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This study aimed at evaluating the impact of a combined-strategies intervention on ICUs nurses' attitudes toward AE reporting.We conducted a quasi-experimental study from January to October 2020 which consisted of an intervention to improve attitudes toward incident reporting among nurses working in 10 intensive care units at a university hospital using the Reporting of Clinical Adverse Events Scale. The intervention consisted of a 2-hour educational presentation for nurse unit managers and a 30-minute in-units educational training for intensive care unit nurses, which encompassed technical aspects of reporting, the reporting process, a nonpunitive environment, and the importance of submitting reports. The educational presentation was reinforced with distributing posters and brochures and biweekly patient safety rounds that inquired about events, reinforced education, and provided follow-up to incident reports.All dimensions were significantly improved. Score increased from 27.4% to 42.1% ( P0.01) for perceived blame, from 35.2% to 52.5% for perceived criteria for identifying events that should be reported ( P0.01), from 34.3% to 46% for perceptions of colleagues' expectations ( P = 0.04), from 37.1% to 51.4% for perceived benefits of reporting ( P = 0.01), and from 29.2% to 51.4% for perceived clarity of reporting procedures ( P0.01).Interventions using a combination of several strategies such as training, safety round, and messaging can be effective and should be considered by hospitals attempting to increase adverse events reporting. Results reinforce the assumption that a nonpunitive environment and the resulting feeling of safety and reassurance are crucial to foster the submission of reports.

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.

Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress.This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured.Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P 0.01 and r = 0.137, P 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P 0.05).This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen.

Childhood asthma still imposes an enormous burden on children and their families. To the best of our knowledge, no study reviewed the literature on the effect of family asthma education on major asthma outcomes. This study aimed to explore the effect of family education programs on major asthma outcomes in children. Quasi-experimental studies and randomized controlled trials were conducted among children with asthma aged 6–18 years and their parents were included. Pub Med, Science Direct, and Trip databases were used to extract data published in English from 2010 to 2021. Twenty-two studies were reported in this review. It was demonstrated that family empowerment interventions were effective in improving the quality of life of children and their parents, asthma symptom control, and pulmonary function. Family education that was specific to medication improved medication adherence, inhalation technique, and asthma control. Family asthma education enhanced asthma management and family functioning. This approach should be a cornerstone of pediatric asthma therapy. It helps health care professionals to build a strong connection and trustful relationship with children with asthma and their families.

Background Routine assessments of patient safety culture within hospitals have been widely recommended to improve patient safety. Experts suggested that mixed-methods studies can help gain a deeper understanding of the concept. However, studies combining quantitative and qualitative approaches exploring patient safety culture are still lacking. This study aimed to explore patient safety culture as perceived by operating room professionals of two university hospitals in Sousse, Tunisia. Methods Based on a mixed-methods approach, a cross-sectional survey followed by semi-structured interviews were conducted over a period of two months (December 2019 to January 2020). This study took place in all the operating rooms of two public university hospitals in the district of Sousse, Tunisia. To collect data for this survey, the French version of the Hospital Survey On Patient Safety Culture was used. For interviews, 13 participants were selected purposively using a critical case sampling approach and a topic guide was prepared. Anonymity and confidentiality were respected. Results Overall, twelve operating rooms, with different surgical specialties, were included in the study. Survey feedback was provided by 297 professionals representing a response rate of 85.6%. Concerning patient safety culture, the 10 dimensions had low scores (below 50%) and were considered “to be improved”. The highest score was found in ‘teamwork within units’ (45%). Whereas, the lowest scores were allocated to ‘non-punitive response to error’ (22.9%), followed by “frequency of adverse event reported” (25.6%) and “communication openness” (26.3%). Per qualitative data, participants provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression, and an existing blame culture in operating rooms. Conclusions The findings of this study showed a concerning perception held by participants about the lack of a patient safety culture in their operating rooms. It seems essential to design, implement and evaluate strategies that promote a positive patient safety culture and obliterate punitive climate in operating rooms.

Background Evidence-based practice (EBP) is an important competency of undergraduate nursing students which should be cultivated before graduation by increasing future healthcare providers’ knowledge, skills and attitudes towards EBP. This study aimed to describe nursing students’ competencies (attitudes, knowledge, skills) in Evidence-based practice (EBP) and to determine factors predicting EBP competency. Methods A descriptive cross-sectional study was conducted at the Higher School of Health Sciences and Techniques of Sousse (Tunisia) among 365 nursing students. Data were collected using the validated Evidence Based Practice Competencies Questionnaire (EBP-COQ). Multiple linear regression was performed to determine factors predicting EBP competencies. Results The overall score of EBP-COQ questionnaire was 3.26 ± 0.53 out of 5. The attitude, skills and knowledge subscales received 4.04 ± 0.41; 3.05 ± 0.77 and 2.70 ± 0.74 as mean scores respectively. Multiple linear regression analysis (table 4) revealed that significant related factors were academic level (β = 0.271, p = 0.001), English-language reading skills (β = 0.435, p p = 0.035) difficulties in obtaining full-text papers (β = − 0.127, p p p Conclusions These results help to understand students’ attitudes, knowledge and skills in EBP and can be therefore a starting point to develop effective strategies for EBP curricula.

Chronic childhood asthma is a leading cause of poor quality of life. Factors associated with this major asthma outcome were controversial. The aim of this study is to assess the quality of life of children and adolescents with mild to moderate asthma and to determine the factors associated with quality of life impairment in this population. This was a descriptive study carried out in the pediatric outpatient clinic of a University Hospital in the center of Tunisia over a period of 3 months (April-June 2018). Participants were children with mild to moderate asthma aged 7 to 17 years. The Pediatric Asthma Quality of Life Questionnaire was used to assess quality of life. Binary logistic regression was performed to identify predictors of asthma-related quality of life. A total of 90 children participated in the study. Almost 68% of children were aged 7 to 11, and nearly 32% were adolescents. The mean of PAQLQ total score was 4.7 ± 1.2. The final logistic regression model demonstrated that asthma symptoms control had the greatest impact on quality of life, followed by acute health care use in the past 12 months (

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.

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.

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

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.

Rosmarinus officinalis L. is a widespread aromatic plant commonly consumed as a tea in traditional cuisine and in folk medicine to treat various illnesses due to its therapeutic properties. To the best of our knowledge, there are no reports on the bioavailability and metabolism of R. officinalis tea polyphenols in humans. This study was aimed at assessing the bioavailability and nutrikinetics of R. officinalis phenolic compounds in healthy humans for the first time. Forty-eight compounds were identified in plasma and urine. Few un-metabolized compounds were detected since rosemary polyphenols were extensively metabolized into phase II conjugates, with rapid appearance and clearance in plasma, pointing to small intestinal absorption. Phase II derivatives of caffeic acid showed kinetics compatible with both intestinal and colonic hydrolysis of rosmarinic acid yielding free caffeic and 3,4-dihydroxyphenyl-lactic acids, which were absorbed and metabolized into phase II derivatives. These metabolites, along with reduced forms of caffeic acid and their phase II metabolites, and those of hydroxyphenylpropionic, hydroxylphenylacetic, benzoic and hippuric acids, highlight the importance of colonic absorption. Total urinary excretion of the phenols added up to 235 µmol, corresponding to 22.3% of the ingested amount (1055 µM). In conclusion, rosemary tea polyphenols are partially bioavailable and extensively metabolized, mainly by the colonic microbiota., We acknowledge financial support received from the Tunisian Ministry of Higher Education and Scientific Research, and from the Spanish Ministry of Economy, Industry and Competitivity (project AGL2015-69986-R).

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.

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 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.

Background Burnout is a major issue among healthcare students and a public health issue in general. Indeed, the consequences of student burnout are as complex such as mental distress factors with smoking and alcohol consumption and unhealthy lifestyle. The aim of this study is to determine the prevalence of burnout among health sciences students and its associated factors. Methods This is a cross sectional descriptive study conducted among 368 students of the Higher School of Health Sciences and Techniques of Sousse (Tunisia) from March to April 2018. The study instrument is the French validated version of the Maslach Burnout Inventory-Student Survey (MBI-SS). This instrument measures academic burnout through 3 dimensions (emotional exhaustion, cynicism and academic efficacy). Data entered and analyzed using the Statistical Package for the Social Sciences (SPSS 20.0). Results The prevalence of burnout was 64.4%. The presence of a diagnosed health problem, a diagnosed mental disorder or sleep problems found to be associated with all the aspects of burnout. Students who live alone are significantly the most emotionally exhausted (p = 0.010), and have the highest levels of cynicism (p = 0.033). Students who had a low socio-economic level are significantly more cynical than those who had a medium or high socio-economic level (m = 3.45, m = 2.81, m = 2.25; p = 0.032 respectively). Furthermore, students who perform leisure activities and practice physical activities had a significantly lower levels of emotional exhaustion (p = 0.007, p = 0.008 respectively). Also, studying with new pedagogical approaches decreased significantly the levels of the different burnout dimensions. Conclusions Burnout is prevalent among Tunisian health sciences students, which can have severe consequences such as anxiety and sleep disorders. Hence why preventive strategies should be applied to encounter this problem and avoid its consequent risks. Key messages Students and teachers must be aware of the phenomenon of burnout and its consequences as an important public health issue. Future interventions to minimize the prevalence of burnout and its negative effects should be conducted by focusing on its associated factors.

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.

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.

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.

Background Primary healthcare centers provide the first contact for patients and it goes without saying that quality and patient safety in these facilities are vital goals and challenges. In fact, it has been identified that a significant proportion of safety incidents caught in hospitals had originated in the earlier levels of care, and some studies have found that errors in primary care can result in severe consequences. Hence why, a developed Patient Safety Culture is a component key to improve patient safety and healthcare quality in these settings. Thus, this study aimed to assess patient safety culture in Tunisian primary healthcare centers and to explore its associated factors. Methods It is a cross-sectional descriptive multicenter study, conducted from January to April 2016 in all the 30 primary healthcare settings of the Tunisian center, partners of the Faculty of Medicine of Sousse. The measurement instrument used was the validated French version of the Hospital Survey on Patient Safety Culture Questionnaire. The data analysis was conducted using the Statistical Package for Social Sciences (SPSS 20.0) and Epi info 6.04d for windows. Results A total of 214 professionals participated in the study, corresponding to a response rate of 85%. The “Teamwork within units” dimension had the highest score (71.5%). The lowest scores were for the dimensions related to “Frequency of events reported” and the “Non-punitive response to errors” (31.4% and 35.4% respectively). Additionally, the “Frequency of reported events” dimension was significantly higher among professionals involved in risk management committees (p = 0.01). Conclusions This study demonstrates that the level of patient safety culture needs to be improved in primary healthcare centers in Tunisia. Strategies to nurture patient safety culture should focus upon building leadership capacity that supports open communication, blame-free environment, teamwork and continuous organizational learning. Key messages Patient safety culture in primary healthcare settings is not as strong to ensure the provision of safe care. A well-designed patient safety initiatives, with organizational policies, must be integrated in order to enhance patient safety and quality of care.

Background A large proportion of maternal deaths are related to the health care system, including the failure of the referral system between maternity wards. The objectives of this study were to determine the frequency and the indications of obstetric referrals in a Tunisian regional care maternity and to assess the conformity of referral mechanisms with the National Perinatality Programme guidelines. Methods A descriptive study was carried out at the regional maternity facility of the regional Hospital of Kasserine in 2018, among parturients referred during a period of three months. Data collection was carried out prospectively from medical records, transfer documents, interviews with parturients and with the nursing staff of the reference maternity hospital. The ICD-10 was used to code recorded indications and diagnoses for referrals. Results A total of 234 parturients were included. Referrals represented 15.1% of the obstetric activity in this facility. There were 26 reasons for referrals and the most common was Maternal care for pelvic organ abnormalities (19.7%) and premature rupture of membranes (12.8%). 34.4% of the referrals were unclassifiable according to ICD-10. Most of the indications for referrals (71.4%) did not conform to the list of referral indications of the NPP. Twenty-eight diagnoses were retained after referrals: the most common was Maternal care for pelvic organ abnormalities (15.8%). In 42% of women, reasons for referral did not match with diagnoses established at the time of the patients' admission to hospital. Conclusions The referral system must be analyzed in order to ensure a maximum level of safety for the mother-child couple through the formalization of the protocols and the promotion of the role of peripheral maternity facilities, which are the structures of first recourse. Key messages The current referral system in the region of Kasserine still faces several challenges that need to be addressed in order to make it more effective. Maternal referral systems are an effective measure to help to reduce preventable maternal deaths, they should be continuously assessed and revised.

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.

Burnout is a major issue among healthcare students and a public health issue in general. Indeed, the consequences of student burnout are as complex as other mental distress factors, such as those concerned with smoking and alcohol consumption, or an unhealthy lifestyle. This study aimed to determine the prevalence of burnout among health sciences students and to determine its associated factors. This is a cross-sectional descriptive study conducted among 368 students of a Tunisian institution using the French validated version of the MBI-SS. The prevalence of burnout was 64.4%. The presence of a diagnosed health problem, a diagnosed mental disorder or sleep problems were associated with burnout. Students who live alone are significantly the most emotionally exhausted (p=0.010) and the most cynical (p=0.033). Students who had a low socio-economic level are significantly more cynical than those who had a medium or high socio-economic level (p=0.032). Performing leisure activities and practicing physical activities were associated with emotional exhaustion (p=0.007, p= 0.008, respectively).In our study, burnout is prevalent among Tunisian health sciences students. Many factors were found to be associated with this syndrome. These findings reinforce the need to establish early preventive strategies to encounter this problem and its consequent risks.

Asthma is a leading cause of acute health care use (AHCU) as defined by hospitalization and emergency department visits (ED). Little was known about factors associated with asthma-related AHCU. This study aimed to identify factors determining AHCU in children and adolescents with asthma. A descriptive study was conducted among children with mild to severe asthma referred to the pediatric outpatient clinic of "Farhat Hached" University Hospital of Sousse (Tunisia) over a period of three months (April-June 2018). We collected data regarding clinical information, the number of hospitalizations and ED visits related to asthma in the past 12 months, asthma management behaviors, and quality of life of children. Multivariable logistic regression was performed using SPSS (20.0). A total of 90 children have participated in the study. The percentage of children aged 7 to 11 years was higher than the percentage of adolescents aged 12 to 17 years (67.8%; 32.2%, respectively). The final logistic regression model demonstrated that asthma severity and inhaler technique increased the odds of AHCU (OR a = 4.6; 95% CI: 1.1-18.1

This article describes the FAIRification process (which involves making data Findable, Accessible, Interoperable and Reusable—or FAIR—for both machines and humans) for data related to the impact of COVID-19 on migrants, refugees and asylum seekers in Tunisia, Libya and Niger, according to the scheme adopted by GO FAIR. This process was divided into three phases: pre-FAIRification, FAIRification and post-FAIRification. Each phase consisted of seven steps. In the first phase, 118 in-depth interviews and 565 press articles and research reports were collected by students and researchers at the University of Sousse in Tunisia and researchers in Niger. These interviews, articles and reports constitute the dataset for this research. In the second phase, the data were sorted and converted into a machine actionable format and published on a FAIR Data Point hosted at the University of Sousse. In the third phase, an assessment of the implementation of the FAIR Guidelines was undertaken. Certain barriers and challenges were faced in this process and solutions were found. For FAIR data curation, certain changes need to be made to the technical process. People need to be convinced to make these changes and that the implementation of FAIR will generate a long-term return on investment. Although the implementation of FAIR Guidelines is not straightforward, making our resources FAIR is essential to achieving better science together.

Introduction Rosemary (Rosmarinus officinalis L.) is an aromatic plant common in Tunisia and it is widely consumed as a tea in traditional cuisine and in folk medicine to treat various illnesses. Currently, most research efforts have been focused on rosemary essential oil, alcoholic and aqueous extracts, however, little is reported on rosemary infusion composition. Objective To investigate compounds present in rosemary tea obtained from Rosmarinus officinalis L. collected in a sub-humid area of Tunisia in order to assess whether the traditional rosemary tea preparation method could be considered as a reference method for rosemary's compounds extraction. Methodology Qualitative characterisation of Rosmarinus officinalis tea obtained after rosemary infusion in boiled water was determined by high performance liquid chromatography coupled with electrospray ionisation quadrupole time-of-flight mass spectrometry (HPLC-ESI-QTOF-MS). Quantitative analysis relies on high performance liquid chromatography with diode array detector (HPLC-DAD). Results Forty-nine compounds belonging to six families, namely flavonoids, phenolic acids, phenolic terpenes, jasmonate, phenolic glycosides, and lignans were identified. To the best of the authors' knowledge eucommin A is characterised for the first time in rosemary. Rosmarinic acid (158.13 μg/g dried rosemary) was the main compound followed then by feruloylnepitrin (100.87 μg/g) and luteolin-3'-O-(2″-O-acetyl)-β-d-glucuronide (44.04 μg/g). Among quantified compounds, luteolin-7-O-rutinoside was the compound with the lowest concentration. Conclusion The infusion method allows several polyphenols present in rosemary tea to be extracted, therefore it could be a reference method for rosemary's compounds extraction. Moreover, traditional Tunisian Rosmarinus officinalis tea consumption is of interest for its rich phenolic content. Copyright © 2017 John Wiley & Sons, Ltd.

Objectif : Evaluer la qualite de la tenue et du remplissage des dossiers medicaux au service mobile d’urgence et de reanimation (SMUR) 05 de Gabes (Tunisie) et proposer des actions correctives. Materiels et methodes : Un audit clinique a ete effectue au SMUR 05 de Gabes. Les dossiers des interventions primaires et primo-secondaires de jour, de nuit et de week-end durant le premier semestre de l’annee 2014 ont ete analyses selon une grille de recueil des donnees contenant 56 criteres inspires du referentiel SMUR et guide d’evaluation de la Societe francaise de medecine d’urgence et Samu-urgences de France 2013. Un score de taux de non-conformite a ete calcule par rubrique. Resultats : 415 dossiers ont ete analyses. Le score des taux de non-conformite le plus eleve (48,5 %) etait relatif a la rubrique « specificites du dossier SMUR ». Le meilleur taux de non-conformite a concerne la rubrique les donnees de surveillance (23,4 %). Concernant l’audit des donnees medicales, son score de non-conformite etait de 24 %. Conclusion : Cet audit a releve des dysfonctionnements mineurs. Ils pourraient etre dus a l’absence d’un referentiel local relatif a la tenue d’un dossier patient en general et au SMUR plus specifiquement. Des mesures correctives ont ete mises en place dans le cadre d’un plan d’action a court et a moyen termes.

Patient education is fundamental in asthma management, especially at pediatric age. It is increasingly recognized as effective in reducing the burden of the disease, but is less clear in improving the quality of life of children with asthma and their parents. This study assessed the effect of an asthma therapeutic education program on pulmonary function and quality of life in children with asthma and their parents.A monocentric randomized controlled trial conducted in Farhat Hached University Hospital of Sousse (Tunisia) from May 2018 to September 2019. Thirty-seven families in the experimental 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.The intervention significantly improved quality of life scores of children and their parents (all p 0.05). Children in the experimental group had significantly better forced expiratory maneuver than children in the control group. Nonetheless, the FEV1/FVC ratio did not show any significant difference in the experimental and control group (p = 0.9; p = 0.14, respectively).This study demonstrated that a long-term family-based asthma education program resulted in better pulmonary function and QOL of children and parents enrolled in the intervention group, particularly children with non-allergic asthma.Family-based asthma education can reduce the burden of allergic and non-allergic asthma on children and their parents through improving their quality of life. Also, the pulmonary function of children with non-allergic asthma was improved due to My Asthma Therapeutic Education intervention.

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 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.

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.

Introduction In 1993, the World Health Organization declared that tuberculosis is a public health emergency of global concern. All efforts were made in accordance with the Millennium Development Goals (MDGs) to reduce the burden of Tuberculosis. The MDG framework built into national priorities and development strategies has, in fact, strengthened epidemiological surveillance and the use of reliable data to make decisions based on objective data. These data are essential for planning, managing the activities of the National Tuberculosis program, monitoring and ongoing evaluation of its performance. In this context, we conducted this study to trace the trend of Tuberculosis incidence rate recorded in the Sousse Region between 1992 and 2016. Methods This is a longitudinal study of the registered data of tuberculosis cases in Sousse between 1992 and 2016. For the trend analysis the software JOINPOINT version 4.5.0.1 was used. This software offers the closest possible regression model of the different points and gives an annual percentage change (APC) with a 95% confidence interval. Results The highest TB incidence rates was recorded in 1993 (85.66 cases per 100 000 inhabitants). Between 1992 and 1997, there was a significant downward trend of TB incidence (APC = -23.2; 95% CI [-28.8, 1]). Between 1997 and 2004 the trend was stable. Between 2004 and 2016, there was a significant upward trend (APC = 8.3; 95% CI: [4.3, 12.4]). Conclusions At the national level, between 1992 and 2002, tuberculosis experienced a fall in incidence rates, as a result of an improvement in the socio-economic level and the organization of tuberculosis control. Since 2004, the trend has been rising. Increased tuberculosis control is advocated to end tuberculosis by 2030 in line with sustainable development goals. Key messages After a significant decrease, the tuberculosis incidence has increased significantly since 2004. The tuberculosis prevention efforts should be intensified to reverse the current trend.

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 < 10-3) and liking school (30.0%, p < 10-3). They were more likely to be aggressive (56.2%, p < 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.

Introduction Currently, the Tunisian medical schools are going through a transition period marked by the reform of medical studies. Their curricula must be adapted to globally recognized medical education guidelines. Aware of the importance of teaching scientific research and public health, they are making efforts to integrate this new approach of education within several levels (undergraduate, postgraduate and continuous professional development). In this perspective, the public health research centres (C4EHPs) created under the CONFIDE project provide an opportunity to support such integration. The progress The Faculty of Medicine of Sousse was founded in the 70s to open up to its local and regional community. So, the public health topic was one of the top priorities. With the reform started in 2011, the importance of this topic has been further developed by integrating many modules that cover different aspects of public health throughout the curriculum. In this context, the materials, modules and information developed within the CONFIDE project complement the existing modules and bring a fresh perspective on the teaching methods. The faculty of Medicine of Sousse will integrate this information in the curricula to promote scientific production by allowing students to build up their scientific research knowledge, develop higher research competencies such as critical-thinking, problem-solving and data interpretation and analysis and train public health specialists to be health policy makers in the future. Conclusions Integrating the new approach based on the achievements of the C4EHP is an essential step for our faculty to develop more training in public health, ensure good quality of its teaching process and participate in the development of health policies that will improve the health of the Tunisian population.

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 < 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.

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.

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.

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.

Introduction An effective referral system is considered as a key to saving mothers' and children's lives. The aims of this study were to determine the frequency and the indications of obstetric referrals in a Tunisian tertiary care maternity and to assess the conformity of referral mechanisms with the National Perinatality Programme (NPP) guidelines. Methods A descriptive study was undertaken among women referred to Farhat Hached University Hospital in Sousse, Tunisia with antenatal complications requiring urgent delivery and those referred while in labour or with immediate post partum complications. The ICD-10 was used to code recorded indications and diagnoses for referrals. Results Referrals represents 15.23% of the obstetric activity in this facility. There were 32 reasons for referrals with the most common being premature rupture of membranes (14.1%) and fetal distress (13.5%). A fifth of the referrals were unclassifiable according to ICD-10. Most of the indications for referrals (95.8%) did not conform to the list of referral indications of the NPP. Twenty eight diagnoses were retained after referrals: the most common of which were prolonged pregnancy (29.5%) and premature rupture of membranes (19.3%). In 41% of women, reasons for referral did not match with diagnoses established at the time of the patients' admission to hospital. Conclusion The current referral system in the region of Sousse still faces several challenges that need to be addressed in order to make it more effective.

This study aimed to determine the frequency and the nature of maternal near miss (NM) events in a population of women attending a tertiary level maternity hospital in Tunisia and to evaluate the care level of this institution according to indicators proposed by the World Health Organization (WHO). We opted for a retrospective medical chart review of cases of NM and maternal mortality that occurred in the year 2010 at the Farhat Hached Maternity University Hospital. NM cases were defined based on the WHO criteria 2009. There were 9957 deliveries, 58 NM events and one case of maternal death. Haemorrhagic (74.1%) and hypertensive disorders (20.7%) were the leading causes of NM. The study showed a low Maternal NM Ratio of 5.86/1000 live births, a relatively low mortality index of 1.7 % and Severe Maternal Outcome Ratio of 5.96/1000 live births. This was the first study to document NM in a Tunisian public maternity. The WHO approach allowed a systematic monitoring of quality of maternal health care. There is a low frequency of maternal morbidity and mortality at the level of this facility. But, more efforts are still needed to document NM events in other types of care facilities in Tunisia. (Afr J Reprod Health 2016; 20[4]: 44-50) Resume Cette etude a pour objectif de determiner la frequence et la nature des cas maternels presque rates (PR) au sein d'une population de femmes dans une maternite de niveau tertiaire en Tunisie et d'evaluer le niveau de soins de cette institution selon les indicateurs proposes par l'Organisation mondiale de la sante (OMS). Nous avons prefere faire un examen medical retrospectif des cas de PR et de mortalite maternelle qui ont eu lieu en 2010 a la Maternite Universitaire Farhat Hached. Les cas de PR ont ete definis selon les criteres de l'OMS de 2009. Il y a eu 9957 accouchements, 58 cas de PR et un cas de deces maternel. Les maladies hemorragiques (74,1%) et hypertensives (20,7%) ont ete les causes principales de PR. L'etude a indique un faible taux de PR maternel de 5,86 / 1000 naissances vivantes, un indice de mortalite relativement faible de 1,7% et un rapport de resultat maternel severe de 5,96 / 1000 naissances vivantes. C'etait la premiere etude a documenter le PR dans une maternite publique tunisienne. L'approche de l'OMS a permis un suivi systematique de la qualite des soins de sante maternelle. Il existe une faible frequence de morbidite et de mortalite maternelles au niveau de cet etablissement. Mais il reste encore beaucoup a faire pour documenter les cas de PR dans d'autres types d'etablissements de soins en Tunisie. (Afr J Reprod Health 2016; 20[4]: 44-50).

The results of this study will help guide public hospital human resource managers in the choice of measures designed to increase the motivation of their employees in order to ensure staff satisfaction as well as quality health care services. .

Objectifs : Etudier les delais de la premiere prise en charge therapeutique des patientes operees et suivies pour cancer du sein au service de gynecologie du CHU Farhat Hached de Sousse en 2013 et de determiner les facteurs associes a ces delais. Methodes : Il s’agit d’une etude descriptive retrospective, effectuee sur les dossiers de patientes diagnostiquees, operees et suivies pour un cancer du sein au Service de Gynecologie du CHU Farhat Hached de Sousse en 2013. Les delais etudies sont : le delai global de premiere prise en charge therapeutique (chirurgie ou chimiotherapie neo-adjuvante), le premier delai intermediaire (le delai d’acces au diagnostic), le deuxieme delai intermediaire (le delai d’acces au premier traitement). Les delais sont presentes sous formes de mediane avec l’intervalle interquartile (IIQ). Resultats : L’echantillon etait constitue de 213 femmes. Le delai median d’acces au diagnostic etait de 13 jours avec un IIQ de [4-34]. Si le premier traitement est chirurgical, le delai median d’acces a l’acte chirurgical etait de 35 jours avec un IIQ de [27-45,7]. S’il s’agit d’une chimiotherapie neo-adjuvante, le delai median etait de 62,5 jours avec un IIQ de [31-122]. Independamment de la nature du premier traitement, le delai median d’acces au traitement etait de 35 jours avec IIQ de [27-50]. Conclusion : Il est capital de maitriser les temps d’attente lors du parcours de soins, a la fois pour le succes du traitement et pour repondre aux besoins des malades.

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.

Fetal macrosomia is associated with an increased risk of adverse outcomes to both the mother and the infant.To determine maternal and neonatal outcomes associated to fetal macrosomia in diabetic and non- diabetic mothers.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.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 (p10-3). 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).Macrosomia increases the risk of maternal and perinatal morbidity particularly when it was associated to maternal diabetes.

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

Background The plant species Rosmarinus officinalis (RO), Thymus algeriensis (TA) and Thymus capitatus (TC) are widely used in traditional medicine in Tunisia. Their bioactivities have been reported before and particularly referred to their essential oils. The main objective of this work was to assess the phytochemical composition, the antioxidant activity, the antibacterial, antifungal, and cytotoxic potential of these 3 plants. Method The High Performance Liquid Chromatography (HPLC), chemical tests and spectrophotometric methods were used for screening, quantification of phytochemicals and for antioxidant activities. Extracts were evaluated for antibacterial potential by the microdilution method. Antifungal activities were tested using the Poisoned food method against: Aspergillus niger and Aspergillus flavus. The cytotoxic potential of the plant extracts was checked using HCT 116 cultures. Results Results revealed that aqueous extracts are not toxic compared to the methanolic extracts. Phenolic compounds were detected and these extracts showed excellent antioxidant activity presenting dose-dependent relationship. For antibacterial potential, all tested strains are more sensitive to Thymus extracts than Rosmarinus extracts. However, for antifungal activities, only Rosmarinus extracts inhibited mycelial growth. HPLC analysis allowed the identification of ten compounds with the abundance of gallic acid. Conclusion This study showed important bioactivities (antioxidant, antimicrobial, and safety potential) of the plant species RO, TA and TC used in traditional medicine.