Cigarette use and exposure to second-hand smoke and tobacco advertising among Tunisian adolescents.

Background: The Global Youth Tobacco Survey was conducted in Tunisia in 2001, 2007, 2010 and 2017. It is the only national survey that examined exposure to second-hand smoke and tobacco advertising among young people, and there has been no description of the trend. Aims: To describe cigarette use trends among Tunisian adolescents and their exposure to second-hand smoke and tobacco advertising from 2001 to 2017. Methods: The Global Youth Tobacco Survey is a school-based cross-sectional survey conducted by the World Health Organization. It uses a two-stage cluster sampling design to obtain a representative sample of students aged 13-15 years. A standardized questionnaire is used for data collection. We compared the prevalence and 95% confidence intervals (CI) of ever and current cigarette use, exposure to second-hand smoke in and outside the home, and exposure to tobacco advertising, over 4 years (2001, 2007, 2010 and 2017). Results: Current cigarette use decreased from 11.1% (95% CI: 10.0-12.3%) in 2001 to 7.7% (95% CI: 6.5-9.0%) in 2017 (P < 0.001). Exposure to second-hand smoke at home decreased from 62.5% (95% CI: 60.7-64.2%) to 46.7% (95% CI: 44.5-49.0%) over the same period (P < 0.001), but exposure outside the home increased from 65.4% (95% CI: 63.7-67.1%) in 2001 to 73.3% (95% CI: 71.2-75.3%) in 2017 (P < 0.001). Exposure to anti-tobacco messages in the media decreased from 87.8% (95% CI: 86.3-89.1%) in 2001 to 64.4% (95% CI: 62.2-66.5%) in 2017 (P < 0.001). Conclusion: While the prevalence of cigarette use and second-hand smoke exposure at home decreased, exposure outside the home increased. Efforts are needed to ensure compliance with smoke-free laws to decrease the prevalence of exposure to second-hand smoke.

Anxiety and Depression Symptoms in At-Risk Pregnancy: Influence on Maternal-Fetal Attachment in Tunisia.

OBJECTIVES: To investigate maternal prenatal anxiety and depression in high-risk pregnancies and examine their influence on maternal-fetal attachment. METHODS: We included 95 hospitalized high-risk pregnant women. The Hospital Anxiety and Depression Scale (HADS) and the Prenatal Attachment Inventory (PAI) were used to assess the primary objective. Internal consistency and construct validity of the PAI were investigated. RESULTS: The average age was 31 years and gestational age ranged from 26 to 41 weeks. Prevalence of depressive symptoms was 20% and anxiety symptoms 39%. Cronbach alpha coefficient of the PAI Tunisian version was 0.8 and the construct validity in favour of one factor model. PAI scores correlated negatively and significatively with the HADS total score (r = - 0.218, p = 0.034) and was attributed to the depression dimension only (r = - 0.205, p = 0.046). CONCLUSIONS FOR PRACTICE: Emotional wellbeing of pregnant women especially in high-risk pregnancies should be explored in order to prevent consequences on women, their growing fetus, and prenatal attachment.

What is already known? Maternal prenatal emotional well-being influences maternal­fetal attachment which has important implications on postnatal bonding. Anxiety and depression disorders during pregnancy could affect women's attachment to their unborn child in a negative way. Research has largely been conducted with the general pregnant population with little focus on at-risk pregnancies, which are associated with increased levels of mood disorders. What this paper adds? This study highlights the impact of depression but not situational anxiety on maternal­fetal attachment in women with high-risk pregnancies, highlighting the importance of assessing and managing psychological disorders during pregnancy to enhance the quality of prenatal bonding.

Assessment of theory of mind in Tunisian verbal children with autism spectrum disorder.

The present study examined performance in Theory of Mind (ToM) in a group of 31 Arabic-speaking verbal children (7-12 years-old) with autism spectrum disorder (ASD), in comparison with neurotypical controls (NT) matched for age and for cognitive abilities. An innovative task in a digital format named "The Tunisian Social Situations Instrument" (TSSI) was used and allowed us to study four different subdomains of ToM: attribution of intention and epistemic ToM (cognitive ToM), affective ToM, and detection of faux pas (advanced ToM). Our study showed impairments in ToM in children with ASD, similar to those reported in the literature. Our findings additionally suggested that affective and advanced ToM, specifically the detection of faux pas, might be more challenging for ASD children than other components of ToM. Future studies with larger number of children may lead us to specify which subdomains are the most impaired in order to develop specific tools targeting these specific impairments.

Validation of the Tunisian Empathy Scale for Children (TESC) in General Population and Children With Autism Spectrum Disorder.

Background: Several empathy assessment tests have been proposed worldwide but none of them took into account cultural variations that seem to affect empathic manifestations. The aim of this study was to create and validate an empathy assessment questionnaire for school-aged Tunisian children entitled "Tunisian Empathy Scale for Children" (TESC). Methods: An evaluative cross-sectional study was conducted. The questionnaire was administered to parents of 197 neuro-typical children and 31 children with autism without associated intellectual deficits, aged between 7 and 12 years. Validation steps included: face validity, content validity, construct validity, and reliability study. A ROC curve analysis was used to investigate the diagnostic performance of the TESC. Results: Face validity was verified with an expert panel. Content validity was examined, and 11 items were removed as irrelevant or not assessable by parents. Exploratory factor analysis extracted four domains that explained 43% of the total variance. All these domains were significantly correlated with the total score (p < 10-3) and are, respectively: empathic behaviors, affective empathy, cognitive empathy, and a combined affective and cognitive domain. The reliability study showed a satisfactory level of internal consistency of the TESC, with a Cronbach's alpha of 0.615.The diagnostic performance of the TESC in relation to autism was evaluated by the ROC curve with a sensitivity and specificity of 84.3 and 62.1%, respectively, for a total score of 16. Conclusion: A 15-item questionnaire assessing empathy in a multidimensional and culturally adapted way was obtained. The psychometric qualities of the TESC were satisfactory.

Linking Global Youth Tobacco Survey (GYTS) data to the WHO Framework Convention on Tobacco Control (FCTC): The case for Tunisia.

INTRODUCTION: The World Health Organization (WHO) had launched the Framework convention on Tobacco Control (FCTC) in 2003 in order to curve the epidemic of tobacco use worldwide. Since most smokers begin to smoke before the age of 18 years, Global Youth Tobacco Survey (GYTS) has been developed in order to monitor tobacco smoking among adolescents. Our aim was to assess smoking among Tunisian youth using GYTS 2017 data. METHODS: GYTS is cross-sectional, two cluster school-based survey to produce a representative sample of students aged 13-15 years. It was conducted in 2017 in 67 secondary schools in Tunisia. The investigation tool was an anonymously answered questionnaire, which contained core questions about six majors tobacco related topics. RESULTS: Lifetime cigarettes and waterpipe prevalence were 7.8% (14.4% of boys, 1.6% of girls, p<0.001) and 7.2% (13% of boys, 2.8% of girls, p<0.001), respectively. Among cigarette smokers, 62.5% were able to buy their own cigarettes. Overall, 23.5% of cigarette smokers and 41.5% of waterpipe smokers were not able to buy their products because of their age. Sixty percent of smokers wanted to quit and 56.4% had already tried to stop. Half of the respondents were exposed to SHS in their homes and 62.1% in indoor public places. CONCLUSIONS: In Tunisia, tobacco prevalence among youth is high. Youth have free access to tobacco products and smoke-free regulations are only partially respected.

Validation of the Tunisian Test for Facial Emotions Recognition: Study in Children From 7 to 12 Years Old.

Background: Facial expressions transmit information about emotional state, facilitating communication and regulation in interpersonal relationships. Their acute recognition is essential in social adaptation and lacks among children suffering from autism spectrum disorders. The aim of our study was to validate the "Recognition of Facial Emotions: Tunisian Test for Children" among Tunisian children in order to assess facial emotion recognition in children with autism spectrum disorders (ASD). Methods: We conducted a cross-sectional study among neurotypical children from the general population. The final version of or test consisted of a static subtest of 114 photographs and a dynamic subtest of 36 videos expressing the six basic emotions (happiness, anger, sadness, disgust, fear and surprise), presented by actors of different ages and genders. The test items were coded according to Ekman's "Facial Action Coding System" method. The validation study focused on the validity of the content, the validity of the construct and the reliability. Results: We included 116 neurotypical children, from 7 to 12 years old. Our population was made up of 54 boys and 62 girls. The reliability's study showed good internal consistency for each subtest: the Cronbach coefficient was 0.88 for the static subtest and 0.85 for the dynamic subtest. The study of the internal structure through the exploratory factor analysis of the items of emotions and those of intensity showed that the distribution of the items in sub-domains was similar to their theoretical distribution. Age was significantly correlated to the mean of the overall score for both subtests (p < 10-3). Gender was no significantly correlated to the overall score (p = 0.15). High intensity photographs were better recognized. The emotion of happiness was the most recognized in both subtests. A significant difference between the overall score of the static and dynamic subtest, in favor of the dynamic one, was identified (p < 10-3). Conclusion: This work provides clinicians with a reliable tool to assess recognition of facial emotions in typically developing children.

Impaired Recognition of Static and Dynamic Facial Emotions in Children With Autism Spectrum Disorder Using Stimuli of Varying Intensities, Different Genders, and Age Ranges Faces.

A multitude of research on facial emotion recognition (FER) in Autism Spectrum Disorders (ASD) have been published since several years. However, these studies have mainly used static high intensity stimuli, including adult and/or children facial emotions. This current study investigated FER in children with ASD using an innovative task, composed of a combination of static (114 pictures) and dynamic (36 videos) subtests, including children, adolescent, and adult male and female faces, with high, medium, and low intensity of basic facial emotions, and neutral expression. The ASD group consisted of 45 Tunisian verbal children, and the control group consisted of 117 tunisian typically developing children. Both groups were aged 7-12 years. After adjusting for sex, age, mental age, and school grade, the ASD group scored lower than controls on all tests except for the recognition of happiness and fear in the static subtest, and the recognition of happiness, fear, and sadness in the dynamic subtest (p ≥ 0.05). In the ASD group, the total score of both the static and the dynamic subtest were positively correlated with the school grade (p < 0.001), but not with age, or mental age. Children with ASD performed better in recognizing facial emotions in children than in adults and adolescents on videos and photos (p < 0.001). Impairments in FER would have negative impact on the child's social development. Thus, the creation of new intervention instruments aiming to improve emotion recognition strategies at an early stage to individuals with ASD seems fundamental.

Characteristics and prognostic factors of COVID-19 among infected cases: a nationwide Tunisian analysis.

BACKGROUND: The outbreak of coronavirus disease (COVID-19) continues to constitute an international public health concern. Few data are available on the duration and prognostic factors of the disease. We aimed to study the recovery time among a Tunisian cohort of COVID-19 confirmed patients and identify the prognostic factors. METHODS: A retrospective, nationwide study was conducted from March 2 to May 8, 2020, recruiting all patients who were diagnosed with COVID-19, by RT-PCR methods, in Tunisia. Data were collected via phone call interview. Kaplan-Meir Methods and Cox proportional hazards regression models were, respectively, used to study the recovery time and estimate its prognostic factors. RESULTS: One thousand and thirty patients with COVID-19 (aged 43.2 ± 18.2 years, 526 female (51.1%)) were enrolled. Among them 141 (14.8%) were healthcare professionals. Out of 173 patients (17.8%) admitted to the hospital, 47 were admitted in an intensive care unit. Among 827 patients who didn't require specialized care, 55.5% were self-isolated at home, while the rest were in specialized centers. Six hundred and two patients were symptomatic. A total of 634 (61.6%) patients have recovered and 45 (4.4%) patients died. The median duration of illness was estimated to be 31 days (95% CI: [29-32]). Older age (HR = 0.66, CI:[0.46-0.96], P = 0.031) and symptoms (HR = 0.61, CI:[0.43-0.81], P = 0.021) were independently associated with a delay in recovery time. Being a healthcare professional (HR = 1.52, CI: [1.10-2.08], P = 0.011) and patients in home isolation compared to isolation centers (HR = 2.99, CI: [1.85-4.83], P < 10¯3) were independently associated with faster recovery time. CONCLUSION: The duration of illness was estimated to be 1 month. However, this long estimated duration of illness may not equate to infectiousness. A particular attention must to be paid to elderly and symptomatic patients with closer monitoring.

Validation of the Tunisian Social Situation Instrument in the General Pediatric Population.

BACKGROUND: In order to better understand the deployment of the theory of mind (ToM) in Tunisian neurotypical children, we have developed a new tool of assessment of the ToM called the "Tunisian Social Situations Instrument" (TSSI). We opted for the creation of this test in view of the intercultural differences in the development of social skills. Our purpose was to validate this tool in general pediatric population. METHODS: It was a cross-sectional evaluative study that aimed to validate the TSSI in the general pediatric population. We initially conducted a beta test and a pre-validation study before taking the initial version of the TSSI on 123 neurotypical children. Then, we followed the typical validation procedure: appearance validity, content validity, construct validity, and reliability study. RESULTS: Regarding the validity of appearance, the TSSI was comprehensible and adapted to the Tunisian pediatric population. About content validity, the exploratory factor analysis extracted 6 factors that explain 69.3% of the total variance. These factors were respectively social clumsiness types 1 and 2, intention attribution, emotional ToM, epistemic ToM, and simple comprehension questions. The subdomains of social clumsiness (types 1 and 2) and emotional ToM had a Cronbach alpha higher than 0.8. This factor structure as well as the significant inter-correlation between subdomains and the global score were in favor of a good construct validity. The internal consistency study showed good reliability of the final version of the TSSI (alpha of Cronbach at 0,809). Regarding the performance of children at the TSSI, we have noticed a significant association between the global score, age, and verbal intelligence. CONCLUSION: This work offers valuable insights about ToM and provides clinicians with a reliable tool to assess social clumsiness and emotional ToM in typically developing children.

ABO blood groups and risk of covid-19.

INTRODUCTION: Coronavirus pandemic has been the subject of a large number of publications, some of which have shown an increased risk of contracting Covid-19 in carriers of blood group A. AIMS: In this study we looked at the profile of blood group phenotype of a series of Tunisian patients with covid-19 admitted to Abderrahman Mami hospital in Ariana . METHODS: Our study included 51 Tunisian patients with SARS-CoV-2 infection admitted to Abderrahmane Mami hospital between late march 2020 and early May 2020. The distribution of blood groups in Covid-19 patients was compared with that of a control group of 1506 patients with no Covid-19 infection as well as with the distribution of blood groups in a population of 63375 voluntary blood donors. RESULTS: Our series, although limited in size, showed a higher prevalence of blood group A among Covid-19 patients, statistically significant compared to ABO blood group distribution among Tunisian blood donors and among a control group of patients without Covid -19. CONCLUSION: these results are in line with data from the literature, particularly on larger series in China.

Implementation of the WHO Framework Convention on Tobacco Control in Tunisia: Progress and challenges.

INTRODUCTION: The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was the first health treaty that requires state parties to adopt and implement the MPOWER package. The aim of this study is to review the current status of tobacco control policies in Tunisia according to the WHO FCTC recommendations. METHODS: This paper is a critical narrative literature review in which information was obtained from peer-reviewed articles, official government documents, reports, decrees and grey literature in French, Arabic and English. RESULTS: Modest progress in FCTC implementation in Tunisia was noted. The smoking ban in public places is not regularly or largely enforced. The advertising and promotion for tobacco and its products is prohibited by law, but, the ban does not cover the display and visibility of tobacco products at points-of-sale, through the internet, and the depiction of tobacco or tobacco use in entertainment media products. Health warnings on tobacco products consist only of text and do not exceed 30% of the main display areas but are expected to increase to 70% with graphics and text when the new law is passed. CONCLUSIONS: Effective intervention efforts are urgently required. These actions should include accelerating the adoption of a new law, enforcing the present law and the new one once adopted, developing an advocacy and argument about the positive impact on state budget balance, increasing taxes, combating smuggling and illicit manufacturing and counterfeiting, increased education, increased smoking cessation support and implementing periodic surveillance.

Premature mortality attributable to smoking among Tunisian men in 2009.

INTRODUCTION: Tobacco smoking is a significant public health threat in the world, a risk factor for many diseases, and has been increasing in prevalence in many developing countries. In this study, we aimed to estimate the burden of premature deaths attributable to smoking among Tunisian men aged 35-69 years in 2009. METHODS: The number of deaths attributable to smoking was estimated using the population attributable risk fraction method. Smoking prevalence was obtained from a nationally representative survey. Causes of death were obtained from the registry of the National Public Health Institute. Relative risks were taken from the American Cancer Society Prevention Study (CPS-II). RESULTS: Total estimated premature deaths attributable to smoking among men in Tunisia were 2601 (95% CI: 2268-2877), accounting for 25% (95% CI: 23.3-26.6) of total male adult mortality. Cancer, cardiovascular and respiratory diseases were the major causes of premature deaths attributable to smoking with 1272 (95% CI: 1188-1329), 966 (95% CI: 779-1133) and 364 (300-415) deaths, respectively. CONCLUSIONS: Tobacco smoking is highly relevant and is related to substantial premature mortality in Tunisia, around double that estimated for the region as a whole. This also has not decreased over the past 20 years. Urgent actions are needed to reduce this pandemic.

Smoking during pregnancy and postpartum among Tunisian women.

OBJECTIVE: The validity of self-reported smoking in population surveys remains an important question yet to be answered. This has been of particular concern in a situation where there is a strong social pressure against pregnant and postpartum women. An associated question is what would be the value of measuring urinary cotinine concentrations in such surveys to obtain validated smoking data. METHODS: Cross-sectional analysis of data on self-reported smoking and urinary cotinine among a sample of 398 pregnant women and recently pregnant, mothers of infants under the age of 2 months, who came to the Family Planning Clinic in Tunis urban area for either prenatal or newborn care. We used quantitative colorimetric urine test based on the könig reaction, in which pink-red chromophores formed from nicotine and its metabolites condensation with barbituric acid were extracted into acetate buffer. RESULTS: The smoking prevalence among Tunisian pregnant women or mothers of newborn infants was 4%. The validity of self-reported daily smoking was relatively low. Among women reporting no smoking at the interview 16% misreported active smoking. According to urinary cotinine values, the smoking prevalence was 18.8%. CONCLUSIONS: These results substantiate the unreliability of self-report on smoking status among women in prenatal and postnatal period and have implications in clinical and education practice.

[Tobacco use among paramedical students in Tunis]. / Le tabagisme chez les étudiants paramédicaux de Tunis.

AIM: To assess smoking habits among Tunisian paramedical students, and their attitudes and knowledge about smoking. METHODS: During the first quarter of the school year 2002-2003 we investigate 1288 paramedical students of the College of Sciences and Techniques of the Health in Tunis. The smoker was the student who declare to smoke daily or by occasionally at the time of the survey. RESULTS: About three quarters of the students (77,2 %) were female and half of them was less than 20 years old. Smokers were those who smoked daily or occasionally. The prevalence of smoking was weak but it was 10 fold higher in male than in female (35,5% vs 3,5%) The rate of the ex-smokers was 4,1 %. Progress in studies does not affect smoking behaviour. The knowledge of tobacco induced diseases was generally good. However, there was substantial underestimation of tobacco contribution to causing bladder cancer, coronary artery disease and peripheral vascular disease. The study evidences insufficient awareness of medical students about their responsibilities for heath education and prevention. CONCLUSION: It is recommended to improve tobacco control educational programs at the paramedical students with elaboration of practical smoking cessation trainings.

[Evaluation of psychological disorders in Tunisian patients with inflammatory bowel disease. A comparative case-control study]. / Evaluation des troubles psychologiques chez les patients Tunisiens porteurs de maladies inflammatoires chroniques de l'intestin. Résultats d'une étude comparative avec un groupe témoin.

AIM: To evaluate the psychological state in Tunisian patients with inflammatory bowel disease using the general health questionnaire in 12 items. METHODS: A prospective case-control study was performed, including 60 cases of Crohn's disease. 60 cases of ulcerative colitis and 60 healthy control subjects. The total score of the general health questionnaire was calculated on the basis of 0-0-1-1 system. RESULTS: The total score of the general health questionnaire was significantly higher in inflammatory bowel disease patients compared to control group (3.70+3,57 vs 0,16+ 0,52, p<0.0001). In inflammatory bowel disease patients, the total score of the general health questionnaire was significantly higher in Crohn's disease patients compared to ulcerative colitis patients (4,40+3,84 vs 3.01+3.18,p=0.03) and in case of active disease compared to quiescent disease (5,57+3.18 vs 1,64+2,78,p<0.0001). CONCLUSION: Psychological disorders are frequent in Tunisian patients with inflammatory bowel disease, essentially in patients with Crohn's disease or in case of active disease.

Prevalence and severity of asthma, allergic rhinoconjunctivitis and atopic eczema in "Grand Tunis" schoolchildren: ISAAC.

The aim of this study was to assess the prevalence and severity of asthma, allergic rhinoconjunctivitis and atopic eczema in 13-14 year old children living in "Grand Tunis". Using the international study of asthma and allergies in childhood (ISAAC) questionnaire, 3350 schoolchildren aged 13-14 years, from the Grand Tunis (Ariana, Ben Arous, Manouba, Tunis) were studied. Our results showed that in the past year 13.2% of children had wheezed, 1.4% had more than 12 attacks and 4.3% had experienced a speech limiting attack. 29.7% had symptoms of allergic rhinoconjunctivitis and 8.3% atopic eczema. The classic preponderance of asthma in boys has not been retrieved in our study. The highest level of wheeze was found in an agricultural area. According the published data, asthma prevalence in Tunisian schoolchildren is intermediate and allergic diseases are perhaps a common childhood diseases in Tunisia.

Epidemiology and prevention of tobacco use in Tunisia: a review.

INTRODUCTION: This paper describes trends in tobacco sales and smoking prevalence in the Tunisian population, it estimates the consequences of smoking on mortality of this population and discusses anti-tobacco actions: educational actions, legislative measures, and price increases. DATA SOURCES: Sales data were collected from the Tunisia tobacco monopoly, smoking prevalence data from surveys conducted by several institutes, and numbers of deaths by causes have been estimated from WHO for 1998 year. RESULTS: Tobacco sales increased from 4.96 g per adult per day in 1981 to 6.3 g in 1993, then decreased widely. The proportion of smokers was 30% in 1996, 55% among men versus 5.6% among women. Among 17 to 24 years old young adults, the proportion of smokers was 29.2% in 1994 (50% among men versus 3.9% among women). Mortality attributable to tobacco in Tunisia has been estimated to 6430 deaths in 1997 (5580 among men versus 850 among women). These deaths represent 22% of total male deaths and 4% of female ones. Anti tobacco measures have been reinforced by the enactment of anti tobacco law. CONCLUSION: Proportion of young smokers remaining high, it is expected that the consequences of tobacco addiction in Tunisia in term of mortality will be even heavier in the next two decades if efficient anti tobacco actions are not implemented.

[Treatment of tobacco dependence: brief and intensive clinical intervention]. / Traitement de la dependance tabagique: conseil minimal et prise en charge organisee.

This article presents a literature review on the different methods of tobacco cessation that proved their efficiency through the recent meta-analyses. Smoking help cessation can consist in a systematic minimal advice that must be achieved physician or other professional of health throughout during their contact with their patients. This minimal intervention permits to get 5% of tobacco abstinence. The intensive clinical intervention is a very useful to higher dependent smokers or presenting anxiety and depressive disorders. It consists in a psychological combined approach by a behavioral and cognitive therapy and a pharmacological approach with two types of treatment: nicotine replacement therapy and the bupropion, the other "methods" not having proven their efficiency. The success rate of this intervention depends in the time of contact and the number of session. In order to promote tobacco cessation, it is necessary to widen the pharmacological product range and to educate health professionals in smoking cessation.