contents · 2017. 4. 2. · mahmoud fikri 1 on 24 january 2017, the 140th session of the who...

Contents

La Revue de Santé dela Méditerranée orientale

Eastern MediterraneanHealth Journal

Vol. 23 No. 2 • 2017 •المجلد الثالث والعشرون عدد 2

EditorialWorking together, increasing responsiveness and capacity building Mahmoud Fikri .............................................................................................................................................................................................................................................................................................65

Research articles Prevalence and determinants of chronic obstructive pulmonary disease among a sample of adult smokers in Baghdad, Iraq, 2014Faris al Lami and Zainab Salim .............................................................................................................................................................................................................................................................67Dentists’ perception of primary health care services in family health and mother and child health clinics in Alexandria, EgyptMaha El Tantawi, Maha A. El-Din Hamza and Marwa M. Sabry ..........................................................................................................................................................................................73Awareness and practice of patients’ rights among hospitalized patients at Wad-Medani Teaching Hospital, SudanAbobaker A.H. Younis 1, Amal H.A. Hassan 1, Eylaph M.-E.H Dmyatti 1, Mehad A.H. Elmubarak 1, Rahma A.A. Alterife 1, Rawan E.O. Salim 1, Samar A.B. Mohamed 1, Wefag S.A.M. Ahmed .......................................................................................................................................................................................................................................................80Prevalence of self-medication among university students in Baghdad: a cross-sectional study from IraqRawa J.K. Al-Ameri, Husham J. Abd Al-Badri and Riyadh K. Lafta .........................................................................................................................................................................................87Evaluation of the prevalence of waterpipe tobacco smoking and its related factors in Tehran, Islamic Republic of IranZahra Hessami, Mohammed R. Masjedi, Reza Ghahremani, Mehdi Kazempour and Habib Emami .........................................................................................................................94Work profile and associated health hazards among nursing students at Mansoura University, EgyptHala S. Abou-Elwafa, Eman O. Khashaba, Abdel-Hady El-Gilany, Samar AbdEl-Raouf ...............................................................................................................................................100واقع إدارة النفايات الطبية السائلة في عدد من مستشفيات مدينة دمشق.................................................................................................................................................................................................................................................................................... حـنـــــان مـحـمـود مـخـيـبـر 110

Report Lebanon’s experience in surveillance of communicable diseases during a mass gathering: Sixth Francophone Games, 2009Nadine Haddad, Walid Ammar, Alfred Khoury, Alex Cox and Nada Ghosn .....................................................................................................................................................................118

WHO events addressing public health prioritiesA regional roadmap to address unopposed marketing of unhealthy foods/beverages to children in the Eastern Mediterranean Region .................................................................................................................................................................................................................................................125

Mahmoud Fikri, Editor-in-chief

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

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

Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics)

Graphics Suhaib Al Asbahi, Diana Tawadros

Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy

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

المجلد الثالث و العشرونالمجلة الصحية لشرق المتوسطالعدد الثاني

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1Regional Director, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt

Editorial

Working together, increasing responsiveness and capacity building Mahmoud Fikri 1

On 24 January 2017, the 140th Session of the WHO Executive Board awarded me the honour of the appointment of Regional Director for the WHO Re-gional Office for the Eastern Mediterra-nean (EMRO), following a nomination by the Regional Committee for the Eastern Mediterranean (1). Since then, WHO Director General Dr Margaret Chan has been very supportive in giving me the opportunity to visit other Re-gional Offices under her guidance and direction. For the last five years EMRO has been led by Dr Ala Alwan and I would like to extend my sincere grati-tude for his efforts in leading EMRO with competence and confidence.

During my statement to the Re-gional Committee in October 2016, I highlighted a number of regional chal-lenges and suggested certain priorities to be taken into account in order to en-able the Region to overcome these diffi-culties. I repeat my statement then that, ‘’I hereby commit to act immediately and work even harder to introduce the proposed changes I advocated for, and all possible ef-forts must be mobilized and made available immediately in order to find appropriate solutions to these challenges; actions must start now. Here, I promise to put WHO on the front line to provide the necessary techni-cal and managerial support to all Member States in the Region by working with them closely. I believe no tangible changes can be made if we are far away from the areas where these changes are needed most.’’

WHO has the technical ability and is equipped to respond to the needs of countries. The General Programme of Work 2014–2019 and the detailed biennium programme budget identify major priority areas for countries that WHO supports within its technical work (2). The vision is to fulfill require-ments and further strengthen and de-velop the five top priority areas, which will be the main agenda during my term as Regional Director. These include emergency preparedness, strengthen-ing health systems, controlling com-municable and noncommunicable diseases, reducing maternal and child mortality, and effectively addressing inequities through focusing on social determinants of health (3).

During my term, greater empha-sis will be placed on specific areas that are negatively affecting the Region, including the eradication of poliomy-elitis, which remains a top priority and continues the achievements made over the past five years (3,4). In addi-tion, it is my aim to achieve progress towards Universal Health Coverage in all countries of the Region in line with the Sustainable Development Goals (SDG) (5,6). This will represent a rich platform for planning and implement-ing health programmes in the coming five years. Together we will be working on supporting human resources devel-opment and capacity building under a leadership programme. EMRO and

country offices can expect to work in a more responsive manner to address the needs of Member States through better utilization of available resources, recruit-ment of qualified staff and ensuring a transparent and a competent working environment. My commitment is to increase the delegation of authority to technical staff in the Regional Office and at the country level in order to encourage competition, creativity, in-novation and excellence. In addition, it is my duty to exert all possible efforts to improve internal coordination within WHO to act as one entity across all levels of the Organization. All possible opportunities will be sought towards working together with other United Nations (UN) agencies, developmental partners and non-governmental organi-zations on related matters such as SDGs and the UN Political Declaration on Noncommunicable Diseases, interna-tional health regulations, various global strategies plans and frameworks (7).

I commit myself to forging stronger cooperation with all WHO Member States and dedicate my experience, knowledge and efforts to serve all countries equally. Finally, I would like to thank all WHO staff, the WHO Regional Committee of the Eastern Mediterranean and the Executive board for their work and look forward to a fruitful future together.

EMHJ • Vol. 23 No. 2 • 2017 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale

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References

1. World Health Organization.Mahmoud Fikri appointed as Re-gional Director for the WHO Eastern Mediterranean Region.Geneva: World Health Organization; 2017 (http://www.who.int/mediacentre/news/notes/2017/Fikri-director-emro/en/, accessed 26 February 2017).

2. World Health Organization. Twelfth General Programme of Work: Not merely the absence of disease (2014-2019). Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/112792/1/GPW_2014-2019_eng.pdf, ac-cessed 1 March 2017).

3. Alwan A. Five years in action: strengthening public health in the Region and beyond. East Mediterr Health J. 2016; 22(12):857–9 (http://www.emro.who.int/emhj-volume-22-2016/volume-22-issue-12/five-years-in-action-strengthening-public-health-in-the-eastern-mediterranean-region-and-beyond.html, accessed 1 March 2017).

4. World Health Organization.Poliomyelitis Fact Sheet. Geneva: World Health Organization; 2016(http://www.who.int/me-diacentre/factsheets/fs114/en/, accessed 1 March 2017).

5. United Nations Development Programme (UNDP).Goal 3 targets. Geneva: UNDP; 2016 (http://www.undp.org/con-tent/undp/en/home/sustainable-development-goals/goal-3-good-health-and-well-being/targets/, accessed 1 March 2017).

6. World Health Organization. Universal health coverage - Sus-tainable Development Goal 3: Health. Geneva: World Health Organization; 2017(http://www.who.int/universal_health_coverage/en/, accessed 1 March 2017).

7. World Health Organization. Framework for action to imple-ment the United Nations Political Declaration on Noncom-municable Diseases, including indicators to assess country progress by 2018. Cairo: WHO Regional Office for the Eastern Mediterranean; 2016 (http://www.emro.who.int/images/stories/ncd/NCD_framework_for_action_-_updated_2014_-_EN_D.pdf?ua=1, accessed 1 March 2017).


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1Department of Community Medicine, College of Medicine, Baghdad University, Baghdad, Iraq (correspondence to: F. Al Lami: [email protected]). 2Ministry of Health, Baghdad, Iraq.Received: 19/04/15; accepted: 10/05/16

Prevalence and determinants of chronic obstructive pulmonary disease among a sample of adult smokers in Baghdad, Iraq, 2014Faris Al Lami 1 and Zainab Salim 2

ABSTRACT This cross-sectional study was conducted to estimate the prevalence and identify determinants of chronic obstructive pulmonary disease (COPD) among a convenience sample of 325 adult smokers in Baghdad, Iraq, 2014. Beside demographic variables, participants had Lung Function Questionnaire to assess respiratory symptoms; individuals with a score of ≤18 had a spirometry examination. Those with FEV1/FVC ratio <70% had post bronchodilator spirometry; those with FEV1/FVC% of <70% and <200 ml improvement of FEV1 were considered COPD cases. Staging of COPD is done according to the degree of FEV1 reduction. The prevalence of COPD was 15.1% (95% confidence interval 11.5-19.4%); 62.5% had moderate and 27.1% had severe COPD. Only 12.5% had a prior physician diagnosis. Age >55 (OR=2.14, 95% confidence interval = 1.04-4.39), and pack year smoking >40 (OR =5.37, 95% confidence interval = 1.70-16.91) were the significant independent determinants. All adult smokers should have a spirometry testing and counseled to stop smoking.

انتشار وعوامل خطورة مرض الانسداد الرئوي المزمن في عينة من البالغين المدخنين في بغداد، العراق، 2014فارس حسن اللامي، زينب سالم كاظم

الخلاصــة: اجريــت هــذة الدراســة القطعيــة عــى عينــة مناســبه مــن 325 مــن البالغــن المدخنــن لتقديــر مــدى انتشــار مــرض الانســداد الرئــوي المزمــن وبعــض عوامــل الخطــورة الكامنــة وراء انتشــاره في بغــداد, العــراق 2014 . اضافــة الى الخصائــص الديموغرافيــة تــم تقديــم "اســتبانة وظائــف الرئــة" لتحديــد الاعــراض التنفســية وتــم فحــص وظائــف الرئــة لــكل شــخص يســجل 18 او اقــل في هــذا الاســتبيان. اذا كانــت نســبة FEV1\FVC أقــل مــن 70% يعــاد الفحــص بعــد اســتعمال الموســعات القصبيــة اذا كانــت النســبة اقــل مــن 70% مــع تحســن اقــل مــن 200 مــل في ال FEV1 اعتبرهــذا دليــل عــى

وجــود مــرض الانســداد الرئــوي المزمــن. كان معــدل انتشــار المــرض 15.1%. 62.5% منهــم مــن النــوع المتوســط و 27.1% مــن النــوع الشــديد وان %12.6 فقــط كان لديهــم تشــخيص ســابق للمــرض مــن قبــل طبيــب. اظهــر تحليــل الانحــدار اللوجســتي وجــود علاقــة معتــدة بــن المــرض والتدخــن اكثــر مــن 40 باكيــت ، وازديــاد الســن اكثــر مــن 55 ســنة. يــوصى باجــراء فحــص وظائــف الرئــة لجميــع البالغــن المدخنــن وتقديــم المشــورة لــرك التدخن.

Prévalence et déterminants de la bronchopneumopathie chronique obstructive dans un échantillon de fumeurs adultes à Bagdad (Iraq) en 2014

RÉSUMÉ La présente étude transversale a été conduite dans le but d’estimer la prévalence de la bronchopneumopathie chronique obstructive (BPCO) et d’identifier ses déterminants dans un échantillon de commodité de 325 fumeurs adultes à Bagdad (Iraq) en 2014. En plus des variables démographiques, les participants devaient remplir un questionnaire sur les fonctions pulmonaires afin d’évaluer les symptômes respiratoires. Les individus ayant obtenu un score inférieur ou égal à 18 devaient se soumettre à un test de spirométrie. Ceux qui présentaient un rapport VEMS/CVF (volume maximal expiré pendant la première seconde d'une expiration forcée/capacité vitale forcée) inférieur à 70 % avaient une spirométrie post-bronchodilatateur ; ceux avec un rapport VEMS/CVF de moins de 70 % et une amélioration du VEMS inférieure à 200 ml étaient considérés comme des cas de BPCO. Les stades de la BPCO sont déterminés en fonction du degré de diminution du VEMS. La prévalence de la BPCO était de 15,1 % (intervalle de confiance à 95 % = 11,5-19,4 %), 62,5 % souffraient de BPCO modérée et 27,1 % d’une BPCO sévère. Un diagnostic médical avait été posé au préalable pour seulement 12,5 % des participants. Un âge supérieur à 55 ans (OR = 2,14, intervalle de confiance à 95 % = 1,04-4,39), et une consommation de paquets-année supérieure à 40 (OR = 5,37, intervalle de confiance à 95 % = 1,70-16,91) était les déterminants indépendants significatifs. Tous les fumeurs adultes devraient bénéficier d’un test de spirométrie et de conseils pour arrêter de fumer.


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Introduction

Chronic obstructive pulmonary disease (COPD) is an important and grow-ing cause of morbidity and mortality worldwide (1–3). The WHO Global Burden of Disease Project estimated that COPD was the fifth leading cause of death worldwide in 2001 and will be the third leading cause by 2020 (1). It is a preventable and treatable disease characterized by airflow limitation that is not fully reversible (3).

In the early stages, COPD can be symptomless; later long episodes of coughing, often with sputum produc-tion, develops. In the later stages, when a large portion of the lung capacity may already have been lost, symptoms of dyspnoea on exertion will develop. Usu-ally COPD is diagnosed in the later stages, and this diagnostic delay may either be due to the patient’s gradual adaptation to a decreasing lung function or because doctors are unaware of, or not responding to, the symptoms (4).

The major risk factor for COPD is cigarette smoking (5), other irritants such as domestic fuel, air pollution and chemical fumes or dust from the en-vironment or workplace can also con-tribute. Older age and male sex are also associated with COPD (6). Spirometry is needed to make a confident diagno-sis of irreversible airway obstruction: (post-bronchodilator FEV1/FVC < 0.7 according to GOLD guidelines (3).

Although around 90% of deaths due to COPD occur in low- or middle-income countries, very few data on the prevalence of this illness are available in these countries (7). In one large study done in the Middle East and North Africa, which included a large sam-ple of individuals aged > 40 years in 10 countries, the overall prevalence of COPD was 3.6% (8). Prevalence increases considerably with age and intensity of smoking, and can vary from 25% in a general smoking population to

approximately 50% in an elderly smok-ing population (9–11).

The objective of the current study was to estimate the prevalence of COPD among a sample of adult smok-ers in Baghdad and to identify certain determinants underlying its develop-ment.

Methods

SampleA cross-sectional study was conducted in 3 primary health care centres in Baghdad, Iraq, during the period 1 May–30 October 2014. There are 118 PHCCs in Al Karekh Directorate of Health (western Baghdad) and 116 in Al Rusafa (eastern Baghdad). After discussion with the officials at the 2 directorates of health, we made a con-venience selection of 3 centres where we had determined that the catchment populations included different socio-economic classes.

The sample size was calculated using the formula n = z2pq/d2

n = (1.96)2 × 0.15 × 0.85/(0.04)2

n = 318We selected 325 individuals to be

included in our study. We invited all cur-rent or former cigarette smokers aged ≥ 35 years attending these 3 primary health care centres for any reason other than respiratory problems and who fulfilled the inclusion criteria to partici-pate in the study until we achieved the required sample size. There were no refusals to participate. Pregnant women and those with contraindications to bronchodilators were excluded.

Previously, a pilot study was done on 10 smokers aged ≥ 35 years in one of the selected primary health care centres to assess the validity of the questionnaire and the time needed to complete the questionnaires and having the spirom-etry test. No changes were made to the questionnaire and the time allocated to complete the tests was adequate.

Data collection Two questionnaires were used and completed by the investigator through direct interviews with the study par-ticipants. The first included questions on sociodemographic data: age, sex, residence, occupation, education, and income. Smoking history was docu-mented as current or former smoker be-sides the number of cigarettes smoked per day and years of smoking. Pack years smoking was calculated by multiplying number of cigarette smoked per day by years of smoking divided by 20 (no. of cigarettes per pack) (2). This was categorized into 3 groups: 1–20, 21–40 and > 40.

History of comorbid chronic dis-eases, including hypertension, diabetes and liver or renal diseases, and any pre-vious diagnosis of chronic bronchitis, emphysema or COPD was recorded.

The second questionnaire was the Lung Function Questionnaire, which comprises 5 questions scored on a 5-point Likert scale (very often = every day, often = most days of the week, sometimes = 1–2 times per week, rarely = < 1 time per week, never = 0 times per week), with lower scores indicating increased risk of airflow ob-struction (12). The questionnaire was administered via face-to-face interview by one of the researchers (ZS). The first 3 questions asked about how often the patients experienced coughing up mu-cus, wheezing and shortness of breath during physical activity. A total score of ≤ 18 suggests an increased risk of airway obstruction (12): all individuals with a score of ≤ 18 on the questionnaire were given a pulmonary function test using the spirometer.

Spirometry Spirometry was performed according to the recommendations of the Ameri-can Thoracic Society (13). We used the Discovery 2 portable spirometer (Futuremed). Every patient who had FEV1/FVC < 70% then underwent


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post-bronchodilator spirometry, using 2 puffs 1 minute apart of inhaled Ven-tolin, and after 30 minutes spirometry was repeated; FEV1/FVC % < 7 0% and < 200 mL improvement of FEV1 is considered irreversible obstruction (COPD). Staging of COPD was then done according to the GOLD clas-sification (3): mild FEV1/FVC < 0.7 FEV1 ≥ 80% of predicted, moderate FEV1 < 0.7 FEV1 ≥ 50–< 80% of pre-dicted, severe FEV1\FVC < 0.7 FEV1 ≥30–<50% of predicted and very severe FEV1\FVC <0.7 FEV1 < 30% of pre-dicted.

Statistical analysisWe used SPSS, version 20, for data en-try and analysis. The chi-squared test of independence was used to test the

association between variables. Logistic regression analysis was applied with the presence of COPD as the outcome vari-able and the demographic and smoking characteristics as independent variables. Odds ratio (OR) and its 95% confi-dence interval (CI) were calculated; P-value < 0.05 was considered statistically significant.

Ethical approval

Ethical approval was obtained from the health research committee in the Iraqi Ministry of Health and the Iraqi Board of Medical Specializations. All participants were informed about the study and verbal approval was obtained before enrolment.

Results

From the total sample of 325 smok-ers and ex-smokers of both sexes, 273 (84%) were males. The mean age was 51.1 [standard deviation (SD) 10.8] years. All were urban residents. Fur-ther demographic characteristics are detailed in Table 1.

Chronic disease was present in 46.5% of the participants, hyperten-sion in 37.8%, diabetes in 18.8% and ischaemic heart diseases in 6.5%. The study sample included current smok-ers (85.8%) and ex-smokers (14.2%). Mean pack years smoking was 40.7 (SD 30.2).

We found that 282 (86.8%) par-ticipants scored ≤ 18 on the Lung

Table1. Distribution of the study group according to chronic obstructive pulmonary disease (COPD) status and sociodemographic characteristics

Sociodemographic characteristics With COPD (n = 48) Without COPD (n = 270) χ2 P-value

No. % No. %

Age (years)

35–44 2 2.0 100 98.0

25.5 < 0.0145–54 17 16.8 84 83.2

55–64 14 20.9 53 79.1

≥ 65 15 31.2 33 68.8

Sex

Male 40 15.0 227 85.00.017 0.897

Female 8 15.7 43 84.3

Education

Illiterate/primary 11 23.9 35 76.1

4.01 0.134Secondary 19 15.7 102 84.3

Higher 18 11.9 133 88.1

Occupation

Unemployed 19 44.2 24 55.8

32.99 < 0.001Employed 25 10.7 219 89.3

Homemaker 4 12.9 27 87.1

Income a

Low 22 21.6 80 78.4

4.94 0.084Middle 21 12.3 150 87.7

High 5 11.1 40 88.9

Crowding index

> 2 29 19.5 120 80.54.17 0.041

≤ 2 19 11.2 150 88.8aLow income > 500 000 Iraqi Dinars; middle income 500 000–1 300 0000 Iraqi Dinars; high income > 1 300 000 Iraqi Dinars.


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Function Questionnaire, i.e. were at risk of COPD (Figure 1). All were given the pulmonary function (spirometry) test; this was obstructive in 59 (20.9%) participants. Those who showed an ob-structive pattern had post-bronchodi-lator spirometry and in 48 (81.3%) the obstruction was irreversible, i.e. COPD. The remaining 11 (18.7%) showed re-versible obstruction (asthma) (Figure 1).

The prevalence of COPD among the study sample was 15.1% (95% CI: 11.5–19.4%): 10.4% had mild (stage I), 62.5% had moderate (stage II) and 27.1% had severe (stage III) COPD. Of the 48 participants identified as having COPD, only 7 (14.6%) had been previ-ously diagnosed with chronic bronchitis by a physician, and only 1 (2.1%) with

COPD, i.e. 40 (83.3%) of the patients with COPD had not been previously diagnosed.

All 216 (66.5%) participants with scores ≤ 18 but who had a normal result for spirometry are considered at risk of developing COPD according to the GOLD classification (3). The mean score was 13.9 (SD 3.6); all participants diagnosed with COPD in our study scored between 7 and 15.

The prevalence of COPD is signifi-cantly higher with older age (P < 0.01); the highest prevalence was reported in the age group ≥ 65 years (31.2%) (Table 1). There was almost equal dis-tribution between males (15.0%) and females (15.7) (P = 0.897). (Table 1). Education level was not a statistically

significant factor for COPD in our par-ticipants (P = 0.134).

The prevalence of COPD was great-er among unemployed participants (44.2%). Only 5.3% of government em-ployees had COPD (P < 0.01). It was also significantly more prevalent among those living where the crowding index was > 2 (19.5%) (P = 0.041).

Similarly, COPD prevalence was greater among those who had other chronic diseases (20.7%) than those without (10.4%) (P = 0.011) (Table 2).

Prevalence of COPD was signifi-cantly higher with increasing pack years smoking. The prevalence was 21.4% among those with > 40 pack years followed by 19.4% among those with 21–40 pack years and only 3.9% among

325 adults ≥35 years with smoking history

Screened by LFQ

282<18 43>18

Perform spirometry

59 obstructions 216 normal7 unable to

complete the test

Post bronchodilator spirometry

48 with COPD 11 with asthma

Figure 1. Schema showing classification of the study sample throughout the study and final assessment


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those with ≤ 20 pack years (P = 0.001) (Table 2).

Logistic regression was used to identify the independent, uncon-founded, risk factors of COPD (as the outcome variable). Two explanatory variables had a statistically significant association with COPD risk: pack years smoking, highest pack year (> 40) (OR =5.37; 95% CI: 1.70–16.91, P = 0.004) and pack year 21–40 (OR = 5.15; 95% CI: 1.62–16.29, P = 0.005), and older age (≥ 55 years) (OR =2.14, 95% CI: 1.04–4.39, P = 0.038) (Table 3).

The remaining variables (sex, marital status, education level, crowding index, body mass index, presence of chronic disease) had no statistically significant association with the outcome.

Discussion

The prevalence of COPD has been widely reported from several countries mainly the developed countries. There is a wide variation in the prevalence reported from different countries due to differences in methodology, diagnostic criteria and type and age of population included.

In the current study on adult smok-ers aged ≥ years, the risk of getting COPD was 86.8%, and the prevalence of COPD was 15.1%. This is similar to the prevalence reported in studies from Sweden (14%), Spain (15%), the Unit-ed States of America (USA) (14.2%), Germany (13.2%) and Turkey (18.1%) (14–18). It is higher than the preva-lence reported in the BREATHE study, which was conducted in Egypt (3.5%),

Jordan (5.4%), Lebanon (5.3%), Syria (6.1%) and the United Arab Emirates (1.9%) (8). The difference in prevalence is because this large study included the general population, i.e. smokers and non-smokers, which accounts for the lower prevalence.

More than two-thirds of COPD cases in the current study were mod-erate stage; more than a quarter had severe and only 10% had the mild type. Similar findings were found in Lebanon with 58.3% of COPD patients having moderate disease, 20.3% severe disease and 17.6% mild disease (19).

In other countries, such as Swe-den, the USA, Japan and Korea, most COPD cases were mild (stage I) fol-lowed by moderate and severe stages (14,16,20,21). This difference could be attributed to including the general population or the early detection of cases due to better health care in these developed countries. This is supported by the finding that more than 83% of the cases were diagnosed as having COPD for the first time during our study. This is supported by the findings of some other studies (19,22). There are 2 possible explanations for the low number of diagnoses of COPD. One is the reluctance of smokers to consult for symptoms they consider normal, such as cough or expectoration. Such patients usually seek medical help only

Table 2. Distribution of the study group according to chronic obstructive pulmonary disease (COPD) status and comorbid chronic disease, body mass index (BMI) and pack years smoking

Factor With COPD (n = 48) Without COPD (n = 270) χ2 P-value

No % No %Chronic disease

Present 30 20.7 115 79.36.5 0.011

Absent 18 10.4 155 89.6BMI

Below normal/normal 14 16.9 69 83.1

0.705 0.703Overweight 18 16.1 94 83.9

Obese 16 13.0 107 87.0

Pack years smoking

≤ 20 4 3.9 99 96.1

15.1 0.00121–40 19 19.4 79 80.6

> 40 25 21.4 92 78.6

Table 3. Multiple logistic regression with chronic obstructive pulmonary disease (COPD) as the dependent variable and selected explanatory variables*

Factora Odds ratio 95% confidence interval P-value

Pack years smoking 0.012

> 40 versus < 20 5.371 1.70–16.91 0.004

21–40 versus < 20 5.150 1.62–16.29 0.005

Age (years) 0.038

55 versus < 55 2.140 1.04–4.39 0.038`

P (model) < 0.001.

Overall predictive accuracy = 84.9%. aThe following variables were also included in the model: sex, marital status, education level, crowding index, income, body mass index, presence of comorbid chronic diseases.


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References

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2. Lopez AD, Shibuya K, Rao C, Mathers CD, Hansell AL, Held LS, et al. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J. 2006;27:397–412. PMID:16452599

3. (GOLD). Global strategy for the diagnosis, management and prevention of COPD – 2016. Global Initiative for Chronic Obstructive Lung Disease; 2016 (http://goldcopd.org/glob-al-strategy-diagnosis-management-prevention-copd-2016/ http://www.goldcopd.org/, accessed 2 March 2017).

4. Van Schayck CP, Chavannes NH. Detection of asthma and chronic obstructive pulmonary disease in primary care. Eur Respir J. 2003;21(Suppl.39):16s–22s. PMID:12572697

5. Marsh S, Aldington S, Shirtcliffe P, Weatherall M and Beasley R. Smoking and COPD: what really are the risks? Eur Respir J. 2006;28:883–4. PMID:17012635

6. Boggia B, Farinaro E, Grieco L, Lucariello A, Carbone U. Burden of smoking and occupational exposure on etiology of chronic obstructive pulmonary disease in workers of southern Italy. J Occup Environ Med. 2008;50(3):366–70. PMID:18332787

7. Halpin DM, Miravitlles M. Chronic obstructive pulmonary disease: the disease and its burden to society. Proc Am Thorac Soc. 2006;3(7):619–23. PMID:16963544

8. Tageldin MA1, Nafti S, Khan JA, Nejjari C, Beji M, Mahboub B, et al. Distribution of COPD-related symptoms in the Middle East and North Africa: result of BREATHE study. Respir Med. 2012;106(Suppl.2):s25–32. PMID:23290701

9. Hasselgren M, Arne M, Lindahl A, Janson S, Lundback B. Estimated prevalences of respiratory symptoms, asthma and chronic obstructive pulmonary disease related to detec-tion rate in primary health care. Scand J Prim Health Care. 2001;19(1):54–7. PMID:11303549

10. Lundback B, Lindberg A, Lindstrom M, Ronmark E, Jonsson AC, Jonsson E, et al. Not 15 but 50% of smokers develop COPD?—Report from the Obstructive Lung Disease in Northern Swe-den studies. Respir Med 2003;97(2):115–22. PMID:12587960

11. Stratelis G, Jakobsson P, Molstad S, Zetterstrom O. Early detec-tion of COPD in primary care: screening by invitation of smok-ers aged 40 to 55 years. Br J Gen Pract. 2004;54(500):201–6. PMID:15006126

12. Yawn BP, Mapel DW, Mannino DM, Martinez FJ, Donohue JF, Hanania NA, et al. Development of the Lung Function Questionnaire (LFQ) to identify airflow obstruction. Int J Chron Obstruct Pulmon Dis. 2010;5:1–10. PMID:20368906

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14. Lindberg A, Bjerg A, Ronmark E, Larsson LG, Lundback B. Prevalence and underdiagnosis of COPD by disease sever-ity and the attributable fraction of smoking: report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med 2006, 100(2):264–72. PMID:15975774

15. Peña VS, Miravitles M, Gabriel R, Jimenez-Ruiz CA, Villas-ante C, Masa JF, et al. Geographic variations in prevalence and underdiagnosis of COPD. Chest. 2000;118(4):981–9. PMID:11035667

16. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971–2000. MMWR Surveill Summ. 2002;51:1–16. PMID:12198919

17. Geldmacher H, Biller H, Herbst A, Urbanski K, Allison M, Buist AS, et al. [The prevalence of chronic obstructive pulmo-nary disease in Germany, result of BOLD study.] Dtsch Med Wochenschr. 2008 Dec;133(50):2609–14 [in German]. PMID 19052996.

18. Gunen H, Savas S, Agil H, Yetkin O, Gulbas G, Mutlu LC, et al. Prevalence of COPD, first epidemiological study of a large region in Turkey. Eur J Int Med. 2008;19(7):499–504. PMID:19013377

19. Salameh P, Waked M. Chronic obstructive pulmonary disease and risk factors in Middle East countries; facts from Lebanon. Beirut: Lebanese University; (www.ul.edu.lb/files/announce-ments/annonce_16_2149_2641.pdf, accessed 14 February 2017).

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21. Yoo KH, Kim YS, Sheen SS, Park JH, Hwang YI, Kim SH, et al. Prevalence of chronic obstructive pulmonary disease in Korea: the fourth Korean National Health and Nutrition Examination Survey, 2008. Respirology, 2011;16(4):659–65. PMID:21342331

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24. Sandelowsky H, Ställberg B, Nager B and Hasselström J. The prevalence of undiagnosed chronic obstructive pulmonary disease in a primary care population with respiratory tract infections – a case finding study. BMC Fam Pract. 2011;12:122. PMID:22047519

when they experience dyspnoea and exacerbations at a relatively advanced stage of the disease. The second is the low use of pulmonary function tests by physicians.

Our study showed that older age and increased pack years smoking are the main factors associated with COPD development. Approximately 1 in 10 pa-tients aged < 55 years and 1 in 4 patients aged 55 years or older had COPD, and

22.4% of those with pack years smoking > 30 develop COPD compared with 7.2% of those with pack years ≤ 30, This is comparable to the findings of other studies (19,22–24). Chronic inhaled cigarette smoke leads to chronic lung inflammatory response, which induces parenchymal tissue destruction and disrupts the normal repair mechanism leading to airway fibrosis and narrowing and a decrease in FEV1 (3).

As this was a cross sectional study any causal relationship cannot be in-ferred. Also we used a convenience sam-ple (non-probability) which comprised attendees of primary health care centres. This could limit the generalizability of the study results.

Funding: None.

Competing interests: None declared.


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1Department of Preventive Dental Sciences, College of Dentistry, University of Dammam, Dammam, Saudi Arabia (Correspondence to: M. El Tantawi: [email protected]). 2Department of Paediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt. 3Faculty of Dentistry, Pharos University, Alexandria, Egypt.

Received: 10/02/14; accepted: 12/10/16

Dentists’ perception of primary health care services in family health and mother and child health clinics in Alexandria, EgyptMaha El Tantawi 1, Maha A. El-Din Hamza 2 and Marwa M. Sabry 3

ABSTRACT This study compared dentists' perceptions of provided services in Family Health (FH) and Mother and Child Health (MCH) clinics. A questionnaire was distributed to 120 dentists in 7 FH and 4 MCH clinics in Alexandria, Egypt in 2012. The questionnaire assessed personal and professional background, perceptions of primary health care (PHC) role, types of services provided, patient recall and referral systems and perception of service quality. The response rate was 100%. More FH dentists perceived their role to include providing care for children and pregnant women. Restorations and scaling were provided by 90% of all dentists. More FH dentists reported providing simple extractions, paediatric extractions and multi-rooted endodontic treatment (P = 0.03, 0.001 and 0.001). In FH clinics, where the performance-based incentive system was implemented, a greater number of patients was served and there was a shift in the type of services provided although dentists had a less positive perception of quality aspects. Thus, there is a need for the establishment of a mission and clear guidelines for the FH clinics to guide service provision.

معارف أطباء الأسنان عن خدمات الرعاية الصحية الأولية في نظم الرعاية الصحية المختلفة ، بالإسكندرية مصرمها محمد على الطنطاوى، مها على الدين حمزة، مروة محمد صبرى

الخلاصــة: تهــدف هــذه الدراســة الى المقارنــة بــن معــارف أطبــاء الأســنان فى عيــادات صحــة الأسرة وعيــادات صحــة الأم والطفــل تجــاه الخدمــات المقدمــة. فلقــد تــم توزيــع اســتبيان عــلى 120 مــن أطبــاء الأســنان في 7 عيــادات صحــة أسرة و 4 عيــادات صحــة الأم والطفــل في الإســكندرية، مــر في عــام 2012. تضمــن الاســتبيان تقييــم للمعلومــات الشــخصية والمهنيــة، ومعــارف أطبــاء الأســنان عــن دورهــم فى مجــال الرعايــة الصحيــة الأوليــة ، وأنــواع الخدمــات المقدمــة، و اســتدعاء المريــض ونظــم الإحالــة وجــودة الخدمــة. وكان معدل الاســتجابة بنســبة 100٪. يرى أطبــاء الأســنان فى عيادات رعايــة الأسرة أن دورهــم يشــتمل توفــر الرعايــة للأطفــال والنســاء الحوامــل. ووجــد أن خدمــات الحشــو وتنظيــف الأســنان قــام بهــا 90٪ مــن أطبــاء الأســنان. وعــدد أكــبر مــن أطبــاء الأســنان فى عيــادات رعايــة الأسرة قــام بإجــراء عاجــات الخلــع البســيطة، وخلــع أســنان الأطفــال وعــاج الجذور المتعــددة (P=0.03, 0.001, 0.001). في عيــادات صحــة الأسرة، حيــث تــم تنفيــذ نظــام الحوافــز القائــم عــلى الأداء، تمــت خدمــة وتحويــل عــدد أكــبر مــن المــرضى وكان هنــاك تحــول في نــوع الخدمــات المقدمــة عــلى الرغــم مــن أن أطبــاء الأســنان أقــل إيجابيــة مــن حيــث ادراكهــم لجوانــب الجــودة فى

الخدمــات المقدمــة. هنــاك حاجــة لإنشــاء رســالة ومبــادئ توجيهيــة واضحــة لعيــادات صحــة الأسرة لتحديــد اتجــاه وأســاليب تقديــم الخدمــات.

Perception des dentistes dans les établissements de santé de la famille et de santé maternelle et infantile vis-à-vis des services de soins de santé primaires à Alexandrie (Égypte)

RÉSUMÉ La présente étude avait pour objectif de comparer la perception des dentistes travaillant dans des établissements de santé de la famille et de santé maternelle et infantile vis-à-vis des services offerts. Un questionnaire a été distribué à 120 dentistes de sept cliniques de santé de la famille et de quatre dispensaires de santé maternelle et infantile à Alexandrie (Égypte) en 2012. Ledit questionnaire évaluait l’expérience personnelle et professionnelle, les perceptions du rôle des soins de santé primaires, les types de services offerts, les systèmes de rappel des patients et d’orientation-recours, ainsi que la perception de la qualité des services. Le taux de réponse a été de 100 %. Davantage de dentistes des établissements de santé de la famille pensaient que leur rôle incluait la prestation de soins pour les enfants et les femmes enceintes. Les restaurations dentaires et le détartrage étaient offerts par 90 % de tous les dentistes. Un plus grand nombre de dentistes en santé de la famille ont déclaré procéder à de simples extractions, à des extractions chez l’enfant et à un traitement endodontique des dents pluriradiculées (p = 0,03, 0,001 et 0,001). Dans les cliniques de santé de la famille, où un système d’incitation reposant sur les performances était mis en place, un plus grand nombre de patients étaient traités, bien que les dentistes aient une moins bonne perception de la qualité. Il est donc nécessaire d’organiser une mission, ainsi que de mettre au point des directives claires pour les cliniques de santé de la famille, afin d’orienter la prestation de services.


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Introduction

An essential element of primary health care (PHC) declared in the Alma Ata conference is an overall focus on pre-vention rather than curative service (1). Since dentistry is essentially a primary care discipline, oral health was later in-tegrated into PHC models. The major-ity of patient care in dentistry occurs in community settings and involves simple procedures which are provided by gen-eral practitioners whose aim is to have a long-term relationship with patients (2). Primary oral health care includes preventive services—health education and promotion (3)—and basic treat-ment such as examination, bitewing ra-diographs, scaling and polishing, simple (1–3 surfaces) fillings and emergency relief of pain and sepsis (4).

In the past, Egypt provided PHC through various systems that sometimes had inadequate referral and integration of several programmes resulting in a fragmented system (5). A gap existed between the services PHC programmes intended to provide and the resources available to support them. This imbal-ance resulted in low salaries, lack of sup-plies and substandard facilities, which caused dissatisfaction among both clients and providers. Although the number of PHC units in Egypt (2.2 units per 10 000 population) was among the highest in Arab countries (5), it had a small impact on health outcomes, especially among disadvantaged groups because it lacked an intersectoral approach (6).

One vertical programme oper-ated through the mother and child health (MCH) clinics and aimed at providing comprehensive integrated preventive, curative and rehabilitative services to mothers during and after pregnancy as well as to their newborns. In 1997, the Ministry of Health started a reform of the health system in order to provide all Egyptians with access to better quality primary and preventive services through the “Family Health Model”, which com-bined public funds and user co-payments according to the ability to pay. In this

model, integrated services were provided under the same roof for the entire family and the family physician/dentist cared for all members of the family regardless of age, gender or type of problem (7). The main features of this model were that it 1) required less time and transportation, 2) had a performance-based incentive system potentially increasing provider accountability for quality standards and reform goals and 3) had an improved referral system. Most MCH clinics, the main providers of PHC in the dental sector, were converted into family health (FH) clinics although some of them re-mained MCH clinics (8).

Sheiham and Williams in their report about reducing oral health inequalities in the Middle East (9) commented that a capitation reimbursement system would offer greater efficiency, equity and patient participation and help in continuity of care as well as patient and dentist sat-isfaction. Experts investigating suitable methods to finance oral health services in the Middle East recommended that oral programmes be incorporated into existing primary care programmes to reduce costs (10).

Studies were conducted to evaluate this performance-based incentive FH care system in the sectors of reproduc-tive health and child care (11), diabetes management (12) and laboratory quality (13), but not in the dental sector. The present study therefore aimed to evaluate and compare the perception of dentists working in MCH and FH clinics in Alex-andria, Egypt regarding the PHC services they provided. This evaluation will help health care policy planners to understand the impact of different financing mecha-nisms on health professionals and their understanding of the services they pro-vide so that better care can be ensured.

Methods

Study design, setting and sampleA cross-sectional study was conducted among dentists working in FH and 4

MCH clinics in Alexandria, Egypt dur-ing October and November, 2012.

Approvals for the study were ob-tained from the Central Directorate for Research and Health Development, Ministry of Health (IRB00006877), Egypt and the Ethics of Dental Research Committee in the Faculty of Dentistry, Alexandria University.

Alexandria includes 8 administra-tive Ministry of Health districts with 60 primary dental care clinics (56 FH and 4 MCH clinics). Districts where there were no MCH clinics were excluded leaving 3 districts included in the study. Clinics were selected in the ratio 1:2 (MCH:FH). Thus, the study covered clinics in the 3 districts of Montazah, Middle and Amreya: 2 MCH clinics and all 3 available FH clinics in the Mid-dle District and 1 MCH clinic and 2 FH clinics (selected randomly) in each of the 2 other districts. All dentists in these clinics were invited to participate in the study (n = 120). Returning the filled questionnaire was considered an im-plicit consent to participate in the study.

Data collectionData were collected using a self-administered questionnaire developed based on previous studies (14,15) and pilot-tested on a sample of 15 dentists, who were not included in the study, to ensure clarity of questions. The ques-tionnaire used close-ended questions where the respondent was asked to select the correct/appropriate answer from among several options or answer on a yes/no basis. The first section in the questionnaire asked about personal and professional background (sex, age, qualification, specialty and number of patients served in the previous year). The second section assessed respond-ents’ perception of their PHC role where they were asked to select from a list of 6 roles (care of children, care of pregnant women, follow-up of schoolchildren, care of all family members, provision of low cost/free services and health education). The third section included 15 procedures that respondents were


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asked to indicate if they provided or not. In addition, they were asked if they recalled patients, referred them to other facilities, types of services these referred patients received, reasons for referral and percentage of patients referred. The last section asked respondents to indicate on a yes/no basis if they were satisfied with the availability, affordabil-ity, suitability and timeliness of services and whether they were satisfied with the services they provided and thought their patients were satisfied or not.

Statistical analysisData were analysed using SPSS, ver-sion 17.0. Comparison between FH and MCH dentists was done using the chi-squared, Fisher exact or Mann–Whitney U tests. The significance level was set at 5%. Bar charts were used for graphical presentation.

Results

The response rate was 100% (all 120 dentists responded; 52 and 68 from FH and MCH clinics respectively). A greater proportion of MCH than FH

dentists were women (89.7% versus 69.2% respectively, P = 0.01). Most of the dentists in both types of clinic held bachelor of dentistry degrees (80.8%) and were <40 years old (60.8%): 31.7% were <30 years old, 29.2% were 30-<40 years, 22.5% 40-<50 years and 16.7% ≥ 50 years. The differences were not statistically significant in either case. Most of the respondents were general dentists (80.3%), followed by public health dentists (10.8%), paediatric dentists (3.3%) and peri-odontists (2.5%). The remaining were specialists in conservative dentistry, fixed prosthodontics and oral surgery. Again the differences were not statisti-cally significant. FH dentists served more patients than MCH dentists (mean 594.7 and 412.9 patients per dentist respectively) with a total of 30 922 and 28 075 patients served in the two types of clinics in the previous year.

More FH than MCH dentists per-ceived the role of PHC to include follow up of schoolchildren (P = 0.05), care of pregnant women (P = 0.05), care of children (P = 0.04), follow up of all fam-ily members (P = 0.03) and provision of

free/low cost services (P = 0.03) (Fig-ure 1). Less than 40% of dentists in both types of clinic thought PHC included providing health education (P = 0.09).

Figure 2 shows the services FH and MCH dentists reported they provided. Restorations and scaling were reported by > 90% of the dentists in both types of clinic. Simple extraction and health education were reported by just over 90% of FH dentists versus just over 70% of MCH dentists (P = 0.03 and 0.09 respectively). Significantly more FH dentists than MCH dentists reported providing paediatric extractions (P = 0.001), multi-root endodontic treat-ments (P = 0.001) and surgical extrac-tions (P = 0.01). Almost half the FH dentists reported providing prosthetic services—complete (P = 0.001) or par-tial (P = 0.0001) dentures—compared with no MCH dentist reporting provid-ing these services.

Significantly more MCH than FH dentists reported that they recalled pa-tients (86.8% versus 61.5%, P = 0.004) (Table 1). Almost all dentists reported referring patients when needed. More MCH than FH dentists reported re-ferring patients to receive paediatric

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Providingfree or lowcost service

Healtheducation

Figure 1 Perception of family health (FH) and mother and child health (MCH) dentists of the role of dental primary health care clinics


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dental services (92.7% versus 42.3%, P < 0.0001), fixed prosthetic procedures (80.9% versus 46.2%, P < 0.0001) and surgical procedures (70.6% ver-sus 36.5%, P < 0.0001). FH dentists monthly referred a significantly higher per cent of their patients than MCH dentists (mean referred = 26.5 and 18.5 respectively, P < 0.0001). Significantly more MCH than FH dentists reported referring patients because equipment/instruments were inadequate (95.6% versus 76.9%, P = 0.005) or dental clinics were not enough (58.8% versus 17.7%, P <0.0001). About 50% of the dentists in both types of clinic reported they referred patients because there was no adequate professional experience to meet the patients’ needs (P = 0.25).

Significantly more MCH than FH dentists reported that the services were available for all (89.7% versus 11.5%, P < 0.0001), affordable (100% versus 7.7%, P < 0.0001) and suitable for patients’ needs (73.5% versus 48.1%, P = 0.004) (Table 2). MCH dentists

reported that patients waited a shorter time to receive services compared to FH dentists (mean = 0.6 versus 2.7 days, P = 0.001). More MCH than FH den-tists perceived patients to be satisfied with services (73.5% versus 42.3%, P = 0.001) while more FH than MCH dentists reported they were personally satisfied with the quality of the service (50.0% versus 27.9%, P = 0.01).

Discussion

Few studies have focused on the as-sessment of PHC delivery in dentistry and dentists’ perception of the services provided (16). Our study compared 2 types of PHC system (FH and MCH) and the perception of dentists working within them. The perception of FH den-tists of their role was more aligned with PHC concepts and they were more satisfied with the services they provided. They served and referred more patients and provided services responding to

the needs of a more varied population. MCH dentists, on the other hand, re-called patients more frequently, and were more oriented to the quality of services and how this impacted patient satisfaction. One of the factors that may explain these differences is the newly introduced system in FH clinics that links performance to financial incen-tives. However, our study results are mixed and do not unequivocally show that the FH system had better perceived outcomes on quality or continuity of care than the MCH system.

Most of the dentists in the 2 types of clinic were women. This reflects the higher proportion of women who graduate from dental schools in Egypt in addition to the fact that male dentists are more likely to leave their jobs in the Ministry of Health because of inad-equate salaries (17). A higher propor-tion of FH dentists were male possibly because these clinics are in remote areas where women may be reluctant to work.

Figure 2 Dental services reported by dentists to be provided in family health (FH) and mother and child health (MCH) clinics (*statistically significant difference at P ≤ 0.05)

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Health education, a core PHC ser-vice, was cited by both FH and MCH dentists as the service least provided. Caring for all family members was less cited as a role than caring for mothers and children which may mean adult males and older clients are considered less of a priority for FH dentists, al-though they are supposed to provide care for the entire family. A gap existed among FH dentists between their per-ception and the reality of the situation: they considered that their role was to provide free/low cost services whereas

only 7.7% thought their services were affordable. These contradictions need to be resolved by developing a mission for FH clinics that reflects the objectives of the system and the purpose for which it was developed.

Almost all FH and MCH dentists reported providing restorative services and scaling, the core services of dental PHC. If the number of services actu-ally provided concurs with the dentists reporting providing these services, then there has been a shift from earlier re-ports of Ministry of Health services in

Egypt where extractions have been the main service provided since the 1980s (18). The greater per cent of restora-tive services may be explained by the population served by the clinics and the possibility that they are in urban areas. It may reflect a generalized time trend and a response to patient profile rather than a strategic shift in philoso-phy of the health care system. There is also the possibility that this change may be related to the performance-based incentive system. It is documented that different financing systems are

Table 1 Patient recall and referral by dentists working in family health (FH) and mother and child health (MCH) clinics

Recall and referral factors FH dentists (n = 52)

MCH dentists (n = 68)

P-value

No. (%) No. (%)

Recalled patients 32 (61.5) 59 (86.8) 0.004

Referred patients to others 51 (98.1) 68 (100) 0.43

Type of services patients are referred to receive

Endodontics 49 (94.2) 66 (97.1) 0.37

Paediatric dentistry 22 (42.3) 63 (92.7) < 0.0001

Fixed prosthodontics 24 (46.2) 55 (80.9) < 0.0001

Surgery 19 (36.5) 48 (70.6) < 0.0001

Partial and complete dentures 3 (5.8) 4 (5.9) 0.64

Other 2 (3.8) 4 (5.9) 0.47

Percentage of patients referred monthly/total number of patients [Mean (SD)] 26.5 (7.3) 18.5 (12.4) < 0.0001

Reasons for referral

Inadequate equipment/instrument for patients' needs 40 (76.9) 65 (95.6) 0.005

Inadequate professional experience for patient's needs 28 (53.8) 32 (47.1) 0.25

Not enough dental clinics 9 (17.7) 40 (58.8) < 0.0001

P ≤ 0.05 statistically significant. SD = standard deviation.

Table 2 Family health (FH) and mother and child health (MCH) dentists’ views of dental services provided

Variable FH dentists (n = 52)

MCH dentists(n = 68 )

P-value

No. (%) No. (%)

Services are available to all levels of society 6 (11.5) 61 (89.7) < 0.0001

Cost of services are affordable by patients 4 (7.7) 68 (100) < 0.0001

Services are suitable for the needs of patients 25 (48.1) 50 (73.5) 0.004

Number of waiting days until patients receive needed services [Mean (SD)] 2.7 (2.4) 0.6 (0.9) 0.001*

Services provided are satisfactory to patients 22 (42.3) 50 (73.5) 0.001

Dentist satisfied with quality of services 26 (50.0) 19 (27.9) 0.01

P ≤ 0.05 statistically significant. SD = standard deviation.


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associated with changes in how dentists and patients respond to health prob-lems (19). A study conducted in the United States of America showed that reimbursing providers increased the number of minimally invasive/preven-tive services offered to children (20). More FH dentists reported providing extractions (simple and surgical), possi-bly because they are the least expensive among the procedures FH clinics of-fer. The greater percentage of dentists reporting paediatric extractions in FH clinics reflects the absence of paediatric dentists. Workforce qualification and availability have a direct effect on oral health (21,22). Endodontic treatment was reported to be provided by more FH than MCH dentists with wider gap in multi-root teeth. These procedures are usually expensive for the lower so-cioeconomic level of MCH patients. In addition, MCH patients are either young children who would be referred elsewhere for endodontic treatment or pregnant women who may not wish to have the procedure for fear it may affect their pregnancy.

More MCH dentists reported recalling their patients, possibly re-flecting the monthly recall routine of pregnant mothers done in MCH clin-ics. The most frequently cited reason for referring patients was inadequate instruments/equipment; fewer den-tists reported limited experience as the reason for referral. This agrees with a study of National Health Service den-tists who reported referring difficult cases (23) and another study of New Zealand general practitioners who re-ferred complex cases to specialists (24). A significantly higher percentage of MCH dentists had referred paediatric patients although there are paediatric dentists in these clinics and although most dentists perceived the follow-up of and care of children as among the roles of dental PHC. This may be explained by the fact that a greater proportion of MCH patients are children compared

to FH patients. It may be difficult there-fore for the few paediatric dentists to cover all their needs. FH dentists had referred a significantly higher number of patients in the previous month. In a PHC context, referral is a main service since FH providers act as gate keepers to the health care system (25). There is a need to establish clear guidelines for the FH clinics and how much their role is to act as gate keepers and pro-vide PHC services with referral of more complex cases or if they should cover the treatment needs of all family mem-bers regardless of the complexity and cost of care. The latter approach seems unrealistic and would go against the rationale for establishing governmental tertiary care facilities. Similarly, Fayle called for a clear delineation of the du-ties of the United Kingdom National Health Service general dental practices and salaried dental services to establish an integrated network of services to meet patients’ needs (26). Experts pro-posing solutions to reduce oral health inequalities in the Middle East have recommended the establishment of na-tional systems to integrate and organize efforts by the different elements of the dental care services (9).

MCH dentists had a more positive perception of the availability, appropri-ateness, timeliness and patient satisfac-tion with the services they provided. However, more FH dentists reported their own satisfaction with provided ser-vices. MCH dentists may have a more patient-centered perspective of quality focusing on patient satisfaction as an outcome whereas FH dentists are more interested in the quantitative indica-tors of quality related to the number of patients they managed directly or referred. A study investigating changes after health sector reform in Suez, Egypt reported increased provider satisfaction and productivity as demonstrated by the rise of physician encounters from 3 to 16 per day (27). Another study used a case–control design to investigate the

effect of a performance-based incen-tive system in FH clinics on providers’ behaviour regarding the delivery of reproductive and child care services in Egypt (11). The investigators reported significant improvement in the quality of family planning, antenatal care and child care services in the clinics where the system was implemented compared to others.

Our study has some limitations. We relied on dentists’ perception to compare the 2 systems which might introduce dentists’ biases. Future stud-ies are needed to complement the data of dentists’ perceptions with unbiased data based on records. In addition, in-formation from the patients’ perspec-tive would add greater depth to the comparison of the 2 models. More re-search is needed to follow the progress of FH towards providing dental PHC according to the Egyptian accreditation standards (28).

Conclusion

Based on our findings, dentists’ percep-tion of the quality services provided and patient satisfaction were more positive among MCH dentists. FH dentists’ perception of their role was more aligned with PHC concepts although this did not necessarily translate to the actual services they provide fulfilling the same role. Based on the participants’ perceptions, the FH system may be suffering from high costs which may prevent patients from utilizing services. In addition, there is a need to develop a mission for FH clinics that is aligned with the purpose for which they were established, taking into consideration the available resources.Funding: None.Competing interests: None declared.


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1University of Gezira, Wad-Medani, Gezira, Sudan (Correspondence to: A.A.H. Younis: [email protected]).Receieved: 15/11/15; accepted: 02/10/16

Awareness and practice of patients’ rights among hospitalized patients at Wad-Medani Teaching Hospital, SudanAbobaker A.H. Younis 1, Amal H.A. Hassan 1, Eylaph M.E.H Dmyatti 1, Mehad A.H. Elmubarak 1, Rahma A.A. Alterife 1, Rawan E.O. Salim 1, Samar A.B. Mohamed 1 and Wefag S.A.M. Ahmed 1

ABSTRACT Patients' rights are a fundamental human right and an important part of modern health care practice. This is a cross-sectional descriptive analytic study, conducted amongst 263 patients at Wadi-Medani Teaching Hospital, Sudan, in March-April 2015. Most patients (95.2%) did not know about the Bill of Rights and most of them (92.8%) were not able to mention any of the patients' rights. The most practiced rights were: the right to be asked for permission before examination (88.1%), proper handling (87.8%), safety of the hospital (87%), presence of a third person when examining a female by a male doctor (85.6%), and admission file confidentiality (75.5%). The awareness of Sudan FMOH Patients' Bill of Rights was very low among patients at Wad-Medani Teaching Hospital, yet they showed a high satisfaction rate probably due to their low socioeconomic status, educational level and expectations. Therefore, awareness of patients' rights must be increased.

وعي وممارسة حقوق المرضى بين المرضى الداخليين في مستشفى واد مدني التعليمي، السودانــنِّيّ الطريفــي، روان الطيــب ســالم، أبــو بكــر عــي يونــس، أمــل حســن عبــد الله، إيــاف محمــد الديمياطــي، مهــاد عبــد الحميــد المبــارك، رحمــة السُّ

ســمر عــوض محمــد، وفــاق صــاح أحمد

الخلاصــة: حقــوق المــرضى مــن حقــوق الإنســان الأساســية، وهــي جــزء مهــم مــن الممارســة في الرعايــة الصحيــة الحديثــة. لقــد كانــت هــذه ــرضى ــم الم ــن معظ ــان 2015. ولم يك ــارس/آذار إلى أبريل/نيس ــن م ــرة م ــاً في الف ــمِلت 263 مريض ــة، شُ ــة ووصفي ــة وتحليلي ــة مقطعي الدراس

ــن معظمهــم )92.8٪( مــن ذِكــر أي حــق مــن حقــوق المــرضى. وكانــت أكثــر )95.2٪( يعرفــون شــيئاً عــن وثيقــة حقــوق المــرضى، كــما لم يتمكَّــتَأْذن قبــل الفحــص )88.1٪(، والتعامــل الســليم )87.8٪(، والســامة في المستشــفى )87٪(، ووجــود حقــوق المــرضى ممارســةً: الحــق في أن يُسْــرضى ــي الم ــم أن وع ــول )75.5٪(. وبالرغ ــف الدخ ــة مل ــر ) 85.6٪(، وسري ــب ذك ــص طبي ــى لفح ــة أنث ــع مريض ــا تخض ــث عندم ــخص ثال شــدني ــفى واد م ــرضى في مستش ــن الم ــداً ب ــاً ج ــرضى منخفض ــوق الم ــول حق ــودان ح ــة في الس ــة الاتحادي ــا وزارة الصح ــي أصدرته ــة الت بالوثيقــادي، ــي والاقتص ــع الاجتماع ــاض الوض ــك إلى انخف ــع ذل ــد يرج ــا، وق ــدل الرض ــاً في مع ــدلاً مرتفع ــروا مع ــرضى أظه ــي، إلا أن الم التعليم

ــادة الوعــي بحقــوق المــرضى. والمســتوى التعليمــي والتوقعــات. ممــا يوجــب زي

Connaissance et pratique des droits des patients parmi les patients hospitalisés de l’hôpital universitaire de Wad-Medani, au Soudan

RÉSUMÉ Les droits des patients constituent un droit humain fondamental et représentent une partie importante de la pratique des soins de santé modernes. Le présent article concerne une étude analytique descriptive transversale menée auprès de 263 patients entre mars et avril 2015. La plupart des patients (95,2 %) n’étaient pas au courant de l’existence de la déclaration des droits, et la majorité d’entre eux (92,8 %) n’était pas en mesure de citer ne serait-ce qu’un droit des patients. Les droits appliqués le plus souvent étaient les suivants : le droit à être consulté avant tout examen clinique (88,1 %), un traitement adéquat (87,8 %), la sécurité des hôpitaux (87 %), la présence d’une tierce personne lors de l’examen d’une patiente par un docteur de sexe masculin (85,6 %), et la confidentialité des dossiers d’admission (75,5 %). Un très faible pourcentage des patients de l’hôpital universitaire de Wad-Medani avait connaissance de la déclaration des droits des patients du ministère fédéral de la Santé soudanais. Pour autant, les patients affichaient un taux élevé de satisfaction, certainement dû à leur faible statut socio-économique, à leur bas niveau d’éducation et à leurs attentes limitées. La connaissance du droit des patients doit donc être améliorée.


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Introduction

Patients’ rights are a fundamental hu-man right, and a quality assurance that measures and protects patients against abuse and discrimination and pro-motes ethical practices (1, 2). Patients’ rights are an important part of modern healthcare practice. Perhaps, patients are one of the most vulnerable groups in society. Therefore, improving the rights of patients is considered a priority in the provision of medical services and one of the medical indices in every society (3). The relationship between physi-cians and their patients has undergone significant changes recently. While a physician should always act according to his/her conscience, and always in the best interests of the patient, equal ef-fort must be made to guarantee patient autonomy and justice. Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and imple-ment patients’ rights (4).

Since the United Nations Decla-ration of Human Rights in 1948 (1), legislation on patients’ rights has been passed worldwide (5). There have been many declarations defining the impor-tance of patients’ rights. The American Hospital Association and the World Medical Association adopted decla-rations of patients’ rights in 1973 and 1981, respectively (4, 6).

The World Health Organization (WHO) research group on patients’ rights and citizens’ empowerment has suggested that each country should articulate its concerns and priorities according to its own cultural and social needs to promote and protect patients’ rights (7). In response, the Sudan Federal Ministry of Health (FMoH) launched a Patients’ Bill of Rights in 2009 (8). This Bill is one of the earliest among Arab countries. The WHO also cautions that “the existence of Patients’ Charters without efforts to raise aware-ness among patients does not improve the quality of health care” (9).

The significance of the present study relies on the fact that patient care is the ultimate goal of medical schools and healthcare institutions. This study offers an opportunity to assess patients’ awareness and satisfaction regarding their rights, and could drive the atten-tion of the community towards this issue. Moreover, there is lack of similar studies regarding this subject locally and regionally. This study was conducted to assess the awareness and practice of patients’ rights among inpatients at Wad Medani Teaching Hospital, Gezira, Sudan.

Methods

Study design and settingThis cross-sectional, descriptive ana-lytical study was conducted between March and April 2015 in Wad-Med-ani Teaching Hospital, Gezira, Sudan, which is the largest governmental hospital outside the capital Khartoum. The hospital has 254 beds with a mean number of 820 admissions per month and a mean bed turnover of 3.8. The study population was selected from all wards of the hospital: internal medicine, surgery, chest and ear, nose and throat.

Sample selectionThe sample size was based on preva-lence of 50% with 95% confidence level and 5% level of significance; the required sample was at least 263 partici-pants. All admitted patients during the study period who agreed to participate and could communicate with us were included. Patients who refused to par-ticipate, were critically ill or could not communicate with us were excluded. A cluster sampling technique was used, in which each department was considered as a cluster. The sample size for each department was proportional to its mean number of admissions, as follows: internal medicine, surgery, chest and ear, nose and throat (147, 92, 1 and 23, respectively). All patients who met

the inclusion criteria were randomly selected.

QuestionnaireThe questionnaire comprised two parts. The first part included questions regard-ing sociodemographic data such as age, sex, marital status, residency, duration of hospitalization and educational status. In the second part the patients’ aware-ness and practice of patients’ rights were evaluated using a 5-point scale. The questions were based on the Sudanese FMoH Patients’ Bill of Rights (8). It consisted of 28 questions in 5 domains: availability of fundamental services (3 questions); access to services (5 ques-tions); appropriate clinical practice (11 questions); appropriate nursing ser-vices (4 questions); and other services (5 questions).

Data collection and analysisThe authors (class of 2017 medical students) interviewed the patients and recorded their answers. The patients’ identities were kept confidential and they were assured that any information given would only be used for scientific research. The response rate was 97.4% of the recruited patients and only a few refused. Data was analyzed using SPSS version 20. P<0.05 was considered to be significant.

Ethical considerationsThe study was approved by the Re-search Ethical Committee, Faculty of Medicine, University of Gezira and the administration of Wad Medani Teaching Hospital. Verbal consent was obtained from the participants.

Results

A total of 263 patients were interviewed. Table 1 shows the sociodemographic characteristics of the study sample: 58.17% were female and 41.8% male and mean age was 45 years (range: 17–90 years). Regarding residency,


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71.5% were from rural areas. Most of the participants were married and around one-third of the patients were single, divorced or widowed. With regard to occupation: 89.1% of men had a job, and among women, 18.3% had a job and 81.7% were housewives. With re-gard to education, 47.1% were illiterate, while 29.3% had primary school educa-tion and 23.6% had secondary school education or above. The mean duration

of hospitalization was 4 days [standard deviation (SD) 2], ranging between 1 and 15 days.

Awareness of Patients’ Rights

Only 4.6% of patients were aware of the Sudanese FMoH Patients’ Bill of Rights. Most patients (93%) were not aware of any of their rights; 2% were aware of 1 of their rights; 3% were aware of 2 rights; and 1% each was aware of 3 or ≥ 4 rights.

Practice of patients’ rightsThe most practiced rights from the patients’ perspective were: appropri-ate handling (87.8%), the right to be asked for permission prior to examina-tion (87.1%), hospital safety (87%), presence of a third person when a male doctor examines a woman (85.6%), and confidentiality of the admission file (74.9%). The least practiced rights were: ease of presenting complaints (52.2%), awareness of hospital sched-uled working hours (51.3%), being informed about medication use and adverse effects (41%), and involvement in decision making (37.6%).

Availability of fundamental servicesAbout half of the patients (51.3%) total-ly disagreed/disagreed about awareness of hospital scheduled working hours, while 43.3% totally agreed/agreed (Ta-ble 2). Similarly, 50.9% totally agreed/agreed upon the presence of a hygienic hospital environment, while 30.8% totally disagreed/disagreed. Most of the participants (87%) totally agreed/agreed about the safety of the hospital and only 11.4% totally disagreed/disa-greed.

Access to servicesWhen asked about the ease of reach-ing different hospital departments: 69.9% of patients totally agreed/ agreed (Table 2). Among these, 10.3% reach different sections by reading building signs, 77.2% by asking for directions and 38.5% had previous knowledge (data not shown). Seventy-three percent of patients totally agreed/agreed about being oriented inside the hospital and only 18.3% totally disagreed/ disagreed. Most of the patients (65.8%) were aware of health providers’ names and titles and 28.1% totally disagreed/disagreed. Concerning the presence of appropriate waiting places in the hospital, 66.5% of respondents totally agreed/agreed, while only 17.1% totally disagreed/disagreed. One hundred and

Table 1 Demographic characteristics of the patients

Index Frequency %Gender (P=0.235)

Male 110 41.8%

Female 153 58.2%

Age (yr) (P=629)

<20 15 5.7%

21–35 68 25.9%

36–50 76 28.9%

51–65 56 21.3%

>65 48 18.3%

Residence (P=0.782)

Rural 188 71.5%

Urban 75 28.5%

Educational level (P=0.091)

Illiterate 124 47.1%

Primary school 77 29.3%

Secondary school 38 14.4%

University 24 9.2%

Postgraduate 00 00%

Occupation (P=0.550)

Male With job 98 89.1%

No job 12 10.9%

Female With Job 28 18.3%

Housewife 125 81.7%

Marital status (P=0.662)

Married 180 68.4%

Single 54 20.5%

Divorced 5 1.9%

Widowed 24 9.1%%

Duration of hospitalization (d) (P=0.779)

Minimum 1

Maximum 15

Mean 4

Standard deviation 2


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Table 2 Patients’ awareness and perception of practice of rights

Fundamental services Totally agree Agree Undecided Disagree Totally disagree

Awareness of hospital scheduled working hours 83%

10640.3%

145.3%

11041.8%

259.5%

Hygienic hospital environment 134.9%

12146%

4818.3%

4216%

3914.8%

Safety of the hospital 2716.3%

18670.7%

207.6%

238.7%

72.7%

Access to services

Ease of reaching different hospital departments 93.4%

17566.5%

176.5%

5019%

124.6%

Orientation inside the hospital 218%

17165%

238.7%

4115.6%

72.7%

Awareness of health providers’ names and titles

218%

15257.8%

166.1%

6424.3%

103.8%

Appropriate waiting places 145.3

16161.2

4316.3%

3412.9%

114.2%

Ease of presenting complaints (n=157) 85.1%

6742.7%

0.00.0%

5031.8%

3220.4%

Clinical practice

Permission asked for physical examination 4115.6%

18871.5%

24.6%

197.2

31.1%

Explanation of physical examination 3312.5%

14956.7%

166.1%

6022.8%

51.9%

Privacy during physical examination 269.9

13350.6%

2710.2%

7327.8%

41.5%

Presence of a third person when examining a woman

2315%

10870.6%

127.8%

95.9%

10.7%

Information about illness and diagnosis 2911%

13752.1%

93.4%

7829.7%

103.8%

Information about treatment plan 249.1%

14052.9%

197.2%

7127%

94.3%

Information about medication and adverse effects

176.5%

10640.3%

3212.2%

9636.4%

124.6%

Involvement in decision making 134.9%

7628.9%

7528.5%

8733.1%

124.6%

Confidentiality of admission file 186.8%

17968.7%

3614.7%

259.5%

51.9%

Surgical consent (n=83) 1315.7%

4554.2%

89.6%

1720.5%

0.00.0%

Awareness of cause of referral (n=184) 137.1%

7440.3%

105.4%

8244.5%

52.7%

Nursing services

appropriate treating and hospitality 6123.2%

17064.6%

155.7%

72.7%

103.8%

Explanation of nursing services 3814.4%

13752.1%

218%

5822.1%

93.4%

Suitability of the wards 3011.4%

13651.7%

3513.3%

4517.1%

176.5%

Doctor calling 176.5%

12647.9%

6324%

4617.5%

114.2%


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fifty-seven respondents had presented with a complaint previously; around half of them (52.2%) totally disagreed/ disagreed about ease of presenting complaints, while 47.8% of them totally agreed/agreed.

Clinical practiceThe majority of participants (87.1%) to-tally agreed/agreed about being asked for permission prior to physical exami-nation and 8.3% totally disagreed/disa-greed (Table 2). Most patients (69.2%) totally agreed/agreed that the doctor explained to them the nature of the physical examination and 24.7% totally disagreed/disagreed. Over half of the patients (60.5%) totally agreed/agreed about being examined in privacy, while 29.3% totally disagreed/disagreed. Con-cerning the presence of a third person when a male doctor examined a female patient, 85.6% totally agreed/agreed, while only 6.6% totally disagreed/disa-greed. Regarding receiving adequate information about their illness and diag-nosis, 63.1% of patients totally agreed/agreed, while 33.5% totally disagreed/disagreed. Almost two-thirds (62.%) of the respondents totally agreed/agreed about receiving adequate information about their treatment plan, while 31.3% totally disagreed/disagreed. Just un-der half (46.8%) of the respondents totally agreed/agreed about receiving adequate information about medica-tion use and adverse effects, and 41% totally disagreed/disagreed. Just over one-third (37.7%) of patients totally disagreed/disagreed about being in-volved in decision making, and a similar number (33.8%) totally agreed/agreed. Eighty-three (31.55%) patients under-went a surgical operation at the hospi-tal. With regard to obtaining surgical consent by the treating doctor: 69.9% totally agreed/agreed and 20.5% to-tally disagreed/disagreed. Almost three-quarters of the patients (75.5%) totally agreed/agreed about the confidentiality of patients’ admission files, while only 11.4% totally disagreed/disagreed.

One hundred and eighty-four (70%) patients had been referred before. Of those, 47.4% totally agreed/agreed that they were aware of the cause of their referral, and the same number totally disagreed/disagreed.

Nursing service

Concerning appropriate treatment and hospitality, 87.8% of patients totally agreed/agreed and 6.5% totally disa-greed/disagreed. When asked about suitability of the wards 63.1% of re-spondents totally agreed/agreed, while 23.6% totally disagreed/disagreed. For doctor response to patients’ request, 54.4% of participants totally agreed/agreed, while 21.7% totally disagreed/disagreed.

Other services

Only 9 (3.4%) patients had met the hospital social workers before. Those patients were asked whether the social worker had provided them with ad-equate information about the available and suitable type of help. Only 5 (55%) patients agreed (data not shown). All patients disagreed about the presence of a hospital therapeutic nutrition service and none of them had met a clinical dietician (data not shown).

Practice of patients’ rights

The most practiced rights in patients’ perspective were: proper handling 87.8%, the right to be asked for per-mission prior to examination 87.1% , safety of the hospital 87%, presence of a third person when examining a female by a male doctor (85.6%) and confi-dentiality of the admission file 74.9%. The least practiced rights in patients’ perspective were: easiness of presenting complaints 52.2%, awareness of work-ing time 51.3%, being informed about medication's use and side effects 41% and Involvement in decision making 37.6%.

Discussion

In this cross-sectional descriptive study we were able to assess the awareness and practice of patients’ rights among hospitalized patients. We found that awareness about patients’ rights was low, and 95.4% of patients did not know that the Sudanese FMoH had pub-lished a Patients’ Bill of Rights. These findings could be explained by the lack of distribution of the Sudanese Patients’ Bill of Rights.

This is consistent with many studies conducted in the region. Kagoya et al. reported that most patients (81.5%) had never heard of the Uganda Patients’ Charter (10). In a study in Tehran, Davati et al. found that most patients (63.4%) had not seen the bill of rights (3). In a similar study in Egypt, Zeina et al. reported that most patients (75%) did not know about the list of patients’ rights (11).

In contrast, a study conducted in Malaysia by Yusuf et al. reported that nearly all patients (90%) were aware of their rights. This could be explained by the revolution in information technol-ogy and the higher educational levels of the patient population, and patients and their family members are much better informed about medical matters and they want the best treatment. Another contributing factor is the rise in the standard of living, which has increased consumer awareness and action, ac-companied by expectations for higher standards of service (12).

Although patients’ awareness was low in our study, there was no significant relationship between sex, age, residency, education and length of stay in hospital and the patients’ awareness. However, a study conducted in the Islamic Repub-lic of Iran showed a significant relation-ship between patients’ educational level, residency and their awareness (13).

Our study revealed that the most practiced rights according to the pa-tients’ perspective were permission


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References

1. United Nations. Universal Declaration of Human Rights; 1948 (http://www.un.org/en/documents/udhr/index.shtml, ac-cessed 16 February 2017).

2. World Health Organization. Basic documents, 45th edition, Supplement, October 2006. Constitution of the World Health Organization. (http://www.who.int/governance/eb/who_constitution_en.pdf, accessed 13 March 2017).

3. Davati A, Seidmortaz SS, Zafarghandi N, Azimi A, Arbab Solimani S. An assessment of Tehran graduated general phy-sicians’ knowledge about the charter of patients’ rights. Int Res J. 2012 Apr;3(4):357–61 (http://www.interesjournals.org/full-articles/an-assessment-of-tehran-graduated-general-

physicians-knowledge-about-the-charter-of-patients-rights.pdf?view=inline).

4. World Medical Associat ion. Declarat ion of L is -bon on the Rights of the Patient (http://www.wma.net/en/30publications/10policies/l4/, accessed 17 February 2017)..

5. World Health Organization. Mental health, human rights and legislation. WHO’s framework (http://www.who.int/men-tal_health/policy/fact_sheet_mnh_hr_leg_2105.pdf, accessed 17 February 2017).

6. Management advisory. A patient’s bill of rights. Chicago: American Hospital Association; 1992 (http://www.injured-

prior to examination, appropriate handling, confidentiality of patients’ admission files, and safety and cleanli-ness of the hospital. In contrast, the least practiced rights were awareness about hospital scheduled working hours, re-ceiving information about treatment adverse effects, presenting complains, awareness about cause of referral, and participation in decision making.

In a study conducted by Kagoya et al. in Mulago Hospital in Uganda (10), the most practiced rights were the right to confidentiality and privacy, medical care, and healthy and safe environment; in contrast, the least practiced rights were participation in decision making, participation or representation in de-velopment of health policies, and treat-ment by a named health worker. The study shows that although the Uganda Patients’ Charter (14) entitles patients to high-quality services in public hospi-tals, unethical conduct such as charging illegal fees, discrimination, absconding from duty, negligence, rudeness to pa-tients and physical and emotional abuse deter timely access to and practicing of patients’ rights (2, 15). Krzych and Ratajczyk in Poland reported that >80% of their patients were aware of their right to: choose a treating physician, refuse the proposed treatment, choose the location of treatment, access to medi-cal records, free meals, pastoral care, provide third parties information about health status, and give information to particular persons by telephone (16).

The present study was conducted in a general governmental hospital in Central Sudan. Hence, it reflects the situation in most of the hospitals in the country. The study might not totally reflect the situation in crowded outpa-tient clinics or that in private hospitals. Another limitation is the lack of similar local studies. There are some difficulties in making comparisons among foreign studies due to different legislation and values, which lead to different percep-tions of patients’ rights and their obser-vance.

Conclusion

Awareness of the Sudanese FMOH Patients’ Bill of Rights was low among patients at Wad-Madani Teaching Hospital. Patients were satisfied about hospital environment, safety, cleanli-ness and access to services. They totally agreed that the most practiced rights included being asked for permission before examination, handling in a professional and humane manner, and keeping admission files confidential.

We make the following recommen-dations.

• Awareness about patients’ rights must be increased by widespread distribu-tion of the Sudanese Patients’ Bill of Rights among the general public. The FMOH should make more efforts to raise awareness through literacy and

linguistic approaches that include au-diovisual messages and public bodies, as well as posters in hospitals.

• Awareness of patients’ rights among health professionals should be as-sessed, as they are responsible for im-plementing such rights. The FMOH should also introduce education about legal aspects of patients’ issues through continuous professional de-velopment programmes.

• Quality control centres should estab-lish a patients’ affairs department in each hospital so that patients are able to demand their rights and present complaints and suggestions.

• The FMOH should commit more funds to ensure availability of basic resources for implementing patients’ rights issues, and improving supervi-sion of health workers.

Acknowledgements

This research was supervised by Dr. Wail N. Mukhtar, Director of the Education Development and Research Center, University of Gezira and Prof. Ahmed A. Mohamadani and Prof. Osman A. Elmustafa for their review and comments. The authors would like to thank the administration of Wad Medani Teaching Hospital for allowing them to interview the patients.Funding: None.Competing interests: None declared.


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worker.org/Library/Patient_Bill_of_Rights.htm, accessed 13 March 2017).

7. Patients’ rights and citizens’ empowerment: through visions, to reality: joint consultation between the WHO Regional Of-fice for Europe, Nordic Council of Ministers and The Nordic School of Public Health, Copenhagen, Denmark 22-23 April; Copenhagen: WHO Regional Office for Europe; 2000 (http://apps.who.int/iris/handle/10665/108313, accessed 17 Febru-ary 2017).

8. Republic of Sudan, Federal Ministry of Health, Department of Quality Assurance. Sudanese Patients’ Bill of Rights. (http://www.fmoh.gov.sd/quality/Docms/patientRights.pdf, ac-cessed 13 March 2017).

9. World Health Organization. Patient’s rights. (http://www.who.int/genomics/public/patientrights/en/, accessed 17 February 2017).

10. Kagoya HR, Kibuule D, Mitonga-Kabwebwe H, Ekirapa-Kira-cho E, Ssempebwa JC. Awareness of, responsiveness to and practice of patients’ rights at Uganda’s national referral hospi-tal. Afr J Prim Health Care Fam Med. 2013;5(1) (http://dx.doi.org/10.4102/phcfm.v5i1.491).

11. Abou Zeina HA, El Nouman AA, Zayed MA, Hifnawy T, El Shabrawy EM, El Tahlawy E. Patients’ rights: a hospital survey in

South Egypt. J Empir Res Hum Res Ethics. 2013 Jul;8(3):46–52. PMID:23933775

12. Yousuf RM, Fauzi ARM, How SH, Akter SFU, Shah A. Hospi-talised patients’ awareness of their rights: a cross-sectional survey from a tertiary care hospital on the east coast of Pen-insular Malaysia. Singapore Med J. 2009 may;50(5):494–9. PMID:19495519

13. Mastaneh Z, Mouseli L. Patients’ awareness of their rights: insight from a developing country. Int J Health Policy Manag. 2013 Aug;1(2):143–6. PMCID:PMC3937911

14. Republic of Uganda, Ministry of Health, Department of Quality Assurance. Uganda Patients’ Charter, October 2009. Kampala: Ministry of Health; 2009 (http://cphl.go.ug/sites/default/files/library-resources/PATIENTS'%20CHARTER.pdf, accessed 17 February 2017).

15. Community of Practitioners on Accountability and Social Action in Health. Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda. (http://www.copasah.net/action-group-for-health-human-rights-and-hivaids-agha.html, accessed 13 March 2017).

16. Krzych KJ, Ratajczyk D. Awareness of the patients' rights by sub-jects on admission to a tertiary university hospital in Poland. J Forensic Leg Med. 2013 Oct;20(7):902–5. PMID:24112342


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1Al-Dora Health-Care Centre for Family Medicine, Al-Karkh Health Directorate, Ministry of Health, Baghdad, Iraq. 2Noncommunicable Diseases Control Department, Public Health Directorate, Ministry of Health, Baghdad, Iraq (Correspondence to H.J. Abd Al-Badri: [email protected]). 3College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq.

Received: 9/3/2016; accepted:12/10/2016

Prevalence of self-medication among university students in Baghdad: a cross-sectional study from IraqRawa J.K. Al-Ameri,1 Husham J. Abd Al-Badri 2 and Riyadh K. Lafta 3

ABSTRACT The objective of this study is to find out the prevalence and determinants of self-medication among college students in Baghdad, Iraq. A cross-sectional survey was conducted in Al-Mustansiriyah and Al-Nahrain universities, Baghdad, from January to April 2015. A multistage random sampling technique was adopted to collect data from 1435 college students using a questionnaire form. The mean age of the joining students was 19.8 years. Females form 53% of the sample. Self-medications use was prevalent among 92.4% of students. Antipyretics and antibiotics were the most used medicines. Self-medication was higher among urban residents (OR= 7.99, P < 0.001). Students living with their families practiced self-medication more than others (OR= 2.501, P = 0.037). Students at health-related colleges showed greater resilience to self-medication (OR=0.455, P = 0.001). Despite free access to healthcare institutions, nine out of ten college students from Baghdad universities have practiced self-medication. Education of students about the safe use of medications and supervision of pharmacies are effective ways to control this malpractice.

معدل انتشار التطبيب الذاتي بين طلاب الجامعة في بغداد: دراسة مستعرَضة من العراقرؤى جعفر العامري، هشام جاسم عبد البدري، رياض خضير لفتة

الخلاصــة: الهــدف مــن هــذه الدراســة هــو معرفــة معــدّل انتشــار التطبيــب الــذاتي ومحدّداتــه بــن طــاب الجامعــات في بغــداد، العــراق. أجريــت دراســة مقطعيــة في جامعتَــيْ المســتنصرية والنهريــن، في بغــداد، في الفــرة مــن يناير/كانــون الثــاني إلى أبريل/نيســان 2015. واعتمــد الباحثون أســلوب أخــذ العينــات العشــوائية المتعــددة المراحــل لجمــع البيانــات مــن 1435 طالبــاً مــن طــاب الجامعــات باســتخدام نمــوذج الاســتبيان. وكان متوســط العمــر لــدى الطــاب الذيــن انضمــوا إلى الدراســة 19.8 عامــاً. وشــكل الإنــاث 53٪ مــن العينــة. وكان اســتخدام الأدويــة الذاتيــة منتــراً بــن ٪92.4 ــذاتي ــر اســتخداماً. وكان معــدّل انتشــار التطبيــب ال ــة الأكث ــة هــي الأدوي ــة الخافضــة للحــرارة والمضــادات الحيوي مــن الطــاب. وكانــت الأدوي أعــى بــن ســكان الحــر (OR= 7.99, P < 0.001). وكان الطــاب الذيــن يعيشــون مــع أسرهــم يمارســون التطبيــب الــذاتي أكثــر مــن غيرهــم(OR= 2.501, P = 0.037). وأظهــر الطــاب في الكليــات ذات الصلــة بالصحــة مرونــة أكــر للعــاج الــذاتي (OR=0.455, P = 0.001). وعــى

الرغــم مــن أن الحصــول عــى الرعايــة الصحيــة مــن المؤسســات مجانيــة، فــإن تســعة مــن كل عرة طــاب مــن جامعات بغــداد قــد مارســوا التطبيب الــذاتي. ويعتــر تعليــم الطــاب لاســتخدام الآمــن للأدويــة والإشراف عــى الصيدليــات مــن الوســائل الفعّالــة لمكافحــة هــذه الممارســات الخاطئة.

Prévalence de l’automédication parmi les étudiants à l’Université de Bagdad : étude transversale iraquienne

RÉSUMÉ La présente étude a pour objectif d’estimer la prévalence de l’automédication et d’en identifier les déterminants parmi les étudiants à l’Université de Bagdad (Iraq). Une étude transversale a été menée dans les universités d’Al-Mustansiriyah et d’Al-Nahrain à Bagdad, entre janvier et avril 2015. Une technique d’échantillonnage aléatoire à plusieurs degrés a été adoptée afin de collecter les données auprès de 1435 étudiants à l’aide d’une questionnaire. L’âge moyen des étudiants ayant participé à l’étude était de 19,8 ans, et 53 % étaient des femmes dans l'échantillon. L’automédication était prévalente pour 92,4 % des étudiants. Les médicaments les plus utilisés étaient les antipyrétiques et les antibiotiques. L’automédication était plus élevée parmi les citadins (OR = 7,99, p < 0,001). Les étudiants vivant encore chez leurs parents pratiquaient davantage l’automédication que les autres (OR = 2,501, p = 0,037). Les étudiants qui suivaient des études dans le domaine de la santé avaient moins tendance à recourir à l’automédication (OR = 0,455, p = 0,001). Malgré un accès libre aux établissements de soins de santé, neuf étudiants sur dix des universités de Bagdad avaient déjà pratiqué l’automédication. Éduquer les étudiants à une consommation sans risque des médicaments et mettre en place une surveillance des pharmacies constituent des moyens efficaces pour remédier à cette mauvaise pratique.


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Introduction

Self-medication defined as patient use of medicines on his/her own initiative or according to advice from a pharma-cist or a layperson instead of consulting a medical practitioner (1). Their use reported as being on the rise in the re-cent years especially among adolescents and young adults worldwide (2).This behaviour varies among countries, age groups, and between the sexes (3).

In the United States of America (USA) 75% of health problems are treated with non-prescription medi-cine (4): opioids are used by 13–18%, followed by stimulants, including am-phetamines (5%), and sedatives (4%) (5). Results from a 2005 study showed that 82% of women and 71% of men in the USA had used a self-medication drug in the previous 6 months (6). This was about twice their number of doctor visits or using a prescription medication (6). In 2008, the retail sales for self-medication medicine approached US$ 17 billion, rising to US$ 26.5 billion in 2014 (7). About 36 million Americans use pain relief medications daily with-out professional health care advice (8). Around 16 500 deaths and 103 000 hospitalizations due to self-medication with non-steroidal anti-inflammatory medicines (NSAIDS) alone are report-ed each year in the USA (9).

Previous studies from the Middle East region revealed a high prevalence of self-medication by university stu-dents, ranging from 98% in a study from Palestine (10) to 55% in a study from Egypt (11). The students in this region used analgesics and herbals, often fol-lowed by vitamins and antibiotics, while opioids, stimulants and tranquilizers were used rarely (12–13). However, in a study carried out among university students in Jordan, antibiotics were the main self-medication used by 67.1% of the study sample (13).

In European countries, the greatest use of self-medication is found in the

United Kingdom and Germany, while Croatia and Greece rank as the least (14). A recent study from the United Kingdom (UK) and Ireland reported that stimulants were the most common-ly used medicines (41.5%) followed by vitamin supplements (29.2%) (15).

Healthcare services in Iraq, includ-ing medication, is open and free; despite this, the practice of self-medication is prevalent.

To the best of our knowledge there have been few if any existing studies conducted in Iraq about self-medica-tion use, especially among university students. The results of this study are important to build baseline data for Iraq.

The aim of this research was to dis-cover the prevalence and determinants of self-medication practice among uni-versity students in Baghdad.

Methods

Sample selection

This cross-sectional survey was con-ducted during the period January–April 2015. A multistage random sampling technique was adopted by selecting 3 universities (Baghdad, Al-Mustansiri-yah and Al-Nahrain) out of the main 5 in Baghdad. Colleges were selected from each university, according to the number of colleges in those universi-ties, variety of available specialties and number of students. See Figure 1 for a schema showing the sampling process. Using stratified random sampling, 50% of the students in the selected classes who were available at the time of the study and accepted to participate were invited to participate in this survey. Subclasses were considered the primary sampling units.

Sample size (17)

N = ([Z2 × P × (1–P)/(E)2] × Deff × sex estimate)/expected response rate

N = (384 × 1.7 × 2)/0.8 = 1633

Level of confidence measure (Z-value): 1.96 (for 95% confidence level)

Margin of error: 0.05Baseline levels of the indicators (P):

0.5Design effect (Deff): 1.7 (16)Expected response rate: 0.8 Number of sex estimates: 2

Data weighting and adjustmentSometimes the sample proportion may differ between strata, thus data must be weighted to represent the population correctly. The overall students’ number in the 3 selected universities was 58 956. The following formula was used for data weighting (17).

Wi is the raw weight for the data P1i is the probability of selection of the Universities, P2i for the colleges, P3i for the grades, P4i for the subclasses, P5i for the students and P6i for students’ age proportion

QuestionnaireA semi structured questionnaire was developed to collect the relevant infor-mation pertaining to the study variables. In addition to information about age, sex, residence and academic grade, the questionnaire included the following questions in regard to self-medication.

• Have you ever used medications by yourself (non-professional prescrip-tion)?

• What are the medicines that you used?

• What was the purpose of taking these medicines?

• Did you experience adverse effects after taking these medications? Did these complications require profes-sional medical intervention?

• Who advised you to take these medi-cines?

Wi = 1

P1i x P2i x P3i x P4i x P5i x P6i


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• What was your source of information about the medicines?

• What were the reasons behind tak-ing medicines without consulting a physician?

• What was your source for purchasing the medicines?The questionnaire was revised by

a scientific committee (community medicine consultants) for reliability and content validity. It was then piloted on a small sample of 30 college students from different universities to test the clarity and the applicability of the study tools, and to identify any difficulties

that may be faced during data collec-tion. The time needed for filling the questionnaire form by students was also estimated during this pilot study. Then, according to the results obtained, any necessary modifications were done. The pilot sample was not included in the study sample. The Kuder–Richardson formula 20 (KR–20) for internal reli-ability was 0.763 (18).

After obtaining official approval and task facilitating documents from the sci-entific committee of the Iraqi Counsel for Medical Specialization and approval from the ethics committee of the same

council, the researchers contacted the Dean’s office of each of the selected colleges to explain the objectives and rationale of the study and to get permis-sion for data collection.

The students were met in the se-lected classes for about 15 minutes to explain and discuss the question-naire items for more clarification be-fore they were asked to complete the questionnaire. The questionnaire was anonymous to avoid causing any em-barrassment to the respondents. Every student was given the complete uncon-ditional choice to participate without

Five universities in Baghdad(Baghdad, Al-Mustansiryah, Al-Nahrain, Al-Iraqia and University of Technology)

Baghdad University (9 of 19 colleges

selected)

Al-Mustansiryah University (8 of 13 colleges selected)

Agriculture, Art, Business, Dentistry, Education,

Engineering, Law, Mass Media, Science

50% (stratified random sampling) of the students in the selected classes

were asked to complete the questionnare

According to class number/grade (each grade is subdivided into

subclasses or groups): 50% of the classes were selected (if there was only 1 class/grade, it was selected)

Academic grades 1 to 4 were included (grades 5 and 6 were

excluded in the medical group and some engineering colleges)

Art, Dentistry, Education,

Engineering, Law, Medicine,

Pharmacology, Science

Al-Nahrain University (7 of 12 colleges selected)

Business, Engineering, Law, Medicine,

Pharmacology, Political Science, Science

Figure 1 Flow-chart showing the sampling frame of the study (probability-proportional-to-size sampling)


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any reward or penalty, and was assured that confidentiality of data throughout the study would be secured and that the data would not be used for purposes other than research.

They were asked to complete the questionnaire. This had been developed from several studies discussing a similar subject and was submitted to the com-mittee in English. It was translated to the Arabic language for the purpose of simplification (and then retranslated into English for validation). Each com-pleted questionnaire was considered as an informed consent for joining the study. The researcher visited each college twice during the day (08:30–14:30). Data collection took about 10 weeks for the 3 selected universities. We distributed 1633 questionnaires; 1435 were completed giving a response rate of 87.9%.

Statistical analysisEach questionnaire was assigned a serial identification number. The data were analysed using SPSS, version 20. The data were presented as mean, standard deviation (SD), frequency and percent-age. Sampling weights were used in the analysis.

The chi–squared test was performed to assess the statistical relations between defined dependent and independent variables. The independent t-test was used to test the mean age difference between users and non-users of self-medication. Binary logistic regression was used to assess the adjusted odds ratio (OR) for association between the independent variables and self-medica-tion; only significant variables found in the bivariate analysis were included in the model. P-value < 0.05, was consid-ered significant.

Results

More than a half the participants were females, 760 (53%). The mean age was 19.8 (SD 1.6) years, range 18–24 years. The majority (91%) were from urban areas (Table 1).

Out of 1435 college students in-cluded in the survey, 1326 (92.4%; 95% CI: 91.0–93.8) were practising self-medication. The most commonly used medications were antipyretics (69.6%), followed by antibiotics (46.1%) and an-algesics (40.1%). Other types of medi-cation used were: antitussives 26.9%; anti-allergy medications 18.2%; vita-mins 17.4%; herbal medicines 10.1%; steroids 3.9% and hormones 2.8%.

Medicines were used for headache relief by 71.1% of self-medicating stu-dents and 54.7% were treating influenza symptoms. Ten students (0.8%) used

Table 1. Sociodemographic characteristics of users and non-users of self-medication among 1435 students, Baghdad, 2015

Characteristic Overall Self-medication t-test (df) P-value

Users (n = 1326)

Non-users (n = 109)

Mean (SD) age (years) 19.8 (1.6) 19.8 (1.6) 19.1 (1.1) 3.701 (1433) < 0.001No. % No. % No. % χ2 (df)

SexMale 675 47 632 93.6 43 6.4 2.727 (1) 0.099Female 760 53 694 91.3 66 8.7

ResidenceUrban 1306 91 1228 94 78 6 54.548 (1) < 0.001Rural 129 9 98 76 31 24

AccommodationFamily 1202 83.8 1124 93. 5 78 6.5 14.111 (1) < 0.001Not with family 233 16.2 202 86.7 31 13.3

UniversityBaghdad 537 37.4 497 92.6 40 7.4 3.034 (2) 0.219Al-Mustansiriyah 454 31.6 426 93.8 28 6.2Al-Nahrain 444 30.9 403 90.8 41 9.2

CollegeHealth related 256 17.8 219 85.5 37 14.5 20.875 (1) < 0.001Not health related 1179 82.2 1107 93.9 72 6.1

Grade1st 455 31.7 422 92.7 33 7.3 51.476 (3) < 0.0012nd 359 25 303 84.4 56 15.63rd 301 21 287 95.3 14 4.74th 320 22.3 314 98.1 6 1. 9Total 1435 100 – 92.4 – 7.6

P < 0.01 is statistically significant. SD = standard deviation.


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self-medication for insomnia and 8 (0.6%) to relieve joint pain; a similar number used it for other types of pain.

Side-effects were reported by 206 (15.5%) self-medicating students. These included allergy (27.7%) and gastric upset (18.0%). Others reported oedema, pallor, dry mouth, numbness, flushing and syncope. Out of the 206 who reported side-effects, 67 (32.5%) reported they required medical inter-vention.

There were a number of reasons for self-medication. The vast majority of students (74.2%) said that it was just for a trivial illness that does not need medical advice and 33.4% reported that they had experienced similar symptoms previously so they repeated the same medication. Other reasons cited were: easy accessibility 15.7%; saving time 14.6%; doctor’s fees 10.9% and crowded clinics and the long waiting time 10.6%.

The medications were bought from a pharmacy by 1232 (92.9%) users. Other sources are detailed in Table 2.

The mean age of users was signifi-cantly higher than that of non-users (t-test = 3.701; P < 0.001). Sex and uni-versity of the students did not show any significant association with use of self-medication. Students from urban ar-eas practised self-medication more than students from rural areas, 94% vs 76% (c2 = 54.548, P < 0.001). Prevalence of self-medications among students liv-ing with their families was significantly higher than those living away from the

family, 93.5% vs 86.7% (c 2 = 14.111, P < 0.001). Details of self-medication rates for other sociodemographic char-acteristics are shown in Table 1.

Logistic regression analysis was performed to identify the determinants of self-medication practice among the sample. Neither age of the students nor their academic grade had any real as-sociation with self-medication (Table 3). Urban residents were about 8 times more likely than rural residents to self-medicate (OR = 7.99, P < 0.001). Stu-dents living with the family were 2 times more likely to practise self-medication than those living in other places (OR = 2.501, P = 0.037).

Discussion

Self-medication is believed to do more harm than good and lead to wastage of resources, development of micro-bial resistance, adverse drug reactions,

prolonged illness and drug dependence (19).

The prevalence of self-medication in this study was 92.4%. Previous studies in the Middle East region showed com-parable results. A study conducted in Oman revealed that 94% of 450 college students had practised self-medication (20). The prevalence of self-medication among 1260 university students was 90.6% in an Iranian study (21). Another Iranian study found that 80% of 300 col-lege students were using medications without professional health advice (22). In a study from Saudi Arabia on 1596 students, 81.2% practised self-medi-cation, especially during the exam pe-riod (12). In a 2007 study from Turkey among 418 volunteer students, 74.9% had practised self-medication (23) and in a 2012 study among 697 college stu-dents from Jordan, the prevalence of self-medication was 67.1% (13).

The most commonly used self-med-ications in our study were antipyretics and antibiotics to treat headache, flu

Table 2 Source of medications among 1326 students who used self-medication, Baghdad, 2015

Drug source No. %Pharmacy 1232 92.9

Home 48 3.6

Friends 32 2.4

Shops 10 0.8

Street 2 0.2

Health staff 2 0.2

Total 1326 100.0

Table 3 Logistic regression analysis for the determinants of self-medication practice among university students in Baghdad

Characteristic B P-value OR 95% CI

Age –0.243 0.383 0.785 0.455–1.354

Urban resident 2.078 < 0.001** 7.990 3.366–18.965

Living with family 0.917 0.037* 2.501 1.057–5.921

Health-related college –0.787 0.001** 0.455 0.288–0.718

Grade 0.645 0.091 1.907 0.902–4.031

Constant 4.111 0.377 61.008 –

B = coefficient of regression. OR = odds ratio. CI = confidence interval. *Significant at < 0.05, **significant at < 0.01.


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and fever. A study done in Saudi Arabia found that 80% of self-medication users were taking antipyretics and NSAIDs for headache and fever (12). In studies from Egypt (11), Turkey (14), Pales-tine (10) and Oman (21), antipyretics and analgesics were the most used self-medications by students.

On our study 46.1% of the students reported self-medication with anti-biotics. Similarly, 46.2% of university students in Oman gave a history of self-medication with antibiotics (21). In a study from Pakistan, self-medication with antibiotics was reported by 47.6% of the students of 6 different universities of Karachi (24). Self-medication with antibiotics was also reported by 44.5% of university students (43.0% medical, 46.0% non-medical) from Benghazi, Libya (25).

A wide variety of medicines are avail-able in pharmacies and stores, and they are easily accessed by the users without any medical consultation. There are no clear rules and control on the over-the-counter medications in the Middle East region, especially in Iraq.

The current study showed that 15.5% of the participants who reported using self-medication had suffered from side-effects. Similarly, a study con-ducted in Kuwait showed that 14.8% of 900 undergraduate medical students re-ported adverse effects. Self-medication caused side-effects among 28.9% of 90 students from Suez Canal University in a cross-sectional study carried out in Egypt (26). Amount of medication, fre-quency of dose as well as the difference in the sample size caused differences in the prevalence of side-effects.

Allergies to certain medicines and gastric upset were the main side-effects for the misused medicines. This was similar to the results from studies con-ducted in Saudi Arabia (12), Jordan (13), Pakistan (24) and the Islamic Republic of Iran (27)

The most common reason reported by the students that encouraged them to use self-medication was that their ill-ness was trivial and was not worth medi-cal intervention. This was also reported in a study carried out in Jordan among 679 university students (13). The same reason was reported in 2 studies from Pakistan (28,29).

The majority of students in the present study got medications from pharmacies or they found them stored in their home. This is similar to reports from previous studies in Saudi Arabia (12) Turkey (23) and Oman (21). That raises the questions about health au-thorities’ supervision in these countries on drug dispensing through pharma-cies. Most of the developed countries have strong supervision and put limits on drug dispensing from pharmacies and tie it to medical prescriptions (30).

Our results revealed no real associa-tion between self-medication practice and age, sex and grade. These findings were in concordance with studies from Palestine (10) and the Islamic Republic of Iran (31). However, a study from Kuwait showed that females practised self-medication significantly more of-ten than males (mostly painkillers for relieving menstrual pain); significant differences were also found in that study for age and grade (32).

Self-medication was significantly more common among students living

with their families. This might be due to the availability of medicines in the home and parental advice for particular medicines. This agrees with the findings of other studies from Saudi Arabia (12), Turkey (23), Palestine (10) and the Islamic Republic of Iran (22). In con-trast, no such association was found in a study carried out among 1296 medical students in Belgrade (33). This differ-ence between European countries and Middle East region might be due to the independence of young adults and stu-dents and the policy for drug dispensing in Europe.

Our study showed a significantly lower prevalence of self-medications use among students of health related colleges. This agreed with a study from Palestine (10), although a study from Ethiopia did not show a similar asso-ciation (34). Students’ medical practice and knowledge about are bad outcomes thought to be the cause.

Students living in the urban area showed a significantly higher associa-tion with self-medication. Availability of medicines in stores and the high num-ber of pharmacies with increases in advertisement for new medicines might be the cause. This agreed with a study from Egypt (26).

Institutional education of students about the safe use of medications should be considered. Strict policies could be introduced to regulate the pro-curement of medications and prohibit their purchase without a prescription through urging pharmacists to dispense them under supervised regulations.Funding: None.Competing interests: None declared.

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1Tobacco Prevention and Control Research Centre; 2Chronic Respiratory Diseases Research Centre; 4Department of Statistics, National Research Institute for Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to M.R Masjedi: [email protected]).

Evaluation of the prevalence of waterpipe tobacco smoking and its related factors in Tehran, Islamic Republic of IranZahra Hessami 1, Mohammed R. Masjedi,2 Reza Ghahremani,3 Mehdi Kazempour 4 and Habib Emami 1

ABSTRACT This study is designed to evaluate the prevalence of waterpipe tobacco smoking and its related factors among Iranian adults. This is a cross-sectional study carried out during 2013/14 in Tehran, Islamic Republic of Iran, among 1830 citizens aged over 15 years. Sampling was through Stratified multistage cluster sampling with proportional allocation within strata. Global Adult Tobacco Survey (GATS) questionnaire for waterpipe consumption was used for data gathering. Data were statistically analyzed by SPSS software. The prevalence of current waterpipe tobacco smoking was 17.6% .Waterpipe use prevalence in men was significantly more than women (24.2% vs. 11.3%). Multivariate analysis showed that age, sex, cigarette consumption, waterpipe consumption at home and ignorance of safety issues significantly influenced current waterpipe smoking (P = 0.001). Thus, prevalence of waterpipe smoking in Iranian adults is high and significant. Tackling waterpipe smoking should be considered in tobacco control programmes. However, further studies in this field are needed.

تقييم معدّل انتشار تدخين الشيشة والعوامل المرتبطة به في طهران، جمهورية إيران الإسلاميةزهرا حسامي، محمد رضا مسجدي، رضا قهرماني، مهدي كاظم بور، حبيب إمامي

الخلاصــة: تــم تصميــم هــذه الدراســة لتقييــم معــدل انتشــار تدخــن الشيشــة والعوامــل المتصلــة بــه بــن البالغــن في إيــران. وهــي دراســة مقطعيــة أجريــت خــال عامَــي 2013 و2014 في طهــران، جمهوريــة إيــران الإســامية، وشــملت 1830 مواطنــاً تزيــد أعمارهــم عــن 15 عامــاً. وتم أخــذ العينات بأســلوب العينــة العنقوديــة المتعــددة المراحــل والطبقيــة مــع تخصيــص نســبي للطبقــات. واســتخدم الباحثــون اســتبيان "المســح العالمــي للتبــغ بــن البالغــن" لجمــع البيانــات حــول اســتهاك الشيشــة. كــما اســتخدموا برنامــج SPSS لتحليــل البيانــات إحصائيــاً. واتضــح أن معــدّل انتشــار تدخــن الشيشــة في الوقــت الحــالي 17.6٪ ، وأن معــدل انتشــار تدخــن الشيشــة بــن الرجــال )24.2٪( أكثــر بكثــر ممــا هــو عليــه بــن النســاء )11.3٪(. وأظهــر التحليــل المتعــدد المتغــرات أن العمــر والجنــس واســتهاك الســجائر، وتدخــن الشيشــة في المنــزل والجهــل بقضايــا الســامة أثــرت بشــكل كبــر على تدخــن الشيشــة في الوقــت الحــالي (P = 0.001(. وعــلى هــذا، فــإن معــدل انتشــار تدخــن تبــغ الشيشــة بــن البالغــن في إيــران مرتفــع وهــام. ويجــب

الأخــذ بالاعتبــار معالجــة تدخــن الشيشــة في برامــج مكافحــة التبــغ. ومــع ذلــك، فــإن الحاجــة ماثلــة إلى المزيــد مــن الدراســات في هــذا المجــال.

Évaluation de la prévalence de la consommation de tabac par pipe à eau et de ses facteurs associés à Téhéran, République islamique d’Iran

RÉSUMÉ La présente étude est conçue pour estimer la prévalence de la consommation de tabac par pipe à eau et de ses facteurs associés dans la population adulte iranienne. Il s’agit d’une étude transversale, conduite entre 2013 et 2014 à Téhéran, en République islamique d’Iran, parmi 1830 citoyens âgés de plus de 15 ans. La technique utilisée était celle de l’échantillonnage en grappe stratifié à plusieurs niveaux avec allocation proportionnelle dans les strates. Le questionnaire de l’enquête mondiale sur le tabagisme chez les adultes pour la consommation de tabac par pipe à eau a été utilisé afin de collecter les données. Celles-ci ont été analysées sur le plan statistique à l’aide du logiciel SPSS. La prévalence de la consommation de tabac par pipe à eau au moment de l’étude était de 17,6 %, et était plus importante chez les hommes que chez les femmes (24,2 % contre 11,3 %). L’analyse multivariée a montré que l’âge, le sexe, la consommation de cigarettes, la consommation de pipe à eau à la maison et l’ignorance des questions de sécurité influençaient de façon significative la consommation de tabac par pipe à eau (p = 0,001). Par conséquent, la prévalence de la consommation de tabac par pipe à eau est élevée et significative parmi les adultes iraniens. La question de la consommation de tabac par pipe à eau devrait être traitée dans le cadre des programmes de lutte antitabac. Néanmoins, d’autres études dans ce domaine sont requises.


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Introduction

The waterpipe is an old method of to-bacco smoking, its origin tracing back 4 centuries in the Middle East, but its use extends around the world (1). Wa-terpipe smoke contains many toxicants and carcinogens. There is evidence of waterpipe smoking-related condi-tions such as lung and cardiovascular diseases, complications of pregnancy, cancers, oral dysplasia and infertility (2–4). Despite the harmful effects, the prevalence of waterpipe smoking is increasing around the world, especially among the young (5). The main reason for this increase is that users perceive the waterpipe as a safer and less addictive alternative to other tobacco products (6,7).

Waterpipe smoking is now consid-ered by the WHO as a general health problem (8). Waterpipe smoking prevalence should therefore be con-sidered as a factor in tobacco control programmes (9–11).

There have been fewer studies on waterpipe smoking than on cigarette consumption. The Islamic Republic of Iran is a country in which waterpipe smoking has a historical origin. In re-cent years, the waterpipe use pattern has changed in the Iranian population. It seems that, compared with the past, waterpipe smoking is currently more commonly seen among the young and among women. According to a study from 2010, traditional restaurants were the first places where students experi-ence tobacco, and the waterpipe was the first type of tobacco they used (12). The prevalence of tobacco smoking is 15% (13), although there are currently no comprehensive and representative studies on the prevalence of waterpipe smoking. The majority of studies on tobacco use study cigarette consump-tion rather than waterpipe smoking, and previous studies on waterpipe smok-ing have mainly been done on special groups. In order to better understand waterpipe consumption trends, find

better ways to fight against it and design prevention and control programmes, we carried out this study to evaluate the prevalence of waterpipe smoking and its related factors in a broad population of Iranian adults.

Methods

This cross-sectional study was con-ducted in November and December 2014 on participants aged 15 years and over in Tehran.

Sample size was calculated using the following formula, assuming a 95% confidence interval (Z1–α/2 = 1.96), precision of 0.03 (d = 0.03), P = 0.5.Thus:

N = 0.5 × 0.5 × (1.962)/0.032 = 1067

Considering a design effect of 1.5 and a missing rate of 15%, the total sam-ple size was calculated as 1840.

Stratified cluster random sampling with proportional allocation within strata was used in this study. Tehran has 22 municipality districts in which there are several zones. A municipality dis-trict was selected randomly from each geographical area of Tehran (north, south, east, west and centre). The fol-lowing districts were selected: District No. 1 in the north, District No. 20 in the south, District No. 14 in the east, District No. 21 in the west and Dis-trict No. 12 in the centre. After this, 2 zones were chosen randomly from each district. Each zone included 1 health centre with several health care workers. We chose 2 health care workers from each zone based on their experience in research programmes and volunteering. After informing them about the aims of the project, they were trained for data gathering.

Data collection was conducted by the healthcare workers under the su-pervision of the Tobacco Prevention and Control Research Centre. Five data collection teams were involved in this study, each consisting of a supervisor

and 2 interviewers. A house in each zone was selected randomly, and in a clockwise direction all the surrounding homes were selected for sampling. After explaining the objectives of the project and obtaining consent, participants aged ≥ 15 years were interviewed.

Data gathering was carried out using the standard Global Adult Tobacco Survey (GATS) questionnaire (14). This has several sections and is designed to evaluate the tobacco smoking habits of adults based on each country's char-acteristics. One section is dedicated to waterpipe smoking habits. We used the questions of this section in addition to some optional questions about wa-terpipe smoking. After inserting some adaptations for the Islamic Republic of Iran, as follows: first, the question-naire was translated to Farsi by a native speaker, fluent in English and familiar with health issues (forward translation). Second, the content was assessed by an expert team and after that an English language native translated it into Eng-lish (back translation). Then the 2 Eng-lish versions were compared. Finally, 4 waterpipe smokers were asked to give their comments on the questionnaire to ensure clarity, and the final version was used in the study.

Our study variables consist of cur-rent waterpipe smoking as the depend-ent variable, and sex, age, education level, marital status, cigarette smoking habits, knowledge about the harmful effects of waterpipe smoking and bans on waterpipe smoking in the home as independent variables.

Current waterpipe smokers are those who use the waterpipe daily or, if less frequently, have smoked waterpipe during the past 30 days. Another group, the lifelong waterpipe smokers, com-prises those who have experienced wa-terpipe smoking, even as little as 1 puff, during their life. Non-waterpipe smok-ers are those who have never smoked a waterpipe in their life. All 3 groups could be cigarette smokers or not.


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All data were analysed using SPSS, version 18. Qualitative variables were reported as percentages and quantita-tive variables as mean and standard de-viation. Current and lifetime waterpipe smoking prevalence was calculated. For evaluating the association between se-lected variables and current waterpipe smoking, logistic regression was used. Unadjusted and adjusted odds ratios were calculated. In all analyses, P ≤ 0.05 was considered statistically significant.

Results

A total of 1830 participants aged ≥ 15 years took part in this study, of whom 883 (48.3%) were male. The mean age was 33.7 (standard deviation 1.37) years. The number of current water-pipe smokers was 316 [17.6%; 95% confidence interval (CI): 15.8–19.2] and 409 (22.6%; 95% CI: 20.6–24.5) were in the lifelong waterpipe smoker category. Sex was a significant factor: 212 of the male participants (24.0%; 95% CI: 21.3–27.0) were current waterpipe users compared with 104 females (11.35%; 95% CI: 9.2–13.3) (P < 0.001) (Table 1).

There was also a significant differ-ence in regard to education level: the lowest waterpipe smoking rate was seen among those with a university educa-tion (97; 30.6%) (P = 0.025). We found that 120 current waterpipe smokers (38.0%; 95% CI: 32.6–43.3) were also current cigarette smokers. The mean age of first waterpipe use was 21.3 (standard deviation 6.3) years. Full demographic characteristics of current waterpipe smokers are shown in Table 1.

Simple and multiple logistic re-gression were used to evaluate the as-sociation between selected variables and current waterpipe smoking (Table 2). In the multivariate analysis, being male [odds ratio (OR) = 3.19, 95% CI: 2.17–4.68], current cigarette smoking (OR = 3.13, 95% CI: 2.02–4.87), and misperceptions about the safety of

waterpipe smoking (OR = 3.58, 95% CI: 1.73–7.42) were positively associ-ated with current use of a waterpipe. Bans on waterpipe smoking in the home were negatively associated with current waterpipe smoking (OR = 0.1 95% CI: 0.06–0.20).

We found that 58.8% of waterpipe smokers and 88.5% of non-waterpipe smokers believed that waterpipe smok-ing could cause serious disease. Less than a third of waterpipe smokers (80; 25.3%) believed that waterpipe smok-ing could cause stroke compared with more than half of the non-smokers (675; 62.0%). Furthermore, 36.7% of waterpipe smokers thought that wa-terpipe smoking could lead to heart attack; 17% did not believed this, and 39% had no information. Additionally, 43d.9% of waterpipe smokers believed that waterpipe smoking could cause lung cancer compares with 78.5% of non-smokers. Nearly three-quarters (70.6%) of waterpipe smokers consid-ered it to be addictive, compared with

87.0% of non-smokers. Half (50.0%) of non-waterpipe smokers thought that the waterpipe was more addictive than cigarette smoking versus only 39.5% of waterpipe smokers; 18.8% of waterpipe smokers considered the waterpipe less addictive than cigarette smoking, but only 13.5% of non-waterpipe smokers agreed (P < 0.001).

Discussion

The study examined waterpipe smoking prevalence in Iranian adults aged 15 years and older. It is unique in this field in the Islamic Republic of Iran. It uses a standard questionnaire and is compara-ble to other similar studies. Almost half of the participants had the experience of waterpipe smoking at some point in their lives, with current smokers ac-counting for 17.6%. According to the results of a study done in the Islamic Republic of Iran, 1% of participants were daily waterpipe smokers (15). The

Table 1. Demographic characteristics of current waterpipe smokers (n = 316) aged ≥ 15 years, Tehran, 2014

Characteristic Waterpipe smokers P-value

No. %

Sex

Male 212 67.1< 0.001

Female 104 32.9

Age (years)

15–17 21 6.6

< 0.001

18–24 95 30.0

25–39 153 48.4

40–54 34 10.7

≥ 55 13 4.3

Marital status

Married 162 51.4

< 0.001Single 141 44.6

Divorced/widowed 13 4.0

Education

Illiterate 10 3.2

0.025Below high school diploma 90 28.5

High school diploma 119 37.7

University 97 30.6

A few values missing in some categories.


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prevalence of current water pipe smok-ing among women in Tehran was 6.3% in 2012 (16). Another study carried out in all provinces of the country found a prevalence of 2.7% for waterpipe smok-ing (17). In a study in a random sample of university students at 2 major uni-versities in the south of the country, re-spondents’ lifetime waterpipe smoking rate was 42.5% and was 18.7% in the last 30 days (18). Prevalence of waterpipe smoking in college students in Tabriz was 8.5% (≥ 1 time per month) (19).

Like cigarette smoking, waterpipe smoking rates differed significantly be-tween the sexes, being twice as high in males as in females. Our findings in this respect are similar to those of studies from Viet Nam (6.4%) and Lebanon (15.0%) (20,21). A 2010 study in the Islamic Republic of Iran also showed that cigarette smoking and waterpipe

smoking were more prevalent among men (15).

However, the difference between males and females in smoking rates is lower for waterpipe smoking than for cigarette smoking. According to the lat-est Iranian statistics on cigarette smok-ing, the rate for males is about 10 times higher than for females (13). This may be due to greater rates of risk-taking behaviour among males and more at-tention of females to their health. However, the tendency to waterpipe smoking can be seen among females in many communities due to the belief that waterpipe use is less hazardous than cigarette smoking. Also, in the Iranian community some cultural and religious barriers exist against cigarette smok-ing for females. In a study done among American university students the rate of waterpipe smoking among men (22%) was significantly greater than

among women (11%) (22). However, underreporting by females should not be overlooked.

In agreement with previous stud-ies (15–19), our results show that the waterpipe tobacco smoking rate among Iranians is increasing each year, and this could be due to the failure of Iranian tobacco control programmes in the field of waterpipe smoking. It should be noted that due to the differences in the methods and sample sizes, these stud-ies are not fully comparable; however, the increasing trend of consumption is inferable.

Many people believe that waterpipe smoking is less harmful than cigarette smoking (7,23). These results show that being informed about causal relation-ships between waterpipe smoking and serious diseases significantly reduces the likelihood of becoming a current user. Our results also show that current

Table 2. Factors associated with current waterpipe smoking among adults aged ≥ 15 years (n = 316), Tehran, 2014

Characteristic Waterpipe smokers (%)

Crude OR (95% CI)

Adjusted OR (95% CI)

Sex

Female 11.0 1.00 1.00

Male 24.0 2.51 (1.94–3.24) 3.19 (2.17–4.68)

Age (years)

15–17 13.6 1.00 1.00

18–24 31.7 2.80 (1.69–9.7) 1.50 (0.73–3.1)

25–39 18.9 1.42 (0.88–2.31) 0.94 (0.43–2.03)

40–54 10.7 0.75 (0.40–1.29) 0.31 (0.12–0.78)

≥ 55 4.0 0.25 (0.10–0.61) 0.04 (0.01–0.13)

Cigarette smoking status

Non-smoker 7.9 1.00 1.00

Current smoker 38.0 5.2 (3.89–6.95) 3.13 (2.02–4.87)

Waterpipe smoking at home

Allowed 63.2 1.00 1.00

Not allowed 11.3 0.06 (0.04–0.09) 0.10 (0.06–0.20)

Waterpipe smoking permitted in all rooms

No 27.3 1.00 1.00

Yes 50.1 7.77 (5.87–1.28) 2.24 (1.42–3.54)

Believe waterpipe smoking causes serious illness

Yes 58.8 1.00 1.00

No 20.6 5.28 (3.67–7.58) 3.58 (1.73–7.42)

OR = odds ratio; CI = confidence interval.


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users significantly believe that waterpipe smoking has no effect on lung cancer, stroke or heart attack. According to a study on adolescents, belief in the harms of waterpipe smoking decreased the likelihood of consumption (24).

Therefore, it seems that promot-ing general knowledge by holding educational programmes could lead to a reduction in waterpipe smoking. Another factor that affects waterpipe smoking is cigarette smoking. Our re-sults show that cigarette smoking, either past or current, increases the likelihood of waterpipe smoking. This relation-ship was seen even after the omission of confounders. Waterpipe use was nearly 2 times greater in cigarette smokers than in non-smokers. This result is similar to many other studies, including the study of Jawad, Lee and Millett in which ciga-rette consumption increased the likeli-hood of waterpipe consumption by a factor of 3 (25), also in a Turkish study cigarette consumption was a factor that increased the likelihood of waterpipe consumption in their population (26).

A ban on waterpipe smoking in the house was inversely associated with cur-rent waterpipe smoking. Those who were not allowed to use waterpipe in their houses were less likely to be cur-rent users. In some studies, waterpipe consumption by the parents or other family members was a risk factor for

children becoming current users (25). Our results demonstrate that exposure to waterpipe smoking in the house, which indicates the current waterpipe use of the family, has a relationship with regular waterpipe consumption by a participant. Waterpipe use should thus be considered seriously by families, par-ticularly parents.

The prevalence of waterpipe con-sumption in this study was higher than seen in previous studies; it seems that consumption in the Islamic Republic of Iran is increasing. This is not only wor-rying but also shows the high interest in waterpipe consumption, which could be due to the misperceptions about the safety of waterpipe use. Another notable point of this study is that al-most 40% of waterpipe users also smoke cigarettes. Waterpipe use was about 2 times more likely among cigarette smokers. This is similar to the findings of other studies which have been done in this field (24,25). Considering the methods used in these studies, it cannot be determined whether cigarette use causes the increase in waterpipe use, or vice versa. More comprehensive studies are needed in this regard.

One limitation of this study is that, given its cross-sectional nature, we cannot draw any causal relationship between waterpipe use and different factors. Additionally, data were gathered

through filling out questionnaires by the participants themselves, which could result in reporting bias. We tried to control this bias by correcting ambigu-ous questions, explaining the questions before the start of the survey, and having experts to help the participants dur-ing the survey. The study population consists of participants over 15 years old from multiple districts in Tehran. Teh-ran is the capital of the Islamic Republic of Iran in which different ethnicities live. In order to generalize the results in the whole population of the Islamic Republic of Iran, it would be neces-sary to do more comprehensive studies, considering locality differences such as urban and rural areas.

The strength of this study lies in its being the first in a general population of the Islamic Republic of Iran to con-sider waterpipe consumption. Using the WHO standard questionnaire makes the results comparable with other study results. Another strong point in this study is the multi stage cluster sam-pling based on the municipality and geographical districts of Tehran. Funding: This project was funded by National Research Institute for Tuber-culosis and Lung Diseases.Competing interests: None declared.

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1Department of Occupational Health and Industrial Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt (Correspondence to: E.O. Khashaba: [email protected]). 2Department of Public Health, Faculty of Medicine, Mansoura University, Egypt. 3Department of Community Health Nursing, Faculty of Nursing, Mansoura University, Mansoura, Egypt.


Work profile and associated health hazards among nursing students at Mansoura University, EgyptHala S. Abou-Elwafa 1, Eman O. Khashaba 1, Abdel-Hady El-Gilany 2 and Samar Abd El-Raouf 3

ABSTRACT Nursing students are increasingly undertaking paid term-time employment to finance their living expenses and studies. The objectives of this study are to estimate its prevalence, factors associated, and possible health hazards. A cross-sectional study was conducted of nursing students using a questionnaire that included sociodemographic and employment data, reasons for working, possible health hazards in the workplace, and perceived effects on academic performance. The prevalence of student paid employment was found to be 23.3%. Being male and belonging to a low social class were independently associated with the likelihood of working while studying. Financial support was the main reason for student employment. Workplace hazards included noise, temperature extremes and psychosocial stressors. Sleep disorders were the most frequent health effects followed by musculoskeletal complaints. Nursing students are at risk from many deleterious health effects which are not covered by occupational health and safety programmes.

مرتَسَم العمل والمخاطر الصحية لدى طلاب التمريض، جامعة المنصورة، مصرهالة سمير أبو الوفا، إيمان عمر خشبة، عبد الهادى الجيلاني، سمر عبد الرؤوف السيد

ــت ــد هدف ــاتهم. ولق ــتهم ودراس ــات معيش ــع نفق ــل دف ــن أج ــل م ــدوام كام ــل ب ــد العم ــوٍ متزاي ــى نح ــض ع ــلاب التمري ــولى ط ــة: يت الخلاصهــذه الدراســة إلى تقديــر معــدّل انتشــار العمــل، والعوامــل المرتبطــة بهــا، والمخاطــر الصحيــة المحتملــة. ولقــد أجــرى هــذه الدراســة المقطعيــة طــلاب التمريــض باســتخدام الاســتبيان الــذي تضمّــن البيانــات الاجتماعيــة والســكانية وبيانــات العمــل، وأســباب العمــل، والمخاطــر الصحيــة المحتملــة في مــكان العمــل، والآثــار المتصــورة عــى الأداء الأكاديمــي. واتضــح أن معــدّل انتشــار عمــل الطــلاب المدفــوع الأجــر23.3٪. ويرتبــط كــون طلبــة التمريــض مــن الذكــور والانتــماء إلى طبقــة اجتماعيــة متدنيــة ارتباطــاً مســتقلًا باحتــمال العمــل أثنــاء الدراســة. وكان الدعــم المــالي هــو الســبب الرئيــي لعمــل الطــلاب. وتشــمل المخاطــر في مــكان العمــل الضوضــاء، ودرجــات الحــرارة القصــوى، والضغوطــات النفســية ــلاب ض ط ــرَّ ــام. ويتع ــلات والعظ ــكاوى في العض ــا الش ــيوعاً تليه ــر ش ــة الأكث ــار الصحي ــي الآث ــوم ه ــات الن ــت اضطراب ــة. وكان والاجتماعي

التمريــض لخطــر العديــد مــن الآثــار الصحيــة الضــارة التــي لا تشــملها برامــج الصحــة والســلامة المهنيــة.

Profil professionnel et risques sanitaires associés parmi les étudiants en soins infirmiers de l’Université de Mansoura, Égypte

RÉSUMÉ Les étudiants en soins infirmiers sont de plus en plus nombreux à avoir un activité rémunérée durant l’année universitaire dans le but de subvenir à leurs besoins et de financer leurs études. La présente étude a pour objectif d’estimer la prévalence de ce type d'activité, les facteurs et les risques sanitaires qui y sont associés. Une étude transversale a été conduite auprès d’étudiants en soins infirmiers à l’aide d’un questionnaire incluant des données socio-démographiques et sur l’emploi, les raisons de travailler, les risques sanitaires possibles sur le lieu de travail, et les conséquences perçues sur les performances universitaires. La prévalence des emplois étudiants rémunérés a été estimée à 23,3 %. Le fait d’être de sexe masculin et l’appartenance à une classe sociale basse avaient une association indépendante avec la probabilité de travailler pendant les études. Un besoin de soutien financier était la raison principale de l’emploi étudiant. Les risques sur le lieu de travail incluaient le bruit, des températures extrêmes et des facteurs de stress psychologiques. Les conséquences sur la santé les plus fréquentes étaient des troubles du sommeil, suivis par des douleurs musculosquelettiques. Les étudiants en soins infirmiers sont exposés à des risques nocifs pour la santé qui ne sont pas pris en compte par les programmes de santé et de sécurité au travail.


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Introduction

Student employment is increasingly found in many countries. Not only do more students work but they also work for longer hours compared to earlier decades (1). Most countries in Western Europe and North America have expe-rienced an increase in student employ-ment. A recent Europe-wide student survey showed that in some countries more than two-thirds of students are employed and their income from employment covers up to 80% of their living and study costs (2). The average student employment rate is around 47% in Europe (1).

Several reasons explain why stu-dents get employed such as increasing costs of higher education and changes in the funding system (3), changes in the expected lifestyle and consump-tion preferences of students (4). Also, the profile of university students has changed as higher education is now more open to students who are more inclined to work during their studies (5) and, finally, universities may now pro-vide opportunities that make combin-ing work and study more feasible (1).

An excessive work load on students may compromise their academic pro-gress. Less study time is associated with lower learning outcomes and a higher probability of dropping out of school (5,6). At the same time, students may work also for positive benefits. Employ-ment may provide necessary work ex-perience and contribute to building a social network that will help find a job in the future (7).

Nursing students are increasingly undertaking paid term-time employ-ment to finance their living expenses and studies (8). Apart from the possible adverse impact on academic progress, nursing workers in hospitals are ex-posed to different occupational risk factors, including exposure to chemical substances, which can be inhaled or

come in contact with the skin, causing deleterious health effects (9).

To the best our knowledge, there has been little research on undergradu-ate employment among nursing stu-dents in developing countries including Egypt. Therefore, the objectives of this study were to estimate the prevalence of employment among undergraduate nursing students in Mansoura Univer-sity, and to assess the factors associated with taking up work and the possible occupational health and safety hazards of working.

Methods

Study design and settingA descriptive cross-sectional study was carried out on undergraduate nursing students in Mansoura University during the academic year 2013-2014.

Sample size and selectionPre-university education for the studied students included a 2-year programme (Technical Nursing Institute or Health Technical Institute-Nursing Section). All students in all academic years were targeted except first-year students who were excluded as they had no experi-ence of work. The total target popu-lation was 1 846 students (including first-year students). The male to female ratio was 1:3, after exclusion of first-year students. A pilot study was conducted on 100 students (not included in the final study) which found that about 23% had worked at some point in their past academic years.

Sample size was calculated accord-ing to the following equation (10): n = Z2 P (1-P)/d2, where n = sample size, Z = Z statistic for 95%confidence level (1.96), P = expected prevalence (proportion) (23%), and d = precision (0.05). The required sample size was found to be 272. To compensate for non-responders, the sample size was increased by 20% and rounded to 330 students.

A stratified random sampling was used proportional to size according to the total number of students in each academic year (1087 after exclusion of all first year students): second year (560 students, 51.5%), third year (306 students, 28.2%) and fourth year (221 students, 20.3%) of the total. Accord-ingly, the sample was distributed pro-portionately as follows: second year (170), third year (93), and fourth year (67) students. Students were recruited by systematic random sampling within each year group according to available student records with a random start then selection of every third student. This led to a total of 352 questionnaires being distributed and 330 question-naires were returned with a response rate of 93.8%.

Data collection toolA self-administered semi-structured questionnaire in Arabic was used for data collection. It included the following information: demographic data, e.g. age, sex, residence, socioeconomic status of the family (11); paid employment information, e.g. working status, age of starting ever work, nature and place of work, the number of work hours per day; reasons for working; possible hazards at the workplace, e.g. physical (noise/vibration/temperature ex-tremes, ionizing radiation, lifting heavy weights), biological, chemical prod-ucts, which may include disinfectants, antiseptics, hazardous drugs and latex exposure, e.g. chlorine, glutaraldehyde, ethylene oxide and cytotoxic drugs, and psychosocial; perceived adverse health effects, e.g. musculoskeletal disorders, sleep disorders, occupational accidents or injuries; pre-employment health and safety training; and perceived effects on academic performance.

The content validity of the ques-tionnaire was evaluated by a jury of 5 occupational medicine staff and the necessary changes were made before pilot testing.


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The questionnaires were distrib-uted to the target students during a suitable break between the rounds (clinical training rounds related to nurs-ing courses at different departments of Mansoura University Hospital) and before lectures under the supervision of one of the investigators to encourage participation and answer their enquir-ies. Each questionnaire required 10–15 minutes to complete.

Ethical considerationsThe study was approved by the Re-search Ethics Committee of the Faculty of Nursing and Faculty of Medicine of Mansoura University, code number [R/15.12.85].

Informed verbal consent of the individuals to participate in the study was obtained before distribution of the questionnaire. All participants were assured of the confidentiality and ano-nymity of the data. Subjects participated voluntarily with a full right to withdraw from the study at any time.

Data analysisData were analysed using the SPSS, version 16 and Epi Info, version 7. Categorical variables are presented as numbers and percentages; the chi-squared test was used for comparison between groups. Quantitative variables are presented as means and standard deviations (SD). Binary stepwise lo-gistic regression analysis was used to determine the independent predictors of student employment as the dichoto-mous outcome variable. Variable found statistically significant in a bivariate analysis were entered into the logistic regression analysis using a forward Wald method. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated. A P-value ≤ 0.05 was considered to be statistically significant.

Results

The age of the sample of nursing stu-dents ranged from 19 to 22 years with a

mean age 20.3 (SD 0.8) years. The over-all prevalence of student employment was 23.3% (Table 1). Table 1 shows the sociodemographic characteristics of the students and their association with student employment. Student employ-ment was significantly higher among male students, those whose fathers had received less than secondary education or worked in non-professional jobs and those and of very low socioeconomic status. Student employment was also significantly lower among second-year students compared to fourth-year stu-dents.

Logistic regression analysis showed that being male (OR = 2.6; 95% CI: 1.44–5.05) and belonging to a family of a very low socioeconomic status (OR = 2.8; 95% CI: 1.34–5.82) were inde-pendently associated with employment while studying. On the other hand, second-year students were significantly less likely to be working (OR = 0.3; 95% CI: 0.16–0.62) (Table 2). Father’s occupation and education were not significant in the logistic regression and were excluded from the final regression analysis of independent variables associ-ated with employment while studying.

Table 3 shows that more than half of the working students started work when they were older than 18 years and the majority worked in the field of nursing. Working students reported that the hospital was the most common place of work (57.1%) and 38.9% worked shifts. The main reason for working while studying was for financial (68.8%) but 54.5% also said they worked to gain experience. More than half of the work-ing students (61.1%) worked 8 hours or more daily and 63.6% had worked for less than 6 months in the past year.

Noise and temperature extremes were the most frequently reported physical hazards (84.4% and 80.5% re-spectively). Only 33.7% of the working students reported exposure to chemi-cal hazards at work while a large per cent (80.5%) mentioned exposure to workplace psychosocial stressors. Lack

of safety training programmes and pro-tective equipment at work were each reported by 68.8% of the working stu-dents. There was higher frequency of occupational health hazards among the students who started work after 18 years of age compared to those who started at a younger age; however, the differ-ence was not statistically significant (P> 0.05) (Table 4).

Working students reported that sleep disorders were the most frequent work-related health effects (85.7%) fol-lowed by musculoskeletal complaints (74.0%) with the most frequent sites being the legs/feet and back. Occupa-tional injuries represented 68.8% of the reported work-related health effects, mostly needle-stick injuries (45.5%) and 32.5% reported having occupation-al infections, mainly of the respiratory tract (Table 5).

Work-related health effects among students who started work after the age of 18 years were more frequently report-ed than that in younger age groups, but these were not statistically significant (P> 0.05). However, both musculo-skeletal complaints and occupational injuries were more frequently reported among female students (75.4%, 71.7% respectively) compared to male stu-dents (24.6%, 28.3% respectively) with statistically significant difference (P = 0.0006, P = 0.01 respectively) (Table 6).

It was found that 15.6% of the work-ing students reported non-attendance of lectures and clinical training due to work load. Also, 17% reported rare at-tendance or non-attendance. More than half (54.5%) of the working stu-dents considered work had a positive effect on their academic performance (Table 7).

Discussion

The prevalence of student employment was 23.3% among nursing students in our study with the percentage of em-ployed students increasing across the academic years (17.1%, 25.8%, 35.8%


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Table 1 Prevalence of student employment and its association with sociodemographic characteristics

Sociodemographic characteristic Total Working student Significance test OR (95%CI)

No. No. (%)

Overall 330 77 (23.3) (19.00–28.22)

Sex

Man 69 29 (42.0) χ2 = 15.7, P≤ 0.001 3.2 (1.75–5.96)

Women (R) 261 48 (18.4) 1

Academic year

Second 170 29 (17.1) χ2 = 9.7, P = 0.001 0.44 (0.23–0.86)

Third 93 24 (25.8) χ2 = 1.9, P = 0.17 0.73 (0.37–1.45)

Fourth (R) 67 24 (35.8) 1

Pre-university education

General secondary school 167 39 (23.4) χ2 = 0.3, P = 0.5 1.19 (0.65–2.19)

Nursing school 40 13 (32.5) χ2 = 2.5, P = 0.1 1.89 (0.79–4.48)

Health/nursing institute (R) 123 25 (20.3) 1

Residence

Urban 89 21 (23.6) χ2 = 0.01, P = 0.9 1.02 (0.55–1.88)

Rural (R) 241 56 (23.2) 1

Father’s education

< Secondary school 79 24 (30.4) χ2 = 4.3, P = 0.03 1.98 (1.01–4.00)

Secondary school 118 29 (24.6) χ2 = 1.6, P = 0.2 1.48 (0.77–2.84)

> Secondary school (R) 133 24 (18.0) 1

Father’s occupation

Non-professional1 110 33 (30.0) χ2 = 4.1, P = 0.04 1.7 (1.01–3.00≥)

Professional/semiprofessional (R) 220 44 (20.0) 1

Mother’s education

< Secondary school 84 20 (23.8) χ2 = 0.4, P = 0.4 1.28 (0.65–2.73)

Secondary school 144 37 (25.7) χ2 = 1.2, P = 0.2 1.42 (0.73–2.75)

> Secondary school (R) 102 20 (19.6) 1

Mother’s occupation

Working 125 24 (19.2) χ2 = 1.9, P = 0.16 0.68 (0.38–1.21)

Not working (R) 205 53 (25.9) 1

Family size

≥ 5 members 259 56 (21.6) χ2 = 1.9, P = 0.16 0.66 (0.33–1.24)

< 5 members (R) 71 21 (29.6) 1

Family income

Just met routine expenses 104 26 (25.0) χ2 = 0.01, P = 0.9 1.04 (0.54–2.16)

Met routine & emergency expenses 148 32 (21.6) χ2 = 0.2, P = 0.63 0.86 (0.43–1.72)

Able to save money (R) 78 19 (24.4) 1

Socioeconomic status

Very low 90 32 (35.6) χ2 = 3.8, P = 0.04 1.96 (1.01–4.12)

Low 75 16 (21.3) χ2 = 0.01, P = 0.9 0.96 (0.42–2.22)

Middle 83 11 (13.3) χ2 = 2.1, P = 0.14 0.54 (0.22–1.32)

High (R) 82 18 (22.0) 11Non-professional includes trade and business (n = 14) and non-working (n = 6) and manual workers (n = 90). R = reference group; OR = odds ratio; CI = confidence interval.


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for second, third, and fourth years respectively). About 91% of working students were engaged in paid and nursing-related work.

Our findings concur with other stud-ies that employment among students in-creases with years of study although the proportion of working students is less among our sample. For example, survey data from 2 496 students in Estonian public and private universities showed that term-time employment was ex-tremely wide-spread among Estonian students and 61% of full-time students worked (1). The survey results also showed that the most important predic-tor for working was age. Older students (over 23 years) were more than three times more likely to have paid jobs than younger students. It is thus clear that when students are older they are more likely to have jobs and they work more on full-time jobs. Students do not wait until they finish their studies before they enter the labour market.

Similarly, in a study of nursing students in metropolitan Sydney, Aus-tralia there was a statistically significant increase in the percentage of students engaging in paid work during term time,

increasing from 70% in Year 1 to 84% in Year 3 and a statistically significant difference was seen in the type of work undertaken, from non-nursing to nurs-ing-related work (12).

In a survey of a second-year cohort of nursing students from a regional university in Australia, more than three-quarters (78%) of students were participating in paid employment. This high number was anticipated because clinical facilities specifically recruit stu-dents at the end of the first year of their Bachelor of Nursing programme to work as assistants in nursing or enrolled nurses (13).

The lower proportion of students working in our study may be due to the Egyptian culture where among moder-ate or high socioeconomic levels, stu-dents depend on their families during study years, which may be similar to some western countries.

In our study, student employ-ment was significantly higher among males while there was no statistically significant difference regarding urban/rural residence. The survey of Estonian students revealed that personal charac-teristics did not seem to be influential in

whether students worked (1). Our find-ings are different from those reported in a study of full-time undergraduate students at the University of Glasgow, Scotland where there was no significant difference between the proportion of male and female students who worked, however, significantly more students who lived at home worked compared to those who lived away (14). This could be explained by the cultural and social norms of Egypt in which males can move about more easily and are free to work while females are more conservative and tend to stay at home after study time.

Despite the fact that undergraduate education is free of charge in Egypt, the main reason for work while studying was for financial support (68.8%); more ad-ditional money for personal needs and more than one reason were mentioned by the participants. This is supported by the fact that student employment in our study was more common among students from families of low socio-economic status. This is similar to the re-sults of the study in Estonia which found that the less the means of a family the more likely it was that a student worked

Table 2 Logistic regression analysis for independent predictors of student employment

Predictor β P-value Adjusted OR (95%CI)1

Academic year

Second year -1.15 0.001 0.3 (0.16- 0.62)

Third year -0.6 0.07 0.5 (0.24-1.07)

Fourth year (R) – – –

Socioeconomic status

Very low 1.03 0.006 2.8 (1.34-5.82)

Low 0.43 0.3 1.5 (0.68-3.51)

Middle -0.15 0.7 0.86 (0.36-2.00)

Higher (R) – – –

Sex

Male 0.9 0.002 2.6 (1.44-5.05)

Female (R) – – –

Constant – -1.09 –

Per cent correctly predicted – 75.5 –

Model χ2 – 31.5; P≤ 0.001 –

1Adjusted for all variables found to be significant in the bivariate analysis.R = reference group; OR = odds ratio; CI = confidence interval.


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in order to be able to support himself or herself (1). They found that while 77% of students from the low-income group

worked for subsistence, only 62% of the middle-income group and 42% of the upper-income group reported this

as a reason. Students from more afflu-ent families were more likely to work for extra income and for general and professional work experience (1). Also, the study of full-time undergraduate students at the University of Glasgow reported that students noted financial necessity, extra cash for fun and work ex-perience as the most important reasons for working (14). A study in Australia in 2011 found that students work to support their lifestyle (15).

Apart from the financial benefits, students have reported greater self-con-fidence, an understanding of the busi-ness world and skills development as benefits of paid work (16,17). Students also perceive paid work will enhance their opportunities for full-time em-ployment on leaving university (18), thus making them more ‘employable’ (19). In addition to providing a source of financial support while completing their nursing education (8), engaging in nursing-related work during the term time has been suggested to improve the “work-readiness” of these students in preparation for graduate practice through the development of personal and professional skills in clinical prac-tice (16).

In our study, the mean number of work hours per day was 10.3. Much longer working hours were reported in other countries. In the study of full-time undergraduate University of Glasgow students, the mean number of hours worked was 14.2 (14). Similarly, the survey of 267 nursing students from a regional university in Australia reported that the average hours spent in paid employment were 14.43 (SD = 10.50) hours per week (13).

In our study, the majority of work-ing students were engaged in nursing-related fields with only 5.6% working in non-nursing related field. This agrees with the survey of a second year cohort of nursing students from a regional uni-versity in Australia, where the majority of students were engaging in nursing-related work (13).

Table 3 Occupational profile of working students

Occupational profile Ever working students (n = 77)

No. (%)

Age of starting ever work (years)

< 151 9 (11.7)

15−18 26 (33.8)

> 18 42 (54.5)

Mean (SD) 18.3 (2.2)

Range 12−20

Number of working years before university education: median (range)

1 (0.5−6)

Field of work (n = 71)2

Nursing related 65 (91.5)

Non-nursing related 4 (5.6)

Both 2 (2.8)

Type of work

Paid 70 (90.9)

Voluntary/unpaid 7 (9.1)

Place of work

Private clinic 12 (15.6)

Hospital 44 (57.1)

Other (pharmacy, store) 21 (27.3)

Work time

Morning 19 (24.7)

Evening 28 (36.4)

Shift 30 (38.9)

Work seasonality

During summer 35 (45.5)

Throughout the year 42 (54.5)

Reason for working3

Financial support for own needs4 53 (68.8)

Gain practical experience 42 (54.5)

Cooperation with different medical teams 9 (11.7)

Guarantee employment opportunity 17 (22.1)

Work hours per day

< 8 30 (38.9)

≥ 8 47 (61.1)

Mean (SD) 10.3 (3.1)

Duration of work (months)

< 6 49 (63.6)

≥ 6 28 (36.4)1Below the legal age of working. 2Some respondents did not answer this question. 3Categories are not mutually exclusive. 4Own needs include smoking, accessories and entertainment. SD = standard deviation.


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Our study showed that subjective noise and temperature extremes were the most frequently reported physical hazards by working students (84.4% and 80.5%; respectively). In a study of daytime decibel levels in 4 medical/surgical nursing units in hospital, it was found that noise levels in patient rooms were significantly higher than in the nurses' station and patient care areas were as noisy as a busy office. However,

nurses’ judgment of noise levels was not enough to make informed decisions for controlling the acoustic hospital envi-ronment (20).

In our study, 33.7% of work-ing students reported exposure to chemical hazards at work. In a study of nurses at the emergency care unit of a university hospital in Brazil, participants confirmed they came in contact with different chemical compounds in their

work environment and they indicated that occupational exposure to these substances can cause health problems (21).

In addition, our study showed that a large proportion of working students re-ported exposure to workplace psycho-social stressors (80.5%). This is similar to the findings of a study of Canadian nurses where nurses were significantly more likely to say that most days at work were “quite a bit” or “extremely” stressful compared to other employed postsecondary-educated women (22).

Our results report subjective sleep quality complaints among 85.7% of the working student nurses, which may be attributed to the fact that about 40% worked shifts and also to the combina-tion of work and studies. Young healthy nurses tolerated the first night shift ex-posure well, as judged by parameters related to quality of sleep. An increased sleep need during work days led to longer total sleep time, but did not lead to longer supplementary sleep episodes (23).

In our study, 74% of the working stu-dents had musculoskeletal complaints mostly in the legs/feet (55.8%) and back (46.7%), with a significantly higher frequency among female students. This

Table 4 Occupational health hazards and protective measures among working students by age at starting work

Occupational health hazards Working students(n = 77)

Age at starting work (years) P-value

< 15(n = 9)

15−18 (n = 26)

> 18(n = 42)

No. (%) No. (%) No. (%) No. (%)

Physical hazards1

Noise 65 (84.4) 7 (10.8) 22 (33.8) 36 (55.4) 0.8

Temperature extremes 62 (80.5) 8 (12.9) 20 (32.3) 34 (54.8) 0.7

Vibration 32 (41.5) 3 (9.4) 11 (34.4) 18 (56.3) 0.8

Radiation 24 (31.2) 3 (12.5) 8 (33.3) 13 (54.2) 0.9

Carrying heavy loads 41 (53.2) 4 (9.8) 15 (36.6) 22 (53.6) 0.8

Chemical hazards 26 (33.7) 3 (11.5) 9 (34.6) 14 (53.7) 0.9

Psychosocial stressors 62 (80.5) 6 (9.7) 20 (32.3) 36 (58.1) 0.3

Lack of safety training programme 53 (68.8) 7 (13.2) 18 (34) 28 (52.8) 0.8

Lack of PPE at work 53 (68.8) 5 (9.4) 20 (37.7) 28 (52.8) 0.41Categories are not mutually exclusive. PPE = personal protective equipment.

Table 5 Frequency of reported work-related health effects among working students

Work-related health effects1 Working students (n = 77)

No. (%)

Musculoskeletal complaints 57 (74.0)

Neck 15 (19.5)

Arm/hand 14 (18.2)

Back 36 (46.8)

Leg/feet 43 (55.8)

Sleep disorders 66 (85.7)

Occupational injuries 53 (68.8)

Needle sticks 35 (45.5)

Fractures 3 (3.9)

Sprains 11 (14.3)

Occupational infection 25 (32.5)

Eye and skin 9 (11.7)

Respiratory tract 16 (20.8)

Bloodborne 5 (6.5)1Categories are not mutually exclusive.


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concurs with a study among Korean nursing students where musculoskel-etal symptoms at any body site were re-ported by 73.3% of the participants. The most commonly reported sites were the shoulder (46.0%), lower back (39.1%), neck (35.6%), feet (25.2%) and lower legs (23.8%) (24). It has been reported that women have a higher musculoskel-etal morbidity than men (25). Greater prevalence or severity of symptoms may be due to the higher demands and constraints that women face or because women are more affected by, or vulner-able to, the health impact of particular demands and constraints (26).

A study at a public hospital in Bra-zil of occupational health hazards for intensive care unit nurses and nursing technicians reported that leg pain and sleep disturbance symptoms were at

critical levels among nurses; among nursing technicians, critical levels were detected for leg and back pains (27).

It is widely accepted that the most common occupational hazard for all health care professionals involved in clinical care is needle-stick and sharps injuries mainly caused by inadequate disposal and recapping of needles (28). This concurs with our study where the most frequently reported occupational injuries among the working students were needle-sticks injuries (45.5%). In addition, a study of the frequency and causes of occupational injuries among nursing students in Turkey reported that needle sticks (47.3%) and broken ampoules during medication prepara-tion (37.8%) were the 2 most common reasons for injuries (29). Also, in a study of 124 nurses working in the emergency

departments of 6 general hospitals in Greece, 77.2% reported exposure to blood or body liquids through the skin due to needle-stick injury (28).

In our study, lack of safety training programmes and protective equipment at work were reported by 68.8% of work-ing students. These findings suggest the need for the integration of occupational health and safety and practical training in the first year curricula with a focus on the prevention of needle-stick injuries and the effective use of personal protec-tive equipment.

The results of our study showed that about 60% of the working students regu-larly attended university and more than half believed that working has a positive effect on their academic performance. Several studies have reported negative consequences of full-time students participating in paid work during term-time in higher education, which include higher stress levels (18), a reduction in leisure and social activities (30,31), missing classes (32), and handing in assignments late (17).

As more nursing students are employed, it is essential that schools of nursing examine the relationship between student employment and ac-ademic performance. A statistically sig-nificant negative relationship was found between students working >16 hours a week and academic performance, espe-cially in high-attrition courses (33).

There were some limitations to our study. The use of self-reports can be prone to error because nurses’ reporting

Table 6 Work-related health effects by age at starting work and sex

Work-related health effects1 Age (years) Sex

< 15 (n = 9)

15–18 (n = 26)

> 18 (n = 42)

P-value Male (n = 29)

Female (n = 48)

P-value

No. (%) No. (%) No. (%) No. (%) No. (%)

Musculoskeletal complaints (n = 57) 6 (10.5) 20 (35.1) 31 (54.4) 0.8 14 (24.6) 43 (75.4) 0.0006

Sleep disorders (n = 66) 8 (12.1) 22 (33.3) 36 (54.5) 0.9 22 (33.3) 44 (66.7) 0.056

Occupational injuries (n = 53) 5 (9.4) 18 (34.0) 30 (56.6) 0.6 15 (28.3) 38 (71.7) 0.01

Occupational infection (n = 25) 3 (12.0) 7 (28.0) 15 (60.0) 0.7 8 (32.0) 17 (68.0) 0.41Categories are not mutually exclusive.

Table 7 Academic achievements of working nursing students

Academic performance (n = 77) No. %

Previous year’s score

Unsatisfactory1 14 18.2

Good 12 15.6

Very good 51 66.2

University attendance

Never 8 10.4

Rarely (once per week) 5 6.5

Average (twice per week) 18 23.4

Regular (daily) 46 59.7

Non-attendance due to work load 12 15.6

Effect of work on academic performance

Positive 42 54.5

Negative 35 45.51Unsatisfactory includes students who had repeated failure, postponed exams and a pass (< 60–65%) score.


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patterns could be influenced by their own knowledge of health conditions and risks. Also the possibility of recall bias cannot be excluded. Furthermore we could not directly assess the occu-pational health hazards (i.e. noise or vibration) in the multiple private sectors where the students work and evaluation depended only on the students’ reports which could be subjective.

Further research is recommended for assessment of sleep disorders and needle stick injuries among working nursing students.

Conclusion

In conclusion, employment is com-mon among nursing students in our university. As reported by the students, working has positive effects on both their education and experience despite having negative health consequences. It is necessary to put in place regula-tions to minimize the adverse health effects of student employment and to enforce child labour laws as 11.7% of the students started work below 15 years i.e. below the legal age of working in Egypt.

It is recommended to provide advice to all incoming and current students on working, perhaps producing a leaflet with information on how to minimize any adverse impact of part-time work on health and academic performance and how to maximize the benefits of working on student potential. It would be useful to implement occupational health and safety training during nurs-ing education as many work-related health effects seem to be modifiable. Funding: None.Competing interests: None declared.

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The Reality of Liquid Medical Waste Management in Damascus Hospitals

ABSTRACT Large quantities of hazardous medical waste are deposited into hospitals wastewaters and these substances could negatively impact public health if not handled properly. The authorities in the Syrian Arab Republic have realized the seriousness of the problem and have issued a number of laws, guidelines and standard specifications relating to this issue since 2004. This study offers a detailed review of these documents and compares them with related World Health Organization publications. A questionnaire was designed based on the national guide for safe management of healthcare waste in order to investigate the reality of liquid medical waste management in a sample of hospitals in Damascus. The questionnaire was subsequently distributed and collected during April and May 2015. The study found that there are a number of negative points in these guidelines as well as several weaknesses in their implementation. The study calls for intensifying efforts to strengthen guidelines; monitoring the possible health problems that could arise due to weak implementation;and proposes a number of suggestions to improve the management of medical liquid waste in hospitals.

الخلاصــة: تعــاني مطروحــات المستشــفيات مــن وجــود كميــات كبــرة مــن النفايــات الطبيــة الخطــرة التــي تؤثــر ســلبياً في الصحــة العامــة إذا ــة الموضــوع وخطورتــه فأصــدرت منــذ العــام 2004 لم يتــم التعامــل معهــا بالشــكل الصحيــح. انتبهــت الجهــات الرســمية في ســورية إلى أهميعــدد مــن القوانــن والأدلــة الوطنيــة والمواصفــات القياســية المتعلقــة بهــذا الأمــر والتــي تمــت مناقشــتها في هــذه الدراســة ومــن ثــم مقارنتهــا مــع منشــورات منظمــة الصحــة العالميــة ذات الصلــة. تبــع ذلــك تصميــم اســتبيان مــن 16 ســؤال بالاعتــاد عــى الدليــل الوطنــي لــإدارة الآمنــة لنفايــات الرعايــة الصحيــة. اســتخدم الاســتبيان في التقــي عــن واقــع إدارة النفايــات الطبيــة الســائلة في عــدد مــن مستشــفيات مدينــة دمشــق وذلــك خــال شــهري نيســان وأيــار 2015. خلصــت الدراســة إلى أنــه عــى الرغــم مــن الجهــود الكثــرة المبذولــة مــا تــزال الوثائــق الرســمية تعــاني مــن بعــض الســلبيات كــا يوجــد ضعــف شــديد في تطبيقهــا عــى أرض الواقــع. تحــذّر الدراســة مــن عــدم تحقــق الفائــدة المرجــوة مــن ــن ــدد م ــم ع ــم تقدي ــة ت ــالي. في النهاي ــت الح ــا في الوق ــدم تطبيقه ــج ع ــة نتائ ــا ومراقب ــرورة تفعيله ــوصي ب ــة وت ــراءات الحكومي ــك الإج تل

المقترحــات التــي يمكــن بتطبيقهــا تحســن إدارة القضايــا المتعلقــة بالنفايــات الطبيــة الســائلة في المستشــفيات.

Réalité de la gestion des déchets médicaux liquides dans les hôpitaux de Damas

RÉSUMÉ D’importantes quantités de déchets médicaux dangereux sont déversées dans les eaux usées des hôpitaux. Ces substances pourraient impacter négativement la santé publique si elles ne sont pas traitées correctement. Les autorités de la République arabe syrienne ont pris conscience de la gravité de ce sujet, et ont par conséquent formulé un certain nombre de lois, de lignes directrices et de normes standard sur cette question depuis 2004. La présente étude a d’abord procédé à un examen détaillé de ces documents, puis les a comparés avec les publications de l’OMS sur le sujet. Un questionnaire a été conçu sur la base du guide national sur la gestion sans risque des déchets des activités de soins de santé dans le but d’enquêter sur la réalité de la gestion des déchets médicaux liquides dans un échantillon d’hôpitaux à Damas. Ce questionnaire a ensuite été distribué et collecté entre avril et mai 2015. L’étude a révélé que les lignes directrices contenaient certains points négatifs et qu’il existait un certain nombre de failles dans leur mise en œuvre. L’étude appelle à intensifier les efforts pour renforcer ces lignes directrices ainsi qu’à procéder à un suivi des éventuels problèmes sanitaires découlant de la faible capacité de mise en œuvre de celles-ci. Enfin, un certain nombre de suggestions ont été faites afin d’améliorer la gestion des déchets médicaux liquides dans les hôpitaux.

واقع إدارة النفايات الطبية السائلة في عدد من مستشفيات مدينة دمشقحـنـــــان مـحـمـود مـخـيـبـر

.)[email protected]( :قسم الهندسة الطبية- كلية الهندسة الميكانيكية والكهربائية- جامعة دمشق، دمشق، الجمهورية العربية السورية، البريد الإلكترونيالإستام:10/02/16، القبول: 29/09/16

1Hanan M. Mukhaiber, Biomedical Engineering Department, School of Mechanical & Electrical Engineering, Damascus University, Damascus, Syrian Arab Republic.


111

المقدمة

تختلــف مطروحــات المستشــفيات اختافــاً كبراً عــن المطروحــات العامــة بســبب الإحتــال ــائلة ــات الس ــن المخلف ــدد م ــد ع ــر لتواج الكب

ــل ]1، 2، 3، 4[: ــا مث ــرة فيه الخط

أقسام . 1 عن الناتجة الممرضة الميكروبات تتصف والتي والمعدية السارية الأمراض عدد مقاومة عى وقدرتها العالي، بتركيزها كبر من المضادات الحيوية، وتسببها بالعديد

من الأمراض كالفروسات المعوية وغرها.

كالفورمالدهيد . 2 المختلفة الكيميائية السوائل التي العضوية وغر العضوية والمذيبات في عديدة أقسام في كبرة بكميات تستخدم المستشفيات مثل المخابر السريرية، والصيانة،

والتعقيم المركزي.

والرصاص . 3 والفضة كالزئبق الثقيلة المعادن الناتج عن خدمات الأسنان، أقسام التصوير المخابر المساعدة، الفنية الأقسام بالأشعة،

السريرية وغرها.

أقسام . 4 عن الناتجة المشعة السائلة المخلفات عى كبر خطر ذات وهي الأورام عاج

الصحة العامة والبيئة.

المضادات . 5 عى الحاوية الصيدلانية المخلفات والتي الأورام لعاج سامة وأدوية الحيوية أكثر المستشفيات في الصرف مياه تجعل مع مقارنةً أمثال 10 –2 بحوالي خطورةً

المطروحات العامة.

بيّنــت الدراســات المختصــة وجــود معامــل الآمــن غــر التخلــص بــن عــال ارتبــاط الصحيــة الرعايــة منشــآت لمطروحــات وانتشــار الأوبئــة )مثــل انتشــار مــرض الهيضــة الملوثــات تحتــوي قــد كــا الكولــرا(. –ــآت ــات منش ــودة في مطروح ــة الموج الكيميائيــالي ــامة، وبالت ــواد س ــى م ــة ع ــة الصحي الرعايمحطــات في الجراثيــم فعاليــة تؤثرعــى قــد

ــة ــة وفعالي ــودة التنقي ــن ج ــل م ــة، وتقل المعالج.]1[ المحطــات

الــصرف معالجــة محطــات لذلــك، وفقــاً الصحــي العــام غــر قــادرة عــى القضــاء عــى الملوثــات الطبيــة الخطــرة الناتجــة عــن المنشــآت الصحيــة إلا إذا صُممــت خصيصــاً للقيــام بهــذه المهمــة؛ وفي حــال تصميمهــا لتقــوم بذلــك فــإن تكاليــف تصميمهــا وصيانتهــا والقيــام بالمراقبــة ــا ــا أنه ــة ك ــتكون مرتفع ــا س ــة لأداءه الدوريــل ــا ضرورة التعام ــن فيه ــن العامل ــب م تتطلبحــذر مــع الميــاه العادمــة المــراد معالجتهــا العــالي التركيــز تخفيــف مــن الرغــم عــى ــال ــزج. وفي ح ــا بالم ــودة فيه ــات الموج للملوثــاء ــة في القض ــر فعال ــات غ ــذه المحط ــت ه كانــبب في ــك سيتس ــإن ذل ــات ف ــك الملوث ــى تل عــصرف ــاه ال ــتخدام مي ــد اس ــراض عن ــل الأم نقــد تصريفهــا إلى المعالجــة لأغــراض الــري أو عن

ــة. ــطحية أو الجوفي ــة الس ــواض المائي الأح

المركــزي المكتــب أجــرى 2008 عــام في ــة ــوحات بيئي ــدة مس ــورية ع ــاء في س لإحصــة؛ ــة والطبي ــة والبلدي ــات المنزلي تضمنــت النفايوصــدرت نتائــج تلــك المســوحات عــام 2009. ــا ــوح في ــذه المس ــج ه ــدول )1( نتائ ــن الج يبفي الصحيــة المنشــآت بمطروحــات يتعلــق

مدينــة دمشــق ]5[.

يبــن الجــدول )1( أن معظــم المنشــآت الصحيــة المستشــفيات، فيهــا بــا دمشــق، مدينــة في تتخلــص مــن الميــاه العادمــة الناتجــة عنهــا عــر تصريفهــا في شــبكة الــصرف الصحــي دون

ــا. ــة له ــة معالج ــام بأي القي

التنويــه إلى أن عــدداً مــن بــد هنــا مــن لا قــد فرضــت الســورية الحكوميــة القوانــن عقوبــات وغرامــات عــى مالكــي المنشــآت ــة ــم بمعالج ــدم قيامه ــد ع ــا عن ــة ومديريه الطبيالنفايــات الطبيــة الســائلة الناتجــة عــن منشــآتهم قبــل طرحهــا في شــبكة الــصرف الصحــي، مثــل ــة ــدات الإداري ــة الوح ــة وجمالي ــون النظاف قان

البيئــة وقانــون ]6[ 2004 لعــام 49 رقــم الســوري رقــم 50 لعــام 2002 ]7[، والأحــدث هــو قانــون البيئــة الســوري رقــم 12 لعــام 2012

.]8[

عــى الرغــم مــن الانتبــاه الحكومــي لهــذه ــام ــع أي اهت ــق م ــك لم يتراف ــكلة إلا أن ذل المشلهــا؛ الحلــول وإيجــاد لدراســتها أكاديمــي ــة ــى أي ــول ع ــن الحص ــن م ــل لم نتمك وبالفعدراســات محكمــة تتنــاول هــذه المشــكلة في مطروحــات موضــوع أن حــن في ســورية. المستشــفيات قــد لاقــى الاهتــام مــن دول الجــوار الســوري مثــل الأردن ]9[، ولبنــان ]10،

.]20-12 ،3[ والعــراق 11[؛

مــن هنــا أتــت فكــرة هــذه الدراســة التــي تهــدف إلى: )1( مراجعــة الوثائــق الحكوميــة ــإدارة ــا ب ــق منه ــا يتعل ــص م ــمية وتلخي الرســن ــفيات م ــائلة في المستش ــة الس ــات الطبي النفايــا ــف فيه ــوة والضع ــاط الق ــح نق ــل توضي أجمــن جهــة وتصميــم اســتبيان يســتند إلى بنودهــا ــق ــتوى تحق ــم مس ــرى، )2( تقيي ــة أخ ــن جه مالإرشــادات والتوجيهــات الرســمية فيــا يتعلــق بــإدارة النفايــات الطبيــة الســائلة في المستشــفيات ضمــن عينــة الدراســة وتبيــان مــا هــو موجــود ــي ــدار الوع ــد مق ــع، )3( تحدي ــى أرض الواق عــفيات ــذه المستش ــن في ه ــد العامل ــي عن الصحفيــا يتعلــق بالتعامــل مــع النفايــات الطبيــة

ــائلة. الس

الطرق

اعتمــدت هــذه الدراســة عــى المنهــج الوصفــي التحليــي باســتخدام الأســلوب الإحصائــي وبدقــة تحليــل التغــر الحاصــل في القيــم المطلقــة ــدأت ــة، فب ــألة المدروس ــة للمس ــب المئوي والنسبمراجعــة الوثائــق الرســمية المتعلقــة بــإدارة المستشــفيات في الســائلة الطبيــة النفايــات في ســورية، وبالاعتــاد عــى تلــك الوثائــق

الجدول 1 نتائج المسوح الحكومية للمياه العادمة في المنشآت الصحية في مدينة دمشق للعام 2008 ]5[ عدد المنشآت التي تعالج المياه

العادمة قبل التخلص منهامركز صحي عدد المنشآت حسب طريقة التخلص من المياه العادمة مستشفى

حفرة مجاريامتصاصية

حفرة مياه مجاري شبكة الصرفالصحي

مجموع خاص عام مجموع خاص عام

1 0 1 108 63 6 57 46 32 14


112

ــد ــؤال بقص ــن 16 س ــتارة م ــم اس ــم تصمي تالعمليــة. البيانــات جمــع في اســتخدامها ــية ــب أساس ــة جوان ــتارة خمس ــت الاس تضمنــات ــن إدارة النفاي ــؤولة ع ــة المس ــي )1( الجه هــد الدراســة، ــة الســائلة في المستشــفيات قي الطبيــا، ــي فيه ــصرف الصح ــة ال ــق معالج )2( طرائ)3( المراقبــة الدوريــة للــصرف الصحــي الناتــج عنهــا، )4( توعيــة العاملــن في المستشــفيات و)5( الصحــي، الــصرف مســائل حــول تطبيــق إجــراءات الحــد الادنــى لــإدارة الآمنــة

ــائلة. ــة الس ــات الطبي للنفاي

شــملت الدراســة الميدانيــة عشريــن مستشــفاَ في مدينــة دمشــق )10 حكوميــة و 10 خاصــة( وتــم ــار 2015. ــان وأي ــهري نيس ــال ش ــا خ تنفيذهــفيات ــة مستش ــارة خمس ــت زي ــه تم ــا أن ــن هن نبأخــرى ولكنهــا رفضــت المشــاركة في الدراســة ــبب ــد بس ــفى واح ــتارة مستش ــض اس ــم رف وتتناقــض الإجابــات الــواردة فيهــا. يوضــح ــات ــة للنفاي ــام المنتج ــبة الأقس ــدول )2( نس الج

ــة. ــة الدراس ــائلة في عين ــة الس الطبي

اُعتمــد أســلوب المقابــات الشــخصية مــن ــم ــتارة، وت ــئلة الاس ــى أس ــة ع ــل الإجاب أجــاشر ــكل مب ــار بش ــات الاستفس ــال المقاب خعــا إذا كانــت الإجــراءات المنفــذة هــي بســبب الأزمــة التــي تعيشــها ســورية أم أنهــا إجــراءات روتينيــة، وتــم التأكيــد مــن الجميــع عــى أن آليــة التعامــل مــع النفايــات الســائلة في المستشــفيات

ــل الأزمــة. ــذ فــترة مــا قب معتمــدة من

النتائج والمناقشة

المتعلقــة الرســمية الوثائــق مراجعــة أولاً- بــإدارة النفايــات الطبيــة الســائلة في المستشــفيات

الجهــات الحكوميــة في ســورية صــدر عــن عــدد مــن الأدلــة الوطنيــة الإرشــادية لتوضيــح الطبيــة النفايــات مــع التعامــل إجــراءات الســائلة في المنشــآت الصحيــة وضرورة معالجــه الــصرف في طرحهــا قبــل النفايــات هــذه الفقــرة هــذه العــام. وســنقوم في الصحــي ــر ــع معاي ــا م ــة ومقارنته ــذه الأدل ــة ه بمناقشــم ــل المعل ــا دلي ــة وهم ــة العالمي ــة الصح منظمحــول تدبــر نفايــات أنشــطة الرعايــة الصحيــة الإرشــادي والكتيــب 2003 عــام الصــادر ــة ــطة الرعاي ــات أنش ــة لنفاي ــول الإدارة الآمن ح

.]4 ،1[ 2006 الصحيــة الصــادر عــام

تشمل هذه الوثائق الرسمية عى:

رقــم . 1 الســورية القياســية المواصفــة عــن 2008 عــام الصــادرة 2580

العربيــة والمقاييــس المواصفــات هيئــة الصناعــة لــوزارة التابعــة الســورية حــول "المخلفــات الســائلة الناتجــة عــن ــبكة ــة إلى ش ــة المنتهي ــاطات الاقتصادي النش

.]21[ العامــة" الــصرف

الرنامــج الوطنــي لإدارة النفايــات المشــعة . 2في ســورية الصــادر عــن هيئــة الطاقــة

الذريــة عــام 2009 ]22[.

ــات . 3 ــة لنفاي ــإدارة الآمن ــي ل ــل الوطن الدليوزارة عــن الصــادر الصحيــة الرعايــة

الصحــة عــام 2010 ]2[.

النظــام الوطنــي لإدارة نفايــات الرعايــة . 4الدولــة وزارة عــن الصــادر الصحيــة .]23[ 2010 عــام الســورية البيئــة لشــؤون

ــم 3603 . 5 ــورية رق ــية الس ــة القياس المواصفالصــادرة عــام 2011 عــن هيئــة المواصفــات التابعــة الســورية العربيــة والمقاييــس

لــوزارة الصناعــة والمتعلقــة بالمخلفــات الســائلة المعالجــة الناتجــة عــن المنشــآت

.]24[ الصحيــة

رقــم . 6 المواصفــة القياســية الســورية هيئــة 2008 عــن الصــادرة عــام 2752

ــورية ــة الس ــس العربي ــات والمقايي المواصفالتابعــة لــوزارة الصناعــة حــول "ميــاه لأغــراض المعالجــة الصحــي الــصرف

.]25[ الأولى" المراجعــة الــري.

هيئــة المواصفــات والمقاييــس العربيــة . 7"مــشروع تعميــم .)2013( الســورية مواصفــة ع ت م: 2013 المخلفــات الســائلة المســموح بطرحهــا إلى البيئــة المائيــة"، وزارة

الســورية ]26[. الصناعــة

تضمنت هذه الوثائق تحديد:

)1( الحــدود المقبولــة مــن العنــاصر في ميــاه الــصرف قبــل طرحهــا إلى شــبكة الــصرف العامــة، والمــواد والمخلفــات غــر المســموح ــة ]4، 24[. ــصرف العام ــبكة ال ــا إلى ش بإلقائه

ــي ــد أعظم ــهر كح ــان )كل ش ــترة الاعتي )2( فالطــوارئ والأوبئــة( مراعــاة حــالات مــع

والجهــة المســؤولة عــن تنفيــذه ]21، 24[.

ــائلة ــات الس ــن النفاي ــص م ــات التخل )3( آليالمشــعة وعمليــة الاعتيــان المتعلقــة بهــا والحــدود المــراد النفايــات لإشــعاع بهــا المســموح

تصريفهــا إلى البيئــة مبــاشرة ]22[.

لتخليــص المعالجــة مــن الأدنــى الحــد )4(ــن ــى م ــد الأع ــن الح ــفى م ــات المستش مطروحــه قبــل صرف ــام ب ــذي يجــب القي ــات وال الملوثهــذه المطروحــات إلى شــبكة الــصرف الصحــي العامــة عنــد عــدم وجــود محطــة معالجــة خاصــة

ــفى ]2[. بالمستش

الجدول 2 نسبة تواجد عدد من الأقسام المنتجة للنفايات الطبية السائلة في عينة الدراسةعدد المستشفيات الحاوية على القسم من عينة الدراسةنسبة تواجده في العينة المدروسةالقسم

20 )جميع المستشفيات(100٪قسم تعقيم مركزي

9519٪قسم أشعة تشخيي

9519٪مخر دمويات

408٪مخر تشريح مرضي

9018٪صيدلية

459٪وحدة غسل كى

7515٪مخابر سريرية

306٪قسم عاج كيميائي

204٪مشرحة

153٪قسم طب نووي


113

)5( إجــراءات الحــد الأدنــى مــن متطلبــات الأمــان الواجــب تطبيقهــا مــن قبــل مؤسســات الرعايــة الصحيــة غــر القــادرة عــى القيــام بأيــة

ــصرف ]2[. ــاه ال ــة لمي معالج

ــة ــية الخاص ــة والقياس ــتراطات العام )6( الاشبميــاه الــصرف الصحــي المعالجــة المســتخدمة في الزراعــة وكذلــك آليــة مراقبــة النوعيــة والتقييــم لمحطــة معالجــة الميــاه العادمــة مــع ضرورة فتــح ســجات رســمية لتوثيــق النتائــج المخريــة ــد ــة عن ــة الحكومي ــات الرقابي ــا للجه وإبرازه

ــا ]25، 26[. طلبه

)7( المهــام المكلفــة بهــا الــوزارات المعنيــة بأمــور إدارة نفايــات الرعايــة الصحيــة. يبــن الجــدول )3( تــوزّع المهــام بــن الــوزارات المختلفــة ]23[.

نستخلص مما سبق:

السائلة . 1 الصحية الرعاية نفايات إدارة تعد ومساهمات تدخات تحتاج معقدة مسألة وتبقى المعنية؛ الجهات من عدد قِبل من المستشفيات هي الحلقة الأهم في هذه العملية السائلة الملوثات معالجة الأفضل من حيث من يمكن ما أقرب المستشفيات عن الناتجة

مصدر توليدها.

الرسمية . 2 الجهات قبل من اهتام يوجد النفايات معالجة بمسألة المعنية السورية الطبية السائلة، فقد اتفق الجميع عى ضرورة معالجة تلك النفايات الناتجة عن المستشفيات العام، الصحي الصرف في إلقاءها قبل بالإضافة إلى رفع مستوى أداء إدارة النفايات السائلة في المستشفيات إلى أعى درجة ممكنة والإجراءات المعاير تطبيق خال من الموضوعة من قبل الجهات الرقابية المختلفة.

لم تتضمن الوثائق الرسمية تحديد آلية معالجة . 3النفايات الطبية السائلة الواجب إتباعها من

وفقاً لحجمها وطبيعة الصحية المنشآت قبل تمنح ألا المفترض من والذي مطروحاتها، أية منشأة صحية ترخيص البناء إذا لم توضح منذ وذلك مطروحاتها معالجة ستتم كيف المراحل الأولية للتصميم وصولًا إلى التشييد

والتشغيل.

إلى . 4 الرسمية الوثائق من أي إشارة عدم المنشآت في متخصصة لجنة وجود ضرورة الأنظمة بإدارة تهتم والمستشفيات الصحية البيئية فيها ومنها النفايات الطبية السائلة وما فيها توافرها الواجب الاختصاصات هي ولا كيفية ربطها بالجهات الرسمية من حيث رفع تقارير الأداء وغرها من الأمور الرقابية

الرورية.

لإدارة . 5 الوطني الدليل بنود مقارنة عند الآمنة لنفايات الرعاية الطبية في سورية ]2[ الإرشادي الكتيب الواردة في التعليات مع الرعاية أنشطة لنفايات الآمنة الإدارة حول العالمية الصحة منظمة عن الصادر الصحية تطابق الدراسة وجدت ،]4[ 2006 عام )1 ( حيث جوانب عدة من بينها تام الخارجة الفضات مياه تصريف شروط شبكات إلى الصحية الرعاية منشآت من المجاري البلدية، )2( معالجة مياه الفضات في الموقع، )3( معالجة الحمأة في الموقع، )4( الموقع. في للسامة الأدنى الحد متطلبات جديدة فقرة الوطني الدليل أضاف ولكن، النفايات إدارة "نظام الحد الأدنى في بعنوان السائلة الخطرة" ذُكرت فيها الشروط السبعة التالية الواجب مراعاتها عند عدم توفر طرق آمنة للتعامل مع الفضات السائلة الخطرة في المؤسسات الصحية )وقد تم في هذه الدراسة البنود هذه تحقيق مدى عن الاستفسار في وذلك المدروسة المستشفيات في السبعة

الفقرة "سادساً" التالية( ]2[:

جمــع مفــرزات مــرضى أجنحــة العــزل ••المصابــن بأمــراض معديــة بعبــوات مناســبة لإجــراء التطهــر الكيميائــي لها

أو لمعالجتهــا حرارياً )الأتــوكاف(.

الكيميائيــة •• المــواد تصريــف عــدم والمــواد الصيدلانيــة والخطــرة إلى نظــام

الــصرف الصحــي.

ــة •• ــائلة المخري ــات الس ــع الفض تجميــل ــرة مث ــات خط ــى مركب ــة ع المحتويالملونــات والفورمالــن بشــكل مســتقل ــهيل ــا لتس ــة إليه ــادة ماص ــة م وإضافعمليــة النقــل وبعــد ذلــك إمــا أن تخضــع أو خامــدة مــادة إلى تحــوّل

للكبســلة.

تخفيــف الســوائل المطهــرة المعتمــدة ••عــى الكلوريــن إلى نســبة أقــل مــن إلقاؤهــا في حفــرة ثــم 0.5% ومــن

امتصاصيــة ولا تلقــى أبــداً في حــوض الترســيب.

ــة •• ــدة ثاث ــد لم ــار ألدهي ــن الغلوت تخزيأيــام بعــد الاســتخدام ثــم تخفيفــه مرتــن بالمــاء ومــن ثــم يلقــى ببــطء في حفــرة امتصاصيــة بعيــداً عــن حــوض

ــيب. الترس

ــن •• ــة ع ــم الناجم ــوائل الجس ــة س معالجأجهــزة شــفط المفــرزات بعــد تجميعهــا ــوكاف ــرارة )أت ــتقل بالح ــكل مس بشــر ــرات غ ــة المطه ــص( أو بإضاف مخصــن 12 ــل ع ــاس لا تق ــدة تم ــة ولم المخففســاعة ثــم يمكــن إلقائهــا بعــد ذلــك في

ــيب. ــواض الترس أح

طمــر أكيــاس الــدم التالفــة في المطامــر ••عــدم حــال وفي المراقبــة؛ النظاميــة

الجدول 3 توزع المهام بين الوزارات وفقاً للنظام الوطني لإدارة نفايات الرعاية الصحية في سورية ]23[.المهام المكلفة بهاالوزارة

عمليات الجمع والنقل والمعالجة وكذلك مراقبة عمليات الفرز عند نقطة التجميع النهائية للنفايات في منشآت الرعاية وزارة الإدارة المحليةالصحية

إدارة نفايات الرعاية الصحية ضمن المنشآت الصحية التابعة لها وكذلك داخل منشآت القطاعات العام والخاص وزارة الصحةوالمشترك المولّدة للنفايات التي تصنف بأنها نفايات رعاية صحية. بالإضافة إلى المراقبة من الناحية الصحية لكافة مراحل

إدارة النفايات الطبيةالمراقبة والتفتيش البيئي عى عمليات إدارة نفايات الرعاية الصحية في جميع مراحلها وتحديد الأضرار البيئية الناجمة عن وزارة الدولة لشؤون البيئة

إدارتها في أي مرحلة من مراحلها بالإضافة إلى المساهمة في رفع الوعي وتدريب الكوادر العاملة في مجال إدارة نفايات الرعاية الصحية وعى تماس معها في جميع المراحل


114

يمكــن المطامــر هــذه مثــل توفــر ــن 1100 ــل ع ــرارة لا تق ــا بح ترميدهدرجــة مئويــة أو تعقيمهــا بالأتــوكاف إذا وجــد فيــه برنامجــاً خاصــاً لهــذا الغــرض. أمــا إذا تعــذرت كل هــذه الخيــارات فيمكــن دفنهــا في حفــرة المــرضى عــن ومعزولــة مغلقــة والــكادر العامــل )يجــب أن يؤخــذ بالاعتبــار موقــع الحفــر وإمكانيــات ــة ــن الترب ــة م ــة المحيط ــب للبيئ التسريفتحهــا أبــداً يجــوز ولا والميــاه(، وتفريغهــا في أحــواض الترســيب أو ــن ــاً م ــي خوف ــصرف الصح ــبكة ال ش

انتشــار العــدوى.

ــورية . 6 ــية الس ــات القياس ــت المواصف وضعــة ــية الخاص ــة والقياس ــتراطات العام الاشبميــاه الــصرف الصحــي المعالجــة المســتخدمة في الزراعــة بــا فيهــا تلــك 26[. في ،25[ المستشــفيات الناتجــة عــن الســوري الوطنــي الدليــل أكــد حــن أنــه في حــال عــدم معالجــة مطروحــات المستشــفيات يمنــع اســتخدام ميــاه مجــاري المستشــفيات للزراعــة منعــاً مطلقــاً تصريفهــا إلى مجــاري يمنــع وكذلــك ــع ــذا المن ــق ه ــة ]2[. ويتواف ــاه الطبيعي المي

ــة ــة العالمي ــة الصح ــورات منظم ــع منش م.]4،1[

ثانيــاً- الجهــة التــي قامــت بالإجابــة عــلى أســئلة الاســتمارة في عينــة الدراســة

تــمّ تحديــد هــذه الجهــة مــن قبــل إدارة كل مستشــفى والتــي اختلــف الموقــع الوظيفــي تــم أنــه لهــا مــن مستشــفى لآخــر، علــاً ــم ــع الاســتارات عــى أن تت ــد توزي ــد عن التأكيالإجابــة عليهــا مــن قبــل الجهــة المســؤولة ــفى. ــائلة في المستش ــة الس ــات الطبي ــن النفاي عــدم ــي ع ــا ه ــام هن ــرة بالاهت ــة الجدي الماحظالمستشــفيات أغلــب عنــد وعــي وجــود ــل ــة تفعي ــة( بأهمي ــن العين ــة )90% م المدروســة ــة العام ــة والصح ــات البيئ ــان منظوم دور لجومكافحــة التلــوث والعــدوى فيهــا وأن تكــون المتعلقــة الأمــور إدارة عــن المســؤولة هــي بالنفايــات الطبيــة الســائلة. ففــي 40% مــن ــة ــد أن الجه ــة نج ــفيات المدروس ــة المستش عينــر ــائلة غ ــة الس ــات الطبي ــن النفاي ــؤولة ع المسخبــرة بهــذا الأمــر مثــل متعهــد التنظيــف،

ــا في ٪50 ــض. بين ــة، إدارة التمري ــم الصيان قســة ــة بمعالج ــة مكلف ــد أي جه ــة لم نج ــن العين مالقضايــا المتعلقــة بالنفايــات الطبيــة الســائلة وتــم الإجابــة عــى الاســتارات فيهــا مــن قبــل جهــات مختلفــة مثــل مديــر التخطيــط والإحصــاء، رئيــس شــعبة التجهيــزات الطبيــة،

رئيــس المكتــب الهنــدسي.

ــة ــة الدراس ــن عين ــة م ــبة المتبقي ــبة للنس بالنس)10%، اثنتــن مــن المستشــفيات(، فنجــد أن ــائلة ــة الس ــات الطبي ــن النفاي ــا ع ــؤول فيه المسهــو قســم مكافحــة العــدوى في المستشــفى النفايــات بــإدارة متخصصــة ولجنــة الأول، الطبيــة الســائلة في المستشــفى الثــاني وهــي تتبــع مبــاشرة لإدارة المستشــفى والتــي بدورهــا تتصــل بــوزارة الصحــة وببلديــة مدينــة دمشــق.

ثالثاً- طرائق معالجة الصرف الصحي

العينــة في المستشــفيات جميــع في توجــد لا الــصرف لمعالجــة محليــة محطــة المدروســة هــذه مــن %85 و عنهــا، الناتــج الصحــي مطروحاتهــا بتصريــف تقــوم المستشــفيات ــة ــي العام ــصرف الصح ــبكة ال ــاشرة في ش مبالمتبقيــة النســبة بينــا معالجــة. أيــة دون الأولى فتقــوم )3 مستشــفيات(، العينــة مــن الــصرف شــبكة إلى مطروحاتهــا بتصريــف الصحــي ولكــن مــع ضــخ الكلــور معهــا؛ ــن ــف م ــام مؤل ــاني نظ ــفى الث ــد المستش ويعتمثــاث بــرك دون أن يتبــع ذلــك ترشــيح رمــي، ــرة ــرك كب ــث ب ــفى الثال ــتخدم المستش ــا يس بينــم ــه لم يت ــة أن ــع ماحظ ــة. م ــة تنقي ــا محط يتبعهذكــر مــدة المكــوث في الــرك في المستشــفين

الثــاني والثالــث.

مطروحــات مــع الكلــور لضــخ بالنســبة المستشــفى، فهــذا الإجــراء غــر منصــوص عليه في أي مــن الدليــل الوطنــي أو منشــورات منظمة الصحــة العالميــة مــن ناحيــة، ومــن ناحيــة أخــرى فهــو لا يترافــق مــع إجــراء فحوصــات ــالي ــات وبالت ــوث في المطروح ــبة التل ــة نس لمعرفإضافتهــا الواجــب الآمنــة الكلــور نســبة للمطروحــات لذلــك يُعــد إجــراء غــر ســليم.

بــا أن أغلــب المستشــفيات تعتمــد بشــكل كي عــى محطــة المعالجــة المركزيــة، لــذا مــن المستشــفيات هــذه تمتلــك أن الــروري ــا. ــة له ــة التابع ــن المحط ــة ع ــات دقيق معلومســعت الدراســة إلى التحقــق مــن امتــاك عينــة الدراســة لتلــك المعلومــات وذلــك عــن طريــق

ــي: ــئلة ه ــن الأس ــدد م ــتارة لع ــن الاس تضمــة ــي العام ــصرف الصح ــبكة ال ــل ش ــل تتص هالتابعــة لهــا المستشــفى بمحطــة معالجــة مركزيــة أم لا، ومــا هــي طبيعــة المعالجــة إن وجــدت ــة لمدروســة ومــا هــي فعاليتهــا. وتبــن أنّ العينــصرف ــبكة ال ــن ش ــات ع ــة معلوم ــك أي لا تمتل

ــا. ــة معه ــة الموصول ــي العام الصح

رابعــاً- المراقبــة الدوريــة للــصرف الصحــي ــج النات

ــفى ــات المستش ــة لمطروح ــة الدوري ــد المراقب تعككل أو لــكل قســم منــه مــن المتطلبــات المهمــة ــات، ــذه المطروح ــمية ه ــة س ــة )1( درج لمعرف)2( قابليتهــا لاشــتعال وقدرتهــا عــى التســبب ــي، )3( ــصرف الصح ــبكة ال ــب ش ــآكل أنابي بتــل ــف عم ــا توق ــة لأنه ــادات الحيوي ــز المض تركيــة... ــات المركزي ــة في المحط ــة البيولوجي المعالج

الخ.

أيضــاً، يجــب تحديــد الجهــة المســؤولة عــن القيام بتلــك المراقبــة بحيــث تحتفــظ هــذه الجهــة بســجات نظاميــة دقيقــة وعلميــة عــن أداء ــدول ــن الج ــم. يب ــة والتقوي ــفى للمقارن المستشــفيات ــا المستش ــوم به ــي تق ــراءات الت )4( الإجــا. ــؤولة عنه ــة المس ــا والجه ــة مطروحاته لمراقب

يبــن الجــدول )4( أن 70% مــن العينــة لا تقــوم ــا لم ــا، بين ــي لديه ــصرف الصح ــة لل ــة مراقب بأييكــن لــدى إحــدى المستشــفيات أيــة معلومــات عــن هــذا الأمــر. توجــد اختافــات بــن النســبة المتبقيــة )25%( مــن حيــث نوعيــة الفحوصــات ــة ــك الجه ــة وكذل ــة المراقب ــال عملي ــذة خ الُمنفجهــة وجــود عــدم إلى بالإضافــة المنفــذة. ــة ــذه المراقب ــن ه ــاً ع ــؤولة فعلي ــة مس حكوميوهــذا مخالــف للوثائــق الرســمية المذكــورة

ــاه. أع

المستشــفيات في العاملــين توعيــة خامســاً- الصحــي الــصرف مســائل حــول

بهــدف تحديــد مســتوى وعــي هــؤلاء العاملــن ــة الســائلة ــة التعامــل مــع النفايــات الطبي بكيفيــتفسر ــة. يس ــة الدراس ــؤالن لعين ــه س ــم توجي تالمستشــفى أعــدت إذا عــاّ الأول الســؤال قائمــة بالمــواد الخطــرة التــي تنتهــي إلى الــصرف ــتخدامها، وفي ــل اس ــب تقلي ــي والواج الصحــا بهــا. لم تتطلــب ــا تزويدن حــال وجودهــا طلبنــخصية ــات ش ــراء مقاب ــة إج ــداف الدراس أهمــع العاملــن في المستشــفيات وإنــا تــم تضمــن


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ــن ــد ضم ــذا البن ــا في ه ــتفسر عنه ــئلة المس الأســص ــؤول المخت ــى المس ــة ع ــتارات الموزع الاسفي كل مستشــفى مــن المستشــفيات العشريــن ــل ــن أج ــئلة م ــن الأس ــة ع ــو بالإجاب ــوم ه ليقــت ــة وكان ــات المطلوب ــى المعلوم ــول ع الحصــات ــص الإجاب ــم تلخي ــة. ت ــة تام ــبة الإجاب نســؤال ــذا الس ــى ه ــفيات ع ــن المستش ــة م المقدم

ــا يــي: ب

لا توجــد أيــة قائمــة بالمــواد الخطــرة المنتهيــة إلى الــصرف الصحــي في 65% مــن عينــة الدراســة، ــم". ــة بـــ "لا أعل ــن العين ــاب 15% م ــا أج بينفقــط )20%( أجابــت بنعــم وتوزعــت إجاباتهــا كالتــالي:5% حــددت القائمــة بالمــواد المشــعة ــددت ــئ(، 5% ح ــض )دم، قي ــرزات المري ومفــواد ــة، الم ــف مخري ــول، كواش ــة بالفورم القائمالمخرشــة، دم، 5% لم تذكــر أي مــواد، بينــا الـ ٪5 ــا ــول بأنه ــادة الفورم ــددت م ــد ح ــرة فق الأخ

ــا. ــدة لديه ــرة الوحي ــادة الخط الم

تقــوم "هــل فهــو الثــاني الســؤال أمــا ــات ــا بآلي ــن لديه ــة العامل ــفيات بتوعي المستشالســائلة الطبيــة النفايــات مــع التعامــل ــالي: ٪80 ــة كالت ــت الإجاب ــا". وكان وخطورتهــا، ــت ب ــم، 15% أجاب ــت بنع ــة أجاب ــن العين م

بينــا 5% أجابــت بــا أعلــم.

نســتنتج مــن الإجابــات عــى هذيــن الســؤالن توعيــة يمكــن كيــف إذ تناقــض وجــود ــات ــع النفاي ــل م ــات التعام ــن آلي ــن ع العاملالطبيــة الســائلة إذا لم تتوفــر في المستشــفيات قائمــة بالمــواد الخطــرة الواجــب التعامــل معهــا

ــذر. بح

الادنــى الحــد إجــراءات تطبيــق سادســاً- الســائلة الطبيــة للنفايــات الآمنــة لــإدارة

الوطنــي الدليــل في عليهــا المنصــوص

أداء مســتوى عــن الدراســة اســتفسرت المستشــفيات فيــا يتعلــق بتطبيــق إجــراءات الحــد الأدنــى لــإدارة الآمنــة للنفايــات الطبيــة الســائلة المنصــوص عليهــا في الدليــل الوطنــي، الســبعة الــشروط هــي الإجــراءات هــذه الواجــب مراعاتهــا عنــد عــدم توفــر طــرق آمنــة للتعامــل مــع الفضــات الســائلة الخطــرة ــا في ــم ذكره ــي ت ــة والت ــات الصحي في المؤسسالفقــرة )أولاً( الســابقة. يبــن الشــكل )1( نســب

ــراءات. ــك الإج ــق تل تحق

بلغــت أعــى نســبة تحقــق 85.7% وهــي لإحــدى ــة ــي لا توجــد فيهــا جهــة معني المستشــفيات التــاء ــوم بإلق ــي تق ــائلة وه ــة الس ــات الطبي بالنفايمطروحاتهــا مبــاشرة في الــصرف الصحــي العــام ــفيات ــة مستش ــد ثاث ــة. توج ــة معالج دون أي

ــراءات الـــ ــق الإج ــب تحق ــا نس ــاوزت فيه تجــفى ــي: )1( المستش ــفيات ه ــذه المستش 70% وه

التــي توجــد فيهــا لجنــة متخصصــة بــإدارة المستشــفى )2( الســائلة، الطبيــة النفايــات ــرك، )3( ــي تســتخدم نظــام مؤلــف مــن 3 ب التإحــدى المستشــفيات التــي لا توجــد فيهــا جهــة معنيــة بالنفايــات الطبيــة الســائلة وتقــوم بإلقــاء مطروحاتهــا مبــاشرة في الــصرف الصحــي العــام دون أيــة معالجــة. بلغــت نســبة التحقــق ٪57 في ــا ــرة تليه ــرك كب ــتخدم ب ــي تس ــفى الت المستش

ــة. ــة تنقي محط

تطبيــق نســبة انخفــاض )1( الشــكل يبــن إجــراءات الحــد الأدنــى لــإدارة الآمنــة في ــذه ــع ه ــوم جمي ــة؛ وتق ــة الدراس ــن عين 75% م

المستشــفيات بإلقــاء مطروحاتهــا مبــاشرة في أيــة إجــراء دون العــام الصحــي الــصرف

ــا. ــة له معالج

الجدول 4 الإجراءات التي تقوم بها المستشفيات لمراقبة مطروحاتها والجهة المسؤولة عنهاالنسبة من العينة عدد المستشفيات من العينة الإجراء المتبع والجهة المسؤولة عنه

٪70 14 لا يوجد٪5 1 لا أعلم٪5 1 اختبار سمية والمسؤول عنها "لجنة إدارة النفايات".٪5 1 إجراء تنظيف دوري لحفرة الصرف والمسؤول عنها "قسم الصيانة".٪5 1 اختبار تسرب، انسداد وتآكل لانابيب والمسؤول عنها "القسم الهندسي".٪5 1 اختبارات سمية، أوبئة و تآكل وذلك من خال عقد مع مخر خارجي.٪5 1 اختبار انسداد مع تنظيف وتمديد بالماء يقوم بها مختص.

شكل 1 نسبة تحقق إجراءات الحد الأدنى لإدراة الآمنة للنفايات الطبية السائلة المنصوص عليها في الدليل الوطني.

٪35

٪10

٪30

٪5

٪15

٪5

٪0 ٪10 ٪20 ٪30 ٪40 ٪50 ٪60 ٪70 ٪80 ٪90

نسبة تحقق إجراءات الحد الأدنى لإدارة الأمنة للنفايات الطبية السائلة

مستشفى واحد

3 مستشفيات

مستشفى واحد

6 مستشفيات

مستشفيان

7 مستشفيات

سةدرا

ة العين

في ت

فياتش

لمس٪ ا


116

الخاتمة والتوصيات

المستشــفيات مطروحــات لخطــورة نظــراً اهتمــت الجهــات الرســمية في ســورية بهــذا الأمــر وقامــت بإصــدار عــدد مــن الأدلــة التــي القياســية والمواصفــات والقوانــن تهــدف بمجملهــا إلى تنظيــم إدارة النفايــات ــدر ــا ق ــن أخطاره ــل م ــائلة والتقلي ــة الس الطبيــرة ــود الكث ــن الجه ــم م ــى الرغ ــكان. ع الإمالمبذولــة في هــذا المجــال مــا تــزال تلــك الوثائــق تعــاني مــن بعــض الســلبيات كــا يوجــد ضعــف شــديد في تطبيقهــا عــى أرض الواقــع. لــذا ــة ــح أهمي ــروري توضي ــن ال ــه م ــا أن وجدنــن ــة ع ــائلة الناتج ــة الس ــات الطبي ــة النفاي معالجالمستشــفيات وكيفيــة القيــام بذلــك وإلــزام

بالتطبيــق. المستشــفيات

ــى لاحظــت الدراســة أن إجــراءات الحــد الأدنلــإدارة الآمنــة لنفايــات الرعايــة الطبية الســائلة ــدم ــع ع ــفيات م ــب المستش ــة في أغل ــر مطبق غــا أو ــة لمطروحاته ــة محلي ــات معالج ــود محط وجحتــى اســتخدام نظــام الــرك ممــا ينــذر بوجــود ــع. ــة للمجتم ــة العام ــى الصح ــي ع ــر بيئ خطــات ــت محط ــر إذا كان ــذا الخط ــة ه ــزداد أهمي ت

ــن ــاني م ــة تع ــي العام ــصرف الصح ــة ال معالجــة ــبب الأزم ــة بس ــص في الفعالي ــكات ونق مشــة ــة حرك ــورية نتيج ــا س ــر به ــي تم ــة الت الحاليــاه ــة باتج ــي الضخمــة الحاصل النــزوح الداخــن ــدد م ــروج ع ــة، وخ ــن جه ــق م ــة دمش مدينــن ــل م ــن العم ــة ع ــة المركزي ــات المعالج محطناحيــة أخــرى. هــذا الأمــر لم يتــم التقــي عنــه

ــاً. ــته لاحق ــل دراس ــة ونأم ــذه الدراس في ه

عــى الرغــم مــن التأكيــد الحكومي عــى ضرورة مراقبــة مطروحــات المستشــفيات بشــكل دوري إلا أنّ هــذا الأمــر غــر مطبــق فعليــاً. خلصــت ــة ــن الأدل ــرة ب ــوة كب ــود فج ــة إلى وج الدراسوالإجــراءات الرســمية الواجــب تطبيقهــا وبــن مــا هــو مطبــق عــى أرض الواقــع ممــا يــدل عــى عــدم الاســتفادة مــن الجهــود الرســمية المبذولــة

في هــذا المجــال.

توصي هذه الدراسة با يي:

ــات ــإدارة النفاي ــة ب ــة متخصص ــكيل لجن )أ( تشــفى. ــائلة في كل مستش ــة الس الطبي

)ب( إنشــاء قاعــدة بيانــات للمــواد المســتخدمة ــات في مختلــف أقســام المستشــفى المنتجــة للنفايــراءات ــد إج ــم تحدي ــن ث ــائلة، وم ــة الس الطبيعمــل دقيقــة تقلــل مــا أمكــن مــن إنتــاج

وترفــع ناحيــة مــن ســائلة طبيــة نفايــات مســتوى الوعــي والحــذر عنــد العاملــن حســب

ــا. ــل معه ــات التعام ــواد وآلي ــة الم طبيع

الطبيــة النفايــات بمعالجــة الاهتــام )ج( لتصميــم الأولى المراحــل منــذ الســائلة

. لمستشــفى ا

ــة ــة المختلف ــات الحكومي ــل دور الجه )د( تفعيــم ــة، وأن يت ــة الوطني ــه الأدل وفقــاً لمــا تــوصي بــل ــذة وتحمي ــة الناف ــن والأنظم ــق القوان تطبيــات ــن عملي ــا ع ــة، فض ــؤوليات القانوني المس

ــة. ــد والمراقب الرص

ــة، ــة وطني ــن وأدل ــر قوان ــا لا تتوف )هـــ( عندميجــب الاعتــاد عــى القواعــد والمعايــر الدوليــة ــة. ــة العالمي ــة الصح ــة لمنظم ــادئ التوجيهي والمب

)و( توســيع النظــام الوطنــي لإدارة نفايــات ــث ــاؤه بحي ــورية وإغن ــة في س ــة الصحي الرعاي

ــائلة. ــة الس ــة الطبي ــات الرعاي ــمل نفاي يش

)ز( إجــراء، في دراســة مســتقلة، تحاليــل مخريــة والصيدلانيــة الكيميائيــة المكونــات لبعــض الناتجــة عــن أقســام معينــة في المستشــفى لتســليط ــن ــوث م ــتوى التل ــن ومس ــى تكوي ــوء ع الض

ــا. ــادرة عنه ــي الص ــصرف الصح ــاه ال مي

1. World Health Organization. Teacher's guide: management of wastes from health-care activities. Amman: WHO Regional Centre for Environmental Health Activities; 2003.

2. Ministry of Health. National guide for safe management of health-care waste in the Syrian Arab Republic. Damascus: Ministry of Health; 2010.

3. Ismaeel ZF and Mahmood TA. Effect of laboratory chemical ef-fluents on the characteristics of hospitals effluents. Iraq Journal of Market Research and Consumer Protection. 2010;2)3(:34-49.

4. World Health Organization. Safe management of wastes from health-care activities. Amman: WHO Regional Centre for Envi-ronmental Health Activities; 2006.

5. Central Bureau of Statistics. The results of environmental surveys: household, municipal and medical wastes in 2008. Damascus: The Cabinet of Syria; 2009.

6. Ministry of Local Administration and Environment. Hygiene law no. 49. Damascus: Ministry of Local Administration and Environment; 2004.

7. Ministry of State for Environmental Affairs. Environmental law no. 50. Damascus: Ministry of State for Environmental Affairs; 2002.

8. Ministry of State for Environmental Affairs. Environmental Law No. 12. Damascus: Ministry of State for Environmental Affairs; 2012.

9. Al-Ajlouni K, Shakhatreh S, Al-Ibraheem N, Jawarneh M. Evaluation of wastewater discharge from hospitals in Amman, Jordan. J Basic Appl Sci. 2013;13)4(:44-50.

10. Jabbour J, Farah J, Abdel-Massih R. Hospital wastewater genotoxicity: a comparison study between an urban and rural university hospital with and without metabolic activation. J Environ Eng Ecol Sci. 2016;5)2(.

11. Abdel-Massih R, Melki P, Afif, C, Daoud Z. )2013(. Detection of genotoxicity in hospital wastewater of a developing country using SOS chromotest and Ames fluctuation test. J Environ Eng Ecol Sci. 2013;2)4( )http://www.hoajonline.com/journals/pdf/2050-1323-2-4.pdf( doi:10.7243/2050-1323-2-4.

12. Rashid GY, Salah F. Estimating and treating wastewaters from district hospitals in Baghdad. Iraq Journal of Civil Engineering. 2008;12:59-75.

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14. Mahmood FY, Abbas WMA. Removal of PO4, NH3 and NO3 from hospital wastewater in Mosul City by SBR technique. Al-Rafidain Engineering Journal. 2009;17)6(:30-44.

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118

ABSTRACT In 2009, Lebanon hosted the 6th Francophone Games. Pandemic A(H1N1)2009 virus presented significant health threat at the time. A surveillance strategy was implemented for the timely detection and management of epidemiological events and outbreaks, in particular for A(H1N1)2009 virus cases. Data were collected and managed daily and feedback was generated through daily bulletins. A total of 299 medical consultations were reported, 29% of which related to infectious diseases. There were 10 cases reported as acute respiratory infections; all tested negative for A(H1N1)2009 virus within 24 hours. Twenty-three cases of gastroenteritis were reported, for which 11 stool cultures were negative. While pandemic A(H1N1)2009 did not interfere with the Games, it was essential to strengthen surveillance and to have timely epidemiological information. This was achieved through preparedness, a multi-disciplinary approach, timely management and coordination.

ــد الأمــراض الســارية خــال إحــدى التجمعــات الحاشــدة: الــدورة السادســة للألعــاب الخــرات المكتســبة في لبنــان في ترصُّ2009 الفرنكوفونية،

نادين حداد، وليد عمّر، الفريد خوري، أليكس كوكس، ندى غصن

الخاصــة: في عــام 2009، اســتضاف لبنــان الــدورة السادســة للألعــاب الفرنكوفونيــة. وفي ذلــك الوقــت كان فــروس A(H1N1) 2009 الوبائــي ــا، ــب وعلاجه ــت المناس ــة في الوق ــداث والأوبئ ــن الأح ــف ع ــد للكش ــتراتيجية للترصُّ ــذَت اس ــد نُفِّ ــراً. وق ــاً كب ــداً صحي ــل تهدي ــي يمث العالمــات ــن المعلوم ــلان ع ــم الإع ــاً، ويت ــدار يومي ــع وتُ مَ ــات تُْ ــت البيان ــروس A(H1N1) 2009. وكان ــن ف ــة ع ــالات الناجم ــبة للح ــيّم بالنس لا ســاك 10 ــارية. وكان هن ــراض الس ــق بالأم ــا تتعل ــة، وكان 29٪ منه ــارة طبي ــن 299 استش ــغ ع ــد أُبْلِ ــة. وق ــرات يومي ــلال ن ــن خ ــة م الارتاعيــغ عنهــا عــى أنهــا التهابــات حــادة في الجهــاز التنفــي، وكانــت جميــع الاختبــارات ســلبية لفــروس A(H1N1) 2009 في غضــون حــالات أُبْلِ A(H1N1) ــروس ــن أن ف ــا. وفي ح ــة منه ــلبية في 11 حال ــراز س ــج زرع ال ــت نتائ ــوي، وكان ــاب مع ــة الته ــن 23 حال ــغ ع ــم أُبْلِ ــاعة. ك 24 س

ــد والحصــول عــى المعلومــات الوبائيــة في الوقــت 2009 الوبائــي العالمــي يتدخــل في الألعــاب الفرنكوفونيــة، كان مــن الــروري تعزيــز الترصُّ

ــاع نَهْــج متعــدد التخصصــات، والتدبــر العلاجــي في الوقــت المناســب والتنســيق. المناســب. وقــد تحقــق ذلــك مــن خــلال الاســتعداد، واتّب

Expérience du Liban en matière de surveillance des maladies transmissibles lors d’un rassemblement de masse : sixième édition des Jeux de la Francophonie , 2009

RÉSUMÉ En 2009, le Liban a accueilli la sixième édition des Jeux de la Francophonie. Le virus pandémique A(H1N1) 2009 représentait une menace sanitaire majeure à l’époque. Une stratégie de surveillance a été mise en place en vue d’une détection et d’une prise en charge rapides des événements épidémiologiques et des flambées, notamment de cas de virus A(H1N1)2009. Les données ont été collectées et gérées sur une base journalière, et une rétroinformation était générée au moyen de bulletins quotidiens. Un total de 299 consultations médicales a été rapporté, dont 29 % en rapport avec des maladies infectieuses. Dix cas d’infections respiratoires aiguës ont été notifiés. Tous se sont révélés négatifs au test de recherche du virus A(H1N1) 2009 réalisé sous 24h. Vingt-trois cas de gastroentérite ont été signalés, pour lesquels 11 coprocultures se sont révélées négatives. Si la pandémie A(H1N1) 2009 n’a pas impacté les Jeux, il était essentiel de renforcer la surveillance et de mettre en place un système d’information épidémiologique rapide. Ces objectifs ont été atteints au moyen d’une préparation, d’une approche multidisciplinaire, ainsi que d’une prise en charge et d’une coordination rapides.

1Ministry of Public Health, Beirut, Lebanon (Correspondence to: N. Haddad: [email protected]). 2University Medical Center − Rizk Hospital, Beirut, Lebanon. 3European Centre for Disease Control and Prevention, Stockholm, Sweden.


Report

Lebanon’s experience in surveillance of communicable diseases during a mass gathering: Sixth Francophone Games, 2009Nadine Haddad 1, Walid Ammar 1, Alfred Khoury 2, Alex Cox 3 and Nada Ghosn 1


119

Introduction

“Mass gathering” refers to the assembly, whether planned or spontaneous, of a large number of people attending a particular event (artistic, religious, social or sporting) for a certain time period (1). Whether the least number of as-sembly is defined as 1 000 or 25 000 (2,3), such events put multiple strains on the host community, particularly in terms of public health implications (1,4). Health risks associated with mass gatherings relate mainly to the increased transmission of communicable diseases, food and waterborne diseases, injuries, environmental threats and bioterrorism (5,6).

Documented experiences show mass gatherings are public health events of international concern, highlighting the need to implement public health and surveillance activities (7–12). Pub-lic health plans during mass gatherings rely on several components, such as disease surveillance and outbreak re-sponse, environmental and food safety, public health response, mass causality preparedness as well as public informa-tion and health promotion (1,5,6).

In 2009, Lebanon hosted the Sixth Francophone Games (6FG) from 27 September to 6 October (13). Ap-proximately 3 000 artists and athletes from 46 countries were expected. A “Francophone village” was designated at the Lebanese University Campus in Hadath (Mount Lebanon province) to accommodate all the participants, in ad-dition to their administrative and medi-cal representatives. The risk of increased transmission of communicable diseases was exacerbated in this event given the context at that time of the pandemic in-fluenza A(H1N1)2009 virus (14). The need for epidemiological surveillance during the Games was expressed by the international organizing committee. As a result, close collaboration between the national medical committee of the 6FG and the Lebanese Ministry of Public Health (MoPH) was established during

the preparation phase for the event. A surveillance team from the Epidemio-logical Surveillance Programme (Esu-moh) was designated to collaborate with the 6FG medical committee before and during the Games. An epidemio-logical surveillance and preparedness plan was developed, specifying needed activities, human resources and partner-ships.

The 6FG surveillance plan had 2 main objectives: i) to describe health events occurring during the Games in order to timely detect epidemiological alerts and outbreaks; and ii) to timely detect and manage A(H1N1)2009 cases in order to mitigate any related risks.

This paper describes the develop-ment of the public health and prepared-ness plan, its implementation before and during the Games and the health events reported during the Games.

Development of the public health and preparedness plan

SettingThe temporary Francophone Village included a village clinic that provided free medical consultations to all par-ticipants, volunteers and administrative personnel. Participants were also able to seek care from their delegations’ medi-cal representatives, when available. The Red Cross was ready at the campus and stadiums to transport patients to nearby hospitals. During the Games, an epidemiological surveillance team, which included 3 epidemiologists, was set up next to the village clinic.

Development of the planAs this was the first time Esumoh had conducted mass gathering surveillance, it was essential to review the experiences of other countries while bearing in mind the health threats that acute respira-tory infections would pose (8,15–21).

A thorough risk assessment was con-ducted in order to identify potential health risks. For each participating country, the websites of their health authorities were reviewed in attempt to build their epidemiological profiles. In addition, news websites were screened for reported national or local outbreaks. Diseases were then prioritized accord-ing to the likelihood of their occurrence during the 6FG. Priority diseases in-cluded acute watery diarrhoea, bloody diarrhoea, acute respiratory infection, non-febrile respiratory syndrome and febrile maculopapular rash (22–32).

The public health and preparedness plan was subsequently developed which included several components: enhanc-ing the national surveillance system, conducting site-specific surveillance, strengthening epidemic intelligence, providing guidelines and training on surveillance and case management, and implementing environmental surveil-lance.

Implementation of the plan before and during the Games

SurveillanceSurveillance during the 6FG relied on enhancing the national communicable diseases surveillance, as well as conduct-ing site-specific surveillance. Official circulars were issued by the MOPH to hospitals in Beirut and Mount Lebanon, requesting them to immediately report all mandatory notifiable diseases for the 6FG period.

Site-specific surveillance was initi-ated at the village clinic. Each medical consultation was documented using a standardized medical form, including information on patient identification, disease signs and diagnosis. In addition, the delegations’ medical representatives were asked to fill a daily zero reporting form specifying the number of acute res-piratory infections, gastroenteritis and


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other febrile diseases. Furthermore, the epidemiological team conducted regu-lar site meetings with the delegations’ medical representatives to enhance col-laboration.

Guidelines and trainingIn an attempt to have a uniform un-derstanding on case definitions and case management (Table 1), specific guidelines were adopted from the na-tional Esumoh surveillance guidelines. The guidelines were incorporated in the 6FG medical booklet, intended for in-ternal use within the village clinic. Prior to the start of the Games, training on site-specific surveillance was conducted for all medical personnel operating at the village clinic as well as the delega-tions’ medical representatives.

Data managementMedical forms and zero-reporting forms were collected and entered daily in specific databases using EpiData, ver-sion 3. Medical diagnoses written on the medical forms were coded using the 10th version of the International Clas-sification of Diseases. Daily analysis was conducted using Excel and compared the relative increase of health events to the previous 3 days.

Epidemic intelligenceEvent-based surveillance was conducted at the national and supra-national levels. Esumoh epidemiologists performed

daily screening of Al-Moktatafat, a daily bulletin that combines all health-related articles published in Lebanese news-papers. In addition, global screening of online sources using MediSys was provided by the European Centre for Disease Prevention and Control.

Environmental surveillanceBefore the 6FG, water samples were taken from the main campus reservoir and several water taps in different loca-tions. Bacteriological results were nega-tive. The campus kitchen was inspected and bacteriological stool cultures were performed for all 15 food handlers. Dur-ing the event, food specimens were col-lected daily from every served meal and preserved at 4–8 °C. They were to be tested in case of a foodborne alert. For entomological surveillance, light traps and filter papers soaked with castor oil were placed in the campus fields and the dormitory halls. Their locations were changed every other day, to optimize capturing. In addition, manual mos-quito captures were done by volunteers in the campus fields.

Reports and feedbackA two-page French bulletin summariz-ing reported cases and alerts was issued daily based on national and site-specific surveillance. Another daily English bulletin, Communicable Diseases Threat Report, for the 6FG was prepared jointly by the European Centre for Disease

Prevention and Control and Esumoh. The bulletins were communicated daily with the 6FG medical committee and delegates, and published on the MOPH website.

Prevention and controlAt the village clinic, the MOPH pro-vided stockpiles of essential drugs and antiviral medications, in addition to sets for specimen collection and personal protective equipment. Any acute res-piratory infection case was considered as suspected A(H1N1)2009 and was isolated in a dedicated room. He/she was treated immediately with antivirals while a sample was taken for testing by real-time reverse transcriptase polymer-ase chain reaction (RT-PCR). Based on the test result, treatment was either continued or suspended. The manage-ment of suspected cases was influenced by the experience in Serbia earlier that year (16). Posters in French focusing on hand hygiene, cough etiquette and influenza prevention were distributed throughout the Francophone Village.

Building partnershipsSeveral collaborations were essential to carry out these surveillance activi-ties. Expertise and technical support were provided by the World Health Organization (WHO) and the Euro-pean Centre for Disease Prevention and Control. WHO provided posters and brochures and supported the presence

Table 1 Case definitions, required specimens and laboratory tests for acute respiratory infection, gastroenteritis and febrile maculopapular rash

Health event Case definition Required specimen Laboratory tests performed

Acute respiratory infection Fever (≥ 38 °C) and one of the following signs: dry or productive cough, sore throat, coryza or sneezing

Nasopharyngeal swab

Real-time reverse transcriptase polymerase chain reaction (RT-PCR)

Gastroenteritis Fever (≥ 38 °C) and acute bloody or watery diarrhoea

Stool culture Bacteriological culture

Febrile maculopapular rash

Fever (≥ 38 °C) and maculopapular rash and cough or coryza or conjunctivitis

Oral swab Measles and rubella IgM serology


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of 2 epidemiologists. The European Centre for Disease Prevention and Control provided epidemic intelligence. Measles Immunoglobulin M (IgM) serology, water bacteriological testing and stool bacteriological culture were referred to the clinical laboratory of the Rafic Hariri University Hospital. Timely RT-PCR testing for influenza virus was provided by the research laboratory of the Rafic Hariri University Hospital. Entomological specimens were sent to the Faculty of Arts and Sciences at the American University of Beirut. Food bacteriological testing was undertaken by Fanar Laboratory of the Ministry of Agriculture.

Activities and events during the Games

Medical consultationsFrom 22 September to 7 October 2009, a total of 299 medical consultations were sought at the village clinic. The average daily number of consultations was 18, with a minimum of 3 (on 3 September) and a maximum of 38 (on 26 September). The main reasons for medical consultations on 26 September were headache and superficial injuries.

The largest proportion of medical consultations related to noncommu-nicable diseases (39%), followed by trauma and related musculoskeletal conditions (32%) and infectious diseas-es (29%). Among infectious diseases, consultations were for respiratory infec-tion (18%), watery gastroenteritis (8%), febrile illness (2%), bloody gastroen-teritis (0.5%) and icteric illness (0.5%) (Figure 1).

Acute respiratory infectionTwenty-one febrile respiratory infec-tions were reported from the village clinic. Medical delegates reported 7 other febrile respiratory infections. No clustering was observed.

Eight nasopharyngeal swabs were collected from patients with febrile res-piratory infection and 2 from patients with febrile syndrome. RT-PCR results were available within 24–48 hours from specimen collection. All swabs tested negative for A(H1N1)2009.

Acute gastroenteritisTwenty-three cases of gastroenteritis were reported from the village clinic and 5 from medical representatives the delegations. Bacteriological culture was performed on 11 stool specimens which all tested negative. On 5 October,

7 cases of watery gastroenteritis were re-ported which was an increase compared to a maximum of 2 in the previous days.

Daily zero reportingA total of 54 zero-reporting forms were received from the medical repre-sentatives of 14 delegations between 26 September and 1 October. Report-ing completeness was calculated as the number of received forms divided by the number of attending delegations. However, calculating daily complete-ness was difficult since delegations had different durations of stay. Nevertheless, considering only the 18 delegations that attended the training had medical repre-sentatives, the overall completeness rate ranged between 28 and 67%.

Environmental samplingBacteriological tests were negative for all water samples. One food handler tested positive for Salmonella sp. and was con-sequently excluded from the kitchen before the beginning of the 6FG. Food samples of the meals offered on 30 September were tested and revealed contamination with coliforms although the cause of the contamination was unknown. Entomological surveillance revealed the presence of Aedes cretinus.

Figure 1 Distribution of clinic consultations by condition during the Sixth Francophone Games, 22 September to 7 October 2009

39

32

18

8

2

0.5

0.5

0 5 10 15 20 25 30 35 40 45

Noncommunicable diseases

Trauma & musculoskeletal conditions

Respiratory infection

Watery gastroenteritis

Febrile illness

Bloody gastroenteritis

Icteric illness

%


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FeedbackEight daily Communicable Diseases Threat Report bulletins were issued in English, and 7 daily bulletins were issued in French. Information was disseminated daily to all stakeholders and uploaded online on the MOPH website.

Discussion

Although Lebanon had had previous experience in hosting regional events, the 6FG was the first mass gathering that integrated epidemiological surveil-lance activities and represents a valu-able learning experience, particularly given in the situation of the pandemic A(H1N1)2009 virus. Preparation with national and international stakeholders was an essential step for establishing and implementing the public health and preparedness plan.

For the success of the 6FG public health plan, collaboration functioned between Esumoh MOPH and all stake-holders and contributors at 3 different levels: with the 6FG medical committee within the Francophone Village, with the ministries involved and the refer-ence laboratories at the national level, and with participating delegations and supranational agencies at the interna-tional level.

The main element in the pandemic mitigation plan was the timely detec-tion, confirmation and case manage-ment of potential A(H1N1)2009 cases. Close collaboration between Esumoh and the reference laboratory ensured timely testing and feedback. Isolation of suspected cases prior to laboratory confirmation was necessary but incon-venient for athletes. Nevertheless, the mitigation plan was efficient as no in-crease in acute respiratory infections was recorded.

Trauma and related musculoskel-etal conditions accounted for almost one-third of the total medical consulta-tions; this was expected during an event

comprising sports competition (6). At the same time, the increase in gastroin-testinal cases was also expected as has been reported in the literature (6,11).

The gastroenteritis alert on 5 Oc-tober was detected one day following onset and coincided with the last day of the 6FG. Delegations were in the process of leaving at the time of detec-tion and therefore the epidemiological investigation was hindered. Only bac-teriological stool culture was available and the laboratory results all came back negative.

Food samples were tested follow-ing the gastroenteritis alert. However, results were only available 10 days after serving the contaminated meal on 30 September. The main lesson for future events would be to have mechanisms in place to ensure food safety so as to avoid possible foodborne infections, which is more effective approach than detecting contamination once it has occurred.

Zero reporting was an innovative tool in such event-specific surveillance. It was useful for detecting cases seek-ing care outside the clinic. However, assessing daily or overall completeness was difficult as the denominator varied daily according to length of stay of the delegations. In addition, delegates with-out medical staff were less compliant. In future similar events, length of stay of delegates should be known in order to adequately monitor completeness.

The presence of Aedes cretinus in en-vironmental samples collected from the Hadath area had already been found in a 2-year mosquito study conducted in Lebanon in 2005 (33). Nevertheless the need to improve the national vector surveillance and control programme is increasing, particularly with the chang-ing climate and ecological conditions that favour vector activity (34).

Conclusion

Mass gatherings present a unique epide-miological situation where the increased

risk of communicable disease transmis-sion can have national and international health implications. Mass gatherings and their associated risks are nowadays regarded as an emerging topic in global health and global epidemiology (12).

The 6FG was the first experience for Lebanon of implementing mass gather-ing surveillance. Although the size of this assembly was smaller compared to other documented regional mass gatherings, it enriches the literature given that most of the publications in the Eastern Mediterranean region relate to the annual Haj and other religious commemorations (35–39).

Our experience shows that, what-ever the type or size of mass gathering, available health infrastructure can be used through careful planning, part-nerships and close coordination with various sectors and actors. In order to replicate the 6FG experience in future events to be held in Lebanon, close col-laboration between the MOPH and other involved ministries is mandatory.

Moreover, surveillance activities should be continued after the mass gathering event ends. It would be ben-eficial to designate focal points from each participating country to provide feedback on the health status of their participants after returning to their home country.

Acknowledgements

We acknowledge the contribution of: Ziad Mansour (WHO Country |Of-fice, Lebanon); Denis Coulombier (European Centre for Diseases Con-trol and Prevention); Jacques Mokhbat (University Medical Center – Rizk Hospital); Pierre Zalouae (Rafik Hariri University Hospital Research Labora-tory), Rita Feghali (Rafik Hariri Univer-sity Hospital, Bacteriology Laboratory); Rima Hage (Ministry of Agriculture, Lebanese Agricultural Research In-stitute); Khouzama Knio (American University of Beirut, Faculty of Arts and


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9. Thackway S, Churches T, Fizzel J, Muscatello D, Armstrong P. Should cities hosting mass gatherings invest in public health surveillance and planning? Reflections from a decade of mass gatherings in Sydney, Australia. BMC Public Health. 2009 Sep 8;9:324.

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11. Landry P, Slama S. Pèlerinages et grands rassemblements: épidémiologie et prévention [Pilgimage and other mass gatherings: epidemiology and prevention]. Rev Med Suisse. 2004;4:1192–5.

12. Global mass gatherings: implications and opportunities for global health security. Report by the Secretariat. Sixty-fifth World Health Assembly. Provisional agenda item 13.8, 16 March 2012 (A65/18).

13. Organisation Internationale de la Francophonie. 6e Edition des Jeux de la Francophone, 27 septembre-6 octobre 2009, Beyrouth, Liban (http://www.francophonie.org/6e-edition-des-Jeux-de-la.html, accessed 17 December 2016).

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15. Jorm L, Thackway S, Churches T, Hills M. Watching the Games: Public Health Surveillance for the Sydney 2000 Olympic Games. J Epidemiol Community Health. 2003;57:102–8.

16. Loncarevic G, Payne L, Kon P, Petrovic V, Dimitrijveic D, Kn-ezevic T, et al. Public health preparedness for two mass gath-ering events in the context of pandemic influenza (H1N1) 2009 – Serbia, July 2009. Euro Surveill. 2009 Aug 6;14(31). pii: 19296.

17. Kreidl P, Buxbaum P, Santos-O’Connor F, Payne L, Strauss R, Hrabcik H, et al. European Football Championship - ECDC Epidemic Intelligence Support. Euro Surveill. 2008;13(7–9).

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Sciences); Ahmad Saleh and Rachelle Louis (Ministry of Public Health, Leba-non).

Funding: Surveillance activities were funded by the Lebanese Ministry of Pub-lic Health, World Health Organization

Country Office in Beirut and the Sixth Francophone Games Committee.Competing interests: None declared.


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المجلد الثالث والعشرونالمجلة الصحية لشرق المتوسطالعدد الثاني

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WHO events addressing public health priorities

Childhood overweight and obesity have reached alarming levels, both globally and in the WHO Eastern Mediterranean Region (EMR). In 2014, an estimated 41 million children under five years of age were overweight or obese, with the Region ranked third in prevalence, closely behind the Region of the Americas (1). Global data shows that in absolute numbers there are more overweight or obese children living in low- and middle-income than high-income countries (1). However, in the EMR, child overweight or obesity has become a notable public health challenge in high-income countries, affecting more than 50% of children in certain age groups (2).

Obesity is a key concern because it may cause chronic noncommunicable diseases, has the potential to negate health gains and may affect quality of life and life expectancy. In the Region, noncommunicable diseases are already re-sponsible for over 50% of mortality and more than 60% of the morbidity burden, with countries facing challenges in responding to current health needs (2). Policy measures that address the prevention of childhood overweight and obesity are of critical importance in preventing and mitigat-ing noncommunicable diseases. A key factor in the rise in childhood overweight and obesity is the widespread growth of an obesogenic environment with increased marketing of foods high in saturated fats, trans-fatty acids, free sugars or salt, specifically targeting children. Studies have shown that the marketing of these types of foods influences children’s food preferences, requests and consumption (3).

In 2010, the Sixty-third World Health Assembly in resolu-tion 63.14 endorsed a set of recommendations on marketing of foods and non-alcoholic beverages to children and called on Member States to restrict marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free-sugars or salt (4).

In 2011, the United Nations (UN) Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases urged Member States to promote the implementation of these recommendations (5). In 2012, the WHO Regional Committee for the Eastern Mediterranean (RC-EMR)

endorsed a regional framework for action, with strategic inter-ventions and indicators to assess country progress, as a road map for countries to implement the UN Political Declaration (6). Subsequently, in 2014, a ministerial panel discussion on the prevention of noncommunicable diseases held during the Sixty-first session of the WHO RC-EMR raised concern over the largely unopposed commercial practices that promote unhealthy products, particularly those targeting children (7), and in 2015, WHO held an open forum on addressing unopposed marketing of unhealthy foods and beverages to children in Amman, Jordan (8).

Recently, WHO organized an expert meeting to finalize a regional roadmap to address unopposed marketing of unhealthy foods/beverages to children in the Eastern Medi-terranean Region held in Cairo, Egypt on 21–22 June 2016 (9). The expert meeting was attended by global and regional experts in the areas of childhood overweight and obesity, marketing, the media and public health, and WHO staff from headquarters and regional levels.The objectives of the meeting were to:

• review the open forum recommendations;

• review the current evidence; and

• agree on a roadmap to address unopposed marketing of unhealthy foods / beverages to children in the Region.

Key challenges in the Region

The Region has a particular problem with childhood over-weight and obesity, with rates reaching as high as 14% and 22% amongst adolescent’s aged 13–15 in some countries (2). There is a well-established evidence base showing that the marketing of unhealthy food and beverages is driving this epidemic (3).

The Region represents a major and rapidly growing market for the unhealthy food and beverage industries and these industries are among the top spenders on marketing. While marketing of unhealthy food and beverages is already extensive, increases in expenditure and the number of com-munication channels mean that it will continue to grow.

A regional roadmap to address unopposed marketing of unhealthy foods/beverages to children in the Eastern Mediterranean Region1

1 This report is extracted from the Summary report on the Expert meeting to finalize a regional roadmap to address unopposed marketing of unhealthy foods/beverages to children in the Eastern Mediterranean Region, Cairo, Egypt 22–21 June 2016 (http://applications.emro.who.int/docs/IC_Meet_Rep_2016_EN_19189.pdf?ua=1, accessed 8 March 2017).


126

Television remains the most important medium for advertising unhealthy food and beverages, but advertising through digital media is also growing rapidly. Extensive use is also made of celebrities and sponsorship of youth-oriented programmes and events. An increasingly common language and culture among young people is extending the reach of marketing beyond national borders, especially via private satellite television broadcasting outlets. This cross-border marketing requires regulation in both source and recipient countries (9).

As a response to the above challenges, WHO launched a regional initiative to address the issue with the support of global experts and through various forms of consultation, to explore strategic ways to address unopposed marketing of food and non-alcoholic beverages specifically targeting children.

Recommendations

The following strategies and interventions for Member States were identified by the experts to address the unopposed marketing of unhealthy foods and beverages.

1. Banning advertising of food high in saturated fats, trans-fatty acids, free sugars or salt to children in all media.

2. Specifying children’s television watching hours for non-advertising of food high in saturated fats, trans-fatty acids, free sugars or salt; for example, non-advertising if 10% of the audience is under 16 years or non-advertising before 22.00 hours.

3. Banning marketing of unhealthy foods and beverages high in saturated fats, trans-fatty acids, free sugars or salt in school premises and surroundings, as well as other places frequent-ed by children (such as hospitals).

4. Introducing effective taxes (above 20%) on sugar-sweet-ened drinks.

5. Mandating interpretive front of pack labelling supported by the public education of both adults and children for nutri-tion literacy.

6. Banning the use of branded and licensed cartoons, toys, gifts and other inducements.

7. Imposing a levy on remaining marketing of unhealthy food and beverages to fund public authorities to monitor impact of policies.

8. Undertaking consistent social marketing and school-based education to increase awareness and understanding of po-tential harms and manipulation caused by unhealthy food and beverage marketing.

9. Adapting school curricula to educate children (and parents) about the manipulative and harmful nature of unhealthy food and beverage marketing.

10. Working with audiovisual and broadcasting authorities (sat-ellite television and other channels) to control cross-border advertising.

11. Setting up a communication mechanism for people to express their concerns.

References

1. World Health Organization. Overweight and obesity: factsheet. Geneva: World Health Organization; 2016 (http://www.who.int/mediacentre/factsheets/fs311/en/, accessed 8 March 2017).

2. World Health Organization. Regional strategy on nutrition 2010–2019. Cairo: Regional Office for the Eastern Medi-terranean; 2010 (http://applications.emro.who.int/docs/EM_RC57_4_en.pdf?ua=1, accessed 8 March 2017).

3. Jolly R. Marketing obesity? Junk food, advertising and kids. Canberra: Parliament of Australia; 2011 (http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parlia-mentary_Library/pubs/rp/rp1011/11rp09, accessed 8 March 2017).

4. World Health Organization 63rd World Health Assembly. Marketing of food and non-alcoholic beverages to children, agenda item 11.9. Geneva: World Health Organization; 2010 (http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R14-en.pdf, accessed 8 March 2017).

5. United Nations General Assembly. High level meeting on prevention and control of non-communicable diseases. New York: United Nations; 19–20 September 2011 (http://www.un.org/en/ga/ncdmeeting2011/, accessed 8 March 2017).

6. World Health Organization. Noncommunicable diseases: regional framework for action. Cairo: Regional Office for the Eastern Mediterranean; 2012 (http://www.emro.who.int/noncommunicable-diseases/framework-for-action/index.html, accessed 8 March 2017).

7. Sixty-first session of the WHO regional committee for the Eastern Mediterranean. Cairo: Regional Office for the Eastern Mediterranean; 2014 (http://www.emro.who.int/about-who/rc61/sixty-first-session-of-the-regional-committee-for-the-eastern-mediterranean.html, accessed 8 March 2017).

8. WHO Regional Office for the Eastern Mediterranean. Open forum on addressing unopposed marketing of unhealthy foods and beverages to children. Amman, Jordan, 13–14 September 2015 (http://apps.who.int/iris/handle/10665/204297, ac-cessed 8 March 2017).

9. WHO Regional Office for the Eastern Mediterranean. Expert meeting to finalize a regional roadmap to address unop-posed marketing of unhealthy foods/beverages to children in the Eastern Mediterranean Region, Cairo, Egypt 21–22 June 2016 (http://applications.emro.who.int/docs/IC_Meet_Rep_2016_EN_19189.pdf?ua=1, accessed 8 March 2017).

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