Evaluation of a school-based peer-led education program for adolescents with asthma in Jordan

University of Technology, Sydney. Faculty of Nursing, Midwifery and Health.Background: Adolescent asthma, despite being prevalent and having the potential to negatively impact quality of life, can be adequately managed using the support of peer-led education initiatives within the school context. Such programs acknowledge the social importance of peers and schools in shaping adolescents' health- related behaviours, utilising the universal influence of peers in a positive way. Aim: The aim of this study was to determine the effect of a peer-led asthma education program (Triple A - Adolescent Asthma Action) on asthma-related quality of life, knowledge of asthma management, and self-efficacy to resist smoking among students with asthma attending high schools in Jordan by three months post intervention. Methods: A cluster-randomised controlled trial was conducted in 4 high schools in Irbid, Jordan, on students with asthma (n = 261) in years 8, 9, and 10. Students in the two intervention schools (n = 132) were involved in TAJ (Triple A in Jordan) over three weeks, whereas students in the two control schools (n = 129) were not involved in any intervention. The trial followed a pilot study that was used to determine whether Triple A was needed and feasible, with adaptations made to adjust for the Jordanian high school context. As the cluster design was used and three baseline covariates were found, a SAS.PROC.MIXED adjusted model was used to account for these issues. Results: The average age of the students with asthma was 15.2 years (SD = 1.23), and the majority were male (56.7%), with almost one third of all the participating students (27.7%) reporting being smokers. Approximately 70% had a professional asthma diagnosis, and the remainder reported recent wheezing in the last 12 months, but had not been diagnosed with asthma by a health care professional. In fact, the proportion of students with asthma in the whole sample proved larger than expected, as asthma symptoms were prevalent (17.15%). The program was well-received by students and school staff and modifications were minimal. The TAJ program resulted in significant improvement in all outcomes measured in students with asthma. Compared to the control group, students with asthma in the intervention schools had statistically and clinically significant improvements in quality of life (mean difference = 1.35, 95% Cl = 1.04 - 1.76), better asthma-related knowledge (mean difference = 1.62, 95% Cl = 1.15 - 2.19), and higher self-efficacy to resist smoking (mean difference = 4.63, 95% Cl = 2.93 - 6.35) at three months follow-up. In particular, the TAJ group had most improvement in quality of life in the symptom sub-domain scores (change in score = 0.97, p < 0.02) in comparison to the activities and the emotions domains. Conclusion: The school-based peer-led education program (TAJ) has been shown to be successful in promoting the health of adolescents with asthma in Jordan. Triple A proved adaptable and effective in another culture and context and may have potential for other health-related issues for adolescents. It is crucial that health promotion programs like TAJ are implemented for adolescents in Jordan

Cigarette smoking in adolescents with asthma in Jordan: Impact of peer-led education in high schools

Background: Peer-led smoking prevention programs focus on teaching adolescentsespecially those with asthma- who are affected most by cigarettes, refusal skills to lower their intention to smoke. The purpose of this study was to determine the impact of a peer-led asthma education program on students who were smokers in terms of self-efficacy to resist smoking, asthma knowledge and asthma-related quality of life

Health in times of uncertainty in the eastern Mediterranean region, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts

Systematic meta-review of supported self-management for asthma: a healthcare perspective

BACKGROUND: Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management. METHODS: We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis. RESULTS: A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval -0.09 to 0.34). CONCLUSIONS: Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care. SYSTEMATIC REVIEW REGISTRATION: RECURSIVE: PROSPERO CRD42012002694 ; PRISMS: PROSPERO does not register meta-reviews

Health in times of uncertainty in the eastern Mediterranean region, 1990�2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100�000 people), which increased by 17·2 since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100�000 people) in 2013, which decreased by 26·9 since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3 since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60�80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7 to 7·5 between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts. Funding Bill & Melinda Gates Foundation. © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY licens

Peer-led education for adolescents with asthma in Jordan: A cluster-randomized controlled trial

OBJECTIVES: To determine the impact of a peer-led education program, developed in Australia, on health-related outcomes in high school students with asthma in Jordan. METHODS: In this cluster-randomized controlled trial, 4 high schools in Irbid, Jordan, were randomly assigned to receive the Adolescent Asthma Action program or standard practice. Bilingual health workers trained 24 peer leaders from Year 11 to deliver asthma education to younger peers from Year 10 (n = 92), who in turn presented brief asthma skits to students in Years 8 and 9 (n = 148) and to other members of the school community in the intervention schools. Students with asthma (N = 261) in Years 8, 9, and 10 completed baseline surveys in December 2006 and 3 months after the intervention. RESULTS: Students from the intervention group reported clinically significant improvements in health-related quality of life (mean difference: 1.35 [95% confidence interval: 1.04-1.76]), self-efficacy to resist smoking (mean difference: 4.63 [95% confidence interval: 2.93-6.35]), and knowledge of asthma self-management (mean difference: 1.62 [95% confidence interval: 1.15-2.19]) compared with the control group. CONCLUSIONS: This trial demonstrated that the Adolescent Asthma Action program can be readily adapted to suit different cultures and contexts. Adolescents in Jordan were successful in teaching their peers about asthma self-management and motivating them to avoid smoking. The findings revealed that peer education can be a useful strategy for health promotion programs in Jordanian schools when students are given the opportunity and training. Copyright © 2012 by the American Academy of Pediatrics

Predictors of warfarin non-adherence in younger adults after valve replacement surgery in the South Pacific

Objectives Globally, mechanical valves are predominant as replacements for adolescents and younger adults with rheumatic heart disease (RHD). Mechanical valve implantation necessitates lifelong antithrombotic management (warfarin) and associated lifestyle modification, with event-free survival largely dependent on international normalised therapeutic ratios (INRs) remaining within the target therapeutic range. There is limited information on factors that may influence warfarin adherence among younger people or those in resource-limited settings. This study sought to identify predictors of warfarin adherence after valve replacement surgery for RHD in Fiji (n=127). Methods A cross-sectional study design was used. Results The sample had a mean age of 31.23 years (SD 13.34) and a mean time-since-surgery of 3.72 years (SD 3.95). Just over half were women (n=71, 56%) and almost two-thirds were indigenous (I-taukei, n=78, 61%). Most had an isolated valve procedure (n=94, 74%) and at the time of survey, they were in New York Heart Association Class I (n=97, 76%). A quarter (n=33, 26%) reported poor adherence with anticoagulation therapy and 13.38% (n=17) reported complete warfarin cessation. While younger age was significantly associated with non-adherence to warfarin therapy (p=0.008), the independent predictors of people who discontinue warfarin completely were those not understanding why warfarin was needed (OR=9.97, p=0.006); a history of forgetting to take warfarin (OR=8.64, p=0.0013) and travel time to heart clinic >1 hour (OR=5.80, p=0.039). Conclusions While medication adherence is complex and multifactorial, the consequences of warfarin non-adherence are potentially catastrophic. These results provide an important first step towards the development of country-specific and disease-specific strategies to improve warfarin adherence

Effectiveness of a 12-week school-based educational preventive programme on weight and fasting blood glucose in “at-risk” adolescents of type 2 diabetes mellitus: Randomized controlled trial

© 2017 John Wiley & Sons Australia, Ltd To assess the effectiveness of a 12-week school-based educational preventive programme for type 2 diabetes by change in weight and fasting blood glucose level in Jordanian adolescents. Sixteen percent of Jordanian adults have obesity-related type 2 diabetes and 5.6% of obese adolescents examined, however one-third unexamined. Rates in Arabic countries will double in 20 years, but this can be prevented and reversed by controlling obesity. A single-blinded randomized controlled trial was conducted in 2 unisex high schools in Irbid, Jordan, in 2012. Intervention and control participants, aged 12 to 18 years, were visibly overweight/obese. They were randomly allocated to the intervention (n = 205) or control (n = 196) groups. At-risk students were assessed before and after the 12-week intervention, for change in weight and fasting blood glucose level following preventive instruction and parent-supported changes. Mean age of participants was 15.3 years with equal percentages of both males (49.4%) and females. Post intervention, the intervention group, demonstrated statistically significant reductions: mean difference of 3.3 kg in weight (P <.000) and 1.36 mg/dL (0.075 mmol/L) in fasting blood glucose (P <.000). School-based early prevention intervention effectively reduced weight and fasting blood glucose in Jordanian at-risk adolescents