Alarming trends in Tobacco use in high school Tunisian adolescents: MedSPAD2013-2021

Background

Tobacco use is a global health concern, with smoking initiation often beginning in adolescence. In Tunisia, published data assessing trends of tobacco consumption at the national level only concerns middle school students aged 13 to 15 years. No data related to high school students are however published yet. We aimed to determine tobacco smoking prevalence in Tunisian adolescents and assess trends from 2013 to 2021.

Methods

Pooled data from three Mediterranean school surveyson alcohol and other drugs (MedSPAD surveys: 2013, 2017, and 2021) were used. Based on three-stage stratification sampling method, teenagers aged between 15 and 17 years, were enrolled. Were not included students enrolled in vocational training centers and out-of-school adolescents. Data collection was performed using a self-administered standardized questionnaire assessing socio-demographic characteristics and risky behaviours. We studied weighted prevalence estimates of cigarettes and water pipe (WP) smoking. All statistical analysis, including trend analysis, were performed with STATA software.

Results

A total of 14.723 students were enrolled with sex ratio (M/F) equal to 0.6 and mean age of 16.2±0.8 years. The prevalence of cigarette smoking increased from 17.8%, to 20.2% then to 24.7% for 2013, 2017 and 2021, respectively. As for WP smoking, its prevalence increased from 14.8%, to 16.7% then to 19.9% for 2013, 2017 and 2021, respectively. Trends analysis concluded to significant increase over study period for cigarettes and WP smoking (p < 10-3). The increase was most alarming for girls regarding WP smoking (consistent increase over the study period).

Conclusions

Our findings underscore the alarming increasing trend for different forms of tobacco smoking among Tunisian youth. It is therefore crucial to strengthen tobacco control measures among young adolescents in order to counteract the tobacco industry’s expanding marketing of new products primarily targeting this population.

Key messages

• The prevalence of cigarette and water pipe smoking increased significantly among high school Tunisian adolescents from 2013 to 2021.

• A better commitment to the implementation of MPOWER measures for tobacco control is therefore urgent.

Leading causes of death in Tunisia, 2020

Background

Mortality data represent a primary source of information for monitoring a population health status over years. In Tunisia, the national Information System on Causes of Death (ISCD) lacks completeness (average coverage rate of 40%); however, in order to examine covid-19’s effect on mortality data, the ISCD was reinforced. We aimed to give an overview of leading causes of death in Tunisia for 2020.

Methods

Data were obtained from Medical Certificates of Cause Of Death (MCCOD) sent by municipalities to the National Institute of Health in accordance with the legislative framework. Causes of Death (CoD) coding process was performed based on the International Classification of Diseases, Tenth Revision (ICD-10). The underlying cause of death was identified based on IRIS software, and mortality statistics were presented based on the world health organization cause-of-death lists for tabulating mortality statistics. Data analysis was performed using SPSS software.

Results

A total of 46.420 MCCOD among 75.365 deaths officially declared by the National Institute of Statistics, were analyzed (coverage rate of 61.2%). The 10 leading causes of death for both sexes, in rank order were: diabetes mellitus, cerebrovascular diseases, covid-19, ischemic heart diseases, external causes of death, digestive and pulmonary malignant neoplasms, conditions of neonatal period, hypertensive diseases, and influenza and pneumonia. Leading causes of infant deaths were: certain conditions originating in perinatal period, congenital malformations, deformations and chromosomal abnormalities, diseases of respiratory system, certain infectious and parasitic diseases, and diseases of nervous system.

Conclusions

The COVID-19 pandemic was an opportunity to improve the Tunisian ISCD’s coverage rate. However, efforts should be maintained to optimize system completeness, and decision makers should be more sensitized regarding the urgent need for system digitalization.

Key messages

• Mortality statistics have shown that covid-19 ranks third among leading causes of death in Tunisia for 2020; and non communicable disease accounted for 6 out of 10 leading causes of deaths.

• The ISCD coverage rate was improved in 2020 reaching 61.2%; however the system digitalization is an essential and sustainable solution to optimize completeness.

Cannabis use in Tunisian adolescents: Alarming trends from 2013 to 2021

Background

Cannabis is the most widely used illicit psychoactive substance worldwide. In Tunisia, the prevalence of cannabis use and its association with other risky behaviours were reported in several publications interesting mainly early adolescence. However, no publications exploring trends based on national epidemiological data are available yet. Our purpose was to determine cannabis prevalence in Tunisian high school adolescents and assess significant trends from 2013 to 2021.

Methods

Pooled data from Mediterranean school surveys on alcohol and other drugs conducted in 2013, 2017, and 2021, were used. Based on three-stage stratification sampling method, first and second grade secondary education students were enrolled. Were not included students enrolled in vocational training centers and out-of-school adolescents. Self-administered standardized questionnaire was used in data collection. We studied weighted lifetime prevalence of cannabis use and chi square test for trend was used for global, by gender and by sector (private/public) trends assessement. STATA software was used for statistical analysis.

Results

A total of 14.723 students were enrolled with sex ratio (M/F) equal to 0.61 and mean age of 16.2±0.8 years. The prevalence of cannabis use increased from 1.4%, to 3.8% then to 7.9% for 2013, 2017 and 2021 respectively. Trend assessement concludes to significant increase in overall cannabis use (p &lt; 10-3). Besides, there was a significant increase in both public and private schools, and among both boys and girls. However, the greatest increase was among male students (3.5% in 2013, 9.2% in 2017 and 16.1% in 2021) (p &lt; 10-3).

Conclusions

Despite the reinforcement of restrictive legislative measures, the prevalence of cannabis use among Tunisian high school adolescents is significantly increasing. Moreover, it’s important to further investigate problematic cannabis use and its effects on adolescents’ physical and mental health.

Key messages

• Trend assessement confirmed the significant increase in lifetime cannabis use in high school adolescents in Tunisia, for both sexes and for both private and public sector.

• This alarming public health issue requires urgent legislation review and close multisectoral collaboration to control supply and demand.

Nonmedical use of anxiolytics among Tunisian students: Connecting the dots from 2013 to 2021

Background

Nonmedical use of prescription drugs such as sedatives and anxiolytics is a fast growing public health threat in several countries. In Tunisia, although several studies have investigated the prevalence of nonmedical use of anxiolytics among school-age students, there is a gap in knowledge regarding trends in anxiolytics misuse. We aimed to determine the prevalence of nonmedical use of anxiolytics and examine trends between 2013 and 2021.

Methods

Pooled data from three Mediterranean school surveys on alcohol and other drugs (MedSPAD I-2013, MedSPAD II-2017, MedSPAD III-2021) were used. Based on three-stage stratification sampling method, teenagers in first and second grades of secondary education, were enrolled. Were not included students enrolled in vocational training centers and out-of-school adolescents. Data collection was performed using a self-administered standardized questionnaire. We studied weighted lifetime nonmedical use of

prescription anxiolytics and performed global and by gender trend analysis. Epi data software was used for data entry and all statistical analysis, were performed with STATA software.

Results

A total of 14.723 students were enrolled with sex ratio (Male/Female) equal to 0.61 and mean age of 16.2±0.8 years. The prevalence of nonmedical anxiolytics’ use increased from 2.1% to 3% then to 8.4% for 2013, 2017 and 2021, respectively. Global and by gender trends analysis concluded to significant increase from 2017 to 2021 (p &lt; 10-3). However, a non-significant increase was revealed from 2013 to 2017.

Conclusions

Our study is the first to confirm a significant increasing trend in non-medical use of anxiolytics among Tunisian adolescents. These findings emphasize the urgent need for early detection of psychological vulnerability among adolescents in order to prevent their engagement in such risky behaviors.

Key messages

• Decision makers should be sensitized regarding the alarming increasing trend in non-medical use of anxiolytics, among Tunisian adolescents.

• The state control of these substances accessibility and early detection of psychological vulnerability, are highly required.

Trans fatty acids policy analysis to prevent non-communicable diseases in Tunisia

Background

Despite the widely published international guidelines for a better implementation of health policies promoting healthy eating habits; the epidemiological situation regarding most weighing heavily non-communicable diseases (NCDs) on global health, is still alarming. We aimed to analyze Tunisian health policies targeting trans fatty acids (TFA) consumption to prevent and control NCDs.

Methods

Based on in-depth policy content analysis and stakeholder interviews, Tunisian policies related to promoting healthy diets and restricting unhealthy consumption of TFA, were identified. Four sub-components of WHO best-buys were assessed: goal to eliminate industrially-produced TFA, legislation to ban their use in food chain, TFA labeling and fiscal policies, and mass media campaign to promote healthy diet and reduce TFA intake. Findings were analyzed based on three main axes of the “policy cube approach”: comprehensiveness of policy content, policy effectiveness and respect of equity principles. For each axis, final assessment was performed based on a Likert scale: low, moderate and high.

Results

Although (3/4) WHO best-buys are covered by the national strategies for NCDs and obesity prevention for 2018-2025 and 2013-2017 respectively. This analysis has revealed moderate level for comprehensiveness of policy content, because ofthe absence of specific mention regarding legislation. A moderate level in policy salience and effectiveness was also highlighted (weak accountability mechanisms and no budget line for effective implementation for all WHO best-buys). A very low respect to equity principles was also underlined with no specific attention regarding vulnerable populations.

Conclusions

Main weaknesses in TFA policies concerned legislation, budget allocation and accountability mechanisms. “Legislation measures” to ban trans-fats use in the food chain and resource mobilization for “nutrition labeling and mass-media campaigns” effective implementation, are recommended.

Key messages

Several weaknesses in TFA policies have been highlighted, mainly related to: legislation, budget allocation, accountability mechanisms and low respect to equity principles. Legislation reinforcement and efficient resource mobilization for “nutrition labeling and mass-media campaigns” effective implementation, are strongly recommended.

Assessment of glycemic control among Tunisian diabetic adults

Background

Diabetes, a major public health issue in Tunisia, is responsible of an increased burden of morbidity and premature mortality. Achieving a good glycemic control is essential for reducing the morbidity-mortality associated with this disease. The purpose of our study was to assess the proportion of uncontrolled diabetes (UD) among Tunisian diabetic adults and assess associated factors.

Methods

A national household survey, stratified at three degrees, was conducted in 2016. As part of this study, we included previously diagnosed diabetic adults aged 20 years or above. Sociodemographic data and medical history were collected using an individual questionnaire, and glycated hemoglobin (HbA1C) was measured using the “A1C Now +” device. The UD was defined based on the American Diabetes Association criteria for the year 2016 (HbA1c ≥7%). Multiple logistic regression model was used to determine factors associated with UD. Adjusted Odds Ratios (AOR) were presented with 95% confidence intervals (CI). All data analysis was performed using SPSS software.

Results

A total of 873 subjects were included with a median age of 61 years and a sex-ratio equal to 0.9. The proportion of UD was (72.8%, 95% CI: [69.1-76.3]). In multivariate analysis, UD was more frequent among rural areas residents (AOR=1.8 [1.1-2.7]), those who had never seen a doctor within the year preceding the survey (AOR=2.2 [1.1-4.2]) and among those on oral antidiabetics (AOR=6.1 [1.9-18.9]) or insulin (AOR=23.8 [7.1-79.8]) compared to those who were following a diabetic diet.

Conclusions

This study highlighted a very high proportion of UD in diabetic Tunisian adults. A better involvement of primary care physicians in overall patient care, and improved availability of antidiabetic drugs for patients, are strongly recommended.

Key messages

Majority of Tunisian diabetic adults aged 20 years or older had an uncontrolled diabetes. Improving patient education and the availability of antidiabetic drugs for diabetic individuals in primary healthcare facilities is essential.

Health care renunciation in Tunisian diabetic patients, 2016

Background

Diabetes management requires access to health care, patient awareness about hygiene and diet measures, and patient adherence to prescribed treatment. Health care renunciation (HCR) can make diabetes management really challenging. We aimed to determine the prevalence of HCR in diabetic Tunisian patients and assess associated factors.

Methods

Data were obtained from the 2016 Tunisian Health Examination Survey, a household survey stratified at three degrees. For each household, two people aged 18 and over were randomly selected. Data were collected using: a household questionnaire and an individual questionnaire (risk behaviours and medical history). Diabetic patients were asked whether, they had renounced any health care service, the last time they needed to seek healthcare. Data analysis was performed with R software.

Results

A total of 880 diabetic patients were included in this survey, with a mean age of 61±12 years and a sex ratio M/F equal to 0.9. The prevalence of HCR was 4.9% (95% CI [3.3-6.5]), higher in men (7.4% VS 2.6% in women, p = 0.003) and higher in urban areas (5.4% VS 3.1 in rural areas, p = 0.09). After multivariate adjustment (taking into consideration age, gender, profession, health insurance and place of residence as independent variables), having no health insurance and being aged more than 50, were significantly associated to HCR, with adjusted Odds Ratios equal to (3.8, 95% CI [1.4-9.2]) and (3.4, 95% CI [1.9-10.1]), respectively.

Conclusions

Our study has highlighted a relatively low prevalence of HCR compared to literature data (4.9% VS 10-15%), explained mostly by methodological differences regarding HCR assessment. HCR in diabetic patients is mostly explained by economic reasons, which show how important is a better organisation of Tunisian public health system to ensure equity in access to health care.

Key messages

Health care renunciation in diabetic Tunisian patients is explained mainly by financial reasons (having no health insurance). Moving further towards improving universal health coverage is a key pillar in the proper management of chronic diseases such as diabetes.

Prevalence, awareness and control of hypertension among Tunisian adults, 2016

Background

Hypertension is becoming increasingly frequent mainly in low and middle income countries. We aimed to assess the prevalence, awareness and control of hypertension among Tunisian adults and identify associated factors with hypertension control.

Methods

Data were obtained from the 2016 Tunisian Health Examination Survey, a household survey stratified at three degrees. Adults (age≥18 years old) were interviewed using an individual questionnaire, then three blood pressure measurement were performed. Participants were considered hypertensive if they were previously diagnosed or had a systolic blood pressure (SBP) ≥140mmhg and/or a diastolic blood pressure (DBP) ≥ 90mmhg during the survey. Were considered under control, treated persons with SBP&lt;140 mmhg and a DBP&lt;90 mmhg. A weighted binary logistic regression was used to assess associated factors with hypertension control. Input model variables were: sociodemographic variables, comorbidities and lifestyle factors.

Results

In this study, 8908 adults were enrolled with a mean age of 42.8±0.2 years old and a sex ratio (M/F) equal to 0.96. Among respondents, 29.3% (95% CI: 28.2-30.5) had hypertension, 60.7% (95% CI: 58.7-62.6) of them were unaware of their disease and only (29.5%, 95% CI: 28.2-30.5) of treated patients had a controlled hypertension. In multivariate analysis, eating more than five fruits and vegetables per day was independently associated with a better hypertension control (AOR=1.7, 95% CI: 1.1-2.5). In addition, participants living in northern Tunisia were more likely to have a controlled hypertension than those living in the south (AOR=1.9, 95% CI: 1.2-2.9).

Conclusions

Almost third of Tunisian adults were hypertensive. Low level of awareness and control of hypertension were found in this study. This highlights the urge to reinforce hypertension screening interventions and to strengthen educational programs on this disease with a focus on blood pressure monitoring and healthy lifestyle measures.

Key messages

Tunisian adults had a low level of awareness and control of hypertension. Reinforcing hypertension screening interventions and increasing awareness about healthy lifestyle measures are recommended.