Search

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.

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.

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.

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

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.

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 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. .

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.

Introduction: Parmi les événements indésirables, ceux liés au circuit des médicaments occupent une place importante et risquent de causer un préjudice grave aux patients. Dans ce contexte, nous avons mené cette étude dans l'optique de décrire et d'évaluer le circuit des médicaments anticancéreux dans un hôpital régional tunisien. Méthodes: Il s'agit d'une étude évaluative du risque lié aux médicaments anticancéreux, type « visite de risque » menée sur une période de 15 jours au cours de l'année 2014 au service de cancérologie de l'hôpital régional de Gafsa (Tunisie). Cette méthode d'évaluation est inspirée de celle conduite par le projet « SECURIMED » développé par le Comité de Coordination de l'Evaluation Clinique et de la Qualité en Aquitaine (CCECQA), en France. Résultats: Dans notre étude, l'observation du circuit des médicaments anticancéreux a révélé certaines insuffisances. On a noté que la répartition des missions des différents acteurs est sujette parfois à des glissements de tâches. Un manque important ainsi que une inadéquation aux normes au niveau des équipements nécessaires pour la préparation et la protection des professionnels manipulant ces médicaments ont été également décelés. Conclusion: La sécurisation du circuit des médicaments devrait être une priorité inscrite dans l'ensemble des démarches nationales et partagée par tous les intervenants et ce dans l'optique d'atteindre un objectif prémium : la qualité de la prise en charge globale et la sécurité des patients.Key words: Risk management, anticancer drugs, patient safety

Introduction : La mortalite maternelle est un probleme majeur de sante mondiale. Une grande proportion de ces deces serait evitable par des soins adequats, une aide a l'accouchement, la disponibilite des soins d'urgence et l'utilisation des outils d'aide a la decision tels que le partogramme. L'objectif etait d'evaluer l'ecart entre ce qui est cense etre fait et ce qui est fait reellement pour les differents parametres situes dans le partogramme au sein d'une maternite de 3 eme niveau et elaborer des recommandations pour la mise en place d'un plan d'action. Methodes : Il s'agit d'une etude descriptive retrospective par audit clinique, effectuee sur un echantillon de 400 dossiers obstetricaux des parturientes ayant accouchees dans la maternite du CHU Farhat Hached durant l'annee 2011. Le referentiel utilise est celui realise par l'Agence Nationale d'Accreditation et d'Evaluation en Sante en l'an 2000, concernant la qualite de la tenue du partogramme. Resultats : La majorite des criteres d'evaluation portant sur la presentation du partogramme etait conforme. Deux criteres concernant la variete de la presentation et le rythme cardiaque foetal etaient non conformes parmi ceux portant sur la surveillance du foetus. Plusieurs criteres en rapport avec la surveillance de la mere etaient non conformes. Aucun des criteres portant sur les traitements administres et les marqueurs d'evenements n'est conforme. Les criteres portant sur la naissance et la surveillance immediate qui etaient non conformes sont : le debut des efforts expulsifs, le mode d'accouchement, l'etat du perinee, la delivrance et la revision uterine. Conclusion : La veritable demarche de l'audit clinique se doit d'aller au-dela du recueil et de l'analyse des donnees, le but final etant l'amelioration des pratiques.

Objective To assess the patient safety culture (PSC) in operating rooms (ORs) and to determine influencing factors. Design A cross-sectional descriptive multicenter study which was conducted over a period of 7 months (October 2014–April 2015) using the French validated version of the Hospital Survey On Patient Safety Culture questionnaire. Setting Of the note, 15 ORs of public and private healthcare institutions. Participants In total, there were 368 participants including surgeons, anesthesiologists, surgical and anesthesia technicians, nurses and caregivers, divided into 316 professionals exercising in public sector and 52 working in private one. Main Outcome Measure(s) A self-administrated questionnaire investigating 10 dimensions of PSC (including 45 items), two items examining the staff perception of patient safety quality and reporting events, and five items regarding demographic characteristics of respondents. Results The participation rate in the study was 70.8%. All 10 dimensions were to be improved. The overall perception of patient safety had a score of 34.9%. The dimension that had the lowest score (20.5%) was the non-punitive response to error, and the one that had the highest score (41.67%) was teamwork in the ORs. Three dimensions were developed in private sector, and none in public hospitals. Conclusion This study showed that the level of the PSC needs to be improved not only in public hospitals but also in private ones. The obtained results highlight the importance of implementing quality management systems and developing PSC.

We determined the profile of respiratory morbidity in family practice in the region a cross-sectional study in 86 primary health care centres in Souse over 1 year (2002-03). Medical records for 3 weeks per season were randomly selected. The International Classification of Primary Care (ICPC) was used to code recorded data. Respiratory diseases ranked first both for reason for consultation (8397/24 882, 33.7%) and for diagnosis made (7788/18 097, 43.0%). Of the 7715 respiratory complaints, cough was the most common complaint (54.8%). Of respiratory diagnoses, 37.1% were acute tonsillitis, 26.5% acute bronchitis and 21.6% were acute respiratory tract infection. Children under 5 years were most affected by acute upper respiratory tract infections (44.5%). Acute bronchitis was the primary diagnosis for patients aged over 45 years.

Background Throughout recent years, Workplace violence in hospital emergency departments has become common problem. Thus, rate of emergency departments workers who are experiencing it is increasing significantly especially since Tunisian revolution. Closely related to reduced job satisfaction and performance. The objective of this study was to have an overview the characteristics of Workplace violence against workers in emergency departments in a secondary healthcare center in Tunisia. Methods We conducted a cross-sectional study in the emergency department in Sidi Bouzid Hospital. The study investigated all types of violence against Emergency department workers including physicians, nurses, admission/registration personnel and security officers. Assaults that occurred during the year of study were included. Data were collected from registers, medical certificate files and interviews with aggressor and aggrieved from October 2014 till October 2015. Socio-demographic characteristics of both of them as well as types of violence were recorded. Data were verified and analyzed using Statistical Package for Social Science (SPSS), software version 18.0. Results A total of 110 participants were enrolled: 27 (25%) physicians, 45 nurses (41%), 16 security officer (14%), 18 workmen (16%) and 4 administrative personnel (4%). The majority (56%) experienced at least one type of work place violence in the past 12 months: 29% exposed to physical violence, 41% to non-physical assaults or verbal abuses and 30% experienced both types of violence. Males were more prone to violence than females (61% vs. 31%). Same results were reported regarding type of violence (physical/verbal). In fact, in either types men were more concerned but insignificant statistically (P = 0.86). Regarding aggressors profile, our results showed that they are mostly males (77%) with a mean age of 36 years (± 12). They were dunk/intoxicated and suffering from mental disorders in 47% and 12% among all cases, respectively. Conclusion Violence against workers in emergency departments is highly common. All categories are affected. Neither men nor women are exempted even if our results concluded a male predominance. All stakeholders should collaborate in order to prevent and tackle this problem.

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

Introduction: Les étudiants en début du cursus suivent la même formation hospitalo-universitaire, cependant, ils sont peu nombreux à choisir délibérément la médecine générale comme discipline d'exercice médical. Notre objectif est de préciser auprès des étudiants en médecine, les facteurs qui déterminent le choix de la médecine générale comme carrière et leur vision de cette discipline. Méthodes: Etude descriptive transversale menée auprès d'un échantillon d'étudiants inscrits à la faculté de médecine de Sousse (Tunisie) pour l'année universitaire 2012-2013. Le recueil des données a été pratiqué par l'intermédiaire d'un questionnaire conçu pour les fins de ce travail. La saisie et l'analyse des données ont été effectuées par le logiciel SPSS 18.0.Résultats: Notre étude a porté sur 388 étudiants dont 69,5% étaient du genre féminin. L'âge moyen était de 22,1 ± 2,8 ans. Cent étudiants (25,8%) avaient un parent cadre de santé sans que cela n'ait une influence sur le choix de carrière. A l'entrée à la faculté, seulement 7,1% (n=27) voulaient faire de la médecine générale leur carrière. Le changement de choix vers la médecine générale est statistiquement différent à l'entrée et à la sortie de la faculté chez les internes finissants. Conclusion: Afin d'attirer davantage les étudiants vers la médecine générale, il serait judicieux d'adopter des changements majeurs touchant l'enseignement théorique et pratique et de modifier les conditions de travail en fonction des attentes des générations futures.Key words: Médecine générale, enseignement médical, choix de spécialité

A contraceptive prevalence survey was conducted among 1277 women of reproductive age, to explore knowledge of and attitudes to contraceptive use and study factors influencing contraceptive use. We found that family planning methods were generally well known. The prevalence of modern contraceptive use was 53.6%, IUDs being the most commonly used followed by sterilization and pills. The public sector was the main source for obtaining contraceptives although pills and condoms tended to be obtained from the private sector. There was a significant correlation between contraceptive use and urban residence.

Introduction: Il est admis que la satisfaction des patients est un indicateur de la qualité des soins. L’objectif de ce travail était de mesurer la satisfaction des patientes du service de gynécologie obstétrique du CHU Farhat Hached de Sousse. Méthodes: Une étude transversale a été menée entre mai et octobre 2005. La collecte des données a été faite par trois internes grâce à des entrevues structurées avec des patientes et à partir d’un questionnaire validé. Résultats: 600 patientes ont été interviewées. L’âge médian était de 30 ans. Prés de quatre vingt cinq pour cent des femmes étaient instruites. Les patientes analphabètes ont exprimé une meilleure satisfaction (score de 56,6 %) par rapport aux autres (p < 10-3). Par ailleurs, nous avons noté : un niveau de satisfaction globale moyen (score de 51%) ; un faible niveau de satisfaction pour la restauration et les conditions de séjour ; un bon niveau de satisfaction pour les soins médicaux et paramédicaux. Les patientes les plus satisfaites étaient celles qui avaient l’impression que leur état de santé s’est amélioré, celles qui s’attendaient à des services de qualité moindre ou de qualité similaire, et celles qui avaient l’intention de recommander l’hôpital à leurs proches. Conclusion: Il est difficile de transposer les résultats de travaux étrangers au contexte tunisien, en raison des différences entre les systèmes de santé d’une part et les caractéristiques socio-démographiques des patientes, d’autre part. En revanche, certains domaines devraient être examinés par des professionnels de la santé afin d'assurer la qualité requise.Key words: Qualité des soins, satisfaction des patients, gynécologie, Tunisie

Background: Primary health care is one of the most important pillars of the Tunisian health care system. However, very little information is available regarding the specificities of general practice and the patterns of morbidity encountered. Methods: We conducted a descriptive study from June 2002 to May 2003 in 85 primary health centres in Sousse during 12 randomly selected weeks in order to describe the variability of the morbidity in all seasons;(3 weeks were randomly selected in each season). Each working day of selected weeks, a systematic sample of patients was identified in each health centre by taking every fifth registered patient. There were 16,271 consultations. The International Classification of Primary Care (ICPC-2) was used to code recorded data of the consultation. Results: There were 24,882 reasons for encounter, a total of 18,097 problems managed by general practitioners (GPs), and 40,190 interventions. There was a predominance of females (62%) and a relatively young population attending the primary health care settings as 50% was aged less than 25 years. According to ICPC-2 chapters, we found that respiratory diseases were the main problems managed in primary health care (43%), followed by digestive (10.1%), locomotive (8.9%), cardiovascular affections (8.7%) and skin diseases (8.4%). These five conditions alone constituted about 80% of the total cases. However, genital conditions for both males and females (1%) as well as psychological and social problems (0.85%) were rarely managed in primary care. Conclusion: The findings will be useful in helping to revise the educational curriculum of medical studies as required in general practice and to plan relevant vocational training for GPs. They will also be important for health policy makers in Tunisia.