Prevalence of benign prostatic hyperplasia among the adult general population of five Middle Eastern Countries: Results of the SNAPSHOT programme.

OBJECTIVES: To present data on the prevalence of benign prostatic hyperplasia (BPH) in five Middle Eastern countries (Egypt, Turkey, Kuwait, Saudi Arabia, and the United Arab Emirates; the latter three forming a Gulf cluster). SUBJECTS AND METHODS: The SNAPSHOT programme was a multi-country, cross-sectional epidemiological survey conducted by telephone in a random sample of the adult general population. Subjects were considered to have BPH if they fulfilled the screening criteria, based on diagnosis, symptoms, and treatments received in the past 12 months. Current prevalence (last 12 months) was estimated. Association with co-morbidities was investigated via multivariate logistic regressions. Quality of life (QoL) was assessed using the three-level EuroQol five-dimensions questionnaire (EQ-5D-3 L). RESULTS: In total, 5034 of 33,486 subjects enrolled in the SNAPSHOT programme were men aged ≥50 years. In all, 998 of these men fulfilled the BPH screening criteria. The overall prevalence of BPH ranged from 13.84% (95% confidence interval[CI] 12.3-15.4%) in Turkey, to 23.76% (95% CI 21.8-25.6%) in Egypt, and 23.79% (95% CI 21.2-26.3%) in the Gulf cluster. Co-morbidities occurred more frequently in men with BPH compared to the non-BPH population (57% vs 31%; P < 0.001). Principal co-morbidities associated with BPH were cardiovascular, renal, and diabetes mellitus (P < 0.001). The men with BPH reported significantly reduced QoL, with lower EQ-5D-3 L utility values (0.8) compared to the male general population (0.9) aged ≥50 years (P < 0.001). CONCLUSION: The prevalence of BPH in these five Middle Eastern countries ranges from 13.84% to 23.79%. BPH has a negative impact on QoL and is associated with high levels of co-morbid diseases, indicating a need to better understand the management of the disease to reduce the impact on healthcare systems.

The clinical burden of allergic rhinitis in five Middle Eastern countries: results of the SNAPSHOT program.

BACKGROUND: The SNAPSHOT program provides current data on the allergic rhinitis burden in the adult general population of five Middle Eastern countries (Egypt, Turkey, Kuwait, Saudi Arabia and the United Arab Emirates, the latter three grouped into a Gulf cluster). METHODS: A multi-country, cross-sectional, epidemiological program conducted by telephone in a random sample of the adult general population; quotas were defined per country demographics. Subjects were screened for allergic rhinitis using the Score For Allergic Rhinitis questionnaire. Current prevalence (last 12 months) was estimated. Disease severity and control were assessed using the Allergic Rhinitis and its Impact on Asthma classification and Rhinitis Control Assessment Test respectively. Quality of sleep, impact on daily activities and quality of life were measured using the Epworth Sleepiness Scale, Sheehan Disability Scale and EuroQol Five-Dimension questionnaire respectively. Multivariate logistic regression analyses were used to investigate risk factors and co-morbidities. RESULTS: 1808 of 33,486 subjects enrolled in the SNAPSHOT program fulfilled the case definition for allergic rhinitis. Prevalence was 3.6% [95% CI 3.2-4.0%] in Egypt, 6.4% [95% CI 5.9-6.9%] in Turkey and 6.4% [95% CI 6.0-6.9%] in the Gulf cluster. Risk factors identified were country, co-morbid asthma and income. Subjects with allergic rhinitis reported a significantly lower quality of life compared to the general population (p < 0.0001). Overall, 55% of allergic rhinitis subjects were moderate/severe and 33% were uncontrolled. Both these groups reported impaired quality of life and quality of sleep and increased impairment of daily activities compared to mild/well-controlled subjects (p < 0.0001). CONCLUSIONS: Although the observed prevalence of allergic rhinitis in these Middle Eastern countries is low compared to western countries, its burden is considerable. Allergic rhinitis in general, and specifically uncontrolled and severe disease, results in a negative impact on quality of life, quality of sleep and daily activities.

Burden of disease associated with asthma among the adult general population of five Middle Eastern countries: Results of the SNAPSHOT program.

BACKGROUND: Asthma affects millions worldwide resulting in a significant disease burden. However, data on asthma burden from the Middle East is limited. This analysis describes the asthma burden in Egypt, Turkey and a Gulf cluster (Kuwait, Saudi Arabia and United Arab Emirates) as part of the SNAPSHOT program. METHODS: SNAPSHOT was an observational, cross-sectional program carried out by telephone in a random sample of the adult general population of the five above mentioned countries. Quotas were defined per country demographics. Subjects were considered to have asthma if they fulfilled the screening criteria, based on the global Asthma Insights and Reality studies. Data collected included demographics, physician consultations, and asthma control (measured by the Asthma Control Test; ACT). Quality of life was assessed using the EuroQol Five-Dimension questionnaire (EQ-5D); and limitations to daily activities using the modified Sheehan Disability Scale (SDS). RESULTS: 939 subjects answered questions related to asthma burden. Overall, 367 (44.2%) reported uncontrolled asthma (ACT≤19), and reported significantly lower EQ-5D-3L utility values (0.6 ±â€¯0.4) and EQ-VAS scores (60.7 ±â€¯24.2) compared to controlled subjects (0.8 ±â€¯0.3 and 75.3 ±â€¯19.8 respectively) (p < 0.0001). A significantly higher proportion with uncontrolled asthma also reported experiencing impact on activities of daily living compared to subjects with controlled asthma (p < 0.0001). Overall, 355 (37.8%) asthma subjects were followed by a physician. However, most visits were unscheduled (695;78.0%). CONCLUSION: Uncontrolled asthma imposes a significant burden in these Middle Eastern countries resulting in increased frequency of healthcare use, lower quality of life, and a higher impact on daily life compared to controlled asthma.

Adherence to COPD treatment in Turkey and Saudi Arabia: results of the ADCARE study.

BACKGROUND: COPD affects millions of people worldwide. Poor treatment adherence contributes to increased symptom severity, morbidity and mortality. This study was designed to investigate adherence to COPD treatment in Turkey and Saudi Arabia. METHODS: An observational, cross-sectional study in adult COPD patients in Turkey and Saudi Arabia. Through physician-led interviews, data were collected on sociodemographics and disease history, including the impact of COPD on health status using the COPD Assessment Test (CAT); quality of life, using the EuroQol Five-Dimension questionnaire (EQ-5D); and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Treatment adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Multivariate logistic regression analysis examined the predictors of non-adherence and the impact of adherence on symptom severity. RESULTS: Four hundred and five COPD patients participated: 199 in Turkey and 206 in Saudi Arabia. Overall, 49.2% reported low adherence (MMAS-8 <6). Of those, 74.7% reported high disease impact (CAT >15) compared to 58.4% reporting medium/high adherence (p=0.0008). Patients with low adherence reported a lower mean 3-level EQ-5D utility value (0.54±0.35) compared to those with medium/high adherence (0.64±0.30; p<0.0001). Depression with HADS score 8-10 or >10 was associated with lower adherence (OR 2.50 [95% CI: 1.43-4.39] and 2.43 [95% CI: 1.39-4.25], respectively; p=0.0008). Being a high school/college graduate was associated with better adherence compared with no high school (OR 0.57 [95% CI: 0.33-0.98] and 0.38 [95% CI: 0.15-1.00], respectively; p=0.0310). After adjusting for age, gender, and country, a significant association between treatment adherence (MMAS-8 score ≥6) and lower disease impact (CAT ≤15) was observed (OR 0.56 [95% CI: 0.33-0.95]; p=0.0314). CONCLUSION: Adherence to COPD treatment is poor in Turkey and Saudi Arabia. Non-adherence to treatment is associated with higher disease impact and reduced quality of life. Depression, age, and level of education were independent determinants of adherence.

Prevalence of asthma among the adult general population of five Middle Eastern countries: results of the SNAPSHOT program.

BACKGROUND: Asthma is a common chronic respiratory disease leading to morbidity, mortality and impaired quality of life worldwide. Information on asthma prevalence in the Middle East is fragmented and relatively out-dated. The SNAPSHOT program was conducted to obtain updated information. METHODS: SNAPSHOT is a cross-sectional epidemiological program carried out in five Middle Eastern countries (Egypt, Turkey, Kuwait, Saudi Arabia, and the United Arab Emirates, the latter three grouped into a Gulf cluster) to collect data on asthma, allergic rhinitis, benign prostatic hyperplasia and bipolar disorder. The survey was carried out by telephone in a random sample of the adult general population with quotas defined according to country demographics. The analysis presented in this paper focuses on asthma. Subjects were screened for asthma based on criteria from the global Asthma Insights and Reality studies. Current prevalence (last 12 months) was estimated. Multivariate logistic regression analyses were used to investigate risk factors related to asthma and the association with allergic rhinitis and other co-morbidities. Quality of life was assessed using the three-level EQ-5D questionnaire. RESULTS: 2124 out of the 33,486 subjects enrolled in the SNAPSHOT program fulfilled the criteria for asthma. The adjusted prevalence of asthma ranged from 4.4% [95% CI: 4.0-4.8%] in Turkey, to 6.7% [95% CI: 6.2-7.2%] in Egypt and 7.6% [95% CI: 7.1-8.0%] in the Gulf cluster. Prevalence was higher (p < 0.0001) in women than men and increased with age (p < 0.0001). Co-morbidities occurred more frequently in asthma subjects compared to the non-asthma population (38% vs. 15% p < 0.0001). Subjects with asthma reported a lower (p < 0.0001) EQ-VAS score (68.2 ± 22.9) compared to the general population (78.1 ± 17.5). The risk factors associated with asthma were age, gender, country, and certain co-morbidities, namely respiratory, cardiovascular, gastrointestinal, nervous, and neurological diseases. CONCLUSION: The observed adjusted prevalence of asthma in the Middle East ranges from 4.4% to 7.6%, which is comparatively lower than the reported prevalence in Europe and North America. Asthma has a negative impact on quality of life, and is associated with high levels of co-morbid diseases, indicating a need for physicians to check for co-morbidities and ensure they are managed correctly in all asthma patients.

Waterpipe Use in the Middle East and North Africa: Data From the Breathe Study.

INTRODUCTION: In recent decades, waterpipe use has gained popularity, notably in the Middle East and North Africa (MENA) region. This study describes waterpipe use and characteristics of waterpipe users among the general population of the MENA region. METHODS: This study was a sub-analysis of the BREATHE study, a cross-sectional survey of chronic obstructive respiratory disease conducted in the general population of 11 countries of the MENA region. The study population consisted of subjects aged ≥40 years who completed the screening questionnaire and who reported waterpipe use (alone or with cigarettes). This questionnaire collected data on demographics, self-reported respiratory symptoms (breathlessness and productive cough), smoking habits (cigarettes or waterpipe) and diagnosis of chronic obstructive respiratory disease, chronic bronchitis or emphysema. RESULTS: Of the 62 086 subjects screened in the BREATHE study, waterpipe use was reported by 2173 subjects (3.5% [95% CI: 3.4%-3.6%]), of whom 934 subjects (43.0%) smoked both waterpipes and cigarettes. The majority of waterpipe users were men (82%) and aged from 40 to 49 years (53.7%). Over 90% of users smoked their waterpipe for ≥1 hour per day. Waterpipe use was associated with an increased risk of productive cough (odds ratio [OR]: 1.49), breathlessness (OR: 1.33), and chronic bronchitis (OR: 1.43), independently of the risk associated with cigarette smoking. In subjects using waterpipe alone (N = 1239), breathlessness was the most frequently self-reported symptom (11.3%), followed by productive cough (6.0%) and chronic bronchitis (2.2%). CONCLUSIONS: Waterpipe smoking in the region is widespread and is associated with an increased risk of respiratory pathology independently of cigarette smoking. IMPLICATIONS: This large general population study reports an elevated risk of respiratory disease associated with waterpipe use independently of cigarette smoking; this finding emphasizes the need for public health policies to curtail the growing spread of waterpipe use by young people in the MENA region.

Comorbidities associated with COPD in the Middle East and North Africa region: association with severity and exacerbations.

OBJECTIVE: To assess the frequency of comorbidities in subjects with COPD and their association with respiratory symptom severity and COPD exacerbations. MATERIALS AND METHODS: This was an analysis of the BREATHE study, a cross-sectional survey of COPD conducted in the general population of eleven countries in the Middle East and North Africa, including Pakistan. The study population consisted of a sample of subjects with COPD for whom the presence of comorbidities was documented. Three questionnaires were used. The screening questionnaire identified subjects who fulfilled an epidemiological case definition of COPD and documented any potential comorbidities; the detailed COPD questionnaire collected data on respiratory symptoms, COPD exacerbations, and comorbidities associated with COPD; the COPD Assessment Test collected data on the impact of respiratory symptoms on well-being and daily life. RESULTS: A total of 2,187 subjects were positively screened for COPD, of whom 1,392 completed the detailed COPD questionnaire. COPD subjects were more likely to report comorbidities (55.2%) than subjects without COPD (39.1%, P<0.0001), most frequently cardiovascular diseases. In subjects who screened positively for COPD, the presence of comorbidities was significantly (P=0.03) associated with a COPD Assessment Test score ≥10 and with antecedents of COPD exacerbations in the previous 6 months (P=0.03). CONCLUSION: Comorbidities are frequent in COPD and associated with more severe respiratory symptoms. This highlights the importance of identification and appropriate management of comorbidities in all subjects with a diagnosis of COPD.

Distribution of body mass index among subjects with COPD in the Middle East and North Africa region: data from the BREATHE study.

BACKGROUND: Data describing the potential relationship between chronic obstructive pulmonary disease (COPD) and body mass index (BMI) are limited within the Middle East and North Africa (MENA) region. OBJECTIVE: To evaluate the distribution of BMI among subjects with COPD in the general population of the MENA region. METHODS: This study was a subanalysis of the BREATHE study, a cross-sectional survey of COPD conducted in the general population of ten countries in the MENA region and Pakistan. The study population consisted of subjects screened for COPD who documented their weight and height. A COPD questionnaire was administered to subjects who screened positively for COPD in order to collect data on patient characteristics, symptom severity, management and burden of disease, comorbidities, and health care resource utilization and data allowing calculation of the BMI. The COPD Assessment Test (CAT) was administered to those screened positively for COPD to collect data on the impact of respiratory symptoms. RESULTS: Nine hundred and ninety-six subjects with COPD, who completed the detailed COPD questionnaire and documented their weight and height, were included in this analysis. The mean BMI was 27.7±5.7 kg/m(2). The proportion of COPD patients with a BMI ≥25 kg/m(2) is significantly higher than the proportion with a BMI <25 kg/m(2) (64.6% [n=643] vs 35.4% [n=353], respectively; P<0.0001). There were no significant differences between the distribution of BMI, ages, sex, COPD symptoms, exacerbations, CAT scores, COPD-associated health care resource consumption, and GOLD severity groups. However, the occurrence of comorbidities such as diabetes and cardiovascular diseases seemed to be significantly associated with obese or morbidly obese status (P=0.02). CONCLUSION: In the MENA region, the majority of COPD subjects were overweight or obese, and comorbidities such as diabetes or cardiovascular diseases are likely to be associated with COPD when BMI is in the obese or morbidly obese ranges.

Illness perception of migraineurs from the general population.

OBJECTIVE: This study aims to describe the cognitive representations of migraine through the migraineurs' discourse. METHOD: A sample of subjects taken at random from a representative sample of the French general population is interviewed about their representations of migraine. A content analysis is performed using the ALCESTE software. RESULTS: The population is composed of 51 subjects. The analysis shows that throughout the corpus, the word 'migraine' does not appear spontaneously. It seems that migraine as a chronic disease that may require long-term treatment is not well understood; people have rather a 'successive crises' representation of illness. In reaction to the crises, it is surprising not to find any clue evoking the field of catastrophsising. However, the cognitive coping strategy of resignation is to be found. The favourite interlocutor to start therapeutic education of the patient is the doctor since subjects say that they do not expect anything of the kind from the media. CONCLUSION: The results allow us to understand better why migraineurs do not consult for their illness and do not follow recommendations concerning treatments utilisation. The results allow to propose interventions that include patient education taking into account patients' cognitive representations of their illness.

Smoking habits in the Middle East and North Africa: results of the BREATHE study.

Few recent comparative data exist on smoking habits in the Middle East and North Africa (MENA) region. The objective of this analysis was to evaluate smoking patterns in a large general population sample of individuals aged ≥ 40 years in ten countries in the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was generated and called. This identified 65,154 eligible subjects, of whom 62,086 agreed to participate. A screening questionnaire was administered to each participant, which included six questions relating to cigarette consumption and waterpipe use. The age- and gender-adjusted proportion of respondents reporting current or past smoking of cigarettes or waterpipes was 31.2% [95% CI: 30.9-31.6%]. This proportion was significantly higher (p < 0.001) in men (48.0%) than in women (13.8%), but no relevant differences were observed between age groups. Smoking rates were in general lowest in the Maghreb countries and Pakistan and highest in the Eastern Mediterranean countries, ranging from 15.3% in Morocco to 53.9% in Lebanon. Consumption rates were 28.8% [28.4-29.2%] for cigarette smoking and 3.5% [3.4-3.6%] for waterpipe use. Use of waterpipes was most frequent in Saudi Arabia (8.5% of respondents) but remained low in the Maghreb countries (< 1.5%). Cumulative cigarette exposure was high, with a mean number of pack · years smoked of 18.5 ± 20.5 for women and 29.1 ± 26.2 for men. In conclusion, smoking is a major health issue in the MENA region.

Distribution of COPD-related symptoms in the Middle East and North Africa: results of the BREATHE study.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. However, its epidemiology in many developing countries is poorly characterised. The objective of this analysis was to evaluate respiratory symptoms which could be COPD-related in a large sample of individuals aged ≥ 40 years in ten countries in the Middle East and North Africa (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was contacted. A screening questionnaire was administered to each eligible participant, which included six questions relating to respiratory symptoms. Of 65,154 eligible subjects, 62,086 agreed to participate and 61,551 provided usable data. The age- and gender-adjusted prevalence of symptoms (persistent productive cough or breathlessness or both) was 14.3% [95% CI: 14.0-14.6%], ranging from 7.2% in UAE to 19.1% in Algeria. Symptoms were more frequent (p < 0.0001) in women (16.7%) than in men (12.2%). The adjusted prevalence of COPD according to the "epidemiological" definition (symptoms or diagnosis and cigarette use ≥ 10 pack · years) was 3.6% [95% CI: 3.5-3.7%] (range: 1.9% in UAE to 6.1% in Syria). COPD was more frequent (p < 0.0001) in men (5.2%) than in women (1.8%). The frequency of symptoms was significantly higher in cigarette smokers (p< 0.001), as well as in waterpipe users (p < 0.026). In conclusion, the prevalence of COPD in this region seems to be lower than that reported in industrialised countries. Under-reporting and risk factors other than smoking may contribute to this difference.

Management of chronic obstructive pulmonary disease in the Middle East and North Africa: results of the BREATHE study.

Chronic obstructive pulmonary disease (COPD) is a potentially severe chronic progressive respiratory condition requiring long-term treatment and frequently involving episodic hospitalisations to manage exacerbations. The objective of this analysis was to document diagnosis, evaluation, treatment and management of COPD-related respiratory symptoms in 1,392 subjects fulfilling an epidemiological definition of COPD identified in a general population sample of 62,086 individuals aged ≥ 40 years in ten countries in the Middle East and North Africa region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan. 442 subjects (31.8%) claimed to have received a diagnosis of COPD from a physician and 287 (20.6%) had undergone spirometry in the previous year. Use of specific treatments for respiratory symptoms was reported by 218 subjects (15.7%). Use of inhaled long-acting bronchodilators together with corticosteroids (53 subjects; 3.8%) and use of oxygen therapy (31 subjects; 2.3%) was very low. 852 subjects (61.2%) had consulted a physician about their respiratory condition at least once in the previous year, with a mean number of consultations of 3.4 ± 3.6. Moreover, 284 subjects (20.4%) had been hospitalised overnight for their COPD, with a mean of 2.3 ± 3.7 hospitalisations per year. Use of all healthcare resources was significantly higher (p < 0.001) in subjects with CAT scores ≥ 10 than in those with scores < 10, and greater in those with exacerbations than in those without. In conclusion, COPD in the region is under-diagnosed, inadequately evaluated and inadequately treated. Nonetheless, COPD symptoms are responsible for considerable healthcare consumption, with high levels of physician consultation and hospitalisation.

The burden of chronic obstructive pulmonary disease in the Middle East and North Africa: results of the BREATHE study.

COPD is a progressive pulmonary disease which may have a profound impact on general health status and quality of life. This article presents data on the burden of COPD obtained from the BREATHE study in the Middle East, North Africa and Pakistan. This study was a large general population survey of COPD conducted in eleven countries of the region using a standardised methodology. A total of 62,086 subjects were screened, of whom 2,187 fulfilled the "epidemiological" definition of COPD. Data on symptoms, perceived disease severity, impact on work, limitations in activities and psychological distress were collected. 1,392 subjects were analysable of whom 661 (47.5%) reported experiencing an exacerbation of their respiratory condition, 49.4% reported comorbidities and 5.5% reported severe breathlessness as measured with the MRC breathlessness questionnaire. The degree of breathlessness, as well as the perceived severity, was correlated with the overall disease impact as measured with the COPD Assessment Test (p < 0.001). 374 subjects (28.4%) reported that their respiratory condition prevented them from working and this proportion rose to 47.8% in subjects who perceived their respiratory condition as severe. 47.9% of subjects reported difficulties in normal physical exertion, 37.5% in social activities and 31.7% in family activities. Psychological distress was reported by between 42.3% and 53.2% of subjects, depending on the item. In conclusion, the burden of COPD is important, and covers central aspects of daily life. For this reason, physicians should take time to discuss it with their patients, and ensure that the management strategy proposed addresses all their needs.

Chronic obstructive pulmonary disease in the adult population within the Middle East and North Africa region: rationale and design of the BREATHE study.

The objective of the BREATHE study was to estimate the regional prevalence of chronic obstructive pulmonary disease (COPD) symptoms within the general population in the Middle East/North Africa (MENA) region and to document risk factors, disease characteristics and management using a standardised methodology. This was an observational population-based survey performed in ten countries in the Middle East and North Africa (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan. A general population sample of 10,000 subjects ≥ 40 years of age in each country or zone was generated from random telephone numbers. Structured interviews were proposed by telephone. A screening questionnaire was administered to each subject collecting information on respiratory symptoms and smoking habits. Subjects with chronic bronchitis or breathlessness and smoking ≥ 10 pack · years fulfilled the epidemiological definition of COPD ("COPD" population). This population then completed a full disease questionnaire, the COPD Assessment Test (CAT) and a cost-of-disease questionnaire. A randomly selected sample was also assessed by spirometry. In all, 457,258 telephone numbers were generated and contact was established with 210,121 subjects, of whom 65,154 were eligible and 62,086 accepted to participate. The overall response rate was 74.2%. 2,187 (3.5%) subjects fulfilled the criteria for the "COPD" population. Evaluable spirometry data were obtained from 1,847 (14.2%) subjects to whom it was proposed. The BREATHE study has collected a large amount of information on COPD variables from a representative sample of the general population of countries in the MENA region, which can be compared with other regional COPD initiatives.

Attitudes and beliefs about COPD: data from the BREATHE study.

Although COPD is a debilitating pulmonary condition, many studies have shown awareness of the disease to be low. This article presents data on attitudes and beliefs about COPD in subjects with respiratory symptoms participating in the BREATHE study in the Middle East and North Africa region. This study was a large general population survey of COPD conducted in ten countries of the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A total of 62,086 subjects were screened, of whom 2,187 fulfilled the "epidemiological" definition of COPD. A detailed questionnaire was administered to these subjects, which documented knowledge about the disease, attitudes to care, beliefs about COPD and satisfaction with treatment. 1,392 subjects were analysable. Overall, 58.6% of subjects claimed to be very well or adequately informed about their respiratory condition. Two-thirds of subjects reported receiving information about COPD from their physician and 10.6% from television; the internet was cited by 6% and other health professionals or patient associations by < 1%. Several inappropriate beliefs were identified, with 38.9% of respondents believing that there were no truly effective treatments, 73.7% believing that their respiratory condition would get progressively worse regardless of treatment and 29.6% being unsure what had caused their respiratory problems. Although 81% of respondents believed that smoking was the cause of most cases of COPD in general, only 51% accepted that it was the cause of their own respiratory problems. Treatment satisfaction was relatively high, with 83.2% of respondents somewhat or very satisfied with their physician's management, in spite of the fact that only 47.5% considered that their physician's advice had helped them manage their respiratory symptoms a lot. In conclusion, awareness of COPD in the region is suboptimal and treatment expectations are undervalued. Better patient education and more effective patient-physician communication are clearly required.

Psychometric evaluation of the COPD assessment test: data from the BREATHE study in the Middle East and North Africa region.

The objective of this study was to assess the validity and performance of the Arabic and Turkish versions of the COPD Assessment Test (CAT) for evaluating the severity and impact of COPD symptoms. The data were obtained from the BREATHE study in the Middle East and North Africa region, a large general population survey of COPD conducted in ten countries of the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), using a standardised methodology. A total of 62,086 subjects were screened, of whom a random sample of 5,681 subjects were administered the CAT by telephone. 5,639 evaluable questionnaires were recovered, representing a completion rate of 99%. In addition, the CAT was administered to an additional 833 subjects fulfilling the epidemiological diagnostic criteria for COPD. Mean scores in the general population were 6.99 ± 6.91 for the Arabic version and 9.88 ± 9.04 for the Turkish version. In patients with COPD, mean scores were 16.2 ± 9.1 and 20.9 ± 10.2 respectively. Scores were consistently higher in smokers than in non-smokers. In the general population, the proportion of respondents fulfilling criteria for COPD rose with higher CAT scores, and particularly above the 80th percentile, where 63% of COPD cases were to be found. This suggests that the CAT may be useful as a case-finding tool in the general population. In the COPD population, healthcare resource consumption rose linearly with CAT score above a threshold score of twenty, arguing in favour of the good criterion validity of the CAT. The internal consistency of the CAT was high (Cronbach's α 0.85 for the Arabic and 0.86 for the Turkish versions) and the factorial structure was unidimensional. In conclusion, this study performed in Arabic and Turkish speaking populations confirms the utility and validity of the CAT as a simple tool to collect data on the severity and impact of COPD symptoms, and suggests that it may potentially be useful as a case-finding tool to identify people at risk for COPD in the general population.

Chronic obstructive pulmonary disease and associated healthcare resource consumption in the Middle East and North Africa: the BREATHE study.

Data on COPD-related healthcare resources use are rarely documented in developing countries. This article presents data on COPD-related healthcare resource consumption in the Middle East, North Africa and Pakistan and addresses the association of this variable with illness severity. A large survey of COPD was conducted in eleven countries of the region, namely Algeria, Egypt, Jordan, Lebanon, Morocco, Pakistan, Saudi-Arabia, Syria, Tunisia, Turkey and United Arab Emirates, using a standardised methodology. A total of 62,086 subjects were screened. This identified 2,187 subjects fulfilling the "epidemiological" definition of COPD. A detailed questionnaire was administered to document data on COPD-related healthcare consumption. Symptom severity was assessed using the COPD Assessment Test (CAT). 1,392 subjects were analysable. Physician consultations were the most frequently used healthcare resource, ranging from 43,118 [95% CI: 755-85,548] consultations in UAE to 4,276,800 [95% CI: 2,320,164-6,230,763] in Pakistan, followed by emergency room visits, ranging from 15,917 [95% CI: 0-34,807] visits in UAE to 683,697 [95% CI: 496,993-869,737] in Turkey and hospitalisations, ranging from 15,563 [95% CI: 7,911-23,215] in UAE to 476,674 [95% CI: 301,258-652,090] in Turkey. The use of each resource increased proportionally with the GOLD 2011 severity groups and was significantly (p < 0.0001) higher in subjects with more symptoms compared to those with lower symptoms and in subjects with exacerbations to those without exacerbations. The occurrence of exacerbations and the CAT score were independently associated with use of each healthcare resource. In conclusion, the BREATHE study revealed that physician consultation is the most frequently COPD-related healthcare resource used in the region. It showed that the deterioration of COPD symptoms and the frequency of exacerbations raised healthcare resource consumption.

Public health impact of human papillomavirus vaccination on prevention of cervical cancer in France.

OBJECTIVE: To evaluate the cervical cancer (CC) reduction at individual and population level following different prevention strategies (age-specific vaccination and/or screening) in France. METHODS: A lifetime Markov model was constructed with 11 health states covering the progression from human papillomavirus (HPV) infection to the development of precancerous lesions, CC and death. A screening module took into account the effects of detection and early treatment. Cohorts of girls were entered into the model at age 11 years; the model was run for 95 years using one-year cycles. RESULTS: Vaccination combined with screening substantially reduced the incidence of precancerous lesions and CC compared with screening alone. Vaccination was beneficial regardless of age at vaccination, but the greatest benefit was obtained with an early vaccination. The clinical results were the best for vaccination at 11-13 years when lifetime horizon was considered, and for vaccination at 15-17 years for shorter observation period. CONCLUSION: The model results indicate that HPV vaccination offers additional protection against CC when combined with screening. The optimum starting age for vaccination varies depending on the observation period duration.

A generally applicable cost-effectiveness model for the evaluation of vaccines against cervical cancer.

OBJECTIVE: This study aimed at evaluating the cost-effectiveness of human papillomavirus virus (HPV) vaccination in France, using a generally applicable succinct cohort model. METHODS: A lifetime Markov cohort model, adapted to the French setting, simulate the natural history of oncogenic HPV infection towards cervical cancer (CC). Additional modules account for the effects of screening and vaccination. The girls' cohort is vaccinated at age 12 and follows current screening. Costs and outcomes (discounted at 3 and 1.5%, respectively) were compared with a cohort receiving screening alone. RESULTS: The model results agreed well with real-life data. Vaccination in addition to screening would substantially reduce the incidence of and mortality from CC, compared with screening alone, at an estimated cost-effectiveness of 9,706 per quality-adjusted-life-year. Sensitivity analysis showed that the discount rate and the parameters related to the disease history have the largest impact on the results. CONCLUSION: This succinct cohort model indicated that HPV vaccination would be a cost-effective policy option in France. It uses readily available data and should be generally applicable to the evaluation of HPV vaccination in a variety of countries and settings.

Asthma patients' perception of their ability to influence disease control and management.

BACKGROUND: Patients' perception of their ability to influence their asthma symptoms has not been sufficiently addressed. OBJECTIVE: To study the relationship between patients' perceived ability to self-care, as approached by internal locus of control (LOC) orientation, and concomitant level of asthma control. METHODS: A cross-sectional study was conducted from May 19, 2004, through July 7, 2005. Asthma patients receiving inhaled corticosteroids and supervised in primary care were identified. Asthma control was measured with the Asthma Control Test. Patients reported their LOC orientation on a 100-mm visual analog scale (0%, "I have absolutely no influence on asthma change," to 100%, "this change only depends on me"). Asthma therapy was obtained from a prescription database. The risk of an internal LOC of less than 50% was studied. RESULTS: Among the 163 patients with documented LOC (mean age, 52 years; 58% female), 72 (44.2%) had an internal LOC of less than 50%. Asthma control was inadequate for 65 of the 157 patients with available data on the global score of the Asthma Control Test (41.4%). Patients with inadequately controlled asthma had a higher risk of a LOC of less than 50% (odds ratio, 2.68; 95% confidence interval, 1.23-5.81). A 3-fold increased risk also appeared for patients older than 65 years compared with those younger than 45 years. Conversely, no association was identified with sex, asthma severity markers, or therapy. CONCLUSIONS: Asthma control was related to internal LOC orientation (ie, perceived ability to self-care). Improved self-care efficiency is a target for adequate disease management.