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

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

Involving the health care system in domestic violence: what women want.

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a "socially accepted way to break the silence." Women expected health care professionals to have an "active conscience"; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

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

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

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

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

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

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

Violence and social capital among young men in Beirut.

BACKGROUND: Research on the links between violence and social capital has produced mixed results and is mainly limited to Western countries. AIMS: To assess the relationship of social capital to physical fights among unmarried boys aged 13-19 years living in three disadvantaged neighbourhoods in the outskirts of Beirut, controlling for variables associated with youth violence. Lebanon has a history of civil and cross-border war, which may influence the production of violence at the individual level. METHODS: 674 boys were interviewed. The dependent variable was being involved in a physical fight in the last 3 months. The independent variable was social capital, classified into six categories: civic engagement and community development; locational capital; trust; reciprocity; hypothetical social support; and social network. RESULTS: One fifth (20%) had been in a fight in the last 3 months. Youth who were members of a group, who had been victimised, who could ask for help from a family member/friend/neighbour when they had a problem, and who liked living in their neighbourhood were more likely to be involved in a fight. CONCLUSION: This research supports the literature that indicates that physical fights are positively related to both individual and social capital variables. Social capital had a detrimental effect on physical fights. This may be related to bonding in a gang-like way. While high levels of social capital are good for other health outcomes and thus should not be reduced, interventions that channel youth energy in positive ways are needed.

Maternal and child health in the occupied Palestinian territory.

The Countdown to 2015 intervention coverage indicators in the occupied Palestinian territory are similar to those of other Arab countries, although there are gaps in continuity and quality of services across the continuum of the perinatal period. Since the mid 1990s, however, access to maternity facilities has become increasingly unpredictable. Mortality rates for infants (age

Women's autonomy and support for wife beating: findings from a population-based survey in Jordan.

The aim of this study is to examine attitudes among married women toward wife beating and to investigate the hypothesis that female individual empowerment is associated with such attitudes within a broader context of societal patriarchy in Jordan. The study uses data from a cross-sectional survey of a representative sample of married women (n = 5,390) conducted in 2002. Associations between acceptance of wife beating and several women's empowerment variables, including decision-making power, as well as other risk factors were assessed, using odds ratios from binary logistic regression models. The key finding is that the vast majority (87.5%) of Jordanian women believe that wife beating is justified in at least one hypothetical scenario, and justification is negatively associated with empowerment variables and some demographic, geographic, and socioeconomic factors.

Consanguinity and reproductive wastage in the Palestinian Territories.

Many studies have found that consanguinity poses a threat to child mortality and health and can also pose a threat to offspring survival before birth. However, there are conflicting findings with some studies having found no increased risk on offspring survival associated with consanguinity. Data from a population-based survey conducted in 2004 in the Palestinian Territories was used to assess the risk of consanguinity on offspring survival. The analysis was conducted on 4418 women aged 15-49 who were asked whether or not they had experienced a stillbirth or a spontaneous abortion. These two outcomes were combined together for the analysis of reproductive wastage. Multivariable negative binomial regression was conducted to calculate the incidence risk ratios (IRR) for each region in the Palestinian Territories separately. The strongest risk factors for reproductive wastage, after controlling for other variables, were found to be consanguinity, age and parity with age presenting the highest IRRs. Standard of living, locality type, education level, women's employment and past intrauterine device use were not found to be significant risk factors for reproductive wastage. In the West Bank only first cousin level of consanguinity was found to be significant and 'hamola' level (or from same family clan) lost its significance after adjusting for other variables. In the Gaza Strip both the first cousin and 'hamola' levels of consanguinity were significant and presented almost equal IRRs of 1.3. In conclusion, consanguinity was found to be a significant risk factor for reproductive wastage.

Care-seeking behavior of women with reproductive health problems from low-income areas of Beirut.

OBJECTIVE: To examine the patterns of care-seeking behavior and provider choice of women with self-reported reproductive health problems from 3 urban communities in Beirut. METHODS: The study was based on a sample of 1869 completed questionnaires from 2051 eligible women (married or had been married, and between 15 and 59 years) obtained during the Urban Health Survey. Associations between community of residence, other background characteristics, and two outcome measures (health care usage and choice of provider) were assessed using logistic regression. RESULTS: Of the 1869 women assessed, 439 (23.5%) reported reproductive health problems; of these, 273 (62%) women sought care for their problems, with the majority (52.5%) using private providers. Younger age, health insurance, and severity and duration of problems were associated with use. Women with higher parity and those with financial problems were significantly more likely to use public and subsidized services. CONCLUSION: The private health sector needs to be more involved in planning, implementing, and offering reproductive health care in low-income communities.

Consanguinity trends and correlates in the Palestinian Territories.

Secondary analysis of the trends and correlates of consanguinity in the Palestinian Territories was conducted using data from two separate surveys in 1995 and 2004. The analysis was conducted on ever-married women aged 15-54 who were asked about their relation to their husband in both surveys. A total of 16,197 women in 1995 and 4971 women in 2004 were successfully interviewed. Consanguinity was found to be widely practised in the Palestinian Territories with rates of total consanguinity reaching 45% of all marriages in 2004. Analysis was conducted with the data from the two surveys combined and this indicated that consanguinity was significantly decreasing with time after controlling for other variables. Age of the women, their age at marriage, region and locality type they lived in and their standard of living were all found to be significant predictors of consanguinity. The education level of the women was not found to be significant. After controlling for the survey year, women's labour force status was also found to be a non-significant predictor of consanguinity. Although consanguinity was found to be significantly decreasing slowly with time after controlling for other variables, the future trends of consanguinity are not known due to the unstable political situation in the territories, which could have a direct effect on marriage patterns.

Disparities in child health in the Arab region during the 1990s.

BACKGROUND: While Arab countries showed an impressive decline in child mortality rates during the past few decades, gaps in mortality by gender and socioeconomic status persisted. However, large socioeconomic disparities in child health were evident in almost every country in the region. METHODS: Using available tabulations and reliable micro data from national household surveys, data for 18 Arab countries were available for analysis. In addition to infant and child mortality, child health was measured by nutritional status, vaccination, and Acute Respiratory Infection (ARI). Within-country disparities in child health by gender, residence (urban/rural) and maternal educational level were described. Child health was also analyzed by macro measures of development, including per capita GDP (PPP), female literacy rates, urban population and doctors per 100,000 people. RESULTS: Gender disparities in child health using the above indicators were less evident, with most showing clear female advantage. With the exception of infant and child survival, gender disparities demonstrated a female advantage, as well as a large urban advantage and an overall advantage for mothers with secondary education. Surprisingly, the countries' rankings with respect to disparities were not associated with various macro measures of development. CONCLUSION: The tenacity of pervasive intra-country socioeconomic disparities in child health calls for attention by policy makers and health practitioners.

Husbands' involvement in housework and women's psychosocial health: findings from a population-based study in Lebanon.

OBJECTIVES: We examined the association between husbands' involvement in housework and the psychosocial health of their wives using data on married couples living in poor neighborhoods in Beirut, Lebanon. METHODS: Data were derived from a cross-sectional survey of 2797 households; 1652 married couples and their families were included in the analysis. An index of husbands' relative involvement in housework was constructed from 25 items focusing on division of housework activities. Logistic regression was used to assess associations between husbands' involvement in housework and wives' self-rated mental health status, marital dissatisfaction, and unhappiness. RESULTS: Husbands' involvement in housework was negatively associated with wives' psychological distress, marital dissatisfaction, and overall unhappiness after adjustment for relevant risk factors. In comparison with wives whose husbands were highly involved in housework, wives whose husbands were minimally involved were 1.60 times more likely to be distressed, 2.96 times more likely to be uncomfortable with their husbands, and 2.69 times more likely to be unhappy. CONCLUSIONS: Our results showed a significant association between husbands' involvement in housework and their wives' psychosocial health.

Distrust, social fragmentation and adolescents' health in the outer city: Beirut and beyond.

This study examined the association between place and components of social capital among adolescents living in three impoverished communities outside of Beirut, the capital city of Lebanon. We utilized a unique data set that includes a wide range of social capital items to assess the association between place, social capital and self rated health. The analyses were based on data collected by trained interviewers during the Spring of 2003 from a stratified random sample of 1294 adolescents aged 13-19 years, drawn from a sampling frame constructed from area maps and detailed household listing of the target population. Descriptive statistics and odds ratios from logistic regression models were used to assess the strength of associations between (1) the social capital items and community of residence and (2) social capital, community and self-rated health controlling for age, sex and income. Findings show that distrust and social fragmentation were generally prevalent among adolescents living in impoverished suburban communities. Even though social networks, especially the presence of family and relatives, were strong, instrumental social exchange was relatively scarce. Social capital items varied significantly by community, and the stock of social capital in one of the three communities surveyed-the Palestinian refugee camp-was quite distinctive. Findings from logistic regression models showed that social capital as measured by a simple index is strongly associated with self-rated health status, controlling for community, age, sex and income. Some implications of the findings are discussed.

HIV/AIDS-related knowledge and its association with socioeconomic status among women: results of Lebanese Survey for Family Health (PAPFAM) 2004.

This article assesses the association of women's HIV/AIDS knowledge of transmission and prevention with socioeconomic status (SES). Data from the 2004 Lebanese PAPFAM (Pan-Arab Project for Family Health) survey were used. The survey was based on a representative household sample (n = 5532 households; n = 3315 women) of ever-married women aged 15 to 55 years. Adjusted analysis revolved around multivariate logistic regression models. 18% of women were knowledgeable of HIV/AIDS transmission methods and 21% of prevention methods. Income and education were significantly related to women's transmission and prevention knowledge. Significant differences were also found by region and media exposure. Women in the richest income quintile were 4 times (95% confidence interval [CI] = 2.43-6.42) more likely to be knowledgeable than those in the poorest. Women with the highest education were 2.57 times more likely (95% CI = 1.98-3.34) to be knowledgeable than those with elementary education or less. These results suggest the need for incorporating contextual regional and population differences for more effective HIV/AIDS awareness campaigns in Lebanon.

Agreement between husband and wife reports of domestic violence: evidence from poor refugee communities in Lebanon.

BACKGROUND: This paper compares husband and wife reports of wife beating using household survey data collected from poor Palestinian refugee communities in Lebanon. METHODS: The analyses are based on a matched data file of 417 currently married couples, drawn from a unique multi-purpose living conditions sample survey of about 3600 Palestinian refugee households interviewed in the spring and summer of 1999. Four outcomes (ever beaten, last year beating, beating during pregnancy, and injuries caused by beating) were analysed using Kappa statistics and per cent agreement. Logistic regression was used to analyse discordant reporting of wife beating during the year preceding the survey. RESULTS: Husband and wives' reports of the four different outcomes are in 'good' agreement as judged by Kappa coefficients, ranging from 0.62 for 'beaten during pregnancy' to 0.69 for 'injuries resulting from beating'. Prevalence estimates of domestic violence are also remarkably similar. However, findings from a multivariate logistic regression model on agreement regarding 'last year beating' show that only age of men was a significant predictor of agreement, controlling for education level, marital duration, region of residence, household size, health status, and consanguinity. CONCLUSIONS: Our findings show that men's self-reports of their violent behaviour against their wives are fairly congruent with those of their spouses, implying that the perpetrators, men, can be 'trusted' in providing basic information on 'beating histories' in epidemiological and demographic population-based investigations in contexts similar to ours. However, care should be taken in studies of young men's current beating behaviour using only their self-reports.

The extraordinary decline of infant and childhood mortality among Palestinian refugees.

This article documents the levels and patterns of infant and child mortality among Palestinian refugees in Jordan, Lebanon and the Palestinian areas based on comparable data from household sample surveys conducted since 1995. The findings show that Palestinian refugees have clear advantage in mortality levels as compared to their non-refugee counterparts in every setting, and refugees living in the camps have similar or lower levels of mortality than their non-camp counterparts, other things being equal. The recent decline of infant and child mortality among this vulnerable segment of the Palestinian population demonstrates the importance of political will in halting the truncation of infant lives. An examination of the mortality patterns by sex and education sheds light on the nature of the decline currently underway.

Determinants of caesarean section in Egypt: evidence from the demographic and health survey.

This paper examines the impact of near birth complications and socio-demographic, healthcare and spatial characteristics of caesarean section in Egypt, using data on 4032 births from the 2000 Egypt Demographic and Health Survey. The hospital caesarean section rate was 22% in Egypt. Fever/vaginal discharge around delivery, birth weight, mother's age and education, birth order, residence and antenatal visits were important determinants of caesarean section. Variations by place of delivery were evident, although complications were more significant determinants of caesarean section in public settings and demographic characteristics were more important in private facilities. Unexpectedly, long labour and bleeding around delivery were not associated with caesarean section, particularly, in private hospitals. In view of the high and rising caesarean section rate in Egypt, monitoring the quality of maternity services in Egypt is imperative. An investigation of the forces sustaining the differential in determinants by place of delivery is needed.