Healthcare-associated infections are 20 times higher in some developing countries than in developed countries [1,2,3,4]. The results of a study on six developing countries, including Egypt, Jordan, Morocco, Sudan, Tunisia and Yemen, showed that about 18% of inpatient admissions were related to adverse events [5].

Pressure ulcers are one of the most common problems faced globally in health care settings [6]. Pressure ulcer or bed sore refers to localized damage to the skin and/or underlying soft tissue, caused by the compression of skin in different parts of the body against a bed, chair or other hard objects. More specifically, the pressure exerted on the tissue reduces blood supply to the skin, leading to the thinning of the epidermis, reduction of subcutaneous fat, and loss of collagen elasticity [7].

Despite technological advances and preventive measures, Pressure ulcers remain a major concern worldwide. The results of a 2020 study showed that in the period 2008–2018, Pressure ulcer prevalence was 12.8% worldwide, 14.5% in Europe, 13.6% in North America, 12.7% in South America, 3% in Asia, 12.6% in the Middle East, and 9% in Australia [8]. Pressure ulcer prevalence in the Eastern Mediterranean Region has varied between 7% and 44.4% [9].

Both intrinsic factors (age, nutritional status, chronic diseases, inactivity, length of stay in the ICU, immune system, radiation therapy, and mental and psychological state) and extrinsic factors (pressure, friction, duration of pressure/friction, skin abrasion, tension, temperature, humidity, trauma, swelling, infection, quality of nursing care, patient repositioning, bed position, and socioeconomic status) play a role in the incidence of Pressure ulcers [10, 11].

Pressure ulcers have many adverse effects on patients, service providers, and the society. Pain caused by Pressure ulcers is one of the most common complaints that causes patient suffering and reduces their quality of life [12, 13]. In addition, they can increase the patient's length of stay and increase the workload of health professionals by causing hospital-acquired infections and disrupting the healing process [14,15,16]. A 2011 study in Germany showed that patients with Pressure ulcers had a longer stay compared to those without Pressure ulcers (19 days versus 9.9 days). In this study, injuries caused by Pressure ulcers increased unnecessary length of stay by 2.6 days. Longer hospital stays and hospital-acquired infections in turn lead to higher mortality rates, with around 60,000 patients worldwide dying as a result of Pressure ulcers every year [17, 18].

Injuries caused by Pressure ulcers are the third most expensive conditions after cancer and cardiovascular diseases, accounting for approximately 4% of the annual health care budget in Europe [14]. For example, a 2018 study in the US showed that the cost of patients with Pressure ulcers was 22.5% higher than that of other patients [19].

In recent years, several studies have been conducted on Pressure ulcer prevalence in ICUs in various Eastern Mediterranean Region countries, each providing part of the picture of the prevalence of Pressure ulcer across the Eastern Mediterranean Region. For example, a Saudi Arabian study reported an acute care Pressure ulcer prevalence of 44.4% and an incidence of 38.6% [20]. A Jordanian study reported an overall Pressure ulcer prevalence of 12% in the health care setting and 29% in the intensive care setting [21].

However, these studies cannot provide a more complete picture for the entire Eastern Mediterranean Region. Therefore, it is necessary to synthesize the results of the studies conducted to help health managers and officials make evidence-based decisions. Therefore, the purpose of this study was to conduct a systematic review and meta-analysis of studies on Pressure ulcer prevalence in ICUs in hospitals across the Eastern Mediterranean Region.

Material and methods

The present study is a systematic review and meta-analysis.

Eligibility criteria

Studies were included in this research if they:

1)

Measured prevalence of pressure ulcers in special wards of hospitals.

2)

Reported data necessary to calculate it.

3)

Were written in English

Studies were excluded if:

1. They were thesis, case series, randomized controlled trials, case-control, commentaries, letters to the editor, book chapters, books, editorials, expert opinions, brief reports, and reviews.

Information sources and search

PubMed through MEDLINE, Web of Science, Scopus, and Google Scholar were searched until 22 September 2023. Search terms included "bed sore", "pressure sore", "pressure ulcer", "decubitus ulcer", hospital, Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen and Palestine by using the AND/OR operators. The electronic search was complemented by hand-searching of the related articles as well as the reference lists of the final studies (Table 1).

Study selection process

Search results were imported and managed via EndNote X8 (Thomson Reuters, New York, USA). Duplicates were firstly removed electronically and then manually. Subsequently, the title and abstract of the included studies were independently screened by two reviewers (PI and FB), and disagreements were finally resolved by helping a third reviewer (MH). Full-text of potential studies were retrieved and reviewed by the two reviewers. In order to obtain inaccessible full-texts or English version of the included papers, email or ResearchGate contact was made by the authors.

Data extraction process

A data extraction sheet was designed and tested by all authors. Two reviewers (PI, MA and FB) extracted data for the country where the study was conducted.

Data items

Data regarding the following items was collected: the name of the first author, year done, average of age, sample size, special ward, and prevalence of pressure ulcers, and an Excel spreadsheet was used for data entry (Table 2). Primary outcome was the overall prevalence rate of pressure ulcers, secondary outcome come Subgroup analyses (Income level of the country, countries, and type of special ward of the hospital) of the included studies.

Table 2 Characteristics of the included studiesQuality assessment

The methodological quality of the eligible studies was assessed using the 5 questions instrument which introduced and applied by Mitton et al. [36]. Each question was given a score of 0 (not present or reported), 1 (present but low quality), 2 (present and mid-range quality), or 3 (present and high quality). Criteria for assessment of quality included literature review and identifying of research gaps; research questions, hypotheses, and design; population and sampling; data collection process and instruments; and analysis and reporting of results. The assessment was conducted by both MA and SS and discrepancies were then resolved either by discussion or by the third reviewer (MH).

Summary measures and synthesis of results

Data were analyzed via the Comprehensive Meta-Analysis software (Version 2.2.064). Cochran’s Q-test and I2 index were used to test heterogeneity. The I2 index was 97.56%, indicating the heterogeneity of the studies. Therefore, a random-effects model was used in this meta-analysis. The effect of variables that could be the potential sources of heterogeneity was examined using the met regression technique. Finally, by using the met regression function, the effect of variables, which potentially accounted for the heterogeneity in the included studies, was examined. The point estimate of the prevalence of pressure ulcers was calculated at the 95% confidence interval (CI) in forest plots, where the size of the box indicates the weight of each study, and the horizontal line indicates the 95% CIs.