Review

Shiva Kargar¹, Alireza Ansari-Moghaddam¹,

¹Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran (Correspondence; S. Kargar: Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.).

Abstract

Background: Smoking is an important risk factor for various diseases, especially cancer.

Aims: To estimate the prevalence of cigarette and waterpipe smoking and its attributable fraction of cancer.

Methods:We searched Medline, Google Scholar, and PubMed for original articles published between 2000 and 2020 that reported the prevalence of waterpipe and cigarette smoking in Middle East countries. Data were analyzed using STATA version 14.

Results: We included 90 articles in this meta-analysis. The pooled prevalence of current cigarette and waterpipe smoking in Middle East countries was 17.41% and 6.92%, respectively. The prevalence of current cigarette and waterpipe smoking in men was significantly higher than in women. In the past decade, the prevalence of cigarette smoking decreased by 7.21% but the prevalence of waterpipe smoking increased by 7.80%. The highest population attributable risk was shown for oesophageal (35.0%), lung (30.50%), and gastric (8.20%) cancers.

Conclusion: The popularity of cigarette smoking is still a public health problem among adults, particularly in men in Middle East countries. About 30% of oesophageal and lung cancers in this region were attributed to cigarette smoking. The increasing trend in waterpipe smoking during the last decade is of concern. Prevention of cigarette and waterpipe smoking should be at the top of health priorities.

Keywords: prevalence, waterpipe smoking, cigarette smoking, Middle East countries, meta-analysis

Citation: Kargar S, Ansari-Moghaddam A. Meta-analysis of prevalence of cigarette and waterpipe smoking and its attributable fraction of cancer among adults in Middle East countries. East Mediterr Health J. https://doi.org/10.26719/emhj.23.077 Received: 28/04/2022; accepted: 09/02/2023

Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Tobacco use is the cause of many preventable diseases and premature death worldwide (1). WHO estimates that smoking-related mortality in developed countries will decrease by 9% from 2002 to 2030, while in developing countries, it will double (2). Previous studies have shown that smoking and hookah use are associated with various diseases, such as lung cancer, oral cancer, cardiovascular disease, and respiratory disease (3). Also, regular use of tobacco can expose a person to high levels of nicotine and cause dependence (4, 5).

The high prevalence of tobacco use is of concern in Middle East Countries, especially among school and university students, and it has been increasing in the last 20 years (6, 7). Smoking prevalence is reported to be higher in men than in women (8).

WHO has identified measures to reduce tobacco use by 25% until 2025. This goal may be undermined by the increase in prevalence in different environments (9). In the last 20 years, waterpipe smoking has become more common than cigarette smoking among young people and is part of a new global epidemic of tobacco use (10). The main factors driving waterpipe use are low cost and ready availability (11). Many people believe that waterpipe smoking is less dangerous than cigarettes and is used in social gatherings (12).

The aimsof this meta-analysis were: (1) to estimate the prevalence of cigarette and waterpipe smoking among adults in Middle East countries, based on age, sex, and year of publication; and (2) to investigate the population risk of common cancers attributed to cigarette and waterpipe smoking in Middle East countries.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform this systematic review and meta-analysis (13). We searched for relevant English-language articles from 2000 to 2020 in PubMed, Google Scholar, and Medline. The search strategy used a combination of terms: smoking, cigarettes, waterpipe, hookah, tobacco, prevalence, Middle-East, and the names of countries in the Middle East.

Inclusion criteria were: (1) cross-sectional studies published from 2000 to 2020; (2) assessment of the prevalence of current, daily, occasional, and regular waterpipe and cigarette smoking in adults; and (3) reports on prevalence of waterpipe and cigarette smoking separately from other forms of smoking. Exclusion criteria were: (1) studies that were not published in English; (2) studies with specific target populations, such as high school students, university students, or pregnant women; (3) no measure of prevalence or data to calculate 95% confidence intervals (CIs); and (4) mixed reports of the prevalence of any tobacco use (cigarettes, water pipe, and smokeless tobacco). We also excluded abstracts for which we could not identify the full text after contacting the corresponding author.

Two researchers independently screened the titles and abstracts of articles to identify eligible articles. We then assessed the full text of the studies and extracted data using an Excel form. The extracted data included: names of authors; year of publication; study setting (country and location); sampling (age, method, number in population, and sex); and prevalence of cigarette and waterpipe smoking and its 95% CIs. The current smoker category included always, sometimes, occasional, daily, and regular smokers.

Statistical analysis

We performed a random-effect meta-analysis to obtain pooled smoking prevalence estimates with 95% CIs. The I2 statistic was used to assess heterogeneity between studies. To explore the sources of heterogeneity, we conducted subgroup analyses by sex, country, residence, and age. Visual examination of the funnel plot and Egger’s test were performed to identify publication bias. All analyses were conducted by STATA-14 statistical software (Stata Corp., College Station, TX, USA). We calculated population attributable risks for common types of cancer, such as gastric, lung, ovarian, bladder, colorectal, oesophageal, liver, and kidney cancers, related to smoking in Middle East countries in males and females, using the formula: PAR = P (RR  1) / P (RR  1) + 1. The relative risk (RR) of cancer caused by smoking was obtained from a previously published meta-analysis, and prevalence (P) was estimated from studies identified in this meta-analysis. RR and 95% CI for gastric, lung, ovarian, bladder, colorectal, oesophageal, liver, and kidney cancers were 1.53 (1.42–1.65), 3.59 (3.25–3.96), 1.05 (0.95–1.16), 1.22 (1.06–1.4), 1.14 (1.10–1.18), 4.18 (3.42–5.12), 1.51 (1.37–1.67), and 1.39 (1.28–1.51), respectively (14–21).

Quality assessment

Loney et al. provided a tool for critical assessment of prevalence studies, which was used to assess the quality of the included studies (22). This instrument included 8 criteria: methodology (1, design; 2, sampling frame; 3, sample size; 4, outcome measures; 5, measurement; 6, response rate); interpretation of results (7, prevalence with CIs and detailed subgroup analysis); and applicability of results (8, are the study subjects and setting similar to those of interest?). The studies received 1 point for each criterion that was met. High-quality studies were rated 7 or 8, medium-quality studies 4–6, and low-quality studies 0–3.

Ethical considerations

The Ethics Committee of Zahedan University of Medical Sciences approved this study (IR.ZAUMS.REC.1401.214).

Results

We identified 1091 articles from the database search; 442 were duplicates, and 372 were excluded because of unrelated titles and after reading the abstract. We assessed the full text of 277 articles, and 187 were excluded for the following reasons: no cross-sectional study, did not measure prevalence rate, insufficient information, focus on specific populations, reports of prevalence of any tobacco use, and absence of full text. Finally, 90 articles were eligible for inclusion in the meta-analysis. Figure 1 shows the flowchart of the study selection. Most of the studies were conducted in the Islamic Republic of Iran (n = 33), Jordan (n = 12), and Saudi Arabia (n = 9). Overall, 744 960 participants aged ≥ 15 years were included in the meta-analysis. The sample size for the studies ranged from 46 to 170 430.

Quality assessment

Fifteen studies were categorized as high quality, 63 as moderate quality, and 12 as low quality. The low-quality studies had the highest pooled prevalence of current cigarette smokers (19.29%, 13.83–26.91%), followed by the moderate-quality studies (18.89%, 15.77–22.63%), and high-quality studies (12.44%, 7.03–22.0%). We found no indication of heterogeneity among the studies (P = 0.37).

Publication bias

The funnel plot revealed a little asymmetry (Figure 2). The P value for Egger’s test was 0.98, implying no publication bias.

Prevalence of current cigarette and waterpipesmoking

The overall pooled prevalence of current cigarette and waterpipe smoking among adults in 17 Middle East countries was 17.41% (95% CI: 13.76–22.03) and 6.92% (95% CI: 3.70–12.93), respectively (Figure 3 and Table 1). The highest prevalence of current cigarette smoking was seen in Iraq (32.0%, 95% CI: 20.20–50.69) and Cyprus (31.40%, 95% CI: 25.86–38.13). The lowest prevalence was in Bahrain (2.60%, 95% CI: 0.70–6.60) and Qatar (8.86%, 95% CI: 6.28–12.48) (P ˂ 0.001, I2 = 93.2%). The highest prevalence for waterpipe smoking was in Iraq (25.0%, 95% CI: 19.10–31.60) and Palestine (20.90%, 95% CI: 17.40–24.70). The lowest prevalence was in Oman (1.10%, 95% CI: 0.60–1.90) and Syrian Arab Republic (1.30%, 95% CI: 0.90–1.90).There was some heterogeneity among the studies (P ˂ 0.001, I2 = 96.7%).

According to sex, 24.86% of men and 4.09% of women smoked cigarettes and 9.55% of men and 5.05% of women smoked waterpipes (Table 1). Therefore, the prevalence of current cigarette and waterpipe smoking in men (P ˂ 0.001,I2 = 99.2%) was significantly higher than in women (P = 0.03, I2 = 77.3%). The prevalence of current cigarette smoking was highest among the age groups 30–39 (16.92%) and 40–49 (14.66%) years, and lowest among the age groups 18–29 (12.98%) and ≥ 60 (8.84%) years, but the difference was not significant (P = 0.28). In contrast, waterpipe smoking was most prevalent in the age groups 18–29 (4.0%) and 30–39 (3.60%) years, and least prevalent in the age groups 50–59 (0.76%) and ≥ 60 (0.84%) years (P ˂ 0.001, I2 = 88.7%). The rural population had a higher prevalence of cigarette smoking and a lower prevalence of waterpipe smoking than the urban population had, but these differences were not significant (P = 0.91, P = 0.66). The prevalence of cigarette smoking decreased from 22.25% (95% CI: 17.48–28.33) during 2008–2011 to 15.04% (95% CI: 11.20–20.21) during 2016–2020. The prevalence of waterpipe smoking increased from 6.03% (95% CI: 3.96–9.17) (P ˂ 0.001, I2 = 83.9%) to 13.83% (95% CI: 9.68–19.76) (P= 0.002, I2 =80.9%) during the same period of time.

Table 2 shows the population attributable risk of smoking for common types of cancer.The highest risk overall was for oesophageal cancer (35.0%), followed by lung (30.50%) and gastric (8.26%) cancers, and in both men and women. Also, because of the higher prevalence of smoking in men, the cancer burden associated with smoking was higher in men than in women.

Discussion

This meta-analysis showed that, between 2000 and 2020, ~20% of adults in the Middle East were cigarette smokers and ~7% were waterpipe users.The study demonstrated that waterpipe and cigarette smoking was more popular in Iraq, Cyprus, and Palestine. In comparison, the lowest prevalence of waterpipe and cigarette smoking was in Oman and Bahrain. Socioeconomic status and different customs and cultures may explain these differences in prevalence.

In this study, the prevalence of cigarette and waterpipe smoking was significantly higher in men than in women. This pattern was similar to other studies, including in Europe (8, 23), which may have been due to the social acceptance of men’s smoking habits. Another study confirmed that men smoke more than women do, regardless of age group (school children, university students, and adults) (24). In previous studies, smoking habits were related to various factors such as age, sex, and level of education (25), and prevalence was higher in people of lower socioeconomic status (26). In this study, the prevalence of cigarette smoking in rural populations was higher than in urban populations, but this difference was not significant. Our results showed that the prevalence of cigarette smoking increased from age 18–29 to 50–59 years, which is consistent with other related studies (27–29). In our study, most cigarette smokers were in the age groups of 30–39 (16.92%) and 40–49 (14.66%) years, and the prevalence was lower in people aged ≥ 60 years. This decrease in cigarette smoking could have resulted from attributable diseases and mortality and a better understanding of the dangers of smoking, and health literacy in the older age group.

The highest prevalence of waterpipe smoking was in the 18–29 and 30–39 years age groups. Other studies also showed that the prevalence of waterpipe smoking among young people has increased (30). This may have been because of the spread of waterpipe smoking as a recreational activity and a lack of awareness or understanding of the health risks in the younger age groups (31). There is a misconception that waterpipe smoking is less harmful than cigarette smoking and this has led to its social acceptance (32). Also, according to our results, the prevalence of waterpipe smoking has increased in the last decade and the prevalence of cigarette smoking has decreased. Other studies have shown that tobacco use has been declining in recent years and the use of alternative tobacco products including e-cigarettes and waterpipes has increased (33).

Smoking increases the risk of some types of cancer, including gastric, lung, and kidney cancers (34, 35). Accordingly, this study demonstrated that 35% of esophageal cancer, 30% of lung cancer, and 8% of gastric cancer in Middle East countries was attributed to cigarette smoking. Additionally, because of the higher prevalence of smoking in men, the burden of smoking-related cancers was also higher in men than in women.

There were a few limitations to this study that should be addressed before interpreting the findings. First, we used the results from self-reporting studies on cigarette and waterpipe smoking, and the categories reported differed (e.g. current, ever, daily, occasional, and regular). Second, the numbers of studies varied between countries. Third, the study populations differed in age distribution, sociodemographic characteristics, workplace and occupation, which might have caused differences in cigarette and waterpipe smoking prevalence. Fourth, the attributable risk was calculated using unadjusted relative risk, even though there were potential confounders, such as blood pressure, diabetes, and socioeconomic status, that could have affected the relationship between smoking and cancer.

Conclusion

This meta-analysis showed that the prevalence of cigarette smoking was high in adults, especially men, in Middle East countries. The increasing trend in the prevalence of waterpipe smoking in the last decade and among young people is worrying and emphasizes that prevention programmes should be at the top of health priorities. The high percentage of esophageal, lung, and gastric cancers in the Middle East was also related to smoking. Therefore, comprehensive tobacco use control programmes are needed to reduce the harm caused by tobacco use in Middle East countries.

Conflict of interest: The authors have no conflicts of interest to disclose.

Funding: There was no source of funding for this project.

References

1. Ekpu VU, Brown AK. The economic impact of smoking and of reducing smoking prevalence: review of evidence. Tobacco use insights. 2015 Jul 14;8:1–35. https://doi.org/10.4137/TUI.S15628 PMID:26242225

2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442. https://doi.org/10.1371/journal.pmed.0030442 PMID:17132052

3. Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol. 2017 Feb 1;46(1):32–43. https://doi.org/10.1093/ije/dyw021 PMID:27075769

4. Aboaziza E, Eissenberg T. Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence? Tob Control. 2015 March;24(Suppl 1):i44–53. https://doi.org/10.1136/tobaccocontrol-2014-051910 PMID:25492935

5. Arshad A, Matharoo J, Arshad E, Sadhra SS, Norton-Wangford R, Jawad M. Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review. BMC Public Health. 2019 Apr 27;19(1):1–11. https://doi.org/10.1186/s12889-019-6680-x PMID:31029118

6. Abu-Rmeileh NM, Alkhuffash O, Kheirallah K, Mostafa A, Darawad M, Al-Farsi Y, et al. Harm perceptions of waterpipe tobacco smoking among university students in five Eastern Mediterranean Region countries: a cross-sectional study. Tob Induc Dis. 2018 May 15;16:20. https://doi.org/10.18332/tid/89966 PMID:31516420

7. Akl EA, Gunukula SK, Aleem S, Obeid R, Abou Jaoude P, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health. 2011 Apr 19;11(1):1–12. https://doi.org/10.1186/1471-2458-11-244 PMID:21504559

8. Kheirallah KA, Veeranki SP, Alzyoud S, Alzoubi A, Walker L, Khader Y, et al. Collision of waterpipe and cigarette smoking epidemics among youth in Arab countries. J Subst Use. 2016;21(5):530–6. https://doi.org/10.3109/14659891.2015.1082159

9. Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA. The prevalence and trends of waterpipe tobacco smoking: a systematic review. PloS One. 2018 Feb 9;13(2):e0192191. https://doi.org/10.1371/journal.pone.0192191 PMID:29425207

10. Martinasek MP, McDermott RJ, Martini L. Waterpipe (hookah) tobacco smoking among youth. Curr Probl Pediatr Adolesc Health Care. 2011 Feb;41(2):34–57. https://doi.org/10.1016/j.cppeds.2010.10.001 PMID:21232693

11. Nakkash RT, Khalil J, Afifi RA. The rise in narghile (shisha, hookah) waterpipe tobacco smoking: a qualitative study of perceptions of smokers and non smokers. BMC Public Health. 2011 May 14;11(1):1–9. https://doi.org/10.1186/1471-2458-11-315 PMID:21569577

12. Aziz-ur-Rahman Niazi NA, Shayan SO, Shafiq Ahmad Joya HO. Waterpipe smoking among Herat University students: prevalence, attitudes, and associated factors. Addict Health. 2020 Oct;12(4):235. https://doi.org/10.22122/ahj.v12i4.277 PMID:33623642

13. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 Jul 21;6(7):e1000097. https://doi.org/0.1371/journal.pmed.1000097 PMID:19621072

14. Liu X, Peveri G, Bosetti C, Bagnardi V, Specchia C, Gallus S, et al. Dose-response relationships between cigarette smoking and kidney cancer: a systematic review and meta-analysis. Crit Rev Oncol Hematol. 2019 Oct;142:86–93. https://doi.org/10.1016/j.critrevonc.2019.07.019 PMID:31387065

15. Ladeiras-Lopes R, Pereira AK, Nogueira A, Pinheiro-Torres T, Pinto I, Santos-Pereira R, et al. Smoking and gastric cancer: systematic review and meta-analysis of cohort studies. Cancer Causes Control. 2008 Sep;19(7):689–701. https://doi.org/10.1007/s10552-008-9132-y PMID:18293090

16. Yan H, Ying Y, Xie H, Li J, Wang X, He L, et al. Secondhand smoking increases bladder cancer risk in nonsmoking population: a meta-analysis. Cancer management and research. 2018 Sep 21;10:3781–91. https://doi.org/10.2147/CMAR.S175062 PMID:30288109

17. Lee PN, Forey BA, Thornton AJ, Coombs KJ. The relationship of cigarette smoking in Japan to lung cancer, COPD, ischemic heart disease and stroke: a systematic review. F1000Research. 2018 Feb 19;7:204. https://doi.org/10.12688/f1000research.14002.1 PMID:30800285

18. Santucci C, Bosetti C, Peveri G, Liu X, Bagnardi V, Specchia C, et al. Dose–risk relationships between cigarette smoking and ovarian cancer histotypes: a comprehensive meta-analysis. Cancer Causes Control. 2019 Sep;30(9):1023–32. https://doi.org/10.1007/s10552-019-01198-8 PMID:31236793

19. Botteri E, Borroni E, Sloan EK, Bagnardi V, Bosetti C, Peveri G, et al. Smoking and colorectal cancer risk, overall and by molecular subtypes: a meta-analysis. Am J Gastroenterol. 2020 Dec;115(12):1940–9. https://doi.org/10.14309/ajg.0000000000000803 PMID:32773458

20. Wang Q-L, Xie S-H, Li W-T, Lagergren J. Smoking cessation and risk of esophageal cancer by histological type: systematic review and meta-analysis. JNCI: J Natl Cancer Inst. 2017 Dec 1;109(12):djx115. https://doi.org/10.1093/jnci/djx115 PMID:29933436

21. Lee Y-CA, Cohet C, Yang Y-C, Stayner L, Hashibe M, Straif K. Meta-analysis of epidemiologic studies on cigarette smoking and liver cancer. Int J Epidemiol. 2009 Dec;38(6):1497–511. https://doi.org/10.1093/ije/dyp280 PMID:19720726

22. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can. 1998;19(4):170–6. PMID:10029513

23. Johnson CA, Palmer PH, Chou C-P, Pang Z, Zhou D, Dong L, et al. Tobacco use among youth and adults in Mainland China: the China Seven Cities Study. Public Health. 2006 Dec;120(12):1156–69. https://doi.org/10.1016/j.puhe.2006.07.023 PMID:17007895

24. Bassiony MM. Smoking in Saudi Arabia. Saudi Med J. 2009 Oct;30(7):876–81. PMID:19838455

25. Wewers ME, Salsberry PJ, Ferketich AK, Ahijevych KL, Hood NE, Paskett ED. Risk factors for smoking in rural women. J Womens Health. 2012 May;21(5):548–56. https://doi.org/10.1089/jwh.2011.3183 PMID:22360694

26. Agaku IT, King BA, Husten CG, Bunnell R, Ambrose BK, Hu SS, et al. Tobacco product use among adults–United States, 2012–2013. MMWR Morb Mortal Wkly Rep. 2014 Jun 27;63(25):542.

27. Moosazadeh M, Salami F, Movahednia M, Amiri MM, Afshari M. Prevalence of smoking in northwest Iran: a meta-analysis. Electron Physician. 2014 Feb 1;6(1):734. https://doi.org/10.14661/2014.734-740 PMID:25763138

28. Fotouhi A, Khabazkhoub M, Hashemi H, Mohammad K. The prevalence of cigarette smoking in residents of Tehran. Arch Iran Med. 2009 Jul;12(4):358–64. PMID:19566352

29. Jaghbir M, Shreif S, Ahram M. Pattern of cigarette and waterpipe smoking in the adult population of Jordan. East Mediterr Health J. 2014 Dec 21;20(9):529–37. https://doi.org/10.3390/ijerph20010082 PMID:36612400

30. Cooper M, Pacek LR, Guy MC, Barrington-Trimis JL, Simon P, Stanton C, et al. Hookah use among US youth: a systematic review of the literature from 2009 to 2017. Nicotin Tob Res. 2019 Nov 19;21(12):1590–9. https://doi.org/10.1093/ntr/nty135 PMID:29961895

31. Akl EA, Jawad M, Lam WY, Obeid R, Irani J. Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J. 2013 Jul 2;10(1):1–10. https://doi.org/10.1186/1477-7517-10-12 PMID:23816366

32. Akl E, Ward K, Bteddini D, Khaliel R, Alexander A, Lotfi T, et al. The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally. Tob Control. 2015 Mar;24(Suppl 1):i13–21. https://doi.org/10.1136/tobaccocontrol-2014-051906 PMID:25618895

33. Lauterstein D, Hoshino R, Gordon T, Watkins B-X, Weitzman M, Zelikoff J. The changing face of tobacco use among United States youth. Curr Drug Abuse Rev. 2014;7(1):29–43. https://doi.org/10.2174/1874473707666141015220110 PMID:25323124

34. Skotsimara G, Antonopoulos AS, Oikonomou E, Siasos G, Ioakeimidis N, Tsalamandris S, et al. Cardiovascular effects of electronic cigarettes: a systematic review and meta-analysis. Eur J Prev Cardiol. 2019 Jul;26(11):1219–28. https://doi.org/10.1177/2047487319832975 PMID:30823865

35. Kim A, Ko H-J, Kwon J-H, Lee J-M. Exposure to secondhand smoke and risk of cancer in never smokers: a meta-analysis of epidemiologic studies. Int J Environ Res Public Health. 2018 Sep 11;15(9):1981. https://doi.org/10.3390/ijerph15091981  PMID:30208628

Tables and Figures

Table 1. Prevalence of current smoking in Middle East countries

Table 2. Population attributable risk of smoking for common types of cancer

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

Figure 2. Funnel plot to check for publication bias.

Figure 3. Overall prevalence of current smoking in Middle East countries.

Razyeh Bajoulvand¹, Mohammad R. Ramezanlou², Naser Derakhshani¹, Salime Goharinezhad^1,3, Mohammad R. Gholami², Fatemeh Toranjizadeh², Nadia Saniee³

¹Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence: S. Goharinezhad, Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.). ²School of Medicine, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. ³Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences (IUMS), Tehran, Islamic Republic of Iran. 4Social

Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Islamic Republic of Iran.

Abstract

Background: The affordability, accessibility, and quality of a primary health care system can make a crucial contribution to mitigation and management of a pandemic. Strong primary health care puts less strain on health systems during times of crisis.

Aims: A systematic mapping review was conducted to identify specific capabilities required to establish resilient primary health care in response to a crisis, and to highlight any research gaps that may need to be addressed.

Methods: A bibliographic search was conducted on PubMed, Scopus, Web of Science, and ProQuest from 2000 to 2021. The data were extracted to map the included studies and categorize published research into a framework of 6 building blocks. A graphical and tabular representation of the data was provided.

Results: A total of 4276 studies were retrieved, and 28 met the final inclusion criteria for the systematic map. Data extraction was done based on study design, year of publication, countries, type of communicable disease, and main interventions to build resilient primary health care. Most studies were conducted in 2020 and 2021 during the COVID-19 pandemic. A large number of studies emphasized telehealth during the pandemic.

Conclusion: This review summarizes > 20 years of research on how primary health care responded to public health emergencies. The review will enable policy-makers to take a broad view of the subject and determine which fields of research are well developed.

Keywords: primary health crisis, disaster, resilience, pandemic, mapping review

Citation: Bajoulvand R, Ramezanlou MR, Derakhshani N, Goharinezhad S, Gholami MR, Toranjizadeh F, et al. Systematic mapping review of measures to strengthen primary health care against pandemics. East Mediterr Health J. 2023;29(6):xxx-xxx http://doi.org/10.26719/emhj.20.xxx Received: 12/06/22, Accepted: 08/12/22

Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

 Introduction

Over the next 50 years, the number of disasters is expected to multiply 5-fold (1). WHO defines a disaster as serious disruption of the function of a community or society, which causes widespread human, social, economic, or ecological losses that cannot be resolved (2, 3). Disasters are divided into 3 broad groups: natural, human-made, and pandemic (4).

The global population is currently in the midst of the COVID-19 pandemic, which has spread rapidly across the world (5). On 22 February 2021, according to Johns Hopkins University, the global death toll from COVID-19 was ~2 500 000, making it the second most devastating event in a century and one of the 15 deadliest pandemics in history (6). Infectious disease epidemics are so widespread and complicated that health systems must have effective programmes to deal with these problems, otherwise, it will place a lot of pressure on the health systems (7–10). Most of the efforts to control COVID-19 have focused on laboratories and hospitals, and the role of primary health care in mitigation, preparedness, response, and recovery has been ignored. The concept of primary health care means making essential health care available to the community at large in a way that is acceptable to them, with their full participation, and at an affordable cost.

Globally, primary health care is recognized as a foundation for health systems due to its unique ability to deliver accessible, cost-effective, and equitable care. In the COVID-19 pandemic, health systems have faced extreme levels of morbidity and mortality, and primary health care has been pivotal in reducing hospital burden, screening, and monitoring. There is no single way to create a resilient primary health care system and it depends on the background and context of each country. Some systems have been able to deal with crises more effectively, and along with controlling the pandemic, they have relieved the pressure on hospitals. A pandemic is a major health crisis that occurs over a large geographical area, crosses international borders, and affects large numbers of people. There is no doubt that the COVID-19 pandemic is a public health crisis and a social, economic, and political crisis affecting all areas of health and life.

This review aimed to identify strategies to strengthen the primary health care system during disasters by reviewing previous literature and empirical evidence, and to provide guidance to policy-makers in designing a more resilient system. By taking into account the literature and new research related to the ongoing COVID-19 pandemic, strategies for strengthening resilience in primary health care were identified and mapped according to 6 building blocks of leadership and governance; health workforce; medical products, vaccines, and technologies; service delivery; health information systems; and health financing.

Methods

Study design

We conducted a systematic mapping review of studies that reported interventions to improve primary health care during health crises, especially pandemics. The review visually summarized evidence production and publication patterns, trends, and themes by categorizing, classifying, and describing the data. Mapping reviews can be helpful especially when there is an abundance of literature. Standard methodology was followed for screening, data extraction, data analysis, and visualizing the findings in systematic mapping. Two main themes were explored in this mapping review: interventions proposed for strengthening primary health care, and research gaps that need to be addressed.

Search strategy

We searched PubMed, Web of Science, Scopus and ProQuest for English-language articles published between 1 January 2000 and 11 July 2021. The search strategy was developed in consultation with a medical librarian (Table 1). The keywords were: primary health care, communicable diseases, epidemic, pandemic, SARS-CoV, MERS-CoV, SARS-CoV-2, disaster, resilience, risk reduction, response, model, best practice, and policy. Additional searches were performed on the WHO website and in Google Scholar. A review of the final list of articles for inclusion in the study was done manually.

Inclusion and exclusion criteria

We included studies that investigated primary health care, disasters (particularly communicable disease epidemics), risk management, and best practices. The following types of study design were included: reviews, reports, perspectives, qualitative, descriptive, mixed-method studies, case studies, and commentaries. Studies that examined similar cases in health sectors other than primary health care, studies published in languages other than English, and conference abstracts were excluded. We only included papers published after 2000 because of the greater diversity of epidemics and pandemics of communicable diseases in the current century.

Study selection process

Two authors screened all the retrieved articles. After elimination of duplicate studies, the titles and abstracts were reviewed and articles that were not consistent with the objectives of the study were excluded. Full texts of the articles were reviewed, and those that did not meet the inclusion criteria or were not related to the study objectives were excluded. A third author appraised the final summary. Endnote X9 reference management software was used to organize the documents.

Data extraction

To identify any flaws in the data extraction form and reach a finalized version, a pilot study was conducted on 5 studies . The final data extraction form included: title, author, country, year, study type, aim of study, type of disaster, disaster management cycle, intervention/experience, barriers/challenges, facilitators, and results. Two reviewers entered the data in Microsoft Excel. The reviewers resolved any disagreement by discussion, with the help of a third author if needed.

Data analysis

The extracted information was analysed using framework analysis, which is a hierarchical approach used to categorize data based on key themes and concepts (11, 12). We used the six building blocks of a health system framework for strengthening health systems (13). The components of this framework were: (1) service delivery: access and barriers to health services; (2) health human resources: availability, gender, and attitude of health workers; (3) medical supplies: availability and stock of selected medical supplies; (4) governance: accountability and community participation; (5) health information: information flow from health facility to the community; and (6) finance: user fees and indirect payments. The data coding process followed predetermined themes according to the 6 building blocks. These formed the basis for broader themes that were subcategorized to increase the explanatory ability of the data (14, 15) using the following steps: (1) familiarization with the data; (2) coding the data to systematically identify and document similarities, differences, and patterns; (3) collecting the coded data and organizing them into a thematic framework by developing a matrix, chart, or table; (4) analysing the data by comparing and contrasting, summarizing, and synthesizing the key issues and themes, and exploring the relationships between them; and (5) drawing conclusions and validating the findings.

Results

Search results

We extracted 4276 articles from the database searches, and included 28 that were relevant to primary health care resilience against communicable disease pandemics (16–43) (Figure 1). During the screening process, 1280 articles were removed because of duplication. In the next phase of screening, the articles were reviewed by title and abstract and 2940 were removed. Finally, during full-text review, 28 articles were excluded because of insufficient information and lack of relevance. Twenty-two studies were conducted in 2020 or 2021 during the COVID-19 pandemic and the remainder in 2010–2019. Most of the studies (75%) of communicable diseases were related to COVID-19, and other diseases were measles, Ebola, cholera, and H1N1 influenza.

Disaster risk management cycle

Only 7 studies were related to the prevention/mitigation phase of disaster management, and 13 to the preparation phase (Figure 2). All 28 studies addressed the response phase but only 2 mentioned the recovery phase.

Country of study

Oman, Liberia, America, South Korea, Qatar, Germany, Sweden, Greece, Papua New Guinea, Singapore, and Islamic Republic of Iran had 1 study each. India, England, Australia, New Zealand, and Brazil had 2 studies each. There were 3 studies in China. There was 1 study from the WHO South-East Asia Region; 1 collaborative study in Australia and Canada; 1 joint study in Australia, Canada, England, and United States of America (USA); and 1 joint study in Guinea, Sierra Leone, and Liberia.

Interventions, challenges, and facilitators identified

In studies of interventions for strengthening primary health care against epidemics and pandemics, 10 themes were identified: telehealth, clinical interventions, vaccination, strengthening health workers (e.g. skills, knowledge, motivation, and capacity to deliver quality health services), continuity of care, policy-making, guidelines, equipment availability, appropriate infrastructure, and education. We classified these into 6 main categories based on the WHO building blocks framework. For each intervention, some challenges and facilitators were identified (Table 2). A list of essential considerations for health policy-makers is shown in Table 3.

Discussion

The present study was conducted to identify the best practices and interventions made by countries to establish strong and resilient primary health care to tackle communicable disease pandemics and health emergencies. In this systematic mapping review, 28 articles from 20 countries were identified and reviewed. The WHO 6 building blocks framework was used to classify the identified categories. Ten subcategories were identified to strengthen primary health care against epidemics and pandemics: telehealth, clinical interventions, vaccination, strengthening health workers, continuity of care, policy-making, guidelines, equipment availability, appropriate infrastructure, and education.

The use of teleconsultation reduces crowding and infection risk in primary health care facilities, especially for high-risk populations (16, 17, 19, 25, 28). Epidemics and pandemics provide many challenges to provision of primary health care. One of the innovative solutions for population health coverage is using technological advances and telehealth (44, 45). Telehealth is one of the most effective and important interventions during epidemics to reduce transmission, especially in quarantine conditions (46, 47). Many high-income countries, such as Australia and the USA have implemented telehealth systems (48).

Continuity of health care, equipment availability, and education were identified as important strategies in strong primary health care systems. These can reduce treatment costs, improve community health, increase patient satisfaction, and reduce unnecessary hospitalization, especially in pandemic and epidemic situations (49–51). Screening and follow-up are widely used for diseases in primary health care and can meet the needs of patients with multiple morbidities (52).

Another strategy identified in our study was strengthening health workers (e.g. skills, knowledge, motivation, and capacity to deliver quality health services). Proactive training of community health workers is necessary to maximize the effectiveness of interventions during a crisis, as well as strengthening the supply chain management of drugs and finding suitable methods of providing supportive supervision when movements are restricted (23, 53, 54). The most important factors in emergency and disaster planning are encouraging healthcare personnel to provide effective services, and enhancing motivation of the workforce (10).

In epidemic and pandemic situations, primary health care centres and hospitals have to provide services for a large number of patients. The continuity of these services requires meticulous planning by officials, formulation of guidelines, and policy-making (10, 55). Decision-making during epidemics and pandemics is not easy. When an infectious disease appears, policy-makers take early actions to try and control onward transmission of the disease. However, decision-making in these situations brings many problems that must be investigated and resolved (56). Countries need to develop rapid and comprehensive research and strengthen strategies for evidence-based policy-making that can handle uncertainty (54, 57, 58).

Medical emergencies pose significant challenges to health systems because of heavy workloads, labour shortages, and reduced willingness of health workers to participate (10, 59). Volunteers can assist health workers in a variety of roles, including patient triage, treatment, and rehabilitation, and primary health care activities can be carried out if they receive proper training (59). Other necessities in epidemics and pandemics are comprehensive individual and family support programmes, attention to the needs of health workers, involvement of community members in addressing challenges, and the design and implementation of preventive planning, according to the number of employees in the primary health care system (10).

The COVID-19 pandemic disrupted routine primary care for various reasons, including fear of infection, travel restrictions, lack of monitoring systems, repurposing of facilities, personal decisions, and restriction of movement (60). This disruption will have negative consequences for the health system in the future. Recurrence of some diseases has resulted from delays in routine vaccination of children under the age of 5 years. It is essential to distribute vaccines and drugs according to the needs of each region and to establish acute care centres rapidly in areas where hospitals are unable to provide adequate care for patients with infection (60).

Effective leadership and good governance are key factors in strengthening the health system in epidemics and pandemics, so that it can assist in various ways, including intersectoral cooperation and construction of appropriate infrastructure. To achieve inter- and intrasectoral cooperation, we have to go beyond isolated thinking. Adoption of a social participation approach to improving health is one aspect of strengthening governance and leadership (61).

The health system needs to establish clear mechanisms to promote better coordination and cooperation among its different components. This can be achieved by fostering a trusting environment and strengthening information management. Another recommendation to improve collaboration across sectors is to adopt the health in all policies approach, which involves assessing the potential impact on the health of every policy before it is implemented, and making it a standard institutional practice (62).

Globally, pandemics and health emergencies have become a major burden on health systems, affecting other health services as well. Countries have adjusted their primary health care systems in response to crises in proportion to their needs and capabilities. Several of these measures indicate the effectiveness of policies and in some cases the need to implement compensatory policies.

This review had some limitations. First, only English-language studies were included; therefore, other important studies in different languages were not retrieved. Second, potentially important studies published before 2000 were not included. Third, there was limited access to Embase and the full text of some studies in our region.

Conclusion

There has been little research showing how to build resilient primary health care systems. Telehealth infrastructure needs to be strengthened because the COVID-19 pandemic is ongoing, and there may be other pandemics in the future that require people to stay at home or avoid visiting health care facilities. To improve primary health care, the workforce plays a vital role; therefore, it is important to address the challenges they face such as heavy workload, lack of protective equipment, and mental and emotional issues. Continuity of routine care during disasters promotes a more resilient public health system; however, this goal is challenged by an inefficient surveillance system, which can be mitigated with electronic health records. Primary health care becomes more resilient when there is community involvement and intersectoral collaboration. Finally, this review highlights that more research into primary health care resilience is needed to inform future plans and policy recommendations for the response to a global pandemic.

Acknowledgements

We would like to thank the Student Centre at Iran University of Medical Sciences for its support. In addition, we acknowledge the assistance of the anonymous reviewers that led to an improved version of the paper.

Conflict of interest: The authors report no potential conflict of interest.

References

1. Shi P. Disaster risk science: Springer Singapore; 2019.

2. Yew YY, Delgado RC, Heslop DJ, González PA. The Yew Disaster Severity Index: a new tool in disaster metrics. Prehosp Disaster Med. 2019 Feb;34(1):8–19. https://doi.org/10.1017/S1049023X18001115 PMID:30600793

3. Garrido J, Saunders W, editors. Disaster risk reduction and land use planning: Opportunities to improve practice. IAEG/AEG Annual Meeting Proceedings, San Francisco, California, 2018. Volume 5; Springer; 2019.

4. Willson K, Lim D. Disaster management in rural and remote primary healthcare settings: a scoping review protocol. JBI Evid Synth. 2020 Jan;18(1):81–6. https://doi.org/10.11124/JBISRIR-D-19-00029 PMID:31343495

5. Cabarkapa S, Nadjidai SE, Murgier J, Ng CH. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: a rapid systematic review. Brain Behav Immun Health. 2020 Oct;8:100144. https://doi.org/10.1016/j.bbih.2020.100144 PMID:32959031

6. Jordà Ò, Singh SR, Taylor AM. Longer-run economic consequences of pandemics? Cambridge, MA: National Bureau of Economic Research; 2020 (working paper 26934; http://www.nber.org/papers/w26934, accessed 8 April 2023).

7. Meskarpour-Amiri M, Shams L, Nasiri T. Identifying and categorizing the dimensions of Iran's health system response to the Covid-19 pandemic. J Military Med. 2020;22(2):108–14.

8. Derakhshani N, Doshmangir L, Ahmadi A, Fakhri A, Sadeghi-Bazargani H, Gordeev VS. Monitoring process barriers and enablers towards universal health coverage within the sustainable development goals: a systematic review and content analysis. Clinicoeconom Outcomes Res. 2020 Aug 25;12:459–72. https://doi.org/10.2147/CEOR.S254946. PMID:32922051

9. Nafar H, Aghdam ET, Derakhshani N, Sani’ee N, Sharifian S, Goharinezhad S. A systematic mapping review of factors associated with willingness to work under emergency condition. Human Resour Health. 2021;19(1):1–10. https://doi.org/10.1186/s12960-021-00622-y

10. Derakhshani N, Maleki M, Pourasghari H, Azami-Aghdash S. The influential factors for achieving universal health coverage in Iran: a multimethod study. BMC Health Serv Res. 2021 Jul 22;21(1):1–13. https://doi.org/10.1186/s12913-021-06673-0 PMID:34294100

11. Furber C. Framework analysis: a method for analysing qualitative data. Afr J Midwifery Womens Health. 2010;4(2):97–100. https://doi.org/10.12968/ajmw.2010.4.2.47612

12. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013 Sep 18;13(1):1–8. https://doi.org/10.1186/1471-2288-13-117 PMID:24047204

13. Organization, WHO. (2007). "Strengthening health systems to improve health outcomes: WHO’s framework for action." Geneva: WHO.

14. Mutale W, Bond V, Mwanamwenge MT, Mlewa S, Balabanova D, Spicer N, et al. Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study. BMC Health Serv Res. 2013 Aug 1;13(1):1–9. https://doi.org/10.1186/1472-6963-13-291 PMID:23902601

15. Zeng W, Li G, Ahn H, Nguyen HTH, Shepard DS, Nair D. Cost-Effectiveness of health systems strengthening interventions in improving maternal and child health in low-and middle-income countries: a systematic review. Health Policy Plan. 2018 Mar 1;33(2):283–97. https://doi.org/10.1093/heapol/czx172 PMID:29253136

16. Al Hasani S, Al Ghafri T, Al Lawati H, Mohammed J, Al Mukhainai A, Al Ajmi F, et al. The Use of Telephone Consultation in Primary Health Care During COVID-19 Pandemic, Oman: Perceptions from Physicians. J Prim Care Community Health. 2020 Jan–Dec;11: 2150132720976480. https://doi.org/10.1177/2150132720976480 PMID:33307943 PMCID: PMC7739075

17. Bassi A, Arfin S, John O, Jha V. An overview of mobile applications (apps) to support the coronavirus disease 2019 response in India. Indian J Med Res. 2020 May;151(5):468–73. https://doi.org/10.4103/ijmr.IJMR_1200_20 PMID:32474557

18. Bell S, Saliba V, Ramsay M, Mounier-Jack S. What have we learnt from measles outbreaks in 3 English cities? A qualitative exploration of factors influencing vaccination uptake in Romanian and Roma Romanian communities. BMC Public Health. 2020 Mar 23;20(1):381. https://doi.org/10.1186/s12889-020-8454-x PMID:32293379

19. Desborough J, Hall Dykgraaf S, Davis S, Kidd M. Reflecting on Australia's five principles for pandemic response in primary care through the lens of early international experiences of COVID-19. Aust J Gen Pract. 2021 Feb 5;50. https://doi.org/10.31128/AJGP-COVID-46 PMID:33543152

20. Kinder K, Bazemore A, Taylor M, Mannie C, Strydom S, George J, et al. Integrating primary care and public health to enhance response to a pandemic. Prim Health Care Res Dev. 2021 Jun 10;22:e27. https://doi.org/10.1017/S1463423621000311 PMID:34109936

21. Miller NP, Milsom P, Johnson G, Bedford J, Kapeu AS, Diallo AO, et al. Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone. J Glob Health. 2018 Dec;8(2):020601. https://doi.org/10.7189/jogh.08.020601 PMID:30023054

22. Subba SH, Pradhan SK, Sahoo BK. Empowering primary healthcare institutions against COVID-19 pandemic: a health system-based approach. J Fam Med Prim Care. 2021 Feb;10(2):589–94. https://doi.org/10.4103/jfmpc.jfmpc_1416_20 PMID:34041046

23. Siekmans K, Sohani S, Boima T, Koffa F, Basil L, Laaziz S. Community-based health care is an essential component of a resilient health system: evidence from Ebola outbreak in Liberia. BMC Public Health. 2017 Jan 17;17(1):84. https://doi.org/10.1186/s12889-016-4012-y PMID:28095824

24. Pan Z, Yang T, Chi C, Wang C. The role of CARDPC in response to COVID-19 in primary care in China. NPJ Prim Care Respir Med. 2020;30:41. https://doi.org/10.1038/s41533-020-00199-4

25. Rawaf S, Allen LN, Stigler FL, Kringos D, Quezada Yamamoto H, van Weel C, et al. Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide. Eur J Gen Pract. 2020 Dec;26(1):129–33. https://doi.org/10.1080/13814788.2020.1820479 PMID:32985278

26. Prado N, Rossi TRA, Chaves SCL, de Barros SG, Magno L, dos Santos H, et al. The international response of primary health care to COVID-19: document analysis in selected countries. Cad Saude Publica. 2020 Nov 20;36(12):e00183820. https://doi.org/10.1590/0102-311X00183820: PMID:33237251

27. Schmidt ME, von Fricken ME, Wofford RN, Libby RC, Maddox PJ. Access to care during a pandemic: improving planning efforts to incorporate community primary care practices and public health stakeholders. World Med Health Policy. 2020 Sep;12(3):274–81. https://doi.org/10.1002/wmh3.369

28. Javanparast S, Roeger L, Kwok Y, Reed RL. The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: a qualitative study. BMC Fam Pract. 2021 Apr 8;22(1):69. https://doi.org/10.1186/s12875-021-01408-w PMID:33832422

29. O’Sullivan B, Leader J, Couch D, Purnell J. Rural pandemic preparedness: the risk, resilience and response required of primary healthcare. Risk Manage Healthc Policy. 2020 Aug 17;13:1187–94. https://doi.org/10.2147/RMHP.S265610 PMID:32904086

30. Gong FF, Hu GY, Lin HQ, Sun XZ, Wang WX. Integrated healthcare systems response strategies based on the Luohu Model during the COVID-19 epidemic in Shenzhen, China. International Journal of Integrated Care. 2021 Feb 2;21(1):1. https://doi.org/10.5334/ijic.5628 PMID:33597832

31. Ku SS, Choe YJ. A public-private partnership model to build a triage system in response to a COVID-19 outbreak in Hanam City, South Korea. Osong Public Health

Res Perspect. 2020 Oct;11(5):339–42. https://doi.org/10.24171/j.phrp.2020.11.5.11 PMID:33117640

32. Al-Zaidan M, Mohamed Ibrahim MI, Mohamed Ghaith A-K, Azza Mustafa M, Mansoor Nawaz M, Samya Al A. Qatar’s Primary Health Care Medication Home Delivery Service: A Response Toward COVID-19. J Multidiscip Healthc. 2021 Mar 17;14:651–7. https://doi.org/10.2147/JMDH.S282079 PMID:33762825

33. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: Lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580–5. http://dx.doi.org/10.1136/bmjinnov-2021-000699

34. Jin H, Lu L, Liu J, Cui M. COVID-19 emergencies around the globe: China’s experience in controlling COVID-19 and lessons learned. Int J Qual Health Care. 2021 Feb 20;33(1): mzaa143. https://doi.org/10.1093/intqhc/mzaa143 PMID:33320189

35. Liaw ST, Kuziemsky C, Schreiber R, Jonnagaddala J, Liyanage H, Chittalia A, et al. Primary care informatics response to Covid-19 pandemic: adaptation, progress, and lessons from four countries with high ICT development. Yearb Med Inform. 2021 Aug;30:44–55. https://doi.org/10.1055/s-0041-1726489 PMID:33882603

36. Rosewell A, Bieb S, Clark G, Miller G, MacIntyre R, Zwi A. Human resources for health: lessons from the cholera outbreak in Papua New Guinea. Western Pac Surveill Response J. 2013 Jul 3;4(3):9–13. https://doi.org/10.5365/WPSAR.2013.4.2.006 PMID:24319607

37. Pingel ES, Llovet A, Cosentino F, Lesser J. Committing to continuity: primary care practices during COVID-19 in an urban Brazilian neighborhood. Health Educ Behav. 2021 Feb;48(1):29–33. https://doi.org/10.1177/1090198120979609 PMID:33322924

38. Williams D, Dilcher M, Dong HF, Lester B, Marshall K, Pink R, et al. Lessons from a system-wide response to a measles outbreak, Canterbury, February-April 2019. N Z Med J. 2020 Sep 25;133(1522):71–83. PMID:32994618

39. Eisele M, Pohontsch NJ, Scherer M. Strategies in primary care to face the SARS-CoV-2 / COVID-19 pandemic: an online survey. Front Med. 2021 Jun 2;8: 613537. https://doi.org/10.3389/fmed.2021.613537 PMID:34150788

40. Ohrling M, Øvretveit J, Lockowandt U, Brommels M, Sparring V. Management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in Stockholm, Sweden, and winter preparations. J Prim Health Care. 2020 Sep;12(3):207–14. https://doi.org/10.1071/HC20082 PMID:32988442

41. Stikova E, Gjorgjev D, Karadzovski Z. Strengthening the early-warning function of the surveillance system: the macedonian experience. NATO Science for Peace and Security Series A: Chemistry and Biology. Springer; 2010:45–58.

42. Goei A. Community care facility-a novel concept to deal with the COVID-19 pandemic: a Singaporean institution’s experience. J Public Health Manag Pract. 2020 Jan/Feb;26(6):613–21. https://doi.org/10.1097/PHH.0000000000001306 PMID:33239528

43. Joulaei H, Honarvar B, Zamiri N, Moghadami M, Lankarani KB. Introduction of a pyramidal model based on primary health care: a paradigm for management of 2009 H1N1 flu pandemic. Iran Red Crescent Med J. 2010;12(3):224–30. https://archive.ircmj.com/article/12/3/70846-pdf.pdf

44. Chauhan V, Galwankar S, Arquilla B, Garg M, Di Somma S, El-Menyar A, et al. Novel coronavirus (COVID-19): Leveraging telemedicine to optimize care while minimizing

exposures and viral transmission. J Emerg Trauma Shock. 2020 Jan–Mar;13(1):20–4. https://doi.org/10.4103/JETS.JETS_32_20 PMID:32308272

45. Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth. 2020 May;67(5):568–76. https://doi.org/10.1007/s12630-020-01591-x PMID:32052373

46. Papadimos TJ, Marcolini EG, Hadian M, Hardart GE, Ward N, Levy MM, et al. Ethics of outbreaks position statement. Part 2: family-centered care. Crit Care Med. 2018 Nov;46(11):1856–60. https://doi.org/10.1097/CCM.0000000000003363 PMID:30312225

47. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020 Aug 1;20(1):1193. https://doi.org/10.1186/s12889-020-09301-4 PMID:32738884

48. Current health expenditure per capita, PPP (current international $) [website]. World Bank; 2021 (https://data.worldbank.org/indicator/SH.XPD.CHEX.PP.CD, accessed 8 April 2023).

49. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x PMID:16202000

50. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res. 2003 Jun;38(3):831–65. https://doi.org/10.1111/1475-6773.00149 PMID:12822915

51. Rezapour R, Dorosti AA, Farahbakhsh M, Azami-aghdash S, Iranzad I. The impact of the Covid-19 pandemic on primary health care utilization: an experience from Iran. BMC Health Serv Res. 2022;22:404. https://doi.org/10.1186/s12913-022-07753-5

52. Stange KC, Ferrer RL. The paradox of primary care. Annals Family Med; 2009 Jul–Aug;7(4):293–9. https://doi.org/10.1370/afm.1023 PMID:19597165

53. Rezapour R, Letaief M, Khosravi A, Farahbakhsh M, Ahmadnezhad E, Azami S, et al. Primary health care quality assessment frameworks: state of the art review. Health Scope. 2022;11(3):e126407. https://doi.org/10.5812/jhealthscope-126407..

54. Moosavi A, Sadeghpour A, Azami-Aghdash S, Derakhshani N, Mohseni M, Jafarzadeh D, et al. Evidence-based medicine among health-care workers in hospitals in Iran: a nationwide survey. J Educ Health Promot. 2020 Dec;9:365. https://doi.org/10.4103/jehp.jehp_335_20 PMID:33575401

55. Koohpayezadeh J, Azami-Aghdash S, Derakhshani N, Rezapour A, Alaei Kalajahi R, Sajjadi Khasraghi J, et al. Best practices in achieving universal health coverage: a scoping review. Med J Islam Repub Iran. 2021 Dec 30;35:191. https://doi.org/10.47176/mjiri.35.191 PMID:36042832

56. Berger L, Berger N, Bosetti V, Gilboa I, Hansen LP, Jarvis C, et al. Rational policymaking during a pandemic. Proc Natl Acad Sci US A.. 2021 Jan 26;118(4):e2012704118. https://doi.org/10.1073/pnas.2012704118 PMID:33472971

57. Sharp A, Jain V, Alimi Y, Bausch DG. Policy and planning for large epidemics and pandemics - challenges and lessons learned from COVID-19. Curr Opin iInfect Dis. 2021 Oct 1;34(5):393–400. https://doi.org/10.1097/QCO.0000000000000778 PMID:34342301

58. Naghibi D, Mohammadzadeh S, Azami-Aghdash S. Barriers to evidence-based practice in health system: a systematic review. Evidence Based Care. 2021 Dec;11(2):74–82. https://doi.org/10.1111/jep.12222 PMID:25130323

59. Karimi Dehkordi N, Abbasi AF, Radmard Lord M, Soleimanpour S, Goharinezhad S. Interventions to improve the willingness to work among health care professionals in times of disaster: a scoping review. Inquiry. 2021 Jan–Dec;58:469580211059959. https://doi.org/10.1177/00469580211059959 PMID:34903077

60. Medina MG, Giovanella L, Bousquat A, Mendonça MHMd, Aquino R. Primary healthcare in times of COVID-19: what to do? Cad Saude Publica. 2020;36:e00149720. https://doi.org/10.1590/0102-311x00149720 PMID:32813791

61. Thomas S, Sagan A, Larkin J, Cylus J, Figueras J, Karanikolos M. Strengthening health systems resilience: key concepts and strategies. Geneva: World Health Organization; 2020 (Health systems and policy analysis; policy brief 36; https://apps.who.int/iris/handle/10665/332441, accessed 8 April 2023).

62. Ardalan A, Rajaei MH, Masoumi G, Azin A, Zonoobi V, Sarvar M, et al. 2012-2025 roadmap of IR Iran’s disaster health management. PLoS Curr. 2012 Jul 16;4: e4f93005fbcb34. https://doi.org/10.1371/4f93005fbcb34 PMID:22953239

Table 1. Complete search strategy for PubMed database

Figure 2. Numbers of studies that addressed the different stages of the risk management cycle.

Özgür Önal,¹ Fatma Y. Evcil,¹Kıymet Batmaz,¹ Betül Çoban¹ and Edanur Doğan¹

¹Suleyman Demirel Universitesi, Tip Fakultesi [Faculty of Medicine, Suleyman Demirel University], Isparta, Türkiye (Correspondence to Fatma Y. Evcil: Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.).

Abstract

Background: Workplace violence is a serious public health problem threatening health care workers worldwide.

Aim: We aimed to determine the prevalence of physical and verbal violence over the previous year and during the career of health workers in countries of the WHO Eastern Mediterranean Region and Türkiye.

Methods: The databases MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest were explored along with reference lists from selected articles. Inclusion criteria were: studies carried out in the WHO Eastern Mediterranean Region or Türkiye, staff working in hospitals and primary health care services, studies on health workers exposed to verbal and/or physical violence by patients/relatives. We initially identified 3513 articles. After further review, 75 studies conducted during 1999–2021 were eligible. These were analysed using MetaXL, version 5.3, and STATA, version 16.

Results: The study covered 69 024 health care professionals from 22 countries. Meta-analysis showed that 63.0% (95% CI: 46.7–79.2) of health care professionals had experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) physical violence. There was no difference for sample size, professional group, quality score or response rate. The frequency of physical and verbal violence in the subgroup analysis was statistically significantly different for country and year.

Conclusion: A variety of questionnaires and time intervals had been used, making it difficult to calculate a standard severity prevalence and compare subgroups. Examining the temporal trend of workplace violence by country and determining how country-specific social factors and policies affect it would be valuable in future studies.

Keywords: verbal violence, physical violence, health care workers, Eastern Mediterranean Region, systematic review, meta-analysis

Citation: Önal Ö, Evcil FY, Batmaz K, Çoban B, Doğan E. Verbal and physical violence against health care workers in the Eastern Mediterranean Region: a systematic review. East Mediterr Health J. 2023;29():xxx–xxx. https://doi.org/10.26719/emhj.XXXX Received: 23/12/22, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Workplace violence is a serious public health problem that threatens health care workers worldwide. Health care workers are an occupational group at high risk of workplace violence (1). The World Health Organization (WHO) has reported that at least 3 out of every 5 health care workers had been exposed to violence over the previous year (2,3). Violence negatively affects the health of all employees working in health institutions, from cleaning staff to doctors. Workplace violence is defined as threats, abuse and attacks that occur in work-related conditions and may affect the health of employees (4). All kinds of behaviours, from threats and insults to murder, are considered within the scope of workplace violence (5).

Violence in the workplace is examined under 2 main headings: physical and psychological. Physical violence is defined as the use of physical force that causes physical, psychological or sexual problems in the exposed person. Many situations, such as pushing, kicking, hitting, slapping and injuring with an object, can be given as examples (4). According to WHO, health workers are exposed to physical violence at rates ranging from 8% to 38% throughout their careers (1). It has been reported that 24.4% of health care workers have been exposed to physical violence in the previous year (3).

Psychological violence is any behaviour that causes the individual to be negatively affected psychologically (4). Verbal violence, such as insulting, shouting, threatening, swearing, etc., is the most common subdimension of psychological violence (6–9). According to WHO, health care workers are exposed to verbal violence at a much higher rate than physical violence (2). A recent meta-analysis in China found that 61.2% of health care workers were exposed to verbal violence in the last year (10).

Violence has a negative mental, physical and social impact. Violence against health care workers is known to cause a number of health issues, including psychological harm, injuries and death. Decreased job satisfaction and staff quitting their positions are also among the consequences (11). Therefore, violence in the health sector is a significant issue that has a direct impact on the health of employees and an indirect impact on the health of patients.

Determining the frequency of the violence that health care workers are exposed to is important for protecting the health of both employees and society. Studies have been conducted on the prevalence of violence among health care workers in different regions, however, we did not find any systematic review or meta-analysis that reported the frequency of violence (physical or verbal) among health care workers in the Eastern Mediterranean Region which compared different subgroups (country, occupation, time interval, sample size, study year, quality score, response rate). One meta-analysis conducted worldwide on this subject examined a specific subgroup and the prevalence of physical violence experienced in the previous year only (12). Detailed examination of health violence in the Eastern Mediterranean Region, as in our study, will reveal the regional dimensions of the problem.

In this study, we aimed to determine the prevalence of physical and verbal violence experienced by health care workers during one year and throughout their careers in countries with sociocultural similarities in the Eastern Mediterranean Region.

Methods

Study design

This study was conducted in accordance with the Preferred Reporting Elements for Systematic Reviews and Meta-analyses (PRISMA) (13) and was registered in the International Prospective Systematic Review Registry (PROSPERO) under the code CRD42022314256.

This meta-analysis was conducted following the checklist of the Meta-Analysis of Observational Studies in Epidemiology guidelines for the design. The specified guideline includes recommendations on reporting background, search strategy, methods, results, discussion and conclusions (14).

Search strategy

We searched 6 academic databases, MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest, with words arranged in accordance with MeSH terms. Search strategies for each database are shown in Table 1. The following search terms were used “physical violence”, “verbal violence”, “workplace violence”, “nurse”, ”doctor”, “health care professional”, “prevalence” and “incidence”.

Study selection and selection criteria

We carried out the research and selection of the studies in line with previously defined inclusion criteria. Studies were included if they met the following criteria: conducted in the countries of the WHO Eastern Mediterranean Region and Türkiye due to their sociocultural proximity; participants working in hospitals and primary health care services; and studies conducted on health workers exposed to verbal and/or physical violence by patients and their relatives. Only observational studies reporting prevalence of violence were included in the systematic review and meta-analysis. Only studies whose language of publication was English were selected.

Studies were excluded if they met the following criteria: randomized controlled trials and systematic reviews; studies whose main research topic was mobbing and burnout; studies in which the cause of violence was conflict and chaos in the country; and studies dealing with only sexual violence in health care professionals.

All the data detected in the literature search were transferred to Excel, and duplicates were removed. Scanning of titles and abstracts for these studies was done by referees (ÖÖ, FYE). Unclear titles/summaries were scanned by another reviewer (KB, BÇ, ED) and discussed by the reviewers until approval for inclusion or exclusion was obtained. All reviewers independently scanned full-text articles using a standardized search tool according to eligibility criteria such as country of study, study design, type of publication and sample studied. Studies meeting all criteria were included in the review. When contradictory conclusions were reached about inclusion or exclusion, these were resolved by discussion.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for the systematic review and selection of studies to be included in the meta-analysis.

Quality assessment

Loney criteria (8 items) were used for the quality scoring of the studies evaluated in this review (15). The criteria were: sampling method (random sample or whole population), sampling frame (defining the study population), sample size (< 355 or ≥ 355), questioning the violent event (using standard measurement form/other), unbiased measurement, response rate (< 70% or ≥ 70%), confidence intervals (CIs) and subgroup details and study subject. The total score was calculated by giving a score to the studies for each item; the overall scores ranged from zero (0) to 8 points, with higher scores indicating higher quality.

Statistical analysis

Data were analysed using MetaXL, version 5.3, and STATA, version 16. Small-study effects and publication bias were examined using the Luis Furuya-Kanamori (LFK) index, the Doi plot and the funnel plot (16). The Doi plot has been reported to be more intuitive and the LFK index more robust than the traditionally used Egger’s regression-intercept test (17). An LFK index value > 1 or 2 or < 2 indicate major asymmetry. For optimal interpretation, at least 5 studies are required, therefore only the LFK index and Doi plots relating to the prevalence of physical and verbal violence in the last year and during the career period were prepared for the subgroups. The LFK index was calculated by applying double arcsin, logit, and no transformation to the prevalence data, and the value with the least asymmetry was used in the analysis. Graphics and tables related to this subject are available from the authors on request.

Both the Cochran Q test and the I2 statistics were used to test the heterogeneity of the data (18). Significant heterogeneity between studies was assumed to be P 50% (19). If significant heterogeneity was observed between studies, a random effects model was adopted to calculate the prevalence of physical and verbal violence; otherwise, a fixed effects model was adopted. The same procedure was followed to generate meta-analytically derived national estimates of the prevalence of workplace violence (physical and verbal) based only on studies available from each country. Meta-analytical estimates could not be calculated for countries with < 2 studies (20). Prevalence estimates for the countries where the studies were conducted (Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Saudi Arabia, Syrian Arab Republic, Türkiye), the year of study (2010 and before vs 2011 and later) and sample size (< 355 and ≥ 355) were analysed by subdividing the professional group (physicians only, nurses only, all health care workers), quality score (< 6 vs ≥ 6) and response rate (< 70% and ≥ 70%). Statistical significance was set at P < 0.05.

Results

Study selection and study characteristics

For the systematic review and meta-analysis, a keywords search was carried out on the 6 academic databases, and 3513 articles were identified (Figure 1). After removing duplicates, 2675 articles were scanned for titles and abstracts. The remaining 274 full texts were reviewed, and we included 75 studies that met the eligibility criteria.

The selected studies were examined under 2 separate headings according to the type of violence, physical and verbal. Prevalence of violence was evaluated in 2 groups according to the time interval as “last year of the study (last year, last 6 months, last 2 months)” and “during career”. From the meta-analysis, 69 (92.0%) studies covered the prevalence of physical violence, 18 (24.0%) covered the frequency of physical violence encountered throughout the career, and 51 (68.0%) covered the frequency of physical violence encountered in the last year. Also from the meta-analysis, 71 (94.7%) studies included the prevalence of verbal violence, 17 (22.7%) the frequency of verbal violence encountered throughout the career, and 54 (72.0%) the frequency of verbal violence in the last year.

The studies included in the systematic review and meta-analysis were conducted between 1999 and 2021. Although violence was examined through the questionnaires in these studies, there was no standard measurement tool used in all of the studies. While the scale developed by WHO/ILO was used in 22 (29.4%) studies, other scales were used in 6 (8.0%) studies. In 47 (62.7%) studies, the questions were created by the researchers, i.e. they did not use any standard scales. The total number of health care workers examined in all studies was 69 024. Among the studies examining physical violence, 50 (66.7%) were from 2011 and later. Data from a total of 61 241 health care workers were assessed in studies on the frequency of physical violence. Fifty (66.7%) studies evaluating the prevalence of verbal violence were conducted in 2011 and later. The total number of health care workers covered in the studies examining verbal violence was 62 261. The countries that had the greatest number of studies on both physical and verbal violence were Türkiye and Saudi Arabia.

The mean quality score (Loney score) for the 75 studies reviewed was 5.2, with 34 (45.4%) scoring ≥ 6 (Table 2). Of the studies reporting the frequency of physical violence, 12 (16.0%) were conducted on physicians only and 23 (30.7%) on nurses only. Ammong those studies reporting the prevalence of verbal violence, 10 (13.4%) included only physicians and 27 (36.0%) included only nurses. An equal number of studies evaluated more than one occupational group for both physical and verbal violence. Since the frequency of verbal violence was examined in many categories in the one (1.4%) study included, and the participants could choose more than one proposition, the net frequency of this type of violence could not be calculated, and only the frequency of physical violence was included in the meta-analysis for that study (21).

For the calculation of the frequency of verbal violence in another study, the category sexual violence, which had been included with non-physical violence, was not included in the frequency of verbal violence (22), which we calculated as 57.9% for that study.

Publication bias was checked using a funnel plot. In the funnel plot analysis, although the prevalence of physical and verbal violence was symmetrical in the studies included in the meta-analysis, mean differences were widely spread. This may have occurred due to variations in sociodemographic characteristics. It was observed that the studies concentrated on a low level of standard errors, an indication that the sample size in most studies was satisfactory.

All studies included in the systematic review, along with their characteristics and the number of violent incidents, are presented in Table 3. The prevalence values obtained from the studies were transformed in accordance with the LFK index scores: transformation with the lowest LFK index was applied. The transformations applied in this framework are detailed in Table 4.

Prevalence of physical violence against health care workers

We analysed 18 studies to determine the prevalence of physical violence encountered by health care workers in the Eastern Mediterranean Region throughout their careers, in the last year, in the previous 6 months, and in the last 2 months (Figure 2). The estimated frequency was 23.4% (95% CI: 16.1–32.0) (Table 5). There was significant heterogeneity among the studies reviewed (Q = 1224.4, P < 0.001, I2 = 99%). The prevalence of physical violence in the last year was calculated at 19.0% (95% CI: 15.4–22.6) by pooling the data reported from 51 studies showing high heterogeneity (Q = 4024.39, P < 0.001, I2 = 99%).

Studies reporting the frequency of physical violence encountered throughout the career were conducted in the Islamic Republic of Iran, Iraq, Jordan, Morocco, Saudi Arabia and Türkiye. Prevalence varied between 8.0% (95% CI: 0.5–15.5) and 39.5% (95% CI: 0.1–97.3) by country, with a statistically significant difference between countries for the prevalence of physical violence (P < 0.027) (Table 5). The prevalence of physical violence in the last year was reported in more studies, and the estimates ranged from 10.6% (95% CI: 2.2–19.1) to 42.2% (95% CI: 33.3–51.1). The frequency of being exposed to physical violence in the last year also differed significantly between countries (P < 0.001).

When the studies were analysed according to the occupation of the health care professionals, the highest frequency of physical violence throughout the career was reported in studies involving only physicians (31.0%; 95% CI: 9.5–52.5). For studies reporting physical violence during the previous year, the highest prevalence (23.4%, 95% CI: 17.0–29.9) was reported in those that included only nurses. There was no statistically significant difference between the frequency of physical violence according to the occupational group for both time intervals investigated (during career, P = 0.412; for the last year, P = 0.147).

For studies examining the frequency of physical violence throughout the career, the prevalence calculated for those conducted in 2011 and later (29.7%; 95% CI: 17.9–41.4) was statistically significantly higher than that for studies conducted over the previous years (15.6%; 95% CI: 10.3–21.0) (P = 0.033). In studies examining the frequency of physical violence during the previous year, there was no significant difference in prevalence between studies conducted in in these 2 periods (P = 0.564).

Studies included in the meta-analysis were further divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Prevalence of verbal violence against health care workers

We analysed 71 studies to determine the prevalence of verbal violence. Data from 17 studies reporting the frequency of exposure to verbal violence during the professional career were pooled and the frequency of verbal violence was estimated at 73.7% (95% CI: 67.8–80.4) (Table 5). The frequency of exposure to verbal violence in the last year was calculated at 59.9% (95% CI: 54.7–65.1) (data from 54 studies). Heterogeneity was found between studies examined for both time intervals (during career Q = 784.76, P < 0.001, I2 = 98%; Q = 10 150.03, P < 0.001, I2 = 99%). The prevalence of verbal violence encountered during the career, in the last year, last 6 months, and last 2 months, and heterogeneity between studies are shown in Figure 3.

When analysed by country of study, the frequency of verbal violence throughout the career ranged from 63.0% (95% CI 46.7–79.2) to 87.0% (95% CI 82.0–92.0) (Table 5). Data obtained from studies conducted in the Islamic Republic of Iran, Iraq, Jordan, Saudi Arabia and Türkiye showed a statistically significant difference (P < 0.001). The frequency reported from studies examining verbal violence over the last year ranged from 45.0% (95% CI 30.7–59.4) to 85.0% (95% CI 83.0–87.0) by country (Table 5). The highest prevalence, 85.0%, was reported from the Syrian Arab Republic, followed by the Islamic Republic of Iran, 80.7%, and Bahrain, 78.0%. There was also a significant difference between the countries included in the meta-analysis for prevalence of verbal violence in the last year (P < 0.001).

Studies that included only physicians reported the highest frequency of verbal violence throughout the career, with a prevalence of 77.0% (95% CI: 67.1–86.8) (Table 5). The frequency of verbal violence reported in the last year was highest in studies that included only nurses (65.5%; 95% CI: 56.9–74.1). However, there was no significant difference between the frequency of verbal violence according to occupational group for both time intervals (during career, P = 0.799; for the last year (P = 0.099).

The frequency of encountering verbal violence throughout the career was higher in studies conducted diring or after 2011. However, the difference was not statistically significant (P = 0.201) (Table 5). For studies conducted in 2010 and before reporting on encountering verbal violence during the last year, the frequency (67.9%; 95% CI: 58.3–77.4) was statistically significantly higher than in studies conducted in 2011 and after (55.9%; 95% CI: 50.1–61.7) (P = 0.035) (Table 5).

Studies included in the meta-analysis were divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Supplementary materials, including Doi plots and funnel plots, are available from the authors on request.

Discussion

In this study, we pooled the prevalence estimates of physical and verbal violence in the workplace against health professionals reported in 75 studies published from 1999 to 2021. A total of 69 024 health care professionals from 22 countries in the WHO Eastern Mediterranean Region and Türkiye having similar sociocultural characteristics were included in the study. Our meta-analysis revealed that 63.0% (95.0% CI: 58.0–68.0) of health care workers in the Eastern Mediterranean Region experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) were exposed to physical violence. During their career, 3 out of every 5 health professionals had been exposed to verbal violence and 1 out of 5 had been subjected to physical violence.

This study provides the first quantitative estimate of the prevalence of physical and verbal violence perpetrated against health professionals in the countries of the WHO Eastern Mediterranean Region. The prevalence estimates presented are based on a pool of 75 studies on health care professionals at all levels of care and various types of profession conducted in many countries in the Region.

Although studies from all countries in the Region were eligible for inclusion, there were none on the prevalence of physical and verbal violence from 10 countries, Afghanistan, Djibouti, Libya, Oman, Qatar, Somalia, Sudan, Tunisia, United Arab Emirates and Yemen. In addition, more than half of the eligible studies were reported from Türkiye (20 studies), Saudi Arabia (12 studies) and the Islamic Republic of Iran (11 studies). It is clear that more studies are needed from the low- and middle-income countries of the Region.

We determined the frequency of physical violence to be 23.4% throughout the career and 19.0% during the last year. Some reviews we examined focused on the prevalence of physical violence in the workplace for health professionals; a wide range of frequencies (2% to 32%) was reported (3,23,24). Li et al., who presented the prevalence estimates of physical violence in all WHO regions and the world in 2018, determined the prevalence of physical violence in the last year in the Eastern Mediterranean Region at 17.1% (12). Corresponding results for other WHO regions were: Africa 20.7%; America 23.6%; Europe 26.4%; Western Pacific 14.5%; Southeast Asia 5.6%; and worldwide 19.3%. Our estimation for the Eastern Mediterranean Region was similar to the world value and higher than some regions (Western Pacific and Southeast Asia) reported by Li et al.

We found the frequency of verbal violence against health care providers was 73.7% during the career and 59.9% for the last year. Previous meta-analyses have reported the frequency of verbal violence from different regions or the frequency of verbal violence experienced by a specific health care profession group in the Eastern Mediterranean Region (25,26). In a 2019 meta-analysis, which included studies from 5 regions of the world, the frequency of exposure to non-physical violence in the last year was 42.5%. The highest frequency was reported from North America (58.7%), followed by Asia (45.5%) and Australia (38.7%). In the same study, the most common subtypes of non-physical violence were 57.6% for verbal abuse and 33.2% for threats (3). In an umbrella review and meta-analysis examining violence against health care professionals, the prevalence of verbal violence was 66.8% (27). In a meta-analysis encompassing studies in China, the frequency of verbal abuse was 61.2% and the frequency of threat 39.4% (10). In all the meta-analyses cited above, the frequency of verbal violence was freater than that of physical violence (3,10,27), similar to our own findings.

In the subgroup analysis, we found no statistically significant relationship between the prevalence estimates for physical and verbal violence that health professionals were exposed to during the career and in the last year or less and sample size, response rate, quality score or professional group. The meta-analysis by Li et al. reported that the prevalence estimates were significantly higher in studies with a sample size ≤ 500, a quality score < 5 or a low response rate (12). However, it has also been found that studies with fewer participants may be associated with higher prevalence estimates that could be attributed to selection bias and publication bias (28). In a 2019 systematic review that evaluated workplace violence as physical and non-physical, nurses had the highest exposure to any type of violence, followed by doctors and other health professionals (3). In another systematic review, nurses were exposed to physical violence more frequently than doctors (12). It is clear that further studies are needed to provide more evidence about violence against health professionals in the workplace.

Our findings indicated that there was a significant difference between countries in terms of the frequency of verbal and physical violence, both throughout the career and during the last year. Data on the frequency of verbal and physical violence throughout the career were available from only 6 countries. Only one study covering 2 countries (Iraq and Jordan) was included in the meta-analysis. These findings suggest that more studies are needed to examine the frequency of physical and verbal violence throughout the career in countries in the Region. The frequency of verbal violence in the last year has been reported in more countries and more studies, however, analysis of publication bias revealed major asymmetry between studies. The results reporting the prevalence of violence in the last year should be carefully evaluated due to the small number of countries involved, the results relating to the frequency of violence throughout the career, and the major asymmetry from publication bias. It should, however, be taken into account that each country has its own particular working environment and conditions and geographical and cultural differences in the perception of violence, and that any standard definition and measurement of violence are not included in the studies.

We found that the year of publication was correlated with the prevalence estimates. In studies conducted in 2011 and later, physical violence throughout the career was significantly more prevalent than in those conducted in 2010 and before. For verbal violence, frequency in the last year was 67.9% in studies published in 2010 and before. This was significantly higher than the results for later years. In contrast, in our study we did not find any significant relationship reported in other systematic reviews on violence in health settings (3,12). The fact that more recent studies reported a higher prevalence of violence in our meta-analysis may be due to the increase in violence in the last decade, or it may be a result of an increase in awareness about workplace violence. Also, the number of studies conducted on violence in health has seen an increase over the past decade, with only 23 of the 75 studies dating from 2010 or earlier.

Our study had certain strengths and weaknesses. There was no standard measurement method in studies conducted to evaluate workplace violence among health professionals. There were definitional differences in terms of severity and typs. The time intervals in which violence was investigated differed in the studies we included. For this reason, we need to consider bias in recall studies that assess long-term violence (for example, throughout the career). The studies examined were analysed according to characteristics such as sample size, quality score and year of study; even so, it should be considered that many other factors may affect the frequency of violence when examining the results. For example, the frequency of violence encountered throughout the career may be greater in older participants, and some participants may not report the violence they have been exposed to for fear of losing their job. A particular behaviour perceived as violence in one society may be perceived as normal in another; a circumstance that may be misleading when comparing results.

Along with these limitations, our research also had some strengths. As far as we know, this is the first study in which physical and verbal violence related to the Eastern Mediterranean Region, which covers a vast geographical area and many countries, are examined together.In addition, within the scope of the study, the frequencies of both physical and verbal violence were discussed separately during the whole career and in the last year. This has allowed the frequency of violence to be discussed for specific time intervals.

Conclusion

Different questionnaires and different time intervals were used in the studies examined. This makes it difficult to calculate a standard severity prevalence and compare subgroups. Using a standard questionnaire in future studies would provide clearer results. In addition, practical interventions in the health sector are still urgently needed. In future research, it would be helpful to examine the temporal trend of workplace violence by country to determine how country-specific social factors and policies affect it and to investigate the causes of violence and methods for prevention.

Funding: None.

Competing interests: None declared.

References

1. Preventing violence against health workers. Geneva: World Health Organization; 2022 (https://www.who.int/activities/preventing-violence-against-health-workers, accessed 1 April 2023).

2. Violence and harassment. Geneva: World Health Organization; 2022 (https://www.who.int/tools/occupational-hazards-in-health-sector/violence-harassment, accessed 1 April 2023).

3. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019; 76(12):927–37. doi:10.1136/oemed-2019-105849.

4. Framework guidelines for addressing workplace violence in the health sector/Joint Programme on Workplace Violence in the Health Sector. Geneva: International Labour Office, International Council of Nurses, World Health Organization, Public Services International; 2002 (https://apps.who.int/iris/handle/10665/42617, accessed 1 April 2023).

5. Jenkins L. Current intelligence bulletin 57. Violence in the workplace. Risk factors and prevention strategies. Cincinnati: Centers for Disease Control and Prevention/NIOSH; 1996 (Publication No. 96-100; https://www.cdc.gov/niosh/docs/96-100/, accessed 1 April 2023).

6. Li P, Xing K, Qiao H, Fang H, Ma H, Jiao M, et al. Psychological violence against general practitioners and nurses in Chinese township hospitals: incidence and implications. Health Qual Life Outcomes. 2018;16(1):1–10. doi:10.1186/s12955-018-0940-9

7. Xing K, Zhang X, Jiao M, Cui Y, Lu Y, Liu J, et al. Concern about workplace violence and its risk factors in Chinese Township Hospitals: a cross-sectional study. Int. J. Environ. Res. Public Health. 2016;13(8):811. doi:10.3390/ijerph13080811

8. Cetinkaya F, Dur N, Akbulut Z, Korkmaz M. Evaluation of the violence experienced by nurses of different generations and their strategies for coping with the stress resulting from violence. Int J Caring Sci. 2018;11(3):1756–62 (https://internationaljournalofcaringsciences.org/docs/48_centicaya_original_11_3.pdf, accessed 10 April 2023).

9. Work-related violence and its integration into existing surveys. Geneva: International Labour Organization, Department of Statistics; 2013:13. (https://www.ilo.org/public/libdoc//ilo/2013/113B09_220_engl.pdf, accessed 16 November 2022).

10. Lu L, Dong M, Wang S bin, Zhang L, Ng CH, Ungvari GS, et al. Prevalence of workplace violence against health-care professionals in China: a comprehensive meta-analysis of observational surveys. Trauma Violence Abuse. 2020;21(3):498–509. doi:10.1177/1524838018774429

11. Violence: occupational hazards in hospital. Cincinnati: Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2002 (https://www.cdc.gov/niosh/docs/2002-101/pdfs/2002-101.pdf?id=10.26616/NIOSHPUB2002101, accessed 18 November 2022).

12. Li YL, Li RQ, Qiu D, Xiao SY. Prevalence of workplace physical violence against health care professionals by patients and visitors: a systematic review and meta-analysis. Int J Environ Res Public Health. 2020;17(1):299. doi:10.3390/ijerph17010299

13. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol. 2021 Jun;134:103–12. doi: 10.1016/j.jclinepi.2021.02.003

14. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000 Apr 19;283(15):2008–12. doi: 10.1001/jama.283.15.2008

15. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can, 1998;19(4): 170–6. PMID:10029513

16. Furuya-Kanamori L, Barendregt JJ, Doi SA. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc. 2018;16(4):195–203. doi:10.1097/XEB.0000000000000141

17. Lin L, Chu H. Quantifying publication bias in meta-analysis. Biometrics. 2018;74(3):785–94. doi:10.1111/biom.12817

18. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11(2):193. doi:10.1037/1082-989X.11.2.193

19. Erickson L, Williams-Evans SA. Attitudes of emergency nurses regarding patient assaults. J. Emerg. Nurs. 2000;26(3);210–5. doi:10.1016/S0099-1767(00)90092-8

20. Valentine JC, Pigott TD, Rothstein HR. How many studies do you need? A primer on statistical power for meta-analysis. J Educ Behav Stat. 2010;35(2):215–47. doi:10.3102/1076998609346961

21. Bayram B, Cetin M, Oray NC, Can IO. Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey. BMJ Open. 2017;7,e013568. doi:10.1136/bmjopen-2016-013568

22. Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res. 2012;12:469. doi:10.1186/1472-6963-12-469

23. Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJG. Patient and visitor violence in general hospitals: A systematic review of the literature. Aggress Violent Behav. 2008;13(6):431–41. doi:10.1016/j.avb.2008.07.001

24. Nikathil S, Olaussen A, Gocentas RA, Symons E, Mitra B. Workplace violence in the emergency department: A systematic review and meta-analysis. Emerg Med Australas. 2017;29(3):265–75. doi:10.1111/1742-6723.12761

25. D’Ettorre G, Mazzotta M, Pellicani V, Vullo A. Preventing and managing workplace violence against healthcare workers in emergency departments. Acta Biomed. 2018;89(4-S):28–36. doi:10.23750/abm.v89i4-S.7113

26. Aljohani B, Burkholder J, Tran QK, Chen C, Beisenova K, Pourmand A. Workplace violence in the emergency department: a systematic review and meta-analysis. Public Health. 2021;196:186–97. doi:10.1016/j.puhe.2021.02.009

27. Sahebi A, Golitaleb M, Moayedi S, Torres M, Sheikhbardsiri H. Prevalence of workplace violence against health care workers in hospital and pre-hospital settings: an umbrella review of meta-analyses. Front Public Health. 2022;10:895818. doi:10.3389/fpubh.2022.895818

28. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of depression and depressive symptoms among resident physicians: systematic review and meta-analysis. JAMA. 2015; 314(22):2373–83. doi:10.1001/jama.2015.15845

References for studies included in this review

Abbas MAF, Fiala LA, Rahman AGA, Fahim AE. Epidemiology of workplace violence against nursing staff in Ismailia Governorate, Egypt. J Egypt Public Health Assoc. 2010;85(1):16. PMID:21073846

Abdellah RF, Salama KM. Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan Afr Med J. 2017;26:21. doi:10.11604/pamj.2017.26.21.10837

Abou-ElWafa HS, El-Gilany AH, Abd-El-Raouf SE, Abd-Elmouty SM, El-Sayed Hassan El-Sayed R. Workplace violence against emergency versus non-emergency nurses in Mansoura university hospitals, Egypt. J Interpers Violence. 2015;30(5):857–72. doi:10.1177/0886260514536278

AbuAlRub RF, Khalifa MF, Habbib MB. Workplace violence among Iraqi hospital nurses. J Nurs Scholarsh. 2007;39(3):281–8. doi:10.1111/j.1547-5069.2007.00181.x

AbuAlRub RF, Al-Asmar AH. Psychological violence in the workplace among Jordanian hospital nurses. J Transcult Nurs. 2014;25(1):6–14. doi:10.1177/1043659613493330

Acik Y, Deveci SE, Gunes G, Gulbayrak C, Dabak S, Saka G, vd. Experience of workplace violence during medical speciality training in Turkey. Occup Med. 2008;58(5):361–6. doi:10.1093/occmed/kqn045

Adib SM, Al-Shatti AK, Kamal S, El-Gerges N, Al-Raqem M. Violence against nurses in healthcare facilities in Kuwait. Int J Nurs Stud. 2002;39(4):469–78. doi:10.1016/s0020-7489(01)00050-5

Ahmed AS. Verbal and physical abuse against Jordanian nurses in the work environment. East Mediterr Health J. 2012;18(4):318–24. doi:10.26719/2012.18.4.318.

Akbolat M, Sezer C, Unal O, Amarat M, Durmus A. The effects of direct violence and witnessed violence on the future fear of violence and turnover intention: A study of health employees. Curr Psychol. 2021;40(9):4684–90. doi:10.1007/s12144-019-00410-x

Alameddine M, Kazzi A, El-Jardali F, Dimassi H, Maalouf S. Occupational violence at Lebanese emergency departments: prevalence, characteristics and associated factors. J Occup Health. 2011;53(6):455–64. doi:10.1539/joh.11-0102-oa

Alameddine M, Mourad Y, Dimassi H. A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLOS ONE. 2015;10(9):e0137105. doi:10.1371%2Fjournal.pone.0137105

Al Anazi RB, AlQahtani SM, Mohamad AE, Hammad SM, Khleif H. Violence against health-care workers in governmental health facilities in Arar City, Saudi Arabia. Sci World J. 2020 Mar 20;2020:6380281. doi:10.1155/2020/6380281

AlBashtawy M, Al-Azzam M, Rawashda A, Batiha AM, Bashaireh I, Sulaiman M. Workplace violence toward emergency department staff in Jordanian hospitals: a cross-sectional study. J Nurs Res. Mart 2015;23(1):75–81. doi:10.1097/jnr.0000000000000075

Albashtawy M. Workplace violence against nurses in emergency departments in Jordan. Int Nurs Rev. 2013;60(4):550–5. doi:10.1111/inr.12059

Algwaiz WM, Alghanim SA. Violence exposure among health care professionals in Saudi public hospitals. A preliminary investigation. Saudi Med J. Ocak 2012;33(1):76–82. PMID:22273653

Alhamad R, Suleiman A, Bsisu I, Santarisi A, Owaidat AA, Sabri A et al. Violence against physicians in Jordan: An analytical cross-sectional study. PLOS ONE. 2021;16(1):e0245192. doi:10.1371/journal.pone.0245192

Alharbi FF, Alzneidi NA, Aljbli GH, Morad SA, Alsubaie EG, Mahmoud SA et al. Workplace violence among healthcare workers in a tertiary medical city in Riyadh: a cross-sectional study. Cureus. 2021;13(5). doi:10.7759/cureus.14836

Al-Omari H. Physical and verbal workplace violence against nurses in Jordan. Int Nurs Rev. 2015;62(1):111–8. doi:10.1111/inr.12170

Al-Omari H, Khait AA, Al-Modallal H, Al-Awabdeh E, Hamaideh S. Workplace violence against nurses working in psychiatric hospitals in Jordan. Arch Psychiatr Nurs. 2019;33(5):58–62. doi:10.1016/j.apnu.2019.08.002

Alqahtani MA, Alsaleem SA, Qassem MY. Physical and verbal assault on medical staff in emergency hospital departments in Abha City, Saudi Arabia. Middle East J Fam Med. 2020;18(2):94–100. doi:10.5742MEWFM.2020.93753

Alsaleem SA, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, vd. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Fam Community Med. 2018;25(3):188–93. doi:10.4103/jfcm.JFCM_170_17

Al-Shaban ZR, Al-Otaibi ST, Alqahtani HA. Occupational violence and staff safety in health-care: a cross-sectional study in a large public hospital. Risk Manag Healthc Policy. 2021;14:1649–57. doi:10.2147/RMHP.S305217

Alshahrani M, Alfaisal R, Alshahrani K, Alotaibi L, Alghoraibi H, Alghamdi E et al. Incidence and prevalence of violence toward health care workers in emergency departments: a multicenter cross-sectional survey. Int J Emerg Med. 2021;14(1):1–8. doi:10.1186/s12245-021-00394-1

Al-Shamlan NA, Jayaseeli N, Al-Shawi MM, Al-Joudi AS. Are nurses verbally abused? A cross-sectional study of nurses at a university hospital, Eastern Province, Saudi Arabia. J Fam Community Med. 2017;24(3):173–80. doi:10.4103/jfcm.JFCM_45_17

Alsmael MM, Gorab AH, AlQahtani AM. Violence against healthcare workers at primary care centers in Dammam and Al Khobar, Eastern Province, Saudi Arabia. Int J Gen Med. 2020;13:667–76. doi:10.2147/IJGM.S267446

Arafa A, Shehata A, Youssef M, Senosy S. Violence against healthcare workers during the COVID-19 pandemic: a cross-sectional study from Egypt. Arch Environ Occup Health. 2021;1–7. doi:10.1080/19338244.2021.1982854

Atawneh FA, Zahid MA, Al-Sahlawi KS, Shahid AA, Al-Farrah MH. Violence against nurses in hospitals: prevalence and effects. Br J Nurs. 2003;12(2):102–7. doi:10.12968/bjon.2003.12.2.11049

Ayranci U. Violence toward health care workers in emergency departments in west Turkey. J Emerg Med. 2005;28(3):361–365. doi:10.1016/j.jemermed.2004.11.018

Ayranci U, Yenilmez C, Balci Y, Kaptanoglu C. Identification of violence in Turkish health care settings. J Interpers Violence. 2006;21(2):276–96. doi:10.1177/0886260505282565

Baig LA, Shaikh S, Polkowski M, Ali SK, Jamali S, Mazharullah L et al. Violence against health care providers: A mixed-methods study from Karachi, Pakistan. J Emerg Med. 2018;54(4):558–66. doi:10.1016/j.jemermed.2017.12.047

Baykan Z, Oktem İS, Cetinkaya F, Nacar M. Physician exposure to violence: a study performed in Turkey. Int J Occup Saf Ergon. 2015;21(3):291–7. doi:10.1080/10803548.2015.1073008

Bayram B, Cetin M, Oray NC, Can IO. Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey. BMJ Open. 2017;7(6):1–10. doi:10.1136/bmjopen-2016-013568

Belayachi J, Berrechid K, Amlaiky F, Zekraoui A, Abouqal R. Violence toward physicians in emergency departments of Morocco: prevalence, predictive factors, and psychological impact. J Occup Med Toxicol. 2010;5(1):1–7. doi:10.1186/1745-6673-5-27

Boz B, Acar K, Ergin A, Erdur B, Kurtulus A, Turkcuer I, et al. Violence toward health care workers in emergency departments in Denizli, Turkey. Adv Therapy. 2006;23(2):364–9. doi:10.1007/BF02850142

Cevik M, Gumustakim RS, Bilgili P, Ayhan Baser D, Doganer A, Saper SHK. Violence in healthcare at a glance: The example of the Turkish physician. Int J Health Plann Mgmt. 2020;35:1559–70. doi:10.1002/hpm.3056

Coskun SC. An analysis of the exposure to violence and burnout levels of ambulance staff. Turk J Emerg Med. 2019;19(1):21–5. doi:10.1016/j.tjem.2018.09.002

Darawad MW, Al-Hussami M, Saleh AM, Mustafa WM, Odeh H. Violence against nurses in emergency departments in Jordan: nurses’ perspective. Workplace Health Saf. 2022;63(1):9–17. doi:10.1177/2165079914565348

Demirci S, Ugurluoglu, O. An evaluation of verbal, physical, and sexual violence against healthcare workers in Ankara, Turkey. J Forensic Nurs. 2020;16(4):E33–E41. doi:10.1097/JFN.0000000000000286

Emam, GH, Alimohammadi H, Sadrabad AZ, Hatamabadi H. Workplace violence against residents in emergency department and reasons for not reporting them; a cross sectional study. Emerg (Tehran). 2018;6(1):e7. PMID:29503832

Erdur B, Ergin A, Yuksel A, Turkcuer I, Ayrık C, Boz B. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey. Ulus Travma Derg.2015;21(3):175–81. doi:10.5505/tjtes.2015.91298

Esmaeilpour M, Salsali M, Ahmadi F. Workplace violence against Iranian nurses working in emergency departments. Int Nurs Rev. 2011;58(1):130–7. doi:10.1111/j.1466-7657.2010.00834.x

Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Ahmadvand H. Psychological violence in the health care settings in Iran: a cross-sectional study. Nurs Midwifery Stud. 2015;4(1):1–6. doi:10.17795/nmsjournal24320

Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Afshani S. Physical violence against health care workers: a nationwide study from Iran. Iran J Nurs Midwifery Res. 2016;21(3):232–8. doi:10.4103/1735-9066.180387

Ghareeb NS, El-Shafei DA, Eladl AM. Workplace violence among healthcare workers during COVID-19 pandemic in a Jordanian governmental hospital: the tip of the iceberg. Environ Sci Pollut Res. 2021;28(43):61441–9. doi:10.1007/s11356-021-15112-w

Gunaydın N, Kutlu Y. Experience of workplace violence among nurses in health-care settings. J Psychiatr Nurs. 2012;3(1):1–5. doi:10.5505/phd.2012.32042

Hamdan M, Abu Hamra A. Workplace violence towards workers in the emergency departments of Palestinian hospitals: a cross-sectional study. Hum Resour Health. 2015;13(1):28. doi:10.1186/s12960-015-0018-2

Hamzaoglu N, Turk B. Prevalence of physical and verbal violence against health care workers in Turkey. Int J Soc Determinants of Health and Health Services. 2019;49(4):844–61. doi:10.1177/0020731419859828

Harthi M, Olayan M, Abugad H, Abdel Wahab M. Workplace violence among health-care workers in emergency departments of public hospitals in Dammam, Saudi Arabia. East Mediterr Health J. 2020;26(12):1473–81. doi:10.26719/emhj.20.069

Honarvar B, Ghazanfari N, Raeisi Shahraki H, Rostami S, Bagheri Lankarani K. Violence against nurses: A neglected and healththreatening epidemic in the university affiliated public hospitals in Shiraz, Iran. Int J Occup Environ Med. 2019;10(3):111–23. doi:10.15171/ijoem.2019.1556

Jafree SR. Workplace violence against women nurses working in two public sector hospitals of Lahore, Pakistan. Nurs Outlook. 2017;65(4):420–7. doi:10.1016/j.outlook.2017.01.008

Jaradat Y, Nielsen MB, Bast-Pettersen R. Psychosomatic symptoms among Palestinian nurses exposed to workplace aggression. Am J Ind Med. 2018;61(6):533–7. doi:10.1002/ajim.22851

Khademloo M, Moonesi FS, Gholizade H. Health care violence and abuse towards nurses in hospitals in North of Iran. Glob J Health Sci. 2013;5(4):211–6. doi:10.5539/gjhs.v5n4p211

Khan MN, Haq ZU, Khan M, Wali S, Baddia F, Rasul S et al. Prevalence and determinants of violence against health care in the metropolitan city of Peshawar: a cross sectional study. BMC Public Health. 2021;21(1):330. doi:10.1186/s12889-021-10243-8

Kisa S. Turkish nurses’ experiences of verbal abuse at work. Arch Psychiatr Nurs. 2008;22(4):200–7. doi:10.1016/j.apnu.2007.06.013

Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res. 2012;12(1):469. doi:10.1186/1472-6963-12-469

Lafta RK, Falah N. Violence against health-care workers in a conflict affected city. Med Confl Surviv. 2019;35(1):65–79. doi:10.1080/13623699.2018.1540095

Mirza NM, Amjad AI, Bhatti ABH, Mirza F, Shaikh KS, Kiani J et al. Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan. J Emerg Med. 2012;42(6):727–33. doi:10.1016/j.jemermed.2011.01.029

Mohamad O, AlKhoury N, Abdul-Baki MN, Alsalkini M, Shaaban R. Workplace violence toward resident doctors in public hospitals of Syria: prevalence, psychological impact, and prevention strategies: a cross-sectional study. Hum Resour Health. 2021;19(1):8. doi:10.1186/s12960-020-00548-x

Oztok B, Icme F, Kavakli H, Gunaydin G, Sener A, Celi̇k G. Evaluation of violence against emergency physicians in Turkey. Eurasian J Emerg Med. 2018;17(4):182–6. doi:10.5152/eajem.2018.20982

Oztunç G. Examination of incidents of workplace verbal abuse against nurses. J Nurs Care Qual. 2006;21(4):360–5. doi:10.1097/00001786-200610000-00014

Pinar T, Acikel C, Pinar G, Karabulut E, Saygun M, Bariskin E et al. Workplace violence in the health sector in Turkey: a national study. J Interpers Violence. 2017;32(15):2345–65. doi:10.1177/0886260515591976.

Picakciefe M, Akca S, Elibol A, Deveci A, Yilmaz N, Yilmaz UE. The analysis of violence against the nurses who are in employee status in Mugla State Hospital, Turkey. HealthMED. 2012;6(11):3626–37.

Rafeea F, Al Ansari A, Abbas EM, Elmusharaf K, Abu Zeid MS. Violence toward health workers in Bahrain Defense Force Royal Medical Services’ Emergency Department. Open Access Emerg Med. 2017;8(9):113–21. doi:10.2147/OAEM.S147982.

Rahmani A, Hassankhani H, Mills J, Dadashzadeh A. Exposure of Iranian emergency medical technicians to workplace violence: a cross‐sectional analysis. Emerg Med Australasia (EMA). 2012;24(1):105–10. doi:10.1111/j.1742-6723.2011.01494.x.

Sadrabad AZ, Bidarizerehpoosh F, Farahmand Rad R, Kariman H, Hatamabadi H, Alimohammadi H. Residents’ experiences of abuse and harassment in emergency departments. J Interpers Violence. 2019;34(3):642–52. doi:10.1177/0886260516645575

Samir N, Mohamed R, Moustafa E, Abou Saif H. Nurses’ attitudes and reactions to workplace violence in obstetrics and gynaecology departments in Cairo hospitals. East Mediterr Health J. 2012;18(3):198–204. doi:10.26719/2012.18.3.198

Sani SG, Tabrizi FJ, Rahmani A, Sarbakhsh P, Zamanzadeh V, Dickens GL. Resilience and its relationship with exposure to violence in emergency nurses. Nurs Midwifery Stud. 2020;9(4):222–8. doi:10.4103/nms.nms_6_20

Shaikh S, Baig LA, Hashmi I, Khan M, Jamali S, Khan MN et al. The magnitude and determinants of violence against healthcare workers in Pakistan. BMJ Glob Health. 2020;5(4):e002112. doi:10.1136/ bmjgh-2019-002112

Shoghi M, Sanjari M, Shirazi F, Heidari S, Salemi S, Mirzabeigi G. Workplace violence and abuse against nurses in hospitals in Iran. Asian Nurs Res. 2008;2(3):184–93. doi:10.1016/S1976-1317(08)60042-0

Teymourzadeh E, Rashidian A, Arab M, Akbari-Sari A, Hakimzadeh SM. Nurses exposure to workplace violence in a large teaching hospital in Iran. Int J Health Policy Manag. 2014;3(6):301. doi:10.15171/ijhpm.2014.98

Towhari AA, Bugis BA. The awareness of violence reporting system among healthcare providers and the impact of new ministry of health violence penalties in Saudi Arabia. Risk Manag Healthc Policy. 2020;13:2057–65. doi:10.2147/RMHP.S258106

Turki N, Afify AA, AlAteeq M. Violence against health workers in family medicine centers. J Multidiscip Healthc. 2016;9:257–66. doi:10.2147/JMDH.S105407

Uzun O. Perceptions and experiences of nurses in Turkey about verbal abuse in clinical settings. J Nurs Scholarsh. 2003;35(1):81–5. doi:10.1111/j.1547-5069.2003.00081.x

Unsal Atan S, Baysan Arabaci L, Sirin A, Isler A, Donmez S, Unsal Guler M et al. Violence experienced by nurses at six university hospitals in Turkey. J Psychiatr Ment Health Nurs. 2013;20:882–9. doi:10.1111/jpm.12027

Zafar W, Khan R, Siddiqui SA, Jamali S, Razzak JA. Workplace violence and self-reported psychological health: coping with post-traumatic stress, mental distress, and burnout among physicians working in the emergency departments compared to other specialties in Pakistan. J Emerg Med. 2016;50(1):167–77. doi:10.1016/j.jemermed.2015.02.049

Table 2. Loney criteria quality scores for 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021

^a1: Random sample or whole population; 2: Unbiased sampling frame; 3: Adequated sample size (≥ 355); 4: Measures were standard; 5: Outcomes measured by unbiased assessors; 6: Adequated response rate (≥ 70); 7: Confidence intervals, subgroup analysis; 8: Study subject defined.

Table 3. Characteristics of the 75 studies reviewed conducted in the WHO Eastern Mediterranean Region and Türkiye during 1999–2021, noting numbers of violent incidents

Table 4. Luis Furuya-Kanamori (LFK) index for the studies reviewed

Table 5. Subgroup analysis of physical and verbal violence reported in 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021

Melese Kitu,^1,2 Kebadnew Mihretie² and Taye Abuhay²

¹Eyu-Ethiopia, Kebele 14, Dagmawi Menelik Sub-city, Bahirdar, Ethiopia (Correspondence to Melese Kitu: Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.).

²College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.

Abstract

Background: Repeated infection with Chlamydia trachomatis causes trachomatous trichiasis (TT). Surgery is the main and preferred method of treatment. However, many people decline surgery despite the availability of free services in nearby health facilities.

Aim: To identify the determinants of surgery refusal among TT patients

Methods: This community-based, case–control study with 676 participants (338 cases, 338 controls) was conducted from 5 October to 17 December 2018. People who had been operated on (controls) and surgery refusals (cases) were selected by systematic random sampling from registration documents. Pre-tested, interviewer-administered, structured questionnaires were used to collect data. We used SPSS, version 23, for the analysis. Multivariate logistic regression was used to identify determinants.

Results: Observing a bad outcome of surgery (adjusted odds ratio (aOR): 3.51, 95% CI: 1.94–6.35) and lack of knowledge about TT (aOR: 1.77, 95% CI: 1.18–2.65) increased the refusal rate for surgery. Having trust in the surgeon (aOR: 0.26, 95% CI: 0.15–0.45), knowledge about eyelid surgery (aOR: 0.32, 95% CI: 0.16–0.64), long duration of trichiasis (aOR: 0.50, 95% CI: 0.31–0.79), decision-making via discussion with the family (aOR: 0.29, 95% CI: 0.13–0.64), frequent epilation (aOR: 0.31, 95% CI: 0.17–0.60) and receiving personal advice (aOR: 0.11, (0.04–0.28) reduced the refusal rate.

Conclusion: Refusing to have TT surgery was significantly related to knowledge, quality of surgery, decision-making capacity and personal influences. A strong system should be designed to reduce unfavourable surgery outcomes as well as to catch and manage poor surgical outcomes.

Keywords: trachomatous trichiasis, surgery refusal, trachoma, eye health, Ethiopia

Citation: Kitu M, Mihretie K, Abuhay T. Determinants of corrective upper eye lid surgery refusals among trachomatous trichiasis patients in Ethiopia: a case–control study. East Mediterr Health J. 2023;29(x):xxx–xxx. https://doi.org/10.26719/emhj.XXXX Received: 27/12/21, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Trachoma, a highly contagious infection caused by the bacteria Chlamydia trachomatis, is the most common cause of eye infections and the eighth most common cause of blindness worldwide (1,2). Repeated infection over many years produces scarring of the inner part of the upper eyelid, which turns the lashes inwards so that they scratch the cornea. When the eyelashes rub on the eye, the condition is called trachomatous trichiasis (TT). Scarring of the cornea impairs vision and causes blindness. Blindness due to trachoma is irreversible once it has occurred, but it can be prevented (3,4).

Trachoma is a public health problem in 42 countries. In 2022, around 125 million people were at risk of blindness due to trachoma and about 1.9 million were either irreversibly blind or visually impaired. It causes about 1.4% of all blindness worldwide (5). The estimated total global burden for TT in June 2022 was 1.7 million (6).

Surgery to correct TT is the main and preferred method in all trachoma blindness control programmes in endemic countries, however some patients – those without entropion (inward turning of the eyelid) and having just a few eyelashes in the periphery – can be managed with epilation (pulling out the eyelashes) (7–9).

Countries will be eligible for consideration of having eliminated trachoma as a public health problem when they have achieved the goal for TT at district level: < 1 case per 1000 total population of trichiasis cases unknown to the health system (10).

In previous years, only 50% of the annual global surgical targets have been achieved. Among the reasons cited by patients for not having the surgery were: lack of time, unavailability of the service, financial constraints for direct and indirect costs, fear of surgery, lack of knowledge and lack of awareness (11–14). Elimination of trachoma as a public health problem is covered in the neglected tropical diseases 2021–2030 road map, which targets global elimination by 2030, in line with Sustainable Development Goal target 3.3 (15).

A 2021 World Health Organization (WHO) alliance report shows that globally 69 266 people received TT surgery, 67% of this was performed in Ethiopia (6). Ethiopia has the highest burden of trachoma worldwide, accounting for 49% of the 136.2 million people at risk globally. In 2021, the WHO reported that almost 460 000 people in Ethiopia required surgery to treat TT (16). From 2015 to 2020, around 628 484 TT operations were carried out. Nevertheless, more than 342 800 people with trichiasis are still at risk of blindness in the country. The prevalence of TT in 2020 was 0.85%, which indicates the need for augmenting the performance of TT surgery and strengthening prevention measures to reduce the number of new cases (17).

Even though TT surgery is provided free or at subsidized cost, only 18–66% of patients agreed to have the treatment (11). A study done in northern Ethiopia showed that nearly one in 2 cases did not utilize TT surgery services (18). A longitudinal study in Gambia showed that only 23% of major TT patients elect to have surgery.

The 2016 trachoma impact survey by the Carter Centre Ethiopia showed the prevalence of TT in Mecha district was 1.9%. From 15 July to 15 September 2017, house-to-house TT screening was carried out in all kebeles (municipalities, administrative divisions) and the campaign report recorded 2275 new TT cases. Only 843 (37.1%) of these had received surgery services within one year (19). Despite being offered surgery free of charge, many refused to have it.

More operations and constructive approaches are needed to achieve TT elimination in the woreda (district). Identifying the reasons for refusing surgery is crucial for TT elimination. Therefore, in this study we aimed to identify the determinants of refusing corrective upper eyelid surgery among TT patients.

Methods

Study design

This community-based, unmatched, case–control study was conducted in Mecha woreda, West Gojjam Zone, Ethiopia, on identified TT patients.

Sample size and sampling procedure

The double population proportion formula was used to determine the sample size at 676 participants.

For this study, refusal to have surgery was defined as a TT patient who has been given the chance (been offered) to be operated on by the health workers but had refused. Cases were defined as individuals aged > 15 years who had been diagnosed with TT and who had been given the chance to be operated on by health workers for corrective upper eyelid surgery but had refused. Controls were individuals aged > 15 years who had been diagnosed with TT and who had been operated on for corrective upper eyelid surgery.

The Central Statistical Agency population projection data for 2017 shows the total population of Mecha district was 372 000. The woreda has 6 urban and 40 rural kebeles (20). According to the district (local) TT patient records, 843 TT patients (controls) who had been operated on were registered in the “service beneficiary registration logbook”, and 1032 TT patients who had had the chance to be operated on but had refused (cases) were registered in the “TT refusal registration logbook”.

The participants were selected by systematic random sampling from the 2017 registration logbooks. First, numbers were assigned to every individual in the log book, and then, using a random number generator, a subset of individuals (participants) was selected for interview. Individuals who were not able to communicate were excluded from the study (e.g. those having a psychiatric illness).

Data collection and tools

A pre tested, interviewer-administered, structured questionnaire was adapted from previous studies and used to collect data (4,11,13–15). The questionnaire was prepared in English and translated to Amharic (local language). Data were collected by 5 nurses and 2 integrated eye care workers (supervisors) who were trained for 3 days by the principal investigator on the study instruments and data collection procedures prior to data collection.

Data management and analysis

The data were entered, cleaned and coded using EpiInfo, version 7. Data were then exported to SPSS, version 23, for further analysis. All required variable recoding and transformation was completed before the final data analysis. First, descriptive statistics were computed to describe the collected data. For the categorical variables, frequency and percent were computed and presented in a table. For the continuous variables, mean and standard deviation (SD) were calculated. Cases and controls were compared via univariate logistic regression and independent t-test. Predictor variables having P-value < 0.2 in the univariate binary logistic regression analysis were entered into the multivariate binary logistic regression model. P-value < 0.05 and 95% confidence intervals (CIs) were used as the cut-off point to identify determinants.

Results

Sociodemographic characteristics

This study was conducted from 5 October to 20 November 2018. A total of 338 corrective upper eye lid surgery refusals (cases) and 338 operated controls were included to the study. Females constituted 197 (58.3%) of the cases and 195 (57.7%) of the controls. The majority of respondents (273, 80.8%) among the cases and 274 (81.1%) among the controls resided in rural areas. Cases and controls differed significantly in age: mean for cases was 48.9 (SD 16.2) years and for controls 52.2 (SD 15.5) years (P = 0.007). There was no significant difference in regard to sex (P = 0.876), marital status (P = 0.891), education status (P = 0.275) or occupation (P = 0.934) (Table 1).

Participant’s condition

Compared with controls, more of the cases had trichiasis in only one eye (OR = 1.68, 95% CI: 1.23–2.40). Mean duration of TT was 5.1 (SD 5.4) years for controls and 3.8 (SD 3.7) years for cases (OR = 0.40, 95% CI: 0.28–0.60). Severe pain due to TT was reported by 79 (23.4%) cases and 109 (32.2%) controls (OR = 0.66, 95% CI: 0.55–0.79). More than half the controls (187, 55.3%) had practised epilation before surgery, whereas only 130 (38.5%) cases had done so (OR = 2.03, 95% CI: 1.49–2.75). The vast majority of the controls (313, 92.6%) said they had trust in the health professionals compared with just under half (165, 48.8%) of the cases (OR = 5.11, 95% CI: 3.19–8.18).

Cases had less knowledge about TT (197, 58.3%) than controls (256, 75.7%) (OR = 2.23, 95% CI: 1.61–3.11). Cases and controls did not differ for access to transport (OR = 0.76, 95% CI: 0.53–1.20). Only 16 (4.7%) cases and 19 (5.6%) controls could move on their own (i.e. needed assistance). Many more controls (243, 72%) had seen a good outcome (success) from surgery than refusals (cases) (141, 41.7%) (OR = 0.55, 95% CI: 0.45–0.68). The vast majority of the case respondents (325, 96.2%) and controls (307, 90.8%) stated that they made decisions about their health and health-related conditions themselves (OR = 0.40, 95% CI: 0.20–0.77). Almost half (161, 47.6%) of the cases and three-quarters (242, 71.6%) of the controls had taken advice from other persons in addition to health workers in regard to undergoing surgery (OR = 0.81, 95% CI: 0.74–0.88).

Determinants of corrective upper eye lid surgery refusal

Variables associated with eyelid surgery refusal in the univariate logistic regression, at P < 0.2, were duration of having TT, getting personal advice, observing a person who had been operated on, knowledge about surgery, knowledge about TT outcome, age, decision-making process in the family, frequency of epilation and trust in integrated eye care workers (Table 2).

Multivariate binary logistic regression analysis showed that those who were more frequent epilators were less likely to refuse surgery (aOR = 0.31, 95% CI: 0.17–0.60). Surgery refusal was 71% lower among patients who decided their health and health related conditions in discussion with family members than those who decided for themselves (aOR = 0.29, 95% CI: 0.13–0.64). Those living with TT for a long time (> 5 years) were 50% less likely to refuse surgery than those who had had it for ≤ 5 years (aOR = 0.50, 95% CI: 0.31–0.79). Respondents who had received personal advice from other sources as well as from health workers were 74% less likely to refuse surgery (aOR = 0.26, 95% CI: 0.14–0.50). Observing poor outcomes of surgery led to a 3.51 times greater likelihood of refusing eyelid surgery (aOR = 3.51, 95% CI: 1.94–6.35). Respondents who had knowledge about eyelid surgery were 68% less likely to refuse (aOR: 0.32, 95% CI: 0.16–0.64). Those who were not knowledgeable about TT were 77% more likely to refuse eyelid surgery than those who were (aOR = 1.77, 95% CI: 1.18–2.65). Refusal to have surgery was 74% lower among respondents who said they had trust in the integrated eye care workers (aOR = 0.26, 95% CI: 0.15–0.45) (Table 2).

Discussion

Refusal to have eyelid surgery diminished with duration of illness. This contradicts the findings of a study done in south Wollo, Mehalsayint district, in which the respondents who had had TT for more than 5 years were 2.56 times more likely not to attend surgery than those in whom the duration of the condition was ≤ 5 years (21). Our findings support those of a study done in southern Tigray, Ethiopia, in which participants who had had trichiasis for > 2 years were 60.2% less likely to refuse surgery than participants who had had the condition for ≤ 2 years (18). In a cohort study in Tanzania on 200 TT patients, surgical coverage at baseline was 16.9%, but one year later the surgical uptake was 44.8% (a reduction of 27.9%) (22). Over time, patients might be requested to attend many surgery programmes, which might increase the probability of making the decision to have the operation. This finding is supported by a study done in northern Ethiopia (23). This might be attributable to the symptoms early on being mild but over time, due to the progressive scarring effect of the bacteria on the eyelid (24), the inturned lashes that scratch the cornea increase in number (minor progresses to major TT) (25), causing severe pain. As the pain increases, patients might be forced to have corrective eyelid surgery treatment to relieve the pain.

Practising more frequent epilation was associated with fewer refusals to have surgery. This is supported by the findings of a study in South Wollo, Mehalsayint, which showed that non-epilators had a 3.22 times greater likelihood of not having surgery than those who had had at least one instance of epilation (21). Even though epilation has an effect comparable to that of surgery for patients with minor TT (< 5 lashes) (9), if it is practised in patients with severe TT, it may become more frequent, adding another load to their day-to-day activities. Consequently, they may choose a treatment that completely cures and gives them respite. Surgery is proven in TT patients to improve the ability individuals to perform productive activities, improve their quality of life and also their vision (26,27). So frequent epilators, probably severe TT cases, may be less likely to refuse the surgery.

We found that refusal to have surgery was lower among individuals who were knowledgeable about the procedure. This is supported by a comparable study from Tanzania which showed that 26% of those accepting to have surgery suggested that better education and advice about the surgery would help to improve services (28). Another qualitative study from Tanzania found that community health workers and patients raised long recovery times, fear of surgery pain and poor anecdotal experiences with surgery as reasons for refusing (29). This was also reinforced by a study done in Basoliben, in which the majority of non-operated respondents (81%) had no knowledge about eyelid surgery (30). Patients who did have knowledge about eyelid surgery knew that surgery was conducted with lidocaine (without pain) (4), takes a short time to complete and requires only a few days to heal and to return to work. This knowledge might help TT patients to decide on accepting to have surgery.

In our study, there was greater refusal to have surgery among individuals who had no knowledge about TT. This is supported by a study done in Tanzania in which 95.7% of surgery acceptors and 87.7% of non-acceptors had knowledge on the progression of TT to blindness (8% less in the non-acceptors) (28). A study on the natural history of TT showed that it is a high risk for blinding corneal opacity (31). Fear of losing vision comes from knowledge about the effects of TT leading to blindness, and could have been a stronger motivator among patients who had been operated on to agree to have the surgery; those who had refused the surgery may have lacked this knowledge.

Refusal to have surgery was lower among those respondents who had trust in the integrated eye care workers. A study in South Wollo showed non-significant results, but a descriptive statistic indicated that 89.6% of respondents among the non-operated and 98.8% among those who had been operated on (9.2% more in controls) had trust in TT surgeons (21). From interviews with 94 surgeons who were still in the programme in West Amhara, 15% mentioned that patients “want an expatriate surgeon (i.e. did not show trust)” as reasons for not presenting for surgery (32). Patients going to the clinic need to have a successful outcome (looking good after surgery), but in clinical trials in the Amhara region, the surgical failure (recurrence) rate varied from 7% to 50%; eye contour abnormalities varied from 19% to 28%; and granuloma varied from 3.2% to 5.6% among surgeons (33,34). Surgeons who had fewer unfavourable outcomes might earn the trust of patients but those who had many unfavourable outcomes might not. Fear of poor outcomes may be one reason for refusing surgery in patients who did not trust TT surgeons.

Refusals were fewer in patients whose deciders for health and health-related conditions were family members compared with themselves as the deciders. Decision-making was the difficult part for many patients in accepting to have surgery (13). Over time, a family member might help to convince non-acceptors to have surgery, and hesitant patients may also be more willing to trust family members.

Getting advice from sources other than (or in addition to) health workers reduces the rate of refusing to have surgery. This is supported by study done in Tanzania which showed that, when another person was involved, 22.3% of respondents among acceptors and 19.2% among non-acceptors (3.2% more in acceptors) agreed to have the surgery (28). This may be due to friends of patients, especially those who had a positive experience of surgery, persuading others to come forward for surgery. In addition, patients could be more willing to trust their leaders. Perhaps this was the reason why most patients who had had the operation were convinced to agree to surgery by kebele leaders and the Health Development Army.

Our study showed that respondents who have seen poor outcomes of surgery were more likely to refuse eyelid surgery. This is supported by a study in Tanzania in which patients in a focus group discussion raised, as a reason for refusing surgery, wanting to see how others in the village did after surgery, and when they saw the rapid recovery of their neighbours, they wanted the surgery for themselves (29). A study in West Amhara showed that, among 94 surgeons who were still in the programme, 9.5% thought that poor surgical quality was one reason for patients not presenting to the clinics (32). Patients who had a positive experience of surgery were the best ambassadors to their communities in terms of persuading others to come forward for surgery. Successful surgery patients would be strong voices in helping to convince the non-acceptors. In contrast, if people see poor outcomes in persons who had had the operation or hear horrible stories about surgery, this might have an effect on their decision whether to undergo surgery.

The study had some limitations. We included TT cases who had been identified by health workers before the data collection. Since the information was collected from controls who had been operated on, the TT severity grading was not measured. There may also have been a certain level of recall bias.

Conclusion

In conclusion, refusing the TT surgery services was significantly related to knowledge, quality of the procedure, decision-making capacity and personal influences. So, offering health education and increasing community awareness about trachoma and its treatment should be encouraged. Poor outcome surgeries are negative provokers of surgery. A strong system should be designed to reduce unfavourable outcomes of surgery as well as to catch and manage poor surgical outcomes.

Acknowledgements

We would like to express our gratitude to Bahir Dar University College of Medicine and Health Sciences and School of Public Health, the data collectors, study participants, administrators and health professionals in each health institutions for giving us important data. We also wish to acknowledge Adugna Alemu and Gedefaw Baze for their contribution in data entry.

Funding: This research work received no funding from any funding agency.

Competing interests: The authors have no competing interests to declare.

References

1. Allen NJ. Eliminating blindness from trachoma infection. Westlake Village, California: Conrad N. Hilton Foundation; 2012 (https://www.hiltonfoundation.org/wp-content/uploads/2019/10/CNHF-TrachomaInPractice-3.pdf, accessed 4 April 2023).

2. Preferred practices for zithromax® mass drug administration. Amsterdam: International Coalition for Trachoma Control; 2013 (https://www.kcco.net/wp-content/uploads/2017/08/ictc_mdatoolkit_english.pdf, accessed 4 April 2023).

3. Solomon AW, World Health O, London School of H, Tropical M, International Trachoma I. Trachoma control: a guide for programme managers. Geneva: World Health Organization, London School of Hygiene & Tropical Medicine, International Trachoma Initiative; 2006 (https://www.who.int/publications/i/item/9241546905, accessed 4 April 2023).

4. Merbs S. Trichiasis surgery for trachoma. Geneva: World Health Organization; 2013.

5. Fact-sheets. Trachoma. Geneva: World Health Organization; 2022 (https://www.who.int/news-room/fact-sheets/detail/trachoma, accessed 5 April 2023).

6. WHO Alliance for the Global Elimination of Trachoma: progress report on elimination of trachoma, 2021. Weekly Epidemiological Record. 2022;97(31):353–64 (https://apps.who.int/iris/bitstream/handle/10665/361290/WER9731-eng-fre.pdf?sequence=1&isAllowed=y, accessed 5 April 2023).

7. Rajak SN, Collin JR, Burton MJ. Trachomatous trichiasis and its management in endemic countries. Surv Ophthalmol. 2012 Mar–Apr;57(2):105–35. doi:10.1016/j.survophthal.2011.08.002

8. Burton M, Habtamu E, Ho D, Gower EW. Interventions for trachoma trichiasis. Cochrane Database Syst Rev. 2015 Nov 13;2015(11):CD004008. doi:10.1002/14651858.CD004008.pub3

9. Rajak SN, Habtamu E, Weiss HA, Bedri A, Zerihun M, Gebre T, et al. Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery. PLoS Negl Trop Dis. 2012;6(8):e1766. doi:10.1371/journal.pntd.0001766

10. Porco TC, Hart J, Arzika AM, Weaver J, Kalua K, Mrango Z, et al. Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) Study Group. Mass oral azithromycin for childhood mortality: timing of death after distribution in the MORDOR trial. Clin Infect Dis. 2019 May 30;68(12):2114–6. doi:10.1093/cid/ciy973

11. Rajak SN, Habtamu E, Weiss HA, Bedri A, Zerihun M, Gebre T, et al. Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery. PLoS Negl Trop Dis. 2012;6(8):e1766. doi:10.1371/journal.pntd.0001766

12. WHO Alliance for the Global Elimination of Blinding Trachoma by the Year 2020: progress report on elimination of trachoma, 2013. Weekly Epidemiological Record. 2014;89(39):421–8.

13. Habtamu E, Burton M. Clearing the trichiasis backlog: experiences in Amhara, Ethiopia. Community Eye Health. 2015;28(90):38. PMID:26692652

14. Alemayehu W, Kello AB. Trichiasis surgery: a patient-based approach. Community Eye Health. 2010 Dec;23(74):58–9. PMID:21311671

15. Jesudason T. New WHO road map for NTD recovery post COVID-19. Lancet Infect Dis. 2020 Aug;20(8):902. doi:10.1016/S1473-3099(20)30566-1

16. Amin A, Sisay A, Jesudason T. Exploring strategies for trachoma elimination in Ethiopia. Community Eye Health. 2021;34(112):62. PMID:35210711

17. The Third National Neglected Tropical Diseases Strategic Plan 2021–2025. Addis Ababa: Ministry of Health; 2021.

18. Adafrie Y, Redae G, Zenebe D, Adhena G. Uptake of trachoma trichiasis surgery and associated factors among trichiasis-diagnosed clients in southern Tigray, Ethiopia. Clin Ophthalmol. 2021 May 10;15:1939–48. doi:10.2147/OPTH.S302646

19. House to house trachomatous trichiasis screening report. Mecha Woreda: Health Office, NTDs; 2017.

20. Population projection for 2017. Addis Ababa: Central Statistical Agency; 2016.

21. Meshesha TD, Senbete GH, Bogale GG. Determinants for not utilizing trachomatous trichiasis surgery among trachomatous trichiasis patients in Mehalsayint District, North-East Ethiopia. PLoS Negl Trop Dis. 2018 Jul 18;12(7):e0006669. doi:10.1371/journal.pntd.0006669

22. Mahande M, Tharaney M, Kirumbi E, Ngirawamungu E, Geneau R, Tapert L, Courtright P. Uptake of trichiasis surgical services in Tanzania through two village-based approaches. Br J Ophthalmol. 2007 Feb;91(2):139–42. doi:10.1136/bjo.2006.103374

23. Habte D, Gebre T, Zerihun M, Assefa Y. Determinants of uptake of surgical treatment for trachomatous trichiasis in North Ethiopia. Ophthalmic Epidemiol. 2008 Sep-Oct;15(5):328–33. doi:10.1080/09286580801974897

24. Burton MJ, Rajak SN, Hu VH, Ramadhani A, Habtamu E, Massae P, et al. Pathogenesis of progressive scarring trachoma in Ethiopia and Tanzania and its implications for disease control: two cohort studies. PLoS Negl Trop Dis. 2015 May 13;9(5):e0003763. doi:10.1371/journal.pntd.0003763

25. Burton MJ, Bowman RJ, Faal H, Aryee EA, Ikumapayi UN, Alexander ND, et al. The long-term natural history of trachomatous trichiasis in the Gambia. Invest Ophthalmol Vis Sci. 2006 Mar;47(3):847–52. doi:10.1167/iovs.05-0714

26. Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Melak B, et al. Impact of trichiasis surgery on daily living: a longitudinal study in Ethiopia. Wellcome Open Res. 2017;2:69. doi:10.12688/wellcomeopenres.11891.2

27. Woreta TA, Munoz BE, Gower EW, Alemayehu W, West SK. Effect of trichiasis surgery on visual acuity outcomes in Ethiopia. Arch Ophthalmol. 2009 Nov;127(11):1505–10. doi:10.1001/archophthalmol.2009.278

28. Bickley RJ, Mkocha H, Munoz B, West S. Identifying patient perceived barriers to trichiasis surgery in Kongwa District, Tanzania. PLoS Negl Trop Dis. 2017 Jan 4;11(1):e0005211. doi:10.1371/journal.pntd.0005211

29. Gupta KM, Harding JC. Why do patients refuse trichiasis surgery? Lessons and an education initiative from Mtwara Region, Tanzania. PLoS Negl Trop Dis. 2018 Jun 14;12(6):e0006464. doi:10.1371/journal.pntd.0006464

30. Aredo KK, Kebede AB, Aychiluhim M, Hordofa MA. Determinants of eye lid surgical care utilization among trachomatous trichiasis patients in rural communities: in the case of Basoliben District, North West Ethiopia. Am J Intern Med. 2014;2(6):156–61. doi:10.11648/j.ajim.20140206.20

31. Bowman RJ, Jatta B, Cham B, Bailey RL, Faal H, Myatt M, et al. Natural history of trachomatous scarring in The Gambia: results of a 12-year longitudinal follow-up. Ophthalmology. 2001 Dec;108(12):2219–24. doi:10.1016/s0161-6420(01)00645-5

32. Habtamu E, Rajak SN, Gebre T, Zerihun M, Genet A, Emerson PM, et al. Clearing the backlog: trichiasis surgeon retention and productivity in northern Ethiopia. PLoS Negl Trop Dis. 2011 Apr 5;5(4):e1014. doi:10.1371/journal.pntd.0001014

33. Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Gashaw B, et al. Oral doxycycline for the prevention of postoperative trachomatous trichiasis in Ethiopia: a randomised, double-blind, placebo-controlled trial. Lancet Glob Health. 2018 May;6(5):e579-e592. doi:10.1016/S2214-109X(18)30111-6

34. Habtamu E, Wondie T, Aweke S, Tadesse Z, Zerihun M, Gashaw B, et al. Predictors of trachomatous trichiasis surgery outcome. Ophthalmology. 2017 Aug;124(8):1143–55. doi:10.1016/j.ophtha.2017.03.016

Table 1. Distribution of sociodemographic characteristics of participants, individuals aged > 15 years from Mecha woreda who had been diagnosed with TT, 2018

P-values from independent t-test and univariate logistic regression.

Cases had been offered corrective upper eyelid surgery but had refused.

Controls had been operated on for corrective upper eyelid surgery.

Table 2. Bivariate and multivariate binary logistic regression on determinants of corrective upper eyelid surgery refusals among trachomatous trichiasis (TT) patients

Cases had been offered corrective upper eyelid surgery but had refused.

Controls had been operated on for corrective upper eyelid surgery.

cOR = crude odds ratio.

aOR = adjusted odds ratio.

CI = confidence interval.

IECWs = integrated eye care workers.

*Statistically significant in multivariate analysis (P < 0.05).

Rasha A. Almubark¹ and Saleh A. Alqahtani^2,3

¹Scientific Affairs Department, Sharik Association for Health Research, Riyadh, Saudi Arabia (Correspondence to Rasha A. Almubark: Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.).

²Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.

³Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, United States of America.

Abstract

Background: Prevalence estimates for overweight and obesity in the Gulf nations, including Saudi Arabia, have increased over the last 4 decades. Although the World Health Organization has encouraged countries to implement initiatives aimed at controlling obesity, limited research has been published on the impact of such initiatives in Saudi Arabia.

Aim: The objective of this review was to assess the epidemiology of overweight and obesity in Saudi Arabia, describe and evaluate the effectiveness of applied interventions and provide recommendations for future directions.

Methods: A narrative review of data from the Global Health Observatory was used to determine yearly estimates of prevalence of overweight and obesity in Saudi Arabia from 1975 to 2016. Large-scale interventions aimed at obesity and risk factors in Saudi Arabia were identified and summarized.

Results: The prevalence estimates of overweight and obesity continued to increase in both men and women from 1990 to 2019 and did not flatten. The overall adult prevalence estimate (overweight plus obesity) is over 60%, and prevalence estimates for paediatric and adolescent subgroups were 20–60%, suggesting that the trend continues. Interventions were identified but their impact on obesity and risk factors was unclear.

Conclusion: Prevalence estimates of overweight and obesity have been steadily increasing in Saudi Arabia since 1975. Initiatives included components that would likely be successful if assembled into a larger and more “whole-of-community” approach sustained over a number of years and continuously undergoing programme evaluation.

Keywords: obesity, epidemiology, public health, Saudi Arabia, interventions

Citation: Almubark RA, Alqahtani SA. Obesity epidemiology and interventions in Saudi Arabia. East Mediterr Health J. 2023;29(x):xxx–xxx. https://doi.org/10.26719/emhj.XXXX  Received: 10/08/21, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Overweight and obesity in Saudi Arabia

The prevalence of overweight and obesity in Saudi Arabia has seen an upward trend over recent decades. As early as the 1990s, public health programmes were implemented to slow or reverse this trend. However, the available literature on the effect of such initiatives in the country is limited.

A 2019 systematic review observed that overweight and obesity among adults had increased significantly in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates over the last 4 decades (1). Risk factors such as sociodemographic characteristics, sedentary lifestyle and an unhealthy diet were identified (1).

Research projects that began data collection in 1990 in Saudi Arabia studied risk factors for high body mass index (BMI) (2–4). A BMI of ≥ 30 kg/m2 is considered obese, and a BMI of 25.0–29.9 kg/m2 is considered overweight (5). Being female and of older age were risk factors for obesity at that time (4). Socioeconomic variables such as being in a high-income family and being illiterate were also associated with higher BMI. The prevalence estimates of overweight and obesity were highest in the Eastern Region (3). On average, BMI was lower in participants living in rural areas and leading traditional lifestyles than among those living in more urbanized environments (2).

By 1996, the prevalence estimates were already high: for obesity in women the estimate was 24% and in men 16%, and for overweight plus obesity the respective estimates were 51% and 45% (3). In a 2019 systematic review, prevalence estimates of overweight and obesity continued to increase in the Gulf countries, including Saudi Arabia (1). A 2004 review noted that the prevalence of physical inactivity was 80% among adults in Saudi Arabia (6). An analysis of dietary data from 1961 through 2007 found that per capita consumption of sugar and other sweeteners and animal products, including meat, eggs and dairy, had significantly increased (7). At the same time, the proportion of fat of vegetal origin in the diet stabilized at 67–68%, suggesting that vegetables and fruit were becoming underrepresented (7). In a recent systematic review, the highest obesity prevalence reported among large Saudi-based studies (sample size > 10 000) was 35.6% (8). The increasing trend in obesity in the country is predicted to cause 2.26 million new cases of type 2 diabetes mellitus, liver disease and liver cancer by 2040 (8). Ambitious nation-wide intervention efforts are thus crucial. A 20% reduction in the prevalence of obesity is projected to avert over 150 000 deaths by 2050 (8).

Interventions aimed at reducing obesity in Saudi Arabia

The World Health Organization (WHO) has been a leader in encouraging countries to implement interventions at all hierarchical levels to address the risk factors for obesity (6,9). An intervention is a public health programme aimed at reducing a particular condition or risk factor in the population (10). As an example, in 2018, the WHO established the Global Action Plan on Physical Activity as part of the Department of Noncommunicable Disease Prevention and Health Promotion, and disseminated the annual Global Move for Health initiative, providing guidance and support to countries to develop policies and programmes aimed at increasing physical activity (11). There has been an uptake in Saudi Arabia of global health initiatives aimed at obesity. In 2014, a call was made to establish an integrated national obesity control programme (12). This programme involved the participation of individuals, families, the community, local government and schools and colleges (through the involvement of the Ministry of Education) (12). There was a strong role for the health sector and the Ministry of Health as well as other sectors, including the private sector (12). As Saudi Arabia has a predominantly young population, focusing efforts on younger individuals to prevent obesity at older ages is a priority (3,13).

Several intervention programmes have been introduced to address obesity or its risk factors at the national level. However, there is a need for an integrated approach to further strengthen these initiatives. With the implementation of the first National Transformation Programme and subsequent National Health Strategy within Vision 2030 in the health system in recent years, several efforts have been undertaken towards reducing the prevalence of obesity (14).

This study aimed to summarize the trend for overweight and obesity in Saudi Arabia from 1990 to 2019, discuss the large-scale interventions undertaken to address obesity or its risk factors, and evaluate the impact of these public health interventions. The intention was to make recommendations for future directions that may be more effective than past efforts.

Method

Design

A narrative rather than a systematic review was chosen because our intention was to provide an informative description rather than an exhaustive scientific one (15). In actuality, the existing evidence was too weak to be summarized in a systematic review or meta-analysis (15). Nevertheless, we intended to be as comprehensive and evidence-based as possible in presentating our results.

Prevalence estimates of overweight and obesity in Saudi Arabia

We used data from the WHO Global Health Observatory to determine the yearly estimate of overweight and obesity prevalence in Saudi Arabia from 1975 to 2016 (16). These data were derived from annual national data from Saudi Arabia submitted to the Global Health Observatory repository, and provided overall estimates as well as separate estimates for men and women (16).

To better understand the problem in subgroups in Saudi Arabia, we reviewed the literature to obtain prevalence estimates for children, regional groups and other subgroups where estimates were available. We used Google Scholar due to its comprehensive coverage (17,18), and searched for the terms “Saudi Arabia”, “obesity”, “overweight”,“body weight status” and “BMI”. We limited the search to articles published in 1990 or later; we only used articles that stated a prevalence estimate of overweight and/or obesity. Although we were interested in the rates in subgroups, we did not gather data about patient subgroups (e.g. people with diabetes) as we determined this was outside the scope of the review. Review articles that provided multiple estimates were cited in place of the original citations. We gathered information on the year of data collection (or year of publication if these data were not reported), sample demographics (adolescents, national estimate, occupational subgroup, paediatric subgroup, regional subgroup), sample size and prevalence of overweight and obesity. For a visual representation of the prevalence rates, we used the ggplot2 R package (19). We plotted datasets containing the rates of overweight and obesity on the same plot as the WHO rates to identify trends in subgroups.

Reviewing large-scale interventions aimed at obesity and risk factors in Saudi Arabia

While reviewing the literature, we also looked for information about large-scale interventions aimed at obesity and risk factors in Saudi Arabia. If a particular initiative or programme was mentioned in an article, further research was conducted to identify more information about the programme such as the programme components and outcomes. Very few programmes were identified that were documented well enough to be described here. We included the programmes and initiatives we could verify with documentation in a table, along with a description of the programme or initiative, the initiating organization and the year initiated.

Results

Overall prevalence of overweight plus obesity

In 1975, the overall prevalence of overweight plus obesity in Saudi Arabia was under 40% (Figure 1). Prevalence of overweight plus obesity was always higher in women, but the difference diminished over time. Overall prevalence of ≥ 50% obesity was reached in 1986, and the estimate continued to rise, albeit with a slight flattening. In 2016, about 60% of adults fell into the category of overweight plus obese.

Interventions

Several obesity-related initiatives have been implemented by governmental agencies such as the Obesity Control Programme initiated by the Ministry of Health in 2013 (9) and the Sports Boulevard Project initiated by the local Riyadh Municipal Authority in 2019 (20) (Table 1). Other initiatives have been implemented by nongovernmental organizations such as the Healthy City Programme led by the WHO, and the Arab Task Force on Obesity Prevention and Physical Activity Promotion in 2010, comprising representatives from a number of Arab countries (21,22). Annotated on the plot in Figure 1 are several obesity-related interventions initiated from 1999. Other programmes were initiated in 2016 by organizations which had aims related to obesity such as the Saudi Arabian Society of Metabolic and Bariatric Surgery and a collaboration between King Saud University, the Arab Nutrition Center and Mars Middle East Inc. (23).

From 1999 to 2019, several obesity-related initiatives implemented in Saudi Arabia could have impacted the obesity epidemic, either overall or among certain subgroups (Table 1).

Assessing impact of interventions

To better understand how the initiatives may have impacted the prevalence of obesity in subgroups, estimates of overweight plus obesity were presented on a scatter plot. The data were separated into 2 periods for ease of interpretation: 1990–1999 (Figure 2) and 2000–2019 (Figure 3). Few estimates were identified in the literature before 2000 (Figure 2), only 3 national estimates, 3 regional estimates and 2 paediatric estimates were identified and added to the plot. The subgroup estimates were quite different from the overall estimates, although not enough to establish a trend. It is, however, important to note that even in this early period, the lowest overweight plus obesity estimate identified in the paediatric subgroup was almost 20%; the other subgroups had a lowest estimate of 40% (3,4,24–28).

For children and adolescents, the lowest estimates were just below 20%, and the highest were within 5% of the overall adult Global Health Observatory rate (Figure 3). This trend appears to have been constant throughout the entire period. There is no evidence that the trend changed during the period when the interventions in Table 1, some of which targeted children, were implemented. A similar pattern was seen with the adolescent subgroup, although the highest estimates identified were within 10% of the overall adult estimate. Regional, national and occupational estimates were within 20% of the overall rate Similar trends were seen with the adult estimates; no subgroup appeared to have lower prevalence estimates than the overall Global Health Observatory estimate.

Discussion

Our review of prevalence estimates for overweight plus obesity in the general population and in subgroups in Saudi Arabia from 1975 until 2019 showed no evidence of levelling off: estimates appear to continue to increase, although the rate of increase slowed. The interventions that were applied may have led to this easing, but no formal programme evaluations were identified that could address the connection between this phenomenon and the effects of any particular programme. As the analysis showed, some subgroups had lower prevalence estimates than the general population and a few had higher ones. Given the increasing trend, one concern is that the younger populations may develop overweight and obesity to the same extent as older groups.

The importance of effective public health interventions should not be underestimated. In addition to the lack of formal, evidence-based evaluations of the interventions identified in Table 1, it is important to be aware of the nature of the interventions (29). They all appear to be “top-down” interventions initiated by policy. Operational capacity, funding and a planned programme evaluation are essential for successful implementation.

These top-down interventions could be compared with similar interventions which have undergone extensive programme evaluation, such as Shape Up Somerville (30). Like many of the interventions listed in Table 1, especially the Sports Boulevard Project, Shape Up Somerville was a community health intervention in Somerville, Massachusetts (United States of America), aimed at improving food intake and physical activity rates with a specific focus on children (30). Like the Al-Haraka Baraka initiative (31), Shape Up Somerville started by focusing on schools, but the programme extended to before and after school and into the community (30). Their initial programme had many components, including a breakfast programme, walking programmes, revision of school activities to include more health components, healthy after school activities and community actions, including working with restaurants to develop healthy menus (30). After the first year, children in the Shape Up Somerville community were compared with children in 2 control communities to gauge how effective the intervention had been (30). A continued effect was demonstrated after 2 years (30).

Shape Up Somerville is an example of a “whole-of-community” obesity prevention effort, and the Shape Up Somerville articles represent programme evaluations of multilevel and multicomponent (MLMC) interventions (10). In a recent review of 14 MLMC interventions to improve health outcomes, 5 of the 8 studies that reported obesity results showed no significant impact but others showed significant reductions in obesity (10). Because these were MLMC interventions, many other positive outcomes were reported such as improved dietary behavior and physical activity patterns (10). It was concluded that MLMC approaches were promising, and were most effective if they could integrate the programme components at the policy level, the community level (including health care) and the interpersonal level (10).

It is likely that the individual efforts listed in Table 1 would have been more effective if integrated into an MLMC. If the school-based interventions in the Healthy City Initiative and Al-Haraka Baraka were actually part of a larger MLMC that also included the RASHAKA programme and the Sports Boulevard Project, and extended from the school setting into the community and family setting, more possibilities would exist. Family events could be conducted in a community setting that connected with school-based interventions and utilized environmental spaces designed for physical activity. However, this would involve monumental coordinating efforts as happened with Shape Up Somerville. The results show, nevertheless, that if these efforts are sustained over many years and are regularly subject to programme evaluations that can shed light on their efficacy, they can reverse the upward trend of obesity in a population.

Our analysis has both strengths and limitations. The main strength, which is also the main point of the article, is that it collates estimates of overweight and obesity in Saudi Arabia as reported in the literature over time and considers them in the context of public health interventions aimed at obesity and its risk factors over the same period. Although this information was available in the literature, it had not all been assembled together to provide a complete picture.

In terms of limitations, the original studies producing the estimates considered in Figures 2 and 3 may not have been of high quality, and thus, these estimates may not have been accurate. The lack of information on the nature, duration and outcomes of the interventions precluded any evaluation of their efficacy. In addition, the methodological approach used in this review was not able to evaluate or assess interventions. Therefore, our review was only able to describe the interventions, but not assess their impact or efficiency.

Even with these limitations, this review guides what has been historically missing from public health interventions aimed at obesity in Saudi Arabia and recommends ways to improve future interventions so that they may not present such limitations to researchers.

Conclusion

Prevalence estimates of overweight and obesity have been steadily increasing in Saudi Arabia since 1975. The various initiatives incorporate components that would likely be successful if assembled into a larger and more comprehensive MLMC sustained for multiple years and continuously undergoing programme evaluations. Using this approach, optimal programmes can be designed to control obesity in the population.

Funding: The authors received no specific funding for this work.

Competing interests: The authors declare that they have no competing interests.

References

1. Balhareth A, Meertens R, Kremers S, Sleddens E. Overweight and obesity among adults in the Gulf States: a systematic literature review of correlates of weight, weight-related behaviours, and interventions. Obes Rev. 2019;20(5):763–93. doi:10.1111/obr.12826

2. Al-Nuaim AA, Bamgboye EA, al-Rubeaan KA, al-Mazrou Y. Overweight and obesity in Saudi Arabian adult population, role of socio-demographic variables. J Community Health. 1997 Jun;22(3):211–23. doi:10.1023/a:1025177108996

3. Al-Nuaim AR, al-Rubeaan K, al-Mazrou Y, al-Attas O, al-Daghari N, Khoja T. High prevalence of overweight and obesity in Saudi Arabia. Int J Obes Relat Metab Disord. 1996 Jun;20(6):547–52. PMID: 8782731

4. Al-Nuaim AR. Population-based epidemiological study of the prevalence of overweight and obesity in Saudi Arabia, regional variation. Ann Saudi Med. 1997 Mar;17(2):195–9. doi:10.5144/0256-4947.1997.195

5. Samara A, Andersen PT, Aro AR. Health Promotion and obesity in the arab gulf states: challenges and good practices. J Obes. 2019;2019:4756260. doi:10.1155/2019/4756260. PMID: 31281673

6. Al-Hazzaa HM. The public health burden of physical inactivity in Saudi Arabia. J Family Community Med. 2004;11(2):45–51. PMID: 23012048

7. Adam A, Osama S, Muhammad KI. Nutrition and food consumption patterns in the Kingdom of Saudi Arabia. Pak J Nutr. 2014;13(4):181–90. doi:10.3923/pjn.2014.181.190

8. Salem V, AlHusseini N, Abdul Razack HI, Naoum A, Sims OT, Alqahtani SA. Prevalence, risk factors, and interventions for obesity in Saudi Arabia: A systematic review. Obes Rev. 2022 Jul;23(7):e13448. doi:10.1111/obr.13448

9. Al-Hazzaa HM, AlMarzooqi MA. Descriptive analysis of physical activity initiatives for health promotion in Saudi Arabia. Front Public Health. 2018 Nov 14;6:329. doi:10.3389/fpubh.2018.00329

10. Ewart-Pierce E, Ruiz MJM, Gittelsohn J. “Whole-of-community” obesity prevention: a review of challenges and opportunities in multilevel, multicomponent interventions. Curr Obes Rep. 2016;5(3):361–74. doi:10.1007/s13679-016-0226-7

11. Let’s be active. Global action plan on physical activity 2018–2030. Geneva: World Health Organization; 2018 (https://www.who.int/news-room/initiatives/gappa, accessed 15 April 2023).

12. Al-Khaldi Y, Alshehri F, Aljoudi A, Rahman S, Abu-Melha W, Mashour M, et al. Towards an integrated national obesity control program in Saudi Arabia. Saudi J Obes. 2014;2(2):49–53. doi:10.4103/2347-2618.147342

13. Population by gender, age group and nationality (Saudi/Non-Saudi). General Authority for Statistics; 2020 (https://www.stats.gov.sa/en/5680, accessed 24 June 2020).

14. Vision 2030. Riyadh: Government of Saudi Arabia; 2017 (http://vision2030.gov.sa/en, accessed 7 Apr 2017).

15. Sutton A, Clowes M, Preston L, Booth A. Meeting the review family: exploring review types and associated information retrieval requirements. Health Info Libr J. 2019 Sep;36(3):202–22. doi:10.1111/hir.12276

16. Global Health Observatory data repository. Prevalence of overweight among adults, BMI ≥ 25, age-standardized. Estimates by country. Geneva: World Health Organization; 2020 (https://apps.who.int/gho/data/view.main.CTRY2430A?lang=en, accessed 13 December 2020).

17. Falagas M, Pitsouni E, Malietzis G, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008 Feb;22(2):338–42. doi:10.1096/fj.07-9492LSF

18. Gehanno JF, Rollin L, Darmoni S. Is the coverage of Google Scholar enough to be used alone for systematic reviews. BMC Med Inform Decis Mak. 2013;13:7. doi:10.1186/1472-6947-13-7

19. R Core Team. A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2014 (http://www.R-project.org, accessed 15 April 2023).

20. Sports Boulevard Project. Riyadh; Royal Comission for Riyadh City; 2020 (https://www.rcrc.gov.sa/en/projects/sports-boulevard-project, accessed 15 April 2023).

21. A short guide to implementing the healthy city programme [Internet]. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2010 (https://apps.who.int/iris/handle/10665/119915, accessed 15 April 2023).

22. Musaiger AO, Al Hazzaa HM, Al-Qahtani A, Elati J, Ramadan J, AboulElla NA, et al. Strategy to combat obesity and to promote physical activity in Arab countries. Diabetes Metab Syndr Obes. 2011 Mar 8;4:89–97. doi:10.2147/DMSO.S17322

23. Khoja T, Melha WA, AlKhaldi Y, Mirza M, Bawahab M, Mufti A, et al. Abha document on control of overweight and obesity in Saudi Arabia. Saudi J Obes. 2016;4(2):88–92. doi:10.4103/2347-2618.197706

24. Binhemd T, Larbi EB, Absood G. Obesity in a primary health care centre: a retrospective study. Ann Saudi Med. 1991 Mar;11(2):163–6. doi:10.5144/0256-4947.1991

25. Al-Shammari SA, Khoja TA, al-Maatouq MA, al-Nuaim LA. High prevalence of clinical obesity among Saudi females: a prospective, cross-sectional study in the Riyadh region. J Trop Med Hyg. 1994 Jun;97(3):183–8. PMID: 8007060.

26. Alsaif MA, Hakim IA, Harris RB, Alduwaihy M, Al-Rubeaan K, Al-Nuaim AR, et al. Prevalence and risk factors of obesity and overweight in adult Saudi population. Nutr Res. 2002 Nov 1;22(11):1243–52. doi:10.1016/S0271-5317(02)00439-6

27. El-Hazmi MA, Warsy AS. Prevalence of overweight and obesity in diabetic and non-diabetic Saudis. East Mediterr Health J. 2000 May;6(2–3):276–82. PMID: 11556013

28. El-Hazmi MA, Warsy AS. Prevalence of obesity in the Saudi population. Ann Saudi Med. 1997 May;17(3):302–6. doi:10.5144/0256-4947.1997.302

29. Padgett DK, Thyer BA, Royse D. Program evaluation: an introduction to an evidence-based approach. Boston: Cengage Learning; 2015:434.

30. Economos CD, Hyatt RR, Goldberg JP, Must A, Naumova EN, Collins JJ, et al. A community intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity (Silver Spring). 2007 May;15(5):1325–36. doi:10.1038/oby.2007.155

31. Al Haraka Baraka (movement is a blessing) programme, Saudi Arabia. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2020 (http://www.emro.who.int/health-education/physical-activity-case-studies/haraka-barakat-saudi.html, accessed 15 April 2023).

Table 1. Summary of obesity-related initiatives in Saudi Arabia, 1999–2019

Figure 1. Overall rates of overweight and obesity, along with rates stratified by sex, for Saudi Arabia, 1975–2016 (several obesity-related interventions initiated starting in 1999 are also indicated on the plot) [data from the Global Health Observatory(16)]

Figure 2. Prevalence estimates of overweight plus obesity in Saudi Arabian Subgroups: 1990 through 1999 [data from the Global Health Observatory(16)]

Fig 3

Figure 3. Prevalence estimates of overweight plus obesity in Saudi Arabian subgroups: 2000–2019 [data from the Global Health Observatory (16)].

Abrar Alshehri^1,2, Saja Almazrou³, Yasser Amer^2,4,5,6,7

¹Clinical Pharmacy Department, Umm Al-Qura University College of Pharmacy, Makkah, Saudi Arabia. ²Adaptation Working Group, Guidelines International Network, Perth, UK. ³Clinical Pharmacy Department, King Saud University College of Pharmacy, Riyadh, Saudi

Arabia. ⁴Pediatrics Department, King Saud University Medical City, Riyadh, Saudi Arabia (Correspondence: Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.; Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.). ⁵Clinical Practice Guidelines and Quality Research Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia. ⁶Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia. ⁷Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria, Egypt

Abstract

Background: Adapted clinical practice guidelines (CPGs) are based on existing recommendations from other developers.

Aims: To produce a mapping summary of the methods used for adaptation of CPGs in the Eastern Mediterranean Region (EMR).

Methods: We conducted a narrative literature review of studies describing adaptation of CPGs in the EMR. Databases and official websites were searched for studies published between 2006 and 2022. We excluded de novo development of CPGs and adaptation of other types of guidelines such as public health guidelines.

Results: As an overview of the current situation of CPG adaptation in the EMR, we identified the 2 main categories of informal and formal adaptation. Six formal adaptation frameworks were used in the EMR: ADAPTE, Adapted-ADAPTE, GRADE-ADOLOPMENT, RAPADAPTE, CAN-IMPLEMENT, and KSU-Modified-ADAPTE. The validation of adapted CPGs to the local context is not well defined in the literature.

Conclusion: Despite the successful use of CPG formal adaptation frameworks, there is no international standardized guidance to identify which framework is most suitable for specific healthcare contexts in the EMR. Each institution has adapted its CPGs differently. A standardized selection tool is needed to enhance the appropriate selection of the adaptation method that fits the local resources and context. We encourage EMR countries and organizations to register their old and new CPG adaptation projects to avoid duplication in guideline synthesis.

Keywords: clinical practice guidelines, guideline adaptation, adaptation methodologies, adaptation frameworks, Eastern Mediterranean Region

Citation: Alshehri AF, Almazrou SH, Amer YS. Methodological frameworks adopted by Eastern Mediterranean countries for adaptation of global practice guidelines to the national context. East Mediterr Health J. 202x;xx(x):xxx-xxx http://doi.org/10.26719/emhj.20.xxx Received 14/01/2022; accepted: 21/11/2022

Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Guideline adaptation is a systematic approach to using or modifying guidelines produced in a particular cultural and organizational setting for application in a different setting. It is a valid alternative to de novo guideline development (1–4). Relevant concepts to adaptation include adoption and contextualization. De novo guideline development is the process of establishing new clinical practice guidelines (CPGs) from primary or secondary literature. Adoption means implementation of guideline recommendations in their entirety, without modification or caveat, in a new healthcare context. In guideline contextualization, additional considerations are required for guideline implementation (e.g. local workforce, training, health systems, equipment, and accessibility) (1–7).

Adaptation of CPGs was not widespread until the ADAPTE Collaboration published its framework in 2006. Guideline adaptation may involve additional work to search for local research, or obtain local consensus, regarding how best to make changes to Guideline recommendations so that care is relevant to the local context (1–3, 5).

Healthcare institutions have a strong interest in obtaining quality evidence to create new CPGs for patient care. However, de novo guideline development is often costly, time-consuming, and requires a highly experienced team who can review and critique published research (3, 5, 6, 8). Healthcare institutions find that adapting CPGs to local practice is practical and feasible, and it helps reduce costs for low-income countries, reduces duplication of efforts, and enhances the effectiveness of high-quality guideline recommendations (3, 5, 9, 10).

Formal guideline adaptation frameworks provide a systematic approach and increase methodological rigor and quality of CPGs (10). From 2006, apart from ADAPTE, several frameworks were established to provide an evidence-based approach to guideline adaptation [e.g. Adapted-ADAPTE, Alberta-Ambassador-Program-Adaptation-Phase, GRADE-ADOLOPMENT, MAGIC (Making GRADE the Irresistible Choice) (or SNAP-IT), RAPADAPTE, Royal College of Nursing, Systematic Guideline Review, Adopt–Contextualize–Adapt Framework, DELBI, KSU-Modified ADAPTE, and PAGE] (5, 11–21, 22).

Four reasons have been identified for guideline adaptation: (1) developing CPGs from 1 or more source guidelines that are then contextualized to intended healthcare settings; (2) implementing, endorsing, or adopting source guidelines; (3) updating an existing guideline; or (4) analysing conflicting recommendations (16).

The ADAPTE Collaboration, performed a systematic review of guideline adaptation and proposed a stepwise structured framework (1, 2, 21). The development process took place between 2005 and 2007 and was refined in 2009 with an updated version of its Guideline Adaptation Manual and Resource Toolkit (1). ADAPTE has been used by many organizations to develop high-quality CPGs through 3 phases (set-up, adaptation, and finalization), 9 modules, and 24 steps (Table 1) (1). In 2010, after evaluating its manual and resource toolkit, the ADAPTE Collaboration dissolved and transferred its resources to the Guidelines International Network (GIN) to make them available to the international community (1, 5, 6). The GIN Adaptation Working Group aims to provide methods, resources, and training to standardize and improve guideline adaptation (1, 23). Among the 111 member organizations and 240 individual members from 61 countries in the GIN, there are 6 organizational members from 4 EMR countries: (1) Think Pink: Bahrain Breast Cancer Society; (2) Ministry of Public Health and Primary Health Care Corporation (Qatar); (3) National Center for Evidence-Based Health Practice, Saudi Health Council, and King Saud University Medical City; and (4) National Authority for Assessment and Accreditation in Healthcare (Tunisia). GIN established 7 regional communities, including an Arab Regional Community, that aimed to support increasing regional interest in evidence-based health care and CPGs (24, 25).

In 2015, Adapted-ADAPTE was published by the Alexandria Center for Evidence-Based Clinical Practice Guidelines (launched in 2008) to support more clarity, simplicity, and practicality, and to reduce the resources and time needed for guideline adaptation projects (18, 19). In 2018, the Egyptian Pediatric Clinical Practice Guidelines Committee was established as a national initiative by faculty staff in the paediatrics departments of 15 Egyptian universities and the Supreme Council of Egyptian University Hospitals. The Committee used Adapted-ADAPTE to adapt 26 national CPGs (26–29).

In 2014, the first adapted CPG published by King Saud University and King Saud University Medical City was followed by guideline adaptation projects that were published as articles and presented at scientific conferences. The 2009 stakeholder expert collaboration between the Quality Management Department and Research Chair for Evidence-Based Health Care and Knowledge Translation in Riyadh led to formation of an organization-wide CPG steering committee and departmental committees that functioned as a CPG programme (30). King Saud University and King Saud University Medical City continue to support guideline adaptation projects at the local (n = 42) and national (n = 8) levels using KSU-Modified-ADAPTE, which was based on Adapted-ADAPTE and the original ADAPTE, with addition of new tools and modification of others, and included a proposed section for guideline implementation tools and strategies (5, 31–34).

In 2017, the GRADE-ADOLOPMENT framework was developed (20). It was the first framework to address CPG adaptation, adoption, and de novo guideline development processes (hence the new acronym ADOLOPMENT). It aimed to develop high-quality guideline recommendations for local use within a short period of time. The ADOLOPMENT process consisted of 3 stages (Table 2) (20, 33, 34). GRADE-ADOLOPMENT was developed as part of a collaborative national CPG initiative between the Saudi Ministry of Health and McMaster University, Canada (20, 35, 36). The GRADE-ADOLOPMENT and KSU-Modified-ADAPTE frameworks did not benefit from each other, probably because the 2 initiatives were ongoing at the same time, and each had a different scope and purpose. The former was based on GRADE and was part of a national initiative, while the latter was based on ADAPTE and was part of an institutional initiative (16).

Future coordination and integration is recommended in CPG projects, especially those with a national scope. Registration of CPG projects is a global recommendation to avoid duplication of efforts. Two existing international registries are available: GIN International Guideline Library and Registry (https://g-i-n.net/international-guidelines-library/), and PREPARE (Practice guideline REgistration for trancPAREncy) that is hosted by the Evidence-Based Medicine Center, University of Lanzhou, China (http://www.guidelines-registry.org/) (37, 38). We further recommend that CPG groups in the EMR should register their finalized and in-progress work to establish a regional database and encourage more networking and collaboration.

RAPADAPTE was also used successfully in the EMR. It benefited from ADAPTE and GRADE methods by extending guideline adaptation to evidence database adaptation, through simplifying mapping of DynaMed evidence ratings to GRADE ratings. RAPADAPTE was used to produce the first national evidence-based CPG for breast cancer in Bahrain (39, 40).

Some limitations of guideline adaptation frameworks were also identified: (1) most were developed and utilized in high-income settings; (2) many lacked formal evaluation of their impact on patient outcomes; (3) many were resource and time consuming; and (4) most often did not describe in detail how to implement adapted guideline recommendations (10, 16).

Wang et al. explored the range of experiences with guideline adaptation from the perspectives of WHO regional and country offices, and identified 2 dominant models (41): (1) a pragmatic approach to copying or customizing WHO guidelines to suit local needs; and (2) building local capacity for evidence synthesis and guideline adaptation frameworks to support local development of national CPGs informed by international CPGs. Their findings could help to improve adaptability of WHO CPGs. They also suggested clarifications to the process of guideline adaptation in WHO and academic literature, to help adaptors and implementers of CPGs to decide upon the appropriate course of action according to their specific circumstances (41, 42).

The aim of the present study was to produce a mapping summary of the methods used for guideline adaptation in the EMR.

Methods

Sources and methods of selection

We conducted a literature review of studies describing CPG adaptation in the EMR. Databases (including Springer link, EBSCO, ProQuest, and PubMed) and governmental or institutional official websites (e.g. GIN) were searched for studies published between 2006 and 2022. For PubMed, the MeSH terms included ((((Eastern Mediterranean Region[Title/Abstract]) OR (“Middle East and North Africa*”[Title/Abstract])) OR (“Gulf Cooperation Council”[Title/Abstract])) AND (“guideline adaptation”[Title/Abstract] OR “adapt*”[Title/Abstract])) AND (“clinical practice guideline*”[Title/Abstract]). We included studies, adapted CPG documents, methodology manuals that addressed adaptation (e.g. WHO Handbook), and reviews that described CPG adaptation in the EMR. We excluded de novo guideline development and adaptation of guidelines other than CPGs, such as public health or social care guidelines. Any studies that focused on subjects other than CPG adaptation (e.g. adaptation of tools and other healthcare quality improvement interventions) were excluded. The search was updated before final submission.

Results and Discussion

Compilation and interpretation of data

The WHO EMR comprises 21 Member States and the occupied Palestinian territory (including East Jerusalem), with a population of nearly 679 million people (43). Table 3 shows a sample of recently adapted CPGs in the EMR. WHO has focused on adapting and implementing CPGs for low-income EMR countries. In November 2015, the WHO Regional Office for the Eastern Mediterranean organized an expert consultation on evidence-based de novo guideline development and guideline adaptation, including experts from Egypt, France, Lebanon, Norway, and Saudi Arabia, as well as WHO staff. Several challenges to producing high-quality CPGs were identified (8).

The first attempt to adapt published CPGs in the EMR was when a panel of 7 committees of oncologists and experts reviewed the 2009 National Comprehensive Cancer Network (NCCN) CPGs (11–14). NCCN published their first CPGs adapted for the EMR in 2014 (12), with an update in 2019 to improve regional recommendations and facilitate access to high-quality evidence (13, 14). NCCN guideline adaptation aimed to develop high-quality standard practice accepted by healthcare practitioners in the EMR. However, the CPGs identified a large gap in knowledge and limited evidence relevant to the CPG health topics in the EMR. These limitations reduced the practical utility and efficiency of the CPGs. The wide range of areas covered by the guidelines was another limitation. The diversity of healthcare services provided in different countries made it difficult to provide standardized guidance throughout the EMR. The socioeconomic situation, limited resources, and infrastructure were other challenges identified (13).

Kidney Disease: Improving Global Outcomes also adapted their CPGs to the EMR in 2014, using a nephrology expert group from the region (9 stakeholders) along with an international nephrology expert. The CPGs did not include a clear description about how they were adapted methodologically and how the CPG group managed the conflicts of interest (15).

In 2017, a collaboration between Weill Cornell Medical College – Qatar Rheumatoid Arthritis Consortium and American University of Beirut GRADE Center in Lebanon resulted in a Middle Eastern adaptation of the American College of Rheumatology guidelines for treatment of rheumatoid arthritis, using GRADE-ADOLOPMENT. The panel searched for local research and modified the guideline recommendations based on cost, health equity, benefits and harms, and acceptability (35).

The Alexandria Center for Evidence-Based Clinical Practice Guidelines finalized 11 guideline adaptation projects between 2010 and 2015 with additional CPG projects in progress. They used Adapted-ADAPTE as a formal guideline adaptation framework, including the AGREE II instrument, to assess CPG quality. Evidence-based guideline recommendation and implementation tools were included in the Adapted-ADAPTE CPGs (18, 27–29). This methodology was used for the guideline adaptation projects of the Egyptian Pediatric Clinical Practice Guidelines Committee (27–29).

In 2013, there was a collaboration between the Saudi Center for Evidence-Based Health Care, a former department of the Ministry of Health, and the GRADE Working Group at McMaster University. This collaboration was initiated to develop Saudi CPGs based on GRADE and the GRADE Evidence to Decision framework, which led to development of GRADE-ADOLOPMENT and 20 national CPGs (20, 36, 44).

In Tunisia, The National Authority for Assessment and Accreditation in Health Care was established in 2012 as an independent public authority supervised by the Ministry of Health, and launched several national projects for health technology assessments, clinical pathways, and CPGs. The CPG projects were generated using GRADE-ADOLOPMENT with methodological support from the American University of Beirut GRADE Center (e.g. breast cancer screening) (45).

In Bahrain, the first national evidence-based CPG for breast cancer was generated in 2019 using RAPADAPTE through a collaboration between Think Pink: Bahrain Breast Cancer Society, National Health Regulatory Authority, Supreme Council of Health, and the former Bahrain Branch of the UK Cochrane Centre. Formulation of the CPG involved an international advisory board and review panel of guideline methodologists, a multidisciplinary expert group of clinicians, and a range of GI tools (39, 40).

In Qatar, SA Qader (graduate nursing student, Hamad Medical Corporation, Doha) and ML King (Faculty of Nursing at University of Calgary in Qatar) led a CPG project for ostomy nursing care, using the AGREE II Instrument and CAN-IMPLEMENT. The latter was originally based on the knowledge-to-action process with an increased focus on guideline implementation (46, 47).

In the United Arab Emirates, a 2020 CPG for type 2 diabetes was adapted by the Emirates Diabetes Society using an informal approach (48).

In the Islamic Republic of Iran, several guideline adaptation projects were conducted. Zadegan et al. were supported by Tehran University of Medical Sciences and the Ministry of Health and Medical Education to adapt a CPG for traumatic brain injury from 2 source guidelines, guided by the AGREE II assessment (16, 49). Another research group adapted CPGs for end-of-life care for patients with cancer, using a modified ADAPTE process in addition to a qualitative study and consensus ratings by a multidisciplinary panel of experts based on local healthcare needs (50).

An early initiative was the Sudan Evidence-Based Medicine Association, which was launched in 2006 to establish infrastructure in health services and medical education for implementing evidence-based health care, with a focus on clinical pathways and other guideline implementation tools and interventions. This association was 1 of the early GIN members in the EMR. Later, the association founders established a new body, Altababa Advanced Training Center, which continued to provide evidence-based healthcare education and training (51, 52). Other Sudanese professional societies have produced CPGs (e.g. for systemic hypertension in adults) using an informal guideline adaptation or adoption approach (53, 54).

A systematic review found that, despite the improved quality of CPGs over the last 2 decades, it remained moderate to low when evaluated by AGREE II (55–57). Another recent AGREE II assessment showed that the number of published CPGs was limited, considering the large geographical area of the EMR. The main AGREE II domains that had high scores were clarity of presentation, scope, and purpose, whereas rigor of development and applicability had low scores. The authors recommended that policy-makers identify areas for improvement of CPGs, such as training of individuals and recruitment of international experts (56).

A systematic review of 24 CPGs published in Gulf Cooperation Council countries found that 32.78% of all articles were published in Saudi Arabia. The data showed poor adherence to CPGs by healthcare professionals, lack of clear guideline implementation strategies, lack of awareness of CPGs, and poor access to evidence (58).

The WHO Regional Office for the Eastern Mediterranean and GIN encouraged and facilitated collaboration and networking for capacity building of guideline adaptation through recognized experts in the region. Collaborators included King Saud University/King Saud University Medical City CPG Programme, American University of Beirut GRADE Center, and National Authority for Assessment and Accreditation in Healthcare and WHO Country Office in Tunisia (5, 8, 45).

The use of formal guideline adaptation methods for production of organizational or national CPGs is 1 of the proposed solutions to address the knowledge gaps in the adaptation process (6, 10).

Evidence-based GA in the EMR is at its initial stage; however, Egypt, Islamic Republic of Iran, Bahrain, Saudi Arabia Tunisia, Qatar, and United Arab Emirates, have already begun adapting CPGs at institutional and national levels using 6 of the formal methods and frameworks. Transparent descriptions of the guideline adaptation processes and high-quality recommendations are the cornerstone for implementing these adapted guidelines. Multidisciplinary teams of local and national stakeholders should be involved in evaluating evidence-based guideline recommendations and their applicability to local settings (8, 10, 59, 60).

Implementation of evidence-based guideline recommendations is the main goal of establishing the CPGs, and the absence of a clear plan for guideline implementation renders any guidelines useless. Guideline implementation tools and strategies, such as failure modes and effects analysis and clinical algorithms, were reported for some of the KSU-Modified-ADAPTE CPGs (e.g. venous thromboembolism prophylaxis, glaucoma, antiemetics for chemotherapy, surgical antimicrobial prophylaxis, and paediatric status epilepticus (5, 32, 61–64). Other adapted CPGs in the EMR did not report guideline implementation projects (e.g. NCCN, Middle East Rheumatoid Arthritis Consortium, Ostomy Care, and Kidney Disease: Improving Global Outcomes) (12, 15, 34, 45).

Currently, validation and applicability of adapted CPGs to the local context are not well defined in the literature. Some CPGs lack information about the adaptation processes and outcomes in health care (8–10). Without a clear understanding of how much time and resources are saved by guideline adaptation, CPG developers or adapters cannot be sure that it is worthwhile. There is no global standardized tool to assess methods for adapting CPGs. However, 2 studies used AGREE II or AGREE Reporting Checklist to assess the adaptation process and quality of CPGs, despite AGREE II being designed more to assess quality of de novo guideline development rather than adaptation (38, 47). An international expert collaborative panel developed an extension of the RIGHT statement, the RIGHT-Ad@pt Checklist, which was designed specifically for reporting adapted CPGs (65). Another extension of AGREE II that informed adaptation of surgical CPGs (AGREE-S appraisal instrument) was recently published (66). Abdul–Khalek and her colleagues showed that only 40% of adapted CPGs reported using a published method or framework for adaptation, and compliance with ADAPTE was variable. The mean score for AGREE II assessment of adapted CPGs was lowest for the rigor of development (56.79%), applicability (50.14%), and editorial independence (42.54%) (67). Apart from the published review that conducted an AGREE II assessment of CPGs in the EMR, clinical validity of the current adapted CPGs was not evaluated (56). Future studies should focus on the usability and health impact of adapted CPGs (31, 61–64).

Formal guideline adaptation frameworks provide clearly defined steps toward achieving adapted evidence-based recommendations, and increased transparency for future groups to understand, evaluate, or imitate the process (6, 58). To date, there is no evidence supporting the efficiency of 1 guideline adaptation framework over another. However, the Adapted-ADAPTE, CAN-IMPLEMENT, GRADE-ADOLOPMENT, KSU-Modified-ADAPTE, and RAPADAPTE frameworks have been updated from the original ADAPTE, and include additional tools, resources, and templates, and input from many experts. The above adaptation methods used in the EMR were based on the original ADAPTE (Adapted-ADAPTE, CAN-IMPLEMENT, and KSU-Modified-ADAPTE) or GRADE (GRADE-ADOLOPMENT) methods, or both (RAPADAPTE) (10, 16, 19).

Early identification of potential barriers and challenges to processes of guideline adaptation and implementation should be incorporated during the planning stage of adaptation projects. Previous studies have suggested possible solutions to address these challenges (16, 61).

The recent wave of published CPGs of variable quality in response to the COVID-19 pandemic has encouraged the international CPG research community to work on novel evidence-based methodologies for rapid production of guidelines that can address such global public health crises. One suggested solution was the use of formal guideline adaptation processes (68).

There are significant knowledge gaps and many barriers to development or adaptation of CPGs in the EMR. Future research with high-quality standards should focus on answering the questions raised in this specific population. Adapted guidelines should be evaluated to improve their applicability and clinical validity for local use. Adapted guidelines should have a clear plan for reviewing and updating, and transparency for further adaptation.

Recommendations to improve collaboration, and share and standardize existing CPGs in the EMR

In 2019, Resolution RC66/R.5 of the WHO EMRO endorsed a regional action plan to increase capacity for evidence-informed policy-making for health. The Regional Network of Institutions for Evidence and Data to Policy highlighted the importance of: (1) developing and regularly updating the priority list for guideline adaptation and development and health technology assessments; (2) establishing evidence-informed decision-making programmes (e.g. national health technology assessment and guideline adaptation and development in collaboration with large academic organizations); and (3) supporting policy development and adapting WHO guidelines for national priorities in member states (68–72).

We add our voice to the call in the 2016 WHO report on developing and adapting evidence-based CPGs in the EMR that promoted a set of actions for academic and healthcare delivery organizations and the WHO EMRO (8). This includes but is not limited to: (1) increased academic staff, healthcare providers, and professionals in clinical epidemiology and guideline methodology; (2) formulation of a regional guideline advisory committee in the WHO EMRO that coordinates with the WHO collaborating centres and centres of excellence in evidence-based health care and CPGs; (3) encouragement of research in evidence-based health care and CPGs; (4) networking with experts and stakeholders in evidence-based health care and CPGs, and collaboration with CPG global organizations like GIN, AGREE Enterprise, GRADE working group, networks, and centres, MAGIC Foundation, and RIGHT Working Group; and (5) exploring different formal adaptation frameworks and methodologies in EMR countries and organizations, and identifying the feasibility and sustainability of each framework (22).

Conclusions

Despite the successful use of formal guideline adaptation frameworks, there is no international standardized guidance to identify which is most suitable for specific healthcare contexts in the EMR. Each institution is adapting its CPGs differently. Several national CPG projects are using different methods within the same countries. A standardized selection tool is needed to enhance the appropriate selection of the adaptation method that fits the local resources and context. We encourage EMR countries and organizations to register their old and new guideline adaptation projects to avoid duplication in CPG formation, especially within the same country, and collaborate with global CPG networks and reference organizations.

Acknowledgements

This study was supported by the Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia. We would like to thank Professor Lubna Al-Ansary, Professor Hayfaa Wahabi, Professor Elie Akl, Professor Zbys Fedorowicz, Professor Mazen Ferwana, Dr. Imad Hassan, Dr. Mohammed Ben Hamouda, Ms. Hella Ouertatani, Dr. Asma Ben Brahem, Ms. Elaine Harrow, and Ms. Alice Bird for their useful advice during the writing of this manuscript. This work was initiated as part of A.F. Alshehri’s Master’s degree, College of Pharmacy, King Saud University. Our results were presented as an oral presentation at the 16th GIN 2021 Online (74).

References

1. The ADAPTE Collaboration (2009). The ADAPTE Process: resource toolkit for guideline adaptation. version 2.0. resources – GIN [website]. Guidelines International Network; 2021 ( https://g-i-n.net/get-involved/resources/, accessed 10 March 2023).

2. Fervers B, Burgers JS, Haugh MC, Latreille J, Mlika-Cabanne N, Paquet L, et al. Adaptation of clinical guidelines: literature review and proposition for a framework and procedure. Int J Qual Health Care. 2006 Jun;18(3):167–76. https//doi.org/10.1093/intqhc/mzi108 PMID: 16766601

3. Fervers B, Burgers JS, Voellinger R, Brouwers M, Browman GP, Graham ID, et al. Guideline adaptation: an approach to enhance efficiency in guideline development and improve utilisation. BMJ Qual; Saf. 2011 Mar 1;20(3):228–36. https//doi.org/10.1136/bmjqs.2010.043257 PMID: 21209134

4. Cuello-Garcia C. The movement for adopting or adapting clinical guidelines and recommendations. J Clin Epidemiol. 2021 Mar;131:166–7. https//doi.org/10.1016/j.jclinepi.2020.12.025 DOI: 10.1016/j.jclinepi.2020.12.025 PMID: 33359985

5. Amer YS, Wahabi HA, Abou Elkheir MM, Bawazeer GA, Iqbal SM, Titi MA, et al. Adapting evidence-based clinical practice guidelines at university teaching hospitals: a model for the Eastern Mediterranean Region. J Eval Clin Pract. 2019 Aug;25(4):550–60. https//doi.org/10.1111/jep.12927. PMID: 29691950.

6. Dizon JM, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC Res Notes. 2016 Sep 13;9(1):1–8. https//doi.org/10.1186/s13104-016-2244-7 PMID: 27623764

7. Birbeck GL, Wiysonge CS, Mills EJ, Frenk JJ, Zhou XN, Jha P. Global health: the importance of evidence-based medicine. BMC medicine. 2013;11(1):1–9. https://doi.org/10.1186/1741-7015-11-223

8. Developing/adapting evidence-based guidelines in the Eastern Mediterranean Region. East Mediterr Health J. 22(4):286–7. http://www.emro.who.int/emhj-volume-22-2016/volume-22-issue-4/developingadapting-evidence-based-guidelines-in-the-eastern-mediterranean-region.html

9. Grimshaw, J., M. Eccles, and I. Russell, Developing clinically valid practice guidelines. J Eval Clin Pract. 1995 Sep.1(1):37–48. https//doi.org/10.1111/j.1365-2753.1995.tb00006.x PMID: 9238556

10. Wang Z, Norris SL, Bero L. The advantages and limitations of guideline adaptation frameworks. Implement Sci. 2018 May 29;13(1):72. https://doi.org/10.1186/s13012-018-0763-4

11. Coordinating office established to advance MENA/NCCN collaboration. Business Wire, 2010 Summer (http://search.ebscohost.com.sdl.idm.oclc.org/login.aspx?direct=true&db=rps&AN=bizwire.c30894883&site=eds-live, accessed 15 August 2022).

12. Jazieh AR. Adaptation of NCCN Guidelines to the Middle East and North Africa Region. J Natl Compr Canc Netw. 2014 Jul 1;12(7):961–2. https://doi.org/10.6004/jnccn.2014.0091

13. Jazieh AR, Azim HA, McClure J, Jahanzeb M. The process of NCCN guidelines adaptation to the Middle East and North Africa Region. J Natl Compr Canc Netw. 2010 Jul 1;8(Suppl_3):S5–7. https//doi.org/10.6004/jnccn.2010.0125 PMID: 20697132

14. Middle East & North Africa (MENA) editions of NCCN guidelines [website]. National Comprehensive Cancer Network (https://www.nccn.org/global/what-we-do/regions/middle-east-north-africa, accessed 10 March 2023).

15. Al Rukhaimi M, Al Sahow A, Boobes Y, Goldsmith D, Khabouth J, El Baz T. et al. Adaptation and implementation of the" Kidney Disease: Improving Global Outcomes (KDIGO)" guidelines for evaluation and management of mineral and bone disorders in chronic kidney disease for practice in the Middle East countries. Saudi J Kidney Dis Transpl. 2014 Jan;25(1):133–48. https//doi.org/10.4103/1319-2442.124536 PMID: 24434398

16. Song Y, Ballesteros M, Li J, García LM, de Guzmán EN, Vernooij RW et al. Current practices and challenges in adaptation of clinical guidelines: a qualitative study based on semistructured interviews. BMJ Open. 2021 Dec 2;11(12):e053587. https//doi.org/10.1136/bmjopen-2021-053587 PMID: 34857574

17. Annual report 2013. Guidelines International Network; 2014 (http://www.g-i-n.net/document-store/annual-reports/g-i-n-annual-report-2013.pdf, accessed 15 August 2022).

18. Amer YS, Elzalabany MM, Omar TE, Ibrahim AG, Dowidar NL. The ‘Adapted ADAPTE’: an approach to improve utilization of the ADAPTE guideline adaptation resource toolkit in the Alexandria Center for Evidence‐Based Clinical Practice Guidelines. J Eval Clin Pract. 2015 Dec;21(6):1095–106. https//doi.org/10.1111/jep.12479 PMID: 26662728

19. Darzi A, Abou-Jaoude EA, Agarwal A, Lakis C, Wiercioch W, Santesso N et al., A methodological survey identified eight proposed frameworks for the adaptation of health related guidelines. J Clin Epidemiol. 2017 Jun;86:3–10. https//doi.org/10.1016/j.jclinepi.2017.01.016 PMID: 28412463

20. Schünemann HJ, Wiecioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V et al. GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017 Jan;81:101–10. https//doi.org/10.1016/j.jclinepi.2016.09.009 PMID: 27713072

21. Palda VA, Graham I, Davis D, Burgers J, Brouwers M, Cluzeau F et al. Guideline adaptation: an appealing alternative to de novo guideline development. Ann Intern Med. 2008 Apr 1;148(7):564. https//doi.org/10.7326/0003-4819-148-7-200804010-00022 PMID: 18378957

22. Yao X, Xia J, Jin Y, Shen Q, Wang Q, Zhu Y et al. Methodological approaches for developing, reporting, and assessing evidence-based clinical practice guidelines: a systematic survey. J Clin Epidemiol. 2022 Jun;146:77–85. https//doi.org/10.1016/j.jclinepi.2022.02.015 PMID: 35271968

23. Working groups [website]. GIN Guidelines International Network; 2022 (https://g-i-n.net/get-involved/working-groups/, accessed 15 August 2022).

24. Regional communities [website]. Guidelines International Network; 2022 (https://g-i-n.net/get-involved/regional-communities/, accessed 15 August 2022).

25. GIN Connect (membership software by Very Connect) [website]. Guidelines International Network (https://connect.g-i-n.net/members/addressbook?roles=Associate%20Member&roles=Consumer%20Organisation&roles=Lower%20Middle%20Income%20Organisation&roles=Partner%20contact&roles=Honorary%20Patron&roles=Individual%20membership&roles=Lower%20middle%20income%20countries%20individual&roles=Organisational%20Member&roles=Patient%20Representative&roles=Student%20membership&signedupfilter=true>, accessed 15 August 2022).

26. Abdel Baky A, Omar T, Amer Y. 2021. Towards evidence-based pediatrics: a national clinical practice guidelines program in Egypt on behalf of the Egyptian Pediatric Clinical Practice Guidelines Committee (EPG). 16th Guidelines International Network Conference 2021 Online [website]. Guidelines International Network; 2021. (https://g-i-n.net/wp-content/uploads/2021/10/GIN-Conference-2021-Abstract-Book.pdf, accessed 10 March 2023).

27. Egyptian Pediatric Clinical Practice Guidelines Committee [website] (http://epg.edu.eg/, accessed 10 March 2023).

28. Moustafa BH, Rabie MM, El Hakim IZ, Badr A, El Balshy M, Kamal NM et al. Egyptian pediatric clinical practice guidelines for urinary tract infections in infants and children (evidence based). Egypt Pediatric Association Gaz 69, 43 (2021). https://doi.org/10.1186/s43054-021-00073-z

29. Abdel Baky A, Fouda EM, Hussein SM, Sobeih AA, Abd Al Razek AA, Hassanain AI, et al. Bronchiolitis diagnosis, treatment, and prevention in children: An evidence-based clinical practice guideline adapted for the use in Egypt based on the 'Adapted ADAPTE' methodology. Egypt Pediatric Association Gaz 2022;70:article number 1. https://doi.org/10.1186/s43054-021-00094-8

30. Wahabi HA, Alansary LA. Great expectations from the chair of evidence-based health care and knowledge translation. Saudi Med J. 2009 Aug;30(8):989–90. PMID: 19668876

31. Ciocson M, Hernandez M, Atallah M, Amer Y. Central vascular access device: an adapted evidence-based clinical practice guideline. J Assoc Vasc Access. 2014;19(4):221–37. https://doi.org/10.1016/j.java.2014.09.002

32. Titi MA, Alotair HA, Fayed A, Baksh M, Alsaif FAA, Almomani Z, et al. Effects of computerised clinical decision support on adherence to VTE prophylaxis clinical practice guidelines among hospitalised patients. Int J Qual Health Care. 2021 Mar 22;33(1):mzab034. https://doi.org/10.1093/intqhc/mzab034

33. Bashiri FA, Albatti TH, Hamad MH, Al-Joudi HF, Daghash HF, Al-Salehi SM et al. Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative. Child Adolesc Psychiatry Ment Health 2021 Feb 8;15(1):6. https://doi.org/10.1186/s13034-020-00351-5 PMID: 33557914

34. Alhabib S, Almadani WH, Owaidah T, Al Khadra A, Amr A, Bakhsh E et al. Evidence-based clinical practice guideline: screening, prophylaxis and management of venous thromboembolism (VTE). Saudi Health Council, National Center for Evidence-Based Medicine; 2021 (https://shc.gov.sa/Arabic/Documents/CPG%20Screening.pdf, accessed 10 March 2023).

35. Darzi A, Harfouche M, Arayssi T, Alemadi S, Alnaqbi KA, Badsha H et al. Adaptation of the 2015 American College of Rheumatology treatment guideline for rheumatoid arthritis for the Eastern Mediterranean Region: an exemplar of the GRADE Adolopment. Health Qual Life Outcomes, 2017 Sep 21;15(1):183. https//doi.org/10.1186/s12955-017-0754-1 PMID: 28934978

36. Saudi Arabian handbook for healthcare guideline development. Riyadh: Ministry of Health; 2014 (https://www.moh.gov.sa/en/Ministry/Structure/Programs/TCP/Documents/Saudi%20Arabian%20Handbook%20for%20Healthcare%20Guideine%20Development-updated16-7.pdf, accessed 10 March 2023)

37. Chen Y, Guyatt GH, Munn Z, Florez ID, Marušić A, Norris SL, et al. Clinical Practice Guidelines Registry: toward reducing duplication, improving collaboration, and increasing transparency. Ann Intern Med. 2021 May;174(5):705–7. https//doi.org/10.7326/M20-7884 PMID: 33721516

38. Harrow E, Twaddle S, Service D, Kopp IB, Alonso-Coello P, Leng G. Clinical Practice Guidelines Registry. Ann Intern Med. 2021 May;174(9):1346–7. https//doi.org/10.7326/L21-0492 PMID: 34543600

39. Alper BS, Tristan M, Ramirez-Morera A, Vreugdenhil MM, Van Zuuren EJ, Fedorowicz Z. RAPADAPTE for rapid guideline development: high-quality clinical guidelines can be rapidly developed with limited resources. Int J Qual Health Care. 2016 Jun 1;28(3):268–74. https//doi.org/10.1093/intqhc/mzw044 PMID: 27097885

40. Sprakel, J, Carrara, H, Manzer, BM, Fedorowicz, Z. A mapping study and recommendations for a joint NGO (Think Pink) and Bahrain Government Breast Cancer project. J Evid Based Med. 2019 Aug;12(3):209–17. https://doi.org/10.1111/jebm.12357 PMID: 31441238

41. Wang Z, Grundy, , Parker, L, Bero L. Variations in processes for guideline adaptation: a qualitative study of World Health Organization staff experiences in implementing guidelines. BMC Public Health 2020 Nov 23;20(1):1758. https://doi.org/10.1186/s12889-020-09812-0 PMID: 33228608

42. WHO handbook for guideline development. 2nd ed. Geneva: World Health Organization; 2014 (https://www.who.int/publications/i/item/9789241548960, accessed 10 March 2023).

43. World Health Organization Regional Office for the Eastern Mediterranean [website] (http://www.emro.who.int/countries.html, accessed 10 March 2023).

44. Al-Hameed FM, Al-Dorzi HM, Abdelaal MA, Alaklabi A, Bakhsh E, Alomi YA, et al. The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in medical and critically ill patients. Saudi Med J. 2016 Nov;37(11):1279–93. https//doi.org/10.15537/smj.2016.11.15268 PMID: 27761572

45. Kahale L, Ouertatani H, Brahem A, Grati H, Hamouda M, Saz-Parkinson Z et al. Contextual differences considered in the Tunisian ADOLOPMENT of the European Guidelines on Breast Cancer Screening. Health Res Policy Syst. 2021 May 13;19(1):80. https//doi.org/10.1186/s12961-021-00731-z PMID: 33985535

46. Qader SAA, King ML. Transcultural adaptation of best practice guidelines for ostomy care : pointers and pitfalls. Middle East J of Nurs. 2015 Apr;9(2):3–12. http://www.me-jn.com/April2015/Ostomy.pdf

47. Harrison MB, Graham ID, Van Den Hoek J, Dogherty EJ, Carley ME, Angus V. Guideline adaptation and implementation planning: a prospective observational study. Implement Sci. 2013 May 8;8:49. https//doi.org/10.1186/1748-5908-8-49 PMID: 23656884

48. Alawadi F, Abusnana S, Afandi B, Aldahmani KM, Alhajeri O, Aljaberi K et al. Emirates diabetes society consensus guidelines for the management of type 2 diabetes mellitus – 2020. Dubai Diabetes Endocrinol J. 2020;26:1–20. https://doi.org/10.1159/000506508

49. Zadegan SA, Ghodsi SM, Arabkheradmand J, Amirjamshidi A, Sheikhrezaei A, Khadivi M et al. Adaptation of traumatic brain injury guidelines in Iran. Trauma Mon. 2016 Mar 20;21(2):e28012. https//doi.org/10.5812/traumamon.28012 PMID: 27626012

50. Irajpour A, Hashemi M, Taleghani F. Clinical practice guideline for end-of-life care in patients with cancer: a modified ADAPTE process. Support Care Cancer 2022 Mar;30(3):2497–505. https://doi.org/10.1007/s00520-021-06558-2 PMID: 34786639

51. Wahabi HA. Rapid response: Health in the Middle East. BMJ 2006;333:815. https://www.bmj.com/rapid-response/2011/10/31/evidence-based-health-care-sudan

52. Sharif A. Share experience: AlTababa group advocacy for evidence based healthcare through empowerment and competency-focused training, Khartoum, Sudan. In: 7th Annual Conference International Society of Evidence Based Healthcare [website]. Ajman: Gulf Medical University; 2016 (https://gmu.ac.ae/evidence-based-healthcare/program-outline.php, accessed 10 March 2023).

53. Abdelgadir HS, Elfadul MM, Hamid NH, Noma M. Adherence of doctors to hypertension clinical guidelines in academy charity teaching hospital, Khartoum, Sudan. BMC Health Services Res. 2019 May 14;19(1):309. https//doi.org/10.1186/s12913-019-4140-z PMID: 31088467

54. Sudan guidelines for the management of systemic hypertension in adults, 2nd ed. Sudan Society of Hypertentsion and Non communicable Diseases Directorate; 2014 (http://ssh-sd.org/guidelines/, accessed 15 August 2022).

55. Alonso-Coello P, Irfan, Solà I, Gich I, Delgado-Noguera M, Rigau D et al., The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care, 2010 Dec.19(6):e58. https//doi.org/10.1136/qshc.2010.042077 PMID: 21127089

56. Almazrou SH, Alsubki LA, Alsaigh NA, Aldhubaib WH, Ghazwani SM. Assessing the quality of clinical practice guidelines in the Middle East and North Africa (MENA) Region: a systematic review. J Multidiscip Healthc. 2021 Feb 9;14:297-309. https//doi.org/10.2147/JMDH.S284689 PMID: 33603389

57. Brouwers M, Spithoff K, Lavis J, Kho M, Makarski J, Florez I. What to do with all the AGREEs? The AGREE portfolio of tools to support the guideline enterprise. J Clin Epidemiol. 2020 Sep;125:191–7. https//doi.org/10.1016/j.jclinepi.2020.05.025 PMID: 32473992

58. Koornneef E, Robben P, Hajat C, Ali A. The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature. J Eval Clin Pract. 2015 Dec;21(6):1006–13. https//doi.org/10.1111/jep.12337 PMID: 25756849

59. Penney GC. Adopting and adapting clinical guidelines for local use. Obstetrician Gynaecologist 2007 Jan;9(1):48–52. https://doi.org/10.1576/toag.9.1.048.27296

60. Wang Z, Norris SL, Bero L. Implementation plans included in World Health Organisation guidelines. Implement Sci. 2015;11:76. https://doi.org/10.1186/s13012-016-0440-4

61. Babiker, A, Amer, YS, Osman, ME, Al-Eyadhy A, Fatani S, Mohamed S et al. Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East. J Eval Clin Pract. 2018; 24: 206– 211. https//doi.org/10.1111/jep.12873 PMID: 29285849

62. Alshowaeir D, Almasoud N, Aldossari S, Alsirhy EY, Osman E, Turjoman A et al. Primary open angle glaucoma management in a tertiary eye care center in Saudi Arabia: a best practice implementation pilot project. JBI Evid Implement. 2020 Dec 5;19(2):208–16. https//doi.org/10.1097/XEB.0000000000000257 PMID: 34061052

63. Al-Salloum HF, Amer YS, Alsaleh KA. Monitoring the adherence to an adapted evidence-based clinical practice guideline on antiemetics in 669 patients with cancer receiving 1451 chemotherapy doses at a University oncology center in Saudi Arabia. J Nature Sci Med. 2021;4(1):33. https//doi.org/10.4103/JNSM.JNSM_10_20

64. AlMohaimeed B, Hundallah K, Bashiri F, AlMohaimeed S, Tabarki B. Evaluation of adherence to pediatric status epilepticus management guidelines in Saudi Arabia. Neurosciences. 2020 Jul;25(3):182–7. https//doi.org/10.17712/nsj.2020.3.20190106 PMID: 32683397

65. Song Y, Alonso-Coello P, Ballesteros M, Cluzeau F, Vernooij RW, Arayssi T et al. A reporting tool for adapted guidelines in health care: the RIGHT-Ad@ pt Checklist. Annals of Internal Medicine. 2022 May;175(5):710–9. https://doi.org/10.7326/M21-4352 PMID: 35286143

66. Antoniou SA, Florez ID, Markar S, Logullo P, López-Cano M, Silecchia G et al. AGREE-S: AGREE II extension for surgical interventions: appraisal instrument. Surg Endosc. 2022 Aug;36(8):5547–58. https//doi.org/10.1007/s00464-022-09354-z PMID: 35705753

Abdul–Khalek RA, Darzi AJ, Godah MW, Kilzar L, Lakis C, Agarwal A et al. Methods used in adaptation of health–related guidelines: a systematic survey. J Glob Health, 2017 Dec;7(2):020412. https//doi.org/10.7189/jogh.07.020412 PMID: 29302318

67. Munn Z, Twaddle S, Service D, Harrow E, Okwen PM, Schünemann H, et al. Developing guidelines before, during, and after the COVID-19 pandemic. Ann Intern Med. 2020 Dec 15;173(12):1012–4. https//doi.org/10.7326/M20-4907 PMID: 32931327

68. Developing national institutional capacity for evidence-informed policy-making for health. East Mediterr Health J. 2021;27(3):314–5. https://doi.org/10.26719/2021.27.3.3141 PMID: 33788222

69. Summary report on the first formal meeting of the regional Network of Institutions for Evidence and Data to Policy (NEDtP) to enhance national capacity for evidence-informed policy-making, virtual meeting 30 March 2021. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2022 (https://apps.who.int/iris/handle/10665/352578, accessed 10 March 2023).

70. Framework for action to improve national institutional capacity for the use of evidence in health policy-making in the Eastern Mediterranean Region [website]. Cairo: World Health Organization Regional Office for the Eastern Mediterranean (http://www.emro.who.int/health-topics/health-information-systems/framework-for-action-to-improve-national-institutional-capacity-for-the-use-of-evidence-in-health-policy-making-in-the-region.html, accessed 10 March 2023).

71. Regional action plan for the implementation of the framework for action to improve national institutional capacity for the use of evidence in health policy-making in the Eastern Mediterranean Region (2020–2024). Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2021 (https://applications.emro.who.int/docs/9789290229124-eng.pdf?ua=1, accessed 10 March 2023).

72. Alshehri A, Almazrou S, Amer Y. Adaptation of clinical practice guidelines in the Middle East and North African (MENA) Countries. In: GIN Conference 2021 Online. [website]. Guidelines International Network; 2021 (https://g-i-n.net/wp-content/uploads/2021/10/GIN-Conference-2021-Abstract-Book.pdf, accessed 15 August 2022).

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Asma Sabermahani,^1,3 Vahid Yazdi-Feyzabadi^2,3 and Salman Bashzar¹

¹Student Research Committee, School of Health Management and Information Sciences; ²Health Services Management Research Centre, Institute for Futures Studies in Health; ³Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Islamic Republic of Iran (Correspondence to Salman Bashzar:Cette adresse e-mail est protégée contre les robots spammeurs. Vous devez activer le JavaScript pour la visualiser.).

Abstract

Background: There is no single method for health technology assessment (HTA) which can be used in all countries to meet all the needs of the health care system policy- and decision-makers. Still, some minimum criteria for performing HTA should be in place in all the HTA structures worldwide, and many HTA agencies have reached a consensus in this regard.

Aim: This study aimed to assess the quality of Iranian HTA reports.

Method: Were examined all the HTA research reports published by the Iranian HTA office up to 2020. The International Network of Agencies for Health Technology Assessment checklist was employed for quality assessment.

Results: A total of 97 reports were examined: only 10.0% had presented complete and appropriate contact details for obtaining further information, and 5.6% clearly stated a conflict of interests. In 87.78% of the reports, the scope of assessment was clearly determined. The quality of the reports was relatively appropriate as well as the details of the sources of information and text search strategies. Legal aspects, economic analysis, ethical implications, social implications and other stakeholder perspectives were taken into account in 7.8%, 74.4%, 11.1%, 8.9%, and 4.4% of the reports, respectively.

Conclusion: As Iranian HTA reports are not of suitable quality, it is recommended that minimum standard criteria be revised and modified in the HTA process so that large-scale health care policy- and decision-makers can make reliable decisions on the basis of the results.

Keywords: health technology assessment, quality assessment, health policy, Iran

Citation: Sabermahani A, Yazdi-Feyzabadi V, Bashzar S. Evaluating the quality of health technology assessment research reports until 2020: the experience of a developing country, Islamic Republic of Iran. East Mediterr Health J. 2023;29(5):xxx–xxx. https://doi.org/10.26719/emhj.23.033

Received: 09/08/21; accepted: 24/10/21

Copyright: © Authors; licensee World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Growing concerns about limiting the increase in health care costs while maintaining and strengthening access to high quality medical care have aroused interest in the better use of medical interventions (1). Discussions about the use of scientific evidence in decision-making have been revolutionized over time and, at present, evidence-based methods are the mainstream approach in many public sectors (2,3). In the health care domain, the evidence-based medical principles for clinical measures have expanded in the context of health care management and policy-making, and the number of experimental studies for raising the awareness of decision-makers is rising (4).

Moreover, advances in technology in recent years have brought about considerable change in medical care and treatment such that, annually, global medical equipment technology presents thousands of products to the market (5). Policy-makers cannot judge the values and consequences of technologies based merely on complex technical data, and for reasonable decision-making, they need to understand the vast economic, social, ethical and legal effects. Since issues relating to health technologies pose constant challenges to health care systems, it must be guaranteed that health technology is accurately evaluated and efficiently and effectively used in health care. For optimal exploitation of the existing resources, the most effective technologies should be propagated and used in light of organizational, social, ethical and economic issues (6).

Owing to the scarcity of resources in health care, decisions should be evidence-based, especially when selecting expensive technologies (16). This has made many countries develop mechanisms for the introduction and reasonable use of such technologies in order to control the costs and prevent them from increasing inordinately, optimally allocate these costs, and prevent the entry of technologies with low safety and effectiveness (6,8).

The most salient example of scientific research conducted to provide input in health care policy-making is, doubtless, found under the health technology assessment (HTA) model (4). This is a multi-disciplinary context of policy analysis research into economic, ethical, social and medical outcomes, as well as the development, propagation and use of health technologies (3). It emerged as a result of increasing concerns about the wide-ranging spread of medical equipment in the 1970s and the funding ability of insurance companies (9). The use of HTA has remarkably expanded in the last 2 decades; it is currently used for the evaluation and estimation of the value of medical technologies (10).

Historically, most HTA agencies have emphasized the development of high-quality evaluation reports which can be used by a wide range of decision-makers, e.g. the Canadian Agency for Drugs and Technologies in Health, the Swedish Council for Health Technology Assessment, the German Agency of Health Technology Assessment at the German Institute for Medical Documentation and Information and agencies in many other European countries (1). Still, organizations are increasingly performing or launching HTA for making certain decisions about resource allocation. For example, the National Institute for Health and Clinical Excellence in the United Kingdom utilizes HTAs for developing guidelines on the use of health technologies in the National Health Service in England and Wales. In Germany, the Institute for Quality and Efficiency in Health Care receives HTA requests from the Federal Joint Committee to make recommendations based on which the pricing and reimbursement for technologies are made (1).

In the Islamic Republic of Iran, HTA was launched in the form of an HTA secretariat at the Health Economy Department of the Network Development and Health Promotion Center in October 2007. The initial stages of its formation were performed with the cooperation and support of professors and researchers for receiving HTA orders and, eventually, receiving HTA reports. The overall project was approved in April 2008 at the Deputy for Coordination, Ministry of Health and Medical Education. In the next stage, the objectives, responsibilities, method of establishment and general structure of the Iranian HTA system were discussed and approved in the policy-making council at the Ministry of Health and Medical Education, supervised by the Deputy for Coordination. Joint expert teams were then formed, and with the consultation of foreign experts, 6 HTA projects were developed and their results were simultaneously presented at the executive meetings to facilitate decision-making. Since March 2010 and following the change in the structure of the Ministry of Health and Medical Education, the deputies for health and treatment were split, and the HTA department at the Technology Evaluation Office started its standard development and health care price-setting activities under the supervision of the Deputy for Treatment with a new structure. Since then, it has published many reports on health technologies.

There is no single method for performing HTA which can meet the needs of all decision-makers, stakeholders, and societies (1): HTA agencies have their own guidelines for the performance and presentation of reports, e.g. the guidelines by the International Network of Agencies for Health Technology Assessment (INAHTA). In the Islamic Republic of Iran, the Ministry of Health and Medical Education, which is the health care service provider and funder of HTA studies, is in charge of performing HTA. Therefore, the present study aimed to assess the quality of Iranian HTA reports from the foundation of HTA until 19 March 2020.

Methods

This descriptive cross-sectional study was conducted in 2020. All the reports from the HTA office in the Islamic Republic of Iran presented under the title of HTA projects, were retrieved from the website of the office of the Department of Health Technology Assessment in the Ministry of Health and Medical Education (http://ihta.behdasht.gov.ir). The inclusion criteria for the reports were: HTA reports, theses, and dissertations compatible with the priorities of the HTA office or available on this office’s list of reports. Then, these reports were evaluated based on a checklist developed by the INAHTA (11). This checklist encompasses 6 domains and has a total of 31 items, including preliminary information (5 items), why the assessment has been undertaken (4 items), how the assessment has been undertaken (10 items), information based on the evaluation and interpretation of the selected data and information (4 items), context (5 items), and post-evaluation events (3 items). This checklist assesses the HTA reports on three levels (yes, partly, no). The checklist was first translated into Farsi by 2 HTA researchers and health policy-makers, and then examined by 7 HTA experts. After expert approval, the checklist was back-translated into English to ensure its reliability and validity. The reports were evaluated by 2 researchers independently, and cases of disagreement were reported to the third researcher to reach a consensus. The data were extracted, input to a researcher-made form in Excel, and then described and analysed using descriptive statistics.

Ethics clearance was obtained from the Kerman University of Medical Sciences ethics board (ethics clearance certificate number IR.KMU.REC.1398.894).

Results

A total of 101 reports were found on the Iranian HTA office website. We eliminated 1 report due to being a duplicate, and 3 due to being non-evaluation reports. Finally, 97 reports were assessed in terms of general features, and 90 reports could be assessed based on the checklist. Of the 97 4eports examined, in terms of the type of technology investigated, the majority focused on therapeutic technologies (equipment) (47.4%), followed by diagnostic and pharmaceutical technologies (both 22.7%) (Table 1).

A number of technologies investigated in the 97 reports dealt with neoplasms (18.6%), followed by technologies dealing with health-related equipment and devices (13.4%), diseases of the nervous system (12.37%), factors affecting health status or contacting health services (10.3%); a full list of distribution according to condition is given in Table 2.

In 61 reports there was 1 first author, 6 reports had 2 first authors, and the authors of 30 reports (31.0%) were unknown. Meanwhile, 34.0% of the HTA studies were conducted by only 9 researchers, each working with his/her own team; in fact, 11 reports were written by a single researcher, 6 were written by a different researcher, and 6 authors conducted 2 studies each.

The greatest cooperation in performing HTA was exhibited by the National Institute for Health Research and the centres affiliated with Tehran University of Medical Sciences and the HTA office of the Ministry of Health and Medical Education (52.58%), the Evidence-Based Medical Research Center at Tabriz University of Medical Sciences (9.27%), and the Health Management and Economy Research Center of Isfahan University of Medical Sciences (2.1%). In 30.9% of cases, the researchers’ organizational affiliation was unknown.

For the first item on the checklist, preliminary information, only 10% of the reports provided complete and appropriate contact details for obtaining further information, while 42.2% of the reports lacked such information. The authors were identified in 8 reports (8.9%), and 5.6% transparently stated their conflict of interests. In 98.9% of the reports there was no statement on being externally reviewed. A short summary in a non-technical language was presented in only 46.7% (Table 3).

Concerning making reference to the policy question, in 57.8% of the reports this was adhered to completely, and partly stated in 31 reports (34.4%). In 74.4% of the reports, reference was made to the research question(s); in 87.8%, the scope of assessment is clearly determined; and in 82.2% there is a proper description of the health technology that has been assessed (Table 3). For the sources of information and text search strategy, the Iranian HTA reports presented precise details about a complete reference list of the included studies (97.8%), databases (86.7%), search strategy (85.6%), and years covered (84.4%). A list of excluded studies was missing in 78.9% of reports.

The findings show that the data extraction method was clearly stated in 68.8% of the reports, and a critical appraisal method was presented in 61.1%. Also, the reports presented appropriate and sufficient information in terms of the description of the method of data synthesis (61.1%) and clear presentation of assessment results (78.9%). Furthermore, in terms of the context of the reports, 74.4% considered the economic analysis; only 11.1% considered the ethical implication and only 7.8% the legal implications. In terms of discussing the findings of the assessment, 84.4% did this properly, 67.8% clearly stated the conclusions from the assessment and only 16.7% made suggestions for further action (Table 3).

Discussion

The majority of technologies evaluated in the Islamic Republic of Iran are therapeutic, diagnostic and medical; most of them deal with noncommunicable diseases or their risk factors. This shows that the epidemiological movement of diseases from communicable to noncommunicable has greatly affected the technologies required by these diseases, which constitute > 60% of the disability-adjusted life years (DALYs) and 70% of global deaths (12). In this regard, the ever-increasing growth of technologies related to these diseases should be taken into account (5).

Our findings indicate that a limited number of researchers conduct the HTA studies: 34.0% had been conducted by only 9 researchers. The majority of these researchers possessed the experience and skills of performing HTA in the Islamic Republic of Iran. Therefore, to properly conduct HTA projects, a sufficient number of HTA experts possessing the required skills should be trained and involved in conducting such projects, and this is an important measure to be taken before establishing official HTA agencies (13). The strong point of Iranian HTAs is the good organizational relationship between most of these researchers and the health care legislator.

Having proper contact details, stating the conflict of interests, and stating whether the HTA report has been reviewed are essential items for ensuring transparency (11). However, our findings revealed that only 10% of the Iranian HTA reports presented complete and proper contact details for obtaining further information, and 42.2% of the reports lacked any such information. Only 5.6% clearly stated the conflict of interests, and 1.1% had any statement about being externally reviewed. The presentation of a short non-technical summary to be understood by a wider audience is optimal (11) and enhances the impartiality and transparency of HTA activity. This summary was included in less than half the reports.

In this study, the scope of assessment was clearly determined in 87.8% of the HTA reports. Drummond et al. explain 15 key principles for improving HTAs (1). The first states that the HTA objectives and scope should be explicit and compatible with its use. Based on this principle, questions which are to be answered should be stated with maximum precision in the form of specific objectives, and, if possible, testable hypotheses should be formed. In HTA, the answers to the main questions should be presented so that the outcome of the assessment can be stated with a shared understanding of the objective and all the evidence required for answering the questions (1). In terms of answering the policy question, > 70% of the Iranian reports made reference to the questions that were to be addressed. Nevertheless, in terms of the policy question, only 57.8% of the reports completely adhered to this principle.

Since HTA aims to provide information for decision-making for policy and action (14), it should adopt appropriate methods for cost–benefit analysis (1,15) and take into account a wide range of evidence and outcomes (1). As for the sources of information and text search strategy, More than 50% of of the Iranian HTA reports presented precise details; the exception was listing excluded studies (22.2% of reports). Evidently, those who perform HTA in the Islamic Republic of Iran have actively searched maximum data based on HTA guidelines.

The HTA process is multi-disciplinary; it examines legal aspects, economic analysis, ethical implications, social implications, and other stakeholder perspectives (16–18). However, the Iranian HTA reports were not outstanding, and most of them failed to consider these factors; most of the reports only discussed economic aspects. It should be kept in mind that the economic assessment of health care interventions, especially new medications and technologies, is often performed to identify the best purchases. Eventually, policy-makers and state institutions may fund a package of general benefits (19); thus, the other aspects related to technologies should also be examined. It is important that HTAs should meet the national, regional and local needs (1). Nevertheless, many Iranian HTAs were developed in the form of safety assessment or cost–effectiveness assessment studies that failed to attend to other aspects of an HTA study.

An important principle proposed by Drummond et al. is the active cooperation of all the key stakeholders with HTA performers (1), but no trace of this principle is found in Iranian HTA reports. Although the HTA structure in the Islamic Republic of Iran is similar to the European HTA core model, there are clear differences between the Iranian HTA structure and that of other organizations, such as those in the United Kingdom (20–22) and Germany (23,24).

Thus, to create an appropriate input for determining the priorities, resource allocation, and decision- and policy-making in technology-related spheres, HTA reports should accurately evaluate their findings, clearly report their conclusions, and make suggestions about further action. Moreover, to comply with a major principle of HTA, a clear distinction should be made between assessment and decision-making (10,25); in other words, since HTA results may not be precisely adopted in decision-making, clear conclusions should be stated in the report. We found that 84.4% of the reports properly discussed the assessment findings, but only 67.8% clearly expressed conclusions from the assessment. Furthermore, suggestions for further action were made only in 16.7% of the reports. No similar study has examined the HTA reports of a country; consequently, no comparison can be made between the status of HTA studies in the Islamic Republic of Iran and other countries. However, on comparison with one available study (26), we can conclude that the Iranian studies have from major problems.

According to a study by Newman et al. on 14 selected HTA organizations around the world, there is widespread support for some principles, such as determining the objectives and scope of HTA, using a wide range of evidence, and HTA impartiality and transparency (27), out of the 15 principles proposed by Drummond et al. for developing an ideal HTA (1). Less support has been provided for some other principles, e.g. generalizability and transferability, transparency in connecting HTA results to decision-making processes, adopting a comprehensive social perspective and monitoring the implementation of HTA results.

This study is limited in that many HTA performers were not identified; thus, lack of access to many researchers led to loss of information on HTA reports, including the method of implementation, and the factors that motivated the researchers to develop such reports.

Conclusion

No single recommendation can be made for HTA studies around the world. Still, in its simplest form, an HTA should possess certain components so that an appropriate input can be offered for policy- and decision-making at the desired levels. Our study discussed the strong and weak points of Iranian HTA reports and showed that there is a considerable space for the advancement of the HTA system in HTA project implementation at the level of international standards. Despite this, the Iranian HTA system has greatly progressed and can have a promising future if an appropriate structure is created and local guidelines for HTA are developed and presented to decision- and policy-makers.

Acknowledgments

This study is based on a health policy-making PhD thesis entitled “The Health Technology Assessment System analysis in the Islamic Republic of Iran and the Presentation of Policy Option”, approved on 10 February 2020 at the Deputy for Research and Technology of Kerman University of Medical Sciences (code: 980000894) and registered at the Ethics Committee (IR.KMU.REC.1398.644). The researchers are grateful to the Deputy for Research and Technology at Kerman University of Medical Sciences.

Funding: This research was funded by the Deputy for Research and Technology at Kerman University of Medical Sciences

Competing interests: The authors declare that they have no competing interests.

References

1. Drummond MF, Schwartz JS, Jönsson B, Luce BR, Neumann PJ, Siebert U, et al. Key principles for the improved conduct of health technology assessments for resource allocation decisions. Int J Technol Assess Health Care. 2008;24(3):244–58. doi:10.1017/S0266462308080343
2. Learmonth M, Harding N. Evidence-based management: the very idea. Public Administration. 2006;84(2):245–66. doi:10.1111/j.1467-9299.2006.00001.x
3. Ciani O, Tarricone R, Torbica A. Diffusion and use of health technology assessment in policy making: what lessons for decentralised healthcare systems? Health Policy. 2012 Dec;108(2–3):194–202. doi:10.1016/j.healthpol.2012.09.017
4. Velasco-Garrido M, Gerhardus A, Røttingen J-A, Busse R. Developing Health Technology Assessment to address health care system needs. Health Policy. 2010 Mar;94(3):196–202. doi:10.1016/j.healthpol.2009.10.002
5. Payam MM, Sari AA, Ay MR, Mobinizadeh MR, Maanavi S. Safety and diagnostic performance of dual-source ct scan in comparison with single source ct scan and conventional angiography in coronary heart diseases. J Hospital. 2010;9(1–2):25–32.
6. Garrido MV, Kristensen FB, Busse R, Nielsen C. Health technology assessment and health policy-making in Europe: current status, challenges and potential: Copenhagen: World Health Organization Regional Office for Europe, European Observatory on Health Systems and Policies, EuropeanNetwork for HTA; 2008 (Observatory Studies Series No 14; https://apps.who.int/iris/handle/10665/107911, accessed 27 October 2021).
7. 7Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al. Review of guidelines for good practice in decision-analytic modelling in health technology assessment. Health Technol Assess. 2004 Sep;8(36):iii–iv, ix–xi, 1–158. doi:10.3310/hta8360
8. Sacchini D, Virdis A, Refolo P, Pennacchini M, De Paula IC. Health technology assessment (HTA): ethical aspects. Med Health Care Philos. 2009 Nov;12(4):453–7. doi:10.1007/s11019-009-9206-y
9. Banta D, Jonsson E. History of HTA: Introduction. Int J Technol Assess Health Care. 2009 Jul;25 Suppl 1:1–6. doi:10.1017/S0266462309090321
10. Angelis A, Kanavos P. Multiple criteria decision analysis (MCDA) for evaluating new medicines in health technology assessment and beyond: the advance value framework. Soc Sci Med. 2017 Sep;188:137–156. doi:10.1016/j.socscimed.2017.06.024
11. A checklist for health technology assessment reports. Southampton: INAHTA Secretariat; 2007 (https://www.inahta.org/wp-content/uploads/2014/04/INAHTA_HTA_Checklist_English.pdf, accessed 27 October 2021).
12. Allen L. Non-communicable disease funding. Lancet Diabetes Endocrinol. 2017 Feb;5(2):92. doi:10.1016/S2213-8587(16)30420-X
13. Vo TQ. Health technology assessment in developing countries: a brief introduction for vietnamese health-care policymakers. Asian J Pharm. 2018;12(01). https://dx.doi.org/10.22377/ajp.v12i01.2340
14. Hailey D, Babidge W, Cameron A, Davignon L-A. HTA agencies and decision makers. An INAHTA guidance document. Stockholm: INAHTA; 2010 (http://pds20.egloos.com/pds/201009/07/46/HTA__Decision_Makers.pdf, accessed 27 October 2021).
15. Tarn T, Smith MD. Pharmacoeconomic guidelines around the world. ISPOR Connections. 2004;10(4):5–15.
16. Banta D. The development of health technology assessment. Health Policy. 2003 Feb;63(2):121–32. doi:10.1016/s0168-8510(02)00059-3
17. Thokala P, Duenas A. Multiple criteria decision analysis for health technology assessment. Value in Health. 2012;15(8):1172–81. doi:10.1016/j.jval.2012.06.015
18. Facey K, Boivin A, Gracia J, Hansen HP, Scalzo AL, Mossman J, et al. Patients' perspectives in health technology assessment: a route to robust evidence and fair deliberation. Int J Technol Assess Health Care. 2010;26(3):334–40. doi:10.1017/S0266462310000395
19. Verguet S, Kim JJ, Jamison DT. Extended cost-effectiveness analysis for health policy assessment: a tutorial. Pharmacoeconomics. 2016 Sep;34(9):913-23. doi:10.1007/s40273-016-0414-z
20. Raftery J. Review of NICE's recommendations, 1999-2005. Bmj. BMJ. 2006 May 27;332(7552):1266–8. doi:10.1136/bmj.332.7552.1266
21. Tosh JC, Longworth LJ, George E. Utility values in National Institute for Health and Clinical Excellence (NICE) Technology Appraisals. Value in Health. 2011;14(1):102–9. doi:10.1016/j.jval.2010.10.015
22. Wonderling D, Sawyer L, Fenu E, Lovibond K, Laramée P. National clinical guideline centre cost-effectiveness assessment for the national institute for health and clinical excellence. Ann Intern Med. 2011 Jun 7;154(11):758–65. doi:10.7326/0003-4819-154-11-201106070-0000
23. Koch K, Lange S. Response to the expertise: procedures and methods of benefit assessments for medicines in Germany, by Geertruida E. Bekkering and Jos Kleijnen. Eur J Health Econ. 2009 May;10(2):233–6. doi:10.1007/s10198-008-0142-1
24. Herpers M, Dintsios C-M. Methodological problems in the method used by IQWiG within early benefit assessment of new pharmaceuticals in Germany. Eur J Health Econ. 2019 Feb;20(1):45–57. doi:10.1007/s10198-018-0981-3
25. Mitton C, Seixas BV, Peacock S, Burgess M, Bryan S. Health technology assessment as part of a broader process for priority setting and resource allocation. Appl Health Econ Health Policy. 2019 Oct;17(5):573–6. doi:10.1007/s40258-019-00488-1
26. Bullement A, Podkonjak T, Robinson MJ, Benson E, Selby R, Hatswell AJ, et al. Real-world evidence use in assessments of cancer drugs by NICE. Int J Technol Assess Health Care. 2020 Jul 10:1–7. doi:10.1017/S026646232000043
27. International Working Group for HTA Advancement, Neumann PJ, Drummond MF, Jönsson B, Luce BR, Schwartz JS, Siebert U, et al. Are Key Principles for improved health technology assessment supported and used by health technology assessment organizations? Int J Technol Assess Health Care. 2010;26(1): 71–8. doi:10.1017/S0266462309990833