Informing mental health policies and services in the EMR: cost-effective deployment of human resources to deliver integrated community-based care.

For EMR countries to deliver the expectations of the Global Mental Health Action Plan 2013-2020 & the ongoing move towards universal health coverage, all health & social care providers need to innovate and transform their services to provide evidence-based health care that is accessible, cost-effective & with the best patient outcomes. For the primary and community workforce, this includes general medical practitioners, practice & community nurses, community social workers, housing officers, lay health workers, nongovernmental organizations & civil society, including community spiritual leaders/healers. This paper brings together the current best evidence to support transformation & discusses key approaches to achieve this, including skill mix and/or task shifting and integrated care. The important factors that need to be in place to support skill mix/task shifting and good integrated care are outlined with reference to EMR countries.

FEV1 and FVC pulmonary function reference values among 6-18-year-old children: a multi-centre study in Saudi Arabia.

It is important to establish lung function reference values for each population. This study aimed to determine the spirometric reference values for healthy Saudi Arabian children and adolescents and to derive prediction equations for these. A cross-sectional study was conducted among healthy schoolboys and girls aged 6-18 years old, selected randomly from the 6 administrative regions of Saudi Arabia. Data were collected by questionnaire and physical examinations including spirometry. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were significantly higher in males than females. Height was the anthropometric variable most strongly correlated with FEV1 (r = 0. 61), more so for males (r = 0.71) than females (r = 0.50). In males the multivariate linear regression model explained 53.9% of FEV1 and 35.1% of FVC variations. In females it explained 25.3% of FEV1 and 16.5% of FVC variations. All changes in R² were statistically significant.

Tobacco control efforts in the Gulf Cooperation Council countries: achievements and challenges.

This paper reports a review into the current state of tobacco use, governance and national commitment for control, and current intervention frameworks in place to reduce the use of tobacco among the populations of the Gulf Cooperation Council (GCC) member states and Yemen. It further reviews structured policy-oriented interventions (in line with the MPOWER package of 6 evidence-based tobacco control measures) that represent government actions to strengthen, implement and manage tobacco control programmes and to address the growing epidemic of tobacco use. Our findings show that tobacco control in the GCC countries has witnessed real progress over the past decades. These are still early days but they indicate steps in the right direction. Future investment in implementation and enforcement of the Framework Convention on Tobacco Control, production of robust tobacco control legislation and the establishment of universally available tobacco cessation services are essential to sustain and strengthen tobacco control in the GCC region.

Physicians medication prescribing in primary care in Riyadh City, Saudi Arabia. Literature review, part 1: variations in drug prescribing.

Rational prescribing is associated with improved safety in drug use, better quality of life for patients and cost-effective care. Medication prescribing is a relatively unexplored area of research in Saudi Arabia and until now most studies have been in the secondary and tertiary health care system. This paper is the first of 3 review articles that form the background for a series of 5 interconnected studies of prescribing patterns and medication errors in the public and private primary health care sectors of Saudi Arabia. A MEDLINE search was conducted to identify papers published in peer-reviewed journals over the previous 3 decades. The paper reviews variations in prescribing patterns and influences on physicians' prescribing behaviour worldwide and in Saudi Arabia.

Physicians' medication prescribing in primary care in Riyadh City, Saudi Arabia. Literature review, part 2: rational prescribing.

Unlike sub-optimal prescribing, rational prescribing, coupled with certain indicators, is associated with improved safety in drug use in terms of selecting appropriate drug for prescribing, better quality of life for patients and cost-effective care. Medication prescribing is a relatively unexplored area of research in Saudi Arabia and until now most studies have been in the secondary and tertiary health care system. This paper is the second of 3 review articles that form the background for a series of 5 interconnected studies of prescribing patterns and medication errors in the public and private primary health care sectors of Saudi Arabia. A MEDLINE search was conducted to identify papers published in peer-reviewed journals over the previous 3 decades. The paper reviews rational prescribing with its indicators, suboptimal prescribing, classification of medication errors, and how to achieve quality in health care prescribing worldwide and in Saudi Arabia.

Physicians' medication prescribing in primary care . in Riyadh City, Saudi Arabia. Literature review, part 3: prescribing errors.

Medication errors are globally huge in magnitude and associated with high morbidity and mortality together with high costs and legal problems. Medication errors are caused by multiple factors related to health providers, consumers and health system, but most prescribing errors are preventable. This paper is the third of 3 review articles that form the background for a series of 5 interconnected studies of prescribing patterns and medication errors in the public and private primary health care sectors of Saudi Arabia. A MEDLINE search was conducted to identify papers published in peer-reviewed journals over the previous 3 decades. The paper reviews the etiology, prevention strategies, reporting mechanisms and the myriad consequences of medication errors.

[Medication prescribing pattern in primary care in Riyadh City, Saudi Arabia]

Physicians' prescribing behaviour is closely linked with patient safety and this area is poorly researched in Saudi Arabia. The objective of this study was to analyse physicians' prescribing patterns and the adequacy of noted information in the primary health care sector in Riyadh city. All medication prescriptions from 5 public (n = 1182) and 5 private (n = 1200) health centres were collected by simple random sampling during 1 working day. Antibiotics were the most commonly prescribed drugs in both sectors. The mean number of drugs per prescription was 2.08 and 2.36 in the public and private sectors respectively. Information and instructions noted on prescriptions varied considerably between private and public health centres. Similarly the medication prescribing pattern differed across the 2 health settings. Primary care physicians in Saudi Arabia need continuing training to improve their prescribing practices.

Medication errors in primary care in Riyadh City, Saudi Arabia.

Medication errors can cause a variety of adverse drug events but are potentially preventable. This cross-sectional study analysed all medication prescriptions from 5 public and 5 private primary health care clinics in Riyadh city, collected by simple random sampling during 1 working day. Prescriptions for 2463 and 2836 drugs from public and private clinics respectively were examined for errors, which were analysed using Neville et al.'s classification of prescription errors. Prescribing errors were found on 990/5299 (18.7%) prescriptions. Both type B and type C errors (major and minor nuisance) were more often associated with prescriptions from public than private clinics. Type D errors (trivial) were significantly more likely to occur with private health sector prescriptions. Type A errors (potentially serious) were rare (8/5299 drugs; 0.15%) and the rate did not differ significantly between the 2 health sectors. The development of preventive strategies for avoiding prescription errors is crucial.

Determinants of physicians' medication prescribing behaviour in primary care in Riyadh City, Saudi Arabia.

This study in Saudi Arabia explored the determinants of physicians' prescribing behaviour in primary care in Riyadh city. A self-administered questionnaire designed to explore factors influencing prescribing (sociodemographic factors; practice setting; continuing education; access to educational materials; pharmaceutical company representatives; and patient factors) was completed by 87 PHC physicians. A factor analysis of 56 variables extracted 7 factors that explained 46% of the variance. Of these, 4 components positively related to perceived good prescribing behaviour could be summarized as: clinical experience of physicians; use of educational materials for continuous updating of medical knowledge; enhanced levels of continuing medical education and willingness to involve patients in decision-making; and working as a team using pharmacists for consultation and emphasizing the role of medical education. The other 3 factors derived from the analysis were less easy to interpret and may have been statistical anomalies (or measurement errors).

Predictors of quality of medication prescribing in primary care in Riyadh City, Saudi Arabia.

Identifying the indicators of good quality medication prescribing assists physicians in preventing medication errors. This study in Riyadh city aimed to examine the relationship between physicians' self-reported influences on prescribing and the quality of their prescribing, defined as the completeness and accuracy of their prescription documentation. A sample of 600 randomly selected prescriptions written by 87 physicians were rated as high or low quality. The same physicians completed a questionnaire to determine the indicators of quality prescribing. The 7 components identified with factor loadings +0.5 or -0.5 were subjected to binary logistic regression modelling. While a range of potential quality indicators of drug prescribing were identified, none of the variables underpinning the 7components/factors survived the binary logistic regression mode. More studies are needed that take into account other quality indicators of medication prescribing in Saudi Arabia.

Effectiveness of three interventions on primary care physicians' medication prescribing in Riyadh City, Saudi Arabia.

A number of strategies have been shown to improve the quality of drug prescriptions. The objective of this study was to implement and assess the effectiveness of 3 interventions on physicians' prescribing and cost containment: training physicians about quality prescribing; regulatory and administrative measures to improve rational drug prescribing; and a multi-faceted approach using 2 these strategies plus additional elements. Three public health centres, 1 for each intervention, were randomly selected; 61 physicians were trained in drug prescribing and completed a pre- and post-training questionnaire; and 100 post-intervention prescriptions from each centre were compared. All 3 interventions effectively improved the quality of drug prescriptions and the notation of drug-related information and trainees returned positive evaluations of the training course. Whether or not physicians' improvement in prescribing will be sustained is unclear and therefore subsequent follow-up evaluations are needed.

National health research system mapping in 10 Eastern Mediterranean countries.

Health research systems in the Eastern Mediterranean Region are not well developed to generate and use knowledge to improve health, reduce inequity and contribute to economic development. This study aimed to provide core data on National Health Research Systems (NHRS) in 10 Eastern Mediterranean countries in order to inform actions to strengthen health research system governance and management. Whilst there were examples of good practice, few countries had a formal NHRS and many basic building blocks needed for an effective system had not been put in place. Although limited in focus, the study provides useful information for countries to initiate action to strengthen their NHRS.

Attitudes to evidence-based medicine of primary care physicians in Asir region, Saudi Arabia.

A questionnaire survey was made of primary health care physicians in Asir region, Saudi Arabia in 1999 to explore their awareness of and attitude towards evidence-based medicine. The 272 respondents welcomed the principles of evidence-based medicine. Awareness and use of extracting journals, review publications and databases was low. Pharmaceutical company sponsored journals were the most commonly read. Bibliographic databases could only be accessed by 13% of respondents and the Internet by only 6%. There was only partial understanding of technical terms used in evidence-based medicine. Absence of a local library and increased patient workload were seen by most respondents as the main obstacles to practising evidence-based medicine.

Group purchasing of pharmaceuticals and medical supplies by the Gulf Cooperation Council states.

An important issue in health care today is the cost of essential pharmaceuticals and medical supplies. To control the increase of health care expenses, in 1976 the Gulf Cooperation Council states began to study the idea of establishing a group purchasing programme for pharmaceuticals and medical supplies. This paper demonstrates the elements of the programme, how it works, what obstacles it faces and how other countries can profit from this experience. It also discusses the future of the group purchasing programme in the light of globalization and how the international changes under the World Trade Organization agreements will affect the programme in future.

Prevalence of hypertension and sociodemographic characteristics of adult hypertensives in Riyadh City, Saudi Arabia.

OBJECTIVES: To estimate the prevalence of hypertension in adults residing in Riyadh city and to study the sociodemographic characteristics of adult hypertensives. DESIGN: Cross-sectional survey. SETTING: Primary Health Care Centres (PHCCs) in Riyadh city selected by stratified random sampling, the subjects resident in each PHCC catchment area were selected by systematic sampling from their records in the PHCCs. SUBJECTS AND METHODS: A total of 1394 adults aged 15 years and over were interviewed and examined during March 1993 to March 1994. The average of three measurements of blood pressure (BP) was taken to represent their current pressures. A subject is considered hypertensive if the average BP reading is 160/95 mm Hg or more, or is currently under treatment. RESULTS: The total hypertensive subjects were 214 giving an overall prevalence of hypertension of 15.4%. Of these 157 (11.3%) subjects were known hypertensives and were under some form of treatment. On the other hand 57 (4.1%) other subjects were newly detected by the study. Hypertension (BP = 160/95 mm Hg or more) was significantly related to age, marriage, education, occupation and employment status and consanguinity. Male subjects had a higher prevalence of hypertension but the differences were not significant. Nationality and income were not related to high BP. CONCLUSION: Hypertension is a problem among adults in Riyadh city. It is significantly related to some sociodemographic and family factors. About 27% of all hypertensives are not aware of their disease and more than 31% of known hypertensives are apparently not well controlled. There is a need for a programme to prevent and control hypertension in Riyadh city. Similar studies need to be done in other areas of the country to estimate the prevalence of hypertension and associated factors as prerequisites for any programme to control the disease.

Population-based epidemiological study on characteristics of risk factors of hypercholesterolemia in Saudi Arabia.

OBJECTIVES: To study the characteristics of risk factors for hypercholesterolemia among the Saudi population. DESIGN: Population-based cross-sectional national epidemiological randomized household survey. SUBJECT: 4548 Saudi subjects, aged 15 years and above. Sample was representative and in accordance with the national population distribution with respect to age, gender, regional and residency, urban vs. rural, population distribution. MEASUREMENT: Height and weight with calculation of body mass index, blood samples were drawn and assayed for glucose and total cholesterol concentration. Hypercholesterolemia (HC) was defined: borderline high HC (5.2-6.2 mmol l-1) and high HC (> 6.2 mmol l-1). Univariate, multivariate, simple logistic, multiple logistic, odd ratio and chi-square were employed in the statistical analysis. RESULTS: The risk of developing HC increased with age by 2% and 1% for each year increase in age for borderline high HC and high HC. The risk of developing HC was significantly higher among female subjects. There was no significant relation between the spectrum of BMI group, underweight to obesity, with risk of developing borderline high or high HC. There was a significant increase in the risk of developing HC among residents of urban communities. There was no significant regional variation for risk of borderline high HC, however, there was a significant increase in the risk of developing high HC among residents of Central and Eastern regions, compared with other regions. CONCLUSION: The characteristics of risk factors for HC among the Saudi population differ in many respects from other populations. Overweight and obesity are not significant risk factors for HC. Rural communities are more at risk of HC than urban communities. The population of the Eastern and Central regions were at significantly higher risk of developing HC. The relatively recent urbanization may account for the low prevalence of HC. It may partially explain the dissociation between obesity and HC. Food habits, both in quantity and quality in rural communities in genetically predisposed homogenous populations may account for the increase in the prevalence of HC in rural communities. There is a need to propagate information about the potential health hazard of obesity and HC among Saudi communities, at large, and specifically in the Eastern and Central regions. There is a need to study the food patterns of rural communities which may explain partially the relative increase in the prevalence of HC in rural communities.

Primary health care physicians' views on periodic health evaluation in Saudi Arabia.

The attitude and beliefs of primary health care physicians regarding periodic health evaluation is critical to determining the most effective and acceptable means for delivering recommended clinical preventive services. We aimed to evaluate the views of primary health care physicians in Saudi Arabia on periodic health evaluation. A self-administered and pre-tested questionnaire was sent to 1235 physicians randomly selected throughout the country. About 90% of the physicians would recommend periodic health evaluations to all or some clients while 10% would not. Almost all (95%) of the physicians were aware of the benefits and costs of periodic health examinations, and were willing to carry it out. Their enthusiasm for performing many items during examinations should be encouraged.

Setting the scene for an ARI control programme: is it worthwhile in Saudi Arabia?

Baseline data on acute respiratory infections (ARI) were collected by a survey questionnaire distributed to physicians of 10% of the health centres randomly selected from each of the five provinces of Saudi Arabia. The physicians estimated that ARI was the cause of sickness in 50% of ill children < 5 years in 1995. None of the physicians had had any training in ARI and they were not aware of any national protocol or programme. Physicians' responses indicated an over-use of antibiotics and diagnostic procedures. A national protocol for diagnosis and treatment of ARI has been prepared and distributed and leaders of primary health care and 55 national trainers have been trained.

Integrating maternal and child health with primary health care in Saudi Arabia.

Integration is an important tool for successful implementation of components of a comprehensive health programme. We describe strategies adopted to integrate the Saudi maternal and child health (MCH) activities with other primary health care (PHC) components in order to achieve optimal quality care. Achieving such integration was one of the specific objectives of the MCH programme. Besides training MCH workers, other important tools of MCH/PHC integration included: organization, supervision, continuing education, data management and health systems research. The strengths and weaknesses of integration are discussed while the opportunities, limitations and implications are reviewed.

Minor surgery at primary care centers in Riyadh, Saudi Arabia.

This study was conducted to review the present situation with regard to training, facilities and performance of minor surgical procedures in primary care, and to look at the way doctors perceive various minor surgical procedures in primary care. Randomly selected primary care doctors working in Riyadh health centers completed a predesigned confidential questionnaire, which was then mailed to the researchers. The questionnaire of data on health centers, such as geographic location, size of catchment area population and number and gender of doctors working there. In addition, demographic data of doctors who completed the questionnaire, as well as their exposure to minor surgery training and performance, were recorded. The doctors were then asked about their perception of the necessity of performing various minor surgical procedures in primary care centers. The study was conducted from June through December of 1994. The completed questionnaires were entered into a personal computer for statistical analysis using the chi-squared test. Of the 231 doctors who participated in the present study, 74% performed some sort of minor surgery during their day-to-day work in the health center. Doctors living in remote areas performed more minor surgery (MS) compared to other areas and male doctors performed more MS than female doctors (P = 0.05). As doctors gained confidence in certain skills such as resuscitation, venous cut-down and handling of trauma and fractures, they performed more MS compared to those who were not confident. A room allocated for MS only was available to 27.7% of doctors, but instruments and equipment were available for over 76% of doctors. The doctor's perception of the necessity for MS was statisticaly higher among MS performers only in cases of removal of benign skin lesions, sebaceous cysts and treatment of burns, compared with non-MS performers. There is a great need for provision of facilities and organized training courses in minor surgical procedures for primary care doctors and nurses.