Determinants of treatment of mental disorders in Lebanon: barriers to treatment and changing patterns of service use.

AIMS: To investigate for the first time the determinants and barriers of seeking help for mental disorders in the Arab world based on a national study: Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (L.E.B.A.N.O.N). METHODS: A nationally representative (n = 2857) and multistage clustered area probability household sample of adults ≥18 years and older was assessed for lifetime and 12 months mental disorders using the Composite International Diagnostic Interview. In addition, detailed information was obtained on help- seeking behaviour and barriers to treatment. RESULTS: In total, 19.7% of the Lebanese with mental disorders sought any type of treatment: 91% of those who sought treatment did so within the health sector. Severity and perceived severity of disorders predicted seeking help, the highest being for panic disorder. The greatest barrier to seek help was low perceived need for treatment (73.9%). Stigma was reported to be a factor only in 5.9% of those who thought about seeking treatment. Eighty per cent of the Lebanese reported they would not be embarrassed if friends knew they were seeking help from a professional. CONCLUSIONS: A small fraction of Lebanese seek help for their mental health problems: female gender, higher education and income are predictors of positive attitudes to help seeking. Severity and recognition of disorders, more than stigma, to get treatment seem to be the most important factors in determining help seeking. The findings underscore the importance of helping the public recognise mental health disorders.

The Use of Complementary and Alternative Medicine among Lebanese Adults: Results from a National Survey.

Objective. To examine the prevalence and correlates of Complementary and Alternative Medicine (CAM) use in Lebanon. Methods. A cross-sectional survey was conducted through face to face interviews on a nationally representative sample of 1,475 Lebanese adults. The survey questionnaire explored the sociodemographic and health related characteristics as well as the types and modes of CAM use. The main outcome in this study was the use of CAM during the last 12 months. Results. Prevalence of CAM use was 29.87% with "folk herbs" being the most commonly used (75%). Two out of five CAM users indicated using it as alternative to conventional therapies and only 28.4% of users disclosed the use of CAM to their physician. CAM use was significantly associated with higher income, presence of a chronic disease, and lack of access to needed health care. Lower odds of CAM use were observed among older adults and those with a higher education level. Conclusions. This study revealed a high prevalence of CAM use in Lebanon. Health policy and decision makers need to facilitate proper regulation and integration of CAM into mainstream medicine and educate health care providers and the public alike on the safe and effective use of CAM therapies.

Association between dietary patterns and the risk of metabolic syndrome among Lebanese adults.

PURPOSE: The main objective of this study was to evaluate the association between dietary patterns and the metabolic syndrome (MetS) and its metabolic abnormalities among Lebanese adults, using data from a national nutrition survey. METHODS: A cross-sectional analysis involving adults aged ≥ 18 years (n = 323) with no prior history of chronic diseases was conducted. Participants completed a brief sociodemographic and 61-item food frequency questionnaire. Anthropometric measurements and fasting blood samples were also obtained. The International Diabetes Federation criteria were used to classify study participants with the metabolic syndrome. Dietary patterns were identified by factor analysis. Multivariate logistic regression analysis was used to evaluate the associations of extracted patterns with MetS and its metabolic abnormalities. RESULTS: Out of 323 participants, 112 (34.6%) were classified as having MetS. Three dietary patterns were identified: "Fast Food/Dessert," "Traditional Lebanese," and "High Protein." Compared with participants in the lowest quintile of the Fast Food/Dessert pattern, those in the highest quintile had significantly higher odds for MetS (OR, 3.13; 95% CI: 1.36-7.22) and hyperglycemia (OR, 3.81; 95% CI: 159-9.14). Subjects with the highest intake of the High Protein pattern had an increased risk for hypertension (OR, 2.98; 95% CI: 1.26-7.02). The Traditional Lebanese pattern showed no association with MetS or its components. CONCLUSIONS: The findings of this study demonstrate a positive association of the Fast Food/Dessert pattern with MetS and hyperglycemia among Lebanese adults. These results may guide the development of improved preventive nutrition interventions in this adult population.

Socio-economic inequality in oral healthcare coverage: results from the World Health Survey.

The objective of this study was to assess socio-economic inequality in oral healthcare coverage among adults with expressed need living in 52 countries. Data on 60,332 adults aged 18 years or older were analyzed from 52 countries participating in the 2002-2004 World Health Survey. Oral healthcare coverage was defined as the proportion of individuals who received any medical care from a dentist or other oral health specialist during a period of 12 months prior to the survey, among those who expressed any mouth and/or teeth problems during that period. In addition to assessment of the coverage across wealth quintiles in each country, a wealth-based relative index of inequality was used to measure socio-economic inequality. The index was adjusted for sex, age, marital status, education, employment, overall health status, and urban/rural residence. Pro-rich inequality in oral healthcare coverage was observed within most of the countries, although lower income countries showed greater levels of relative inequality than higher income countries. Overall, lowest coverage and highest relative inequality were found in the low-income countries. The findings of this study may inform policies for oral health at global and national levels. To achieve universal coverage in oral healthcare, relevant interventions should reach the poorest population groups.

Study of KIR genes in Lebanese patients with tuberculosis.

A total of 103 Lebanese tuberculosis (TB) cases and 38 controls without TB were studied for the killer cell immunoglobulin-like receptors (KIR) genotypic profile using polymerase chain reaction sequence-specific primers. Patients and controls were assigned to the AA, AB or BB genotypes based on their A or B haplotype genetic make-up, and KIR gene frequencies were compared. We found an increase in the KIR A haplotype in TB patients compared to controls, and only KIR 2DL3 was found to be significantly more prevalent among TB patients. This confirms the findings of another unique international study performed in the Mexican population showing a greater repertoire of inhibitory KIR genes among TB patients than controls.

Dietary exposure to essential and toxic trace elements from a Total diet study in an adult Lebanese urban population.

This study assesses, by the Total diet study approach, the adequacy of micronutrient intake (Co, Cu, Fe, Mn, Ni, Zn) and the dietary exposure of a Lebanese adult urban population to two toxic elements (Cd, Pb). The foods that made up the average 'total diet' were derived from a previous individual consumption survey. A total of 1215 individual foods were collected, prepared and cooked prior to analysis. Analytical quantification was performed using inductively coupled plasma mass spectrometry. Average daily intakes of Co (11.4 microg/day), Cu (1104.19 microg/day), Fe (13.00 mg/day), Mn (2.04 mg/day), Ni (126.27 microg/day) and Zn (10.97 mg/day) were below toxicological reference values and were found to satisfy nutritional recommendations, except for manganese in men and iron in women. Average dietary exposure to Pb and Cd represented 3.2% and 21.7% of the respective provisional tolerable weekly intakes. Estimates of dietary intakes of iron appeared to be inadequate for 63% of adult women. These findings should constitute a current measure of assessing the adequacy and safety of foods consumed in Lebanon and may be a basis for future monitoring studies.

Nationwide study of drug resistance among acid-fast bacilli positive pulmonary tuberculosis cases in Lebanon.

OBJECTIVE: To assess the prevalence of drug resistance among smear-positive sputum specimens from pulmonary tuberculosis (TB) cases in Lebanon. DESIGN: Between July 2002 and April 2004, 224 newly diagnosed TB cases and 21 previously treated TB cases were collected nationwide. Mycobacterium tuberculosis isolates were tested against isoniazid (INH), rifampicin (RMP), streptomycin (SM) and ethambutol (EMB) using the BACTEC-TB system. RESULTS: M. tuberculosis and non-tuberculous mycobacteria (NTM) isolates were recovered from 190 and 15 new cases, respectively, and from 16 and 1 previously treated cases, respectively. Overall drug resistance among new TB vs. previously treated TB cases was 19.5% and 75%, and for single drugs it was INH (12% vs. 63%), RMP (3% vs. 56%), SM (12% vs. 44%) and EMB (3% vs. 44%). The overall rate of multidrug resistance (MDR) was 5.8% (1% vs. 62.5%). The male:female ratio was 1.3:1; most were young adults. CONCLUSION: Relatively moderate single drug resistance and very low MDR rates were found among new TB cases, while among previously treated TB cases very high resistance and MDR resistance rates were detected. Such findings underline the need for ongoing stringent control measures to curb the spread of M. tuberculosis and its deleterious effects.

Comparative performance of PCR-based assay versus microscopy and culture for the direct detection of Mycobacterium tuberculosis in clinical respiratory specimens in Lebanon.

SETTING: American University of Beirut Medical Center, Lebanon. OBJECTIVE: To assess the performance of a polymerase chain reaction (PCR) using primers that flank 542 bp within IS6110 in Mycobacterium tuberculosis (TB) vs. microscopy and BACTEC culture, in the diagnosis of tuberculosis. DESIGN: A total of 82 clinical respiratory pulmonary specimens and 73 samples from BACTEC vials were tested by the three methods. RESULTS: Of 24 smear-positive culture-positive (SP-CP) and 11 smear-negative culture-positive (SN-CP) TB specimens, PCR detected 83% and 64%, respectively. Among 17 specimens yielding mycobacteria other than tuberculosis (MOTT), the PCR was positive in 33% SP-CP and 14% SN-CP specimens. Among the 73 BACTEC vials, PCR was positive in 36 of 38 (95%) yielding culture-positive TB, and in one of 20 (5%) yielding culture positive MOTT. None of the 30 smear-negative culture-negative (SN-CN) clinical specimens and 15 of the CN vials were positive by PCR. The overall sensitivity of PCR was 77% and 95% for TB detection in respiratory specimens and BACTEC vials, respectively, and the specificity was 94% in both. CONCLUSIONS: Because a substantial number of TB cases are missed, especially in SN-CP specimens, a PCR-based assay utilizing these primers cannot be used reliably, alone, in clinical laboratory diagnosis of mycobacterial respiratory infections.

Comparative study of antituberculous drug resistance among Mycobacterium tuberculosis isolates recovered at the American University of Beirut Medical Center: 1996-1998 vs 1994-1995.

PURPOSE: To study the overall current prevalence of antituberculous drug resistance among M. tuberculosis isolates recovered at the American University of Beirut Medical Center (AUBMC) between 1996-1998 in comparison to those reported on isolates recovered in 1994-1995. MATERIALS AND METHODS: Seventy-four consecutive M. tuberculosis isolates recovered from the same number of newly diagnosed cases of tuberculosis (TB), between January 1996 and December 1998 (referred to as 1998), were tested against isoniazid (INH), rifampicin (RIF), streptomycin (STM) and ethambutol (ETH), using the BACTEC-TB susceptibility procedure and system. The results were compared to those reported on the isolates recovered in 1994-1995 (referred to as 1995). RESULTS: A comparison between the results obtained in 1998 vs 1995 showed the following, respectively: The male to female ratio was 3.1:1 vs 2:1 and the mean ages were almost similar in males, 33.4 vs 34.1 years but were slightly higher in females 38.2 vs 32.7 years. Children (< or = 15 yrs) represented 10.8% vs 8.3% of the study population. The prevalence of resistance, to one or more drugs, was almost the same, 24% vs 26% but the overall percentages of single drug resistance were generally higher in 1998 vs 1995 against all the tested drugs except INH: INH (20.2% vs 23.9%), RIF (16.2% vs 12.5%), STM (13.5% vs 7.3%) and ETH (8.1% vs 3%). Among the resistant isolates, the profiles of resistance indicated decrease in resistance to one and two drugs, 6.7% vs 11.5% and 5.4% vs 10.4%, respectively, but showed increase in resistance to three and four drugs, 8.1% vs 2.1% and 4% vs 2.1%, respectively. Increase in resistance to two or more drugs was also observed, 17.6% vs 14.6%, and the prevalence of multidrug resistance, defined as resistance to at least both INH and RIF, was also increased, 14.7% vs 11.4%. CONCLUSIONS: This study shows a high prevalence and persistence of TB drug resistance tested in our Medical Center in Lebanon. In addition, the shift in the increase of resistance from one and two drugs to three and four drugs are very ominous and should be considered when treating patients in this country. Moreover, such information calls for scrutinizing the existing local TB control programs as part of the global efforts to minimize the incidence of this highly morbid infectious disease.

Drug-resistant Streptococcus pneumoniae in the Lebanon: implications for presumptive therapy.

A total of 50 consecutive clinical isolates of Streptococcus pneumoniae, collected between 1996 and 1998, were tested against six antimicrobial agents using the E-test. The percentages of fully resistant (R) and intermediately-R strains, respectively, were: benzyl penicillin 18 and 38%, amoxycillin-clavulanate 6 and 12%, cefuroxime 22 and 16%, ceftriaxone 2 and 16%, and clarithromycin 10%. Fully and or intermediately multidrug-resistance (two or more drugs) was seen in 44% of the isolates, 18% being fully resistant. The MIC breakpoint for cefaclor is not defined by the National Committee for Clinical Laboratory Standards (NCCLS) but MICs showed that: 76% of the isolates had an MIC of < or = 8 mg/l, 4% had an MIC of 16 mg/l and 20% had an MIC of > or = 32 mg/l. There was agreement between the E-test Pen MIC results and the 1 microg oxacillin (oxa) disk diffusion screen test for the 22 susceptible and the nine fully R strains but not for the 19 strains with Pen MICs between 0.1 and 1 mg/l; this shows the importance of MIC determination in such isolates. Penicillin and multiply antibiotic-resistant pneumococci are spreading in Lebanon, emphasizing the necessity to reconsider current treatment regimens in this country.