Cardiovascular Epidemiology and Prevention Research Laboratory (CAVEPLA)
The CAVEPLA Team has initiated a number of research projects and strategy development
activities over recent months
Mental Health Promotion Strategy:
There has been an increasing awareness of the importance of mental health and well-being
in Tunisia which led to the implementation of a national program for mental health in 1990.
To reinforce this program, the MOH decided this year to develop a national strategy for
mental health promotion. A national committee was convened and worked on the strategy
for three months. Faten Tlili from CAVEPLA is a member of this committee. A workshop was
held in May 2013 to discuss the different components of this strategy. This led to a second
version of the strategy that will be discussed by another committee of experts soon. The
strategy is organized around three axes. The first is the promotion of mental health through
the reinforcement of existing preventive programs, developing the capacities of civic society
for promotion, developing regional policies, developing competencies of professionals and
implementing a communication plan. The second axis is improving the quality of care. The
third is developing information systems and research. The implementation of this strategy
has been viewed as crucial given the burden of mental disease in the country and the
increased awareness of the impact of mental health on the general health of individuals. This
strategy has been conceived in line with the recommendations of WHO.
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Women’s health and gender inequality
During the World Social Forum in Tunisia March 2013, Professor Habiba Ben Romdhane
presented the result of the team investigations on women’s health and epidemiologic
transition focusing on inequalities. A meta-analysis is being undertaken by
the Tunisian
Epidemiological Study on CHD in 2010 (thanks to funding from the MedCHAMPS Project
and the Reproductive Age Mortality Study (RAMAOS)). The first results of this analysis
highlighted the magnitude of inequalities that are particularly striking for NCDs. Access to
health facilities, screening and treatment of breast cancer, are y linked to socioeconomic
status (SES) including level of education, and to the living area (coastal and urban areas vs
inland and rural ones). The high levels of obesity in women reflect traditional gender roles
and gender inequality . Maternal mortality is correlated to level of education and SES. The
study highlighted the lack of strategies targeting social inequalities.
A national group for advocacy on women’s health has now been created. This group plans to
organize a couple of conferences in different governorates of the country.
Partnership on Strategy of Health Platform
Tunisian RESCAP-MED team has launched the National Observatory on Social Determinants
of Health Inequity (NOSDHI).The mission of NOSDHI is to :
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Undertake studies on social inequalities in health.
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Establish a database on social inequalities in health.
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Publish reports on specific issues of health inequalities.
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Inform researchers, policy makers and stakeholders on inequalities and their impact
on health.
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Contribute to the development of strategies to reduce health inequalities.
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Strengthen the capacity of stakeholders in research on inequalities.
•
Undertake advocacy for reducing social inequalities in health
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The first public activity was organized on 29 June 2013 in the South West Region (Gafsa
governorate) . As a partner on the Platform for Strategy for Health for Gafsa Population ,
NOSDHI supported research activities, capacity building and advocacy for the Platform .
The regional members of the Platform are 30 representatives of the civil society and 30
representatives of the health sector.
Academic activities
Research
Several CAVEPLA junior researchers have recently discussed their theses at the Faculty of
Medicine of Tunis. Topics included:
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Social Determinants of Maternal Mortality in Tunisia: results of the National Survey,
Hichem Abidi, April 2013
Our goal was to develop a statistical model to identify variables associated with direct causes
of maternal mortality in Tunisia. For this, we used the graphical modeling. To estimate this
model from our data set, we used backward stepwise selection. This method It assumes that
the true graph initially contains all the interactions between selected variables and
eliminates in a stepwise process the edge associated with the largest p-value (which exceeds
the significance threshold we set at 5% in our study). The procedure stops when all p-values
are below this threshold.
According to the graphical model, maternal mortality from direct causes is statistically
associated with the absence of ultrasound, a low standards of living, absence of prenatal
care and a late prenatal care . The risk of maternal death increases three fold in the
absence of prenatal care. Moreover, women who have low standards of living are two and a
half times more likely to die than those with a high standard of living.
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•
Causes of Death at Reproductive age: results of the Tunisian RAMOS, Wafa Allouche,
June 2013
A total of 1611 deaths were investigated. Cancers, except for breast and uterus
cancers, were the leading cause of death (18,4%) followed by the cardiovascular diseases
(CVD) (14,9%), then breast cancer (11,7%) and violent deaths (10,1%).
There was a marked difference according to education, region, area (rural/urban) and
income.
82 of deaths (5%) were maternal deaths; 67.2% of maternal death causes were direct causes
and 32.8% were indirect. The maternal mortality rate was 44.83/100,000 live births. The
mean age of women was 36±9.6 years. The deaths among Tunisian women in reproductive
age were responsible of 65,644 Years of Life Lost (YLLS). Maternal deaths were responsible
of 3584 YLLSs lost which represents 5.5% of the total YLLS.
This study highlighted the causes of deaths among young Tunisian women. Cancers and CVD
are the leading causes of deaths. This represents a clear wake-up call to tackle the newly
emerging non- communicable diseases. Gender sensitive prevention policies should be
implemented .Community-based interventions may offer the most promising approach.
•
Metabolic disorder prevalence in Tunisia: Karima Makni
A cross-sectional study including 8007 individuals aged 35-70 years, drawn by stratified
random sampling of 2 stages .
Prevalence of metabolic syndrome according to NCEPIII modified definition was 30% with
predominant involvement of women (36.1% against 20.6% for men). Hypercholesterolemia
was more common among women (21.5% against 16.1% for men) and its prevalence
increased with age up to 65 year old (25.6%) and in the coastal regions (28.7% in Tunis
District, 23% in the Central East and 16.8% in the North East). These inter-regional gradients
were explained partially by differences in urbanization and lifestyle between regions.
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Acute coronary syndromes’ risk factors: a prospective multicenter study. Results
from 1178 patients
Mounira Ayari, June 2013.
The Tunisian Epidemiological Study on Acute Coronary Syndrome "TEPS-ACS " conducted
with support from the MedCHAMPS Project was the data source of the thesis . It was a
prospective multicenter study including 1178 patients admitted for ACS in cardiology units in
Tunis District centers during the period from July 2009 to June 2010.
The Patients were predominantly male (ratio sex = 2.57). The ACS was mainly observed from
45 year old in men and decreased from 65 year old. This distribution appears later in women
with a delay of ten years (p<0.0001). Family history of CHD and stroke were reported
respectively for 24.9% and 9.6% of patients. Coronary risk factors (CRF) were dominated by
tobacco (64.6%), hypertension (47.6%), diabetes (42.8%), dyslipidemia (27.5%) and obesity
(19.9 %). The average of CRF number was 1.95 ± 1.16 in women against 1.61 ± 1.1 in men (p
<0.001). Despite the absence of any known CRF, 14.2% developed an ACS. However, 33.3%,
27.1% and 25.4% had respectively one, two or three CRFs.
The ACS admissions’ reasons were distributed into three diagnostic classes, the ST+ (48.8%),
ST-TR+ (33.3%) and ST-TR- (17.9%). These frequencies differed significantly according to age
(p = 0.02). ST+ class was more frequent in the less than 45 year old. ST-TR+ was more
common for 75+ year old. ST + was more common among men (53%) and current smokers
(49.2%). The other classes were more frequent in women. Family and personal previous
ischemic heart diseases and CRF were more frequent in the ST-TR-with respective
proportions of hypertension, diabetes, dyslipidemia, smoking and obesity of 60.8%, 49.3%,
44.1 %, 36% and 30.2% respectively.
Master on Public Health ,
Olfa Saidi, July 2013
Evaluation of global cardio-vascular risk according to Framingham model.
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This study investigated the magnitude and social determinants of the global cardiovascular risk. The Framingham model was used to calculate the overall 10-year
cardiovascular risk of subjects without cardiovascular disease. The probability of the event’s
occurrence during the next 10 years . We defined three classes :
Low risk : <10%
Risk Medium : [10%-20%[
High risk >=20)
Ten year global cardiovascular risk in the Tunisian population is already substantial, affecting
almost a third of men and one in ten women
The gender difference was striking and statistically significant: 27.2% [25.7 to 28.7] of men
had high risk , three fold higher than 9.7% [8.8 to 10.5] of women.
Higher 10-year global cardiovascular risk was associated with social disadvantage in men and
women; thus illiterate, divorced and adults without professional activity had a significantly
higher risk of having a cardiovascular event within 10 years. Those living in an urban area
also had a higher risk.
This is a major health challenge which will require not only a strategy for high risk individuals
but also effective population-wide interventions to reduce cardiovascular risk factors
through education, information and evidence-based policies.
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