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.

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.

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.

The prevalence of obesity among saudi males in the Riyadh region.

Attendees of 15 health centers in urban and rural areas in the Riyadh region were screened for obesity during May and June 1994. Systemic selection yielded 1580 Saudi males for analysis. The mean age was 33.6 +/- 13.5 years and body mass index (BMI) was 26.9 +/- 5.7 kg/m(2). Only 36.6% of subjects were their ideal weight (BMI < 25 kg/m(2)), while 34.8% were overweight (BMI 25-29.9 kg/m(2)), 26.9% were moderately obese (BMI 30-40 kg/m(2)) and 1.7% were morbidly obese (BMI > 40 kg/m(2)). Middle age, lower education and joblessness predicted a higher risk for obesity. Patients living in a rural areas had greater BMIs than those living in urban areas (P <0.01). Forty percent of overweight participants did not think they were so. The high prevalence of obesity and the lack of awareness among those afflicted emphasizes the need for community-based programs for preventing and reducing obesity, since weight control is effective in ameliorating most of the disorders associated with obesity, such as Type II non-insulin-depedent diabetis mellitus, hypertension, stroke, heart disease, sleep apnea syndrome and osteoarthritis of the knees. Young parents who are at risk of developing obesity and who play a central role in perpetuating it in their offspring should be the target of obesity-prevention programs.

Care of asthmatic patients in primary health care centers.

This is a retrospective study of the medical records of asthamtics using a predesigned form. The purpose of the study is to define the number of patients registered as asthamatics at a random selection of primary health care centers (PHCCs) in Riyadh and to describe sociodemographic, clinical and management characteristics of this population of asthmatics with a view to recommending changes which might improve the care for asthma patients. Patients from 60 primary health care centers were studied. There were 2081 asthamatic patients found in the studied PHCCs (out of 255,145 surveyed), giving a rate of 0.8%. Out of all the patients, 32.8% were children 16 years of age or below and 24.7% were above 5 years of age. The male to female ratio was 1.2:1. The presenting symptoms were cough in 82.3% and shortness of breath 64.8%. Atopic disorders such as eczema and allergic rhinitis were recorded in 27.7%. PHCCs diagnosed 61.9% depending on history and clinical examination. Out of all patients, 10.6% did not utilize a PHCC, 29.5% were referred to a specialist and 8.7% needed admission to the hospital one or more times. Oral salbutamol was used in more than 45.7% of the patients. The number of registered bronchial asthma patients at the PHCCs was very low. Even when registered, asthmatic patients are getting suboptimal care. The present study provides a basis for intervention and a baseline from which to measure the benefits of intervention. It also provides the strongest possible support for the Ministry of Health, who recently initiated a National Asthma Program.

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 and the ongoing move towards universal health coverage, all health and social care providers need to innovate and transform their services to provide evidence-based health care that is accessible, cost-effective and with the best patient outcomes. For the primary and community workforce, this includes general medical practitioners, practice and community nurses, community social workers, housing officers, lay health workers, nongovernmental organizations and civil society, including community spiritual leaders/healers. This paper brings together the current best evidence to support transformation and 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

Pour que les pays de la Région de la Méditerranée orientale puissent répondre aux attentes créées par le Plan d'action mondial sur la santé mentale 2013-2020 et pour faciliter le mouvement continu vers la couverture sanitaire universelle, tous les acteurs de la prestation de soins socio-sanitaires doivent faire preuve d'innovation et transformer leurs services afin de fournir des soins de santé fondés sur des bases factuelles qui soient accessibles, d'un bon rapport coût-efficacité et procurent les meilleurs résultats pour les patients. Pour ce qui est des personnels aux niveaux primaires et communautaires, ceci concerne les médecins généralistes, les infirmières praticiennes, les infirmières communautaires, les travailleurs sociaux communautaires, les responsables des logements sociaux,les travailleurs de la santé non professionnels, les membres des organisations non gouvernementales et de la société civile, y compris les leaders et les guérisseurs spirituels communautaires.Le présent article rassemble les meilleures bases factuelles actuellement disponibles à l'appui de cette transformation et examine les approches principales à cet égard, y compris l'éventail des compétences et/ou la délégation des tâches et les soins intégrés.Les facteurs importants qui doivent être en place à l'appui de l'éventail des compétences/la délégation des tâches et de bons soins intégrés sont présentés dans le contexte des pays de la Région de la Méditerranée orientale

Cutaneous leishmaniasis in Riyadh region: four-year study of the epidemiologic and clinical features.

A retrospective study of 11,802 patient records with cutaneous leishmaniasis in Riyadh region was conducted during the period 1987 to 1990. The following findings resulted from the study. The incidence rate declined from 244.2 to 106.5 per 100,000 population. The infection was mainly among non-Saudi men in their working years. The Saudis represented 33% of the total number of patients. The Saudi patients were mainly young, below 15 years of age, with almost equal men/women distribution. The non-Saudis were found to have more multiple lesions; 65% of them had three or more lesions compared with 10% in Saudis. The lesions were mainly on the exposed parts of the body such as the face (20%), neck (3.3%), upper limbs (23.3%), and lower limbs (15%). Agricultural areas such as Riyadh vicinity, Al-Kharj, Shagraa, and Al-Koweeya showed consistently the highest foci of infections. The infections were highest in winter and lowest in summer.

Smoking behaviour and attitudes among adult Saudi nationals in Riyadh City, Saudi Arabia.

OBJECTIVE: To measure the smoking behaviour and attitudes among Saudi adults residing in Riyadh City, the capital of the Kingdom of Saudi Arabia. DESIGN: Cross-sectional survey. SETTING AND SUBJECTS: Primary health care centres (PHCCs) in Riyadh City were selected by stratified random sampling. Subjects resident in each PHCC catchment area were selected by systematic sampling from their records in the PHCCs; 1534 adults aged 15 years and older were interviewed during January to April 1994. MAIN OUTCOME MEASURES: Self-reported smoking prevalence; age of smoking initiation; daily cigarette consumption; duration of smoking; reasons for smoking, not smoking, and quitting smoking; intentions to smoke in the future; and attitudes toward various tobacco control measures. RESULTS: 25.3% of respondents were current smokers, 10.2% were ex-smokers, and 64.5% had never smoked. About 79% of all smokers started smoking between the ages of 15 and 30 years, and 19.5% before age 15. Significantly higher smoking prevalence and daily cigarette consumption were associated with being male, single, and being more highly educated. Relief of psychological tension, boredom, and imitating others were the most important reasons for smoking, whereas health and religious considerations were the most important reasons for not smoking among never-smokers, for quitting among ex-smokers, and for attempting to quit or thinking about quitting among current smokers. About 90% of all subjects thought that they would not smoke in the future. Physicians and religious men were identified as the most effective anti-smoking advocates by a much higher proportion of respondents (44%) than nurses, health educators, and teachers (each less than 5%). Health and religious education were generally cited as more effective in deterring smoking than tobacco control laws and policies. CONCLUSIONS: Cigarette smoking is prevalent among Saudi adults in Riyadh, particularly males, most of whom begin to smoke rather early in life and continue for many years. Health and religious education should be the cornerstone for any organised tobacco control activities, which are urgently needed to combat the expected future epidemic of smoking-related health problems.

Asthma in Saudi Arabia: is the system appropriate for optimal primary care?

The objective of the study was to assess the suitability of the structure of Primary Health Care Centers to cater to the needs of patients with asthma. Standards for optimal care were defined by the authors. The worst deficiencies identified were in the availability peak flow meters, inhaler devices and antiinflammatory drugs. Assessment of the optimal structure for asthma care was found to demonstrate variance with national standards. More effort is recommended in central development of guidelines. This assessment can be used to measure future changes in asthma care.

Missed Opportunities for Immunization: A Saudi Arabia survey.

Missed opportunities for immunization were studied at five Saudi health centers. Of 383 children studied, 77.8% were up-to-date with their immunization, 10.2% had real contraindications, and 12.0% missed opportunities. Only 48.8% of mothers were up-to-date. We recommend that immunization be made available at all clinics and that presentation of immunization cards be required.

Transcultural attitude towards being overweight in patients attending health centers, Riyadh, Saudi Arabia.

OBJECTIVE: To assess differences in body weights among various nationalities living in Riyadh and find out the effect of sociodemographic characteristics of participants on their attitudes towards body weight. METHODS: In May and June of 1992, 4144 health center patients of various nationalities in Riyadh were surveyed about their attitudes towards the overweight. A survey of attitudes of 4144 health center participants of various nationalities in Riyadh towards the overweight were conducted during May-June 1992. Fifteen health centers representing the five arbitrarily divided sections of Riyadh (North, South, East, West, and Central) participated in the study. Every third patient was included if he or she satisfied the criteria. Participants were asked to complete a questionnaire and to have their height and weight recorded. The body mass index (BMI) was calculated for all patients and their opinions about their weights were compared with the BMI. RESULTS: Obesity was more common among other Arabs (43.8%) and Saudis (36.4%) than Indians (27.6%) and Westerners (30.1%). Female subjects were more obese than their male counterparts in all nationalities. The body weights increased with age, fewer physical activities, low levels of education, and marital status. All these differences were statistically significant. When comparing positive predictive value of the opinion of the participants with their BMI, it was found that the Indians (87.2%) were less likely to be correct when they judge their degree of overweight than Saudis (92.2%), Westerners (92.8%), and other Arabs (95.4%). However, positive predictive values varied with the participants sociodemographic characteristics. CONCLUSION: The findings in the present study of higher proportion of patients with obesity in the study group stresses the importance of promoting programs aimed at preventing or reducing obesity in the community.

Intralesional treatment of cutaneous leishmaniasis with sodium stibogluconate antimony.

BACKGROUND: Cutaneous leishmaniasis represents a difficult disease to manage in endemic areas. Systemic treatment is hampered by both expense and compliance. Side effects may play a major role in this aspect as well. METHODS: The effectiveness of intralesional treatment of leishmaniasis was investigated. Seven hundred and ten patients were treated with injections of sodium stibogluconate intralesionally. The clinical diagnosis was confirmed by demonstrating the parasite in the smears obtained from the lesion. Fine insulin needle was used to infiltrate the lesion with sodium stibogluconate (0.5 to 1.0 mL). RESULTS: Generally eight injections were sufficient, but some of the complicated lesions needed up to 24 injections. Sixty-two percent of patients were men. The majority of the study population (64%) were children below 15 years of age. The results showed that 72% of lesions healed completely, 23.9% showed some improvement, while 4.1% showed some deterioration. Lesions of the lips, cheeks, chin, and neck healed faster than lesions in other parts of the body. Side effects were mild and limited to pain at the site of the injection and hyperpigmentation in those who were treated by folk medicine. CONCLUSIONS: Intralesional treatment is as effective as the standard systemic antimonials. It offers a less expensive alternative and a low side effects profile. Our findings confirmed the findings of earlier workers. It is recommended for treatment of cutaneous leishmaniasis in endemic areas.

Role of primary care physicians in the care of epileptic patients.

OBJECTIVES: To assess the utilization and efficiency of the primary health care (PHC) centres in the delivery of care to epileptic patients. DESIGN: Sixty health centres were randomly selected to represent various socioeconomic classes and urban/ rural population in Riyadh. The study was conducted during August 1993. A predesigned data form was used to ascertain socio-demographic characteristics of patients, clinical features, health centre profile and health care resources available to epileptic patients. PHC doctors completed these forms for all epileptic patients found in their health centre register which entered in PC computer for analysis. RESULTS: At the end of the study, 131 epileptic patients were found in the health centre register which accounted for 0.05% (0.03% in urban and 0.1% in rural). The majority of patients 80.2% were 30 years old or below. Out of all patients 77.1% attended health centres for up to six times. At least one referral to hospital or admission were recorded in 53.4% and 20.6% of patients respectively. PHC doctors thought that 31.3% were not compliant. Family history of epilepsy was positive in 12.9% of patients. CONCLUSION: The number of epileptic patients registered as epileptic at health centres were too low. There is a need to design a policy for detection of cases, training of PHC doctors and cost effective mobilization of resources to PHC centres so to attract more epileptic patients to use the health centres.

Role of primary health care in the control of schistosomiasis. The experience in Riyadh, Saudi Arabia.

The control programme for schistosomiasis in Saudi Arabia was started in 1975 as a central vertical programme. With the adoption of the primary health care approach a pilot scheme that integrated the control of all endemic diseases, including schistosomiasis, within the functions of primary health care centres was carried out. In Riyadh, the scheme was started in 1984 when subcentres for the control programme were established as a first step for complete integration. A training programme was extended to personnel in primary health care centres, including physicians, nurses, and health inspectors with the help of experts from World Health Organization (WHO). A survey of the population at risk in areas with high prevalence was done regularly accompanied by treatment of cases. Snail control was an important activity of the health inspectors with a three months repeat of the control procedures. The result of this programme is a significant reduction in the prevalence of both urinary and intestinal schistosomiasis, from 13.2% in 1983 to 0.17% in 1989. Among the 7453 water sources surveyed in 1989, only 7 were positive for snails (0.1%). About two thirds of those who were affected were expatriates coming from areas of high prevalence of schistosomiasis. Details of the control programme and its impact on the control of the disease are presented in this paper.

PIP: Between 1984 and 1986 in Saudi Arabia, the Ministry of Health began integrating the schistosomiasis control program into the existing primary health care (PHC) system by setting up substations or subcenters in Al-Aflaj, Al-Kharj, Al-Qwai, Hotat Bani Tammin, Al-Majmea, and Al-Zufli in the Riyadh Region of the Central Province. Substation or subcenter staff conducted case detection (via collection of stool and urine samples of household members in the catchment area), snail control, and health education, and administrated chemotherapy (praziquantel) for all patients with positive stool of urine samples. Between 1983 and 1989, the prevalence of schistosomiasis fell from 13.2 to 0.17%. In 1983, it was higher among Saudis than non-Saudis (91.1% vs. 8.9%). It fell during the study period among Saudis (91.1-32.6%) and increased among non-Saudis (8.9-67.4%). The non-Saudis were from Egypt, Yemen and the Sudan, all areas of high schistosomiasis prevalence. 20-39 year olds had the highest prevalence rate (54.7%). No children under 5 years old and no school age children were infected with Schistosoma species. The integrated PHC program improved its treatment and follow-up activities as evidenced in the fall by the dropout rate (54.4%-22%). The number of positive water sources for the snails harboring Schistosoma species first increased due to stepped-up efforts to survey water sources (1.8-2.2%, 1984-1986), then fell to 0.09% (7 out of 7453 sources). A possible activity to further improve schistosomiasis efforts is screening of expatriate workers from infected countries.

High prevalence of clinical obesity among Saudi females: a prospective, cross-sectional study in the Riyadh region.

A cross-sectional study of 1385 Saudi females attending 15 health centres in urban and rural areas in the Riyadh region was conducted during September and October 1992 to determine the prevalence of obesity and its associated factors. The mean age was 32.2 +/- 11.7 years and body mass index (BMI) 29.2 +/- 7.0 kg m-2. Only 26.1% of subjects were their ideal weight (BMI < 25 kg m-2), while 26.8% were overweight (BMI 25-29.9 kg m-2), 41.9% were moderately obese (BMI 30-40 kg m-2) and 5.1% were morbidly obese (BMI > 40 kg m-2). High-risk groups for obesity were mostly middle aged, multiparous housewives. Patients living in rural areas had greater BMIs than those living in urban areas (P < 0.01). Thirty per cent of overweight participants did not think they were overweight. The study emphasizes the need for community based programmes for preventing and reducing obesity since weight control is effective in ameliorating most of the disorders associated with obesity such as Type 2 non-insulin dependent diabetes mellitus, hypertension, stroke, heart disease, sleep apnoea syndrome and osteoarthritis of the knees. The focus of efforts should be directed towards young mothers who are at risk of developing obesity and who play a central role in perpetuating it in their offspring.