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Sources of health education for international Arab pilgrims and the effect of this education on their practices towards health hazards in hajj, 1427 H (2006)

The Saudi Ministry of Health provides numerous curative and prophylactic services during hajj. One of these services is the health education program to increase the awareness of pilgrims on the health hazards that they may encounter. This cross-sectional study was conducted to identify the sources of health education to international Arab pilgrims, and to assess the degree of benefit from this education, during Hajj 1427 H. Study subjects were selected by stratified random cluster sampling. A self-administered questionnaire was used for data collection.
Important health education messages were evaluated, whether pilgrims had received health education on these topics, and whether received in their native countries, on their way to Saudi Arabia, or in Saudi Arabia. Also, pilgrims knowledge was evaluated on 9 important hajj topics: ensuring the expiry dates of foods; food storage; avoiding crowded areas; washing hands before and after eating; avoiding used shaving blades; using the wrist band; avoiding other people's nasal secretions; taking the meningitis vaccine before coming to hajj; using an umbrella; and use of face-mask. The final score was calculated out of 9, after which pilgrims were divided into two groups: those who scored 5 and above as having good knowledge and those who scored 4 and under as having poor knowledge.
A total of 500 pilgrims participated in this study, representing 15 Arab countries. The highest proportion (20.2%) came from Egypt, while the lowest came from Mauritania (3.0%); 90% were male; their ages ranged from 11 to 84 years (mean 43.5, Standard deviation ± 11.9); 53.0% had an education level of university and above, while 6.2% were illiterate; those performing hajj for the first time were 67.4%; 95.8% had come with an organized hamla. Transportation into Saudi Arabia was by airplanes (75.6%), cars or buses (21.2%), or ships (3.2%).
Over two-thirds (73.8%) had received health education, either in their native countries (64.6%), on their way (40.8%), or after reaching Saudi Arabia (45.4%).
To simplify analysis and comparison, international Arab countries were divided into 3 categories: Arabian Gulf countries, non-gulf Asian Arab countries, and African Arab countries. The highest health education had been provided to Arabian Gulf pilgrims (83.0%), and the lowest among Non gulf Asian Arabic Countries (54.6%). This difference in health education was statistically significant (p < 0.0001).
The most frequent channel used for providing health education to pilgrims in native countries was television (56.7%), pamphlets (45.5%) and lectures (44.9%).
All participating pilgrims answered that the ministries of health (MOH) were the largest source of health education in their native countries (69.0%), followed by hajj hamlas (44.0%) and Ministries of hajj (30.0%).
Regarding the timing of starting health education at native countries, 31.3% stated that it started one month before hajj, 27.2% two months before hajj, 19.5% with the beginning of the hajj journey, and 22.0% did not know. Among all participants who had received health education in their native countries, 45.5% believed that the timing of providing health education at their native countries was enough, 27.6 thought it was not enough, and 26.9 had no opinion.
About 41% stated that they had received health education on their way to Saudi Arabia. The percentage was highest among those who came by land (46.2%), followed by those who came by sea (43.8%) and air (39.2%), but there was no statistically significant difference (p = 0.41).
Among those who had received health education on their way to Saudi Arabia and had arrived by airplanes, channels used were pamphlets (49.3%), lectures (43.2%), and advice from other pilgrims (29.7%). Among pilgrims who had traveled by land, pamphlets were also used most frequently (61.2%), lectures (51.0%), and other pilgrims advice (32.7%). Among those who had traveled by sea, pamphlets (85.7%), followed by audio cassette (42.9%), and other pilgrims advice (42.9%).
After reaching Saudi Arabia, only 45.4% stated that they had received health education; pamphlets were the most frequent channel used (64.8%), followed by posters (37.9%) and television (30.4%). Among those who declared having received health education in Saudi Arabia, 60.8% stated that the MOH was the largest source of health education, followed by the Ministry of Hajj (56.8%) and general security (20.7%). Over half had received health education in Saudi Arabia at arrival points (58.1%), followed by all holy places (53.7%), and hotels in Makkah (37.0%).
Regarding knowledge of the pilgrims of important Hajj topics, those with good knowledge constituted 58.2%, and those with poor knowledge 41.8%.
Regarding the effect of health education on knowledge of pilgrims of health hazards, among those who had received health education, 58% had good knowledge and 42.0% had poor knowledge. Among those who had not received any kind of health education, 58.8% had good knowledge, and 41.2% had poor knowledge. The association of the effect of health education on knowledge of pilgrims was not statistically significant (P= 0.56).
The effect of health education on practices of pilgrims towards health hazards is demonstrated in Table 1.

Editorial note:

The main objective of health education in hajj is to increase the awareness of pilgrims on the health hazards that they may encounter, mainly focusing on food and personal hygiene, precautions to minimize acquiring infections from others, heat-related illness, use of identifying wristbands, avoidance of crowds, and hygienic head shaving.[1,2]
Each country should provide health education on the hazards encountered during hajj to their native pilgrims before hajj, since they know the cultural, social, and educational background of their people, resulting in more effective health education.[3] In this study, about two thirds of pilgrims had received health education in their native countries. The highest percent was among Gulf countries, which is expected, considering their better economical condition which may enhance the ability to use different educational channels. In comparison with a previous study,[4] there was a significant improvement in the provision of health education in Gulf countries from 54.3% to 83%, but fell in other Arab countries from 67% to about 60% in our study.
Pamphlets were the most common channel used to deliver health messages to pilgrims of Gulf countries, while television was the most common in other Arab countries. Pamphlets and TV are good examples of mass media but remain a one way channel of communication. Direct and interpersonal communication, such as lectures and doctors' advice are more persuasive and effective. The superiority of interpersonal communication over mass media for creation of motivational effect has been well documented.[5]
Health education received on the way to Saudi Arabia had an advantage that pilgrims were located in one place at the same time. However, less than half the pilgrims had received health education by this means, with better health education provided to those traveling by land. This could be due to longer available time for those who used land transportation arriving by buses with organized hamlas.
Less than half the international Arab pilgrims stated that they had received health education in Saudi Arabia in spite of the large effort made by the kingdom during hajj, when large numbers of pamphlets, posters, and tapes are distributed to pilgrims in many languages annually to achieve this purpose.[6] This could be due to lack of pilgrims time, or distribution of educational materials in areas where pilgrims are scarce.
Among pilgrims who had received health education in Saudi Arabia, over 50% had received it at arrival points, but only 12% received it in Mina where hajjis reside for more than 3 days, and which represents a good location for provision of health education.
Heat exhaustion and heatstroke are common and can be fatal during Hajj, as evidenced by one study that reported over 1700 fatalities in a single Hajj season, most of which were judged to be heat related.[7] In spite of its importance, only less than 50% of pilgrims received messages regarding the importance of taking precautions to avoid direct exposure to the sun.
Head shaving is one of the common practices among male hajjees. Using razor blade, especially if this blade was used by another, can increase the risk of blood borne infections such as HIV and hepatitis B and C from infected individuals.[2] In spite of the importance of this issue, the message given in this regard was received by less than 50% of pilgrims in our study. However, when compared with previous studies,[4] the practices of pilgrims of shaving their head hair has improved. Only about one-third of pilgrims chose razor blade for head shaving, only 2.3% of whom shared their blades with others, and over 50% of pilgrims chose to shave their heads at specialized barbershops.
Every year the messages provided to pilgrims should be reviewed according to changes in health hazards. Nowadays, with Hajj occurring during the winter months, the hazard of rain has emerged, which requires more health education efforts. However, this was found to be the least message given in our study.
This study has demonstrated that health education received by international Arab pilgrims remains inadequate.
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