Access to and utilisation of antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia: a pilot cross-sectional survey.

OBJECTIVES: Identifying key barriers to accessing quality-assured and affordable antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia and investigating their (1) utilisation patterns of antibiotics, (2) knowledge about antimicrobial resistance (AMR) and (3) perception of the quality of antimicrobials received. DESIGN: Pilot cross-sectional survey. SETTING: Data were collected from five health facilities in the Kiryandongo refugee settlement (Bweyale, Uganda), three camps for internally displaced persons (IDPs) in the Dar Sad district (Aden, Yemen) and a district with a high population of Venezuelan migrants (Kennedy district, Bogotá, Colombia). Data collection took place between February and May 2021. The three countries were selected due to their high number of displaced people in their respective continents. PARTICIPANTS: South Sudanese refugees in Uganda, IDPs in Yemen and Venezuelan migrants in Colombia. OUTCOME MEASURE: The most common barriers to access to quality-assured and affordable antimicrobials. RESULTS: A total of 136 participants were enrolled in this study. Obtaining antimicrobials through informal pathways, either without a doctor's prescription or through family and friends, was common in Yemen (27/50, 54.0%) and Colombia (34/50, 68.0%). In Yemen and Uganda, respondents used antibiotics to treat (58/86, 67.4%) and prevent (39/86, 45.3%) a cold. Knowledge of AMR was generally low (24/136, 17.6%). Barriers to access included financial constraints in Colombia and Uganda, prescription requirements in Yemen and Colombia, and non-availability of drugs in Uganda and Yemen. CONCLUSION: Our multicentred research identified common barriers to accessing quality antimicrobials among refugees/IDPs/migrants and common use of informal pathways. The results suggest that knowledge gaps about AMR may lead to potential misuse of antimicrobials. Due to the study's small sample size and use of non-probability sampling, the results should be interpreted with caution, and larger-scale assessments on this topic are needed. Future interventions designed for similar humanitarian settings should consider the interlinked barriers identified.

Next generation support and stronger institutions for evidence-informed policy-making.

Evidence-informed policy-making benefitted from much-needed attention and resources during the COVID-19 pandemic (1). As a result, 3 key movements and innovations are now making it possible to provide better evidence support (higher quality and more aligned to the speed of advisory and decision-making) for policy-making than ever.

Knowledge, attitudes, and practices toward COVID-19 prevention in Yemen: a community-based cross-sectional study.

Background: Pandemics, especially in fragile war-torn countries like Yemen, challenge their already strained health systems. Community adherence to pandemic prevention measures is necessary to curb the severity and spread of emerging pandemics - which is influenced by factors, such as people's knowledge and attitudes toward the pandemic. No studies in Aden have been published on the communities' knowledge, attitudes, and practices (KAP) toward COVID-19 prevention to date. To understand adherence to pandemic prevention measures in contexts with fragile health systems, this study investigated KAP of Yemeni participants toward the COVID-19 pandemic. Methods: We conducted face-to-face semi-structured questionnaires among 400 eligible participants whom were identified for participation in this study through systematic household sampling from eight districts in Aden, Yemen. Eligible participants were Yemeni community members who were ≥ 18 years, living for more than 10 years in Yemen, and were willing to voluntarily participate in the study. The questionnaire included questions surrounding the participants' COVID-19 knowledge (e.g., awareness of spread and prevention), attitudes (e.g., willingness to accept the vaccine or other prevention measures), and prevention practices during the pandemic (e.g., mask wearing, social distancing, vaccine uptake). Total KAP scores were calculated. Univariate and bivariate statistical analyses were conducted using STATA 13 software. Results: From January to May 2021 we conducted 400 questionnaires with Yemeni community members. The average age was 41.5 ± 14.5 years (range 18-86 years). The results demonstrated that the participants in this study had an intermediate knowledge (53%) and fair attitude (58%) scores. However, participants reported very poor COVID-19 prevention practices- with only 11% demonstrating these practices. Only 25% (100/400) practiced social distancing, 25% (98/400) wore a mask, and only 6% (27/400) of participants accepted (at least one dose of) the COVID-19 vaccine. Factors associated with increased knowledge were being male, married, and surprisingly those having a primary and middle school education levels (p < 0.05). Also participants who were diagnosed with COVID-19 or had a family member diagnosed with COVID-19 (vs. those not diagnosed OR = 2.08, 95% CI 1.07-3.78, p < 0.05) were more likely to know that the vaccine protects against severe COVID-19 infection and were more likely to apply good practices such as accepting the vaccine (OR = 2.65, 95% CI 1.17-6.00, p < 0.05) compared to those who were not. Conclusion: These findings raise awareness for the need of community-oriented education programs for COVID-19 which considers associated factors to improve the level of public knowledge, attitudes, and practices.

Factors associated with reporting good maternal health-related knowledge among rural mothers of Yemen.

Increasing women's knowledge about maternal health is an important step towards empowering them and making them aware of their rights and health status, allowing them to seek appropriate health care. In Yemen, the ongoing conflict has hampered the delivery of health information to women in public health facilities. This study examined rural women's knowledge of, and attitude towards, maternal and child health in Yemen and identified the factors associated with good maternal health knowledge. The study was conducted between August and November 2018. A sample of 400 women aged 15-49 years who had delivered in the 6 months prior to the survey were systematically selected from selected public health facilities in Abyan and Lahj. Women were interviewed using a structured questionnaire to gather data on their demographic and economic characteristics, obstetric history and responses to health knowledge and attitude questions. Women's knowledge level was assessed as poor or good using the mean score as a cut-off. Chi-squared test and multiple logistic regression analysis were used to identify statistically significant factors associated with good maternal health knowledge. The percentage of women who had good knowledge was 44.8% (95% CI: 39.8-49.8). Women's attitude towards maternal health was negative in the areas of early ANC attendance, managing dietary regime and weight during pregnancy, facility delivery, PNC visits, cord care and mother and child health management. Women with primary education, whose husbands had received no formal education, who had their first ANC visit from the second trimester of pregnancy and who had fewer than four ANC visits were more likely to have poor health knowledge. Conversely, those with higher household income and only one child were more likely to have good maternal health knowledge. Overall, women's knowledge on maternal and child health care in rural areas of Yemen was low. Strategies are needed to increase rural women's knowledge on maternal and child health in this conflict-affected setting.

Adult mortality before and during the first wave of COVID-19 pandemic in nine communities of Yemen: a key informant study.

INTRODUCTION: Widespread armed conflict has affected Yemen since 2014. To date, the mortality toll of seven years of crisis, and any excess due to the COVID-19 pandemic, are not well quantified. We attempted to estimate population mortality during the pre-pandemic and pandemic periods in nine purposively selected urban and rural communities of southern and central Yemen (Aden and Ta'iz governorates), totalling > 100,000 people. METHODS: Within each study site, we collected lists of decedents between January 2014-March 2021 by interviewing different categories of key community informants, including community leaders, imams, healthcare workers, senior citizens and others. After linking records across lists based on key variables, we applied two-, three- or four-list capture-recapture analysis to estimate total death tolls. We also computed death rates by combining these estimates with population denominators, themselves subject to estimation. RESULTS: After interviewing 138 disproportionately (74.6%) male informants, we identified 2445 unique decedents. While informants recalled deaths throughout the study period, reported deaths among children were sparse: we thus restricted analysis to persons aged ≥ 15 years old. We noted a peak in reported deaths during May-July 2020, plausibly coinciding with the first COVID-19 wave. Death rate estimates featured uninformatively large confidence intervals, but appeared elevated compared to the non-crisis baseline, particularly in two sites where a large proportion of deaths were attributed to war injuries. There was no clear-cut evidence of excess mortality during the pandemic period. CONCLUSIONS: We found some evidence of a peak in mortality during the early phase of the pandemic, but death rate estimates were otherwise too imprecise to enable strong inference on trends. Estimates suggested substantial mortality elevations from baseline during the crisis period, but are subject to serious potential biases. The study highlighted challenges of data collection in this insecure, politically contested environment.

Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting.

Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020−February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children <5 years (11%) compared to other age groups (p < 0.001), for children from other nationalities (4%) compared to Yemeni children (p < 0.001) and for girls (21%) compared to boys (30%) (p < 0.031). Conclusion: Understanding and addressing the cause of these disparities and improving guidelines for COVID-19 screening among children will improve access to care and control of the COVID-19 pandemic.

Impact of the COVID-19 pandemic on the utilisation of health services at public hospitals in Yemen: a retrospective comparative study.

BACKGROUND: The COVID-19 pandemic has led to a global crisis, creating an unprecedented situation, which has taken the world by storm, overshadowing on all life' aspects and having a significant impact on the health systems of most countries. In this study, the delivery of health services is investigated both before and during the outbreak of the COVID-19 pandemic at public hospitals in Yemen to assess the impact of COVID-19 on the utilisation of health services. METHOD: Data collected from 127 hospitals in Yemen were reviewed using the DHIS2 system. The data represented 3 months before the outbreak of COVID-19 between January and March 2020 and during the outbreak of COVID-19 outbreak between April and June 2020. The results were then compared with the same period in 2019. The utilisation pattern of healthcare services during the period of investigation was compiled and analysed by applying a generalised estimating equation (GEE) to examine the effects of the COVID-19 outbreak in Yemen. The data collected from the targeted hospitals included information related to consultations, surgeries, deliveries, C-sections and penta-3rd dose immunisation. RESULTS: The trendline of health services used during the pandemic showed a gradual decline beginning from April 2020 for consultations, surgeries and penta-3rd dose utilisation. The GEE model revealed a significant effect (p<0.05) during the outbreak compared with preoutbreak in the consultation services (B=-1,343.9; 95% CI -1,767.2 to -920.6; χ2=38.718), surgeries (B=-54.98; 95% CI -79.13 to -30.83, χ2=19.911) and penta-3rd dose (B=-24.47; 95% CI -30.56 to -18.38 and χ2=62.010). As for deliveries and C-sections, the results were shown to be statistically non-significant. CONCLUSION: The impact of COVID-19 on continuity of health services delivery in Yemen has been distinct and profound, where the study revealed that the number of the consultations, surgeries and number of vaccinated children have been declined during the COVID-19 pandemic, likely due to the partially lockdown measures taken and fear of being infected. However, the deliveries and C-section services remained nearly in the same level and did not affect by the COVID-19 pandemic.

Assessing Antimicrobial Resistance, Utilization, and Stewardship in Yemen: An Exploratory Mixed-Methods Study.

Antimicrobial resistance (AMR), largely driven by irrational use of antimicrobials, is a global, multifaceted problem calling for a complete understanding of all contributory factors for effective containment. In conflict settings, war-wounds and malnutrition can combine with existing social determinants to increase demand for antibiotics, compounding irrational use. In this study, we focus on Yemen, a low-income country with active conflict for the last 5 years, and analyze the current status of awareness and stewardship efforts regarding AMR. We performed a survey of prescribers/physicians and pharmacists to describe perceptions of AMR prevalence, antibiotic use practices, and stewardship in Yemen, supported by a nonsystematic scoping literature review and a key informant interview. Participants (96%, N = 54) reported a perceived high AMR prevalence rate. Prescribers (74%, 20/27) reported pressure to prescribe broad-spectrum antibiotics. In the majority of cases (81%, 22/27), antimicrobial sensitivity tests (AST) were not performed to inform antibiotic choice. The main barrier to AST was cost. Most pharmacists (67%, 18/27) sold antibiotics without prescriptions. Amoxicillin (including amoxicillin-clavulanate) was the most-commonly prescribed (63%, 17/27) or dispensed (81%, 22/27) antibiotic. AST was rated the least important solution to AMR in Yemen. While there was awareness of a high AMR rate, stewardship is poor in Yemen. We note that barriers to the use of AST could be addressed through the deployment of reliable, affordable, quality rapid diagnostics, and AST kits. Compulsory continuing education emphasizing the use of AST to guide prescribing and patients' awareness programs could help avoid irrational use.

Lower urinary tract symptoms among male medical students and its relationship with khat chewing habit: A cross-sectional study.

OBJECTIVE: To determine the prevalence of the khat chewing habit among male medical students and its relationship with urinary tract symptoms. METHODS: This is a cross-sectional study on male medical students at the University of Aden, Yemen, during the period 3 to 14 April 2016. The study tool was a self-administered predesigned questionnaire containing selected personal background information, habits of chewing khat, and the standard Arabic version of the International Prostate Symptom Score (IPSS). RESULTS: A total of 220 students completed the questionnaire; 46% of them reported using khat regularly. Fifty-four (53.5%) students who chewed khat used it on a daily basis, and the vast majority of them (76%) spent more than 4 hours in a typical khat session. The main ± SD (median) IPSS of students who reported using khat was 10.48 ± 8.39 (10) compared with students who did not chew khat 2.89 ± 3.41 (2). The majority (90%) of the non-khat chewing students had a mild degree of lower urinary tract symptoms (LUTS) and none of them reported a severe degree, while 39.6%, 46.5%, and 13.9% of the khat chewing students reported mild-, moderate-, and severe-degree LUTS, respectively. There was a significant difference between khat chewing and non-khat chewing students in all LUTS (domains of IPPS symptoms), except the nocturia symptom. CONCLUSION: The khat chewing habit is prevalent among male medical students, and it is strongly correlated with LUTS as measured by IPPS.

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

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

Implementation of an educational module on nosocomial infection control measures: a randomised hospital-based trial.

BACKGROUND: Previous cross-sectional studies have reported limited knowledge and practices among nurses regarding controlling nosocomial infections (NIs). Even though health institutions offer many irregular in-service training courses to solve such issues, a three year-nursing educational programme at institutions is not adequate to enable nurses to handle NIs. Therefore, this study aims to evaluate the implementation of an educational module on NIs control measures among Yemeni nurses. METHODS: A single-blinded randomised hospital-based trial was undertaken involving 540 nurses assigned to two intervention groups and a waitlist group. Intervention group-1 received a face-to-face training course comprising 20 h spread over six weeks and a hard copy of the module, while intervention group-2 only received the hard copy of the module "without training". In contrast, the waitlist group did not receive anything during the period of collecting data. A self-administered NI control measures-evaluation questionnaire was utilised in collecting the data from the participants; before the intervention, at six weeks and 3 months after the end of the intervention. The period of data collection was between 1st May and 30th October 2016. RESULTS: The results from collecting and analysing the data showed a statistically significant difference in the mean knowledge scores between the intervention groups that were detectable immediately post-intervention with a mean difference (MD) of 4.31 (P < 0.001) and 3 months after the end of the intervention (MD = 4.48, P < 0.001) as compared to the waitlist group. Similarly, the results showed a statistically significant difference in the mean practice scores between the intervention groups immediately post-intervention (MD = 2.74, P < 0.001) and 3 months after the intervention (MD = 2.46, P < 0.001) as compared to the waitlist group. Intervention-1 (face-to-face training + module) was more effective than intervention-2 (module only) in improving Yemeni nurses' knowledge and practices regarding NI control measures compared to the waitlist group. CONCLUSION: The findings of this study found that intervention-1 could be offered to nurses in the form of an in-service training course every six months. The NI course should also be included in nursing curricula, particularly for the three-year-nursing diploma in Yemen. TRIAL REGISTRATION: Nosocomial infection educational module for nurses ISRCTN19992640 , 20/6/2017. The study protocol was retrospectively registered.

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

OBJECTIVES: To improve prevention and control response to the cholera outbreak, we sought to assess and compare the community's cholera awareness and needs in high and low epidemic areas in Aden. METHODS: A community-based comparative survey was conducted in 2017. We used multi-stage cluster sampling. Eligible household heads in high and low epidemic areas were interviewed. The data collected from both areas using a pretested questionnaire. RESULTS: Cholera cases and mortality were higher in high epidemic areas compared with low epidemic areas. Socioeconomic, water, sanitation, and hygienic conditions were poorer in high epidemic areas compared with low epidemic areas. Knowledge of cholera transmission and prevention was sub-optimal in both areas. We found a mismatch between the delivered education and distributed preventive materials. CONCLUSIONS: Stakeholders should tailor the design, content, and implementation of future cholera prevention and control methods to meet the needs of the community. Future educational camping should focus on the transmission prevention, including vaccination. Education and sustainable interventions should be implemented to improve the water, sanitation, and hygiene.

Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study.

BACKGROUND: Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. METHODS: This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018. RESULTS: Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. CONCLUSIONS: Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.

Randomized community trial on nosocomial infection control educational module for nurses in public hospitals in Yemen: a study protocol.

BACKGROUND: Nosocomial infections remain a global health problem and they are considered as one of the leading causes of increased morbidity and mortality. In-service training courses related to infection control measures can help nurses to make informed and therapeutic decisions which could prevent or reduce the incidence of nosocomial infections. This study protocol is of a hospital-based trial to develop, implement and evaluate an educational module on nosocomial infection control among nurses in public hospitals in Yemen. This study is currently ongoing and at the analysis stage. METHODS: A three-arm single-blinded randomized community hospital-based trial was conducted to evaluate the effectiveness of a newly developed nosocomial infection control educational module among nurses in public hospitals in Yemen. To ensure effective delivery and acquisition of knowledge, the Situated Learning Theory was applied during the course of the intervention. A total of 540 Yemeni in-ward nurses, who had three years nursing diploma and at least a year of working experience in the selected public hospitals were recruited in this study. The hospitals were the unit of randomization whereby eight hospitals were assigned randomly to intervention and waitlist groups. Intervention group-1 (n = 180) received an educational module supported by audio-video CD and a training course for eight weeks. Intervention group-2 (n = 180) was given only the educational module with audio-video CD (without the training course). The waitlist group received no intervention during the period of data collection but they will be given the same training and learning materials after the completion of the study. DISCUSSION: This study contributes to the lack of a nosocomial infection control educational module for nurses in Yemen. It is hoped that the educational module will serve as an effective approach to increase the nurses' knowledge and improve their practices regarding nosocomial infection control measures and hence decrease the prevalence of nosocomial infections in the future. TRIAL REGISTRATION: ID: ISRCTN19992640, Date of registration: 20/6/2017. This study protocol was retrospectively registered.

Correction to: Randomized community trial on nosocomial infection control educational module for nurses in public hospitals in Yemen: a study protocol.

[This corrects the article DOI: 10.1186/s12912-019-0333-3.].

Global Burden of Multiple Myeloma: A Systematic Analysis for the Global Burden of Disease Study 2016.

Introduction: Multiple myeloma (MM) is a plasma cell neoplasm with substantial morbidity and mortality. A comprehensive description of the global burden of MM is needed to help direct health policy, resource allocation, research, and patient care. Objective: To describe the burden of MM and the availability of effective therapies for 21 world regions and 195 countries and territories from 1990 to 2016. Design and Setting: We report incidence, mortality, and disability-adjusted life-year (DALY) estimates from the Global Burden of Disease 2016 study. Data sources include vital registration system, cancer registry, drug availability, and survey data for stem cell transplant rates. We analyzed the contribution of aging, population growth, and changes in incidence rates to the overall change in incident cases from 1990 to 2016 globally, by sociodemographic index (SDI) and by region. We collected data on approval of lenalidomide and bortezomib worldwide. Main Outcomes and Measures: Multiple myeloma mortality; incidence; years lived with disabilities; years of life lost; and DALYs by age, sex, country, and year. Results: Worldwide in 2016 there were 138 509 (95% uncertainty interval [UI], 121 000-155 480) incident cases of MM with an age-standardized incidence rate (ASIR) of 2.1 per 100 000 persons (95% UI, 1.8-2.3). Incident cases from 1990 to 2016 increased by 126% globally and by 106% to 192% for all SDI quintiles. The 3 world regions with the highest ASIR of MM were Australasia, North America, and Western Europe. Multiple myeloma caused 2.1 million (95% UI, 1.9-2.3 million) DALYs globally in 2016. Stem cell transplantation is routinely available in higher-income countries but is lacking in sub-Saharan Africa and parts of the Middle East. In 2016, lenalidomide and bortezomib had been approved in 73 and 103 countries, respectively. Conclusions and Relevance: Incidence of MM is highly variable among countries but has increased uniformly since 1990, with the largest increase in middle and low-middle SDI countries. Access to effective care is very limited in many countries of low socioeconomic development, particularly in sub-Saharan Africa. Global health policy priorities for MM are to improve diagnostic and treatment capacity in low and middle income countries and to ensure affordability of effective medications for every patient. Research priorities are to elucidate underlying etiological factors explaining the heterogeneity in myeloma incidence.

Skin Cancer: ClinicoPathological Study of 204 Patients in Southern Governorates of Yemen.

BACKGROUND: Skin cancer is a group of heterogeneous malignancies, in general classified into nonmelanoma skin cancer (NMSC) and melanoma skin cancer (MSC). Incidences are high in many parts in the world with considerable geographical and racial variation. In the Yemen, there has been scarce information about skin cancer. The aim of this study was to evaluate the demographic characteristics and histological trend of skin cancer in Southern Governorates of Yemen. MATERIALS AND METHODS: This retrospective study covered 204 cases of skin cancer at the Modern Histopathology Laboratory and Aden Cancer Registry and Research Center, Faculty of Medicine and Health Sciences, University of Aden, for the period 20062013. Data were classified regarding different demographic and tumor related variables and analyzed using CanReg4 for cancer registry and SPSS (version 21). RESULTS: The commonest encountered skin cancer was NMSC (93.1%). Generally, skin cancer appears slightly more frequently in females than males with a 1:1.06 male: female ratio, with a mean age of 62.9 years. Slightly higher than onethird (36.3%) were from Aden governorate. The head and neck proved to be the most common site in both males and females (58%). Basal cell carcinoma (BCC) is the most common histological type of skin cancer (50.5%). CONCLUSIONS: Skin cancer is a common cancer in patients living in southern governorates of Yemen. The pattern appears nearly similar to the international figures with a low incidence of MSC.

Breast Cancer Knowledge, Perception and Breast Self- Examination Practices among Yemeni Women: an Application of the Health Belief Model.

BACKGROUND: The incidence of breast cancer is rapidly increasing in Yemen with recent indications of constituting one-third of female cancers. The main problem in Yemen remains very late presentation of breast cancer, most of which should have been easily recognisable. Since stage of disease at diagnosis is the most important prognostic variable, early diagnosis is an important option to be considered for control of breast cancer in low resourced settings like Yemen. In the present study, we aimed at describing breast cancer knowledge, perceptions and breast self-examination (BSE) practices among a sample of Yemeni women. MATERIALS AND METHODS: This cross-sectional study covered 400 women attending four reproductive health centres in Aden, Yemen through face-to-face interview using a structured questionnaire during April - July 2014. We collected data on sociodemographic characteristics, knowledge about breast cancer, and screening practices as well as respondents' perceptions based on the five sub scales of the Health Belief Model (HBM): perceived susceptibility; perceived severity; perceived barriers; perceived benefits; and self-efficacy. The response format was a fivepoint Likert scale. Statistical Package for Social Sciences (SPSS 20) was used for statistical analysis. Statistical significance was set at p<0.05. Logistic regression analysis was conducted with BSE as a dependent variable. RESULTS: The mean age of women was 26.5 (S.D=5.6) years. The majority (89.0%) had never ever performed any screening. Two-thirds of respondents had poor knowledge. Perceived BSE benefits and self-efficacy and lower BSE barriers perception were significant independent predictors of BSE practice. CONCLUSIONS: Poor knowledge and inadequate BSE practices are prevailing in Yemen. The need for implementing culturally sensitive targeted education measures is mandatory in the effort to improve early detection and reduce the burden of breast cancer.

Process evaluation of school-based peer education for HIV prevention among Yemeni adolescents.

In 2005, a survey was conducted among all the 27 high schools of Aden, which revealed low levels of knowledge on major prevention measures, and a high level of stigma and discrimination towards people living with HIV (PLWH). The results served as a baseline for implementing a school-based peer education intervention for HIV prevention in the 27 schools of Aden. In 2008, and after 3 years of implementation, a quasi-experimental evaluation was conducted, which revealed that the peer education intervention has succeeded in improving HIV knowledge and skills; and in decreasing stigmatization of PLWH. This process evaluation aims to give a deeper understanding of the quasi-experimental evaluation which was conducted in the 27 high schools of Aden, and to highlight the factors that facilitated or inhibited school peer education in such a conservative Muslim setting. Qualitative methodologies were pursued, where 12 focus group discussions and 12 in-depth interviews were conducted with peer educators, targeted students, school principals, social workers, and parents of peer educators. Results revealed that school-peer education was well received. There was an apparent positive effect on the life skills of peer educators, but the intervention had a lesser effect on targeted students. Key enabling factors have been the high quality of training for peer educators, supportive school principals, and acceptance of the intervention by parents. These findings are important for improving the life skills and peer education intervention at the school level, and in better planning and implementation of life skills and peer programmes at a national scale.

Trends of breast cancer and its management in the last twenty years in Aden and adjacent governorates, Yemen.

BACKGROUND: Breast cancer is the most common cancer of women and the principal cause of death in middle aged women. The objective of this study was to describe the trend of breast cancer and its management in Aden and adjacent south-eastern governorates of Yemen during the last 20 years. PATIENTS AND METHODS: This is a retrospective analysis of previous studies on patients with breast cancer in Aden and adjacent south-eastern governorates, Yemen (January 1989 through December 2007). The studied variables were: sex, age, time and type of presentation, disease stage, pathological types and the performed surgical treatment. The sources of information were the treatment registry of Aden health office, archives of Al-Gamhouria teaching hospital; major referral and other public and private hospitals in Aden and Aden Cancer Registry. RESULTS: The total number of patients was 476, 99% being females. The age range was 19-88 years. The most affected age was 30-50 years (60.5%), 95% presenting after one month of having breast symptoms. Forty-five percent presented with signs of advanced local disease, while 59.2% had palpable axillary lymph nodes on presentation. Early breast cancer (stages I-II) occurred in 47%, and late breast cancer (stages III-IV) in 51.5%. Invasive ductal carcinoma was the commonest pathology (89.3%). The main surgical treatment was mastectomy (modified radical mastectomy (50%). CONCLUSION: Breast cancer is predominantly a disease of young with late presentation and advanced disease. Improving health awareness and earlier diagnosis of the disease by health education, encouraging breast self-examination, and providing the mammography equipment and mammary clinics in hospitals are recommended. Establishment of oncology and radiotherapy centers in Aden is a necessity.