Epidemiology of infantile hydrocephalus in Saudi Arabia: birth prevalence and associated factors.

INTRODUCTION: Hydrocephalus is a common central nervous system disorder in children. In spite of its importance, it has not been subjected to sufficient epidemiological studies, particularly in the developing countries. The aim of this study was to provide information from a representative series of newly diagnosed cases of infantile hydrocephalus on the birth prevalence, associated factors and mortality. METHODOLOGY: A prospective study was conducted over a 1-year period from April 1996 to March 1997 in the city of Al-Madinah Al-Munawarah, Saudi Arabia. Except for neural tube defects and brain tumors, all cases of hydrocephalus diagnosed within the first 28 days of life were included. A control group of 104 subjects was studied for comparison. Information about antenatal, natal and early postnatal periods were obtained by interviewing the mothers of the newborns. RESULTS: During the study period, 26 cases of infantile hydrocephalus were detected. The birth prevalence was 1. 6 per 1,000 live births. There was no sex preponderance as the male to female ratio was 1.2:1. Multiple pregnancies were detected in 21 (81%) cases. Nineteen (73%) cases were the product of consanguineous parent and 4 patients had a positive family history of hydrocephalus. The number of preterm infants was 16 (62%). The number of low birth weights (less than 2,500 g) was 18 (69%). An Apgar score of less than 8 occurred in 18 (69%) cases. The mode of delivery was vaginal in 15 (58%) women. The 6 months mortality rate was 23% (6 infants). CONCLUSION: The birth prevalence of infantile hydrocephalus in this study was significantly higher than in the developed countries. A positive family history of hydrocephalus, low birth weight, low Apgar score and abdominal delivery were found to be associated factors. The mortality rate in the first 6 months of life was significantly higher in hydrocephalus infants than in controls.

Appraisal of clinical, psychosocial, and environmental health of elderly in Saudi Arabia: a household survey.

This was a cross-sectional national survey of the elderly population of Saudi Arabia conducted between January 1994 and December 1995. The participants' physical, mental, social, and environmental health status were assessed in a personal interview during which a structured data form was completed by a trained research team. Data on 6,139 elderly participants have been analyzed: 64.2 percent were males mean age: 69.2 +/- 7.8 years which was higher than females 68.0 +/- 7.6 years (P < 0.0001). The widowhood (46.7%) status was also higher than the widowerhood (4.1%) and 9.3 percent of the participants were never married. The proportion of female illiterates (95.8%) was higher than the males (71.4%). The proportion of participants with definite psychopathology was 33.8 percent and this increased with age and higher among females than males. Overall, 18.8 percent were dependent on others for ADL. Other clinical findings included visual impairment (46.1%) and difficulty in hearing (19.9%). However, a sizeable majority (72.2%) enjoyed good health. Only 3.7 percent lived alone. The proportion of the elderly taking part in any recreational exercise was 14.7 percent and only 4.3 percent had any experience of physical therapy. There were no special hospital wards for the elderly patients, and they were treated by general internists. There is a need for a national cost-effective program for the care of the elderly. The present widespread primary health care centers can be upgraded to coordinate the proposed services.

Prevalence and determinants of smoking in three regions of Saudi Arabia.

OBJECTIVES: To study the prevalence and determinants of cigarette smoking among Saudi nationals in three regions of Saudi Arabia. PARTICIPANTS: A sample of 8310 individuals aged 15 years and above from both sexes, randomly selected from the three regions, using a stratified cluster sampling technique. DESIGN: A cross-sectional, household, community-based survey. Using a predesigned and tested questionnaire, the participants were interviewed by primary care physicians. The interview covered personal, social, and educational characteristics of the respondents, and also included questions about their smoking status, duration of smoking, and daily cigarette consumption. MAIN OUTCOME MEASURES: Association between current smoking and sociodemographic variables, in univariate and multivariate analysis. Degree of interaction between the different determinants of cigarette smoking. RESULTS: The overall prevalence of current smoking was 21.1% for males and 0.9% for females. Most smokers (78%) were young to middle-aged (21-50 years old). Smoking prevalence was higher among married people, among uneducated people, and among those in certain occupations: manual workers, businessmen, army officers, and office workers. CONCLUSIONS: Cigarette smoking is an important public health problem in Saudi Arabia. A more intense and comprehensive tobacco control effort is needed.

Factors associated with health perception of Saudi elderly.

To study the pattern and determinants of health perception among Saudi elderly a cross-sectional house-hold survey of 6,139 elderly in Saudi Arabia performed between January 1994 and December 1995. A stratified two stage sampling technique was used to select the elderly subjects (60 years and above). Using a pre-designed, pre-tested questionnaire, the subjects' physical, mental, social and environmental health status and health perception were assessed via personal interviews completed by trained researchers. The poor health perception was predominant among females and more with advanced age (75 years and more). It was also found to be associated with more social and economical underprivileges, and independence as measured by an Activity of Daily Living (ADL) scale. Multivariate analysis revealed the most significant determinants of poor perception of health as follows: inability to perform prayers standing (OR = 3.36; p < 0.0000), and the number of diagnoses (OR = 3.33; p = 0.000). A significant correlation was found between hospital visits, number of diagnoses and health perception. These socio-demographic and socio-medical factors found to be important determinants of health perception among Saudi elderly need to be modified.

Referral from primary care to hospitals in saudi arabia: 1) quality of referral letters and feedback reports.

BACKGROUND: Referral between primary care and hospitals is of great importance for patient care and follow-up. This study was conducted because of the importance of the quality of referral letters and feedback reports. OBJECTIVES: To evaluate the quality of referrals from primary health care (PHC) centers to general hospital in four regions in Saudi Arabia. METHODS: This was a cross-sectional study of a random sample of referrals from the PHC centers. The first sampling unit was the general hospitals to which the health centers refer. A random sample of health centers was then selected based on their distance from the hospitals. This was followed by randomly selecting 30 referrals from each health center. The referral letters and the corresponding feedback reports were then studied for quality by scoring the components of each. The data was entered in a personal computer using the Stat Pack Gold Statistical Package. The chi-square was used to compare the different scores across the regions and T-test was used to compare the cumulative scores. MAIN OUTCOME MEASURES: The quality of referral letters and feedback reports was defined according to the standardized components using a scoring system. RESULTS: The most frequently mentioned items in the referrals were demographic data (100%), specialty referred to (93.3%) and reason for referral (82.7%). Other important items in the feedback reports including the name of the treating physician (81.8%), diagnosis (86.0%), and decision on follow-up (80%) were missing. The quality of referral letters was poor in 23%, with 81% as the corresponding figure for the feedback reports with some variation between the different regions. CONCLUSIONS: The quality of referral letters and feedback reports is poor and needs to be improved. This can be achieved through implementing the quality assurance programme.

Perception of supervisors of their role in primary health care programmes in Saudi Arabia

This study was conducted to explore the perception supervisors had of their role in primary health care programmes. A self-administered postal questionnaire was used and a response was received from 135 out of 159 supervisors. The survey showed that supervisors had a reasonable understanding of the functions of supervision and they generally face the same difficulties. Supervisors spent most of their time solving technical problems and conducting field visits. The majority believed that they had reasonable status and enough support from the higher authorities. However, there is still a great need for formal training of supervisors. This should be incorporated into the quality assurance programme that has recently been introduced

Long-term care experience in Saudi Arabia.

The objective of this study was to ascertain the clinical and epidemiological pattern of long-term care inpatients in Saudi Arabia. A cross-sectional survey of all long-term care inpatients facilities in the Ministry of Health was conducted during the period January-June 1994. Trained research teams consisting of physicians, social workers, nurses and medical record officers completed a pre-designed data form. They interviewed the treating teams, patients and their relatives. The data form consisted of socio-demographic data of patients, the duration of their stay in hospital and their clinical, social and psychological characteristics. In addition, the perceptions and preferences of doctors, patients, and their relatives about patient management in hospital vs home care were sought. Out of all patients, 61.3% were males, while 52.7% were elderly patients (> or = 60 years of age). Forty-three percent did not need any nursing care or required only routine nursing care. The treating doctors believed that 44.9% of patients could be cared for at home. However, 45.2% of the patients preferred to stay in hospital, while 67.5% of their relatives preferred institutional care. It is concluded that there is a need to plan for more cost-effective facilities for these patients. The proposed health services have to be culturally acceptable in order to encourage patients and their relatives to utilize them.

Career choices among Saudi medical students.

PURPOSE: To identify the career choices, intended practice locations, and reasons for career choices of final-year Saudi medical students. METHOD: A total of 302 final-year students at the four Saudi medical colleges were asked to complete a self-report questionnaire at the end of the 1994 academic year. RESULTS: A total of 253 students (84%) responded (149 men and 104 women). The most frequently chosen specialties were internal medicine (17%), surgery (16%), pediatrics (14%), and obstetrics-gynecology (11%). Twenty-seven percent were not sure of their future career choices. More of the men chose surgery, but more of the women chose obstetrics-gynecology and ophthalmology. The leading reasons for selecting a specialty were "personal interest," "a chance to help people," "availability of postgraduate training," "few specialists in the country," and "prestige." The most frequently chosen locations for postgraduate training were Saudi Arabia (56%) and Canada (40%). The qualifying examinations the students wished to pass were mostly the Canadian boards (49%) and the Arab boards (48%). A majority intended to practice in hospitals (90%) and in cities (85%). CONCLUSION: The small proportions of students who chose family medicine and some other specialties indicate that the current drastic deficiency of trained Saudi primary health care physicians will continue unless targeted strategies to produce more of these physicians are undertaken.

Predictors of smoking among male junior secondary school students in Riyadh, Saudi Arabia.

OBJECTIVE: To determine the prevalence and determinants of cigarette smoking among intermediate (junior secondary) schoolboys in Riyadh, Saudi Arabia. PARTICIPANTS: A sample of 1382 students (ages 12-19 years) in 45 classes randomly selected from 15 schools, using a two-stage stratified cluster sampling scheme. DESIGN: Students in the selected classes were requested to complete an anonymous questionnaire, under the supervision of trained interviewers. Univariate and multivariate statistical analyses of potential risk factors were performed. SETTING: Intermediate schools in Riyadh, Saudi Arabia. MAIN OUTCOME MEASURES: Association between current smoking and socio-demographic variables, history of smoking, age of smoking initiation, smoking behaviour among family members, knowledge of the harmful effects of smoking, and whether smoking is allowed in the presence of relatives and acquaintances. RESULTS: The prevalence of current smokers was 13.2% overall, ranging from 3.2% in those 12-13 years old to 31.1% in those aged 18-19. Some of the variables (nationality, father's education, and smoking allowed in the presence of parents or teachers) found to be associated with current smoking in a univariate analysis were no longer significantly associated with smoking in the multivariate analysis. By multivariate analysis, knowledge of the harmful effects of smoking, age, smoking allowed in the presence of friends or brothers, and previous smoking were statistically significant determinants of current smoking. CONCLUSIONS: Current health education activities against smoking should be continued and extended to the young population to further reduce the prevalence of smoking and its health consequences. Religious antipathy toward smoking should be emphasised in any local anti-smoking campaigns.

Future specialty and practice intentions among saudi medical students.

OBJECTIVE: The objective of the study is the identification of the specialty intentions, the reason behind that choice and the preferred practice location of the study population. METHODOLOGY: A cross sectional study was conducted using a self administered questionnaire distributed at the end of the academic year 1994. One hundred and forty nine (149) male and 104 female graduating medical students representing the four medical colleges in Saudi Arabia were included RESULTS: The four major clinical specialties were selected by more than half of the students; Internal Medicine (17%), Surgery(16%), Paediatrics (14%) and Obstetrics (11%). Twenty seven percent were not sure of their future career choice. Primary health care was chosen by only 1.6% of the students. More men chose Surgery but more women chose Obstetrics and Ophthalmology. DISCUSSION: "Financial incentives", "no night duties", "social reasons" and "less responsibilities" were the less frequently mentioned reasons for career choice. The qualifications in view were mostly Canadian Board for 49% of the students and Arab Board for 48% of them. The most frequently preferred locations for postgraduate training were Saudi Arabia (56%) and Canada (40%). The majority intended to practice in hospitals (90%) and in cities (85%). CONCLUSION: The current drastic deficiency of trained Saudi Family Physicians will continue unless targeted strategies to produce more generalists are undertaken.

Culturally acceptable health care services for Saudi's elderly population: the decision-maker's perception.

This article reports on a study carried out in 1993 to elicit the opinions of decision makers (medical and non-medical) as to the types of facilities, locations and culturally acceptable levels of health care appropriate for the elderly in Saudi Arabia. In addition, the study sought to find out the procedures and likely constraints in the development of future health care services for the elderly. An opinion survey was carried out on a randomly selected sample of decision makers, drawn from: hospitals of 100-bed capacity or more; and, from directorates of education, agriculture, police, municipalities, commerce, transport and media, in each of the regions of Saudi Arabia. A predesigned Arabic questionnaire was completed by the respondents during February-April, 1993. Of the 244 respondents, the most important categories of elderly to be cared for were considered to be those with handicaps, the chronically ill, and those without family support. The non-medical decision makers gave higher scores to these alternatives than did the medical decision makers (P < 0.05). Use of the family home for elderly health care was rated as the most appropriate, followed by medical rehabilitation centres, and only then by hospitals. Non-medical respondents gave more emphasis on rehabilitation centres (P < 0.02). Medical respondents thought that primary care doctors (87.2%), physiotherapists (87.2%) and general nurses (78.2%) can adequately fulfil the needs of most elderly patients. In contrast, non-medical respondents demanded the presence of specialist doctors (72.3%), specialist nurses (78.9%), laboratory and X-ray facilities to run such services (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-waiting outpatients: target audience for health education.

The study examines the meaning of waiting time in an outpatient department. Attention is payed to the activities of the patients and companions during the waiting time, the potential for health education programmes during the waiting time and the form such a health education programme should take. The setting was the King Khalid University Hospital Outpatient Department, Riyadh, Saudi Arabia. The study sample was selected by a systematic random sample approach of one in every 10 patients or companions visiting the clinic in a period of 2 weeks. The results showed an average waiting time of 148 min with a standard deviation of 11 min. Patients currently engage in reading, sleeping or talking during long waiting time. However, they showed a preference for health education programmes for specific diseases such as heart disease, diabetes mellitus and bowel diseases during the waiting time. Leaflets were favoured to be the most preferred mode for disseminating such information. A sizeable proportion of patients also wanted religious programmes included. We conclude that education programmes for preferred specific health topics at outpatient clinic services would be of potential benefit to patients' overall health.

The pattern of antenatal visits with emphasis on gestational age at booking in Riyadh Health Centres.

1344 expectant mothers were selected by random sampling from the catchment population of 15 health centres in Riyadh. The health centres were taken to represent all areas of urban Riyadh. These mothers were asked to complete a pre-designed questionnaire in Arabic and undergo a structured interview by trained midwives to explore their knowledge, attitude and practice toward antenatal visits. It was found that the average gestational age at booking was 13 weeks. The number of antenatal visits achieved during the current pregnancy was 6. 97% of expectant mothers were aware of the importance of antenatal visits. Various demographic characteristics were studied in relation to the number of antenatal visits achieved and the gestational age at booking. It was found that the level of education of both husband and wife and poor obstetric history significantly affected gestational age at booking, (P-values) were less than 0.03 and 0.002 respectively). However the family income and gestational age at booking affected the number of antenatal visits (P-values were less than 0.0003 and 0.0001 respectively). The respondents' most striking reason for non-compliance was related to accessibility to health centre. 23.3% thought that the health centres were far away from their residence and they needed to involve the husbands in driving them to health centres. Recommendations were given to improve aspects of accessibility and inviting more antenatal visits in addition to improving quality of such service.

PIP: Based on 1344 survey responses from women attending 15 primary health care centers in Riyadh, Saudi Arabia, from March to October, 1992, this study examined the relationship between obstetric history, socioeconomic factors, and gestational age at entry to the clinics and gestational age of infants. The 15 health centers served more than 25% of the total city population. Saudis and non-Saudis could not be distinguished by age, gestational age at booking, or numbers of prenatal visits. Saudis had more children, and fewer used health centers (78.7% for Saudis vs. 93.5% for non-Saudis). Better-educated mothers, who believed in the necessity of prenatal care, were younger, less parous, booked earlier for prenatal care, and paid more visits; differences were statistically significant. 90% of mothers received prenatal care at least three times, 75% made six or more visits, and 6.7% attended for the first time after 28 weeks gestation. Mothers aged under 20 years made more prenatal visits than those aged over 30 years. Highly educated mothers and mothers aged under 20 years had more prenatal visits. Employed mothers and primiparous women had earlier bookings and more visits than housewives. Multiple linear regression analysis revealed that early prenatal care was related to poor obstetric history, higher level of education, and better income. Saudis reported greater problems with access to facilities than non-Saudis. 79.1% of the women preferred delivering in a hospital, and 11.9% preferred health center delivery. Only 1.5% insisted on home delivery. The mean gestational age at booking was 13 weeks, and the average number of prenatal visits was six. The Health Ministry recommendation was 13 visits, of which nine should be before 36 weeks gestation.

A prospective study of the morbidity pattern of patients seen at a university primary care clinic.

Information on the morbidity pattern of patients seen at a primary care clinic is sparse or not available for most countries in the Middle East including Saudi Arabia. A prospective study of all new patients at the primary care clinic of King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia was therefore carried out over a period of one year (1991G to 1992G). An analysis of the morbidity pattern of 9,441 new patients seen over this period is hereby reported. There is a male prepondence overall and more than 70% of the patients were below 40 years of age. III-defined illnesses, diseases of the skin, genitourinary, digestive, musculoskeletal and respiratory diseases accounted for more than 70% of the patients. About one-third of the patients, mainly those with diseases of the skin and genitourinary systems, were referred for specialist care. It is conceivable that the commonly observed pattern of diseases in this study may change over a period of time either due to the interventions adopted by the primary care clinics or as part of social development or as a cumulative effect of both. The primary physician has to be aware of such a change by periodically analyzing the available morbidity pattern.

Intralesional treatment of cutaneous leishmaniasis with sodium stibogluconate antimony.

BACKGROUND: Cutaneous leishmaniasis represents a difficult disease to manage in endemic areas. Systemic treatment is hampered by both expense and compliance. Side effects may play a major role in this aspect as well. METHODS: The effectiveness of intralesional treatment of leishmaniasis was investigated. Seven hundred and ten patients were treated with injections of sodium stibogluconate intralesionally. The clinical diagnosis was confirmed by demonstrating the parasite in the smears obtained from the lesion. Fine insulin needle was used to infiltrate the lesion with sodium stibogluconate (0.5 to 1.0 mL). RESULTS: Generally eight injections were sufficient, but some of the complicated lesions needed up to 24 injections. Sixty-two percent of patients were men. The majority of the study population (64%) were children below 15 years of age. The results showed that 72% of lesions healed completely, 23.9% showed some improvement, while 4.1% showed some deterioration. Lesions of the lips, cheeks, chin, and neck healed faster than lesions in other parts of the body. Side effects were mild and limited to pain at the site of the injection and hyperpigmentation in those who were treated by folk medicine. CONCLUSIONS: Intralesional treatment is as effective as the standard systemic antimonials. It offers a less expensive alternative and a low side effects profile. Our findings confirmed the findings of earlier workers. It is recommended for treatment of cutaneous leishmaniasis in endemic areas.

Vitiligo: Epidemiology and clinical pattern at King Khalid University Hospital.

The incidence of vitiligo at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia was 2.5% for the period from 1985-1990. The majority (96.1%) were Saudis. Approximately 64% were below the age of 30 years and the average was 25.6+/- SD 13.7 years. Fifty-six percent of the patients were males and 43% were females. More than half of the patients had the lesions for a period between one and nine years and 17.17% had them for more than 15 years. Only 12% had a positive family history of vitiligo. The majority (54%) of the lesions were in exposed areas. The associated diseases with vitiligo are also reported. It appears that the clinical pattern of vitiligo is not different from what is reported in other studies.

Role of primary health care in the control of schistosomiasis. The experience in Riyadh, Saudi Arabia.

The control programme for schistosomiasis in Saudi Arabia was started in 1975 as a central vertical programme. With the adoption of the primary health care approach a pilot scheme that integrated the control of all endemic diseases, including schistosomiasis, within the functions of primary health care centres was carried out. In Riyadh, the scheme was started in 1984 when subcentres for the control programme were established as a first step for complete integration. A training programme was extended to personnel in primary health care centres, including physicians, nurses, and health inspectors with the help of experts from World Health Organization (WHO). A survey of the population at risk in areas with high prevalence was done regularly accompanied by treatment of cases. Snail control was an important activity of the health inspectors with a three months repeat of the control procedures. The result of this programme is a significant reduction in the prevalence of both urinary and intestinal schistosomiasis, from 13.2% in 1983 to 0.17% in 1989. Among the 7453 water sources surveyed in 1989, only 7 were positive for snails (0.1%). About two thirds of those who were affected were expatriates coming from areas of high prevalence of schistosomiasis. Details of the control programme and its impact on the control of the disease are presented in this paper.

PIP: Between 1984 and 1986 in Saudi Arabia, the Ministry of Health began integrating the schistosomiasis control program into the existing primary health care (PHC) system by setting up substations or subcenters in Al-Aflaj, Al-Kharj, Al-Qwai, Hotat Bani Tammin, Al-Majmea, and Al-Zufli in the Riyadh Region of the Central Province. Substation or subcenter staff conducted case detection (via collection of stool and urine samples of household members in the catchment area), snail control, and health education, and administrated chemotherapy (praziquantel) for all patients with positive stool of urine samples. Between 1983 and 1989, the prevalence of schistosomiasis fell from 13.2 to 0.17%. In 1983, it was higher among Saudis than non-Saudis (91.1% vs. 8.9%). It fell during the study period among Saudis (91.1-32.6%) and increased among non-Saudis (8.9-67.4%). The non-Saudis were from Egypt, Yemen and the Sudan, all areas of high schistosomiasis prevalence. 20-39 year olds had the highest prevalence rate (54.7%). No children under 5 years old and no school age children were infected with Schistosoma species. The integrated PHC program improved its treatment and follow-up activities as evidenced in the fall by the dropout rate (54.4%-22%). The number of positive water sources for the snails harboring Schistosoma species first increased due to stepped-up efforts to survey water sources (1.8-2.2%, 1984-1986), then fell to 0.09% (7 out of 7453 sources). A possible activity to further improve schistosomiasis efforts is screening of expatriate workers from infected countries.

Public attitude towards acceptability, availability, and accessibility of immunization services in Riyadh.

A study of accessibility, availability, and acceptability of immunization was carried out by interviewing 1422 parents selected randomly from the catchment areas of 15 health care centers in Riyadh. The parents were included if they had children who were under two years or who had not completed the essential immunization necessary for issuing birth certificates. The demographic data of parents and children were also obtained. The majority, 1270 (89.3%) parents said they would immunize their children to protect them against diseases while only 25 (1.8%) of the parents said they immunize their children to obtain the birth certificate. Of all parents, 87.3% strictly followed the immunization schedule. Mothers in the younger age group, with higher education and whose husbands are in the higher occupational category had higher compliance rates than others. Various reasons were given for this failure. Parents (21.4%) attributed failure to attend the scheduled immunizations to inaccessibility to the service, for example the distance which needed transport, or non-availability of father to accompany the family to the health center. Other reasons for failure were due to false perception of the necessity, the indications and the contradictions of immunization. It was found that parents who failed to comply with the immunization schedule were more likely to have more than the average number of children.