Supporting Public Health Research Capacity, Quality, and Productivity in a Diverse Region.

Public health research plays a critical role in strengthening health systems and improving their performance and impact. However, scholarly production in public health coming from the Eastern Mediterranean Region (EMR) remains well below the world average and lacks a tangible growth trend over time. During the seventh Eastern Mediterranean Public Health Network Regional Conference, a roundtable session brought together a panel of public health experts representing Global Health Development/Eastern Mediterranean Public Health Network affiliates, universities or academia, and research institutions from the region, where they shared insights on the current situation of public health research; challenges and barriers to research facing the different countries in the EMR and the region in general; and how research agendas, productivity, and quality can be supported through strengthening research capacity in the region. Although the region is diverse in terms of health system capacity and socioeconomic development, several common challenges were identified, including a lack of strategic prioritization to guide health research, insufficient funding, ineffective transfer of knowledge to policy and practice, limited availability of research facilities, and limited national and international research collaboration. Occupied countries and countries in a state of conflict, such as Palestine, face additional barriers, such as personal and social security, lack of control of borders and natural resources, travel and movement restrictions, and confidentiality challenges because of the continuing war conditions and occupation. However, there have been success stories in the EMR regarding research publications and their positive and effective impact on policy and decision-makers. To improve research resilience and public health care in the region, a collaborative approach involving institutions, policymakers, and relevant stakeholders is critical.

Assessment of adherence to infection prevention and control guidelines among dentists in the West Bank and Jerusalem.

Background: Adherence to infection prevention and control (IPC) guidelines is mandatory in healthcare service provision. Aims: We assessed the knowledge and adherence to IPC guidelines among dentists in the West Bank and Jerusalem. Methods: A self-administered questionnaire was distributed to a convenience sample of dentists in the West Bank and Jerusalem between 12 March 2019 and 9 May 2019. The total sample comprised 395 dentists, categorized into good compliance and fair compliance according to a scale developed from 32 questions. The Chi-squared test was used to compare the 2 categories. Data were analysed using SPSS, version 25. Results: Overall compliance with IPC guidelines was low; only 18.5% of respondents reported good compliance. Compliance with basic principles such as wearing gloves and changing them for each patient and using autoclaves to sterilize equipment was high. Good compliance was significantly associated with age, years of experience, and year of graduation, P = 0.045, P = 0.036 and P = 0.007, respectively. Providers in the north of West Bank and public sector workers were significantly associated with good compliance, P = 0.018 and P ≤ 0.0001, respectively. Experiencing a needle stick injury and the number of needle stick injuries experienced were significantly inversely associated with good compliance, P ≤ 0.001. Conclusion: Based on our results, there is a need for substantial improvements in compliance with IPC guidelines by dentists in the West Bank and Jerusalem; mandatory education and training regulated by governing institutions would be very helpful.

Consumption of fruits and vegetables among adolescents in Arab Countries: a systematic review.

BACKGROUND: Adolescents' consumption of fruits and vegetables is inadequate in most Arab countries, leading to a higher risk of poor health outcomes. This systematic review evaluates fruits and vegetables intake among adolescents in Arab countries, the proportion of adolescents meeting the dietary guidelines in these countries, and the dietary assessment tools used to assess fruits and vegetables intake. METHODS: Four databases were searched, MEDLINE, PUBMED, EMBASE, and Web of Science. Studies were eligible if they reported fruit or vegetable consumption among adolescents aged 10 to 19 in 22 Arab countries. The risk of bias in the included studies was assessed by two reviewers independently using the risk of bias tool developed by Hoy et al. Data were extracted and synthesized into three categories; frequency of fruits and vegetables consumption, mean fruits and vegetables consumption, and percentage of adolescents meeting fruits and vegetables consumption recommendations. RESULTS: The review included 44 articles utilizing 41 cross-sectional studies. Most studies were school-based, and data was collected from both males and females using self-administered questionnaires. Of those, validated questionnaires were used in 28 studies. According to the World Health Organization recommendation, most studies defined five fruits and vegetables servings as the adequacy cutoff point; other definitions were used in some studies. The reported mean consumption ranged between 6.1 times per week and 4.5 servings of fruits and vegetables per day. The proportion of those who met the recommendations of eating five servings per day ranged between 10 and 29%. Fruits were shown to have a lower daily intake than vegetables (4.2 to 53.7% for fruits and 7.8 to 66.3% for vegetables). DISCUSSION: This review indicated inadequate fruits and vegetables consumption among adolescents in Arab countries and highlighted an increased risk of non-communicable diseases and malnutrition prevalence. A limitation was the incomparability of available data between countries. Further in-depth research on the core reasons behind adolescents' inadequacy in fruits and vegetables consumption is recommended.

Prevalence of overweight, obesity, and associated factors among adolescents in the occupied Palestinian territory: a cross-sectional study.

BACKGROUND: Overweight and obesity are multifactorial conditions that are spreading fast in both developing and developed countries. They are emerging as a major public health threat among children and adolescents, and present a serious morbidity and mortality burden. Adolescence is a critical period in which lifestyle and dietary behaviours are shaped that persist into adulthood. Therefore, adolescents are an ideal study target in terms of estimating the magnitude of the problem, understanding its risk factors and investigating potential effective intervention programmes. This study assesses the prevalence of overweight, obesity, and associated factors among adolescents in Palestinian schools. METHODS: Weighted analysis was conducted on data from the Palestinian Micronutrient Survey, a national cross-sectional study carried out in 2013 by the Palestinian Ministry of Health in collaboration with UNICEF. For sample selection, stratified cluster random sampling was used. This school-based survey involved 2400 male and female adolescents aged 15-18 years in government schools in the West Bank and Gaza Strip. Data were analysed at univariate, bivariate, and multivariate levels, by the use of proportions, confidence intervals, and logistic regression. In the original survey, written informed consent was obtained from parents and guardians of the participants. A letter of approval to use the study data was obtained from the Ministry of Health (who own the data). The study was also approved by the Ethics Committee of the Institute of Community and Public Health. FINDINGS: The analysis indicates a prevalence of 23·6% (95% CI 20·6-26·5) for overweight and obesity, with a prevalence of 26·1% in the West Bank and 19·5% in the Gaza Strip. The multivariate analysis revealed that the likelihood of overweight and obesity was significantly higher for adolescents from the West Bank than from the Gaza Strip, for those eating two main meals or less than for those eating three meals, for those who reported a high frequency of vegetable intake, and those who observed a diet for weight loss. INTERPRETATION: The data suggest that one in every four adolescents is overweight or obese, which is an alarming statistic and calls for attention. The high prevalence can be attributed to different lifestyles, eating behaviours, and dietary intake, which affect energy balance. These factors should be investigated within social, political, and economic contexts, and addressed comprehensively, first at the level of individuals and family, and then at the level of schools and the community. It should be noted that the original study included students in the 10th grade and 11th grade only, whereas adolescence covers a wider age group (10-19 years). FUNDING: None.

Quality of life of type 2 diabetes mellitus patients in Ramallah and al-Bireh Governorate-Palestine: a part of the Palestinian diabetes complications and control study (PDCCS).

PURPOSE: Type 2 diabetes mellitus (T2DM) is a considerable impact on physical health as well as on emotional and social wellbeing. This study aimed to investigate the quality of life and its associated factors among Palestinians with T2DM. METHODS: A cross-sectional study including 517 patients (68% female) was conducted in eleven primary health care clinics located in Ramallah and al-Bireh governorate of the West Bank. To assess socio-demographic data, risk factors and diabetes control, interviews, physical examinations, anthropometric measurements, and blood and urine tests were performed. The validated Arabic version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire was carried out on all patients to measure Quality of Life (QoL). A multivariable regression analysis was performed. RESULTS: The average weighted impact (AWI) score was -3.38 (95% CI: -3.55 to -3.21, range: -9.00 to 0.12). This indicates that diabetes was perceived as having a considerable negative impact on the quality of life. The life domains 'freedom to eat', 'physical activities', and 'work-life' were the most negatively impacted. Males and individuals living with diabetes for a prolonged time were associated with a more significant negative impact on quality of life. CONCLUSION: The study showed that diabetes generally had a negative impact on QoL and identified the demand for diabetes management programs tailored to patient needs and different patient groups, as well as health policies that put patients in the center of diabetes care.

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey.

CONTEXT: Evidence from prior public health emergencies demonstrates palliative care's importance to manage symptoms, make advance care plans, and improve end-of-life outcomes. OBJECTIVE: To evaluate the preparedness and capacity of palliative care services in the Middle-East and North Africa region to respond to the COVID-19 pandemic. METHODS: A cross-sectional online survey was undertaken, with items addressing the WHO International Health Regulations. Nonprobabilistic sampling was used, and descriptive analyses were conducted. RESULTS: Responses from 43 services in 12 countries were analyzed. Half of respondents were doctors (53%), and services were predominantly hospital based (84%). All but one services had modified at least one procedure to respond to COVID-19. Do Not Resuscitate policies were modified by a third (30%) and unavailable for a fifth (23%). While handwashing facilities at points of entry were available (98%), a third had concerns over accessing disinfectant products (37%), soap (35%), or running water (33%). The majority had capacity to use technology to provide remote care (86%) and contact lists of patients and staff (93%), though only two-fifths had relatives' details (37%). Respondents reported high staff anxiety about becoming infected themselves (median score 8 on 1-10 scale), but only half of services had a stress management procedure (53%). Three-fifths had plans to support triaging COVID-19 patients (60%) and protocols to share (58%). CONCLUSION: Participating services have prepared to respond to COVID-19, but their capacity to respond may be limited by lack of staff support and resources. We propose recommendations to improve service preparedness and relieve unnecessary suffering.

Country and gender differences in the association between violence and cigarette smoking among youth.

BACKGROUND: Exposure to violence in youth may be associated with substance use and other adverse health effects. This study examined cigarette smoking in two middle-income areas with different levels and types of exposure to violence. METHODS: Association of exposure to verbal and physical violence with cigarette smoking in the West Bank oPt (2008) and in Jujuy Argentina (2006) was examined using cross-sectional surveys of 14 to 17-year old youth in 7th to 10th grade using probabilistic sampling. RESULTS: Violence exposure rates were more than double for Palestinian girls (99.6% vs. 41.2%) and boys (98.7% vs. 41.1%) compared with Argentinians. The rate of current cigarette smoking was significantly higher among Argentinian girls compared with Palestinian girls (33.1% vs. 7.1%, p < 0.001). Exposure to verbal violence from family and to physical violence increased the odds of current cigarette smoking, respectively, among Argentinian girls (aOR = 1.3, 95% CI = 1.0-1.7; aOR = 2.5, 95%CI = 1.7-3.8), Palestinian girls (aOR 2.2, 95%CI = 1.1-2.4; aOR = 2.0, 95%CI = 1.1-3.6) and Argentinian boys (aOR = 1.5, 95%CI = 1.1-2.0; aOR = 2.2, 95%CI = 1.6-3.0), but not among Palestinian boys. CONCLUSION: Findings highlight the importance of producing context and gender specific evidence from exposure to violence, to inform and increase the impact of targeted smoking prevention strategies.

Lung Function and Respiratory Health of Populations Living Close to Quarry Sites in Palestine: A Cross-Sectional Study.

Environmental exposure to dust from quarrying activities could pose health dangers to the population living nearby. This study aimed to investigate the health effects of dust exposure on people living close to quarry sites and compared them with those who live far from the quarry sites. A cross-sectional comparative study was conducted among 79 exposed participants, who lived less than 500 m away from the quarry sites, and 79 control participants who lived more than 500 m away. All participants answered a questionnaire on dust exposure at home and health effects, as well as performed a lung function test in which both reported and measured health effects were investigated. People who live in close proximity to the quarry sites reported exposure to dust at home (98%), land destruction (85%), plant leaves covered with dust (97%), and an inability to grow crops (92%). The exposed group reported significantly higher eye and nasal allergy (22% vs. 3%), eye soreness (18% vs. 1%), and dryness (17% vs. 3%), chest tightness (9% vs. 1%), and chronic cough (11% vs. 0%) compared to the control group. Lung function parameters were significantly lower among the exposed group compared to the control group; mean forced vital capacity (FVC) was 3.35 L vs. 3.71 L (p = 0.001), mean forced expiratory volume in the first second (FEV1) was 2.78 L vs. 3.17 L (p = 0.001). Higher levels of airway restriction were found among the exposed group. Among the exposed group, lung function parameters worsened with the increasing closeness of home to the quarry site. This study demonstrates the negative health effects of environmental dust exposure among two communities living near quarry sites in Palestine. The results highlight the importance of developing and strictly enforcing rules and regulations in Palestine to protect population health.

Complications of type 2 diabetes mellitus in Ramallah and al-Bireh: The Palestinian Diabetes Complications and Control Study (PDCCS).

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine. METHODS: The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors. RESULTS: 517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%). CONCLUSION: Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

Seroprevalence of hepatitis E virus among blood donors in Qatar (2013-2016).

BACKGROUND: Hepatitis E virus (HEV) is an RNA virus transmitted mainly through zoonotic transmission or fecal-oral route. More than 80% of Qatar's population are expatriates, including many coming from hyperendemic countries; thus, it is important to estimate the seroprevalence and to compare between different nationalities. The results can be useful in alerting blood banks to the importance of HEV screening. STUDY DESIGN AND METHODS: Samples from 5854 blood donations provided by Hamad Medical Corporation were tested in the period between June 2013 to June 2016. Samples were tested for the presence of anti-HEV immunoglobulin (Ig)G and IgM antibodies and viral RNA using real-time polymerase chain reaction (PCR). Descriptive statistics, bivariate analysis, and multivariate logistic regression were used. RESULTS: Anti-HEV seroprevalence was 20.7%. A total of 1198 and 38 donations tested positive for IgG and IgM antibodies, respectively. Of the IgM-positive donations four tested positive by PCR. A significant association was detected between HEV seroprevalence with age and nationality. CONCLUSION: The seroprevalence of anti-HEV was high in Qatar. Since HEV IgM and RNA were detected, this suggests the possibility of HEV transmission by transfusion. Blood banks in Qatar and the region should consider screening for HEV, especially when transfusion is intended to pregnant women or immunocompromised patients.

Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990-2013: findings from the Global Burden of Disease Study 2013.

OBJECTIVES: We used findings from the Global Burden of Disease Study 2013 to report the burden of musculoskeletal disorders in the Eastern Mediterranean Region (EMR). METHODS: The burden of musculoskeletal disorders was calculated for the EMR's 22 countries between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, death, years of live lost, years lived with disability and disability-adjusted life years (DALYs). RESULTS: For musculoskeletal disorders, the crude DALYs rate per 100 000 increased from 1297.1 (95% uncertainty interval (UI) 924.3-1703.4) in 1990 to 1606.0 (95% UI 1141.2-2130.4) in 2013. During 1990-2013, the total DALYs of musculoskeletal disorders increased by 105.2% in the EMR compared with a 58.0% increase in the rest of the world. The burden of musculoskeletal disorders as a proportion of total DALYs increased from 2.4% (95% UI 1.7-3.0) in 1990 to 4.7% (95% UI 3.6-5.8) in 2013. The range of point prevalence (per 1000) among the EMR countries was 28.2-136.0 for low back pain, 27.3-49.7 for neck pain, 9.7-37.3 for osteoarthritis (OA), 0.6-2.2 for rheumatoid arthritis and 0.1-0.8 for gout. Low back pain and neck pain had the highest burden in EMR countries. CONCLUSIONS: This study shows a high burden of musculoskeletal disorders, with a faster increase in EMR compared with the rest of the world. The reasons for this faster increase need to be explored. Our findings call for incorporating prevention and control programmes that should include improving health data, addressing risk factors, providing evidence-based care and community programmes to increase awareness.

The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013.

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost-YLLs) and nonfatal outcomes (years lived with disability-YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments.

BACKGROUND: Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. METHODS: Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. RESULTS: Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. DISCUSSION: CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Cardiovascular risk factor trends in the Eastern Mediterranean region: evidence from four countries is alarming.

OBJECTIVES: Many Eastern Mediterranean countries are undergoing dramatic socioeconomic, demographic and life style changes and face noncommunicable disease (NCD) epidemics. We evaluated recent trends in major NCD risk factors in occupied Palestinian territories (OPT), Turkey, Syria and Tunisia. METHODS: We searched published and unpublished sources for systolic blood pressure (SBP), diabetes, smoking, body mass index (BMI), and cholesterol trends for both men and women aged 35-84 in each country from 1995 to 2009. RESULTS: Smoking prevalence was stable over time in Tunisia and Syria, but decreasing in Turkey (annual change -0.9%) and OPT (annual change -0.7%). Mean BMI (annual change of 0.1% for Turkey, 0.2% for OPT and Tunisia and 0.3% in Syria) and diabetes (annual change of 0.3% for Turkey, 0.4% for OPT and Tunisia and 0.7% in Syria) prevalence increased in each country. SBP levels increased slightly in Tunisia and Syria but decreased in OPT and Turkey. CONCLUSIONS: Recent risk factor trends are worrying. Good quality data on the extent and determinants of NCDs are essential to respond the changing health needs of populations with burgeoning NCD epidemics.

Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries.

OBJECTIVES: To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. METHODS: A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. RESULTS: Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100% in each country. The top policies were mostly population level interventions and health systems' level policies. CONCLUSIONS: Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed.

Non-communicable diseases in the Arab world.

According to the results of the Global Burden of Disease Study 2010, the burden of non-communicable diseases (cardiovascular disease, cancer, chronic lung diseases, and diabetes) in the Arab world has increased, with variations between countries of different income levels. Behavioural risk factors, including tobacco use, unhealthy diets, and physical inactivity are prevalent, and obesity in adults and children has reached an alarming level. Despite epidemiological evidence, the policy response to non-communicable diseases has been weak. So far, Arab governments have not placed a sufficiently high priority on addressing the high prevalence of non-communicable diseases, with variations in policies between countries and overall weak implementation. Cost-effective and evidence-based prevention and treatment interventions have already been identified. The implementation of these interventions, beginning with immediate action on salt reduction and stricter implementation of tobacco control measures, will address the rise in major risk factors. Implementation of an effective response to the non-communicable-disease crisis will need political commitment, multisectoral action, strengthened health systems, and continuous monitoring and assessment of progress. Arab governments should be held accountable for their UN commitments to address the crisis. Engagement in the global monitoring framework for non-communicable diseases should promote accountability for effective action. The human and economic burden leaves no room for inaction.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries.

BACKGROUND: Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. METHODS AND FINDINGS: Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey. CONCLUSION: Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Tobacco in the Arab world: old and new epidemics amidst policy paralysis.

The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region.

Preventing type 2 diabetes among Palestinians: comparing five future policy scenarios.

OBJECTIVE: This paper aims to provide estimates of future diabetes prevalence in the West Bank, occupied Palestinian territory (oPt), and to compare five future policy scenarios for diabetes prevention. DESIGN: We created and refined a mathematical Markov model that integrates population, obesity and smoking trends to estimate future diabetes prevalence. Model parameters were derived from the literature. Diabetes incidence was estimated using DISMOD software. We developed the model for the Palestinian population based on data available for the period 2000-2010, and validated the model by comparing predicted diabetes prevalence to subsequent actual observed diabetes prevalence rates. SETTING: West Bank oPt. RESULTS: Palestinian diabetes mellitus prevalence estimated by the model (for adults aged 25 or more) was 9.7% in 2000, increasing to 15.3% by 2010. Prevalence in men increased from 9.1% to 16.9% and in women from 10.2% to 13.6%. Comparisons of the model results with the observed prevalence in the Palestinian Family Health Survey showed a close fit. The model forecasts were 20.8% for 2020 and 23.4% for 2030. A 2.8% reduction in diabetes prevalence could be achieved if obesity trends start to decline by 5% in a 5-year period. If obesity prevalence was reduced by 35% in 10 years, as suggested by the WHO, diabetes prevalence might be decreased by 20%. CONCLUSIONS: The model estimates an increase in the prevalence of diabetes which poses a large challenge to the health system. However, if bold but reasonable action is taken, effective interventions could reduce diabetes prevalence and hence the number of patients with diabetes.