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Editorial: Hajj and the public health significance of mass gatherings

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Ziad A. Memish 1

1Deputy Minister of Health for Public Health, Director of the World Health Organization Collaborating Centre for Mass Gathering Medicine & Professor, College of Medicine, Al Faisal University, Riyadh, Kingdom of Saudi Arabia (Correspondence to: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Mass gatherings (MG) refer to groups of people measured in the thousands, some definitions suggest 25 000 and above [1,2]. MG present unique health challenges distinct from the average population cohort of the same size. Within the context of an exploding global population, widely accessible air travel and unprecedented frequency of MG, health issues relating to MG medicine are more commonly encountered. Safeguarding individual and mass health at such gatherings is termed public health security [3].

MG-related infection is an emerging subspecialty in global epidemiology and while an extensive body of information and experiences now exists, not all are published and accessible to MG planners and public health administrators,and vital information awaits dissemination [4]. Infectious diseases have long played a substantial part in shaping human history and continue to be an issue of pressing concern. In this era of the “flat world”, globalization facilitates the spread of numerous infectious agents to all corners of the planet. No locale is too remote for a threatening pathogen, be West Nile Virus arriving in the United States or Rift Valley Fever reaching the Arabian Peninsula [5].

Public health risks focus on infectious agents both specific to humans (which are broadly and uniformly distributed) and zoonoses (infectious agents transmitted from animals to humans) which tend to be far more localized in their geographical distribution. Research has shown that emerging​

infectious diseases have roughly quadrupled over the past 50 years, and pathogens that originate in wild animals (wildlife zoonoses) account for the majority of such diseases. Further, the frequency of infectious disease emergence correlates highly with human population density, the density of mammalian species and human population growth. Some data exist indicating that emerging diseases (specifically zoonoses) are more likely to be seen in tandem with progressive global warming [6].

The role played by travel, migration, trade and human exchanges in the propagation of epidemic infectious disease is well known. Almost one billion people cross international borders each year. In 2008, there were 924 million international arrivals, 16 million more than 2007 [7]. Travel-related infection is reaching previously uncharted dimensions of scale and complexity and it is the Hajj experience that provides invaluable insights in predicting travel-related health challenges.

Hajj is the largest and most long-standing annual MG event on earth. It is the site of some of the greatest crowd densities known to man. Following an exponential rise in the past decade, Hajj is now the most internationally, ethnically, demographically and clinically diverse assembly today. The numbers of non-Saudi pilgrims attending the Hajj routinely exceed 2 million people, travelling to Makkah from over 180 countries, pushing the Hajj congregation towards the 3 million mark. The sheer dimensions of Hajj demand extraordinary imagination and agility from planners.

Because of the wide global attendance, international partnerships and collaborations in this process are increasingly necessary, as countries sending pilgrims ensure their fitness for travel and, later, continue to monitor the impact of the returning pilgrims to their countries of origin. The scale and diversity of Hajj presents an enormous public health security challenge to Saudi Arabian authorities who, as functionaries to the Custodians of the two holy sites (Makkah Al Mukarramah and Medina Al Munnawarah) must provide extensive, multi-faceted programmes to serve the “Guests of God” [8].

Because of this remarkable scale, and its annual occurrence, preparations for the public health safety and security of this event are extraordinarily challenging, requiring an intensely collaborative approach. Multiple domestic agencies must work together to prepare for Hajj within a matter of months. While most MG of this scale have the greater part of a decade to prepare, Saudi Arabia readies itself for the massive influx within a mere 11-month lead time demanding precision in organization and the surge deployment of massive semi-permanent infrastructures and manpower.

Such efforts are accomplished through intense inter-Ministry collaboration. Saudi authorities, including the Ministry of Health (MOH), the Ministry of Hajj, the Ministry of Interior (MOI), the Saudi Red Crescent and other government health sectors, including the Saudi Arabian National Guard Health Affairs, the Ministry of Defence and Aviation (MODA) and the Security forces, come together with a common focus of public health security. Collectively these agencies have accumulated decades of experience managing Hajj from every aspect, whether it be management and repatriation of the sick at Hajj, anticipating crowd turbulence or handling the arrival of over a million and a half head of cattle for ritual sacrifice.

With over 1.3 billion Muslims globally, many more seek to make Hajj than can be safely accommodated. In a delicate choreography of diplomacy and service, Saudi Arabia must balance the dual roles of both Custodian to the Holy Sites and Guardians to the Guests of God. Representatives of the Saudi authorities must safeguard Hajj for millions annually while at the same time carefully controlling its access to maintain public health safety and security.

Note must be made of the important work facilitated by the Saudi immigration authorities which safeguards public health, possibly one of the largest public health interventions today. Saudi Arabia provides visas to every eligible pilgrim, setting an annual quota of 1000 visas per million populations for every country. Access to all holy sites is strictly limited to visa and permit holders. The visa application process facilitates enforcement of basic public health requirements by specifying visa eligibility based on evidence of mandatory immunization (including against polio and yellow fever for pilgrims arriving from countries with active disease and meningococcal disease for all pilgrims, all important causes of disease at Hajj). Immigration thus becomes a tool facilitating public health security for such a massive gathering [9].

Given the complex, multi-factorial elements that comprise the preparation for Hajj, Hajj medicine clearly falls within the realm of public health security and must be recognized as such. Further, because of the Kingdom’s ability to effectively surge public health resources at short notice, it is in a position to make a unique contribution to other gatherings facing bioterrorism or disaster preparedness demands through exchange of information and experiences. Surge capacity is integral to public health security in which the Kingdom has exceptional experience. It is for those reasons that Saudi Arabia was recognized and acknowledged to be a World Health Organization Collaborating Centre for MG Medicine in September 2012 tasked with training, research and providing guidance and advice to MG administrators across the globe.

References

  1. Arbon P, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehospital and Disaster Medicine, 2001, 16:150–158.
  2. Mitchell JA, Barbera MD. Mass gathering medical care: a twenty-five year review. Prehospital and Disaster Medicine, 1997, 12:72–79.
  3. Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Medicine and Infectious Disease, 2009, 7:226–230.
  4. Memish ZA et al.Emergence of medicine for mass gatherings: lessons from the Hajj. Lancet Infectious Diseases, 2012, 12:56–65.
  5. Balkhy HH, Memish ZA. Rift Valley fever: an uninvited zoonosis in the Arabian peninsula [Review]. International Journal of Antimicrobial Agents, 2003, 21:153–157.
  6. Blancou J et al. Emerging or re-emerging bacterial zoonoses: factors of emergence, surveillance and control. Veterinary Research, 2005, 36(3):507–522.
  7. United Nations World Tourism Organization. UNWTO world tourism barometer (2009) (http://unwtp.orh/facts/eng/pdf/barometer/UNWTP_barom09_1_en_excrept.pdf, accessed 1 October 2013).
  8. Ahmed QA, Memish ZA. Hajj medicine for the Guests of God: a public health frontier revisited. Journal of Infection and Public Health, 2008, 1:57–61.
  9. Memish ZA, Al-Rabeeah AA. Health conditions of travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj and Umra) for 1434 (2013). Journal of Epidemiology and Global Health, 2013, 3:59–61.

Editorial: Health preparedness and legacy planning at mass gatherings in the EMR: a WHO perspective

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Nicolas Isla 1 and Isabelle Nuttall 2

1Technical Officer, Global Alert and Response Operations, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland.
2Director, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland.
EMHJ, 2013, 19(Mass Gathering):S7-S8

As more countries commit to hosting large, international mass gatherings, health preparedness planning is requiring more research and collaborative efforts. A growing body of researchers and policy-makers view mass gatherings as important opportunities for positive legacy for the community and visitors. This special edition of the Eastern Mediterranean Health Journal is a good example of a respected scientific publication offering its pages to researchers to share their experiences studying small, medium and large events; religious, sporting and cultural events; one-off events and events that recur in the same location year after year. This work, and the work of others, will help future hosts to assess options, to adapt and build existing systems and to evaluate their effectiveness through the acquired experience and mounting evidence generated by past organizers.

The Eastern Mediterranean Region (EMR) is host to some of the world’s largest mass gatherings. Each year the Kingdom of Saudi Arabia welcomes upwards of 3 million pilgrims from around the world; the Formula 1 motor racing championship is being held in two EMR countries in 2013 and Qatar is set to host the FIFA World Cup in 2022. There are a large number of other mass gatherings in the Region of all sizes and purposes, each with their own specific risks.

The World Health Organization (WHO) continues to build an interdisciplinary mass gathering programme that offers guidance, tools and expertise that public health authorities can use before planning an event. This mandate was provided by a decision at the 130th Executive Board Meeting in January 2012 advising the Secretariat to, among other activities, “multisectoral guidance on planning, management, evaluation and monitoring of all types of mass gathering events with specific emphasis on sustainable preventive measures including health education and preparedness”. In response, WHO has developed a three-point strategy for supporting countries with mass gathering health planning:

  • Capacity development and support for Member States and host organizations – protecting public health at mass gatherings
  • Establishment of governance, resources, tools and methodologies
  • Shaping the discipline: leadership and communication.

WHO has worked with organizers of some of the largest events including the London Olympics and the 2012 UEFA European Football Championship in Poland and Ukraine, Hajj and the World Youth Day. In addition, over the past year, a network of Collaborating Centres on mass gatherings has been established to act as regional hubs for best practice in mass gathering health preparedness planning. These Collaborating Centres are working with WHO Regional and Country Offices to promote public health planning and positive legacy development as a key area of investment for mass gathering organizers. The Ministry of Health of Saudi Arabia, Public Health England in the United Kingdom, the Institute of Public Health of Vojvodina in Serbia and the Disaster Research Centre and Flinders University in Australia are currently Collaborating Centres.

WHO is also working closely with international sporting federations, such as the International Olympic Committee, to encourage knowledge transfer between successive hosts and to make health preparedness a central pillar of any event.

Health planning, however, is only one component of the complex choreography of preparedness that needs to be undertaken. WHO's efforts to support health authorities in mass gathering health planning is in line with the all-hazard and whole-of-society approaches driving public health risk management under the International Health Regulations(2005). Mass gatherings, which are most often bound by immutable time frames, known years in advance, are test-beds for achieving better integration between sectors that can be applied in other public health contexts and emergencies. Furthermore, WHO has developed a framework for legacy research based on four areas of health system improvement:

  • improved medical and hospital services
  • strengthened public health system
  • an enhanced living environment
  • increased health awareness.

WHO has worked with a number of countries in the EMR including with the Ministry of Health of Iraq with which a workshop on mass gathering health preparedness was held in Amman in October 2012. An international team of experts from WHO and a representative from Public Health England worked with responsible health authorities from the Ministry of Health and District Health authorities from Karbala to improve health preparedness in the areas of on surveillance, pre-hospital casualty management, food and water safety, risk communication, coordination, preparedness and social mobilization. Likewise, WHO is currently working closely with Ministry of Health of the Kingdom of Saudi Arabia to manage risks associated with the emergence of the Middle East Respiratory Syndrome Coronavirus in the context of Hajj.

From the articles in this special edition on mass gathering, the reader will understand the complexity involved in planning a mass gathering. This collection of papers will provide a sense of the research being undertaken in the EMR to better understand the risks associated with mass gatherings and potential solutions to prevent and mitigate these risks during the event and achieve a long-term benefit from the experience. WHO will continue to work closely with any Member State on mass gathering health preparedness and planning.

Information sources

  1. Resolutions and Decisions, Annexes. Executive Board, 130th Session, Geneva, 16–23 January 2012 (http://apps.who.int/gb/ebwha/pdf_files/EB130-REC1/B130_REC1-en.pdf#page=17, accessed 7 October 2013).
  2. Global Alert and Response (GAR).Communicable disease alert and response for mass gatherings [webpage](http://www.who.int/csr/mass_gatherings/en/, accessed 7 October 2013).
  3. Global Alert and Response (GAR).Communicable disease alert and response for mass gatherings. Key considerations [webpage] (http://www.who.int/csr/mass_gathering/en/index.html, ,accessed 7 October 2013)
  4. International Health Regulations [webpage] (http://www.who.int/topics/international_health_regulations/en/, accessed 7 October 2013).

Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims

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A. Turkestani,1 M. Balahmar,2 A. Ibrahem,2 E. Moqbel 2 and Z.A. Memish 3

الاستفادة من العاملين في التثقيف الصحي لتحسين معرفة الحجاج بالسلوكيات الصحية في موسم الحج 1432/2011

عبد الحفيظ تركستاني، منيرة بلحمر، عادل إبراهيم، عصام مقبل، زياد ميمش

الخلاصـة: هدفت هذه الدراسة إلى تقييم الأثر القصير المدى على المعرفة الصحية للحجيج بعد تقديم رسائل نوعية من رسائل التثقيف الصحي. واختيرت عينة عشوائية من 6 نقاط لدخول الحافلات. واستخدمت الدراسة استبياناً يملؤه المشاركون في الدراسة بأنفسهم لتقييم معرفتهم قبل التدخل التثقيفي وبعده. وقد استكمل هذا الاستبيان 278 حاجاً. وكانت هناك زيادة ملحوظة في نسبة المشاركين الذين أجابوا إجابات صحيحة على جميع الأسئلة بعد التدخل التثقيفي (P<0.05). وذكر جميع المستجيبين تقريباً أنهم استفادوا من التثقيف الصحي، وأفادوا بنجاح العاملين في التثقيف الصحي في إيصال الرسائل. وأبلغ 19 حاجاً (%7.2) فقط أنهم تلقوا سلفاً رسائل صحية تثقيفية قبل وصولهم إلى المملكة العربية السعودية. وقبل هذا التدخل التثقيفي، كان %50 فقط من المستجيبين يعرفون أن الحلاقة المأمونة تقي من انتشار الأمراض المنقولة عن طريق الدم، وارتفعت هذه النسبة إلى %84.7 بعد التدخل التثقيفي. وأثبت التثقيف الصحي المباشر للحجاج فعاليته في تحسين المعرفة الصحية على المدى القصير.

ABSTRACT The main objective of this study was to assess the short-term effect on health knowledge among pilgrims after being provided specific health education messages.A random sample of 6 entry-point buses was selected. A self-administered questionnaire was used to assess knowledge before and after intervention; 278 pilgrims completed the questionnaire.There was a significant increase in the proportion of participants who answered all questions correctly after the educational intervention (P<0.05). Almost all respondents stated that they benefited from the health education and that the health educator was successful in delivering the messages. Only 19 (7.2%) reported that they had already received relevant health education messages prior to their arrival in Saudi Arabia. Before the intervention just 50% of the respondents knew that safe shaving prevents dissemination of bloodborne diseases; this rose to 84.7% after the intervention. Direct health education to pilgrims is effective in improving short-term health knowledge.

L'éducation sanitaire pour améliorer les connaissances des pèlerins de la Mecque en 2011 (Hajj 1432) sur les comportements favorables à la santé

RÉSUMÉ L'objectif principal de la présente étude était d'évaluer l’effet à court terme de certains messages d’éducation sanitaire sur les connaissances des pèlerins en matière de santé. Nous avons choisi comme échantillon aléatoire les personnes présentes à bord de six bus à l’entrée du site. Pour évaluer les connaissances avant et après l’intervention, nous avons utilisé un questionnaire auto-administré, que 278 pèlerins ont rempli.Le pourcentage de participants ayant répondu correctement à l’ensemble des questions était significativement plus élevé après l’intervention d’éducation sanitaire (P < 0,05). Presque tous les participants ont affirmé que cette intervention leur avait été utile et que l’éducateur avait bien fait passer les messages. Seules 19 personnes (7,2 %) ont déclaré qu'elles avaient déjà reçu des informations pertinentes en matière d’éducation sanitaire avant d’arriver en Arabie saoudite. Avant l’intervention, seuls 50 % des participants savaient qu’un rasage sans risque contribuait à prévenir la propagation des maladies à transmission hématogène ; ils étaient 84,7 % à le savoir après l’intervention. Communiquer des messages d'éducation sanitaire directement aux pèlerins est efficace pour améliorer les connaissances à court terme en la matière.

1Department of Public Health, Mecca Regional Health Directorate, Mecca, Saudi Arabia.
2Department of Preventive Medicine, Jeddah Health Directorate, Jeddah, Saudi Arabia.
3Department of Public Health, Ministry of Health, Riyadh, Saudi Arabia (Correspondence to Z.A. Memish: This email address is being protected from spambots. You need JavaScript enabled to view it.).
EMHJ, 2013, 19(Mass Gathering):S9-S12

Introduction

Health education has been described as a process by which individuals or groups learn to behave in a manner conducive to the promotion, maintenance or restoration of health[1].Communication in relation to health education involves various modes, e.g. lectures, discussions, symposia, posters, public address, and radio and television messages. Each mode has its own merits, drawbacks and scope of effectiveness. Messages may also have to overcome communication barriers (e.g. physio­logical, psychological, environmental and cultural). The effectiveness of a particular mode of health education varies according to the setting in which it is delivered[2,3]to a specific group [4]. It has been observed that different methods may be especially suitable for different groups of people depending upon their age, sex, educational qualification, background and the nature of their employment [1].

The Hajj has become the epicentre of the mass migration of millions of Muslims of various ethnic diversities. No other mass gathering can compare in scale or in regularity[5]. The preparedness plans made before the Hajj season ensure the optimum provision of health services for pilgrims to Saudi Arabia, and have been set up to minimize disease transmission both during their stay in the country and upon their return home[6].Health education is one of the principal services provided for pilgrims from their arrival. Health education of pilgrims, through the Health Education Ambassadors (HEA) programme, which was launched as an innovative approach in 1428 AH (2007 CE), is one of the principal activities supporting those plans.

The HEA module aimed at achieving 2 specific objectives:

  • Provide effective health education to pilgrims in their mother tongue at their dormitories in the holy places.
  • Encourage medical students to actively take a health education role during the Hajj.

Both objectives were achieved through inviting medical and health science students to voluntarily enrol in an HEA team. Volunteers agreed to undergo a training programme focusing on communication skills, the ethics of volunteer work and the important health messages to be delivered to arriving pilgrims. The messages were basically designed to cover issues related to healthy behaviour during the performance of the Hajj, for example, personal hygiene, measures protective against infectious respiratory droplets, avoiding exposure to direct sun, and proper ways of using razors. This programme benefited by making use of the students in Mecca who are often fluent in foreign languages in addition to Arabic.

In Hajj in 1431 AH (2010 CE), the HEA programme was extended to cover pilgrims arriving at King Abdul Aziz International Airport, 19 km north of Jeddah, the main aviation entry port for pilgrims. The messages were delivered to them in the Pilgrim’s City, just outside the Hajj terminal, while they waited aboard buses that would transport them to the holy places. Challenges to providing the training included the preoccupied state of pilgrims while completing their registration formalities on arrival. During Hajj 1432 AH (2011 CE), analysis of passenger flow within Pilgrim’s City showed that loading a bus takes about 4–6 minutes for pilgrims and up to 20–25 minutes for their luggage. This meant that the pilgrims waited in the stationary buses for about 20 minutes while waiting for luggage arrival and loading, prior to departure. This was determined to be the ideal time to deliver health messages. The HEA volunteers were organized into teams of 2: one volunteer was responsible for conveying messages aided by a pictorial chart while the other distributed a copy of the multilingual health message pictorial leaflet to each pilgrim.

This method of health education was intended to provide more effective health education. The executive committee of the Hajj recommended studying this new educational approach to determine its effectiveness. Therefore, the main objective of this study was to assess the short-term effect on health knowledge among pilgrim after they had been given specific health education messages.

Methods

Through a pre- and post-intervention study design, a random sample of 6 buses was selected from a total of about 300 buses on the last day of work in the Pilgrims City at King Abdul Aziz International Airport. Sample size was calculated to find a difference of at least 20% in improvement of level of knowledge of the participants after conducting the intervention. Considering a confidence level at 95% and a power of 80%, the estimated sample size was 244; this was increased to 300 to compensate for expected missing data. Since each bus accommodated about 50 pilgrims on average, 6 buses were adequate to saturate the estimated sample size,giving a total of around 300 pilgrims. The response rate was 92.7%: 278 completed questionnaires returned.

The total number of pilgrims aboard these buses was 300. The health educators boarded the buses, described the purpose of the study, and then invited pilgrims to participate. Those who agreed were asked to fill out a self-administered questionnaire (pre-test). The questionnaire had been designed and validated for a similar trial carried out the previous year for the local authority to assess the knowledge of pilgrims about healthy behaviour during Hajj (unpublished report).Reliability was assured by Cronbach’s alpha test which gave a value of 0.88; this is considered an acceptable reliability level.

The intervention included the health education messages provided through the HEA programme using a pictorial chart as well as the distribution of pictorial pamphlets. This was followed by assessment of knowledge using the same questionnaire (post-test).

Data were verified, assessed for quality, then analysed using SPSS, version 16.0.

Results

The response rate for completion of the pre-intervention questionnaire was 92.7% (n = 278) and 89.3% (n = 268) for completion of the post- intervention questionnaire. The proportion of pilgrims giving correct answers showed a significant increase on the post-test (Table 1)(P < 0.05). While around two-thirds of respondents (69.1%) indicated that pilgrims,whether healthy or sick, should consult a physician before departing for the Hajj, the figure was more than 80% after the intervention. Similarly,before the intervention just over two-thirds (68.7%) said that toothpaste is the only item that can be shared between 2 or more individuals; this increased to 94.4% after the intervention (Table 1).

The greatest improvement in knowledge was seen for the item relating to shaving: only half of the respondents knew that safe shaving with disposable tools prevents dissemination of some bloodborne diseases (e.g. HIV and hepatitis B) before intervention;this rose to 84.7% after the educational intervention (Table 1).

Almost all pilgrims (99.6%) agreed the HEA programme aboard the buses was beneficial, with 98.9% evaluating the health educator as successful in delivering the health education messages.

When asked about the importance of receiving health education messages in their home countries before departing to the Hajj, the overwhelming majority of the participants (92.4%) supported the idea. However, only 7.2% (n =19) stated that they had already received relevant health education messages in their home country.

Discussion

This study showed that using the educational intervention improved short-term knowledge in the population studied.

Volunteers have been documented to be effective health education providers[7].The HEA programme depends on volunteers from various medical faculties and health institutes in the Mecca region; their enthusiastic participation was essential to the health education programme. Student volunteer opinion, as well as that of mutawefs (guides), about the HEA programme was assessed during previous Hajj seasons (unpublished report), but the impact of these messages on the knowledge of pilgrims was not assessed. Our findings showed significant improvement in the short-term knowledge level among intervention recipients. This effect has been established in previous studies in similar settings, including India [1] and Saudi Arabia [4];the authors recommended that health education-focused programmes should be conducted in small groups, preferably via specific topic lectures.

The low rate for receiving pre-departure health education messages among those affluent enough to afford to travel by air and participate in the Hajj indicated a notable lapse in pre-travel preparation in the study population, and a need for home country educational interventions.

The limited time available to conduct the current health education intervention presented a significant limitation. It was conducted on the last day that pilgrims were arriving at King Abdul Aziz International Airport, and most were Arabic speakers. This population was not representative of all pilgrims. Also, it was not possible to obtain directly-paired responses from each of the pilgrims, and statistical analysis was therefore based on the overall percentages of pre- and post-test correct questionnaire responses.

Recommendations

The HEA programme should continue in the coming Hajj seasons with the inclusion of pilgrims at other portals of entry to Saudi Arabia, especially in Prince Mohammed Ibn Abdul Aziz International Airport in Medina.

A study of wider scope should be planned for the next Hajj season.

An additional study would be worthwhile to determine whether or not the intervention actually resulted in any change in health among pilgrims during the Hajj and in the following weeks, compared with those who did not participate in the intervention, along with the specifics of any diagnosis.

Methods to provide standardized, pre-departure, health education to pilgrims scheduled to participate in the Hajj should be explored. Health education materials should be prepared in concert with the Ministry of Health. This could include information provided to foreign travel agencies, additional links to health education posts already provided within Saudi Arabia, and shared through working with air carriers and charter companies serving Hajj ports of entry to provide in-flight health education videos.

Consideration should be given to investigating methods of educating those who enter the country using other means of transportation, including ships.

References

  1. Saha A, Poddar E, Mankad M. Effectiveness of different methods of health education: a comparative assessment in a scientific conference. BMC Public Health, 2005, 5:88.
  2. Nishtar S et al. Posters as a tool for disseminating health related information in a developing country: a pilot experience. Journal of the Pakistan Medical Association, 2004, 54:456–460.
  3. Werner RT Sr, Wilson JM. Are health education conferences effective? An evaluation of knowledge gain in a three-day institute. Health Education, 1981, 12:22–24.
  4. Abolfotouh MA. The impact of a lecture on AIDS on knowledge, attitudes and beliefs of male school-age adolescents in the Asir Region of southwestern Saudi Arabia. Journal of Community Health, 1995, 20:271–281.
  5. Memish ZA. The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims. Euro Surveillance : European Communicable Disease Bulletin, 2010, 15:19671.
  6. Memish ZA et al. Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1. Lancet, 2009, 374:1786–1791.
  7. Haroun HM et al. Assessment of the effect of health education on mothers in Al Maki area, Gezira state, to improve homecare for children under five with diarrhea. Journal of Family and Community Medicine, 2010, 17:141–146.

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