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Background Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. Methods Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. Results Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. Conclusion Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.

Diabetes mellitus in all its forms has been rapidly increasing worldwide, especially in the Eastern Mediterranean Region.This national study aimed to assess the prevalence and clinical aspects of diabetes mellitus in Lebanon with special focus on type 1 (T1DM).A national multistage, random household sample survey was conducted, using face-to-face interviews with 1 questionnaire per household. A total of 4500 households were selected from all areas based on a pre-existing sampling frame of the Lebanese population.The prevalence of previously diagnosed diabetes mellitus in the surveyed population of 17 832 persons (mean age ~36 years) was 7.95%. The prevalence of T1DM in particular was estimated at 0.1%, or almost 1% of all detected cases of diabetes mellitus. Most persons with diabetes mellitus reported obtaining their usual care from endocrinologists rather than primary healthcare physicians. Delayed performance of haemoglobin A1c test was reported in 25% of 1418 patients. Hypoglycaemic episodes recently occurred in 30% of patients; of whom, at least one third required medical attention, including hospital admission. Diagnosed complications were reported in 22% of cases, with retinopathy being the most common.Prevalence of T1DM in this population was lower than international estimates. Diabetes mellitus management appears to be deficient, based on delays in standard control testing, hypoglycaemic episodes and diabetes mellitus-related complications. Coordination of diabetic care management should be devolved to primary healthcare physicians, who can keep track of the need for referral to various types of diabetes mellitus care.انتشار داء السُّكَّرِيّ في لبنان وخصائصه: مسح وطني.إبراهيم بوعرم، سليم أديب.يتزايد انتشار داء السُّكَّرِيّ بكل صوره سريعاً في جميع أنحاء العالم، خاصةً في إقليم شرق المتوسط.تمثَّلَ الهدف من هذه الدراسة الوطنية في تقييم انتشار داء السُّكَّرِيّ وأعراضه السريرية في لبنان، مع التركيز خاصةً على النمط 1 من داء السُّكَّريّ.أُجري مسح وطني متعدد المراحل على عينة عشوائية من الأسر من خلال عقد مقابلات وجهاً لوجه باستخدام استبيان واحد فقط لكل أسرة. وبلغ إجمالي عدد الأسر المُختارة 4500 أسرةٍ من جميع المناطق، استناداً إلى إطار موجود سلفاً لأخذ العينات من السكان اللبنانيين.بلغت نسبة انتشار داء السُّكَّرِيّ الذي شُخِّصَ سابقاً في السكان الذين شملهم المسح والبالغ عددهم 17832 شخصاً (متوسط العمر هو 36 عاماً تقريباً) 7.95٪. وقُدر انتشار النمط 1 من داء السُّكَّريّ بحوالي 0.1٪، أو 1٪ تقريباً من جميع الحالات التي اكتُشفت إصابتها بداء السُكَّريّ. وأفاد معظم المصابين بداء السُكَّريّ بأنهم يحصلون على خدمات الرعاية المعتادة من أطباء الغدد الصماء، لا من أطباء الرعاية الصحية الأولية. وأُبلغ عن تدنِّ أداء اختبار HbA1C في 25٪ من 1418 مريضاً. وحدثت مؤخراً نوبات انخفاض السكر في الدَّم لحوالي 30٪ من المرضى؛ واحتاج ثلثهم على الأقل رعاية طبية استلزمت دخول المستشفى. وأُبلغ عن وجود مضاعفات لدى 22٪ من الحالات، وكان أكثرها شيوعاً هو اعْتِلال الشَّبَكِيَّةِ.كان انتشار النمط 1 من داء السُّكَّريّ بين هذه الفئة السكانية أقل من التقديرات الدولية. ويبدو أن هناك قصوراً في علاج داء السُّكَّريّ بسبب التأخر فيإجراء الفحوصات الدورية، ونوبات نقص السكر في الدم، والمضاعفات المرتبطة بداء السُّكَّريّ. وينبغي أن تؤول مسؤولية التنسيق بشأن التدبير العلاجي لداء السُّكَّريّ إلى أطباء الرعاية الصحية الأولية، الذين يمكنهم متابعة الحاجة بالإضافة الإحالة للحصول على أنواع مختلفة من خدمات الرعاية الصحية لداء السُّكَّريّ.Prévalence et caractéristiques cliniques du diabète au Liban : enquête nationale.Le nombre des cas du diabète, sous toutes ses formes, a augmenté rapidement dans le monde entier, et en particulier dans la Région de la Méditerranée orientale.Cette enquête nationale visait à évaluer la prévalence et les caractéristiques cliniques du diabète sucré au Liban, en mettant l’accent sur le diabète de type 1.Une enquête nationale par sondage à plusieurs degrés a été menée auprès des ménages sélectionnés de manière aléatoire utilisant des entretiens en présentiel et plus particulièrement. Au total, 4 500 ménages ont été sélectionnés dans toutes les régions à partir d’un cadre d’echantillonnage de la population libanaise.La prévalence d’un diabète déjà diagnostiqué parmi les 17 832 personnes interrogées (âge moyen de 36 ans) était de 7,95 %. La prévalence du diabète de type 1 en particulier a été estimée à 0,1 %, soit près de 1 % de tous les cas de diabète détectés. La plupart des personnes souffrant de diabète ont indiqué être habituellement suivies par un endocrinologue plutôt que par un médecin de soins de santé primaires. Un retard dans la réalisation du test d’hémoglobine A1c a été signalé chez 25 % des 1 418 patients. Des épisodes d’hypoglycémie sont récemment survenus chez 30 % des patients, parmi lesquels un tiers au moins nécessitaient des soins médicaux, y compris une admission à l’hôpital. Des complications ont été diagnostiquées dans 22 % des cas, la rétinopathie étant la plus courante.La prévalence du diabète de type 1 au sein de cette population était inférieure aux estimations internationales. La prise en charge du diabète semble être insuffisante en raison des retards concernant la réalisation des tests de suivi ainsi que des épisodes d’hypoglycémie et des complications liées à la maladie. La coordination de la gestion des soins aux diabétiques devrait être confiée aux médecins de soins de santé primaires, qui peuvent répondre aux besoins des patients en les orientant vers les différents types de soins.

The main aim of this national survey was to identify the levels of colorectal cancer screening knowledge and uptake in Lebanon.A total of 1200 participants were enrolled in this cross-sectional household survey targeting the Lebanese population aged 50 years and above. The sample was recruited using a two-stage stratified cluster sampling approach.Of the total sample, 38.3% knew about any screening test for colorectal cancer but only 7.5% had ever used any. Thirty-nine percent of the participants rated their risk of getting colorectal cancer as very low or low, and only 53.5% were confident in their ability to undertake a screening test. Almost all participants agreed that medical advice and test reimbursement would encourage them to do a screening test. At the multivariate analysis level, hearing of an awareness campaign in the last two years showed the strongest association with the knowledge of a colorectal cancer screening test with an estimated ORThis national study highlights an alarming lack of uptake and low levels of knowledge of colorectal cancer screening tests even though it is among the most prevalent cancers in Lebanon and its prevalence has been continuously increasing in the past years. The evidence suggests that people who had an experience with colorectal cancer diagnostic tests, either personally or through a family member, and those who have heard of an awareness campaign about colorectal cancer in the last two years are more likely to know its screening tests.Colorectal cancer screening knowledge and uptake in Lebanon are limited and justify the need for public health interventions. This study gives evidence that awareness campaigns, coupled with the involvement of medical providers and the reimbursement of screening test fees, would alleviate the burden of colorectal cancer in Lebanon.

This Letter to the Editor aims to reflect on the current challenges to increase the coverage of COVID-19 vaccination in the fragile and conflict-affected setting of Lebanon, which is currently experiencing one of the biggest economic crises globally as well as a recent surge in COVID-19 cases. Addressing the supply- and demand-related factors affecting vaccination would increase COVID-19 vaccine coverage and prevent the complete collapse of an already overwhelmed Lebanese health care system.

ObjectivesThis study aimed to assess the capacities and governance of Lebanon’s health system throughout the response to the COVID-19 pandemic until August 2020.DesignA qualitative study based on semi-structured interviews.SettingLebanon, February–August 2020.ParticipantsSelected participants were directly or indirectly involved in the national or organisational response to the COVID-19 pandemic in Lebanon.ResultsA total of 41 participants were included in the study. ‘Hardware’ capacities of the system were found to be responsive yet deeply influenced by the challenging national context. The health workforce showed high levels of resilience, despite the shortage of medical staff and gaps in training at the early stages of the pandemic. The system infrastructure, medical supplies and testing capacities were sufficient, but the reluctance of the private sector in care provision and gaps in reimbursement of COVID-19 care by many health funding schemes were the main concerns. Moreover, the public health surveillance system was overwhelmed a few months after the start of the pandemic. As for the system ‘software’, there were attempts for a participatory governance mechanism, but the actual decision-making process was challenging with limited cooperation and strategic vision, resulting in decreased trust and increased confusion among communities. Moreover, the power imbalance between health actors and other stakeholders affected decision-making dynamics and the uptake of scientific evidence in policy-making.ConclusionsInterventions adopting a centralised and reactive approach were prominent in Lebanon’s response to the COVID-19 pandemic. Better public governance and different reforms are needed to strengthen the health system preparedness and capacities to face future health security threats.

Purpose This study aims to evaluate trends in the increasing costs of oncology drugs procured by the Lebanese Ministry of Public Health (MOPH) between 2014 and 2016 and to assess the impact of the introduction in mid-2015 of new immunotherapy drugs for the treatment of lung cancer on the overall and specific costs of that treatment. Methods A secondary analysis of data from the MOPH Cancer Drug Scientific Committee data base was conducted using a total of 18,133 cancer files between 2014 and 2016. Results Over the 3-year period, about $140 million (USD) was spent on cancer drugs by the MOPH free cancer drug dispensing program. The expenditures increased by 27% after immunotherapy was phased in. The average cost of drugs per patient per year measured across all cancer types increased from $7,000 in 2014 to $8,400 in 2016. Trastuzumab, approved for treating human epidermal growth factor receptor 2–positive breast cancer ranked first in total expenditures for 2014-2015. By 2016, two new immunotherapy drugs had topped the list: pembrolizumab ranked first and nivolumab ranked third, representing 64% of the total cost of lung cancer treatment and approximately 19% of the total yearly budget; beneficiaries represented only 3% of all patients. Conclusion This update documents the increasing financial impact of newer cancer drugs on the procurement process in the middle-income country of Lebanon. The trend is aligned with the financial burden of cancer drugs worldwide, which calls for a collaborative global response to this crisis.

Waterpipe tobacco smoking (WTS) has become a serious public health threat in the Middle East and beyond. To estimate the prevalence rates of cigarette and WTS among Lebanese women and describe characteristics associated with each behavior. Secondary analysis of women's health data obtained in a national survey in 2010. Of 2,255 selected women, 78 percent reported no or past long-term WTS. Among the 12 percent of regular waterpipe smokers, 40 percent were light users (mean three waterpipe heads weekly), while 60 percent were heavy users (mean of 11 heads per week). About 70 percent were never or past long-term cigarette smokers. Younger age, location within Greater Beirut (GB) and having professional employment were significantly associated with use of WTS. Older age, GB location, lower education, and ever-married were significantly associated with cigarette smoking. WTS is becoming a socially normative behavior among empowered professional women, who can spare the time and expense to engage in this behavior in easily accessible cafés, which prohibit cigarette smoking. Government, media, and NGO campaigns against smoking should target waterpipe use, not only in Lebanon but also across the Arab world and among Arab communities in the Diaspora with messages different from anti-cigarette campaigns.

Dementia characterized by gradual cognitive decline is an increasing public health problem due to population ageing. This study aims at assessing the prevalence and determinants of cognitive decline among Lebanese older adults.Secondary analysis of data from a cross-sectional sample of 502 elders from two Lebanese governorates was conducted. Cognitive decline was assessed using the Arabic Version of 16-item Informant Questionnaire on Cognitive Decline for the older adults (A-IQCODE 16). A multivariable logistic regression model assessed the associations of socio-demographic, clinical and behavioral factors with the presence of cognitive decline.Almost one of six Lebanese older adults (14.8%) scored below 3.34. Higher odds of cognitive decline were associated with higher age, being female, having heart disease and suffering from depression. Pack-years of cigarette smoking showed a protective effect and this relationship seems to be only statistically significant among older adults aged more than 75 years.Screening programs of cardiovascular risk factors and early detection of depression are 'best buy' public health interventions that could prevent cognitive decline among Lebanese older adults. Differential survival bias seems the reasonable explanation for the protective effect of smoking that is not the common finding from the literature.

Advances in population health outcomes risk being slowed—and potentially reversed—by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.

Country-specific hip fracture incidence rates (IRs) and longevity allow the Fracture Risk Assessment Tool (FRAX) to be adapted to individual countries. Secular trends can affect tool calibration. Data on hip fracture IRs in the Middle East is scarce, and long-term secular trend studies are nonexistent. Using the Ministry of Public Health hip fracture registry, we calculated age- and sex-specific hip fracture IRs in Lebanon, from 2006 to 2017, among individuals aged ≥50 years. We used Kendall's tau-b (τb) test to determine the correlation between time and hip fracture IRs, and calculated both the annual % change in IRs and the % change in IR compared to the baseline period (2006 to 2008). The registry recorded 6985 hip fractures, 74% at the femoral neck, 23% intertrochanteric, and 3% subtrochanteric. Men constituted 32% of the population, and were significantly younger than women (76.5 ± 11.0 years versus 77.7 ± 10.3 years; p < 0.001). Annual overall IRs, per 100,000, ranged from 126.6 in 2014 to 213.2 in 2017 in women, and 61.4 in 2015 to 111.7 in 2017 in men. The average women to men IR ratio was 1.8 (range, 1.5 to 2.1). IRs steadily increased with age, and IR ratios increased in parallel in both sexes, with a steeper and earlier rise (by 5 years) in women. Data showed a consistent decline in hip fracture IRs starting in 2006 in women, and in 2009 in men. There was a significant negative correlation between time (2006 to 2014) and hip fracture IRs in women (τb = -0.611, p = 0.022) but not in men (τb = -0.444, p = 0.095). The steady decrease in IRs reversed after 2015 in both sexes. This long-term data on secular trends in the Middle East is novel and consistent with worldwide changes in hip fracture rates. The impact of such changes on national FRAX-derived estimates is unclear, should be assessed, and may necessitate an update in the FRAX Lebanon calculator. © 2019 American Society for Bone and Mineral Research.

Eating disorders (ED) are prevalent mental illnesses composed mainly of anorexia nervosa, bulimia nervosa and binge eating disorders. Anxiety disorders are another set of mental illnesses, with phobic disorder (PD) being the most prevalent disorder. ED and PD are highly comorbid. The aim of this study is to assess, in 131 individuals attending an outpatient clinic for different health issues, the level of fear related to situations generating avoidance such as in social anxiety and specific phobias according to the fear questionnaire (FQ), the level of disgust according to the disgust scale (DS-R) and the vulnerability towards ED according to the SCOFF scale to demonstrate that high levels of both fear and disgust increase the vulnerability towards ED. The study demonstrated that the level of disgust increased when fear increases (r = 0.377, p 0.001 for the first part of the FQ; r = 0.225, p = 0.01 for the second part of the FQ). Moreover, individuals with vulnerability towards having an ED presented a higher level of disgust than individuals without this vulnerability (p = 0.009). Furthermore, individuals with vulnerability towards ED have a higher level of anxiety related to PD subtypes (p = 0.008 for agoraphobia; p = 0.001 for injection/blood phobia) as well as to social anxiety (p = 0.01), independently from having a depressive or another anxiety disorder. In the multivariate analysis, a history of psychiatric consultation has been the only significantly different parameter between individuals with or without vulnerability towards ED (p = 0.0439). Accordingly, fear and disgust are negative emotions that seem to be clinically associated which better explains the comorbidity of ED with PD. LEVEL OF EVIDENCE: Level III. Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Emotional intelligence (EI) is known to be a risk factor for several types of addiction. The purpose of this study was to investigate, in a cross-sectional design, the presence of a relationship between the level of EI and nicotine dependence in a sample of Lebanese adults. A self-administered questionnaire was used to determine the sociodemographic characteristics, the level of nicotine dependence, and the level of EI in a sample of 142 Lebanese participants from the community. The sample was 51.4% women, with a mean age of 33.9 years. There was no difference in EI level between smokers and non-smokers (p = 0.66), and there were no associations between EI level and the level of nicotine dependence (p = 0.59). However, EI was positively correlated with age (p = 0.023). Due to the fact that smokers have been dependent on nicotine for many years and that EI is known to increase with age, findings suggest that low EI may be a risk factor for initiation, rather than maintenance, of nicotine dependence.

Evaluation of bone marrow involvement (BMI) is paramount in diffuse large B-cell lymphoma (DLBCL) for prognostic and therapeutic reasons. PET/CT scanner (PET) is now a routine examination for the staging of DLBCL with prognostic and therapeutic implications. This study evaluates the role of PET for detecting marrow involvement compared to bone marrow biopsy (BMB). This monocentric study included 54 patients diagnosed with DLBCL between 2009 and 2013 and who had FDG PET/CT in a pre-treatment setting. A correlation analysis of the detection of BMI by PET and BMB was performed. A prognostic evaluation of BMI by BMB and/or PET/CT and correlation with an overall 2-year survival were analyzed. PET was more sensitive for the detection of BMI than BMB (92.3% vs. 38.5%). It can be considered a discriminatory Pre-BMB test with a negative predictive value of 97.6%. In addition, BMI by PET had a prognostic value with strong correlation with progression-free survival (PFS) (HR = 3.81; p = 0.013) and overall survival (OS) (HR = 4.12; p = 0.03) while the BMB had not. PET shows superior performance to the BMB for the detection of marrow involvement in DLBCL. It may be considered as the first line examination of bone marrow instead of the biopsy.

Background Cervical cancer is a very common malignancy amongst women worldwide. Pap smear is an effective and inexpensive screening test in asymptomatic women. The aim of this paper was to assess the prevalence of Pap smear screening for cervical cancer among Lebanese women and to determine associated sociodemographic and psychosocial characteristics. Methods This national survey included 2255 women, selected by multi-stage random cluster sampling across Lebanon. A questionnaire about practices and perceptions related to cervical cancer screening was developed based on the “Health Belief Model”. Results The weighted national prevalence of “ever-use” of the Pap smear for screening purposes was 35%. Most important determinants of screening behavior were: residence within Greater Beirut, higher socio-economic status and educational attainment, marriage status, presence of a health coverage, awareness of Pap smear usefulness, knowing someone who had already done it, and a balance between perceived benefits and perceived barriers to Pap smear screening. Conclusion Regular information campaigns regarding the availability and effectiveness of the test should be devised, targeting in priority the sexually vulnerable women in Lebanon. Moreover, healthcare providers should be encouraged to discuss with their patients the opportunity of obtaining a Pap smear.

e18917Background: Lebanon is facing a mounting burden from cancer with heavy financial consequences on the healthcare system. This study aims to evaluate increasing trends in the cost of oncology d...