The epidemiology of infant deaths in the Armenian parish records of Lebanon.

It is difficult to study time trends in mortality from most developing countries due to the lack of an appropriate data base. The present investigation is based on data from parish records of the Armenian Apostolic churches in Lebanon. Death and baptismal registers have been regularly maintained in these churches from 1863. Infant deaths were identified in the registers of the 13 churches. Available data on these deaths were abstracted, coded and analysed. Denominators for the different periods of study and for the various churches were calculated from baptismal records. The study shows that there has been a constant drop in the infant deaths over the review period. Infant mortality rates were higher in the parishes located in refugee camp areas. The most important recorded causes of death included diarrhoea and pneumonia. A study of clustering of deaths by time and place revealed a major epidemic of measles with high fatality in 1926. This epidemic had been previously unrecorded. The present study demonstrates the use of non-traditional data sources to assess long-term secular trends of mortality.

Reliability and validity of self and proxy reporting of morbidity data: a case study from Beirut, Lebanon.

We compared the self-reported illnesses (heart disease, back pain, rheumatoid arthritis, hypertension, and pulmonary disease) and smoking histories of 100 cases and 100 controls matched for age and sex with reports of this information from proxy informants from the same household in two areas in the city of Beirut. In addition, both cases and controls were given physical examinations to evaluate the accuracy of the responses. The level of agreement between the responses of subjects and of their informants varied from one condition to the other. Heart disease had the highest level of agreement, with the proportion of agreement greater than 93% for the cases and the controls and having chi values of 0.79 and 1.0, respectively. The report of back pain exhibited the lowest level of agreement, with responses showing a proportion of agreement of 74% for the cases and 90% for the controls, with chi values of 0.49 and 0.50, respectively. In comparing the responses of subjects and proxy informants with the results of physical examinations, heart disease had the highest level of agreement (J index ranged from 0.69 to 0.84), and back pain had the lowest level of agreement (J index ranged 0.42 to 0.48). These results show that proxy informants are good respondents for members of the same household and that health interview surveys are accurate for data collection of well defined chronic conditions.

Measures of social class based on education for use in health studies in developing countries.

In this paper we consider the appropriateness of education, compared to occupation and income, as a measure of social class for use in health-related studies in developing societies in transition. Three evaluation criteria were used, namely, the feasibility of constructing the measure, its sensitivity in reflecting relevant social class life conditions, and its ability to produce a family-level measure of social class. We used two data sets from community health surveys in areas of Amman city, Jordan, and in Beirut city, Lebanon, to define a family-based average educational score. We then proceeded, using the Beirut data, to test the score's ability to discriminate social class effects on family health, compared to a more standard representation based on the educational level of the head of the family. It was found that the performance of the average educational score was often better than, but not consistently superior to, the educational level of the head of the family.

Effect of urban versus rural residence and of maternal education on infant health in South Lebanon.

A sample of 253 women from rural and urban areas of south Lebanon were visited for 18 months after delivery. Information was collected on patterns of reproduction, infant feeding, and use of the health services. The findings indicate that educated women and women living in urban areas were better off in terms of family formation patterns, immunisation, and well-baby care. The importance of educating women, particularly in rural areas, as a policy that can be varied to improve child health and growth is thus emphasised. The study also indicates, however, the special need for health education programmes directed to all mothers to emphasise proper breast-feeding patterns and the importance of preventive health care for infants. The findings also indicate the need for a more diversified system of delivering health care in which properly trained paramedical personnel take part, particularly in rural areas.

A population-based survey of loss and psychological distress during war.

Research on the psychological effects of war has been conducted on a limited number of population groups and has generally failed to study the experience of particular losses while warfare was still in progress. This paper presents the results of a household surveillance study of 5788 displaced and non-displaced civilians conducted during the summer 1982 war in Lebanon. In order to determine demographic differences in the psychological response to war and help identify population groups possibly at-risk for mental disorder, an interview checklist of symptoms of psychological distress was developed and administered to a key informant in each household. The occurrence of psychological distress symptoms varied significantly by age, sex, nationality, socio-economic status, loss of physical health and economic loss. A more detailed analysis of the psychological effect of displacement or loss of one's home during war is presented. Displacement group differentials suggest that psychological distress may be more frequently perceived post-war and that both social integration and social isolation may play important roles in mediating the perception of psychological distress during war.

The impact of war on the physical and mental health of the family: the Lebanese experience.

This paper addresses the impact of war-related stressful life events on the health of families living through the war conditions prevailing in Lebanon for the past 12 years. Health outcome is represented by indicators of somatization, depression, psychological symptoms, interpersonal relations and marital relations. Associations are described between elements of war stress and the health outcome variables for mothers, fathers and adolescents in a sample of Beirut families. The role of the mediating factors of social support and social class is also discussed.

Women's health problems in the Arab World: a holistic policy perspective.

The paper reviews key health problems of women in the Arab World. It relies on data and information from international yearbooks, regional data bases, and small scale field studies. The relevant context in which women live; of lingering illiteracy rates, lack of access to cash income, and increasing poverty is described. Reproductive health is reviewed within this context pointing to trends of delayed marriage and declining fertility in some countries while other countries maintain high levels. Similar variability is observed in contraceptive use rates and the interaction of contraception and health is discussed. Evidence points to high levels of reproductive morbidity. The socio-cultural context is found particularly relevant to pregnancy and childbirth, seen as natural processes by women, to experiences of menopause, and to violence against women, particularly female circumcision. A holistic policy perspective is suggested to address these problems.

Gender and sexual health in clinical practice in Lebanon.

This study examines the readiness of obstetricians/gynecologists (Ob/Gyns) in Lebanon to provide sexual consultation, their degree of comfort when discussing issues of sexual health, and their attitudes regarding assessment, treatment, and referral. Data on these concepts were collected through face-to-face interviews with 286 randomly selected Ob/Gyns. Most Ob/Gyns reported feeling comfortable discussing sexuality during consultations, which they attributed much more to professional experience than to training. Most Ob/Gyns reported giving proper time for management of sexual health issues and follow-up, as these issues are brought up frequently by their women clients. However, results suggest that only one-third (31%) of Lebanese Ob/Gyns nearly always take the initiative in asking patients about their sexual health. Moreover, almost 45% of participating Ob/Gyns did not recognize a strong relationship between reproductive health and sexual functioning. Gender was not found to be an important predictor for any of the indicators measured in the present study. Ob/Gyns in Lebanon are significant consultants on various sexual issues, and they need better postgraduate training, continuing medical education, and access to medical congress resources on the topic of sexuality and its relationship to reproductive health.

Infant mortality in Bekaa-Lebanon, 1979.

PIP: The study purpose was to determine the magnitude of infant mortality in the Bekka Mohafazat of Lebanon, to define its major causes, to try to correlate it with other possible influencing factors, and to determine whether the implementation of a new program for the treatment of diarrhea and prevention of its complications (sponsored by UN Agencies) should be a priority for Lebanon. The previously estimated birthrate for rural areas in Lebanon was 40/1000 and the estimated infant mortality rate was 60/1000. For this study to include around 60 cases of infant death, a sample of at least 25,000 was necessary. All newborns in the August 1976 to August 1979 period were studied; this meant 16 villages in 4 Qada's of Bekaa. A standard questionnaire was designed so that data could be obtained to record birthrate, infant mortality, causes of infant deaths and some other parameters. Parents were asked whether infants who died experienced diarrhea, respiratory symptoms, rash, or other major signs prior to death. The total sample size was 10,923. There were 997 newborns in the study period; 53 of these infants died within the 1st year of life. Data obtained for the whole Bekaa Mohafazat revealed a birthrate of 30.4/1000 and an infant mortality rate of 53.1/1000. Qada Baalbeck showed the highest birthrate (36.4/1000) as well as infant mortality rate (66.2/1000). The lowest infant mortality rate was found in Qada's Zahle (39.1/1000), and the lowest birthrate was noted in Qada's Hermel (18.9/1000). Of the total infant deaths, 47.1% had diarrhea prior to death and 43.4% had undefined conditions which reflects the parents' inability to assess objectively and to remember correctly the conditions of their infants before deaths. The remaining 9.5% cases had cough or rash prior to death. The study was conducted during July and August when diarrheal diseases are generaely more common, and this might have led to an overreporting of diarrhea as a condition prior to death. Prior to death, 50.8% of total deaths were treated in a hospital; 69.8% were treated by a physician at different levels of health care. No correlation was found between infant mortality and feeding habits of the newborns. No correlation was found between infant mortality and the mother's age and education, birth order, sex and age at death of the newborn.^ieng

Serum immunoglobulin levels in normal children and adults in the Lebanese and other Arab Middle Eastern populations.

Serum immunoglobulin levels were determined in 1000 serum samples of normal middle easterners. Ig levels in mothers at delivery were normal except for a depressed IgG level. In cord blood the level of IgG was higher than its level in mothers, but no IgA or IgD was found. IgD was formed in some instances in the sera of infants in the first week of life. IgG showed a pattern similar to that described by others with the lowest values at 1-2 months, increasing gradually so that by 1-3 years the normal adult blood level is reached. IgA levels continued to increase with age and although no definite explanation is available, it is interesting to speculate on the possible relationship to the increased incidence of intestinal parasitism. IgM showed significant differences between males and females being higher in the latter. IgD levels reached maximum levels by 3-5 years, and mean levels ere lower after the 14th year.

An overview of the development of studies on fertility.

PIP: Statistics show that fertility in Arab countries is still high compared with prevailing rates in developed countries and the levels attained in some developing countries during the past decade. Most fertility studies in the Arab world have been functional, descriptive and analytical. They have not attempted to develop theories on fertility and its determinants that would reflect current situations. Efforts are being made at both the individual and institutional levels to encourage theoretical research. Family planning still dominates Arab fertility studies, but it is necessary to cover other concepts such as the supply of children, the demand for children, and the determinants which pertain to both the individual and the surroundings affecting these concepts. Sources of information on fertility in the Arab world need to be collected, confined to a research center or university within the Arab world, and made available to Arab researchers. Studies on various Arab societies, designed by Arab researchers, need to be undertaken.^ieng

The changing role of Arab women.

PIP: The change in the role of Arab women is assessed by examining the status of development factors known to influence the labor force participation of women. Data are presented on the following: levels of education, fertility, urbanization, and the economic structure of countries within the Economic Commission for Western Asia (ECWA) region. 2 indicators are used to assess the educational level of the female population in the Arab countries, i.e., the level of illiteracy among adult females and the proportion of female enrollment in schools. The female illiteracy rates continue to be high in the Arab countries, but the rates have been decreasing in time, which points to the rising status of Arab women. The 1975 enrollment rates for the 6-11 age group indicate that the wide disparities among the Arab countries in terms of the education of adult women are likely to continue, for the percent of females not attending primary school ranges from 95% in Oman to 15% in Lebanon. The discrepancy between the sexes is also likely to continue, for female enrollment is lower than male enrollment in all Arab countries. Little variation exists in the fertility rates among the Arab countries despite the disparity among them in terms of the illiteracy rates of the adult female population. Even though some Arab women are showing lower levels of fertility, the family size in Arab society is still generally large, leaving the Arab woman with a relatively short portion of her life span that can be devoted to productive labor outside the home. Agriculture is still a large sector in the populous Arab countries, and the work of women in traditional agriculture is undertaken mostly as part of family labor and is not always considered to be labor force participation. Female economic activity rates are very low in comparison to male activity rates in Arab countries of the ECWA region. The service sector includes the categories of economic activity considered in Arab society to be suitable for women, i.e., teaching, nursing, and domestic service. Some of the factors that may have prevented more apparent labor force participation of women in Arab countries are the high level of female illiteracy, the largely agricultural structure of the economies, and the high level of fertility in almost all of the Arab countries.^ieng

Breastfeeding and contraceptive patterns postpartum: a study in South Lebanon.

PIP: An 18 month follow-up of the breastfeeding and postpartum contraceptive use patterns of 253 women in south Lebanon served by a community-based family planning services program has suggested an independent negative relationship between the duration of breastfeeding and the pattern of starting contraception postpartum. Moreover, it has revealed a pattern of contraceptive use involving periodic switching between the pill and withdrawal. This switching pattern was shown to be mainly due to a preference among the women for using the pill combined with a low tolerance for its side effects. Contraceptive use patterns influenced women's ability to achieve their fertility desires, with 99 pregnancies occurring during the study period, 79 of which were not desired. The results of the study emphasize the importance of a user-oriented approach in community-based family planning services programs, with a wider base of services and more individualized contacts with the women being served.^ieng

A study of clustering of cases of leukemia, Hodgkin's disease and other lymphomas in Bahrain.

One hundred and twenty five cases of leukemia, Hodgkin's disease, and other lymphomas were compared with 125 matches controls for space, and time and space clustering in the State of Bahrain. These cases and controls were identified from hospital, pathology and death registries over a period of ten years. Thirty-one percent of the cases living in cities had "effective contact' with at least another case compared to 8.7 percent of the city controls, at a distance of "effective contact' equal to or less than 100 meters. no differences were observed as to the number of "effective contacts' between the cases and controls residing in the villages. When the combined data from the villages and urban areas were analyzed using two different methods, no significant clustering could be reported. Although space clustering in the urban areas is attributed to a hypothesized transmissible or exposure factor, the possibility that such clustering is due to some common characteristics of the persons with these conditions has to be considered.

Comparing women's reports with medical diagnoses of reproductive morbidity conditions in rural Egypt.

This article is based on a survey of a random sample of 509 ever-married nonpregnant women residing in two villages in the Giza Governorate of Egypt, each of whom responded to a questionnaire on symptoms of gynecological conditions and then was accompanied to the village health center for a gynecological exam. A response rate of 91 percent was achieved. The article focuses on reproductive tract infections and genital prolapse, highly prevalent conditions in the community. The women's reports of symptoms are compared with the medical diagnoses, using indicators of sensitivity, specificity, positive and negative predictive values, and percentage of agreement. The findings show that women's reports of vaginal discharge agree moderately well with the physicians' observations but are not good predictors of the occurrence of reproductive tract infections. Women's reports of the symptoms of prolapse do not agree well with medical diagnoses of the condition. The findings are analyzed, taking into account the social context of the lives of the women surveyed to arrive at conclusions as to how to improve ways of learning from women themselves about gynecological problems in the community.

PIP: During November 1989 to July 1990 in two villages in Giza Governate, Egypt, medical and social scientists compared self-reports of 509 ever married women with medical diagnoses to determine the feasibility of using a questionnaire for a community diagnosis. The assumption was that a questionnaire is an inexpensive data collection method to identify women's health problems in developing countries. Based on self-reports, 77% of the women had vaginal discharge. 68% of these women considered the discharge as unusual. When the researchers compared self-reports with medical diagnoses of the presence of reproductive tract infection (RTI), they found a relatively high sensitivity (79%) but a low specificity (26%) for presence of discharge. The positive predictive value and percentage of agreement were 53% and the Kapp statistic was only 5%, indicating little agreement between self-reported symptoms and clinical or laboratory diagnostic status. Comparison of self-reports of at least one of the two symptoms of genital prolapse with clinical diagnoses of genital prolapse revealed a rather low sensitivity (36-50%, depending on severity of the prolapse) and relatively high specificity (76%). The positive predictive value and percentage of agreement were 66% and 54%, respectively, and the Kapp statistic was 11%, indicating poor agreement between self-reported symptoms and clinical or laboratory diagnostic status. 90% of the 40 women with uterine prolapse had first degree prolapse, but all 40 also had some vaginal prolapse. Women with more severe anterior vaginal prolapse or posterior and anterior vaginal prolapse plus uterine prolapse were more likely to report symptoms than those having posterior vaginal prolapse and uterine prolapse (56% vs. 17%; p 0.05). These findings show that vaginal discharge, considered as a symptom or sign, is not a good predictor of RTIs.

Concepts and measures of reproductive morbidity.

This paper presents a conceptual and methodological framework developed by an interdisciplinary group of researchers to diagnose reproductive morbidity at the community level. The paper also presents a determinants structure that delineates the health and social factors hypothesized to influence reproductive morbidity. The high prevalence of reproductive-morbidity conditions revealed by implementation of the study framework in two villages of Giza in Egypt is reported. Based on this research experience and the process of presenting its results to the larger professional community, the paper discusses policy implications of the study in terms of reproductive-health services, education and training programs and research efforts for measurement of reproductive ill-health at a community setting.

PIP: An interdisciplinary group of researchers developed a conceptual and methodological framework to determine the extent of the problem of reproductive morbidity at the community level in Middle Eastern society and then, in turn, to improve reproductive health conditions in women. It conducted an exploratory study in a family planning clinic in Cairo, Egypt; a medical workshop on clarification of the symptomatology of reproductive morbidity; and a focus group in a village in Giza, Egypt, to ensure that the reproductive morbidity questions of interview questionnaires were appropriate and complete. The group tested the accuracy of the questionnaires in 2 villages in rural Giza (509 women). Field workers went to the women's homes to administer the questionnaire on characteristics of the household during the first visit. During the second visit, they administered the questionnaire on reproductive morbidity, and then the social researcher went with the women to the health center so the women could undergo a gynecological examination. 50% of the women had reproductive tract infections, especially vaginitis. 56% had prolapse, and prevalence increased significantly with age. 63% had anemia, especially 14-19 year olds (76%). Just 24 women (5%) had no reproductive morbidity. About 50% had at least 3 reproductive conditions. The leading problems reported by the women were vaginal discharge (77%), dysmenorrhea (71%), perceived delay in conception (48%), stress incontinence (37%), and pain during intercourse (36%). Feeling of heaviness below, probably indicating prolapse, was the only symptom which increased with age (p = .03). 41% had been pregnant in the last 2 years. 77% delivered at home. Leading conditions during pregnancy were headache (59%) and discharge (45%), and those after delivery were fever and discharge/inflammation (30% for both). The interdisciplinary group proposed 3 mechanisms which are of utmost importance to policy: conducting similar research in other communities, expansion of reproductive health services at the community level, and implementing changes in the education and training programs of health professionals and social scientists.

A community study of gynecological and related morbidities in rural Egypt.

This study assesses the prevalence of gynecological and related morbidity conditions in a rural Egyptian community. A medical examination was conducted on a sample of 509 ever-married, nonpregnant women. For gynecological morbidities, genital prolapse was diagnosed in 56 percent, reproductive tract infections in 52 percent, and abnormal cervical cell changes in 11 percent of the women. For related morbidities, anemia was present in 63 percent of the women, followed by obesity (43 percent), hypertension (18 percent), and urinary tract infection (14 percent). Regression analysis of risk factors demonstrated the contribution of social conditions and medical factors to these diseases. Reproductive tract infections were shown to occur more frequently with uterovaginal prolapse, IUD use, presence of husband (regular sexual activity), and unhygienic behavior. Genital prolapse increased with age and number of deliveries. Age, recent pregnancy, education, socioeconomic class, and workload showed significant associations with related morbidity conditions. This evidence challenges national health programs to go beyond safe motherhood, child survival, and family planning in its services to women, and to consider the social context of health as well.

PIP: The prevalence of gynecological and related morbidity in a rural Egyptian community was assessed as part of the Program of Research and Technical Consultation in Family Resources. Child Survival, and Reproductive Health. A medical examination was conducted on a sample of 509 ever-married, nonpregnant women from November 1989 to July 1990. A logistic regression using Generalized Linear Interactive Modeling was performed for each type of morbidity. For gynecological morbidities, genital prolapse was diagnosed in 56%, reproductive tract infections in 52%, and abnormal cervical cell changes in 11% of the women. For related morbidities, anemia was present in 63% of the women, followed by obesity (43%), hypertension (19%), and urinary tract infection (14%). Most of the women were suffering from at least 1 morbidity, with only 3% free of all the morbidity conditions considered. Gynecological morbidity, together with urinary tract infection and syphilis, showed that 35% of the women had 1 morbidity, 34% had 2, and 17% had 3 or more morbidities. Regression analysis of risk factors demonstrated that social conditions and medical factors contributed to these diseases. Reproductive tract infections occurred more frequently with uterovaginal prolapse, IUD use, presence of husband (regular sexual activity), and unhygienic behavior. Genital prolapse increased with age and number of deliveries. Age, recent pregnancy, education, socioeconomic class, and workload revealed significant associations with related morbidity conditions. The risk of anemia was significantly related to age and to a pregnancy within the previous 2 years. With every increase of 1 year of age, the risk of hypertension increased by 9%. For every increase of 1 year of age, the risk of obesity increased by 7%. Women with the highest level of education had a 3 times greater risk of urinary tract infection than did uneducated women, while women of low-middle socioeconomic status had almost 4 times the risk of women in the lowest class.