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Background A different ethos with respect to the perception of medical ethics prevails in societies in transition such as those in the Arabian Peninsula, which makes it difficult to apply international principles of bioethics in medical practice. This study aimed to develop and psychometrically test an instrument that measures physicians’ awareness of bioethics and medical law and their attitudes towards the practice of medical ethics. Additionally, it examined physician correlates influencing the awareness of bioethics. Methods Following a rigorous review of relevant literature by a panel of experts, a 13-item instrument, the Omani physicians’ bioethics and medical law awareness (OBMLA) questionnaire was developed with the aim of assessing physicians’ awareness of bioethics and medical law. The study tool’s construct validity and internal consistency reliability were examined by exploratory factor analysis (EFA) and Cronbach’s alpha. In a cross-sectional study, the questionnaire was distributed among a random sample of 200 physicians at a tertiary hospital in Muscat, Oman. Participant characteristics that may influence awareness of bioethics and medical law were explored. Results The EFA of the OBMLA questionnaire resulted in three well-loading factors: (1) Physicians’ bioethics practice subscale (2) incentive related bioethics subscale and (3) medical law awareness subscale. Internal consistency reliability ranged between Cronbach’s α: 0.73–0.8. Of the total 200 participants, 52% reported that teaching medical ethics during medical school was inadequate. The overall mean (standard deviation, SD) of the bioethics awareness score and Omani medical law awareness were 27.6 (3.5) and 10.1 (2.1) respectively. The majority of physicians (73%) reported that they frequently encountered ethical dilemmas in their practice and 24.5% endorsed the view that unethical decisions tended to occur in their practice. Conclusion The study provides an insight into the practice of bioethics, and the awareness of bioethics and medical law among physicians in a teaching hospital in Oman. The OBMLA questionnaire appears to be a valid and reliable tool to assess a physician’s awareness of bioethics and medical law. In this preliminary study, it appears that participants have suboptimal scores on the indices which measure practice and awareness of bioethics and medical law.

Objectives: This study aimed to describe changes in self-efficacy (SE) and social support (SS) 12 months after the MOVEdiabetes trial, an intervention designed to increase physical activity (PA) among adults with type 2 diabetes mellitus in Oman. Methods: The original MOVEdiabetes trial was conducted between April 2016 and June 2017 in Muscat, Oman. The intervention group (IG) received personalised PA consultations, pedometers and monthly messages using a web-based application, while the comparison group received usual care. Self-reported SE and SS from family and friends were assessed using validated psychosocial scales. Results: Of the 232 original participants in the trial, a total of 174 completed the 12 months follow-up study period (response rate: 75%). However, based on intention-to-treat analysis with several imputation procedures for missing data at 3 and/or 12 months, there was a significant increase in SE scores in the IG (+10.3, 95% confidence interval [CI]: 7.1–13.5; P

Background The Gulf Cooperation Council (GCC) countries relied, until recently, solely on import duties for tobacco products. The agreement for the introduction of an excise and value added tax (VAT) in 2016 and 2017, respectively, in most GCC countries, was a major breakthrough for public health. There is, however, ample room for improvement. Methods The study examines the outcomes of tax reforms, for both public health and public finances, based on the World Health Organization (WHO) recommendations and best practices worldwide. Tax simulations were performed using the WHO TaXSiM model. The study is based on data from Saudi Arabia, the only GCC country for which sufficient data existed. Results We recommend a stepwise tax reform, which involves increasing the current ad valorem excise tax rate, phasing out import duties keeping total tax share constant and introducing a minimum excise, and finally switching to a revenue-neutral specific excise. Specific excises must be adjusted for inflation and income increases. If implemented, cigarette tax reform simulations show that the recommended reforms would lead to a higher than 50% increase in cigarette prices, 16% reduction in cigarette sales and almost 50% increase in total cigarette tax revenue. A significant number of cigarette-related deaths would be averted. Conclusions The recommended tax reforms are expected to lead to significant improvements in both public health and tobacco tax revenues. Our results provide useful insights that are of relevance to the whole GGC region. The effectiveness of the reforms, however, requires a strong tax and customs administration, including the establishment of a good database to monitor and advance public health.

The quality of life (QoL) of the caregivers of children with autism spectrum disorder and intellectual disabilities has received limited attention in emerging economies such as those of the Arabian Gulf region. The aims of this investigation were threefold and sought to contribute to the gap in the literature by exploring the following issues in Oman: (i) to examine the socio-demographic characteristics of caregivers of children with autism spectrum disorder (ASD), intellectual disabilities (ID) and typical development (TD); (ii) to compare health satisfaction of caregivers of children with ASD, ID, and TD and (iii) to ascertain the relationship between QoL and socio-demographic factors among the families caring for children with ASD. Two-hundred and twenty caregivers seeking consultation for their children with ASD were recruited for this study, in addition to the control group (caregivers of children with ID, n= 109), and caregivers of children with TD (n= 125). The overall number of participants was 454. An Arabic version of the World Health Organization Quality of Life (WHO QOL-BREF) was employed to measure QoL and health satisfaction. Compared to the caregivers of children with ID and TD, the caregivers of children with ASD scored lower on indices of QoL and reported poorer health status. Socio-demographic factors such as higher education were associated with improved QoL, which often entailed steady employment and higher-income. This study suggests that poor QoL appears to be pervasive in caregivers of children with ASD in Oman. Given the increase in the reported prevalence of ASD, QoL should be considered when devising interventions and services for children presenting with these difficulties and their caregivers. This evidence-based research lays the foundation for systemic interventions and future allocation of resources.

BackgroundThe economic cost of smoking has been determined in many high-income countries as well as at a global level. This paper estimates the economic cost of smoking and secondhand smoke (SHS) exposure in the six Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates), for which no detailed study exists.MethodsWe used data from the Global Burden of Diseases Study 2016 and the cost-of-illness approach to estimate direct costs (healthcare expenditures) and indirect costs (productivity losses due to morbidity and mortality). Indirect cost was estimated with and without the inclusion of musculoskeletal disorders, using the human capital approach.ResultsTotal cost of smoking and SHS was estimated to be purchasing power parity (PPP)$ 34.5 billion in 2016, equivalent to 1.04% of the combined gross domestic product (GDP). SHS accounted for 20.4% of total cost. The highest proportion of indirect cost resulted from smoking in men and middle-aged people. The main causes of morbidity cost from smoking and SHS were chronic respiratory diseases and type 2 diabetes mellitus, respectively. Cardiovascular diseases were the main contributor to mortality cost for both smoking and exposure to SHS. Including musculoskeletal disorders increased total cost to PPP$ 41.3 billion (1.25% of the combined GDP).ConclusionThe economic cost of smoking and SHS in the GCC states is relatively low compared with other high-income countries. Scaling-up implementation of evidence-based policies will prevent the evolution of a tobacco epidemic with its negative consequences for health and public finances.

Aim To explore the prevalence and correlates of depressive symptoms among parents/primary care providers of children with autism spectrum disorder (ASD). Design and methods A cross-sectional analytical study was conducted among a systematic random sample of parents/caregivers of children with diagnosis of ASD in Muscat, Oman. Depressive symptoms were quantified using the Patient Health Questionnaire-9. Findings The response rate was at 86% (n = 80) and the prevalence of depressive symptoms, at 71.3% (95% confidence interval, 60.5-80.1). Logistic regression analyses indicated that unemployment and being the sole parent/caregiver in the family were both significant correlates of depressive symptoms. Practice implications With an increase in the number of children being diagnosed with ASD, multidimensional preventive and remedial service programs for parents/caregivers will be essential.

Purpose. Evidence from industrialized/developed countries showed that colorectal cancer (CRC) incidence rates have significantly dropped due to the widespread use of colonoscopy. In Arab countries, however, the CRC had been reported to have increased. Despite the concerted effort in the primary prevention and widespread use of colonoscopy, to our knowledge, there have been no reports of the prevalence rate of CRC among colonoscopy recipients from Oman. This study aims to explore the CRC prevalence estimates over selected sociodemographic characteristics among colonoscopy-recipients at a tertiary hospital in Oman over five years of follow-up. The regional variations in Oman were also examined in this study. Methods. This hospital-based cross-sectional study reviewed reports of colonoscopies performed over 5-years of retrospective follow-up at a tertiary hospital in Oman. CRC prevalence estimates were calculated over age, gender, governorate, and time of follow-up. Results. A total of 442 CRC cases were enumerated among 3701 colonoscopies, with an overall CRC prevalence estimate of 11.9 per 100 colonoscopies (95% CI: 10.9, 13.0). Gender-specific CRC prevalence was higher among males compared with females (13.3 vs. 10.5). Age-specific CRC prevalence increased with advancing age, from 2.8 among those less than 40 years of age to 26.5 among aged 70 years or more. Regional CRC prevalence was highest among residents in Batinah Governorate. Over the 5-years of follow-up, there was a slow rise in CRC prevalence with an annual increment of 0.59%. Conclusion. The study provides supportive evidence for a steady increase in CRC prevalence over age categories and years of follow-up and depicted the variations of gender-specific CRC prevalence estimates over increasing age categories. The study calls for timely formulation and adoption of national CRC screening programs centered on the colonoscopy use as primary prevention and maximizing its utilization and efficiency.

As a major neurodevelopmental disorder, Autism Spectrum Disorder (ASD) encompasses deficits in communication and repetitive and restricted interests or behaviors in childhood and adolescence. Its etiology may come from either a genetic, epigenetic, neurological, hormonal, or an environmental cause, generating pathways that often altogether play a synergistic role in the development of ASD pathogenesis. Furthermore, the metabolic origin of ASD should be important as well. A balanced diet consisting of the essential and special nutrients, alongside the recommended caloric intake, is highly recommended to promote growth and development that withstand the physiologic and behavioral challenges experienced by ASD children. In this review paper, we evaluated many studies that show a relationship between ASD and diet to develop a better understanding of the specific effects of the overall diet and the individual nutrients required for this population. This review will add a comprehensive update of knowledge in the field and shed light on the possible nutritional deficiencies, metabolic impairments (particularly in the gut microbiome), and malnutrition in individuals with ASD, which should be recognized in order to maintain the improved socio-behavioral habit and physical health.

Studies conducted in the West countries suggest that sleep habits and disordered sleep are common among children with autism spectrum disorder (ASD). To explore the rates of sleep habits and disord...

Background Despite evidence of the benefits of physical activity in the management of type 2 diabetes, it is poorly addressed in diabetes care. This study aimed to identify the prevalence and correlates of meeting ≥600MET-min/wk. (150 min/wk) of physical activity and sitting time in adults with type 2 diabetes in Oman. Approaches to encourage physical activity in diabetes care were explored. Methods A cross-sectional study using the Global Physical Activity Questionnaire was conducted in 17 randomly selected primary health centres in Muscat. Clinical data including co-morbidities were extracted from the health information system. Questions on physical activity preferences and approaches were included. Patients were approached if they were ≥18 years, and had been registered in the diabetes clinic for >2 years. Results The questionnaire was completed by 305 people (females 57% and males 43%). Mean age (SD) was 57 (10.8) years and mean BMI (SD) was 31.0 (6.0) kg/m2. Duration of diabetes ranged from 2 to 25 (mean 7.6) years. Hypertension (71%) and dyslipidaemia (62%) were common comorbidities. Most (58.4%) had an HbA1c ≥7% indicating poor glycaemic control (55% in males vs 61% in females). Physical activity recommendations were met by 21.6% of the participants, mainly through leisure activities. Odds of meeting the recommendations were significantly higher in males (OR 4.8, 95% CI 2.5–9.1), individuals ≤57 years (OR 3.0, 95% CI 1.6–5.9), those at active self-reported stages of change for physical activity (OR 2.2, 95% CI 1.2–4.1) and those reporting no barriers to performing physical activity (OR 2.7, 95% CI 1.4–4.9). Median (25th, 75th percentiles) sitting time was 705 (600, 780) min/d. Older age (>57 years) was associated with longer sitting time (>705 min/d) (OR 2.8, 95% CI 1.7–4.6). Preferred methods to support physical activity in routine diabetes care were consultations (38%), structured physical activity sessions (13.4%) and referrals to physical activity facilities (5.6%) delivered by a variety of health care providers. Conclusions The results suggest that intervention strategies should take account of gender, age, opportunities within daily life to promote active behaviour and readiness to change. Offering physical activity consultations is of interest to this study population, thus development and evaluation of interventions are warranted. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4643-7) contains supplementary material, which is available to authorized users.

Objectives: This study aimed to develop and validate a health education programme to encourage breast cancer awareness and early detection behaviours among Arab women. Methods: This study took place between December 2015 and March 2016. The Enabling Systems Raising Awareness model was used to develop a breast cancer health education programme which was subsequently implemented by trained health educators at three female-only fitness clubs in Muscat, Oman. Breast cancer knowledge among 53 women was assessed using the breast module of the Cancer Awareness Measure before and after each health education session. Overall pre- and post-session knowledge scores were then compared. Additionally, three focus group discussions were conducted with 10 participants from each location. Thematic analysis was used to analyse the transcribed discussions and collect feedback on the programme. Results: The health education sessions resulted in a statistically significant increase in overall mean knowledge scores ( P

Background Adequate physical activity (PA) is considered essential in diabetes management. However, evidence on the best method of promoting PA within diabetes care is inconclusive. The current work identifies perceptions on the acceptability of Intervention Group Participants (IGP) and Project Officers (POs) about the “MOVEdiabetes” intervention programme aimed at increasing PA in adults with type 2 diabetes in Oman (a retrospectively registered trial). Methods The “MOVEdiabetes” programme (PA consultations, pedometers and WhatsApp messages) was delivered by the POs (primary health care practitioners) in four primary care centres within a one-year cluster randomised control trial. Recruitment and retention were measured from trial attendance records. Programme satisfaction, appropriateness, and content suitability were assessed using exit surveys for both the IGP (interview based) and POs (self-administered). Open text questions on perceptions to the study programme were also included. Results Participants were randomised to an intervention group (IG, n = 122) or comparison group (CG, n = 110). The overall retention rate at three and 12 months was 92.7% [110(90.2%) IG vs 105(95.5%) CG] and 75% [82(67.2%) IG vs 92(83.6%) CG] respectively. Most (n = 14, 87.5%) POs and more than half (n = 49, 59.8%) IGP perceived the programme as very appropriate and many reported that they were “quite/ very satisfied” with the programme (n = 16, 100% PO’s and n = 71, 86.6% IGP). Two thirds (n = 55, 66.0%) of IGP were very/quite likely to recommend the programme to others. PA consultations, use of pedometers and Whatsapp messages were well perceived by all. Participants recommended the inclusion of dietary advice and PA promotion for the general public. Exploring PA facilities within the community was suggested by POs. Conclusions The “MOVEdiabetes” programme achieved a high retention rate and was perceived as satisfactory and appropriate. Results from this study suggest that it is worthwhile exploring the use of the “MOVEdiabetes” programme in clinical practice and further community links. Trial registration International Standard Randomised Controlled Trials No: ISRCTN14425284. Registered retrospectively on 12th April 2016.

Vitamin or mineral supplementation is considered to be the most commonly used medical treatment for autism spectrum disorder (ASD), in addition to other interventions such as neurological and psychological interventions. There is not much evidence of therapeutic efficacy between vitamin and mineral supplementation and improvements in ASD. However, several researchers have noted that patients with ASD have various metabolic and nutritional abnormalities including issues with sulfation, methylation, glutathione redox imbalances, oxidative stress, and mitochondrial dysfunction. There is some evidence that vitamin and mineral supplementation may support these basic physiologic processes. Recently, the nutritional status of ASD patients has been gaining focus in this particular area. Pointing out the nutritional status as a potential etiological factor for attention/communication disorders, more importance has been given to this particular point. Moreover, autistic specific considerations like the feature and behavior of ASD might be increased or at least fall in the higher risk due to the sub-optimal nutritional status.

Objectives Early diagnosis and prompt treatment of mental and behavioral disorders in preschoolers is critical for a better prognosis, ultimately leading to improved quality of life for both the child and the family. Our study investigated the clinical profile of mental and behavioral disorders in children < 7 years of age, seeking consultation at Sultan Qaboos University Hospital, Muscat, Oman, between 1 June 2006 and 31 December 2010. The objective was to explore demographic variables, intervention types, and annual trends. Methods This retrospective, descriptive study was conducted by reviewing the electronic records of preschoolers seeking consultation on mental and behavioral disorders at the Department of Behavioral Medicine. The diagnosis was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Results The total number of cases was 466, the majority (77.9%) being boys. The cumulative frequencies and annual hospital-based prevalence rates were estimated for each category of mental and behavioral disorders. Our findings showed increased service utilization among preschoolers, as reflected in the annual trend and case-specific prevalence rates. While comorbidity was common, the most frequent disorders encountered were attention deficit hyperactivity disorder (70.8%), developmental language disorder (23.6%), autism spectrum disorders (20.2%), and disruptive behavior disorders (11.6%). The most commonly prescribed drugs/supplementation were risperidone (18.7%), atomoxetine (9.7%), omega-3 (8.8%), and methylphenidate (6.2%). Conclusions Consultations for mental and behavioral disorders are being sought for Omani preschoolers. Beside pharmacotherapy, other interventions, which are an integral part of a much desired multidisciplinary approach should be introduced. Readdressing the missing needs is essential for a comprehensive approach to managing mental and behavioral disorders. H.M. Sultan Qaboos Grant

Omar A Al-Farsi,1 Yahya M Al-Farsi,1,2 Marwan M Al-Sharbati,3 Samir H Al-Adawi31Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman; 2Department of Epidemiology, School of Public Health, Boston, MA, USA; 3Department of Behavioural Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman Abstract: Previous studies carried out in Euro-American populations have unequivocally indicated that psychological disorders of the CASD (caregivers of children with autism spectrum disorder) are marked with high levels of stress, anxiety, and depression. This finding has been attributed to the reaction of having to care for a child with neurodevelopmental disorders. While there have been reports on autism spectrum disorder in Arab/Islamic countries such as Oman, there is no study from this region, to our knowledge, reporting the performance of indices of stress, anxiety, and depression among CASD. This study aimed to examine whether there is variation in the performance of indices of stress, depression, and anxiety explored via Depression, Anxiety and Stress Scale 21 among CASD, caregivers of children with intellectual disabilities, and caregivers of typically developing children. All indices of stress, depression, and anxiety were higher in CASD compared to other caregivers in the control group. This study corroborates with other studies carried out in other populations that caring for children impacts the mental health status of caregivers. Therefore, there are strong grounds to contemplate the mechanism to help such a vulnerable group of family caregivers. Keywords: stress, anxiety, depression, caregivers, autism, Oman

Maha AH Sulaiman,1 Yahya M Al-Farsi,1 Maha M Al-Khaduri,2 Jumana Saleh,3 Mostafa I Waly4,5 1Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoudh, Sultanate of Oman; 2Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoudh, Sultanate of Oman; 3Department of Biochemistry, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoudh, Sultanate of Oman; 4Department of Food Science and Nutrition, College of Agricultural and Marine Sciences, Sultan Qaboos University, Al-Khoudh, Sultanate of Oman; 5Nutrition Department, High Institute of Public Health, Alexandria, Egypt Purpose: Literature emerging from Western countries has reported increased levels of serum oxidative stress markers among polycystic ovarian syndrome (PCOS) women. In the Arab region, there is limited research about the association between oxidative stress and PCOS. This study aimed to compare sociodemographic and clinical characteristics, sex hormones, and oxidative stress indices between PCOS women and non-PCOS women and to investigate the correlation between oxidative stress biomarkers and sex hormones.Methods: This hospital-based case-control study was conducted among reproductive-aged women. The study included 51 women diagnosed with PCOS (as per Rotterdam 2003 criteria) and 45 control women who were not diagnosed with PCOS. Serum samples were collected to measure the mean levels of the following sex hormones: total testosterone, dehydroepiandrosterone sulfate, estradiol and progesterone, as well as to measure biomarkers of oxidative stress including glutathione peroxidase (GPx), glutathione reductase (GR), glutathione (GSH), and total antioxidant capacity (TAC).Results: PCOS women exhibited clinical characteristics including irregular menses, hirsutism, and acne compared to the control group (P≤0.05). Significant differences were observed in the waist-hip ratio of PCOS women compared to controls (P=0.004). GPx and GR activity levels appeared to be higher among PCOS women compared to controls; however, no statistically significant differences were observed between the two groups (P>0.05). PCOS women had lower GSH and TAC levels compared to controls with a statistically significant difference observed for GSH levels (P=0.006). Correlation analysis showed a significant negative correlation between estradiol and TAC in the total sample (r=-0.284, P=0.005).Conclusion: This study provides supportive evidence that oxidative stress might play a role in the pathogenesis of PCOS and, hence, oxidative stress parameters could be suggested as diagnostic markers for early diagnosis of high-risk groups. Also, the study provides supportive evidence that obesity and sex hormones, particularly estradiol, in PCOS may contribute to enhanced oxidative stress. Keywords: PCOS, oxidative stress, Oman, case-control, anthropometric, glutathione

The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18–29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.

Introduction Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. Methods This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. Results A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. Conclusions Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.

Background Waterpipe tobacco smoking (WTS) prevalence in the Eastern Mediterranean Region (EMR) is among the highest in the world and it is increasing with time. This paper aims to investigate waterpipe harm believes among university students who smoke waterpipe in five EMR countries. Methods This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Palestine, Oman, and the United Arab Emirates (UAE). Participants were recruited from among young adult students (18-29 years) at selected universities in each country. Data were collected using an Internet-based survey. Participants were included if they were waterpipe tobacco smokers and at least 18 years of age (including users of cigarettes, WTS, and dual users). Results In most countries, participants (70%-80%) had initiated WTS with a friend or several friends with the exception of Palestinians where 31% started smoking with family members and Egyptians where 22% started smoking alone. More than 70% of the participants from Oman, UAE and Egypt started smoking in a café; or restaurants while around 50% of the participants from Jordan and Palestine started smoking at home or someone else's home. Sixty percent had smoked waterpipe and 44.5% had smoked cigarettes in the past 30 days. Most participants from the five countries were aware that WTS can cause harm during pregnancy. Around 30% of participants had misperceptions about waterpipe as a cause of cancer or death. Participants from Egypt seemed to have the least knowledge about WTS harm. Those who smoked cigarettes in the past 30 days had generally good knowledge about WTS harms compared to waterpipe smokers. Conclusions Misperception of waterpipe harm is common among university students in the five EMR countries. Culturally adapted awareness champagnes targeting young adults including university students are needed in all countries

Background Waterpipe smoking originated in the Eastern Mediterranean region. It is highly prevalent among university students, and has been increasing in popularity despite mounting evidence showing it is harmful to health. The aim of this study was to measure preferences for waterpipe smoking and determine which product characteristics are most important to smokers. Methods Participants in 5 countries (Egypt, Jordan, Oman, Palestine, and UAE) completed an Internet-based discrete choice experiment to reveal their preferences for, and trade-offs between, the attributes of hypothetical waterpipe smoking sessions. Participants were presented with waterpipe lounge menus, each with 6 fruit-flavored options and 1 tobacco flavored option, in addition to an opt out option. Participants were randomized to either receive menus with a pictorial+text health-warning message or no message. Multinomial and nested logit models were used to estimate the impact on consumer choice of attributes and between-subject assignment of health warnings respectively. Results On average, participants preferred fruit-flavored varieties to tobacco flavor. They were averse to options labelled with higher nicotine content. Females and non-smokers of cigarettes were more likely than their counterparts to prefer flavored and nicotine-free varieties. Participants exposed to a health warning were more likely to opt out. Conclusions Fruit-flavored tobacco and lower nicotine content labels, two strategies widely used by the industry, increase the demand for waterpipe smoking among young adults. Waterpipe-specific regulation should limit the availability of flavored waterpipe tobacco and require accurate labelling of constituents. Waterpipe-specific tobacco control regulation, along with research to inform policy, is required to curb this emerging public health threat.

Background Waterpipe tobacco smoking is a global public health problem that originated in the Eastern Mediterranean region (EMR). It is highly prevalent among university students, and has been increasing in popularity despite mounting evidence showing it is harmful to health. The aim of this study was to evaluate responses to various health warning messages and their location on waterpipe devices, among young residents of EMR countries. Methods Adult university students who were waterpipe smokers completed an Internet-based survey across 5 EMR countries (Egypt [N=728], Jordan [N=790], Oman [N=117], Palestine [N=772], and UAE [N=180]). The survey evaluated their responses to text-only and pictorial waterpipe-specific health warnings and their location on waterpipe devices. Results Among both text-only warnings and text + pictorial warnings, messages that communicated harm to children were rated highest in raising concerns about the health consequences of smoking and in motivating smokers to think about quitting. In terms of warning location, the mouthpiece was rated as most noticeable to smokers. Conclusions This study is the first to compare responses to waterpipe-specific health warnings across EMR countries. Requiring health warnings on waterpipe devices may be an effective policy to educate smokers about the consequences of waterpipe use.

Background: As part of formative work to inform an interventional design to increase physical activity (PA) in patients with type 2 diabetes in Oman, this qualitative study aimed to determine health professionals' perception of barriers and opportunities, personnel responsibilities and plausible PA promotional approaches.Methods: Four focus group discussions were carried out with groups of health care professionals (family physicians, dieticians and health educators, managers and general practitioners). All discussions were audio recorded and transcribed. Responses were analysed using a thematic analysis.Results: Barriers to PA reported by participants (n = 29) were identified at three levels: health care system (e.g. deficient PA guidelines); individual (e.g. obstructive social norms) and community (e.g. lack of facilities). Participants felt that a multilevel approach is needed to address perceived barriers and to widen current opportunities. In the presence of various diabetes primary care providers, the potential for dieticians to include individualised PA consultations as part of their role was highlighted. Participants felt that consultations should be augmented by approaches within the community (volunteer support and/or appropriate facilities). However, despite lack of experience with technology supported approaches and motivational tools, the telephone application "WhatsApp" and use of pedometers were considered potentially suitable. The need for training in behaviour change techniques and clearly communicated intervention guidelines was emphasised.Conclusions: A multi-component approach including PA consultations, possibly led by trained dieticians, technological routes for providing support along with community mapping for resources appear to offer promising approaches for further PA intervention studies within diabetes primary health care.

Dysfunction of the serotoninergic and glutamatergic systems is implicated in the pathogenesis of autism spectrum disorder (ASD) together with various neuroinflammatory mediators. As the kynurenine pathway (KP) of tryptophan degradation is activated in neuroinflammatory states, we hypothesized that there may be a link between inflammation in ASD and enhanced KP activation resulting in reduced serotonin synthesis from tryptophan and production of KP metabolites capable of modulating glutamatergic activity. A cross-sectional study of 15 different Omani families with newly diagnosed children with ASD (n = 15) and their age-matched healthy siblings (n = 12) was designed. Immunological profile and the KP metabolic signature were characterized in the study participants. Our data indicated that there were alterations to the KP in ASD. Specifically, increased production of the downstream metabolite, quinolinic acid, which is capable of enhancing glutamatergic neurotransmission was noted. Correlation studies also demonstrated that the presence of inflammation induced KP activation in ASD. Until now, previous studies have failed to establish a link between inflammation, glutamatergic activity, and the KP. Our findings also suggest that increased quinolinic acid may be linked to 16p11.2 mutations leading to abnormal glutamatergic activity associated with ASD pathogenesis and may help rationalize the efficacy of sulforaphane treatment in ASD. Autism Res 2016, 9: 621-631. © 2015 International Society for Autism Research, Wiley Periodicals, Inc.

Urinary stones are a common problem in Oman and their composition is unknown. The aim of this study is to analyze the components of urinary stones of Omani patients and use the obtained data for future studies of etiology, treatment, and prevention. Urinary stones of 255 consecutive patients were collected at the Sultan Qaboos University Hospital. Stones were analyzed by Fourier transform infrared spectrophotometer. The biochemical, metabolic, and radiological data relating to the patients and stones were collected. The mean age was 41 years, with M:F ratio of 3.7:1. The common comorbidities associated with stone formation were hypertension; diabetes, benign prostate hyperplasia; urinary tract infection; obesity; and atrophic kidney. The common presentation was renal colic and flank pain (96 %). Stones were surgically retrieved in 70 % of patients. Mean stone size was 9 ± 0.5 mm (range 1.3–80). Stone formers had a BMI ≥ 25 in 56 % (P = 0.006) and positive family history of stones in 3.8 %. The most common stones in Oman were as follows: Calcium Oxalates 45 % (114/255); Mixed calcium phosphates & calcium oxalates 22 % (55/255); Uric Acid 16 % (40/255); and Cystine 4 % (10/255). The most common urinary stones in Oman are Calcium Oxalates. Overweight is an important risk factor associated with stone formation. The hereditary Cystine stones are three times more common in Oman than what is reported in the literature that needs further genetic studies.

Aim The aim of this study was to estimate the prevalence and predictors of depression among Oman adult population attending primary healthcare clinics (PHCs) in Muscat Governorate in 2011. Methodology A cross-sectional study was conducted on 2005 participants attending 27 different PHCs in Muscat Governorate during 2011. A Patient Health Questionnaire (PHQ-9), together with a socio-demographic and relevant clinical data questionnaire was administered. Results Of the 2005 participants, 61.8% were women and 42.1% were of 25-50 age group. Of the total, 44.4% were employed, of whom 51% were government employees. The prevalence of depression among them was 8.1%. The adjusted odds ratios generated by logistic regression models indicated that depression was significantly associated with age greater than 50 years old (OR = 2.23; 95% CI 1.07, 4.22; P = 0.04), female (OR = 1.34; 95% CI 1.12, 3.82; P = 0.03), married (OR = 1.91; 95% CI 1.11, 3.30; P = 0.02), graduated or attended higher education (OR = 1.40; 95% CI 1.03, 2.66; P = 0.04), working in the private sector if employed (OR = 1.72; 95% CI 1.08, 2.75; P = 0.02), and having chronic illness such as diabetes mellitus, hypertension, asthma, heart, thyroid, and renal diseases (OR = 1.82; 95% CI 1.03, 3.51; P = 0.01). Conclusion The rate of depression appears to be in the lower range compared to rate reported from elsewhere. Some socio-cultural factors that may contribute to the present findings are discussed.

Maha AH Sulaiman,1 Yahya M Al-Farsi,1 Maha M Al-Khaduri,2 Mostafa I Waly,3 Jumana Saleh,4 Samir Al-Adawi5 1Department of Family Medicine and Public Health, 2Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, 3Department of Nutrition and Food Sciences, College of Agricultural and Marine Sciences, 4Department of Biochemistry, 5Department of Behavioral Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Sultanate of Oman Purpose: Previous studies in Euro-American populations have shown that women with polycystic ovarian syndrome (PCOS) have increased levels of “psychological burden”. While PCOS has been reported in Arab countries such as Oman, there is a dearth of studies of the occurrence of psychological burden among PCOS women in the Arab region. This study aimed to compare sociodemographic and clinical characteristics of PCOS women diagnosed with non-PCOS women and prevalence of severity of depression, anxiety and stress and to explore the association between PCOS and indices of psychological disturbances after adjusting for potential confounding factors.Patients and methods: This hospital-based case–control study was conducted among women aged 16–49years. The study included 52 women diagnosed with PCOS (as per Rotterdam 2003 criteria) and 60 control who were PCOS-free. The presence of psychological burden – depression, anxiety and stress – was quantified using Depression, Anxiety and Stress Scale-21 (DASS-21).Results: The crude odds ratios (ORs) generated by logistic regression models indicated an increased risk of depression, anxiety and stress among women with PCOS compared to controls. The adjusted OR also indicated an increased risk of depression (OR =1.10; 95% confidence interval [CI] 0.50, 2.43), anxiety (OR =1.09; 95% CI 0.47, 2.52) and stress (OR =1.45; 95% CI 0.68, 3.12), However, no statistical differences were observed along the three psychological distresses (p>0.05) between the two study groups.Conclusion: The study indicates that the presence of PCOS is associated with an increased risk of psychological burden. If this study will withstand further scrutiny, meeting psychological needs of such population would need to be contemplated. Keywords: PCOS, depression, anxiety, stress, Oman, case–control

BACKGROUND It is indicated that Oman is witnessing an increase in issues pertinent to alcohol and psychoactive substance use. AIM The aim of this study was to identify the characteristics of Omanis with substance use disorder attending a specialized hospital in Oman and the pattern of their utilization of healthcare services. A related aim was to ascertain the age group most vulnerable to alcohol and substance use in Oman. METHOD A cross-sectional study was conducted in a tertiary care center specialized for treatment of those engaging in substance use in Oman. The participants in the study were selected from a convenience sample among patients seeking consultation at the center for alcohol and substance use. A six-part questionnaire was designed to obtain information regarding socio-demographic background, clinical history, healthcare utilization and perceived hurdles to access. Chi-square analyses were used to evaluate the significance of differences among categorical data. Logistic regression modelling was used to obtain measures of association after adjusting for confounding factors. RESULTS Among the patients (n = 293) seeking cessation therapy, 99% were male and less than 30 years of age. Peer influences on the initiation of substance use were significant. Most patients had a history of polysubstance use, including intravenous substance use. Cannabis and alcohol were the first substances consumed by most patients and Hepatitis C and psychiatric disorders were found to be the most common co-morbidities. The participants that reported use of cannabis and benzodiazepines were more likely to perceive "improvement" upon receiving treatment. CONCLUSION This study indicated that males below 30 years of age with a history of polysubstance use were likely to attend a hospital specialized in treating substance use disorder in Oman. This study identified information regarding socio-demographic background, risk factors and perceived hurdles to healthcare that could serve as groundwork for further studies conducted on newly emerging issues of substance use in Oman.

Background Benefits of physical activity in the management of diabetes are well documented. However, evidence on the effectiveness of interventions integrating physical activity in diabetes care is sparse especially in the countries of the Gulf Cooperation Council. The results from this study will increase our understanding of the use of multi-component interventions aimed at increasing physical activity levels in inactive adults with type 2 diabetes in primary health care in Oman. Methods/design The study is a one year 1:1 cluster randomized controlled trial of the MOVEdiabetes programme (intervention) versus usual care in eight primary health care centres in Oman. The MOVEdiabetes programme utilizes face to face physical activity consultations promoting 150 min of moderate to vigorous physical activity per week (≥600MET-mins/week), pedometers to self-monitor step counts and monthly telephone WhatsApp messages for follow up support. Inactive adults with type 2 diabetes and no contraindication to physical activity will be recruited over a two months period, and followed up for 12 months. To demonstrate a 50% between group difference in physical activity levels (MET-mins/week) over 12 months, (at a power of 80%, and significance level of 5%), 128 participants would be required to complete the study (64 in each arm). Based on a drop-out rate of 20%, 154 participants would require to be recruited (77 in each arm). Assuming a recruitment rate of 70%, 220 potential eligible participants would need to be approached. The primary outcome is change in levels of physical activity measured by the Global Physical Activity Questionnaire. In addition, accelerometers will be used in a sub group to objectively assess physical activity. Secondary outcomes include changes in metabolic and cardiovascular biomarkers, change in self-reported health, social support, self-efficacy for physical activity, and perceived acceptability of the program. All intervention delivery and support costs will be monitored. Discussion This study will contribute to the evidence on the feasibility, cultural acceptability and efficacy of interventional approaches for increasing physical activity in primary care for persons with type 2 diabetes in Oman. Trial registration International Standard Randomised Controlled Trials No: ISRCTN14425284 . Registered 12 April 2016.

Genetic, nutrition, and environmental factors have each been implicated as sources of risk for autism. Oxidative stress, including low plasma levels of the antioxidant glutathione, has been reported by numerous autism studies, which can disrupt methylation-dependent epigenetic regulation of gene expression with neurodevelopmental consequences. We investigated the status of redox and methylation metabolites, as well as the level of protein homocysteinylation and hair mercury levels, in autistic and neurotypical control Omani children, who were previously shown to exhibit significant nutritional deficiencies in serum folate and vitamin B12. The serum level of glutathione in autistic subjects was significantly below control levels, while levels of homocysteine and S-adenosylhomocysteine were elevated, indicative of oxidative stress and decreased methionine synthase activity. Autistic males had lower glutathione and higher homocysteine levels than females, while homocysteinylation of serum proteins was increased in autistic males but not females. Mercury levels were markedly elevated in the hair of autistic subjects vs. control subjects, consistent with the importance of glutathione for its elimination. Thus, autism in Oman is associated with decreased antioxidant resources and decreased methylation capacity, in conjunction with elevated hair levels of mercury.

Spirulina (SP) ( Arthrospira platensis ; previously Spirulina platensis ) is a filamentous blue-green microalga (cyanobacterium) with potent dietary phytoantioxidant and anticancerous properties. We investigated the chemopreventive effect of SP against 7,12-dimethylbenz[ a ]anthracene (DMBA)–induced rat breast carcinogenesis, and further studied its underlying mechanisms of action in vitro . Remarkably, SP cleared DMBA-induced rat mammary tumors, which was clearly confirmed by morphological and histological methods. SP supplementation reduced the incidence of breast tumors from 87% to 13%. At the molecular level, immunohistochemical analysis revealed that SP supplementation reduced expression of both Ki-67 and estrogen α. More interestingly, molecular analysis in the in vitro experiments indicated that SP treatment inhibited cell proliferation by 24 hours, which was accompanied by increased p53 expression, followed by increased expression of its downstream target gene, Cdkn1a (alias p21 or p21 Waf1/Cip1 ). In addition, SP increased Bax and decreased Bcl-2 expression, indicating induction of apoptosis by 48 hours after SP treatment. To our knowledge, this is the first report of in vivo chemopreventive effect of SP against DMBA-induced breast carcinogenesis in rat, supporting its potential use in chemoprevention of cancer.

Children with special needs such as those with autism spectrum disorder have been recorded as ostracized and stigmatized in many parts of the world. Little is known about whether such negative views are present among mainstream teachers in Oman. A cross-sectional study was conducted to evaluate school teachers’ awareness about autism spectrum disorder in an urban region in Oman. A total of 164 teachers were randomly enrolled from five schools. Misconceptions about autism spectrum disorder were found to be common among mainstream teachers in the country. We posit that such lack of awareness was likely to be rooted with sociocultural patterning as well as conflicting views often “spun” by the scientific community and mass media. Enlightened views toward children with autism spectrum disorder should be presented to Omani teachers to overcome misconceptions and negative attitudes toward children with autism spectrum disorder.

Objective: Few studies have examined clinical and demographic profile of attendees at a walk-in psychiatric clinic in countries rav aged by wars. The aim of this study is to quantify the characteristics of attendees of an open walk-in psychiatric clinic in a general hospital in Baghdad and the suburb towns of Iraq in the year 2010. Methods: As part of a retrospective survey, information on specific variables (socio-demographic background, clinical characteristics and attendance rate) were sought from medical records in the year 2010 ( January to December). Results: Despite the shortcomings expected from a country coming out of the ravage of war, the survey included 2,979 attendees (1,864 [63%] males and 1,115 [37%] females) to a walk-in psychiatric clinic who fulfilled the inclusion criteria. The profile of attendees indicated that a majority of the cohort was self-referred with a predominance of employed males, aged 19 to 49 years, residing in Baghdad City. Depression and psychosis were the most common diagnosis given. Conclusion: The observed patterns are discussed within the available literature relevant to consultation liaison psychiatry, and specific to situations in Iraq and Arab/Islamic cultural patterning.