Comparaison du score individuel de précarité des Centres d'examens de santé, EPICES, à la définition socio-administrative de la précarité

Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial?

BACKGROUND

Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days.

METHODS

Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator.

RESULTS

46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints.

CONCLUSIONS

This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff.

TRIAL REGISTRATION

Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.

Relationship between children's eating behavior (1-6 years) and body mass index: a cross-sectional study in French maternal-infant protection centers within the Parisian region

BACKGROUND

Early detection of obesity-promoting dietary behavior patterns improves the identification of at-risk families and the implementation of interventions. This is accomplished through the use of the Child Eating Behavior Questionnaire (CEBQ). No study has been conducted using the CEBQ in children followed in Essonne's Maternal-Infant Protection (PMI) centers. We investigated, in a cross-sectional design, the differences in children's eating behavior with PMI follow-up according to their weight status.

METHODS

A questionnaire addressed to parents was collected in PMI centers. Multiple hierarchical regression analysis was used to investigate the predictability of the child's CEBQ on body mass index (BMI).

RESULTS

From January to April 2022, 850 children were selected, from which 500 (aged 1-6 years) were included, and of whom 10.6% were obese. There was a significant positive association between 'Food Responsiveness', 'Enjoyment of Food' and BMI. In contrast, there was a significant negative association between 'Satiety Responsiveness', 'Slowness in Eating' and BMI. Besides, 'Food approach' and 'food avoidance' behaviors were positively and negatively related to BMI z-scores, respectively.

CONCLUSION

Due to significant differences in children's eating behavior according to their weight, it is needed to raise awareness among parents about their impact on them.

Health-related quality of life, remission and low lupus disease activity state in patients with systemic lupus erythematosus

OBJECTIVES

To measure the association between SLE remission and scores of patients-reported outcome (PRO) measures.

METHODS

We performed a prospective cohort study of SLE patients with a 2-year follow-up, using Lupus Patient-Reported Outcome (LupusPRO), Lupus Quality of Life (LupusQoL), Systemic Lupus Erythematosus Quality of Life (SLEQOL) and 36-item Short Form (SF-36) questionnaires. Remission was defined as remission off treatment (ROFT) and remission on treatment (RONT) according to the definitions of remission in SLE consensus. Mixed models accounting for repeated measures were used to compare groups as follow: ROFT and RONT vs no remission and lupus low disease activity state (LLDAS) vs no LLDAS.

RESULTS

A total of 1478 medical visits and 2547 PRO questionnaires were collected during the follow-up from the 336 recruited patients. A between-group difference in PRO scores reaching at least 5 points on a 0-100 scale was obtained in the following domains: lupus symptoms (LLDAS: +5 points on the 0-100 scale, RONT: +9, ROFT: +5), lupus medication (LLDAS: +5, RONT: +8, ROFT: +9), pain vitality (LLDAS: +6, RONT: +9, ROFT: +6) of LupusPRO; role emotional (LLDAS: +5, RONT: +8), role physical (RONT: +7 and ROFT: +7), bodily pain (RONT: +6), mental health (RONT: +5) and social functioning (RONT: +6) of SF-36. In contrast, a between-group difference reaching at least 5 points was not achieved for any of the LupusQoL and SLEQOL domains.

CONCLUSIONS

RONT, ROFT and LLDAS were associated with significant and clinically relevant higher QoL in most PRO domains of the LupusPRO (disease specific) and SF-36 (generic) questionnaires, but not with LupusQoL and SLEQOL disease-specific questionnaires.

Costs associated with informal health care pathway for patients with suspected Lyme borreliosis

OBJECTIVES

To compare the direct and indirect medical costs for patients with suspected Lyme borreliosis according to whether or not they had used an informal care pathway.

PATIENTS AND METHODS

We retraced the care pathways of participating patients by a prospective questionnaire survey and a retrospective analysis of care records. Direct and indirect costs were estimated using a micro-costing method from different perspectives. We compared the costs of patients who had consulted a "Lyme Doctor" (informal care pathway) with those who had only used the formal care pathway. Non-parametric tests were appraised the significance of the differences between the two groups of patients.

RESULTS

Out of 103 eligible patients, 49 (including 12 having used an informal health care pathway) agreed to be investigated. Five expenditure items entirely borne by patients were significantly higher for patients following an informal care pathway: productivity loss (3041 ± 6580 vs 194 ± 1177 euros, p = 0.01), alternative therapies (3484 ± 7308 vs 369 ± 956 euros), biological tests sent abroad (571 ± 1415 vs 17 ± 92 euros, p < 0.01), self-medication (918 ± 1998 vs 133 ± 689, p = 0.02) and transport (3 094 ± 3456 vs 1 123 ± 1903p = 0.01).

CONCLUSIONS

From the patient's standpoint, the informal care pathway involving consultation with a Lyme Doctor is far more expensive than the formal care pathway. More specifically, the patient has to bear the costs of alternative treatments and repeated, non-recommended examinations.

The Acti-Pair program helps men with prostate cancer increase physical activity with peer support: a mixed method pilot study

Background

Although the health benefits of physical activity (PA) are recognized, prostate cancer patients do not follow PA recommendations. Barriers to PA, whether physical, environmental or organizational, are known. Furthermore, even when these barriers are overcome, this achievement is not systematically accompanied by lifestyle change. Many strategies have shown to be effective in increasing patient adherence to PA. This study aims to assess the feasibility and the viability of the Acti-Pair program which combines three strategies: peer support, a personalized and realistic PA project, and support from health and adapted physical activity professionals in a local context.

Methods and analysis

We conducted a pilot study utilizing a mixed qualitative and quantitative methodology, employing feasibility and viability assessments. Quantitative assessments included recruitment, retention adherence rates, process and potential effectiveness (PA and motivation) indicators; while qualitative methods were used to evaluate the program's practicality, suitability and usefulness. Indicators of potential effectiveness were assessed before and after the intervention using a Wilcoxon test for matched data. Qualitative data were collected through semistructured interviews conducted by two researchers with various program stakeholders. The study lasted for 3 years.

Results

Twenty-four patients were recruited over a 25-month period. Forty-two percent of patients completed the program 3 months after the beginning. We recruited 14 peers and trained nine peers over a 10-month period. The program was coordinated extensively by adapted PA professionals, while health professionals were involved in recruiting patients and peers. Self-reporting of moderate to vigorous PA was increased after the Acti-Pair program initiation [42.86 (30.76) at baseline to 53.29 (50.73)]. Intrinsic motivation significantly increased after participation in the Acti-Pair program [1.76 (1.32) before the intervention vs. 2.91 (1.13) after the intervention]. The key player to support the Acti-Pair program in the field has been the PA support system. The main challenge has been the difficulty of health professionals in promoting PA.

Discussion

This pilot study has shown that the Acti-Pair program is feasible and viable. It will allow us to extend the peer support intervention to other contexts and assess the effectiveness of this intervention and its generalization.

Impact of experiencing multiple vulnerabilities on fetal growth and complications in women with hyperglycemia in pregnancy

BACKGROUND

In women with hyperglycemia in pregnancy living in France, psychosocial deprivation is associated with both earlier and greater exposure to the condition, as well as poorer maternofetal prognosis. We explored the impact of this and two other socioeconomic vulnerability indicators-food insecurity and poor language proficiency-on adherence to prenatal care and maternal and fetal outcomes.

METHODS

In a socially deprived suburb of Paris, we selected women who delivered between 01/01/2012 and 31/12/2018 and received care (nurse, dietician, diabetologist evaluation, advice, regular follow-up to adjust insulin doses if requested) for hyperglycemia in pregnancy. We analyzed the associations between individual psychosocial deprivation, food insecurity, French language proficiency (variables assessed by individual questionnaires) and fetal growth (main outcome), as well as other core maternal and fetal outcomes.

RESULTS

Among the 1,168 women included (multiethnic cohort, 19.3% of whom were Europeans), 56%, 17.9%, and 27.5% had psychosocial deprivation, food insecurity, and poor French language proficiency, respectively. Forty-three percent were prescribed insulin therapy. Women with more than one vulnerability had more consultations for diabetes. The rates for small (SGA), appropriate (AGA), and large-for-gestational-age (LGA) infant were 11.4%, 76.5% and 12.2%, respectively. These rates were similar in women with and without psychosocial deprivation, and in those with and without food insecurity. Interestingly, women with poor French language proficiency had a higher odds ratio of delivering a small- or large-for-gestational age infant than those with good proficiency.

CONCLUSION

We found similar pregnancy outcomes for women with hyperglycemia in pregnancy living in France, irrespective of whether or not they had psychosocial deprivation or food insecurity. Optimized single-center care with specialized follow-up could contribute to reduce inequalities in maternal and fetal outcomes in women with hyperglycemia in pregnancy.

Home-based pulmonary rehabilitation for adults with severe asthma exposed to psychosocial chronic stressors

OBJECTIVE

To evaluate the effects of a home-based pulmonary rehabilitation (PR) programme on hyperventilation symptoms, anxiety and depressive symptoms, general fatigue, health-related quality of life (HRQoL) and exercise capacity in adults with severe asthma who have been exposed to psychosocial chronic stressors.

METHODS

Data on 111 non-selected consecutive adults with severe asthma who enrolled in an 8-week home-based PR programme (weekly supervised 90-min session) was retrospectively analysed. Chronic stressors included physical, sexual and psychological violence and/or a traumatic experience related to an intensive care unit stay. Hyperventilation symptoms (Nijmegen questionnaire), Hospital Anxiety and Depression Scale, Fatigue Assessment Scale, COPD Assessment Test, Six-Minute Stepper Test and Timed-Up and Go test were assessed at baseline and after PR.

RESULTS

At baseline, participants who have been exposed to chronic stressors (n = 48, 43.2%) were younger, more often female, more often treated for anxiety and depressive disorders, and had a higher score for anxiety symptoms, hyperventilation symptoms and a poorer HRQoL, compared to those who had not been exposed to chronic stressors (p < 0.05). All the study assessments were statistically improved after PR for both groups (p < 0.001). Anxiety and depressive symptoms, fatigue and health-related quality of life questionnaires were also clinically improved based on the minimal clinically important difference.

CONCLUSION

A large proportion of adults with severe asthma, mainly women, have been exposed to chronic stressors at the time of starting a PR programme, resulting in higher anxiety symptoms and hyperventilation symptoms. However, it did not prevent these individuals from benefiting from PR.

The mediating effect of fatigue in impaired quality of life in systemic lupus erythematosus: mediation analysis of the French EQUAL cohort

OBJECTIVES

Mediation analyses were conducted to measure the extent to which musculoskeletal (MSK) flares and depression affected physical health through excessive fatigue.

METHODS

Mediation analyses were performed in a large multicentre cohort of SLE patients. Domains of the LupusQoL and SLEQOL questionnaires were selected as outcomes, MSK flares according to the SELENA-SLEDAI flare index (SFI-R) score and depression defined by Center for Epidemiologic Studies-Depression scale (CES-D) scale as exposures and different fatigue domains from MFI-20 and LupusQoL questionnaires as mediators. For each model, total, direct, indirect effects and proportion of effect mediated by fatigue (i.e. proportion of change in health-related quality of life) were determined.

RESULTS

Of the 336 patients, 94 (28%) had MSK flares at inclusion and 99 (29.5%) were considered with depression. The proportion of the total effect of MSK flares on physical health impairment explained by fatigue ranged from 59.6% to 78% using the LupusQOL 'Physical health' domain and from 51.1% to 73.7% using the SLEQOL 'Physical functioning' domain, depending on the fatigue domain selected. The proportion of the total effect of depression on physical health impairment explained by fatigue ranged from 68.8% to 87.6% using the LupusQOL 'Physical health' domain and from 79.3% to 103.2% using the SLEQOL 'Physical functioning' domain, depending on the fatigue domain selected.

CONCLUSIONS

The effect of MSK flares and depression on physical health impairment is largely mediated by fatigue. Thus, the patient's perception of disease activity as measured by physical health is largely influenced by fatigue. In addition, fatigue has a significant negative impact on quality of lifeof SLE patients with depression.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01904812.

Association between social vulnerability profiles, prenatal care use and pregnancy outcomes

BACKGROUND

Evaluating social vulnerability is a challenging task. Indeed, former studies demonstrated an association between geographical social deprivation indicators, administrative indicators, and poor pregnancy outcomes.

OBJECTIVE

To evaluate the association between social vulnerability profiles, prenatal care use (PCU) and poor pregnancy outcomes (Preterm birth (PTB: <37 gestational weeks (GW)), small for gestational age (SGA), stillbirth, medical abortion, and late miscarriage).

METHODS

Retrospective single center study between January 2020 and December 2021. A total of 7643 women who delivered a singleton after 14 GW in a tertiary care maternity unit were included. Multiple component analysis (MCA) was used to assess the associations between the following social vulnerabilities: social isolation, poor or insecure housing conditions, not work-related household income, absence of standard health insurance, recent immigration, linguistic barrier, history of violence, severe dependency, psychologic vulnerability, addictions, and psychiatric disease. Hierarchical clustering on principal component (HCPC) from the MCA was used to classify patients into similar social vulnerability profiles. Associations between social vulnerability profiles and poor pregnancy outcomes were tested using multiple logistic regression or Poisson regression when appropriate.

RESULTS

The HCPC analysis revealed 5 different social vulnerability profiles. Profile 1 included the lowest rates of vulnerability and was used as a reference. After adjustment for maternal characteristics and medical factors, profiles 2 to 5 were independently associated with inadequate PCU (highest risk for profile 5, aOR = 3.14, 95%CI[2.33-4.18]), PTB (highest risk for profile 2, aOR = 4.64, 95%CI[3.80-5.66]) and SGA status (highest risk for profile 5, aOR = 1.60, 95%CI[1.20-2.10]). Profile 2 was the only profile associated with late miscarriage (adjusted incidence rate ratio (aIRR) = 7.39, 95%CI[4.17-13.19]). Profiles 2 and 4 were independently associated with stillbirth (highest association for profile 2 (aIRR = 10.9, 95%CI[6.11-19.99]) and medical abortion (highest association for profile 2 (aIRR = 12.65, 95%CI[5.96-28.49]).

CONCLUSIONS

This study unveiled 5 clinically relevant social vulnerability profiles with different risk levels of inadequate PCU and poor pregnancy outcomes. A personalized patient management according to their profile could offer better pregnancy management and reduce adverse outcomes.

Adapted educational health program among deprived subjects with prediabetes

AIMS

Assess the feasibility and benefit of a health educational program on global metabolic status in prediabetic deprived subjects.

DESIGN

Case control study.

METHODS

693 subjects (466 men, 227 women), aged 16 to 95 years with prediabetes and low socioeconomic status, consulting at the IPC Center were included between September 2015 and June 2016. Subjects were invited to participate in 4 workshops (2 nutrition, 2 physical activities). One year after their inclusion (visit 1), they were offered a second health check-up (visit 2). Participants were classified into 3 groups: 1) Intervention group (INTG, N=133): complete process 2) Control group (CG, N=415): Only a second health check-up, no workshop participation; 3) Abandoned group (AG, N=145). All groups were compared.

RESULTS

After considered confounding factors, fasting blood glucose and SBP levels variation between visit 1 and visit 2 differed significantly between the CG and INTG. In the INTG with higher diminution of fasting glucose, 90% reported eating healthy food since nutrition workshop and 51%. reached objectives (The same trend was observed for physical activity.

CONCLUSION

An educational program among deprived prediabetic tended to limit fasting glucose increment, improve metabolic status and encourage healthy lifestyle despite difficulties in convincing subjects to participate.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]

INTRODUCTION

Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations.

OBJECTIVE

The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals.

MATERIAL AND METHODES

This is a national survey conducted by questionnaire in all French maternities.

RESULTS

Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized.

CONCLUSION

A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

A comparison of individual and ecological indicators of social deprivation and their association with hospital efficiency in the context of infectious diseases in two French general paediatric departments

BACKGROUND

To identify deprivation indicators usable in everyday practice and included in medico-administrative databases, particularly with infectious diseases, which represent the greatest proportion of hospitalizations. Our objective was to compare ecological indicators to individual questionnaires and apply both types to the study of the impact of deprivation on hospital efficiency.

METHODS

We conducted an epidemiological observational prospective multicentre study in two French public hospitals between 20 October 2016 and 20 March 2017. Children hospitalized for one of the four most common infectious diseases were included and their parents were asked to answer the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) questionnaire. The ecological indicator French DEPrivation index (FDep) was derived from patients' address, both at the zip code and at a smaller geographical area (IRIS [ilôts de regroupement pour l'information statistique]) level. Correlation and concordance between the three indicators were assessed. The endpoint used to assess the impact on hospital efficiency was the ratio between patients' length of stay (LOS) and the national LOS of their disease-related group.

RESULTS

Data were available for 540 patients with a mean age of 9 mo. A total of 56.1% of patients were considered deprived with EPICES, 50.4% with zip code FDep and 45.7% with IRIS FDep. Concordance between EPICES and either type of FDep was <0.1. There was no increase in LOS compared with national LOS with any of the indicators.

CONCLUSIONS

Individual and ecological indicators do not measure the same aspects of deprivation. The decision to use one or the other must be carefully weighed when studying the impact of deprivation on the healthcare system.

Soluble Receptor of Advanced Glycation End-Products (sRAGE) in Pediatric Asthma: A Prospective Study in 68 Children Aged 7 Years

Background: Asthma is a chronic inflammatory disease of the airways common in children. Soluble advanced glycation end-product receptor (sRAGE) is a blood biomarker of lung damage and inflammation. We sought to determine whether it could also be a biomarker in childhood asthma. Methods: We conducted a prospective, observational, analytical study at Clermont-Ferrand University Hospital. We measured plasma sRAGE levels in asthmatic and healthy children aged 7 years. Results: Of the 68 children assessed, 15 (22.05%) presented asthma. All presented normal respiratory function. The mean plasma sRAGE level was 1875 pg/mL in the children with asthma and 1794 pg/mL in the healthy children (p = 0.525). The mean plasma sRAGE level was significantly decreased with tobacco exposure during pregnancy: 1478 pg/mL versus 1870 pg/mL without (p = 0.007). Lower levels were observed in children living in apartments (1557 pg/mL) than in those living in houses (1863 pg/mL) (p = 0.031). Conclusions: No difference was observed in plasma sRAGE levels in children with asthma in our well-treated and controlled population. Environmental exposure may affect these levels. Further studies are required to better characterize the role of sRAGE.

Trends of influenza vaccination coverage in pregnant women: a ten-year analysis from a French healthcare database

Pregnant women have a high risk of severe influenza, associated with obstetrical complications. The World Health Organization (WHO) has recommended influenza vaccination for all pregnant women since 2012. The vaccination coverage remains low worldwide, and in Europe, due to a lack of proposition from the health care providers, and a high refusal rate from the women. The primary aim of this study was to estimate the influenza vaccination coverage (IVC) in a population of pregnant women in France, and to analyse its evolution from 2009 to 2018. The secondary objective was to describe the vaccinated population and to find determinants associated with the vaccination. This retrospective cohort study is based on the EGB French health care database, a representative sample of the French population containing data from the health insurance system. All pregnant women who delivered medically or spontaneously over the 2009–2018 period were included. In the 2009–2018 period, only 1.2% pregnant women were vaccinated against influenza (n = 875/72,207; 95% CI 1.14–1.30). The IVC slightly increased after the 2012 WHO recommendation, from 0.33 to 1.79% (p < 0.001) but remained extremely low (4.1% in 2018). Women younger than 25 years old had a low coverage (0.6%) whereas women over 35 years old were more likely to get the influenza vaccine (1.7%; OR: 2.82, 95% CI 2.14–3.71). The vaccination behavior was not influenced by multifetal pregnancy or parity, but socio-economically deprived women were less likely to be vaccinated (OR: 0.81, 95% CI: 0.67–0.98). Women with pre-existing medical conditions had an overall higher vaccination rate (2.5%; OR: 2.32, 95% CI: 1.94–2.77). The vaccine was mainly prescribed by family physicians (58%). Influenza vaccination in pregnant women in France remains very low, particularly in younger, healthy women, and measures such as information campaigns towards pregnant women and studies of the knowledge, attitudes, and practices of the health care professionals need to be undertaken to improve the coverage.

Diagnosis of advanced cervical cancer, missed opportunities?

Background

Cervical cancer is common worldwide. Despite the existence of primary and secondary prevention strategies, the survival rate is decreasing in France due to an increasing proportion of advanced-stage cancer. Our objective was to determine the factors associated with a diagnosis of cervical cancer at advanced stages in an urban population in France.

Methods

A retrospective study was conducted on all consecutive records of patients diagnosed with cervical cancer between January 2006 and December 2018 in a single center in Paris. The data collected were demographic characteristics, medical and gynecological history, circumstances of diagnosis, diagnostic and therapeutic management. The patients were divided into two groups according to the FIGO 2018 stage at diagnosis: group A stages IA1 to IB2 and group B advanced stages IB3 to IVB.

Results

Among 96 patients who were diagnosed with cervical cancer, 25 (26%) were in group A and 71 (74%) in group B. Women in group B had less frequently received regular gynecological care than in group A (36% vs 84.2%, p < 0.001) and fewer had Pap test screening in the previous 3 years (30.4% vs 95.0%, p < 0.001). Parity greater than 3 was more frequent in group B (69.6% vs 42.9%, p = 0.031). The diagnosis was made during a routine examination or cervical smear in only 9.23% and 16.18% respectively in group B, versus 60% of cases in 45.82% of cases in group A (p < 0.001 and p = 0.003). Vaginal bleeding was observed in 85.29% in group B versus 36% in group A (p < 0.001). Histological type was squamous cell carcinoma 87.32% of group B and 56% of group A (p < 0.001).

Conclusion

Diagnosis of cervical cancers at advanced stages occurred mostly in women who did not benefit from the recommended screening. Universal access to screening is necessary for the prevention and early treatment of cervical cancer.

Precariousness, Diabetes Control and Complications in French Guiana

AIMS

The social parameters of an individual impact the incidence of cardiovascular diseases. French Guiana, an overseas French territory with a lower standard of living than France, has a prevalence of diabetes mellitus that is twice that of mainland France. In this context we aimed to study the relation between precariousness, diabetes complications and glycemic control.

METHODS

A multicenter prospective cohort was initiated since May 2019. 1243 patients were included and their outcomes and history were compared between the precarious and non-precarious based on their EPICES score, a score that measures social isolation and precariousness.

RESULTS

73.3% of the sample was considered precarious. Retinopathy was significantly more frequent among the deprived. There were no significant differences for other macro or microvascular complications.There was a significant difference in Glycated Haemoglobin between the precarious and non-precarious groups (8.3% (67 mmol/l) vs 8.8% (73mmol/l)). After adjusting for potential confounders, precariousness was no longer associated with poor glycemic control; the independent factors significantly associated with poor glycemic control were: not being fluent in French, having creole or portugese as mother language, and not having any insurance.

CONCLUSIONS

Precariousness is a risk factor for retinal complications in patients with diabetes mellitus in French Guiana. In this chronic disease, the universal healthcare system alleviates health inequalities for many, but not all, diabetic complications.Translation and cultural mediation may further reduce health inequalities in this multicultural territory where a substantial proportion of the population is not fluent in French.

The role of personality traits in inpatient pulmonary rehabilitation response in patients with chronic obstructive pulmonary disease

BACKGROUND

The effectiveness of pulmonary rehabilitation (PR) is a critical issue for chronic obstructive pulmonary disease (COPD) patients. However, PR response is marked by a strong heterogeneity, partially unexplained to date. We hypothesized that personality traits defined by the Five-Factor Model could modulate the effect of inpatient-PR.

OBJECTIVE

The aim was to assess the associations between these five personality traits and PR outcomes.

METHODS

74 persons with COPD admitted for a 5-week inpatient PR program had a personality assessment at the start of the program (T1). Exercise capacity, quality of life, sensory and affective dyspnea dimensions were assessed at T1 and at the end of the program (T2). Their evolution was evaluated using the delta score between T2 and T1. PR response was defined using the minimal clinically important change score for each of them. A composite response was established distinguishing the poor responders' group, made of patients who responded to 0, 1 or 2 parameters and the good responders' group, with patients who responded on 3 or 4 indicators.

RESULTS

Logistic regressions analyses highlighted that those with a high level of openness [OR = 0.36, 95% CI = 0.15-0.74, p < 0.01] were less likely to respond on quality of life, controlling for socio-demographic factors and the severity of the disease.

CONCLUSION

This study shows that the investigation of the personality constitutes an interesting perspective for better understanding the interindividual differences observed between patients in the PR response. Tailoring clinical intervention to the patient's personality could be a promising prospect for optimizing PR effectiveness.

Validation of the 'EPICES' social deprivation score in a population of women who have just given birth: a French cross-sectional study

OBJECTIVES

To assess the diagnostic performance of the EPICES score for identifying social deprivation during pregnancy in a population of women in the immediate postpartum period.

STUDY DESIGN

This cross-sectional survey took place between 5th June and 5th August 2017, among women who had just given birth in either of the maternity units in Clermont-Ferrand, France.

METHODS

A self-administered questionnaire was completed by women. The questionnaire came in two parts: the EPICES index and the criteria for social deprivation defined by French law. These criteria were chosen to define the reference standard. The women were classified into two groups, living in precarious circumstances or not, according to the criteria defined by the French law (reference standard). To determine the most relevant threshold of the EPICES score, the precision associated with the threshold (the fraction of those predicted positive who are true positives: positive predictive value) was balanced with its sensitivity. EPICES scores above the threshold were classified as deprived, those below as non-deprived.

RESULTS

Of the 947 women who gave birth during the study period, 700 (73.9%) completed the self-administered questionnaire. The best trade-off between precision and sensitivity was obtained with a threshold of 22. For this threshold value, the positive predictive value was 42.3% and the sensitivity 70.3%.

CONCLUSIONS

The EPICES score with a threshold validated in the population of pregnant women is a useful, rapid, and easy-to-use tool that makes it possible to identify maternal deprivation at an individual level.

Rhinovirus Infection and Familial Atopy Predict Persistent Asthma and Sensitisation 7 Years after a First Episode of Acute Bronchiolitis in Infancy

Background: We set out to assess the risk factors for asthma outcome in a cohort of infants who experienced their first episode of acute bronchiolitis. Methods: A cohort of 222 infants who were included during a first episode of acute bronchiolitis was prospectively followed. Herein, we present the results of their assessments (symptom history, skin prick tests, specific IgE assay, respiratory function tests) at age seven. Results: Of the 68/222 (30.6%) children assessed at age seven, 15 (22.05%) presented with asthma and were mainly males (p = 0.033), 14 (20%) had respiratory allergies, 17 (25%) presented atopic dermatitis and none had a food allergy. Family history of atopy was associated with asthma and sensitisation to aeroallergens at age seven (p = 0.003, p = 0.007). Rhinovirus (hRV) infection and rhinovirus/respiratory syncytial virus (RSV) co-infection were significantly associated with asthma at age seven (p = 0.035, p = 0.04), but not with the initial severity of bronchiolitis. Eosinophil counts at ages three and seven were significantly higher in the asthmatics (p = 0.01, p = 0.046). Conclusion: Any infant, especially male, presenting a first episode of acute bronchiolitis due to hRV with a family history of atopy should be closely monitored via follow-up due to a higher risk for asthma at school age.

Factors associated with SARS-CoV2 infection and care pathways among the most vulnerable populations living in Marseille: a case control study

BACKGROUND

The Covid-19 pandemic has led to substantial and unexpected increases in morbidity and mortality in France. Vulnerable populations housed in accommodation centres have a greater risk of infection because collective housing and their dependence on social support services mean it is more difficult to apply preventive measures. They are also at greater risk of developing severe forms of Covid-19 and waiting longer before seeking healthcare (for Covid-19 or other) treatment. We aimed to identify the factors associated with SARS-CoV2 infection in the most vulnerable populations in the city of Marseille.

METHODS

The study sample comprised users of various services provided by the association AAJT in Marseille, France, some presenting symptoms suggestive of Covid-19 and others not. All had routine health surveillance provided by AAJT's dedicated healthcare team between March 2020 and May 2020. Using univariate and multivariate analyses, we studied the influence of several variables on morbidity associated with Covid-19.

RESULTS

The study included 64 participants, 29 of whom tested positive for Covid-19 and 35 control subjects. Median age was 21.16 years old. Individuals in the 'Covid-19 case' group (p < 0.005) - which included persons testing positive and those suspected of being infected - were younger. The study sample's male/female ratio was seven. In our multivariate analyses, living in a shared apartment and poor adherence to social distancing measures were factors associated with Covid-19 infection. Furthermore, mental health problems - such as anxiety disorder - were very frequent in the study sample.

CONCLUSIONS

Allocating more and specific housing units to structures providing accommodation services to the most vulnerable people would seem to be a decisive factor in controlling the spread of SARS-CoV2, and deserves more attention from public authorities.

Prognosis in Head and Neck Cancer: Importance of Nutritional and Biological Inflammatory Status

OBJECTIVES

To determine the importance of nutritional status, social status, and inflammatory status in the prognosis of head and neck cancer.

STUDY DESIGN

Single-center retrospective study of prospectively collected data.

SETTING

Tertiary referral center.

METHODS

Ninety-two consecutive patients newly diagnosed for cancer of the upper aerodigestive tract without metastases were assessed at time of diagnosis for several prognostic factors. Nutritional status was assessed by the nutritional risk index, social status by the EPICES score, and inflammatory status by the systemic inflammatory response index. The primary endpoint was overall survival.

RESULTS

In multivariable analysis, the main prognostic factors were the TNM classification (hazard ratio [HR] = 3.34, P = .002, for stage T3-4), malnutrition as assessed by the nutritional risk index (HR = 3.64, P = .008, for severe malnutrition), and a systemic inflammatory response index score ≥1.6 (HR = 3.32, P = .02). Social deprivation was not a prognostic factor.

CONCLUSION

Prognosis in head and neck cancer is multifactorial; however, malnutrition and inflammation are important factors that are potentially reversible by early intervention.

Evaluation of socio-economic insecurity in peripheral artery disease patients

The social and economic environment has become a major determinant of cardiovascular health. The objective of our study was to assess socio-economic insecurity in patients with symptomatic PAD. The PRECAR study was a non-interventional prospective cohort study. Patients were recruited from the Vascular Medicine and Surgery Departments of Grenoble-Alpes University Hospital or during a consultation as part of the therapeutic education program "On the move! Better understanding and better living with arterial disease". The analysis of socio-economic and environmental data was based on the EPICES score (a reliable index used to measure individual deprivation) and INSEE parameters (level of education and socio-professional category). Cardiovascular risk factors were also recorded. 150 patients with symptomatic PAD were included between November 2017 and June 2018. 84% were men. In our population 54% (CI95% 45.7 - 62.1) were in a precarious situation compared to 40% (CI95% 39.8 - 40.2) in the general population, according to the EPICES score (P<0.001). Levels of education were low and patients with a baccalaureate or higher education degree were under-represented. Executives, intellectuals and intermediate professions were also under-represented in the PAD population. This data opens new perspectives on the social characterisation of patients that may contribute to improving the outcomes of patients with peripheral vascular disease.

Impact of socioeconomic status in patients hospitalised for COVID-19 in the Greater Paris area

In the USA, coronavirus disease 2019 (COVID-19) is more likely to affect and kill African Americans [1], which raises the question of the contribution of several factors, including genetic background, socioeconomic status (SES), and comorbidities [2]. According to the French National Institute of Statistics and Economic Studies (INSEE) the highest excess mortality rate in France, during March and April 2020, linked to COVID-19 was found in the Seine-Saint-Denis (SSD) district [3]. SSD is the poorest district of Greater Paris [4]. We hypothesise that precarity influences the initial severity of COVID-19.

Individual precarity seems to be associated with the initial severity of COVID-19 in hospitalised patients under the age of 70 years. Low socioeconomic status may contribute to the excess mortality observed in the poorest district of Greater Paris.https://bit.ly/3kuStXS

Gender does not impact the short- or long-term outcomes of home-based pulmonary rehabilitation in patients with COPD

Pulmonary rehabilitation, whether performed at home or in a specialised centre, is effective in the management of COPD. As gender-related differences in COPD were previously reported, we aimed to evaluate the impact of gender on pulmonary rehabilitation outcomes in the short, medium and long term.

In this retrospective observational study of 170 women and 310 men with COPD, we compared the outcomes of an 8-week home-based pulmonary rehabilitation programme including an individualised plan of retraining exercises, physical activities, therapeutic education, and psychosocial and self-management support. Exercise tolerance, anxiety, depression, and quality of life (QOL) were assessed using the 6-min stepper test (6MST), Hospital Anxiety and Depression Scale (HADS) and Visual Simplified Respiratory Questionnaire (VSRQ), respectively. Assessments were carried out before, immediately after the pulmonary rehabilitation programme (T2) and at 8 (T8) and 14 months (T14).

At baseline, women were younger (mean 62.1 versus 65.3 years), more often nonsmokers (24.7% versus 7.7%) and had a higher body mass index (28 versus 26.4 kg·m⁻²). They more often lived alone (50.6% versus 24.5%) and experienced social deprivation (66.7% versus 56.4%). They had significantly lower exercise tolerance (−34 strokes, 6MST) and higher anxiety and depression (+3.2 HADS total score), but there were no between gender differences in QOL (VSRQ). Both groups showed similar improvements in all outcome measures at T2, T8 and T14 with a tendency for men to lose QOL profits over time.

Despite some differences in baseline characteristics, women and men with COPD had similar short-, medium- and long-term benefits of a home-based pulmonary rehabilitation programme.

Despite some differences in baseline characteristics, women and men with COPD had similar short-, medium- and long-term benefits of a home-based pulmonary rehabilitation programmehttps://bit.ly/2XfFakK

Disease-specific quality of life following a flare in systemic lupus erythematosus: an item response theory analysis of the French EQUAL cohort

OBJECTIVE

To explore, at an item-level, the effect of disease activity (DA) on specific health-related quality of life (HRQoL) in SLE patients using an item response theory longitudinal model.

METHODS

This prospective longitudinal multicentre French cohort EQUAL followed SLE patients over 2 years. Specific HRQoL according to LupusQoL and SLEQOL was collected every 3 months. DA according to SELENA-SLEDAI flare index (SFI) and revised SELENA-SLEDAI flare index (SFI-R) was evaluated every 6 months. Regarding DA according to SFI and each SFI-R type of flare, specific HRQoL of remitting patients was compared with non-flaring patients fitting a linear logistic model with relaxed assumptions for each domain of the questionnaires.

RESULTS

Between December 2011 and July 2015, 336 patients were included (89.9% female). LupusQoL and SLEQOL items related to physical HRQoL (physical health, physical functioning, pain) were most affected by musculoskeletal and cutaneous flares. Cutaneous flares had significant influence on self-image. Neurological or psychiatric flares had a more severe impact on specific HRQoL. Patient HRQoL was impacted up to 18 months after a flare.

CONCLUSION

Item response theory analysis is able to pinpoint items that are influenced by a given patient group in terms of a latent trait change. Item-level analysis provides a new way of interpreting HRQoL variation in SLE patients, permitting a better understanding of DA impact on HRQoL. This kind of analysis could be easily implemented for the comparison of groups in a clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01904812.

Low-level HIV viremia is associated with low antiretroviral prescription refill rates and social deprivation

Optimal management of patients experiencing persistent low-level viremia (LLV) remains challenging and poorly understood. This study aimed to assess the association between poor antiretroviral treatment (ARV) adherence and persistent LLV. ADHELOW is a sub-study of the ECHEC cohort comprising HIV-infected adults with virological failure (viral load>50 copies/mL). Patients were recruited in 2013-2015 from 4 French university hospitals. Those with LLV (i.e., ≥2 viral load measurements between 50 and 500 copies/mL) were selected and matched on age and sex to 3 controls with virological suppression. The adherence rate was estimated using pharmacy-delivered prescription refills over one year. Overall, 60 patients were included (15 LLV and 45 controls). Mean age was 50.20 years, M/F sex ratio was 14 and mean EPICES (social deprivation) score was 42.90. In univariable analyses, LLV patients had significantly lower adherence (<80%: 53.30% vs. 6.67%, p < 0.01) and were more likely to have an EPICES score >40.2 (60.00% vs. 24.44%, p < 0.01). In multivariable analysis, these two variables remained significantly associated with LLV (OR 31.49, CI 95% [4.54-218.70]) and OR 11.00 (CI 95% [1.87-218.70], respectively). Poor long-term treatment adherence, estimated by prescription refills, was strongly associated with LLV. This reinforces the message that adherence counseling should be the primary intervention to overcome LLV.

Social deprivation among socio-economic contrasted french areas: Using item response theory analysis to assess differential item functioning of the EPICES questionnaire in stroke patients

Background

Multiple approaches have been proposed to measure low socio-economic status. In France the concept of precariousness, akin to social deprivation, was developed and is widely used. EPICES is a short questionnaire that was developed to measure this concept. This study aimed to evaluate Differential Item Functioning (DIF) in the EPICES questionnaire between contrasted areas: mainland France, French West Indies (FWI) and French Guiana (FG).

Methods

The population was taken from the INDIA study, which aimed to evaluate the impact of social inequalities on stroke characteristics and prognosis. Eligible people were patients referred to neurology or emergency departments for a suspicion of stroke. We assessed the DIF using hybrid ordinal logistic regression method, derived from item response theory.

Results

We analysed 1 553 stroke patients, including 768 from FWI (49.5%), 289 from FG (18.6%) and 496 from mainland (31.9%). We identified five items with a moderate to large DIF in area comparisons: “meeting with a social worker”, “complementary health insurance”, “home-owning”, “financial difficulties” and “sport activities”. Correlation between EPICES score and the latent variable was strong (r = 0.84).

Conclusion

This is the first attempt to assess the DIF of the EPICES score between different French populations. We found several items with DIF, which can be explained by individual interpretation or local context. However, the DIFs did not lead to a large difference between the latent variable and the EPICES score, which indicates that it can be used to assess precariousness and social deprivation between contrasted areas.

Individual and neighbourhood socioeconomic inequalities in cognitive impairment: cross-sectional findings from the French CONSTANCES cohort

OBJECTIVES

Despite the recent awareness of the environment impact on brain ageing, the influence of the neighbourhood socioeconomic status on cognitive impairment remains unclear. Here, we investigated the effects of individual and neighbourhood deprivation on cognitive impairment in middle-aged and young-old people.

DESIGN

Cross-sectional study.

SETTINGS

21 Health Screening Centres in the entire French metropolitan territory.

PARTICIPANTS

A total of 44 648 participants (age range: 45 to 69 years) from the French CONSTANCES cohort were included in the analyses.

MAIN OUTCOMES

Associations between the overall cognitive score (based on a standardised battery of cognitive tests administered by neuropsychologists) and individual deprivation (Evaluation of Deprivation and Inequalities in Health Screening Centres; EPICES score) and geographical deprivation (French Deprivation Index; FDep index).

RESULTS

Based on the EPICES score (validated cut-off ≥30.17), 12% of participants were considered to be deprived. After mutual adjustment, individual and geographical deprivation were associated with higher cognitive impairment in a multilevel logistic regression analysis that was also adjusted for sociodemographic, lifestyle and health factors. Specifically, individual deprivation was associated with an odds increase of 55% (OR=1.55, 95% CI: 1.45 to 1.66). The risk of global cognitive impairment progressively increased with the neighbourhood deprivation level, evaluated by the FDep index (reference Q1; Q2: OR=1.09, 95% CI: 0.98 to 1.20; Q3: OR=1.15, 95% CI: 1.04 to 1.27; Q4: OR=1.15, 95% CI: 1.04 to 1.28; Q5: OR=1.25, 95% CI: 1.13 to 1.39).

CONCLUSION

Our results suggest that the neighbourhood socioeconomic deprivation level is associated with cognitive impairment, independently of the individual deprivation level. A better understanding of this association could help to define new prevention strategies to target high-risk residents and high-risk geographical areas in order to reduce social health inequalities.

Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study

Background

The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission.

Methods

The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score.

Results

Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = − 1.85 [95% CI − 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders.

Conclusions

Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients.

Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013

Masticatory Capacity and Mortality: The Preventive and Clinical Investigation Center (IPC) Cohort Study

Poor oral health (OH) has been associated with mortality, but the association between OH components and mortality remains imprecise. The present observational study aimed to investigate if there is an association between oral masticatory efficiency and cardiovascular (CV) mortality in a large French subject cohort. The study was based on a cohort of 85,830 subjects aged between 16 and 94 y at recruitment. The follow-up extended from 2001 to 2014 and the mean follow-up was 8.06 ± 2.73 y. The number of deaths totaled 1,670. Full-mouth examinations were performed. Dental plaque, dental calculus, gingival inflammation, missing teeth, and masticatory units were recorded. Masticatory units represent the number of natural or prosthetic opposing premolars and molar pairs and can be considered an accurate indicator for masticatory efficiency. Causes of death were ascertained from death certificates. Cox regression analyses were used to calculate hazard ratios (HRs). In the fully adjusted model, the number of masticatory units <5 is associated with an HR of 1.72 (95% confidence interval [CI], 1.54 to 1.91) for all-cause mortality, HR of 1.41 (95% CI, 1.01 to 1.99) for CV mortality, HR of 1.76 (95% CI, 1.44 to 2.15) for cancer mortality, and HR of 1.85 (95% CI, 1.55 to 2.20) for non-CV and noncancer mortality. Significant statistical associations with the other oral variables were also found for all-cause mortality, cancer mortality, and non-CV and noncancer mortality in the adjusted models. Our study indicates that after full adjustment, all oral parameters are associated with all-cause, cancer, and non-CV and noncancer mortality. However, the low number of masticatory units is associated with an increased risk of CV mortality. We highlight the association of masticatory units and CV mortality.

Influence Of Socioeconomic Deprivation On Short- And Long-Term Outcomes Of Home-Based Pulmonary Rehabilitation In Patients With Chronic Obstructive Pulmonary Disease

Background

Pulmonary rehabilitation (PR) improves exercise tolerance and quality of life in patients with chronic obstructive pulmonary disease (COPD), regardless of disease severity. Socioeconomic deprivation has been linked to the incidence of COPD; however, little is known about its impact on PR outcomes.

Methods

In this retrospective observational study, 459 COPD patients were enrolled and dichotomized into socially deprived (n=276) and non-socially deprived (n=183) groups based on a cut-off of 30.17 in the EPICES questionnaire (Evaluation of Deprivation and Inequalities in Health Centers), which evaluates socioeconomic disadvantage. The PR program consisted of once-weekly home sessions for 8 weeks, and consisted of an individualized plan of retraining exercises, physical activities, therapeutic education, and psychosocial and motivational support. Exercise tolerance, anxiety and depression, and quality of life were assessed using the 6 min stepper test (6MST), Hospital Anxiety and Depression Scale (HADS), and Visual Simplified Respiratory Questionnaire (VSRQ). Assessments were made before the PR program (baseline) and then at 2 (T2), 8 (T8), and 14 (T14) months after baseline.

Results

Compared with the non-socially deprived group, socially deprived patients were younger, more frequently women, active smokers, and living alone, and belonged to lower socioprofessional categories. At baseline, 6MST, VSRQ, and HADS measures were lower for the socially deprived than the non-socially deprived group. At T2, T8, and T14, there were no significant between-group differences in any outcome, and the percentage of patients showing clinically important improvements was the same in both groups.

Conclusion

Home-based PR is effective for COPD patients in the short and long term, regardless of socioeconomic status.

Hospital-based home care for young children newly diagnosed with type 1 diabetes: Assessing expectations and obstacles in families and general practitioners

AIMS

This study aimed to evaluate whether hospital-based home care was desired by the parents of children diagnosed with type 1 diabetes (T1D) under the age of 5 years and their general practitioners, and to identify the main expectations and obstacles to its implementation.

METHODS

This descriptive bicentric study in France was performed between November 2016 and November 2017. Data were collected by interviewing 57 families of children diagnosed with diabetes before the age of 5 years and the corresponding 30 general practitioners. The primary endpoint was the families' or general practitioners' acceptance of home-based care after diagnosis.

RESULTS

A high proportion of families and physicians (86% and 93%, respectively) expressed a wish for hospital-based home care, most of whom considered it essential (79% and 87%, respectively). Low-income families were less likely to accept this care pathway (P<0.001). The families' expectations regarding home care were help with social care, the management of emergencies, and return to school. The physicians' main request was improved interprofessional collaboration.

CONCLUSION

Hospital-based home care seems to be an acceptable transition after conventional care for children just diagnosed with T1D. Multidisciplinary support, personalized social care, and access to welfare benefits may improve acceptance rates, especially among low-income families.

Impact of fruits and vegetables vouchers on food insecurity in disadvantaged families from a Paris suburb

BACKGROUND

Social inequalities in nutrition lead a high number of families to struggle with food insecurity, even in developed countries. We aimed to assess the impact of fruits and vegetables vouchers on food security among disadvantaged households from a Paris suburb.

METHODS

We used a pre-post assessment design. Families answered face-to-face questionnaires on food consumption and food security status before and after a randomly assigned intervention. Households in the intervention group received vouchers to buy exclusively fruits and vegetables over one year. Both intervention and control groups benefitted from nutritional education through workshops performed by dieticians during the study period. The Household Food Security Module (HFSM) was used to assess food security status of households at inclusion. Food Insufficiency Indicator (FSI) was used to assess food security at inclusion and follow-up. Evolution of FSI on both groups was evaluated using McNemar test.

RESULTS

Among the 91 families included between May 2015 and May 2016, 64 completed the post assessment questionnaire. At inclusion, 68.3% of families were experiencing food insecurity and 78.1% were experiencing food insufficiency. No association was found between food consumptions and food security status. After one-year follow-up, the prevalence of food insufficiency was significantly decreased in the intervention group (61.8%, with p value = 0.03), and unchanged in the control group.

CONCLUSION

In this pilot study, food insufficiency was significantly decreased in families receiving vouchers for fruits and vegetables over a one-year period.

TRIAL REGISTRATION

NCT02461238, registered 3 June 2015 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02461238.

[When proportionate universalism becomes relative: Access to care of self-employed persons]

The policy designed to address social inequalities in health (SIH) currently does not integrate the specificities of self-employed persons, who nevertheless occupy an intermediate position in the mortality gradient observed since the 1990s. Qualitative analysis of the care pathway of precarious people, financed by the French Directorate of health care services (DGOS), despite its limitations, highlights the difficulties encountered by self-employed persons in the use of the health system in its present state and shows the poor perception of these difficulties, due to the limitations of the available evaluation tools of individual precarity, the representations of professional and institutional actors, or the absence of response in the field of social solidarity. Supported by documentary analysis, these observations question the meaning of the concept of equity in terms of social protection measures for this socioeconomic category, the proportionate universalism of the measures taken, and suggest new approaches to globally and more effectively address SIH.

Recruitment of precarious families in an interventional study: Lessons from the French "Fruits and vegetables at home" (FLAM) trial

Background

The FLAM study was set up in order to assess the effectiveness of FV vouchers allowed to low-income households, on their FV consumption. The aim of the present study was to investigate issues associated with conducting interventional trials in disadvantaged populations using the FLAM study as an example of reaching target populations and recruitment difficulties.

Methods

Families were recruited in Saint-Denis city (North Paris suburb), via social and municipal structures. Main interest variables in the study (food consumptions) were collected using face-to-face food interviews, either at home or municipal facilities. A qualitative analysis was performed among people who refused to participate in order to understand the barriers to participation.

Results

A total of 95 parents-child pairs were included from May 2015 to May 2016. The families were mostly in precarious situation (63.3%), and most of parents were unemployed (71.3%). Almost the two third of children and 79.4% of parents were small consumers of FV (less than 3.5 servings per day). Several reasons for non-participation were reported including time constraints, understanding and mistrust issues.

Conclusions

Though using facilitating strategies, we recruited fewer participants than expected. The population finally included was mainly made of precarious families with a low consumption of FV. These results highlight the importance of identifying effective facilitating strategies to improve recruitment in disadvantaged populations.

Trial registration

ClinicalTrial.gov no. NCT02461238, on June 3, 2015, retrospectively registered.

Factors associated with social deprivation among older persons living with HIV

Aging persons living with HIV may develop multiple health problems, including comorbidities, and altered physical and mental health, earlier than non-infected people. They may also experience social deprivation. We assessed the prevalence of social deprivation and its relationship with health indicators in older persons living with HIV. An 18-month, multicenter, cross-sectional study was carried out between 2013 and 2014 focusing on patients ≥50-years of age followed-up in 12 dedicated HIV medical hospital units located in the South of France and involved the VISAGE study group. Social deprivation was measured with the EPICES (Evaluation of Deprivation and Inequalities in Health Examination Centers) score (ES) and defined as ES ≥30.17. The following data were recorded: health indicators (gender, age, body mass index), comorbidities, frailty markers, socioeconomic, behavioral and age-related variables. Among 509 patients recruited, 494 completed the ES social deprivation evaluation. Mean age was 58.5 ± 7.0 years and 72.9% were male. The prevalence of social deprivation was 49.0%. Multivariable logistic regression analysis showed that higher social deprivation was significantly linked to alcohol consumption (OR = 4.07 [95%CI: 1.23-13.48]), risk of depression (OR = 3.59 [95%CI: 2.26-5.70]), chronic obstructive pulmonary disease (OR = 3.10 [95%CI: 1.36-7.09]), hepatitis C (OR = 1.96 [95%CI: 1.10-3.52]), and chronic pain (OR = 1.11 [95%CI: 1.01-1.21]). Social deprivation was not related to HIV status. Our study showed that not only did older patients with HIV suffer from social deprivation, but they also received little support from social workers. Physicians should be aware of this situation and should systematically evaluate social deprivation in order to provide comprehensive targeted care involving global, social, and psychological support to reduce the burden of social deprivation.

Relationship between Tobacco Craving and Quality of Life among French Students: Results of a Cross-Sectional Study

BACKGROUND

Understanding the factors leading to smoking cessation is of primary importance in reducing the death burden. Recently introduced in the DSM-5, craving is a potentially promising mechanism involved in relapse, but its articulation with quality of life and deprivation on tobacco student's consumers has never been investigated.

OBJECTIVES

Our study explores the relationship between tobacco craving and sub-dimensions of quality of life when controlling effect of deprivation on a youth population with tobacco consumption.

METHOD

Comparison between deprived and non-deprived students were conducted with online questionnaires on demographic data, level of dependency, perceived quality of life, deprivation and craving. Multivariate linear regression with backward procedure was conducted to assess the predictive validity of these variables on craving. Finally, Bayesian analysis was conducted to evaluate the model proposed by the regression.

RESULTS

One hundred and seventy-four participants were included. Craving was significantly correlated with all the other variables and increases when the level of deprivation rises, while it decreases when physical health improves. These results are confirmed by Bayesian linear regression. Conclusions/Importance: Environmental and social factors are usually overlooked when it comes to understanding individuals, deeply rooted biological mechanisms such as craving. Working on physical health is of interest to diminished craving and improves the quality of life during smoking cessation and thereby to support success on the student population. Consequences for the triadic neurocognitive model of addiction are discussed.

Disruption in time projection and non-adherence to long-term therapies

OBJECTIVE

Patients' non-adherence to medical prescriptions is a crucial issue in contemporary medicine because it can jeopardize care efficacy. Non-adherence is especially frequent in patients with chronic diseases. In this article, we propose that a particular condition, which we call disruption in time projection, is a cause of non-adherence to medication therapies in chronic diseases.

METHODS

A questionnaire was administered to 120 hospitalized people with type 2 diabetes addressing three psychological constructs defining time projection: patience/impatience in a fictive monetary scenario (preferring to receive €1,500 in 1 year or €500 today), magnitude of temporal horizon (greater or lesser ability to imagine future events) and perception of the degree of physical similarity of current self to self at 1 year, 5 years and 10 years from the present. In addition, the questionnaire evaluated adherence to medication, social deprivation and depression.

RESULTS

In the multivariate analyses, two factors were associated with adherence to medication: patience (P<0.001) and long temporal horizon (P=0.006). Two factors were associated with HbA1c ≥8% (64 mmol/mol): non-adherence to medication (P=0.003) and short temporal horizon (P=0.011). Three factors were associated with long temporal horizon: adherence to medication (P<0.001), patience (P<0.001) and the existence of grandchildren (P=0.002). Social deprivation (P<0.001), non-adherence (P<0.001), female gender (P=0.002) and short temporal horizon (P=0.050) were associated with impatience. Finally, an association of adherence to expected similarity in the future to current self, impatience, short temporal horizon, social deprivation and depression was also shown in a multiple correspondence analysis.

CONCLUSION

What we termed a disruption in time projection may be a unique determinant for non-adherence to long-term therapy and, therefore, may influence the outcome of chronic diseases. We hypothesize that this is involved in both intentional and unintentional non-adherence and that it represents the loss of a protective mechanism. If this novel concept is to be confirmed in other settings and generalized to other chronic diseases, the recognition of its role in disease prognosis may help orient the teaching and practice of medicine.

Association between individual and neighbourhood socioeconomic factors and masticatory efficiency: a cross-sectional analysis of the Paris Prospective Study 3

Background

There is a lack of evidence on the impact of socioeconomic factors on masticatory efficiency. The present study investigates the relationship between individual and neighbourhood socioeconomic factors (main exposure) and the number of masticatory units (MUs) used as surrogate of the masticatory efficiency (main outcome).

Methods

In this cross-sectional study nested in the Paris Prospective Study 3, 4270 adults aged 50–75 and recruited from 13 June 2008 to 31 May 2012 underwent a full-mouth examination. Number of MUs defined as pairs of opposing teeth or dental prostheses allowing mastication, number of missing teeth and gingival inflammation were documented. The individual component of the socioeconomic status was evaluated with an individual multidimensional deprivation score and education level. The neighbourhood component of the socioeconomic status was evaluated with the FDep99 deprivation index. Associations were quantified using marginal models.

Results

In multivariate analyses, having less than 5 MUs was associated with (1) the most deprived neighbourhoods (OR=2.27 (95% CI 1.63 to 3.17)), (2) less than 12 years of educational attainment (OR=2.20 (95% CI 1.66 to 2.92)) and (3) the highest individual score of deprivation (OR=3.23 (95% CI 2.24 to 4.65)). Associations with education and individual score of deprivation were consistent across the level of neighbourhood deprivation. Comparable associations were observed with the number of missing teeth. Associations with gingival inflammation were of lower magnitude; the relationship was present for deprivation markers but not for education.

Conclusion

Poor masticatory efficiency is associated with low educational attainment and high deprivation scores.

[Socioeconomic inequalities and kidney transplantation]

Studies at the population level must take into account the effect of social insecurity and socioeconomic inequalities on the patient outcomes. Socioeconomic inequalities depend on many determinants that are socially determined. In renal transplantation, these social determinants are not registered in the databases. The European Deprivation Index (EDI) is a composite index of social vulnerability with a French version. The EDI is an ecological measure of deprivation including the individual perception of basic needs for daily life that is called "subjective poverty". The Townsend index, Carstairs index and the Index of Multiple Deprivation are other ecological index available. It has been demonstrated in the United States that socioeconomic indicators of deprivation were associated with both the access to the waiting list for renal transplantation and transplantation failure. In France, socioeconomic deprivation may also affect the access to the waiting list and outcome of transplantation. This article is a review about deprivation and renal transplantation.

Inpatient satisfaction with medical information received from caregivers: an observational study on the effect of social deprivation

BACKGROUND

The main objective of this study was to explore the relationships between inpatients' social differentiation and satisfaction with the medical information delivered by caregivers.

METHODS

In four departments of a teaching hospital, patients were enrolled as well as their attending physician and one of the nurses assigned to them. Structured survey questionnaires were administered face-to-face to patients and caregivers. Patients were asked to rate their satisfaction with the medical information received, the quality and duration of the interactions with the caregivers, and their experience regarding their involvement in medical decision-making. Caregivers were asked to rate their perception of the patients' social position and involvement in medical decision-making. Social deprivation was assessed using the EPICES score in particular. The statistical analysis was mainly descriptive and completed by a structural equation model.

RESULTS

A sample of 255 patients, 221 pairs of patient-physician and 235 pairs of patient-nurse were considered. One third of the patients (32.7%) were identified as socially deprived. They were significantly less satisfied with the information they received on their health status or their treatment; 56.7% of patients thought that they received sufficient explanations without having to ask. This proportion was significantly lower in socially deprived patients (42.3%) compared to not deprived patients (63.6%, p < 0.01). Patients' reported involvement in medical decision-making was significantly lower for socially deprived patients (75.0% vs 89.0%, p < 0.001). The structural equation model showed that the main determinant of patients' satisfaction regarding medical information was their perceived involvement in informed medical decision-making (CFI = 0.998, RMSEA = 0.022).

CONCLUSIONS

These findings suggest that physicians and nurses need training on communication targeted towards vulnerable patients, in order to improve the accessibility of medical information, and thus to reduce health inequalities.

Lifestyle intervention program in deprived obese adult patients and their non-deprived counterparts

INTRODUCTION

Although it is known that the prevalence of obesity is high in deprived patients, the link between deprivation and obesity, and the impact of deprivation on compliance and efficacy of a lifestyle intervention program are not known.

MATERIALS AND METHODS

Deprivation was assessed in 40 patients (23 Females, mean±SD age: 49±17 years) from the diabetology department and 140 patients (101 Females, age: 50±15 years) from the nutrition department of Bordeaux University hospital. Eighty-seven patients suffering from obesity were evaluated before and after a tailored, multidisciplinary lifestyle intervention. Deprivation was assessed using EPICES scores. Deprivation was defined with an EPICES score > 30.

RESULTS

Deprived patients suffering from obesity had significantly higher current (43.8 ±8.4 versus 40.9 ± 5.5 kg/m2, p = 0,02) and maximal BMI (46.1± 8.6 versus 42.3± 5.2 kg/m2, p = 0.002) compared to non-deprived obese. Percentage of body weight loss was not different according to deprivation (4.74 ± 0.75 versus 4.65 ± 1.04%, p = 0.9). EPICES scores were not different according to adherence to lifestyle intervention program (20.5 ± 8.5 versus 29.9 ± 3.9 versus 29.0 ±2.5, no follow up versus partial follow up versus total follow up, p = 0,58).

CONCLUSION

Deprived patients suffering from obesity have a more serious disease than non-deprived patients. However, neither compliance to the lifestyle intervention program nor body weight loss differed between deprived patients with obesity and non-deprived ones. Deprivation should not be a limitation when enrolling patients with obesity in lifestyle intervention programs.

Psychosocioeconomic Precariousness, Cognitive Decline and Risk of Developing Dementia: A 25-Year Study

BACKGROUND

This study investigates the relationship between psychosocioeconomic precariousness, cognitive decline and risk of developing dementia.

METHODS

The sample consisted of 3,710 subjects aged ≥65 years. Psychosocioeconomic precariousness was assessed with a ratio consisting of 8 self-reported items of poor socioeconomic status and psychosocial vulnerability.

RESULTS

Participants who were considered as precarious (n = 1,444) presented greater cognitive decline (β = -0.07; p = 0.0067) after adjusting for various confounders. They also had a 36% increased risk of developing dementia (hazard ratio 1.36, 95% confidence interval 1.17-1.57; p < 0.0001) over the 25-year follow-up period.

CONCLUSION

Psychosocioeconomic precariousness is associated with greater cognitive decline and increased risk of developing dementia. This relationship can be explained in light of the concept of cognitive reserve and strengthens the need to consider psychosocioeconomic precariousness of elderly individuals in the definition of successful ageing policies.

The presence of cardiovascular disease does not modify the weak impact obesity has on health-related quality of life in patients with hip osteoarthritis in the KHOALA cohort

OBJECTIVE

In people with hip osteoarthritis (OA), the impact of obesity on health-related quality of life (HRQoL) remains unknown. Also whether cardiovascular conditions can modify the obesity-HRQoL relation has not been explored. We aimed to (1) study the cross-sectional relationship between body mass index (BMI) and HRQoL in symptomatic hip OA patients and determine whether cardiovascular comorbidity modifies this relationship and (2) examine the impact of BMI on the course of HRQoL over time.

METHODS

We used data from the first 3 years of follow-up from the KHOALA study, which recruited patients from 2007 to 2009. HRQoL was assessed by the SF-36 and OAKHQOL questionnaires at baseline and during follow-up. We determined BMI and presence of cardiovascular disease by the Groll score. Associated factors at baseline and predictors of HRQoL over time were evaluated by multiple linear regression.

RESULTS

For 222 hip OA patients included, mean (SD) BMI was 26.9 (4.4) kg/m²; 37 (17.1%) had at least one cardiovascular comorbidity. Increased BMI but not presence of cardiovascular comorbidity was associated with poor HRQoL. Increased BMI affected mainly physical and social HRQoL dimensions (up to -1.0 points, 95% CI [-1.6;-0.4]; P=0.002). The BMI-HRQoL relationship was not modified by the presence of cardiovascular disease. BMI was not associated with the course of HRQoL.

CONCLUSION

In patients with hip OA, BMI had an independent weak negative impact on HRQoL that was not modified by cardiovascular comorbidities. Neither of these factors affected HRQoL change during a 3-year follow-up.

Migrant adults with diabetes in France: Influence of family migration

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There is a high prevalence of poorly controlled diabetes in migrants.

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Family gathering is associated with a better control of diabetes.

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Exploration of migration’ story is important in the health care process.

Aim

To explore the influence of migration and this parameters on the control of diabetes.

Methods

A cohort of migrant patients with type 2 diabetes was recruited in a center affiliated to the French national insurance system situated in a department with important migratory phenomenon. Patients fulfilled a questionnaire about diabetes, their migration history, and the EPICES score (deprivation score). We have explored by univariate and multivariate analysis if any of the characteristics of migration could be related to the control of diabetes. This cohort was compared to a non-migrant control group of age and sex-matched patients.

Results

We included 72 patients, 36 women and 36 men from 20 different countries. The mean age was 57.7 ± 9.6 years. A migration for family reunification was associated with better diabetes equilibrium (Risk of having an HbA1c ⩾8% (63.9 mmol/mol): OR 0.07 (95% IC [0.005–0.86], p = 0.04). The migrant patients who wished to share their time between France and country of origin during their retirement had a better glycaemic control than the migrant patients who would like to go alone into their country (OR 0.08 [0.01–0.78], p = 0.03). Compared to the non migrant group, the EPICES score was higher in the migrant group (52.8 vs. 28.3, p < 0.05), HbA1c was also higher in the migrant group (8.4 vs. 6.7% (68 vs. 50 mmol/mol)).

Conclusions

We may fear that migrants share an increased risk of uncontrolled diabetes. Individual migration could be a risk factor of uncontrolled diabetes. Knowing the migration history of migrant patients is fundamental to understand some barriers of care.

Improving access and continuity of care for homeless people: how could general practitioners effectively contribute? Results from a mixed study

OBJECTIVES

To analyse the views of general practitioners (GPs) about how they can provide care to homeless people (HP) and to explore which measures could influence their views.

DESIGN

Mixed-methods design (qualitative -> quantitative (cross-sectional observational) → qualitative). Qualitative data were collected through semistructured interviews and through questionnaires with closed questions. Quantitative data were analysed with descriptive statistical analyses on SPPS; a content analysis was applied on qualitative data.

SETTING

Primary care; views of urban GPs working in a deprived area in Marseille were explored by questionnaires and/or semistructured interview.

PARTICIPANTS

19 GPs involved in HP's healthcare were recruited for phase 1 (qualitative); for phase 2 (quantitative), 150 GPs who provide routine healthcare ('standard' GPs) were randomised, 144 met the inclusion criteria and 105 responded to the questionnaire; for phase 3 (qualitative), data were explored on 14 'standard' GPs.

RESULTS

In the quantitative phase, 79% of the 105 GPs already treated HP. Most of the difficulties they encountered while treating HP concerned social matters (mean level of perceived difficulties=3.95/5, IC 95 (3.74 to 4.17)), lack of medical information (mn=3.78/5, IC 95 (3.55 to 4.01)) patient's compliance (mn=3.67/5, IC 95 (3.45 to 3.89)), loneliness in practice (mn=3.45/5, IC 95 (3.18 to 3.72)) and time required for the doctor (mn=3.25, IC 95 (3 to 3.5)). From qualitative analysis we understood that maintaining a stable follow-up was a major condition for GPs to contribute effectively to the care of HP. Acting on health system organisation, developing a medical and psychosocial approach with closer relation with social workers and enhancing the collaboration between tailored and non-tailored programmes were also other key answers.

CONCLUSIONS

If we adapt the conditions of GPs practice, they could contribute to the improvement of HP's health. These results will enable the construction of a new model of primary care organisation aiming to improve access to healthcare for HP.