Tobacco Research in the Eastern Mediterranean Region: A Scoping Review of Published Studies from Seven Countries.

While surveillance on a global scale has been showing a decline in tobacco smoking in the past decade, rates in the Eastern Mediterranean Region (EMR) remained stable with some countries showing rising trends. This study aimed to analyze the landscape of tobacco research in the EMR, present data on publication trends, and identify research gaps and opportunities to guide future tobacco research in the region. We conducted a scoping review of tobacco research in seven countries from January 2000 to December 2013. Three hundred and forty eight studies were identified, the majority of which were published in international journals and in English language. There was an increase in publications over time, with a significant positive linear trend (p = 0.03). Descriptive cross-sectional and case-control studies were the most common study designs (67.0%), and only 8% were longitudinal studies. Papers that reported, in part or solely, on waterpipe tobacco smoking (WTS) constituted 25.6% of the total publication pool. Tobacco consumption was treated as an exposure variable in half of the papers and mostly in relation to cancer and cardiovascular diseases, as an outcome measure in 37.7%, and as a confounding variable in 14.7% of the papers. Studies that examined associations of tobacco with other behaviors (5.3%) were lacking. The scarcity of high-evidence tobacco research in the EMR, together with the relatively deficient data on WTS and associations with other factors warrant the need for discussions on research priority setting and guidance on funding allocations in the region.

Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries.

The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.

Waterpipe Tobacco Smoking among University Students in Three Eastern Mediterranean Countries: Patterns, Place, and Price.

Background: The objective of this study was to examine waterpipe tobacco smoking patterns, places of smoking, and prices paid among university students in the Eastern Mediterranean Region. Methods: A cross-sectional online survey was administered to a convenience sample of university students in three countries. Participants were young adults (18-29 years) who were ever waterpipe smokers, from Egypt (n = 728), Jordan (n = 790), and Palestine (n = 722). Measures included past-30-day waterpipe smoking, frequency, intensity, place of smoking, and prices paid per waterpipe smoking session and for packaged waterpipe tobacco. Logistic regression models evaluated the factors associated with past-30-day waterpipe smoking. Results: Past-30-day waterpipe smoking (prevalence) was observed among 60.7%, 67.7% and 63.1% of students from Egypt, Jordan, and Palestine, respectively. Among past-30-day smokers, past-5-day waterpipe smoking (frequency) was observed among 28.9%, 51.5%, and 48.6% of participants, respectively. Smoking in a café was highest among participants from Egypt (74.0%), followed by those from Palestine (44.8%), and Jordan (43.0%). Mean price paid per session was USD 0.99 (Egypt), USD 8.07 (Jordan), USD 6.05 (Palestine). The corresponding mean prices per packet were USD 0.86, USD 4.96, and USD 5.55, respectively. Predictors of past-30-day waterpipe smoking included younger age of initiation, male gender, employment, and smoking waterpipe alone. Conclusions: This study contributes to our understanding of waterpipe smoking patterns, places of smoking, and prices paid among young adults in a region with alarmingly high smoking rates. Understanding waterpipe smoking behaviors can inform the design of policy and educational interventions to curb its rising threat.

Smoking behavior of males attending the quit tobacco clinics in Bahrain and their knowledge on tobacco smoking health hazards.

BACKGROUND: One third of Bahraini adult (20-64 years) males and 7.0% of females use some form of tobacco. The corresponding rates for cigarette and waterpipe tobacco smoking (WTS) are 11.0% and 6.0%, respectively. The objective of the study was to determine the knowledge on tobacco smoking and past smoking related behavior of male patients attending the Quit Tobacco Clinics (QTC) in Bahrain. METHODS: A sample of 339 male clinic attendees was taken proportional to the population distribution in the three QTC at Al Hoora Health Center, Hamad Kanoo Health Center, and Bank of Bahrain and Kuwait Health Center. Data collection was performed until the sample size was completed (September 2015 to December 2016). Knowledge on the health effects of cigarette and WTS was examined based on 10 statements on cigarette and similar ones on WTS. Respondents "agreeing" with the statements were considered knowledgeable and those "disagreeing" or responding "don't know", not knowledgeable. All the "agree" responses for cigarette/WTS were summed across the 10 health effects and average health knowledge scores for cigarette/WTS were computed. RESULTS: Most of the study participants were Bahraini nationals, ever married and educated with at least secondary level. The majority (65.8%) of participants smoked a single type of tobacco product, and the rest, two (28.0%) or three or more (6.2%). Age of starting cigarette and WTS was 16.2 ± 4.0 and 19.3 ± 6.7 years, respectively. The majority (81%) smoked in the presence of other family members and 26.3% in the presence of a child. 76.2% smoked in the presence of others in their cars. 18.9% of the attendees had quit smoking at the time of interview. 81% of the participants knew about the hazards of both cigarette and WTS with a significantly higher (p = 0.0001) mean knowledge score for cigarette (93.3 ± 3.0%) than WTS (85.2 ± 2.1%). CONCLUSION: The relative lack of knowledge on the hazards of WTS in a sample of Arab country population with an increasing trend of WTS warrants the attention of health policy makers in the country and region.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. AIMS AND OBJECTIVES: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. METHODS: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. RESULTS: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. CONCLUSION: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Outcomes of children with attention deficit/hyperactivity disorder: global functioning and symptoms persistence.

Many adolescents with ADHD show antisocial behaviour and low educational achievement. These issues have not been validated in the World Health Organization Eastern Mediterranean Region. The objective of this study was to assess the global functioning and behaviour of children with ADHD growing into adolescence 10 years after initial diagnosis. Parents were interviewed using a structured questionnaire, Conner's Short Version Test and the Children's Global Assessment Scale. Nearly half of our sample had low academic achievement and 36% had no friends. A quarter of the cases were smokers, one admitted abusing drugs and one had attempted suicide. One third of the sample continued to have ADHD symptoms. Adolescents with ADHD had similar school performance and peer relationships to those reported previously, but differences with regard to drug use, suicide and other impulsive behaviour. A follow-up study into adult life using a control group is recommended.

The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors.

BACKGROUND: The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010). METHODS: We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010. FINDINGS: Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases--especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis--increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place. INTERPRETATION: Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world--although these disorders do still persist in LICs--whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed. FUNDING: Bill & Melinda Gates Foundation.

An institutional approach to support the conduct and use of health policy and systems research: The Nodal Institute in the Eastern Mediterranean Region.

BACKGROUND: The use of health policy and systems research (HPSR) to support decision making in health systems is limited in the Eastern Mediterranean Region (EMR). This is partly due to the lack of effective initiatives to strengthen regional HPSR capacities and promote its use in decision making. This paper offers a structured reflection on the establishment and core functioning of a HPSR Nodal Institute for the EMR with specific focus on the approach used to support the conduct and use of HPSR. It seeks to gain better understanding of the activities conducted by the Nodal Institute, the methods by which the Nodal Institute implemented these activities, and the outcomes of these activities. METHODS: A multi-faceted approach was implemented by the Nodal Institute in collaboration with regional academic/research institutions, Sub-Nodes. The overall approach was a phased one that included the selection of Sub-Nodes, mapping of academic/research institutions in the EMR, stakeholders' meetings, and HPSR capacity building workshops, and culminated with a regional meeting. RESULTS: The mapping of academic/research institutions in the EMR resulted in the identification of 50 institutions, of which only 32 were engaged in HPSR. These institutions have the highest HPSR involvement in information/evidence (84%) and the lowest in human resources for health (34%). Their main HPSR focus areas included quality of healthcare services, patient safety, management of non-communicable diseases, and human resources for health. Regional HPSR challenges among these institutions were identified. The validation and ranking questionnaires resulted in the identification of country-specific HPSR priorities according to stakeholders in three countries. From these results, cross-cutting HPSR priorities among the countries related to primary healthcare, non-communicable diseases, human resources for health, as well as cross-cutting HPSR priorities among stakeholders and according to stakeholders of the countries, were extracted. CONCLUSION: The Nodal Institute in the EMR is a promising initiative to support the conduct and use of HPSR in health policies. The approach and findings reported in this paper allow for the development of opportunities towards the building of capacity for HPSR in the region and other countries and provide a roadmap for academic/research institutions interested in HPSR in the region.

Bereavement and Grief Among Employees in an Arab University Setting: A Cross-Sectional Study.

BACKGROUND: Several mental health outcomes develop following bereavement. Little research has examined bereavement in the workplace and the associated risk factors, particularly in Arab populations. OBJECTIVES: The objectives of this cross-sectional study were to determine the sociodemographic characteristics of bereaved employees, measure the prevalence of their dysfunction, establish the type of closeness and conflict in their relationship with the deceased, determine the available resources to the bereaved, and determine the proportion of bereaved employees who needed help. METHODS: A study was conducted on Arabian Gulf University employees (91) in Bahrain. The revised Two Track Bereavement Questionnaire (TTBQ3-CG11) was utilized to assess bereavement outcomes. RESULTS: The response rate of the study was 28%. The composition of the study population was as follows: 51.6% males, 37.4% in the age range of 40-49 years, 86.8% married, 39.6% Bahraini, and 51.6% academicians. Over half of the participants had biopsychosocial dysfunction, 35.2% had active relational grief and trauma (ARGT), 36.3% had a conflict with the deceased, and half were close to the deceased. Total TTBQ3-CG11 scores showed that 28.6% of the bereaved had a low score (14-22), 61.5% medium (23-28), and 9.9% high (29 or more), with more females than males in the high category. The majority reported receiving adequate support from the administration and colleagues following their loss. CONCLUSION: There is a need to establish bereavement policies and procedures at tertiary educational institutes. This study may inform future policies to advance bereavement services in the educational institutions of the region.

Knowledge and attitudes of medical students toward death: a cross-sectional comparative study between an Arab and a Western University.

BACKGROUND: Cultural factors influence attitudes toward death, and gender disparities are evident. Prior studies show that medical students have limited knowledge about death and are uncomfortable with it. Moreover, there is limited research that has examined factors that influence medical students' knowledge and attitudes toward death. OBJECTIVES: The objectives of the study were to compare cultural and gender differences in relation to knowledge and attitudes toward loss and grief and to screen for complicated grief among medical students at the Arabian Gulf University and the University of Toronto. METHODS: A cross-sectional study was disseminated to medical students at both universities in 2022. The variables in the survey included four parts: demographic characteristics of the participants, religious observance, history of encountering loss of a loved one, grief following loss, attitude toward death, and learning about how to deal with grief and death during medical school. The brief grief questionnaire and the death attitude profile-revised scales were used. RESULTS: The study sample consisted of 168 medical students, with 74.1% being female. Complicated grief scores were higher among Arabian Gulf University students (3.87 ± 2.39) than among University of Toronto students (2.00 ± 1.93) and were higher for participants with a higher degree of religious observance in both schools (p < 0.05). Death avoidance (p = 0.003), approach acceptance (p < 0.001), and escape acceptance (p = 0.038) domains were significantly higher among Arabian Gulf University students than among University of Toronto students. Almost three-quarters of University of Toronto students reported not being taught about grief, compared to 54% of Arabian Gulf University students. CONCLUSIONS: Arabian Gulf University medical students scored higher on complicated grief, most likely due to cultural and religious factors. Females at both institutions as well as those who indicated a higher level of religious observance reported higher scores of complicated grief. The study highlights how cultural and religious beliefs influence medical students' attitudes toward death and bereavement. It provides valuable insight into the knowledge and attitudes of medical students toward loss.

Injury burden in individuals aged 50 years or older in the Eastern Mediterranean region, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019.

Background: Injury poses a major threat to health and longevity in adults aged 50 years or older. The increased life expectancy in the Eastern Mediterranean region warrants a further understanding of the ageing population's inevitable changing health demands and challenges. We aimed to examine injury-related morbidity and mortality among adults aged 50 years or older in 22 Eastern Mediterranean countries. Methods: Drawing on data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we categorised the population into adults aged 50-69 years and adults aged 70 years and older. We examined estimates for transport injuries, self-harm injuries, and unintentional injuries for both age groups, with sex differences reported, and analysed the percentage changes from 1990 to 2019. We reported injury-related mortality rates and disability-adjusted life-years (DALYs). The Socio-demographic Index (SDI) and the Healthcare Access and Quality (HAQ) Index were used to better understand the association of socioeconomic factors and health-care system performance, respectively, with injuries and health status in older people. Healthy life expectancy (HALE) was compared with injury-related deaths and DALYs and to the SDI and HAQ Index to understand the effect of injuries on healthy ageing. Finally, risk factors for injury deaths between 1990 and 2019 were assessed. 95% uncertainty intervals (UIs) are given for all estimates. Findings: Estimated injury mortality rates in the Eastern Mediterranean region exceeded the global rates in 2019, with higher injury mortality rates in males than in females for both age groups. Transport injuries were the leading cause of deaths in adults aged 50-69 years (43·0 [95% UI 31·0-51·8] per 100 000 population) and in adults aged 70 years or older (66·2 [52·5-75·5] per 100 000 population), closely followed by conflict and terrorism for both age groups (10·2 [9·3-11·3] deaths per 100 000 population for 50-69 years and 45·7 [41·5-50·3] deaths per 100 000 population for ≥70 years). The highest annual percentage change in mortality rates due to injury was observed in Afghanistan among people aged 70 years or older (400·4% increase; mortality rate 1109·7 [1017·7-1214·7] per 100 000 population). The leading cause of DALYs was transport injuries for people aged 50-69 years (1798·8 [1394·1-2116·0] per 100 000 population) and unintentional injuries for those aged 70 years or older (2013·2 [1682·2-2408·7] per 100 000 population). The estimates for HALE at 50 years and at 70 years in the Eastern Mediterranean region were lower than global estimates. Eastern Mediterranean countries with the lowest SDIs and HAQ Index values had high prevalence of injury DALYs and ranked the lowest for HALE at 50 years of age and HALE at 70 years. The leading injury mortality risk factors were occupational exposure in people aged 50-69 years and low bone mineral density in those aged 70 years or older. Interpretation: Injuries still pose a real threat to people aged 50 years or older living in the Eastern Mediterranean region, mainly due to transport and violence-related injuries. Dedicated efforts should be implemented to devise injury prevention strategies that are appropriate for older adults and cost-effective injury programmes tailored to the needs and resources of local health-care systems, and to curtail injury-associated risk and promote healthy ageing. Funding: Bill & Melinda Gates Foundation.

Association of health warning labels and motivation to quit waterpipe tobacco smoking among university students in the Eastern Mediterranean Region.

INTRODUCTION: This study aimed to determine associations between health warning label content and motivation to quit waterpipe smoking by gender and smoking location. METHODS: Convenience samples of university students in three Eastern Mediterranean countries - Egypt (n=442), Jordan (n=535) and Palestine (n=487) - completed an online survey assessing health warning labels. Multinomial logit regression models were conducted to determine the association between different variables, particularly gender and smoking location, with motivation to quit. RESULTS: In Palestine, female smokers were more motivated to quit waterpipe smoking when seeing textual warning labels related to children (T2) and pregnancy (T6) [T2: 1.8 (95% CI: 1.1-2.8), T6: 2.7 (95% CI: 1.6-4.3)] compared to males. Similar results were found in Jordan [T2: 1.6 (95% CI: 1.0-2.6), T6: 1.8 (95% CI: 1.1-3.0)]. As for the smoking location, home-only smokers in Palestine were more likely to quit in response to the following warnings: waterpipe smoking is addictive T1: 2.3 (95% CI: 1.4-3.7), harmful for children T2: 2.3 (95% CI: 1.4-4.1), harmful for the baby during pregnancy T6: 2.4 (95% CI: 1.3-4.3), and to believe that quitting reduces the health risks T9: 1.8 (95% CI: 1.0-3.1). These results were not found in Jordan nor Egypt. Smokers reported that the most noticeable location of a HWL on a waterpipe device is the mouthpiece. CONCLUSIONS: A better understanding of motivation to quit and its association with various warnings and smoking location could guide countries on which warnings to require in legislation and where best to require them particularly in relation to location.

Burden of Transport-Related Injuries in the Eastern Mediterranean Region: A Systematic Analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Transport-related injuries (TIs) are a substantial public health concern for all regions of the world. The present study quantified the burden of TIs and deaths in the Eastern Mediterranean region (EMR) in 2017 by sex and age. METHODS: TIs and deaths were estimated by age, sex, country, and year using Cause of Death Ensemble modelling (CODEm) and DisMod-MR 2.1. Disability-adjusted life years (DALYs), which quantify the total burden of years lost due to premature death or disability, were also estimated per 100000 population. All estimates were reported along with their corresponding 95% uncertainty intervals (UIs). RESULTS: In 2017, there were 5.5 million (UI 4.9-6.2) transport-related incident cases in the EMR - a substantial increase from 1990 (2.8 million; UI 2.5-3.1). The age-standardized incidence rate for the EMR in 2017 was 787 (UI 705.5-876.2) per 100000, which has not changed significantly since 1990 (-0.9%; UI -4.7 to 3). These rates differed remarkably between countries, such that Oman (1303.9; UI 1167.3-1441.5) and Palestine (486.5; UI 434.5-545.9) had the highest and lowest age-standardized incidence rates per 100000, respectively. In 2017, there were 185.3 thousand (UI 170.8-200.6) transport-related fatalities in the EMR - a substantial increase since 1990 (140.4 thousand; UI 118.7-156.9). The age-standardized death rate for the EMR in 2017 was 29.5 (UI 27.1-31.9) per 100000, which was 30.5% lower than that found in 1990 (42.5; UI 36.8-47.3). In 2017, Somalia (54; UI 30-77.4) and Lebanon (7.1; UI 4.8-8.6) had the highest and lowest age-standardized death rates per 100,000, respectively. The age-standardised DALY rate for the EMR in 2017 was 1,528.8 (UI 1412.5-1651.3) per 100000, which was 34.4% lower than that found in 1990 (2,331.3; UI 1,993.1-2,589.9). In 2017, the highest DALY rate was found in Pakistan (3454121; UI 2297890- 4342908) and the lowest was found in Bahrain (8616; UI 7670-9751). CONCLUSION: The present study shows that while road traffic has become relatively safer (measured by deaths and DALYs per 100000 population), the number of transport-related fatalities in the EMR is growing and needs to be addressed urgently.

Smoking prevalence in the Eastern Mediterranean Region.

BACKGROUND: Three global reports issued by the World Health Organization (WHO) track and report on trends in the prevalence of tobacco smoking from 2000 to 2025 based on data from national surveys. AIMS: This review aimed to compare regional and country-level projections for current tobacco smoking as presented in the WHO trend reports. These changes were considered in the context of improved monitoring and tobacco control policies. METHODS: Regional and country-level results in the WHO trend reports were considered in terms of the projected percentage point increase of current tobacco smoking between 2000 and 2025. Data on national surveys and policy implementation came from the relevant WHO reports. RESULTS: In the 2019 trend report, the prevalence of current tobacco smoking among males is projected to decrease by less than 2 percentage points by 2025. Eight countries featured in both the 2015 and 2019 WHO trend reports. Seven of these countries indicated a more encouraging projection (a decline in their projected increase between 2000 and 2025) for current male tobacco smoking in the 2019 report than in the 2015 report. For five out of these seven countries, their monitoring and tobacco control policy implementation improved over the same period. CONCLUSION: Countries in the Region should implement additional national surveys to improve the accuracy of prevalence estimates, allow further projections to be performed and motivate policy-makers to make positive policy changes. Solutions to under-reporting biases during surveys should be considered. Governments should use trend projections to guide effective tobacco control policies to reduce tobacco use in the Region.

Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries.

INTRODUCTION: Males have a higher prevalence of waterpipe tobacco smoking (WTS) than females in most Eastern Mediterranean Region (EMR) countries, with a smaller gender gap than that of cigarette smoking. The objective of this study was to determine gender differences among university students with respect to WTS initiation, smoking behavior, tobacco flavors, and expenditure on WTS, in four EMR countries. METHODS: A cross-sectional online survey was conducted based on convenient samples of ever waterpipe smokers among university students in four EMR countries (Egypt, Jordan, Occupied Palestinian Territories, and the United Arab Emirates) in 2016. The total samples included 2470 participants. Study participants were invited through flyers, university portals, emails and Facebook, followed by emails with links to the internet survey. RESULTS: Females (80.4%) were more likely than males (66.4%, p<0.001) to be in the younger age group (18-22 years) and they were less likely to be current waterpipe smokers (females, 60.0%; males 69.5%, p<0.001). Two-thirds of students across both genders smoked their first waterpipe at the age of 15-19 years, with more females starting with family members. Over one-third of males and 14.9% of the females usually smoked ≥10 heads (p<0.001). About half (46.6%) of females smoked for less than half an hour compared to 30.5% of males (p<0.001). Only 1% of females smoked non-flavored tobacco compared to 11% of males (p<0.001). There was a significant (p=0.05) positive correlation (r=0.808) with respect to tobacco flavor usually smoked between males and females with apple/double apple being the most popular. CONCLUSIONS: There were gender differences in WTS in several aspects. The study has implications for educational establishments, tobacco control and women civil society groups, as well as policymakers.

Quality, safety and performance management in primary health care: from scoping review to research priority setting and implementation plan in the Eastern Mediterranean Region.

INTRODUCTION: Strong primary health care (PHC) leads to better health outcomes, improves health equity and accelerates progress towards universal health coverage (UHC). The Astana Declaration on PHC emphasised the importance of quality care to achieve UHC. A comprehensive understanding of the quality paradigm of PHC is critical, yet it remains elusive in countries of the Eastern Mediterranean Region (EMR). This study used a multistep approach to generate a policy-relevant research agenda for strengthening quality, safety and performance management in PHC in the EMR. METHODS: A multistep approach was adopted, encompassing the following steps: scoping review and generation of evidence and gap maps, validation and ranking exercises, and development of an approach for research implementation. We followed Joanna Briggs Institute guidelines for conducting scoping reviews and a method review of the literature to build the evidence and gap maps. For the validation and ranking exercises, we purposively sampled 55 high-level policy-makers and stakeholders from selected EMR countries. We used explicit multicriteria for ranking the research questions emerging from the gap maps. The approach for research implementation was adapted from the literature and subsequently tailored to address the top ranked research question. RESULTS: The evidence and gap maps revealed limited production of research evidence in the area of quality, safety and performance management in PHC by country and by topic. The priority setting exercises generated a ranked list of 34 policy-relevant research questions addressing quality, safety and performance management in PHC in the EMR. The proposed research implementation plan involves collaborative knowledge generation with policy-makers along with knowledge translation and impact assessment. CONCLUSION: Study findings can help inform and direct future plans to generate, disseminate and use research evidence to enhance quality, safety and performance management in PHC in EMR and beyond. Study methodology can help bridge the gap between research and policy-making.

Correction: The Knowledge Translation Status in Selected Eastern-Mediterranean Universities and Research Institutes.

[This corrects the article DOI: 10.1371/journal.pone.0103732.].

Determinants of family size in a Gulf Arab state: a comparison between two areas.

AIMS: The rapid economic transition in the Gulf Arab countries has resulted in marked changes in fertility and marriage patterns and a decrease in the number of children per family. Yet little is known about the determinants of family size in urban and less urban areas. METHODS: A cross-sectional study was carried out on 450 Kuwaiti women aged 20-60 years who attended health care centres in Al Asima and Al Jahra governorates. A semi-structured questionnaire was administered through face-to-face interview which included variables on socio-demographic characteristics, family size, actual and ideal spacing, marriage related variables, health conditions and utilization of health services. Both univariate and multivariate analyses were performed to identify the factors that affect family size. RESULTS: The socio-economic indicators were significantly better in Al Asima, the capital, than in Al Jahra, a less urbanized area. On average, family size for the total sample was 5.97 +/- 0.114 with a larger size (6.27 +/- 0.242) in Al Jahra than in Al Asima (5.80 +/- 0.118) but without a significant difference. Al Jahra women reported a larger number of deliveries and past pregnancies but a lower usage of contraceptive measures. The total fertility rate was 3.65 in Al Asima, 3.84 in Al Jahra and 3.71 births per woman in the total population. Family size was inversely related to the educational level of women and their husbands. Currently employed women had a smaller family size (5.22 +/- 0.119) than the unemployed (6.81 +/- 0.187); p < 0.0005. Health problems in the interviewee or her husband played a minor role in the decision to have more children. Families where the husband was the decision-maker on the number of children had a significantly larger family size (6.91 +/- 0.451) than families where the couple both participated in the decision (5.83 +/- 0.129; p = 0.032). The duration of marriage, ideal number of children, age of women at last delivery, number of rooms and the crowding index had significant positive effects on family size, whereas age at first delivery, duration between two consecutive pregnancies and history of past abortions were inversely related to family size in the stepwise multiple regression analysis. CONCLUSIONS: Although women in the less urbanized areas in the Gulf Arab populations are more disadvantaged with respect to socio-economic characteristics than women in the more urbanized areas, there were no significant differences in family size in these contrasting communities. The impact of socio-demographic characteristics on family size was minor compared to factors related to fertility and the husband's desire to have more children. Fertility and family planning policies should consider these issues in order to promote more effective programmes.

Lung cancer epidemiology among the Bahraini population, 1998-2011.

BACKGROUND: Lung cancer is the fourth most common cancer in the Gulf Cooperation Council countries among males and the third among females. It is the commonest cancer among Bahraini males accounting for 16.9% of all cancers and the third in Bahraini females contributing to 5.8 % of all female cancers. The aim of this study was to describe the epidemiology of lung cancer among the Bahraini population during the period 1998-2011. METHODS: All Bahraini registered lung cancer cases in the national cancer registry from 1 January 1998 to 31 December 2011 were included in the study. Incidence rates were calculated using the CANREG software, in which the annual crude incidence rates, age specific incidence rates and the age standardized incidence rate (ASR) were computed. RESULTS: Six hundred sixty-four lung cancer cases (72.4%, males and 27.6% females) were diagnosed during the study period. The annual average number of cases was 47.5 per year. The mean age at diagnosis during the study period was 68.7±11.7 years. The average annual ASR was 26.1/100,000 among males and 10.0/100,000 among females. There was a tendency for a decreased trend of the ASR during 1998-2011 in both sexes. Twenty-six percent of lung cancer cases were squamous cell carcinoma and 17.9% adenocarcinoma. The grades of 70.3% were unknown and 13.4% were poorly differentiated. The stage was unknown for 65.0% of the cases, while 18.5% had distant metastasis and 9.8% were localized. The majority (88.9 %) of the lung cancer cases were dead by the end of the study period with a five-year survival rate of 3.0%. CONCLUSION: A welcomed decline in the incidence of lung cancer has been noted over the past 14 years. However, more efforts should be put to reduce the proportion of lung cancer cases with unknown stage and grade. The incidence of histological types, which are strongly dependent on tobacco smoking, notably small cell, squamous cell and large cell carcinomas, accounted for over one third of lung cancer cases. Future research should be directed towards better understanding of the lung cancer risk factors and the effectiveness of tobacco control measures in in the country.