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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.

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.