Preparing ethical review systems for emergencies: next steps.

Ethical review systems need to build on their experiences of COVID-19 research to enhance their preparedness for future pandemics. Recommendations from representatives from over twenty countries include: improving relationships across the research ecosystem; demonstrating willingness to reform and adapt systems and processes; and making the case robustly for better resourcing.

Developing the Eastern Mediterranean Health Journal to support public health research in the Region (Editorial).

Since 1995, the Eastern Mediterranean Health Journal (EMHJ) has sought to publish public health research, regionally and globally, in accordance with the mandate and goals of the World Health Organization (WHO). As part of a family of WHO journals, the EMHJ is an open access public health journal and makes no charge for review or publication of accepted papers, allowing research manuscripts as well as policy-related works from institutions with different financial status an opportunity to be published and remain freely accessible to all. Supporting countries that are developing their health research base remains an important focus for the EMHJ, in line with the WHO Thirteenth General Programme of Work 2019-2023 (GPW13), and its mandate to strengthen research on public health priorities.

WHO collaborating centres in the Eastern Mediterranean Region: an agenda for action and improvement (Editorial).

The World Health Organization (WHO) is the key United Nations specialized agency dedicated to promoting population health and health outcomes. In order for the Organization to achieve its strategic objectives, WHO designates selected institutions as collaborating centres to assit with carrying out WHO core activities. The Eastern Mediterranean Region (EMR) currently hosts 45 collaborating centres (as of December 2018), which is only 5% of the 832 WHO collaborating centres located worldwide, and yet EMR countries host about 10% of the global population. The reason for this discrepency could be a reflection of the limited public resources allocated to health research in the Region. However, it may also highlight the fact that resources and opportunities for establishing effective collaborating centres in the EMR still remain untapped.

Improving evidence informed policy-making for health in the Eastern Mediterranean Region (Editorial).

Health policies should be based on a sound understanding of the problems, issues and context in which they operate, for which they require reliable data and information for action. The policies should also be informed by the best available research evidence, which also helps in better capturing the problem, understanding existing trends and patterns, and setting reasonable objectives that can be achieved using effective interventions. More importantly, research can provide evidence of comparative effectiveness of alternative interventions for a given public health issue; the costs and feasibility of implementing each intervention; and efficiency of the proposed interventions (policies) in comparison with alternative interventions.

Changes in dietary habits, physical activity and status of metabolic syndrome among expatriates in Saudi Arabia.

The aim of this paper is to assess the impact of living in Saudi Arabia on expatriate employees and their families' behavioural cardiovascular risk factors (BCVRFs), and to examine the association between changes in BCVRFs and metabolic syndrome (MetS). A cross-sectional study was conducted on 1437 individuals, aged ≥ 18 years, from King Saud University in Riyadh, Saudi Arabia. We used the World Health Organization STEPS questionnaire to ask every participant questions about BCVRFs twice: (1) to reflect their period of living in Saudi Arabia and (2) to shed light upon life in their country of origin. Their mean age was 40.9 (11.7) years. The prevalence of BCVRFs was as follows: tobacco use in 156 (11%), physical inactivity in 1049 (73%) low intake of fruit and vegetables in 1264 (88%) and MetS in 378 (26%). Residing in Saudi Arabia had reduced physical activity and intake of fruit and vegetables. There was also a significant increase in the fast food consumption. In conclusion, living in Saudi Arabia had a significant negative effect on BCVRFs. However, there was no statistically significant association between changes in fruit and vegetable intake and physical activity and MetS status, except that intake of fast food was lower among participants with MetS.

Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region.

BACKGROUND: Health research institutions in the Eastern Mediterranean Region (EMR) can play an integral role in promoting and supporting Knowledge Translation (KT). Assessing institutions' engagement in KT and bridging the "research- policy" gap is important in designing context-specific strategies to promote KT and informing funding efforts in the region. AIMS: The objective of this study was to explore the engagement of EMR institutions in KT activities. METHODS: A cross-sectional survey of institutions undertaking health research in the 22 EMR countries was undertaken. The survey covered institutional characteristics, institutional planning for research, national planning for health research, and knowledge management, translation and dissemination. RESULTS: 575 institutions were contacted of which 223 (38.3%) responded. Half the sampled institutions reported conducting priority-setting exercises, with 60.2% not following a standardized approach. Less than half institutions reported frequently/ always (40.5%) involving policymakers and stakeholders in setting priorities for research on health. Only 26.5% of respondent institutions reported that they examine the extent to which health policymakers utilize their research results. Moreover, only 23.3% reported measuring the impact of their health research. CONCLUSIONS: There is still misalignment between national health research priorities and actual research production, and KT activities are still rarely undertaken by institutions in the EMR. National governments and international funding agencies are called to support research production and translation in the EMR. Institutions and researchers are also called to produce policy-relevant research and be responsive to the needs and priorities of policy-makers.

The integration and management of noncommunicable diseases in primary health care (Guest Editorial).

Noncommunicable diseases (NCDs) are a great burden in the Eastern Mediterranean Region (EMR) and, if no strategic intervention is taken, the burden is forecast to become even heavier, particularly with the additional impact of ageing populations. Currently, 62% of deaths in the EMR are due to NCDs. However, by 2030 this proportion is projected to increase to nearly 70%. The EMR is disproportionately affected by NCDs as a result of the Region's rapid urbanization and the globalization of unhealthy behaviours. Moreover, many of the EMR countries have health systems whose structures are not designed for the prevention, early detection and management of NCDs.

Health research institutional mapping: an Eastern Mediterranean Regional perspective.

BACKGROUND: Research-conducive environments are mandatory for planning, implementing and translating research findings into evidence-informed health policies. AIM: This study aimed at comprehensive situation analysis of health research institutions in the Region. METHODS: We collected data on: institutional characteristics, research scope, capacity building, ethics, governance and resources. RESULTS: We contacted 575 institutions, of which, 223 (38.8%) responded, indicating that they conducted population research (82%). Reported studies were mostly in medicine, public health and epidemiology, while reported capacity building mainly focused on scientific writing (20.6%), research proposal writing (18%) and quantitative research methods (17%). Most institutions reported having collaborating partners (82%) - predominantly national (77%). Sixty-four percent of institutions received their own funding, with 48% reporting always having access to national databases. CONCLUSION: Governments in the Eastern Mediterranean Region and international funding agencies are called upon to support health research production through increasing allocated support and capacity building in health research.

Promoting bioethics in the Eastern Mediterranean Region (Editorial).

Bioethics addresses a broad swathe of human enquiry, ranging from the allocation of scarce health resources to cultural sensitivities over reproductive health. Historically an increasing number of nations have created official bodies to provide advice to their executive and legislative branches, and often to the general public, about bioethics. Termed "National Ethics / Bioethics Committees", such bodies are appointed by ministries of health, education, science and technology, or legislatures to synthesize available evidence and offer recommendations about concurrent issues in bioethics, especially as such issues bear on potential needs to develop national policies and to adopt legislations. Health research has grown substantially in the low- and middle-income countries, including the Eastern Mediterranean Region (EMR), with clinical trial activity in some of its nations tripling between 2008 and 2011. However, indigenous scholarship and expertise are essential when examining the complex debates over how health research is conducted and whether effective oversight can be promoted in resource-limited Member States. Moreover, the notion of ethics in any capacity draws in sensitive matters pertaining to cultural and religious values, and applying western concepts of bioethics in their entirety, may not always be an appropriate course to take.

Substance use prevention: evidence-based intervention.

The global substance use problem is a serious public health concern that affects not only health, safety and well-being of communities, but also social and economic development. It particularly affects children, young people and their families. All Member States should set substance use prevention measures and programmes as a priority in order to promote health and reduce social harm. During the past few decades there has been a significant advance in prevention science that has led to the development of international prevention standards and globally accepted evidence-based interventions. This review looks into the key requirements, components and strategic interventions needed for a public health approach to prevention of substance use and disorders, and its health and social consequences. It aims at supporting Member States and civil society to identify the key elements that support countries and local communities to increase the number of substance use protective approaches in relation to risk factors across all relevant domains.

Development of an Eastern Mediterranean Region search strategy for biomedical citations indexed in PubMed.

PubMed, a 'barrier-free' bibliographic database covering biomedical and health disciplines, has been successfully used to identify a multitude of indicators that assist in analyzing global trends for biomedical research productivity. The current study represents an original attempt to develop and optimize an Eastern Mediterranean Region (EMR) search strategy in PubMed to pave the way for subsequent descriptive analyses. The refined EMR search strategy contains elaborate syntaxes which facilitate controlling the search process and maintaining a proper balance between sensitivity and precision of the obtained results. Country-specific citation data were manually scanned for false positive publications. Our results indicate that publication productivity increased nearly five-fold in the EMR from 2004 to 2013. Five countries (Islamic Republic of Iran, Egypt, Saudi Arabia, Tunisia and Pakistan; in order of total publications) contributed to 80% of all EMR publications during this period. Each of the remaining 17 EMR countries contributed less than 4%. We believe that the methodology presented in this study can be used in conjunction with other metrics to extract invaluable indicators to describe EMR health research systems.

Assessment of World Health Organization Collaborating Centres in the Eastern Mediterranean Region.

Following in-house training, there was a need for assessing perceived performance of World Health Organization (WHO) collaborating centres in the Eastern Mediterranean Region, with special relevance to WHO's programme of work. Thus, a questionnaire was shared with responsible officers covering: selection process, frequency of communication, monitoring mechanisms, key delivered activities, and identified gaps during implementation. These included: tendency to implement regular activities, weak technical capacity and communication, and discrepancies between planned activities and actual implementation. Recommendations for centres included: establishing communication plan/modalities, selecting activities of global/regional nature, and mobilizing resources for work plan implementation. Recommendations for responsible officers included: carefully explaining updated WHO rules and regulations; ensuring that specific terms of reference are set as per WHO's global/regional mandates; setting up regular communication mechanisms; agreeing on regular monitoring and coordination modalities; and ensuring that redesignation planning takes place during the 4th year of prior designation period.

Research agenda on persistent and unpredictable threat of influenza and emerging respiratory infections: a public health necessity in the Eastern Mediterranean Region (Guest Editorial).

Infectious diseases continue to represent a significant threat to global health security, particularly in the context of increasing globalization, interconnectedness and interdependence. Chief among such threats are influenza viruses and other respiratory pathogens, such as Middle East Respiratory Syndrome coronavirus (MERS-CoV), because of their risk of high transmissibility and acuity of illness. Annual epidemics of seasonal influenza cause an estimated 3-5 million cases of severe illness and more than 500 000 deaths, with the prospect of pandemic influenza viruses causing far greater impact. In addition, the appearance of severe acute respiratory syndrome (SARS) in 2003, widespread and continued outbreaks of avian influenza A (H5N1) since 2004, the H1N1 pandemic in 2009 and emergence of MERS CoV in 2012 reflect the seriousness of public health challenges posed by influenza and emerging respiratory infections.

The independent effects of maternal obesity and gestational diabetes on the pregnancy outcomes.

BACKGROUND: Obesity and gestational diabetes (GDM) in pregnancy are recognized risk factors for adverse outcomes, including cesarean section (CS), macrosomia and preeclampsia. The aim of this study was to investigate the independent effect of GDM and obesity on the adverse pregnancy outcomes at term. METHODS: A retrospective cohort of postpartum women, in King Khalid University Hospital, were stratified according to body mass index (obese ≥30 kg/m2, non-obese <30 kg/m2) and the results of GDM screening into the following groups, women with no obesity and no GDM (reference group), women with no obesity but with GDM, women with obesity but no GDM and women with both GDM and obesity. Adverse pregnancy outcomes included high birth weight, macrosomia, CS delivery and preeclampsia. Multiple logistic regression used to examine independent associations of GDM and obesity with macrosomia and CS. RESULTS: 2701 women were included, 44% of them were obese and 15% had GDM. 63% of the women with GDM were obese. There was significant increase in the percentage of macrosomia, P < 0.001, high birth weight, P < 0.001, CS, P < 0.001 and preeclampsia, P < 0.001 in women with GDM and obesity compared to the reference group. Obesity increased the estimated risk of CS delivery, odds ratio (OR) 2.16, confidence intervals (CI) 1.74-2.67. The combination of GDM and obesity increased the risk of macrosomia OR 3.45, CI 2.05-5.81 and the risk of CS delivery OR 2.26, CI 1.65-3.11. CONCLUSION: Maternal obesity and GDM were independently associated with adverse pregnancy outcomes. The combination of both conditions further increase the risk.

The importance of insufficient national data on sexual and reproductive health and rights in international databases.

Looking at SRHR as an isolated set of elements, as is the current practice, does not do justice to the needs and rights of people and communities and may be one of the reasons why challenges remain in the attainment of SRHR for all. SRHR Infographic snapshots were developed for all 194 WHO Member States and included 120 indicators covering a broad range of policy, health systems and service delivery interventions. The snapshots were created using data less than 10 years old publicly available in data repositories maintained by international and global agencies. Data availability was not consistent across countries with low and lower-middle income countries having higher data availability (71%) compared to high income countries (40%). SRHR data that is easily accessible and consistently reported can improve accountability and opportunities for learning to improve people-centred approaches to accelerate the attainment of SRHR for all.

The independent effects of second hand smoke exposure and maternal body mass index on the anthropometric measurements of the newborn.

BACKGROUND: Exposure to tobacco smoke during pregnancy, whether as active smoking or by exposure to secondhand smoke (SHS), is associated with adverse pregnancy outcomes including low birth weight (LBW) and small for gestational age infants due to the effect of tobacco on the anthropometric measurements of the newborn. This effect might be masked by maternal obesity as it increases fetal weight. The objectives of this study were to estimate the independent effects of maternal exposure to SHS and maternal body mass index (BMI) on the anthropometric measurements and on the prevalence of macrosomia and LBW among term infants. METHODS: Data were collected from women in the postnatal ward following delivery. Participants were stratified into six groups based on the BMI (underweight <18 kg/m², non-obese 18-29.9 kg/m2, and obese ≥30 kg/m²) and the SHS exposure status (exposed and non- exposed), to examine the independent effects of BMI and SHS on infants' anthropometry. Multiple regression analysis was used to explore the independent associations between the six groups and the risk of delivering a macrosomic or LBW infant. RESULTS: Infants of women exposed to SHS had significantly reduced anthropometric measurements compared to infants of unexposed women. The odds of delivering a macrosomic baby increased to 9-fold for women with BMI of ≥30 kg/m² compared to non-obese women; odds ratio (OR) 9.18, 95% Confidence Interval (CI) (1.01, 9.37); p = 0.04, this risk was attenuated to 1.5-fold in women exposed to SHS, OR 1.53, 95% CI (1.19, 12.1); p < 0.0001. The odds of delivering an LBW infant were more than doubled in underweight women compared to non-obese women, OR 2.15, 95% CI (1.001, 4.57); p = 0.034, and were further increased to almost 3-fold for women who were exposed to SHS, OR 2.71, 95% CI (1.82,4.045); p = 0.02. CONCLUSION: Exposure to SHS was associated with reduced anthropometric measurements of the newborn and increased rate of LBW infants, irrespective of maternal BMI. Maternal obesity was associated with increased risk of delivering a macrosomic infant; conversely maternal underweight was associated with increased risk of delivering an LBW infant.

Effects of secondhand smoke on the birth weight of term infants and the demographic profile of Saudi exposed women.

BACKGROUND: Maternal exposure to tobacco smoke during pregnancy is associated with detrimental effects on the mother and the fetus including; impaired fetal growth, low birth weight and preterm delivery. In utero exposure to tobacco is implicated in the etiology of many adults' diseases including obesity, diabetes and hypertension.The objectives of this study were to evaluate the effects of Secondhand Tobacco Smoke (SHS) exposure on newborns' anthropometric measurements and to compare the demographic profile of the women exposed to SHS to those who were not. METHOD: This is a retrospective cohort study investigating the effects of SHS during pregnancy on newborns' anthropometry. Women who self-reported SHS exposure were compared with those not exposed. The primary outcomes were birth weight, newborn length and head circumference. Univariate analysis and multivariate regression analysis were performed. Adjusted differences with 95% confidence intervals were calculated. RESULTS: Mothers exposed to SHS constituted 31% of the cohort. The mean birth weight of infants of exposed mothers was significantly lower by 35 g, 95% CI: 2-68 g, (P = 0.037) and the mean length was shorter by 0.261 cm, 95% CI 0.058-0.464 cm, (P = 0.012) compared to the infants of unexposed mothers. Women exposed to SHS, were younger, of lower parity and more likely to be illiterate than those who were not exposed in addition, exposed women were less likely to be primiparous. CONCLUSION: The prevalence of exposure of Saudi pregnant women to SHS is high at 31% and it is associated with reduced birth weight, and shorter length of the newborn.