Screening and determinant of suspected developmental delays among Egyptian preschool-aged children: a cross-sectional national community-based study

Background

Early childhood life is critical for optimal development and is the foundation of future well-being. Genetic, sociocultural, and environmental factors are important determinants of child development.

Aim

The objectives were to screen for suspected developmental delays (DDs) among Egyptian preschool children, and to explore the determinants of these delays based on sociodemographic, epidemiological, maternal, and child perinatal risk factors.

Methods

A national Egyptian cross-sectional developmental screening of a representative sample of preschool children (21,316 children) aged 12 to 71 months. The Revised Denver Prescreening Developmental Questionnaire (R-PDQ) followed by the Denver Developmental Screening Test, 2nd edition (DDST) was used.

Results

Each screened child manifested at least one of six developmental categories. Either typical development, gross motor delay (GM), fine motor adaptive delay (FMA), Language delay (L), Personal-social delay (PS), or multiple DDs. The prevalence of preschool children with at least one DD was 6.4%, while 4.5% had multiple DDs. Developmental language delay was the most prevalent, affecting 4.2% of children. The least affected domain was GM (1.9% of children). Boys were more likely to have DD than girls. Children in urban communities were more likely to have at least one DD than those in rural areas (OR = 1.28, 95%CI: 1.14–1.42), and children of middle social class than of low or high social class (OR = 1.49, 95%CI: 1.30–1.70 & OR = 1.40, 95%CI: 1.23–1.59 respectively). The strong perinatal predictors for at least one DD were children with a history of postnatal convulsions (OR = 2.68, 95%CI: 1.97–3.64), low birth weight (OR = 2.06, 95%CI: 1.69–2.52), or history of postnatal cyanosis (OR = 1.77, 95%CI: 1.26–2.49) and mothers had any health problem during pregnancy (OR = 1.73, 95%CI: 1.44–2.07). Higher paternal and maternal education decreased the odds of having any DD by 43% (OR = 0.57, 95% CI: 0.47–0.68) and 31% (OR = 0.69, 95%CI: 0.58–0.82) respectively.

Conclusion

This study demonstrates a considerable attempt to assess the types and the prevalence of DD among preschool children in Egypt. Perinatal factors are among the most common determinants of DD in preschool children and the majority could be preventable risk factors.

Prevalence and risk factors of disabilities among Egyptian preschool children: a community-based population study

Background

Child disability has significant implications on their well-being and healthcare systems. Aim: This survey aimed to assess the magnitude of seven types of disability among Egyptian children aged 1 < 6 years and their socio-demographic, epidemiological, and perinatal predictors.

Methods

A national population-based cross-sectional household survey targeting 21,316 children from eight governorates was conducted. The screening questionnaire was derived from the WHO ten-question survey tool validated for identifying seven disability categories.

Results

The percentage of children with at least one disability was 8.1% as follows: speech/communication (4.4%), Mobility/physical (2.5%), Seizures (2.2%), Comprehension (1.7%), Intellectual impairment (1.4%), Visual (0.3%) and Hearing (0.2%). Age was not found to affect the odds of disability except for visual disability (significantly increased with age (AOR = 1.4, 95% CI:1.1–1.7). Male sex also increased the odds of all disabilities except visual, hearing, and seizures. Convulsions after birth significantly increased the odds of disability as follows: hearing (AOR = 8.1, 95% CI: 2.2–30.5), intellectual impairment (AOR = 4.2, 95% CI: 2.5–6.9), and mobility/physical (AOR = 3.4, 95% CI: 2.3–5.0). Preterm delivery and being kept in an incubator for more than two days after birth increased the odds for visual disability (AOR = 3.7, 95% CI: 1.1–12.1 & AOR = 3.7, 95% CI: 1.7–7.9 respectively). Cyanosis increased the odds of seizures (AOR = 4.7, 95% CI: 2.2–10.3). Low birth weight also increased the odds for all disability domains except for visual and hearing. Maternal health problems during pregnancy increased the odds for all types of disability except hearing and seizures. Higher paternal education decreased the odds for all disabilities by at least 30% except for vision and hearing.

Conclusion

The study found a high prevalence of disability among Egyptian children aged 1–6 years. It identified a number of modifiable risk factors for disability. The practice of early screening for disability is encouraged to provide early interventions when needed.

National screening for developmental delays and their determinants among Egyptian school age children: A step towards implementing life skills programs

Aim

This study aimed to estimate the national prevalence of developmental delays (DDs) and their determinants among Egyptian children aged 6 to 12 years. Such estimation is a prerequisite step toward the application of Life Skill Education (LSE) programs that will potentiate children’s future capabilities.

Methods

Vineland Adaptive Behavior Scales” was used as a reliable and diagnostic test for DDs screening during this national cross sectional study. Gross motor (GM), fine motor (FM), daily living skills, communication, and socialization skills were assessed. The multivariate logistic regression analysis was used to identify factors associated with DDs. The Adjusted Odds Ratio (AOR) with a 95% Confidence Interval was estimated to indicate the strength of association. A p-value of <0.05 was used to declare statistical significance.

Results

Out of the 20324 surveyed school-aged children, 7.4% were found to have at least one delay. Communication deficits were the most common (6.4%) followed by delay in daily living skills (2.0%). The final model of logistic regression had a good fit for seven variables out of the sociodemographic, epidemiological characteristics, maternal and perinatal problems that were associated with a higher likelihood of at least one DD: Children suffering from any convulsions (AOR = 4.32; 95% CI: 3.18–5.88), male gender (AOR = 1.86; 95% CI: 1.65–2.09), birth weight less than 2.5 kg (AOR = 1.77; 95% CI: 1.40–2.24), history of maternal health problem during pregnancy (AOR = 1.64; 95% CI:1.34–2.01), children staying in an incubator for more than two days (AOR = 1.57, 95% CI: 1.29–1.91), having less educated fathers (AOR = 1.55, 95% CI: 1.24–1.95) and belonging to the middle social class (AOR = 1.40, 95% CI: 1.24–1.58).

Conclusion

The identified types and determinants for each DD are allowing for the implementation of tailored programs for school children’s life skills promotion for achieving the most sustainable effects on children’s biological and psychological health and well-being.

A national screening for the prevalence and profile of disability types among Egyptian children aged 6–12 years: a community-based population study

Aim

This study aimed to determine the prevalence of disability domains among Egyptian children in the age group of 6–12 years as well as assess their socio-demographic, epidemiological, and perinatal predictors.

Methods

A national population-based cross-sectional household survey targeting 20,324 children from eight governorates was conducted. The screening questionnaire was derived from the WHO ten-question survey tool validated for the identification of disabilities.

Results

The prevalence of children with at least one type of disability was 9.2%. Learning/ comprehension was the most prevalent type (4.2%), followed by speech/communication (3.7%), physical/ mobility and seizures (2.2% for each), intellectual impairment (1.5%), visual (0.7%), and hearing (0.4%). The commonest predictors for disabilities were children who suffered from convulsions or cyanosis after birth and maternal history of any health problem during pregnancy. However, preterm and low birth weight (LBW) babies or being admitted to incubators for more than two days were strong predictors for all disabilities except hearing disability. A history of jaundice after birth significantly carried nearly twice the odds for seizures (AOR = 2.2, 95% CI:1.5–3.4). History of difficult labor was a predictor of intellectual impairment (AOR = 1.5, 95% CI:1.1–2.0). A disabled mother was a strong predictor for all disabilities except seizures, while a disabled father was a predictor for visual and learning/ comprehension disabilities (AOR = 3.9, 95% CI:2.2–7.1 & AOR = 1.6, 95% CI:1.1–2.4 respectively). Meanwhile, both higher maternal and paternal education decreased significantly the odds to have, physical/ mobility and Learning/ comprehension by at least 30%.

Conclusion

The study found a high prevalence of disability among Egyptian children aged 6–12 years. It spotted many modifiable determinants of disability domains. The practice of early screening for disability is encouraged to provide early interventions.

National screening for Egyptian children aged 1 year up to 12 years at high risk of Autism and its determinants: a step for determining what ASD surveillance needs

This study aimed to provide a national estimate of the prevalence of the high risk of autism spectrum disorder (ASD) and their determinants. A national screening survey was conducted for 41,640 Egyptian children aged 1 to 12 years in two phases. Tools used were Vineland's Adaptive Behavior Scales, Modified Checklist for Autism in Toddlers, Gilliam Autism Rating scale, and Denver II Developmental screening test. The overall prevalence of children at high risk of ASD was 3.3% (95% CI:3.1%–3.5%). Children living without mothers in homes, suffered from convulsions (AOR = 3.67; 95%CI:2.8–4.8), a history of cyanosis after birth (AOR = 1.87; 95% CI:1.35–2.59) or history of LBW babies (AOR = 1.53; 95% CI:1.23–1.89) carried higher odds of being at high risk of ASD.

Promoting weaning practices and growth of Egyptian infants by using communication for behavioral development approach

Background

Access to various affordable and nutritious foods is considered a challenging factor for households with limited resources affecting the proper weaning practices. In order to motivate communities to adhere to the right and proper weaning practices, the social aspect should be considered through close communication with the targeted communities. This study aimed to evaluate how impactful the use of the principles of Communication for Development (C4D) that respect parents’ beliefs and their cultural norms is in improving the weaning practices and growth of infants in an Egyptian village.

Methods

An interventional three-phase study was conducted for three years. The intervention targeted 464 mothers of infants up to 2 years of age. C4D interventions encouraged each mother to provide her baby with nutritious and varied options through age-appropriate introduction and diversification of nutrient-rich complementary foods under the slogan “ enjoy meals like a baby”. The effectiveness of the approach was measured by five essential weaning practices: Introduction of solid, semi-solid, or soft foods, Minimum dietary diversity, minimum meal frequency, Minimum acceptable diet, and consumption of iron-rich foods.

Results

There was marked and significant improvement in the awareness and of the majority of the weaning practices’ indicators as a result of the interventions. This was noticed for the timely introduction of complementary foods which increased from 36.7% to 82.0%, the minimum meal frequency indicator (3–5) which increased from 25.3% to 67.3%, iron-rich or fortified food (68.0% to 82%) as well as a regular checkup for baby health at the health unit (71.3%). Indicators that were improved but failed to achieve the target were the “Minimum Dietary Diversity” (reached 32%) and the minimum acceptable diet (reached 22.0%). A significant effect on linear growth especially for females is evidenced by the remarkable decrease in wasting (from 31.5% to 11.1%) and obesity (from 12.0% to 0%) associated with a considerable decrease in underweight (from 40% to 16.7%).

Conclusion

Targeting caregivers through the C4D approach have succeeded in providing them with the support required for the provision of adequate nutrition for their infants that had significantly marked improvement in growth indices of their infants.

A national prevalence and profile of single and multiple developmental delays among children aged from 1 year up to 12 years: an Egyptian community-based study

Objective

This study aimed at providing a national prevalence of single and multiple developmental delays (DDs) among 41,640 Egyptian children aged 1 to 12 years and exploring DDs’ associated risk and protective factors.

Methods

A national household survey from eight governorates of Egypt representing the four major subdivisions of Egypt was conducted through systematic probability proportionate to size. All enrolled children were assessed according to Vineland Adaptive Behavior Scales, (VABS) as a reliable screening questionnaire for identifying categories of DDs that were verified by pediatrics’ specialists.

Results

The overall prevalence of children with DDs was 6.7%. The prevalence of a single DD was 3.9% versus 2.8% multiple DDs. Communication deficit was the most prevalent type (5.3%). Lower prevalence was identified for fine motor delay (1.0%), gross motor delay, and socialization deficit (1.5% each). Whereas deficits in daily life skills (self-help and adaptive behavior delay) amounted to 2.3%. Living without mothers and/or fathers in homes was associated with increased odds of having DDs by one and a half times (OR = 1.72 and OR = 1.34 respectively). Multiple logistic regression analysis revealed the most predictors for DDs including children who suffer from convulsions after birth (OR = 3.10), low birth weight babies (OR = 1.94), male sex (OR = 1.75), mothers having health problems during pregnancy (OR = 1.70) and belonging to middle socioeconomic status (OR = 1.41). Children who suffered from cyanosis after birth was found to be at risk for any or multiple DDs. Difficult labor was significantly associated with increased odds for multiple DDs (OR = 1.55). Higher paternal and maternal education was associated with decreased odds to have any DDs by 40% (OR = 0.60 and OR = 0.58 respectively).

Conclusions

The detected prevalence of DDs is within the estimated range of prevalence of DDs for the pediatric population. The majority of the detected risk factors are preventable. Developmental screening is recommended to be implemented in all primary care settings as a routine practice.

A comparison of the performance of normal middle social class Egyptian infants and toddlers with the reference norms of the Bayley Scales -third edition (Bayley III): A pilot study

Background

Developmental assessment is an important facility for early detection and intervention of developmental delay in children. Objective: to assess the performance of a sample of middle social class Egyptian infants and toddlers on Bayley Scales of Infant and Toddler Development-third edition (Bayley III), and to compare their cognitive, motor, and communication scores with that of the reference norms.

Methods

It was a cross-sectional pilot study, included 270 children aged 18–42 months. Mothers filled a questionnaire including questions about family socioeconomic background, perinatal history, and family history. Physical examination and growth assessment of children were performed. Developmental assessment of cognitive, language and motor skills was performed using the Bayley III scales and compared the American norm scores with the Egyptian mean scores.

Results

The mean cognitive, language and motor composite scores were 92.5+18.5, 91.76+ 15.6, and 95.67+18.9 respectively. All were lower than the American mean (100+ 15) with highly significant differences. About one-fourth of the enrolled Egyptian children had below-average composite scores according to the US cutoff point. The ranks of Egyptian children on the American versus the Egyptian percentile curves were significantly different.

Conclusion

Mean values of all assessed developmental domains of Egyptian children are within the norm-referenced average of Bayley III, but lower than the recorded American mean. Assessing Egyptian children according to the American norms may result in overestimating developmental delay. This pilot study raised the question about using different cutoff points suitable for the developmental trajectory of Egyptian children. Answering this question needs further studies on Bayley-III after cultural adaptation and standardization, using a larger, more diverse, and representative sample of the Egyptian population.

Assessing the Effective Communication Channels to Reduce Child and Adolescent Marriage in Rural Communities of Egypt

BACKGROUND: Low levels of scholarly achievement, poverty, and geographical isolation are all known to be linked to early marriage. AIM: This study aimed at identifying the most credible and the best-suited communication channels (CCs) to reach rural communities for motivating them to reduce child and adolescent marriage. METHODS: This study was a community-based cross-sectional systematic formative research. The study targeted 1000 wives who were ever married women in childbearing period aged 15–49 years and their husbands in 21 rural village units of two governorates of Upper Egypt through questionnaires. Decisions concerning the choice of the best-suited CCs were based on their reach, frequency, managerial feasibility, and effectiveness. The investigated CCs included: modern social media (search browser engine/Facebook group and/or twitter/YouTube or messaging through WhatsApp or any mobile app), traditional mass media (T.V/Radio/Reading), and interpersonal communication (talk with religious leaders/partners/friends/doctors/health promoters). Comparisons between different CCs were done using odds ratios (OR) and 95% confidence intervals (CI). RESULTS: A vast majority of the surveyed wives (96.6%) were married at an age ranging from 15 to 24 years. The spread of social media through smartphones was limited to only one-third of wives and their husbands through mainly searching on YouTube (31.7% of wives and 27.8% of husbands). Television was the most accessible means of mass media for both wives and husbands (72.5% and 63.3%, respectively). The most credible and the best-suited CCs methods for wives were talking with the health promotors and doctors with 2 times significantly higher (OR = 2.0, CI = 1.7–2.4 for each one) than that with the search on YouTube and 3 times significantly higher (OR = 3.1, CI = 2.5–3.7 and OR = 3.1, CI = 2.6–3.8, respectively) than that for social media using browser engine. For husbands, the odds of the most credible and the best-suited CCs methods were more than 1½ times higher for the talk with the health promotors than the search on You Tube (OR = 1.6, CI = 1.3–2.0) or the search using browser engine (OR = 1.6, CI = 1.3–1.9), Whereas the odds were one and a third higher for the talk with the doctor than the search on You Tube (OR = 1.3, CI = 1.1–1.6) or the search using browser engine (OR = 1.6, CI= 1.1–1.6). Significant difference was detected in favor of the traditional media as the most credible source of information only for wives’ intention to postpone their children early marriage. CONCLUSIONS: Despite the availability of recent social media worldwide, rural communities with high illiteracy have limited access to the internet and limited availability of smartphones. Interpersonal communication is considered their most effective CCs for achieving equity in reducing child marriage. It seems vital during the implementation of any strategies toward reproductive health to use not only the media broadcasts, but also to rely on the channels that are most credible and suitable for the targeted communication to support meeting the unmet need.

Determinants Influencing Awareness and Healthy Practices among a Sample of Insulin-dependent Diabetic Egyptian Patients: A Rural Community-based Study

BACKGROUND: The prevalence of diabetes mellitus (DM) is predicted to increase over the coming years. AIM: The objectives of the study were to measure the level of awareness and healthy practices related to five healthy domains and assess the effect of different demographic characteristics, glycated hemoglobin (HbA1c) level, and body mass index (BMI) on these levels among diabetic patients in a rural Egyptian village. METHODS: A cross-sectional study was done on 300 selected insulin-dependent diabetic patients resident in an Egyptian village. Data were collected using a questionnaire covering five domains: General disease awareness and management compliance practice, check-up, foot care, diet, and physical activity. HbA1c and BMI were also measured as an impact of the management adherence. RESULTS: The study found that more than three quarters of the participants (82.0%) were uncontrolled or poorly uncontrolled (HbA1c >8) diabetics and 76.0% were either obese or morbidly obese. Total awareness and practices percentage scores were low (42.4 ± 16.8% and 40.5 ± 12.3%, respectively). The linear regression model showed that high educational level had significantly positive effects on both the total awareness and practice scores as well as their domains. The study found that female participants and those having relatives with DM had significantly higher diet awareness and practice scores (p < 0.05). Younger age had significantly higher scores on foot care and diet awareness scores, physical activity, general disease awareness, and management compliance practices domains. CONCLUSION: The studied awareness and practice domains were inadequate. Their improvement is cornerstones to impact glycemic control of diabetics and control their health risks, especially in rural communities.

Egyptian patients’/guardians’ experiences and perception about clinical informed consent and its purpose: Cross sectional study

Background

Informed consent (IC) is a healthcare standard emphasizing the meaning of human dignity as clarified in the Universal Declaration of Human Rights. Data about IC practices in Egypt is insufficient. This study aimed to assess the Egyptian patients’/guardians’ experiences about IC and their expectations about its practices’ purposes in general and according to the type of the healthcare facility.

Methods

Self-administered questionnaire was carried out for 1092 participants who had undergone or were scheduled to a procedure requiring an IC at three studied types for Egyptian health care facilities. Ten statements were ranked twice by the participants to reflect their perception of IC purpose as per what is currently practiced and what they believe should be practiced.

Results

IC implementation varies significantly (p<0.05) across the health care facilities in Egypt. The percentage of its implementation at the non-governmental facilities, governmental facilities, and university hospital was 85.9%, 77.8%, and 63.8 respectively. The first three ranked purposes of the current IC practices were: “Helping patient/guardian decide (64.9%)”, “Documenting patient’s/guardian’s decision (59.3%)”, and “Having shared decision (57.3%)”. The perceived purposes of IC to be practiced were: “Informing the patient/guardian (68.4%)”, “Making sure patient/guardian understand (65.3%)” and “Documenting patients/guardians decisions (65.1%)”. “Being a meaningless routine” was reported by the majority to be ranked as a low purpose for IC current and preferred practices.

Conclusion

The practice of IC is common within the Egyptian medical community. Participants believe that information disclosure “Making sure patients understand” has to help in IC decision making and its main purpose. However, unfortunately, this is not perceived as a current purpose of IC. There was consensus agreement that documenting the patient’s/guardian’s decision and informing the patient/guardian are perceived as both important current and preferred purposes for IC practices.

Accelerating Hepatitis C virus elimination in Egypt by 2030: A national survey of communication for behavioral development as a modelling study

Aim of the work

This study aimed at assessing the dominance of risk practices associated with HCV endemicity in Egypt and detecting the behavioral development level concerning different aspects of HCV risk behaviors with respect to age and gender. The survey highlights the most cost-effective strategies that could accelerate HCV elimination in Egypt.

Subjects and methods

A national household survey targeted 3780 individuals (age range: 10–85 years). The sample was a systematic probability proportionate to size from 6 governorates representing the six major subdivisions of Egypt. The indicators used for assessing the behavioral development level towards HCV included six domains: awareness (7 indicators), perceived risk (5 indicators), motivation with the intention to change (4 and 5 indicators for males and females respectively), trial, rejection or adoption (6 and 5 indicators for males and females respectively).

Results

The study revealed that along the continuum of behavior development, the percentage of the participants who acquired half of the scores was as follows: 73.1% aware, 69.8% developed perceived risk, 80.6% motivated with only 28.9% adopting the recommended behaviors, 32% rejected them, 2.3% were in the trial stage versus 35.8% who did not try any. Adolescents had significantly lower levels of development for almost all domains when compared to adults. Statistical higher significance was detected in favor of adults, employees, married, Lower Egypt governorates, and university-educated participants (p<0.001) regarding awareness, perceived risk, and motivation scores. More than half of the participants incorrectly believed that contaminated food, sharing food utilities, contaminated water, mosquitoes, and schistosomiasis would lead to HCV transmission.

Conclusion

Egypt would be closer to HCV elimination when cost-effective strategies are directed not towards creating awareness, perceived risk or motivation to change- (at an acceptable level)- but towards motivating adopting risk-reduction behaviors for HCV, tackling misconceptions and reinforcement of social support.

Strengths of community and health facilities based interventions in improving women and adolescents’ care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt

Background

Provision of emergency obstetric care is considered the key for maternal mortality reduction worldwide. This study evaluated the impact of community- and facility-based educational programs on provision of emergency obstetric care in Egypt. The study focused on evaluating utilization of the available health services and care seeking behaviors of mothers in the childbearing period.

Methods

We implemented a package of community- and facility-focused educational interventions in two of Egypt’s lowest income governorates. At facility level, health professionals at rural health units from 21 villages over 5 years were trained. Mass media gathering, individual teaching at health facilities, printed materials and home-based care sessions were provided. Collectively, these interventions were designed to focusing on recognition of the early warning signs during pregnancy, delivery and postpartum period for timely referral to hospitals for 20,494 women and adolescents mothers.

Results

The impact of the interventions was highly reflected on the percent of mothers received care during their pregnancy period. Proper antenatal care at governmental or private health facilities was raised dramatically from 0.6 to 59.3% and those who utilized at least one family planning method from 61.4 to 74.4%. Accordingly, the rate of complications significantly reduced during pregnancy (38.1 to 15.1%), during delivery (24.1 to 13.1%) and during postpartum (81.7 to 7.0%). As an impact to the improvement, there was a marked reduction in adolescent pregnancy by 55% and better birth outcome with a reduction in the percent of stillbirth by 11.5%.

Conclusion

It is important to provide a comprehensive package that works at both improving qualities of care as well as empowering women by knowledge to first aid measures at the community level. The cost-effective way to empower mothers to provide first aid measures as emergency obstetric care is to adopt the outreach approach which could be more influential than mass media campaigns for the at-risk and vulnerable and low-income communities.

Egyptians' social acceptance and consenting options for posthumous organ donation; a cross sectional study

Background

Organ donation has become one of the most effective ways to save lives and improve the quality of life for patients with end-stage organ failure. No previous studies have investigated the preferences for the different consenting options for organ donation in Egypt. This study aims to assess Egyptians’ preferences regarding consenting options for posthumous organ donation, and measure their awareness and acceptance of the Egyptian law articles regulating organ donation.

Methods

A cross sectional study was conducted among 2743 participants over two years. Each participant was required to rank eleven consenting options from 1 (most preferred) to 11 (least preferred), and to report his awareness and acceptance of the seven articles of the Egyptian law of organ donation.

Results

47% of the participants expressed willingness to donate their organs after death. This percentage increased to 78% when consenting options were explained to participants. “Informed consent by donor only” was the most preferred type of consent for one third of respondents. Awareness of the law articles regulating organ donation was relatively low ranging from 56% to 23%.

Conclusion

Currently, around half of the Egyptian population agree to posthumous organ donation. This percentage could be increased significantly by raising the awareness about how the process of donation could be regulated and how the patient’s right of decision could be protected.

Stunting and its Determinants among Governmental Primary School Children in Egypt: A School-based Cross-sectional Study

BACKGROUND: In developing countries, stunting among children is a major public health concern. It affects all aspects of children’s lives; its effects are not constrained to physical wellbeing but reach out to mental, social, and spiritual wellbeing. AIM: The aim of this study is to determine the prevalence of stunting in some of the Egyptian governmental primary school children and its nutritional and socioeconomic determinants. METHODS: A cross-sectional observational study was conducted on primary school children aged 6–12 years. General demographic, socioeconomic, and anthropometric data, as well as dietary pattern, were collected. RESULTS: Out of 1740 children, 7.8% were stunted. Not eating eggs and dairy products had the most profound effect on stunting in children (p < 0.001). Not having meals on time, skipping breakfast, and having <3 meals per day were predictors of stunting (p = 0.003, p = 0.00, and p = 0.008, respectively). Mother’s education (p = 0.005) followed by family income (p = 0.007) was the most affecting social factors. CONCLUSION: There are many nutritional factors associated with stunting as skipping breakfast, not having meals on time, and having <3 meals per day. Scarcity in nutritive foods as eggs and dairy products and increased soft drink intake can lead to stunting. There are many enabling social factors for stunting as mother’s education and family income. However, the effects of these factors can be modified by health awareness.

Impact of Nutritional Health Education on Knowledge and Practices of Mothers of Anemic Children in El Othmanyia Village – Egypt

BACKGROUND: In Egypt, more than one in four children suffers from some degree of anemia. AIM: This study was carried out to assess and improve the nutritional knowledge and risky nutritional habits of the mothers of anemic children aged 2–12 years old in El Othmanyia village. MATERIALS AND METHODS: An interventional study was conducted among anemic children aged 2–12 years old and their mothers in El Othmanyia village, Egypt. The study passed through three stages over 1 and ½ years; pre-interventional assessment of awareness (n = 350), educational interventions targeting anemic children and their mothers, and post-interventional evaluation of change in awareness and practice. RESULTS: The mean knowledge % score of mothers increased significantly after the intervention (82.2 ± 14.2 vs. 6.3 ± 5.8, respectively). Furthermore, the mean hemoglobin of the studied children increased significantly after the intervention (11.1 ± 0.7 vs. 10.5 ± 0.7). The percent of children with anemia decreased significantly from 100% to 40.3% after the intervention (p < 0.001). CONCLUSION: The knowledge and practices of mothers are moving in a desirable direction after the health education intervention. Hence, nutrition education is an appropriate, effective, and sustainable approach to combat iron deficiency anemia. Recommendations: A multiple interventional strategies between different ministries to set policies and guidelines that support the healthy nutritional behavior among children are recommended.  

Vulnerability and Weaknesses of Eating Habits of Overweight School Children as an Entry Risk for COVID-19

BACKGROUND: In developing countries, overweight among children becomes an alarming problem and a health concern. Obesity is a factor in disease severity of coronavirus disease (COVID-19) having the greatest impact on patients. AIM: The aim of this study was to determine the prevalence of overweight in some of the Egyptian governmental primary school children, its nutritional and socioeconomic determinants. Special focus was directed to identify the current dietary practices including risky nutritional habits of overweight children as a weak point leading to increasing their vulnerability to catching COVID-19 infection. METHODS: A cross-sectional observational study was conducted on primary school children aged 6–12 years. General demographic data, socioeconomic data, dietary pattern, intake of a diversity of nutrient-rich food versus calorie-dense food, and anthropometrical data were collected. RESULTS: Of 1600 child, there were 8% overweight who are considered at risk of COVID-19 infection. Considering the weekly share of the stomach, only one-third of the food consumed by overweight children is nutrient-rich, with high consumption of French fries and Candies (once per day among 95% and 78 % of overweight children, respectively). Moreover, 90% of them consume sugar-sweetened beverages (SSB) more than once per day. The majority of overweight children belonged to small, middle- income families, and had illiterate or read and write mothers. CONCLUSION: Overweight children eat narrow diversity of nutrient-rich food that includes vegetables, fruits, protein, and dairy products. They eat more calorie-dense foods, every day. The increase of family income increased the likelihood of having overweight children with a high intake of SSB, candies, and chips; consumption of snacks between meals and before sleep. Protective predictors against overweight were highly educated mothers, taking breakfast before school, having dinner, and taking meals on time. RECOMMENDATION: Nutritional behavioral education aiming at choosing nutritious and varied options of food that is effective for improving children’s nutritional status is the key to decreasing vulnerability toward COVID 19.

Common Phobias among Egyptian Primary Schoolchildren: An Emergency Trigger for Panic Disorder due to Corona Pandemic

BACKGROUND: In the wake of the adverse situation we are currently facing globally due to the coronavirus pandemic outbreak, it is normal to feel stressed, confused, and scared but what is abnormal is to turn this to panic. Phobias are more pronounced than fears. They develop when a person has an exaggerated or unrealistic sense of danger that may be evolved to experience panic attacks. AIM: Our objective was to identify the prevalence of most common phobias as well as panic disorder (PD) due to the coronavirus pandemic among Egyptian primary schoolchildren and their determinants. METHODS: A cross-sectional study was conducted among 2015 schoolchildren from 3 to 6 grades in three governorates of Egypt. Seven types of phobias were investigated: Agoraphobia, phobias from darkness, animal, untreatable illness (mainly coronavirus), insects, height, and social phobia. The child’s self-reported PD symptoms were assessed using DSM-IV with psychiatric diagnoses. RESULTS: Almost two-thirds of the surveyed primary schoolchildren have phobias of the low score (<9) versus one-third who had high phobias score (61.% vs. 35%, respectively) with highly significant difference (p < 0.001). The most prevalent phobias were from heights (66.5%) followed by darkness (60.0%). The important predictors of phobias were: Being a male child, living in an urban area, and studying at governmental school at fifth or sixth-grade residence. The prevalence of PD due to the corona epidemic is very high, it is reported by almost half of the surveyed primary schoolchildren. Fear of losing any of their family members, especially grandparents, was reported to be the highest PD symptom (97%). CONCLUSION AND RECOMMENDATION: Phobia from heights and darkness was the most common. The prevalence of PD due to the coronavirus epidemic is reported to be very high. Calming down children who might be experienced with a phobia that is triggering their PD is recommended.

Enhancing the value of women’s reproductive rights through community based interventions in upper Egypt governorates: a randomized interventional study

Background

In 2012, the WHO described the quality of health care as the route to equity and dignity for women and children.

Aim of the work

To provide community based support and empowerment to women in childbearing period to seek optimal prenatal, natal and postnatal healthcare. Achieving this is anticipated to decrease maternal morbidity and mortality in Egypt.

Subjects and methods

An interventional study was conducted among women in childbearing period in the poorest two governorates of Upper Egypt. The study passed through three stages over three and a half years; pre-interventional assessment of awareness (n = 1000), educational interventions targeting the health providers and all women in childbearing period in their communities (n = 20,494), and post-intervention evaluation of change in awareness of their rights for prenatal, natal and postnatal care (no = 1150).

Results

The studied indicators relating to receiving care in pregnancy, labor, and puerperium have changed dramatically as a result of the study interventions. Results of the study showed that before interventions, the surveyed women had inaccurate knowledge regarding most of the items related to their rights. The percentages of women aware of their right to have pregnancy card increased and those who possessed a pregnancy card were doubled with a significant percent change of more than 25%. Some indicators showed more than 75% improvement, including; percent of surveyed women who knew that it’s their right to follow up their pregnancy and to deliver with a specialized doctor, a trained nurse or at an equipped health facility, and those who knew their right to have at least two home preparations necessary for safe delivery at home.

Conclusion and recommendations

More work is needed in order to achieve the targeted reduction of maternal mortality. This could be achieved by ensuring accessible and high quality care provided by the governmental health facilities together with increasing the awareness of women regarding their rights in receiving such care.

The Interaction of Social, Physical and Nutritive Factors in Triggering Early Developmental Language Delay in a Sample of Egyptian Children

BACKGROUND:

Language acquisition and child development during the early years of life depend on multiple interacting factors.

AIM:

To explore potential factors that can impact language development in 2 groups of Egyptian children, one with normal language development and the second with delayed development. Also, to explore to what extent can the involvement of impaired motor development potentiate the risk of developmental language delay.

METHODS:

This cross-sectional case-control study involved Egyptian children belonging to the middle socioeconomic class between 18 and 36 months of age. Children were classified according to their performance on language domain of Bayley Scales of Infant and Toddler Development (Bayley-III) into two groups, infants with the average or above score (control group) and those having below-average scores (cases). Motor development was assessed on the same scale. Factors affecting language development were tested, including socio-demographic, obstetric, and maternal medical factors in addition to Infant Feeding Practices.

RESULTS:

The independent factors lowering the language scores were early introduction of complementary food, low family income, history of delivery problems, pregnancy-related diseases of the mother, and maternal education. Impaired motor development appears as a further highly significant risk factor to the previously mentioned factors

CONCLUSION:

In Egyptian children, delayed language development is severely affected by the interaction of medical, social and nutritional factors. Providing adequate maternal health care during pregnancy and childbirth, regular developmental monitoring at each child visit, and screening for such risk factors, can reduce size of the problem and promote child’s social and psychological development.

Effect of Counteracting Lifestyle Barriers through Health Education in Egyptian Type 2 Diabetic Patients

BACKGROUND: Egypt is among the world top 10 countries in diabetes prevalence. It is the first country among the MENA region. Healthy lifestyle education and support help people with diabetes to improve health outcomes. Many physical and psychological barriers can hinder patients from following a healthy lifestyle. AIM: This study aimed to examine the effect of lifestyle modification educational sessions in helping Egyptian patients to overcome main barriers of diabetes self-management through improving nutritional behaviours, physical activity, medication compliance, and blood glucose monitoring. METHODS: A cohort study included 205 patients with type 2 diabetes. Baseline assessment of patients' lifestyle behaviours and barriers using personal diabetes questionnaire of Louisville University, with both anthropometric and blood glucose assessment. Interventional lifestyle health education was provided weekly through multiple integrated techniques, followed by a post-intervention assessment to evaluate the effect of the health education sessions. Statistical analysis was done to identify any statistically significant difference before and after the health education intervention. RESULTS: There was a significant improvement of the post-education mean scores of the studied behaviours when compared with the pre-education scores of the participants’ behaviours (p < 0.001). There was also a significant reduction in the barriers facing patients to diabetes self-management including nutritional barriers (P < 0.001), medication compliance barriers (P < 0.001) with a percent change (43%), physical activity barriers (p < 0.001), and blood glucose monitoring (p < 0.001) with a percent change (44%).There was a statistically significant positive correlation between improvement of medication compliance (P = 0.027), blood glucose monitoring(P = 0.045), and glycated haemoglobin of the study participants CONCLUSION: lifestyle modification education of type 2 diabetic patients can overcome the main barriers of following a healthy lifestyle and improve their anthropometric measures and blood glucose level.

Potential Risk Factors of Developmental Cognitive Delay in the First Two Years of Life

BACKGROUND: The first two years of life constitute a critical period of rapid change. The events during this phase prepare the child for subsequent developmental competency.AIM: To determine the potential risk factors that affect an infant’s cognitive development in the first two years of life in a sample of Egyptian infantsSUBJECTS AND METHODS: A cross-sectional comparative study included 655 male and female infants. Their age ranged from 3 – 24 months. Bayley Scales of Infant and Toddler Development (Bayley III) were used for cognitive assessment. Perinatal and nutritional data were recorded. Levels of serum Zinc, Copper, Iron, vitamin B12 and complete blood count (CBC) were assessed in a subsample of 193 infants.RESULTS: Infants having below the average cognitive composite score (CCS) represented 38.47% of the whole sample. The risk of having a low average (CCS) was determined by multiple factors. Poor maternal education and low family income were the most significant social risk factors (OR = 2.19, p = 0.0003; OR = 1.64, p = 0.002 respectively). Prematurity and complicated labor represented significant perinatal risks (OR = 1.22, p = 0.005; OR = 2.39, p =0.001respectively). Bottle feeding versus breastfeeding in the first six months of life was the most significant nutritional predictor of low average (CCS) (OR = 1.79, p = 0.001). Infants with low average (CCS) had significantly lower levels of serum zinc and vitamin B12 than those with average scores. CONCLUSION: Multiple factors appear to interact affecting the early cognitive development of Egyptian infants. Prematurity, complicated labour, poor maternal education, low family income and micronutrient deficiency are the main risk factors. Studying these factors is of great value in directing governmental intervention efforts.

Determinants of Exclusive Breastfeeding in a Sample of Egyptian Infants

BACKGROUND: Breastfeeding is an optimum, healthy, and economical mode of feeding an infant. However, many preventable obstacles hinder exclusive breastfeeding in the first six months of life. AIM: We aimed to assess the social-, maternal- and infant-related factors disturbing exclusive breastfeeding in the first six months of life. METHODS: It is a retrospective study included 827 dyads of mothers and infants older than 6 months (411 exclusively breastfed, 311 artificially-fed and 105 mixed feds). Mothers were interviewed to obtain sociodemographic information, maternal medical history and perinatal history and a detailed history of infant feeding. RSULTS: Many factors were found to support the decision for artificial feeding rather than exclusive breastfeeding, including maternal age < 25 years (OR = 2.252), child birth order > 3rd (OR = 2.436), being a primi-para (OR = 1.878), single marital status (OR = 2.762), preterm infant (OR = 3.287) and complicated labor (OR = 1.841). Factors in favor of mixed feeding included cesarean section (OR = 2.004) and admission to the Neonatal Intensive Care Unit (OR = 1.925). CONCLUSIONS: Although it isn’t a community-based study and its results can’t be generalised, plans to improve health and development of children are preferable to include the following: health education and awareness programs about the importance of exclusive breastfeeding should be directed for young and first-time mothers. Improved antenatal care to reduce perinatal and neonatal problems; and training, monitoring, and supervising community health care workers to recognise labour complications and provide support and knowledge to lactating mothers.

An educate, test, and treat programme towards elimination of hepatitis C infection in Egypt: a community-based demonstration project

BACKGROUND

Egypt has one of the highest prevalences and burdens of hepatitis C virus (HCV) worldwide, and a large government treatment programme. However, identifying and treating people who are infected in rural communities can be a substantial challenge. We designed and evaluated a comprehensive community-led outreach programme for prevention, testing, and treatment of HCV infection in one village in northern Egypt, with the goal to eliminate HCV infection from all adult villagers, and as a model for potential adoption in rural settings.

METHODS

A community-based education and test-and-treat project was established in Al-Othmanya village. The programme consisted of community mobilisation facilitated by a network of village promoters and establishment of partnerships; an educational campaign to raise awareness and promote behavioural changes; fundraising for public donations in the local community; and comprehensive testing, diagnosis, and treatment. For the educational campaign, we used public awareness events, house-to-house visits, and promotional materials (eg, booklets, cartoons, songs) to raise awareness of HCV and its transmission, and changes in knowledge, attitudes, and practices were measured through the use of a survey done before and after the educational campaign. Comprehensive testing, linkage to care, and treatment was offered to all eligible villagers (ie, those aged 12-80 years who had not previously been treated for HCV). Testing was done by use of HCV antibody and hepatitis B surface antigen (HBsAg) rapid diagnostic tests, with HCV-RNA PCR confirmation of positive cases, and staging of liver disease by use of transient elastography. HCV-RNA-positive participants were offered a 24-week course of sofosbuvir (400 mg orally, daily) and ribavirin (1000-1200 mg orally, daily) with an assessment of cure (sustained virological response) at 12 weeks after completion of treatment (SVR12).

FINDINGS

Between June 6, 2015, and June 9, 2016, 4215 (89%) of 4721 eligible villagers were screened for HCV antibodies and HBsAg. Of these participants, 530 (13%) were HCV antibody positive and eight (<1%) were HBsAg positive. All HCV-antibody-positive individuals had an HCV-RNA assay, and 312 (59%) were HCV-RNA positive. All 312 completed a full baseline assessment with staging of liver disease, and 300 (96%) were given 24 weeks of sofosbuvir and ribavirin treatment within a median of 2·3 weeks (IQR 0·0-3·7) from serological diagnosis. 293 (98%) of the treated participants achieved SVR12. 42 (13%) HCV-RNA-positive participants had cirrhosis as determined by transient elastography, of whom 12 (29%) were diagnosed with hepatocellular carcinoma on the basis of α-fetoprotein measurement and ultrasound. 3575 (85%) of 4215 eligible villagers completed the baseline and after educational campaign survey, and awareness, knowledge, and adoption of safer practices to prevent HCV transmission all significantly increased (p<0·0001).

INTERPRETATION

This community-led educate, test-and-treat demonstration project achieved high uptake of HCV testing, linkage to care and treatment, and attainment of cure in one village, as well as awareness and adoption of practices to prevent transmission in the community. This approach could be an important strategy for adoption in rural settings to complement the national government programme towards the elimination of HCV in Egypt.

FUNDING

Egyptian Liver Research Institute and Hospital.

Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study

BACKGROUND

The 69th World Health Assembly approved the Global Health Sector Strategy to eliminate viral hepatitis by 2030. Although no virological cure exists for hepatitis B virus (HBV) infection, existing therapies to control viral replication and prophylaxis to minimise mother-to-child transmission make elimination of HBV feasible. We aimed to estimate the national, regional, and global prevalence of HBsAg in the general population and in the population aged 5 years in 2016, as well as coverage of prophylaxis, diagnosis, and treatment.

METHODS

In this modelling study, we used a Delphi process that included a literature review in PubMed and Embase, followed by interviews with experts, to quantify the historical epidemiology of HBV infection. We then used a dynamic HBV transmission and progression model to estimate the country-level and regional-level prevalence of HBsAg in 2016 and the effect of prophylaxis and treatment on disease burden.

FINDINGS

We developed models for 120 countries, 78 of which were populated with data approved by experts. Using these models, we estimated that the global prevalence of HBsAg in 2016 was 3·9% (95% uncertainty interval [UI] 3·4-4·6), corresponding to 291 992 000 (251 513 000-341 114 000) infections. Of these infections, around 29 million (10%) were diagnosed, and only 4·8 million (5%) of 94 million individuals eligible for treatment actually received antiviral therapy. Around 1·8 (1·6-2·2) million infections were in children aged 5 years, with a prevalence of 1·4% (1·2-1·6). We estimated that 87% of infants had received the three-dose HBV vaccination in the first year of life, 46% had received timely birth-dose vaccination, and 13% had received hepatitis B immunoglobulin along with the full vaccination regimen. Less than 1% of mothers with a high viral load had received antiviral therapy to reduce mother-to-child transmission.

INTERPRETATION

Our estimate of HBV prevalence in 2016 differs from previous studies, potentially because we took into account the effect of infant prophylaxis and early childhood vaccination, as well as changing prevalence over time. Although some regions are well on their way to meeting prophylaxis and prevalence targets, all regions must substantially scale-up access to diagnosis and treatment to meet the global targets.

FUNDING

John C Martin Foundation.

Early and long term anamnestic response to HBV booster dose among fully vaccinated Egyptian children during infancy

OBJECTIVE

To evaluate early and long term anamnestic response to a booster dose of HBV vaccine among non-seroprotected children.

SUBJECTS AND METHOD

A national community based project was carried out on 3600 children aged 9 months to 16 years, fully vaccinated during infancy. They were recruited from 6 governorates representing Egypt. It revealed that 1535 children (42.8%) had non sero-protective anti-HBs (<10 IU/L) and were HBsAg or anti-HBc negative. A challenging dose of 10 μg of mono-valent Euvax HBV vaccine was given to 1121/1535 children. Quantitative assessment of anti-HBs was performed to detect early (2-4 weeks) and long term (one year) anamnestic responses.

RESULTS

Early anamnestic response developed among 967/1070 children (90.3%).Children having detectable anti-HBs (1-9 IU/L) significantly developed early anamnestic response (90%) compared to 85% with undetectable anti-HBs (<1 IU/L), P < 0.001. Multiple logistic analysis revealed that undetectable anti-HBs, living in rural residence and children aged 15-16 years were the most significant predicting risk factors for the absence of early anamnestic response (<10 IU/L), with AOR 2.7, 2.7 & 4.7 respectively. After one year, long term anamnestic response was absent among 15% of children who previously showed early response. Poor early anamnestic response and undetectable pre-booster anti-HBs were the significant predicting risk factors for absent long term anamnestic response, with AOR 18.7 & 2.7 respectively.

CONCLUSION

Immunological memory for HBV vaccine outlasts the presence of anti- HBs and HBV vaccination program provides effective long term protection even in children showing waning or undetectable concentrations of anti-HBs. This signifies no need for a booster dose especially to healthy children.

Effectiveness of hepatitis B virus vaccination program in Egypt: Multicenter national project

AIM

To assess the effectiveness of hepatitis B virus (HBV) vaccination program among fully vaccinated children.

METHODS

A national community based cross-sectional study was carried out in 6 governorates representing Egypt. A total of 3600 children aged from 9 mo to 16 years who were fully vaccinated with HBV vaccine during infancy were recruited. Face to face interviews were carried out and sera were evaluated for hepatitis B surface antigen (HBsAg), anti-HBV core antibodies (total) and quantitative detection of hepatitis B surface antibody using enzyme linked immunoassays techniques. Samples positive to HBsAg/anti-HBV core antibodies were subjected to quantitative HBV-DNA detection by real time polymerase chain reaction with 3.8 IU/L detection limit.

RESULTS

Sero-protection was detected among 2059 children (57.2%) with geometric mean titers 75.4 ± 3.6 IU/L compared to 3.1 ± 2.1 IU/L among non-seroprotected children. Multivariate logistic analysis revealed that older age and female gender were the significant predicting variables for having non sero-protective level, with adjusted odds ratio 3.3, 9.1 and 14.2 among children aged 5 to < 10, 10 to < 15 and ≥ 15 years respectively compared to those < 5 years and 1.1 among girls compared to boys with P < 0.01. HBsAg was positive in 0.11% and breakthrough infection was 0.36% and 0.39% depending on positivity of anti-HBc and DNA detection respectively. The prevalence of HBV infection was significantly higher among children aged ≥ 7 years (0.59%) compared to 0.07% among younger children with odds ratio equal to 8.4 (95%CI: 1.1-64.2) and P < 0.01.The prevalence was higher among girls (0.48%) than boys (0.29%) with P > 0.05.

CONCLUSION

The Egyptian compulsory HBV vaccination program provides adequate protection. Occult HBV infection exists among apparently healthy vaccinated children. Adherence to infection control measures is mandatory.

Prioritizing High-Risk Practices and Exploring New Emerging Ones Associated With Hepatitis C Virus Infection in Egypt

BACKGROUND

The aim of this study was to identify and prioritize the risky behaviors and explore the newly emerging pi related to Egyptian habits that may lead to HCV transmission.

METHODS

From January 2011 until January 2012, a case control study matched on socio demographic factors was conducted comparing 540 hepatitis C patients and their contacts who were HCV serologically negative (102 subjects). They were randomly selected from six governorates representing Upper Egypt, Lower Egypt, Middle and Canal regions. The questionnaire covered demographic data, risk exposures, behaviors, and practices for HCV infection. Focus group discussions were done with groups of professionals in Hepatology to discuss the observed emerging risk practices in Egypt.

RESULTS

In univariate analysis, invasive medical procedures, wound stitches, illiteracy and marriage were significantly associated with HCV infection. Among women, delivery at home by traditional birth attendant was associated with 3 times (OR=2.91, CI=1.23-6.98) and 4 times (OR=3.94, CI=1.44-11.35) increase in HCV risk than delivery at hospital and by doctors respectively. Among males, shaving at barbershops was associated with 2 fold increase in the risk of infection (OR=2.6, CI=1.44-4.89). Newly observed emerging risk practices were: sharing scarves' pins by veiled women in same houses, sharing loofah for personal cleaning and sharing toothpaste among family members.

CONCLUSION

Increasing risk of HCV infection in Egypt reinforces the need for strict implementation of effective HCV prevention programs according to the prevailing risk behaviours.

Monitoring progress of the role of integration of environmental health education with water and sanitation services in changing community behaviours

The health benefits of clean water, improved sanitation and better hygiene are now more recognized than ever before. The objective of the present study focused on monitoring the progress of behavioural changes towards appropriate behaviours related to water, environment and sanitation (WES). This was achieved through assessing the baseline community behaviours towards WES, exploring to what extent community hygienic behaviours had changed towards desirable and sustainable behaviours, through monitoring progress. The expected behavioural changes are results of an integrated package; safe water supply, sanitation, and hygiene education interventions produced by governmental and non-governmental organizations. The monitoring progress consisted of three household surveys that were administered over three years in four Egyptian districts within three Governorates; Fayoum, Beni Suef, and El-Menia. Behavioural changes were detected through special observation checklist indicators. These indicators were 7, 6, and 9 indicators each for personal hygienic behaviours, proper handling of drinking water, and proper use and maintenance of simple constructed sanitary latrines. The results from the baseline to mid-term and final surveys suggested improvement in the majority of the household behaviours towards the desirable behaviours. The proportions of the householders who practiced desirable behaviours were not to the same levels in the four districts. The results provide support to the concept that integrated interventions can produce a significant sustainable improvement in health promotion.

Improving the roles of rural women in health and environmental issues

Safe water supply, sanitation facilities and safe environments are the priorities of the communities in the villages of Upper Egypt. However, personal hygienic behaviors need improvement for substantial promotion of family health. This cannot be met without the full participation of women in their various roles in their communities. Accordingly, 375 females belonging to rural villages of Egypt (VHVs) volunteered to have a role in health and sanitation aspects and disseminate hygienic messages to their communities. The objective of this study was to assess and upgrade the levels of awareness, attitude and practice of VHVs towards environmental sanitation, sanitary housing, personal hygiene, safe water, food safety, sanitary sewage and refuse disposals. Implementation of environmental health education courses resulted in significant improvement of VHVs' awareness, attitude and practice towards the majority of the environmental topics that were addressed. Similar extensive courses are recommended for the promotion of environmental sanitation in other communities.