[Medical demography in Tunisia: current situation and perspectives]. / Demographie medicale en Tunisie: etat actuel et perspectives.

BACKGROUND: Health human resources management is one of the important determinants of health care access equity. AIMS: To analyse the trend of Tunisian medical density during 2000-2009 and to predict its situation by 2024. METHODS: Current medical density was calculated using Bar Council of Physicians of Tunisia database. Medical density was calculated and analysed for the period 2000-2009 then modelled by 2024 (estimate of needs and supply). RESULTS: The active medical density raised by 36% during the period 2000-2009 with a higher increase for specialists. The proportion of non-active physicians rose from 4.6% to 15.2% in 2009. Increasing feminization of medical density and persistence of its regional disparities. By the year 2024, 217 physicians for 100,000 inhabitants would be required while the supply would correspond to 212/100 000 inhabitants. CONCLUSION: medical human resources have indeed globally improved. However, some lacks remain and adequate measures are required, based on a rational planning directed to satisfy the population needs and to allow health equity.

Nutrition transition among adolescents of a south-Mediterranean country: dietary patterns, association with socio-economic factors, overweight and blood pressure. A cross-sectional study in Tunisia.

BACKGROUND: The increase in the burden of chronic diseases linked to the nutrition transition and associated dietary and lifestyle changes is of growing concern in south and east Mediterranean countries and adolescents are at the forefront of these changes. This study assessed dietary intake and association with socio-economic factors and health outcomes among adolescents in Tunisia. METHODS: Cross-sectional survey (year 2005); 1019 subjects 15-19 y. from a clustered random sample. Dietary intake was assessed by a validated semi-quantitative frequency questionnaire (134 items) as was physical activity; the Diet Quality Index International measured diet quality; dietary patterns were derived by multiple correspondence analysis from intakes of 43 food groups. Body Mass Index (BMI) ≥ 85th and 95th percentile defined overweight and obesity. Waist Circumference (WC) assessed abdominal fat. High blood pressure was systolic (SBP) or diastolic blood pressure (DBP) ≥ 90th of the international reference for 15-17 y., and SBP/DBP ≥ 120/80 mm Hg for 18-19 y. RESULTS: Energy intake levels were quite high, especially for females. The macro-nutrient structure was close to recommendations but only 38% had a satisfactory diet quality. A main traditional to modern dietary gradient, linked to urbanisation and increased economic level, featured an increasing consumption of white bread, dairy products, sugars, added fats and fruits and decreasing consumption of oils, grains, legumes and vegetables; regarding nutrients this modern diet score featured a decreasing relationship with total fat and an increase of calcium intake, but with an increase of energy, sugars and saturated fat, while vitamin C, potassium and fibre decreased. Adjusted for age, energy and physical activity, this modern pattern was associated with increased overweight in males (2nd vs. 1st tertile: Prevalence Odds-Ratio (POR) = 4.0[1.7-9.3], 3rd vs. 1st: POR = 3.3[1.3-8.7]) and a higher WC. Adjusting also for BMI and WC, among females, it was associated with decreased prevalence of high blood pressure (2nd vs. 1st tertile: POR = 0.5[0.3-0.8], 3rd vs. 1st tertile: POR = 0.4[0.2-0.8]). CONCLUSION: The dietary intake contrasts among Tunisian adolescents, linked to socio-economic differentials are characteristic of a nutrition transition situation. The observed gradient of modernisation of dietary intake features associations with several nutrients involving a higher risk of chronic diseases but might have not only negative characteristics regarding health outcomes.

[Estimated cost of managing invasive cervical cancer in Tunisia]. / Estimation du coût de la prise en charge du cancer invasif du col de l'utérus en Tunisie.

In Tunisia, cervical cancer incidence is about 4.8 per 100,000, but the diagnosis is often made too late, with 5-year survival rates of 35% or less. Given the budgetary constraints facing the health system, and taking into account the low incidence of cervical cancer in Tunisia, the comparative cost effectiveness analysis of screening programs must be strongly considered by policy and decision-makers. A retrospective study to estimate the average direct cost of managing cervical cancer during the first year after diagnosis was conducted among patients with cervical cancer diagnosed in 2003 at the Salah Azaiez Cancer Institute in Tunis. The study included 64 patients with cervical cancer. The direct medical cost is equal to the sum of the respective consumable costs related to hospitalization, ambulatory care, diagnostic tests, surgical procedures, chemotherapy and radiation. Regarding the in-patient hospital stay, the overall cost of a hospital day is a macro-cost including the accommodation expenses themselves, as well as staff costs and non-specific drugs. An extrapolation of the cost of care has been done at the national level; the method used consisted in multiplying the mean of the direct medical costs according to the FIGO stage by the number of incident cases at national level, for the corresponding stage. The distribution by FIGO stage was derived from the Cancer Registry of the northern region of the country. This extrapolation is an estimate, It assumes that the costs of care are similar in other health facilities, and secondly, it assumes that the distribution by FIGO stage according to that of the northern region's registrar is approximately the same at the national level. The results showed that the direct medical care cost of cervical cancer ranged from 777 to 7458 DT (431 to 4143 euro) with an average of 3180 +/- 1390 DT (1766 +/- 772 euro). The national cost was estimated at 877,680 DT (486,847 euro). Although, the cost of care for cervical cancer in Tunisia does not represent a considerable burden for health system, cervical cancer screening remains the best intervention to improve cancer survival rates.

Nutritional status of Tunisian adolescents: associated gender, environmental and socio-economic factors.

OBJECTIVE: To assess the nutritional status of Tunisian adolescents and associated factors. DESIGN: A cross-sectional study based on a national stratified random cluster sample. SUBJECTS AND METHODS: In all, 1,295 boys and 1,577 girls aged 15-19 years, of whom 28.4 % had already left school. Socio-economic characteristics of the parents, anthropometric measurements, food behaviours and physical activity of the adolescents were recorded during home visits. RESULTS: Prevalence of underweight, overweight and obesity (WHO/National Center for Health Statistics reference) were, respectively, 8.1 %, 17.4 % and 4.1 % among boys and 1.3 %, 20.7 % and 4.4 % among girls; abdominal obesity was highly prevalent among both sexes. Prevalence of overweight differed by region (from 11.5 % to 22.2 %) and was higher in urban v. rural areas for males (21.7 % v. 10.4 %) but not for females (21.7 % v. 19.2 %). These differences were partially mediated by socio-economic and lifestyle factors for males. For females, influence of cultural factors is hypothesised. In rural areas, overweight was more prevalent among boys of higher economic level households, having a working mother or a sedentary lifestyle; for girls, prevalence increased with the level of education of the mother. In urban areas, prevalence of overweight was related to eating habits: it was higher for boys with irregular snacking habits and for girls skipping daily meals. Urban girls having left school were also more overweight. CONCLUSION: Overweight and abdominal obesity in late adolescence have become a true public health problem in Tunisia with the combined effects of cultural tradition for girls in rural areas, and of rapid economic development for boys and girls in cities.

[Delays in acute myocardial infarction treatment: results of a multicenter study in the district of Tunis (Tunisia)]. / Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres. Résultats d'une étude multicentrique.

OBJECTIVE: We aimed to assess the acute myocardial infarction management in Tunis public hospitals during one year (from March 2000 to February 2001). METHOD: A standard questionnaire was designed to record prospective data on 740 patients with a follow up during 28 days. Multivariate analysis was performed using the logistic regression model with all-factors as well as age, gender, CHD risk factors as predictors of the delay and fatality. 54% of patients were admitted during the first 6 hours after the onset of symptoms. In multivariate analysis, the delay of consultation is significantly correlated with gender (OR = 2.3, p < 0.001), age (OR = 1.02, p < 0.01) and health insurance (OR = 1.5, p < 0.01). 90% of patients consulted in emergency wards. The emergency ambulance transported 19.6% of patients. 48% of patients underwent early revascularisation of thrombolysis, 51% on men vs 31% on women (p < 0.01). The fatality rate was higher on women 14% vs 6.4% on men (p < 0.01) at 5 days and 27.2% vs 13.6% at 28 days. In multivariate analysis, the principal fatality predictive factor was age (RR = 1.08, p < 0.001) and delay (2.56 p < 0.001) and tobacco smoking (RR = 2.83, p < 0.0001). CONCLUSION: This study highlighted the problem of acute myocardial infarction management in public hospitals in Tunisia and it constitutes a baseline to assess different interventions focusing on cardiovascular diseases control and surveillance.

[The cost of acute myocardial infarction management: the Tunisian experience]. / Cout direct medical de la prise en charge de l'infarctus du myocarde en phase aigue.

OBJECTIVE: To assess the medical direct cost of acute myocardial infarction. METHOD: Data are recorded through a prospective study in 7 wards of cardiology of the District of Tunis during one year: from November 2001 to October 2002. Cost of hospital stay, biologic analyses, drugs, functional investigations and possible non surgical cardiologic intervention (IC) was calculated. RESULTS: 632 AMI cases are recorded, the death rate is 7.8%. The average of hospital stay was 13.3 days. 49.1% of patients benefited from thrombolytic therapy, 55.5% benefited from a coronary angiography and 16.1% of an act of IC. The mean of direct cost (CGM) was 2171 Tunisian Dinars and the median was 1731 DT, of whom room costs 31.7%, 22.5% acts of IC, 7.2% drugs, 26.2% functional investigations and 12.4% biological analyses. The mean cost of IC was 3030 +/- 401 DT. CONCLUSION: The methodology of our study remains original in our country and can be used to assess the other aspects of AMI as other diseases cost management.

[Assessment of cancer incidence in Tunisia 1993-1997]. / Estimation a l'echelle nationale de l'incidence des cancers en Tunisie 1993-1997.

The objective of this study is to estimate in Tunisia on a national scale the incidence of the main cancerous localizations for the period 1993-1997 while taking results of registers of the cancer of the region of the North, Sousse and Sfax as a basis. After having verified the relation of exponential type between the incidence of cancers and the life expectancy at the birth (Evo) in a certain number of country we extrapolated levels of governorates incidence included in registers of the North, Sousse and Sfax to the other governorates while taking the similarity of the Evo level as a basis. The incidence rate of in all localizations are 100.11/100.000 for male and 86.4/100.000 for female. The main cancerous localizations for male are the lung (20.8/100.000) the bladder (10.7/100.000), the cutaneous cancers (7.2/100.000) and the prostate (6.1/100.000). For female the main localization are the breast (19.7/100.000), skin (5.8/100.000) and the cervix uteri (4.8,100.000). These results illustrate the interest of tobacco control, screening of the breast cancer of and cervix uteri cancer, as components fundamental of the cancer control.