov.tr/Lists/Yaynlar/Attachments/548/SEGE-2011.pdf, accessed 5 March 2018).
24. Nardone A, de Ory F, Carton M, Cohen D, van Damme P, Davidkin I, et al. The comparative sero-epidemiology of varicella zoster
virus in 11 countries in the European region. Vaccine. 2007 Nov 7;25(45):7866–72. https://doi.org/10.1016/j.vaccine.2007.07.036
PMID:17919788
25. van Rijckevorsel GG, Damen M, Sonder GJ, van der Loeff MF, van den Hoek A. Seroprevalence of varicella-zoster virus and
predictors for seronegativity in the Amsterdam adult population. BMC Infect Dis. 2012 06 21;12(1):140. https://doi.org/10.1186/1471-
2334-12-140 PMID:22721551
26. Varicella and herpes zoster vaccines: WHO position paper, June 2014. Wkly Epidemiol Rec. 2014 Jun 20;89(25):265–87.
PMID:24983077
27. Nardone A, de Ory F, Carton M, Cohen D, van Damme P, Davidkin I, et al. The comparative sero-epidemiology of varicella zoster
virus in 11 countries in the European region. Vaccine. 2007 Nov 7;25(45):7866–72. https://doi.org/10.1016/j.vaccine.2007.07.036
PMID:17919788
28. Halloran ME, Struchiner CJ, Longini IM Jr. Study designs for evaluating different efficacy and effectiveness aspects of vaccines.
Am J Epidemiol. 1997 Nov 15;146(10):789–803. https://doi.org/10.1093/oxfordjournals.aje.a009196 PMID:9384199
29. Silhol R, Alvarez FP, Arena C, Amoros JP, Flahault A, Hanslik T, et al. Micro and macro population effects in disease transmission:
the case of varicella. Epidemiol Infect. 2010 Apr;138(4):482–90. https://doi.org/10.1017/S0950268809990896 PMID:19796448
30. Heininger U, Braun-Fahrländer C, Desgrandchamps D, Glaus J, Grize L, Wutzler P, et al.; SCARPOL Team. Seroprevalence of var-
icella-zoster virus immunoglobulin G antibodies in Swiss adolescents and risk factor analysis for seronegativity. Pediatr Infect
Dis J. 2001 Aug;20(8):775–8. https://doi.org/10.1097/00006454-200108000-00011 PMID:11734740
301
Book 24-03.indb 301 13/06/2018 09:44:10


Ali Albelbeisi 1, Zalilah Mohd Shariff 1, Chan Yoke Mun 1, Hejar Abdul-Rahman 2 and Yehia Abed 3
Department of Nutrition and Dietetics; 2Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia,
1
Serdang, Selangor, Malaysia (Correspondence to: Zalilah M. Shariff: [email protected]). 3Department of Public Health, Faculty of Public Health,
Al Quds University, Gaza, Palestine.
Abstract
Background: Growth faltering in early life can adversely affect health in later childhood and adulthood. Growth
monitoring of children can provide evidence to help formulate effective strategies to address growth problems but such
information on Palestinian children is lacking.
Objectives: This study aimed to determine the growth patterns of children under 2 years in Gaza, Palestine.
Methods: This retrospective cohort study was conducted in 2014 in 10 randomly selected primary health care clinics in 5
governorates of Gaza. Weight and length data were obtained from the health cards of children born in 2012, and z-scores
were calculated and compared with the WHO Growth Standard (2006).
Results: A total of 2 632 children’s cards were included at the beginning of the study. Weight-for-age and weight-for-
length decreased from birth to 6 months to about –0.40 SD but increased afterwards to –0.11 SD and 0.34 SD at 24 months
respectively. Length-for-age declined after 6 months, reaching –0.85 SD at 24 months. At 6 months, the prevalence of
underweight and stunting were 5% and 9% but at 24 months, the prevalence was 4% and 20% respectively. Wasting was
highest at 6 months (10%) but decreased to 3% at 24 months. Significantly more girls were stunted at 9, 12 and 18 months
(P < 0.001), underweight at 24 months (P < 0.05) and wasted at 12 months (P < 0.05). Early life faltering in length was more
pronounced than weight, with stunting occurring in one fifth of boys and girls by 2 years of age.
Conclusions: Preventive strategies are urgently needed to address early life causes of undernutrition, particularly
stunting, in Palestinian children in Gaza.
Keywords: Young children, growth faltering, underweight, stunting, wasting
Citation: Albelbeisi A; Mohd Shariff Z; Chan YM; Abdul Rahman H; Abed Y. Growth patterns of Palestinian children from birth to 24 months. East
Mediterr Health J. 2018;24(3):302–310. https://doi.org/10.26719/2018.24.3.302
Introduction show that faltering in weight often starts around 4

months whereas stunting starts from birth (15). Growth
Undernutrition is the underlying cause of death in 45%
faltering in early life can adversely affect health in later
of all deaths among children under 5 years of age (1). The
childhood and adulthood with effects ranging from
global prevalence of stunting, underweight and wasting
among children under 5 years has been reported to be cognitive deficits to risk of chronic diseases (16–18).
23%, 14% and 10% respectively, with most undernourished Growth monitoring of children facilitates early
children are living in Asia and Africa (2,3). In developing identification of growth deviation and the period of
countries, 29.9%, 19.4% and 10% of children under 5 years greatest risk for malnutrition. With such information,
were stunted, underweight and wasted respectively effective strategies can be formulated to address the
(4,5). In the Middle East, 3.9%, 9.7%, and 4.4% of children specific growth problem (19). As growth information on
under 5 years were reported to be underweight, stunted Palestinian young children is lacking, this study was
and wasted respectively (5). In Palestine, stunting (10.3%) conducted to track the growth status of children from
remains the most prevalent form of undernutrition birth to 2 years so as to inform the growth patterns and
among children under 5 years, followed by underweight prevalence of undernutrition of children during this
(2.5%) and wasting (2.4%) (6). critical period of growth.
The first 2 years of life are characterized by high
energy and nutrient requirements to meet the needs Methods
for growth and development (7–9). Inadequate dietary
Study setting, design and subjects
quality and frequent infections are important risk factors
for undernutrition in young children (10,11). Infants in This retrospective cohort study was conducted from April
low- and middle- income communities often experience to June 2014 in 10 randomly selected primary health care
growth faltering in the first 2 years of life and evidence clinics in 5 governorates of the Gaza Strip. Five clinics
suggests that growth faltering commonly starts at 4–6 were selected from 20 clinics of the United Nations Relief
months of age (12–14). Data from developing countries and Work Agency (UNRWA) and another 5 clinics from 54
302
Book 24-03.indb 302 13/06/2018 09:44:10

clinics of the Ministry of Health (MoH). Each governorate for children were defined as WAZ, LAZ and WLZ below 2
was represented by 1 UNRWA and 1 MoH clinic. A total standard deviations (SD) of the median (22).
of 8 852 health cards of children born in the year 2012 Ethics approval
were available in these 10 clinics and were screened for
study eligibility (healthy, i.e. no physical disability and The study protocol was approved by the Ethics Committee
diseases, appropriate for gestational age). The sample size for Research Involving Human Subjects of the Faculty of
calculation was based on the World Health Organization Medicine and Health Sciences, Universiti Putra Malaysia
formula. A prevalence of wasting of 34.3% among children and the Helsinki Ethics Committee of Gaza Strip.
under 2 years in Gaza and a 1.9% margin of error were Permissions to conduct the study in MoH and UNRWA
used in the calculation (20,21). The minimum sample size clinics were obtained from the Department of General
was 2382, and a total of 2650 health cards were selected Administration and Human Resources Development and
(10% more cards were added in case of excluded children the Health Affairs Centre of UNRWA respectively.
who had a biologically improbable anthropometric Data analysis
observation, and to improve precision). Upon screening, SPSS for Windows, version 21, was used for data analysis.
6463 health cards were eligible for the study from which Descriptive statistics were used to describe continuous
2650 health cards were randomly selected in proportion and categorical data. The chi-squared test was used
to the percentages of refugee and non-refugee children in to examine the association between prevalence of
each governorate. Random sampling of clinics and health undernutrition and gender. Subjects were excluded (18
cards was done using a computerized table of random at birth, 61 at 6 months, 68 at 9 months, 52 at 12 months,
numbers. 43 at 15 months, 28 at 18 months and 3 at 24 months)
Measurements when one of their anthropometric observations was
considered to be biologically improbable according to the
In both UNRWA and MoH clinics, each newborn is
cut-offs defined by the World Health Organization (19).
assigned a health card which contains information on
Specifically, the cut-offs are LAZ < –5 SD or > +3 SD, WAZ
sociodemographics, birth, medical conditions, schedule
< –5 SD or > +5 SD or WLZ < –4 SD or > +5 SD.
of vaccination and growth monitoring (birth to 2 years).
In clinics, recumbent weight and length of children
are measured by nurses using standard techniques for Results
children 2 years and below. Portable infant electronic A total of 2632 (2650 – 18) children were included at the
scales (Seca Chica 345) and paediatric length measuring beginning of the study, 1307 (49.7%) boys and 1 325 (50.3%)
mats (Seca 210) arre used to measure recumbent weight girls (Table 1). The proportions of children from the 5
and length respectively. Growth data are available at birth, governorates were 920 (35.0%) (Gaza), 511 (19.4%) (North),
6, 9, 12, 15, 18 and 24 months on the child health card. In 376 (14.3%) (Middle), 503 (19.1%) (Khanyounis) and 322
this study, age and sex-specific z-scores for weight-for- (12.2%) (Rafah). The median birth weight and length were
age (WAZ), length-for-age (LAZ) and weight-for-length 3.30 kg and 50 cm respectively. A total of 1 016 (38.6%)
(WLZ) of the children were calculated using WHO Anthro children were born at the 40th week of gestation and
software (version 3). Underweight, stunting and wasting the median gestational age was 39 (SD 0.93) weeks. The
Table 1. Sample characteristics (n = 2632)

Characteristic No. (%) Median (SD) Min–Max
Sex
Male 1307 (49.7%)
Female 1325 (50.3%)
Governorate
North 511 (19.4%)
Gaza 920 (35%)
Middle 376 (14.3%)
Khanyounis 503 (19.1%)
Rafah 322 (12.2%)
Refugee status
Refugee 1744 (66.3%)
Not a refugee 888 (33.7%)
Family size (persons) 6 (2.11) 3–15
1–4 625 (23.7%)
5–8 1560 (59.3%)
≥9 447 (17%)
303
Book 24-03.indb 303 13/06/2018 09:44:10

Table 1. Sample characteristics (n = 2632) (concluded)

Characteristic No. (%) Median (SD) Min–Max
Mother’s employment status
Working 191 (7.3%)
Housewife 2441 (92.7%)
Father’s employment status
Working 2241 (85.2%)
Not working 391(14.8%)
Educational level
Illiterate or read and write only 0 (0%)
Primary school 806 (30.6%)
Secondary school 813 (30.9%)
Above secondary school 1013 (38.5%)
Number of siblings (persons)
1–3 1144 (43.5%) 4 (2.11)
4–6 1041 (39.5%)
≥7 449 (17%)
Birth weight (kg) 3.30 (0.29) 2.55–3.90
Birth length (cm) 50.0 (1.84) 45.50–53.50
Gestational age (weeks)
38 584 (22.2%) 39 (0.93)
39 774 (29.4%)
40 1016 (38.6%)
41 258 (9.8%)
Age breastfeeding stopped (months)
6–8.9 696 (26.4%) 10 (2.31) 6–18
9–11.9 1304 (49.6%)
12–14.9 474 (18%)
15–17.9 152 (5.8%)
≥ 18 6 (0.2%)
median age of infants when breastfeeding stopped was the prevalence of wasting (10% to 2.8%) but an increasing
10 (SD 2.31) months, with 2 000 (76.0%) mothers stopping trend for stunting prevalence (9% to 20.4%) (Figure 2a).
breastfeeding before their infant reached 12 months of A significantly greater proportion of girls were stunted
age. than boys at 9, 12 and 18 months (P < 0.001) but at 24
Table 2 presents the median z-scores for WAZ, LAZ months the proportion was similar for boys (20.1%)
and WLZ of the children. The trends of WAZ, LAZ and and girls (20.6%) (Figure 2b). More boys than girls were
WLZ from birth to 24 months are shown in Figure 1. In underweight at 9 months (P < 0.001) but by 24 months,
the first 6 months of life, the median WAZ and WLZ were underweight was significantly more prevalent in girls
lower than LAZ. Specifically, WAZ at birth was below (5.0%) compared with boys (3.4%) (P < 0.05) (Figure 2c). The
the median (–0.07 SD), declined further to –0.35 SD at 6 proportion of girls and boys with wasting was similar for
months but increased thereafter and remained relatively at all time points except at 12 months where wasting was
stable by 24 months. LAZ started above the median (0.06 more prevalent in girls (P < 0.05) (Figure 2d).
SD) at birth, increased to 0.17 SD at 6 months but declined
thereafter, reaching –0.85 SD at 24 months. At birth, Discussion
WLZ was –0.17 SD, decreased to –0.40 SD at 6 months Undernutrition in Palestine is largely determined by the
but increased to above the median by 12 months and worsening political and socioeconomic conditions in
increased slightly thereafter. the country (23). In 2013, the Palestinian Central Bureau
Figure 2 illustrates the prevalence of undernutrition of Statistics reported that 11 out of 100 children under 5
by age and sex of the children. None of the children years suffered chronic malnutrition or stunting (23). The
was underweight, stunted or wasted at birth. From 6 to prevalence of stunting in Palestine increased from 7.5%
24 months, while the prevalence of underweight was in 2000 to 10.9% in 2010 with the Gaza Strip recording
relatively stable (~ 5%), there was a decreasing trend in a stunting prevalence of 10.4% (23). In 2010, a United
304
Book 24-03.indb 304 13/06/2018 09:44:11

Table 2 Z-scores for weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) of children 0–24 months (both sexes
combined)
Variable At birth 6 months 9 months 12 months 15 months 18 months 24 months
Weight (kg) 3.30 7.20 8.30 9.20 10 10.50 11.50
(2.55 to 3.90) (4.30 to 11.50) (4.80 to 13.20) (6.50 to 14.80) (6.90 to 15.30) (6.60 to 15.80) (7.80 to 16.50)
Length (cm) 50 67 71 75 78 81 84
(45.5 to 53.5) (56 to 72) (62 to 77) (63 to 81.6) (65 to 85) (66.5 to 89) (71.7 to 95)
WAZ –0.07 –0.35 –0.23 0.05 –0.09 –0.03 –0.11
(–1.78 to 1.37) (–4.14 to 3.49) (–4.35 to 3.74) (–3.52 to 4.07) (–3.57 to 3.67) (–3.89 to 3.34) (–3.61 to 2.67)
LAZ 0.06 0.17 –0.06 –0.18 –0.06 –0.25 –0.85
(–2.05 to 2.34) (–4.50 to 2.97) (–4.89 to 2.84) (–4.10 to 2.85) (–4.57 to 2.73) (–4.89 to 2.87) (–4.92 to 2.57)
WLZ –0.17 –0.40 –0.09 0.18 0.17 0.18 0.34
(–3.97 to 3.76) (–3.61 to 4.81) (–3.88 to 4.35) (–3.90 to 4.07) (–4 to 3.83) (–3.98 to 3.81) (–3.96 to 3.77)
Values are median (range).
0.4
WLZ
0.2
WAZ
-0.2
z-score
-0.4
-0.6
-0.8
LAZ
-1
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age (months)
Figure 1 Median anthropometric z-scores of Gazan children relative to the World Health Organization growth standards. Sample: n = 2 650;
subjects were excluded when one of their anthropometric observations was considered to be biologically improbable (18 were excluded at
birth, 61 at 6 months, 68 at 9 months, 52 at 12 months, 43 at 15 months, 28 at 18 months and 3 at 24 months)
Nations Children’s Fund (UNICEF) report indicated that 2 times greater than reported in previous studies (23–25),
the prevalence of stunting among children under 5 years although underweight and wasting rates prevalence
of age had increased from a national average of 7% in 2004 were similar.
to 10% in 2006, with a significant difference between the
In our study, the proportion of undernutrition was
West Bank (8%) and the Gaza Strip (13%) (24). In recent
years, stunting has been the most prevalent form of significantly more prevalent in girls compared with boys.
undernutrition (~10%) as compared to underweight and A review of child health differences in 15 Arab countries
wasting in Gazan children under 5 years (24,25). Our showed that girls had a higher rate of stunting than
study showed that stunting prevalence at 24 months was boys in 5 countries, including Palestine, and girls had
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Book 24-03.indb 305 13/06/2018 09:44:11

(a) Overall prevalence of undernutrition (both sexes) (b) Length-for-age < -2 SD according to sex
25
25
20
20
15
15
%
%
10 10
5 5
0 0
Birth 6 9 12 15 18 24 Birth 6 9 12 15 18 24
Age (months) Age (months)
(c) Weight-for-age < -2 SD according to sex (d) Weight-for-length < -2 SD according to sex
8
12
7
6 10
5 8
4
%
6
%
3
4
2
2
1
0 0
Birth 6 9 12 15 18 24 Birth 6 9 12 15 18 24
Age (months) Age (months)
Figure 2 Prevalence of undernutrition among Gazan children: 2b shows significant differences in prevalence at 9, 12 and 18 months (P
< 0.001); 2c shows significant difference in prevalence at 9 (P < 0.001) and 24 (P < 0.05) months; and 2d shows significant difference in
prevalence at 12 months (P < 0.05)
a significantly higher rate of wasting in Jordan, Sudan below the standard mean at 1 month and faltered
and Tunisia (26). In 2003, the Palestinian Central Bureau thereafter until 24 months, with the growth faltering
of Statistics showed that the prevalence of stunting and pattern more pronounced for LAZ than WAZ. In contrast,
underweight among Palestinian girls was higher than weight-for-height (WHZ) started above the standard
boys (27). However, the 2010 Palestinian family survey mean but faltered slightly until 9 months and increased
showed that the prevalence of underweight, stunting and thereafter to around the standard mean by 24 months of
wasting among boys under 5 years was higher than that age (14). For countries in North Africa and the Middle East,
in girls (28). Similarly, studies in Africa have reported that the analysis further showed that WAZ, HAZ and WHZ in
the rate of undernutrition among boys was consistently Egypt increased from 1 month to 12 months but declined
higher than that in girls (29,30). Important determinants thereafter. In Jordan, WAZ and HAZ started above the
of such differences included low socioeconomic status, standard mean but gradually declined to –0.41 SD and
older siblings of a similar gender, birth order and gender –0.74 SD respectively at 59 months. On the other hand,
bias (31,32). Therefore, a possible reasons for the gender WHZ showed a fluctuating pattern of decrease and
disparities in Palestine could be low socioeconomic increase with the z-scores well above the standard mean.
status, the family set-up, and gender bias. Similar to our results, in both countries, HAZ faltering
We showed that WAZ and WLZ of Gazan children was more pronounced than WAZ and WHZ (14).
faltered from birth to 6 months but increased thereafter. There are several explanations for the observed
LAZ however, increased from birth to 6 months but growth faltering in children under 2 years in the
declined after this age. An analysis of growth faltering Gaza Strip. Sub-optimum breastfeeding and frequent
among children under 5 years in 54 developing countries infections can contribute to weight and length faltering
showed that height-for-age (HAZ) and WAZ were slightly in the first 6 months of life (33). The 2014 survey of the
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Book 24-03.indb 306 13/06/2018 09:44:11

Palestinian Central Bureau of Statistics reported that Because of time constraints, our study was conducted
exclusive breastfeeding rates averaged at 38.6% from retrospectively. Retrospective designs have a number
birth to 5 months of age (34). Growth faltering among of limitations which may lead to the exclusion of
Palestinian children could also be attributed to the early some subjects from contributing to the study, and
introduction of complementary foods. A study published the possibility of observational bias arising from
in 2007 reported that about 62% of children under 5 years measurements or documenting errors. Therefore, we
in the Gaza Strip received complementary foods before 6 used a large sample and excluded subjects who had
months of age (35). Lower weight-for-age, length-for-age, improbable measurements from the analysis.
and higher risk of infections are significantly associated
Our study showed that stunting, a form of chronic
with early feeding of complementary foods to infants
undernutrition, was prevalent among the children
(36–38). In addition, food insecurity has been shown to
under 2 years in the Gaza Strip, Palestine. Promoting
adversely affect the growth status of children under
5 year (39,40). In the Occupied Palestinian Territories, adequate antenatal and postnatal care, breastfeeding
food insecurity continues to be prevalent and about 85% and appropriate complementary feeding practices
of the population are food insecure (41,42). Gordon and is important because length faltering has important
Halileh in 2013 reported the determinants of stunting health consequences for infants and young children.
among 9 051 Palestinian children aged < 5 years; these In a resource-constrained setting such as the Gaza
were: lower birth weight (P < 0.001), age > 12 months (P Strip, timely micronutrient supplementation or food
< 0.001), higher levels of food insecurity (P < 0.001), lower fortification could also improve the health and nutrition
household socioeconomic index (P < 0.001), maternal of these children. Further studies, however, are needed
illiteracy (P < 0.01), and absence of supplementation to to ascertain specific nutrition interventions that could
breastfeeding during the first 4 months of the life (P < effectively prevent growth faltering among children
0.05) (43). under 2 years in the Gaza Strip.
Acknowledgement
We thank the staff at the MOH and UNRWA health care clinics for their support and cooperation in the study.
Funding: None.
Schémas de croissance des enfants palestiniens de la naissance à l’âge de 24 mois
Résumé
Contexte : Le ralentissement de la croissance en début de vie peut avoir un impact négatif sur la santé plus tard dans
l’enfance et à l’âge adulte. Le suivi de la croissance des enfants fournit des données permettant d’élaborer des stratégies
efficaces pour lutter contre les problèmes de croissance, mais de telles données n’existent pas pour les enfants palestiniens.
Objectifs : La présente étude visait à déterminer les schémas de croissance des enfants de moins de deux ans à
Gaza (Palestine).
Méthodes : Cette étude de cohorte rétrospective a été conduite en 2014 auprès de 10 dispensaires de soins de santé
primaires sélectionnées au hasard dans cinq gouvernorats de Gaza. Les données sur le poids et la taille ont été obtenues à
partir de carnets de santé d’enfants nés en 2012, et les z-scores ont été calculés et comparés à l’aide des Normes OMS de
croissance (2006).
Résultats : Au total, 2632 carnets de santé d’enfants ont été inclus au début de l’étude. Le poids pour l’âge et le poids pour
la taille baissaient entre la naissance et six mois jusqu’à environ -0,40 écart type, mais augmentaient ensuite en passant
à -0,11 ET à 0,34 ET respectivement à l’âge de 24 mois. La taille pour l’âge chutait après 6 mois, et atteignait -0,85 ET à
24 mois. À 6 mois, la prévalence du déficit pondéral et du retard de croissance était de 5 % et 9 %, mais à 24 mois elle était
de 4 % et 20 % respectivement. L’émaciation était la plus élevée à 6 mois (10 %), mais passait à 3 % à 24 mois. Un nombre
significativement plus élevé de filles présentait un retard de croissance, à 9, 12 et 18 mois (p < 0,001), ainsi qu’un déficit
pondéral à 24 mois (p < 0,05) et une émaciation à 12 mois (p < 0,05). Le ralentissement de la croissance affectant la taille
en début de vie était plus prononcé que celui du poids, avec une émaciation survenant chez un cinquième des garçons et
des filles âgées de 2 ans.
Conclusions : Des stratégies de prévention sont requises de toute urgence afin de lutter contre les causes de dénutrition
en début de vie, et particulièrement contre le retard de croissance, chez les enfants palestiniens de Gaza.
307
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‫ شهر ًا‬24 ‫أنامط نمو األطفال الفلسطينيني حتى سن‬

‫ حييى عابد‬،‫ هيجر عبد الرمحن‬،‫ شان من‬،‫ زليلة رشيف‬،‫عيل البلبييس‬
‫ ومن شأن رصد نمو األطفال‬.‫ يمكن أن يؤثر تعثر النمو يف مراحل العمر املبكرة تأثري ًا ضار ًا عىل الصحة يف مرحلتي الطفولة املتأخرة والبلوغ‬:‫اخللفية‬
‫ إال أنه ال تتوفر مثل تلك املعلومات بالنسبة لألطفال‬،‫فعالة من أجل التصدي ملشكالت النمو‬ ّ ‫أن يوفر براهني للمساعدة يف صوغ اسرتاتيجيات‬
.‫الفلسطينيني‬
.‫ هدفت هذه الدراسة إىل حتديد أنامط نمو األطفال دون السنتني يف قطاع غزة بفلسطني‬:‫األهداف‬
‫ حمافظات يف‬5 ‫ عيادات خمتارة من عيادات الرعاية الصحية األولية يف‬10 ‫ يف‬2014 ‫ ُأجريت دراسة األتراب رجعية األثر هذه يف عام‬:‫طرق البحث‬
‫ وتم حساب الدرجات املعيارية ومقارنتها بمعيار‬،2012 ‫ واستُمدت بيانات الوزن والطول من البطاقات الصحية لألطفال مواليد عام‬.‫قطاع غزة‬
.)2006( ‫منظمة الصحة العاملية لنمو األطفال‬
‫ ولوحظ انخفاض نسبة الوزن مقابل العمر والوزن مقابل الطول من‬.‫ال يف بداية الدراسة‬ ً ‫ طف‬2632 ‫ ُأدرجت البطاقات الصحية ملا جمموعه‬:‫النتائج‬
‫ شهر ًا عىل‬24 ‫ عند سن‬0.34‫ و‬-0.11 ‫ وإن ازدادت النسبتان الحق ًا لتصال إىل‬،-0.40 ‫ أشهر بانحراف معياري بلغ نحو‬6 ‫امليالد حتى سن‬
.‫ عىل التوايل‬%20‫ و‬%4 ‫ شهر ًا‬24 ‫ يف حني بلغ معدل االنتشار يف سن‬،%9‫ و‬%5 ‫والتقزم‬ ّ ‫ بلغ معدل انتشار نقص الوزن‬،‫ أشهر‬6 ‫ وعند سن‬.‫التوايل‬
‫ وبلغ اهلزال أعىل مستوياته عند‬.‫ شهر ًا‬24 ‫ عند سن‬-0.85 ‫ مسجلة انحراف ًا معياري ًا مقداره‬،‫ أشهر‬6 ‫وانخفضت نسبة الطول مقابل العمر بعد‬
،)0.001 < P( ‫ شهر ًا‬18‫ و‬12‫ و‬9 ‫ وسجلت اإلناث معدالت أعىل للقزامة عند سن‬.‫ شهر ًا‬24 ‫ عند سن‬%3 ‫) وإن انخفض إىل‬%10( ‫ أشهر‬6 ‫سن‬
‫ وبدا تعثر الطول يف مراحل العمر املبكرة أكثر بروز ًا من‬.)0.05 < P( ‫ شهر ًا‬12 ‫ واهلزال عند سن‬،)0.05 < P( ‫ شهر ًا‬24 ‫ونقص الوزن عند سن‬
.‫ مع حدوت التقزم يف ُخس األطفال الذكور واإلناث بحلول عامهم الثاين‬،‫تعثر الوزن‬
ّ ‫ ال سيام‬،‫ ثمة حاجة ملحة العتامد اسرتاتيجيات وقائية من أجل التصدي ألسباب نقص التغذية يف مراحل العمر املبكرة‬:‫االستنتاجات‬
‫ يف‬،‫التقزم‬
.‫صفوف األطفال الفلسطينيني يف غزة‬
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29. Kabubo-Mariara J, Ndenge GK, Mwabu DK. Determinants of children’s nutritional status in Kenya: evidence from demographic
and health surveys. J. Afr. Econ. 2009;18(3):363–87. https://doi.org/10.1093/jae/ejn024
30. Lwambo N, Brooker S, Siza J, Bundy D, Guyatt H. Age patterns in stunting and anaemia in African schoolchildren: a cross-sec-
tional study in Tanzania. Eur J Clin Nutr. 2000 Jan;54(1):36–40. PMID:10694770.
31. Dey I, Chaudhuri R. Gender inequality in nutritional status among under five children in a village in Hooghly district, West
Bengal. Indian J Public Health. 2008;52(4):218–20. PMID:19189827
32. Pande RP. Selective gender differences in childhood nutrition and immunization in rural India: the role of siblings. Demography.
2003;40(3):395–418. PMID:12962055
33. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al.; Maternal and Child Undernutrition Study Group. Ma-
ternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008 Jan 19;371(9608):243–60.
34. Palestinian multiple indicator cluster Survey 2014: monitoring the situation of children and women. Ramallah: Palestinian Cen-
tral Bureau of Statistics; 2015 (https://mics-surveys-prod.s3.amazonaws.com/MICS5/Middle%20East%20and%20North%20Africa/
State%20of%20Palestine/2014/Final/State%20of%20Palestine%202014%20MICS_English.pdf, accessed 30 November 2017).
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2007;3(1428):58–65.
36. Kimani-Murage EW, Madise NJ, Fotso JC, Kyobutungi C, Mutua MK, Gitau TM, et al. Patterns and determinants of breastfeed-
ing and complementary feeding practices in urban informal settlements, Nairobi Kenya. BMC Public Health. 2011 05 26;11(1):396.
http://dx.doi.org/10.1186/1471-2458-11-396 PMID:21615957
37. Kalanda BF, Verhoeff FH, Brabin BJ. Breast and complementary feeding practices in relation to morbidity and growth in Ma-
lawian infants. Eur J Clin Nutr. 2006 Mar;60(3):401–7. http://dx.doi.org/10.1038/sj.ejcn.1602330 PMID:16306929
38. Tessema M, Belachew T, Ersino G. Feeding patterns and stunting during early childhood in rural communities of Sidama, South
Ethiopia. Pan Afr Med J. 2013 Feb 26;14:75. http://dx.doi.org/10.11604/pamj.2013.14.75.1630 PMID:23646211
39. Ali D, Saha KK, Nguyen PH, Diressie MT, Ruel MT, Menon P, et al. Household food insecurity is associated with higher child
undernutrition in Bangladesh, Ethiopia, and Vietnam, but the effect is not mediated by child dietary diversity. J Nutr. 2013
Dec;143(12):2015–21. http://dx.doi.org/10.3945/jn.113.175182 PMID:24089419
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40. Psaki S, Bhutta ZA, Ahmed T, Ahmed S, Bessong P, Islam M, et al.; for MALED Network Investigators. Household food access
and child malnutrition: results from the eight-country MAL-ED study. Popul Health Metr. 2012 12 13;10(1):24. http://dx.doi.
org/10.1186/1478-7954-10-24 PMID:23237098
41. Radi SM, El-Sayed NA, Nofal LM, Abdeen ZA. Ongoing deterioration of the nutritional status of Palestinian preschool children in
Gaza under the Israeli siege. East Mediterr Health J. 2013 Mar;19(3):234–41. PMID:23879074
42. United Nations World Food Programme and Food and Agricultural Organization of the United Nations. West Bank and Gaza
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310
Book 24-03.indb 310 13/06/2018 09:44:11

Review EMHJ – Vol. 24 No. 3 – 2018
Factors affecting empathetic patient care behaviour among medical

doctors and nurses: an integrative literature review
Muntaha Elayyan 1, Janet Rankin 2 and MW Chaarani 3
Department of Nursing, Hamad Medical Corporation, Doha, Qatar (Correspondence to: M. Elayyan: [email protected]). Faculty of Nursing,
1
University of Calgary in Qatar, Doha, Qatar. 3Department of Orthopedic Surgery, Hamad Medical Corporation, Doha, Qatar.
Abstract
Background: Healthcare professionals’ empathic behaviour is an important component of quality health care. Patients’
reports suggest that empathy is often lacking. Specific factors that may facilitate or inhibit empathetic behaviour have
not been extensively examined. In Qatar, empathy may be affected by a completely multicultural, multilinguistic setting
where healthcare professionals and patients interact.
Aim: The purpose of this integrative literature review is to provide the latest evidence on factors that influence the
demonstration of empathetic behaviour of nurses and physicians toward patients and to draw general conclusions that
increase understanding.
Methods: A literature search was conducted in CINAHL, Medline (Ovid), PsycINFO, Psychology and Behavioral Sciences
Collection, Middle Eastern and Central Asian Studies, Education Research Complete, ERIC, Health Source: Nursing/
Academic databases, and Google Scholar to identify relevant studies. A total of 18 quantitative and qualitative studies that
satisfied the inclusion criteria were selected to be included in the review.
Results: Three high order factors are described: organizational, personal and interpersonal, and demographic factors.
Seven subfactors included: burnout, increased workload, lack of organizational support, training workshops, patient
behaviour, inappropriate role modelling, and informal, experiential learning.
Conclusion: The organizational culture is strongly implicated in inhibiting empathy. Healthcare providers’ empathetic
responses to patients are linked and connected to a well-resourced, collegial, professional organizational environment
that builds empathy towards everyone (not only patients).
Keywords: Compassion, Healthcare Professionals, Communication, Barriers, Facilitators
Citation: Elayyan M; Rankin J; Chaarani MW. Factors affecting empathetic patient care behaviour among medical doctors and nurses: an integrative
literature review. East Mediterr Health J. 2018;24(3):311–318. https://doi.org/10.26719/2018.24.3.311
Introduction Methods
This integrative review synthesizes current publications An integrative review is “a form of research that reviews,
about medical doctors’ and nurses’ capacity to show critiques, and synthesizes representative literature on a
empathy. The review was conducted as a preliminary topic in an integrated way such that new frameworks
step to explore these health professionals’ empathy in and perspectives on the topic are generated” (8). Our
the Arabian Gulf Region where empathy has not yet been review used Knafl and Whittemore’s 5-step process (9):
studied. (1) problem identification, (2) literature search, (3) data
It is our view that, internationally, a high degree of evaluation, (4) data analysis, and (5) presentation.
empathy toward patients is important for all healthcare Problem identification
professionals. This view is supported by research
Knowledge about the factors that affect the demonstration
indicating that empathy is implicated in patients’ trust,
of empathetic behaviour by medical doctors and nurses is
satisfaction and compliance (1-5). However, research
not well developed.
also shows that healthcare professionals often ignore
opportunities for acts of empathy (6), and patients Sources
are treated with detached functionality rather than Databases accessed included Cumulative Index to
empathetically (7). Nursing and Allied Health Literature (CINAHL), Medline
This review was conducted to respond to the question: (Ovid), PsycINFO, Psychology and Behavioral Sciences
what are the inhibiting and facilitating factors that affect Collection, Middle Eastern and Central Asian Studies,
the demonstration of empathetic behaviour by medical Education Research Complete, ERIC, Health Source:
doctors and nurses toward patients? Nursing/Academic, and Google Scholar. We searched for
311
Book 24-03.indb 311 13/06/2018 09:44:11

publications from 2000 to 2015 using the terms empath*, Compilation and interpretation of data
nurs*, therapeutic communicat*, communicat*, factor*, Analysis was carried out in 3 phases: data reduction,
influenc*, barrier*, facilitator*, perception*, perspective*, and data display and data comparison (9). It involved
points of view. The initial search generated 1408 articles. iterative comparisons seeking higher-order thematic
Preliminary scan for inclusion and exclusion clusters across data sources. During data reduction
a categorization structure was developed. Foremost,
Following Knafl and Whittemore (9), the topical articles
this was a strategy for managing data from each study.
were evaluated for eligibility using titles and abstracts.
Relevant data were entered into a literature review matrix
Delimiters included: (i) written in English; (ii) peer-
that was used to facilitate constant comparison, focused
reviewed; (iii) primary sources; and (iv) addressed
on finding patterns, themes, variation, and relationships
facilitators and barriers for empathy. A manual search of
among the barriers and facilitators. The extracted data
article reference lists yielded 18 additional articles. Grey
were then displayed in a graph and a chart to enhance
literature was excluded. Ultimately, 24 articles met the
the visualization of themes and patterns. The data
inclusion criteria. comparison phase involved grouping data together to
Critical appraisal determine if there were higher- and lower-order themes.
The next step included a 10-item Critical Appraisal Finally, the interpretation and integrated findings were
Skills Programme (10) that was applied to the qualitative represented in a newly created conceptual model that
research, and Barker’s 12-item critical appraisal tool (11) depicts barriers and facilitators of empathy (Figure 2).
to assess the quantitative studies. Six articles were rated
as low-quality studies and excluded. Eighteen articles Results
were included in the final review: 5 qualitative and 13 Three high-order themes that affect empathy emerged:
quantitative (Figure 1). organizational, personal and interpersonal, and
1408 (databases)
Excluded based on title

718
Eligible for abstract review

690
Excluded based on abstract
and duplication
570
Eligible based on inclusion/
exclusion criteria
120
Excluded based on
inclusion/exclusion criteria
79
Thorough review
of each article
41
18 (manual search of
references) = 59
Excluded due to irrelevancy
to focused topic
35
Subjected to critical
scientific appraisal of
the evidence
24
Eliminated due to poor
quality of evidence
6
Papers included in
the review
18
Figure 1. Selection process of studies
312
Book 24-03.indb 312 13/06/2018 09:44:11

Empathy
Organizational Personal and Demographic

factors interpersonal factors
factors
Gender
Barriers Facilitators
Barriers Facilitators
Level of
Burnout experience
Training Informal,
– Emotional Patient
workshops experiential
exhaustion behaviors
learning
– Physical exhaustion
– Depersonalization Specialty
Inappropriate
role
Increased workload modeling
– Time pressure
– Short staffing
Lack of organizational
support
Figure 2. Conceptual framework representing barriers and facilitators of empathy
demographics. These categories, though useful to support et al. examined 21 healthcare professionals’ viewpoints
an analysis of empathy, are linked and overlapping. The of the practicalities of empathy in clinical practice (13).
major themes are not mutually exclusive but provide a Under the theme external barriers, the authors found that
useful way to conceptually frame the findings. shortened consultation times led to reduced empathy.
Likewise, under the theme obstacles to improving
Organizational barriers
communication, Klitzman found that time pressure
The demonstration of empathy is vulnerable to was an obstacle for physicians’ empathy (14). Students
organizational factors that may compromise healthcare balancing heavy course loads and mastering clinical skills
professionals’ intentions to provide empathetic care. find it difficult to express empathy in their interactions
Lack of organizational support with patients (13,15). Hojat et al., using the Jefferson
Scale of Physician Empathy found a decline in medical
Healthcare professionals’ ability to demonstrate and students’ mean empathy scores from programme entry
practice empathetic behaviour is largely influenced by to completion (15). The research linked time pressures to
organizational support. Lack of organizational support students’ reduced levels of empathy. Similarly Ward et
may include decreased availability of resources; lack of al. noted a significant reduction in mean empathy score
support from supervisors for empathetic care; and failure from admission to the end of the programme in a group
to acknowledge bonds between staff and patients. Schell of undergraduate nursing students (16).
and Kayser-Jones (12) studied the care provided to dying
Burnout
patients and reported that lack of organizational support
could be an impediment for healthcare professionals’ Burnout is closely linked to the daily pressures and pace
empathy during end of life care. Similarly, Bayne et al. (13) of work faced by health professionals. Shanafelt et al.
reported that physicians who feel unsupported by their (17) cited Maslach, Jackson and Leiter (1996) when they
administration are more prone to lack empathy. stated: “Burnout is a syndrome of depersonalization,
emotional exhaustion, and a sense of low personal
Workload
accomplishment that leads to decreased effectiveness
Lack of empathy is partly attributed to increased at work” (p. 358). Empathetic behaviour toward patients
workload. An overly demanding pace of work is is reduced as a result of healthcare professionals’
exhausting and health professionals simply do not have emotional exhaustion, burnout, lack of sleep, workload
the emotional energy to demonstrate empathy (13). Bayne and physical exhaustion (13,15,18,19). Thomas et al. studied
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Book 24-03.indb 313 13/06/2018 09:44:11

the relationship between decreased levels of empathy Patients’ behaviour

and burnout among 545 medical students, using the Evidence suggests that the response of healthcare
Interpersonal Reactivity Index to measure dimensions of professionals varies according to the type of emotion
empathy and the Maslach Burnout Inventory to measure that is expressed by patients (6,24,25). Sheldon et al.
depersonalization, emotional exhaustion and personal reported on a study with 74 nurses to explore their
accomplishment (19). The authors found a significant empathetic responses to patients’ emotion (24). Nurses
reduction in empathy with increased depersonalization had a significant increase in affective response to sadness
(P < 0.02). Similarly, Brazeau et al. surveyed 90 medical versus anger. Kennifer et al. recruited 48 oncologists and
students and showed that a high level of burnout was audiotaped their responses to patients (25). A subset of 44
correlated with a decreased level of empathy (18). Hojat recordings in which patients expressed at least 1 negative
et al. found that lack of sleep, and heavy workload, emotion were analysed. The oncologists scored higher
resulted in a loss of empathy among medical students in responding to sadness than to fear. Likewise, Hsu et
(15). Those healthcare professionals who were assessed al. found that patients’ expressions of grief and family
as not suffering from burnout adopted strategies to strain are more likely to induce an empathetic response
guard themselves against potential sources of emotional than the response generated by patients who are angry
tension (13). or distrustful of their doctors (6). Hojat et al. found that
Organizational facilitators medical students had reduced empathy for patients
whose behaviour was judged as demanding, difficult,
Despite the different organizational factors that exert a
hostile, insulting, unappreciative and/or malingering
negative influence on empathy, evidence suggests that
(15). Bayne et al. supported these findings, adding drug
strategies implemented by organizations can enhance
seeking to the list of patients unlikely to receive empathy
empathetic behaviour of healthcare professionals.
(13).
Training workshops
Inappropriate role modelling
Training can improve empathetic skills. Razavi et al.
Role modelling is one of the ways that healthcare
found significant enhancement of effective empathy
professionals learn how to interact empathetically with
3–6 months after 105 hours of an empathy training
patients (14,15,18). Brazeau et al. used a questionnaire
programme that used videotapes of simulated interviews
to study the relationship between medical students’
to evaluate the ability of 115 oncology nurses to use empathy and the general climate of professionalism,
emotional words (20). They found that nurses who had which was defined within characteristics such as
empathetic training used fewer neutral expressions than altruism, accountability, duty, excellence and service (18).
untrained nurses, particularly 3 months after training (P Based on the results of 90 responses they found that the
= 0.055). Furthermore, the level and depth of emotional level of empathy was positively related to the professional
expression was significantly increased in nurses who did climate.
the training in comparison to untrained nurses (P = 0.023
and 0.016, respectively). Chism and Magnan studied 223 Personal and interpersonal facilitators
nurses and found that empathy training was significantly Experiential, informal learning
more effective for people who identified themselves as Bayne et al. used grounded theory to develop a model of
spiritual (P < 0.01) (21). Similar positive results from an empathy that highlighted 2 types of empathy: initial and
organizational intervention were reported by DiLalla genuine (13). Initial empathy is a primary level empathy
et al. who examined 1181 medical students’ self-rating that is superficial and can be taught. Genuine empathy
of empathy after attending wellness sessions (22). The is a deeper level of empathy that rests in the capacity
wellness training resulted in greater empathy (P < 0.01). to imagine and to “walk in a patient’s shoes”. Klitzman
Dow et al. designed an intervention study whereby interviewed 50 doctors who had experienced serious
professors from the drama/theatre department acted illness and identified that this experience served as a
emotionally with 14 internal medicine residents in a catalyst that enabled them to connect with their patients
controlled environment to assess weather empathy could at a deeper level, showing more genuine empathy (14).
be learned using theatre techniques (23). Evaluation before, Demographic factors
and 4 months after the intervention, relied on observed
Significant variance in healthcare professionals’ empathy
interactions between practitioners and patients in clinical
has been attributed to personal demographic differences
visits. The intervention group showed a significant
related to gender, experience and area of practice (16,22,
improvement in listening, nonverbal communication,
24,26).
respect for dignity, and overall impression (P _ 0.01) but
no significant improvement in verbal communication (P Evidence suggesting that female healthcare
= 0.058). professionals are more empathetic to patients than
men are was consistent across studies (15,19,22,27-29).
Personal and interpersonal barriers DiLalla et al. evaluated self-ratings of empathy by
Empathy is a human interaction that is relational and is 1181 medical students and healthcare practitioners to
influenced reciprocally by the behaviour and responses investigate variations according to gender, experience
of the other person. and age (22). They found that women had significantly
314
Book 24-03.indb 314 13/06/2018 09:44:11

higher empathy scores (P < 0.001). Ward et al. found that As with healthcare organizations around the world, in
among undergraduate nursing students empathy was Qatar, cost-effectiveness has become a prevailing driver
significantly higher in women (29). Quince et al. found and health professionals are being tasked with increasing
the same gender related difference in empathy among workloads. In light of the findings of this integrative
medical students (28). review, it rests on healthcare leaders and managers
Healthcare professionals’ level of experience is to monitor the increasing veracity of healthcare
another factor influencing the demonstration of professionals’ work to ensure that duty shifts, assigned
empathy. Bayne et al. found that physicians with more workload and working conditions are reasonable and
experience demonstrated more empathetic behaviour not too taxing. Managerial/leadership focus on empathy
(13). A similar finding was reported in the study of Ward should support the development of the professional
et al. of nursing students in which mean empathy scores environment, which has been shown to support empathy.
were higher among nursing students with the most Health professionals who experience their work within
clinical experience (29). In contrast, a subsequent study collegial, empathetic working relationships are key to
by Ward et al. found a decline in empathy measured at building a culture of empathy.
the beginning and end of 1 academic year (16). Training and organizational support are insufficient
There is evidence that the level of health professionals’ without appropriate role modelling (14). In Qatar, there
empathy differs among specialty areas (15,26,27). In a are many highly committed experienced practitioners
study of 456 medical students, Hojat et al. found that who contribute an important resource to develop
those who pursued their residency training in psychiatry empathetic behaviour. Brazeau et al. stressed the
had the highest mean empathy scores (127.0), while importance of enhancing role models’ awareness of their
anaesthesiology had the lowest (116.1) (15). Kataoka et al. responsibility to model explicitly empathetic care that
used the Jefferson Scale of Empathy (JSE) with 285 female can be constantly developed and refined for each instance
physicians (26). The results showed that physicians in of practice (18). This refined modelling of empathy is
people-oriented specialties, such as general internal important with patients who have been characterized as
medicine and psychiatry, showed significantly higher difficult or those expressing anger (30).
empathy scores than physicians in technology-oriented Finally, an implication from this integrative review is
specialties, such as anaesthesiology and surgery (P < the significant research finding that female healthcare
0.001). professionals are more empathetic to patients than men
are. This finding can be utilized in a highly selective
Discussion and implications way. Quince et al. indicated that there might be a natural
Despite that there has been no research conducted in empathetic difference between genders that would have
the Arabic Gulf Region, implications can be drawn from implications in job selection (28). Appointing women to
this integrative review. The health workforce in Qatar jobs in which patients need a lot of empathetic care is one
is dominated by multinational professionals who likely of the ways to utilize women’s empathetic advantage.
differ, both from one another, and with patients in their Conclusion
cultural approaches to communication and interactions.
This review adds to the limited body of literature
The patients for whom they provide care also differ in their
about facilitators and barriers to health professionals’
nationalities and cultures. One of the routine challenges
empathetic behaviour toward patients. The evidence
facing healthcare workers in Qatar is a language barrier
shows how these factors are inter-related and may work
between themselves and their patients. The initial
together to affect empathetic behaviour. The review
findings for this review identified the importance of
revealed a dearth of research being conducted in the
educational programmes to increase and maintain
professionals’ empathetic awareness and practice. In Arabian Gulf within the unique context of health care that
Qatar, the emphasis of health professionals’ empathy has developed here. From our perspective, it is important
training needs to focus on nonverbal communication to begin to generate knowledge from this region.
that respects the cultural diversity of patients in Qatar. Overall, the results identified that some of the inhibiting
This includes lessons in culturally sensitive physical factors for empathy are related to organizational issues.
gestures and the appropriate and inappropriate use of We suggest that this integrative review and the future
physical touch. This literature review reinforces the need research it generates are an important contribution to the
for health professionals in Qatar to learn optimal ways work of healthcare administrators. The findings indicate
to manage and care for patients who do not speak the that empathy is more than a personal characteristic
same language as the caregiver. The language barriers that is promoted within each individual’s practice.
and social hierarchies that manifest in Qatar generate The capacity for healthcare providers to demonstrate
tensions and frustrations that demand that healthcare empathy is linked and connected to a well-resourced,
professionals learn how to respond with empathy to collegial, professional organizational environment
angry or hostile patients (and with one another). Such that builds empathy (not only towards patients) as the
training sessions need to be offered on a regular basis, cultural norm. Administrative strategies to support
as a way to check the level of burnout and to foster and individual empathetic behaviour include periodic
maintain empathetic skills. empathy training; careful monitoring of overwork and
315
Book 24-03.indb 315 13/06/2018 09:44:12

fatigue; and identification of key role models whose focus of contemporary healthcare providers. It is an on-
experience provides a way for them to embrace and going, dynamic, organizational and interpersonal issue
embody empathy. Ultimately, this integrative review
suggests that strategies to address factors that impede that every member of the healthcare complex must take
or facilitate empathy should be made an important seriously.
Funding: None.
Facteurs influant sur le comportement empathique dans les soins prodigués aux
patients par les médecins et les infirmières : analyse documentaire intégrative
Résumé
Contexte : Le comportement empathique des professionnels des soins de santé est une composante importante d’une
prise en charge de qualité. Selon les dires des patients, il semble que l’empathie soit souvent manquante. Les facteurs
spécifiques qui facilitent ou inhibent le comportement empathique n’ont pas été largement étudiés. Au Qatar, l’empathie
peut être affectée par un environnement complètement multiculturel et plurilingue au sein duquel les professionnels des
soins de santé et les patients ont des interactions.
Objectif : L’objet de la présente analyse documentaire intégrative est de fournir les derniers éléments d’information sur
les facteurs qui influencent l’expression du comportement empathique des personnels infirmiers et des médecins vis-à-
vis des patients et permettent de tirer des conclusions générales qui augmentent la compréhension.
Méthodes : Une recherche documentaire a été menée sur CINAHL, Medline (Ovid), PsycINFO, Psychology and Behavioral
Sciences Collection, Middle Eastern and Central Asian Studies, Education Research Complete, ERIC, Health Source :
Nursing/Academic databases, et Google Scholar pour identifier les études pertinentes. Au total, 18 études quantitatives et
qualitatives qui répondaient aux critères d’inclusion ont été sélectionnées pour être incluses dans l’analyse.
Résultats : Trois facteurs d’ordre importants sont décrits : il s’agit des facteurs organisationnels, personnels et
interpersonnels, et démographiques. Sept sous-facteurs comprenaient : l’épuisement professionnel, l’augmentation de la
charge de travail, les ateliers de formation, le comportement des patients, le manque d’appui organisationnel, les modèles
à suivre inappropriés, et l’apprentissage expérientiel informel.
Conclusion : La culture organisationnelle est fortement impliquée dans l’inhibition de l’empathie. Les réactions
empathiques des prestataires de soins face aux patients sont associées à un environnement organisationnel professionnel
collégial, bien doté en ressources, établissant une empathie autour de chacun (et pas seulement des patients).
‫ استعراض تكاميل‬:‫العوامل التي تؤثر عىل السلوك التعاطفي يف رعاية املرىض يف صفوف األطباء وأطقم التمريض‬
‫للدراسات السابقة‬
‫ حممد الشعراين‬،‫ جانيت رانكني‬،‫منتهى عليان‬
‫ وتشري تقارير املرىض إىل انعدام‬.‫ يمثّل السلوك التعاطفي للعاملني يف جمال الرعاية الصحية مكون ًا مه ًام لتوفري الرعاية الصحية اجليدة‬:‫اخللفية‬
‫ يمكن‬،‫ ويف قطر‬.‫موسعة من قبل للعوامل املحددة التي يمكن أن تسهل أو تثبط السلوك التعاطفي‬ ّ ‫ ومل جتر أي دراسة‬.‫التعاطف يف كثري من األحيان‬
‫أن يتأثر التعاطف مع املرىض بالسياق الذي يتفاعل فيه العاملون يف جمال الرعاية والصحية واملرىض مع بعضهم البعض والذي يتسم بتعدد الثقافات‬
.‫واللغات بشكل تام‬
‫ الغرض من هذا االستعراض التكاميل للدراسات السابقة هو توفري أحدث الرباهني عن العوامل التي تؤثر عىل إبداء أطقم التمريض‬:‫اهلدف‬
.‫ واخلروج باستنتاجات عامة لتعزيز الفهم‬،‫واألطباء سلوك ًا تعاطفي ًا نحو املرىض‬
‫ وقواعد‬PsycINFO‫ و‬Medline (Ovid) ‫ وقاعديت البيانات‬CINAHL ‫ ُأجري بحث عن الدراسات السابقة يف الفهرس العلمي‬:‫طرق البحث‬
‫ ومركز معلومات املوارد‬،‫ والبحوث التعليمية الكاملة‬،‫ ودراسات الرشق األوسط وآسيا الوسطى‬،‫بيانات جمموعة علم النفس والعلوم السلوكية‬
»‫ وحمرك بحث «جوجل سكوالر‬،‫قواعد البيانات األكاديمية‬/‫ال عن قواعد بيانات التمريض‬ ً ‫ فض‬:Health Source ‫ وقاعدة بيانات‬،‫التعليمية‬
.‫ دراسة كمية وكيفية استوفت معايري إدراجها يف االستعراض‬18 ‫ وجرى اختيار ما جمموعه‬.‫للتعرف عىل الدراسات ذات الصلة‬
‫ كام تضمنت سبعة عوامل‬.‫ والسكانية‬،‫ والشخصية والتواصلية‬،‫ العوامل التنظيمية‬:‫ وهي‬،‫ تصف الدراسة ثالثة عوامل عالية التصنيف‬:‫النتائج‬
،‫ واالقتداء بنامذج غري مالئمة‬،‫ واحللقات التدريبية وسلوك املرىض‬،‫ وانعدام الدعم املؤسيس‬،‫ وزيادة عبء العمل‬،‫ اإلهناك‬:‫فرعية عىل النحو التايل‬
.‫والتعلم غري الرسمي القائم عىل التجربة‬
316
Book 24-03.indb 316 13/06/2018 09:44:12

ِّ :‫االستنتاج‬
ً ‫تشكل الثقافة املؤسسية عام‬
‫ فريتبط التجاوب التعاطفي ملقدمي الرعاية الصحية إزاء املرىض بتوفر‬.‫ال قوي ًا يف تثبيط التعاطف مع املرىض‬
.)‫ تبني التعاطف مع اجلميع (وليس املرىض فحسب‬،‫بيئة مؤسسية مزودة باملوارد الكافية وقائمة عىل العمل اجلامعي وتتسم باملهنية‬
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24. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K. Nurse responsiveness to cancer patient expressions of
emotion. Patient Educ Couns. 2009 Jul;76(1):63–70. http://dx.doi.org/10.1016/j.pec.2008.11.010 PMID:19110396
25. Kennifer SL, Alexander SC, Pollak KI, Jeffreys AS, Olsen MK, Rodriguez KL, et al. Negative emotions in cancer care: do oncol-
ogists’ responses depend on severity and type of emotion? Patient Educ Couns. 2009 Jul;76(1):51–6. http://dx.doi.org/10.1016/j.
pec.2008.10.003 PMID:19041211
26. Kataoka HU, Koide N, Hojat M, Gonnella JS. Measurement and correlates of empathy among female Japanese physicians. BMC
Med Educ. 2012 06 22;12(1):48. http://dx.doi.org/10.1186/1472-6920-12-48 PMID:22726449
27. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement,
and relationship to gender and specialty. Am J Psychiatry. 2002 Sep;159(9):1563–9. http://dx.doi.org/10.1176/appi.ajp.159.9.1563
PMID:12202278
28. Quince TA, Parker RA, Wood DF, Benson JA. Stability of empathy among undergraduate medical students: a longitudinal study
at one UK medical school. BMC Med Educ. 2011 10 25;11(1):90. http://dx.doi.org/10.1186/1472-6920-11-90 PMID:22026992
29. Ward J, Schaal M, Sullivan J, Bowen ME, Erdmann JB, Hojat M. Reliability and validity of the Jefferson Scale of Empathy in un-
dergraduate nursing students. J Nurs Meas. 2009;17(1):73–88. http://dx.doi.org/10.1891/1061-3749.17.1.73 PMID:19902660
30. Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med. 2007 May;22(5):696–700. http://dx.doi.org/10.1007/s11606-
006-0102-3 PMID:17443382
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WHO events addressing public health priorities EMHJ – Vol. 24 No. 3 – 2018
Meeting of the Eastern Mediterranean Research Ethics Review

Committee1
This report is extracted from the Summary report on the Meeting of the Eastern Mediterranean Research Ethics Review Committee, Cairo, Egypt,
1
22–23 October 2017 (http://applications.emro.who.int/docs/IC_Meet_Rep_2017_16772_EN.pdf?ua=1, accessed 17 April 2018).

Citation: WHO Regional Office for the Eastern Mediterranean. Meeting of the Eastern Mediterranean research ethics REview committee. East
Mediterr Health J. 2018;24(3):319–320. https://doi.org/10.26719/2018.24.3.319
Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO
licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
The World Health Report 2013: Research for Universal human rights, safety and well-being of all human
Health Coverage (1) emphasized WHO’s role in advancing participants in research; and ensuring compliance with
research that addresses the dominant health needs of the International Ethical Guidelines for Health-Related
its Member States, supporting national health research Research Involving Humans (3).
systems, setting norms and standards for the proper During discussions, participants highlighted the need
conduct of research and accelerating translation of for bioethics capacity-building in the Region, including
research findings into health policy and practice. In further capacity development of RERC members
2010, the 63rd World Health Assembly (2) recognized the (themselves) through possible online courses and
contribution of research to development of solutions participation in WHO activities. They also discussed the
to health problems and endorsed the WHO strategy on situation of multi-centre studies and exemptions versus
research for health. This strategy aims to ensure the expedited review.
highest norms and standards of good research within The recommendations of the 2016 RERC meeting
WHO, and provide support to Member States in taking were reviewed and discussed with participants. Detailed
relevant actions to strengthen national health research statistics were presented including the number of
systems. reviewed proposals from projects funded under the
Research proposals recommended for WHO funding Improving program Implementation through Embedded
through different grant schemes require methodological Research (iPIER), Research in Priority Areas of Public
and ethical review. In 2017, the Eastern Mediterranean Health (RPPH); and Tropical Disease Research (TDR) over
– Research Ethics Review Committee (EM/RERC) was the years.
reformulated with the essential function to review the The RERC checklists for reviewers and principal
protocols of all health research projects involving human investigators (PIs) were thoroughly reviewed based on
subjects submitted to WHO for funding in the Region. the modifications recommended by the RERC during
The Committee has the authority to verify that ongoing its 2016 meeting (4). More amendments were made to
studies comply with the Organization’s policies and the RERC checklist for PIs, especially for the sections
regulations for conduct of health research in the Region, on minors (less than 18 years old), pregnant women and
and it may suspend or terminate approval for ongoing emergency contexts.
studies under its jurisdiction. The Committee reviewed the recommendations
In order to ensure compliance with WHO policies and of two recent meetings and their implications for its
regulations, the EM/RERC members meet on an annual work, i.e. the Regional Bioethics Summit for the Eastern
basis to follow up WHO-supported health research in the Mediterranean/Arab States, held in Muscat, Oman,
Region. The 2017 annual meeting was organized by the April 2017 (5); and a workshop on teaching bioethics and
WHO Regional Office for Eastern Mediterranean (WHO/ research ethics, held in Damascus, Syrian Arab Republic,
EMRO) from 22 to 23 October 2017 at the Regional Office August 2017 (6). Both meetings focused on the functions
in Cairo, Egypt. The objectives of the meeting were to: and work of national bioethics and ethics committees and
• review RERC’s work during 2016–2017; recommended strengthening their internal mechanisms,
role in promoting bioethics, health research ethics,
• agree on modalities for taking forward the coordination and cooperation. The Committee discussed
recommendations of recent meetings; and ways to take forward the recommendations of these
• plan future work in light of the Programme Budget meetings and proposed the following actions.
for 2018–2019.
Recommendations
The meeting was chaired by Professor Gamal Serour,
Based on the discussions during the meeting, the
Director, International Islamic Center for Population
following actions were recommended for the Committee
Studies and Research (IICPSR), Egypt.
and WHO Secretariat.
Summary of discussions 1. Developing terms of reference for the RERC,
The EM/RERC has two mandates: reviewing the health including the duration of assignment (considering
research proposals involving human subjects subjected to the model of the tuberculosis Green Light
funding by WHO to ensure protecting dignity, integrity, Committee).
319
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WHO events addressing public health priorities EMHJ – Vol. 24 No. 3 – 2018
2. Developing a list of FAQs to be posted online in 5. Encouraging principal investigators of WHO-

relation to ethical review as a guide for research funded proposals to publish their papers and make
applicants. manuscript submission conditional with receiving
3. Developing a template for informed consent forms, payments.
including for genetic and biobank-related research, 6. Considering holding side meetings for the RERC
and for RERC clearance. during global and regional bioethics summits.
4. Identifying a modality to link the RERC with
national committees.
References
1. World Health Organization. World Health Report 2013: research for universal health coverage. Geneva: world Health Organiza-
tion; 2013 (http://www.who.int/whr/2013/report/en/).
2. Sixty-third World Health Assembly. Geneva, Switzerland 17-21 May 2010 (http://www.who.int/mediacentre/events/2010/wha63/
en/).
3. Council for International Organizations of Medical Sciences (CIOMS). International ethical guidelines for health-related re-
search involving humans. Geneva: CIOMS; 2016 (https://cioms.ch/wp-content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.
pdf).
4. WHO Regional Office for the Eastern Mediterranean (EMRO). Meeting of the Eastern Mediterranean Research Review Ethics
Review Committee. Cairo: EMRO; 2016 (http://www.emro.who.int/rpc/rpc-news/meeting-of-the-eastern-mediterranean-re-
search-review-ethics-review-committee.html).
5. WHO Regional Office for the Eastern Mediterranean (EMRO). Eastern Mediterranean/Arab states regional summit of national
ethics and bioethics. Cairo: EMRO; 2017 (http://www.emro.who.int/rpc/rpc-events/regional-summit-of-national-ethics-and-bio-
ethics-committees.html).
6. UNESCO & WHO. Workshop “Teaching Bioethics and Research Ethics” 27-30 August 2017, Damascus, Syrian Arab Republic
(http://www.unesco.org/new/en/syria-crisis-response/regional-response/single-view/news/unesco_beirut_promotes_ethics_
teaching_and_research_in_syri/).
State of Kuwait Prize for the Control of Cancer, Cardiovascular Diseases and Diabetes
in the Eastern Mediterranean Region
The State of Kuwait Prize for the Control of Cancer, Cardiovascular Diseases and Diabetes in the Eastern Mediterranean
Region is one of several Foundation awards, administered by the World Health Organization, to acknowledge the work of
well-known scientists, researchers or dedicated people who have made an outstanding contribution in prevention, control
or research in one or more of the following disease groups: cancer, cardiovascular disease and diabetes.
The prize consists of a bronze medal and a sum of money, which is presented at the WHO Regional Committee for the
Eastern Mediterranean by the Committee’s Chairman.
More information about the eligibility criteria and access to the online application form is available at: http://kuwaitprize.
emro.who.int/
320
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Eastern Mediterranean Health Journal Members of the WHO Regional Committee for the Eastern Mediterranean
IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon
the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic
epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses
Tunisia . United Arab Emirates . Yemen
all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and
individuals within and outside the Region.
‫البلدان أعضاء اللجنة اإلقليمية ملنظمة الصحة العاملية لرشق املتوسط‬
‫املجلة الصحية لرشق املتوسط‬
‫ مجهورية إيران اإلسالمية‬. ‫ ليبيا‬. ‫ تونس‬. ‫ البحرين‬. ‫ باكستان‬. ‫ اإلمارات العربية املتحدة‬. ‫ أفغانستان‬. ‫األردن‬
‫ وهى منرب لتقديم السياسات واملبادرات اجلديدة يف الصحة العامة‬.‫هى املجلة الرسمية التى تصدر عن املكتب اإلقليمى لرشق املتوسط بمنظمة الصحة العاملية‬
‫ وخاصة ما يتعلق منها بإقليم رشق‬،‫ ولتبادل اآلراء واملفاهيم واملعطيات الوبائية ونتائج األبحاث وغري ذلك من املعلومات‬،‫واخلدمات الصحية والرتويج هلا‬ ‫ املغرب‬. ‫ مرص‬. ‫ لبنان‬. ‫ الكويت‬. ‫ قطر‬. ‫ فلسطني‬. ‫ عُ امن‬. ‫ العراق‬. ‫ الصومال‬. ‫ السودان‬. ‫ جيبويت‬. ‫اجلمهورية العربية السورية‬
‫ واملراكز املتعاونة مع منظمة‬،‫ وكذا املنظامت غري احلكومية املعنية‬،‫ والكليات الطبية وسائر املعاهد التعليمية‬،‫ وهى موجهة إىل كل أعضاء املهن الصحية‬.‫املتوسط‬ ‫ اليمن‬. ‫اململكة العربية السعودية‬
.‫الصحة العاملية واألفراد املهتمني بالصحة ىف اإلقليم وخارجه‬
Membres du Comité régional de l’OMS pour la Méditerranée orientale
La Revue de Santé de la Méditerranée Orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran
EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne
offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des Somalie . Soudan . Tunisie . Yémen
services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa-
tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux
membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes
concernés au sein et hors de la Région.
EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website:
http://www/emro.who.int/emhj.htm
EMHJ information for authors is available at its website:

http://www.emro.who.int/emh-journal/authors/
EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web Correspondence
of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index
Editor-in-chief
Medicus for the WHO Eastern Mediterranean Region (IMEMR).
Eastern Mediterranean Health Journal
WHO Regional Office for the Eastern Mediterranean
P.O. Box 7608
© World Health Organization (WHO) 2018. Some rights reserved. Nasr City, Cairo 11371
This work is available under the CC BY-NC-SA 3.0 IGO licence Egypt
(https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Tel: (+202) 2276 5000
Fax: (+202) 2670 2492/(+202) 2670 2494
Disclaimer Email: [email protected]
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever
on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation
of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO
in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published
material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use
of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or
policies of the institutions with which they are affiliated. Subscriptions and Permissions
If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization,
publication and do not necessarily represent the decisions, policy or views of the World Health Organization. Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email:
[email protected]). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for
the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the
ISSN 1020-3397 Eastern Mediterranean, at the above address; email: [email protected].
Cover 24-03.indd 4-6 6/6/2018 3:36:28 PM

EMHJ – Vol. 24 No. 3 – 2018 Eastern Mediterranean La Revue de Santé de la
Editorial
Coverage
Yetmgeta Abdella, Ali Akbar Pourfathollah, Hmida Slama and May Raouf.................................................................................................235
Research articles
Bakht Ali, Nighat Nisar and Faryal Nawab.............................................................................................................................................................237
Tala Al-Rousan, Zaker Schwabkey, Lara Jirmanus and Brett D. Nelson........................................................................................................243
Shyam Sundar Ganguly, Kamalesh Sarkar, Samir Al-Adawi and Abdul Aziz Al-Mahrezi.......................................................................254
Jasim Al-Asadi, Shukrya Khalaf, Aqeel Al-Waaly, Alaa Abed and Sabah Shami...........................................................................................262
Eastern Mediterranean Health Journal Vol. 24 No. 3 – 2018

Malak Aoun, Norlena Hasnan and Hassan Al-Aaraj............................................................................................................................................269
Mohammed Al Ghobain, Anwar Ahmed, Zynab Abdrabalnabi, Wjdan Mutairi and Ali Al Khathaami.............................................277
Emirates
Ayesha Siddiqua, Rania Dghaim and Caroline Barakat-Haddad.....................................................................................................................283
Ayla Açikgöz and Belgin Ünal......................................................................................................................................................................................295
Ali Albelbeisi, Zalilah Mohd Shariff, Chan Yoke Mun, Hejar Abdul-Rahman and Yehia Abed..............................................................302
Reviews
review
Muntaha Elayyan, Janet Rankin and MW Chaarani...........................................................................................................................................311
Meeting of the Eastern Mediterranean Research Ethics Review Committee............................................................................319
The World Health Organization has been at the forefront of the movement to improve access to affordable and quality assured blood and
blood products as mandated by successive World Health Assembly resolutions.
Volume 24 / No. 3 3 ‫ عدد‬/ ‫املجلد الرابع والعرشون‬

March/Mars 2018 ‫آذار‬/‫مارس‬
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EMHJ – Vol. 24 No.

3 – 2018 Eastern Mediterranean La Revue de Santé de la

Eastern Mediterranean Health Journal Vol. 24 No. 3 – 2018

Volume 24 / No. 3 3 ‫ عدد‬/ ‫املجلد الرابع والعرشون‬

Cover 24-03.indd 1-3 6/6/2018 3:36:28 PM

EMHJ information for authors is available at its website:

Cover 24-03.indd 4-6 6/6/2018 3:36:28 PM

Eastern Mediterranean La Revue de Santé de la

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International Advisory Panel

Library and printing support

Cover and internal layout designed by Diana Tawadros and

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products. the blood system; strategic partnerships and collaboration

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Adherence to antiretroviral therapy in HIV-positive, male

Sciences, Karachi, Pakistan (Correspondence to: Nighat Nisar: [email protected])

Introduction adherence to ART was 70–89% among HIV patients who

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Methods for the quantitative data. Frequencies and percentages

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Observance du traitement antirétroviral chez les consommateurs de drogue par voie

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Health needs and priorities of Syrian refugees in camps and urban

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Table 1 Summary of qualitative findings (n = 185)

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Table 1 Summary of qualitative findings (n = 185) (concluded)

Table 2 Demographic information on refugee focus group participants (n = 185)

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Table 3 Syrian refugees’ perceptions of their health situation in Jordan (n = 34)a

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Screening for dysglycaemia using anthropometric indices in an adult

Introduction dysglycaemia. In the available literature, various

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Index Normoglycaemic Dysglycaemic

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Index Males Females

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Dépistage de la dysglycémie au moyen d’indices anthropométriques dans une

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Burnout among primary school teachers in Iraq: prevalence and risk

Introduction Therefore, it becomes extremely important to

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