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

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

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

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

SARS-CoV-2 seroprevalence in Aden, Yemen: a population-based study.

BACKGROUND: In Yemen, initial surveillance of coronavirus disease 2019 (COVID-19) focused primarily on patients with symptoms or severe disease. The full spectrum of the disease remains unclear. To the best of the authors' knowledge, this is the first seroprevalence study performed in Yemen. METHODS: This cross-sectional investigation included 2001 participants from all age groups from four districts in Aden, southern Yemen. A multi-stage sampling method was used. Data were collected using a well-structured questionnaire, and blood samples were taken. Healgen COVID-19 IgG/IgM Rapid Diagnostic Test (RDT) Cassettes were used in all participants. All positive RDTs and 14% of negative RDTs underwent enzyme-linked immunosorbent assay (ELISA) testing (WANTAI SARS-CoV-2 Ab ELISA Kit) for confirmation. RESULTS: In total, 549 of 2001 participants were RDT positive and confirmed by ELISA, giving a prevalence of COVID-19 of 27.4%. The prevalence of immunoglobulin G was 25%. The prevalence of asymptomatic COVID-19 in the entire study group was 7.9%. The highest prevalence was observed in Al-Mansurah district (33.4%). Regarding sociodemographic factors, the prevalence of COVID-19 was significantly higher among females, housewives and subjects with a history of contact with a COVID-19 patient: 32%, 31% and 39%, respectively. CONCLUSION: This study found high prevalence of COVID-19 in the study population. Household transmission was common.

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

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

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

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

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

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

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

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

Evaluation of a school-based HIV prevention intervention among Yemeni adolescents.

BACKGROUND: This article describes an evaluation of a school-based peer education intervention for HIV prevention among students in twenty seven high schools in Aden, Yemen. The intervention was developed after a survey among the same population in 2005, which revealed a high level of stigma towards people living with HIV (PLWH) and a low level of HIV knowledge. METHODS: In a quasi-experimental design students who received the peer education intervention (78.6%) were compared with students who did not receive the intervention (21.4%). No systematic procedure was applied in selecting students for the intervention condition. Data were collected using a self-administered questionnaire from a sample of 2510 students from all 27 high-schools in Aden governorate. To increase internal validity, students were also compared with a cohort control sample surveyed in 2005, which was a random sample of 2274 students from the same schools. RESULTS: Sixty eight percent of students targeted by peer education had good knowledge scores, compared with 43.3% of students not targeted by peer education (χ(2) = (df = 1) = 111.15, p < .01). Multi-level regression analysis revealed that, although there was a significant difference among schools, the intervention effect of peer education at the individual level was significant; students who received peer education had a statistically higher knowledge score(9.24 out of 12.0) compared with those not targeted (7.89 out of 12.0), OR = 2.11, 95% CI = 1.04-4.27, p < .05). Compared with the 2005 cohort control sample, students targeted by peer education had better knowledge on the modes of transmission and prevention and fewer misconceptions; and knowledge on the use of condoms increased from 49.4% to 67.8%. In addition, students who received the peer education interventions suggested significantly more actions to provide care and support for PLWH. Also, the levels of stigma and discrimination were much higher among the 2005 cohort control group, compared with those who received the peer education intervention. CONCLUSION: The school-based peer education intervention has succeeded in improving levels of knowledge on modes of transmission and prevention, and in decreasing levels of stigma and discrimination in a culturally conservative setting.

Immunization coverage and its determinants among children 12-23 months of age in Aden, Yemen.

OBJECTIVE: To assess the immunization status of children aged 12-23 months and its determinants in Aden, Yemen. METHODS: This cross-sectional survey was conducted between March and July 2007 during which time mothers of 680 children from 37 randomly selected clusters in Aden, were interviewed. Information on socio-demographic profiles and children`s immunization status was obtained. Immunization coverage of all officially provided vaccines was assessed. Analysis of association between immunization coverage and the socio-demographic characteristics were tested using logistic regression analysis with the immunization status as the dependent variable. RESULTS: We found that 83.1% had complete, 10.4% had partial, and 6.5% were never immunized. The immunization card retention rate was 84.9%. The immunization coverage was 92.9% for Bacillus-Calmette-Guerin, 89.6% for Oral Polio Vaccine-3, 86.6% for Diphtheria, Pertusis and Tetanus-3 and Hepatitis-B vaccination, and 89.1% for measles. Multivariate analysis showed that children with an immunization card (odds ratio [OR]=14.71; 95% confidence interval [CI]: 8.50-25.44) were more likely to have complete immunization, while children with older aged mothers (OR=0.41; 95% CI: 0.22-0.77) were more likely to have complete immunization. CONCLUSION: Despite the high immunization coverage, 16.9% of children did not have complete immunization, and this rate was lower among children of older mothers, and those who retained their immunization cards. Raising awareness of immunization and increasing access to health services must be strengthened.

Daytime urinary incontinence among kindergarten children in Aden Governorate, 2003.

Daytime urinary incontinence is an involuntary or intentional voiding of urine in an awake child who is old enough to have developed control, and has a variable prevalence throughout the world. In Yemen, data regarding this problem are almost absent. In this study from the capital city of Aden, we aimed to: (1) determine the prevalence of daytime incontinence in kindergarten children aged 4-6 years, (2) identify the relation between daytime enuresis with personal and family characteristics of the children studied, and (3) describe the severity and characteristics of daytime enuresis in the studied children. A cross-sectional comparative study was undertaken in all kindergarten children aged 4-6 years in Aden Governorate and 1061 responded. Data were obtained by using a precoded self-administered questionnaire completed by the parents. The questionnaire consisted of two parts: personal and family characteristics of the studied children and the presence of daytime incontinence. The second part was responded if there was history of daytime incontinence, and contained information on the severity and possible associated factors. Daytime incontinence was encountered in 34 cases (3.2%); 18 were females. Significant differences between cases and incontinence-free children were encountered in birth order and type of kindergarten (P < 0.05). Majority (85.3%) had severe form of daytime incontinence. Bed wetting and combined day and night wetting were more frequent among males, whereas urinary symptoms (urgency, squatting, dysuria, dribbling) were more frequent among females. Working mother and frightening and emotionally stressful events in the 6 months preceding the study were significantly associated with daytime incontinence, while parents' education, punishment for daytime incontinence, and the presence of family history of incontinence were insignificant. In conclusion, this is the first study from Yemen reporting the prevalence of enuresis, similar to previous reports. Further studies are needed to explore this problem in our region to end the misery of the child and the family.

Five years cancer incidence in Aden Cancer Registry, Yemen (2002-2006).

The population-based Aden Cancer Registry (ACR) started its activities in 1997. The objective of the registry is to establish a reliable magnitude of cancer in the area covered and the first report was published in 2003. The present article describes data from the second report of cancer incidence over a five year period (2002-2006). Internationally accepted standardized cancer registration methodologies described by IACR and IARC were used. CanReg-4 using ICDO-3 and ICD-10 were applied in the data processing and analysis. Results showed no difference in the overall incidence between the males and females (ratio was 0.83:1) and age standardized rate s(ASR) per 100,000 inhabitants were 30.2 and 31.1. The five most common cancers were breast cancer, leukemia, non-Hodgkin's lymphomas (NH lymphoma), brain cancer and Hodgkin's disease (16.6%, 12.6%, 7.8%, 5.2% and 4.4%, respectively). Among males, leukemia was the first followed by NH lymphoma, Hodgkin's disease, brain and liver. In females, breast was the first, then leukemia, NH lymphoma, thyroid and brain cancer. The highest ASR for males (145 per 100,00 inhabitants) was observed at age 70-74 years whereas for females, two peaks (each 105 per 100,000 inhabitants) were equally noticed at age 60-64 and 70-74 years. Generally, females showed equal or higher incidence compared to males until age 55-59 where males reported higher incidence. The overall pattern of cancer incidence in this report is not much different from that in the previous report. Furthermore, the report generally indicates that the pattern of the most common registered cancer bears some similarities with the adjacent Gulf Cooperation Council States with which we share many characteristics, despite differences that warrant further investigation.

Process evaluation of a three-year community-based peer education intervention for HIV prevention among Yemeni young people.

This community process evaluation highlights key enabling factors that facilitated the implementation of a community peer education program for youth HIV prevention in four poor and vulnerable areas of Aden, Yemen. It also explains the implementation process and provides a deeper understanding of the impact evaluation outcomes, which revealed improved HIV knowledge and risk perception and decreased stigma and risky behavior. This process evaluation was based on qualitative methodologies, where five focus group discussions and 15 in-depth interviews were conducted among 52 participants: community peer educators, community focal points, targeted young people, and local councils. The results revealed that contributing factors to implementing the peer education program had been community participation, mobilization of targeted communities, and capacity building of all those included in the intervention. Existing community-based organizations like the Social Service Centre played a key role in building trust with the targeted communities and linking HIV peer education intervention to other existing community services. This process evaluation could provide lessons learned for replicating similar youth peer education programs in conservative communities.

Colorectal cancer among Yemeni patients. Characteristics and trends.

OBJECTIVE: This study aimed to describe the characteristics and trends of colorectal cancer registered in Aden Cancer Registry. METHODS: A retrospective analysis of all registered cancers (1735) was performed at Aden Cancer Center, University of Aden, Aden, Yemen from the years 1997-2001, to describe colorectal cancers with regards to age, sex and residency distribution, subsites and histopathology, and incidence rates. RESULTS: The results indicate that digestive system cancers are the most common cancers (17.1%); and colorectal cancer (28%) is the most common of these. Developing countries characteristics of this cancer are clear. These include a relatively high proportion of early-onset tumor (19.3% of cases were <40 years), and left sided subsite distribution (49.4% of cases were in the rectum and rectosigmoid junction). CONCLUSION: Further analytical studies, to address the community-related risk factors, public education, and screening programs for colorectal cancer are mandatory.

Assessment of the nutritional status of end-stage renal disease patients on maintenance hemodialysis.

We assessed the nutritional status of 50 patients on maintenance hemodialysis by performing anthropometric measurement (pre and post dialytic weight, height, mid-upper arm circumference (MUAC) and related biochemical analysis. The malnutrition score was calculated from the body mass index (BMI), MUAC, hemoglobin, clinical signs of nutritional deficiencies and gastrointestinal manifestations. Stepwise multiple logistic regression analysis was carried out with malnutrition as a dependent variable. There was equal number of men and women in the study with a mean age of 39.5+/-12.1 years. The main cause of renal failure was arterial hypetension (30%), followed by glomerulonephritis (22%). The mean period of hemodialysis was 1.2 +/- 0.9 years. The mean total knowledge score about avoidable food was 2.86+/-1.59 (Total=6) and only 14% have a satisfactory knowledge score. A significant difference between men and women was found in the mean predialytic (52.1+/-9.6 kg) and post dialytic weight (50.0+/-9.7 kg) P< 0.05, while there was insignificant difference in the mean MUAC (22.6+/-3.3 centimeters) and BMI (20.3+/-2.9 kg/meter 2 ). The malnutrition score showed 70% of moderately malnourished patients and 20% severely malnourished. Abnormal biochemical parameters were encountered in the majority of patients. Old age (>/=50 years) was significantly associated with malnutrition. All the patients received only six hours of dialysis a week, which was inadequate dose and had the major impact on the patient's nutritional status. We conclude that poor nutritional status was detected among a significant number of patients with poor dietary knowledge and practices. Increased risk of malnutrition was significantly associated with older age (>/=50 years) and inadequate dialysis dose.