Cancer registration in the Middle East, North Africa, and Turkey (MENAT) region: A tale of conflict, challenges, and opportunities.

Cancer registration is a core component of national and regional cancer control strategies. In the Middle East, North-Africa and Turkey (MENAT) region, capacity and resources for cancer registration is variable and shaped by multiple contextual challenges. This viewpoint maps out practical recommendations around cancer registration, in an attempt to inform cancer control planning, policy, and implementation. The recommendations laid out in this viewpoint are informed by the discussions held at the Initiative for Cancer Registration in the MENAT (ICRIM) virtual workshop, which convened registry managers, policy makers, and international agencies from 19 countries in the MENAT region. The discussions were distilled in four categories of recommendations, revolving around cancer registration procedures, collaborative governance, putting cancer registration on the map, and capacity building. This viewpoint provides a much-needed mapping of practical recommendations around cancer registration, informed by direct key stakeholders in the region. These practical recommendations offer a road map for policy making, cancer control planning, and future regional capacity strengthening initiatives.

Psychosocial determinants of intention to seek palliative care among the public in lebanon: A cross-sectional study.

Objectives: This study aimed to assess the psychosocial determinants of intention to seek palliative care for the client themselves, or intention to enroll a family member in palliative care among the public in Lebanon. Methods: A cross-sectional study was initiated in 2020 on a convenience sample of adults permanently living in the Greater Beirut (GB) area; people with no current or previous experience with palliative care either for themselves or for someone dear to them were included. Verbal consent was obtained before data collection, and participants received a questionnaire to be self-completed, statistical analysis was performed using SPSS statistics version 23.0. Results: A total of 875 participants with a mean age of 42 years were interviewed, of whom 24 participants (2.7%) had had a previous experience with PC, either personally or with someone very close to them. The best-fit multivariate predictive model for intention to use PC included older age, positive attitude, and higher perceived control on one's health. The multivariate model for intention to recommend use was significantly associated with a positive attitude, higher perceived control, and lower perceived barriers. Conclusions: Promotional activities should be conducted to provide the Lebanese public with accurate, detailed, and direct information about the benefits of PC, involving essentially physicians. Future research should explore the decision-making process in "real-time" situations, and within our specific psychosocial, cultural, and organizational context.

Epidemics and local governments in struggling nations: COVID-19 in Lebanon.

Municipalities in Lebanon represent local governments at the basic community level. The proximity of the municipality to the local community and its knowledge of available resources, can be crucial in easing the impact of any disaster. This study aimed to document the range of preparedness/reactivity of municipalities as COVID-19 swept through Lebanon. A qualitative case study was implemented to explore municipal response to control the epidemic, using in-depth semi-structured interviews with twenty-seven stakeholders from nine municipalities across all governorates in Lebanon. In each municipality, participants included mayors/deputy mayors, available members of municipal councils, prominent community leaders, health care professionals, and managers of local NGOs. The collected data were analyzed using the comparative thematic analysis. The socioecological model was adopted to illustrate the dynamic interplay between the barriers and facilitators at all ecological levels. The response to the pandemic differed significantly in volume and nature among different municipalities across regions, with rural areas clearly disadvantaged in terms of adequacy and completeness of response. Barriers consistently mentioned by most municipalities included economic collapse and poverty, shortage in resources, lack of support from the central government, stigma, lack of awareness, underreporting, flaws in the MOPH surveillance system, impeded accessibility to healthcare services, limited number and weak role of municipal police, increased mental illnesses, and political patronage, favoritism, and interference. On the other hand, increased donations, community engagement, social support and empathy, sufficient human resources, the effective role of healthcare systems, and good governance were identified as key facilitators. The socioecological model identified several multi-level facilitators and loopholes which can be addressed through a suggested strategic "roadmap" providing evidence-based interventions for future epidemics. It is crucial meanwhile that the central government strengthens the administrative and financial resources of municipalities in preparing and rapidly deploying the expected optimal response.

Cancer Registration in the Middle East, North Africa, and Turkey: Scope and Challenges.

PURPOSE: National cancer control strategies have been identified as essential tools for reducing and managing the growing burden of cancer in low- and middle-income countries. Cancer registration is an instrumental component of any cancer control strategy, providing the data to inform effective cancer policy. In the Middle East, North Africa, and Turkey (MENAT) region, cancer registration varies immensely and faces multifaceted challenges including protracted conflict. This study investigates and maps out the present capacities and outputs of cancer registration in the MENAT region and identifies thematic barriers facing implementation and utilization of cancer registry data. MATERIALS AND METHODS: We used a self-administered online survey with open and close-ended questions targeting national and institutional cancer registry managers in the MENAT countries. RESULTS: Registry managers from 19 MENAT countries reported the presence of 97 population-based, 48 hospital-based, and 24 pathology-based registries. Most population-based registries were well- or partially developed. Lack of accurate death records, complete medical records, and communication between stakeholders and deficiencies in trained personnel were critical challenges that were more severe in active conflict zones and neighboring conflict-affected regions. Cancer registration challenges included weak health infrastructure, absence of legislation mandating cancer registration, and disruption of cancer registration because of active conflict and loss of funding. Refugee host countries, such as Lebanon, Turkey, and Jordan, also reported conflict-related challenges including refugee mobility and lack of accurate data on forced migrants. CONCLUSION: This study provides a much-needed understanding of the current landscape and contextual challenges affecting cancer registration in the MENAT. These data are important for identifying areas on which to focus regional capacity-strengthening initiatives.

Trends in Breast Cancer Staging at Diagnosis Associated with Screening Campaigns in Lebanon.

Introduction: Mammography screening has been shown to improve early breast cancer (BC) detection, by shifting the disease at diagnosis to locally confined stages, offering lighter treatments and better prognoses. BC awareness campaigns calling for annual mammography screenings have been ongoing in Lebanon since 2002. Changes in BC staging at diagnosis as a consequence of documented improvements in mammography uptake remain to be described. Materials and Methods: We reviewed 2,822 BC cases identified by pathology reports in the American University of Beirut Medical Center between the years 1990 and 2015. After age stratification, we have trended the extracted stages versus time. Results were compared between the prescreening (1990-2001) and the postscreening period (2002-2015). Results: During the postscreening period, stage I represented 31%, stage II 47%, stage III 14%, and stage IV 8% of the cases. Stage I cases had more than doubled whereas stage III cases showed a mirror decrease compared with the years before the implementation of awareness campaigns. The increase in stage I was significantly more prominent in women aged 40 years and older (from 14% to 32%), compared with the younger group. Shifts in staging happened in parallel with a concurrent rise in reported uptake of mammography screening. Conclusions: Our findings demonstrate significant trends in earlier detection, which are likely associated with an increase in screening uptake and an awareness of BC as a public health issue. Staging data from hospitals all over Lebanon should be available for building national evidence. The Ministry of Public Health should require reporting of BC stage at diagnosis to the National Cancer Registry, as part of the annual cancer incidence reporting in Lebanon.

Association between substance use disorders and self- and other-directed aggression: An integrated model approach.

Our study's objective is to determine whether substance use disorders' association with aggression differs according to the type of substance and/or the form of aggression, within the same population. We used data from the National Survey on Drug Use and Health across 2008-2014, with a pooled sample of 270,227 adult respondents. We used regression models to estimate the odds ratios for those having alcohol and/or drug use disorder(s) perpetrating (a) each form of aggression compared with no aggression and (b) other-directed compared with self-directed aggression. Alcohol use disorder alone and drug use disorder(s) alone were both associated with significantly increased odds of committing self-directed, other-directed, and combined aggression. Individuals with drug use disorder(s) alone were more likely to commit other-directed than self-directed aggression (adjusted odds ratio = 1.46, 95% CI = 1.04-2.05). Individuals with alcohol use disorder alone were not likely to commit one over the other (adjusted odds ratio = 1.20, 95% CI = 0.90-1.61). In conclusion, the integrated model of aggression based on the stress-diathesis model is a relevant framework to study risk factors for aggression. Further research is needed to identify longitudinal predictors of directionality of aggression.

Cost of Oncology Drugs in the Middle-Eastern Country of Lebanon: An Update (2014-2016).

PURPOSE: This study aims to evaluate trends in the increasing costs of oncology drugs procured by the Lebanese Ministry of Public Health (MOPH) between 2014 and 2016 and to assess the impact of the introduction in mid-2015 of new immunotherapy drugs for the treatment of lung cancer on the overall and specific costs of that treatment. METHODS: A secondary analysis of data from the MOPH Cancer Drug Scientific Committee data base was conducted using a total of 18,133 cancer files between 2014 and 2016. RESULTS: Over the 3-year period, about $140 million (USD) was spent on cancer drugs by the MOPH free cancer drug dispensing program. The expenditures increased by 27% after immunotherapy was phased in. The average cost of drugs per patient per year measured across all cancer types increased from $7,000 in 2014 to $8,400 in 2016. Trastuzumab, approved for treating human epidermal growth factor receptor 2-positive breast cancer ranked first in total expenditures for 2014-2015. By 2016, two new immunotherapy drugs had topped the list: pembrolizumab ranked first and nivolumab ranked third, representing 64% of the total cost of lung cancer treatment and approximately 19% of the total yearly budget; beneficiaries represented only 3% of all patients. CONCLUSION: This update documents the increasing financial impact of newer cancer drugs on the procurement process in the middle-income country of Lebanon. The trend is aligned with the financial burden of cancer drugs worldwide, which calls for a collaborative global response to this crisis.

Bladder Cancer in Lebanon: Incidence and Comparison to Regional and Western Countries.

Lebanon has one of the highest estimated age-standardized incidence rate (ASR(w)) of bladder cancer (BC) worldwide. The aim of this study is to analyze the incidence rates for BC in Lebanon over a period of 7 years and to compare them to the rates in other countries. Data were obtained from the Lebanese National Cancer Registry for the currently available years 2005 to 2011. The calculated ASR(w) and age-specific rates were expressed as per 100 000 population. From 2005 to 2011, BC has been ranked as the third most common cancer in Lebanon. It accounted for 9.0% of all newly diagnosed cancer cases excluding nonmelanoma skin cancer. It ranked second in males and ninth in females. The average ASR(w) over this period was 31.2 in men and 7.3 in women. These incidence rates are among the highest worldwide across all age groups in both sexes. This study shows that the incidence of BC in Lebanon is high and it is among the highest worldwide. It is important to reduce the risk of BC through tobacco control and by decreasing exposure to avoidable environmental and occupational risk factors.

Geriatric cancer trends in the Middle-East: Findings from Lebanese cancer projections until 2025.

OBJECTIVE: By 2020, 70% of all cancers will occur in patients aged 65years and older, causing an increase in related morbidity, mortality, and cost. This study projects cancer trends in the elderly population in Lebanon, a country experiencing accelerating aging trends. Findings will guide future policy decisions regarding geriatric oncology in Lebanon and the surrounding Arab world. MATERIALS AND METHODS: Cancer incidence rates were derived for men and women 65years and above, divided into three age groups: 65-69years, 70-74years, and 75years and above. Raw data were obtained from the National Cancer Registry reports 2003-2010. The eight consecutive year data were used to project the incidence until 2025 using a logarithmic model. The Average Annual Percent Change in incidence rates was calculated to determine whether it would significantly increase, decrease, or remain stable over time. RESULTS: Incidence rates are projected to increase significantly in all age groups of both genders until 2025. In men, the fastest rise is expected in prostate cancer, followed by bladder, lung, colorectal, and NHL. In women, the rise will be fastest in breast, followed by colorectal, lung, NHL, and ovary. Projected rates increase faster in the "younger" age group 65-69 compared to the "oldest" ≥75, both in men and women. Only kidney and liver cancers continue to rise significantly after 75. CONCLUSIONS: Cancer incidence is projected to increase in individuals between 65 and 74years of age. Lebanese and Middle Eastern physicians must implement adapted therapeutic strategies in the management of the increasing caseload among frail, elderly patients.

Factors associated with waterpipe tobacco smoking among Lebanese women.

Waterpipe tobacco smoking (WTS) has become a serious public health threat in the Middle East and beyond. To estimate the prevalence rates of cigarette and WTS among Lebanese women and describe characteristics associated with each behavior. Secondary analysis of women's health data obtained in a national survey in 2010. Of 2,255 selected women, 78 percent reported no or past long-term WTS. Among the 12 percent of regular waterpipe smokers, 40 percent were light users (mean three waterpipe heads weekly), while 60 percent were heavy users (mean of 11 heads per week). About 70 percent were never or past long-term cigarette smokers. Younger age, location within Greater Beirut (GB) and having professional employment were significantly associated with use of WTS. Older age, GB location, lower education, and ever-married were significantly associated with cigarette smoking. WTS is becoming a socially normative behavior among empowered professional women, who can spare the time and expense to engage in this behavior in easily accessible cafés, which prohibit cigarette smoking. Government, media, and NGO campaigns against smoking should target waterpipe use, not only in Lebanon but also across the Arab world and among Arab communities in the Diaspora with messages different from anti-cigarette campaigns.

Sociological Transition and Breast Cancer in the Arab World: the Experience of Lebanon

Background: Breast cancer is the leading cause of cancer death among females in Lebanon. This study aimed at analyzing its epidemiology in the country over time. Methods: Data were extracted from the Lebanese National Cancer Registry (NCR) for the years 2004 through 2010. Age-standardized and age-specific incidence rates for cancers per 100,000 population were calculated. Results: Breast cancer ranked first, accounting for an average of 37.6% of all new female cancer cases in Lebanon during the period of 2004-2010. Breast cancer was found to have been increasing faster than other hormone-related women's cancers (i.e. of the ovaries and corpus uteri). The breast cancer age-standardized incidence rates (world population) (ASRw) increased steadily from 2004 (71.0) to 2010 (105.9), making the burden comparable to that in developed countries, reflecting the influence of sociological and reproductive patterns transitioning from regional norms to global trends. The age-specific incidence rates for breast cancer rose steeply from around age 35-39 years, to reach a first peak in the age group 45-49 years, and then dropped slightly between 50 and 64 years to rise again thereafter and reach a second peak in the 75+ age group. Five-year age-specific rates among Lebanese women between 35 and 49 years were among the highest observed worldwide in 2008. Conclusion: Breast cancer is continuously on the rise in Lebanon. The findings of this study support the national screening recommendation of starting breast cancer screening at the age of 40 years. It is mandatory to conduct an in-depth analysis of contributing factors and develop consequently a comprehensive National Breast Cancer Control strategy.

Patterns and determinants of mammography screening in Lebanese women.

The associations of ever using and/or repeating a mammography test with psychosocial and socio-demographic factors were surveyed in 2014 among Lebanese women ≥ 40. A sample of 2400 women was selected across Lebanon. Variables with significant bivariate associations with various types of behaviors were entered in multivariate analysis. Of the total, 105 women (4·4%) had never heard of mammography as a tool for early breast cancer detection. Among the remaining 2295, 45% had ever used it, of whom 10% had obtained it for the first time within the 12 months preceding the survey. Repeaters were 67% of 926 women who had the time opportunity to do so (median lifetime frequency: 2). Older age, higher socio-economic status (SES) and living within the Greater Beirut (GB) area were significantly associated with ever-use. Within GB, psychosocial factors such as perceived susceptibility and benefits were most strongly associated with ever-use. Outside GB, socio-economic advantage seemed to mostly affect ever-use. Only 4% reported opposition from husbands to their mammography, and husband's support was significant for adherence to mammography guidelines mostly outside GB. Higher education emerged also as a significant socio-demographic determinant for ever-repeating in all regions. Perceived comfort of the previous test strongly affected the likelihood of repeating it. Providing mammography free-of-charge may alleviate some obstacles among women with socio-economic disadvantage. Stressing that good results one year do not make the cancer less likely or repeating the test less important, as well as improving the comfort of mammography testing could ensure test repeating.

Determinants of the nutritional status of older adults in urban Lebanon.

AIM: To assess the nutritional status, and its association with sociodemographic factors, health and functional status of community-dwelling older adults living in the Greater Beirut area. METHODS: This was a cross-sectional study involving 905 randomly selected community dwelling older adults aged ≥65 years living in Greater Beirut (Beirut and surrounding suburbs). Participants completed a standardized questionnaire on sociodemographic factors, health characteristics, and functional and nutritional status, based on the Mini Nutritional Assessment. RESULTS: Among the older adults who participated in the study, 2.8% (95% CI 0.01-0.03) were malnourished, and 45.5% (95% CI 0.42-0.48) were at risk of malnutrition. Sociodemographic variables were not associated with the nutritional status. Variables significantly associated with poorer nutritional status were: poor perception of general health (OR 1.58, 95%CI 1.28-1.97), more chronic diseases (OR 2.05, 95% CI1.26-3.33), poor perception of oral health (OR 1.36, 95% CI 1.14-1.61), depressive disorders (OR 1.76, 95% CI 1.30-2.40), higher body mass index (OR 1.98, 95% CI1.67-2.34) and disability (OR 5.80, 95% CI 1.96-17.11). CONCLUSIONS: The present study showed an unacceptable risk of malnutrition among Lebanese older adults, independent of age, sex and socioeconomic status. The presence of comorbidities, treated or not, affecting general and oral health emerged as major determinants of poor nutrition. Geriatr Gerontol Int 2017; 17: 424-432.

Aging gracefully in Greater Beirut: are there any gender-based differences?

Background: The implications of rapid aging of the Lebanese population are under-researched. No national studies have so far investigated the living conditions and the health status of urban Lebanese elderly across gender. This was a cross-sectional study involving 905 randomly selected community dwelling elderly aged ≥65 years living in Greater Beirut. Gender differences were assessed among participants who completed a standardized questionnaire on socio-demographic factors, nutritional, health, and functional characteristics. The sample included 533 men (59%) and 372 women (41%). Elderly were regrouped into 'younger elderly' (≤70 years), and 'older elderly' (>70 years) which represented respectively 44.3% and 55.7% of the total population. Women, regardless of their age, were less educated and more likely to live alone. Moreover, poor nutritional status, self-perceived health, absence of physical activity, comorbidity, polymedication and depression were significantly higher among women. 'Older elderly' women became significantly more functionally disabled compared with men of their age. This study evidenced that Lebanese elderly women were disadvantaged regarding their socio-economic, health and functional status. It is requested a nationwide effort to improve the socio-economic status and the health of Lebanese elderly, especially women.

Financial Burden of Cancer Drug Treatment in Lebanon.

BACKGROUND: The Ministry of Public Health (MOPH) in Lebanon provides cancer drugs free of charge for uninsured patients who account for more than half the total caseload. Other categories of cancer care are subsidized under more stringent eligibility criteria. MOPH's large database offers an excellent opportunity to analyze the cost of cancer treatment in Lebanon. MATERIALS AND METHODS: Using utilization and spending data accumulated at MOPH during 20082013, the cost to the public budget of cancer drugs was assessed per case and per drug type. RESULTS: The average annual cost of cancer drugs was 6,475$ per patient. Total cancer drug costs were highest for breast cancer, followed by chronic myeloid leukemia (CML), colorectal cancer, lung cancer, and NonHodgkin's lymphoma (NHL), which together represented 74% of total MOPH cancer drug expenditure. The annual average cancer drug cost per case was highest for CML ($31,037), followed by NHL ($11,566). Trastuzumab represented 26% and Imatinib 15% of total MOPH cancer drug expenditure over six years. CONCLUSIONS: Sustained increase in cancer drug cost threatens the sustainability of MOPH coverage, so crucial for socially vulnerable citizens. To enhance the bargaining position with pharmaceutical firms for drug cost containment in a small market like Lebanon, drug price comparisons with neighboring countries which have already obtained lower prices may succeed in lowering drug costs.

Trends in mammography utilization for breast cancer screening in a Middle-Eastern country: Lebanon 2005-2013.

INTRODUCTION: In Lebanon, annual national breast awareness campaigns were started in 2002 during the international breast month of October to promote the utilization of mammography for women aged ≥ 40. The impact of the campaigns has been assessed periodically since 2003. Results of 2003-2005 campaigns have been published previously. OBJECTIVES: To measure the prevalence of two behavioral outcomes of interest: ever-use of mammography, and repeat mammography in the previous 12 months among ever-users. The prevalence was described by region and age group. The aim was to document the effectiveness of the program towards reaching a nationally defined goal of 80% screening coverage. METHODS: The survey's sampling frame was developed incrementally, and since 2005 it has included women aged ≥ 40 from all areas of Lebanon. The sample size has also increased incrementally from 1200 in 2005 to 2400 in 2013. Results have been tabulated biannually and presented as historical trends with regional and demographic variations covering a 9-year period. RESULTS: In all six consecutive surveys presented here, the mean age of participating women was about 50 years. Year-by-year increases in utilization indicators were detected, with consistent differences in favor of the more urban areas in and around the capital city Beirut and its suburbs (Greater Beirut or GB). By 2013, ever-utilization had reached 43% (41-45) and recent mammography 20% (18-22) nationwide. Utilization was significantly more important in the age group 50-59 compared with the age group 40-49 or ≥ 60. While recent rates have increased nationwide, they have reached a plateau of about 25% in GB and are tending to the same level in other areas. DISCUSSION AND CONCLUSIONS: While initial progress was slow, it has been accelerating in the last 4-5 years, indicating that the message is being accepted by a larger audience of targeted women at each iteration. However, concern remains that women between 40 and 50 and those >60 are not responding as well as desired to the screening message, for reasons currently under investigation.

Screening for cardiovascular risk in asymptomatic users of the primary health care network in Lebanon, 2012-2013.

INTRODUCTION: In 2012, the Ministry of Public Health in Lebanon piloted a service of multifactorial cardiovascular screening in the publicly subsidized Primary Health Care (PHC) Network. We present an epidemiological analysis of data produced during this pilot to justify the inclusion of this service in the package of essential services offered through PHC and to present a preliminary cardiovascular risk profile in an asymptomatic population. METHODS: A total of 4,205 participants (two-thirds of which were women) aged at least 40 years and reportedly free from diabetes, hypertension, dyslipidemia, and cardiovascular disease (CVD) were screened. The screening protocol used a questionnaire and direct measurements to assess 5 modifiable cardiovascular risk factors; total cardiovascular risk score was calculated according to a paper-based algorithm developed by the World Health Organization and the International Society of Hypertension. RESULTS: Approximately 25% of the sample displayed metabolic impairments (11% for impaired blood glucose metabolism and 17% for impaired systolic blood pressure), and 6.6% were classified at total cardiovascular risk of 10% or more. Just over one-quarter of the sample was obese, almost half had a substantially elevated waist circumference, and 41% were smokers. Men were significantly more likely to screen positive for metabolic impairment than women, and women were more likely to be obese. CONCLUSION: The implementation of a multifactorial screening for CVD among asymptomatic subjects detected a substantial proportion of previously undiagnosed cases of high metabolic risk, people who could now be referred to optimal medical follow-up.

What matters in the patients' decision to revisit the same primary care physician?

OBJECTIVE: To assess the priority of various aspects of the patient-primary care physician relationship in the decision to visit again that same physician. STUDY SETTINGS: A total of 400 community residents in Ras Beirut, Lebanon. STUDY DESIGN: A cross-sectional community based study sampled by a nonrandom sex-education quota-based procedure. DATA COLLECTION: Participants were asked to fill a survey where they indicated the ranking of nine items by importance in their decision to revisit the same physician. The nine items were chosen from three categories of factors: professional expertise of the physician; characteristics of the patient-physician relationship, office organization. RESULTS: Having a physician that gives the patient adequate time for discussion prevailed as rank 1 and luxurious clinic ranked as 9th. Affordability was one of the main concerns among men, those with poor health and those of lower socioeconomic status. Accessibility of the physician's phone was considered highly important among women and those of lesser education status. CONCLUSIONS: This study emphasizes the importance of adequate time with the patient, accessibility and affordability of the physician in maintaining continuity of care and patient satisfaction, beyond mere medical expertise.

Barriers to breast cancer screening and treatment among women in Emirate of Abu Dhabi.

OBJECTIVES: The objectives of this study were to explore attitudes and beliefs among major national groups of women resident in the Emirate of Abu Dhabi (EAD) in relation to breast cancer screening and treatment. DESIGN: A qualitative study utilizing age and nationality specific focus group discussions and interviews in all parts of EAD. SETTING: Study was conducted among women living in various areas of EAD during April-September 2009. PARTICIPANTS: A total of 329 participants divided into four nationality groups and categorized into two functional groups (well women and regular screeners) were included in this study and participated in 46 focus groups and 30 personal interviews. RESULTS: Some differences in beliefs, perceptions and opinions related to stated causes of breast cancer, preferences regarding breast care services, financial considerations, trust in health services and cultural attitudes towards breast cancer were observed across nationality and age groups. CONCLUSIONS: New information has been obtained that will shape more focused awareness messages, emphasizing on decreasing fear and shame, discouraging use of cauterization and herbal preparations in delaying care, and activating the role of older female peers in favor of breast screening. Ensuring a sufficient number of trained female health care providers and devising creative approaches to ensure preventive health care costs to reimburse non-nationals are structural changes to the health care system which may further improve breast health for all women in EAD.

Use of herbal medications and their perceived effects among adults in the Greater Beirut area.

OBJECTIVES: To measure the magnitude of use of so-called "herbal medications" with or without prescribed drugs and to assess the benefits and adverse effects perceived by herbal users in the Greater Beirut area. METHODS: A sample survey of 480 adults (18-65) in the Greater Beirut (GB) area was conducted over a one-month period in 2009. RESULTS: The estimated weighted prevalence of herbal use in the previous 12 months in GB was 58.9% (56.7-61.2). Most of the 293 users (72.4%) believed that their use had been of no benefit, but 70% thought use was relatively safe. Of users, 53% were concomitantly using conventional drugs for a chronic condition yet only 45% had thought of informing their physician about herbal use. Among the "concomitant users" 60% had suffered some form of adverse effects. CONCLUSIONS: There is a relatively high prevalence of herbal medicine use in Greater Beirut, with an important rate of self-reported adverse effects, especially among those who suffer chronic conditions, and little exchange of information on this between patients and doctors. Data indicate the need to educate patients about realities associated with abusive use, expected benefits and potential drug-herb interaction. Patients on chronic medications should not be left to actually experience adverse effects in order to discover that herbal medicines are not always effective or innocuous.