Abdulaziz A. Al-Mulhim, JBO&G*, Abdulrahman M. Al-Qurashi, PhD†

Departments of *Obstetrics/Gynecology and †Microbiology, Collegeof Medicine, King Faisal University, Dammam, Saudi Arabia

المقدمة:يعيش طفيلي التكسوبلازما داخل الخلايا، وهو ذو انتشار واسع في جميع أنحاء العالم، ولا تسبب إصابة  الشخص الطبيعي الذي يتمتع بمناعة كاملة، بطفيلي التكسو بلازما أية أعراض، ولكن قد تسبب  الإصابة بهذا الطفيلي في وقت الحمل مخاطر على الجنين.

هدف الدراسة:تحديد معدل انتشار الإصابة بالتكسو بلازما لدى النساء الحوامل.

طريقة الدراسة: أجريت هذه الدراسة في مستشفى الملك فهد الجامعي بالخبر، تم جمع مائة وخمسة وسبعين عينة من النساء الحوامل، هذه العينات تم فحصها لوجود الأجسام المضادة للتوكسوبلازما من نوع (I.G.G) و (I.G.M) .

نتائج البحث والاستنتاجات:تبين أن عدد النساء الحوامل اللاتي أصبن بطفيلي التكسوبلازما كانت قليلة جداً (1من 175) وأن عدد النساء الحوامل اللاتي أصبن في الماضي كان (69) من أصل        (175) إمرأة (39.4%)، وكانت كل حالات الولادة طبيعية بالرغم من وجود طفل مصاب بالتوكسوبلازما (1من 175).

الكلمات المرجعية: طفيل التوكسوبلازما، النساء، الحوامل.

Background: Toxoplasma gondii is an obligate intracellular protozoa of worldwide distribution. In immunocompetent adults, it is usually the cause of asymptomatic infection. However, infection during pregnancy poses a special risk because of the teratogenic effect of toxoplasma.

Objective: Determine the sero-prevalence of toxoplasmosis in pregnant women and newborn infants in King Fahd Hospital of the University, Al-Khobar, Eastern Province.

Methods: In this hospital-based study, sera from 175 pregnant females were screened for toxoplasma IgG and IgM.

Results and Conclusion: A very low number (N=1/175, 0.57%) of pregnant mothers seroconverted during pregnancy, although many (N=69/175, 39.4%) were recorded with inactive toxoplasmosis during pregnancy. Delivery was normal in all cases except for a small number (N=1/175, 0.57%) of newborns (as recorded from cord blood) who were positive for toxoplasmosis.

Key Words: Toxoplasma, pregnant women

Correspondence to:

Dr. Abdulaziz A. Al-Mulhim, College of Medicine, King Faisal University, P.O. Box 40093, Al-Khobar 31952, Saudi Arabia



Toxoplasma infection is universal in all countries of the world.1 The definitive host is the domestic cat, its feces being the main source of infection. Human infection is acquired mainly through contact with an infected cat, ingestion of tissue cyst, under­cooked or raw livestock meat.2 Studies con­ducted on the prevalence of toxoplasmosis in Saudi Arabia are mainly hospital-based. No community-based studies on the sero­prevalence of toxoplasmosis in humans in Saudi Arabia have so far been conducted. The current study was motivated by the fact that though some work on toxoplasmosis in pregnant mothers in Saudi Arabia has been conducted,3-7 the new technique of micro­particle enzymes immunoassay (MEIA) was not used in any of these except two.8,9 However, the latter were not community-based.

                The study aimed at determining the seroprevalence of toxoplasmosis in pregnant mothers (seroconversion during pregnancy) and infants born to these mothers. It is a part of a larger study of seroprevalence of toxoplasmosis in males and females of all ages in the Eastern Province.


This was a hospital-based study conducted at King Fahd Hospital of the University (KFHU). The study population comprised pregnant mothers and later their infants attending the antenatal clinic at KFHU. Sera from pregnant mothers in their second and third trimesters (a sample of 175) and later from the cord blood of the infants of these mothers were collected to determine IgM. Blood specimens were collected by vena­puncture by trained medical personnel under the supervision of members of the research team. The specimens were taken to the nearest primary health care center; serum was prepared and stored at 20oC for further analysis by the MEIA for IgG and IgM.10

                In this test, IMX Toxo IgG assay results of less than 2.94 IU/mL were considered negative for IgG antibody to T. gondii. IMX Toxo IgG assay results of greater than or equal to 2.94 IU/mL were considered posi­tive for IgG antibody to T. gondii and may indicate past inactive infection. Sera from subjects who were positive for IgG were tested for IgM using the same technique: IMX Toxo IgM (MEIA) for IgM. IMX Toxo IgM assay indexes of less than 0.500 are negative for IgM antibody to T. gondii. IMX Toxo IgM antibody to T. gondii in­di­cates acute active infection. Ma­ternal blood was collected from a peri­­pheral vein by vena­puncture and cord blood was collected from a large vein on the fetal side of the placenta immediately after delivery.

                Data were analyzed by computer, using SPSS version 6. Analysis of variance, Chi-square and T-tests were used as appropriate, taking significant values of p to be < 0.05.


Seroprevalence of toxoplasmosis in preg­nant mothers and their infants

Table 1 shows toxoplasma antibodies (IgG) in pregnant mothers during pregnancy. The ages of the pregnant women ranged from 25-35 (25±8) years. Of the 175 pregnant women included in the samples, 69 (39.4%) were found to be seropositive with values ranging from 0.6 to 300 IU/ml. Of these, only one mother was found to have active infection (0.57%).

                Table 2 shows the perinatal outcome and IgM levels in the cord blood of infants born to the mothers in the sample. One infant was found to have active toxoplasmosis (value of 0.5% for IgM). However, he had no abnormalities. The IgM values of the other cord samples were negative. The deliveries of the pregnant mothers were normal in all 175 cases: fetal weight ranged from 2.5-3.9 kg (mean=2.8 ± 1.2). There were no abor­tions, stillbirths or premature deliveries.


Table 1: Toxoplasma antibodies IgG in pregnant mothers during pregnancy*

No. of pregnant mothers

Age (years)

(Mean ±)

No (%) Positive in second trimester

Distribution of IgG values

No (%) of seroconversion


25 – 35

(25 ± 8)

69 (39.4)

5.6 – 300

1 (0.56)

*Positive at 2.94 IU.mL or higher

Table 2: Perinatal results of pregnant mothers and IgM levels in cord blood

No. of cord blood

State of delivery

Fetal Weight




Distribution of IgM in

Distribution of IgM

samples examined



Mean Range

± SD



cord blood



Normal = 175









*Stillbirth, premature, and abortion = 0



The diagnostic technique (MEIA) used in the present study is a relatively new tech­nique, but has been well docu­mented by other researchers. The technique was evaluated at 15 clinical locations in Europe and the USA. A high sensitivity of 97%, as well as a high specificity of 99.8%, was recorded.10-12

                It has already been shown that for the general population in the Eastern Province, the inactive toxoplasmosis (IgG levels) was about 25%, which is rather high.5 That for the pregnant mothers was even higher (39.4%).

                It is, however, comparable to that re­corded for the Dammam area (42.1%) and higher than that for the Hofuf area (22.7%).5,13 Other investigators have recorded similar values in other areas of the Kingdom.4-7,14 This seroprevalence in pregnant mothers  of the present study is in accordance with epi­de­mi­ological surveys in the Eastern Re­gion.13 However, there was a very low level (1 of 175) of seroconversion (active toxoplas­mosis), and congenital transmission occur­red in this study similar to that level recorded in the Dammam area (1/152) and that recorded over all of Saudi Arabia (9/1863).5

                The perinatal outcome of the pregnancy in this study is remarkably favorable. There were no abortions, stillbirths or premature deliveries, or congenital anomalies. This has a significant bearing on screening and management. According to our findings only those at high risk need be screened, since it may not be cost effective to routinely screen all pregnant mothers.


1.     Frejj BJ, Sever JL. Toxoplasmosis: Paediatric in Review 1991;72:227-36.

2.     Heyneman D, Goldsmith R. Tropical Medicine and Parasitology. Prentice Hall International, 1992;942.

3.     Kandil OF, Gamal-Eddin FM, Hosni MA, El-Dasougi IT. Toxoplasmosis among healthy parous women in Saudi Arabia. J Egyp Soc Parasit 1979; 9:481-90.

4.     Basalamah A, Seribour F. Toxoplasmosis in pregnancy – a survey of 1000 pregnant Saudis and non-Saudis attending King Abdulaziz University, Jeddah. Saudi Med J 1981; 2:125-9.

5.     Abbas SA, Basalamah A, Serebour F, Alfonso M. The prevalence of Toxoplasma Gondii antibodies in Saudi women and the outcome of congenital infection among newborns in Saudi Arabia. Saudi Med J 1986;7:346-54.

6.     Al-Mesharim A, Chowdhury M, Chattopadhyaya S, De-Silva S. Screening for toxoplasmosis in pregnancy. Int J Gyn Obstet 1989; 29:39-45.

7.     El-Sebai MM. Study on toxoplamosis in Qasseem, Saudi Arabia. Journal of the Egyptian Soc Parasit 1991; 21:273-5.

8.     El-Hady HM. Toxoplasmosis among pregnant mothers in Abha, Saudi Arabia. J Egyptian Soc Parasit 1991; 21:811-5.

9.     Ikram HH. Antibody to toxoplasma gondii among pregnant women in Medina Munawara. J Pak Med Assoc 1992; 42:44-5.

10.   Valcavi PP, Natali A, Soliani L, Montalo S, Deltoic G, Cheezi C. Prevalence of anti-toxoplasma gondii antibodies in the population of the area of Parma (Italy). Europ J of Epidemiol 1995; 11:333-7.

11.   Lyasu V, Robert A, Schaefer L, Maciozek J. Multicenterevaluation of a new commercial assay for detection of immunoglobulin M antibodies to Toxoplasma gondii, Multicenter Study Group. Europ J of Clin Microb and Infect Dis 1995; 14:487-93.

12.   Pitothory JJ, Reiter OI, Berthelot F, Milgram M, Deloye J, Perlersen E. Performance of European laboratories testing serum samples for  Toxoplasma gondii.  Europ J Clin Microb Infect Dis 1996; 15:45-9.

13.   Yanaza A, Kumari P. Prevalence of toxoplasma antibodies in blood donors in Al-Hassa. Ann of Saudi Med 1994; 14:230-2.

14.   Al-Amari OM. Prevalence of antibodies to Toxoplasma gondii among blood donors in Abha, Asir region, South




Abdullah I.Al-Sharif, FFCM(KFU),* Yahia M. Al-Khaldi, ABFM†

*The General Directorate of Health Affairs, Aseer Region, † Health Science Collegefor Boys, Abha, Saudi Arabia

هدف البحث: :يهدف هذا البحث إلى معرفة أنماط وتكاليف الأدوية التي تم صرفها من مراكز الرعاية الصحية الأولية بمنطقة عسير للمصطافين الذين استخدموا خدمات هذه المراكز.

طريقة البحث :أجريت هذه الدراسة خلال  صيف 1998م وذلك بتوزيع الاستمارات التي قام بتصميمها الباحثان على مراكز الرعاية الصحية الأولية بالمنطقة.وقد اشتملت هذه الاستمارة على عمر ،جنس،جنسية المريض،تشخيص المرض بالإضافة اسم وكمية الدواء الموصوف من قبل الطبيب المعالج.

بعد انتهاء فصل الصيف ،تم تفريغ هذه الاستمارات حسب أنماط الأدوية وكمياتها  بواسطة ممرضين ومساعدي صيادلة مدربين ،تم حساب تكاليف الأدوية اعتماداً على قائمة أسعار الأدوية التي تم الحصول عليها من إدارة التموين الطبي بمديرية الشئون الصحية بمنطقة عسير.

النتائج:بلغ مجموع وصفات  المصطافين التي تم تقييمها 96327 وصفة طبية، مثلت ما يقارب  25% من إجمالي الوصفات الطبية لمستخدمي المراكز الصحية  خلال نفس الفترة.

بلغت التكاليف  الإجمالية للأدوية المصروفة للمصطافين الذين استفادوا من خدمات المراكز الصحية   190533 ريال سعودياً( 50808 دولاراً أمريكياً) ،وهو  ما يمثل حوالي 20% من إجمالي تكاليف الأدوية المصروفة  لجميع من استفادوا من الخدمات العلاجية للمراكز الصحية خلال هذه الفترة. كلفت المضادات الحيوية ومضادات الألم ما نسبته 42% و21% على التوالي من إجمالي هذه التكاليف.

الخلاصة:وجد في هذه الدراسة أن تكاليف الأدوية التي صرفت للمصطافين الذين زاروا مراكز الرعاية  الصحية بمنطقة عسير أثناء فصل الصيف قد بلغت ما يقارب  20%   من إجمالي تكاليف الأدوية التي صرفت لمراجعي هذه المراكز أثناء نفس الفترة  مما يحتم على المخططين الصحيين الأخذ في الحسبان هذه الزيادة عند حساب الميزانية الدوائية للمنطقة.

الكلمات المرجعبة :تكاليف، الأدوية، مراكز الرعاية الصحية الأولية، المصطافين، منطقة عسير.

Objectives:Recognize the patterns and the cost of the drugs dispensed to summer visitors who attended Primary Health Care Centers (PHCCs) in Aseer region.

Methods:This study was conducted in Aseer region during the summer of 1998. The investigators designed and distributed special forms on which were blanks for names, age, sex, diagnosis and drugs that were prescribed for summer visitors who attended PHCCs in Aseer region. At the end of season, all the forms were collected and analyzed manually by well-trained nurses and assistant pharmacists. The cost of the drugs was calculated according to the price list provided by the Medical Supply Department.

Results:A total of 96327 forms were evaluated. These represented 25% of the total number of prescriptions issued by PHCC physicians during the summer season. The

Correspondence to:

Dr. Abdullah I. Al-Sharif, P.O. Box 1129, Abha, Saudi Arabia

total cost of the dispensed drugs was estimated as 190533 SR (50808$). About 20% of what was dispensed was for summer visitors who had utilized the PHCCservices in Aseer region. Antibiotics and painkillers cost 42% and 21% of the total cost respectively.

Conclusion:This study showed that the cost of drugs for summer visitors in Aseer region was 20.5% of the total drug cost. This additional cost should be considered in planning the drug budget.

Key Words:Cost, primary health care centers, summer visitors, Aseer region.


Aseer region has become one of the most common summer resort areas in Saudi Arabia. Thousands of tourists come to this region every summer to spend their vacation and to enjoy different recreational and scientific activities.1 During the summer of 1997, it was estimated that the total number of summer visitors was 1.3 million.2 Two different studies found that there was a dramatic increase in the utilization of primary health care services by these visitors, which resulted in an overload of the services.3,4 Both studies found that most of the visitors attended the clinics for curative purposes and were eventually prescribed medications.3,4 As a matter  of fact, expenditures, particularly  for diagnostic and therapeutic aspects of the health care services, had become very high.  Although the patterns and the cost of the health care services are important, there has been no report or study on them.

                The objectives of this paper are to recognize the patterns and the cost of the drugs dispensed to the visitors who utilized the primary health care services in Aseer region during the summer season of 1998.


This study was conducted in the Aseer region during the summer season of 1998. The investigators designed special forms which were distributed to all PHCCs in the region. On each form were the name, sex, and residence of the patient as well as the diagnosis, types and quantities of drugs dispensed, and the duration for which they were to be taken. A summer visitor was defined as any person who came from other regions of Saudi Arabiaor other countries during the summer. All visitors who attended PHCCs for medical care during this season were provided with the above-mentioned form which was completed by the treating physicians at the end of each consultation. At the end of the summer, all forms were collected and analyzed. The types and amounts of drugs that were documented in those forms were analyzed manually by well-trained nurses and pharmacists' assistants. The drugs were classified according to the essential drug list in primary health care 5 while the costs of drugs were calculated according to the drug price list provided by the medical supply department in the Directorate General of the Health Affairs, Aseer region.

                The following formula was used to estimate the total cost of the dispensed drugs during the study period. E = A x B. 'E' represents the total estimated cost of dispensed drugs, 'A' represents the average cost of each prescription, 'B' represents the total number of prescriptions issued during the study period.  


The PHCCphysicians in the Aseer region issued a total of 387727 forms and prescriptions during the summer. Twenty–five percent (96327 forms) were for the visitors who utilized the PHCCs health services. Eighty- thousand of those forms were evaluated for this study. The remaining forms (17%) were excluded due to the lack of information on the quantity of the dispensed drugs and the duration for which they were to be taken.

                The actual cost of dispensed drugs for the visitors was 190533 SR (50,808$). On average, each prescription cost 2.4 SR. The total cost of the dispensed drugs for all clients who attended P HCCs during the study period was estimated as 930545 SR. As a result, 20.5% of the cost of the dispensed drugs was for the visitors who utilized PHCC services during the study period. The costs of the dispensed drugs are summarized according to their pharma-cological group in Table 1.

Table 1:Patterns and cost of drugs that were dispensed from PHCCs in Aseer region for summer visitors in 1998

Pharmacological group

Cost in SR

Cost in $

% of cost





Pain killers &





Drugs for ARI




Drugs for gastro-

  intestinal diseases




Creams, drops and









Drugs for hyper-

  tension & diabetes












                In the current study, antibiotics cost accounted for 42% of the total cost, painkillers such as Paracetamol and Non-Steriod Anti-inflammatory Drugs (NSAID) cost 21%, drugs that were used for the management of respiratory and gastrointestinal morbidity represented 16%, and 7.7% of the total drugs cost respectively. Multivitamins, ointments, creams and other less commonly used drugs made up less than 10% of the total cost.    


Management of common health problems and the provision of essential drugs are two important elements of primary health care.5 Most morbidity reports from PHC settings in Saudi Arabia revealed that 40-60% of consultations were for acute respiratory infections (ARI).6-9 It is evident that though most acute respiratory diseases are self-limiting illnesses that do not need anti-microbial therapy,10 studies have found that most ARI cases were given antibiotics.11-15 Our study revealed that 42% of the total cost of  the drugs dispensed for summer visitors  was for antibiotics. This finding is similar to that reported by Berman who found that antibiotics were the most commonly prescribed drugs and accounted for 50% of the total drug budget.16  

                In spite of the lack of evidence of the effectiveness of remedies commonly prescribed by physicians for the relief of coughs and sore throat 9,17 it was found that 16% of the total cost of the dispensed medication covered such remedies. To rationalize the prescription for ARI, it is mandatory to set limits to the protocol issued by Khoja et al.12

                Painkillers such as Paracetamol and NSAIDs accounted for 21% of the total cost of drugs. These drugs are commonly prescribed for the relief of fever, muscular, and skeletal aches. Their overuse is dan-gerous and could lead to many medical problems such as liver, kidney, and gastric diseases. PHCC physicians and pharmacists should give priority to educating patients on this issue.

                Gastrointestinal diseases were the second on the list of health problems among the summer visitors.2 However, the drugs prescribed for such problems accounted for 7.7% of the total cost. The reasons for the discrepancy between the high rate of gastrointestinal disorders and low cost of medications prescribed may be that most of gastrointestinal problems do not need antibiotics and can be treated with cheap drugs including oral rehydration solutions and antacids.

                Generally, the cost of the dispensed drugs for summer visitors represented about 20.5% of the total of drugs dispensed during the study period. Drug costs in this study were based on actual prices. In addition to the fact that 17% of the forms were not evaluated, the absence of other studies for comparison as well as the wide variations in the prices of drugs between government and private sectors suggest that there should be caution in interpreting the results in this study.

                In conclusion, this study showed that the cost of the dispensed drugs for summer visitors was 20.5% of the total drug cost. This additional cost should be considered in the planning of the drug budget for Aseer region.


1.     Al-Kahtani MM. Tourism. Principles and Concepts. Applied Study in Aseer Region, Kingdomof Saudi Arabia. 2nd ed. Al-Alm Publisher; 1997. (Arabic version).

2.     Al-Kahtani MM, Ibrahim AA. Size of tourism flow and characteristics of summer visitors to Aseer Region in 1997. Analytic study. Abha (KSA): Chamber of Commerce and Industry; Abha: 1997. (Arabic version).

3.     Mahfouz AAR, Hamid A. An epidemiologic study of primary care service utilization of summer visitors to Abha, Asir region. J Community Health 1993; 18:121-5.

4.     Al-Sharif AI, Al-Khaldi YM, Al-Shahrani AM. Utilization of primary health care during summer. Saudi Medical Journal 2000; 21(4): 376-8.

5.     Al-Mazrou Y, Al-Shehri S, Rao M, Khoja TA. Principles and practice of primary health care. 1st ed. Riyadh; Ministry of Health; 1991.

6.     Al-Shamari SA, Jarallah JA, Olbubuyide IO, Bamgboye EA. A prospective study of the morbidity pattern of patients seen at university primary care clinic. Ann Saudi Med 1994; 14(1):22-5.

7.     Khattab MS, Campbell J, Badawi I. Morbidity pattern in study health problem for patients attending primary care clinics, King Faisal Military Hospital, Khamis Mushayt. Saudi Medical Journal 1997; 18(3): 231-5.

8.     Annual Health Report - Kingdomof Saudi Arabia. Riyadh; Ministry of Health: 1998.

9.     AL-Faris EA, Altaweel A. Audit of prescribing patterns in Saudi primary health care: What lesson can be learned? Ann Saudi Med 1999; 19(4): 317-21.

10.   Windark A, Tomasik T, Jacobs HM, de Melker RA. Are antibiotics overprescribed in Poland? Management of upper respiratory tract infections in primary health care region of Warszawa, Wola. Family Practice 1996; 13(5): 445-9.

11.   Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections and bronchitis. JAMA 1998; 279:875-7.

12.   Khoja TA, Al-Mohammed KK, Al-Hawwas M, Al-Qurashi M. National protocol for diagnosis and treatment of acute respiratory infections among children in health centers and small hospitals.2nd ed. Riyadh; Ministry of Health:1997.

13.   Al-Nooman NN, Al-Khafajei AMB. The misuse of antibiotics in acute respiratory infections in children, a problem-solving learning exercise. Eastern MediterraneanHealth Journal 1997; 3(2): 345-56.

14.   Mainous AG  III, Hueston WJ, Clark JR. Antibiotics and upper respiratory infection .Do some folks think there is a cure for common cold? Fam Pract 1996; 42:357-61.

15.   Rosenstein N, Phillips WR, Gerber MA, et al. The common cold: principles of judicious use of antimicrobial agents. Pediatrics 1998; 101(suppl): S181-4.

16.   Berman JR, Zaran FK, Rybak MJ. Pharmacy-based antimicrobial monitoring service. American Journal of Hospital Pharmacy 1992; 49:1701-6.

17.  Iqbal I, Pervez S, Biag S. Management of children with acute respiratory infections (ARI) by general practitioners in Multan: An observational study. J Pak Med Assoc 1997; 47(24): 24-8.




Abdulaziz Al-Mazam, DFETP*, Ashry G. Mohamed, Dr. PH†

*Saudi Field Epidemiology Training Program, †Family and Community Medicine Department, Collegeof Medicine, King Saud University, Riyadh, Saudi Arabia

مقدمة:يعتبر الربو مشكلة صحية شائعة ازداد معدل انتشارها في المملكة العربية السعودية خلال العقود الأخيرة. توجد مصانع للطوب في مدينة بحرة ساهمت في ازداد معدل تردد مرضي الربو إلى المراكز الصحية الأولية بها

هدف الدراسة:أجريت تلك الدراسة لتحديد عوامل الخطورة للربو في بحرة.

طريقة الدراسة:تم اختيار 110 حالة ربو و110 من الأصحاء في نفس العمر و الجنس للمقارنة وتم تعبئة استبيان بالمقابلة الشخصية يشمل بيانات عن العوامل الشخصية والبيئية التي يعتقد أنها عوامل خطورة للربو.

نتائج الدراسة:كان متوسط العمر لحالات الربو 22.36+16,7 عاما و 22.77+16,7 للأصحاء وتتكون كل مجموعة من 64 ذكرا (58%) و 46 أنثي(42%) وكان هناك ارتباط ذو دلالة إحصائية معنوية بين بعد المنزل عن مصانع الطوب ومعدل انتشار الربو (خي المربع للارتباط الخطى = 26,6) واظهر التحليل اللوجستي الانحداري أن السكن داخل مسافة كيلومتر واحد من المصانع يزيد احتمال الإصابة بالربو خمسة أضعاف(نسبة الترجيح= 5,1 فترة الثقة=2,33-11,16)كما اثبت ايضا أن وجود تاريخ عائلي للإصابة بالربو (نسبة الترجيح= 4,6 فترة الثقة=2,16-9,78) أو حساسية الأنف(نسبة الترجيح= 3,39 فترة الثقة=1,49-7,69) أو الجلد(نسبة الترجيح=4,6 فترة الثقة=1,53-13,87) وعدوي الجهاز التنفسي المتكررة (نسبة الترجيح = 4,1 فترة الثقة=1,79-9,22) تزيد احتمال الإصابة بالربو في بحرة.

الاستنتاجات والتوصيات: أن السكن قرب مصانع الطوب ووجود تاريخ عائلي للإصابة بالربو وحساسية الأنف أو الجلد وعدوي الجهاز التنفسي المتكررة عوامل خطورة للربو ويوصى بالسكن بعيدا عن مصانع الطوب وإجراء دراسة بيئية لقياس نسبة ملوثات الهواء ببحرة.

الكلمات المرجعية: الربو , صناعة الطوب, تلوث الهواء, أمراض الحساسية.

Background: Asthma is a common health problem whose prevalence in Saudi Arabia has risen over the last few decades. Brick factories in the city of Bahrah have exacerbated the problem, and increasing numbers of asthma cases are attending local primary health care centers.

Objective: Determine the risk factors of asthma in Bahrah.

Materials and Methods: The study was comprised of 110 cases of bronchial asthma resident in Bahrah who were diagnosed by the treating physicians and 110 healthy controls matched in age and sex. A questionnaire was completed from cases and controls, consisting of data regarding personal, familial, indoor and outdoor environmental factors that may be potential risk factors to asthma. Bivariate and multivariate logistic regression analyses were done to assess risk factors.

Correspondence to:

Dr. Ashry G. Mohamed, Family and Community Medicine Department (34), College of Medicine and KKUH, P.O. Box 2925, Riyadh 11461, Saudi Arabia

Results: The mean ages of cases and controls were 22.4 (± 16.7) and 22.8 (± 16.1) years, respectively. Each group consisted of 64 males (58%) and 46 (42%) females. There was a significant association between distance from houses to brick factories and bronchial asthma (Chi square for linear trend = 26.6, p<0.001). Multivariate logistic regression analysis showed that living within one kilometer of a brick factory (OR=5.1, CI=2.33-11.16), family history (OR=4.6, CI=2.16-9.78), allergic rhinitis (OR=3.39, CI=1.49-7.69), skin atopy (OR=4.6, CI=1.53-13.87) and recurrent respiratory tract infections (OR=4.1, CI=1.79-9.22) were independent risk factors for asthma in Bahrah.

Conclusions and recommendations: Brick factories, family history and history of rhinitis, skin atopy, or recurrent respiratory tract infections are risk factors of bronchial asthma. An in-depth study to asses air pollution in Bahrah is recom­mended. People are advised not to live near brick factories.

Key Words: Bronchial asthma, brick factories, air pollution, allergic diseases.


INTRODUCTION Asthma is a common condition that affects 5-10% of the population worldwide.1 Al­though known since antiquity, asthma has only recently been defined as being only partially reversible.2 It places a substantial burden on family, health care services and on society as a whole. In children, it im­pairs ability to enjoy or take part in sporting events, it affects sleep patterns and school attendance.   In adults, it affects the quality of life and days of work.3,4

                It is widely accepted that there is an increase in morbidity and mortality due to bronchial asthma.5 This may be attributed to environmental and social changes such as rapid urbanization, increased exposure to indoor allergens and occupational exposure.1,6

                In the Kingdom of Saudi Arabia, the prevalence of asthma was 12%, with vast regional variations ranging from less than 10% in Dammam to 23% in Hail.7 Bahrah is a semiurban area in the middle of the desert along the highway between Makkah and Jeddah. Two brick factories are located near houses in the city. In the last few years the number of asthma cases attending local primary health care centers (PHCCs) has risen. This study aims to examine the risk factors of asthma in Bahrah.


A case control design was used to execute the study. Assuming that the prevalence of exposure among the controls was 20%, study power of 80% at 95% confidence level with 1:1 case control ratio, a sample size of 110 cases and 110 controls was determined.

                All cases of bronchial asthma residing in Bahrah diagnosed by treating physicians and consistent with diagnostic criteria of asthma in the national protocol1 and attending the outpatient clinics of the two PHCCs in Bahrah were included until the predetermined sample size was recruited.  For each case, a control of corresponding age and sex was chosen from visitors to PHCCs in Bahrah with no history of asthma, nor complaint of respiratory symptoms.

                Data were collected by means of a struc­tured questionnaire completed by personal interviews with cases and controls. Parents of children aged less than 10 years were interviewed to complete the questionnaire. Data consisted of personal characteristics, e.g. age, sex, medical history and environ­mental exposures, e.g. to indoor plants, ani­mals and smoking.

                To determine the distance from houses to brick factories a map of the city drawn to the scale of 1.5: 1000000 was used. The houses were located on the map and the distance to the nearest factory was measured and converted into actual distances. Cases were considered severe if they reported history of admission to hospital as a result of asthma.

                Data were checked for completeness and consistency. SPSS software was used for data analysis. Chi-square for linear trend was used to assess association between bronchial asthma and distance from houses to factories. The odds ratio and its 95% confidence interval were used as a measure of risk. Factors found to be significantly associated with asthma in bivariate analysis were submitted to multivariate logistic regres­sion analysis for control of confounders.


A sample of 110 cases and 110 controls were included in the study. Each group consisted of 64 males (58%) and 46 (42%) females.  The mean ages for cases and con­trols were 22.4 (± 16.7) and 22.8 (± 16.1 years), respectively.

                Table 1 shows that there is no association between education and bronchial asthma (P0.05).  The risk of asthma is significantly higher among housewives and students than other groups (OR=3.29, CI=1.21- 9.02 and OR= 2.92, CI=1.42-7.03, respectively).  Persons with family history of asthma face more than


Table 1: Personal factors among cases and controls of bronchial asthma in Bahrah, Saudi Arabia



No. (%)


No. (%)


Confidence interval



46 (41.8)

43 (39.9)


R & R

4 (3.6)

11 (10.0)




31 (28.2)

27 (24.5)




16 (14.5)

17 (15.5)



Secondary and above

13 (11.8)

12 (10.9)




Manual worker

15 (13.6)

30 (27.3)


House wife

23 (20.9)

14 (12.7)




6 (5.5)

7 (6.4)



Student and preschool

38 (34.5)

26 (23.6)



Retired and jobless

28 (25.5)

33 (30.0)



Family history:


78 (70.9)

34 (30.9)




32 (29.1)

76 (69.1)

Allergic rhinitis:


69 (62.7)

16 (14.5)




41 (37.3)

94 (85.5)

Skin allergy:


33 (30.0)

7 (6.4)




77 (70.0)

103 (93.6)

Recurrent resp. infections:


68 (61.8)

15 (13.6)




42 (38.2)

95 (86.4)

Table 2: Environmental factors among cases and controls of bronchial asthma in Bahrah, Saudi Arabia



No. (%)


No. (%)


Confidence interval

Home smoking:


39 (35.5)

40 (36.4)




71 (64.5)

70 (63.6)

Indoor plants:


43 (39.9)

34 (30.9)




67 (69.1)

76 (69.1)

Indoor animals:


34 (30.9)

17 (15.5)




76 (69.1)

93 (84.5)

Building materials:

Red brick

15 (13.6)

17 (15.5)


Cement and Wood

86 (78.2)

90 (81.1)




9 (8.2)

3 (7.2)



Ground materials:


17 (15.5)

24 (21.8)



33 (30.0)

49 (44.5)




60 (54.5)

37 (33.6)



Use of insecticides


80 (72.7)

78 (70.9)




30 (27.3)

32 (29.1)

Cleansing materials



3 (2.7)

5 (4.5)



14 (12.7)

27 (24.5)




93 (84.5)

78 (70.9)



Table 3: Distance between houses of cases and controls of bronchial asthma and brick factories and roads in  Bahrah, Saudi Arabia

Distance in kilometers


No. (%)


No. (%)

Chi square for linear trend


Confidence interval

Occurrence of asthma:

< 1

66 (60)

22 (20)





23 (20.9)

47 (42.7)




16 (14.5)

24 (21.8)




5 (4.5)

17 (15.5)


Distance to the road:

< 1

18 (16.4)

23 (20.9)





80 (78.2)

72 (65.5)




4 (3.6)

10 (9.1)




2 (1.8)

5 (4.5)



Severity of asthma:

< 1

60 (63.8)

22 (20.0)





18 (19.1)

47 (42.7)




11 (11.7)

24 (21.8)




5 (5.3)

17 (15.5)




five-fold the risk of its occurrence com­pared to those without such history (OR=5.45, CI=2.93-10.2). Persons suffer­ing from allergic rhinitis, skin atopy or recurrent respiratory infections face an increased risk of asthma (OR=9.89, CI=4.87-20.31; OR=6.31, CI=2.55-17.67 and OR=10.5, CI=5.11-21.89 respectively).

                Table 2 reveals the risk of asthma to be significantly high among persons living in houses with concrete courtyards, or with pets (OR=2.45, CI=1.26-5.01 and OR= 2.29, CI=1.02-5.17, respectively). The risk of asthma is also high, but not statistically significant, among persons who have indoor plants or those who use chemical cleansing agents (OR=1.43, CI=0.79-2.62 and OR=1.99, CI=0.37-13.15 respectively).

                Table 3 shows that there is significant linear association between both the occurrence and severity of bronchial asthma with the distance from houses and brick factories (P<0.001). The highest risk was among those living within one kilometer of the factories (OR=10.2, CI=3.07-38.63 and OR=9.27, CI= 2.79 - 35.23, respectively). There was no linear trend between distance from the main road in Bahrah and occurrence of asthma (P0.05).

                Table 4 shows the result of multivariate logistic regression analysis of factors found to be significantly associated with asthma in  bicariate  analysis. Persons living within more   than   five-fold  the  risk  of   asthma

Table 4: Results of multiple logistic regression analysis



Confidence intervals

Distance < 1 km



Family history






Skin atopy



Recurrent respiratory tract infections



compared to those living further away (OR=5.1, CI=2.33-11.16). Also, persons with posi­tive family history of asthma, skin atopy, allergic rhinitis and recurrent respiratory infections are at high independent risk of asthma (OR=4.6, CI=2.16 - 9.7; OR=4.6, CI=1.53-13.87; OR=3.4, CI=1.49-7.69 and OR=4.1, CI=1.79-9.22, respectively).


Asthma is the most common chronic disease in children3 and an important disease among adults.3,8 Risk factors of asthma vary from place to place according to  several factors, including urbanization.9

                This study revealed that allergic rhinitis and atopic dermatitis increased the risk of asthma. Many other studies support this finding and have shown the co-existence of allergic rhinitis and asthma.10-13 Zhao et al used multivariate logistic regression anal­ysis and found a high significant risk of asthma among persons with allergic rhinitis or itchy rash.14 El-Gamal et al reported independent association between personal history of allergy and bronchial asthma.15  Immunological studies have shown that children with atopic dermatitis present non-specific bronchial hyperactivity (58-82%) which is a risk factor for later development of asthma.16,17

                Recurrent respiratory tract infections were found to be an independent risk factor for bronchial asthma in the present study (OR=4.1, IC=1.79-9.22).  Paul et al con­sidered viral respiratory diseases as a defined risk factor for developing asthma.18 Martinez et al found also that recurrent lower respiratory tract infection in early life triggers the development of asthma later in life.19

                The present study revealed that persons with family history of bronchial asthma were at high risk of developing asthma (OR=4.6, CI=2.16–9.78). The same finding was reported by Infante-Rivard who found increased significant risk of asthma among those with familial history of asthma.20 Al-Frayh et al supported this finding and reported that 35.9% of children who wheeze have mothers with asthma and 40.7% have fathers with asthma.21 Studies of twins have shown a significant increase in concordance among monozygotic twins compared to dizygotic twins, providing evidence for genetic predisposition.22 How­ever, no gene or genes involved in the inheritance of atopy and asthma have been identified.23

                Environmental tobacco smoke was suggested as a risk factor for bronchial asthma.24,25 The present study did not support this suggestion. In children, this inconsistency may be explained by the observation that more parents whose children had been diagnosed as asthmatic had quit smoking than parents of healthy controls.26 In agreement with the present finding, Pewits found that smoking does not appear to be related to asthma per se in adults when chronic conditions are removed and those at risk do not smoke, quit smoking or smoke very little.27

                Distance from home to brick factory as a measure of exposure to air pollution was found to be a significant risk factor for both the occurrence and severity of asthma. Living near these factories (? 1 Km.) carried the highest risk (OR=5.1, CI=2.33 – 11.16). These factories burn fuel and tar to heat bricks. This pollutes air with SO2, NO2, CO2 and CO particles.28 Several mechanisms have been proposed to explain the pollution-induced asthma. These include damage to airway epithelium, induced changes in lung function and enhanced release of inflammatory mediators.29

                This study shows the presence of animals at home to be a risk factor for asthma (OR=2.27). However, the risk was not statistically significant (CI= 0.93–5.55).  Many investigators have studied the etiological significance of animal handlers and suggested that they had high risk of asthma.30,31

                Regarding the role of exposure to indoor plants, the present study reveals  an  insignificant association between indoor plants and asthma (OR= 1.43, CI=0.79 – 2.62). This finding is inconsistent with reports of high sensitization of allergic patients to regional pollens.32 The in­consistency may be due to differences in exposure to specific regional pollens. Precise measurement of pollen allergens can also  give more accurate results about the role of plants and pollens. The lack of precise measurement for detailed environ­mental factors and the small sample size were the main limitations of the present work.


An in-depth environmental study to assess  the levels of air pollutants in Bahrah is highly recommended.  People should not live near brick factories. Atopic diseases, e.g. allergic rhinitis and atopic dermatitis, should be prevented through the avoidance of inhalant and cutaneous allergens, parti­cularly by those with positive family history of asthma.        


1.     The National Scientific Committee of Bronchial Asthma. The National Protocol for Management of Asthma.  MOH, KSA, 2000.

2.     McFadden ER Jr.  Natural history of chronic asthma and its long-term effects on pulmonary function. J Allergy Clin Immunol 2000;105(2 Pt 2):S535-9.               

3.     Von Mutius E.  The burden of childhood asthma.  Arch Dis Child 2000;82(suppl 2): II2-5.

4.     O’Neill BA. The burden of pediatric asthma. Eur Respir Rev 1994; 4:49-62.

5.     Frank BH, Victoria P, Falay BR, Zelli A, Cooksey J, Richardson J. Prevalence of asthma and wheezing in public school children. Annals of Allergy 1997;79: 80-4.

6.     Mormile F,  Chioppini F,  Ciappi  GG.  Deaths

        from asthma in Italy(1974 – 1988): is there a relationship with changing pharmacological approaches. J Clin Epidem 1996; 49: 1459-66.

7.     Al-Frayh. Bronchial asthma in Saudi Arabia: regional variation and impact of allergens. 2nd scientific report 1416 H: page 22.

8.     Moran SE, Strachan DP, Johnston IDA, Anderson HR.  Effects of exposure to gas cooking in childhood and adulthood on respiratory symptoms, allergic sensitization and lung function in young British adults. Clinical and Experimental Allergy 1999;29:1033-41.

9.     Kaur B, Anderson HR, Austin J, Burr M, Harkins L, Strachan OW, Warner JO. Preva­lence of asthma symptoms, diagnosis and treatment in 12-14 year old children across Great Britain(International Study of Asthma and Allergies in childhood, ISAAC).  BMJ 1998; 316:118-24.

10.   Corren J. Allergic rhinitis and asthma: How important the link? J Allergy and Clinical Immunology 1997; 99:5781-6.

11.   Greisner WA, Settipane RJ, Settipane GA. Coexistence of asthma and allergic rhinitis: a 23 years follow up study of college students. Allergy Asthma Proc 1998;19:185-8.

12.   Pedersen PA, Weeke ER. Asthma and allergic rhinitis in the same patients. Allergy 1983;38: 114-9.

13.   Lundback B. Epidemiology of rhinitis and asthma. Clinical and experimental Allergy 1998;28:3-10.

14.   Zhao TB, Wang HJ, Chen YZ, Xiao ML, Duo LK, Liu G, Lau YL, et al.  Prevalence of childhood asthma, allergic rhinitis and eczema in Urumqiand Beijing.  J Paediatr. Child Health 2000;36:128-33.

15.   El-Gamal FM, Kordy MNS, Ibrahim MA, Bahnassy AI. Epidemiology of bronchial asthma.  Saudi Med J 1993;14:419-23.

16.   Marin A, Eseverri JL, Botey J. From atopic dermatitis to asthma. Allergol Immunopathology 1998;26:114-9.

17.   Brinkman L, Aslander MM, Raaijmaker JA, Lammers JW, Koenderman L, Bruijnzeel-Koomen CA. Bronchial and cutaneous responses in atopic dermatitis patient after allergen inhala­tion challenge.  Clinical Experimental Allergy 1997;27:1043-51.

18.   Pauli G, Bessot JC, Quoix E.  Effect of the environment on the development of respiratory allergies. Rev Pneumol Clin 1989; 45:231-6.

19.   MartinezFD. Role of respiratory infection in the onset of asthma and chronic obstructive pulmonary disease. Clinical and Experimental Allergy 1999;29:53-8.

20.   Infante-Rivard C.  Childhood asthma and indoor environmental risk factors.  Am J Epidem 1993;137:834-44.

21    Al-Frayh A, Bener AB, Al-Jawadi TQ.  Prevalence of asthma among Saudi children.  Saudi Med J 1992;13:521-4.

22.   Hollaway JW, Beghe B, Holgate ST. The genetic basis of atopic asthma.  Clinical and Experimental Allergy 1999;29:1023-32.

23.   Lara ML, Marque Z, Yunis JJ, Layriss Z, Carvallo-Gill FE, Mani SM, Makhataze NJ, Pocino M, Granja C, Yunis E. Immunogenetics of atopic asthma. Clinical and Experimental Allergy 1999;29:60-71.

24.   Dubus JC, Bodiou AC, Millet V. Respiratory allergy in children and passive smoking.  Arch Pediatric 1999;6:355-8.

25.   Willers S, Axmon A, Feyerabend C, Nielsen J, Skarping G, Skerfving S.  Assessment of en­viron­mental tobacco smoke exposure in children with asthmatic symptoms by questionnaire and cotinine concentrations in plasma, saliva and urine. J Clin Epidem 2000;35:715-21.

26.   Micheal DL, Bronnimann S, Anthony EC.  Asth­matic risk factors and bronchial reactivity in non-diagnosed asthmatic adults. European J Epidem 1995;11:541-8.

27.   Kumar A, Vaidyanathan G, Laksmikantan KR. Cleaner brick production in India, a trans-sectional initiative. UNEP Industry and Environ­ment 1998;21:77-80.

28.   Chew FT, Goh DT, Ooi BC, Saharom R, Huj Js, Lee BW.  Association of ambient air pollution levels with acute asthma exacerbation among children in Singapore.  Allergy 1999;54:320-9.

29.   Gupta S, Bidania RK, Hambs J, Agarwal MK.  Role of animal danders as inhalant allergens in bronchial asthma in India. J Asthma 1996; 33: 339-48.

30.   Tunnicliffe WS, Fletcher TJ, Hammond K, Roberts K, Custovic A, Simpson A, Woodcock A, Ayres JG.  Sensitivity and exposure to indoor allergens in adults with differing asthma severity. European Respiratory Journal 1999;13: 654-9.

31.   Custovic A, Simpson B, Simpson A, Hallam C, Craven M, Woodcock A.  Relationship between mite, cat and dog allergens in reservoir dust and ambient air.  Allergy 1999;54:612-5.

32.   Baratawidjaja IR,  Baratawidjaja  PP, Darwis A, Soohwee L, Fook-Time C, Bee-Wahl, Baratawidjaja KJ.  Prevalence of allergic sensiti­za­tion to regional inhalants among allergic patients in Jakarta, Indonesia.  Asian Pac J Allergy Immunology 1999;17: 9-12.




Latifa S. Al-Sowielem, FFCM, Department of Family and Community Medicine,

Collegeof Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة:تقييم جودة الملصقات التثقيف الصحي  المعروضة بمراكز الرعاية الصحية الأولية

منهج الدراسة :دراسة مقطعية تم أجراؤها على عينة عشوائية مكونة من 138 ملصق معروض في ثلاثة مركز للرعاية الصحية الأولية، بمدينة الخبر. تم اعداد استمارة تقييم لجمع المعلومات. كما أستخدم نظام معايير لقياس ملاءمة الملصقات حسب معايير معدة مسبقاًً.

نتائج الدراسة:كانت المواضيع التي تناولتها الملصقات من ضمن المشاكل الصحيةالسائدة بالمملكة العربية السعودية في 134 (97.1%) من الملصقات. وقد كانت مدة العرض في أكثر من ثلث الملصقات اكثر من عام. كما كان مصدر المعلومات غير معلوم في 74 (53.6%) ملصقا. و أظهر التقييم أن 109 (79.0 %) من الملصقات ذات نوعية عالية..

الاستنتاجات:أظهرت الدراسة أن نوعية الملصقات مرضية نسبيا ما عدا عدم ملاءمتها لبعض المواصفات. و يتوجب استخدام تقييم الملصقات ضمن تقييم برامج التثقيف الصحي بمراكز الرعاية الصحية الأولية.

الكلمات المرجعية:التثقيف الصحي – ملصقات – تقييم – الرعاية الصحية الأولية

Background: Health Education (HE) is vital to each of the seven other central ele­ments of Public Health Care (PHC). HE must be carefully planned and implemented. A crucial part of HE is planning, production and placement of effective HE posters.

Objective: Assess the quality of health education posters in Al-Khobar PHC centers.

Methods: A cross-sectional study of a sample of 138 HE posters in three PHC centers in Al-Khobar was conducted. The quality of posters in relation to set criteria was measured using a data sheet and scoring system developed by the investigator.

Results: The health education subjects displayed were among the common health problems in Saudi Arabia in 134 (97.1 %) of the posters.More than one-third (34.8%) had been displayed for more than one year. In 74 (53.6%) of the posters, the source of scientific information was unknown. The assessment showed that 109 (79%) posters were of optimal quality.

Conclusion: The study showed that the health education posters in PHC centers in Al-Khobar were relatively satisfactory, though they did not fulfill some of the required criteria. Health education posters should be included in the assessment of health education programs in primary health care centers.

Key Words: Health education, posters, assessment, primary health care.

Correspondence to:

Dr. Latifa S. Al-Sowielem, Department of Family and Community Medicine, College of Medicine, King Faisal University, P.O. Box 2714, Dammam 31461, Saudi Arabia




Health Education (HE) is an important component of Primary Health Care (PHC) and is listed by the World Health Organization as one of its eight essential elements.1  Moreover, it is central to each of the other seven elements. Several studies have shown that health education programs don’t always meet expectations.2 Many reasons are given for this. Health Education succeeds when it is carefully planned and implemented.

                The reluctance of many health educators to evaluate their programs is documented in literature.3 One author indicated the difficulty in making a “balanced appraisal of the effectiveness of an intervention in the area of health education”.4 Evaluation is a continuous process conducted by the teacher and learner throughout patient education. By using the evaluation process, both parties benefit from the feedback that reinforces success and readdresses problems.5

                In many health centers in Saudi Arabia, the most commonly used method of HE is through wall posters. These, as well as other HE activities, are hardly ever evaluated. This raises the question of whether these wall posters are put up to fulfill the objectives of the first PHC element or just for decorative purposes, i.e., to make the PHC center more appealing and attractive.

                Consequently, this study was initiated with the aim of assessing  the quality of  health education posters in Al-Khobar PHC Centers. Assessment is perceived in two components; one is an assessment of the posters by the investigator, the other is assessment of the posters from the point of view of health center attendees. This paper addresses only the first component.

                Health education posters were appraised with regard to a set of variables designed by the investigator. It was suggested that this study would compensate for the deficiency in the local literature on posters as a method of health education. The results may be of use to planners and administrators in PHC in Al-Khobar and Saudi Arabia at large.


This is a cross-sectional study  which was conducted in March, 2000. Three PHC centers were selected randomly from the 11 PHC centers in the town of Al-Khobar using simple random sampling technique. A proportional random sampling technique was used to select 138 (51%) posters from a total of 270 displayed in the three PHC centers.

                A data sheet was designed and administered by the investigator to assess each poster. The variables in the data sheet included the subject of the poster and its importance, duration of display, designer, presence of scientific error(s), clarity of health message, language of the poster, acceptability and suitability of the health message, size, colors, attractiveness of the poster and other variables.

                A scoring system was developed by the investigator as a measure of assessment of  poster quality. The  ten variables used were: clarity of the health message through the text and/or picture, simplicity of language, presence of scientific errors in the write-up or the picture, acceptability of the health message for the community, cultural suitability of the picture, and size, color, and attractiveness of the poster. Each variable was given one point if it was present in the poster, or zero if not. The score for each poster was calculated as the sum of the points. The poster was considered of optimal quality if it achieved a score of seven points or more. The information for the duration of display of the poster was given by either the doctor or the head nurse.All vari­ables were pre-coded, entered and analyzed using the Statistical Package for Social Science (SPSS) version 6.0. Frequency distribution tables were generated. Chi-squared test was used to assess the significance of differences between categories. A p-value of 0.05 or less was considered indicative of statistical significance.


A total of 138 health education posters were analyzed. Fifty-four of them (39.1%) were in Primary Health Center 1, 48 (34.8%) in PHC Center 2 and 36 (26.1%) in PHC Center 3. Most of the posters (71.7%) in these health centers had both written material and pictures; some had written material only (15.2%), or pictures only (12.3%). The health education subjects that were displayed were among the common health problems in Saudi Arabia in 134 (97.1%) of the posters. Regarding the duration of posters, 48 or more than a third of them (34.8%) had been displayed for more than one year, 39 (28.3%) for 1–6 months, while for 21 (15.2%) the duration of display was unknown (Table 1).

                The designer's name was written on most of the posters but was unknown for 16 (11.6%). Out of 138 posters, 46 (33.3%) were designed by the PHC health education department, 38 (27.5%) by health center nurses and only 3 (2.2%) by doctors. The rest were designed by schools or were taken from advertising pamphlets. Very few posters showed scientific errors, either in the write-up (2.2%) or in the pictures (1.4%).


Table 1: Summary of parameters used for assessing health education posters


Frequency (%)

Subjects related to common health problems

134 (97.1)

Duration ( one year)

48 (34.8)

Designer "HE Department"

46 (33.3)

Designer "Nurses"

38 (27.5)

Designer "Doctors"

3 (2.2)

Designer "Others"

35 (25.4)

Designer "Unknown"

16 (11.6)

Scientific errors in the write-up

3 (2.2)

Scientific errors in pictures

2 (1.4)

Clarity of health message

112 (81.2)

Language simplicity

121 (87.7)

Acceptability of health message

130 (94.2)

Appropriate description of health message

104 (75.4)

Suitable size

111 (80.4)


94 (68.1)

Suitable colors

117 (84.8)

Table 2: Distribution of posters by subject and health center



General &   Public Health             (%)

Oral &    Dental Health         (%)

Adult  problems (%)

MCH & Nutrition (%)


Health Center 1

15 (62.5)

  8 (21.1)

   9 (30.0)

22 (47.8)

54 (39.1)

Health Center 2

  5 (20.8)

17 (44.7)

14 (46.7)

12 (26.1)

48 (34.8)

Health Center 3

  4 (16.7)

13 (34.2)

7 (23.3)

12 (26.1)

36 (26.1)


24 (100)

38 (100)

30 (100)

46 (100)

138 (100)

p-value 0.024


                Clarity of the health message was observed in 112 (81.2%) of the posters. The language used was simple in 121 (87.7%) of the posters. Arabic was used in 117 (84.8%), English in only 5 (3.6%) and both languages in 16 (11.6%) of the posters. The health message was considered acceptable from the cultural and social points of view for the Saudi community in 130 (94.2%) posters.

                The pictures were thought to describe the message appropriately in 104 (75.4%) of the posters. One hundred and eleven (80.4%) of them could be easily seen or read from a distance but the script in the remaining posters was too small to be read. A large proportion, 94 of the posters (68.1%) were attractive and the choice of colors in 117 (84.8%) was esthetically pleasing.

                The source of scientific information was unknown in 74 (53.6%) of the posters, but only 4 (5.4%) of them showed scientific errors in the sentences. Thirty-seven posters (26.8%) were from medical books, and 11 (8%) from pamphlets that were already available (Table 1).

                Table 2 shows that the difference among the three Public Health Care centers regarding the distribution of posters by subject was statistically significant (p= 0.024). A large number of posters that addressed general and public health problems (63%) and mother and child health/nutrition issues (48%) were in PHC Center 1, whereas near­ly half of the posters on adult health problems (47%) and oral/dental health messages (45%) were in PHC Center 2.

                An assessment of the posters by the score scheme showed that 109 (79.0 %) posters were of optimal quality. Out of these, only 43 (39.4%) posters scored 9 points or more. However, only 8 (5.8%) out of the 138 posters scored 3 points or less.  

DISCUSSION                                         The total number of HE posters in the three PHC centers was reasonable, considering the availability of wall space and attendees’ flow lines. Almost all the posters addressed important health issues. It was hoped that this would improve health awareness among the attendees. 

                More than a third of the posters had been on display for more than one year. New posters with important health messages  attract the attention of attendees and       although there is no fixed rule, posters should be changed every 3-6 months. By this time most of the regular PHC center attendees would have read the posters, perhaps more than once.

                It is important that the designer be known, so the source of a poster can be traced in the event of any scientific error. However, for about 12% of the posters the designer was unknown. Moreover, very few doctors contributed to the design of the posters.

                More than half of the posters did not indicate their source of information. This is alarming since health information meant for the public must be extracted from authentic sources. In fact, the source must be shown on the poster. The choice of health messages should not be left to just anyone to formulate, regardless of his training, as this may result in inaccurate information. Though more than 90% of the 74 posters of unknown source had no scientific error in the sentences, there is no justification for allowing the display of posters without control and authority.

                Fortunately, only a few of the sentences and pictures in 2-3 posters had any scientific errors. The health message was clear and simple in almost all of the posters. They were mostly in Arabic, which conforms to the local culture. The relatively small number of non-Arabic speaking attendees justifies the small number of posters in English.

                The opinion of attendees on the posters was not sought. It is important to evaluate the level of acceptability and com­pre­hen­sion of the target population by seeking the opinion of the attendees.

                Some health messages were stressed more than others in some PHC centers. There should be a rational distribution of posters by subject in the health centers. This is vital as the choice of health education messages should be determined according to the priorities of health problems encountered in the PHC centers. However, this cannot be achieved without coordination among the concerned persons involved in HE.

                To be effective in this community, all HE activities should be carefully planned, organized, implemented and evaluated by the HE administration. Health Education is vital for a good, responsible and forward-looking health service. Similarly, evaluation is an essential component of a good HE program6 and HE posters should be part of the evaluation in any health setting.

               A Health Education poster is no ordinary piece of writing. It is implicit in the principle of an effective HE poster that certain criteria be observed before its display. The health message in a poster should be written, revised, pilot-tested and finally corrected before being put on display.7


I would like to thank Professor Hassan Bella for initiating this study and for his assistance and support. Also my thanks and appreciation to Dr. Hafiz Omer who helped with the analysis. I am thankful to the Director of the Al-Khobar Government Health Center and the Directors of the other health centers involved for facilitating this study.


1.     World Health Organization. Primary health care concepts and challenges in a changing world; Alma-Atarevisited. Division of Analysis, Research and Assessment Current Congress, ARA paper No. 7, WHO 1996; 38.

2.     Loiselle CG, Delvigne-Jean Y. Health Education programs: Elements of  critiquing. Can Nurse 1998;  94:42-6.

3.     Popham WJ. A strategy to encourage the evaluation of health education  programs. Eval Health Prof 1993; 16: 379-84.

4.     Van Driel WG, Keijsers JF. An instrument for reviewing the effectiveness of health education and health promotion. Patient Educ Couns 1997; 30: 7-17.

5.     Rankin SH, Stallings KD. Evaluation:  determining and documenting patient learning outcomes. In: Patient Education:  Issues, Principles and Practices. 3rd ed. Philadelphia; Lippincott Raven Publishers; 1996, 220.

6.     Scotney N. Evaluation of Health Education Methods: In Health Education Rural Health Series; African Medical and Research Foundation; 1983, p. 129.

7.     Sebai ZA, Bella HA. Health Education Methods: In Health Education: Principles and Methods. (Arabic), 1st ed. Al-Kheraiji Publishing, 1996; 119-20.




Eissa I. Aleissa, SBFM, Al-Rabwa Center for Postgraduate Studies in Family Medicine, Ministry of Health, Riyadh, Saudi Arabia

هدف الدراسة:الهدف الأول: تقدير مدى انتشار السلوكيات ذات العلاقة بالصحة  مثل تدخين السجائر، تعاطي الكحوليات، استعمال الأدوية المحظورة، الاتصال الجنسي اللا شرعي، قيادة السيارة تحت السن القانوني عشر، ممارسة الرياضة بين المراهقين السعوديين في مدينة الرياض. الهدف الثاني: دراسة العلاقة بين تدخين السجائر والسلوكيات أعلاه.  

طريقة الدراسة:دراسة مقطعية في مدينة الرياض حيث تم اختيار 1473 ]852 ذكر ( 57.8%) و 621 أنثى (42.2%)[مراهق سعودي أعمارهم 11 إلى 21 سنة زاروا المراكز الصحية العشرة المختارة بطريقة عشوائية وطلب منهم إكمال استبيان مكون من 23 سؤال. جزء من هذه الاستبيان  استعمل لقياس مدى انتشار بعض السلوكيات عند المراهقين. تم جمع هذه الاستبيانات في غضون شهر من 15 مايو 1998 إلى 15 يونيو 1998 .  

نتائج الدراسة: أظهرت الدراسة أن 12.7% من المراهقين في العينة مدخنون وأن الذكور يدخنون أكثر من الإناث ( 19.0% مقابل 4.0%) ، المدخنون الذكور يمارسون الرياضة بدرجة أقل من غير المدخنين وذلك بدلالة إحصائية ( معامل< 0.025). 4.5% فقط من العينة تعاطوا الكحول، 6.4% ذكروا استعمال الأدوية المحظورة و 8.0% مارسوا الجنس الغير شرعي. كما تبين الدراسة وجود علاقة ذات دلالة إحصائية بين التدخين وممارسة السلوكيات أعلاه. كذلك وجد بأن 41.1% من الذكور تحت سن 18 يقود السيارة و 45.1% من الذين يقودون السيارة من العينة تعرضوا إلى حادث سيارة.

الاستنتاجات والتوصيات:ن انتشار بعض السلوكيات السيئة ذات العلاقة بالصحة في مدينة الرياض هي أقل من مثيلاتها في الدول الغربية. كما أن التدخين يعتبر البوابة لممارسة السلوكيات السلبية الأخرى. وتبين الدراسة أيضاً شدة الحاجة لتطبيق بعض برامج مكافحة التدخين مثل منع التجارة به واستعماله في الأماكن العامة لتقليل انتشاره. يوصى بتطبيق أنظمة المروربشكل صارم.

الكلمات المرجعية :المراهقين السعوديين ، السلوكيات ، المراكز الصحية .

Background: The primary aim of the study was to calculate the prevalence of some of the health risk associated behavior like insufficient amount of  exercise, cigarette smoking, alcohol intake, illicit drug use, driving below age of 18, and illegal sexual practices among the Saudi adolescents in Riyadh city. The second was to study the association between cigarette smoking and the above behaviors.

Material and Methods: It was a cross-sectional survey with 1473 Saudi adolescents, 852 males (57.8%) and 621 females (42.2%) aged 11 to 21 years attending the selected 10 Primary Health Care Centers (PHCCs) were invited to complete a 23-item questionnaire. Part of the questionnaire was used to measure the frequency of

Correspondence to:

Dr. Eissa I. Aleissa, P.O. Box 15945, Riyadh 11454, Saudi Arabia

some adolescent behavior. These questionnaires were collected within a period of one month from 15 May to 15 June 1998. The PHCCs were selected randomly in Riyadh city.

Results: The prevalence of cigarette smoking was 12.7%, males smoking more than females (19.0% vs. 4.0%); male smokers exercised significantly less than nonsmokers (p<0.025). Only 4.5% of the sample reported alcohol use, 6.4% reported illicit drug use, and 8.0% reported illegal sexual practice. There is a statistically significant association between smoking and other risk behavior. It was found that 41.1% of males below the age of 18 drive a car, and 45.1% of the study sample that drive had a car accident.

Conclusions: The prevalence of illicit drug use, alcohol intake, and illegal sex in Riyadh city is much less than in the west. Cigarette smoking is an antecedent to more negative behavior. Antismoking programs including the prevention of the sale and use of cigarettes in public places are needed to decrease its prevalence. The application of firm traffic laws is also essential.

Key Words: Saudi adolescents, primary health care centers, behaviours.



                Adolescence is a transitional period from childhood to adulthood characterized by rapid physical, social, mental, and The definition of this period differs from one country to another. The American Medical Association and the American Academy of Pediatrics define adolescents as persons between 11 to 21 years of age.2 The World Health Organization (WHO) considers 10-19 years as the period of adolescence,3 while some literature defines adolescents as those aged between 13-19 years.4

                Estimates suggest that approximately 30% of the world's population is currently between 10 and 24 years of age,3 three-quarters of whom are in developing countries.5,6 About 25% of the population in the Kingdom of Saudi Arabia is aged between 11-21 years.7

                Most causes of mortality and morbidity in adolescents, such as car accidents, alcohol use, drug addiction and cigarette smoking can be prevented by simple preventive health measures including health education and counseling, the cornerstone of medical care for adolescents.8-10

                Saudi society is different from western societies in many respects. It is a conservative society with a clear Islamic culture. The pattern of adolescent problems is expected to be different from that in the west. For example, teenage pregnancy is considered an adolescent problem in the west since most are illegitimate and may end in abortion with its attendant medico- legal complications, as well as social and financial problems.11,12

                Few local studies have been done on adolescent medicine and health problems, and the prevalence of the associated health risk factors. It is hoped that this study will be the first of many further studies. 

                The aims of this study are  (1) to calculate the prevalence of some health-related behaviors including amount of exercise, cigarette smoking, drug abuse, alcohol intake, driving below age of 18, and illegal sexual behavior among the Saudi adolescents in Riyadhcity, and (2) to study the association between cigarette smoking and the above practices.



Riyadh city, the capital of Saudi Arabia has a population of 3.1 millions, 69% of which are Saudis.13 It is served by 58 primary health care centers. Each primary care center is divided into two; one half served by male doctors for male patients, the other by female doctors for female patients.

Study Design       

This was a cross sectional survey.

Subjects [Study population] and Setting

The study population consisted of Saudi adolescents of both sexes, aged between 11 and 21 years who attended 10 PHCCs over a period of one month from 15 May to 15 June 1998. The ten centers in Riyadh city were randomly selected.

Source of Data and Data Collection

A two-page questionnaire was designed. A pilot study was done in the Al-Rabwa Health Center, where 50 questionnaires were distributed to 35 males and 15 female Saudi adolescents. Some changes were made accordingly.

                A letter of authorization was obtained from the Department of Health Affairs of the Riyadh Region, Department of Primary Health Care to perform the study in the PHCCs. Each questionnaire had a brief in­tro­duction stating the aim of the survey, and asking for the subjects' cooperation. It also indicated that the information given would be treated with extreme confidentiality.

                The questionnaires were distributed to the selected centers. Each doctor in the selected PHCCs was given the questionnaires and asked to invite the Saudi adolescents attending his clinic to participate in the study during the study period. The purpose of the research was fully explained to the doctors in the chosen PHCCs. The doctors were informed to write “subject refused” on the questionnaire when the subject refused to fill in the second part (see below).

                The questionnaires consisted of 23 items. It was divided into two parts to assure the subject of his/her security in disclosing sensitive information. The first part, written in English, was to be filled in by the doctor. This had seven items on age, sex, height, weight, diagnosis of current problem, and any chronic illnesses. The second part in Arabic was to be filled by the subject in the clinic. It had 16 items on marital status, number of children, pregnancies, abortions, level of education, occupation, whether parents were alive, whom he/she lived with. The remaining items were used to measure health-risk associated behavior, including ex­ercise or the lack of it, such as swimming, walking, playing football, etc., defined as at least three hours weekly; cigarette smoking; alcohol and drug intake; sexual activity; driving below the age of 18, etc. These items were close-ended questions with Yes or No answers.

                There were no questions on income, family size, or ethnic or social classification. Also, no questions were asked on the type of the drug used, frequency of the use of alcohol or when the habit of smoking began. There were no questions either on the num­ber of sexual partners with regard to those who were sexually active.

                The study sample consisted of 1473 Saudi adolescents, 852 males (57.8%) and 621 females (42.2%). Generally, both of the questionnaires were completed. However, a small percentage, especially among the younger and female adolescents, did not respond to the final items.

Data analysis and statistical methods

The data was entered in the computer using program DATASTAR and was analyzed with the SYSTAT program. The data entered were counterchecked. Frequency distributions and cross tabulations of the variables were done. Further, the analysis of the association between cigarette smoking and other negative behavior was done using Chi square test.


Socio-demographic data

                Table 1 shows the age and sex distri­bution of the study subjects. It indicates that two thirds of the sample was 16 years old and above. Subjects aged 19-21 years old constitute 35.8%, 44.7% of the subjects were 15-18 years old, and 19.6% were 11-14 years old. The mean age of the study sample was 17.1 + 2.7.

Table 1: The age and sex distribution of study sample (Saudi adolescents) in Riyadh city, May 1998


Male n=852

Female n=621



No. (%)

No. (%)

No. (%)


14 (1.6)

19 (3.0)

    33 (2.2)


31 (3.6)

36 (5.8)

   67 (4.5)


41 (4.8)

38 (6.1)

  79 (5.4)


61 (7.1)

48 (7.7)

109 (7.4)


74 (8.7)

52 (8.4)

126 (8.6)


84 (9.9)

  63 (10.1)

147 (10.0)


121 (14.2)

57 (9.2)

178 (12.1)


129 (15.1)

  78 (12.6)

207 (14.1)


112 (13.1)

  75 (12.1)

187 (12.7)


98 (11.5)

  92 (14.8)

190 (12.9)


87 (10.2)

  63 (10.1)

150 (10.2)





Health risk associated behaviors among Saudi adolescents

                Table 2 displays the practice of some health-related behavior among Saudi adolescents. It was found that male adolescents tend to exercise more often than females, 643 (75.5%) vs. 169 (27.2%). The overall prevalence of cigarette smoking is 12.7% (n=187) among the study sample, the habit being more common in males (19.0%) than females (4.0%). Of the adolescents aged less than 14, 1.4% (n= 4) reported smoking cigarettes. It was also found that male smokers exercised significantly less than non-smokers. The percentages were 68.5% vs. 77.4%, respectively (c2 = 6.44, dƒ= 1, P < 0.025).

                Only 52 (6.1%) of the males and 14 (2.3%) of the females reported that they had used alcohol (at least once). Despite this low prevalence of alcohol use, i.e. 4.5% in the whole sample, it was found that there was a strong association between alcohol intake and cigarette smoking in both sexes. Of the males, 23.5% of the smokers took alcohol whereas only 2.0% of the non-smokers did (c2 = 100.5, dƒ = 1, P < 0.001). In female adolescents the percentages were 35.3% vs. 1.4% (c2 = 47.7, dƒ=1, P < 0.001).

                The prevalence of drug use in this survey was 6.4%  (10.6% and 0.8% in male and female subjects, respectively). It was also found that more smokers used illicit drugs than non-smokers. Of the males, 9.3% of smokers used drugs against only 1.1% of non-smokers, but the association was not statistically significant (c2 =0.123, dƒ = 1, P=0.72). The percentages were 8.0 % vs. 0.5% among the female adolescents, and the association between the cigarette smoking and drug use among females was statisti­cally significant (c2 =9.15, dƒ=1, P < 0.01).

                The prevalence of illegal sexual activity among adolescents in this survey was 8.0%; it was more among males than females (11.9% vs. 2.7%). It was also found that there was statistically significant association between smoking and illegal sexual activity. Of the male smokers, 33.3% had been sexually active as against 6.9% of non-smokers (c2 = 81.6, dƒ = 1, p < 0.001). Also, 40% of the female smokers had been sexually active as against only 1.2% of the female non-smokers (c2 = 107.1, dƒ=1, P<0.001).


Car driving

In response to the question: Do you drive a car? 526 (35.7%) answered yes  (i.e. 60.4% of males and 1.8% of females have driven a car). Of those who drove, 237 (45.1%) had had a car accident. Of these 44.1% were males and 90.9% females. The number of male subjects below the age of 18 years who drove was 175, making 41.1% of the total number at this age.


Adolescents and exercise

In this survey, only 55.1% of the whole sample took any exercise. It was found that male adolescents did more exercise than females. Most exercise is done in groups e.g. football games; unlike female adoles­cents, males are allowed to practice these sports outside their homes. So, the only exercise that the girls have is done indoors (mainly at home) which is rather irregular. It was reported that 71% of the adolescents in  the USA exercised regularly.14 Low physi­cal activity was found to be associated with other risk behaviors in teenagers.15 This study shows that those who smoke ciga­rettes take less exercise.

Risk behaviors among Saudi adolescents

As we know, the most common causes of morbidity among adolescents are behavio­ral,16 and most risky behavior pat­terns start in adolescence. For example, it has been found that over three fourths of smokers begin to smoke as teenagers.17,18

                Cigarette smoking is a bad habit. Its prevalence rate in this study among Saudi male adolescents attending the PHCCs was 19.0%. This is higher than that reported by Jarallah and his colleagues who found that 13.2% of Saudi male adolescents aged 12-19 years old smoked.19 Other studies have reported that about 12% of Saudi adoles­cents in intermediate and high schools are current smokers.20 Additional studies have estimated that the prevalence rate of cigarette smoking among Saudi secondary school boys in Riyadh City was 21.8%.21 The prevalence of smoking among female adolescents was less; among the 19-21 year-olds in this survey it was 7.4%. One study estimated its prevalence as between 8.6% and 11.6% among female university students in Riyadh City.22 A comparison with studies from other countries showed that in Egypt, the percentages are 7% and 0.2% among male and female adolescents, respectively.3 In developed countries it ranges from 20% to 42% with equal sex ratio.14,17,18,23-25

                The prevalence of other risky behavior mentioned in this study is less than that of western countries. In this study, 4.5% of the study sample reported alcohol intake, while in the UK, a survey showed that over two thirds of 12-17 years old drank alcohol.26 In the USA, 81% of high school students drank alcohol.23,27 In other developed countries, its prevalence ranged from 40 to 80%.28 There was no way to make an adequate compari­son between the prevalence of illicit sexual activity of 8.0% among Saudi adolescents, considerably less than its prevalence in the west.14,16,29

                The prevalence of drug use among males in this survey is 10.6%, but the types of drugs used were not identified. One of the local studies showed that the prevalence rate of volatile substance abuse among Saudi male students was 5.3% and it was signifi­cantly associated with cigarette smoking.30 A study, done by Bewley and his colleagues in the UK, found that only 6% of British adolescents used drugs. This is less than our figure.31 In the USA, it is more prevalent, since over 30% of high school students report using marijuana.27,28,32,33 

                This risky behavior increased in pre­valence with the increasing ages of the subjects because of the difficulty of control. Why is this risky behavior more common among males than females? In western countries adolescent girls are freer to travel abroad with little supervision from parents and society, unlike Saudi girls who are not. Besides, the risky behavior is less common in Saudi society than in western societies, because of: (1) Islamic laws that prevent the use of alcohol and prohibit the sex trade, (2) the presence of the religious police "an old organization where civilians are responsible for the supervision of people and punish­ment of anybody who does not follow Islamic rules in the society of Saudi Arabia" and (3) the strict adherence to the rules of Islam in the Kingdom.

                Bad habits lead to more bad habits because of peer pressure. In this study, a strong association was found between alcohol, illicit sex, illicit drug use and cigarette smoking. The same findings also generally resulted from previous studies.28

Car accidents among adolescents

In Saudi Arabia, females are not allowed to drive but some drive in the villages and the desert. Most of those who drove have had car accidents. Motor vehicle accidents constitute a large proportion of the deaths among US adolescents. It is the leading cause of death in this age group.34 This study showed 45.1% of males who drive have had an accident that ended in injury. More effort, therefore, is needed to reduce the prevalence of these accidents.


From this study, it is concluded that the prevalence of illicit drug use, alcohol intake, and illegal sexual activity in Riyadh, Saudi Arabia is much less than in most countries of the world. It has also been found that illegitimate pregnancies are rare. This is attributed to the adherence of Islamic rules and the educational system that emphasizes religious teaching. Religion is, therefore, an important factor that should be taken in consideration in any health education program.

                It is vital to emphasize the importance of school health clinics that provide a variety of health services such as counseling, health education, immunization, and other preven­tive measures that help reduce adolescent morbidity and mortality.

                Antismoking programs should be estab­lished, including the prohibition of the sale and use of cigarettes in public places, alongwith application of firm traffic laws, including those forbidding adolescents aged less than 18 years from driving.


I would thank all the doctors working in the selected PHCC for their cooperation. Also, I would thank Dr. Lubna Alansari for her help in critical reading and advice.


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