Public-health challenges in the Middle East and North Africa

Development of an evidence-informed governance and stewardship framework for elderly healthcare in Iran: A qualitative study

Background

The ageing population poses significant challenges to healthcare systems, necessitating the establishment of high-functioning, integrated frameworks for elderly healthcare. This study aimed to explore the key challenges associated with the stewardship of elderly care in Iran and to develop a holistic stewardship framework.

Methods

For this qualitative study, thirty semi-structured interviews were conducted with key Iranian healthcare stakeholders, utilizing purposive and snowball sampling during 2021-2022. Inductive open coding was utilized to generate new concepts related to key stewardship challenges. The World Health Organization's conceptual framework, outlining the three stewardship tasks, served as the basis for crafting a tailored framework for elderly healthcare stewardship in Iran.

Results

Fourteen main challenges and 38 sub-challenges were identified for elderly healthcare stewardship in Iran, categorized according to the WHO framework's three stewardship tasks. Challenges related to WHO stewardship task 1, involving health policy formulation and vision definition, included challenges in vision definition, planning, policymaking, and intergovernmental institutional superiority. Challenges related to WHO stewardship task 2, delineating governance and stewardship through control and regulation, encompassed issues such as support for the elderly, system responsiveness, behavior of healthcare providers, organizational structure, and cross-sectoral leadership challenges. Challenges associated with WHO stewardship task 3, about the use of collective intelligence, explored stakeholder collaboration, information for decision-making, and challenges within the elderly information system, covering data documentation, reporting, analysis, accessibility, distribution, and circulation. Subsequently, a framework was developed, covering areas like defining the vision and direction of health policy, managing information systems, evidence-informed policymaking, and delivering elderly health services with a holistic approach.

Conclusion

The present framework shows how a management information system, guided by evidenced-informed policymaking and the formulation of customized health policies, can facilitate the provision of elderly health services based on identified needs. It presents a governance and stewardship pathway that can be adopted by Iranian health policymakers and similar middle-income countries facing analogous challenges in ageing and aged care system stewardship, serving as a model for developing their own frameworks.

Burden of Ischemic Heart Disease and Its Attributable Risk Factors in North Africa and the Middle East, 1990 to 2019: Results From the GBD Study 2019

BACKGROUND

The North Africa and Middle East (NAME) region has one of the highest burdens of ischemic heart disease (IHD) worldwide. This study reports the contemporary epidemiology of IHD in NAME.

METHODS AND RESULTS

We estimated the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs), and premature mortality of IHD, and its attributable risk factors in NAME from 1990 to 2019 using the results of the GBD (Global Burden of Disease study 2019). In 2019, 0.8 million lives and 18.0 million DALYs were lost due to IHD in NAME. From 1990 to 2019, the age-standardized DALY rate of IHD significantly decreased by 33.3%, mostly due to the reduction of years of life lost rather than years lived with disability. In 2019, the proportion of premature death attributable to IHD was higher in NAME compared with global measures: 26.8% versus 16.9% for women and 18.4% versus 14.8% for men, respectively. The age-standardized DALY rate of IHD attributed to metabolic risks, behavioral risks, and environmental/occupational risks significantly decreased by 28.7%, 37.8%, and 36.4%, respectively. Dietary risk factors, high systolic blood pressure, and high low-density lipoprotein cholesterol were the top 3 risks contributing to the IHD burden in most countries of NAME in 2019.

CONCLUSIONS

In 2019, IHD was the leading cause of death and lost DALYs in NAME, where premature death due to IHD was greater than the global average. Despite the great reduction in the age-standardized DALYs of IHD in NAME from 1990 to 2019, this region still had the second-highest burden of IHD in 2019 globally.

Global Burden of Ischemic Stroke in Young Adults in 204 Countries and Territories

BACKGROUND AND OBJECTIVES

To estimate the rates of incidence, death, and disability-adjusted life years (DALYs) of ischemic stroke in young adults aged 15-49 years and the relevant risk factors by sex, age group, and sociodemographic index (SDI) in 204 countries and territories.

METHODS

Data from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2019 study were used. The estimated annual percentage changes (EAPCs) were calculated to evaluate the temporal trends from 1990 to 2019. We also estimated the risk factors contributing to DALYs resulting from ischemic stroke.

RESULTS

From 1990 to 2019, the global age-standardized incidence (EAPC = -0.97), death (EAPC = -0.11), and DALYs rates (EAPC = -0.55) of ischemic stroke in young adults decreased. The largest increases in age-standardized incidence, death, and DALYs rates were observed in the low and low-middle SDI quintiles. At the regional level, North Africa and the Middle East and Southeast Asia showed the largest increases in the age-standardized incidence, death, and DALYs rates of ischemic stroke. The age-standardized incidence rate was higher among young women than among young men in 2019. Globally, a high environmental temperature, high body mass index (BMI), and a high fasting plasma glucose contributed to the largest increases in age-standardized DALYs rates between 1990 and 2019. In the same period, the largest increases in the age-standardized DALYs rates in high-SDI and low-SDI regions were attributable to high environmental temperatures and alcohol use, respectively.

DISCUSSION

The burden of ischemic stroke in young adults continues to increase in low-SDI regions such as North Africa and the Middle East and Southeast Asia. There were differences in the primary risk factors related to the burden of ischemic stroke in different SDI regions. Targeted implementation of cost-effective policies and interventions is an urgent need to reduce the burden of ischemic stroke in young adults.

Cardiovascular disease prevention and management in the COVID-19 era and beyond: An international perspective

Despite some indicators of a localized curtailing of cardiovascular disease (CVD) prevalence, CVD remains one of the largest contributors to global morbidity and mortality. While the magnitude and impact of the coronavirus disease 2019 (COVID-19) pandemic have yet to be realized in its entirety, an unquestionable impact on global health and well-being is already clear. At a time when the global state of CVD is perilous, we provide a continental overview of prevalence data and initiatives that have positively influenced CVD outcomes. What is clear is that despite attempts to address the global burden of CVD, there remains a lack of collective thinking and approaches. Moving forward, a coordinated global infrastructure that, if developed with appropriate and relevant key stakeholders, could provide significant and longstanding benefits to public health and yield prominent and consistent policy resulting in impactful change. To achieve global impact, research priorities that address multi-disciplinary social, environmental, and clinical perspectives must be underpinned by unified approaches that maximize public health.

Weight patterns among mother-child pairs in the Middle East and North African Region

AIM

We aim to evaluate weight status in mother-child household pairs and patterns specific to over-nutrition households and double burden households.

METHODS

We used nationally representative data from the most recent Demographic and Health Survey (2001-2014) in the Middle East & North African (MENA) Region (n = 45,104) to examine weight status of mother-child dyads. Under-nutrition households were defined as mothers with underweight and children with wasting; over-nutrition households as mothers with overweight/obesity and children with overweight; and double burden households as mothers with underweight and children with overweight or mothers with overweight/obesity mother and children with wasting. Survey-adjusted multinomial logistic regression were used to quantify predictors of weight patterns.

RESULTS

Across the MENA region, 8.6% of households were experiencing double burden malnutrition, 11% were experiencing over-nutrition and 0.2% were experiencing under-nutrition. Wealthier households with older mothers, higher birth-order children, more educated parents and private water access were more likely to be over-nutrition or double burden households. Compared to over-nutrition households, double burden households were poorer and more likely to have a child with low birthweight.

CONCLUSIONS

Over-nutrition is the most common unhealthy weight pattern, followed by double-burden; socioeconomic status and birth weight are consistent predictors of unhealthy mother-child pairs.

Epidemiological features of HIV/AIDS in the Middle East and North Africa from 1990 to 2017

The growing trend of HIV/AIDS is a major concern in the Middle East and North Africa (MENA) regions, as its incidence in the region has increased by 31% in the last decade. The study population in the countries of the MENA region included 21 countries with a population of approximately 400 million. The Global Burden of Disease database was used to calculate the number of HIV/AIDS cases. Modeling for each country is based on the availability and quality of data. The highest incidence rates of HIV/AIDS were in Sudan, United Arab Emirates (UAE), Tunisia, and Iran, respectively, and the highest mortality rates were in Sudan, UAE, Oman, and Morocco, respectively. The incidence, prevalence and mortality rates, as well as the disability adjusted life years (DALYs) rate declined in 2017 compared to 1990. The highest percentage of changes in DALY rates was reported for Turkey, the United Arab Emirates (UAE), and Sudan, respectively, and the lowest for Qatar, Kuwait, and Bahrain. In general, unsafe sex had the highest impact on the DALY index in all countries in the region except Iran and Bahrain. Policymakers should therefore be encouraged to develop harm reduction programs for people living with HIV, and invest globally in reducing HIV prevalence rates in commercial sex workers, people who inject drugs, and men who have sex with men in the region, as well as eliminating mother-to-child HIV transmission.

Barriers to and Facilitators of Adherence to Clinical Practice Guidelines in the Middle East and North Africa Region: A Systematic Review

The current review aims to investigate the barriers to and facilitators of the adherence to clinical practice guidelines (CPGs) in the Middle East and North Africa (MENA) region. English language studies published between January 2010 and May 2019 were searched on PubMed, Embase, and EBSCO. The barriers were categorized as clinician-related factors, such as lack of awareness of familiarity with the CPGs, and external factors, such as patients, guidelines, and environmental factors. The search identified 295 titles, out of which 15 were included. Environmental factors, specifically lack of time, resources, incentives, availability, and costs of treatment or diagnostic tests, training, and dissemination plans were the most commonly identified barriers. The familiarity with or awareness of healthcare professionals about the guideline, guideline characteristics, lack of agreement with the guidelines and preference in clinical judgment, physician self-efficacy, and motivation were reported to a lesser extent. Few studies reported on the compliance of facilitators with the guidelines including disseminating and advertising guideline materials, education and training on the guidelines, regulatory and financial incentives, and support from institutions. The review highlights that the studies on barriers to and facilitators of compliance with CPGs in the MENA region are limited in number and quality.

The Profile of Non-Communicable Disease (NCD) research in the Middle East and North Africa (MENA) region: Analyzing the NCD burden, research outputs and international research collaboration

Objectives

Despite the rising risk factor exposure and non-communicable disease (NCD) mortality across the Middle East and the North African (MENA) region, public health policy responses have been slow and appear discordant with the social, economic and political circumstances in each country. Good health policy and outcomes are intimately linked to a research-active culture, particularly in NCD. In this study we present the results of a comprehensive analysis of NCD research with particular a focus on cancer, diabetes and cardiovascular disease in 10 key countries that represent a spectrum across MENA between 1991 and 2018.

Methods

The study uses a well validated bibliometric approach to undertake a quantitative analysis of research output in the ten leading countries in biomedical research in the MENA region on the basis of articles and reviews in the Web of Science database. We used filters for each of the three NCDs and biomedical research to identify relevant papers in the WoS. The countries selected for the analyses were based on the volume of research outputs during the period of analysis and stability, included Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Turkey and the United Arab Emirates.

Results

A total of 495,108 biomedical papers were found in 12,341 journals for the ten MENA countries (here we consider Turkey in the context of MENA). For all three NCDs, Turkey's output is consistently the highest. Iran has had considerable growth in research output to occupy second place across all three NCDs. It appears that, relative to their wealth (measured by GDP), some MENA countries, particularly Oman, Qatar, Kuwait and the United Arab Emirates, are substantially under-investing in biomedical research. In terms of investment on particular NCDs, we note the relatively greater commitment on cancer research compared with diabetes or cardiovascular disease in most MENA countries, despite cardiovascular disease causing the greatest health-related burden. When considering the citation impact of research outputs, there have been marked rises in citation scores in Qatar, Lebanon, United Arab Emirates and Oman. However, Turkey, which has the largest biomedical research output in the Middle East has the lowest citation scores overall. The level of intra-regional collaboration in NCD research is highly variable. Saudi Arabia and Egypt are the dominant research collaborators across the MENA region. However, Turkey and Iran, which are amongst the leading research-active countries in the area, show little evidence of collaboration. With respect to international collaboration, the United States and United Kingdom are the dominant research partners across the region followed by Germany and France.

Conclusion

The increase in research activity in NCDs across the MENA region countries during the time period of analysis may signal both an increasing focus on NCDs which reflects general global trends, and greater investment in research in some countries. However, there are several risks to the sustainability of these improvements that have been identified in particular countries within the region. For example, a lack of suitably trained researchers, low political commitment and poor financial support, and minimal international collaboration which is essential for wider global impact.

Awareness of stroke among patients attending primary healthcare services in Abha, Southwestern Saudi Arabia

Objectives:

To examine the awareness about major symptoms, risk factors, and response to stroke among the population in Abha, Southwestern Kingdom of Saudi Arabia. Improving stroke-related knowledge may advance stroke prevention and reduce pretreatment delay and disabilities.

Methods:

We conducted a cross-sectional study among a representative sample of primary healthcare adult patients between January-May 2016 and used a validated Arabic questionnaire to evaluate the participants’ awareness about stroke.

Results:

The study involved 1472 adults. Only 63.6% and 43.7% of participants correctly recognized thrombosis and hemorrhage as types of stroke. Commonly identified risk factors were hypertension (55.8%), dyslipidemia (45.8%), and smoking (41.9%). Sudden severe headache (54.1%), dizziness (51.0%), and difficulty in speaking (44.3%) were the most frequently recognized symptoms. The most frequently reported correct responses to stroke were contacting a doctor (73.0%), going to the hospital (67.2%), and calling an ambulance (52.4%). Improper responses to stroke (ignoring the condition or self-prescription) were noted in 18.8% of participants. Logistic regression revealed that physicians, nurses, friends and relatives as a source of knowledge were significantly associated with a lower insufficient knowledge of stroke symptoms and risk factors. On the other hand, women, persons above 40 years old, and married persons were significantly more prone to have insufficient knowledge about a proper response to stroke.

Conclusion:

Our study revealed a notable deficit of knowledge about warning symptoms, risk factors, and proper response to stroke. Health education strategies to improve stroke awareness are required and could potentially prevent and improve the outcome of stroke.

Current status of stroke in Qatar: Including data from the BRAINS study

BACKGROUND

Qatar is located on the north-eastern coast of the Arabian Peninsula. Qatari natives account for less than 15% of the population while the largest migrant group comprising 60% derives from South Asia. Despite projections that stroke burden in Qatar will increase with population ageing, epidemiological studies focusing on stroke in Qatar are relatively scarce.

METHOD

We reviewed the available epidemiological publications relating to Qatar. In addition, we have added to this knowledge by incorporating Qatari data from the on-going Bio-Repository of DNA in Stroke, an independent multinational database of stroke patients.

RESULTS

Qatar has low reported incidence and mortality rates of 58 and 9.17 per 100,000 per year, respectively, which may be explained by its middle-aged migrant worker majority population. Correspondingly, South Asian migrants in Qatar suffered younger strokes than Qatari natives (48.7 vs 63.4 years, P < 0.001). Among the most common risk factors identified in stroke patients were hypertension (77.9%), diabetes (43.8%) and hypercholesterolemia (28.5%). Ischaemic stroke was the most frequent subtype amongst migrant South Asians (71.1%). The majority of stroke cases had computed tomography and/or magnetic resonance imaging scans, but only 11.1% of ischaemic strokes were thrombolysed. Qataris on one-year follow up were more often found to have died (6.5% vs 0.3%) and had further stroke/transient ischaemic attack events (17.4% vs 6.4%, P = 0.009) compared to South Asians.

CONCLUSION

The burden of stroke is increasing in Qatar, and considerable disparities are observed between the native and migrant populations which likely will require different approaches to management by its healthcare system.

Costs associated with management of non-communicable diseases in the Arab Region: a scoping review

BACKGROUND

Global mortality rates resulting from non-communicable diseases (NCDs) are reaching alarming levels, especially in low- and middle-income countries, imposing a considerable burden on individuals and health systems as a whole. This scoping review aims at synthesizing the existing literature evaluating the cost associated with the management and treatment of major NCDs across all Arab countries; at evaluating the quality of these studies; and at identifying the gap in existing literature.

METHODS

A systematic search was conducted using Medline electronic database to retrieve articles evaluating costs associated with management of NCDs in Arab countries, published in English between January 2000 and April 2016. 55 studies met the eligibility criteria and were independently screened by two reviewers who extracted/calculated the following information: country, theme (management of NCD, treatment/medication, or procedure), study design, setting, population/sample size, publication year, year for cost data cost conversion (US$), costing approach, costing perspective, type of costs, source of information and quality evaluation using the Newcastle-Ottawa Scale (NOS).

RESULTS

The reviewed articles covered 16 countries in the Arab region. Most of the studies were observational with a retrospective or prospective design, with a relatively low to very low quality score. Our synthesis revealed that NCDs' management costs in the Arab region are high; however, there is a large variation in the methods used to quantify the costs of NCDs in these countries, making it difficult to conduct any type of comparisons.

CONCLUSIONS

The findings revealed that data on the direct costs of NCDs remains limited by the paucity of this type of evidence and the generally low quality of studies published in this area. There is a need for future studies, of improved and harmonized methodology, as such evidence is key for decision-makers and directs health care planning.

Non-Alcoholic Fatty Liver Disease in Africa and Middle East: An Attempt to Predict the Present and Future Implications on the Healthcare System

Non-alcoholic fatty liver disease (NAFLD) encompasses a group of hepatic diseases that range in severity. NAFLD is increasingly recognized as an epidemic among different populations, including those in Africa and the Middle East. The objective of this narrative review is to document the prevalence of and risk factors for NAFLD in Africa and the Middle East and the potential implications on the healthcare systems. An in-depth search on Google Scholar, Medline and PubMed was conducted using the terms "non-alcoholic fatty liver disease" and "non-alcoholic steatohepatitis", in addition to "prevalence and risk factors for NAFLD", with special emphasis on Africa and the Middle East countries. There were three types of epidemiological studies that included prevalence, risk factors and management/complications of NAFLD. There was noticeable variation in the prevalence of NAFLD among different countries, based on the variation in the prevalence of risk factors (type 2 diabetes, obesity, metabolic syndrome and dyslipidemia) and the diagnostic tool used in the study. However, the highest prevalence rate was reported in some Middle East countries. In Africa, there were few studies about NAFLD and most reported variable prevalence rates. There is an increasing prevalence of NAFLD as a result of the increasing risk factors, particularly in the Middle East, while in Africa, the situation is still unclear. Health providers in these regions are faced with many challenges that need urgent plans.

Landscape of Research on Older Adults' Health in the Arab Region: Is It Demography-Driven or Development-Dependent?

Objectives

To describe the quantity, methods, themes, and collaboration profiles of research on older adults' health in the Arab world, and map research productivity against demographic, economic, and development indicators.

Methods

A scoping review of research on older adults' health drawing from 7 databases and covering the period 1994-2013.

Results

Aging research output has increased 6-fold over the study period, with middle-income countries showing the sharpest rise. The majority of the reviewed publications are descriptive in nature, oriented toward examining the extent of disease or factors associated with various morbidity and mortality outcomes (88.5%). Despite the increasing regional instability, there is a dearth of studies on "seniors in emergencies." Collaboration with international coauthors (16.0%) has been more frequent than with regional coauthors (4.2%). Correlation analysis suggests that research production has been more strongly influenced by literacy rates than by population aging indicators, Gross Domestic Product, or government investment in research and development.

Discussion

This study lays the basis for a "roadmap" for research on older adults' health in the Arab region. It calls for cooperation among various stakeholders to produce a targeted and well-informed research agenda that is more responsive to emerging and context-specific needs of older adults in the region.

Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

Type 2 diabetes (T2D) and its complications form a global healthcare burden but the exact impact in some geographical regions is still not well documented. We describe the healthcare resource usage (HRU) associated with T2D in Africa, the Middle East, South Asia, Eurasia and Turkey.

RESEARCH DESIGN AND METHODS

In the fifth wave of the International Diabetes Management Practices Study (IDMPS; 2011-2012), we collected self-reported and physician-reported cross-sectional data from 8156 patients from 18 countries across 5 regions, including different types of HRU in the previous 3-6 months. Negative binomial regression was used to identify parameters associated with HRU, using incidence rate ratios (IRRs) to express associations.

RESULTS

Patients in Africa (n=2220), the Middle East (n=2065), Eurasia (n=1843), South Asia (n=1195) and Turkey (n=842) experienced an annual hospitalization rate (mean±SD) of 0.6±1.9, 0.3±1.2, 1.7±4.1, 0.4±1.5 and 1.3±2.7, respectively. The annual number of diabetes-related inpatient days (mean±SD) was 4.7±22.7, 1.1±6.1, 16.0±30.0, 1.5±6.8 and 10.8±34.3, respectively. Despite some inter-regional heterogeneity, macrovascular complications (IRRs varying between 1.4 and 8.9), microvascular complications (IRRs varying between 3.4 and 4.3) and, to a large extent, inadequate glycemic control (IRRs varying between 1.89 and 10.1), were independent parameters associated with hospitalization in these respective regions.

CONCLUSIONS

In non-Western countries, macrovascular/microvascular complications and inadequate glycemic control were common and important parameters associated with increased HRU.

Review of Health Systems of the Middle East and North Africa Region

Countries in the Middle East and North Africa (MENA) region share important sociocultural features but also differ significantly on a number of dimensions, including methods and approaches to addressing the health of their national populations. This article is a systematic analysis of the health systems of the region, including a review of health patterns and services to address them. A number of health systems dimensions are discussed, including the organization of biomedical and traditional medical services, access to health services, financing and resourcing mechanisms, and leadership and governance issues. Current and future challenges that need to be addressed by countries to ensure more efficient and responsive systems are also reviewed.

Women in Saudi Arabia and the Prevalence of Cardiovascular Risk Factors: A Systematic Review

Background. Cardiovascular disease (CVD) is one of the leading causes of death in Saudi Arabia. Saudi women in particular are more susceptible as there are sociocultural restrictions on female physical activities that may lead to high prevalence of CVD risks, especially obesity, and physical inactivity. This study aims to systematically review the published articles related to the prevalence of CVD risk among women in Saudi Arabia. The search strategy covers all published articles that assess the risk factor of CVD in Saudi Arabia from January 2000 to December 2015, using the following sources: Medline, Embase, and PsycINFO. A total of 61 studies were included. Results. Prevalence among Saudi women of smoking ranged from 1.1% to 9.1%, hypertension was 21.8%, diabetes ranged from 9.6% to 27.6%, overweight was 27%, and obesity was 40.23%, and physical inactivity ranged from 53.2% to 98.1%. Hypercholesterolemia prevalence on Saudi women on average was 24.5%, while metabolic syndrome ranged from 13.6% to 40.3%. Conclusion. The prevalence of CVD risk factors is high among women in Saudi Arabia especially in obesity and physical inactivity. Public health authorities must implement solutions from a gender specific aspect to reverse the trend and decrease the prevalence of CVDs among Saudi women.

Measuring Efficiency of Health Systems of the Middle East and North Africa (MENA) Region Using Stochastic Frontier Analysis

OBJECTIVE

The main purpose of this study is to measure the technical efficiency of twenty health systems in the Middle East and North Africa (MENA) region to inform evidence-based health policy decisions. In addition, the effects of alternative stochastic frontier model specification on the empirical results are examined.

METHODS

We conducted a stochastic frontier analysis to estimate the country-level technical efficiencies using secondary panel data for 20 MENA countries for the period of 1995-2012 from the World Bank database. We also tested the effect of alternative frontier model specification using three random-effects approaches: a time-invariant model where efficiency effects are assumed to be static with regard to time, and a time-varying efficiency model where efficiency effects have temporal variation, and one model to account for heterogeneity.

RESULTS

The average estimated technical inefficiency of health systems in the MENA region was 6.9 % with a range of 5.7-7.9 % across the three models. Among the top performers, Lebanon, Qatar, and Morocco are ranked consistently high according to the three different inefficiency model specifications. On the opposite side, Sudan, Yemen and Djibouti ranked among the worst performers. On average, the two most technically efficient countries were Qatar and Lebanon. We found that the estimated technical efficiency scores vary substantially across alternative parametric models.

CONCLUSION

Based on the findings reported in this study, most MENA countries appear to be operating, on average, with a reasonably high degree of technical efficiency compared with other countries in the region. However, there is evidence to suggest that there are considerable efficiency gains yet to be made by some MENA countries. Additional empirical research is needed to inform future health policies aimed at improving both the efficiency and sustainability of the health systems in the MENA region.

Barriers for setting up a pulmonary rehabilitation program in the Eastern Province of Saudi Arabia

BACKGROUND

Pulmonary rehabilitation (PR) programs proven to be one of the most effective treatment options for respiratory diseases; yet, they are not well-established in hospitals in Saudi Arabia.

AIM

To determine the main barriers for setting up PR programs in Saudi Arabia.

METHODS

A cross-sectional study was conducted in the Eastern Province of Saudi Arabia. Health care providers involved in treatment of chronic obstructive pulmonary disease (COPD) patients were recruited from 22 general government hospitals. Data were collected using questionnaires: Full version if they had heard about PR before the study, and a short version if they had not heard about PR before.

RESULTS

A total of 123 health care providers were recruited (physicians [n = 44], nurses [n = 49], and respiratory therapists/technicians [n = 30]). Only 3.2% of the recruited health care providers had heard about PR programs before. According to the health care providers, the main barriers for setting up PR programs were a lack of (1) hospital capacity (75.6%), (2) trained health care providers (72.4%), and (3) funds (48.0%). There were significant differences in barriers reported by the health care providers. Compared to physicians, nurses were more likely to nominate the PR costs as a barrier (18.0% vs. 38.8%; P < 0.05).

CONCLUSION

There is a worrisome lack of knowledge regarding content and benefits of PR programs among Saudi health care providers treating COPD patients. These findings imply that improving awareness and increasing education of the health care providers regarding PR will be required before PR can be more widely implemented as an integral treatment modality for patients with COPD in Saudi Arabia.

Cardiovascular disease research activity in the Middle East: a bibliometric analysis

OBJECTIVES

The Middle East has a high prevalence of noncommunicable chronic diseases. The objective of this article was to quantify the research activity in cardiovascular disease (CVD) in the Middle East over the last 10 years.

METHODS

A Medline search was conducted using medical subject headings and author affiliation to retrieve research articles published from the Middle East between 2003 and 2012 (inclusive).

RESULTS

Middle Eastern countries produced only 3% of the total number of CVD research articles in the world. However, the overall trend showed an increase in the number of articles over the years, mainly from Turkey and Iran. Within this region, the ratio of CVD to non-CVD publications was highest in Qatar (0.23). Lebanon ranked first in the number of CVD publications per million persons (PMP) averaging 194.2 publications PMP and Turkey ranked highest in the number of CVD publications per US$1000 gross domestic product (GDP) per capita averaging 954 CVD publications per US$1000 GDP per capita.

CONCLUSIONS

Although there has been a drive towards greater publication of CVD papers in the last decade, research activity in the Middle East still lags behinds developed countries. Greater productivity is anticipated to emerge to accompany the recent significant investment in research in Gulf countries.

Epidemiology and clinical presentation of stroke in Upper Egypt (desert area)

BACKGROUND

Stroke is a common cause of morbidity and mortality worldwide. Four out of five strokes occur in the low- and middle-income countries. This study aims to find lifetime prevalence of stroke in Upper Egypt and to identify clinical presentations and possible risk factors of stroke in this population.

METHODS

This is a door-to-door (every door) study conducted on all inhabitants in Al Kharga district (representative of western desert) and Al Quseir city (representative of eastern desert). The study was conducted in two stages, and every stage consisted of three phases (screening, diagnostic, and investigatory).

RESULTS

The total lifetime prevalence of stroke was 8.5/1,000 in the population aged 20 years and more. It increased with advancing age and was higher among males than females among all age groups except in the childbearing period (20 years to <40 years of age). Lifetime prevalence of ischemic stroke (7.2/1,000) was higher than hemorrhagic stroke (1.1/1,000). Hemiparesis and hemiplegia were the commonest presentation of stroke. Headache, vomiting, and vertigo were found to be significantly more common accompaniments of hemorrhagic stroke. The most common risk factor was hypertension, followed by hyperlipidemia and diabetes mellitus.

CONCLUSION

The total lifetime prevalence of stroke in the population aged 20 years and more in Upper Egypt (desert area) lies within the range that is recorded in developing countries. Clinical presentation and risk factors are similar to those recorded from developing and developed countries.

Prevention of type II diabetes mellitus in Qatar: Who is at risk?

Background: Type II diabetes mellitus (DM) is one of the leading chronic diseases in Qatar as well as worldwide. However, the risk factors for DM in Qatar and their prevalence are not well understood. We conducted a case-control study with the specific aim of estimating, based on data from outpatients with DM in Qatar (cases) and outpatient/inpatient controls, the association between demographic/lifestyle factors and DM. Methods: A total of 459 patients with DM from Hamad General Hospital (HGH) outpatient adult diabetes clinics, and 342 control patients from various outpatient clinics and inpatient departments within Hamad Medical Corporation (HMC) (years 2006–2008), were recruited. The association between risk factors and DM was evaluated using bivariate and multivariable logistic regression analyses. In addition to odds ratios (OR) and 95% confidence intervals (95% CI), we estimated the population attributable risk fractions for the DM demographic/lifestyle risk factors. Results: Qatari nationality was the strongest risk factor for DM (adjusted OR = 5.5; 95% CI = 3.5–8.6; p < 0.0001), followed by higher monthly income (defined as ≥ 3000 Qatari Riyals, adjusted OR = 5.1; 95% CI = 3.0–8.7; p < 0.0001), age >65 years (adjusted OR = 3.3; 95% CI = 0.9–11.4; p = 0.06), male gender (adjusted OR = 2.9; 95% CI = 1.8-4.8; p < 0.0001), obesity (BMI ≥ 30, adjusted OR = 2.2; 95% CI = 1.5-3.2; p < 0.0001), no college education (adjusted OR = 1.7; 95% CI = 1.2–2.6; p = 0.009), and no daily vigorous/moderate activity (adjusted OR = 1.5; 95% CI = 0.9–2.3; p = 0.12). Among Qatari nationals, obesity was found to be the main risk factor for DM (unadjusted OR = 3.0; 95% CI = 1.6–5.6; p < 0.0001), followed by no college education (unadjusted OR = 2.7; 95% CI = 1.5–5.1; p = 0.001), while consanguinity did not appear to play a major role in predicting DM (unadjusted OR = 1.5; 95% CI = 0.8–2.8; p = 0.21). Our findings further suggested that eliminating obesity and improving access to education may reduce DM cases by up to one third for the population at large (31.7% and 26.8%, respectively) and up to half (46.9% and 49.3%, respectively) for Qatari nationals. Promoting physical activity may reduce the burden of DM by up to 9.4% for the population at large and up to 17.3% for Qatari nationals. Conclusions: Demographic/lifestyle factors appear to be the main risk factors for the high DM levels observed in Qatar, with a contribution that outweighs that of genetic risk factors. While further evaluation of DM risk factors among the Qatari population (as opposed to the resident population) is important and of interest, these findings highlight the need to focus short-term DM interventions on addressing demographic/lifestyle risk factors to achieve substantial and timely declines in DM levels.

The curse of wealth - Middle Eastern countries need to address the rapidly rising burden of diabetes

The energy boom of the last decade has led to rapidly increasing wealth in the Middle East, particularly in the oil and gas-rich Gulf Cooperation Council (GCC) countries. This exceptional growth in prosperity has brought with it rapid changes in lifestyles that have resulted in a significant rise in chronic disease. In particular the number of people diagnosed with diabetes has increased dramatically and health system capacity has not kept pace. In this article, we summarize the current literature to illustrate the magnitude of the problem, its causes and its impact on health and point to options how to address it.

Stroke in Saudi Arabia: a review of the recent literature

Stroke is a major cerebrovascular disease resulting in high mortality and persistent disability in adults across the world. Besides coronary heart disease and cancer, stroke is the commonest cause of death in most industrialized countries. Survivors of stroke are often left with severe mental and physical disabilities, which create a major social and economic burden, ranking as the second most common cause of death worldwide and a major source of morbidity. The Kingdom of Saudi Arabia (KSA) is the largest country in the Middle East occupying approximately four-fifths of the Arabian Peninsula supporting a population of more than 28 million. Stroke is becoming a rapidly increasing problem and an important cause of illness and deaths in Saudi Arabia. However, compared with the developed countries, research regarding the incidence, prevalence and their socio-demographic properties of stroke is still insufficient due to lack of appropriate studies being conducted in these specified areas. This review aims to discuss the range of the aspect of stroke in Saudi Arabia from the literature published.

Assessment of iron deficiency in the context of the obesity epidemic: importance of correcting serum ferritin concentrations for inflammation

BACKGROUND

The correction of serum ferritin (SF) concentrations for inflammation because of infectious or parasitic diseases was recently proposed, especially in developing countries, but in many countries, adiposity has become the main cause of inflammation.

OBJECTIVE

We assessed, overall and by adiposity status, the bias in the estimation of iron deficiency (ID) on the basis of uncorrected SF.

DESIGN

A cross-sectional survey in 2010 in Rabat-Salé, Morocco, used a random sample of 811 women aged 20-49 y. Adiposity was assessed by body mass index (BMI) (in kg/m²) (normal: BMI <25; overweight: BMI ≥25 to <30; obese: BMI ≥30), waist circumference, and body fat. Inflammation was indicated by a C-reactive protein (CRP) concentration >2 mg/L. ID was indicated by an SF concentration <15 μg/L. The correction factor of SF for inflammation was derived from our sample. Differential effects of SF correction on ID status on the basis of adiposity were assessed by models that included adiposity × correction interactions and accounted for the within-subject correlation.

RESULTS

The prevalence of overweight was 33.0% and of obesity was 34.0%. Inflammation (42.3%) was strongly linked with adiposity (20.1%, 37.6%, and 68.4% in normal, overweight, and obese subjects, respectively; P < 0.0001). SF increased from a CRP concentration >2 mg/L. The correction factor of SF was 0.65. The prevalence of ID (37.2% compared with 45.2%; difference -8.0%, P < 0.0001) was underestimated by not correcting SF, and the difference increased with adiposity (-2.9%, -8.5%, and -12.4% in normal, overweight, and obese subjects, respectively; P-interaction < 0.0001). Analogous results were observed for other adiposity measures.

CONCLUSION

In developing countries where ID remains prevalent but rates of obesity are already high, corrected SF should be used when assessing ID status, even if infectious or parasitic diseases are no longer widespread. This trial was registered at clinicaltrials.gov as NCT01844349.

The Imperative of Public Health Education: A Global Perspective

This review positions public health as an endeavour that requires a high order of professionalism in addressing the health of populations; this requires investment in an educational capacity that is designed to meet this need. In the global context, the field has evolved enormously over the past half century, supported by institutions such as the World Bank, the World Health Organization and the Institute of Medicine. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. Talented and well-motivated individuals are attracted by its multidisciplinary and transdisciplinary environment, and the opportunity to achieve interventions that make real differences to people's lives. The field is globally competitive and open to many professional backgrounds based on merit. Its competencies correspond with assessments of population needs, and the ways in which strategies and services are formulated. Thus, its educational planning is needs-based and evidence-driven. This review explores four public health education levels: graduate, undergraduate, continuing professional education and promotion of health literacy for general populations. The emergence of accreditation schemes is examined, focusing on their relative merits and legitimate international variations. The role of relevant research policies is recognized, along with the need to foster professional and institutional networks in all regions of the world. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it.

The chain of survival for ST-segment elevation myocardial infarction: insights into the Middle East

Although coronary heart disease is the leading cause of morbidity and mortality in the Middle East (ME), not much is known about patients with ST-segment elevation myocardial infarction (STEMI) from this region. The STEMI Chain of Survival can be used to target regional improvements in patient care. We tried to adopt a modified chain of survival for STEMI to highlight the challenges and difficulties and the possible solutions to improve the STEMI care in the Middle East based on the few data available.

Assessing the state of health research in the Eastern Mediterranean Region

Member states across the Eastern Mediterranean region face unprecedented health challenges, buffeted by demographic change, a dual disease burden, rising health costs, and the effects of ongoing conflict and population movements - exacerbated in the near-term by instability arising from recent political upheaval in the Middle East. However, health actors in the region are not well positioned to respond to these challenges because of a dearth of good quality health research. This review presents an assessment of the current state of health research systems across the Eastern Mediterranean based on publicly available literature and data sources. The review finds that - while there have been important improvements in productivity in the Region since the early 1990s - overall research performance is poor with critical deficits in system stewardship, research training and human resource development, and basic data surveillance. Translation of research into policy and practice is hampered by weak institutional and financial incentives, and concerns over the political sensitivity of findings. These problems are attributable primarily to chronic under-investment - both financial and political - in Research and Development systems. This review identifies key areas for a regional strategy and how to address challenges, including increased funding, research capacity-building, reform of governance arrangements and sustained political investment in research support. A central finding is that the poverty of publicly available data on research systems makes meaningful cross-comparisons of performance within the EMR difficult. We therefore conclude by calling for work to improve understanding of health research systems across the region as a matter of urgency.

International financial institutions and health in Egypt and Tunisia: change or continuity?

The revolutions in Egypt and Tunisia appeared to herald a re-casting of International Monetary Fund and World Bank policy across the region. Public pronouncements by the heads of both institutions in the months following February 2011 acknowledged flaws in their approach to macroeconomic advice, against a background of worsening socioeconomic indicators, widespread youth unemployment, and widening health inequalities. Evidence on the ground, however, suggests continuity rather than change in international financial institution policies in Egypt and Tunisia, notwithstanding the emergence of a powerful new player-the European Bank for Reconstruction and Development. In the long term, new electoral realities and hardening public opposition in both countries seem likely to force a fundamentally different relationship between regional governments and the major international financial institutions than existed before 2011.

A text messaging-based smoking cessation program for adult smokers: randomized controlled trial

BACKGROUND

Despite promising data in Western countries, there is a dearth of research into the efficacy of text messaging-based smoking cessation programs in other settings, including the Middle East, where smoking prevalence rates are higher.

OBJECTIVE

This paper reports cessation rates observed in SMS Turkey, a text messaging-based smoking cessation program for adult smokers in Ankara, Turkey.

METHODS

This study was a small-scale, parallel-group randomized controlled trial (RCT) conducted in Ankara, Turkey. Participants were adult daily smokers who were seriously thinking about quitting in the next 15 days and living in Ankara, Turkey. The text messaging intervention, SMS Turkey, provided 6 weeks of daily messages aimed at giving participants skills to help them quit smoking. Messages were sent in an automated fashion, except 2 days and 7 days after the initial quit day. On days 2 and 7, the research assistant manually assigned participants to content "paths" based on whether they were still not smoking or had relapsed. The control arm received a brochure that provided similar information about smoking cessation. The main outcome measure was self-reported 3-month sustained abstinence, verified by carbon monoxide (CO) readings. Neither participants nor researchers were blinded to arm assignment.

RESULTS

The 151 participants were randomly assigned to 1 of 2 groups: 76 to the SMS Turkey intervention group and 75 to the brochure control group. Using intention to treat, all 151 participants were included in analyses. Three-month cessation trends were not significantly higher in the intervention group: 11% intervention vs 5% control had quit (χ(2)(1)=1.4, P=.24; R(2)=2.0, 95% CI 0.62-6.3). When the sample was stratified by sex, female intervention participants (14%, n=5) were significantly more likely to have quit at 3 months than female control participants (0%, n=0; χ(2)(1)=3.7, P=.05). Among light smokers (ie, those smoking less than 20 cigarettes per day), intervention participants (17%, n=5) also were significantly more likely to have quit compared to control participants (0%, n=0; χ(2)(1)=5.3, P=.02). We noted no difference in cessation rates for males or heavy smokers. Participants experienced significant technology problems during the study. Some participants received duplicate text messages at least once during the trial; others failed to receive some program messages. Neither receiving duplicate messages (χ(2)(1)=0.12, P=.73), or missing 5 or more program messages (χ(2)(1)=0.75, P=.39) negatively affected quitting rates.

CONCLUSIONS

Although the study was not powered to detect statistically significant differences, as the primary aim was to provide estimates of effect size that could be used to better inform a power analysis for a larger trial, findings provide optimism that SMS Turkey may be able to affect quitting rates in environments with high smoking prevalence, such as Ankara, Turkey. The SMS Turkey software program did not work as well as it did 2 years previous. The system will need to be updated to maintain software compatibility with ongoing technology evolution.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00912795 http://clinicaltrials.gov/ct2/show/NCT00912795 (Archived by WebCite® at http://www.webcitation.org/6Ch1cIA8l).

Interest in technology-based and traditional smoking cessation programs among adult smokers in Ankara, Turkey

Background

Little is known about the demand for smoking cessation services in settings with high smoking prevalence rates. Furthermore, acceptability of text messaging and Internet as delivery mechanisms for smoking cessation programs in non-developed countries is under-reported. Given the cost effectiveness of technology-based programs, these may be more feasible to roll out in settings with limited public health resources relative to in-person programs.

Findings

148 adult smokers took part in a community-based survey in Ankara, Turkey. Two in five (43%) respondents reported typically smoking their first cigarette within 30 minutes of waking. Many participants expressed a desire to quit smoking: 27% reported seriously thinking about quitting in the next 30 days; 53% reported at least one quit attempt in the past year. Two in five smokers wanting to quit reported they were somewhat or extremely like to try a smoking cessation program if it were accessible via text messaging (45%) or online (43%).

Conclusions

Opportunities for low-cost, high-reach, technology-based smoking cessation programs are under-utilized. Findings support the development and testing of these types of interventions for adult smokers in Turkey.

The population attributable fraction of stroke associated with high blood pressure in the Middle East and North Africa

BACKGROUND

Hypertension and the prevalence of stroke are increasing in the Middle East and North Africa. This study aims to quantify the contribution of hypertension to the development of stroke at the country-level by calculating the sex-specific population attributable fraction (PAFs).

METHODS

The most recent sex-specific prevalence data was used, along with age-adjusted hazard ratio (HR) estimates for ischemic and hemorrhagic stroke associated with hypertension from the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence data were then used to calculate the PAFs for each country in the region with the relevant data.

RESULTS

In the 10 countries with nationally-representative data, the PAFs in men ranged from 16.3% in Kuwait to 60.7% in Morocco for hemorrhagic stroke and 7.2% in Kuwait to 38% in Morocco for ischemic stroke. The equivalent PAFs for stroke deaths related to hypertension in women ranged from 12.4% in United Arab Emirates to 48.6% in Bahrain for hemorrhagic stroke and from 10.3% in UAE to 46% in Morocco for ischemic stroke.

CONCLUSION

Overall, up to 60% of stroke can be attributed to the high blood pressure in the Middle East. Stroke is a preventative disease, with this information and better prevention strategies, this region can aim to lower the prevalence of stroke.

Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of β-blockade

BACKGROUND

The prevalence and clinical consequences of hypertension in countries in Africa and the Middle East have not been studied as well as in other regions.

SCOPE

We have reviewed the literature on the epidemiology and management of hypertension and related cardiovascular complications in countries within Africa and the Middle East. A PubMed search for countries in the region and 'hypertension' was supplemented by articles identified from reviews, and by literature suggested by the authors.

FINDINGS

The prevalence of hypertension is >20% in some countries in the Middle East and Africa, despite an average population age that is some 10-15 years lower than those of developed countries. Hypertension in these countries is associated with an increased risk of cardiovascular risk factors and cardiovascular disease, as elsewhere. Awareness rates of hypertension are low. Hypertension and its complications are undertreated, and mortality rates from cardiovascular disease are higher than in developed countries.

CONCLUSION

Available resources should be brought to bear on the management of hypertension in these countries. In particular, a recent downgrading of the importance of β-blockers in hypertension management guidelines needs to be reassessed. These agents are as effective as other antihypertensive classes both on blood pressures and on cardiovascular event rates. General concerns over an increased rate of new-onset diabetes with β-blockers have been overstated, although these agents should be avoided in metabolic syndrome.

The epidemiology of stroke in the Middle East and North Africa

Stroke is the second leading cause of death in the world. In the Middle East and North Africa stroke is increasingly becoming a major health problem, with projections that deaths from it will nearly double by 2030. This systematic review aims to bring together age-adjusted epidemiological data of stroke in this region. A literature review of five databases was conducted. Twenty-three papers met the criteria. The incidence of stroke varied extensively among studies. Studies reported rates from 29.8 per 100000 people in Saudi Arabia to 57 per 100000 people in Bahrain. Furthermore, the 28-day case mortality rate also differed among studies, ranging from 10% in Kuwait to 31.5% in Iran. The rates are comparable with those in the Western world; however, the population of the region is younger. The Middle East and North Africa are lacking in data on the epidemiology of stroke. There is an urgent need to develop strategies to prevent and better care for stroke patients in the Middle East and North Africa.

Health equity in Lebanon: a microeconomic analysis

Background

The health sector in Lebanon suffers from high levels of spending and is acknowledged to be a source of fiscal waste. Lebanon initiated a series of health sector reforms which aim at containing the fiscal waste caused by high and inefficient public health expenditures. Yet these reforms do not address the issues of health equity in use and coverage of healthcare services, which appear to be acute. This paper takes a closer look at the micro-level inequities in the use of healthcare, in access, in ability to pay, and in some health outcomes.

Methods

We use data from the 2004/2005 Multi Purpose Survey of Households in Lebanon to conduct health equity analysis, including equity in need, access and outcomes. We briefly describe the data and explain some of its limitations. We examine, in turn, and using standardization techniques, the equity in health care utilization, the impact of catastrophic health payments on household wellbeing, the effect of health payment on household impoverishment, the equity implications of existing health financing methods, and health characteristics by geographical region.

Results

We find that the incidence of disability decreases steadily across expenditure quintiles, whereas the incidence of chronic disease shows the opposite pattern, which may be an indication of better diagnostics for higher quintiles. The presence of any health-related expenditure is regressive while the magnitude of out-of-pocket expenditures on health is progressive. Spending on health is found to be "normal" and income-elastic. Catastrophic health payments are likelier among disadvantaged groups (in terms of income, geography and gender). However, the cash amounts of catastrophic payments are progressive. Poverty is associated with lower insurance coverage for both private and public insurance. While the insured seem to spend an average of almost LL93,000 ($62) on health a year in excess of the uninsured, they devote a smaller proportion of their expenditures to health.

Conclusions

The lowest quintiles of expenditures per adult have less of an ability to pay out-of-pocket for healthcare, and yet incur healthcare expenditures more often than the wealthy. They have lower rates of insurance coverage, causing them to spend a larger proportion of their expenditures on health, and further confirming our results on the vulnerability of the bottom quintiles.

Income and the use of health care: an empirical study of Egypt and Lebanon

In middle-income Arab countries such as Egypt and Lebanon, income-associated equity in health care remains an elusive policy objective in part due to a relatively high reliance on out-of-pocket payments in financing care. This article examines the effect of income on the use of outpatient and inpatient health care services in Egypt and Lebanon using econometric analysis of cross-sectional data from the World Health Organization. In light of noticeable differences in income and public financing arrangements, these two countries serve as interesting case studies. Multivariate regression results suggest that Egyptian respondents were more likely to use health services than their Lebanese counterparts, holding all else constant, and that this effect was particularly evident for outpatient care. A higher income and insurance increased the likelihood of outpatient use more so than inpatient use, with these effects more pronounced in Lebanon. Overall, lower-income groups tended to report having worse health levels and paying more out-of-pocket on health care as a share of income than did higher-income groups. At the same time, these socioeconomic disparities in health appeared to be greater in Lebanon than in Egypt. Economic barriers to the use of health services are discussed within the context of health financing policy reforms aimed at improving equity in access to care in countries such as Egypt and Lebanon.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW

Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action.

RECENT FINDINGS

Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers.

SUMMARY

Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.

Can action on health achieve political and social reform?

Public debate about health is rare in Arab countries. But getting the social and political issues underlying health problems onto the agenda could have wider effects on the region's political stagnation