A surveillance summary of smoking and review of tobacco control in Jordan

Abstract The burden of smoking-related diseases in Jordan is increasingly evident. During 2006, chronic, noncommunicable diseases (NCDs) accounted for more than 50% of all deaths in Jordan. With this evidence in hand, we highlight the prevalence of smoking in Jordan among youth and adults and briefly review legislation that governs tobacco control in Jordan. The prevalence of smoking in Jordan remains unacceptably high with smoking and use of tobacco prevalences ranging from 15% to 30% among students aged 13-15 years and a current smoking prevalence near 50% among men. Opportunities exist to further reduce smoking among both youth and adults; however, combating tobacco use in Jordan will require partnerships and long-term commitments between both private and public institutions as well as within local communities.</p

Colorectal cancer survival in Jordan 2003-2007

As in other less developed countries in the region and elsewhere, cancers are becoming a major cause of morbidity and mortality in Jordan. Globally, colorectal cancer (CRC) is the second most common cancer in women and the third most common cancer in men. In Jordan, CRC is the second most common cancer in women and the most common in men. There is little known about survival from CRC in Jordan and few survival studies have been conducted in comparable Eastern Mediterranean countries. As the first study of its type in Jordan, this thesis aimed at estimating CRC survival among Jordanian patients and comparing them with survival estimates among other populations. The thesis explored the relationship between CRC and socio-demographic characteristics, clinical manifestations, treatment, diabetes mellitus – for which the prevalence in Jordan is very high - and treatment sites. The study augmented existing Jordan Cancer Registry data by gathering additional case mix information and completing missing fields. CRC was classified according to international classification of oncology (ICD-O third edition in addition to the International Classification of Diseases, ICD-10) as C18.0-C20.9. The vital status of the patients was ascertained from Civil Registration Bureau based on use of the unique National Identification number of the patients with follow-up to 31 December, 2010. The survival duration of each case was determined as the time difference (in days) between the date of incidence (index date) and the date of death, date of loss to follow-up or the closing date for follow-up (31 December, 2010). Observed and relative CRC survival rates were calculated among a study population of 1,896 Jordanian colorectal patients aged 15 to 99 years of age, diagnosed with first invasive primary CRC from January 2003 to December 2007. The Kaplan-Meier method was used to determine the observed survival probability over time. The logrank test was used to estimate whether the difference in survival estimates was statistically significant between the groups. The complete approach of estimation of observed survival probability was used. Cox proportional hazard regression was used to assess the effect of each variable after simultaneously controlling the effects of potential confounders. With half of the sample aged 60 years and above, males were predominant (55.5 percent) with the majority of the sample (75.4 percent) residing in the central part of Jordan. The vast majority of the cases (63.5 percent) were diagnosed with colon cancer, with regional metastasis present in 58.9 percent. No significant difference was found in the distribution of colon and rectum cancer by sex. Adenocarcinoma was the most commonly found tumor (84.4 percent) compared to mucinous tumors which was found in 7.8 percent of the patients. In addition, 62.7 percent of the cases were classified as moderate and 14.9 percent as poor. The percentages of rectum cancer patients with moderate and poor/anaplastic types of cancer were higher than in colon cancer patients. The majority of patients (77.9 percent) underwent surgery, which was mostly elective (82.0 percent). A significantly higher occurrence of these elective surgeries was found among rectum cancer (87.7 percent) than colon cancer patients (78.7 percent). Curative treatment was found to be a more common form of treatment for colorectal cancer patients (76.5 percent) than palliative (23.5 percent). Of those undergoing surgery, 4.8 percent has died within 30-days of resection, with a significantly lower mortality among patients aged ≤ 65 years (2.9 percent) than the over 65 years age group (7.1 percent). Thirty days postoperative mortality was significantly higher among colon cancer patients (5.3 percent), patients with more advanced tumours and those who underwent emergency operations. Results of this study revealed that the incidence of CRC in the Jordanian population to be low compared to developed countries. However, this low incidence is similar to CRC incidence rates in other countries in the region. During the 5-year study period, the overall crude colorectal cancer incidence rate for males was 5.6 per 100,000 population, and 5.1 per 100,000 populations in females. The overall Age Standardized colorectal incidence rate (ASR) among males was 15.5 per 100,000 populations compared to 12.5 per 100,000 populations among females. For colon cancer, the crude incidence rate was 5.4 per 100,000 populations in males and 4.1 per 100 000 populations in females, while ASR for males was 11.1 and 8.4 for females. Alternatively, the crude incidence rate for rectum cancer was 3.0 per 100,000 population for males and 2.4 per 100,000 population for females, and the respective ASR incidence rates was 6.1 per 100,000 males and 4.9 per 100,000 females. Unexpectedly, results showed a high percentage (13.8 percent) of CRC patients among the young age groups (i.e. less than 40 years of age) with insignificant differences between the sexes. The age specific incidence rates were found to increase with age. The study revealed that 5-year observed and relative survival probabilities for colorectal cancer to be 57.7 and 61.3 percent respectively, with higher probability for colon cancer. These results showed good survival estimates of colorectal cancer compared to developed countries as well as the most developed countries in the region and across the Asian continent. The slightly higher observed colorectal survival rates among females were found to be insignificantly different than those for males. Patients aged 45 through 59 years had the highest survival estimates among all age groups, and the 75 years and above age group the lowest. The highest survival estimates were found among patients living in the central parts of Jordan, and the poorest was significantly noted in the south. Moreover, the observed and relative survival estimates were consistently highest during Year 1 and lowest during Year 5. Mucinous and serous tumors showed the poorest survival rates among the colorectal cancer, with higher 5-year relative survival rates among the mucinous and serous type of colon (52.4 percent) compared to rectum cancer (42.8 percent). With more than half of the colon patients (57.2 percent) and rectal patients (62 percent) having a regional spread; a higher proportion of colon cancers (24.1 percent) were found to have distant metastasis, than rectum cancer patients (20.5) and an equally low (11 percent) had localized CRC at diagnosis. Results also showed that observed and relative survival rates from localized and regional colon cancer were better than survival from rectum cancer in the same stages at 1, 3 and 5-years of diagnosis. Results also indicated that observed survival became poorer with increasing age for both localized and regional tumours. This observation was applicable for both males and females. In recognizing appropriate surgery as the most important aspect of colorectal cancer treatment, the observed survival probability for colorectal cancer patients who underwent surgery was found significantly higher than that for patients who did not undergo surgery. This scenario was similarly observed for both colon and rectum. Conversely, the overall relative survival rates for patients who underwent surgery declined from 96.2 percent to 62.6 percent between the first and fifth year and from 86.5 percent to 23.5 percent for patients who did not undergo surgery. In addition, no significant difference was found between colorectal survival estimates for patients who underwent elective surgery and those who underwent emergency surgery. This was held true for both colon and rectum cancer. A multivariable analyses done to examine the adjusted odds of death within 30 days of surgery and selected variables revealed that the odds of dying were significantly higher among colorectal cancer patients older than 65 years (OR 2.3, 95percent CI: 1.3-4.1), those with distant tumors (OR 3.6, 95percent CI: 2.0-6.2); and those who were operated upon as an emergency (OR 2.3, 95percent CI: 1.2-4.1). Study findings indicated that colorectal cancer patients who received chemotherapy treatment had better survival for almost the first four years. However this was not a statistically significant result. Similarly, colon cancer patients who received chemotherapy treatment had better survival rates for nearly four years, compared to rectum cancer patients had better survival rates for the first two years from receiving chemotherapy. In terms of treatment sites (hospitals), results showed that 32.4 percent of cases were treated at public health facilities, 23.4 percent at King Hussein Cancer Center (KHCC), 18.4 percent at the teaching hospitals, 16.8 percent at the private health facilities, and only 9.1 percent at other sites. The results of Cox proportional hazards ratios, after adjusting for age, extent of disease, place of residence, surgery, chemotherapy, radiotherapy and intent of treatment, have shown that patients who received treatment in private hospitals as well as in the King Hussein Cancer Center, had better survival rates compared to those who received their treatment in the public sector. Finally, this study revealed that the mean survival for colorectal cancer patients with diabetes mellitus was significantly lower than that for patients without diabetes (Log-Rank test, p=0.0359). The study also revealed a significant relationship between diabetes mellitus and colon cancer survival, where diabetic patients with colon cancer were less likely to survive compared to non-diabetic patients with colon cancer. However, no significant association was observed regarding diabetic patients with rectum cancer. In addition, multivariate analysis identified diabetes mellitus as a significant predictor associated with lower observed survival, where diabetic patients were one and one-half times more likely to be at risk of dying compared to non-diabetic patients. Age group 75 years or older, regional and distant metastasis of disease were shown to be independent prognostic factors for observed survival in this multivariate analysis. The Cox proportional hazard model showed that age, place of residency, extent of disease, and morphology to be significant predictors for colorectal cancer survival. Colon cancer patients aged 75 years and above had 2.2 times higher risk of death than those aged 44 years or less ( HR=2.2, 95percent CI: 1.5-3.1). Rectum cancer patients residing in the central region of the country had a 27 percent lower risk of death compared with those who resided in the North (HR=0.73, 95percent CI: 0.56-0.95). Colon and rectum cancer patients with regional metastasis had three times and one and the half times higher risk of death than those with localized disease respectively (Colon: HR=3.3, 95percent CI: 2.0-5.6); (Rectum: HR=1.6, 95percent CI: 1.1-2.5). Moreover, colon patients with distant metastasis had fourteen times higher risk of death and rectum cancer patients portrayed four and the half times higher risk of death than those with localized disease (Colon: HR=14.0, 95percent CI: 8.0-23.8); (Rectum: HR=1.6, 95percent CI: 2.8-7.5). Colon patients with poor or anaplastic grade had almost twice the risk of death than those with well grade (HR=1.9, 95percent CI: 1.1-3.2). On the other hand, patients diagnosed with mucinous rectum cancer had 1.4 times higher risk of death than those with adenocarcinoma (HR=1.4, 95percent CI: 1.1-2.1). Sex, grade and year of diagnosis were insignificant predictors across all three models (CRC, colon and rectum). The main highlights of the study findings included a higher than expected incidence and a poorer than expected colorectal survival among the younger population, a large variation in survival rates based on the place of residency, and a significantly poorer survival among diabetic patients. Results of this study prompted a set of recommendations to assist national efforts in preventing and improving the survival of colorectal cancer in Jordan. These recommendations included various actions and measures to strengthen health service provision; assure provision of health care by expanding services; improve monitoring by promoting policy and research; and improve and strengthen data quality measures. Specifically, the study recommended screening to be made at a younger age in Jordan than in other developed countries as a result of the high percentage of CRC (13.8percent) among young age groups (<40 year) that was reported in the study. Conducting further research to investigate the reasons for poor survival rates among younger CRC patients is presented as a strong study recommendation. In addition, introducing managed clinical networks as an approach for reducing the variation in survival between the different hospitals was presented as a worthwhile recommendation. Undoubtedly, improving public health efforts to reduce the prevalence of Diabetes Mellitus, in addition to undertaking further research to explain the increased mortality among diabetic colorectal patients are presented as valuable recommendations in this study. Finally, the study recommended that the Jordan Cancer Registry play a major role in following-up with cancer patients to examine the quality of cancer services that they receive

Microbial Load of Chicken Shawerma and the Handlers’ Compliance with Food Safety Practices in Jordan

Background: Shawerma is a popular traditional food in the Eastern Mediterranean region. Aim: The aim of this study was to assess the shawerma handlers’ compliance with food safety practices and determine the microbial load and pathogenic organisms in the ready-to-eat chicken shawerma sandwiches in the restaurants of Amman, Jordan. Methods: This cross-sectional study used mixed methods including observational checklists to determine the compliance of food safety practices by 120 chicken shawerma handlers from 40 randomly selected restaurants in Amman. Additionally, pathogenic microorganisms were assessed by laboratory analysis in the ready-to-eat chicken shawerma sandwiches. Results: Only 2.5% and 10% complied, respectively, with separating knives and boards used for chicken from the ones used for vegetables. The compliance for maintaining proper temperatures for freezers and chillers were only 62% and 67%, respectively. As for hand-washing techniques and using disposable drying papers, the adherence was 5% and 7.5%, respectively. Laboratory analysis showed that 27.5% of the ready-to-eat shawerma had unacceptable levels of microorganisms. Conclusion: Our findings showed poor compliance of food safety practices in chicken shawerma restaurants of Amman. There is a need for capacity building and periodic evaluations of food handlers’ knowledge and practices within a comprehensive food safety program, carried out by qualified trainers. Keywords: chicken shawerma, food safety, Jorda

The Impact of the COVID-19 Pandemic on Female Sexual Function in Jordan: Cross-sectional Study.

BackgroundSexual function is a complex physiological process controlled by neurovascular and endocrine mechanisms that are affected by stressful events. The sexual response cycle consists of four main phases, which are sexual desire or libido, arousal or excitement, orgasm, and resolution. The COVID-19 outbreak is one of the most stressful events historically, causing several unpleasant consequences, including major physical and mental disorders, and sexual dysfunction and alteration in sexual behavior are possible anticipated consequences of the pandemic. Moreover, there are social taboos related to sexual behavior in Jordan, and the current knowledge on changes in Jordanian female sexual function during COVID-19 pandemic is limited.ObjectiveThis study aims to evaluate the impact of COVID-19 on women's sexual function during the early COVID-19 pandemic in Jordan.MethodsThis is a cross-sectional study that employed a web-based survey to follow 200 female individuals from the general population in Jordan. The survey evaluated sexual function both during COVID-19 and 6 months prior to the pandemic. The primary outcomes investigated in this study were the changes in sexual intercourse frequency and sexual function aspects, including desire, arousal, satisfaction, orgasm, lubrication, and pain during sexual activity. Data were analyzed using paired t test, McNemar test, Pearson correlations, and multiple linear regression using SPSS 25.ResultsDuring the COVID-19 pandemic, the participants' sexual intercourse frequency increased while their sexual satisfaction was significantly changed. The proportion of participants who had 0-2 times per week of sexual intercourse was decreased during the COVID-19 pandemic compared with that before the pandemic (n=90, 45% vs n=103, 51.5%; P=.02). Conversely, the number of female individuals with 3-7 times per week of sexual intercourse increased after the pandemic compared with the prepandemic state (n=103, 51.5% vs n=91, 45.5%; P=.04). Female sexual satisfaction was significantly reduced after the COVID-19 pandemic compared with that before the pandemic (3.39 vs 3.30; P=.049). The other categories of sexual function, including desire, arousal, satisfaction, orgasm, lubrication, and dyspareunia showed no significant changes during the COVID-19 pandemic compared with the previous 6 months. There were no significant differences between the total sexual function mean scores during COVID-19 (15.73) compared with the prepandemic scores (15.85; P=.41). The total score of female sexual function during the pandemic was negatively associated with the participants' age and education level. Correlations between various demographics and sexual function categories during the COVID-19 pandemic were identified.ConclusionsThis is the first study exploring female sexual function during the COVID-19 outbreak in Jordan. The results suggest that COVID-19-associated stress is influencing women's sexual function, necessitating the provision of adequate emotional and physiological well-being support for women during similar crises

Strengthening Primary Healthcare in Jordan for Achieving Universal Health Coverage : A Need for Family Health Team Approach

Achieving Universal Health Coverage (UHC) is a strategic objective of the Jordanian government and has been prioritized in its strategies and plans. However, there are several challenges affecting primary healthcare in Jordan and the health system in general that prevent Jordan from achieving UHC. This paper highlights the importance of team-based care in the form of Family Health Teams (FHTs) to realize Jordan’s goal of achieving UHC. FHTs are a team-based approach that brings together diverse professionals to provide a comprehensive, efficient, patient-centered primary care system that meets the changing needs of Jordan’s population and refugees. However, the implementation of FHT may encounter obstacles, including individual, organizational, institutional, and external barriers. To overcome such obstacles, several actions and processes need to be taken, including political commitment and leadership, implementing good governance and policy frameworks, allocating resources and funding, multisectoral collaboration, and engagement of communities and stakeholders. The successful implementation of FHTs requires participation from government officials, parliamentarians, civil society, and influential community, religious, and business leaders. A strategic policy framework, effective oversight, coalition building, regulation, attention to system design, and accountability are also essential. In conclusion, adopting the FHT approach in Jordan’s Primary Healthcare system offers a promising path towards achieving UHC, improving healthcare access, quality, and efficiency while addressing the unique challenges faced by the country’s healthcare system.Peer reviewe

Psychosocial and emotional well-being of Syrian refugee children and adolescents in Jordan : In-camp versus out-of-camp comparative analysis

There is a notable gap in understanding how different living arrangements influence the psychosocial and emotional well-being of Syrian refugee children and adolescents. Moreover, limited literature exists on the comparison between in-camp and out-of-camp living situations. The aim of this study was to compare the psychosocial and emotional status between camp and non-camp Syrian refugee children and adolescents living in Jordan. A nationwide school survey was conducted in Jordan from December 2022 to April 2023 and targeted children (8–11 years) and adolescents (12–18 years), encompassing Jordanians, Syrians, and Palestinians, both in camps (camp refugees) and urban areas (urban refugees). In this paper, the analysis was limited to Syrian refugees. A total of 1,420 children and 1,249 adolescents were included. Children in camps had higher rates of hyperactivity (12.7% vs 8.3%) and total difficulties (19.3% vs 13.9%) compared to urban dwellers. However, they had lower rates of bedtime problems (12.8% vs 17.0%) and problematic internet use (19.9% vs 34.8%). Camp adolescents had higher rates of separation anxiety disorder (44.0% vs 37.8%) and conduct problems (22.2% vs 15.0%), but lower rates of poor physical functioning (43.3% vs 52.3%) compared to urban adolescents. Adjusted analysis showed lower odds of generalized anxiety disorder (OR=0.59), problematic internet use (OR=0.39), and bedtime problems (OR=0.67) for camp children. However, they had higher odds of emotional symptoms (OR=1.47), hyperactivity (OR=2.08), and overall difficulties (OR=1.50). Camp adolescents had higher odds of overall difficulties (OR=1.49) but lower odds of poor physical functioning (OR=0.67) compared to urban adolescents. In conclusion, children in refugee camps had lower rates of problematic internet use and bedtime issues but higher rates of hyperactivity and overall difficulties than urban children. Similarly, camp adolescents faced more total difficulties but reported better physical functioning than their urban peers. The complex interplay between living conditions and well-being underscores the need for tailored mental health interventions for displaced populations.Peer reviewe

Frequent Mental Distress, Chronic Conditions, and Adverse Health Behaviors in the Behavioral Risk Factor Surveillance Survey, Jordan, 2007

INTRODUCTION: Recent evidence indicates that chronic diseases and mental illness are associated. In the Middle Eastern country of Jordan, chronic diseases and frequent mental distress (FMD) are increasing; however, the capacity for mental health care is limited. The objective of this study was to determine the association between FMD, chronic conditions, and adverse health behaviors in Jordan. METHODS: The third cycle of the Jordan Behavioral Risk Factor Surveillance Survey (2007) served as the data source for this study. The sample consisted of 3,612 noninstitutionalized Jordanian adults aged 18 years or older. Logistic regression was used to obtain odds ratios for the association between chronic conditions, health behaviors, and FMD adjusted for age, sex, marital status, education, income, and employment. RESULTS: In the adjusted models, people with hypertension (adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.6–2.7), high cholesterol (AOR, 2.3; 95% CI, 1.6–3.2), diabetes (AOR, 1.6; 95% CI, 1.1–2.4), and asthma (AOR, 2.2; 95% CI, 1.5–3.1) and smokers (AOR, 1.5; 95% CI, 1.1–2.0) were more likely to have FMD than people without each of these conditions. Adults who reported vigorous physical activity were less likely to have FMD (AOR, 0.6; 95% CI, 0.4–0.9) than their less active counterparts. CONCLUSIONS: In Jordan, FMD was associated with several chronic conditions. As a result, we suggest additional research to examine the complex relationship between FMD and chronic conditions. More doctors in the primary health care system should be trained in mental health

Collaborative strategies for implementing NCD “best buys” in the eastern Mediterranean and Africa: addressing challenges, creating opportunities, and charting the way forward

Noncommunicable diseases (NCDs) are an increasing public health challenge in both the Eastern Mediterranean Region (EMR) and Africa, where they contribute to premature mortality and overall disease burden. Despite the availability of cost-effective “Best Buy” interventions, implementation across these regions has been uneven due to various barriers, including limited resources, inadequate multi-sectoral collaboration, and competing health priorities. These challenges are compounded by emerging public health threats like mental health disorders and environmental factors such as air pollution, recently integrated into the expanded “5×5” framework for NCD prevention and management. This paper presents findings from a roundtable held during EMPHNET’s 8th Biennial Regional Conference, which focused on strategies to implement and scale up “Best Buy” interventions in the EMR and Africa. The roundtable gathered regional and global experts to examine successful NCD prevention efforts, explore implementation barriers, and highlight collaboration opportunities. Discussions centered on the need for tailored, context-specific interventions, stronger multi-sectoral partnerships, and increased political commitment to address the growing NCD burden. Sustainable financing was emphasized, with recommendations for establishing innovative funding mechanisms, such as regional NCD and mental health-related funds. Building workforce capacity was highlighted as critical to improving NCD management in resource-constrained settings, particularly through task-shifting models and NCD integration into training programs like the Field Epidemiology Training Program. The discussions underscored the urgency of adopting a whole-of-system approach to addressing NCDs, leveraging lessons from the COVID-19 pandemic to strengthen health systems, especially primary health care, and integrate NCD prevention efforts into broader health agendas across both regions

Advancing one health implementation in the Eastern Mediterranean region: insights from the EMPHNET 8th biennial roundtable

Countries in the Eastern Mediterranean region (EMR) face interconnected risks at the human, animal, and environmental interface. This Perspective synthesizes lessons from a roundtable convened during the EMPHNET 8th Biennial Regional Conference (Amman, 15–18 September 2024) to identify near-term actions to operationalize One Health. The two-hour session featured five presentations, a panel, and open discussion with 68 participants from human, animal, and environmental health, food safety, life sciences, and social sciences. Rapporteur notes and slides were independently reviewed by two authors and consolidated into cross-cutting themes. Five priorities emerged: workforce development and mentorship; governance and multisectoral coordination; surveillance, data integration, and joint risk assessment; financing and sustainability; and climate and environmental determinants. Participants emphasized Competencies for One Health Field Epidemiology (COHFE)-aligned competency pathways, institutionalized coordination with defined roles, interoperable surveillance products using shared case definitions, early joint risk assessments with explicit triggers, and sustained cross-sector rapid response capacity. They called for embedding One Health tasks in national budgets, aligning external support to government plans, and integrating health within climate policies and investments. Egypt case illustrated national organization of governance, surveillance, and financing. The roundtable offers a practice-oriented entry point for EMR decision makers to operationalize One Health in the near term

Antimicrobial resistance in the Eastern Mediterranean Region: experiences, challenges, and perspectives

Antimicrobial resistance (AMR) is a rapidly growing global health threat that undermines the effectiveness of first-line treatments for serious infectious diseases. During the Eighth Regional Conference of the Eastern Mediterranean Public Health Network (EMPHNET), held in Amman, Jordan, from September 15–18, 2024, this critical issue took center stage under the theme “Advancing Public Health Preparedness and Response.” A dedicated roundtable discussion on AMR explored the challenges of implementing effective AMR surveillance, the widespread misuse of antibiotics, and the urgent need for a One Health approach that integrates human, animal, and environmental health. Speakers emphasized that political commitment, sustainable funding, and cross-sector collaboration are essential to curbing AMR, particularly in the Eastern Mediterranean Region (EMR), where factors such as high antimicrobial consumption, conflict, weak health systems, and poor access to regulated antibiotics exacerbate the problem. The discussion also highlighted the critical roles of laboratories and infection prevention and control (IPC) programs in healthcare settings, both of which are central to AMR surveillance and stewardship. Global efforts, including the WHO’s Global Action Plan on AMR and the AMR Multi-Stakeholder Partnership Platform, were recognized as vital frameworks for fostering international cooperation and guiding regional responses. The roundtable concluded with a call for strengthened governance, enhanced laboratory capacities, improved surveillance systems, scaling up IPC programs and enhanced public awareness campaigns to confront the rising threat of AMR in the EMR