Exploring knowledge, attitudes and practice toward medication therapy management services among pharmacists in Yemen

Medication therapy management (MTM) refers to the activities provided by pharmacists that patients recognize as evidence of care being provided. It encompasses the services that patients value and consider valuable. Many developing nations like Yemen have had poor implementation of MTM services. Thus, this research assessed the Knowledge, Attitudes, and Practices (KAP) of Yemen pharmacists regarding MTM. We conducted a cross-sectional study using a self-administered questionnaire among pharmacists in Sana'a, Yemen. They were recruited through convenience sampling. The alpha level of 0.05 was used to determine statistical significance. Four hundred and sixty-one (461) pharmacists completed the questionnaire. About 70% were working in community pharmacies and 57.3% had (1-5) years of experience in pharmacy practice. The younger pharmacists had a higher level of knowledge than pharmacists with older age with median and IQR of 1.2(1.2-1.4) and 1.2(1-1.4) respectively (p < 0.001). Yemen pharmacists have positive attitudes toward MTM indicating a moderated level of attitudes with a median and IQR of 3.8(3.5-4). Hospital pharmacists expressed more positive attitudes toward MTM (P < 0.001) than pharmacists from other areas of practice. Only 11% of sampled pharmacists frequently offered MTM services. The top MTM service reported by Yemen pharmacists was "Performing or obtaining necessary assessments of the patient's health status". However, "Formulating a medication treatment plan" received the least provided MTM service among Yemen pharmacists. Even though MTM services are not commonly utilized in pharmacy practice, Yemeni pharmacists have positive attitudes concerning MTM. Efforts are needed to enhance their MTM knowledge and the value of providing MTM services as well as to develop a culture of continuing pharmacy education about MTM among pharmacists.

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen

BACKGROUND

Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen.

OBJECTIVE

To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen.

METHODS

This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores.

RESULTS

The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score.

CONCLUSION

Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

Red blood cell alloimmunization in blood transfusion-dependent β thalassemia major patients in Sana'a City-Yemen

The development of erythrocyte alloantibodies complicates transfusion therapy in β thalassemia major patients. These antibodies increase the need for blood and intensify transfusion complications. Data on erythrocyte alloimmunization is scarce in Yemeni thalassemia patients. We studied the frequency of alloimmunization in multitransfused β-thalassemia major patients and investigated risk factors that affect antibody formation. Blood samples were taken from 100 β thalassemia major patients who received multitransfused leukodepleted packed red-blood cells. Antibody screening and identification were performed by indirect antiglobulin test using the gel column technique. All patients were tested for autoantibodies using autocontrol and direct antiglobulin test. No adsorption test was done as no autoantibodies were detected in any patient. In our study of 100 β-thalassemia patients, 50 were male and 50 were female with ages ranging from 1 to 30 years. Alloantibodies were present in 6% of patients, while no autoantibodies were detected. Of the 17 alloantibodies identified, the majority were directed against Kell (41.2%) and Rh (29.4%) blood groups. Alloimmunization was significantly associated with age group and sex (p = 0.013, p = 0.030), respectively in β thalassemia major patients. The development of alloantibodies was not significantly associated with duration, total number of transfusions and splenectomy (P = 0.445, P = 0.125, P = 0.647). No autoantibodies found in patients with β thalassemia major. The study found low rates of erythrocyte alloimmunization in multitransfused β-thalassemia major patients, but significant alloantibodies were produced primarily from Kell and Rh blood groups, suggesting the need for providing phenotypically matched cells for selective antigens to improve transfusion efficiency.

Healthcare workers' compliance with the catheter associated urinary tract infection prevention guidelines: an observational study in Yemen

BACKGROUND

Catheter-associated urinary tract infection is a global problem but it can be prevented with the appropriate implementation of evidence-based guidelines. This study was conducted to assess the level of compliance of healthcare workers with the catheter-associated urinary tract infection prevention guidelines during the insertion of a urinary catheter.

METHODS

An observational study using a descriptive cross-sectional design was conducted at Sana'a City hospitals, Yemen. All the nurses and physicians from the governmental, teaching, and private hospitals were eligible to participate in the study. The data collection was performed through convenience sampling from March 2020 to December 2020, using a structured observational checklist prepared specifically for this study.

RESULTS

The majority of the urinary catheter insertions were performed by nurses. There were no written policy or procedures for an urinary catheter insertion and no in-service education or training departments in the majority of the hospitals. The overall mean score of compliance was 7.31 of 10. About 71% of the healthcare workers had a high or acceptable level of compliance and 29% had an unsafe level of compliance. Compliance was low for maintaining aseptic technique throughout the insertion procedure, using a single use packet of lubricant jelly, performing hand hygiene immediately before insertion, and securing the urinary catheter once inserted. Factors affecting the healthcare workers compliance were gender, the working ward/unit of the healthcare workers, the availability of a written policy/procedure and a department or unit for in-service education.

CONCLUSION

Yemeni healthcare workers' overall compliance was acceptable but it was unsafe in several critical measures. There is an urgent need for developing, implementing, and monitoring national guidelines and institutional policy and procedures for catheter-associated urinary tract infection prevention. Periodical in-service education and training programs and adequate access to the necessary materials and supplies are paramount.

COVID-19 vaccine acceptability among healthcare workers in Yemen

Background

Acceptability of COVID-19 vaccine by healthcare workers (HCWs) can affect its acceptability by the general population.

Aim

To assess COVD-19 vaccine acceptability among HCWs in Sana'a, Yemen.

Methods

We conducted a multicentre cross-sectional study among 391 HCWs in Sana'a, Yemen, from January to March 2022. We used a self-administered questionnaire to collect data on the demographics, profession, academic qualifications, and experience of HCWs, as well as their COVID-19 vaccine acceptability or hesitancy. We used univariate and multivariable logistic regression to analyse the association between the independent variables and vaccine hesitancy (P < 0.05).

Results

Of the 391 HCWs, only 194 (49.6%) were willing to accept the COVID-19 vaccine. The most frequent reasons for vaccine hesitancy were fear of adverse reactions (77.7%), concerns about unknown effects of the vaccine in the future (73.1%), and uncertainty about the safety of new vaccines (69.5%). Female gender and working in the public sector were independent predictors of vaccine hesitancy among the HCWs.

Conclusion

Nearly half of the HCWs in Sana'a, Yemen, were willing to accept the COVID-19 vaccine. Female gender and working in the public health sector were independent predictors of vaccine hesitancy. We recommend further studies to compare COVID-19 acceptability among HCWs in the public and private sectors in Yemen.

Perception, attitude, and practice toward research among medical students in Hadhramout University, Yemen

BACKGROUND

Research is an important element in the improvement of the quality of health services provided to the public. It is documented that globally; medical students apply research in their school life. In Hadhramaut University, medical students work on research in groups, and it is an important part of the curriculum. There is a formal assessment of the student's research, but there is still a gap regarding individual viewpoints and challenges faced. This study aimed to assess perception, attitude, and practice toward research among medical students at Hadhramout University.

METHODS

This is a cross-sectional descriptive study which was conducted among medical students. This study was undertaken in Hadhramout University in Al-Mukalla district, Yemen, during the academic year 2016-2017. A self-administered pilot-tested questionnaire was used for data collection to assess perception, attitude, and practice toward the research during the educational year 2016-2017.

RESULTS

A total of 265 completed responses were received. The majority had a low Knowledge score (72%). However, the majority had a positive attitude toward research (90.9%). Eighty-three students reported participation in research work. However, (44.4%) expressed research interest. Many barriers were highlighted by students including a lack of time (78.4%) and a lack of training in statistics (75.9%).

CONCLUSION

The study identified several barriers for undergraduate medical students to undertake research. It is important that these barriers should be addressed in curriculum development, so that students can retain their motivation to engage effectively in research.

The syntax of wh-questions in unaccusative and (Un)ergative structures in Mehri language: A Phase-based approach

The Mehri Language is an endangered language spoken in eastern Yemen, a sub-group of the Semitic language family, and a Southern Arabic language. The syntax of Mehri wh-questions has not been explored within minimalism; hence, there is a morpho-syntactic need to provide a modern analysis of wh-questions in order to show how the interrogative structures can be derived. This study aims to examine the syntax of the wh-question movement in Mehri's unaccusative/ergative and unergative structures and answer the following questions within Chomsky's (2000 and 2008) Phase-based Theory: (i) Does the Mehri language allow fronting of wh-phrases to [Spec-CP]? And (ii) how can wh-movement in Mehri unaccusative and (un)ergative structures be accounted for? This work presents a novel analysis of wh-question movement in unaccusative/ergative and unergative structures in Mehri; it demonstrates that the source head C triggers the movement of wh-adjunct and wh-subject phrases. In wh-adjunct extraction, two strategies are employed: overt wh-fronting and wh-in-situ; when the head Foc inherits an edge feature from C, wh-adjunct overtly undergoes movement from its original position within v*P to the left peripheries of [Spec-FocP] and subsequently to [Spec-CP]. When the lexical wh-adjunct remains within v*P, its question features covertly move to [Spec-CP], because the head Foc does not inherit an edge feature from C. In wh-subject extraction, the wh-subject overly undergoes movement to [Spec-CP] because C obligatorily inherits the edge feature to the head Top, which triggers movement of the illogical subject in unaccusative/ergative structures and the logical external specifier in unergative structures to [Spec-CP]. Moreover, Mehri obeys the Phase Impenetrability Condition of Chomsky, where wh-subject and wh-adjunct phrases must pass through certain phases until [Spec-CP].

A case-control study to evaluate hematological indices in blood of diabetic and non-diabetic individuals in Ibb City, Yemen

Diabetes mellitus (DM) is a chronic, metabolic illness characterized by an elevation of blood sugar levels. Patients with diabetes show changes in hematological indices. The study aimed to determine hematological indices, ESR, CRP, blood pressure (BP), and weight and their relationship with a fasting blood sugar (FBS) level and different variables in diabetic mellitus patients (DM) compared with healthy control (HC). A total of 202 participants (102 DM group and 100 HC group) were selected randomly. Data were collected using a questionnaire. Blood samples were collected from different places and investigated in Zain Medical Laboratories in Ibb City, Yemen (September 2022 to May 2023). GraphPad Prim was used to analyze the results. P-value ≤ 0.05 was considered statistically significant. The mean and standard deviation of age, weight, gender, residence, marital status, education levels, economic status, regular exercise, following a strict diet, and family history of diabetes revealed significant differences between DM and HC groups (P < 0.0001, P = 0001, P = 0.0027, P = 0.0002, P < 0.0001, P < 0.0001, P = 0.0002, P = 0.0011, P < 0.0001 and P = 0.0001, respectively). FBS results, systolic and diastolic BP, MCV, WBCs, monocytes, eosinophils, and platelets displayed significant differences between both groups (P < 0.0001, P < 0.0001 and P = 0.0404, P = 0.0191, P < 0.0001, P = 0.0253, P < 0.0001, and P = 0.0229, respectively). ESR exhibited statistical significance (P < 0.0001), while CRP displayed no significance. A Pearson's correlation showed that weight, Hb, RBCs, PCV, and WBCs were statistically negatively correlated with FBS whereas other hematological indices showed no correlation with FBS. In conclusion, DM patients had relatively higher levels of MCV, WBCs, eosinophils, platelets and ESR than the control group.

First report of molecular identification of Phytophthora infestans causing potato late blight in Yemen

Late blight, caused by Phytophthora infestans, is one of the most destructive potato diseases in the world. In Yemen, identification of P. infestans still depends on a visual survey and external examination of late blight symptoms. The objective of this study was to isolate and identify P. infestans by using advanced methods. We collected 71 disease samples and isolated the pathogen using the tuber slice method. To identify an isolated pathogen, we performed morphological characterization and gene sequence analysis of the coding genes for internal transcribed spacers. We used Koch's hypotheses to confirm the previous results. In our study. The morphological characters of the mycelium pattern of P. infestans isolates in Yemen were profusely branching, fluffy, and white. The sporangia showed remarkable limoniform papillate sporangial shape. with average length and width of 30.6 and 28.6 µm, respectively. The sequences analysis showed high homology with a degree of identity ranging from 98 to 100% to the database sequences on GenBank. Pathogenicity tests showed that the P. infestans was the causal agent. To our knowledge, this is the first study of the isolation and characterization of P. infestans in Yemen.

Access to global wheat reserves determines country-level vulnerability to conflict-induced Ukrainian wheat supply disruption

The Russia-Ukraine conflict reduced global wheat supplies, yet the food security implications vary across countries. We identify a 39% decrease in Ukrainian wheat exports in 2022 resulting in >70% import losses in some of the countries most vulnerable to these disruptions, with substantial impacts felt in Egypt, Oman, Saudi Arabia, Libya, Mauritania, Yemen and Lebanon. Differential impacts are a function of access to capital and international trade, suggesting the need for policy measures to defuse the impending food crisis.

Oral cancer knowledge, attitudes, and practices among senior dental students in Yemen: a multi-institution study

BACKGROUND

The "Knowledge, attitude, and practice (KAP)" approach is crucial in health system. Appreciating the current KAP status will reveal the extent of the efficiency of applied health strategies, and subsequently help to determine the appropriate health policy to be employed for improving the health indicators of a given disease/condition, including Oral Cancer (OC). This large-scale cross-sectional study aimed to assess knowledge, attitude, and practice on OC among senior dental students in Yemen.

METHODS

A pre-validated online questionnaire was used for data collection. It consisted of a series of close-ended questions on knowledge, attitudes and practices related to OC. Yemeni dental students in clinical levels (4th and 5th years) from nine dental schools based in four major cities were invited to complete the survey. The SPSS Version 28.0 was used for data analysis. Differences by different grouping factors were assessed by Chi-squared and Mann Whitney-U tests, as appropriate.

RESULTS

A total of 927 students completed the questionnaire: a response rate of 43%. While the majority identified smoking (93.8%), and smokeless tobacco (92.1%) as potential risk factors of OC, only 76.2% recognized sun exposure as a risk factor for lip cancer and only 50% were aware of old age as a risk factor of OC. Regarding clinical signs of OC, 84.1% reported that OC can present as non-healing ulcer, but only two thirds of the participants recognized that OC can present as a white and/or red lesion. With respect to practices, although 92.1% reported asking their patients regarding oral habits, only 78% reported they regularly carry out a soft tissue examination. Only 54.5% of the participants considered themselves to be well-trained to provide smoking cessation advice, and 21% were confident regarding their knowledge on OC. The 5th year students showed significantly better knowledge and practices than the 4th year students did (p < 0.01).

CONCLUSION

The study suggests significant gaps in knowledge, attitudes, and practices of senior dental students in Yemen regarding OC. The findings also underscore the urgent need to improve OC teaching and training of undergraduate dental students, and to provide periodic well-structured continuing professional development activities for dental professionals.

Anticholinesterase and anti-inflammatory constituents from Caralluma awdeliana, a medicinal plant from Yemen

From the dichloromethane (DCM) fraction of the crude ethanolic extract of Caralluma awdeliana, four pregnane glycosides and a flavone glycoside were isolated using a bio-guided isolation approach. The different extracts of C. awdeliana were subjected to in vitro enzyme inhibitory assays of anticholinesterases (AChE and BChE) and anti-inflammatory (COXs and 5-LOX). The highest inhibitory activity was exhibited by DCM fraction against COX-1, COX-2, and 5-LOX with IC₅₀ of 4.8 ± 0.5 μg/mL, 0.68 ± 0.2 μg/mL, and 39.5 ± 3.0 μg/mL, respectively. The DCM showed also a moderate activity against AChE (IC₅₀ 384.72 ± 3.6 μg/mL), and BChE (IC₅₀ 384.72 ± 3.6 μg/mL). The repeated chromatography of DCM fraction resulted in the isolation of two new pregnane glycosides, namely awdeliosides A (1) and B (4), two known ones, namely caratuberosides B and D, along with the known flavone glycoside identified as luteolin 4 -O-neohesperidoside. All the isolated compounds were tested for their in vitro enzyme inhibitory assays. Among the isolated compounds, awdelioside B (4) showed the most potent effect against COX-1 with IC₅₀ value of 10.99 ± 0.35 μM, compared to standard celecoxib (IC₅₀ 230.74 ± 2.62 μM). All the isolated compounds showed weak anticholinesterase, except a moderate activity observed for awdelioside B (4) against BChE with IC₅₀ value of 15.63 ± 3.5 μM, compared to standard donepezil (IC₅₀ 0.77 ± 0.0088 μM).

Key cytokines and hematological parameters in patients with uncomplicated falciparum malaria in Hodeidah, Yemen

Immunity to malaria has a major role in controlling disease and pathogenesis with cytokine production being involved in almost every phase of the immune response. The present study aimed to assess hematological variables and to measure plasma levels of TNFα, IFNγ and IL10, their ratios, and their relation to parasitemia among patients with uncomplicated falciparum malaria in Hodeidah, Yemen. Forty patients with uncomplicated P. falciparum monoinfection and 40 healthy age and sex-matched controls were enrolled in the study. Parasitological diagnosis was confirmed, and parasite density was estimated. Plasma cytokine levels, hematologic parameters, and the presence of gametocytes were determined. Results revealed higher TNFα, IFNγ and IL10 in patients than in controls. A relatively higher IL10 production was demonstrated by the significantly lower TNFα/IL10 and IFNγ/IL10 ratios in patients than in controls. TNFα and IL10 correlated positively with parasite density. Lower Hb levels, RBC, lymphocyte and platelet counts, and higher neutrophil and reticulocyte counts were observed in patients compared to controls. Reticulocyte count was higher and IFNγ level was lower in the presence of gametocytes. Conclusively, uncomplicated falciparum malaria is associated with the ability to regulate the production of pro-inflammatory and anti-inflammatory cytokines. This mediates parasite clearance while simultaneously avoiding severe pathology.

Unveiling air pollution patterns in Yemen: a spatial-temporal functional data analysis

The application of spatiotemporal functional analysis techniques in environmental pollution research remains limited. As a result, this paper suggests spatiotemporal functional data clustering and visualization tools for identifying temporal dynamic patterns and spatial dependence of multiple air pollutants. The study uses concentrations of four major pollutants, named particulate matter (PM2.5), ground-level ozone (O3), carbon monoxide (CO), and sulfur oxides (SO2), measured over 37 cities in Yemen from 1980 to 2022. The proposed tools include Fourier transformation, B-spline functions, and generalized-cross validation for data smoothing, as well as static and dynamic visualization methods. Innovatively, a functional mixture model was used to capture/identify the underlying/hidden dynamic patterns of spatiotemporal air pollutants concentration. According to the results, CO levels increased 25% from 1990 to 1996, peaking in the cities of Taiz, Sana'a, and Ibb before decreasing. Also, PM2.5 pollution reached a peak in 2018, increasing 30% with severe concentrations in Hodeidah, Marib, and Mocha. Moreover, O3 pollution fluctuated with peaks in 2014-2015, 2% increase and pollution rate of 265 Dobson. Besides, SO2 pollution rose from 1997 to 2010, reaching a peak before stabilizing. Thus, these findings provide insights into the structure of the spatiotemporal air pollutants cycle and can assist policymakers in identifying sources and suggesting measures to reduce them. As a result, the study's findings are promising and may guide future research on predicting multivariate air pollution statistics over the analyzed area.

On the forecastability of food insecurity

Food insecurity, defined as the lack of physical or economic access to safe, nutritious and sufficient food, remains one of the main challenges included in the 2030 Agenda for Sustainable Development. Near real-time data on the food insecurity situation collected by international organizations such as the World Food Programme can be crucial to monitor and forecast time trends of insufficient food consumption levels in countries at risk. Here, using food consumption observations in combination with secondary data on conflict, extreme weather events and economic shocks, we build a forecasting model based on gradient boosted regression trees to create predictions on the evolution of insufficient food consumption trends up to 30 days in to the future in 6 countries (Burkina Faso, Cameroon, Mali, Nigeria, Syria and Yemen). Results show that the number of available historical observations is a key element for the forecasting model performance. Among the 6 countries studied in this work, for those with the longest food insecurity time series, that is Syria and Yemen, the proposed forecasting model allows to forecast the prevalence of people with insufficient food consumption up to 30 days into the future with higher accuracy than a naive approach based on the last measured prevalence only. The framework developed in this work could provide decision makers with a tool to assess how the food insecurity situation will evolve in the near future in countries at risk. Results clearly point to the added value of continuous near real-time data collection at sub-national level.

Multidimensional study of factors influencing sustainable construction adoption in Yemen: insights for implementing sustainable practices

Despite political volatility, Yemen's construction sector is gradually progressing to satisfy the country's housing needs. Most construction projects, however, employ traditional construction methods and have yet to be able to adopt sustainable construction, which is economically feasible, socially responsible, and environmentally beneficial. To support sustainable construction, this study analyzes various factors that might drive sustainable practices in construction projects in Yemen. These drivers are discovered from the literature and validated by experts using grey Delphi. Forty-four drivers were approved across three dimensions: economic, social, and environmental. These drivers are assessed using grey AHP. The economic factor is determined to be the most crucial in the adoption of sustainable construction. Competitiveness, improved well-being, and improved indoor environmental quality are rated as the top economic, social, and environmental dimensions, respectively. Overall, competitiveness is acknowledged as the most important driver for the implementation of sustainable practices in Yemen's construction projects. The study's findings were discussed with the experts who were involved in the evaluation. The findings were agreed upon, and it was underlined that a proactive approach from both construction project participants and public authorities can increase the competitiveness of sustainable construction. Additional policies to promote competitiveness of sustainable construction are also advocated.

Situation analysis of optometric education in the Eastern Mediterranean Region

Background: There is a scarcity of research evidence about the state of optometric education in the Eastern Mediterranean Region (EMR). Aims: To survey the state of optometric education offered within the EMR to provide evidence for policy-makers and stakeholders. Methods: Twenty-two purposively selected key academic stakeholders completed a semistructured questionnaire about the state of optometric education in their respective countries between August 2021 and January 2022. Results: Data from 19 (86%) of the 21 countries and 1 territory were included in the analysis. Eight (36.4%) countries offered bachelor’s degree programmes and 5 (22.7%) offered a diploma, but 6 (27.3%) did not offer any optometry education. Saudi Arabia offered a Doctor of Optometry programme. Programmes were accredited by an accreditation body and programmes in 7 countries underwent periodic quality audits. Morocco had the highest average number of graduates per annum (n = 305), while Yemen had only 20. Conclusion: EMR countries differ with respect to numbers of optometric education programmes, curricular competency levels, and systems to monitor quality standards. There is a need for regional collaboration to foster harmonization towards offering quality optometric education programmes.

The transition from development and disaster risk reduction to humanitarian relief: the case of Yemen during high-intensity conflict

Discussions on how humanitarian aid and disaster responses can link better with development and disaster risk reduction (DRR) have occurred for decades. However, the reverse transition, from development to relief, is still poorly understood. Using the case of Yemen, this study analyses whether and how development and DRR activities adapted to the emerging humanitarian crisis when conflict escalated in the country. It concentrates on governance strategies, actors, challenges, and opportunities at the nexus of development, disaster, and humanitarian responses. Semi-structured interviews and focus-group discussions with aid and societal actors were conducted remotely and in Jordan. The findings show gaps in knowledge and coordination in the movement from development and DRR to relief, but also reveal spaces and opportunities to advance towards enhanced integration of action before, during, and after an emergency. This paper contributes to the literature on this nexus and critically argues for a more integrated approach to conflicts and disasters.

Status of the Coastal Marine Environment in the Southern Red Sea, Yemen, as Reflected by Elements Accumulated in the Skeletons of Scleractinian (Stony) Corals

The purpose of this study was to assess the level of anthropogenic contamination as well as to collect more data concerning the mineral composition of scleractinian corals from Southern Red Sea, Hodeidah Governorate, Yemen. The mass fractions of 31 elements were determined in the skeleton of nine coral colonies collected in the vicinity of the south-western coast of Yemen. All measurements were conducted by Instrumental Neutron Activation Analysis (INAA). The final results concerning the distribution of considered elements were comparable and, in some cases, inferior to those reported worldwide. The determined mass fractions of V, Cr, Mn, Fe, Ni, and Zn as Presumably Contaminating Elements (PCE) together with the mass fractions of the same elements previously reported in the literature regarding Red Sea Pleistocene corals permitted calculating the individual Contamination Factor (CF) and collective Pollution Load Index (PLI). In spite of high mass fraction values of Mn and Fe in only a few coral colonies, for all investigated places, the PLI values corresponding to studied areas were less than unit, suggesting the investigated areas could be considered as uncontaminated.

Risk assessment of atherosclerotic cardiovascular diseases before statin therapy initiation: Knowledge, attitude, and practice of physicians in Yemen

BACKGROUND

Risk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline.

METHODS

A cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces.

RESULTS

A total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day.

CONCLUSION

Physicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized.

Cost saving in primary versus tertiary level of reproductive health services in Sana'a, Yemen, 2013: a comparative cross-sectional study

OBJECTIVES

To estimate the cost saving for utilisation of vaginal delivery (VD), antenatal care (ANC) and an intrauterine device (IUD) services at primary health level facilities (PHLF) instead of tertiary health level facilities (THLF) in Sana'a.

DESIGN

A comparative cross-sectional study.

SETTING

Eight PHLF in Sana'a governorate and three THLF in Sana'a city.

PARTICIPANTS

A total of 180 women aged (15-45 years) were enrolled equally from PHLF and THLF. Sixty women attended for each reproductive health service (VD, ANC and IUD services).

PRIMARY AND SECONDARY OUTCOME MEASURES

The direct and indirect costs of services at PHLF and THLF, and the cost saving for utilisation of PHLF instead of THLF.

RESULTS

The median of direct medical cost (DMC) of VD, ANC and IUD services were US$43.86, US$14.77 and US$9.07 at THLF compared with US$19.54, US$0.93 and US$11.17 at PHLF, respectively. The DMC difference of VD, ANC and IUD services between THLF and PHLF was US$24.32, US$13.84 and US$-2.1, respectively. Regarding the direct non-medical costs (DNMC), the median of VD, ANC and IUD services were US$43.05, US$19.07 and US$17.27 at THLF compared with US$13.96, US$0.00 and US$0.00 at PHLF, respectively. The DNMC difference of VD, ANC and IUD service between THLF and PHLF was US$29.09, US$18.07 and US$16.27, respectively. Moreover, the median of indirect cost (INDC) for VD, ANC and IUD services were US$23.93, US$9.49 and US$10.44 at THLF compared with US$7.90, US$1.59 and US$1.06 at PHLF, respectively. The INDC difference of VD, ANC and IUD service between THLF and PHLF was US$16.03, US$7.90 and US$9.38, respectively.

CONCLUSION

The study found the utilisation of VD, ANC and IUD services at PHLF instead of THLF is a considerable cost saving for families. Therefore, shifting the utilisation of services from THLF to PHLF reduces the financial burden affecting individuals, families and their productivity.

Knowledge, attitude, perceived barriers, and practices among pharmacists regarding risk assessment of cardiovascular disease: a cross-sectional study in Yemen

BACKGROUND

Risk evaluation of atherosclerotic cardiovascular diseases can guide the decision-making on various preventive measures, such as initiating or deferring statin therapy. Pharmacists can play an active part in the risk evaluation and primary prevention of atherosclerotic cardiovascular diseases. Thus, our study aimed to assess the pharmacists' knowledge, attitude, perceived barriers, and practices regarding risk assessment of atherosclerotic cardiovascular disease.

MATERIALS AND METHODS

A cross-sectional study was conducted among 500 pharmacists using a structured validated questionnaire between November 2020 and February 2021. The Mann-Whitney and Kruskal-Wallis tests were used to analyze the data.

RESULTS

A total of 456 pharmacists completed the questionnaire out of 500 distributed (91.2% response rate). Over 60% of participants responded with never or rarely for two out of five cardiovascular diseases (CVD) prevention practices. The lowest pharmacist-patient counseling practices were for side effects of statin medication (14.5%) and reviewing the patient's medications to avoid potential statin-drug interactions (31.8%). Participants had a high positive attitude (median = 34 out of 40). The three major barriers for risk assessment were the lack of support (74.8%), the lack of resources (70.6%), and inadequate training (48.7%). Interestingly, having ≤75 customers a day, community pharmacies, PharmD degree, age ≥30 years, and experience ≥6 years were significantly associated (p < .05) with higher CVD prevention activities and counseling practices.

CONCLUSION

Pharmacists have a high positive attitude toward CVD risk assessment. However, they had insufficient knowledge and only provided limited activities and counseling services for CVD prevention and statin therapy. Participants perceived several barriers to CVD risk assessment services in pharmacies. Therefore, it is necessary to remove these impediments for pharmacists to be more involved in CVD risk assessment and prevention. Also, continuing medical education and adequate training for pharmacists are required.

Vaccine hesitancy from parents and healthcare providers perspectives in Hadhramout Governorate, Yemen: a mixed-method study protocol

INTRODUCTION

Although immunisation prevents the death of millions of infants and children each year, the vaccination coverage of routine childhood vaccination does not reach its target. The reasons for low vaccination uptake can be related to both demand and supply side determinants. The prevalence of vaccine hesitancy is increasing globally. However, data on vaccine hesitancy in low-income Arabic countries are scarce. To investigate this issue in Yemen, an Arabic low-income country, we aim to examine the link between vaccine hesitancy and the immunisation status of children living in Costal Hadhramout, Yemen, from the perspective of their parents and healthcare providers.

METHODS AND ANALYSIS

We will use a mixed-method research design. The study will be conducted in Costal Hadhramout in three phases. Phase 1 will involve a situational analysis using secondary data from records of the national expanded immunisation programme in Costal Hadhramout to examine the trend for previous years. Phase 2 will be a quantitative study aimed at assessing the prevalence of vaccination status of children aged <2 years and the determinants of parental vaccine hesitancy perception through a validated questionnaire. Lastly, phase 3 will be a qualitative study that explores vaccine hesitancy in Yemen using in-depth interviews and focus group discussions with parents and healthcare providers, respectively.

ETHICS AND DISSEMINATION

The study has been approved by the Research Committee of the Faculty of Medicine, University Kebangsaan Malaysia. The findings will be disseminated via publication in peer-reviewed academic journals, academic conferences and public presentations.

Biomonitoring coastal pollution on the Arabian Gulf and the Gulf of Aden using macroalgae: A review

The transporting of oil via the Arabian Gulf for centuries has resulted in the pollution of the coasts by heavy metals, and therefore, remediation actions are needed. In this review, we first evaluated heavy metal pollution on the coasts by assembling the research on published metal concentrations in sediments and water bodies surrounding the Arabian Peninsula. Research revealed uneven pollution of heavy metals, meaning that before remediation, the most polluted sites should be found. This could be done most conveniently using biomonitoring. The Arabian Peninsula is a unique ecoregion due to the extremely high temperature in summer, and therefore, it needs its specific standardization procedure for biomonitoring. To get an overview of the current information on biomonitoring, we gathered a dataset of 306 published macroalgal observations from the Arabian Gulf and the Gulf of Aden. The heavy metal concentration dataset of macroalgae was analyzed with a multivariate principal component analysis. As a result of the published works elsewhere and our data analysis, we recommend that green Ulva and brown Padina species are used in the biomonitoring of heavy metal pollution on the Arabian Peninsula's eastern and southern coasts. However, more species might be needed if these species do not occur at the site. The species incidence should first be monitored systematically in each area, and common species should be used. The species used should be chosen locally and sampled at the same depth at low tide in spring or early summer, from February to May, before the hottest season. The composite samples of different apical sections of the thallus should be collected. The standardization of the monitoring processes benefits future remediation actions.

Humanitarian (in)security: risk management in complex settings

Attacks against humanitarian aid workers have received increasing attention in the media, particularly high-profile incidents such as those against the hospitals of Médecins Sans Frontières in Afghanistan, Syria, and Yemen. Concurrently, scholarly research has given rise to a number of articles, white papers, and books on humanitarian insecurity. Most of this work centres on external threats, neglecting the internal mechanisms that humanitarian organisations use to mitigate security situations. This paper builds on the existing literature by focusing on the decision-making processes of humanitarian organisations, drawing on data collected from 16 security managers or advisers. The findings reveal that several factors contribute to contextual uncertainty and complexity, including recipient perceptions, local government actions, the behaviour of other non-governmental organisations (NGOs) in the area, logistical issues, risk variance within a single location, and organisational mandate. Furthermore, the results indicate that NGOs utilise a combination of decision-making processes to determine how to manage security in high-risk environments.

Wild edible plants traditionally collected and used in southern Yemen

BACKGROUND

The local wild edible plants (WEPs) are still used traditionally in the rural communities in Yemen, but this traditional knowledge is still undocumented and has been never reported before. Therefore, this study is the first ethnobotanical survey on WEPs conducted in Yemen.

METHODS

The study is based on two field surveys made in two periods 1988-1992 and 2014-2016 to document the wild plants used as edible by local indigenous peoples in 23 districts belonged to five governorates, in southern Yemen. Information data were collected by oral face-to-face interviews from 250 informants. Citations numbers were calculated for each species.

RESULTS

A total of 58 plant species belonged to 37 genera and 21 families are reported as wild edible plants consumed in southern Yemen. Apocynaceae was the dominant plant family with 18 species followed by Asteraceae (6) and Malvaceae (5). The most widely used edible parts are stem, leaf and fruit with more than 17 species for each. Herbs were reported as the most important sources (31 species), followed by shrubs (16) and trees (9). Most of reported wild edibles (48 species parts) are consumed in raw form; only 12 of them are cooked. Seven wild edible plants were collected in dry season, 16 species throughout the year and 38 in rainy season. In this study, 58 wild plants were reported for the first time as food in Yemen. Comparing the southern Yemeni findings to those from other world countries, 12 of them are new WEPs eaten only in southern Yemen, while 46 species are shared in the use in different world countries practically in East Africa and Arab countries.

CONCLUSIONS

The results data reflect the strong relationship between the local peoples and the local WEPs as potential sources insure food security. The traditional use of these WEPs is attributed to food shortage, nutritional values and local cultural tradition. The study is of great importance in preserving the traditional and knowledge heritage from being lost due to the risks of time, war and immigration.

The nitrogen and phosphorus footprints of food products in Yemen over the last 57 years

Food nitrogen (N) and phosphorus (P) footprints are indicators for determining the losses of N and P over food production (FP) and food consumption (FC) chain. Yemen is an interesting case because, given the country's heavy dependence on food imports, food insecurity, and poverty, the N footprint (NF) and P footprint (PF) could affect its future development. However, NF and PF over time have not yet been studied in Yemen. Therefore, this is the first paper to compute the NF and PF in Arabian Peninsula (a case study from Yemen) by an adjusted model of N-Calculator, by computing virtual N (VNFs) and virtual P (VPFs) factors for main foodstuffs. The NF (kg N cap^-1 year^-1) and PF (kg P cap^-1 year^-1) elevated from 5.56 and 1.20 in the 1960s to 15.2 and 4.79 during 2011-2017, respectively, while the national NF (Gg [10⁹ g] N year^-1) and national PF (Gg P year^-1) increased from 27.7 and 6.77 in the 1960s to 358 and 122 during 2011-2017, respectively. Cereal was the largest contributor to the NF and PF in Yemen over the past 57 years. FP contributes approximately 80% and 86% of the total NF and PF during 2011-2017. Therefore, if possible, the best way for consumers and farmers in Yemen to decrease NF and PF is to focus efforts on increasing FP and FC of foodstuffs with less VNFs and VPFs. The consumption of vegetable-fruit, legumes, starchy, eggs, poultry, and fish should be increased as their NF and PF are low. However, people in Yemen suffer from shortage of resources and lack of awareness, and thus they do not have the opportunity to choose foodstuffs that are low in NF and PF. Accordingly, policymakers should encourage integrated approaches that introduce powerful tools for controlling crop and livestock production in conjunction with enhancements in nutrient use efficiency.

Universality and Normativity of the Attachment Theory in Non-Western Psychiatric and Non-Psychiatric Samples: Multiple Group Confirmatory Factor Analysis (CFA)

This study tests for the first time the validity of universality and normativity assumptions related to the attachment theory in a non-Western culture, using a novel design including psychiatric and non-psychiatric samples as part of a comprehensive exploratory and advanced confirmatory framework. Three attachment assessments were distributed to 212 psychiatric outpatients and 300 non-psychiatric samples in Yemen. The results of the fourteen approaches of exploratory factor analysis (EFA) produce a similar result and assertion that the psychiatric outpatients tend to explore attachment outcomes based on multi-methods, while the non-psychiatric samples suggest an attachment orientation based on multi-traits (self-other). The multiple group-confirmatory factor analysis (MG-CFA) demonstrates that the multi-method model fits the psychiatric samples better than the non-psychiatric samples. Equally, the MG-CFA suggests that the multi-traits model also fits the psychiatric samples better than the non-psychiatric samples. Implications of the results are discussed.

Exploring the historical distribution of Dracaena cinnabari using ethnobotanical knowledge on Socotra Island, Yemen

BACKGROUND

In this study, we present and analyze toponyms referring to Socotra Island's endemic dragon's blood tree (Dracaena cinnabari) in four areas on the Socotra Archipelago UNESCO World Heritage site (Republic of Yemen). The motivation is the understanding of the past distribution of D. cinnabari trees which is an important part of conservation efforts by using ethnobotanical data. We assumed that dragon's blood trees had a wider distribution on Socotra Island in the past.

METHODS

This research was based on field surveys and interviews with the indigenous people. The place names (toponyms) were recorded in both Arabic and the indigenous Socotri language. We grouped all toponyms into five different categories according to the main descriptor: terrain, human, plant, water, and NA (unknown). Also, this study identified current and historical Arabic names of dragon's blood trees of the genus Dracaena through literature review.

RESULTS

A total of 301 toponyms were recorded from the four study areas in Socotra Island. Among names related to plants, we could attribute toponyms to nine different plants species, of which six toponyms referred to the D. cinnabari tree, representing 14.63% of the total phytotoponyms in the category. Three historical naming periods prior to 2000 could be identified. The most commonly used name for dragon's blood trees (D. cinnabari, D. serrulata, D. ombet) appears to be "ahrieb" "إعريهب" and its resin "dum al-akhawin" "دم الأخوين," while derived (mixed-cooked) products are called "eda'a" "إيدع," while regionally different names can be found.

CONCLUSION

The place names that refer to D. cinnabari are herein suggested to represent remnant areas of once large populations. Therefore, the toponyms may support known hypotheses based on climate models that D. cinnabari had a wider distribution on Socotra Island in the past. This study also confirmed the historical importance of dragon's blood.

Mind the gap: what explains the rural-nonrural inequality in diarrhoea among under-five children in low and medium-income countries? A decomposition analysis

BACKGROUND

Diarrhoea poses serious health problems among under-five children (U5C) in Low-and Medium-Income Countries (LMIC) with a higher prevalence in rural areas. A gap exists in knowledge on factors driving rural-non-rural inequalities in diarrhoea development among U5C in LMIC. This study investigates the magnitude of rural-non-rural inequalities in diarrhoea and the roles of individual-level and neighbourhood-level factors in explaining these inequalities.

METHODS

Data of 796,150 U5C, from 63,378 neighbourhoods across 57 LMIC from the most recent Demographic and Health Survey (2010-2018) was analysed. The outcome variable was the recent experience of diarrhoea while independent variables consist of the individual- and neighbourhood-level factors. Data were analysed using multivariable Fairlie decomposition at p < 0.05 in Stata Version 16 while visualization was implemented in R Statistical Package.

RESULTS

Two-thirds (68.0%) of the children are from rural areas. The overall prevalence of diarrhoea was 14.2, 14.6% vs 13.4% among rural and non-rural children respectively (p < 0.001). From the analysis, the following 20 countries showed a statistically significant pro-rural inequalities with higher odds of diarrhoea in rural areas than in nonrural areas at 5% alpha level: Albania (OR = 1.769; p = 0.001), Benin (OR = 1.209; p = 0.002), Burundi (OR = 1.399; p < 0.001), Cambodia (OR = 1.201; p < 0.031), Cameroon (OR = 1.377; p < 0.001), Comoros (OR = 1.266; p = 0.029), Egypt (OR = 1.331; p < 0.001), Honduras (OR = 1.127; p = 0.027), India (OR = 1.059; p < 0.001), Indonesia (OR = 1.219; p < 0.001), Liberia (OR = 1.158; p = 0.017), Mali (OR = 1.240; p = 0.001), Myanmar (OR = 1.422; p = 0.004), Namibia (OR = 1.451; p < 0.001), Nigeria (OR = 1.492; p < 0.001), Rwanda (OR = 1.261; p = 0.010), South Africa (OR = 1.420; p = 0.002), Togo (OR = 1.729; p < 0.001), Uganda (OR = 1.214; p < 0.001), and Yemen (OR = 1.249; p < 0.001); and pro-non-rural inequalities in 9 countries. Variations exist in factors associated with pro-rural inequalities across the 20 countries. Overall main contributors to pro-rural inequality were neighbourhood socioeconomic status, household wealth status, media access, toilet types, maternal age and education.

CONCLUSIONS

The gaps in the odds of diarrhoea among rural children than nonrural children were explained by individual-level and neighbourhood-level factors. Sustainable intervention measures that are tailored to country-specific needs could offer a better approach to closing rural-non-rural gaps in having diarrhoea among U5C in LMIC.

Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers

The war in Yemen, described as the world's 'worst humanitarian crisis,' has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health worker interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana'a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analysed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation - characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access - was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.

Myxobdella socotrensis sp. nov., a new parasitic leech from Socotra Island, with comments on the phylogeny of Praobdellidae (Hirudinida: Arhynchobdellida)

The Socotra Archipelago (Yemen) is remarkable for unique ecosystems and high endemism, for which it is often referred to as the "Galápagos of the Indian Ocean". Here we describe a new parasitic leech Myxobdella socotrensis sp. nov. from Socotra, the largest island of the archipelago. The new species was found in a freshwater spring attached to the endemic crab Socotrapotamon socotrensis (Hilgendorf, 1883) (Crustacea: Potamidae). Based on its morphology, ecology and a phylogenetic analysis of DNA sequence data (12S, 18S, 28S and COI gene markers), the new leech species is classified into the highly diversified family Praobdellidae (Hirudinida: Arhynchobdellida), distributed in tropical regions of Africa, Asia and Central and South America. The praobdellid leeches are known to infest mammalian mucous membranes, however, some taxa are associated with other hosts, namely crabs, amphibians and birds. By its morphology, the new species fits quite well in the current concept of the genus Myxobdella Oka, 1917. However, the monophyly of Myxobdella was not supported here by molecular data, pointing at the need of a more comprehensive systematic revision of the genus and family. As far as known, Myxobdella socotrensis sp. nov. is endemic to the Socotra Island, but more data are needed to understand its evolutionary origin, biology and distribution.

Resilience to maintain quality of intrapartum care in war torn Yemen: a retrospective pre-post study evaluating effects of changing birth volumes in a congested frontline hospital

BACKGROUND

Fragile and conflict-affected states contribute with more than 60% of the global burden of maternal mortality. There is an alarming need for research exploring maternal health service access and quality and adaptive responses during armed conflict. Taiz Houbane Maternal and Child Health Hospital in Yemen was established during the war as such adaptive response. However, as number of births vastly exceeded the facility's pre-dimensioned capacity, a policy was implemented to restrict admissions. We here assess the restriction's effects on the quality of intrapartum care and birth outcomes.

METHODS

A retrospective before and after study was conducted of all women giving birth in a high-volume month pre-restriction (August 2017; n = 1034) and a low-volume month post-restriction (November 2017; n = 436). Birth outcomes were assessed for all births (mode of birth, stillbirths, intra-facility neonatal deaths, and Apgar score < 7). Quality of intrapartum care was assessed by a criterion-based audit of all caesarean sections (n = 108 and n = 82) and of 250 randomly selected vaginal births in each month.

RESULTS

Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71)). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume.

CONCLUSIONS

Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes; to enable safe care during birth for as many women as possible.

Availability of Essential Medicines in a Country in Conflict: A Quantitative Insight from Yemen

Background: Medicine and medical supplies are often in short supply in countries suffering from the scourge of conflict. Effective medicine supply policies are lacking in many low- and middle-income countries (LMICs), particularly during conflict. This study aimed to assess the availability of essential medicines in both the public and private healthcare sectors. Methods: The study was conducted by administering a survey from November 2017 to February 2018 using the World Health Organization/Health Action International (WHO/HAI) guidelines and methodology. Thirty healthcare facilities in thirteen districts from three governorates in Yemen were included in the assessment of thirty essential medicines. The results were reported as frequencies and percentages of outlets with available medicines on the day of data collection. Results: A set of 30 vital and essential medicines were selected from the list of essential medicines that are used in healthcare centers in Yemen to treat prevalent diseases. In general, only 52.8% of the selected medicines were available in public and private healthcare settings. The distribution and availability of medicines in the three governorates were approximately equal. The availability of medicines was better in the private healthcare settings, specifically 73.3% in private hospitals and approximately 79.7% in private pharmacies. Conclusions: The availability of essential medicines during this state of conflict in three governorates in Yemen is low, in both public and private hospitals and healthcare centers. Many of the medications that were not available are used to treat chronic illnesses.

Estimating access to health care in Yemen, a complex humanitarian emergency setting: a descriptive applied geospatial analysis

Background

In conflict settings, data to guide humanitarian and development responses are often scarce. Although geospatial analyses have been used to estimate health-care access in many countries, such techniques have not been widely applied to inform real-time operations in protracted health emergencies. Doing so could provide a more robust approach for identifying and prioritising populations in need, targeting assistance, and assessing impact. We aimed to use geospatial analyses to overcome such data gaps in Yemen, the site of one of the world's worst ongoing humanitarian crises.

Methods

We derived geospatial coordinates, functionality, and service availability data for Yemen health facilities from the Health Resources and Services Availability Monitoring System assessment done by WHO and the Yemen Ministry of Public Health and Population. We modelled population spatial distribution using high-resolution satellite imagery, UN population estimates, and census data. A road network grid was built from OpenStreetMap and satellite data and modified using UN Yemen Logistics Cluster data and other datasets to account for lines of conflict and road accessibility. Using this information, we created a geospatial network model to deduce the travel time of Yemeni people to their nearest health-care facilities.

Findings

In 2018, we estimated that nearly 8·8 million (30·6%) of the total estimated Yemeni population of 28·7 million people lived more than 30-min travel time from the nearest fully or partially functional public primary health-care facility, and more than 12·1 million (42·4%) Yemeni people lived more than 1 h from the nearest fully or partially functional public hospital, assuming access to motorised transport. We found that access varied widely by district and type of health service, with almost 40% of the population living more than 2 h from comprehensive emergency obstetric and surgical care. We identified and ranked districts according to the number of people living beyond acceptable travel times to facilities and services. We found substantial variability in access and that many front-line districts were among those with the poorest access.

Interpretation

These findings provide the most comprehensive estimates of geographical access to health care in Yemen since the outbreak of the current conflict, and they provide proof of concept for how geospatial techniques can be used to address data gaps and rigorously inform health programming. Such information is of crucial importance for humanitarian and development organisations seeking to improve effectiveness and accountability.

Funding

Global Financing Facility for Women, Children, and Adolescents Trust Fund; Development and Data Science grant; and the Yemen Emergency Health and Nutrition Project, a partnership between the World Bank, UNICEF, and WHO.

Assessing barriers and solutions for Yemen energy crisis to adopt green and sustainable practices: a fuzzy multi-criteria analysis

Currently, the renewable energy sectors have dynamically revolved around targeting green turbulence, mainly due to increased customer environmental awareness. Therefore, this paper investigates green initiatives. The results show barriers and explain the strategies for adopting green renewable energy sources in Yemen. The political barrier has the highest weight of 0.191, while technical barrier sored the second highest weight of 0.181. The weights of managerial and information energy were found to be 0.18 and 0.17, respectively. Market barrier weighed the lowest score of 0.12, while economic barrier (0.15 weight) is the barrier to develop renewable energy road map. The research developed a comprehensive decision making framework to identify major barriers, sub-barriers, and develop plans for green energy in Yemen. Fuzzy analytical hierarchal process (FAHP) results indicate that the category of political obstacles is more important than other obstacles. Yemen has undergone power reforms and achieved better energy efficiency, compared to the countries that have applied imperfect. Economic efficiency in Yemen is the lowest among the considered barriers. Twenty-five percent of the considered barriers were identified with an alarming efficiency of 0.5%. The effects of FTOPSIS show that the planned explanation "developing research methods to achieve green innovation in renewable" energy is significant to address the obstacles to green innovation in renewable energy.

Cholera knowledge, socioeconomic and WaSH characteristics in Aden - Yemen, 2017: a community-based comparative survey

OBJECTIVES

To improve prevention and control response to the cholera outbreak, we sought to assess and compare the community's cholera awareness and needs in high and low epidemic areas in Aden.

METHODS

A community-based comparative survey was conducted in 2017. We used multi-stage cluster sampling. Eligible household heads in high and low epidemic areas were interviewed. The data collected from both areas using a pretested questionnaire.

RESULTS

Cholera cases and mortality were higher in high epidemic areas compared with low epidemic areas. Socioeconomic, water, sanitation, and hygienic conditions were poorer in high epidemic areas compared with low epidemic areas. Knowledge of cholera transmission and prevention was sub-optimal in both areas. We found a mismatch between the delivered education and distributed preventive materials.

CONCLUSIONS

Stakeholders should tailor the design, content, and implementation of future cholera prevention and control methods to meet the needs of the community. Future educational camping should focus on the transmission prevention, including vaccination. Education and sustainable interventions should be implemented to improve the water, sanitation, and hygiene.

Fluted-point technology in Neolithic Arabia: An independent invention far from the Americas

New World archaeologists have amply demonstrated that fluted point technology is specific to Terminal Pleistocene American cultures. Base-fluted, and rarer tip-fluted, projectile points from the Americas have been well-documented by archaeologists for nearly a century. Fluting is an iconic stone tool manufacturing method and a specific action that involves the extraction of a channel flake along the longitudinal axis of a bifacial piece. Here we report and synthesize information from Neolithic sites in southern Arabia, demonstrating the presence of fluting on a variety of stone tool types including projectile points. Fluted projectile points are known from both surface sites and stratified contexts in southern Arabia. Fluting technology has been clearly identified at the Manayzah site (Yemen) dating to 8000-7700 cal. BP. Examination of fluted points and channel flakes from southern Arabia enable a reconstruction of stone tool manufacturing techniques and reduction sequences (chaines opératoires). To illustrate the technological similarities and contrasts of fluting methods in Arabia and the Americas, comparative studies and experiments were conducted. Similarities in manufacturing approaches were observed on the fluting scars of bifacial pieces, whereas technological differences are apparent in the nature and localization of the flute and, most probably, the functional objective of fluting in economic, social and cultural contexts. Arabian and American fluted point technologies provide an excellent example of convergence of highly specialized stone tool production methods. Our description of Arabian and American fluting technology demonstrates that similar innovations and inventions were developed under different circumstances, and that highly-skilled and convergent production methods can have different anthropological implications.

Forecasting Internally Displaced Population Migration Patterns in Syria and Yemen

OBJECTIVES

Armed conflict has contributed to an unprecedented number of internally displaced persons (IDPs), individuals who are forced out of their homes but remain within their country. IDPs often urgently require shelter, food, and healthcare, yet prediction of when IDPs will migrate to an area remains a major challenge for aid delivery organizations. We sought to develop an IDP migration forecasting framework that could empower humanitarian aid groups to more effectively allocate resources during conflicts.

METHODS

We modeled monthly IDP migration between provinces within Syria and within Yemen using data on food prices, fuel prices, wages, location, time, and conflict reports. We compared machine learning methods with baseline persistence methods of forecasting.

RESULTS

We found a machine learning approach that more accurately forecast migration trends than baseline persistence methods. A random forest model outperformed the best persistence model in terms of root mean square error of log migration by 26% and 17% for the Syria and Yemen datasets, respectively.

CONCLUSIONS

Integrating diverse data sources into a machine learning model appears to improve IDP migration prediction. Further work should examine whether implementation of such models can enable proactive aid allocation for IDPs in anticipation of forecast arrivals.

Outcome of Imatinib Treatment in Yemeni Patients With Chronic Myeloid Leukemia and the Influence of Nonadherence to Treatment and Duration of Previous Hydroxyurea Therapy

BACKGROUND

In a developing country like Yemen, data are limited regarding the outcome of imatinib treatment of chronic myeloid leukemia and the effect of nonadherence to imatinib treatment and previous duration of hydroxyurea treatment.

PATIENTS AND METHODS

A longitudinal cohort study, which included 164 Yemeni patients, was performed. Data regarding the disease characteristics, adherence to treatment (the medication possession ratio) and outcome were analyzed.

RESULTS

After a median follow-up of 60 months and a median duration of imatinib treatment of 46 months, 79 (48.2%) patients were adherent to treatment. In adherent patients, the overall survival and progression-free survival (PFS) were 78 (98.7%) and 73 patients (92.4%), respectively and major molecular response (MMR) rates at 12 months and at 46 months were 32 (41.0%) and 45 patients (57.0%), respectively, compared with 67 (78.8%), 51 (60%), 5 (6.9%), and 2 patients (2.4%), respectively, in nonadherent patients (P < .001 for all parameters). Nonadherence to imatinib treatment and duration of hydroxyurea treatment of more than 12 months before starting imatinib were found to adversely affect PFS in univariate (hazard ratio [HR], 7.5 and 9.7, respectively and P < .001 for both) and multivariate (HR, 5.6 and 9.3; P = .001 and P < .001, respectively) analysis. High risk Sokal score was found to adversely affect PFS in univariate analysis (HR of high to low risk, 2.8; P < .022) but not in multivariate analysis.

CONCLUSION

Yemeni patients who were adherent to imatinib therapy achieved response rates similar to that of international standards. Nonadherence to imatinib treatment and previous duration of hydroxyurea treatment for more than 12 months, as a proxy of long interval between diagnosis and starting imatinib treatment, reduced the optimal response to imatinib therapy.

coli</i>, Sana'a Hospitals, Yemen

BACKGROUND AND OBJECTIVES

The occurrence of multi-drug resistance (MDR) Escherichia coli is one responsible for raised mortality and morbidity and was reported as major health problem. Class 1 integrons has crucial role in distributing antibiotic resistance genes among bacteria. Present work was aimed to determine the prevalence of class 1 integrons and its association with antibiotic resistance in MDR E. coli isolated from patient's body fluid and tissues from 6 health centers in Sana'a, Yemen.

MATERIALS AND METHODS

A cross-sectional study a total of 198 E. coli from patients diagnosed with infection that had been referred to 6 hospitals and medical diagnostic from July, 2017 to August, 2017 in Sana'a, Yemen. Susceptibility of E. coli isolates to 15 antibiotics using the disc diffusion method. Conventional polymerase chain reaction was used for detection of class 1 of integrons in 100 randomly selected MDR E. coli.

RESULTS

Overall 174 (87.9%) of 198 E. coli isolates were MDR. Class 1 integrons were detected in 67% of the randomly selected 100 of 198 MDR E. coli. A significant range (p<0.05-p<0.0001) was identified between presence of class 1 integrons and resistance to ceftriaxone, aztreonam, cefepime, amoxicillin-clavulanic acid, cefotoxime, cefepime-clavulanic acid, ceftazidime-clavulanic acid, ciprofloxacin, ceftazidime, norfloxacin and trimethoprim-sulfamethoxazole, while no significant difference were identified between integron class 1 and resistance to gentamicin, amikacin, nitrofurantoin and imipenem.

CONCLUSION

High MDR E. coli isolates were detected in this study, among them the prevalence of class 1 integrons is the most common. The significant association between class 1 integrons and resistance to common prescribed antibiotics in hospitals in Sana'a, Yemen.

Antioxidant, Antimicrobial and Wound Healing Potential of Jatropha variegata - An Interesting Plant Endemic to Yemen

BACKGROUND AND OBJECTIVE

Jatropha variegata is traditionally used in Yemeni folk medicine for antiseptic and hemostatic purposes. In this study, the methanolic extract of the plant leaves was evaluated for its antioxidant, antibacterial and wound healing activity.

MATERIALS AND METHODS

The antioxidant activity was assessed using 1,1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging assay. The antibacterial activity against Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa was tested using disc diffusion and broth microdilution assays. In vivo, the ability of the extract to accelerate wound healing in rats was evaluated using both wound area measurements and histological analyses.

RESULTS

The leaves extract exhibited strong antioxidant activity with an IC50 value of 16.7 μg mL-1. The extract exhibited moderate antibacterial activity against S. aureus with inhibition zones of 10.6 mm, and the Minimum Inhibitory Concentration (MIC) value was 5 mg mL-1. The extract significantly accelerated the rate of wound healing closure compared to those treated with the vehicle. In addition, histopathological analyses of wound granulation tissues showed significantly better healing signs after 14 days in the extract-treated groups, with denser collagen deposition at the injury site.

CONCLUSION

The leaves of J. variegata appear to contain bioactive compounds that may be utilized clinically in combating oxidative stress and in wound management.