Objective: Our aim was to determine the effectiveness, feasibility, and necessary cultural adaptations of evidence-based interventions directed at tobacco use, unhealthy diet, and physical inactivity in adults and children in three different sectors: workplace, neighborhood and schools. Materials and Methods: We conducted in Sousse, Tunisia an interventional study through a quasi-experimental design (pre-post with intervention and control groups) to prevent non communicable disease risk factors. The intervention group included different settings and pre and post assessment concerned independent groups (schools with 1929 and 2170 participants, workplaces with 914 and 1098 participants and community with 940 and 1001 participants respectively at pre and post assessment). It was located in the delegation of Sousse Jawhara and Sousse Erriadh. The control group with similar settings (schools with 2074 and 2105 participants, workplaces with 861 and 1015 and community with 940 and 976 participants respectively at pre and post assessment) was located in the delegation of Msaken from the region of Sousse. Results: Tobacco use decreased among neighborhood (26.2% to 23.2%, p = 0.13) workplace (39.2% to 37.5%, p = 0.43) and schools (5.7% to 4.8%, p = 0.19) participants. In control group, it increased significantly in schools and neighborhood. Participants who consumed five fruits and vegetables daily increased significantly in all settings in intervention group (from 30% to 33.2% in schools, 47.5% to 52.1% in workplace and 39.4% to 58.4% in neighborhood). However in control group it increased only in schools and neighborhood. An improvement in physical activity practice was seen both in intervention and control group among adults participants but not in schools. Conclusion: The “Together in Health” project for the prevention of risk factors for NCD is an example of a loco-regional initiative. Such initiatives can only be beneficial with a structure organized by the government.
According to the World Health Organization (WHO), chronic diseases are responsible for 36 million deaths in 2008 [
The global epidemic of NCDs was responsible for 63% of all deaths, including at least one quarter before the age of 60. The NCD deaths are projected to increase by 15% overall between 2010 and 2020 (to reach 44 million deaths). Only 20% of these deaths occurred in high-income countries, while 80% occurred in the low-in- come and middle-income countries. The expected number of deaths from NCDs will increase from 35 million in 2005 to 41 million in 2015, at the same time, years of life lost adjusted for disability (DALYs) will increase from 725 to 808 million [
Like most North African and Arab countries, Tunisia, is going through an epidemiologic transition [
Most of what we know about the prevention of NCDs comes from the experience of developed countries where many of these diseases have been the object of successful interventions. This includes for example the Pawtucket Heart Health program of the United States of America and the Isfahan Healthy Heart program in Iran [
The concept of integrated NCD prevention as an essential component of existing health system with a focus on health promotion at the population level could be the way that our country must take to significantly reduce the future epidemic of these diseases.
The project “Together in Health” is an example of an integrated chronic disease prevention programme in an intersectoral approach that goes beyond the health care system. It was implemented by the Chronic Disease Prevention Research Center in Sousse Tunisia with the partnership of different academic departments from Farhat Hached University Hospital, with different regional authorities (Health, Education, Youth and physical activities) and NGOs (Tunisian Heart Foundation). At international level, the centre has partnered with the Institute of Health and Welfare in Helsinki, Finland, and its programme broadly follows the North Karelia project in Finland [
Our aim was to determine the effectiveness, feasibility, and necessary cultural adaptations of evidence-based interventions directed at tobacco use, unhealthy diet, and physical inactivity in adults and children in three main sectors: workplace, neighbourhood and workplace.
We conducted in Sousse, Tunisia an interventional study through a quasi-experimental design (pre-post with intervention and control groups). The intervention group included different settings (schools, workplaces and neighborhood) was located in the delegation of Sousse Jawhara and Sousse Erriadh. The control group with similar settings was located in the delegation of Msaken from the region of Sousse (
The studied populations were composed, in school settings from schoolchildren of colleges of Sousse aged 11 to 16 years old in 7th and 9th grade, in workplaces from workers in 6 enterprises with 3 in intervention and 3 in control group and in the community from adults aged 18 to 65 years in households from delegations of Sousse Jawhara, Sousse Riadh and Msaken.
Sample size calculation in the different settings were based on a significance level of α = 0.05%, power of test β = 20%, two sided test of hypothesis and 6% change in risk factors levels (smoking, unhealthy diet and physical inactivity) giving a total sample of 4000 schoolchildren in school settings, 2000 workers in workplaces and 2000 adults from households in communities.
For the school and community settings, the pre and post-assessment concerned random samples from these settings, while in workplace, we selected a convenience sample of 3 enterprises in the intervention and 3 enterprises in the control group with similar characteristics regarding the total number of workers and sex composition.
In schools, the intervention group and control group were randomly selected from all colleges of the intervention and control zones respectively with nine schools selected in the intervention and 8 schools selected in the control group. In the community, we randomly selected 500 households in the intervention and control group respectively and included all adults aged 18 years and more in these households.
We used a pretested and standardized questionnaire to evaluate knowledge of, attitudes towards and beliefs on the three risk factors for chronic disease: unhealthy diet, physical inactivity and tobacco use. We also collected biometric measures such as height, weight and waist circumference in three settings.
The questionnaire was self-administered in schools with the presence of trained medical doctors to assist filling out the questionnaires. It was administered by interview in workplaces and households. All questionnaires were completed anonymously.
To define overweight and obesity among schoolchildren, we used the recent international cut-off values of BMI according to age and sex [
Definition of smoker: Among adults, we asked participants, “Do you currently smoke any tobacco products, such as cigarettes, cigars, or pipes?” Smokers were the participants who responded yes to this question. Among adolescents, smoker is the person who smoked at least one cigarette last month among adolescent [
The intervention program was prepared by the project team to address chronic disease risk factors. In this program we were coached and trained by a team from north Karelia project (Finland) and the actions were adapted to our context.
School based intervention program consisted mainly on the creation of leaders groups among teachers and schoolchildren. Then, education sessions were animated by teachers about physical activity and healthy diet promotion and tobacco use prevention, workshops were organized by the team of the project and schoolchildren leaders in each school with the presence of parents on three different topics tobacco prevention and physical activity and healthy diet promotion. We also organized sports tournament intra and inter colleges and offered free management of obesity in schools.
Intervention program in the workplace consisted mainly on the projection of educative film for employees and interactive educative sessions with the occupational physician, workshops animation about healthy diet and motivation to quit smoking, an open sensitization days in workplaces with three different topics (smoking, physical activity, diet), free physical activity sessions for employees and free smoking cessation consultation in work- place.
Intervention program in neighborhood consisted mainly on open sensitization days on three different topics (smoking, physical activity, diet), distribution of flyers, animation of radio sessions to promote healthy diet and physical activity and to control tobacco use.
Statistical analysis was performed using the SPSS 10.0 software. We used descriptive statistics (frequencies, means and standard deviation) and chi square test to compare percentages with 0.05 as a level of significance.
This study was undertaken with respect of the rights and integrity of people. For schoolchildren, parents gave their informed consent. We obtained approval from University Hospital Farhat Hached ethical committee.
For adults in households and workplaces, we obtained an informed consent. The intervention consisted on educational messages which haven’t any harmful consequences.
In schools, number of participants was respectively at pre and post assessment 1929 and 2170 in intervention group and 2074 and 2105 in control group. The proportion of boys was respectively at pre and post assessment 50.2% and 48.7% in intervention group (p = 0.35) and 46.5% and 47.7% in control group (p = 0.45). In workplace, number of participants was respectively at pre and post assessment 914 and 1098 in intervention group and 861 and 1015 in control group. The proportion of males was respectively at pre and post assessment 64.7% and 65.5% in intervention group (p = 0.7) and 59% and 61.4% in control group (p = 0.29). In neighborhood, number of participants was respectively at pre and post assessment 940 and 1001 in intervention group and 940 and 976 in control group. The proportion of males was respectively at pre and post assessment 43.2% and 44.2% in intervention group (p = 0.67) and 28.8% and 34.3% in control group (p = 0.01) (
In schools, the proportion of schoolchildren who consume 5 fruits and vegetables improves significantly in intervention group from 30% to 33.2% (p = 0.027). Tobacco use and overweight decreased in intervention group but not significantly however in control group it increased significantly in control group (
In workplace, the participants who do recommended level of physical activity and consume 5 fruits and vegetables daily increased significantly in intervention group. Proportion of hypertension and obesity decreased significantly in intervention group and increased significantly in control group (
In neighborhood, the participants who do recommended level of physical activity and consume 5 fruits and vegetables daily increased significantly both in intervention and control group. Tobacco use decreased not significantly in intervention group but increased significantly in control group. Hypertension decreased significantly in intervention group (
Community interventions in “Together in Health” program were successful in improving some lifestyle and NCDs risk factors. To improve the effectiveness and feasibility of our program, several society actors have been targeted in their respective sectors such as children in schools and adults in the workplace. Shea et al. [
Intervention group | Control group | ||||
---|---|---|---|---|---|
Pre assessment | Post assessment | Pre assessment | Post assessment | ||
Schools | Response rate | 1929 (93.1) | 2170 (91.9) | 2074 (96.0) | 2105 (93.9) |
Sex (boys) n (%) | 968 (50.2) | 1045 (48.7) | 965 (46.5) | 1003 (47.7) | |
Age mean (SD) | 13.2 (1.2) | 13.2 (1.2) | 13.4 (1.3) | 13.3 (1.2) | |
workplace | Response rate | 914 (76.7) | 1098 (67.5) | 861 (72.5) | 1015 (77.5) |
Sex (men) n (%) | 591 (64.7) | 719 (65.5) | 508 (59.0) | 623 (61.4) | |
Age mean (SD) | 32.2 (8.1) | 33.8 (8.1) | 35.4 (8.7) | 38.9 (8.8) | |
Neighborhood | Response rate | 940 (73.5) | 1001 (74.3) | 940 (73.1) | 976 (62.5) |
Sex (men) n (%) | 406 (43.2) | 442 (44.2) | 271 (28.8) | 335 (34.3) | |
Age mean (SD) | 37.2 (13.2) | 39.2 (13.6) | 38.6 (13.7) | 40.4 (13.9) |
Intervention group | Control group | |||||
---|---|---|---|---|---|---|
Pre assessment n (%) | Post assessment n (%) | p value | Pre assessment n (%) | Post assessment n (%) | p value | |
Do recommended level of physical activity | 554 (29.1) | 536 (25.5) | 0.01 | 434 (21.1) | 425 (21.2) | 0.88 |
Consume 5 fruits and vegetable daily | 565 (30.0) | 702 (33.2) | 0.027 | 821 (40.2) | 695 (35.0) | 0.001 |
Consume tobacco | 110 (5.7) | 104 (4.8) | 0.19 | 155 (7.5) | 193 (9.2) | 0.048 |
Obese or overweight | 533 (27.6) | 564 (26.0) | 0.24 | 416 (20.1) | 540 (25.6) | <0.001 |
Intervention group | Control group | |||||
---|---|---|---|---|---|---|
Pre assessment n (%) | Post assessment n (%) | p value | Pre assessment n (%) | Post assessment n (%) | p value | |
Do recommended level of physical activity | 253 (28.3) | 414 (37.9) | <0.001 | 262 (31.2) | 626 (42.9) | <0.001 |
Consume 5 fruits and vegetable daily | 421 (47.5) | 558 (52.1) | 0.04 | 504 (60.9) | 613 (62.2) | 0.57 |
Consume tobacco | 350 (39.2) | 410 (37.5) | 0.43 | 250 (31.7) | 308 (30.6) | 0.62 |
Obese or overweight | 435 (47.6) | 615 (56.0) | <0.001 | 509 (59.1) | 693 (68.3) | <0.001 |
Hypertension | 146 (16.2) | 140 (12.8) | 0.027 | 112 (13.3) | 236 (23.3) | <0.001 |
Intervention group | Control group | |||||
---|---|---|---|---|---|---|
Pre assessment n (%) | Post assessment n (%) | p value | Pre assessment n (%) | Post assessment n (%) | p value | |
Do recommended level of physical activity | 141 (15.1) | 400 (40.1) | <0.001 | 141 (15.0) | 375 (38.5) | <0.001 |
Consume 5 fruits and vegetable daily | 368 (39.4) | 579 (58.4) | <0.001 | 483 (51.4) | 663 (67.9) | <0.001 |
Consume tobacco | 242 (26.2) | 232 (23.2) | 0.13 | 135 (14.4) | 178 (18.3) | 0.02 |
Obese or overweight | 580 (61.7) | 656 (65.5) | 0.79 | 578 (61.5) | 642 (65.8) | 0.05 |
Hypertension | 325 (35.8) | 311 (31.4) | 0.04 | 274 (29.3) | 296 (30.3) | 0.625 |
effective strategies for community mobilization: social marketing, education program in middle school and in the workplace, screening and referral of high-risk individuals, the education of health professionals and changes in physical environments. Thus, it is necessary to identify key stakeholders for effective intervention mainly to adapt environment because it’s an important determinant of health [
The school is a privileged area that can target a large number of young people. The intervention implemented in Finland since 1978 in the community has, in fact, included a school-based intervention “The North Karelia Youth Project” [
Parental involvement can be done in schools but also in the context of interventions programs in occupational settings where adults spend most of their time. The work environment has potentially important effects on the behaviour of workers’ health and risk factors for several diseases [
Guidelines for health promotion in the workplace suggest that these programs should be given at different levels to facilitate sustainable behavior change. At the individual level, a program should include several educational strategies. At the organizational level, employers and the various agencies such as the occupational health should strengthen and encourage positive action on health (for example, by providing healthy food options in the cafeteria). Finally, at the community level, these programs of health promotion in the workplace can be actively disseminated by employees to their families and social networks [
During the last two decades, we have noticed an increased interest in interventions to promote health at the community level. This is due to the fact that risk factors for non communicable diseases are determined by individual behaviors that themselves depend largely on social and environmental context. This has led many researchers and public health professionals to implement actions and compains to change not only individual behavior but also social norms, public policy and physical environment [
Among the most effective interventions, one can cite the example of Finland [
The revolution context in Tunisia which coincided with the intervention period of our projects made structural changes difficult to achieve because of other competing priorities and turnover of the main stakeholders involved in the different settings.
This is the first intervention at the community level done in Tunisia through a quasi-experimental research design with a control group and power based samples. However, the absence of randomization in this case could be the cause of non comparability of the two groups representing then a certain limit in this study. But more important than the comparability between the two groups is, rather to be considered, the comparability intra group before and after the intervention. Furthermore, we admit the quasi experimental design couldn’t confirm that observed changes were due to intervention program.
The intervention lasted three years. This time duration may seem limited compared to other international studies, however we do not have other studies with such an important time in Tunisia especially as the conditions under which the intervention took place with the occurrence of the Tunisian revolution in the middle of the project that increased the efforts to involve new leaders and adapt to the new socio-political conditions.
The socio-political conditions after the revolution also made it that the authorities and policy makers at the Ministry of Health and other sectors (Ministry of Interior, education, finance, urban design...) had other priorities and challenges than the fight against non-communicable diseases and their risk factors. Thus, multi-sectoral and structural measures that are most important in this area were very limited in our program given the circumstances described above.
The “Together in Health” project for the prevention of risk factors for NCD is an example of a loco-regional initiative. This initiative has shown that it is possible to design and implement activities to promote health in various settings with the support of the community. Such initiatives can only be beneficial if they became widespread in oil stains manner within a structure organized by the government.
This paper was based on a project funded by “United Health Group” and by the Research Unit “Santé UR12SP28”: Epidemiologic transition and prevention of chronic disease of the Ministry of Higher Education (Tunisia).
JihenMaatoug,ImedHarrabi,RafikaGaha,LarbiChaieb,NejibMrizek,SouadAmimi,LamiaBoughammoura,GouiderJeridi,HabibGamra,HassenGhannem, (2015) Three Year Community Based Intervention for Chronic Disease Prevention in Epidemiological and Political Transition Context: Example of Tunisia. Open Journal of Preventive Medicine,05,321-329. doi: 10.4236/ojpm.2015.58036