Faysal El Kak

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objective to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes. Design a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health. Setting childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon. Participants in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected. Measurements the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008. Findings the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries. Key conclusions and implications for practice there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.

Factors associated with alcohol and/or drug use at sexual debut among sexually active university students: cross-sectional findings from Lebanon

BackgroundSexual activity accompanied by substance use can impair youth decision-making and enhance risk-taking behaviors. Less is known, however, about the sexual values, perceptions and subsequent sexual practices of youth whose sexual debut occurs while using alcohol/drugs.MethodsA cross-sectional anonymous online survey was conducted in April-August 2012 among undergraduate and graduate university students (aged 18 to 30) attending the 4th largest private university in Beirut. Pearson’s Chi-square and regression models were run using Stata/IC 10.0.Results940 university students had engaged in oral, anal and/or vaginal sex, of whom 10% admitted to having had consumed alcohol or taken drugs at sexual debut, a behavior that was more common in the males, less religious, non-Arabs, students living alone or who had lived abroad. Students who used alcohol/drugs at sexual debut were twice as likely to have: their first oral and vaginal sex with an unfamiliar partner [odds ratio (OR) = 2.6, 95% confidence interval (CI): (1.6, 4.2) and OR = 2.1 (1.2, 3.5), respectively], controlling for sex, nationality, current relationship status, living abroad after the age of 12, and spirituality. Students who had sex the first time while using alcohol/drugs were three times as likely to report having had 11 or more subsequent sexual partners versus one or two [OR = 3.0 (1.5-6.0)]; and almost twice as likely to ever engage in something sexual they did not want to do [OR = 1.7 (1.1, 2.8)]. Perceived peer pressure to have sex by a certain age [OR = 1.8 (1.1, 2.9)], and perceived peer norms to consume alcohol/drugs before sex [OR = 4.8 (2.3, 9.9)] were also strong correlates of having sex for the first time while using alcohol and/or drugs.ConclusionsFindings stress the importance of sexuality education for youth, and the need to begin understanding the true interplay – beyond association - between youth sexual practices and substance use behaviors from a broader public health perspective.

Reproductive tract infections (RTIs) among married non-pregnant women living in a low-income suburb of Beirut, Lebanon

INTRODUCTION This study aimed to identify reproductive tract infections (RTIs) in married, non-pregnant women, aged 18 to 49 years, living in a low-income suburb of Beirut, and to investigate the relationship between demographic and socioeconomic factors and these infections. METHODOLOGY Among 1,015 women recruited for the study, 502 were found eligible and 441 were medically examined. Appropriate specimens were collected for Nisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, candidiasis, and bacterial vaginosis. RESULTS The results showed a relatively high prevalence of RTIs (28.2%). The prevalence rates of different agents were as follows: 22.9% of the women were positive for T. vaginalis, 8.8% for candidiasis, 4.5% for bacterial vaginosis, and 1% for N. gonorrhea; none of the women were positive for C. trachomatis. Regression analysis showed that women between the ages of 30 and 39 were twice more likely to have T. vaginalis as compared to younger women. Furthermore, women whose husbands were taxi drivers were at higher risk of acquiring T. vaginalis (OR = 2.2) as compared with women whose husbands occupation was listed as skilled/unskilled. This conclusion can be drawn for the odds of developing any RTI (OR = 2.15). Moreover, those participants with the lowest income were twice as likely to have any RTI compared to those with higher incomes. CONCLUSIONS This study shows a relatively high prevalence of RTIs (T. vaginalis mainly). It urges further in-depth research on cultural practices and economic factors to understand the pattern of sexual behavior in this community.

Postponing sexual debut among university youth: how do men and women differ in their perceptions, values and non-penetrative sexual practices?

This study aimed to investigate gender differences in reasoning influencing the postponing of sexual debut among university youth in Lebanon. Findings aimed to develop understandings that might help inform future research on, and programme implementation of, young peoples reproductive and sexual health. A cross-sectional survey of sexuality and sexual practices, attitudes and perceptions was conducted among private university students in Lebanon using a secure online method. Of 1838 participating students, 48.7% indicated they had never engaged in oral, anal or vaginal sex (i.e., penetrative sexual activity) during their lifetime (n = 895). Common socio-cultural concerns regarding sexual initiation included: gaining a bad reputation (47%), social rejection (58%), religion (70%) and parental disapproval (61%). Women were four times more concerned than men regarding loss of reputation and self-respect, six times more so regarding parental disapproval and three times more likely to be concerned with societal disapproval. Intrapersonal concerns included fear of contradicting ones own beliefs (67%), feeling guilty afterwards (62%) and losing self-respect (55%). Women were four times more likely to feel loss of self-respect and six times more likely to think sex was disgusting. Underlying reasons for postponing sexual intercourse are linked to adopted fears and social pressures that are internalised, and reinforce existing gender inequalities and reaffirm discriminatory gender norms.

HIV/AIDS-related knowledge and its association with socioeconomic status among women: results of Lebanese Survey for Family Health (PAPFAM) 2004.

This article assesses the association of women’s HIV/AIDS knowledge of transmission and prevention with socioeconomic status (SES). Data from the 2004 Lebanese PAPFAM (Pan-Arab Project for Family Health) survey were used. The survey was based on a representative household sample (n = 5532 households; n = 3315 women) of ever-married women aged 15 to 55 years. Adjusted analysis revolved around multivariate logistic regression models. 18% of women were knowledgeable of HIV/AIDS transmission methods and 21% of prevention methods. Income and education were significantly related to women’s transmission and prevention knowledge. Significant differences were also found by region and media exposure. Women in the richest income quintile were 4 times (95% confidence interval [CI] = 2.43-6.42) more likely to be knowledgeable than those in the poorest. Women with the highest education were 2.57 times more likely (95% CI = 1.98-3.34) to be knowledgeable than those with elementary education or less. These results suggest the need for incorporating contextual regional and population differences for more effective HIV/AIDS awareness campaigns in Lebanon.

Hymen protection and the sexual practices, perceptions, and attitudes of female university students from Lebanon

To investigate associations between hymen protection and womens alternative sexual practices, perceptions, and attitudes.

Undertaking the First Online Sexuality Survey among Private University Students in Lebanon : Process, Challenges and Lessons Learned

Background The taboo surrounding reproductive and sexual health in the Middle East and North African (MENA) region, specifically among unmarried youth, has resulted in an incomplete and inaccurate documentation of the status of youth sexual and reproductive health (SRH). Documenting regional research processes and successes can support SRH researchers in promoting evidence-based services and local policies. This paper describes the process, challenges and lessons learned during the first online research study in the MENA to assess university students’ sexual practices, values and perceptions. Methods An online survey was completed by 2,182 university students attending the 4th largest private university in Lebanon. Results An online SRH survey among Arab youth must be carefully developed with the cultural context and its prevailing issues in mind. Careful attention must be paid to any translation process specifically regarding tone and choice of certain sexual terms. The online program/software must be thoroughly piloted for possible technical flaws, language support, and web browser compatibility. Inter-disciplinary collaboration between the research team, IT and IRB offices is crucial in order to conduct an ethicallyappropriate technically-functional online survey. Conclusion Online survey methods hold great promise for surveying SRH and other sensitive topics in Lebanon and the MENA.

Practice and attitudes towards immunization among Lebanese obstetricians and gynecologists

ABSTRACT We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13–15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.

Perspectives of displaced Syrian women and service providers on fertility behaviour and available services in West Bekaa, Lebanon

Abstract Prior to the conflict, Syria had relatively high fertility rates. In 2010, it had the sixth highest total fertility rate in the Arab World, but it witnessed a fertility decline before the conflict in 2011. Displacement during conflict influences fertility behaviour, and meeting the contraceptive needs of displaced populations is complex. This study explored the perspectives of women and service providers about fertility behaviour of and service provision to Syrian refugee women in Bekaa, Lebanon. We used qualitative methodology to conduct 12 focus group discussions with Syrian refugee women grouped in different age categories and 13 in-depth interviews with care providers from the same region. Our findings indicate that the displacement of Syrians to Lebanon had implications on the fertility behaviour of the participants. Women brought their beliefs about preferred family size and norms about decision-making into an environment where they were exposed to both aid and hardship. The unaffordability of contraceptives in the Lebanese privatised health system compared to their free provision in Syria limited access to family planning services. Efforts are needed to maintain health resources and monitor health needs of the refugee population in order to improve access and use of services.

The Relaxation Exercise and Social Support Trial (RESST): a community-based randomized controlled trial to alleviate medically unexplained vaginal discharge symptoms

AbstractBackgroundSymptoms such as medically unexplained vaginal discharge (MUVD) are common and bothersome, leading to potentially unnecessary use of resources.MethodsA community-based individually randomized controlled trial to assess the effectiveness of a relatively simple, culturally appropriate multi-component intervention on reducing reported MUVD, among women suffering from low-moderate levels of common mental distress. The setting was a socio-economically deprived, informal settlement in the southern suburbs of Beirut, Lebanon. The intervention comprised up to 12 group sessions implemented over a six-week period, each divided into a psychosocial and a relaxation exercise component. The primary outcome was self-reported MUVD, which was defined as a complaint of vaginal discharge upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Blinding on the intervention status was not possible for both logistic and ethical reasons, especially as knowledge of involvement in the intervention was integral to its delivery. Intent to treat analysis was used.ResultsOf 75 women randomized to the intervention, 48% reported MUVD at 6 months compared with 63% of 73 in the control group (difference of -15%, 95% confidence interval (CI) -31%, 0%, p=0.067). Adjustments for baseline imbalances and any factors relating to consent had no appreciable effect on these results. The risk of MUVD was reduced in absolute terms by 2.4% for each intervention session attended (95% CI -4.9%, 0.0%, p=0.049). While there was also marginal evidence of a beneficial effect on anxiety, there was no evidence of mediation of the effect on MUVD through measures of common mental disorders.ConclusionThis study confirms that MUVD is an important public health problem. While the benefits of this intervention may appear modest, the intervention offers an opportunity for women to enhance their problem-solving skills as well as use physical relaxation techniques that can help them deal with stressful in their lives. Further research is needed in a variety of contexts, for different populations and preferably involving larger randomized trials of such an intervention.Trial registration* Title of trial: The Relaxation Exercise and Social Support TrialISRCTN assigned: ISRCTN98441241Date of assignation: 10/09/2010Link: http://www.controlled-trials.com/ISRCTN98441241 * Also registered at the Wellcome Trust register: http://www.controlled-trials.com/mrct/trial/469943/98441241