I. Bouanene

Obstetric and psychological characteristics of women seeking multiple abortions in the region of Monastir (Tunisia): results of a cross-sectional design

BackgroundRepeat abortion is a public health concern favored by many obstetric and social factors.The purpose of our study was to identify associated factors to repeated abortion in the region of Monastir (Tunisia). Common mental disorders (CMD) such as anxiety and depression were also evaluated in women seeking voluntary repeated abortion.MethodsWe carried out a cross sectional study between January and April 2013 in the Reproductive Health Center (RHC) of the region of Monastir in Tunisia (This study is part of a prospective design on mental disorders and intimate partner violence among women seeking abortions in the RHC).Among women referred to the RHC we selected those seeking voluntary abortion (medical or surgical method). Data on women’s demographic characters, knowledge and practices about contraceptive methods and abortion were collected the abortion day via a structured questionnaire. Data about anxiety and depression status were evaluated during the post-abortal control visit at 3–4 weeks following pregnancy termination.ResultsOf the 500 interviewed women, 211 (42.2 %; CI95% [37.88 – 46.52]) were seeking repeated abortions. Multivariate analysis showed that increased age, lower level of women school education, single status, poor knowledge about birth control methods and history of conflict/abuse by a male partner, were uniquely associated with undergoing repeat compared with initial abortion.CMD were significantly higher in women undergoing second or subsequent abortion (51.1 %) single and lower educated women. Women relating a history of conflicts/abuse report more CMD than others (30.6 % vs 20.8 %).ConclusionHealth facilities providing abortion services need to pay more attention to women seeking repeat abortion. Further studies are needed to well establish the relation between the number of abortion and the occurrence and the severity of CMD.

Women’s knowledge, attitudes and practice about breast cancer screening in the region of Monastir (Tunisia)

Breast cancer remains a worldwide public health problem. In Tunisia, it is considered to be the primary womens cancer and causes high morbidity and mortality. This study aimed to investigate female knowledge, attitudes and practice of breast cancer screening in the region of Monastir (Tunisia). We conducted a descriptive cross-sectional design exploring knowledge, attitudes and practices of women in the region of Monastir on breast cancer screening. The study was conducted in health centres of this region from 1 March 2009 to 30 June 2009. Data were collected via a structured questionnaire containing 15 items on demographic status, knowledge of risk factors and screening methods and attitudes towards the relevance and effectiveness of breast cancer screening. A scoring scheme was used to score womens responses. A total of 900 women agreed to take part in the study. Their mean age was 41.6±12.4 years and 64% did not exceed the primary level of education. According to the constructed scores, 92% of participants had poor knowledge of the specific risk factors for breast cancer and 63.2% had poor knowledge of the screening methods. Proper practice of breast cancer screening was observed in 14.3% of cases. Multiple logistic regression analysis showed that good knowledge of risk factors and screening methods, higher level of education and positive family history of breast cancer were independently correlated with breast cancer screening practice. This study revealed poor knowledge of breast cancer and the screening methods as well as low levels of practice of breast cancer screening among women in the region of Monastir. Results justify educational programs to raise womens adherence to breast cancer screening programs in Tunisia.

Gender differences in adverse childhood experiences, collective violence, and the risk for addictive behaviors among university students in Tunisia

Adverse childhood experiences (ACE) have been linked to a variety of addictive behaviors. The recent adaptation of the ACE measure by the World Health Organization (WHO) allows for the assessment of the negative role of additional adverse experiences, such as extra-familial violence. To date, the relationship between extra-familial violence and addictive behaviors has not been assessed. We report the contribution of ACEs, including the new scales for extra-familial violence, on the risk for mental health problems and addictive behaviors by gender in a sample of young adults in Tunisia. We conducted a cross sectional study in Tunisia during 2014, where we recruited 1200 young university adults who completed the validated Arabic version of the WHO ACE questionnaire in a university setting. Results indicated that intra-familial adversities were associated with increased risk for addictive behaviors, particularly in males. ACEs were also associated with increased risk for mental health problems with women showing more difficulties than men. Exposure to peer, community and collective violence was higher in males than in females and logistic regression confirms that exposure to extra-familial violence increased the risk for addictive behaviors both in male and females by two to three-fold. Mental health problems were associated with peer violence and substance abuse in males, but not in females. Results demonstrate for the first time the contribution of exposure to extra-familial violence on risk for addictive behaviors. Results highlight the need for addressing mental health and addiction in a community with high burden of adversity and violence.

Predictors of smoking relapse in a cohort of adolescents and young adults in Monastir (Tunisia)

BackgroundSmoking prevalence in adolescents and young adults is substantially elevated in Tunisia. Moreover, there is a lack of knowledge regarding the effectiveness and associated factors in smoking cessation interventions among adolescents and young adults. This study aims at identifying the major factors leading to smoking relapse among adolescents and young adults in the region of Monastir, Tunisia.MethodsWe carried out a prospective cohort study at the smoking cessation center of the University hospital of Monastir, Tunisia. The population study consisted of all adolescents and young adults (15–30 years) consulted during a period of two years (2009 – 2010). A questionnaire was used to explore the patient’s sociodemographic characteristics, smoking history, nicotine dependence (Fagerstrom test) and anxiety / depression (Hospital Anxiety and Depression Scale). A telephone survey was conducted in July 2011 to assess smoking cessation results. A multivariate Cox regression was used to identify predictors of smoking relapses.ResultsA total of 221 adolescents and young adults were included in this study with a mean age of 25.5 ± 3.9 years. At follow up, 59 study participants (26.7%) were abstinent and the overall median abstinence was 2 months. In the multivariate analysis smoking relapse was associated with being an adolescent patient (HR 2.16; 95% CI: 1.54-3.05), medium or higher nicotine dependence at baseline (HR 2.66, 95% CI: 1.06-7.05 and HR 3.12, 95% CI: 1.20-8.12 respectively), not receiving treatment (HR 1.70, 95% CI: 1.25-2.33) and have friend who is a smoker (HR 1.63; 95% CI: 0.96-2.79).ConclusionThe results of this study provide important information about beneficial effect of smoking cessation support for adolescent and young adults. More efforts must be deployed to deal with contributing factors to smoking relapse.

Cervical cancer screening: women's knowledge, attitudes, and practices in the region of Monastir (Tunisia).

BACKGROUND In Tunisia, cervical cancer is considered the second leading cancer in women and causes high morbidity and mortality. This study aimed to investigate womens knowledge, attitudes, and practices of cervical cancer screening in the region of Monastir (Tunisia). METHODS We conducted a cross-sectional study exploring the cervical cancer screening knowledge, attitudes, and practices of women in the region of Monastir. The study was conducted in health centers in this region from 1st March to 30th June 2009. Data were collected using a structured questionnaire containing 15 items on demographic status, knowledge of risk factors and screening methods, and attitudes toward the relevance and effectiveness of cervical cancer screening. RESULTS A total of 900 women agreed to take part in the study. Their mean age was 41.6±12.4 years and 64% did not exceed the primary level of education. According to the constructed scores, 22.8% of the participants had good knowledge of cervical cancer risk factors and 38.2% had good knowledge of screening methods. Multiple logistic regression analysis showed that women aged 45 and older, married, with good knowledge of risk factors and screening methods were more likely to undergo cervical cancer screening (P-value<0.01). CONCLUSION This study provides useful information that could be utilized by both researchers and those involved in public health programs. The results show the need for educational programs to enhance womens adherence to cervical cancer screening programs in Tunisia.

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

BACKGROUND The penicillin therapy of β 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.

Age assessment in canine and premolar by cervical axial sections of cone-beam computed tomography

Age estimation in adults is a challenge in both anthropological and forensic situations compared to sub-adults age estimation. The present study explored, for the first time, the cervical zone of single rooted teeth. The deposition of secondary dentin is responsible for a decrease in the volume of the dental pulp cavity with aging, and therefore is often used as an age indicator. The current study aimed at estimating the chronological age among adults by measuring the pulp/dentin area ratio (physiological ratio) by axial sections at cervical region of maxillary canine and mandibular second premolar. The sample consisted of 120 cone beam CT images of 120 Tunisians whose age ranged from 22 to 67, from the database of a private clinic of radiology. The first axial section of chosen teeth without enamel was selected. Linear regression models were derived for canine, premolar and for all variables to predict the age. They indicated that dentin deposition on canine and premolar have almost the same correlation with age (r=-0.838 and -0.837 respectively). The residual standard errors (RSE), when these regression equations applied for the entire sample, were ranged between 8.27, 8.29 and 7.06 for canine, premolar and for all variables respectively. Tested for younger ages (from 22 to 44years) the RSE decreased considerably and thus ranged between 4.32, 4.72 and 4.05. The outcomes of this study show that the physiological ratio is a useful variable for assessing age with a satisfying accuracy.

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.

Epidemiology and medical cost of hospitalization due to rotavirus gastroenteritis among children under 5 years of age in the central-east of Tunisia.

Data on the economic burden of rotavirus infection in Tunisia are needed to inform the decision to include rotavirus in routine childhood immunizations. This study aimed to describe the epidemiological profile of rotavirus disease in central-east Tunisia and to estimate its hospital cost. In the first stage - the prospective collection of epidemiological data - we enrolled all patients < 5 years old who were hospitalized for acute diarrhoea at 5 university paediatric departments in central-east Tunisia during the period 2009-2011. Rotavirus was responsible for 65 (23.3%) of the 279 cases enrolled. In the second stage, cost data were collected retrospectively using an activity-based costing method from the medical records of the children who were positively diagnosed with rotavirus. The average cost of care per child was TD 433 (SD 134). This is a significant economic burden in Tunisia, where a safe and effective vaccine is available but not yet introduced to the immunization schedule.

934 Prevalence and Risk Factors of Paediatric Rotavirus Gastroenteritis in Tunisia

Background and Aims Group A rotaviruses are a major cause of severe acute gastroenteritis (AGE) in children under 5 years of age worldwide. The purpose of this study was to estimate the proportion of rotavirus gastroenteritis and identify its determinants among children admitted to Tunisian hospitals. Methods We set up active rotavirus hospitalization surveillance in 10 Tunisian cities. From May 2009 through October 2010, we enrolled 550 children < 5 years of age who were hospitalized with a diagnosis of AGE. Stool samples were obtained for rotavirus testing and genotype investigation using ELISA and multiplex RT-PCR. Results The prevalence of rotavirus infection was 27.3% (95% CI 23.6–31). Infants < 2 years of age were most frequently affected (91.6%). The most dominant rotavirus genotype was G3P[8], which accounted for 40.4% of cases. On multivariate analysis, rotavirus was significantly associated with the episode occurring in the winter season (aOR 6.73; 95% CI 3.45–3.31), vomiting (aOR 3.05; 95% CI 1.37–6.75), fever (aOR 1.84; 95% CI 1.10–3.07) and dehydration (aOR 8.20; 95% CI 3.45–19.47). Conclusion The determination of rotavirus infection prevalence and its risk factors will help us to better understand the epidemiology of the disease in our country in order to develop effective preventive measures, including vaccines.