Mapping University-Based Master of Public Health Programs in the Arab world.

Background: The Arab world faces numerous health challenges that mandate a competent public health workforce and strengthening public health education. Objective: To analyze university-based Master of Public Health (MPH) programs offered at Faculties of Public Health (FPH) and of Medicine (FM) in Arab countries. Methods: We searched a regional database of academic public health institutions, conducted a search of university websites, and reviewed websites of the Association of Arab Universities and World Directory of Medical Schools. A factsheet for each MPH program was emailed to deans of respective faculties for validation and completion. We examined associations between presence of such programs and population size and Human Development Index (HDI). Findings: A total of 19 FPH and 10 FM at 28 universities offer MPH programs (7 programs per 100 million population). Ten countries offer no MPH programs; the remaining 12 offer 1-5 programs each. Ten MPH programs were initiated over 45 years (1965-2009) and another 19 over 10 years (2010-2019). No correlation was observed between offering an MPH program and the country's HDI or population size. Less than half of the programs admit students from fields outside health. FPH and FM-based programs are comparable in offering core disciplines but FPH programs offer more Social and Behavioral Sciences (83% vs. 60%). More FM-based programs provide practicum training (78% vs. 53%); 10 programs offer none. Epidemiology, alone or with Biostatistics, and Health Management and Policy are the two most frequently offered MPH concentrations. None of the MPH programs offer a concentration on public health in conflict or humanitarian crises; only one offers a certificate on the theme. Only three programs, all FPH-based, reported international accreditation. Conclusions: The recent increase in MPH programs in Arab countries is encouraging. Critical gaps are absence of MPH programs in 10 countries, less coverage of the social sciences, and lack of practicum experience in 10 programs. Upgrading and promoting public health education across the region to fill these gaps calls for collaboration among existing MPH programs. More in-depth analysis of the history and mission of these programs, as well as their admission criteria and curricula, is needed.

Episiotomy practice in the Middle East: A Lebanese teaching tertiary care centre experience.

PROBLEM: There is lack of data on the rate of episiotomy in Lebanon and the study's hospital. BACKGROUND: Only a few studies have addressed episiotomy practice in Lebanon and the Middle East and they show varying rates. AIM: To identify the rate, and change in rate, of episiotomy practice over the years at a teaching hospital in Lebanon and to assess whether maternal age, parity, fetal weight, woman's hospital admission class, and physician's gender were associated with episiotomy. We also tested the association between episiotomy and postpartum hemorrhage and/or high degree perineal tears. METHODS: A retrospective observational study was conducted on 1756 records for women having a normal vaginal birth at a single centre from January 2009 to January 2014. FINDINGS: The rate of episiotomy at the hospital was very high, with 97.4% of women receiving an episiotomy in 2009. A major decrease in the rate was identified with a decline from 97.4% in 2009 to 73.3% in January 2014. Episiotomy was found to be associated with parity, maternal age, and with high degree perineal tears. DISCUSSION: The episiotomy rate at this centre remains higher than the 10% rate recommended by the World Health Organization, although there has been a significant reduction after a call for restrictive rather than liberal use. CONCLUSION: Raising awareness among providers appeared to play a significant role in reducing this rate, although more efforts remain warranted. Other strategies - such as raising awareness of women about potential risks of episiotomy - are also worth exploring.

Health research in a turbulent region: the Reproductive Health Working Group.

The Reproductive Health Working Group (RHWG) was established in 1988 in Cairo to advance research in the Arab countries and Turkey on the health of women, broadly defined. The paper considers the ways in which the group contributed to global health conversations through three examples of interdisciplinary research that, in privileging local contexts, modified or even challenged prevailing approaches to health and often raised entirely new issues for consideration. The three examples cited in the paper are: (i) the network's early research on reproductive morbidity; (ii) a broad set of ongoing studies on childbirth/maternal health; and (iii) emerging research on health and conflict. The paper discusses how the RHWG has strengthened research capability in the region, and explores the reasons for the longevity of this research network.

Perspectives of displaced Syrian women and service providers on fertility behaviour and available services in West Bekaa, Lebanon.

Prior to the conflict, Syria had relatively high fertility rates. In 2010, it had the sixth highest total fertility rate in the Arab World, but it witnessed a fertility decline before the conflict in 2011. Displacement during conflict influences fertility behaviour, and meeting the contraceptive needs of displaced populations is complex. This study explored the perspectives of women and service providers about fertility behaviour of and service provision to Syrian refugee women in Bekaa, Lebanon. We used qualitative methodology to conduct 12 focus group discussions with Syrian refugee women grouped in different age categories and 13 in-depth interviews with care providers from the same region. Our findings indicate that the displacement of Syrians to Lebanon had implications on the fertility behaviour of the participants. Women brought their beliefs about preferred family size and norms about decision-making into an environment where they were exposed to both aid and hardship. The unaffordability of contraceptives in the Lebanese privatised health system compared to their free provision in Syria limited access to family planning services. Efforts are needed to maintain health resources and monitor health needs of the refugee population in order to improve access and use of services.

Health and ecological sustainability in the Arab world: a matter of survival.

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

The Relaxation Exercise and Social Support Trial (RESST): a community-based randomized controlled trial to alleviate medically unexplained vaginal discharge symptoms.

BACKGROUND: Symptoms such as medically unexplained vaginal discharge (MUVD) are common and bothersome, leading to potentially unnecessary use of resources. METHODS: A community-based individually randomized controlled trial to assess the effectiveness of a relatively simple, culturally appropriate multi-component intervention on reducing reported MUVD, among women suffering from low-moderate levels of common mental distress. The setting was a socio-economically deprived, informal settlement in the southern suburbs of Beirut, Lebanon. The intervention comprised up to 12 group sessions implemented over a six-week period, each divided into a psychosocial and a relaxation exercise component. The primary outcome was self-reported MUVD, which was defined as a complaint of vaginal discharge upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Blinding on the intervention status was not possible for both logistic and ethical reasons, especially as knowledge of involvement in the intervention was integral to its delivery. Intent to treat analysis was used. RESULTS: Of 75 women randomized to the intervention, 48% reported MUVD at 6 months compared with 63% of 73 in the control group (difference of -15%, 95% confidence interval (CI) -31%, 0%, p=0.067). Adjustments for baseline imbalances and any factors relating to consent had no appreciable effect on these results. The risk of MUVD was reduced in absolute terms by 2.4% for each intervention session attended (95% CI -4.9%, 0.0%, p=0.049). While there was also marginal evidence of a beneficial effect on anxiety, there was no evidence of mediation of the effect on MUVD through measures of common mental disorders. CONCLUSION: This study confirms that MUVD is an important public health problem. While the benefits of this intervention may appear modest, the intervention offers an opportunity for women to enhance their problem-solving skills as well as use physical relaxation techniques that can help them deal with stressful in their lives. Further research is needed in a variety of contexts, for different populations and preferably involving larger randomized trials of such an intervention. TRIAL REGISTRATION: * Title of trial: The Relaxation Exercise and Social Support Trial ISRCTN assigned: ISRCTN98441241 Date of assignation: 10/09/2010 Link: http://www.controlled-trials.com/ISRCTN98441241* Also registered at the Wellcome Trust register:http://www.controlled-trials.com/mrct/trial/469943/98441241.

Health-related quality of life of Gaza Palestinians in the aftermath of the winter 2008-09 Israeli attack on the Strip.

BACKGROUND: We document the health-related quality of life (HRQoL) of people living in the Gaza Strip 6 months after 27 December 2008 to 18 January 2009, Israeli attack. METHODS: Cross-sectional survey 6 months after the Israeli attack. Households were selected by cluster sampling in two stages: a random sample of enumeration areas (EAs) and a random sample of households within each chosen EA. One randomly chosen adult from each of 3017 households included in the survey completed the World Health Organization Quality of Life instrument, in addition to reported information on distress, insecurities and threats. RESULTS: Mean HRQoL score (range 0-100) for the physical domain was 69.7, followed by the psychological (59.8) and the environmental domain score (48.4). Predictors of lower (worse) scores for all three domains were: lower educational levels, residence in rural areas, destruction to one's private property or high levels of distress and suffering. Worse physical and psychological domain scores were reported by people who were older and those living in North Gaza governorate. Worse physical and environmental domain scores were reported by people with no one working at home, and those with worse standard of living levels. Respondents who reported suffering stated that the main causes were the ongoing siege, the latest war on the Strip and internal Palestinian factional violence. CONCLUSION: Results reveal poor HRQoL of adult Gazans compared with the results of WHO multi-country field trials and significant associations between low HRQoL and war-related factors, especially reports of distress, insecurity and suffering.

Reproductive tract infections (RTIs) among married non-pregnant women living in a low-income suburb of Beirut, Lebanon.

INTRODUCTION: This study aimed to identify reproductive tract infections (RTIs) in married, non-pregnant women, aged 18 to 49 years, living in a low-income suburb of Beirut, and to investigate the relationship between demographic and socioeconomic factors and these infections. METHODOLOGY: Among 1,015 women recruited for the study, 502 were found eligible and 441 were medically examined. Appropriate specimens were collected for Nisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, candidiasis, and bacterial vaginosis. RESULTS: The results showed a relatively high prevalence of RTIs (28.2%). The prevalence rates of different agents were as follows: 22.9% of the women were positive for T. vaginalis, 8.8% for candidiasis, 4.5% for bacterial vaginosis, and 1% for N. gonorrhea; none of the women were positive for C. trachomatis. Regression analysis showed that women between the ages of 30 and 39 were twice more likely to have T. vaginalis as compared to younger women. Furthermore, women whose husbands were taxi drivers were at higher risk of acquiring T. vaginalis (OR = 2.2) as compared with women whose husbands occupation was listed as skilled/unskilled. This conclusion can be drawn for the odds of developing any RTI (OR = 2.15). Moreover, those participants with the lowest income were twice as likely to have any RTI compared to those with higher incomes. CONCLUSIONS: This study shows a relatively high prevalence of RTIs (T. vaginalis mainly). It urges further in-depth research on cultural practices and economic factors to understand the pattern of sexual behavior in this community.

The relaxation exercise and social support trial-resst: study protocol for a randomized community based trial.

BACKGROUND: Studies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health. METHODS/DESIGN: This is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used. DISCUSSION: The results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress). TRIAL REGISTRATION: The trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241.

Summer 2006 war on Lebanon: a lesson in community resilience.

The internally displaced persons (IDPs) during the July 2006 war in Lebanon exhibited a high level of community resilience, affirmed by relief agencies and public health professionals. Data from personal observations, interviews, meetings and published material were used to examine factors contributing to this resilience. Findings suggested that community resilience is a process rather than an outcome. The sense of a collective identity, prior experience with wars and social support networks have contributed to building up IDP's resilience over time, while community cohesiveness, adequate public health interventions, social solidarity and a connected political leadership helped to sustain it during and shortly after the war. This paper examines implications for public health professionals and argues for a paradigm shift in disaster relief practice.