Therapeutic education of patients with coronary heart disease: Impact of digital platform monitoring in preventing major cardiovascular events in Tunisia: Study protocol

BACKGROUND

Faced with the increase in the number of chronic diseases with the aging of the population, and with the observation of the insufficiency of therapeutic control, a new need has emerged, that of having a patient as a partner in care.

METHODS

This study is a randomized controlled trial. Patients with coronary heart disease will be recruited from one clinical site and randomly assigned into two groups: the intervention group and the control group. All participants will be followed up for a total of one year (with three-time points for data collection). Patients who are assigned to the intervention group will receive therapeutic education at first. The digital platform will then allow healthcare providers to accompany them outside the hospital walls. The primary outcome is the incidence of major cardiovascular events within one year of discharge. Main secondary outcomes include changes in health behaviors, medication adherence, and quality of life score. The digital platform is a multi-professional telemonitoring platform that allows care teams to accompany the patient outside the hospital walls. It allows the collection and transmits information from the patient's home to the therapeutic education team. All data will be secured at a certified host. The patient application provides data on compliance, adherence to physical activity (number of steps taken per day), adequate diet (weight gain, food consumed during the meal, compliance with low-salt or salt-free diet, diabetic diet), smoking cessation, as well as medication adherence. Access to educational tools (digital media) is provided to all initial program participants. These tools will be updated annually by the rehabilitation team on the recommendations. The platform also offers the possibility of organizing an individual or group remote educational session (videoconference modules allowing group and individual sessions), a secure integrated caregiver-patient messaging system. The control group will receive the usual controls at the hospital.

DISCUSSION

To offer a complete solution of care to our patients, we have thought of setting up a digital platform that aims to monitor the patient and strengthen their abilities to manage their condition daily. This pilot experience could be generalized to several services and disciplines. It could be used in several research works.

TRIAL REGISTRATION

Trial registered with the Pan African Clinical Trial Registry (PACTR202307694422939). URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24247.

Video games and Facebook addiction among Tunisian adolescents: prevalence and associated factors

OBJECTIVES

As social media and online gaming technology have developed very rapidly over the last two decades, their paired issues are of growing concern worldwide. The aim of our study was to assess the prevalence of video game and Facebook addiction and its predictive factors among Tunisian in school adolescents.

METHODS

We conducted a cross-sectional study among in school adolescents in Sousse, Tunisia, over the first academic term of the 2019-2020 school year using a self-administered questionnaire to a randomly selected representative sample of 1,353 students. The valid Arabic version of the Bergen Facebook Addiction Scale (BFAS), the Video Game Addiction Scale (GAS-7), the Beck Depression Inventory Short Form (13 items) and the Screen for Child Anxiety Related Disorders (SCARED-C) were used to assess facebook addiction disorder (FAD), internet gaming disorder (IGD), depression and anxiety respectively.

RESULTS

More than one in four pupils (26.1 %; CI 95 %: 23.8-28.4 %) were identified as problematic video game users and almost a third of participants (32.5 %; CI 95 %: 30-35 %) reported FAD. IGD was significantly associated with FAD (p<0.001). Likewise, pupils exhibiting depressive symptoms as well as those with anxiety symptoms were significantly more likely to be problematic video games and Facebook users (p<0.001 for each). Being addicted to Facebook (AOR=1.83, 95 % CI: 1.18-2.81), experiencing anxiety disorders (AOR=2.43, 95 % CI: 1.52-3.88), being male (AOR=2.51, 95 % CI: 1.95-3.23) and spending more than 4 h per day surfing the net (AOR=2.55, 95 % CI: 1.65-3.96) were the determinants of IGD in the multivariate analysis. Similarly, being addicted to video games (AOR=1.82, 95 % CI: 1.21-2.73), experiencing anxiety disorders (AOR=1.85, 95 % CI: 1.20-2.86), having experienced academic failure (AOR=1.73, 95 % CI: 1.16-2.56), and spending more than 4 h per day on social media (AOR=3.75, 95 % CI: 2.38-5.90) were the predictors of FAD.

CONCLUSIONS

The prevalence of problematic use of video games and Facebook is alarmingly high. Identifying risk factors can help screen high-risk adolescents. We need additional prevention measures addressing not just adolescents, but all risk factors.

Bullying victimization among adolescents: Prevalence, associated factors and correlation with mental health outcomes

INTRODUCTION

Knowledge of the risk factors of bullying victimization in adolescents is crucial for the implementation of preventive measures. This study aimed to determine the prevalence and associated factors of bullying victimization and to identify its correlation with mental health outcomes among middle school students in Tunisia.

METHODS

A cross-sectional study was conducted using a multi-stage cluster sampling technique to recruit a sample of 1111 students from 10 middle schools in El kef (Tunisia). The revised Olweus Bully/Victim Questionnaire was used to assess the prevalence and types of bullying victimization and the perceived efforts of others to counteract bullying. The Strengths and Difficulties Questionnaire (SDQ) was used for screening emotional and behavioral problems. Multivariate logistic regression analysis was conducted to determine associated factors of bullying victimization. Additionally, we tested whether emotional and behavioral problems were present for bullying victims.

RESULTS

The findings reported that 45.8% (95%CI = 45.5-46.0), of the total number of participants experienced school bullying victimization. Multivariate logistic regression analysis, revealed that repeating a grade (OR = 1.82, 95%CI = 1.31-2.54), having a working father (OR = 17.68; 95%CI = 2.29-136,15), and having a working mother (OR = 1.88, 95%CI = 1.39-2.53) were the factors significantly associated with bullying victimization. Nevertheless, a higher mother's educational level (OR = 0.76, 95%CI = 0.67-0.88) was a protective factor against bullying victimization. The self-reported SDQ revealed that the total difficulties score was significantly higher among victims (17.46 ± 5.30 vs. 20.86 ± 5.06, p<0.01).

CONCLUSIONS

This study showed that the prevalence of bullying in middle schools was high and it significantly led to mental health problems. National policies for bullying prevention within schools are potentially needed. Improving students' problem-solving and soft skills is also essential.

Risk factors for impaired quality of life in diabetic patients in Tunisia

INTRODUCTION

Quality of life preservation is crucial in the management of chronic diseases, in particular diabetes.

AIM

To identify risk factors for the impaired quality of life of Tunisian diabetic patients.

METHODS

A cross-sectional study that collected type 1 and type 2 diabetic patients, selected by convenience sampling was conducted. Diabetic patients received a self-administered questionnaire in Arabic containing general and clinical data and a validated Arabic version of the "Diabetes Health Profile -18".

RESULTS

Three hundred and thirty-three type 1 and type 2 diabetic patients, whose age was ≥ 40 years in 78.1% of cases with a sex ratio of 0.94, were collected. The answers to the questionnaire highlighted a globally impaired quality of life for the diabetic patients with an average of 30.21 (7.06). Binary regression analysis presented globally significant models reflecting impairment risk factors for diabetic patients' quality of life. Female gender (AOR= 1.7; p= 0.036), comorbidities associated with diabetes (AOR = 1.23; p<10-3), diabetes complications (AOR= 1.45; p=0.041) and irregular medical follow-up (AOR=4.19; p<10-3) were risk factors for impaired diabetic patients' quality of life.

CONCLUSION

This study underlines the major role of a holistic diabetic patient care for better identification and management of risk factors of impaired quality of life.

A Qualitative Study on the Use of the Hospital Safety Index and the Formulation of Recommendations for Future Adaptations

The Hospital Safety Index is a tool developed by the World Health Organization and the Pan American Health Organization in 2008 and updated in 2015. Although it is the most widely used instrument of its kind to assess the level of hospital preparedness, scientific literature on its application in real life is scarce. This study aimed to investigate the use of the Hospital Safety Index to assess disaster preparedness in healthcare facilities. A retrospective, qualitative study employing semi-structured online interviews was conducted to gather the opinions and perspectives of professionals who have experience in applying the Hospital Safety Index. Authors of scientific publications using the Hospital Safety Index were recruited. A semi-structured interview guide was developed. It addressed different phases of data collection with the Hospital Safety Index, the challenges and facilitators of using it, and recommendations for future adaptations. Data were analysed using inductive thematic analysis. Nine participants who were from three countries (Serbia, Sri Lanka, and Indonesia) and had different professional backgrounds (medical doctors, engineers, spatial planners, etc.) participated in this study. A total of 5 themes and 15 subthemes emerged during data analysis. Most of the participants reported their reasons for choosing the Hospital Safety Index as being its comprehensiveness and the fact that it was issued by the World Health Organization. The tool appears to be very specific and allows investigators to spot details in hospitals; however, it is not easy to use, and training is highly encouraged to learn how to navigate the different components of the tool. Governmental support is a crucial facilitator for investigators to be able to enter hospitals and conduct their evaluations. Overall, the tool has a lot of potential, and it should be used to reach a broader audience, such as community members, and assess the preparedness of other facilities that can take part in the response to disasters (hotels, stadiums, schools, etc.). Nevertheless, it still needs more adaptations to be tailored to different contexts and settings.

[Predictive factors for the level of knowledge, attitudes and quality of life of Tunisian diabetics : 1007 cases]

AIM OF THE STUDY

To study the predictors of knowledge level, attitudes and quality of life of type 1(T1D) and type 2 (T2D) Tunisian diabetics POPULATION AND METHODS: We undertook an analytical cross-sectional study. The questionnaire was administered in Arabic and contained a section collecting socio-demographic, clinical and diabetes-specific data. The following sections contained the Arabic-translated and validated versions of the "Simplified Diabetes Knowledge Scale", the "Diabetes Attitude Scale-3" and the "Diabetes Health Profile-18" to assess level of diabetes knowledge, attitudes towards the disease and diabetics' quality of life.

RESULTS

We collected 186 T1D (18.5%) and 821 T2D (81.5%) completed questionnaires. A good level of knowledge about diabetes was indicated in T1D patients by glycemic self-monitoring and by secondary and university education, urban housing, stable employment, insulin therapy and prior therapeutic education, while regular medical follow-up was of particular importance in T2DM patients. Smoking and diabetes complications were predictors of a negative attitude towards the disease in T1D and T2D respectively. Diabetics' Impaired quality of life was predicted by age < 40 years and a low level of knowledge about diabetes in T1D and by female sex, insulin therapy and a low level of knowledge about diabetes in T2D.

CONCLUSION

Predictors of the level of knowledge, attitudes and quality of life of diabetics may be a basis for establishing a therapeutic education program tailored to the different populations.

Prevalence and associated factors of perinatal depression among working pregnant women: a hospital-based cross-sectional study

Perinatal depression is a major public health problem having serious negative impacts on personal, family, and child developmental outcomes. This study aimed to determine the prevalence of major depressive disorder (MDD) and its associated factors in working pregnant women. This descriptive, cross-sectional study was performed on 389 working pregnant women enrolled from four Tunisian public maternity hospitals. Data collection tools were the sociodemographic, obstetric, family relationships, and work environment questionnaire, and the Center for Epidemiologic Studies Depression Scale (CES-D). The mean score of depression was 27.39 ± 6.97 and 76.1% of women had major depressive symptoms using cutoff points on the CES-D ≥ 23. Family income, diagnosis with a chronic illness, history of depression, and employment categories were associated with major depressive symptoms. In multivariate analyses, family income and work posture were significantly associated with MDD. These results suggest an increased burden of MDD during pregnancy in Tunisian women. Prevention, early detection, and interventions are needed to reduce the prevalence of perinatal depression.

Evaluating the level of disaster preparedness of Tunisian University Hospitals using the Hospital Safety Index: a nationwide cross-sectional study

Background

Mid-way through the 'Sendai Framework for Disaster Risk Reduction 2015-2030', many nations are spending time, money and effort to enhance their level of preparedness facing disasters, on the other hand communities, countries and even continents are being left behind.

Objectives

This study was conducted aiming at evaluating the level of disaster preparedness and response of Tunisian University Hospitals.

Methods

This is a cross-sectional nationwide study conducted in Tunisia, from November 2020 to April 2021. Including 9 Tunisian University Hospitals and using the Hospital Safety Index. The data were analysed using the 'Module and safety index calculator'.

Results

This study showed that 7 out of the 9 University Hospitals were assigned the 'B' category of safety with overall safety indexes that ranges between 0.37 and 0.62. Also, 4 out of 9 University Hospitals had safety scores less than 0.20 regarding their emergency and disaster management.

Conclusions

This is the first study to evaluate disaster preparedness and response of university hospitals in Tunisia and in north Africa. It showed that the lack of knowledge, resources and willingness, are the most important issues that needs to be addressed in order to enhance the preparedness of Tunisian hospitals.

Psychometric properties of a French version of the Jefferson Scale of Empathy

OBJECTIVE

To assess the reliability and construct validity of a French version of the Jefferson Scale of Empathy-Students.

METHODS

A cross-sectional study was performed among undergraduate medical students in Tunisia. A total of 833 students completed a French version of the JSE-S using convenience sampling. To identify the internal consistency aspect of the reliability, Cronbach's alpha coefficient was computed. Moreover, to assess the construct validity, the sample was randomly divided into two groups. Data from the first group (n=415) were subjected to exploratory factor analysis (EFA), with principal axing factoring (PAF) and oblimin rotation, to re-examine the underlying factor structure of the scale. Data from the second group (n=419) were used for confirmatory factor analysis (CFA) to confirm its latent variable structure. Some goodness-of-fit indices were used to assess the hypothesized model. Gender groups were compared using a t-test to check the known-group validity.

RESULTS

Reliability analysis reported an acceptable level of internal consistency, with an overall Cronbach's alpha of 0.78 (95% CI [0.75,0.80]). EFA identified a two-factor structure, accounting for 27.4% of the total variance. The two-factor model produced good fit indices when item correlated errors were considered (χ²/df = 1.95, GFI = 0.92, CFI = 0.90, PCFI = 0.79, PGFI = 0.73 and RMSEA = 0.04). Female students had a statistically significant higher empathy scores than male students (t ₍₈₃₀₎ = - 4.16, p < .001).

CONCLUSIONS

The findings support the construct validity and reliability of a French version of the JSE for medical students. This instrument appears to be useful for investigating empathy among French-speaking populations.

Arabic version of the simplified diabetes knowledge scale: psychometric and linguistic validation

Introduction

the simplified diabetes knowledge scale is used to obtain a general assessment of diabetic´s knowledge about diabetes and its care. For clinical and methodological purposes, it was relevant and necessary to develop an Arabic version of this instrument. Thus, the aim of this study was to translate and validate the simplified diabetes knowledge scale (SDKS) into Arabic to measure the knowledge of Arabic-speaking diabetics.

Methods

a methodological validation study of the simplified diabetes knowledge scale, following the guidelines of Vallerand was carried out. A convenience sample of diabetics followed in eight basic health centers in Sousse region and in Farhat Hached and Sahloul University Hospitals was recruited. An Arabic questionnaire including the demographic and clinical data of the diabetic and the final experimental version of the simplified diabetes knowledge scale was used.

Results

a sample of 333 diabetics was recruited. Content validity of the final experimental version was 0.94. Reliability assessed by Cronbach´s alpha coefficient (0.812), by test-retest correlation coefficient (> 0.60) and by internal consistency after deletion of each item (from 0.788 to 0.816) were acceptable except items 19 and 20 which had to be reformulated. Construct validity analysis identified that three items among the 20 ones (12, 17 and 20) required reformulation. Inter-item correlation matrix showed that the majority of items were not correlated with each other. Validation process was ended by establishing standards table.

Conclusion

this study showed the Arabic version of the simplified diabetes knowledge scale had good validity and reliability.

Nurse students' perception of the academic learning environment in Tunisian institutes of nursing sciences: A multisite cross-sectional study

BACKGROUND

A learning environment is an important determinant of students' learning behaviours, professional competencies, and academic performances. It is also an essential indicator of the quality of teaching programmes. To date, there is not a Tunisian study, that analysed nurse students' perceptions of the educational environment.

AIMS

This study aimed to assess the perception of Tunisian higher nursing institutes students regarding the quality of the learning environment, and identify the factors associated with it.

DESIGN

Multi-site cross-sectional survey.

SETTING

Five universities of nursing sciences in Tunisia.

PARTICIPANTS

Undergraduate nursing students (n = 736).

METHODS

A cross-sectional descriptive study was conducted during the academic year 2019-2020. The Dundee Ready Educational Environment Measure (DREEM) questionnaire was used to describe the students' perceptions of the learning environment. The participants were recruited using a convenience sampling method. Statistical analyses were performed using SPSS version 20. One-way analysis of variance and t-test were used to compare the DREEM scores and socio-demographic/academic characteristics. A p-value of less than 0.05 was considered significant.

RESULTS

The mean overall DREEM score was 110.92 ± 20.55, indicating a positive perception of the learning environment. The year of study was significantly associated with total DREEM scores, with first-year students scoring higher than third- and second-year students (p = 0.035). The perception of the learning environment varied significantly among the five institutes (p < 10^-3). Demotivated atmosphere, lack of a support system, poor timetable organisation, and teacher-centred learning were revealed as problematic areas that needed improvement (individual score < 2). Our adapted version of the DREEM obtained acceptable internal consistency (Cronbach's alpha coefficient of 0.881).

CONCLUSIONS

The study reported positive perceptions of the students regarding their academic learning environment. However, the DREEM scores reflected a traditional learning environment. It is essential to re-engineer the curriculum and shift the teaching paradigm towards 'student-centred curriculum' to enhance both the effectiveness and the efficiency of the learning environment.

Assessing patient safety culture in 15 intensive care units: a mixed-methods study

BACKGROUND

Within hospitals, intensive care units (ICUs) are particularly high-risk areas for medical errors and adverse events that could occur due to the complexity of care and the patients' fragile medical conditions. Assessing patient safety culture (PSC) is essential to have a broad view on patient safety issues, to orientate future improvement actions and optimize quality of care and patient safety outcomes. This study aimed at assessing PSC in 15 Tunisian ICUs using mixed methods approach.

METHODS

A cross-sectional mixed methods approach using a sequential explanatory design was conducted from December 2019 to January 2020. The first quantitative stage was conducted in 15 ICUs belonging to the two university hospitals in the region of Sousse (Tunisia). All the 344 healthcare professionals (clinical staff) working for more than 1 month in these ICUs were contacted in order to take part in the study. In the second qualitative stage 12 participants were interviewed based on purposive sampling.

RESULTS

All of the PSC dimensions had a score of less than 50%. The developed dimension was 'teamwork within units' (48.8%). The less developed dimensions were 'frequency of event reporting' (20.8%), 'communication openness' (22.2%) and 'non-punitive response to error' (19.7%). Interviews' thematic analysis revealed four main themes including "Hospital management/system failure", "Teamwork and communication", "Error management" and "Working conditions".

CONCLUSION

This research revealed that PSC is still in need of improvement and provided a clearer picture of the patient safety issues that require specific attention. Improving PSC through the use of quality management and error reporting systems may help to improve patient safety outcomes.

Translation, psychometric evaluation and validation of the "diabetes health profile-18" questionnaire in Arabic

INTRODUCTION

measuring quality of life requires an instrument validated in the population language. The purpose of our study was to translate and analyze the psychometric properties of the literary Arabic version of the "diabetes health profile (DHP)-18".

METHODS

we conducted a methodological study for psychometric evaluation and validation of the DHP-18, following the steps of the cross-cultural validation described by Vallerand. A convenience sample of people with diabetes was collected for this purpose. The developed questionnaire included participants' demographic characteristics, diabetes data and the experimental version of the DHP-18 questionnaire. Validity, reliability and questionnaire standards establishment were carried out.

RESULTS

a sample of 333 diabetics was recruited. Test-retest correlation coefficient (r = 0.985; p<0.01) and Cronbach's alpha coefficient (alpha = 0.840) showed that the experimental version was accurate in terms of temporal stability and internal consistency. The content validity index was 0.84 and showed that the questionnaire statements accurately measured the concepts under study. The exploratory principal axis factoring, using the orthogonal varimax rotation, allowed the extraction of a factorial solution with four independent factors, grouping the 18 items of the questionnaire. Correlation coefficients between the three corresponding dimensions of the theoretical model of the questionnaire were low and positive, between 0.431 and 0.535, confirming that each dimension measured a unique content.

CONCLUSION

the literary Arabic version of the DHP-18 has proven to be valid, reliable and ready for use in clinical practice in Tunisian people with diabetes.

Assessing the impact of a family empowerment program on asthma control and medication use in children with asthma: A randomized controlled trial

PURPOSE

In pediatric asthma, family empowerment education has been beneficial for the quality of life, pulmonary function, and family functioning. Few studies addressed the impact of a family empowerment program on asthma symptom control, acute healthcare use (AHCU), and medication use in children with asthma. This study aimed to assess the effect of a family empowerment intervention on asthma symptom control, AHCU, inhaler technique, and controller adherence in children with asthma.

DESIGN AND METHODS

A single-center study using a randomized controlled design was conducted in a university hospital in the center of Tunisia from May 2018 to September 2019. Eighty-two families were randomly assigned to the intervention group (n = 41) of 8 weeks of group training sessions, or to the control group (n = 41) of usual care education. Thirty-seven families in the intervention group and 39 families in the control group received allocated intervention at baseline. Thirty-four families in each group completed the study at the 12-month follow-up.

RESULTS

At baseline, the intervention and control groups were statistically comparable (p > .05). At follow-up, there were significant differences between the intervention and the control group in asthma symptom control, χ² (1, N = 34) = 9.950, p = .002, and inhalation technique, χ² (1, N = 34) = 5.916, p = .01. For AHCU and adherence to asthma controller, there was no significant difference between groups, χ² (1, N = 34) = 3.219, p = .07, χ² (1, N = 34) = 0.541, p = .46, respectively. The difference within time in asthma symptom control and inhalation technique was significant (p = 10^-3 , p = .001; respectively).

PRACTICE IMPLICATIONS

This study demonstrated that a family empowerment program significantly improved asthma symptom control and inhaler technique in children with asthma aged 7-17 years. This intervention could be clinically useful and time-saving for pediatric nurses.

Availability, utilization and quality of emergency obstetric care services in Sousse, Tunisia

Introduction

emergency obstetric care (EmOC) is a high-impact priority intervention strongly recommended for improving maternal health outcomes. The objectives of this study were to assess the availability, utilization, and quality of emergency obstetric care services in the Governorate of Sousse (Tunisia).

Methods

a cross-sectional study was conducted among public health facilities which performed deliveries in Sousse in 2017. Data were collected by consulting clinical records and registers and interviewing staff using WHO EmOC tools. Emergency obstetric care (EmOC) indicators were calculated.

Results

only the University maternity Unit functioned as full comprehensive EmOC facility. No other public facility provided all the 7 Basic EmOC signal functions 3 months prior to the survey. The unperformed signal functions were: administration of parenteral antibiotics, manual removal of placenta and assisted vaginal delivery. The number of EmOC facilities was 0.72 per 500,000 inhabitants. The met need for EmOC was 89.5%. The proportion of caesarean section was 24.2%. The direct obstetric case fatality rate was 0.159% and intrapartum and very early neonatal death rate was 0.65%.

Conclusion

raising maternity facilities to a minimum level of basic EmOC status would be a major contributing step towards maternal mortality reduction.

Exploring patient safety culture in emergency departments: A Tunisian perspective

BACKGROUND

Emergency departments (EDs) are considered a high-risk environment because of the high frequency of adverse events that occur within. Measuring patient safety culture is an important step that assists healthcare facilities in planning actions to improve the quality of care provided to patients. This study aims to assess patient safety culture within EDs and to determine its associated factors.

METHODS

A cross-sectional study conducted among professionals from all the EDs of public and private healthcare institutions in Tunisia. It spread from June to September 2017. We used the validated French version of the Hospital Survey on Patient Safety Culture questionnaire.

RESULTS

In total, 11 EDs were included in the study, with 442 participants and a participation rate of 80.35%. All the ten dimensions of patient safety culture were in need of improvement. 'Teamwork within units' scored the highest with 46%, however, the lowest score was attributed to 'the frequency of adverse events reporting' (19.6%). Several factors have been found significantly related to safety culture. Private EDs have shown significantly higher scores regarding nine patient safety culture dimensions.

CONCLUSION

This study showed a concerning perception held by participants about the lack of a patient safety culture in their EDs. Also, it provided baseline results giving a clearer vision of the aspects of safety that need improvement.

A baseline assessment of patient safety culture and its associated factors from the perspective of critical care nurses: Results from 10 hospitals

INTRODUCTION

Critical care nurses are considered the key to patient safety improvement and play a vital role in enhancing quality of care in intensive care units (ICUs) where adverse events are frequent and have severe consequences. Moreover, there is recognition of the importance of the assessment and the development of patient safety culture (PSC) as a strategic focus for the improvement of patient safety and healthcare quality, notably in critical care settings.

OBJECTIVES

This study aimed to assess critical care nurses' perception of PSC and to determine its associated factors.

METHODS

This cross-sectional study was conducted among nurses working in the ICUs of the Tunisian centre (six Tunisian governorates). The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture questionnaire, comprising 10 dimensions and a total of 50 items.

RESULTS

A total of 249 nurses from 18 ICUs participated in the study, with a participation rate of 87.36%. The dimensions scores ranged between 17.2% for the dimension "frequency of events reported" and 50.1% for the dimension "teamwork within units". Multivariable logistic regression indicated that respondents who worked in private hospitals were five times more likely to have a developed PSC (adjusted odds ratio [AOR]: 5.34; 95% confidence interval [CI], [2.28, 12.51]; p < 10^-3). Similarly, participants who worked in a certified hospital were two times more likely to have a more developed PSC than respondents who work in noncertified hospitals (AOR: 2.51; 95% CI, [.92-6.82]; p = 0.041). In addition, an increased nurse-per-patient ratio (i.e., reduced workload) increased PSC (AOR: 1.10; 95% CI, [1.02-1.12]; p = 0.018).

CONCLUSION

This study has shown that the state of critical care nurses' PSC is critically low and these baseline results can help to form a plan of actions for improvements.

Assessing patient safety culture and its associated factors in 12 emergencies across Tunisia

Background

Although the emergency departments (EDs) are the front line of the public health system, they are considered high-risk environments because of the shocking frequency of adverse events, within. Developing safety culture among EDs professionals, as a strategic focus, remains a priority. The purpose of this study is to measure safety culture in EDs and to determine its associated factors.

Methods

This is a cross-sectional and multicenter study, conducted among professionals from all the EDs of public and private healthcare institutions in central Tunisia. It was conducted from June to September 2017. The instrument tool used was the self-administered Hospital Survey On Patient Safety Culture questionnaire translated and validated by the CCECQA. Data entry and analysis were performed using SPSS 20.0 and Epi info 6. Also, ethical considerations were taken into account.

Results

In total, the study included 442 participants from 12 ED, with a participation rate of 80.35%. All the ten dimensions of safety culture were all to be improved. As for 'teamwork within units', it scored the highest with 46%, however, the lowest scores were attributed to 'the frequency of reported adverse events' (19.6%) followed by 'the non-punitive response to error' (19.8%). Private EDs have shown significantly higher scores regarding nine safety culture dimensions. Also, the size of the hospital was significantly associated with all dimensions of the safety culture.

Conclusions

This study has shown that the level of safety culture needs to be improved in public and private EDs and also underlines the importance of developing the safety culture and the implementation of safety and quality management systems.

Key messages

Patient safety culture is to be improved in Tunisian emergencies, although it is significantly more developed in private settings. A punitive culture still reigns in Tunisian healthcare context.

Disaster preparedness level of university hospitals of Sousse -Tunisia

Background

Disasters, whether natural or man-made, are unpredictable. The health care systems, represented by hospitals, are on the front lines of the emergency and disaster response. Tunisian health structures, must be able to cope with a case of mass influx of victims following any disasters. Therefore, we conducted this study to describe the level of disaster preparedness of University Hospitals of Sousse - Tunisia.

Methods

A simple descriptive quote is the basis of a data collection, conducted between September and October 2019 and performed in both University Hospitals of Sousse - Tunisia (Farhat Hached and Sahloul). The measuring instrument used in this study is the 'Hospital Safety Index' designed by the World Health Organization in 2008.

Data was analyzed using the 'Module and safety index calculator' which calculates a specific score for each module (structural safety, nonstructural safety and emergency and disaster management) and an overall score for hospital safety, and assigns an appropriate classification which can be “c/C” corresponds to a score from 0 to 0.35, “b/B” from 0.36 to 0.65, or “a/A” from 0.66 to 1.

Results

The overall safety index class of both hospitals was 'B'. Sahloul University Hospital was classified as 'a' in both structural and nonstructural safety modules and classified as 'c' in the emergency and disaster management module, in the other hand Farhat Hached University Hospital was classified as 'c' in structural safety module and classified as 'b' in both nonstructural safety and emergency and disaster management modules.

Conclusions

The hospitals' current levels of emergency and disaster management needs to be improved. Actually, both patients and staff safety as well as the hospital's ability to function during and after emergencies and disasters are potentially at risk. In both hospitals, intervention measures are needed in the short term.

Key messages

Appropriate disaster management should be based on a clear plan, preparedness and collaborative and effective efforts on the part of the community and the different organizations involved. A safe hospital needs to assure that its services remain accessible and functioning at maximum capacity, before, during and immediately after the impact of emergencies and disasters.

Assessment of patient safety culture in intensive care units and factors affecting it

Background

The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors.

Methods

It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture.

Results

A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased.

Conclusions

This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients.

Key messages

The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

Polysubstance use among adolescents in Tunisia

Background

Poly-substance use is a global public health problem associated with significant adverse social and health effects. Adolescents are increasingly affected by this risky behaviour. The objective of our study was to describe the poly-substance use and to determine the association between the different types of substance use among middle school students in the Region of Kairouan in Tunisia.

Methods

A cross-sectional study was conducted in 2017 among middle school students in the Region of Kairouan in Tunisia using a self-administered questionnaire for data collection.

Results

A total of 494 students participated in the survey. Tobacco, alcohol, cannabis and psychotropic drug uses were reported respectively by 7.9%, 7.3%, 6.3% and 14.3% of the students. Among the surveyed students, the poly-consumption of the four substances: alcohol, tobacco, cannabis and psychotropic medication without medical prescription was reported by 2.83% of the students. Among these poly-consumers, 57.1% were male. Poly substance use was found to increase with the level of study (21.4%, 28.6% and 50% respectively in grades 7, 8 and 9). In our study, among the smokers, 64.1% reported alcohol use, 69.2% reported cannabis use and 43.6% reported psychotropic drug use. Associations between tobacco use and other substances use were significant (p &lt; 10-3). This association was significant for both boys and girls. In addition, 71% and 26% of alcohol users were respectively cannabis and psychotropic drug users. Alcohol use was significantly associated with cannabis and psychotropic drug use (p &lt; 10-3). This association was significant for both boys and girls.

Conclusions

Adolescents are particularly vulnerable to multiple risky behaviors including substance use. Appropriate prevention and control strategies based on a participatory approach involving parents, teaching and medical staff should be put in place to combat this scourge.

Key messages

Despite a relatively low prevalence of poly-substance use among the surveyed students, a particular attention should be drawn to the phenomenon of psychotropic drug use without medical prescription. There is an urgent need for the implementation of an effective substance use prevention program in school settings in Tunisia where monitoring is one of its core components.

Capacity building in the public health field in the Tunisian medical faculties

Over the past years, Tunisia has experienced important reforms in the field of public health. The Tunisian medical faculties (Universities of Sfax, Tunis el Manar, Sousse and Monastir) play a key role in this endeavor by training public health professionals who can contribute to the modernization of the health system. Funded by the EC through Erasmus+ programme, the CONFIDE project (coordinated by Babes-Bolyai University, having as EU partners the Universities of Southern Denmark and Trnava, and the above mentioned Tunisian universities) has established the Research into Policy training programme by strengthening their capacity to provide public health training.

The Research into Policy training programme has been delivered by the Centres for Evidence into Health Policy (C4EHPs) established within the Tunisian partner universities for the needs of CONFIDE. The training programme was implemented in four steps: (1) train the trainer sessions - the European experts trained 18 Tunisian trainers; (2) shadowing sessions - the trainers participated in shadowing sessions in the European partner institutions; (3) training delivery - the CONFIDE trainers, assisted by the European experts, delivered the training to an interdisciplinary group of 25 students and professionals; (4) internships - the students participated in internships in local health institutions. Three modules have been built within the Research into Policy training programme: Public health research, Health promotion policies and Evidence based public health policy. They contributed to increasing the public health knowledge and skills of the professionals trained.

The training programme was well received by the Tunisian universities and the material developed so far during the project was adapted to the Tunisian context in the third step of implementation. On the long term, the project is expected to have an impact at the national level and produce updates at curricula level in the Tunisian medical faculties.

Key messages

Research into Policy training programme developed by the EC partners and culturally adapted by the Tunisian partners to the Tunisian public health context. Research into Policy training is a well-received tool for the high quality learning process in the public health field in Tunisian medical faculties.

Evaluation of teamwork in operating rooms in a Tunisian university hospital

Background

Teamwork is fundamental to ensuring the quality of care and patient safety in operating rooms. It has been shown that the occurrence of adverse events is closely linked to a poor quality of teamwork in these settings. Thus, this study aimed to assess teamwork in different operating rooms of the university hospital of Sahloul Sousse (Tunisia).

Methods

It is a descriptive cross-sectional study with convenience sampling, conducted in operating rooms of the university hospital of Sahloul Sousse (Tunisia) between February and April 2018. The measuring instrument was the validated observation grid 'Communication and Teamwork Skills Assessment Tool (CATS) '. Teamwork is assessed through 4 domains (Situation awareness, Coordination, Communication, Cooperation). Behaviors are marked in rows each time they occur and are rated for quality in columns labeled “Observed and Good,” “Variation in Quality” (meaning incomplete or of variable quality), and “Expected but not Observed.”

Results

A total of 51 interventions were observed. Good coordination between the team members was noted, as well as good cooperation within the teams. A variation of quality level of communication with the patient was noted in 31.4% of cases, also communication about the context, the situation and recommendation among caregivers is not quite good with a percentage of 39.2%. Moreover, the work environment was rated as good in 84.3% of cases.

Conclusions

Some failures in teamwork were noted, hence it is important to take corrective measures for better practice and better patient management in such a complex environment, the operating rooms, where there is a strong need for team coordination.

Key messages

There is a direct relationship between the quality of care and the effectiveness of teamwork. It is necessary to eliminate the barriers to communication, in order to prevent adverse events.

Tunisian Nurses experiences of their humanitarian mission in the ''Choucha” Refugee Camp

Background

Participation in a humanitarian mission can be considered as a heroic work especially for health professionals. In 2011, a refugee camp was set up in southern Tunisia. The objective of this study was to describe and better understand the experience of Tunisian nurses in the Choucha refugee campbased on the Meleis transition theory.

Methods

We conducted a qualitative, phenomenological study among 14 nurses using an interview guide. Data analysis was carried out according to the method of Giorgi, from which 5 core themes and 28 sub-themes had emerged.

Results

This studydescribed the experience of nurses as a passage between 4 different phases: before, during, after the passage to the refugee camp and the memory.Five core themes emerged from our research:1) Trigger events: 3 sub-themes were evoked for the reason of participation: motivation, commitment and expectations; 2) Professional and interpersonal relationships marked the integration of the interviewees despite some misunderstandings, 3) Coping, 4) The impacts are mostly positive, and 5) Feelings that expressed emotions and nostalgia. For the transition, the last stage, which is the appreciation of the past moments, indicated the passage from an unbalanced state to stability.

Conclusions

Looking at the lived experience of the nurses and the transition experience described by the participants, this study found that the lack of training of the nurses previous to the humanitarian mission was the major barrier to making a healthy transition. These findings can contribute to raise the awareness, preparation and education of nurses to improve the experiences of future caregivers who will participate in humanitarian missions.

Key messages

It seems essential to set up training program focusing on preparation and debriefing of nurses to support them in achieving a healthy transition in their humanitarian mission in refugee camps. Training health care professionals before their participation to humanitarian mission in refugee camps can be among the factors that enhance the quality of care provided to refugee populations.

A picture of the adolescents dietary habits in Tunisia

Background

Adolescence is one of the main growth periods of life during which dietary needs are specific and where diet quality is important for healthy development. Nonetheless, unhealthy eating behaviours are common among adolescents including over consumption of unhealthy fast food, sugar and fat and skipping meals. Exposure to unhealthy eating can lead to chronic conditions such as obesity and diabetes. In this context, we conducted this study to describe the quality of the diet of middle school students in the Region of Kairouan in Tunisia.

Methods

This is a cross-sectional study conducted in 2017 among middle school students in the Region of Kairouan. Data collection was carried out using a self-administered questionnaire.

Results

In this study, 494 students were included. In terms of food type, fast food meals (sandwiches) were the most preferred type of food (52.6%). Daily consumption of vegetables and fruit was reported by 48.8% of students. Among the participants, 46.8% reported daily consumption of olive oil. Daily water consumption was less than one liter for 32% of the college students. Daily coffee and/or tea consumption concerned 53.8% of respondents. In the current study, 39.3% of the students reported that they consume more than three meals per day and 26.7% declared that they often skip the breakfast. In our study, 62.8% of the participants had reported their dissatisfaction with their nutrition education, 54.9% sought to know the food composition and 57.9% reported that they have a willingness to adopt a healthy eating.

Conclusions

A quality and diversified diet can cover the specific nutritional needs of adolescents. A diet inspired by the Mediterranean food is to be encouraged. Further studies should be conducted among adolescents to evaluate the impact of a healthy and balanced diet on health and school achievement.

Key messages

The quality of diet of Tunisian adolescents is to be improved. Effective comprehensive programs for healthy lifestyle promotion are needed to improve the eating behaviour among Tunisian adolescents.

Herbal medicine use and its associated factors in the region of Sousse (Tunisia)

Background

Patients use medicinal plants as the first-line treatment for many chronic and acute medical conditions. The lack of access to conventional health care, historical, cultural and economic considerations contributes to the important use of these plants. The purpose was to identify medicinal plants used by primary Health Care Centers' visitors in the region of Sousse (Tunisia) and to assess its associated factors.

Methods

A cross-sectional descriptive study was conducted among Primary health care centers' visitors of the region of Sousse (Tunisia) in 2018. We randomly selected 18 primary health centers and 50 participants were chosen from each center. Data were collected using a pre-tested questionnaire, filled through a direct interview with participants which explores: socio-demographic variables and medicinal plants' use (name of plants, symptoms, methods of preparation, routes of administration, plant source, tolerance and side effects).

Results

900 persons were included with a female predominance (72.4%). The median age of participants was 48 years ranging from 18 to 93. 65.2% (n = 587) of them report using medicinal plants to heal. The most common sources of information were family (90.5%), beliefs and traditions (56.4%). Fifty-three (53) plants were used to treat different disorders. The most used plants are: verbena (81.6%), rosemary (53.3%), mint (52%) and thyme (45.1%). The most reported treated symptoms were: flu and gastro-intestinal disorders. Plants utilization was associated to: lower age, female gender, marital status, high level of education and social existence of protection coverage.

Conclusions

Plants use should be based on well-conducted scientific results specifying the mechanism of action of plants, the therapeutic and toxic dose through researches on local plants samples and extracts.

Key messages

It seems essential to train health professionals on herbal therapy during their studies and practice. The further step after this picture of the herbal medicine use in the Region of Sousse, is to evaluate the safety and the efficacy of their use.

Association between smoking cessation and quality of life among patients with COPD in Tunisia

Introduction

Smoking cessation is the most important step to limit the complications of chronic obstructive pulmonary disease (COPD). Outcomes from studies that assessed the association between health-related quality of life (HRQL) and smoking cessation have been controversial. This study aimed to assess the relationship between HRQL and smoking cessation in patients with COPD in Tunisia.

Methods

A cross-sectional study was carried out in the two main primary care centers in the center of Tunisia over a period of three months (April-June 2016). Clinic and socio-demographic data were collected from patients' records. HRQL was assessed by the Medical Outcomes Study Short-form 36 (SF-36). This instrument is composed of two dimensions: physical and mental components. The questionnaire outcomes were described as means and standard deviation. T-test was performed to assess the statistical difference between the dependent and categorical variables.

Results

A total of 249 COPD patients participated in the study with a mean age of 67.77±11.13. Of this sample, 169 (67.9%) ceased smoking. The average period of smoking cessation was 10 years. The mean of total HRQL score in patients who ceased smoking was lower in comparison to patients who did not quit smoking (40.65±24.49, 43.37±24.49; respectively). The T-test reported a significant difference between the physical component of HRQL and smoking status. Patients with current smoking status had a better physical component score in comparison with patients who quit smoking (43.76±22.62, 37,86±18.21, p = 0.04, respectively). No significant differences were found between smoking cessation, mental component, and HRQL total score (p = 0.89, p = 0.39; respectively).

Conclusions

This study revealed that smoking cessation was associated with the physical component of HRQL. The smoking dependence in patients with COPD could explain this finding. Health care professionals should work harder on effective smoking cessation strategies.

Key messages

These findings suggested that HRQL was better among patients who did not quit smoking. Patients who did not cease smoking reported better physical status and poorer mental status in comparison with patients who quit smoking.

Evaluation of teamwork and its associated factors in the emergency rooms of Sousse - Tunisia

Background

In recent years, patient safety has become a priority and a major target for improvement especially in the emergency rooms. According to the French National Authority for Health, 1/3 of serious adverse events could be avoided thanks to better coordination and better communication between the teams. Thus, this study aimed to describe the perceptions of healthcare professionals in the emergency rooms of Sousse-Tunisia regarding teamwork, and to determine the factors influencing it.

Methods

It is a descriptive cross-sectional study, conducted between December 2018 and April 2019. It included all the caregivers working in all the emergency rooms of Sousse-Tunisia. The measurement tool used in this study was “Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)” Teamwork Perception Questionnaire. Data were coded and analyzed by The Statistical Package for Social Sciences (SPSS 20.0).

Results

A total of 110 participants were recruited with a participation rate of 72.36%. Nurses represent more than half of the respondents (56.4%). Average work experience was 7.27 years. The Teamwork overall score was 2.5±0.5. The most developed dimension was leadership (2.7±0.8) and the less developed dimension was communication (2.3±0.7). Women had a significantly higher overall score than men (2.6±0.5, 2.4±0.3, p = 0.017). Results also showed that emergency technicians have significantly higher overall score than doctors and nurses (p = 1 × 10-5). The overall score also varied significantly across the hospitals (p = 0.016).

Conclusions

Our results showed that the level of teamwork still needs to be improved. Furthermore, various factors are associated with teamwork, and that should be taken into consideration to guide the future interventions.

Key messages

There is a direct relationship between the quality of care and the effectiveness of teamwork. It is necessary to focus on the affecting factors of teamwork, in order to prevent adverse events.

[Delivery of twin pregnancy and materno-fetal prognosis in a level 3 Tunisian University Center: a retrospective study about 399 cases]

En dépit des progrès obstétricaux et pédiatriques, les grossesses gémellaires représentent une situation à haut risque aussi bien pour le déroulement de la grossesse que pour l´accouchement et reste encore une situation angoissante pour l´équipe obstétricale. Le but de cette étude était de décrire la pratique des accouchements des grossesses gémellaires au service de gynécologie obstétrique de Sousse, de décrire le pronostic maternel et fœtal et d´analyser les facteurs pouvant l´influencer. Nous avons réalisé une étude descriptive, rétrospective portant sur les accouchements des grossesses gémellaires sur une période de deux ans. Ont été incluses dans l´étude les grossesses gémellaires ayant atteint au moins 28 semaines d´aménorrhée (SA) et les femmes ayants une grossesse gémellaire compliquée d'une mort fœtale in utéro. Ont été exclues les femmes ayant une grossesse gémellaire et ayant accouchés avant 28 SA. Les grossesses bi-choriales bi-amniotiques représentaient 67% des cas, contre seulement 11,5% de grossesses mono-choriales bi-amniotiques et 3% de grossesses mono-choriale mono-amniotique. Nous avons recensé 52 césariennes programmées. Le travail a été spontané dans 304 cas. Il a été déclenché dans 43 cas. Au total 178 parturientes ont accouché par voie basse (44,6%), contre 215 par voie haute (53,9%). Le taux de césarienne pour le deuxième jumeau était de 1,5%. Quand l'accouchement était par voie basse, 19 cas de complications ont été observés (10,7%). Nous avons analysé le score d'Apgar du premier jumeau et du deuxième jumeau en fonction du mode d'accouchement. Il n'y a pas eu de différence statistiquement significative du score d'Apgar entre les deux voies d'accouchement. La morbi-mortalité périnatale est plus importante pour le deuxième jumeau que pour le premier jumeau. La morbidité maternelle en cas d´accouchement par voie basse était supérieur à la morbidité en cas d´accouchement par césarienne. Il n´y a pas de différences significatives dans le score d´Apgar selon que les enfants sont nés par voie basse ou par césarienne.

Assessing patient safety culture in 18 Tunisian adult intensive care units and determination of its associated factors: A multi-center study

PURPOSE

This study aimed to assess patient safety culture (PSC) in intensive care units (ICUs) and to determine the factors affecting it.

MATERIALS AND METHODS

This is a cross-sectional study, conducted from October to November 2017 among professionals practicing in the ICUs of the Tunisian center. After obtaining institutional ethics committee's approval and administrative authorizations, an anonymous paper-based questionnaire was distributed to the participants after obtaining their consent to take part in the study. The measuring instrument used is the French validated version of the "Hospital Survey on Patient Safety Culture" questionnaire.

RESULTS

A total of 402 professionals, from 18 ICUs and 10 hospitals, participated in the study with a participation rate of 82.37%. All dimensions were to be improved. The most developed dimension was teamwork within the unit (47.87%) and the least developed dimension was the non-punitive response to error (18.6%). Seven dimensions were significantly more developed in private institutions than in public ones. Results also show that when workload is reduced, the PSC was significantly increased.

CONCLUSION

This study has shown that the PSC in ICUs needs improvement and provided a baseline results to get a clearer vision of the aspects of security that require special attention.

Adolescent’s substance use and suicidal thoughts in Tunisia

Background

Experimentation with substance use is common during adolescence. Substance use may result in many health-related problems and contribute to adolescent suicidal behavior. We conducted this study to examine the relationship between substance use and suicidal ideation.

Methods

This is a cross sectional study conducted among a representative sample of 2020 adolescents enrolled in Tunisian secondary schools using a self-administered questionnaire.

Results

The prevalence of tobacco, alcohol and cannabis use was respectively 3.7% (95% CI [2.87%-4.52%]), 4.4% (95% CI [3.5%-5.29%]) and 0.8% (95% CI [0.40%-1.18%]) Overall, 17.0% (95% CI [15.3%-18.6%]) reported having suicide ideation during the past 12 months. Tobacco (Odds Ratio = 2.61; 95% CI = 1.59–4.29), alcohol (Odds Ratio = 2.77; 95% CI = 1.76–4.36), and cannabis use (Odds Ratio = 4.98; 95% CI = 1.85–13.96) were significantly associated with suicidal thoughts among adolescents (p &lt; 10-3).

Conclusions

This cross study has shown a significant association between substance use and suicidal ideation. This relationship can be bidirectional and suicidal ideation and substance use may affect each other.

Key messages

In his study, the prevalence of substance use was relatively low and was associated with suicidal ideations. The reciprocal link between the two problems and their co-occurrence should be taken into account when planning preventive substance use and suicide programs.

Obstetrical complications treated in the maternities of the region of Sousse (Tunisia)

Background

About 800 women die each day worldwide due to complications related to pregnancy, childbirth or in the postpartum period. The objective of this study was to describe the activity of the public maternities in the Governorate of Sousse (Tunisia) and to identify obstetrical complications treated in these facilities.

Methods

A cross sectional study of all public health facilities, which performed deliveries in Sousse was conducted in 2017 (Five maternities: one University maternity and four peripheral ones). Data were collected by reviewing clinical records and registers of these maternities for the year 2016.

Results

In total, in the health visited structures, there were 13427 deliveries in 2016, the majority of them (78.8%) took place at the university maternity of Farhat Hached hospital. Of these deliveries, 3397 were performed by caesareans (25.3%). In 2016, there were three maternal deaths and 69 very early neonatal deaths. There were 2036 direct obstetric complications treated in the five maternities visited. The most frequently encountered direct complications were: ’obstructed/prolonged labor’ (41.21%), ’severe pre-eclampsia/eclampsia’ (19.5%) and ’ante and postpartum haemorrhage’ (15.18%). The most encountered indirect obstetrical complications were: gestational diabetes and anaemia.

Conclusions

The reduction of maternal and neonatal mortality requires the existence of a functioning basic health care system that provides all pregnant women and their newborns with timely access to skilled care, particularly when a complication occurs. The provision of this qualified care requires also the presence of qualified personnel working in a suitable professional environment.

Key messages

The majority of obstetrical complications occur in university maternity and this is due to excessive references from peripheral maternities. Peripheral maternities need to be strengthened with material and human resources.

Suicidal ideation among Tunisian adolescents and the association with adverse life experiences

Background

Youth suicidality is a significant public health problem. Understanding the factors leading to suicide is essential to implement effective preventive efforts. In this context, this study was conducted to assess the link between suicidal ideation and adverse life experiences among Tunisian school aged youth.

Methods

A cross-sectional survey was conducted among a sample of 2020 secondary school adolescents in 2016. An anonymous self-administered questionnaire was used to collect data. The adverse life events measured were: domestic violence, parental divorce, physical aggression, sexual abuse and a familial antecedent of suicide.

Results

Overall, 17.0% (95% CI [15.3%-18.6%]) reported having suicide ideation during the past 12 months with no gender difference (16.3% among girls and 17.3% among boys, p = 0.62). Among the participants, 26.7% experienced at least one adverse life experience. Those who reported domestic violence (Odds Ratio = 8.93; 95% CI = 6.84–11.66), parental divorce (Odds Ratio = 3.02; 95% CI = 1.57–5.79), physical aggression (Odds Ratio = 6.97; 95% CI =5.14–9.46), sexual abuse (Odds Ratio = 8.69; 95% CI =3.94–19.15), familial antecedent of suicide (Odds Ratio = 8.17; 95% CI = 5.75–11.60) were associated with increased odds of suicide ideation.

Conclusions

The prevalence of suicidal ideation observed in the survey area was relatively high and associated with all the measured life adverse events. These factors should be included in a suicide screening tool to be integrated in a suicide prevention program.

Key messages

Suicidal ideation among adolescents was associated with all the measured life adverse events. Identifying adolescents at higher risk of suicide and help them to cope with their adverse experiences could be effective to prevent taking action to attempt suicide.

School bullying among Tunisian adolescents: prevalence and psychosocial outcomes

Background

Bullying is a serious public health concern affecting the emotional well-being of pupils. We conducted this study to examine the prevalence of bullying, its psychosocial associated factors and the perceived involvement of parents, teachers, and classmates to counteract this behavior.

Methods

This is a cross-sectional study conducted in 2015 among a representative sample of pupils enrolled in 14 colleges in Sousse using the revised Olweus Bully/Victim Questionnaire.

Results

We included 1584 students aged between 11 and 15 years. The prevalence of bullying and victimization was 16.0% [95% CI: 14.2%, 17.8%] and 11.3% [95% CI: 9.7%, 12.9%] respectively. Four groups of students were identified, 11.7% were classified as pure victims, 7.8% as pure bullies, 3.2% as bully-victims and 75.5% as bystanders. Compared to other groups, the bully-victims were less likely to report a feeling of empathy (38.3%, p &lt; 10-3) and liking school (30.0%, p &lt; 10-3). They were more likely to be aggressive (56.2%, p &lt; 10-3) and disintegrated in the class (30.6%, p = 0.002). Among the victims, 11.1% reported that their parents contacted the school several times to stop their victimization. The majority of the middle school students perceived that their classmates (54.1%) and teachers (39.5%) did nothing to counteract the bullying behavior.

Conclusions

The school institution is expected to be for pupils a highly meaningful space for social, emotional and academic development. Parents, teachers and students should learn effective ways to handle the bullying problem since it has been emphasized that the most effective programs are comprehensive targeting students, schools, families, and the community.

Key messages

This is the first study conducted in Tunisia to highlight the extent of school bullying. Our findings can help to raise awareness of parents, school staff and policy makers about bullying.

Estimation of direct cost related to asthma among school-age children with asthma

Background

Childhood asthma still imposes a substantial burden on the health care system and community. Its management requires a significant direct cost. Several factors can influence the cost of asthma management, particularly severe asthma. There is scant information about the predictors of asthma-related cost. Thus, the purpose of this study was to estimate direct asthma-related cost among children with chronic asthma and to identify factors that have the greatest contribution to change it.

Methods

This cross-sectional study was carried out in Farhat Hached University Hospital in Sousse (Tunisia, Africa) over a period of three months (April-June 2018) among children with asthma aged 7-17 years. The direct cost was defined as the costs of health resources utilization and medication related to asthma in the past 12 months. Purchasing power parity technique was used to convert TND to USD. Multiple linear regression was performed to examine the association between dependent and independent variables.

Results

A total of 90 subjects participated in the study. The mean age was 9.81±2.56 and 55.6% were male. The annual mean of the total direct cost was USD 616.71±454. Multivariate analysis showed that the severity of asthma, inhalation technique and emotional domain of QOL predict asthma cost and that the latter was the best predictor (p = 0.005, p = 0.03, p = 0.004, respectively). This data indicates that for one child with mild asthma, correct inhaler technique, and moderate impairment of emotional function QOL domain, estimated asthma direct cost was equal to 1035.21 USD per 12 months.

Conclusions

This study showed that higher severity of asthma, incorrect inhaler technique and a lower score of emotional function increased direct cost related to asthma. These results are useful for health care providers and community since they provide information about the impact of modifiable risk factors on direct asthma cost.

Key messages

For one child with mild asthma, correct inhaler technique, and moderate impairment of emotional function QOL domain, estimated asthma direct cost was equal to 1035.21 USD per 12 months. Higher severity of asthma, incorrect inhaler technique and a lower score of emotional function increased direct cost related to asthma.

Intravenous lidocaine as adjuvant to general anesthesia in renal surgery

The role of intraoperative intravenous lidocaine infusion has been previously evaluated for pain relief, inflammatory response, and post-operative recovery, particularly in abdominal surgery. The present study is a randomized double-blinded trial in which we evaluated whether IV lidocaine infusion reduces isoflurane requirement, intraoperative remifentanil consumption and time to post-operative recovery in non-laparoscopic renal surgery. Sixty patients scheduled to undergo elective non-laparoscopic renal surgery under general anesthesia were enrolled to receive either systemic lidocaine infusion (group L: bolus 1.5 mg/kg followed by a continuous infusion at the rate of 2 mg/kg/hr until skin closure) or normal saline (0.9% NaCl solution) (Group C). The depth of anesthesia was monitored using the Bispectral Index Scale (BIS), which is based on measurement of the patient’s cerebral electrical activity. Primary outcome of the study was End-tidal of isoflurane concentration (Et-Iso) at BIS values of 40–60. Secondary outcomes include remifentanil consumption during the operation and time to extubation. Et-Iso was significantly lower in group L than in group C (0.63% ± 0.10% vs 0.92% ± 0.11%, p < 10^–3). Mean remifentanil consumption of was significantly lower in group L than in group C (0.13 ± 0.04 µg/kg/min vs 0.18 ± 0.04 µg/kg/min, p < 10^–3). Thus, IV lidocaine infusion permits a reduction of 31% in isoflurane concentration requirement and 27% in the intraoperative remifentanil need. In addition, recovery from anesthesia and extubation time was shorter in group L (5.8 ± 1.8 min vs 7.9 ± 2.0 min, p < 10^–3). By reducing significantly isoflurane and remifentanil requirements during renal surgery, intravenous lidocaine could provide effective strategy to limit volatile agent and intraoperative opioids consumption especially in low and middle income countries.

Bullying Among Tunisian Middle School Students: the Prevalence, Psychosocial Associated Factors and Perceived Involvement of Parents, Teachers and Classmates

BACKGROUND

Bullying is a serious public health concern remarkably common among youth. Involvement in bullying can lead to deleterious effect on the emotional well-being of pupils. The aim of this study was to assess the prevalence of bullying, its psychosocial associated factors and the perceived involvement of parents, teachers, and classmates to counteract this behavior.

STUDY DESIGN

A cross-sectional study.

METHODS

We conducted this study in 2015 among a representative multistage sample of 1584 students enrolled in middle schools in the Region of Sousse using the revised Olweus Bully/Victim Questionnaire. It assesses the prevalence of bullying and covers qualitative details of bullying including psychosocial factors and perceived efforts of others to counteract bullying.

RESULTS

11.7% of respondents were classified as pure victims, 7.8% as pure bullies, 3.2% as bully-victims and 75.5% as bystanders. Compared to other groups, the bully-victims were less likely to report a feeling of empathy and liking school. They were more likely to be afraid of being bullied, aggressive and to have fewer friends in the class. Only 30.3% of the victims indicated that they told someone about being bullied. The majority of the middle school students perceived that classmates (54.1%) and teachers (39.5%) did nothing to counteract bullying.

CONCLUSIONS

Information about bullying is critical and must be gathered before effective intervention is planned. Parents, teachers and students should learn effective ways to handle the bullying problem since the most effective programs are comprehensive targeting students, schools, families and the community.

Response to clopidogrel and of the cytochrome CYP2C19 gene polymorphism

INTRODUCTION

Clopidogrel (clopi) is a prodrug widely prescribed in the management of coronary artery disease and requires the intervention of hepatic cytochrome P450 2C19 (CYP2C19) for its activation. However, there is interindividual variability in response to clopi despite the use of recommended doses. Thus, the studies have highlighted the effect of the CYP2C19 gene polymorphism or Cyp2C19 gene on the response to clopi and particularly Cyp2C19 * 2 which may be associated with an increased risk of major cardiovascular events or MACE.

OBJECTIVE

To evaluate the effect of Cyp2C19 * 2 polymorphism on MACE occurrence and hemorrhagic complications in patients treated with clopi.

METHODS

We carried out a descriptive longitudinal study including 71 patients placed under clopi for a minimum duration of one month. Genotyping of the Cyp2C19 allele was performed by conventional polymerase chain reaction (PCR). After a follow-up period of 495 ± 183 days, we performed a statistical analysis to evaluate the association between the Cyp2C19 * 2 polymorphism and the occurrence of MACE or hemorrhagic complications.

RESULTS

Among our patients, 51% had an angioplasty, 42% medical treatment and 7% a coronary artery bypass surgery. In our study population, 52% were heterozygous (HTZ), 28% homozygous (HMZ) healthy * 1 / * 1 and 20% HMZ had the loss of function allele * 2 / * 2. The allelic frequency of Cyp2C19 * 2 was 46%. Follow-up mean duration was of 495 ± 183 days. During this period, the prevalence of MACE was 11% and that of hemorrhagic complications was 13%. In our study, we did not observe a significant association between the occurrence of MACE or hemorrhagic complications with the genotype carrying the Cyp2C19 * 2 allele.

CONCLUSION

Among patients treated with clopi, wearing a Cyp2C19 * 2 function loss allele didn't seem to be associated with a significantly higher risk of MACE, nor a significantly lower risk of hemorragic complications. This suggests the necessity of larger studies.

Smoking and associated factors among school teenagers in the city of Sousse (Smoking and school teenagers)

BACKGROUND

Tobacco use among teenagers in an increasing concern for the international community, especially with the fact that early experimentation is now identified as a risk factor for durable consumption and addiction.

AIM

To study Tobacco use and its determinants amongteenagers in the city of Sousse.

METHODS

A descriptive cross-sectionalstudy was carried out among a sample of teenagers enrolled in the city of Sousse (Tunisia) in 2016-2017. A two-stage sampling was conducted for the selection of adolescents. Data were collected using a self-administered questionnaire in Arabic language.

RESULTS

The sample consisted of 330 students. The prevalence of smoking was 9.7%(95% CI6,7% ;13%), with a male predominance (14.4% vs 6.3%). The mean age of onset of tobacco was 14.65 ± 1.38 years. 44.8% of parents ignore their children's smoking. The mean dependence score was 4.77 ± 3.6 (HONC test).  Factors significantly associated with smoking were gender, age, educational level, repeating school years, relationship with parents and teachers, presence of smokers in the environment, knowledge about the health risks of tobacco.

CONCLUSION

Sensitizationactions should be strengthened within schools, starting even in primary schools, in collaboration with teachers, family and health professionals. In addition, more effective and rigorous enforcement of legislation is essential.

Prevalence and Predictors of Internet Addiction among College Students in Sousse, Tunisia

BACKGROUND

Internet represents a revolution in the world of technology and communication all over the world including Tunisia. However, this technology has also introduced problematic use, especially among students. The current study aimed to determine the prevalence of Internet addiction among college students and its predictors in the region of Sousse, Tunisia.

STUDY DESIGN

A cross-sectional study.

METHODS

The current study was conducted in the colleges of Sousse, Tunisia in 2012-2013. A self-administrated questionnaire was used to collect data from 556 students in 5 randomly selected colleges from the region. Collected data concerned socio-demographic characteristics, substances use and internet addiction using the Young Internet Addiction Test.

RESULTS

The response rate was 96%. The mean age of participants was 21.8±2.2 yr. Females represented 51.8% of them. Poor control of internet use was found among 280 (54.0%; CI95%: 49.7, 58.3%) participants. Low education levels among parents, the young age, lifetime tobacco use and lifetime illicit drugs use were significantly associated with poor control of internet use among students (P<0.001). While, the most influential factor on internet use among them was under-graduation with an adjusted odds ratio of 2.4 (CI95%: 1.7, 3.6).

CONCLUSIONS

Poor control of internet use is highly prevalent among the college students of Sousse especially those under graduate. A national intervention program is required to reduce this problem among youth. A national study among both in-school and out-of-school adolescents and young people would identify at-risk groups and determine the most efficient time to intervene and prevent internet addiction.

[Safety culture in Tunisian primary health care: A multicenter study]

AIMS

To assess safety culture in primary healthcare centres and to explore its associated factors.

METHODS

This multicentre cross-sectional descriptive study was conducted in the 30 primary healthcare centres in central Tunisia and used the validated French version of the Hospital Survey on Patient Safety Culture questionnaire' (HSOPSC).

RESULTS

A total of 214 professionals participated, corresponding to a response rate of 85%. The ?Teamwork within centres? dimension had the highest score (71.5%). However, two safety dimensions had very low scores: ?Frequency of event reporting?, ?Non-punitive response to errors? with percentages of 31.4% and 35.4%, respectively. Among the associated factors, the ?Frequency of reported events? dimension was significantly higher among professionals involved in risk management committees (p = 0.01).

CONCLUSION

This study demonstrates that the level of safety culture needs to be improved in primary healthcare centres in Tunisia and also highlights the need to implement a quality management system in primary healthcare centres.

[Prevalence and associated factors of alcohol consumption among students of the Sousse region of Tunisia]

Aim: This study was designed to assess the prevalence of alcohol consumption and factors associated with alcohol consumption among students of the Sousse region of Tunisia. Methods: This was a cross-sectional study conducted among 556 students of Sousse universities during the 2012-2013 academic year, using an anonymous self-report questionnaire. Data capture and statistical analysis were performed with SPSS software 18.0. Results: Our study population was composed of 268 males (48.2%) with a mean age of 21.8 ± 2.1 years. Eighty-four students (15.1%) had consumed alcohol at least once. On multivariate analysis, male gender (OR = 6.94; 95%CI = [2.32-20.72]), smoking (OR = 13.21; 95%CI = [6.20-27.78]), drug use (OR = 32.22; 95%CI = [6.73-154.26]) and parental alcohol consumption (OR = 4.31; 95%CI = [1.70-10.91]) were the factors significantly associated with alcohol consumption among students. Conclusion: This study was designed to determine the characteristics of alcohol consumption among Tunisian students. Alcohol consumption levels were comparable to those reported in the general population and were significantly related to smoking and drug use. The next step of this study will consist of developing strategies to prevent risk behaviours in the student population.

[Mobile emergency care medical records audit: the need for Tunisian guidelines]

Objective: This study was designed to assess the quality of the Gabès (Tunisia) mobile emergency care medical records and propose corrective actions.Materials and methods: A clinical audit was performed at the Gabès mobile emergency care unit (SMUR). Records of day, night and weekend primary and secondary interventions during the first half of 2014 were analysed according to a data collection grid comprising 56 criteria based on the SMUR guidelines and the 2013 French Society of Emergency Medicine evaluation guide. A non-conformance score was calculated for each section.Results: 415 medical records were analysed. The highest non-conformance rates (48.5%) concerned the “specificities of the emergency medical record” section. The lowest non-conformance rates concerned the surveillance data section (23.4%). The non-conformance score for the medical data audit was 24%.Conclusion: This audit identified minor dysfunctions that could be due to the absence of local guidelines concerning medical records in general and more specifically SMUR. Corrective measures were set up in the context of a short-term and intermediate-term action plan.

Associated outcomes to fetal macrosomia: effect of maternal diabetes

BACKGROUND

Fetal macrosomia is associated with an increased risk of adverse outcomes to both the mother and the infant.

AIM

To determine maternal and neonatal outcomes associated to fetal macrosomia in diabetic and non- diabetic mothers.

METHODS

It is a descriptive retrospective study conducted in Tunisia. We included in this study all patients who delivered newborns having a birth weight above 4kg during 2013. Multivariate analysis was performed using binary logistic regression to identify the complications associated to macrosomic pregnancies with diabetes.

RESULTS

Among the 10186 deliveries registered during the study period, 821 mothers gave birth to macrosomic newborns. The prevalence of macrosomia was 8.1%, and macrosomic newborns who had a birth weight of 4500 g or greater were 1.06%. Macrosomia was significantly higher in males (p <10-3). The rate of cesarean delivery was 47.9%. The most frequent adverse maternal and neonatal outcomes were perineal tears (3.6%), post-partum hemorrhage (0.6%), shoulder dystocia (4.9%) and neonatal intensive care unit admission (7.6%).The proportion of maternal diabetes was 9.3%. Macrosomic pregnancies with diabetes appear to be significantly associated with cesarean delivery (OR=2.22), postpartum hemorrhage (OR=6.69) and neonatal intensive care unit admission (OR=4.18).

CONCLUSION

Macrosomia increases the risk of maternal and perinatal morbidity particularly when it was associated to maternal diabetes.