[Knowledge and practices of the steps prior to the sterilization of heat-resistant medical devices: Study at University Hospital Centre of Sahloul, Sousse-Tunisia - 2022]. / Connaissances et pratiques des étapes préalables à la stérilisation des dispositifs médicaux thermorésistants : étude au centre hospitalo-universitaire Sahloul, Sousse-Tunisie ­ 2022.

OBJECTIVES: The standard process of central sterilization is crucial for the optimal functioning of the operating room. The outcome of this process is closely linked to the steps preceding the steps prior to the sterilization step itself. These steps include pre-disinfection carried out in the operating rooms and other stages, namely washing, drying and packaging, which must be performed in the central sterilization unit. In this context, this study aimed to describe the knowledge of the staff in the operating rooms and the central sterilization unit at Sahloul University Hospital in Sousse (Tunisia) in 2022, regarding the steps prior to the sterilization of reusable thermoresistant medical devices and to describe their practices in terms of compliance with these steps. METHOD: A descriptive study was conducted from January 2022 to June 2022 with the aforementioned staff, using a self-administered questionnaire to assess their knowledge of the pre-sterilization steps and a direct observation audit of their practices with regard to these steps. Both measurement instruments were pre-tested. RESULTS: Out of 102 self-administered questionnaires (knowledge assessment) distributed to the staff concerned, only 80 were returned and correctly filled out, giving a response rate of 78.4%. Participants' responses regarding the order of steps prior to the sterilization were incorrect in 64% of cases. With regard to the evaluation of professional practices, 224 observations were made in the study area (practice audit). In 82% of these observations, the pre-disinfection step was confused with the washing step. The use of Betadine brushes and scrubbing pads for device washing was noted in 89.3%, along with the absence of swabbing of the canals and hollow parts in 9.4% of cases and the absence of drying of the canals with compressed air. CONCLUSION: Mastery of the steps prior to sterilisation of reusable thermoresistant medical devices was insufficient in our institution, suggesting the importance of reinforcing the implementation of the procedure through a continuous training program followed by action plans.

Évènements indésirables dans un hôpital universitaire tunisien : incidence et facteurs de risque.

OBJECTIVE: To determine the incidence and risk factors of adverse events (AE) in a Tunisian university hospital. METHOD: We carried out a longitudinal observational study in 2016 over a period of 3 months in the Sahloul university hospital of Sousse, Tunisia. Data were collected using a pretested form filled by doctors previously trained in the collection methodology, upon each visit to all hospitalized patients. RESULTS: Overall, 1,357 patients were eligible. We identified 168 AEs in 131 patients with AEs incidence of 12.4% (95% CI: [7.41 - 17.38]), and patient incidence of 9.7% (95% CI: [4.63 - 14.76]). The incidence density of AEs was 1.8 events per 100 days of hospitalization. Hospital acquired infection and unplanned readmission related to previous healthcare management were the most common AEs (43.4 and 12.5% respectively). Multivariate analysis revealed as independent factors of AEs: surgery (P = 0.013; RR = 1.68; CI: [1.11-2.54]), the use of central-venous-catheter (P < 10-3; RR = 4.1 ; CI: [2.1-8]), tracheotomy (P = 0.001; RR = 21.8; CI: [3.7-127.8]), transfusion (P = 0.014; RR = 2.1; CI: [1.16-3.87]) and drug intake (P = 0.04; RR = 2.2; CI: [1.04-4.7]). CONCLUSION: The present study showed a high incidence of AEs and the involvement of invasive devices in their occurrence. Thus, targeted interventions are needed.

[Adverse events in a Tunisian university hospital: incidence and risk factor] / Évènements indésirables dans un hôpital universitaire tunisien : incidence et facteurs de risque.

OBJECTIVE: To determine the incidence and risk factors of adverse events (AE) in a Tunisian university hospital. METHOD: We carried out a longitudinal observational study in 2016 over a period of 3 months in the Sahloul university hospital of Sousse, Tunisia. Data were collected using a pretested form filled by doctors previously trained in the collection methodology, upon each visit to all hospitalized patients. RESULTS: Overall, 1,357 patients were eligible. We identified 168 AEs in 131 patients with AEs incidence of 12.4% (95% CI: [7.41 – 17.38]), and patient incidence of 9.7% (95% CI: [4.63 – 14.76]). The incidence density of AEs was 1.8 events per 100 days of hospitalization. Hospital acquired infection and unplanned readmission related to previous healthcare management were the most common AEs (43.4 and 12.5% respectively). Multivariate analysis revealed as independent factors of AEs: surgery (P = 0.013; RR = 1.68; CI: [1.11-2.54]), the use of central-venous-catheter (P < 10–3; RR = 4.1 ; CI: [2.1-8]), tracheotomy (P = 0.001; RR = 21.8; CI: [3.7-127.8]), transfusion (P = 0.014; RR = 2.1; CI: [1.16-3.87]) and drug intake (P = 0.04; RR = 2.2; CI: [1.04-4.7]). CONCLUSION: The present study showed a high incidence of AEs and the involvement of invasive devices in their occurrence. Thus, targeted interventions are needed.

[Adverse events in a Tunisian university hospital: incidence and risk factors]. / Évènements indésirables dans un hôpital universitaire tunisien : incidence et facteurs de risque.

OBJECTIVE: To determine the incidence and risk factors of adverse events (AE) in a Tunisian university hospital. METHOD: We carried out a longitudinal observational study in 2016 over a period of 3 months in the Sahloul university hospital of Sousse, Tunisia. Data were collected using a pretested form filled by doctors previously trained in the collection methodology, upon each visit to all hospitalized patients. RESULTS: Overall, 1,357 patients were eligible. We identified 168 AEs in 131 patients with AEs incidence of 12.4% (95% CI: [7.41 – 17.38]), and patient incidence of 9.7% (95% CI: [4.63 – 14.76]). The incidence density of AEs was 1.8 events per 100 days of hospitalization. Hospital acquired infection and unplanned readmission related to previous healthcare management were the most common AEs (43.4 and 12.5% respectively). Multivariate analysis revealed as independent factors of AEs: surgery (P = 0.013; RR = 1.68; CI: [1.11-2.54]), the use of central-venous-catheter (P < 10–3; RR = 4.1 ; CI: [2.1-8]), tracheotomy (P = 0.001; RR = 21.8; CI: [3.7-127.8]), transfusion (P = 0.014; RR = 2.1; CI: [1.16-3.87]) and drug intake (P = 0.04; RR = 2.2; CI: [1.04-4.7]). CONCLUSION: The present study showed a high incidence of AEs and the involvement of invasive devices in their occurrence. Thus, targeted interventions are needed.

Demographic and seasonal characteristics of respiratory pathogens in neonates and infants aged 0 to 12 months in the Central-East region of Tunisia.

BACKGROUND: This study aimed to characterize the epidemiology of pathogenic respiratory agents in patients aged 0 to 12 months and hospitalized for acute respiratory infections in Tunisia between 2013 and 2014. METHODS: A total of 20 pathogens, including viruses, Mycoplasma pneumoniae, and Streptococcus pneumoniae, were detected using molecular sensitive assays, and their associations with the patient's demographic data and season were analyzed. RESULTS: Viral infectious agents were found in 449 (87.2%) of 515 specimens. Dual and multiple infectious agents were detected in 31.4% and 18.6% of the samples, respectively. Viral infection was predominant in the pediatric environment (90.8%, P < 0.001), male patients (88.0%), and spring (93.8%). Rhinovirus was the most detected virus (51.8%) followed by respiratory syncytial virus A/B (34.4%), coronavirus group (18.5%), adenovirus (17.9%), and parainfluenza viruses 1-4 (10.9%). Respiratory Syncytial virus A/B was significantly associated with gender (38.0% male cases vs 28.3% female cases, P = 0.02). Infections by Adenovirus, Bocavirus, and Metapneumovirus A/B increased with increasing age of patients (predominated cases aged 6-12 months, P < 0.001). S. pneumoniae was detected in 30.9% of th tested samples. In 18.2% of the negative viral infections, only S. pneumoniae was identified. CONCLUSION: A predominance of the rhinovirus infection was observed in this study. Coronavirus subtypes were described for the first time in Tunisia. The observed different pathogenic profiles across age groups could be helpful to avoid the misclassification of patients presenting with ARIs at the triage level when no standardized protocol is available. This study will provide clues for physicians informing decisions regarding preventive strategies and medication in Tunisia.

School-Based Intervention as a Component of a Comprehensive Community Program for Overweight and Obesity Prevention, Sousse, Tunisia, 2009-2014.

INTRODUCTION: Combating obesity at an early age, by improving physical activity and nutrition-related behaviors, is vital to the prevention of more critical health concerns in adulthood. This intervention study evaluated the effectiveness of a school-based component of a community behavioral intervention on overweight and obesity rates of adolescents in Sousse, Tunisia. METHODS: A quasi-experimental school-based intervention was conducted with an intervention group (in Sousse Jawhara and Sousse Riadh) and a control group (in Sousse Msaken). The intervention (which was a physical activity and nutrition program) lasted 3 years, with data at preintervention collected during the 2009-2010 school year and at postintervention collected during the 2013-2014 school year. Descriptive statistics and multivariate analysis were used to determine the effect of the intervention on risk of excess weight. RESULTS: Results showed a significant increase in fruit and vegetable intake by the intervention group (P = .04). The intervention group had an increase in students in the normal weight category (P = .03) and a decrease in students in the overweight category (P = .03).The intervention effect was a protective factor against excess weight for the participating schoolchildren (OR, 0.84; P = .02). CONCLUSION: This study showed that a school-based intervention is successful in increasing healthy dietary habits and in reducing risk of excess weight. It also showed the importance of a multisectoral approach to provide an environment conducive to healthy behaviors for adolescents.

Smoking prevalence in a factory in the region of Sousse- Tunisia.

BACKGROUND: Smoking is a public health problem because of its high prevalence and its serious consequences at all levels. AIM: The aim of this study was to determine the prevalence of smoking among workers in a private company and describe the characteristics of smokers to guide prevention efforts. METHODS: It is a cross-sectional study conducted in 2010 among all employees of a private company. Data collection was done by a questionnaire administered by interview. RESULTS: The participation rate was 90.4%. All smokers were men, with a prevalence of active smoking among men of 57.9%. The mean age of smokers was 33.2 ± 8 years, significantly lower than nonsmokers. The comparison between smokers and nonsmokers according to occupational category showed a statistically significant difference. Among smokers, 43.6% were in the contemplation stage and 46.3% at the stage of preparation for smoking cessation. CONCLUSION: An intervention for prevention and fight against smoking in the workplace should be established for the promotion of employee health.

Predictive Factors for Successful Smoking Cessation in Tunisian Smokers, Sousse-Tunisia: 2015-2020.

OBJECTIVE: Since 2009, the unit of smoking cessation at Sahloul University Hospital - Tunisia was founded. In this context, the objective of our study was to determine the factors associated with smoking cessation in Tunisian smokers. METHODS: It was a descriptive prospective study over five-years-period 2015-2020. We included all patients who willingly came to the anti-smoking consultation of the Sahloul University hospital Sousse Tunisia. Data were collected during the consultation of all patients. We proceeded to a univariate and then multivariable analysis to identify the predictive factors of smoking cessation. RESULTS: Over 5 years, we included 450 patients, mainly males (91.3%). The average age of the consultants was 46 ±15.58 years. The average age of the first cigarette among our patients was 16.83± 4.34 years. The likelihood of smoking cessation was higher among males (p=0.004, OR=9.708), patients attending minimum 3 anti-smoking consultations (p<10-3, OR=5.714), patients benefiting from nicotine replacement therapy (p=0.034, OR=2.123), with high motivation score for smoking cessation (p=0.001, OR=1.980) and with an advanced age of the first cigarette (p<10-3, OR=1.096). However, the likelihood of smoking cessation was lower among coffee and alcohol consumers (p=0.002, OR=0.252) and smokers with less than 5 years smoking habit (p=0.011, OR=0.069). CONCLUSION: Although the decision to stop smoking is a personal one, it requires medical and psychological support as highlighted by our findings. Our study showed that assiduity and medical assistance for tobacco cessation increase smokers' chances of quitting.

[Therapeutic education in patients with coronary artery disease: impact on smoking cessation]. / Éducation thérapeutique chez les patients coronariens : impact sur le sevrage tabagique.

AIM OF THE STUDY: To describe the results of a therapeutic education program (cessation rate and success factors) among smoking coronary patients followed in the smoking cessation clinic at Sahloul University Hospital in Sousse during the period from 2015 to 2020. PATIENTS AND METHODS: A descriptive cross-sectional study was conducted among smokers with coronary artery disease who presented to the smoking cessation clinic at Sahloul University Hospital during the period from 2015 to 2020. The data collection was done by reviewing the records of smokers. We defined cessation as complete and continuous abstinence at 1 week, at 3 months, at 6 months and at 12 months and more. The study of cessation success factors involved subjects whose cessation was maintained for 1 year or more. RESULTS: Among 93 patients with coronary artery disease, the prevalences of smoking cessation rates were 54.8% (n = 51), 44.1% (n = 41), 35.5% (n = 33), 31.2% (n = 29), and 24.7% (n = 23) at 1 week, 1 month, 3 months, 6 months, and 12 months respectively. In univariate analysis, the number of visits greater than or equal to three (p = 0.000) and nicotine treatment (p = 0.018) were significantly associated with successful smoking cessation at 12 months. In multivariate analysis, being non-active (p = 0.028) with a Fagerstrom score <7 (p = 0.040) and three or more visits (p = 0.005) were the independent factors associated with successful smoking cessation at 12 months. CONCLUSION: The evaluation of the smoking cessation axis of therapeutic education of the coronary patient with tobacco addiction at the Sahloul University Hospital, allowed us to note that the cessation rate is comparable or even higher than that of other studies. However, the rate of maintenance of this cessation at 1 year and more proved to be low despite the strong motivation of the consultants. This observation allows us to better orientate the areas of improvement in the management of our consultants.

Educational effectiveness of simulation in teaching health science students Smoking cessation: A Systematic Review.

BACKGROUND: Simulation is one of the educational tools that can be used in the learning process to help with smoking cessation. AIM: To synthesize all the publications studying the contribution of simulation as an educational tool in the acquisition of skills to help with smoking cessation. METHODS: We performed a systematic review of the Francophone and Anglophone literature over the past 24 years (1997 to 2020) using the PubMed, Science Direct and Cochrane Library databases. RESULTS: A total of 14 articles were included. The most used methods were thestandardized patient, role play and video projection with discussion. The simulation hasnot only proved its effectiveness in terms of acquiring knowledge and self-confidencein the management of the smoking patient in the short term, but also in the acquisition of verbal and non-verbal skills in the long term. CONCLUSION: This review highlighted the interest of simulation as an educational tool to acquire skills to help with smoking cessation regardless of the method used.

Trends of Healthcare-associated Infections in a Tuinisian University Hospital and Impact of COVID-19 Pandemic.

BACKGROUND: Although efforts to manage coronavirus disease 2019 (COVID-19) pandemic have understandably taken immediate priority, the impacts on traditional healthcare-associated infection (HAI) surveillance and prevention efforts remain concerning. AIM: To describe trends in HAIs in a Tunisian university hospital through repeated point prevalence surveys over 9 years, assess the impact of measures implemented for COVID-19 pandemic, and to identify associated factors of HAI. METHODS: The current study focused on data collected from annual point prevalence surveys conducted from 2012 to 2020. All types of HAIs as defined by the Centers for Disease Control and Prevention (CDC) were included. Data collection was carried out using NosoTun plug. Univariate and multivariate logistic analysis were used to identify HAI risk factors. RESULTS: Overall, 2729 patients were observed in the 9 surveys; the mean age was 48.3 ± 23.3 years and 57.5% were male. We identified 267 infected patients (9.8%) and 296 HAIs (10.8%). Pneumonia/lower respiratory tract infections were the most frequent HAI (24%), followed by urinary tract infection (20.9%).The prevalence of infected patients increased from 10.6% in 2012 to 14.9% in 2020. However, this increase was not statistically significant. The prevalence of HAIs increased significantly from 12.3% to 15.5% (P =.003). The only decrease involved is bloodstream infections (from 2% to 1%). Independent risk factors significantly associated with HAI were undergoing surgical intervention (aOR = 1.7), the use of antibiotic treatment in previous 6 months (aOR = 1.8), peripheral line (aOR=2), parenteral nutrition (aOR=2.4), urinary tract within 7 days (aOR=2.4), central line (aOR = 6.3), and prosthesis (aOR = 12.8), length of stay (aOR = 3), and the year of the survey. Young age was found as protective factor (aOR = .98). CONCLUSION: Contrary to what was expected, we noticed an increase in the HAIs rates despite the preventive measures put in place to control the COVID-19 pandemic. This was partly explained by the vulnerability of hospitalized patients during this period.

Temporal and climate characteristics of respiratory syncytial virus bronchiolitis in neonates and children in Sousse, Tunisia, during a 13-year surveillance.

This study established the correlation between respiratory syncytial virus (RSV) bronchiolitis and climate factors in the area of Sousse, Tunisia, during 13 years (2003-2015), from neonates and children <= 5 years old and hospitalized in Farhat Hached University-Hospital of Sousse. The meteorological data of Sousse including temperature, rainfall, and humidity were obtained. RSV detection was carried out with the direct immunofluorescence assay. The impact of climate factors on viral circulation was statistically analyzed. From 2003 to 2015, the total rate of RSV bronchiolitis accounted for 34.5% and peaked in 2007 and 2013. RSV infection was higher in male cases and pediatric environment (p<0.001) and was detected in 47.3% of hospitalizations in intensive care units. The epidemic of this pathogen started in October and peaked in January (41.6%). When the infectivity of RSV was at its maximum, the monthly average rainfall was high (31 mm) and the monthly average temperature and the monthly average humidity were at their minimum (11 °C and 66%, respectively). RSV activity was negatively correlated with temperature (r = - 0.78, p = 0.003) and humidity (r = - 0.62, p = 0.03). Regression analysis showed that the monthly average temperature fits into a linear model (R2 = 61%, p < 0.01). No correlation between RSV activity and rainfall was observed (p = 0.48). The meteorological predictions of RSV outbreaks with specific Tunisian climate parameters will help in determining the optimal timing of appropriate preventive strategies. In the area of Sousse, preventive measures should be enhanced since October especially, when the temperature is around 11 °C and humidity is above 60%.

Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges.

BACKGROUND: Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs). METHODS: We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers' workplace. RESULTS: Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038). CONCLUSION: This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country.

Tobacco use: the main predictor of illicit substances use among young adolescents in Sousse, Tunisia.

Introduction Early adolescence is a critical period usually associated with experimentation with illicit substances. In Tunisia few studies explored these risk behaviors among young adolescents. Aims To evaluate the prevalence and the predictors of the use of illicit substances among the young adolescents of Sousse. Methods A cross-sectional study was conducted in the region of Sousse, Tunisia during the 2013/2014 school year among 4272 schoolchildren in 16 public middle schools. Data about psychosocial characteristics and risk behaviors among the schoolchildren, their parents, their siblings and their friends were collected anonymously using a self-administrated questionnaire. Results Females represented 50.5% of participants. The mean age of schoolchildren was 13.3 (±1.2) years. Lifetime illicit substances use prevalence was 2.9% [confidence interval (CI) 95%: (2.4%-3.4%)] and lifetime use of tobacco prevalence was 12.9% [CI 95%: (11.9%-13.9%)]. The age of tobacco onset was significantly younger to the age of experimentation with illicit substances. Insomnia, sadness and illicit substances use among peers were associated with illicit substances use among participants. While the most influential risk factor on illicit substances use was current cigarette smoking with an adjusted odds ratio (OR) of 7.2 [CI 95%: (4.5-11.2)]. Conclusion A national substances use prevention program should be implemented in the schools of Tunisia with an emphasis on tobacco use prevention.

Hospitalizations for communicable diseases in a developing country: prevalence and trends-Monastir, Tunisia, 2002-2013.

BACKGROUND: In spite of the epidemiological transition, communicable diseases remain a public health problem and represent a significant cause of morbidity and mortality worldwide, especially in developing countries. This study aimed to determine the crude and standardized prevalence rates of hospitalizations for communicable disease (HCD) and to assess trends in HCD by age and sex at a university hospital in Tunisia over a period of 12 years (2002-2013). METHODS: All cases of HCD from 2002 to 2013 in the university hospital departments were included. Data collected from the regional register of hospital morbidity were used. The discharge diagnoses were coded according to the International Classification of Diseases, 10th revision (ICD-10). RESULTS: HCD represented 17.45% of all hospitalizations during the study period (34 289/196 488; 95% confidence interval 17.28-17.62%). The median age at the time of admission was 31 years (interquartile range (IQR) 15-52 years). The median hospital length of stay (LOS) was 5days (IQR 3-9 days). The crude prevalence rate (CPR) was 5.41 per 1000 inhabitants. The CPR was highest among patients aged ≥65 years. The four communicable disease categories that represented 70% of all HCD were abdominal infection, skin infection, genitourinary infection, and lower respiratory tract infection. The majority of HCD decreased over time; however, there was a significant increase in HIV diseases, tuberculosis, and viral hepatitis. CONCLUSION: This study provides evidence of the epidemiological transition, showing a decline in communicable diseases, which needs to be sustained and improved.

Rheumatic heart disease in a developing country: Incidence and trend (Monastir; Tunisia: 2000-2013).

BACKGROUND: The penicillin therapy of ß hemolytic streptococcal pharyngitis has aided in the decrease of rheumatic heart disease (RHD) in developing countries. Tunisia is an endemic area, however, and incidence of RHD is weakly documented. We aimed at establishing the standardized incidence rate (SIR) of RHD in Monastir governorate and at determining RHD prevalence among hospitalized patients in two cardiology departments. METHODS: From the regional register of Monastir Hospital morbidity, we have selected newly diagnosed patients with RHD, residents of Monastir, and hospitalized to the 2 cardiology departments between 2000 and 2013 (2001 not included). FINDINGS: We studied 676 newly admitted patients. We estimate 1060 to be the number of new annual RHD cases in Tunisia. The SIR per 105 person-years was 10.97, being 9.3 in men and 19.1 in women, respectively. We have notified a negative trend of crude incidence rate/105 Inhabitants (Inh) (CIR) (r=-0.23, p<10-3), and a strong positive correlation between age and CIR/105 Inh (r=0.989, p<10-4). RHD lethality was 1%. We have registered 728 hospitalizations for RHD, representing 2.5% of all cardiology hospitalizations [95% CI: 2.3-2.7%], with a prevalence for 13.3% for women aged 15-29years. The median hospital stay was 9days (IQR: 5-15). CONCLUSION: Our results confirm the RHD incidence decrease, consistent with epidemiological transition in Tunisia. We have also emphasized on the close trend of RHD with age and the predominance of RHD among women especially at the procreation age.

A 3-Year Workplace-Based Intervention Program to Control Noncommunicable Disease Risk Factors in Sousse, Tunisia.

OBJECTIVE: To assess the effectiveness of a 3-year workplace-based intervention program on the control of the main noncommunicable disease risk factors (poor nutrition, physical inactivity, and tobacco use) among the employees of Sousse, Tunisia. METHODS: We conducted a quasi-experimental study (pre- and postassessments with intervention and control groups) in six companies of the governorate of Sousse in Tunisia.The intervention program consisted of health education programs (eg, workshops, films and open sensitization days). We also scheduled free physical activity sessions and free smoking cessation consultations. RESULTS: Our intervention program showed meaningful improvement among the employees toward dietary and physical activity behaviors but not for tobacco use. CONCLUSIONS: Workplace is a crucial setting for health promotion, and future programs should consider a multisectoral approach to control the main noncommunicable disease risk factors.