Abstract
To date there has been no previous research into a possible association between psychological distress and gynecologic symptoms in the Arab world. We hypothesized that psychological distress would be associated with specific gynecologic complaints as well as with psychosocial factors.
We conducted a cross-sectional study of women attending gynecology clinics in Beirut, Lebanon. The study sample consisted of 355 women aged 18 to 49 years who were seeking healthcare from gynecologists affiliated with two general teaching hospitals in Beirut. Psychological distress was assessed using the General Health Questionnaire (GHQ). Gynecologic complaints were assessed by asking women about presenting gynecologic symptoms.
Women who visited the gynecologists for specific complaints, for post-surgical follow-up, or for insertion of coils or other services were more likely to be distressed than women who were attending for a general checkup (χ2= 9.466, p = 0.024). About 50% of women who reported abdominal pain or breast pain also reported significant psychological distress. Only bleeding and infertility were not significantly associated with psychological distress.
It is concluded that a high proportion of women who attend gynecology clinics with specific complaints report psychological distress. Our findings highlight the importance of considering the psychological component of gynecological morbidity.
Keywords: psychological distress, psychiatric epidemiology, gynecology, primary health care
INTRODUCTION
Depression is recognized as a major factor contributing to disability around the world1. Women tend to be disproportionately affected by disability and depression, both of which are major threats to a good quality of life and the ability to sustain family life. We know that most people with psychiatric disturbances do not consult a mental health specialist2,3. Since the work of Michael Shepherd focussed attention on the nature and prevalence of psychiatric disturbances in primary healthcare settings4, major initiatives by the World Health Organization have been implemented in order to study mental health in primary care settings around the world5–7. Despite the gender differences in the prevalence and incidence of depression8–10, few studies have been conducted in practices composed primarily of women – that is, gynecological practices.
The few studies that have investigated the problem of psychological distress in gynecology outpatient clinics have found that on average about 50% of women who attend these clinics are estimated to show higher levels of psychological distress than have been found in studies of other general hospital outpatient clinics11. Gynecology clinics are an important outpatient setting because gynecologists provide services for women of reproductive age and beyond, thus functioning as primary care providers for many women12. We could find only 12 studies of psychological distress and psychiatric comorbidity among women attending to gynecology clinics13–24. Of these, only two studies were conducted in developing countries17,18, and none were undertaken in the Arab world. Investigators found a high prevalence (10–53%) of psychological distress among women attending gynecology clinics13–24. However, the estimated incidence of psychological distress in developing and developed countries differed in studies using the same instruments. The pattern of the relationship between distress and gynecological morbidity may also differ between developed and developing countries.
Lebanon is an Arab country on the eastern shore of the Mediterranean Sea, and has a population of 3 million people. Lebanese culture is a mixture of traditional Arabic and recent influences (mainly from France and the USA). The health system is dominated by a profit-oriented private sector. Although 40% of the population of Lebanon have some type of health insurance, outpatient visits are not covered. The purpose of the present study was to assess psychological distress among gynecology patients in Lebanon and to examine the relationship between psychological distress and specific patterns of gynecological morbidity. Understanding the mental health needs of women attending gynecology clinics in Lebanon is an important step towards developing effective health services and intervention strategies. By making these data available to clinicians who are treating women in Lebanon and other Arab countries, we hope to increase interest in and sensitivity to the psychological components of help-seeking among women in gynecological settings. To our knowledge, this study is the first investigation of the relationship between psychological distress and gynecologic complaints in the Arab world.
METHODS
Sampling frame
The sampling frame for the study consisted of female patients seeking gynecological care from gynecologists affiliated with two general teaching hospitals in Beirut in 1997. The two categories of patients selected were patients attending outpatient departments for gynecological services and patients attending private gynecology clinics. At each of the clinics, consecutive patients aged 18 to 49 years attending for gynecological services were interviewed over a period of 2 months. Women who were attending for prenatal care or because of obstetrical problems were excluded. The study protocol was approved by the Committee on Human Research at the Johns Hopkins University School of Hygiene and Public Health and by the American University of Beirut Institutional Review Board.
Instruments
Data were collected by means of face-to-face interviews using two structured instruments, namely the 28-item General Health Questionnaire25 (GHQ) and an instrument designed specifically for the project by the first author.
Psychological distress
Psychological distress was assessed using the 28-item version of the 60-item GHQ developed by Goldberg25 to study psychological distress in primary care and community settings. The 28-item GHQ provides four scores, which measure somatic symptoms, anxiety and insomnia, social dysfunction and severe depression, respectively. Examples of items include ‘been feeling unhappy and depressed’, ‘lost much sleep over worry’, ‘been having hot and cold spells’, ‘thinking of yourself as worthless’ and ‘scared and panicky’. The GHQ-28 is a brief screen for current psychological distress (3–4 minutes) and is strongly correlated with current, stressful life events and psychiatric treatment. The instrument has been translated into Arabic and has been used in research in Arabic-speaking countries26 and in primary care settings from developing countries27. The 28-item GHQ questionnaire was scored as recommended by Goldberg25, with a threshold of > 4 identifying a ‘case’ of psychological distress.
Reason for index visit
Each woman was asked about the main reason for her current visit – that is, whether the visit was for a check-up, related to specific complaints, was a follow-up after surgery, or was a visit for some other reason.
Gynecological complaints
Each woman was provided with a list of common complaints to facilitate identification of the reason for her visit. The list was based on the most common complaints found in a gynecological morbidity survey conducted in Beirut28, and consisted of the following: bleeding; menstrual problems; vaginal discharge; groin pain; itching and irritation; burning sensation during urination; back pain; breast pain or congestion; infertility. Each complaint was considered as a separate dichotomous variable (coded 1 if present and 0 if absent).
Medical illness
A checklist of 23 chronic conditions was used to collect data on medical comorbidity. The list of conditions consisted of common medical conditions seen in outpatient settings, including hypertension, diabetes, asthma, thyroid disease, kidney disease, anemia, cancer, cataracts and back pain. The summary score consisted of the number of conditions that were reported. For analyses, we dichotomized medical illness (coded 1 if at least one chronic medical condition was present, and 0 if no such condition was present).
Social support
Social support was assessed by means of questions about the availability of and satisfaction with personal assistance in dealing with emotional problems, financial problems, health problems, housework, and social and recreational issues. A score of 1 was given for each domain if the woman reported having personal assistance with that domain, and 0 if such a resource was not available. The five domains were summed to form a total score ranging from 0 to 5. This scale was previously used by Farhood et al.29.
Life events
Stressful life events are those events that are associated with natural occurrences such as birth, pregnancy, marriage or death in the family. A total of 26 life events experienced in the recent past by the family were assessed as described by Farhood29. The impact of life events was recorded on a 3-point impact scale where 0 = event not occurring or having no impact, 1 = mild or moderate impact and 2 = severe impact. A summary score was obtained by adding the impact element for each individual in the study across the 26 events.
Other covariates
Each respondent was asked a series of questions covering place of residence, age, education, marital status, number of children and employment status. They were also asked about the availability of a regular source of healthcare.
Analytic strategy
Bivariate associations between distress and gynecological morbidity, and other important variables were assessed. Potential multi-collinearities of independent variables were then examined by looking at pair-wise associations. Multiple logistic regression analysis with forward selection was used to estimate the probability of experiencing psychological distress after adjusting for covariates identified in the bivariate analyses. The variables included in the model were gynecological complaints with higher than 15% frequency of reporting which were significantly associated with psychological distress at the bivariate level, in addition to other covariates that were significantly correlated with psychological distress. Interaction terms were then added to the model and checked if they displayed any statistically significant effect. The Bonferroni correction method was used to control the overall error rate by dividing the latter by the total number of tests performed. Thus the observed significance level was adjusted for multiple comparisons. The data analyses were performed using SPSS version 7.5.
RESULTS
Study sample
Of the 360 female patients who were approached, and eligible for interview, 322 patients completed the interviews (90% participation rate), 33 patients had an incomplete interview (9%) and 5 patients declined participation in the study. Comparison of women who completed the interview with those who had an incomplete interview revealed no significant differences in demographic data apart from marital status. A higher proportion of women who had incomplete interviews were unmarried compared with those who had complete interviews (χ2= 4.916, p = 0.027). The two groups also differed with regard to the presence of chronic illness. Women who had incomplete interviews were more likely than others to report at least one chronic condition (81.8% vs. 57.1 χ2 = 7.559, p = 0.006). In total, 355 female respondents considered for the study were seen by gynecologists in two hospitals. Of these women, 208 patients were visiting private clinics and a further 147 patients were seen by gynecologists in outpatient departments. Of the 355 patients who participated in this study, 308 women completed the GHQ.
Comparison of the two groups of patients from private clinics and outpatient departments revealed that the women who presented to outpatient departments were significantly more likely than the private patients to have a lower level of education (χ2 = 135.17, p < 0.001), to be in the age group 18–24 or 44–50 years (χ2= 9.38, p = 0.025), to have a larger number of children (χ2 = 10.13, p = 0.017), and to have visited the doctor for a check-up or other preventive services (χ2 = 15.76, p< 0.001). There was no significant difference between the two groups with regard to marital status.
Baseline characteristics
Table 1 shows the profile of the study sample. In total, 48% of the women were from Beirut. The age range of the participants was 18–50 years, with a mean age of 34.45 years. Approximately one-third of the women had received a university education, a further 22.3% had received secondary education, and 47.3% had received less than a secondary education. A total of 144 women (40.6%) reported having no chronic medical condition. The rest reported at least one such condition, but the majority reported only one condition. The most frequently cited condition was migraine, followed by anemia, psychological problems, ulcer and hypertension. More than two-thirds of the women (83.4%) were married. The majority of the respondents (68.9%) were seeking care mainly for gynecological complaints. A total of 61 women (17.4%) were attending the clinic for a general check-up. The rest of the sample was attending the clinic for other preventive services such as intrauterine device (IUD) insertion (8.8%), for a consultation about contraceptive use, to obtain a prescription, or to make a follow-up visit after surgery (3.7%).
Table 1.
Sample Characteristics.
| Characteristics | Number | Percentage |
|---|---|---|
| Place of interview | ||
| Outpatient department | 147 | 41.1 |
| Private clinics | 208 | 58.6 |
| Place of residence | ||
| Beirut | 169 | 47.6 |
| Outside Beirut | 186 | 52.4 |
| Age (years) | ||
| 18–24 | 54 | 15.2 |
| 25–34 | 115 | 32.4 |
| 35–44 | 139 | 39.2 |
| 45–49 | 47 | 13.2 |
| Education | ||
| None or elementary | 72 | 20.3 |
| Intermediate | 96 | 27.0 |
| Secondary | 79 | 22.3 |
| University | 108 | 30.4 |
| Marital status | ||
| Married | 296 | 83.4 |
| Single | 36 | 10.1 |
| Divorced/separated or widowed | 23 | 6.5 |
| Number of children* | ||
| None | 69 | 22.3 |
| 1–2 | 104 | 33.7 |
| ≥3 | 135 | 44.0 |
| Employment status* | ||
| Unemployed | 262 | 74.0 |
| Employed | 92 | 26.0 |
| Chronic medical conditions | ||
| None | 211 | 40.6 |
| One or more | 144 | 59.4 |
| Reason for visit* | ||
| Gynecological complaint(s) | 242 | 68.9 |
| Check-up | 61 | 17.4 |
| Follow-up after surgery | 13 | 3.7 |
| Other | 28 | 8.8 |
Totals do not add up to 355 due to missing or inapplicable information
Psychological distress
The internal reliability of the 28-item GHQ was assessed using the study data. The resultant Cronbach’s α value was 0.91. The bivariate analyses of psychological distress and other covariates in the study are shown in Table 2. Women who visited the gynecologists for specific complaints, for follow-up after surgery, for insertion of an IUD or for other services were more likely to be psychologically distressed than women who were attending for a general check-up (χ2= 9.466, p = 0.024). Table 2 also shows the complaints in rank order of proportion of high scorers. The highest proportion of high scorers for psychological distress was among women who presented with abdominal pain, followed by those who complained of breast pain. Around 50% of women who reported abdominal pain or breast pain were psychologically distressed. The only two gynecological complaints that were not significantly associated with psychological distress were bleeding and infertility. The presence of any of the other complaints was statistically significantly associated with an increased likelihood of experiencing psychological distress. The proportion of psychological distress among women who reported specific complaints ranged from 26.3% to 48.9%.
Table 2.
Sample characteristics according to presence of psychological distress as assessed by the General Health Questionnaire (score > 4): percentage values are shown
| Characteristics | Psychological distress (n = 75) |
No psychological distress (n = 233) |
χ2F-test and p-value |
|---|---|---|---|
| Age (years) | |||
| 15–24 | 32.0 | 68.0 | p > 0.05 |
| 25–34 | 27.1 | 72.9 | |
| 35–44 | 19.5 | 80.5 | |
| 45–49 | 23.1 | 76.5 | |
| Education | |||
| Illiterate/can read and write | 29.0 | 71.0 | p > 0.05 |
| Intermediate | 19.3 | 80.7 | |
| Secondary | 21.2 | 78.8 | |
| University | 27.8 | 72.2 | |
| Marital status | |||
| Single | 37.5 | 62.5 | p > 0.05 |
| Married | 23.4 | 76.6 | |
| Divorced/separated or widowed | 15.0 | 85.0 | |
| Number of children | |||
| None | 29.6 | 70.4 | p = 0.071 |
| 1–2 | 28.4 | 71.6 | |
| > 3 | 16.7 | 83.3 | |
| Stressful life events | |||
| Low score | 17.2 | 82.8 | p = 0.005 |
| High score | 31.1 | 68.9 | |
| Social support | |||
| Mean score | 4.24±0.59 | ||
| 4.79±1.13 | NA | p < 0.001 | |
| Reason for visit | |||
| Gynecological complaint(s) | 26.9 | 73.1 | p = 0.024 |
| Check-up | 7.7 | 92.3 | |
| Follow up after surgery | 33.3 | 66.7 | |
| Other | 29.2 | 70.8 | |
|
Gynecological complaints (only those who reported the complaint are included; n = number with specific complaint) | |||
| Abdominal pain(n = 51) | 48.9 | 51.1 | p < 0.001 |
| Breast pain (n = 29) | 44.4 | 55.6 | p = 0.035 |
| Irritation and itching (n = 43) | 42.9 | 57.1 | p = 0.022 |
| Vaginal discharge (n = 74) | 41.9 | 58.1 | p = 0.002 |
| Groin pain (n = 77) | 38.5 | 61.5 | p = 0.017 |
| Menstrual irregularity (n = 111) | 35.5 | 64.5 | p = 0.021 |
| Back pain (n = 91) | 35.1 | 64.9 | p = 0.062 |
| Burning sensation on urination (n = 51) | 32.6 | 67.4 | p = 0.022 |
| Bleeding (n = 17) | 28.6 | 71.4 | p = 0.925 |
| Infertility (n = 43) | 26.3 | 73.7 | p = 0.858 |
NA, Not available
With regard to the predisposing factors, there was no significant variation in psychological distress with age and level of education. However, stressful life events, a regular source of care, and social support were all significantly associated with psychological distress. A higher level of psychological distress was found among women with high scores for life events compared with women with low scores (31.1% vs. to 17.2%; χ2 = 7.967, p = 0.005). Among those women with no regular source of care, 45.9% were psychologically distressed, compared with 15.8% of those who had a regular source of care (χ2 = 30.747, p = < 0.001). With regard to social support, women who were psychologically distressed had a lower total score for support than women who were not psychologically distressed, and the difference in mean scores was significant (F= 29.877, p < 0.001). Single women were not more likely to be psychologically distressed than married, divorced or widowed women. Taking into account only married women, the association between psychological distress and number of children was of borderline significance (p = 0.071), with women who had three or more children being less likely to experience psychological distress than women who had fewer children. Insurance, income, employment and clinic location were not found to be significantly correlated with psychological distress.
The results of the multivariable models are shown in Table 3. All potentially influential covariates were included in multivariable models if they were statistically significant (p < 0.05) in univariate analyses. Women without a regular source of care were more likely to experience psychological distress as measured by the GHQ than were those with a regular source of care (adjusted odds ratio (OR) = 7.56, 95% confidence interval (CI) = 3.37, 15.57). With regard to gynecological complaints, women with menstrual problems were more likely to experience psychological distress as measured by the GHQ than were those without menstrual problems (adjusted OR = 3.37, 95% CI = 1.68, 6.77). In addition, women who reported groin pain were nearly three times more likely than women who did not report such pain to experience psychological distress (OR = 2.97, 95% CI = 1.41, 6.24). A goodness-of-fit diagnostic and plots of the deviance residuals vs. fitted values predicted by each of the models showed that the coefficient estimates were not appreciably influenced by any one observation. We also considered several potential interaction terms. However, none of the latter reached the level of significance (p = 0.05).
Table 3.
Relationship between personal characteristics and presence of psychological distress, adjusting for potentially influential covariates shown in the table and life events and social support scores (entered as continuous variables); 95% confidence intervals are shown in parentheses*
| Personal characteristic | Odds ratio for presence of psychological distress |
|---|---|
| Does not have a regular source of medical care (reference group has a regular source of care) |
7.56† (3.67, 15.94) |
| Menstrual problems (reference group has no menstrual problems) |
3.37† (1.68, 6.77) |
| Groin pain (reference group has no groin pain) |
2.97† (1.41, 6.24) |
Variables not retained after forward selection were age, education, marital status, type of clinic, reason for visit, vaginal discharge, and abdominal pain
p < 0.01
DISCUSSION
One in four women who were attending gynecology clinics in two major hospitals in Beirut, Lebanon, reported significant psychological distress as assessed by means of a standardized questionnaire. Our finding was consistent with the average rates reported in the World Health Organization study on mental illness in primary care settings from 15 centers around the world27. However, the proportion of distressed women was lower than that reported from other studies conducted in gynecology clinics using the GHQ17–20,23, but similar to the rates reported from developing countries such as India and Nigeria17,18. In all countries, the high frequency of psychological distress among gynecology patients would appear to merit attention and further study13–24.
Before we discuss our findings and place them within the context of other studies, the potential limitations of this study deserve comment. Because the study was cross-sectional, we were unable to delineate fully the temporal relationships between psychological distress and gynecological complaints. Although our samples were not randomly selected from gynecology clinics in Beirut, the study sample was similar with regard to age, marital status and number of children to a sample of women selected from 27 clinics in Beirut for a study on reproductive health28. Our sample had a higher, proportion of illiterate and unemployed women, as might be expected in view of the fact that the participating clinics serve sections of Beirut that have low socioeconomic status. We were unable to determine whether any of the women whom we surveyed would have fulfilled standard criteria for major depression or for any other psychiatric disorder. In addition, we could not ascertain whether physicians assessed patients for psychological distress, discussed ways of reducing such distress with these women, or treated depression. We may have found reduced levels of psychological distress if the women were interviewed after doctor visits. These are all considerations for future research on the health services in Lebanon.
Limitations notwithstanding, our study showed that a significantly higher proportion of women with a specific gynecological complaint report psychological distress compared with women who attend for a regular check-up. Considering each gynecological symptom separately, the highest proportion of women experiencing psychological distress was among those complaining of abdominal pain (48.9%), and the lowest proportion was among those with infertility (26.3%). The results of our study confirm that depressive symptoms are common in gynecological practice, and together with the findings of other studies they highlight the importance of gynecology settings in the detection of psychological distress.
Table 4 summarizes the findings of published studies and lists the salient features in terms of population surveyed, instruments used for assessment, the prevalence of psychological distress, and factors associated with psychiatric morbidity. The table lists studies from the USA, UK, Belgium, Australia and Austria, as well as from India and Nigeria, and also includes our study based in Lebanon. Many of the investigations employed the GHQ as a measure of psychological distress, as we have done here25. As assessed by the GHQ, rates of psychological distress ranged from 33% to 53% among different samples derived from gynecology outpatient clinics17–20,23. Investigators from the UK and Australia reported a somewhat higher frequency of psychological distress (46–53% of women)19,20,23. In contrast, studies in India and Nigeria found rates of 33% and 35%, respectively17,18. Our study found that 24% of women attending gynecology clinics in Lebanon were experiencing psychological distress. Our literature review revealed that women attending gynecology clinics in developing countries reported slightly lower rates of psychological distress than the rates reported by women in developed countries, but a large number of women were affected in all of these countries.
Table 4.
Summary of studies that have estimated the prevalence of psychological distress in women attending gynecological clinics
| Study | Design | Sample | Assessment instrument |
Prevalence of psychological distress |
Factor(s) associated with psychiatric morbidity |
|---|---|---|---|---|---|
| Sainsbury, 196021(UK) |
C |
n = 1513 aged 20–59 years, from two general hospitals |
MPI | Gynecology patients tended to have high neuroticism scores; |
N/A |
| Munro, 196922 (UK) |
C |
n = 164, first attenders, mean age 37 years |
Foulds Personal Illness Inventory |
10% | Vague complaints Excessive menstrual or postmenopausal bleeding |
| Ballinger, 197723 (UK) |
L |
n = 272 aged 40–55 years |
GHQ and standard psychiatric interview |
53% (GHQ) | Hysterectomy |
| Byrne, 198419 (UK) |
C |
n = 230 new referrals, aged 18–65 years |
GHQ and PSE | 46% (GHQ) 29% (PSE) |
Marital status Age Pelvic pain Life events |
| Abiodun et al., 199218(Nigeria) |
C | n = 233 | GHQ and PSE | 35% | History of induced abortion Previous marriage Having no children Menstrual abnormalities Chronic pelvic pain Unsupportive husband |
| Chaturvedi et al., 199417 (India) |
C |
n = 100, 50 gynecological outpatients, and 50 inpatients |
GHQ and PSE | 33% GHQ 36% PSE |
Uterine prolapse infections |
| Wancata et al., 1996)16 (Austria) |
C |
n = 728 inpatients (241 patients from a gynecological department |
CIS | 21% | Single Low socioeconmic status Rural |
| Worsley et al., 1997)20 (Australia) |
C | n = 97 | GHQ | 50% | Role problems Menstrual problems Psychologically oriented illness |
| Miranda etal., 1998)14 (USA) |
C | n = 205 | PRIME-MD | 48% | Physical abuse Sexual abuse |
| Buekens et al. (1998)13 (Belgium) |
C | n = 2174 | Goldberg Depression Scale |
35% (≥ 2 symptoms) 19% (≥4 symptoms) |
N/A |
| Alvidrez and Azocar, 199924 (USA) |
C | n = 217 | PRIME-MD | 44% | Fewer than half of the women meeting criteria for depression identified themselves as depressed |
| Spitzer et al., 200015 (USA) |
C | n = 3000 | PRIME-MD | 20% | Functional impairment Disability days Healthcare use Psychosocial stressors |
| Chaaya et al., 2003 (this study) (Lebanon) |
C | n = 308 | GHQ | 24% | Menstrual problems Groin pain Regular source of medical care Stressful life events Social support |
C, cross-sectional; CIS, Clinical Interview Schedule; GHQ, General Health Questionnaire; L, longitudinal; N/A, not applicable; MPI, Maudsley Personality Inventory; PSE, Present State Examination; PRIME-MD, primary care evaluation of mental disorders
Table 4 clearly shows that a variety of factors appear to be related to psychiatric morbidity among women attending gynecology clinics. In the UK, hysterectomy and complaints about abnormal menstrual bleeding23 and pelvic pain19 were found to be more frequent among women who experienced psychological distress. In Australian gynecological patients, the women with psychological distress also had more complaints about menstrual problems20. In Nigeria, psychological distress was most commonly associated with infertility18. In India, an increased prevalence of psychological distress was reported in patients with uterine prolapse and pelvic infections who were selected equally from inpatient and outpatient gynecological clinics17. Complaints that were found to be significantly associated with psychological distress in our study sample (e.g. abdominal pain, menstrual irregularity) have therefore been reported in other studies from both developing and developed countries17–20,23. Our study demonstrated the remarkable similarity of the specific gynecological complaints associated with psychological distress among women from different countries.
In conclusion, our findings further highlight the importance of considering the psychological component of gynecological morbidity. Since women attending gynecology clinics show high levels of psychological distress, the mental health needs of these women may also be substantial. In Lebanon as well as in other countries, gynecologists should be trained both to recognize mental disorders in the outpatient setting, and to assess when treatment and referral are necessary. This will help to ensure a high quality of healthcare in gynecology settings.
Current knowledge on this subject
No previous research has investigated a possible association between psychological distress and gynecological symptoms in the Arab world
On average 50% of women attending gynecology outpatient clinics are estimated to be distressed
The estimated rates of psychological distress in developing and developed countries were different in studies using the same instruments
What this study adds
A high proportion of women who attend gynecology clinics with specific complaints report psychological distress
The specific gynecological complaints associated with psychological distress are remarkably similar among women from different countries
It is important for gynecologists to consider the psychological component of gynecological morbidity
ACKNOWLEDGEMENTS
This study was supported in part by the Andrew Mellon Fund and the University Research Board at the American University of Beirut.
Footnotes
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Contributor Information
M. M. Chaaya, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
H. R. Bogner, Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
J. J. Gallo, Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
P. J. Leaf, Department of Mental Hygiene, Johns Hopkins University, Baltimore, Maryland, USA
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