FEBRILE ILLNESSES


PATTERN OF FEBRILE ILLNESSES IN CHIL DREN SEEN AT A PEDIATRIC AMBULATORY CARE SETTING

Youssef A Al-Eissa,FRCPC*, Sameeh S. Ghazal, MRCP†, Fahad A. Al-Zamil, CABP*, Abdullah A. Al-Salloum, CABP*, Abdullah O. Al-Omair, FRCP*, Mohammed N. Al-Nasser, FAAP*

Department of *Pediatrics, College of Medicine, King Saud University and †Sulaimania Children’s Hospital, Riyadh, Saudi Arabia

مقدمة:تعتبر الحمى من أكثر أعراض أمراض الأطفال بروزاً ويشكل الأطفال المصابون بالحمى نسبة ضحمة من المراجعين لاطباء طب الأطفال وطب العائلة.

هدف الدراسة:إبراز نمط الأمراض الحمية لدى الأطفال المراجعين لعيادات طب الأطفال الخارجية.

طريقة الدراسة:أجريت دراسة مستقبلية امتدت على مدى عام كامل وشملت جميع الأطفال المصابين بالحمى الذين تم فحصهم وعلاجهم في عيادتين أوليتين خارجيتين بمستشفى الأطفال بالسليمانية في مدينة الرياض. وتم جمع المعلومات وتحليل البيانات اللازمة لتحقيق أهداف الدراسة.

نتائج الدراسة: تم التعرف على 4086 طفل مصاب بالحمى من مجموعة 16173 طفل مراجع للعيادتين وجرى تقييمهم للتعرف على أسباب أمراضهم الحمية وقد فاق عدد الأولاد المصابين عدد البنات ولوحظ ارتفاع نسبة الاصابة بالحمى لدى الأطفال الذين تراوحت أعمارهم بين 4 أشهر و 24 شهراً. وجد أن السبب الرئيسي لحمى هؤلاء الأطفال هو التهابات الجهاز التنفسي العلوي (75%) والغالبية العظمى من هذه الالتهابات كانت نتيجة الاصابة بالتهاب الرشح أو البرد الفيروسية. أما الالتهابات المعدية المعوية الفيروسية والالتهابات الرئوية فقد شكلت كل منها ما نسبته 5% من الأمراض المسببة للحمى. وكان هناك انخفاض واضح في معدل الاصابة بالالتهابات البكتيرية الخطيرة مثل التهاب السحايا (5و0% ) والتهابت الجلد والعظام أو المفاصل(8و1% ) والتهاب المجاري البولية (7و0% ).

وأدخل المستشفى فقط 9% من الأطفال المصابين بالحمى وأما الباقين فقد أعطى 64% منهم مضادات حيوية عن طريق الفم.

الاستنتاجات:التقييم السريري الصحيح والتصرف الحكيم في إجراء الفحوصات المخبرية وصرف المضادات الحيوية للأطفال المصابين يمثل الاستراتيجيات المثلى في ممارسة العناية الصحية الأولية.

الكلمات المرجعية:تجرثم الدم، حمى، الالتهاب المعدي المعوي، التهاب السحايا، التهاب الأذن الوسطى، التهاب الرئة، التهاب الجهاز التنفسى العلوي، التهاب المجاري البولية. 

Background: Fever is the most common sign of childhood illnesses and febrile children constitute a substantial proportion of the practice of pediatrics and family medicine.

Objectives: To highlight the pattern of febrile illnesses in children attending pediatric ambulatory health-care settings.

Methods: A one-year prospective study was conducted on febrile children who were consecutively seen and managed at two walk-in primary-care clinics in Sulaimania Children's Hospital, Riyadh. Data collection and analysis were structured around the principal study objectives.

Correspondence to:

Prof. Youssef A. Al-Eissa, Department of Pediatrics (39), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia

Results: Among the 16,173 children seen, 4086 (25.3%) were identified as having a fever and evaluated to determine the aetiology of their febrile illness. Boys outnumbered girls and a significant increase in the frequency of febrile illnesses was noted in children 4 to 24 months of age. Upper respiratory tract infections were the commonest cause of fever (75%) and most of these infections were viral rhinopharyngitis. Viral gastroenteritis and pneumonia were prominent diagnoses, each accounting for 5% of febrile illnesses. Notably of low frequency were serious bacterial infections, such as meningitis (0.5%), cellulitis and bone or joint infection (1.8%) and urinary tract infection (0.7%). Only 9% of the febrile children required hospitalization. The ambulatory management of the other febrile children included the prescription of oral antibiotics to 64% of them.

Conclusion: The proper clinical assessment of these febrile children and the prudent use of laboratory tests and antimicrobials remain the most important management strategies in primary health-care practice.

Key Words: Bacteremia, Fever, Gastroenteritis, Meningitis, Otitis Media, Pneumonia, Upper respiratory tract infection, Urinary tract infection.


 

INTRODUCTION

Fever is the most frequent presenting symptom in many ambulatory health care settings.1 The evaluation of a child with a fever is one of the primary-care physician’s most perplexing clinical situations. Fever may herald the onset of a serious and life-threatening disease such as meningitis, or it may be the sole manifestation of a mild self-limited viral infection. Several studies confirm the observation that most acute febrile illnesses in children are of presumed viral aetiology and require little more than supportive therapy.2  Hence, the most important issue for primary-care physicians is to focus on the fever’s aetiology and to rule out serious diseases.1,2 

                Although distinguishing a child with a viral illness from one with bacterial meningitis is usually not difficult, there may be considerable overlap in the clinical appearance of children with fever without source due to viral aetiology with those with occult bacterial infection.3 Thus the clinical evaluation of these febrile children is a complex series of steps based on history and physical examination as well as an appreciation of important variables such as age, severity of fever and observation of the child.  This series of steps represents a rich database that allows the health-care provider to separate those children requiring laboratory evaluation from those who have minor illnesses. The ability to distinguish the truly sick child from the majority with trivial illnesses is a skill obtained through training and experience. Assessment must be done in a relaxed and comfortable setting. The child should be given antipyretics and approached in a gentle non-threatening manner.

                This study was conducted in the pediatric walk-in clinics of Sulaimania Children’s Hospital (SCH), Riyadh, with the aim of highlighting the pattern of febrile illnesses in children attending these pediatric ambulatory health care settings.

SUBJECTS AND METHODS

Sulaimania Children’s Hospital (SCH) is located in a heavily populated area of Riyadh City and serves different socioeconomic strata of the Saudi community, mostly of middle and lower socio-economic status. The hospital ambulatory care services are very busy and only two walk-in clinics were assigned for this study. Febrile children aged 14 years and younger who consecutively presented to these two walk-in primary-care clinics between March 1997 and February 1998 made up the study cohort. Fever was defined as a documented temperature of 38.00C or higher per rectum (or “rectal equivalent”). A rectal equivalent temperature was calculated by adding 0.50C to the oral temperature and 0.80C to the axillary temperature.

                The data collection and analysis were structured around the principal study objectives, namely, the pattern of febrile illnesses in children seen in the clinics. Patient evaluation and management were completed by the attending pediatricians. Demographical information, pertinent historical and physical findings, laboratory data, diagnosis and treatment were recorded. Laboratory or radiographical investigations, including complete blood cell count, urinalysis, cultures of throat, blood, cerebrospinal fluid, urine and other body fluids, and chest or bone x-rays were performed at the discretion of the attending pediatricians.

                A serious bacterial illness was defined as bacterial growth of a known pathogen in cultures of blood (bacteraemia), spinal fluid (meningitis), joint fluid (septic arthritis) or urine (urinary tract infection) with the relevant clinical signs and symptoms. Pneumonia was confirmed by finding a new discrete infiltrate on the chest film that was read by a radiologist. Viral illness was either a diagnosis of exclusion when cultures were sterile (e.g., throat or stool cultures) and no source on the physical examination could explain the fever, or a diagnosis of a specific viral entity, such as chickenpox. Viral studies were not done because of limited laboratory resources.

                Patients’ charts were subsequently reviewed by one of the research co-investigators and relevant information was extracted. The study protocol was approved by the Hospital Research Committee.

RESULTS

Among the 16,173 consecutive children seen in the two walk-in clinics, 4086 (25.3%) children within the specified age range, 0 to 14 years, were febrile. The age distribution is presented in Table 1. Boys outnumbered girls (1.2:1). The age distribution of febrile patients showed a significantly sharp increase in the frequency of febrile illnesses among children 4-24 months of age, with an approximate rate of 49% of total study patients. The number of children with various febrile illnesses did not vary significantly by sex distribution.

Table 1:Age distribution of 4086 febrile children seen in the pediatric walk-in clinics of Sulaimania Children's Hospital (SCH)

Age in months

No. of patients (%)

   0-1

90 (2.2)

   1-3

74 (1.8)

  4-12

1066 (26.1)

13-24

  918 (22.5)

25-36

552 (13.5)

37-60

556 (13.6)

61-168

830 (20.3)

                The different febrile illnesses assigned to the study participants were grouped into 10 clinical diagnostic categories and are depicted in Table 2 to provide an interesting single overview of the pattern of febrile illnesses. Upper respiratory tract infection (URTI) was the commonest cause of fever among children attending the hospital pediatric ambulatory care areas, accounting for 75% of study febrile children; the majority of the URTI were presumably  of  viral  aetiology,  because  bacterial pathogens were rarely isolated from our tested patients. Notably of  low frequency

Table 2:Pattern of febrile illnesses among 4086 children seen in pediatric walk-in clinics of SCH

Clinical diagnosis

No. (%)

Upper respiratory tract infection

3070 (75.1)

Rhinopharygitis (coryza)

1736(42.5)

Pharyngitonsillitis

798 (19.5)

Otitis media

536 (13.1)

Lower respiratory tract infection

242 (5.9)

Croup/Bronchiolitis

  66 (1.6)

Pneumonia

176 (4.3)

Gastroenteritis

212 (5.2)

Bacteraemia

  16 (0.4)

Meningitis

  20 (0.5)

Cellulitis/Osteomyelitis/

Septic arthritis

  72 (1.8)

Urinary tract infection

  28 (0.7)

Chickenpox

  48 (1.2)

Measles

  18 (0.4)

Miscellaneous

360 (8.8)

Table 3:Management of 4086 febrile children seen in the pediatric walk-in clinics of SCH

Management

No. (%)

Hospitalization

380 (9.3)

Outpatient antibiotic therapy

2620 (64.1)

were meningitis, invasive infections other than pneumonia, and classical viral exanthems. The miscellaneous group included healthy well looking febrile children without localizing signs, children with fever associated with non-specific rash, and children with fever developing within 24 hours of DPT vaccination.

                In Table 3, it is of interest to note that the rate of admission was low. It is clear that the majority of pediatric infections were managed on an ambulatory basis; two-thirds of the patients were given oral antibiotics. Hospitalization occurred in patients who required further diagnostic studies or inpatient treatment of the underlying disease of the fever. 

DISCUSSION

Fever is the most common sign of illness in children and is of concern to both parent and physician. Febrile children comprise a substantial proportion of the practice of pediatrics and family medicine.3 Approximately, 25-35% of all encounters in such ambulatory care settings for children were prompted by fever alone.4,5 Furthermore, fever in children leads to a high number of telephone calls to health care facilities. In our study, 25% of children presenting to the pediatric ambulatory settings had fever. Hence, the evaluation of the febrile child is a constant and demanding feature of any pediatric or family and community medicine practice.

                The majority of children who present with fever are less than 3 years of age.3,6 This was confirmed in this study where two-thirds of our febrile patients were less than 36 months of age and the highest frequency of fever was found in children 4-12 months of age. The most common diagnoses documented in our pediatric patients with acute febrile illness were URTIs which were responsible for 75% of the cases; the majority of the URTIs were presumably of viral aetiology, and about one-third of these cases had pharyngiotonsillitis or otitis media. Similar findings were previously reported.7 Lower respiratory tract infection, particularly pneumonia, and viral gastroenteritis was also prominent diagnoses, each accounting for approximately 5% of our patients with acute febrile illnesses. Our data are in agreement with the previous reports.3 Low socio-economic status and overcrowding in houses have been well documented as risk factors for respiratory infections in developing countries.8 Our data have demonstrated an increased incidence of these infections among children. Thus, apart from any medical consequences, respiratory tract infections impose a heavy economic burden on the community.9 These infections cause more than one-third of all deaths among children under 5 years of age in the developing world,9 frequently surpassing gastroenteritis as the leading cause of death.10 In our study, accurate data regarding bacterial and viral aetiologies for acute respiratory infections in children were lacking because of the difficulty in making microbiological diagnosis in ambulatory care settings. Most fevers in our pediatric patients were most likely of viral origin, self-limited and unlikely to be associated with any serious consequences.

                Our study shows that approximately 9% of the febrile children seen in the ambulatory settings required hospitalization. Therapeutic considerations in primary health care practice may be guided by the knowledge of the major contribution of viral diseases to febrile illnesses in children. The use of antibiotics can be confined to those with clearly defined indications for treatment (e.g., tonsillitis, otitis media and pneumonia) and those whose clinical presentation and systemic bacterial cultures warrant parenteral antibiotic therapy. The appropriateness of prescribing antibiotics is the major decision in the management of infections, particularly respiratory ones. That decision is important since the likelihood of the effectiveness of the antibiotic therapy must be balanced against cost, the inconvenience of administering medication to young children, side-effects and reactions, and possibly a harmful effect in a community resulting from changes in the bacterial flora and antibiotic sensitivity.11,12 In the USA, 53-71% of the patients seen for the common cold were given antimicrobials.13 Our data showed similar practice among physicians working in ambulatory care settings.

                In conclusion, this study represents a local experience with a convenient sample population presenting to a pediatric ambulatory care setting. The vast majority of febrile pediatric patients were children 3 years of age and younger suffering from a viral illness. The proper clinical assessment, accompanied by the prudent use of laboratory tests and appropriate medications, remains the best  guide  to  the management of febrile children.

REFERENCES

1.     O’Neill MB. Fever in Children. Can J Paediatr 1994; 2:48-9.

2.     Wright PF, McKee KT, Sell SH.  Patterns of illness in the highly febrile young child: epidemiologic, clinical, and laboratory correlates.  Pediatrics 1981; 67:694-700.

3.     Baraff LJ, Lee SI. Fever without source: management of children 3 to 36 months of age. Pediatr Infect Dis J 1992; 11:146-51.

4.     Radetsky M. The clinical evaluation of the febrile infant. Primary Care 1984; 11:395-405.

5.     McGowan JE, Bratton L, Klein JO, Finland M. Bacteremia in febrile children seen in a “walk-in” pediatric clinic. N Engl J Med 1973; 288: 1309-12.

6.     Soman M. Characteristics and management of febrile young children seen in a university family practice. J Fam Pract 1985; 21:117-22.

7.     Al-Eissa YA, Familusi JB, Al-Zamil FA, et al. Profile of children hospitalized for their first febrile convulsion in Riyadh, Saudi Arabia. J Trop Geogr Neurol 1992; 2:124-8.

8.     Stansfield SK. Acute respiratory infections in the developing world: strategies for prevention, treatment and control.  Pediatr Infect Dis J 1987; 6:622-9.

9.     Harsten G, Prellner K, Heldrup J, Kalm O, Kornfalt R. Acute respiratory tract infections in children: a three-year follow-up from birth. Acta Paediatr Scand 1990; 79:402-9.

10.   Denny FW, Loda FA.  Acute respiratory infections are the leading cause of death in children in developing countries.  Am J Trop Med Hyg 1986; 35:1-2.

11.   Baraff LJ, Bars JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics 1993; 92:1-12.

12.   Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for Pediatric upper respiratory tract infections. Pediatrics 1998; 101 (Suppl):163-5.

13.   Rosentein N, Phillips WR Gerber MA, Marcy M, Schwartz B, Dowell SF. The common cold - Principles of judicious use of antimicrobial agents. Pediatrics 1998: 10l (Suppl): 181-4.


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PSYCHIATRIC EMERGENCIES


PSYCHIATRIC EMERGENCIES AT A UNIVERSITY TEACHING HOSPITAL IN EASTERN SAUDI ARABIA

Osama M. Mahgoub, FRCPsych, Department of Psychiatry, College of Medicine, King Faisal University, Dammam, Saudi Arabia

مقدمة: هذه دراسة للحـالات النفسية التى مثلت لقسم الحوادث والطوارئ بمستشفى عام تعليمي سعودي.

طريقة الدراسة: عينة متـتالية من الـحالات النفسية على مدى ستة أشهر بقسم الحوادث والطوارئ بمستشفى عام تعليمي بالخبر  ( شرق السعودية  )  تم دراستها مستقبليا .  التشخيص كان على أساس التقسيم العاشر الدولي للأمراض الخاصة بالإضطرابات العقلية والسلوكية .

نتائج الدراسة: كان هناك 273 زيارة ناتجة عن 182 شخص  أساسي و37 شخص قامــوا بعمل 91 زيارة متكررة (33 %).   تراوح العمر في المجموعة الأساسية  مابين 5 إلى 82 عاما ونسبة 75 % كانت أعمـارهم دون 38 عاما . أغلبـية المجموعة الأسـاسية (78 %)  ومكرري الزيــارات (97,3 %) كانوا سعوديين. أغلب المجموعــة الأســاسية (52,7 %) كانـــوا  متزوجــين ولــكن (40,5 %)  فقط من مكرري الزيارات كانوا كذلك. العائلة كانت المصدر السائد للتحويل لكلا المجموعة الأساسية (53,8 %) ومكرري الزيارات ( 60 %). الإضطرابات الوجدانية كانت التشـخيص  الشائع في كلا المجمـوعة الأسـاسية (31,7 %) والزيارات المتكررة (39,6%). أغلب أفراد المجموعة الأساسية (57,7 %) والزيارات المكررة (56%) تم معـالجتها  بقسم الحـوادث والطوارئ  مع إعطائهم مواعيد بعيادة الأمراض النفسية الخارجية وبالكـاد نسـبة تعـلو عـن الخــمس (22%) المجموعة الأساسية، وعن الربع (25,3%) من الزيارات المتكررة تم تنويمهم بعنبر الأمراض النفسية مع سيادة الإضطرابات الوجدانية بين الاثنين.

الاستنتاج : يقترح التدريب النفسي الكـافي لأطباء الرعاية الصحية الأولية وتأسيس خدمات نفسية بالمجتمع للتدخل في الأزمات .

الكلمات المرجعية: قسم الحوادث والطوارئ ، الأمراض النفسية ، المملكة العربية السعودية .

Background: This is a study of psychiatric presentations to an Accident and Emergency (A & E) Department of a Saudi general teaching hospital.

Patients and Methods: Consecutive series of psychiatric presentations over 6 months to the A & E Department of a general teaching hospital at Al-Khobar, Eastern Saudi Arabia, were prospectively investigated. Diagnoses were made according to ICD-10 Classification of Mental and Behavioral Disorders.

Results: There were 273 visits, accounted for by 182 index subjects and 37 subjects who made 91 repeat visits (33.3%). The age range of the index group was 5 to 82 years, with 75% below 38 years of age. The majority of the index group (78%) and repeaters (97.3%) were Saudi. Most index subjects (52.7%) were married, but only 40.5% of repeaters were so. Family was the predominant source of referral of both index (53.8%) and repeat visits (60%). Mood disorders were the commonest diagnoses at both index (31.7%) and repeat visits (39.6%). Most index subjects (57.7%) and

Correspondence to:

Dr. Osama M. Mahgoub, Associate Professor and Consultant Psychiatrist, King Fahd Hospital of the University, P.O. Box 40252, Al-Khobar 31952, Saudi Arabia

repeated visits (56%) were managed at the A &E Department and given psychiatric outpatient appointment. Just over one-fifth (22%) of the index subjects and a little over a quarter (25.3%) of repeated visits were admitted to the psychiatric ward, Mood Disorders being predominant among both.

Conclusion: Adequate psychiatric training of primary health care physicians and the establishment of crisis intervention community psychiatric services are            advocated.

Key Words: Accidents and Emergency Department, Psychiatry, Saudi Arabia


 

INTRODUCTION

A psychiatric emergency has been defined as: "any disturbance in thought, feelings or actions for which immediate therapeutic intervention is necessary".1

                In 1952, the Maudsley Hospital , in UK pioneered the establishment of Emergency Psychiatry Department providing round the clock walk-in service.2 Subsequent studies from the UK,3-5 the USA,6 Nigeria7 and the Kingdom of Saudi Arabia (KSA)8,9 described characteristics of attendants, their diagnoses and management. Males were generally over-represented and attendance was more often after official working hours;4,5 and a proportion varying from 6%3 to 43%2 made repeat visits. The diagnoses varied across studies. Some showed a predominance of psychoses5 while in others, the commonest were neuroses2 or Deliberate Self-Harm (DSH).4

                Accordingly, the author carried out a prospective study to investigate socio-demographic, clinical characteristics and management of psychiatric presentations at the A & E Department of a general teaching hospital in Eastern Saudi Arabia and to compare and contrast findings with national, and international studies.

MATERIAL AND METHODS

The study took place at King Fahd Hospital of the University (KFHU), which is a tertiary referral hospital with a walk-in A & E Department operating round the clock at Al-Khobar in the Eastern Province of KSA.

                A psychiatric Outpatient Department (OPD) has operated since 1981, and an 18-bed inpatient unit functioned at the time of the study. The psychiatric OPD which runs 8 clinics per week was staffed by 5 faculty psychiatrists, a number of postgraduate residents, and 2 experienced service residents together with 4 faculty clinical psychologists. The Kingdom has established regional hospitals for their care of substance abusers. At KFHU, the emergency room physicians, who have little formal psychiatric training, made initial evaluation and more often, referred the patient to the psychiatric resident on-call, who was called from the Psychiatric Department during working hours; i.e., from 8 am – 4 pm or from his residence outside working hours and over weekends. An on-call consultant psychiatrist was also available during working hours, and/or over the phone, outside working hours and at weekends.

                The study included a consecutive series of psychiatric presentations to the A & E Department from 1st January to 30th June 1996. Patients were interviewed and initially managed by the psychiatric resident on-call and data was documented in a structured format. This included sociodemographic data, time of presentations, source of and reasons for referral, past psychiatric and drug abuse history, psychiatric assessment by a semi-structured interview, provisional psychiatric diagnosis according to ICD-1010 and management.

                Cases were peer reviewed the following day or subsequent Saturday for cases presented at weekends in a morning conference attended by 2 or 3 faculty psychiatrists. Diagnoses were made according to ICD-10.

Statistical Methods

Data was analyzed using an IBM Compatible personal computer. Epi INFO-6 programe11 was used for data entry and analysis. P-value of 0.05 or less was considered significant.

RESULTS

There were 288 psychiatric presentations out of a total of 68098 A & E visits, giving psychiatric consultations a rate of 0.42% of the total attendance. Data were inadequate for 15 records and were therefore, excluded from further analysis. The remaining 273 visits were accounted for by 182 index subjects and another 37 subjects comprising 27 males and 10 females, who were responsible for a total of 91 repeat visits (33.3%).

A.  Index subjects (N: 182):

These included 99 males and 83 females; 78% of whom were Saudi. Their age range was 5 to 82 years; their mean age, standard deviation (SD), was 32.78, 11.550 years, with 38% below 38 years of age, the values for males and females were 32.95, 11.59 and 32.578, 11.569 years respectively. The difference between the mean ages of the sexes was statistically insignificant (Kruskall-wallis H test = 0.019, degrees of freedom = 1 and p-value = 0.89).

Area of residence:

Of the index group, 73% were from Al-Khobar and Dammam, a town about 25 kilometers away.

Marital status:

Of the group, 72 subjects (39.6%) including 56 males and 16 females were single, 96 subjects (52.7%) consisting of 35 males and 61 females were married and 12 subjects (6.6%), made up of 6 males and 6 females were divorced or separated and data were missing for 2 male subjects. The difference between males and females on the marital status was statistically significant. Chi-square test = 28.35, degrees of freedom=2 and p=0.0000007.

Time of presentation:

Of the group, 48.35% presented during working hours, i.e., 8 am – 4 pm, and 51.65% out-of-hours i.e., 4 pm – 8 am.

Sources of referral:

Of the group, 98 (53.8%) comprising 45 males and 53 females were brought in by their families, 21.45 were self-referral, 9.8% were by the Police and/or Red Crescent, 7.1% a sponsor and 6% were from other sources. Significantly, more females than males were brought by family (53/83 vs. 45/99 respectively); Chi-square Yates corrected = 5.43, p=0.019.

Reasons for referral:

Seventy-three percent were on account of psychiatric or suspected psychiatric disorders, 10.4% were due to shortage of psychotropic drugs, 6% on account of DSH; 3.3% who were exclusively males, because of aggressive behavior, and 7.1% for other reasons.

Drug abuse history:

Twenty-three subjects (12.6%), all males, had a positive past history of drug abuse.

Past psychiatric history:

Of the group, 64.8% had a positive past psychiatric history.

Psychiatric assessment:

Table 1 illustrates the diagnoses of the index group.

Disposal:

Of the group, 105 (57.7%) were managed at the Emergency Room (ER) and given OPD appointment for follow-up. The common diagnoses among them were: mood disorders in 36 (34.2%), schizophrenia in 29 (27.6%), neuroses in 22 (20.9%); representing 12% of total index visits, and other conditions in 17 (16.1%). Besides  4.3% were managed at the ER and sent home, 3.8% were admitted to the main hospital, 22% were admitted to the psychiatric inpatient unit, the commonest diagnoses among whom were: mood disorders in 47.5%, followed by schizophrenic disorders in 30% while neuroses were rather infrequent, encountered in 10%. Other measures were taken on a further 12%.

B.  Repeaters

The mean age of the repeaters and SD was 30.7 and 7.9 years respectively, 48.6% of them were single, 40.5% were married and 10.8% were separated or divorced. The majority (97.3%) were Saudi. Ninety-one repeated visits were made. The frequency of their visits was as follows: 25 subjects (67.6%) made 2 visits, 7 subjects (18.9%) made 3 visits and 5 subjects (13.5%) made 4 visits. Most of subjects (81%) were from Al-Khobar and Dammam;, 56% of the visits were during working hours and 44% were out-of-hours. The sources of their referral were as follows: 60% were brought by family, 27.4% were self-referral, 11% males by Red Crescent and/or Police and 1% by other sources. With regard to reasons of referral, 69.2% were on account of psychiatric or suspected psychiatric illness, 18.75 were due to a shortage of drugs, 6.6% and exclusively males were due to aggression and 5.5% due to other reasons. As ascertained at their first presentations, 73% had a positive past psychiatric illness. Ten male subjects (27%) had abused drugs.

Psychiatric diagnoses:

Table 2 shows the diagnosis per visit.

Disposal:

Of the repeated visits, 56% were managed at the A & E and sent home with a psychiatric OPD appointment for follow-up, 5.5% were managed at the A & E and sent home, 2% were admitted to the main hospital and 23 (25.3%) were admitted to the psychiatric ward. These were accounted for by 12 subjects whose frequency of admissions was as follows: 3 subjects were admitted once, 7 subjects were admitted twice and 2 subjects were admitted thrice. Their diagnoses were as follows: 11 (47.8%) episodes of mood disorders, commonly mania or hypomania, 10 (43%) episodes of schizophrenic disorders and 2 (8.7%) for substance related disorders and finally 11% received other management.

DISCUSSION

In this study, the psychiatric consultation rate of 0.42% of the total A & E visits was low compared with figures of 1.8% in the UK4 and 3.9% in the USA studies.6 Besides sample difference, some emergencies might have presented to other psychiatric services in the area. The majority were young and males outnumbered females, concurring with reports from the UK,3,4 Nigeria7 and Saudi Arabia.8,9 Subjects were mostly married, which was akin to USA series.6 At variance with reported preponderance of visits after hours,4,5,12,13 most visits were during hours, like similar findings in a large series in the UK.2 The majority, and significantly females were brought by their families in contrast with lower frequency of such referral in a USA study,6 but was in consonance with a


 

Table 1: Diagnoses of index visits

Diagnoses (ICD-10)

Males

Females

Total

N (%)

Organic mental disorders (F00-F09)

3

0

3 (1.6)

Mental and behavioral disorders due to psychoactive substance (F10-F19)

6

1

7 (3.8)

Schizophrenia, schizotypal and delusional disorders (F20-F29)

32

     16

48 (26.4)

Mood disorders (F30-F39)

30

     28

58 (31.7)

Neurotic, stress-related and somatoform disorders (F40-F48)

     10

23*

33 (18.1)

Disorders of adult personality (F60-F69)

5

1

6 (3.3)

Mental retardation (F70-F79)

1

0

1 (0.5)

Deliberate Self-Harm

4

7

  11 (6)

Extra-pyramidal symptoms

4

1

5 (2.7)

Others

3

3

6 (3.3)

No psychiatric disorder

1

3

4 (2.2)

Total

99

83

182 (100)

*Chi-square test, Yates corrected = 8.28, p=0.004

Table 2: Diagnoses of repeat visits

Diagnoses (ICD-10)

Males

Females

Total

N (%)

Mental and behavioral disorders due to psychoactive substance (F10-F19)

4

   0

   4 (4.4)

Schizophrenia, schizotypal and delusional disorders (F20-F29)

     27

  5

32 (35)

Mood disorders (F30-F39)

     20

16

   36 (39.6)

Neurotic, stress-related and somatoform disorders (F40-F48)

0

  2

  2 (2.2)

Disorders of adult personality (F60-F69)

4

  0

  4 (4.4)

Mental retardation (F70-F79)

2

  0

  2 (2.2)

Extra-pyramidal symptoms

2

  1

  3 (1.7)

No psychiatric disorder

0

  2

  2 (2.2)

Total

65

26

91 (100)


 

similar study in a Saudi culture,8 cultural factors being the probable explanation as females are often accompanied by a first degree relative or a husband when visiting a hospital. Self-referral was the second most frequent mode of referral, whereas it was the commonest in a UK study.13 Red Crescent and/or Police referral, more significant among males, was infrequent in this sample which agreed  with lower frequency of such referral in the Nigerian7 and UK studies.13 The most frequent reasons for referral were understandably psychiatric disorders, similar to findings in UK series,12,13 followed by a shortage of drugs. The latter reason was not present in Western reports yet documented in a national study.9 DSH as a cause of referral is relatively high in western studies, ranging from 5%14 to 39%.4 In contrast, it was rather low in this series which was consistent with reported low frequency of DSH in a limited hospital-based study in this culture.15 Discordant with the high frequency of violence reaching 40% in some Western reports,14 this studyshowed comparatively low frequency of aggression. Cultural factors were the probable explanation, social disorganization and fights are infrequent in this culture due to strong moral codes.16 Furthermore, alcohol, which is one of the commonest causes of violence1 is prohibited and hence alcoholism and its related problems are rather rare. At both index and repeat visits, a proportion of male subjects gave a history of drug abuse which conforms with report showing preponderance of males among drug abusers who also had an increased psychiatric comorbidity.1 Just over a quarter of index visit subjects, had a negative past psychiatric history and most of them were first episode psychiatric disorders. However, they could have presented to the psychiatric OPD routinely rather than to the A &E for a quick access to psychiatric service to avoid the long waiting lists. Other authors in the UK noted a similar trend.12

                Using ICD-10 diagnosis,10 mood disorders were the prevalent diagnosis at index visits similar to UK study.14 Similarly, they were the commonest disorders among repeat visits, those admitted at both index and repeat visits and those given OPD appointments for follow-up but in contrast with a national study9 where neurotic conditions were the most prevalent. A probable explanation was that the latter study, which was retrospective, involved a large sample, used a different system of classification and covered several years.

                The majority of index and repeat visits, were managed at the A & E Department and often given psychiatric OPD appointment for follow-up or sent home. This concurred with national9 and international reports.4,5

                Western reports show that 10%14 to 40%1 of psychiatric patients seen at A & E Department were admitted to the psychiatric unit. In this study, over one-fifth of the index subjects and nearly one-third of repeaters were admitted, a figure which was close to a national study which documented nearly a quarter admissions.9

                The majority of index subjects and repeaters were managed at the A & E and were given psychiatric OPD for follow-up.

                As a majority of neurotic subjects were managed at the A & E Department and minority were hospitalized, it seemed that a proportion of them had misutilised the emergency services. They could have been managed initially by well-trained primary health care physicians and referred to psychiatric OPD if required.

                As mood and neurotic disorders were prevalent among index subjects, it is advocated that (a) adequate training be given to primary health care physicians to identify and manage these common disorders, (b) an allowance be made for walk-in services for the renewal of prescriptions at the psychiatric OPD clinics, (c) telephone or home-based crisis intervention services led by a psychiatrist and community psychiatric nurse for management of potential deliberate-harm subjects or other disturbed patients be established to lessen the pressure on and optimize the utilization of A & E psychiatric services at this facility.

ACKNOWLEDGMENT

The author would like to than residents at the Department of Psychiatry and the staff at the Medical Record of the hospital for their cooperation in data collection. Thanks are also extended to the consultant psychiatrists at the departments for their thorough discussions of the diagnoses.

REFERENCES

1.  Kaplan HI, Sadock BJ, Grebb JA, editors, Kaplan and Sadock's Synopsis of Psychiatry, Egypt:  Mass Publishing Co; 1995.

2.   Lim MH. A Psychiatric Emergency Clinic: A Study of Attendance Over Six Months. Br  J  Psychiatry 1983; 143: 460-6.

3.     Haw C, Lanceley C, Vickers S. Patients at a Psychiatric Walk-in Clinic-Who , How, Why  and When. Bulletin of the Royal Collegeof psychiatrists 1987; 11:329-32.

4.     Dunn J , Fernando R. Psychiatric presentations to an accident and emergency  department. Psychiatric Bulletin 1989; 13:672-4.

5.     McPhillips  MA ,  Spence SA. Emergency work at an Inner London psychiatric hospital: a study of assessment  made over six months. Psychiatric Bulletin1993;17: 84-6.

6.     Bassuk EL, Winter R, Apsler R . Cross- Cultural Comparison of British and American Psychiatric emergencies. Am J Psychiatry 1983; 140:180-4.

7.     Adeniran  RA , Sijuwola  OA. A Nigerian psychiatric emergency services: factors associated with utilization. Psychiatric  Bulletin  1993; 17: 589-91.

8.     El-Gaaly  AA,  Rahim FEMA, Al-Wohaibi AA. Psychiatric Emergency at King  Khalid  University Hospital. Saudi   Med  J  1987; 8 (4): 382-6.

9.     Qureshi  NA, Al-Amri  AH, Abdelgadir MH, Al-Beyari  TA. A study of utilization pattern of   psychiatric emergency services ( PES) in  Al-Qassim Region, Saudi Arabia. Saudi Med J 1997;18 (2): 137-43.

10.   World Health Organization . The ICD-10 Classification of Mental and  behavioural Disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO; 1992.

11. World   Health Organization. EPI   INFO   6. A word processing database and statistical program for public health. Version 6. Geneva: WHO; 1994.

12.   Kehoe RF ,  NewtonR. Do patients need a psychiatric emergency clinic? Psychiatric Bulletin  1990;14: 470-2.

13.   Ellis D, Lewis S. Psychiatric presentations to an A & E  department. Psychiatric Bulletin  1997, 21: 627-30.

14.   Crawford  MJ , Kohen  D. Urgent psychiatric assessment in an inner city. A & E Department. Psychiatric Bulletin 1997; 21: 625-6.

15.   Mahgoub OM, Al-Freihi HM, AL-Mohaya  SA, AL-Nahdi  MS. Deliberate Self-Harm in Eastern Saudi - Arabia: A Hospital based study. Annals of Saudi  Medicine 1988; 8(2):126-30.

16.  Dubovsky  SL. Psychiatry in Saudi Arabia. American Journal of Psychiatry 1983; 140: 1455-9.


-0001-11-30

NON-FATAL OCCUPATIONAL


NON-FATAL OCCUPATIONAL INJURIES ADMITTED TO HOSPITALS AMONG GENERAL OR GANIZATION FOR SOCIAL INSURANCE WORKERS IN AL-KHOBAR CITY, SAUDI ARABIA: EXPERIENCE OF ONE YEAR

                                                                                                          

Kasim M. Al-Dawood, FFCM(KFU), Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

أهداف الدراسة: 1- تحديد معدل الاصابات المهنية غير المميته والتي احتاجت إلى دخول المستشفيات الخاصة بمدينة الخبر خلال أثنى عشر شهراً للعمال المؤمن عليهم في المؤسسة العامة للتأمينات الاجتماعية. 2- وصف طبيعة وخصائص ونتيجة هذه الاصابات. 3- تقييم الكلفة المادية المباشرة للعلاج الطبي لهذه الإصابات.

الطريقة:هذه دراسة طولية تتكون من عمال مؤمن عليهم لدى المؤسسة العامة للتأمينات الاجتماعية في مقر عملهم حيث تتم الترتيبات لدخولهم عند الحاجة إلى مستشفيين خاصين تم اختيارهم عشوائياً, تم استخدام نموذج لتجميع المعلومات الضرورية من المريض أو من ملفه الطبي عند دخوله للمستشفى.

نتائج الدراسة:كان معدل الاصابة هو 7.1/1000 عامل متفرغ. كل المصابين كانوا ذكوراً وبلغ السعوديون منهم ما نسبته 5و1% بينما بلغ المنتمون منهم لشبه الجزيزة الهندية إلى 74.8% وبلغ الفليبينيون ما نسبته 13.2% . كانت اصابات اليدين والأصابع من أكبر نسب مواقع الاصابة في الجسم وبلغت 32.1% تلتها الاصابات للأماكن المتعددة ( 20.7% ) واصابات الأطراف السفلى     (20.5% ) واصابات الرأس والرقبة ( 11.5% ) والظهر ( 9.5% ) .السقوط كان السبب الرئيسي للإصابة في 33.4% من العينة تلاه الإصابات ذات العلاقة بالآلات عند 23.9% والاجسام الساقطة عند 14.5% وحوادث السيارات عند 12% من العينة وكان معظم المنومين من المصابين             (77.8%) قد مكثوا في المستشفى مدة أقل من أسبوع بينما مكث 7.1% من العينة مدة أطول من 3 أسابيع.  الغياب عن العمل بسبب الإصابة لمدة أكثر من 3 أسابيع كان عند 35.5% من العينة, ولمدة أقل من أسبوع كان عند 9 ,24% من العينة. معظم الحالات )65%) زارت العيادات الخارجية من 2 – 7 مرات.  بلغت الكلفة المباشرة للعلاج للدخول للمرة الواحدة لكل اصابة أقل من 2000 رياال سعودي عـــــند 63.9% من الحالات في مستشفى واحد ( 1 دولار أمريكي = 3.75 ريال سعودي).

الاستنتاجات:معدل الإصابات في هذه الدراسة كان أقل ولكنه مقارب للمعدلات المثيله من دراسات أكبر من دول أخرى. الإصابات المهنية التي احتاجت إلى الدخول للمستشفيات مثلت ما مقداره       13.8% من اجمالي الإصابات المهنية المؤمن عليها لدى المؤسسة العامة للتأمينات الاجتماعية بشكل عام خلال سنة 1995م وكانت هذه الاصابات مسئوله عن مصاريف طبية كبيرة ومعاناة بشرية وفقدان للإنتاج.

بناءًا على نتائج هذه الدراسة ينصح بأن تقوم المؤسسة العامة للتأمينات الاجتماعية بدراسة الأسباب التي أدت إلى هذا الوضع السائد من أجل تغييره إلى الأفضل.

الكلمات المرجعية:الاصابات المهنية، الخبر، المملكة العربية السعودية.

Correspondence to:

Dr. Kasim M. Al-Dawood, Associate Professor, Department of Family & Community Medicine, College of Medicine, King Faisal University, P.O. Box 2290, Al-Khobar 31952, Saudi Arabia

Objectives: (1) To determine the incidence rate of non-fatal occupational injuries requiring admission into private hospitals in Al-Khobar city during a 12-month period among workers insured by the General Organization for Social Insurance (GOSI). (2) To describe the pattern, characteristics and outcome of these injuries. (3) To estimate their subsequent direct medical costs.

Methods: This is a cohort study design. The cohort consisted of workers at workplaces where insurance cover ensured admission into two private hospitals selected randomly in Al-Khobar city. A data-collecting sheet was used to collect the necessary data from both the patient and his medical file on admission into hospital.

Results: The injury incidence rate was 7.1 per 1,000 full-time workers. All injured workers were males. Grouped by nationality, 1.5% were Saudis, 74.8% from the Indian subcontinent and 13.2% Filipinos. Main injury sites included hands and fingers (32.1%) multiple parts (20.7%), lower limbs (20.5%), eyes, head and neck (11.5%) and back (9.5%). Falls were the main cause of injury (33.4%), followed by tools-related injuries (23.9%), falling objects (14.5%) and car accidents (12.0%). The majority of admissions (77.8%) were for periods less than 1 week with only 7.1% for more than 3 weeks. Absence from work was more than 3 weeks and less than 1 week in 35.5% and 24.9% of the admissions, respectively. The majority of the cases (65.0%) visited clinics 2-7 times. Direct medical cost per admission was less than SR 2,000 in 63.9% of the cases in one hospital (1 USD = SR 3.75).

Conclusions: The incidence rate was lower than, but comparable to those rates estimated in more detailed surveys from other countries. Occupational injuries requiring admission into hospitals contributed to 18.3% of the total cases of injuries among insured people during year 1995 and were responsible for significant medical charges, human suffering and loss of productivity. Based on the results of this study, it is recommended that GOSI should study the reasons behind the current situation and find appropriate solutions.

Key Words: Occupational injuries, hospital admissions, Al-Khobar, Saudi Arabia


 

INTRODUCTION

The Kingdom of Saudi Arabia (KSA) is considered one of the fastest industrializing countries. The 1995 annual statistics of the Ministry of Industry and Electricity indicated that the number of factories had increased at a rate of 163% over 13 years.1 As a result of this increase, more workers were needed and occupational accidents resulting from the increasing exposure to various potential occupational hazards have become unavoidable. Workers with occupational injuries are seen by private hospitals, which are able to provide suitable medical care for which they are paid by GOSI. By law, establishments employing 10 or more workers have to have their employees insured with GOSI.

                Epidemiological studies of occupational accidents are needed to identify high-risk industries and the pattern or nature of these injuries in order to formulate suitable preventive measures. Few studies on this have been carried out in Saudi Arabia. The studies of Al-Ghamdi,1 Al-Sibai,2 Al-Khawashki,3 Taha and Ballal,4 Ballal,5,6 were limited to specific objectives different from the ones considered in this study.

                In United States (US), severe occupational traumatic injury was included in the 10 leading problems in occupational Safety and Health.7-9

                Judging from the number and type of studies done in this country it is clear that there is a paucity of information in Saudi Arabia on occupational injuries, both general and severe. To the best of the investigator's knowledge, no study has been done in Saudi Arabia on severe occupational injuries requiring admission to hospitals. A study of this kind would show the number, type and the severity of occupational injuries, and give more information on nature of the severe occupational injuries, their causes, the risk factors and their outcome. The objectives of this study were to: (1) Determine the incidence rate of non-fatal occupational injuries requiring admission to the private hospitals in Al-Khobar city during a 12-month period among GOSI insured workers; (2) Describe the pattern, characteristics and outcome of these injuries; (3) Estimate their subsequent direct medical costs.

MATERIAL AND METHODS

This is a cohort study with 1-year follow-up. The cohort consisted of 65,915 workers at work places where the insurance cover ensured admission to 2 hospitals in Al-Khobar city, Eastern Saudi Arabia. These 2 private hospitals were selected (chosen by cluster sampling) randomly from a total of 6 private hospitals serving GOSI workers in Al-Khobar city. In this study, non-fatal occupational injury was defined as any occupational injury that did not end in death of the worker but required admission to the hospital. The GOSI, considers an injury as occupational if it is sustained during the course or work, while traveling to or from work or to the place where meals are usually taken or while on official assignment away from the usual place of work.1 All GOSI registered workers who were admitted as inpatients to these hospitals due to occupational injuries during the study period were included. Patients who were only treated at emergency or at outpatient departments and were not admitted to the hospital were excluded. In Saudi Arabia, private sector workers are not seen in government hospitals.

                The relevant information was collected at the time of admission to the hospital. The investigator designed the data-collecting sheet used to collect data. The source of data was the patient and his medical record. Data was collected by the investigator himself using the same data sheet for the entire sample. Data of exposure variables included age, nationality, date, time of injury, cause of injury, place of injury and the treating hospital. Outcome variables included the number of days admitted to the hospital, anatomical body part injured (author's own classification). Subjects were followed thereafter to determine other outcome variables like days absent from work, number of clinic visits and cost of treatment (done only for one hospital due to administrative constraints). Unfortunately, denominators by nationality and by other variables were not supplied by GOSI, as they were not available. The collected data was checked and entered in a personal computer. Data analysis was performed using the SPSS/PC+ statistical package and the following tests and data presentation were applied: construction of frequency distribution, contingency tables, Chi-squared test for qualitative variables, and t-tests for quantitative and continuous variables. A test was considered statistically significant at P-value < 0.05.

RESULTS

Incidence of occupational injuries in the sample

The response rate in the study was 100%. During the study period there was a total of 468 admissions, 213 (45.5%) of which were in Hospital A. During the same period, there were a total of 65,915 exposed workers. The overall annual incidence of occupational injuries requiring admission was 7.1 per 1000 workers (1.7 for Saudis and 7.4 for non-Saudis). The annual incidence rate in hospital A was 5.6 per 1000 compared to 9.0 per 1000 in hospital B (Table 1).

Table 1: Incidence rate of occupational injuries per 1,000 workers by nationality and  hospital in  the  cohort   of  65,915 workers

Variable

Number

Incidence rate per 1000 workers

Saudis

7/4092

1.7

Foreigners

461/61823

7.4

Hospital A

213/37655

5.65

Hospital B

255/28260

9.0

Pattern of occupational injuries

Less than two-thirds of the sample population (64.7%) was aged below 35 years and the vast majority of the sample was from the Indian subcontinent (74.8%), Filipinos (13.2%) and only 1.5% were Saudis. Most of the work injuries occurred inside the workplace (89.7%).

                The main causes of the injuries were falls (33.8%); tools-related (23.9%), falling objects (14.5%) and car accidents (12.0%). The main body parts injured were hands and fingers (32.1%), followed by multiple parts (20.7%), lower limbs (20.5%), eyes, head and neck (11.5%) and back (9.5%) (Table 2).

                The majority of admissions (77.8%) were for periods of less than one week while only 7.1% of admissions stayed in hospital for periods of more than 3 weeks. However, the majority of admissions (35.3%) resulted in subsequent absence from work for a period of more than 3 weeks, while 24.9% of admissions resulted in absence from work for periods lasting less than one week. Following discharge from hospital, 65.0% of the injured persons had between 2-7 visits to the outpatient clinics, 8.2% had 2 visits or less, 17.6% between 8-14 visits, while 9.2% attended the clinics more than 15 times.

                In Hospital A, the cost of medical care for the majority of the admissions (63.9%) was less than SR 2000 per admission, while the cost for 22.1% was between SR 2000 – 4000 per admission, and more than SR 4000 per admission for the remaining 13.9%.

Table 2: Nationality, cause of injury and body parts injured in 468 admitted employees in the cohort of 65,915 workers

Variable

No. (%)

Nationality

Saudis

  7 (1.5)

Indian subcontinent

344 (74.8)

Filipinos

  61 (13.3)

Other Arabs

38 (8.3)

Others

10 (2.1)

Cause of injury

Fall

158 (33.8)

Tools related

112 (23.9)

Falling objects

  68 (14.5)

Car accidents

  56 (12.0)

Lifting

25 (5.3)

Fire

21 (4.5)

Others

28 (6.0)

Body parts injured

Hands and fingers

150 (32.1)

Multiple parts

  97 (20.7)

Lower limbs

  96 (20.5)

Eyes, head and neck

54 (11.5)

Back

    43 (9.2)

Others

    28 (6.0)

                Table 3 shows selected admission features in relation to the two hospitals under study. The number of clinic visits, admission days, and absence from work in days were associated significantly with the hospitals in question. Similarly, there was a significant association between  the  anatomical  part injured   and  period  of  absence  from   work


 

Table 3: Frequency of clinic visits, admission days and absenteeism distributed by hospitals

Variable

Total

No. (%)

Hospital A

No. (%)

Hospital B

No. (%)

p-value

Clinic visits

<2

38 (8.2)

  26 (12.3)

12 (4.7)

2-7

303 (65.0)

153 (72.5)

150 (58.8)

<0.0001

8-14

  82 (17.6)

20 (9.5)

  62 (24.3)

15

43 (9.2)

12 (5.7)

  31 (12.2)

Admission in days

1-7

360 (77.8)

178 (84.8)

182 (71.9)

8-14

  50 (10.8)

17 (8.1)

  33 (13.0)

<0.003

15-21

20 (4.3)

  3 (1.4)

17 (6.7)

21

33 (7.1)

12 (5.7)

21 (8.3)

Absence in days

1-7

113 (24.9)

52 (25.0)

61 (24.9)

8-14

  92 (20.3)

49 (23.6)

43 (17.6)

<0.009

15-21

  88 (19.4)

49 (23.6)

39 (15.9)

21

160 (35.3)

58 (27.9)

102 (41.6)


 

(p<0.0001), length of hospitalization (p<0.003), number of clinic visits (p<0.001) and the cost of treatment (p<0.017). The cause of occupational injury was significantly associated with period of absence from work (p<0.001) and admission days (p<0.01).

                There were insufficient data to suggest significant associations between the different age groups with parts of body injured, length of absence from work, duration of hospitalization, number of clinic visits or cost of medical care. Place of injury was associated significantly with parts of body injured (p<0.001) and duration of hospitalization (p<0.001). Time of injury was not found to be significantly associated with period of hospitalization, absence from work or cost of treatment.

DISCUSSION Incidence of occupational injuries

The overall calculated incidence of occupational injuries requiring admission to hospitals was 7.1 per 1000 insured workers in the 1-year period of study. This rate represents 18.3% of the total cases of occupational injuries among GOSI insured employees in the Kingdom of Saudi Arabia calculated earlier in 1995.1 This rate represents only the severe occupational injuries requiring admission to hospital. The rate in the present study is less than the rates of 1.58%, 1.06% and 7% reported by different investigators.10-12 However, it agrees with the range between 0.49% - 1.52% reported from Iowa in 1990.13

                The incidence rate of occupational injuries in Hospital B (9 per 1000) was higher than in Hospital A (5.65 per 1000). This may be explained by the fact that the former is busier than the latter. The incidence of occupational injuries among non-Saudis was approximately four times that of Saudis. This result supports earlier similar finding.6

Pattern of occupational injuries Age and nationality

The majority of the injured were under 35 years. This supports other studies, which showed that the highest rates of accidents were among workers under the age of 35 years.3,14-19 The general trend in these studies is a decline in incidence with advancing age. However, this depends on the age structure of the whole population. An alternative explanation could be related to the fact that experience increases with advancement in age. Saudis had much lower rates than non-Saudis (nationals of the Indian subcontinent and the Philippines). These findings are in conformity with an earlier study carried in the same region where workers from the Indian subcontinent had the highest incidence rate (139 per 1000), followed by Filipinos (106 per 1000) and then Saudis (87 per 1000).6 This may be explained in part by the social stresses experienced by these expatriates, such as differences in the social environment and probably the psychological trauma of being absent from their families. Moreover, hired foreign employees may be engaged in more risky jobs.1,4 Johnston's review of 20 selected studies, all of which assessed the relationship between stress, and occupational injury shows significant relationship between injury and stress.20 Inability to understand the language was found to be an important reason for the high rate  of accidents among migrant laborers in Australia during their first five years after taking residence in the country.21

Cause of injury and body parts involved

The most common cause of injury found in the study was falls (33.8%). Reports from within Saudi Arabia found it the second leading cause of injury,1,5 while it was the prime cause of occupational spinal cord injury (SCIs) elsewhere.22 Tools-related injuries ranked second in this study but were the commonest source of injury in a large study conducted in this country.1 Manual work puts the upper limbs more at risk of injury. This type of work could explain the high rate of hand and finger injuries in the present study. This agrees with other studies.3,5,18,23-26

Duration of admission to hospital and absence from work

Fortunately, most of the injuries sustained by the studied population were mild judging by the length of stay in hospital. However, the length of stay in this study was longer than the average length of stay of 4.4 days reported by Williams.27 Man-days lost due to occupational injury can be used as an index of case severity and economic impact for both the employee and employer.25 Frumkin reported that approximately half the respondents in his study had missed more than 3 days of work, and 15% had missed more than one month.28 It was therefore, not surprising to find a significant association in this study between parts of body injured and the period of absence from work (p<0.0001), period of admission in days (p=<0.003), number of clinic visits (p=<0.001) and cost of treatment (p=<0.017). Hand and finger injuries in particular, can cause long spells of absence.5 Reports from Taiwan showed that the severity of injury determined the duration of morbidity and the magnitude of future productivity.29 Indirect cost due to sickness and absence increases when the absence is paid, as is the case in this study.

Direct medical cost

The average cost of inpatient management for the majority of the injured was less than SR 2000. A figure close to this was reported from injuries managed in 1995 but was much higher than the cost for year 1983.1 The increase in cost over the period indicated in the Average Cost of Treatment (ACT) may be explained by the rise in medical costs. However, in other countries the total cost was much more than the figure reported earlier from Saudi Arabia (SR 14,173,031). For example, in one study, the average medical charges incurred by patients injured at work and requiring hospitalization was US Dollars 10,910 per patient.27 The treatment cost of work related injuries in 1986 in USA amounted to 34.8 billion US Dollars and almost doubled in 1991.30,31

Comparing the two hospitals

Hospital B is a busy hospital with a higher turnover rate of patients than to hospital A. The latter is known to admit patients requiring longer periods of admission and rehabilitation. This may explain the variation in incidence of occupational injuries requiring admission between the 2 hospitals. Similarly, this may have played a part in the differences between the 2 hospitals on the variables shown in Table 3.

                In conclusion, the present study showed considerable incidence rate of occupational injuries requiring admission into 2 hospitals, which was lower than, but reasonably comparable to those rates estimated in more detailed surveys for comparable periods. These injuries represented 18% of the total cases of injuries among insured people during year 1995.1 The injuries were responsible for significant medical charges, human suffering and loss of productivity. The young were more at risk.

                Although the finding of this study may not be generalized beyond the study population, it is recommended that: (1) GOSI should study the reasons behind the current situation in order to find solutions for it. (2) Further applied research be done on general and severe injuries.

ACKNOWLEDGMENT

The investigator wishes to express his thanks and gratitude to Prof. S.G. Ballal and Dr. Hafiz Omer from the Department of Family and Community Medicine for their advice and computer assistance. My thanks also go to the administrators of the two hospitals and to all persons involved in the study for their cooperation.

REFERENCES

1.     Al-Ghamdi AS. Occupational injuries and mortality among the insured employees with General Organization for Social Insurance in the Kingdom for the period 1983–1996 [dissertation]. Dammam: King Faisal Univ.; 1997.

2.     Al-Sibai A, Hammed AA. Three years experience of vascular injuries. Annals of Saudi Medicine 1988; 8: 309.

3.     Al-Khawashki HMI. Pattern of wrist injuries in Riyadh, Saudi Arabia. Saudi Medical Journal 1994;15:239-42.

4.     Taha A, Ballal SG. Work-related hazards in small industries in Al-Khobar Area, Pilot Study. Proceedings of the 3rd Safety and Occupational Health Conference and Exhibition, 1996 May 25–30; Dammam, Saudi Arabia.

5.     Ballal SG. Pattern of accidents in an iron factory in the Eastern provinceof Saudi Arabia. Saudi Medical Journal 1996; 17 (6): 772–8.

6.     Ballal SG. Ocular trauma in an iron forging industry in the Eastern province, Saudi Arabia. Occup Med 1997; 47: 77–80.

7.     Millar JD. Summary of “Proposed National Strategies for the Prevention of Leading Work-related Diseases and Injuries, Part I”. Am J IndMed 1988; 13: 223-40.

8.     Stone PW. Traumatic Occupational Fatalities in South Carolina, 1989– 90. Public Health Rep 1993; 108: 483–8.

9.     Neumark D, Johnson RW, Bresnitz EA, Frumkin H, Hodgson M, Needleman C. Costs of occupational injury and illness in Pennsylvania. J Occup Med 1991; 33: 971-6.

10.   Firth H, Herbison GP. Occupational injuries in Dunedin. NZ Med J  1990; 103 10. Firth (891): 265-6.

11.   Layne LA, Landen DD. A descriptive analysis of non-fatal occupational  injuries to older workers using a national probability sample of hospital emergency departments. J Occup Environ Med 1997; 39 (9): 855-65.

12.   Layne LA, Castillo DN, Stout N, Castlip P. Adolescent occupational injuries requiring hospital emergency department treatment:  a nationally representative sample. Am J Public Health 1994; 84 (4): 657– 60.

13.   Fuortes LJ, Merchant JA, Van-Lier SF,Burmeister LF, Muldoon J. 1983 Occupational injury hospital admissions in Iowa: a comparison of the agricultural and non-agricultural sectors. Am J IndMed 1990; 18 (2): 211–22.

14.   Heyer NJ, Framklin GM. Work-related traumatic brain injury in Washington State, 1988 through 1990. Am J Public Health 1994; 84: 1106-9.

15.   Suruda A, Floccare D, Smith G. Injuries from tire and wheels explosions during servicing. Ann Emerg Med 1991; 20: 848-51.

16.   Kisner SM, Fosbroke DE. Injury Hazards in the construction industry. J Occup Med 1994; 36: 137–43.

17.   Clemmer DI, Mohr DL, Mercer DJ. Low back injuries in a heavy industry 1,  worker and workplace factors. Spine 1991; 16: 824-30.

18.   Harker C, Matheson AB, Ross JA, Seaton A. Occupational accidents presenting to the accident and emergency department. Arch Emerg Med 1992; 9: 185-9.

19.   Waller JA, Payne SR, Skelly JM. Injuries to carpenters. J Occup Med 1989; 31:687-92.

20.   JohnstonJJ. Occupational injury and stress. J Occup Environ Med 1995; 37:1199-203.

21.   Corvalan CF, Driscoll TR, Harrison JE. Role of migrant factors in work-related fatalities in Australia. Scan J Work Environ 1994;20:364–70.

22.   Rosenberg NL, Gerhart K, Whiteneck G. Occupational spinal cord injury:  Demographic and etiologic differences from non-occupational injuries. Neurology 1993;43: 1385– 8.

23.   Schober SE, Handke JL, Halperin WE, Moll MB, Thun MJ. Work-related injuries in minors. Am J IndMed 1988; 14:585– 95.

24.   Hertz RP, Emmet EA. Risk factors for occupational hand injury. J Occup Med 1986; 28: 36–41.

25.   McCurdy SA, Schenker MB, Lassiter DV. Occupational injury and illness in the semi-conductor manufacturing industry. Am J IndMed 1989; 15: 499–510.

26.   Dufort VM, Kotch JB, Marshall SW, Waller AE, Langley JD. Occupational injuries among adolescents in Dunedin, New Zealand, 1990  - 1993. Ann Emerg Med 1997; 30 (3): 266–73.

27.   Williams JM, Higgins D, Furbee PM, Prescott JE. Work-related injuries in a rural emergency department population. Acad Emerg Med 1997; 4:277–81.

28.   Frumkin H, Williamson M, Magid D, Holmes JH, Grisso JA. Occupational Injuries in a Poor Inner-City Population. J Occup Environ Med 1995; 37 (12): 1374–82.

29.   Liu YH, Lin MR, Wang JD. Cost and determinants of morbidity from work-related disabling injuries in Taiwan. Occup Environ Med 1995; 52: 138 – 142.

30.   Rubens AJ, Oleckno WA, Papaeliou L. Establishing guidelines for the identification of occupational injuries: A systematic appraisal. J Occup Environ Med 1995; 37: 151–9.

31.   Hanrahan LP, Moll MG. VIII Injury Surveillance. Am J Public Health 1989; 79 (Suppl.): 38- 45.


-0001-11-30

PREMARITAL HEALTH


ACCEPTANCE OF PREMARITAL HEALTH COUNSELING IN RIYADH CITY, 1417H

Nabil H. Al-Kahtani,ABCM, Chest Diseases Department, Ministry of Health, Riyadh, Saudi Arabia

مقدمة:الاستشارة الصحية قبل الزواج قد تكون جديرة بالاهتمام كأحد الجوانب التي تفي بمطالب الطب الوقائي. وتعتبر مهمة للتشخيص الجيني والوقاية الوراثية، ومن الأمراض السارية ومنها الأمراض التي تنتقل بالجنس.

هدف الدراسة: لتحديد قبول فكرة الاستشارة قبل الزواج، والتعرف على بعض العوامل التي قد تؤثر في قبولها بين المراجعين السعوديين لمراكز الرعاية الصحية الأولية في مدينة الرياض بالمملكة العربية السعودية.

طريقة الدراسة :هذه دراسة مقطعية، تشمل عينة مختارة من المراجعين السعوديين لمراكز الرعاية الصحية الأولية بمدينة الرياض خلال العام 1417هـ، وذلك بطريقة العينة متعددة المراحل متضمنة التوزيع الطبقي المتساوي والتي استخدمت لاختيار 484 شخص من عدد متساوي من الذكور والاناث متزوجين وغير متزوجين أعمارهم أكبر من 18 عاماً. وقد تم استخدام استبيان مسبق لجمع البيانات المطلوبة والتي تم جدولتها واختبارها إحصائياً.

نتائج الدراسة:أوضحت الدراسة أن 2و75% من مجموعة الدراسة يقبلون بفكرة الاستشارة الصحية قبل الزواج حيث تأثرت الموافقة ايجابياً ًًًبتقدم العمر وخبرة الزواج والمستوى التعليمي والفهم للمسائل الصحية من منظور اسلامي. وقد وافق 42% بتقنينها. وقد فضل 82% منهم أن تكون ذات خصوصية. و42% وافقوا عليها بغض النظر عن ارتفاع تكلفتها. كما أنهم يفضلون هذه الاستشارة في القطاع الصحي الحكومي.

التوصيات:توصي الدراسة بالعمل على تطبيق الاستشارة الصحية قبل الزواج بالممكلة العربية السعودية كون أنها مقبولة من مجموعة الدراسة. وعمل الدراسات لتحديد عناصر الاستشارة قبل الزواج، وطرق تطبيقها وتقنينها على أسس ديموجرافية المجتمع السعودي. اضافة إلى القيام ببرنامج تثقيف للمجتمع عن الاستشارة الصحية قبل الزواج مع مشاركة علماء الدين.

الكلمات المرجعية: اتجاهات، الاستشارات الصحية قبل الزواج، الممكلة العربية السعودية.

Background: Health counseling before marriage can be a most worthwhile and satisfying aspect of preventive medicine. It is important in genetic diagnosis and the prevention of hereditary, sexually transmitted and other infectious diseases.

Objectives: To determine the acceptance of the concept of Premarital Health Counseling (PMHC), and to identify some factors, which may efect this acceptance among Saudis who attend Primary Health Care Center in Riyadh, Kingdom of Saudi Arabia (KSA), 1417H.

Methods: The present study is a cross-sectional one with a selected sample of Saudis who attended the Primary Health Care Centers in Riyadh during the year 1417H. A multistage sampling and equal allocation stratified sampling within was used to select 484 persons comprising an equal number of males and females, married and single  above the age  of 18 years. A pre-designed pre-tested questionnaire sheet was

Correspondence to:

Dr. Nabil H. Al-Kahtani, P.O. Box 105275, Riyadh 11646, Saudi Arabia

used  to  collect the  required data, which  were  then  tabulated and statistically analyzed.

Results: The study indicated that 364 (75.2%) of the study population accepted the concept of Premarital Health Counseling.  PMHC was positively affected by the advancing age, experience of marriage, educational level and well-understood Islamic-health related issues. Out f those who accepted the concept, 273 (75%) agreed on the exchange of PMHC certificates between couples to be married and 152 (42%) agreed on the implementation of legislation on PMHC. Also, 298 (82%) of them wanted PMHC to be confidential and 168 (46%) agreed to the concept despite its cost. As regards the location of PMHC, most of participants who agreed to PMHC would prefer it to be given at governmental establishments.

Recommendations: The study recommended the implementation of PMHC in Saudi Arabia, since it was accepted by the study population. However, further studies should be carried out to determine the details to be incorporated in the PMHC, their implementation and legislation on demographic basis of the Saudi community. Also, a community health education program for PMHC has to be devised in collaboration with Islamic leaders.

Key Words: Attitudes, Premartial Health Counseling, Premarital counseling, Saudi Arabia.


 

INTRODUCTION

The operational definition used in this study for Premarital Health Counseling  (PMHC) would involve a consultation during which history would be taken and medical examination as well as laboratory investigations done for persons planning to marry, in order to screen for inherited and communicable diseases.

                Health counseling before marriage can be a worthwhile and a most satisfying aspect of preventive medicine.1 One important aspect of PMHC is genetic counseling.2 This reduces the number of offspring that may be affected by a disorder, by defining the need for treatment (e.g. phenylketonurea) or assisting the couple to decide whether or not to avoid pregnancy in presence of a high risk of abnormality.3

                The issue of PMHC is of great importance in Saudi Arabia because of high prevalence (55%) of consanguineous marriages.4-6 Offspring of these marriages may have such diseases as hereditary hearig impairment, mental retardation, autosomal recessive osteopetrosis and blood disorders such as thalassaemia.7,8 Furthermore, the risk of bearing a child with a birth defect in these marriages is approximately 6-8% for each pregnancy, a figure which is double the reported incidence of serious birth defects or mental retardation in the population at large.9 Premarital exposure to some infectious diseases such as hepatitis B virus, and rubella during pregnancy which are easily prevented by premarital vaccination may result in physical or mental disorders in the newborn.10,11

                The objective of the study was to determine the acceptance of the concept of PMHC and to identify some factors , which may influence the acceptance among Saudi who attended Primary Health Care Center in Riyadh city, KSA, 1417H.

METHODOLOGY

                The present study is a cross-sectional one, conducted in 13 (20%) Primary Health Care Centers (PHCCs) located in Riyadh city selected by systematic random sampling. The study sample was a total of 484 persons consisting of an equal number of Saudi males and females, married and single above the age of 18 years. Multistage sampling, and equal allocation stratified sampling within, was used to estimate the size of the study sample, using the following equation, N=Z2,pq/D2 (N=the maximum sample size required, D=A 95% - CI is desired with d=0.05,12).  To ensure a reliable study, the following formula is used: N=(Za/2 / CI)2 + 3 where Za/2=1.96, CI=95%, and width 0.1.

                A pre-designed pre-tested questionnaire sheet was used to collect the required data. Cronbach's Coefficient Alpha, with standardized variable method, was used to measure the internal consistency and reliability of the questionnaire items.14 It was found to be 0.7.15 The author interviewed all participants, and the definition of PMHC was stated in Arabic to them. The questionnaire covered independent (age, sex, etc) and dependent variables (attitudes on medical, social, and religious ideas pertaining to PMHC).

                Summated ratings (Likert's scale) was used to assist the study group attitudes toward PMHC. Five grades were used for the attitude scale, strongly agreed, agreed, neutral, diagreed, and strongly disagreed. Desirable attitudes were given scores of five and four.15 The median of scores one to five was used to determine the end attitude of the participants (agreed, disagreed, etc.).

                After complete data collection, it was tabulated and statistically analyzed.

RESULTS

                As table 1 shows, the majority of participants 364 (75.2%) accepted the concept of PMHC. Others, including participants who were neutral or did not accept PMHC totaled 120 (24.8%). Generally, those who accepted PMHC had a higher mean age (31.89 + 9.74) than those who didn't (28.7 + 11.12) (p<0.003). The lowest percentage of acceptances (40%) was found among those aged less than 20 years. On the other hand, the highest percentage was found among those aged 30-34 and 35-39 years. These differences were found to be statistically significant. Acceptance was not affected by sex, (Table 2).

Table 1: Participants' acceptance of PMHC by age in Riyadh city, 1417H

Age in years

Accept

Total

N (%)

<20

18 (40.0)

45

20-24

87 (83.7)

104

25-29

70 (63.1)

111

30-34

57 (87.7)

65

35-39

51 (87.9)

58

40-44

42 (85.7)

49

45+

39 (75.0)

52

Total

364 (75.2)

484

X26=56.05, p<0.05

Table 2: Distribution of participants by acceptance of PMHC and sex in Riyadh city, 1417H

Sex

Male

Female

Total

N (%)

N (%)

N

Accept

184 (76.03)

180 (74.38)

364

Others*

  58 (23.97)

  62 (25.62)

120

Total

242 (50.0)

242 (50.0)

484

*Neutral and do not accept PMHC

X21=0.19, p0.05

                Experience of marriage significantly affected the participants' acceptance of PMHC. Out of those who had been married more than once, 62 (89.9%) accepted the PMHC compared to only 111 (62.4%), among those who had no experience of marriage (p<0.05), (Table 3).

                Concerning educational level, the highest percentage of those who accepted PMHC was


 

Table 3: Distribution of  participants  by social  characteristics and PMHC acceptance in Riyadh city, 1417H

Variable

Accept

Total

X2

p-value

N (%)

Marriage experience

Absent

  111 (62.36)

178

24.92

<0.05

Only once

191 (82.7)

231

More than once

62 (89.9)

  69

Total

364 (75.21)

484

Level of education

Illiterate

  61 (71.0)

  86

11.8

<0.05

Prim & Second & Diploma

179 (70.8)

253

Bachelor & Higher

124 (85.5)

145

Total

364 (75.2)

484

Occupation

Professional

29 (100)

  29

54.55

<0.05

Lower professionals

  54 (56.80)

  95

Non-manual skilled

157 (89.20)

176

Manual skilled

6 (100)

   6

Partially skilled

12 (100)

12

Housewives

  50 (79.40)

63

Students

  51 (56.70)

90

Unempoloyed

  5 (38.50)

13

Total

   364 (75.20)

        484

NB: In calculation of Chi-square, professionals and lower professionals were pooled together and non-manual, manual and partly skilled were also pooled together

Table 4: Islamic-related issues affecting acceptance of PMHC in Riyadh city, 1417H

Islamic-related issues

Accept (N=364)

N (%)

Others (N=120)

N (%)

p-value

Believe in fate doesn't affect the acceptance

305 (84)

16 (13)

0.0001

Fatwa will not affect acceptance

310 (85)

15 (13)

0.0001

Participation of Imam will affect the        acceptance

337 (93)

49 (41)

0.0001

Table 5: Attitudes of participants accepting PMHC towards factors encouraging its practice in Riyadh city, 1417H

Item

Agree

N (%)

Total

p-value

Certificate between families

273 (75.00)

364

0.0001

PMHC Law

152 (41.76)

364

0.03

Inclusion of PMHC in the curricula

339 (93.13)

364

0.0001

PMHC confidentiality

298 (81.87)

364

0.0001

Costly PMHC

168 (45.05)

364

0.3

PMHC Location

Government hospitals

311 (85.44)

364

< 0.0001

Primary Health Care Centers

247 (67.86)

364

Private sector

171 (46.98)

364


 

found among the highly educated individuals 124 (85.5%), compared to 61 (71%) among illiterate participants (Table 3).

                Relating participants' acceptance of PMHC to their occupations, a statistical significant difference was found (p<0.05). Unemployed partcipants, students and lower professionals were the least likely to respond positively to PMHC (38.5%, 56.7% and 56.8% respectively) (Table 3).

                Misunderstood Islamic based issues negatively affected the study population's acceptance of PMHC as 104 persons (87%) of those who did not accept PMHC related attitudes to God's will (p<0.0001). Only 15 (13%) of those who did not accept PMHC did so despite the presence or absence of Fatwa (p<0.0001). Regarding the participation of Imam in a community-based health education program, 337 (93%) of participants who accepted PMHC welcomed the idea, compared to 49 (41%) of those who did not accept PMHC (p<0.0001) (Table 4).

                Of the participants who accepted the concept of PMHC, 273 (75%) persons agreed to voluntary exchange health fitness certificate between the couple to be married (p<0.001). In contrast, 212 (58%) rejected mandatory marital health fitness certificate (p<0.001). Confidentiality was the request of 298 (81.87%) participants and nearly 339 (93%) agreed to the inclusion of PMHC in school curricula. The cost of PMHC could hinder its practice among 196 (55%) participants who accepted it (Table 5).

                On the questions of the location of PMHC, 311 (85.4%) of the participants who accepted PMHC preferred it to be based in a governmental hospital, and 247 (67.9%) preferred it in PHCCs, in comparison to 171 (46.9%) who preferred it to be in the private sector (p<0.0001).

DISCUSSION

PMHC is a new and interesting health issue that needs to be investigated and discussed, especially in Islamic Arabic cultures, and more precisely in the Saudi community where consanguineous marriage represents more than 50% of all marriages, a rather high rate compared with many other countries.25,26 The present study can be the basis for further investigations of PMHC. Moreover, results discussed in the present study may require further investigations. It is necessary to mentions that, there have been few studies on premarital counseling and premarital medical examination in the Arab world.

                The majority of participants 364 (75.2%) accepted the concept of PMHC, and those who accepted it were older than those who rejected it. The group that had the lowest percentage of acceptance of PMHC were aged less than 20 years. This finding can be explained by the fact that more exposure to life's experiences, a higher level of education, and marriage increases interest on health issues, particularly the health of offspring and consequently the acceptance of PMHC. There was no statistical difference on the attitudes on PMHC acceptance between males and females. This may be attributed to the present improvement of te social status of Saudi women e.g., female education, involvement in various occupations, etc.

                On the question of marriage, the present study revealed that individuals who had an experience of marriage were significantly more accepting of the PMHC concept than individuals who had never been married. Also, participants who had been married many times were more accepting of the concept of PMHC than those who were still in their first marriage. Participants who had been married at least once have more knowledge and a greater awareness of the spouse's health problems. In addition, participants who were not married were usually younger, and were perhaps less educated and consequently less likely to accept PMHC. Similar findings were reported  in  Egypt where single  people were  seen  to be the least likely to accept    premarital   conseling   and    examination.16

                The majority of participants had an educational level above primary schools. This may have played a part in the positive acceptance of PMHC among the study group, as higher education means better knowledge of health matters.

                On the participant's occupation, it was revealed that, PMHC acceptance increased among the higher social classes to as much as 100% among professional, in comparison with unemployed participants who had the  lowest  percentage  of  PMHC  acceptance (38.5%).

                The position of Islam is to prevent fetal malformations as far as possible. The Prophet Mohammad, peace be upon him, through many Hadiths directed attention toward inherited matters, and the careful choice of partners for marriage.17 Participation of Islamic leaders in community health education could have an important enhancing role in community acceptance of PMHC, as participation of the Imam and the presence of a religious fatwa can positively change the atttitude of about 53% of those who didn't accept PMHC (41% and 13% respectively) (Table 4). In Western countries, religious men take part in premarital counseling.18,19 More health education from the Islamic point of view is needed, especially for young inexperienced  persons  and  the  uneducated    individuals.

                Medical examination and laboratory tests are mandatory prior to marriage application20-22 in many countries such as the USA and China because of some important health problems, like STDs, and hereditary diseases. The study showed that, voluntary exchange of marital health fitness certificate, between the two applicants for marriage had a good response among the participants accepting PMHC. However, if PMHC certificate became mandatory the percentage of acceptance would drop. This finding indicates that a community-based health education on the issue of PMHC legislation is necessary. Health education is one of the important means of encouraging the community to accept this idea23 and the inclusion of information of PMHC in the school curricula, could be the basis on which knowledge on health matters pertaining to the PMHC concept and its future acceptance could be built. Moreover, the assurance of the confidentality of information given during PMHC would ensure its continued success.24

                Practicing PMHC in governmental establishments is preferred to its being given in the private sectors. This may be due to the high cost involved in private health care sectors, as 54% of participants who accepted the concept were not willing to participate if PMHC were costly.

CONCLUSIONS

The present study revealed that, 364 (75.2%) of study population accepted the concept of PMHC. Advancing age, experience of marriage, educational level and well-understood Islamic-related health issues positively influenced its acceptance. The participants who accepted PMHC concept agreed to the exchange of PMHC certificates between couples to be married but rejected the enforcement of PMHC by legislation. The need for confidentiality was stressed, a preference for its practice at governmental health establishments rather than private hospitals and the cost of the service were considered important.

RECOMMENDATIONS

The following are recommended:

1.     The implementation of PMHC in Saudi Arabic, as it was accepted by the study population.

2.     Execution of further studies to determine what should constitute PMHC, its implementation and its legislation on demographic basis of the Saudi community.

3.     A community-based health education program for PMHC has to be devised in collaboration with Islamic leaders, to raise the level of awareness and acceptance of the community toward the concept of PMHC particularly with the following in mind: (a) that it should be directed mainly to single and young persons; (b) that school curricula should include PMHC education.

4.     PMHC be free of charge in the governmental health institutes, or the cost minimal in the private sector.

5.     The assurance of total confidentiality.

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1.     Benson RC. Current obstetric & gynecological diagnosis & treatment. Psychologic aspects of gynecologic practice. 5th ed. Beirut, Lebanon: Librairie du liban. 1984.

2.     Last JM, Wallace R. Public health & preventive medicine. Genetic and Public Heatlh. 13th ed. USA: Prentice-Hall International Inc. 1992.

3.     Cassens BJ. Preventive medicine and public health. Epidemiology, and prevention of selected acute illnesses. 2nd ed. USA: Williams & Wilkins, 1992.

4.     Awad HM. Autosomal recessive osteopetrosis. Annals of Saudi Medicine 1994; 14(2):102-6.

5.     Kasim A, Adnan A. Risk factors of mental retardation in children attending an educationally subnormal/mental school in Dammam, Saudi Arabia. Annals of Saudi Medicine 1993; 13(4):355-9.

6.     Alwan AS Hamamy H. Hereditary disorders in the Eastern Mediterranean Region of World Health Organisation. Proceedings of the symposium on the medical genetics in the setting of middle eastern population. Riyadh: King Abdulaziz Cityfor Science and Technology, 1993.

7.     El-Hazmi MA. Genetic diseases in Saudi Arabia: A model for national awareness and care programme. Saudi Medical Journal 1992; 13(6): 514-20.

8.     Ohlsson A. Better prenatal care in Saudi Arabia. Annals of Saudi Medicine 1985; 5(3):169-75.

9.     Milnnsky A. Hereditary and your family's health. Baltimore, USA: The John Hopkins UniversityPress, 1992.

10.   Hu Z. Observation on prevention of hepatitis B virus transmission between newly-married couples by HbsAg vaccine. Chung, Hua, Liu, Hsing, Ping, Hsueh, Tsa, Chih (abstracts medline search) 1991;12(4):222-5.

11.   Serdula M, mark J, Remington P, Ibara C, White M. Premarital rubella screening program: From identification to vacination of susceptible women in the state of Hawaii. Public Health Rep 1986; 101(3):329-33.

12.   Daniel WW. Biostatistics: A foundation for analysis in health science. 4th ed. New York, USA: John Wiley & Sons, 1987.

13.   Streiner DL, Norman GR. Health measurement scales (A practical guide to their development and use). Oxford UK: OxfordMedical Publication, 1989.

14.   Holman TB, Larson JH, Harmer SL. The development and predictive validity of a new premarital assessment instrument: The preparation for marriage questionnaire. Family Relations 1994; 43:46-52.

15.   Marion P, Gendel E, Cortese P. Planning and implementing health education in schools. California, USA: Mayfield Publishing Company, 1987.

16.   Eshra D, Dorgham L, El-Sherbeni A. Knowledge, attitudes, and practice towards premarital counseling, and examination. J EgyptPublic Health Assoc 1989; 64(1-2):1-15.

17.   Al-Bar MA. Malformed fetus, and genetic diseases, etiology, signings, and control. Jeddah, KSA: Dar Almanar, 1991.

18.   Jones EF, Stahmann RF. Clergy beliefs, preparation, and practice in premarital counseling. The Journal of Postoral Care 1994; 48(2):181.

19.   Steiner P, David K. Involvement of rabbis in counseling, and referral for genetic conditions: result of a survey. Am Hum Genet 1993; 53(5):1359-65.

20.   Holder WR, Knox JM. Syphilis in pregnancy. Med Clin of North Am 1972; 56(5):1151-60.

21.   Rutkow IM, Lipton JM. Some negative aspects of state health departments' policies related to screening for sickle cell anemia. Am J Public Health 1974; 64(3):217-21.

22.   Horton R. Western eyes on China's eugenics law. Lancet 1995; 15:346 (8968):131.

23.   Murphy EA, Chase GA. Principles of genetic counseling. Chicago, USA: Year Book Medical Publishers INC, 1975.

24.   Gostin L, Curran W, Clark M. The cases against compulsory case finding in controlling AIDS – testing, screening and reporting. Am J Law Med 1987; 12(1):7-53.

25.   Al-Abdulkareem AA, Ballal SG. Consanguineous marriage in an urban area of Saudi Arabia: rates and adverse health effects on the offspring. J Community Health 1998; 23(1):75-83.

26.    Al-Husain M, Al-Bunyan M. Consanguineous marriages in Saudi population and the effect of inbreeding on prenatal and postnatal mortality. Ann Trop Pediatr 1997;17(2):155-60.


-0001-11-30

ALTERNATIVE MEDICINE


THE PATTERN OF ALTERNATIVE MEDICINE USE AMONG PATIENTS ATTENDING HEALTH CENTRES IN A MILITARY COMMUNITY IN RIYADH

Eiad A. Al-Faris,MRCGP, Department  of Family  and  Community  Medicine,       College of Medicine, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة : أجريت هذه الدراسة لتحديد نسبة انتشار وطريقة استعمال الطب البديل في قطاع عسكري في المجتمع السعودي.

طريقة الدراسة: تم اختيار 310(ثلاثمائة وعشرة) مريض بالغ عند زيارتهم للعيادة على مدى ستة أسابيع. طلب من هؤلاء المرضى الإخبار عن المشاكل الصحية التي تزعجهم بالإضافة لاستعمالهم للطب البديل والطب الحديث في حل مشاكلهم الصحية.

نتائج الدراسة: استعمل 46% من المرضى الطب البديل في الماضي خلال فترة حياتهم، واستعمل 19% منهم الطب البديل خلال الإثنى عشر شهراً الماضية.

وقام 5ر16% منهم بزيارة الطبيب الشعبي، وكانت نسبة مستعملي الأعشاب تساوي حوالي 7ر8% من الأشخاص الذين أجريت عليهم الدراسة، والعسل بنسبة 5ر4% أما الحبة السوداء فكانت نسبة استعمالها 3% والكي استعمله شخص واحد فقط . ووجد أن النساء وخصوصاً ربات المنزل والأميات منهن لديهن ميل أكثر لاستخدام الطب البديل.

- فضل حوالي 68% من الأشخاص في عينة البحث استعمال الطب الحديث على الطب البديل.

- كان المصدر الرئيسي للمعلومات عن الطب البديل هو الأقارب (77%).

- وجد أن نسبة كبيرة من الأشخاص المصابين بالاكتئاب استعملوا الطب البديل (53%) أو زاروا الطبيب الشعبي (33%).

-  وجد أن معدل التكلفة المادية لزيارة الطبيب الشعبي تساوي حوالي (166 ريال سعودي) وهي أكثر مما تكلفه مثيلتها في الولايات المتحدة الأمريكية (6ر27 دولار أي ما يعادل حوالي 100 ريال سعودي).

الاستنتاجات: هناك حاجة ماسة لتثقيف الناس حول الطب البديل والطريقة الصحيحة لاستخدامه وذلك عن طريق وسائل الإعلام والعاملين في القطاع الصحي، ويخص بذلك ربات البيوت وغير المثقفين.

- هناك حاجة كذلك لإجراء استقصاء على المجتمع من خلال زيارات منزلية بحيث يقوم بالمقابلة أشخاص من غير القطاع الصحي (كالمدرسين مثلاً) وذلك تجنباً للتحيز وإعطاء إجابات فيها مجاملة للفريق الصحي.

الكلمات المرجعية : الطب البديل - المملكة العربية السعودية - التثقيف عبر وسائل الإعلام.

Background: Alternative Medicine (AM) is gaining popularity worldwide.

Objectives: This study was conducted to determine the prevalence and pattern of AM use in a military sector of the Saudi community.

Correspondence to:

Dr. Eiad A. Al-Faris, Associate Professor and Consultant, Family Medicine, Department of Family & Community Medicine (34), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461

Methods: Three hundred and ten adult patients, visiting their family physicians over 6 weeks from the 1st of June 1998, were selected by systematic random sampling. They were asked to report worrying health problems and their use of modern medicine (MM) and AM.

Results: Forty-six percent of the patients had used AM before and about 19% had used it in the past 12 months. Alternative medicine practitioners were visited by 16.5% of the study population. Herbal medicine users represented 8.7% of the study population, honey (4.5%), the black grain Nigella sative (3%) and cautery was used by one person only. Women, housewives and the illiterate were more likely to use AM. About 86% of all the study population preferred MM. The main source of information about AM was relatives (77%). A large proportion of patients who reported depression used AM (53%) or visited AM practitioners (33%). The average cost per visit to an AM pratitioner (166 Saudi Riyals) was higher than that in the USA ($27.60=100 Saudi Riyals).

Conclusion: There is a need to educate the public through the media and health professionals on the appropriate use of AM; housewives and the illiterate should be targeted. A community-based household survey using interviewers not associated with the health system such as teachers (to avoid bias) is needed.

Key Words: Alternative medicine, Saudi Arabia, Media education.


 

INTRODUCTION

                Alternative medicine (AM) is widely practiced  and is gaining popularity  worldwide.1-4 The scope of AM is enormous and includes all therapeutic procedures and practices which fall outside the mainstream of medical practice.5 Different terms such as complementary, unconventional, unorthodox and others6 have been used to describe AM. Many reasons have been adduced to the huge upsurge and expenditure on AM; these include fear of iatrogenic illnesses, the demand for greater patient participation in treatment, the growth of awareness of health issues, and the failure of conventional treatment.5

                AM practices in Saudi Arabia originate partly from the Islamic religion. The advice for Muslims to look for treatment for their illnesses comes from Prophet Mohammed, Peace be Upon Him (PBUH) Hadeeth. “Oh! People take treatment and medication, as Allah did not put an illness without putting a treatment for it except one: senility (old age)”.7 

                AM practices include: (a) Reading the Quran and puffing over  the affected part of the body: it was narrated that Prophet Mohammed (PBUH) had done this  himself and for  his companions. (b) Cautery, blood letting, honey and black grain stated in  Hadeeths of Prophet Mohammed (PBUH).

                A cross-sectional study of patients attending health centers found that 24% had used AM during the previous six months.8  In another study, 73% of patients admitted to hospital received oil and/or Ghee as folk medicine,9 and 72% of them did so because of the persistent advice from their relatives.  At an outpatient pediatric orthopaedic clinic in a tertiary care hospital in Riyadh, it was found that 22% of the patients had cautery over the preceding 11 month period.10

                Some forms of AM are well known but others are exotic, or mysterious, still others are dangerous.11 In Saudi Arabia, several studies have reported the serious side effects of some AM practices.9,11-14 Lamb bile was prescribed by a faith healer for 14 diabetic patients. Of these, 12 were hospitalized for gastrointestinal complaints.6 The use of some types of herbal medicine is known to cause liver toxicity.15

                In spite of its importance, little is known about the overall prevalence, cost and pattern of AM use in different sectors of the Saudi population. Doctors’ understanding of the pattern of AM use, the characteristics of users and patients’ perception is important for a successful doctor - patient encounter. Studies in Saudi Arabia have been conducted in hospital in-patient settings,9,16 the use of a single type of AM,9,10,13,17 and AM practitioners through interviews18 or patients attending primary health care (PHC) centres in a small city,8 but there has been no community survey. To the best of the author's knowledge, this is the first study on the prevalence and pattern of AM use among patients in a military population in a large city in Saudi Arabia attending their health centres.

                This study was conducted to increase our understanding of the pattern of use of AM in a sector of the Saudi community at the National Guard (NG) residential compound. The focus was on the following questions:- The extent of AM use among the study population? The types of AM commonly used? The sociodemographic factors that distinguish AM users from non-users? The perceived health problems for which AM is commonly used? The patients’ perception of the benefit and safety of AM vis a vis MM? The patients’ perception of the causes of their reported health problems?

SUBJECTS AND METHODS Data Collection

The records of the study population  including name, address,  age and phone number were accessible through the computer. The initial plan was to collect the information through telephone interviews based on the assumption that it would be a better representation of the whole population.  A few phone calls were made, but the response rate was poor. Some of the responders were suspicious of the research team's intentions especially when a female patient was to be interviewed. Therefore, face to face interviews were set up at the health centers.

Study Site

The NG residential  compound, located at Kashm Alaan in the east part of Riyadh has a population of  approximately 60,000 residents, all of whom are Saudi military personnel and their families. Of the total, 18000 (30%) persons were aged 18 years or above. PHC is provided through ten satellite clinics run by 30 physicians. Each clinic has a well-defined catchment area. Around 200,000 encounters took place during 1997 at the ten clinics.19

Subjects

The study population targeted was the adult patients, aged 18 years or more, attending the ten satellite clinics over a six-week period, from the first of June 1998.

                The required sample size  was estimated as 225. This was based on the assumption that 30% of the patients would have used AM over the past 12 months as shown in a previous Saudi study,8 with an estimated error  of +6% within 95% level of confidence. Some adjustment was made in the sample size for an expected response rate of 80%. Therefore, a sample size of 300 patients was used. Patients were selected by a systematic random sample.20 Care was taken to make the sample size for each health center proportionate to the population size of its catchment area. The patients were asked about AM use during the 12 months before the interview. Therefore, the results were considered representative of the year from June 1997 to May 1998.

The Interview

Six trained social workers interviewed the selected patients using a pre-designed Arabic data collection form. Each of them interviewed 3 patients while being observed by the author as part of the  training and to increase and safeguard reliability.

The interview was described to the respondents as a survey  designed to assess their beliefs and practices when faced with health problems. No mention was made of AM while recruiting the respondents. Confidentiality was promised from the start. The initial sequence and wording of the questions was based on the study by Eisenberg.3 The interview, which averaged 15 minutes in length, started with questions on the respondent’s health, health worries and his or her interaction with physicians during the past 12 months.

The interviewer then assessed the respondent’s health problems by stating, “Have you suffered or are still suffering from the following health problems?. Twenty-three common health problems were named followed by the question, “What other important health complaints do you have?” The 23 health problems included common symptoms (such as back pain, digestive problems, headache and fatigue) as well as specific diagnoses such as diabetes, epilepsy, hypertension and cancer.

The respondents were then asked to identify the three (or fewer) “most bothersome or serious” health problems from the list they had just been given. These health problems are referred to here as “principal health conditions”. The respondents were asked whether they had seen their medical doctor for each principal health condition during the past 12 months and what their perception of these interactions had been.

At this point, they were asked about their use of unconventional therapy. The respondents were asked whether they had ever used one or more of 10 unconventional therapies for their principal health conditions and, if so, whether they had used any of them in the past 12 months. The 10 unconventional therapies included: (1) Cautery (2) Herbs (3) Water and oil (4) Quran (5) Honey (6) Black grain (7) Fracture fixation (8) Chemicals (9) Acupuncture (10) Jinni (Muslims believes in this as one of the supernatural beings able to assume human or animal form and often at the service of men: also spelled genie or Jinnee) removal from the patient body by sheik. For example, a respondent listing back problem as a principal health condition was asked whether he or she had used any of the ten unconventional therapies for this problem during the past 12 months. The respondents were next asked whether they had used “any other therapy not generally provided by most clinics and hospitals”.

When patients reported the use of AM during the past 12 months, the questions were asked to elicit the following information: The names of the unconventional therapies used or AM providers visited for each of the principal health problems, number of times used, the average charge per visit and opinion on the AM used, reasons for AM use, experience of side effects and the patients’ demographic characteristics. The patient was also asked if he/she had informed his or her doctor about AM use.

Data Analysis

The data were entered into a personal computer and both the chi-square and the odds ratio were used. The conventional < 0.05 level of statistical significance was used to determine the difference between groups.

RESULTS

Out of a total of 320 patients targeted for the study, 310 agreed to participate (97%). All the patients included in the study are Saudi, (men 49% and women 51%).  About half of them were below 35 years of age and one


 


 

Table 1: Univariate associations between use of Alternative Medicine (AM) over the past 12 months and variables of interest

Total*

No (%)

Persons used AM

No (%)†

Odds Ratio (95%   confidence Internal)

p-value

Sex:

Male

145 (48.8)

9 (6.2)

1.0

0.0000002

Female

152 (51.2)

46 (30.2)

6.6 (2.9-15.1)

Age

50 yrs

15 (5.1)

  1 (6.7)

1.0

35-49 yrs

140 (47.1)

         28 (20)

3.5 (0.45-74)

0.31

25-34 yrs

98 (33)

  23 (23.5)

4.29 (0.54-92)

0.18

18-24 yrs

  44 (14.8)

5 (11.4)

1.79 (0.17-44)

1.00

Education

Before primary school

86 (30.5)

30 (34.9)

4.5 (1.7-12.3)

0.001

Primary school

71 (25.1)

11 (15.5)

1.55 (0.51-4.8)

0.55

Intermediate school

66 (23.4)

7 (10.6)

1.0

High school

  45 (16)

5 (11.1)

1.05 (0.27-4.1)

1.00

University or more

  14 (5)

3 (21.4)

2.3 (0.4-12.4)

0.37

Marital status

Single

  39 (12.8)

4 (10.3)

1.0

Married

263 (86.5)

       54 (20.5)

2.3 (0.7-7.9)

0.19

Widowed

  1 (0.3)

0

Divorced

  1 (0.3)

0

Occupation

Soldier

116 (38.8)

8 (6.9)

1.0

Student

  35 (11.7)

7 (20)

3.4 (0.99-11.9)

0.046

Housewife

138 (46.2)

42 (30.4)

5.9 (2.5-14.4)

0.000006

Others

10 (3.3)

1 (10)

-

0.54

Place of brought up

Desert

19 (6.2)

2 (10.5)

1.0

Village

  42 (13.8)

7 (16.7)

1.7 (0.3-13.3)

0.71

Other cities

171 (56.1)

       29 (17)

1.74 (0.35-11.52)

0.74

Three big cities‡

  73 (23.9)

       17 (23.3)

2.6 (0.5-18.0)

0.34

*the total is less than 310 due to missing data

†the denominator is not always 58 due to missing variables for few   ‡ Riyadh, Jeddah, Eastern Region


 

Table 2: The proportion of users of different types of AM among the 310 study population during the past 12 months period and over life

Types of AM

No (%)

Am user over life

143 (46.0)

AM use over the past 12 months

58 (18.7)

AM practitioner visit

51 (16.5)

Sheikh visit

43 (14.0)

Attar visit

19 (6.1)

Herbal medicine

27 (8.7)

Honey

14 (4.5)

Black grain

9 (3)

Others

10 (3.2)

Total

310 (100)

third had no formal education (Table 1). The majority of the study population were married and were either soldiers (for men) or housewives. Women, housewives and persons who had no formal education were found more likely to use AM.


 

The proportion of patients who had ever used AM was 46%, 19% had used it during the past 12 months, (Table 2) . About 17% of the patients visited one or more kinds of AM practitioners like a sheik for reading the Quran with oil and water (14%), or the attar (apothecary, herbalist: a person who prepares


 

Table 3: Use of AM for the 10 most frequently reported principal health conditions

Condition

Reporting Condition

No (%)

Used AM in past 12 months

No (%)*

Saw AM practitioner in past 12 months

No (%)*

Therapies most commonly used

Headache

94 (30.3)

20 (21.3)

7 (7.4)

Sheikh visit for reading Quran, herbs, attar preparations, black grain

IBS†

55 (17.7)

14 (25.5)

           1 (1.8)

Herbs, honey and black grain and sheikh visit for reading Quran

Hair fall

51 (16.5)

10 (19.6)

           0 (0)

Sheikh visit for reading Quran and herbs

Abdominal pain

49 (15.8)

3 (6.1)

           0 (0)

Honey and sheikh visit for reading Quran

Back pain

40 (12.9)

      12 (30)

           2 (5)

Sheikh visit for reading Quran, herbs, honey

Asthma

34 (11.0)

5 (14.7)

           2 (5.9)

Herbs, Attar prepartions

Diabetes

30 (9.7)

4 (13.3)

           0 (0)

Sheikh visit for reading Quran, herbs

Anxiety

30 (9.7)

8 (26.7)

           1 (3.3)

Sheikh visit for reading Quran

PUD‡

20 (6.5)

       6 (30)

           1 (5)

Herbs, honey and black grain

Depression

15 (4.8)

       8 (53.3)

           5 (33.3)

Sheikh visit for reading Quran

10 most common

266 (85.8)

     52 (19.5)

         52 (19.5)

*Percentages are for those who reported the condition

†IBS=Irritable bowel syndrome    ‡PUD=Peptic ulcer disease


 

and sells crude drugs – herbs, roots and other ingredients – and practices healing)  (6.1%). Herbal medicine users accounted for 8.7%, honey (4.5%) and the black grain Nigella sativa (3%) (Table 2). Although only one patient used cautery in the past year, 18 (5.8%) patients were cauterized before.

Pattern of AM use

The vast majority of the patients (86%) reported a principal health problem over the past year. Table 3 summarizes the rate of AM use for the ten most common principal health problems. On the average, one in five respondents (19.5%) used AM for principal health problems (Table 3). Among all the conditions studied, the frequency of AM use was highest for headache (20), irritable bowel syndrome (IBS) (14) and backpain (12). The proportion of patients with depression who used AM (53%) was higher than that of patients with other conditions. The highest frequency of visits to AM practitioners’ was for headache (7 patients) and depression (5 patients). The average cost of any AM practitioner visit was 166 Saudi Riyals (SR), a  visit to a sheik to read the Quran with oil and water (125 SR) and the average cost of buying herbs and black grain from the attar was 200 SR.

                For the study population, the perceived causes of health problems were destiny (64%), hereditary factors (7.4%), envy (7%) and acquired problems (5.5%). The main reasons for using AM were its success in treating previous health problems (28%) and unreliable doctor's diagnosis (21%), reliability of AM (17%) and inaccessibility of MM facilities (7%). Compared with AM, MM was perceived by a higher proportion of the total respondents as beneficial (96% vs 57%) and safe (95% vs 48%) (Table 4). Compared with patients who used MM only, a higher proportion of AM users perceived AM as beneficial, while a lower proportion perceived it as safe (Table 4). Among the patients who had used AM over the past year, 50 (92%) had not had side effects at all, two had had minimal side effects, two had side effects for which medical advice was sought, but none needed admission in to hospital.

                The patients were asked to name the three most important health problems and the type of treatment used for each, and their satisfaction with the treatment was explored. There was no statistically significant difference between AM and MM users in the rate of satisfaction. About 86% of all the study population preferred MM, while 1% preferred AM, and 12% preferred using both types. The main sources of information about AM were relatives (11%), neighbours (48%) and friends (39%). The media constituted only 8.3% of the information sources. Out of those who used AM, 40% said they would use it again. The majority would not volunteer any information to their doctors about AM use (72%) and those who would not advise their relatives or friend to use it constituted 70%. 

DISCUSSION

The patients who participated in the present study were recruited from health facilities. Nevertheless, the sample could be considered representative  of a significant proportion of the compound population, as statistics revealed that more than 90% of the residents visited their health centre annually19. Our discovery at the early stages of the study that it was socially unacceptable to discuss health matters on the phone necessitated our conduct of the study among patients attending their health facilities. Nevertheless, the data obtained revealed some trends in thinking, perception and practice of a significant number of the target population. The validity of the study results was raised by factors such as: the high response rate (97%), the appropriate sample size and the method used for data collection i.e interview rather than self-reported questionnaires, because of the high illiteracy rate (27% of the study population could not write).

                The proportion of patients who had used AM over the last year was 19%. It was envisaged that the conduct of the study in a health facility run by persons associated with the health facility could introduce some unfairness or bias. Furthermore, the indication that 72% of the study subjects  would not  inform their doctors about AM use suggests that an underestimation of the rate of AM use was likely and patients would feign more favourable comments in favour of MM. The figure is lower than that reported from some developed countries,  34% in USA,3 48.5% in Australia,4 23% in Denmark, and 49% in France21. However, the percentage of patients who visited AM practitioners (16.5%) is more than the USA figure (11%)3  and the U.K. figure (10%),2 but less than in  Australia (20.3%). The rate of herbal medicine use in the current study (8.7%) is higher than in the USA  (3%), but less than the Australian study (9.9%). The finding of only one patient who was cauterized over the last year and that of 5.8% of the patients were cauterized before indicates either that cautery is becoming less popular among residents or that there is increased awareness of its dubious benefits and its possible side effects.

                Women, housewives and individuals who had no formal eudcation were found more likely to use AM; these three characteristics are interrelated.  In general, the females have less education than males in Saudi Arabia22,23. This agrees with Gupta's findings that most parents who decided to treat their children with AM were illiterate.9 The demographic characteristic associated with AM use  in western studies are different from the findings in this study.4

                There is a wide variation among countries in  the types of AM practiced and the mode of practice. In Western studies, the common types include relaxation techniques, ginseng, chiropractic osteopathy, massage, image, mineral supplements and homeopathy.2-4 The types of AM practiced in Saudi Arabia are, however, quite different. A study of around 120 AM practitioners in different parts of the Kingdom of Saudi Arabia found that the majority  were illiterate: 28% used cautery, 25% read the Quran and 45% used herbs as treatment modalities.18 In the present study, visiting a sheik to read the Quran and the use of herbs were found the most popular. In the Arar study, herbs constituted the main type of AM used (23.9%). Reading of the Quran (2.9%), visit to an attar (1.6%) and cautery (1.2%) were used by  smaller proportions of patients.8

Compared with patients who reported other ailments, patients who reported depression were found more likely to use AM (53%) or visit AM practitioners (33%). In the perception of Saudis a doctors’ main job was to treat organic illnesses; there was stigma attached to psychological disorders.24,25 Therefore, when they have psychological illnesses the symptoms they present with are usually organic rather than psychological.24,26,27 This indicates that the proportion of psychological disorders could be more than is reported by patients.

Why do the majority of  patients who use AM  not inform their doctors? The patients probably surmise that AM is unacceptable to their doctors and would not be encouraged. The doctors are also probably not aware of the importance of obtaining information on AM use and would not ask about it. This needs to be investiged in future studies so that compaign for education on such practices would be better planned.

The perception of AM as dangerous by 70% of patients who used AM compared with 48% of those who used MM may be an indication of  increased awareness of the AM users on the risks involved.

RECOMMENDATIONS

There is a great need for the education of the public through the media and by health professionals on the use of AM for the management of some health problems. Medical doctors should enquire about the history of AM use in the patients' medical history. The adverse effects and benefits of both MM and AM should also be discussed. Certain groups e.g. housewives and the illiterate should be targeted in the education drive on AM. In addition to destiny  (perceived by patients as the major cause of illness), the importance of preventing the known physical and psychological causes of these illnesses should not be underestimated. The establishment of channels of communication between physicians and faith healers should be considered. There is a need for a community-based household survey with trained interviewers, with no connection to the health system e.g. teachers or university students.

ACKNOWLEDGMENT

My sincere gratitude goes to the social workers who participated in the data collection.

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2.     Wood G, Dorozynski A, Lie LG, Zinn C, Josefson D, and Ingram L. Complementary Medicine is booming worldwide.  BMJ 1996; 131-3.

3.     Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, and Delbanco TL. Unconventional medicine in the United Statescost and pattern of use. N Engl J Med 1993; 328 : 246-52.

4.     MacLennan AH, WilsonDH, and Tylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347 : 569-73.

5.     Ginsburg M. Complementary Medicine. The practitioner 1990; 234: 111.

6.     Al-Qahtani MS. Hepatic and Renal toxicity among patients ingesting sheep bile as an unconventional remedy for diabetes mellitus in Saudi Arabia. Morbidity and Mortality Weekly Report 1996; 45 : 941-3.

7.     Prophet Mohammed (PBUH) Hadeeth narrated by Ahmed in Al-Mosned and Abo Daood and Al-Tormedhi.

8.     Ajaji N, Taha AZ, and Al-Subier AG. Prevalence of utilization of native medicine among primary care consumers. Saudi Med J 1998;  19: 551-4.

9.     Gupta M, and Chowdery MSA. A common practice of traditional medicine with oil and/or Ghee, as folk medicine  in children of Southern Saudi Arabia. Ann Saudi Med 1990; 10: 378-82.

10.   Watt HG. Cutaneous cautery (Al Kowi): A study in pediatric orthopedic clinic in central Saudi Arabia. Ann Saudi Med 1989;  9: 475-8.

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