40 ans des Soins de Santé de Base en Tunisie d'Alma Ata à Astana. Il est temps de revitaliser la première ligne des soins

In order to readjust the national policy of Basic Health Care (SSB) to the declaration of Primary Health Care (SSP) of Astana (2018), 40 years after that of Alma Ata (1978), this paper summarizes the lessons learned from the international and national experience of PHC / SSB and presents the originator lines of the roadmap of the second version of SSB in Tunisia. WHO and Unicef have identified four lessons from PHC policy: 1. Political leadership, prioritizing primary care. 2. Sufficient funding to ensure the availability of basic services and their access by the population served. 3. Health personnel specifically trained in primary care, with decent working conditions. 4. A support strategy for the quality of care, based on financial and moral motivation. In Tunisia, the history of SSBs has memorized images of successes such as the organization of simulation sessions for the preparation of the “oral rehydration solution”, “mobile teams” of home visits, “deadlines” for monitoring vaccination and “school social action units” for multisectoral management of the problem of school backwardness. The "Think Tank" groups, having reflected on the perspectives of SSBs in Tunisia, came up with a roadmap made up of four fundamental axes. 1. Creation of a National Health Insurance Fund (CNAS), affiliated with the Ministry of Health, and promoting prevention and health promotion. 2. Focus on non-communicable diseases, both young and old. 3. Establishment of a periodic health assessment, stratified by sex and age, guiding health behaviors and "self-care" skills. 4. The development of “nursing homes”, providing continuous care, by multi-functional and multidisciplinary teams. Thus, the reform of the SSB policy of Tunisia, by referring to the Astana declaration and the cumulative national expertise, is essential to revitalize the first line of care and ensure the Tunisian population a "health for all", leaving no one behind”.     

Place du Bilan Médical Périodique dans les Soins de Santé de Base en Tunisie

The objective of primary health care is to reduce mortality and morbidity. This kind of care was very efficient in communicable diseases, malnutrition and maternal and neonatal diseases; however, their impact on non communicable diseases and mental disorders control is not obvious. In Tunisia, primary health care was introduced in the early 1980s; a lot of progress were notified in particular in health of mothers and children in particular, but only slightly in non communicable diseases control and mental health promotion. Therefore, a new approach would be strongly recommended to remedy this situation. The Medical Periodic Check-up (MPC) implemented in North America would have a positive impact in the prevention and management of non communicable diseases. What would be the place of this MPC in primary health care in Tunisia? The MPC has two main objectives: the prevention of specific diseases and health promotion. However, despite its efficiency and usefulness, the MPC could be costly, especially for countries with limited resources. Current evidence suggests that the most appropriate approach would be to take periodic preventive health visits tailored to the level of risk. The frequency of visits depends on the age, sex and state of health of the individual. In conclusion, there are strong arguments in favor of the introduction of MPC in primary health care in Tunisia, especially among adults in non communicable diseases control strategy. However, it''s highly be recommended that the BMC should be oriented according to the risk levels in order to optimize resources. It is also important to educate and the public, especially women and young adults, to benefit from periodic medical and dental examinations.     

Le chemin vers la Médecine de Famille en Tunisie. Analyse stratégique

Background:

Health system reforms in many countries have shown that the delivery of integrated primary health care services according to family medicine is the most efficient approach to achieve universal health coverage. In Tunisia, the issue is therefore the capacity of our health system to integrate a care approach based on family practice.

Aim:

To assess the preparedness to implement family medicine in our country

Methodology:

this is a qualitative study carried out over a period of 9 months during the year 2017.Based on a WHO protocol addressing the 13 pillars of family practice, our study explores health policy context, actors (using interviews with key informants at national, regional and local level) and health content.

Results:

Family practice model is a strategic priority in Tunisia. However, this political recognition suffers from a lack of operationalization, in relation with continuing medical training, registration of patients and families by doctors, referral system, minimum package of essential care/ essential drugs and quality of care monitoring as well as community involvement..

Conclusion:

Our situation analysis reveals that the delivery of integrated care based on family practice model; enforce to adopt a comprehensive and operational health policy that goes beyond the academic aspects.     

Stratégies des pays Maghrébins dans la lutte contre le cancer

Objectives:

Describe the cancer control strategies adopted by the Maghreb countries and identify their main weaknesses.

Methods:

Data on cancer epidemiology and "Cancer plans" in the Maghreb were collected through a search in bibliographic databases, on GLOBOCAN and the sites of international and national organizations responsible for surveillance and cancer control.

Results:

In the Maghreb, cancer registries observed low population coverage (Morocco: 20%; Tunisia: 60%; Algeria: 82%) and a lack of computerization. Primary prevention strategies remains insufficient as evidenced by the high prevalence of smoking in 2018 (Tunisia: 26%; Algeria: 19%; Morocco: 14%). Screening coverage for major cancers are still low in the Maghreb; In Tunisia for example the levels observed for cervical and breast cancers are respectively 14% and 10%. Regarding cancer care, the main problem is a limited access to cancer health services,   due to poorly decentralized infrastructure and equipment (Morocco: six oncology centers; Algeria: three oncology centers; Tunisia: only one institute specializing in cancer care). Palliative care is mainly supported by civil society in the Maghreb countries.

Conclusion:

The resources dedicated to cancer control in the Maghreb are limited, explaining its poor performance. Better governance in cancer control is required, with the adoption of multisectoral approach for prevention, and the strengthening of cancer surveillance and research.     

Prise en charge des diabétiques. Etude comparative de deux structures de santé contrastées

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.     

Soutien au réseau des services de garde montréalais dans la prévention et la gestion de la COVID-19 : un service à 3 pôles

SettingFrom April 2020, in sight of child care reopening, the Direction régionale de santé publique de Montréal (DRSPM) conducted a situational analysis with its child care (CC) partners in order to learn about the challenges they envisioned in their role in preventing and managing COVID-19. The CC partners requested access to preferred public health support.InterventionThe DRSPM established a service consisting of three components: (1) telephone support available 6 to 7 days/week for CC managers facing a COVID-19 situation; (2) a regional committee combining four Montreal representatives of CC associations and one from the Ministère de la Famille; (3) prevention brigades formed by front-line health workers from the Centres intégrés universitaires de santé et de services sociaux (CIUSSS).OutcomesThis health promotion intervention (1) enabled CC services to handle the pandemic with better capability and confidence through facilitating access to accurate and positive information; (2) supported the commitment and collaboration of CC services by acting as a mediator between them and decision-makers; and (3) responded to the psychosocial needs of community members.ImplicationsThis service helped to adjust public policy and promote community resilience by raising awareness of the importance of balancing COVID-19 prevention and the collateral impacts of the pandemic.     

Hépatite C : Etat des lieux de la littérature Tunisienne (1991-2019)

Background:

Hepatitis C virus (HCV) is one of the leading causes of chronic liver disease and liver cancer related deaths in Tunisia.

Aim:

Perform a systematic review on viral hepatitis C in Tunisia between 1991 and 2019.

Methods:

A global search of HCV-specific documentation in Tunisia in bibliographic data search sites.

Results:

Tunisia is a low endemic country for hepatitis C with a prevalence that not exceed 1% in the general population. Several studies have focused on populations at risk of HCV contamination such as hemodialysis and polytransfused patients. The prevalence of hepatitis C is higher in these groups. In relatively small series, a clear predominance of genotype 1 and subtype 1b has been reported in Tunisia with a lower co-circulation of the other genotypes. Several polymorphisms of cytokine and chemokine genes can influence the clearance or persistence of HCV infection. Tunisian studies have focused on the efficacy of conventional dual therapy (pegylated IFN + ribavirin) by analyzing the predictive factors linked to SVR and mutations associated with resistance to viral inhibitors. No publication has discussed the effectiveness of new direct-acting antivirals in Tunisia.

Conclusion:

This review of the literature provides an update on the status of hepatitis C in Tunisia and reveals a lack of investigations on new directacting antivirals.     

Profil des initiatives communautaires de riposte contre la pandémie COVID-19 en Tunisie

Introduction:

Colorectal cancer (CRC) is a real public health issue in Tunisia. A screening program based on fecal immunological occult blood test, followed in case of a positive test by colonoscopy, was launched in Tunis region in 2016. We aimed to evaluate this screening program in order to make recommendations for a better implementation of this program in years to come.

Methods:

A mixed approach has been adopted with a quantitative component based on the production of indicators related to activity, monitoring and screening quality; and a qualitative component conducted through focus groups with frontline health care professionals (HCP) and individual interviews with those lost to follow-up after a positive screening test. SWOT analysis was then performed in order to assess main strengths, weaknesses, opportunities and threats of the program.

Results:

This study showed a coverage rate of 41.2% [40.5-41.8] for population consulting the first line of care, and an effective participation rate estimated at 23.1% [22.6-23.6]. Out of 5856 tests performed, 6% (n=352) were non-treatable and 6.7 % (n=390) were positive. Only 18.6% (n=72) of those tested positive had undergone colonoscopy. A total of 26 polyps, 03 cases of cancer and 04 cases of dysplasia were recorded. SWOT analysis pointed out that the variable adherence of HCP, lack of awareness of general population regarding CRC screening, the non-acceptability of colonoscopy without sedation with a problem of affordability for its realization in the private sector, and long appointments delays in public sector, were main weaknesses and of this program.

Conclusion:

This evaluation underlined certain strengths regarding the program implementation and revealed, in return, several shortcomings which certainly impair the program’s effectiveness and efficiency. The involvement of the national health insurance fund in CRC screening tests and colonoscopies reimbursement, as well as the establishment of a performance-based payment modality for HCP, constitute main key pillars to reach success and sustainability for any CCR mass screening program in Tunisia.     

L’économie comportementale au service de la santé

The COVID-19 pandemic is bringing about far-reaching structural changes on both the economy and public health, and conventional methodologies have to be fine-tuned to assist public health decision making. In this context, behavioural economics, which is situated at the crossroads between economics and social psychology, is an undeniably innovative field. In contrast with conventional models, the economic models of behavioural economics incorporate psychological and social determinants to produce more accurate predictions of individual behaviour. In the last 20 years, the scientific community has been using this approach’s quantitative tool, experimental economics, in many areas of health, including prevention, promotion, human resources and social signage. Studies have come up with effective solutions that have improved best public health practices and provided sources of inspiration that should not be overlooked in the fight against COVID-19. They have allowed natural human behaviour to take a central role again, helped us to understand how the social and economic environment influences individuals, and enabled us to anticipate human reactions and so make faster adjustments to public policies.     

Débats autour des races canines et de la santé publique à Montréal et au Québec (2016–2019)

ObjectivesWe examine the public policies that have been formulated to reduce the incidence of dog bites. We do so to encourage the adoption of policies aligned with One Health promotion.MethodsThis case-study research involved an ethnographic approach. Our qualitative analysis derived from participant observation, policy documents, media coverage, and interviews with stakeholders in Montreal (Quebec).ResultsFollowing on from a human fatality due to dog bite injuries, the City of Montreal decided to ban certain types of dogs based on their ‘breed.’ In the ensuing discussions, the ‘Calgary model’ emerged as an alternative to breed-specific legislation. These discussions led to a change in policy direction for Montreal, and for Quebec as a whole. Furthermore, we discerned marked improvements with respect to intersectoral coordination in the wake of this controversy.Conclusion‘Policy mobilities’ offer a useful conceptual apparatus for understanding how public policies for dog bite prevention are polarized around controversial proposals, to the detriment of discussions that focus on policy implementation.     

Adult cancer prevention in primary care: patterns of practice in Québec.

We conducted a survey of a representative sample of all primary care physicians in the province of Québec to ascertain their patterns of preventive practice with respect to cancer in four anatomical sites: breast, colon-rectum, cervix, and lung. A stratified random sample of 430 physicians in general practice was interviewed individually and weighted population estimates derived. Physicians report teaching breast self-examination to their patients (96 per cent), performing breast examination (99 per cent), taking pap tests routinely (91 per cent), and pursuing anti-smoking counseling (98 per cent). Very few of them report submitting their patients over 50 years of age to annual mammography (8 per cent) or checking for occult blood in stools in patients over 45 years of age (15 per cent). Many still use routine chest X-rays as an early detection measure of cancer of the lung (77 per cent); an estimated 41 per cent use sputum cytology for the same purpose. Preventive practices, when in-use, are carried out mainly in the context of major encounters with patients such as general check-ups. Less than 28 per cent of the population is estimated to be reached by this strategy for prevention. The unrealized potential for prevention through capitalizing on all encounters with primary care physicians is important, and should stimulate creative efforts to enhance preventive activities in medical practice.     

E-learning pour la Continuité de la Formation en Ophtalmologie Pendant la Pandémie COVID-19 : Degré de Satisfaction des Résidents de l'Institut Hédi Raies d'Ophtalmologie de Tunis

Introduction:

COVID-19 pandemic created great challenges for the continuity of medical education. At the Hédi Raies Institut of Ophthalmology of Tunis (HRIO), the need to ensure continuity in the teaching of ophthalmology has stimulated the development of a new e-learning resource based on clinical case studies.

Aim: 

To evaluate level of satisfaction of HRIO residents in regard to clinical case-study-based e-learning of ophthalmology.

Methods:

Cross-sectional survey including 40 ophthalmology residents doing their internship at the ROHI during the first half of 2020. Learners were tutored in e-learning via the Moodle online learning platform and using a problem-solving format based on clinical case studies describing various ophthalmologic conditions. Data collection was carried out through an online survey after four months of training, designed to assess learners'' satisfaction with the e-learning.

Results:

Mean age of participants was 29.95 ± 1.73 years. The majority had found the navigation easy, the content relevant to their training objectives, and were satisfied with the discussion forums as a method of communication. All respondents were satisfied with clinical cases presented through the platform and felt that they helped them to better understand the content. Among them, 97.5% considered that this teaching method corresponded to their training needs. There was a statically significant difference in the level of knowledge before and after e-learning teaching, taking into account the residents'' appreciation (p<0.001).

Conclusions:

This study highlights the importance of virtual learning in ophthalmology in the era of the COVID-19 pandemic. E-learning is well appreciated by ophthalmology residents, relatively easy to integrate to their training program, and reduces issues of time, patient availability and case exposure.     

Bienvenue aux champions tunisiens de la rédaction médicale scientifique, à la revue «La Tunisie Médicale»

As part of the strategy for developing its editorial performance Tunis''Med''2030, based on productivity, quality and visibility, the journal "La Tunisie Medicale" (ISSN: 0041-4131, IeSSN: 2724-7031), focused on the identification of Tunisian champions of scientific medical writing, to invite them to submit editorials, describing the prospects for the development of their specialties, and motivating young researchers from low-income countries to excellence academic. The identification of these leaders in scientific medical research was based on the new edition of the Research.com platform (https://research.com/scientists-rankings/medicine) of December 2021. After contacting these national champions of scientific writing, the journal "La Tunisie Medicale" hopes on the one hand to improve its scientific citation and its international notoriety and on the other hand to provide a framework for partnership between national immigrant skills and young researchers residing in the country, under the teaches the social responsibility of scientific research.     

Aspects médicaux, éthiques et déontologiques de la grève de la faim en milieu carcéral

Background: A hunger strike is a common form of protest in prison and is a potential cause of many types of problems, both for facility administrators and health care staff. Issues of conflict of rights and obligations involved, and how to treat people who are subject, have created major controversies. Objectives: To identify and review published studies that discuss the medical, ethical and legal considerations of managing a hunger strike in a prison setting from a physician''s perspective. Methods: A database search using "Medline" "Ovid" and "Science Direct was conducted to identify relevant publications. We included case series, guidelines and, review articles. Results: The physician must clearly inform the striker of the risks and provide clinical assessment and regular monitoring of the concerned. The role of the psychiatrist is to detect an initial mental pathology underlying or secondary to fasting and assess the capacity of the striker''s judgment. Thus, the clinician is faced with two paradoxical obligations: to assist and respect the striker''s will. In addition, medical intervention is possible if the prognosis is life-threatening even without the patient''s consent. Conclusion: The current practice of non-consensual attitude among hunger-striking seeking in detention needs a closer inquiry. Medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.     

The Self-Care Motivation Model: Theory and Practice in Healthy Human Development

Effective health education and behavior motivation programs are needed to promote the compliance of children and young adults with preventive health care practices. Health promotion and primary prevention programs must consider the entire individual as well as his or her environment if positive behavior changes are to be maintained. This paper introduces an innovative model for self-care motivation curriculum development. The model prescribes the use of value clarification, enhanced physical/cognitive/affective awareness, positive lifestyle choices, and self-reinforcement skills training whereby individuals learn to become self-motivated and reinforcing agents for their own primary preventive health practices. It is theorized that by developing self-care and self-regulation skills, students will achieve and maintain higher levels of wellness, thus improving the quality of their lives and ensuring healthy human development.