Integrating health across the Sustainable Development Goals in the Eastern Mediterranean Region: Assessment of Voluntary National Reviews from 18 countries.

Voluntary National Reviews are the formal mechanism for countries to report on progress and share lessons learned on SDG implementation. We assessed the Voluntary National Reviews submitted by countries in the WHO Eastern Mediterranean Region to note the reported progress on Sustainable Development Goal (SDG) implementation, the review preparation process and how health is positioned and framed to identify priorities for accelerating progress on the health-related SDGs. We extracted quantitative and qualitative data from 26 Voluntary National Reviews from 18 countries submitted during the period 2016 to January 2022. We focused on three areas: SDG implementation, the review preparation process and the positioning of health in the reviews. Three assessors conducted the data extraction based on the agreed framework according to their language of expertise (Arabic, English and French). One assessor supervised the whole process for consistency. If there was a doubt in interpretation, it was discussed and agreed among the assessors. Countries have established a mechanism for SDG implementation under high-level leadership, engaged in multistakeholder consultations, aligned and mainstreamed SDGs to national plans, and created a monitoring and review mechanism. Countries reported use of national participatory approach for the report preparation. The prioritization of both health and well-being (SDG3) and economic growth (SDG8) in the reports is unique compared to other regional and global assessments. Health was often framed around disease and health care provision without linkages to societal inequities and structural challenges. The reports indicated good progress in SDG implementation. Addressing upstream issues and the determinants of health requires the health sector to take a more strategic approach in advocating for health and well-being. Further research is needed to demonstrate how to address synergies and trade-offs of policy choices and identify the co-benefits of addressing health in the context of fiscal instability and widening inequities in the region.

Achieving and Maintaining Equitable Health Outcomes for all, Including for Future Generations.

Sustainable health equity means achieving and maintaining equitable health outcomes for all people, including for future generations. It encompasses realizing the right to health, setting the conditions for leading a healthy life, and fulfilling the full range of human rights. Achieving sustainable health equity requires that public services be designed and provided, and public policies be developed through empowering, inclusive, participatory, accountable, and democratic processes and mechanisms.

Exclusive Breastfeeding: Barrier analysis amongst Omani mothers.

Objectives: This study aimed to examine individual barriers and supports to exclusive breastfeeding (EBF) and identify potential policy and programmatic interventions in Oman, where less than a quarter of Omani infants under six months are exclusively breastfed. Methods: A cross-sectional barrier analysis (BA) was carried out among a purposive sample of Omani women who were selected and interviewed by trained enumerators in health clinics in various parts of the country. A BA tool, adapted for the Omani context, covered 12 common determinants of behaviour adoption using open-ended questions regarding participants' perceptions about EBF including positive and negative consequences, self-efficacy and social norms. Qualitative analysis involved coding and tabulating as well as thematic analysis. Results: This study included a total of 45 'doers' (who exclusively breastfed their infants) and 52 'non-doers' (who did not). Mothers reported that motivations for EBF include the perception that it leads to healthier children and is easy to do, readily available and therefore convenient, as well as that there is an high level of family support for breastfeeding. Barriers included perceived milk insufficiency and mother's employment. Conclusion: To achieve the EBF target of 50% for 2025, public health action should focus on emphasising the benefits and convenience of EBF and building women's confidence in their ability to produce sufficient milk. These efforts will require increasing the knowledge and skills of community and healthcare workers and establishing monitoring mechanisms. Extended paid maternity leave and supportive workplace policies are necessary to encourage working women to exclusively breastfeed.

Interventions and Programs to Promote Breastfeeding in Arabic-Speaking Countries: A Scoping Review.

INTRODUCTION: Low prevalence of exclusive breastfeeding in the Arab world is concerning and suboptimal breastfeeding is a leading child health risk factor in several Arab States. Breastfeeding education has the capacity to improve breastfeeding knowledge and practice, thus positively impacting infant and maternal health. The purpose of this review is to identify and examine the impact of breastfeeding promotion interventions across the Arab world. METHOD: A scoping review of the literature was conducted across seventeen databases for relevant publications published through October 2021 to find studies in Arab countries, that involved breastfeeding as an intervention component. Twenty-one articles met inclusion criteria and were reviewed. RESULTS: Individual and community based educational interventions offer the opportunity to positively impact the knowledge, attitudes, and practices of breastfeeding in new mothers in Arab countries. Increased breastfeeding has the potential to lead to improved neonate and maternal health. In addition to significant benefits found across individual and community-based interventions in a variety of Arab countries, there is also evidence that interventions that improve the knowledge of health care professionals and/or the practices of a health care system can contribute to subsequent increases in breastfeeding rates. DISCUSSION: Breastfeeding education is a low-cost and high-impact public health tool that can impact infant and maternal health and potentially increase breastfeeding adherence in the Arab world.

What is already known on this subject? Breastfeeding has major long-term effects on the health and development of children as well as women's health. Combined health systems and community interventions more than double exclusive breastfeeding rates globally. The most cost-effective ways to promote exclusive breastfeeding include counselling and supportive interventions in multiple settings. What this study adds? Multi-component educational and supportive interventions increase breastfeeding initiation and duration among mothers in the Arab world. The most successful interventions among Arab women include education as well as pre- and post-partum support. Education and training for health professionals on the importance of breastfeeding can have broad-reaching impact on improving breastfeeding rates.

A Critique of National Physical Activity Policy in Oman Using 3 Established Policy Frameworks.

BACKGROUND: This paper aimed to assess the development process, content, and early implementation of Oman's national physical activity plan of action to identify strengths and areas for improvement. METHODS: Data were extracted from 4 documents: national noncommunicable diseases policy, physical activity plan of action, and 2 World Health Organization Mission Reports. Three policy frameworks and approaches (physical activity content analysis grid, health-enhancing physical activity policy audit tool, and policy cube approach for diet-related noncommunicable diseases) were used. RESULTS: The findings demonstrated that policymakers engaged a broad range of sectors in developing a national plan. It aligned with many of the elements from the 3 policy frameworks (ie, multisectoral approach, political commitment/leadership, identification of national goals and targets, time frame for implementation). The main gaps included the lack of a specified sustainable funding mechanism, systems for monitoring progress, and an emphasis on general interventions, with limited focus on specific target groups. CONCLUSION: A range of sectors were engaged in the development of Oman's national physical activity plan of action, with strong political commitment and using global guidance and local evidence. Establishing a strong accountability framework, including a clear financing mechanism, is critical for Oman to meet its target for a 10% relative reduction in physical inactivity by 2025.

Physical activity and the built environment: perceptions of policy-makers in Oman.

The prevalence of physical activity is low in the Sultanate of Oman. The built environment is a key barrier to physical activity in the region. Our aim is to examine urban planners' perceptions of the relevance and feasibility of the proposed urban planning and design interventions in the draft WHO technical package on physical activity. Semi-structured interviews were conducted with 11 professionals using a pre-tested interview guide. Interviews were audio-recorded and transcribed. Content analysis based on the socio-ecological framework (policy, physical, socio-cultural and information environment) was used to identify the perceived urban design challenges and solutions. Urban sprawl due to haphazard urban and transport design, limited accessibility to parks and sports facilities, negative perceptions about active travel and limited understanding of physical activity were key challenges identified by interviewees. Participants suggested strengthening governance through policy and intersectoral collaboration, improving community design and accessibility to parks, considering the needs of diverse populations and improving knowledge and attitudes of physical activity as priority when adapting the WHO technical package to Oman. Mid-level managers prioritized three interventions from the package: the need for political commitment and capacity building on how the built environment can promote physical activity, a national political on physical activity that promotes a safe infrastructure for active transport, and accessibility to sports and recreational facilities. Negative perceptions of active travel and cultural expectations that constrain mobility requires a society-wide paradigm shift, the first objective of the WHO global action plan.

Randomized open-label trial of docosahexaenoic acid-enriched fish oil and fish meal on cognitive and behavioral functioning in Omani children.

OBJECTIVE: This study aimed to examine the effect of docosahexaenoic acid (DHA)-enriched fish oil supplement and meal of grilled fish on cognitive and behavioral functioning manifested as attention-deficit/hyperactivity disorder in primary school students 9 to 10 y of age in Muscat, Oman. METHODS: This randomized open-label trial involved two types of interventions: fish oil supplement or one serving (100 g) of grilled fish per day (Sunday through Friday) for 12 weeks. Red cell total lipid DHA levels were assessed. The Verbal Fluency Test, Buschke Selective Reminding Test, and Trail Making Test were used to measure cognitive functioning. Behavioral functioning was assessed using a standardized Arabic version of the National Initiative for Children's Health Quality Vanderbilt Assessment Scales. All measurements were carried out before and after intervention. RESULTS: DHA levels increased by 72% and 64% in the fish oil (mean, 3.6%-6.2%) and fish-meal (mean, 3.4%-5.6%) groups, respectively (P = 0.000). The Trail Making Test was the only cognitive test that demonstrated marked differences between groups: Median interquartile range difference between pre- and postintervention in the Trail Making Part B score was 61.5 (SE, 19.3, 103.2) in the fish oil versus fish-meal group, 24.5 (SE, -15.2, 74.7, P = 0.005). The Vanderbilt Assessment Scales also showed significant differences between groups (P < 0.001). CONCLUSION: This study contributed to available evidence on the cognitive and behavioral benefits of DHA in healthy school children. Expanding the food fortification program with DHA-enriched fish oil should be considered as part of broader policy to improve child health.

Descriptive Epidemiology of Sitting Time in Omani Men and Women: A Known Risk Factor for Non-Communicable Diseases.

OBJECTIVES: Sedentary behaviors (too much sitting as distinct from too little exercise) are associated with increased risk of non-communicable diseases. Identifying the prevalence and sociodemographic correlates of sitting time can inform public health policy and prevention strategies. METHODS: A population-based national survey was carried out among Omani adults in 2008 (n = 2 977) using the Global Physical Activity Questionnaire, which included a measure of total sitting time. Bivariate and regression analyses examined the associations of total sitting time with sociodemographic correlates (gender, age, education, work status, marital status, place of residence, and wealth). RESULTS: The proportion who sat for ≥ 7 hours/day was significantly higher in older than in younger adults (men: 22.0% vs. 14.6%, p < 0.010; women: 26.9% vs. 15.2%, p < 0.001, respectively). The odds ratio (OR) for prolonged sitting was half for men who were not working compared to those who were (p < 0.050). For younger women, the OR for sitting ≥ 7 hours/day was nearly a third for educated women compared to least educated (p = 0.035). For older women, the OR for prolonged sitting was more than double for married women compared to unmarried (p < 0.001). CONCLUSIONS: One in five Omani adults was identified as sitting for prolonged periods, at levels understood to have deleterious health consequences. Higher-risk groups include older adults and working men. With sitting time identified as a key behavioral risk to be targeted for the prevention of non-communicable diseases, further research is needed to understand the factors associated with domain-specific sitting time in order to guide prevention programs and broader public health approaches.

Tobacco Control in Oman: It's Time to Get Serious!

Tobacco use is the world's leading cause of preventable morbidity and mortality. Although Oman remains a country with the lowest tobacco use in the Arab Gulf States, the prevalence of tobacco use is projected to increase to 33.3% by 2025. In 2005, Oman acceded to the World Health Organization's Framework Convention on Tobacco Control, an international treaty with numerous obligations aiming to reduce the global burden of tobacco use. This paper documents, for the first time, Oman's experience in tobacco control by providing a descriptive analysis of the evolution of tobacco control policies in relation to the country's international obligations. In order to curb tobacco use and maintain current low prevalence levels, the paper concludes that Oman needs to accelerate action in adopting the highest attainable policies recommended by the World Health Organization's MPOWER package.

Addressing physical inactivity in Omani adults: perceptions of public health managers.

OBJECTIVE: To explore barriers and solutions to addressing physical inactivity and prolonged sitting in the adult population of Oman. DESIGN: Qualitative study involving semi-structured interviews that took place from October 2011 to January 2012. Participants were recruited through purposive sampling. Data collection and analysis was an iterative process; later interviews explored emerging themes. Interviews were audio-recorded and transcribed and continued until data saturation; this occurred by the tenth interviewee. Thematic content analysis was carried out, guided by an ecological model of health behaviour. SETTING: Muscat, Oman. SUBJECTS: Ten mid-level public health managers. RESULTS: Barriers for physical inactivity were grouped around four themes: (i) intrapersonal (lack of motivation, awareness and time); (ii) social (norms restricting women's participation in outdoor activity, low value of physical activity); (iii) environment (lack of places to be active, weather); and (iv) policy (ineffective health communication, limited resources). Solutions focused on culturally sensitive interventions at the environment (building sidewalks and exercise facilities) and policy levels (strengthening existing interventions and coordinating actions with relevant sectors). Participants' responses regarding sitting time were similar to, but much more limited than those related to physical inactivity, except for community participation and voluntarism, which were given greater emphasis as possible solutions to reduce sitting time. CONCLUSIONS: Given the increasing prevalence of chronic disease in Oman and the Arabian Gulf, urgent action is required to implement gender-relevant public health policies and programmes to address physical inactivity, a key modifiable risk factor. Additionally, research on the determinants of physical inactivity and prolonged sitting time is required to guide policy makers.

Correlates of Omani adults' physical inactivity and sitting time.

OBJECTIVE: To inform public health approaches for chronic disease prevention, the present study identified sociodemographic, anthropometric and behavioural correlates of work, transport and leisure physical inactivity and sitting time among adults in Oman. DESIGN: Cross-sectional study using the WHO STEPwise study methodology. SETTING: Sur City, Oman. SUBJECTS: Men and women aged 20 years and older (n = 1335) in the Sur City Healthy Lifestyle Study who had complete data for demographic variables (gender, age, education, work status and marital status), BMI and behavioural risk factors ­ smoking and dietary habits plus physical inactivity and sitting time (the outcome variables). RESULTS: The highest level of physical inactivity was in the leisure domain (55.4 %); median sitting time was about 2 h/d. Gender-stratified logistic regression models found that the statistically significant (P < 0.05) correlates of inactivity (in one or more domains) were age, work status and fruit and vegetable intake in women, and age, education, work status, marital status and BMI in men. Gender-stratified linear regression models found that the statistically significant correlates of sitting time were age, work status and BMI in women and education in men. CONCLUSIONS: Findings suggest that public health interventions need to be gender responsive and focus on domain-specific physical inactivity. In the Omani context, this might include gender-segregated exercise facilities to promote leisure physical activity among women and walking-friendly environmental initiatives to promote transport physical activity among men. Further evidence on barriers to physical activity and factors that influence prolonged sitting is required to develop relevant public health interventions.

Associations of physical activity and sitting time with the metabolic syndrome among Omani adults.

Most findings on associations of physical activity and sedentary behavior with the metabolic syndrome are from developed countries; thus, we examined these relationships in adults from Sur, Oman. The Sur Healthy Lifestyle Survey (n = 1,335) used the World Health Organization (WHO) Stepwise methodology to assess chronic disease risk factors. Odds ratios for the metabolic syndrome were estimated using logistic regression models for domains of physical activity (work, transport, and leisure) and sitting time, and adjusted for confounding variables. Compared to their counterparts doing the least physical activity, lower odds of the metabolic syndrome were observed among those with higher work activity (0.60; 95% confidence interval (CI): 0.45, 0.80) and transport activity (0.69; 95% CI: 0.47, 1.00), but not leisure activity (0.91; 95% CI: 0.64, 1.32). Odds of the metabolic syndrome were higher in those who sat for ≥ 6 h daily compared to <3 h daily (odds ratio = 1.60, 95% CI: 1.04, 2.44), but not after further adjustment for physical activity. This is the first evidence from the Arabian Gulf on associations of physical activity and sitting time with the metabolic syndrome and provides empirical evidence to inform national physical activity guidelines, policies and programs.

Women's autonomy, education and employment in Oman and their influence on contraceptive use.

Since 1970 political and economic changes have brought about great improvements in health and education in Oman, and since 1994 the government has provided free contraceptives to all married couples in primary health care centres. Despite rapid socio-economic development, the fertility rate was 4.2 in 2001. The aim of this study was to define baseline data on ever-married women's empowerment in Oman from a national study in 2000, analyse the correlates of women's empowerment and the effect of empowerment on unmet need for contraception. Two indicators of empowerment were used: women's involvement in decision-making and freedom of movement. Bivariate analysis was used to link these measures and their proxies, education and employment status, with use of a family planning method. Education was a key indicator of women's status. Unmet contraceptive need for women exposed to pregnancy was nearly 25%, but decreased significantly with educational level and paid employment. While empowered women were more likely to use contraception, women's education was a better predictor of "met need" than autonomy, as traditional factors and community influence remain strong. For nearly half the 1,830 women in the study, the husband decided whether contraception was used. Fewer than 1% were using contraception before their first child as women are expected to have a child within the first year of marriage.

Implementation of the WHO Multicentre Growth Reference Study in Oman.

The World Health Organization (WHO) Multicentre Growth Study (MGRS) Middle East site was Muscat, Oman. A survey in Muscat found that children in households with monthly incomes of at least 800 Omani Rials and at least four years of maternal education experienced unconstrained growth. The longitudinal study sample was recruited from two hospitals that account for over 90% of the city's births; the cross-sectional sample was drawn from the national Child Health Register. Residents of all districts in Muscat within the catchment area of the two hospitals were included except Quriyat, a remote district of the governorate. Among the particular challenges of the site were relatively high refusal rates, difficulty in securing adherence to the protocol's feeding recommendations, locating children selected for the cross-sectional component of the study, and securing the cooperation of the children's fathers. These and other challenges were overcome through specific team building and public relations activities that permitted the successful implementation of the MGRS protocol.