Management of diabetics. Comparative study of two contrasting health structures.

BACKGROUND: The proportion of total Tunisian with Diabetes reached 15.5% in 2016. The objective of this study was to analyze diabetic's management in contrasted health care settings. METHODS: Mixed methodology (quantitative and qualitative) with explanatory design was used in contrasted health care structures (a primary health center (PHC) and the National Institute of Nutrition and Food Technologies (INNTA)). Interviews with health providers and patients were than condcuted in both centers to explain quantitative findings. RESULTS: Quality of care assessement was performed among 100 patients in the PHC and 96 in the hospital. Glycemic control was reached in less than 30 % of the cases in both centers. Although clinical evaluation was better in the PHC, conducting ECGs, measuring of HbA1c  and  LDL-Ch were far from being optimal. The qualitative study did supply some hypotheses explaining these gaps: treatments shortage and lack of laboratory assessments specifically pointed in PHC settings, potentially lower its attractiveness, thus compounding overcrowding and stressful working conditions in hospitals. These last points as well as poor communication and overloaded clinics in hospital were major sources of providers and patient dissatisfaction. CONCLUSION: This study made it clear that primary health care is a cornerstone in diabetes management. However, it is crucial to strengthen primary health care centers by operational technical support (laboratory equipements and quality information system) as well building capacities of health professionals in information, education and communication.

Tunisian population quality of life: a general analysis using SF-36.

BACKGROUND: The SF-36 is the instrument for measuring the health relatedquality of life (HRQOL) of patients in many clinical and national studies to describe the health status of populations, by obtaining comparable data on health status internationally. AIMS: This study aimed to obtain population norms for the Tunisian version of SF-36 and to assess the association between socio HRQOL scores with the demographic characteristics of the Tunisian population. METHODS: Face-to-face interviews for a cross-sectional study were carried out in 2005 to collect socio demographic and environmental variables as well as self-reported quality of life. A representative sample of 6543 aged between 35 and 70 years old were selected. RESULTS: All scores had a high level of internal consistency reliability coefficient. HRQOL score levels were associated with sociodemographic characteristics and a decrease as age increased. The averages of the physical and mental component summary were 53+/-8 for males and 47.7+/-10 for females. CONCLUSIONS: This study was the first to address the general Tunisian population. This study shed light on factors associated with HRQOL in the Tunisian context.

Comparing Strategies to Prevent Stroke and Ischemic Heart Disease in the Tunisian Population: Markov Modeling Approach Using a Comprehensive Sensitivity Analysis Algorithm.

BACKGROUND: Mathematical models offer the potential to analyze and compare the effectiveness of very different interventions to prevent future cardiovascular disease. We developed a comprehensive Markov model to assess the impact of three interventions to reduce ischemic heart diseases (IHD) and stroke deaths: (i) improved medical treatments in acute phase, (ii) secondary prevention by increasing the uptake of statins, (iii) primary prevention using health promotion to reduce dietary salt consumption. METHODS: We developed and validated a Markov model for the Tunisian population aged 35-94 years old over a 20-year time horizon. We compared the impact of specific treatments for stroke, lifestyle, and primary prevention on both IHD and stroke deaths. We then undertook extensive sensitivity analyses using both a probabilistic multivariate approach and simple linear regression (metamodeling). RESULTS: The model forecast a dramatic mortality rise, with 111,134 IHD and stroke deaths (95% CI 106567 to 115048) predicted in 2025 in Tunisia. The salt reduction offered the potentially most powerful preventive intervention that might reduce IHD and stroke deaths by 27% (-30240 [-30580 to -29900]) compared with 1% for medical strategies and 3% for secondary prevention. The metamodeling highlighted that the initial development of a minor stroke substantially increased the subsequent probability of a fatal stroke or IHD death. CONCLUSIONS: The primary prevention of cardiovascular disease via a reduction in dietary salt consumption appeared much more effective than secondary or tertiary prevention approaches. Our simple but comprehensive model offers a potentially attractive methodological approach that might now be extended and replicated in other contexts and populations.

Abdominal vs. overall obesity among women in a nutrition transition context: geographic and socio-economic patterns of abdominal-only obesity in Tunisia.

BACKGROUND: Most assessments of the burden of obesity in nutrition transition contexts rely on body mass index (BMI) only, even though abdominal adiposity might be specifically predictive of adverse health outcomes. In Tunisia, a typical country of the Middle East and North Africa (MENA) region, where the burden of obesity is especially high among women, we compared female abdominal vs. overall obesity and its geographic and socio-economic cofactors, both at population and within-subject levels. METHODS: The cross-sectional study used a stratified, three-level, clustered sample of 35- to 70-year-old women (n = 2,964). Overall obesity was BMI = weight/height(2) ≥ 30 kg/m(2) and abdominal obesity waist circumference ≥ 88 cm. We quantified the burden of obesity for overall and abdominal obesity separately and their association with place of residence (urban/rural, the seven regions that compose Tunisia), plus physiological and socio-economic cofactors by logistic regression. We studied the within-subject concordance of the two obesities and estimated the prevalence of subject-level "abdominal-only" obesity (AO) and "overall-only" obesity (OO) and assessed relationships with the cofactors by multinomial logistic regression. RESULTS: Abdominal obesity was much more prevalent (60.4% [57.7-63.0]) than overall obesity (37.0% [34.5-39.6]), due to a high proportion of AO status (25.0% [22.8-27.1]), while the proportion of OO was small (1.6% [1.1-2.2]). We found mostly similar associations between abdominal and overall obesity and all the cofactors except that the regional variability of abdominal obesity was much larger than that of overall obesity. There were no adjusted associations of AO status with urban/rural area of residence (P = 0.21), education (P = 0.97) or household welfare level (P = 0.94) and only non-menopausal women (P = 0.093), lower parity women (P = 0.061) or worker/employees (P = 0.038) were somewhat less likely to be AO. However, there was a large residual adjusted regional variability of AO status (from 16.6% to 34.1%, adjusted P < 0.0001), possibly of genetic, epigenetic, or developmental origins. CONCLUSION: Measures of abdominal adiposity need to be included in population-level appraisals of the burden of obesity, especially among women in the MENA region. The causes of the highly prevalent abdominal-only obesity status among women require further investigation.

Health system challenges of NCDs in Tunisia.

OBJECTIVES: The objective of this study was to present a qualitative 'situation analysis' of the healthcare system in Tunisia, as it applies to management of cardiovascular disease (CVD) and diabetes. A primary concern was the institutional capacity to manage non-communicable diseases (NCDs). METHODS: Research took place during 2010 (analysis of official documents, semi-structured interviews with key informants, and case studies in four clinics). Walt and Gilson's framework (1994) for policy analysis was used: content, actors, context, and process. RESULTS: Problems of integration and coordination have compounded funding pressures. Despite its importance in Tunisian healthcare, primary health is ill-equipped to manage NCDs. With limited funds, and no referral or health information system, staff morale in the public sector was low. Private healthcare has been the main development filling the void. CONCLUSION: This study highlights major gaps in the implementation of a comprehensive approach to NCDs, which is an urgent task across the region. In strategic planning, research on the health system is vital; but the capacity within Ministries of Health to use research has first to be built, with a commitment to grounding policy change in evidence.

Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries.

OBJECTIVES: To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. METHODS: A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. RESULTS: Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100% in each country. The top policies were mostly population level interventions and health systems' level policies. CONCLUSIONS: Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed.

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries.

BACKGROUND: Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. METHODS AND FINDINGS: Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia; $39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and $1,3000,000,000 and 378439 LYG in Turkey. CONCLUSION: Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives.

Fairness in healthcare finance and delivery: what about Tunisia?

Anecdotal evidence on hidden inequity in health care in North African countries abounds. Yet firm empirical evidence has been harder to come by. This article fills the gap. It presents the first analysis of equity in the healthcare system using the particular case of Tunisia. Analyses are based on an unusually rich source of data taken from the Tunisian HealthCare Utilization and Morbidity Survey. Payments for health care are derived from the total amount of healthcare spending which was incurred by households over the last year. Utilization of health care is measured by the number of physical units of two types of services: outpatient and inpatient. The measurement of need for health care is apprehended through a rich set of ill-health indicators and demographics. Findings are presented and compared at both the aggregate level, using the general summary index approach, and the disaggregate level, using the distribution-free stochastic dominance approach. The overall picture is that direct out-of-pocket payments, which constitute a sizeable share in the current financing mix, emerge to be a progressive means of financing health care overall. Interestingly, however, when statistical testing is applied at the disaggregate level progressivity is retained over the top half of the distribution. Further analyses of the distributions of need for--and utilization of--two types of health care--outpatient and inpatient--reveal that the observed progressivity is rather an outcome of the heavy use, but not need, for health care at the higher income levels. Several policy relevant factors are discussed, and some recommendations are advanced for future reforms of the health care in Tunisia.

Obesity and association with area of residence, gender and socio-economic factors in Algerian and Tunisian adults.

INTRODUCTION: The epidemiological transition has resulted in a major increase in the prevalence of obesity in North Africa. This study investigated differences in obesity and its association with area of residence, gender and socio-economic position among adults in Algeria and Tunisia, two countries with socio-economic and socio-cultural similarities. METHODS: Cross-sectional studies used stratified, three-level, clustered samples of 35-70 year old adults in Algeria, (women n = 2741, men n = 2004) and Tunisia (women n = 2964, men n = 2379). Thinness was defined as Body Mass Index (BMI) = weight/height <18.5 kg/m(2), obesity as BMI ≥30, and abdominal obesity as waist circumference/height ≥0.6. Associations with area of residence, gender, age, education, profession and household welfare were assessed. RESULTS: Prevalence of thinness was very low except among men in Algeria (7.3% C.I.[5.9-8.7]). Prevalence of obesity among women was high in Algeria (30.1% C.I.[27.8-32.4]) and Tunisia (37.0% C.I.[34.4-39.6]). It was less so among men (9.1% C.I.[7.1-11.0] and 13.3% C.I.[11.2-15.4]).The results were similar for abdominal obesity. In both countries women were much more obesity-prone than men: the women versus men obesity Odds-Ratio was 4.3 C.I.[3.4-5.5] in Algeria and 3.8 C.I.[3.1-4.7] in Tunisia. Obesity was more prevalent in urban versus rural areas in Tunisia, but not in Algeria (e.g. for women, urban versus rural Odds-Ratio was 2.4 C.I.[1.9-3.1] in Tunisia and only 1.2 C.I.[1.0-5.5] in Algeria). Obesity increased with household welfare, but more markedly in Tunisia, especially among women. Nevertheless, in both countries, even in the lowest quintile of welfare, a fifth of the women were obese. CONCLUSION: The prevention of obesity, especially in women, is a public health issue in both countries, but there were differences in the patterning of obesity according to area of residence and socio-economic position. These specificities must be taken into account in the management of obesity inequalities.

Gender obesity inequities are huge but differ greatly according to environment and socio-economics in a North African setting: a national cross-sectional study in Tunisia.

INTRODUCTION: Southern Mediterranean countries have experienced a marked increase in the prevalence of obesity whose consequences for gender related health inequities have been little studied. We assessed gender obesity inequalities and their environmental and socio-economic modifiers among Tunisian adults. METHODS: Cross-sectional survey in 2005; national, 3 level random cluster sample of 35-70 years Tunisians (women: n = 2964, men: n = 2379). Overall adiposity was assessed by BMI = weight(kg)/height(m)(2) and obesity was BMI≥30, WHtR = waist circumference to height ratio defined abdominal obesity as WHtR≥0.6. Gender obesity inequality measure was women versus men Prevalence Proportion Odds-Ratio (OR); models featuring gender x covariate interaction assessed variation of gender obesity inequalities with area (urban versus rural), age, marital status or socio-economic position (profession, education, household income proxy). RESULTS: BMI was much higher among women (28.4(0.2)) versus men (25.3(0.1)), P<0.0001) as was obesity (37.0% versus 13.3%, OR = 3.8[3.1-7.4], P<0.0001) and abdominal obesity (42.6% versus 15.6%, 4.0[3.3-4.8], P<0.0001). Gender obesity inequalities (women versus men adjusted OR) were higher in urban (OR = 3.3[1.3-8.7]) than rural (OR = 2.0[0.7-5.5]) areas. These gender obesity inequalities were lower for subjects with secondary education or more (OR = 3.3[1.3-8.6]), than among those with no schooling (OR = 6.9[2.0-23.3]). They were also lower for those with upper/intermediate profession (OR = 1.4[0.5-4.3]) or even employees/workers OR = 2.3[1.0-5.4] than those not professionaly active at all (OR = 3.3[1.3-8.6]). Similar results were observed for addominal obesity. CONCLUSION: The huge overall gender obesity inequities (women much more corpulent than men) were higher in urban settings, but lower among subjects of higher education and professional activity. Reasons for gender inequalities in obesity and their variation with socio-economic position should be sought so that appropriate policies to reduce these inequalities can be implemented in Tunisia and similar settings.

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.

Social determinants of health in Tunisia: the case-analysis of Ariana.

BACKGROUND: Few research projects have analyzed how social determinants of health impact cities in North Africa. The sustained growth in these countries has nevertheless proven to exacerbate health disparities and create many social and economic inequalities. This strategic analysis examines selected social determinants of health in a major urban centre of Tunisia, identifies the most influential stakeholders able to influence equity/inequity, and reviews the accomplishments and need for action to foster health equity. METHODS: This analysis was performed through a literature review and participatory research methods that included focus groups discussions and interview with key informants. RESULTS: Access to health care, changes in lifestyles, housing issues and gender-related inequities are prime, socially-determined elements that affect health in Ariana. CONCLUSION: Recognition of emerging health issues is needed along with improved inter and intrasectoral coordination among stakeholders. The community-participatory approach used in this paper proved to be a useful scoping technique for this setting. A similar methodology could be used by other researchers as a first step toward health equity action at a city level.

[Epidemiological transition and health impact of cardiovascular disease in Tunisia]. / La transition epidémiologique ses determinants et son impact sur les systemes de sante a travers l'analyse de la tendance des maladies cardiovasculaires en Tunisie.

OBJECTIVE: We aim at analysing the increase of CVDs in the Tunisian hospitals in order to assess the burden of NCDs in the transitional context. METHODS: Data are recorded through the Tunisian National Morbidity and Mortality Survey (TNMMS). In order to assess the CVDs (CHDs vs RHDs) trend, two representative samples of Cardiology Departements patients were compared one is selected from the TNMMS and the second from the hospitalisations recorded in 1992. Causes, stay duration, status at the end of the hospitalisation, transfer to another hospital and patients socio-demographic characteristics are recorded and compared for the two periods. All the diagnosis are coded referring to the DMC 10. To analyze the determinant of the epidemiological transition, we have elaborated the CVD causal pattern and we have documented all their determinants. RESULTS: CHD rate has dramatically increased, while RHD has decreased especially on men. In 1992, 39.2% of men and 11.8% of women were admitted for CHD. In 2002, these rate are respectivly 58.8% and 38.2% while RHD rates were, in 1992, 11.8% on men and 25.3% on women vs 4.4% and 11.7% respectively. CONCLUSION: This study has confirmed that so far controlling transmitted diseases seems to be successful, Tunisian people are about to face a new problems as hypertension, obesity, diabetes and tobacco smoking. The new challenge with the burden of diseases requires the implementation of a national strategy relevant to the epidemiological, social and economical transition. Population needs and cost effectiveness of interventions assessment is crucial to set the national priorities.

[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.

[Tunisian health profile: present state and trends]. / Profil de sante de la Tunisie: etat actuel et tendances.

We will try to value the Tunisian Health Profile, its present state and its tendencies. Data have been collected by various sources, in particular international and national organism. The total fertility rate passed from 8 in 1966 to 2.01 in 1999. Besides a light ageing of the population is started (9% of the population are aged of more than 60 years in 1999). Death rates recorded a decrease, mainly of the infantile mortality (140%@1000 in 1966 against 24.7%@1000 in 1999) and the maternal mortality (68.9 per 100,000 living births in 1994 against 220 in 1980-1984). The life expectancy at birth passed from 51 years in 1966 to 72.4 years in 1999. According the morbidity we attend the receding of the majority of transmitted diseases. Resources injected in the system of cares also evolved: The medical density passed from 1 per 6700 inhabitants in 1966 to 1 per 1300 in 1999. Tunisia recorded the most elevated scores for the preventive activities in particular at the vaccinal coverage. The global evolution of the Tunisian health profile is marked by the epidemiological transition buy which pass the country currently. This phase is delicate because it's generating of a growth of care expenses. Decision-makers must be careful to consider advantage priorities and the profitability of the investments.