Kassem Kassak

Human resources for health planning and management in the Eastern Mediterranean region: facts, gaps and forward thinking for research and policy

BackgroundThe early decades of the 21st century are considered to be the era of human resources for health (HRH). The World Health Report (WHR) 2006 launched the Health Workforce Decade (2006–2015), with high priority given for countries to develop effective workforce policies and strategies. In many countries in the Eastern Mediterranean Region (EMR), particularly those classified as Low and Low-Middle Income Countries (LMICs), the limited knowledge about the nature, scope, composition and needs of HRH is hindering health sector reform. This highlights an urgent need to understand the current reality of HRH in several EMR countries.The objectives of this paper are to: (1) lay out the facts on what we know about the HRH for EMR countries; (2) generate and interpret evidence on the relationship between HRH and health status indicators for LMICs and middle and high income countries (MHICs) in the context of EMR; (3) identify and analyze the information gaps (i.e. what we do not know) and (4) provide forward thinking by identifying priorities for research and policy.MethodsThe variables used in the analysis were: nurse and physician density, gross national income, poverty, female literacy, health expenditure, Infant Mortality Rate (IMR), Under 5 Mortality Rate (U5MR), Maternal Mortality Rate (MMR) and Life Expectancy (LE). Univariate (charts), bivariate (Pearson correlation) and multivariate analysis (linear regression) was conducted using SPSS 14.0, besides a synthesis of HRH literature.ResultsResults demonstrate the significant disparities in physician and nurse densities within the EMR, particularly between LMICs and MHICs. Besides this, significant differences exist in health status indicators within the EMR. Results of the Pearson correlation revealed that physician and nurse density, as well as female literacy in EMR countries were significantly correlated with lower mortality rates and higher life expectancy. Results of the regression analysis for both LMICs and MHICs reveal that physician density is significantly associated with all health indicators for both income groups. Nurse density was found to be significantly associated with lower MMR for the two income groups. Female literacy is notably related to lower IMR and U5MR for both income groups; and only with MMR and LE in LMICs. Health expenditure is significantly associated with lower IMR and U5MR only for LMICs. Based on results, gap analysis and the literature synthesis, information gaps and priorities were identified.ConclusionThe implication of the results discussed in this paper will help EMR countries, particularly LMICs, determine priorities to improve health outcomes and achieve health-related Millenium Development Goals.

HIV/AIDS among female sex workers, injecting drug users and men who have sex with men in Lebanon: results of the first biobehavioral surveys.

Objectives:To measure HIV prevalence and associated risk factors among female sex workers, injecting drug users (IDUs) and men who have sex with men (MSM) in Lebanon and the prevalence of hepatitis B virus and hepatitis C virus among IDUs. Methods and design:A cross-sectional survey of 135 female sex workers, 81 IDUs and 101 MSM was recruited using respondent-driven sampling. A structured interview was conducted by members of nongovernmental organizations working with these populations and blood was collected for serological testing. Results:HIV prevalence was 3.7% among MSM but no HIV cases were detected among female sex workers or IDUs. Among IDUs, prevalence of hepatitis C virus antibody was 51% and prevalence of hepatitis B virus surface antigen was 5%. Three-quarters of MSM had nonregular male sexual partners during the last year but only 39% reported using a condom every time. There was evidence of overlapping HIV risk: 36% of MSM and 12% of IDUs reported that they had sold sex. Previous testing for HIV was lowest among MSM (at 22%) despite their having the highest level both of knowledge about HIV and of perception of being at risk of HIV infection (67%). Conclusion:Prevention efforts at greater scale are needed to reach these at-risk populations in Lebanon. These should target MSM in particular, including access to HIV testing, but will need to address and overcome stigma. For IDUs, surveillance and prevention efforts should integrate both hepatitis C virus and HIV.

Distribution of hepatitis C virus genotypes among injecting drug users in Lebanon

BackgroundThe aim of this study is to determine the prevalence of anti-HCV among injecting drug users (IDUs) in Lebanon, to establish the current prevalence of HCV genotypes in this population and to determine whether demographic characteristics and behavioral variables differ between participants who were HCV-RNA positive and those who were HCV-RNA negative or between the different genotypes. Participants were recruited using respondent-driven sampling method. The blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by ELISA. Anti-HCV positive samples were subjected to RNA extraction followed by qualitative detection and genotyping.ResultsAmong 106 IDUs, 56 (52.8%) were anti-HCV-positive. The two groups did not differ in terms of age, marital status, and nationality. As for the behavioral variable, there was a trend of increased risky behaviors among the HCV-RNA positive group as compared to the HCV-RNA negative group but none of the variables reached statistical significance. Half (50%) of the 56 anti-HCV-positive were HCV-RNA positive. Genotype 3 was the predominant one (57.1%) followed by genotype 1 (21%) and genotype 4 (18%).ConclusionsThe predominance of genotype 3 seems to be the predominant genotype among IDUs in Lebanon, a situation similar to that among IDUs in Western Europe. This study provides a base-line against possible future radical epidemiological variant that might occur in IDUs.

The providers of health services in Lebanon: a survey of physicians

BackgroundEmerging from civil distress carries with it major challenges to reforming a health system. One such challenge is to ensure an adequate supply of competent human resources. The objective of this study was to assess the supply of physicians in Lebanon in 1998, with an assessment of their practice patterns and capacity building.MethodsLists of members of physicians associations were examined to determine the number of physicians in Lebanon and their geographical distribution. A self-administered survey targeted 388 physicians (5%) randomly stratified by the five regions of Lebanon. Some 377 providers reported information on their demographic profile, practice patterns and development. Further, information on continuing education activities was acquired.ResultsIn Lebanon, the overall physician-to-population ratio was 248 per 100, 000, characterized by an evident maldistribution at the intracountry regional level. Physicians worked 38 hours per week examining on average 21 patients per day, with an average time of 30 minutes spent per visit. They also reported spending 11% of their time waiting for patients. Respondents reported a very wide range of income, with 90% earning less than USD 2,000 per month. Moreover, the continuing education profile revealed a total of 43.7 hours per year, similar to that required for board certification in many developed countries. Conference attendance was the dominant continuing education activity (95% of respondents) and consumed most of the time allotted for continuing education, reported at 32 hours per year.Discussion and conclusionVarious economic indicators point to an oversupply of physicians in Lebanon and a poor allocation of their time for capacity building. Therefore, it is crucial for decision-makers to closely monitor the increasing supply of providers and institute appropriate intervention strategies, taking into consideration appropriate provision of good-quality services and ensuring that continuing education activities are well established, organized and monitored.

Cost of work-related injuries in insured workplaces in Lebanon

OBJECTIVE To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers. CONCLUSION The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.

Hepatitis B Virus and Hepatitis C Virus Infections among Female Sex Workers and Men Who Have Sex with Men in Lebanon: Prevalence, Risk Behaviour and Immune Status

BACKGROUND The aim of our study was to study the prevalence of and the risk behaviours associated with the hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among two high-risk groups: female sex workers (FSW) and men who have sex with men (MSM). Furthermore, since vaccination is a key component of HBV prevention programs, the immune status of HBV infection in these two high-risk groups was evaluated. METHODS Participants included in this study were part of a bio-behavioural surveillance study done to assess HIV prevalence among four vulnerable groups in Lebanon. Participants were recruited using a respondent-driven sampling method. The total number of eligible participants were 101 MSM and 103 FSW. Blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by enzyme-linked immunosorbent assay. RESULTS None of the 204 individuals tested has been exposed to HCV. In the 101 MSM, only one (0.99%) was an HBsAg carrier and one (0.99%) was confirmed as anti-HIV-positive. Among FSW, 30% showed they were immune to HBV compared with only ~10% among MSM. The distribution of socio-demographic characteristics and potential risk factors in both groups were shown. CONCLUSION Our results highlight the urgent need to raise awareness among FSW and MSM and their health care providers of the availability and benefits of HBV vaccination in Lebanon. In addition, and due to the absence of vaccines against HCV and HIV, education programs aiming at behavioural changes should be intensified.

Exploring the Relationship between Accreditation and Patient Satisfaction – The Case of Selected Lebanese Hospitals

BACKGROUND Patient satisfaction is one of the vital attributes to consider when evaluating the impact of accreditation systems. This study aimed to explore the impact of the national accreditation system in Lebanon on patient satisfaction. METHODS An explanatory cross-sectional study of six hospitals in Lebanon. Patient satisfaction was measured using the SERVQUAL tool assessing five dimensions of quality (reliability, assurance, tangibility, empathy, and responsiveness). Independent variables included hospital accreditation scores, size, location (rural/urban), and patient demographics. RESULTS The majority of patients (76.34%) were unsatisfied with the quality of services. There was no statistically significant association between accreditation classification and patient satisfaction. However, the tangibility dimension - reflecting hospital structural aspects such as physical facility and equipment was found to be associated with patient satisfaction. CONCLUSION This study brings to light the importance of embracing more adequate patient satisfaction measures in the Lebanese hospital accreditation standards. Furthermore, the findings reinforce the importance of weighing the patient perspective in the development and implementation of accreditation systems. As accreditation is not the only driver of patient satisfaction, hospitals are encouraged to adopt complementary means of promoting patient satisfaction.

Reliability and validity of an adapted Arabic version of the Scoliosis Research Society-22r Questionnaire.

Study Design. Cross-sectional validation and reliability assessment study of Arabic version of Scoliosis Research Society-22 (SRS-22r) Questionnaire. Objective. To develop and validate the Arabic version of the SRS-22r questionnaire. Summary of Background Data. The diagnosis and treatment of adolescent idiopathic scoliosis may influence patient quality of life. SRS-22r is an internationally validated questionnaire used to assess function/activity, pain, self-image, and mental health of patients with scoliosis. It has been translated into several languages but not into Arabic language. Therefore, a valid health-related quality-of-life outcome questionnaire for patients with spinal deformity is still lacking in Arabic language. Methods. The English version of SRS-22r questionnaire was translated, back-translated, and culturally adapted to Arabic language. Then, 81 patients with idiopathic adolescent scoliosis were allocated randomly into either the reliability testing group (group 1) or the validity testing group (group 2). Group 1 patients completed Arabic version of SRS-22r questionnaire twice with 1-week interval in-between. Cronbach &agr; and intraclass correlation coefficient were measured to determine internal consistency and temporal reliability. Group 2 patients completed the Arabic version of SRS-22r questionnaire and the previously validated Arabic version of 36-Item Short Form Health Survey (Short Form-36) questionnaire concurrently, and Pearson correlation coefficient was obtained to assess validity. Results. Content analysis, internal consistency reliability, test/retest reproducibility (intraclass correlation coefficient range: 0.82–0.90), and test of concurrent validity showed satisfactory results. Function/activity and satisfaction with management domains had a lower Cronbach &agr; (0.58 and 0.44, respectively, vs. 0.71–0.85 range for others). Self-image/appearance and satisfaction with management had a lower correlation with domains of the 36-Item Short Form Health Survey. Conclusion. An Arabic version of the SRS-22r questionnaire has been developed and validated. This questionnaire will aid health care workers and researchers in evaluation of patient perception of the deformity, satisfaction with treatment, and quality of life in Arabic-speaking populations. Level of Evidence: 3

The Clinical Impact of 6-Min Walk Test Distance as a Predictor of Complications in Patients Undergoing Major Surgery

Significantly reduced 6-min walk test (6MWT) distances, in our opinion, reflect limited functional health status of patients undergoing the test. This is an additional tool for patients and surgeons to consider in deciding whether to proceed with major surgical procedures or opt for medical treatment. The poor 6MWT results may also swing physicians to abandon, altogether, open traditional surgeries in favor of newer technologies/procedures. In a study by Bauger et al., 6MWT was performed on patients with severe aortic stenosis who were considered a very high surgical risk for traditional approach [1]. The mean 6MWT distance walked was 165.3 ± 79.7 m which reflected the health status of those high-risk patients. Similarly on examining our data, we noted that a 6MWT distance of 250 m may be a ‘‘cut-off distance’’ below which the surgical risks and complications are significantly increased. Surgeons should deliberate the findings of reduced 6MWT distances (\250 m) very seriously with their patients before proceeding with surgery. Again, alternative approaches should be considered. In the case of severe aortic stenosis, for example, transcatheter aortic valve implantation should be considered first rather than proceeding with traditional open thoracotomy surgery. In reference to the linear regression model adopted in this study, it actually included all independent variables, and only those that demonstrated significance (P\ 0.05) were reported in the results section. Finally, we totally agree with Straatman et al., algorithms in assessing patients preoperatively and in the immediate 24 h, which are essential tools in improving health care delivery, outcomes, and cost containment [2].