Depression and loneliness among Sub-Saharan immigrants living in the greater Paris area: results from the MAKASI empowerment stepped wedge cluster randomised controlled trial

PURPOSE

The MAKASI intervention aimed to empower Sub-Saharan African immigrants living in precarious situations in the Paris metropolitan area. Because there are factors specifically related to immigration that may increase the risk for common mental disorders, the present study aimed to examine participants' levels of depression and loneliness and analyze the effect of the intervention on depression and loneliness.

METHODS

The MAKASI study was designed as a stepped wedge cluster randomized trial. Study participants were recruited through an outreach program led by a nongovernmental organization and randomly assigned to two clusters, with an intervention delay of 3 months between them. Participants were assessed for 6 months after inclusion and the effect of the intervention on depression and loneliness was assessed using generalized linear mixed models. The study was conducted from 2018 to 2021 and took in consideration whether being interviewed during one of the Covid-19 confinement had an effect on the results.

RESULTS

Between 2018 and 2021 a total of 821 subjects participated in the Makasi study. High levels of depression and loneliness were found in the study population. We found no effect of the intervention on depression [95% CI 0.77 to 2.40]. Similarly, no effect of the intervention was found on loneliness [95% CI 0.87 to 2.54].

CONCLUSIONS

The intervention tested did not appear to improve the level of depression and loneliness among participants. However, the high prevalence of mental and emotional problems in the study population suggests a public health crisis among immigrants in the greater Paris area.

CLINICAL TRIAL REGISTRATION NUMBER

 Trial registration Clinicaltrials.gov, NCT04468724 (July 13, 2020).

Immigrants' health empowerment and access to health coverage in France: A stepped wedge randomised controlled trial

Throughout Europe, migration-related health inequalities are mirrored by large inequalities in health coverage. There is a need to develop novel strategies to secure access to health insurance for immigrants in Europe, in order to meet the shared Sustainable Development Goal of universal health coverage. We evaluated the impact of an original health-related empowerment intervention on access to health coverage among vulnerable, mostly undocumented immigrants in France. As part of the MAKASI study, we adopted an outreach approach and developed a community-based intervention with and for immigrants from sub-Saharan Africa living in precarious conditions in the Greater Paris area. This participatory intervention was grounded in the theory of individual empowerment. Using a stepped wedge randomised design, we first conducted a robust evaluation of the effect of the intervention on access to health coverage at three and six months post-intervention. We then investigated whether the intervention effect was mediated by a health empowerment process. Between 2018 and 2021, a total of 821 participants - 77% of whom were men - were recruited in public spaces and followed up for six months. Participants had been living in France for four years on average, 75% of them had no residence permit, and 44% had no health coverage at the time of inclusion. The probability of accessing health coverage increased by 29 percentage points at six months post-intervention (p < 0.01). This improvement was partially mediated by a health empowerment process, namely a reinforcement of participants' knowledge of and capacity to access available social and health resources. A health empowerment intervention largely improved access to health insurance among vulnerable immigrants in France. Our findings may be transferred to other settings where immigrants are entitled to health insurance. This study offers promising perspectives - beyond information provision and direct referral - to reduce migration-related inequalities in health coverage.

Bridging the knowledge gap of biomedical HIV prevention tools among sub-saharan african immigrants in France. Results from an empowerment-based intervention

INTRODUCTION

Biomedical HIV prevention tools are available in France to prevent new infections. However, evidence suggests a lack of knowledge of these tools among sub-Saharan African immigrants, who are particularly affected by HIV due to social hardship, an indirect factor of HIV acquisition. We analysed the impact of an empowerment-based intervention on the knowledge of treatment as prevention (TasP), pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) in a population of precarious sub-Saharan African immigrants.

METHODS

Data were collected throughout the MAKASI project. Following an outreach approach, participants were recruited in public places based on their precarious situations and followed for six months (0, 3, 6 months) between 2018 and 2021. Participants were randomized into two groups and received an empowerment intervention sequentially (stepped wedge design). We used random-effects logistic regression models to evaluate the intervention effect on the knowledge of biomedical HIV prevention tools. ClinicalTrials.gov Identifier: NCT04468724.

RESULTS

The majority of the participants were men (77.5%), and almost half of them had arrived in France within 2 years prior to inclusion (49.3%). At baseline, 56% of participants knew about TasP, 6% knew about PEP and 4% knew about PrEP. Receiving the intervention increased the odds of knowing about PEP (aOR = 2.02 [1.09-3.75]; p < 0.026). Intervention effects were observed for TasP and PrEP only after 6 months. We found significant time effects for PEP (at 3 months, aOR = 4.26 [2.33-7.80]; p < 0.001; at 6 months, aOR = 18.28 [7.39-45.24]; p < 0.001) and PrEP (at 3 months, aOR = 4.02 [2.10-7.72]; p < 0.001; at 6 months, aOR = 28.33 [11.16-71.91]; p < 0.001).

CONCLUSIONS

We showed that the intervention increased the knowledge of biomedical HIV prevention tools. The effect of the intervention was coupled with an important time effect. This suggested that exposure to the intervention together with other sources of information contributed to increased knowledge of biomedical HIV prevention tools among precarious sub-Saharan African immigrants.

Low knowledge of antiretroviral treatments for the prevention of HIV among precarious immigrants from sub-Saharan Africa living in the greater Paris area: Results from the Makasi project

INTRODUCTION

In France, combination prevention tools, particularly antiretroviral treatment for HIV prevention has been available for several years. We described the knowledge of these antiretroviral treatments among immigrants from sub-Saharan Africa, who are particularly affected by HIV, and the factors associated with this knowledge.

METHODS

The data come from the Makasi study, which was conducted between 2019 and 2020 among precarious immigrants from sub-Saharan Africa recruited through a community-based outreach approach in the greater Paris area (n = 601). We described levels of knowledge of HIV treatment effectiveness (HTE), treatment as prevention (TasP), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP), by sex with chi2 test. We investigated factors associated with their knowledge with logistic regressions adjusted for sociodemographic characteristics, living conditions and sexual behaviors (p≤0.2).

RESULTS

Respondents were mostly men (76%), from West Africa (61%), in precarious situation: 69% were unemployed, 74% were undocumented and 46% had no health coverage. Among this population, knowledge of HIV preventive treatments was heterogeneous. While HTE was well known (84%); TasP was known by only half of the respondents (46%), and PEP and PrEP were hardly known: 6% and 5%, respectively. Multivariate regressions models showed that these antiretroviral treatments for the prevention of HIV was better known by people with a higher level of education (PEP: aOR = 3.33 [1.09-10.20], p = 0.03; HTE: aOR = 4.33 [1.87-10.04], p<0.001), those who had a social network in France (TasP: aOR = 1.90, [1.33-2.73], p<0.001), those who had access to the health system and those who were exposed to sexual risks (TasP: aOR = 3.17, [1.03-9.69], p = 0.04; PrEP: aOR = 2.60 [0.72-9.34], p = 0.14).

CONCLUSIONS

There is a need for specific communication on antiretroviral treatment for HIV prevention that targets sub-Saharan immigrants, particularly those who have no access to the health-care system and those who are less educated.

Knowledge of HIV prevention biomedical tools among African immigrants in France: the Makasi project

Background

In France, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) have been available for several years. However, there is still no evidence on the level of knowledge of these HIV prevention tools among immigrants from sub-Saharan Africa living in precarious situations, a population particularly affected by HIV. The aim of this study is to describe the knowledge of these tools in this population and analyse the factors associated with this knowledge.

Methods

The data mobilized are from the Makasi interventional research that was conducted between 2018 and 2020 among immigrants from sub-Saharan Africa in precarious situations in the greater Paris area. Using data collected from 601 participants, we described levels of knowledge of HIV treatment effectiveness, treatment as prevention (TasP), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP), by sex with a chi2 test. We investigated factors associated with their knowledge with logistic regressions adjusted for sociodemographic characteristics, living conditions and sexual behaviors (p ≤ 0.2).

Results

The population surveyed was predominantly men (76%), from West Africa (61%) and in a precarious situation: 69% were unemployed, 74% were undocumented, 46% had no health coverage and 13% were homeless. In this population, knowledge of antiretroviral treatments for HIV prevention was heterogeneous: the effectiveness of HIV treatment was well known (84%), but only half of the respondents (46%) were aware of TasP and very few knew about PEP and PrEP: 6% and 5% respectively. Multivariable-adjusted models showed that these tools was better known by educated people, those who had a social network in France, those who have had access to the health system and those who were exposed to sexual risks.

Conclusions

While sub-Saharan African immigrants know the effectiveness of HIV treatment and use certain prevention tools such as HIV testing, they are not aware of PEP and PrEP.

Key messages

Health empowerment and access to health coverage among immigrants in France: the Makasi intervention

Background

The Makasi community-based research project offered an innovative health-related empowerment intervention to immigrants from sub-Saharan Africa living in precarious situations in the greater Paris area, to reduce their social vulnerability and their exposure to HIV. Our objective is to evaluate the impact of the intervention on access to health coverage in this population.

Methods

Participants were recruited based on precariousness criteria in public places in Ile-de-France (squares, railway stations, markets, etc.) by mobile teams of social workers and health mediators. Following a stepped-wedge design, participants were randomised into two groups receiving the intervention sequentially (immediately in one group and 3 months later in the other). We evaluated the impact of the Makasi intervention on access to health coverage among 821 individuals observed at 0, 3, and 6 months, between 2018 and 2021. We implemented random-effects panel models - allowing for unobserved heterogeneity - using a Heckman selection approach to correct for attrition. Finally, we used seemingly unrelated regressions (SUR) to examine the extent to which the effect of the intervention was mediated by health-related empowerment.

Results

Participants - 77% of which were men - had been living in France for 4 years on average. 44% of them had no health coverage at the time of inclusion. Our results provided evidence for a significant impact of the Makasi intervention on participants’ access to health coverage, with an 18 percentage-point increase in the probability of accessing health coverage 6 months after having received the intervention (p &lt; 0.01). The mediation analysis revealed that this effect operated partly through an empowerment process in terms of knowledge of social and health resources.

Conclusions

We showed that a health empowerment intervention provided by social workers and health mediators largely favours access to health rights for immigrants in precarious situations.

Key messages

• A health empowerment intervention improved access to health coverage among immigrants from sub-Saharan Africa living in precarious situations in France.

• Improvement in access to health coverage was found to be partly mediated by reinforcement of participants’ health literacy in terms of social and health resources.

Is empowerment in sexual health measurable? A scoping review of definitions and measurement indicators

The concept of empowerment in sexual health is widely used in health promotion. This scoping review aims to identify how it is defined and measured. PubMed, Sage Journals, PsycInfo and the Web of Science are data sources. The inclusion criteria for studies were as follows: (1) an analysis of empowerment in sexual health, (2) quantitative evaluation and (3) publication in a peer-reviewed journal in French or English since January 1996. Data were extracted using a summary table of the definitions and indicators of empowerment in sexual health. Of the 2181 articles found, 29 met the inclusion criteria. Only 4 studies on 29 clearly defined empowerment in sexual health. Five dimensions emerged from the indicators used in the 29 studies in relation to sexual empowerment (social participation, participation in decision making, power to act, sexual health knowledge and gender norms), with two types of indicators: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Most studies concerned women and focused on individual empowerment, with a lack of measure of collective and structural levels of empowerment. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. This set could be systematically used in each study based on sexual empowerment concept, completed by supplementary indicators considering the specific context.

Non-participation to a longitudinal and interventional survey on the psychological impact of the COVID-19 pandemic among healthcare workers (PSYCOVER) in France

Introduction

We conducted a national longitudinal survey among healthcare workers in the context of the Covid-19 pandemic, (1) to assess mental health and (2) to describe the results of an intervention to improve capacity of resilience. Non-participation is rarely studied despite being an important methodological matter when performing studies on mental health.

Objectives

The study aims to describe and identify the factors associated with non-participation of healthcare workers to the intervention part of a national longitudinal study on the psychological impact of the COVID-19 pandemic.

Methods

Participants were recruited from April to October 2021 via an Internet link widely disseminated. Data collected include participant’ socio-demographic, occupational and working conditions, general health, professional burnout and mental health. The intervention proposed the use of tools for self-management of stress and resilience (PsySTART-Responder® and Anticipate.Plan.Deter™ program). A robust Poisson regression was used to identify factors associated with non-participation.

Results

Among 724 participants, 41% participated to the intervention part. Factors associated to non-participation to the intervention were to work with few or no COVID-19 patients, and low scores in the anxiety scale. Social determinants, occupational characteristics or general health were not associated with non-participation.

Conclusions

Our study provides a better understanding of the participation of healthcare workers that was not frequently studied. The results logically suggest lower participation among those with better mental health and not directly concerned with management of COVID-19 patients. Non-participation to the intervention was not associated with social factors, which is an argument in favour of using such a design/intervention in a socially heterogeneous population.

Disclosure

No significant relationships.

Trends in social exposure to SARS-Cov-2 in France. Evidence from the national socio-epidemiological cohort–EPICOV

Background

We aimed to study whether social patterns of exposure to SARS-CoV-2 infection changed in France throughout the year 2020, in light to the easing of social contact restrictions.

Methods

A population-based cohort of individuals aged 15 years or over was randomly selected from the national tax register to collect socio-economic data, migration history, and living conditions in May and November 2020. Home self-sampling on dried blood was proposed to a 10% random subsample in May and to all in November. A positive anti-SARS-CoV-2 ELISA IgG result against the virus spike protein (ELISA-S) was the primary outcome. The design, including sampling and post-stratification weights, was taken into account in univariate and multivariate analyses.

Results

Of the 134,391 participants in May, 107,759 completed the second questionnaire in November, and respectively 12,114 and 63,524 were tested. The national ELISA-S seroprevalence was 4.5% [95%CI: 4.0%-5.1%] in May and 6.2% [5.9%-6.6%] in November. It increased markedly in 18-24-year-old population from 4.8% to 10.0%, and among second-generation immigrants from outside Europe from 5.9% to 14.4%. This group remained strongly associated with seropositivity in November, after controlling for any contextual or individual variables, with an adjusted OR of 2.1 [1.7–2.7], compared to the majority population. In both periods, seroprevalence remained higher in healthcare professions than in other occupations.

Conclusion

The risk of Covid-19 infection increased among young people and second-generation migrants between the first and second epidemic waves, in a context of less strict social restrictions, which seems to have reinforced territorialized socialization among peers.

Higher risk, higher protection. COVID-19 risk among immigrants in France: results from the population-based EpiCov survey

Background

Immigrants and ethnic/racialized minorities have been identified as being at higher risk of coronavirus disease-19 (COVID-19) infection, but few studies report on their exposures and prevention behaviours. This study aims to examine the social distribution of COVID-19 exposure (overcrowding, working outside the home, use of public transport to go to work) and prevention behaviours (use of face masks, washing hands, respect for physical distance) in France during the first wave of the epidemic.

Methods

We used the EpiCov population-based survey from a random sample of individuals aged 15 years or more. We determined the distribution of the self-reported outcomes according to migratory status and sex, using χ² tests. We modelled the probability of outcomes with logistic regression. Finally, we focused the analysis on the Greater Paris area and accounted for neighbourhood characteristics.

Results

A total of 111 824 participants were included in the study. Overall, immigrant groups from non-European countries were more exposed to COVID-19-related factors and more respectful of prevention measures. The probability of overcrowding and the use of public transport was higher for immigrants from sub-Saharan Africa [adjusted odds ratio (aOR) = 3.71 (3.19; 4.32), aOR = 6.36 (4.86; 8.32)] than for the majority population. Immigrant groups were less likely to have a non-systematic use of face masks and to breach physical distancing than the majority population [for immigrants from sub-Saharan Africa, aOR = 0.32 (0.28; 0.37) and aOR = 0.71 (0.61; 0.81), respectively]. Living in a neighbourhood with a higher share of immigrants was associated with higher exposure and better prevention behaviours.

Conclusions

In France, immigrants had a higher exposure to COVID-19-related factors and more systematic prevention behaviours.

Longitudinal survey on the Psychological Impact of the COVID-19 Pandemic in Healthcare Workers (PsyCOVer) in France: study protocol

INTRODUCTION

In the pandemic, healthcare professionals face even higher levels of stress. It is therefore a priority to estimate the impact of the pandemic on mental health and to propose targeted strategies to improve resilience. The aims of the study were to (1) assess the mental health of healthcare professionals working with patients with COVID-19 and identify social determinants that may increase the risk of negative outcomes; and (2) test the effectiveness of an intervention to improve the resilience of healthcare professionals in France.

METHODS AND ANALYSIS

To evaluate the first objective, a national longitudinal study will be carried out among healthcare professionals working with patients with COVID-19. Participants will be recruited via an internet link that will be widely disseminated on social media, mailing lists, medical boards and French medical journals. Primary outcomes are mental health distress/symptoms and resilience. Secondary outcomes are burnout, social and occupational supports and substance use. To meet the second objective, an interventional study will be conducted. The main outcome is the effectiveness of the PsySTART-Responder and the Anticipate.Plan.Deter program. Qualitative analyses will be conducted to understand the strategies used to cope with the pandemic.

ETHICS AND DISSEMINATION

The study protocol was approved by the Sorbonne Université Ethical Committee (No 2020-CER-2020-27) and was declared to French Commission on Information Technology and Liberties, CNIL (N°2222413, 20-05-2021). The results of this study will provide a better understanding of mental health and social inequalities in mental health among healthcare professionals working in the pandemic; data about the effectiveness of the PsySTART-Responder and the Anticipate.Plan.Deter interventional program in France.

Increased risk of job strain and mental health among first and second-generation migrants in France

Background

Immigrants often have more difficult working conditions than natives in Europe, which could particularly expose them to psychosocial work factors and participate to a deteriorated mental health. This study aims to 1) describe the prevalence of job strain across origin and its determinants in France 2) verify whether the association between job strain and mental health hold across all population groups.

Methods

We used the national Conditions de travail-Risques Psychosociaux 2016 survey (N = 24, 640) which is representative of the active population in France. Mental health was measured by Generalized Anxiety Disorder (GAD-Mini). Among employed persons, we described the prevalence of job strain according to migratory status and by sex. Then we modelled the probability to be exposed to job strain with Poisson regressions. Finally we modelled the probability to have a Generalised Anxiety Disorder in each group of population with Poisson regressions.

Results

The prevalence of job strain was 44% among first-generation immigrants from Africa and 50% among second-generation immigrants (not EU, not Africa) vs 32% in the non-immigrant population, p &lt; 0.0001)., with differentiated gender patterns. After adjustment on sociodemographic and occupational characteristics, women were more likely to be exposed to jobstrain [aIRR=1,30 [1,24;1,37]] as well as second-generation immigrants from Africa (aIRR=1,10 [1,00;1,21]). Job strain was associated with Generalised Anxiety Disorder in all groups of population.

Conclusions

Immigrants are more exposed to job strain in France and more research is needed to understand this increased risk. Additionally, job strain was associated with anxiety in all immigrant groups and could contribute to immigrants' deteriorated mental health.

Key messages

First and second generation immigrants are more exposed to job strain than non-immigrants in France. This increased risk is only partially explained by the type of jobs they hold.

Prevalence of psychosocial risks among immigrants in France and associations with mental health: findings from the national French Working Conditions Survey

PURPOSE

Few studies examined psychosocial risks among immigrants and explored their association with mental health. Our study aims to 1) describe the prevalence of job strain and iso-strain according to migratory status and model the probability of exposure, 2) verify whether the association between job strain, iso strain and anxiety holds for all immigrant groups.

METHODS

We used the nationally-representative cross-sectional French Working Conditions Survey (N = 24 640). Anxiety was measured with the GAD-Mini. We described the prevalence of job strain and iso-strain according to migratory status and sex. We used multivariate Poisson regressions to model the probability to be exposed to job strain and iso-strain. We described the prevalence of anxiety according to migratory status and sex. In each immigrant group, we modelled the probability of anxiety according to sociodemographic characteristics, lifetime suicidal attempt and job strain/iso-train.

RESULTS

Overall, there were important variations in psychosocial risks prevalence, with immigrants groups more exposed than majority population. After adjustment, being first-generation immigrant from Africa remained associated with job strain (aIRR = 1.21 [0.99; 1.47]), and being second-generation immigrant from Africa with iso-strain (aIRR = 1.33 [1.05; 1.69]). The prevalence of anxiety was the highest in second-generation immigrants from Africa (12%). In this population, job strain and iso-strain were associated with anxiety (aIRR job strain = 2.70[1.22;6.01]; aIRR iso-strain 4.26 [2.29;7.92]).

CONCLUSION

Our study provides first estimates of psychosocial risks among first and second-generation immigrants in France and shows that immigrants are particularly exposed to job strain and iso-strain, which could contribute significantly to their mental health.

Were immigrants on the frontline during the lockdown? Evidence from France

In France, immigrants' excess of mortality was higher than natives' during the Spring 2020 lockdown. Were immigrants in frontline jobs and more exposed to Covid-19? Based on a nationally representative survey, we model the probability to work in a frontline job according to migratory status, taking sociodemographic and occupational characteristics into account. Compared to natives (Metropolitan France), being an African immigrant was associated to higher probability to work in a frontline job [adjusted odds ratio (aOR) = 1.82 (1.23-2.71)], as well as being born in French Overseas Departments [aOR = 1.64 (1.23-2.18)], reflecting racial division of work and higher Sars-Cov-2 exposure of immigrant and minority populations.

Deterioration of mental health and insufficient Covid-19 information among disadvantaged immigrants in the greater Paris area

OBJECTIVES

The aim of this study is to provide information on changes in mental health among disadvantaged immigrants from Sub-Saharan Africa in the Greater Paris area and their level of information about Covid-19.

METHODS

Prior to the Covid-19 epidemic, the Makasi community-based cohort followed 850 immigrants from sub-Saharan Africa in the Greater Paris area. Between the 1st of April and the 7th of June 2020, all participants scheduled for a follow-up survey were systematically included into an additional COVID-19-related wave of data collection (N = 100). We compared participants' type of housing, level of food insecurity, work and mental health (PHQ9) before and during the first COVID-19-related lockdown, using paired-Mc Nemar chi-2 tests. We next described their level of information on Covid-19 and policy measures, broken down by sex.

RESULTS

Among the 100 participants, 68% had no legal residence permit. Food insecurity was more often reported during lockdown than before (62% vs 52%). 9% of participants had a score indicative of severe depression (PHQ9) before lockdown and 17% afterwards (p = 0.17). Only 51% knew about the possibility of asymptomatic transmission of the COVID-19 virus.

CONCLUSIONS

This study brings original information on a hard-to-reach population group. Our results suggest that the lockdown had a detrimental impact on various economic and mental health aspects among disadvantaged migrants residing in the Greater Paris area.

Immigrants facing Covid 19 containment in France : An ordinary hardship of disaffiliation

•

The precarious immigrant population is often invisible because it is at the interstices of care devices and, in the current epidemic context, isolation facilities.

•

Confinement affects individuals' abilities to act, and generates a "disaffiliation process" to placing this precarious immigrant population even more on the margins of society.

•

Covid-19 crisis exacerbates pre-existing difficulties, generating not so new situations for these precarious immigrant population.

•

Need to formulate specifics interventions : targeted outreach intervention, participatory approach and deliberative spaces ; promote health promotion intervention; right based intervention.

In order to limit the spread of the SARS-CoV-2 virus, the majority of governments have introduced population containment. Certain population groups, including immigrants in precarious situations, are experiencing the impact of this measure in a brutal manner. This article is based on accounts of containment experiences collected by telephone within the framework of a pre-existing intervention research carried out among immigrants to France from Sub-Saharan Africa who are in a precarious situation. It highlights certain social effects of containment and the logics at work in the precarious situations. This research shows how this a priori unprecedented situation affects individual capacities to act and generates a ‘disaffiliation process’ causing individuals to shift towards ‘social non-existence’, repeating lived experiences and exacerbating pre-existing logics. The ordeal of containment proves to be an ordinary experience for these individuals.

Does exposure to workplace hazards cluster by occupational or sociodemographic characteristics? An analysis of foreign-born workers in Australia

BACKGROUND

Disparities in exposure to occupational hazards may be linked to social position as well as the type of job a person holds. This study aimed to describe the prevalence of exposure to workplace hazards among three migrant worker groups and to assess whether social disparities in exposure for these groups remain after adjusting for occupational characteristics.

METHODS

Data were collected in 2017/2018 from 1630 Australian workers born in New Zealand, India, and the Philippines. Weighted estimated prevalence of exposure to 10 carcinogens and four psychosocial hazards (discrimination, job strain, vulnerability, and insecurity) was calculated for sociodemographics and occupation. Regression estimated the likelihood of exposure by sociodemographics after adjustment for occupational characteristics.

RESULTS

Exposure to workplace hazards ranged from 11.7% (discrimination) to 61.2% (exposed to at least one carcinogen). Compared with workers born in India, New Zealand born workers were over twice as likely to be exposed to diesel engine exhaust (adjusted odds ratio [aOR] = 2.60) and 60% more likely to be exposed to at least one carcinogen (aOR = 1.60) but less likely to be exposed to any psychosocial hazard. Social disparities by country of birth, sex, age, education, and number of years in Australia, as well as company size, employment type, and hours, worked remained associated with greater likelihood of reporting one or more workplace hazards after adjusting for occupational characteristics.

CONCLUSION

Examining sociodemographic as well as occupational characteristics helps to clarify groups most likely to be exposed to workplace hazards who can be hidden when examining occupational characteristics alone.

Finding the missing link: when community-based outreach in public space is key to engage migrants in health prevention programmes in Paris, France

BACKGROUND

One of the classic challenges for prevention programmes is reaching the populations they serve. In France, a substantial number of African migrants living with HIV acquired their infection after migrating. The aim of this paper is to better understand the characteristics of the population reached by a community-based outreach approach.

METHODS

We compared sociodemographic characteristics across three different groups in the Paris greater area: (1) the general African migrant population (Population census), (2) the African migrant population using either the regular healthcare system or the system for vulnerable populations (PARCOURS Survey) and (3) the African migrant population reached through a community-based mobile unit (Afrique Avenir). Comparisons were conducted according to sex, age, region of origin, duration of residence and occupational and legal statuses using χ² tests.

RESULTS

The migrants reached by the mobile unit were mostly men (69%), 52% of whom were younger than 35 years old. They more often lived in precarious situations than did the general sub-Saharan population (49% vs 35% were unemployed, respectively, p<0.001) and the ones accessing the regular healthcare system. Fewer of them lived in precarious situations than did migrants seeking healthcare consultations for vulnerable populations (42% in the mobile unit vs 54% in healthcare consultations were undocumented, p<0.028).

CONCLUSION

Our study shows that the outreach approach can constitute a missing link in the prevention chain among sub-Saharan African migrants, reaching a group that differs from the general migrant population and from the migrant population in healthcare services-not only the newly arrived migrants who live in more precarious situations but also those who have been in France for several years and are still affected by social hardship.

Participatory development and pilot testing of the Makasi intervention: a community-based outreach intervention to improve sub-Saharan and Caribbean immigrants' empowerment in sexual health

Background

Sub-Saharan and Caribbean immigrants are particularly affected by HIV in Europe, and recent evidence shows that a large portion of them acquired HIV after arrival. There is a need for efficient interventions that can reduce immigrants’ exposure to HIV. We describe the pilot phase of a community-based empowerment outreach intervention among sub-Saharan and Caribbean immigrants in the greater Paris area aimed at 1) constructing the intervention, 2) assessing its feasibility, and 3) assessing the feasibility of its evaluation based on a stepped-wedge approach.

Methods

1) To develop the intervention, a literature review was conducted on existing interventions and participatory approaches developed, including the constitution of peer groups. 2) To assess the intervention’s feasibility, a pilot was conducted between April 2018 and December 2018. A daily register was used to collect data on sociodemographic characteristics of all persons who visited the mobile team to assess eligibility and acceptability. 3) To assess the feasibility of performing a stepped-wedge trial to evaluate the intervention, we compared eligibility, enrolment and retention at 3 months in two arms (immediate vs deferred). Chi-squared tests were used to compare reach and retention between the two arms.

Results

Intervention development. The Makasi intervention was designed as an outreach intervention that starts with the persons’ capacities and helps them appropriate existing resources and information and obtain knowledge about sexual health, based upon motivational interviewing techniques.

Intervention Feasibility. Between April 2018 and December 2018, a total of 485 persons were identified as eligible. Participation in the intervention was proposed to 79% of eligible persons. When proposed, the persons enrolled in the intervention with a response rate of 69%. Some were lost to follow-up, and 188 persons were finally included.

Evaluation Feasibility. The proportions of eligible (45 and 42%) individuals and of enrolled individuals (65 and 74%) were similar and not significantly different in the immediate and deferred arms, respectively.

Conclusions

A community-based outreach intervention aimed at improving sub-Saharan and Caribbean immigrants’ empowerment in sexual health is feasible. The pilot phase was key to identifying challenges, designing a relevant intervention and validating the stepped-wedge protocol for evaluation.

When and why? Timing of post-migration HIV acquisition among sub-Saharan migrants in France

Recent studies highlighted that many HIV-positive migrants in Europe acquired their infections post-migration. However, the timing of these infections is not always known. This study aims to estimate the timing of post-migration HIV acquisition among sub-Saharan migrants in France and to understand the correlates of post-migration infection.

Refusal to provide healthcare to sub-Saharan migrants in France: a comparison according to their HIV and HBV status

Background

In this study, we aim to measure and compare the frequency of reported denial of care in sub-Saharan African migrants living in the Paris area, according to their HIV and HBV status and social and migration characteristics.

Methods

The ANRS-PARCOURS study is a life-event survey conducted in 2012-13 in healthcare facilities in the Paris area, among three groups of sub-Saharan migrants recruited in primary care centres (N = 760; reference group), in dedicated centres for HIV care (N = 922; HIV group) and in centres for chronic hepatitis B care (N = 777; CHB group). Characteristics associated with refusal of care since arrival in France were identified using a logistic regression model.

Results

Compared to the reference group (6%, P < 0.001), the reported refusal of care was twice as high in the HIV group (12%) and the CHB group (10%). In the multivariate analysis, men and women living with HIV were at greater risk of being denied care (aOR = 2.20[1.14-4.25] and 2.24[1.25-4.01]). Women covered by the specific health insurance (HI) for precarious or undocumented migrants were also at higher risk (aOR = 2.07[1.10-3.89] and 2.69[1.18-6.10], respectively). The risk was also increased in men who remained for at least one year without permit of residence or without HI and among those who were threatened in their country.

Conclusion

Refusals to provide healthcare are frequent and deleterious situations especially for migrants living with HIV. Health decision makers, public insurance bodies and health professional councils must address this issue to improve equity in the healthcare system.

Social and structural factors and engagement in HIV care of sub-Saharan African migrants diagnosed with HIV in the Paris region

Migrants from sub-Saharan Africa (SSA) are often diagnosed at an advanced stage of HIV, and many of them have harsh living conditions. We aimed to evaluate the entry into care after HIV diagnosis and examine the related social determinants. The ANRS PARCOURS study is a life-event survey conducted in 2012-2013 in the Paris region among. Time between HIV diagnosis of SSA migrants living diagnosed HIV positive in France and HIV care and the determinants was assessed yearly by using mixed-effects logistic regression models. Among a total of 792 participants, 94.2% engaged in HIV care within the year of HIV diagnosis, 4.3% in the following year and 2.5% beyond the second year after diagnosis. The participants were more likely to engage in HIV care during years when they were effectively covered by health insurance and if the HIV test was carried out at the initiative of the doctor. Immigration for economic reasons or owing to threats in his/her country of origin was associated with delayed engagement in HIV care. Additionally, 4.3% of treated participants discontinued HIV care at least once at the time of the survey and more often if diagnosed at an advanced HIV disease stage and financially dependent.

[Residence permit for medical reasons: An obstacle to permanent residence status. Results of the ANRS Parcours Study]

OBJECTIVES

Various associations in France have denounced for a long time the difficulties encountered by foreigners with a residence permit for medical reasons to access permanent residence status (10-year resident's card or French nationality). The objective of this study was to determine whether there is a real discrimination towards foreigners with a residence permit for medical reasons, with all other things being equal.

METHODS

This study was based on data from the retrospective quantitative ANRS Parcours survey, conducted in 2012-2013 among 1,705 Sub-Saharan immigrants with HIV/AIDS or Hepatitis B in Ile-de-France. This life-event survey reconstructed the immigrant's permit history. Discrete time logistic models were then used to model the factors associated with obtaining a permanent residence permit and the impact of a residence permit for medical reasons on this probability. Control variables were used to take into account the level of education, the reason for arrival in France, the period of arrival, the duration of stay.

RESULTS

A residence permit for medical reasons has a negative impact on access to permanent residence status (aOr between 0.15 and 0.27 across subgroups, P < 0.01). Additionally, the time required to obtain permanent residence status has increased since 2005 compared to before 1996 for all foreigners participating in the survey.

CONCLUSIONS

The results of this study suggest discrimination towards people with a residence permit for medical reasons in terms of access to permanent residence status, thereby placing their access to health care at stake.

Access to health insurance coverage among sub-Saharan African migrants living in France: Results of the ANRS-PARCOURS study

BACKGROUND

Migrants' access to care depends on their health insurance coverage in the host country. We aimed to evaluate in France the dynamic and the determinants of health insurance coverage acquisition among sub-Saharan migrants.

METHODS

In the PARCOURS life-event retrospective survey conducted in 2012-2013 in health-care facilities in the Paris region, data on health insurance coverage (HIC) each year since arrival in France has been collected among three groups of sub-Saharan migrants recruited in primary care centres (N = 763), centres for HIV care (N = 923) and for chronic hepatitis B care (N = 778). Year to year, the determinants of the acquisition and lapse of HIC were analysed with mixed-effects logistic regression models.

RESULTS

In the year of arrival, 63.4% of women and 55.3% of men obtained HIC. But three years after arrival, still 14% of women and 19% of men had not obtained HIC. HIC acquisition was accelerated in case of HIV or hepatitis B infection, for migrants arrived after 2000, and for women in case of pregnancy and when they were studying. Conversely, it was slowed down in case of lack of a residency permit and lack of financial resources for men. In addition, women and men without residency permits were more likely to have lost HIC when they had one.

CONCLUSION

In France, the health insurance system aiming at protecting all, including undocumented migrants, leads to a prompt access to HIC for migrants from sub-Saharan Africa. Nevertheless, this access may be impaired by administrative and social insecurities.

How to use sequence analysis for life course epidemiology? An example on HIV-positive Sub-Saharan migrants in France

BACKGROUND

Life course epidemiology is now an established field in social epidemiology; in sociodemography, the quantitative analysis of biographies recently experienced significant trend from event history analysis to sequence analysis. The purpose of this article is to introduce and adapt this methodology to a social epidemiology question, taking the example of the impact of HIV diagnosis on Sub-Saharan migrants' residential trajectories in the Paris region.

METHODS

The sample consists of 640 migrants born in Sub-Saharan Africa receiving HIV care. They were interviewed in healthcare facilities in the Paris region within the PARCOURS project, conducted from 2012 to 2013, using life event history calendars, which recorded year by year their health, family and residential histories. We introduce a two-step methodological approach consisting of (1) sequence analysis by optimal matching to build a typology of migrants' residential pathways before and after diagnosis, and (2) a Cox model of the probability to experience changes in the residential situation.

RESULTS

The seven-clusters typology shows that for a majority, the HIV diagnosis did not entail changes in residential situation. However 30% of the migrants experienced a change in their residential situation at time of diagnosis. The Cox model analysis reveals that this residential change was in fact moving in with one's partner (HR 2.99, P<0.000) rather than network rejection.

CONCLUSION

This original combination of sequence analysis and Cox models is a powerful process that could be applied to other themes and constitutes a new approach in the life course epidemiology toolbox.

TRIAL REGISTRATION NUMBER

NCT02566148.

Understanding Settlement Pathways of African Immigrants in France Through a Capability Approach: Do Pre-migratory Characteristics Matter?

With the increase in asylum-related immigration since 2015, understanding how immigrants settle in a new country is at the centre of social and political debate in European countries. The objective of this study is to determine whether the necessary time to settle for Sub-Saharan Africa immigrants in France depends more on pre-migratory characteristics or on the structural features of the host society. Taking a capability approach, we define settlement as the acquisition of three basic resources: a personal dwelling, a legal permit of a least 1 year and paid work. We use data from the PARCOURS survey, a life-event history survey conducted from 2012 to 2013 that collected 513 life histories of Sub-Saharan African immigrants living in France. Situations regarding housing, legal status and activity were documented year by year since the arrival of the respondent. We use a Kaplan-Meier analysis and chronograms to describe the time needed for settlement, first for each resource (personal dwelling, legal permit and paid work) and then for the combined indicator of settlement. Discrete-time logistic regressions are used to model the determinants of this settlement process. Overall, women and men require 6 and 7 years (medians), respectively, to acquire basic resources in France. This represents a strikingly long period of time in which immigrants lack basic security. The settlement process varies according to gender, but very few sociodemographic factors influence settlement dynamics. Therefore, the length of the settlement process may be due to structural features of the host society.

[Health care access of Sub-Saharan African migrants living with chronic hepatitis B]

Objective: The objective of this study was to analyse health care access of Sub-Saharan African migrants living with chronic hepatitis B (CHB) in France. Methods: The ANRS-Parcours survey was a life-event survey conducted in 2012-2013 among Sub-Saharan African migrants recruited by health care facilities managing CHB in the Paris region. Data were collected by face-to-face interview using a biographical grid and a standardized questionnaire. Results: 96.4% of the 619 participants basic health insurance coverage with CMU universal health insurance coverage in 18.6% of cases and AME state medical assistance in 23.4% of cases. One-third of basic health insurance beneficiaries did not have any complementary health insurance and 75.7% had long-term disease status. The median time to acquisition of health insurance cover after arrival in France was one year. 22.0% of participants reported delaying health care for financial reasons since their arrival in France and 9.7% reported being refused health care usually due to refusal of CMU or AME. Health care access was effective within one year of the diagnosis. Delayed health care access was more common among people without health insurance coverage in the year of diagnosis. Patients lost to follow-up for more than 12 months were rare. Conclusion: Sub-Saharan African migrants living with chronic hepatitis B rapidly access health insurance coverage and health care. However, barriers to health care access persist for some people, essentially due to absent or incomplete health insurance cover and refusal of care for AME or CMU beneficiaries.

"Times Are Changing": The Impact of HIV Diagnosis on Sub-Saharan Migrants' Lives in France

Background

Migrants account for 35% of HIV diagnoses in the European Union (ECDC/WHO 2014). Little is known about the impact of such a lifelong infection diagnosis on lives that are already disrupted by migration. In this paper, we assess the impact of HIV diagnosis on activity, union, well-being among African migrants living in France, the second group most affected by HIV after MSM. We compare it with the impact of the diagnosis of Hepatitis B, another lifelong infection affecting African migrants.

Methods

We use the ANRS PARCOURS survey, a retrospective life-event survey led in 2012–2013 in 74 health structures in Paris greater area which collected 926 life histories of Sub-Saharan migrants living with HIV and 779 with Hepatitis B. We modelled the probability year by year since 18 years of age until data collection to lose one’s activity, to experience a conjugal break up and degradation of well-being and we estimated the impact of migration and of HIV and Hepatitis B diagnoses on these probabilities, after adjustment on other factors, thanks to discrete-time logistic regressions.

Results

Migration entailed loss of activity and conjugal break up, though HIV diagnosis after migration did not statistically impact on these outcomes. Yet HIV diagnosis had a massive negative impact on well-being (aOR = 11.31 [4.64–27.56] for men and 5.75 [2.79–11.86] for women). This negative impact on well-being tended to diminish for persons diagnosed after 2004. The negative impact of HIV diagnosis on African migrants’ well-being seems to be attenuated in the last decade, which hints at a normalization of the subjective experience of HIV diagnosis.

Effects of plant extracts and essential oils as feed supplements on quality and microbial traits of rabbit meat

The effects of dietary supplementation of onion, cranberry,  strawberry and essentials oils on meat quality were analysed. Five groups of 48 Grimaud female weaned rabbits received the supplemented or the control ration; the experimental unit was a cage of 6 rabbits. Each experimental diet contained 10 ppm of added active ingredients.  Rabbits were fed with the experimental diets for 4 wk before determining slaughter and carcass traits and determining the pH at 1 and 24 h post mortem (pHu) of the <em>Longissimus dorsi</em> (LD) and the <em>Biceps femoris</em> (BF) muscle, left and right, respectively. Cooking loss, drip loss and L*, a* and b* color parameters were obtained of the right<em> </em>LD and for ground meat and antioxidant status (TBARS, DNPH, Folin Ciocalteu). Only the pHu of the LD muscle for the strawberry supplemented group was significantly lower when compared to the control group (P=0.04). However, we note that for the pH of the LD, the average was less than 6 for the meat of animals who received a diet enriched in polyphenols, compared to the control group. Plant extract supplementation did not influence meat quality traits, growth performance or oxidative stability. But under aerobic and anaerobic conditions, our results indicate that diet supplementation with extracts rich in polyphenols, especially with essential oils, had a small bot sporadic positive effect in reducing bacterial microflora compared to the control group (P&lt;0.05). In conclusion, plant extracts and essential oils can be used in a rabbit diet without adverse effects on performance and meat quality traits. This effect could be optimized by investigating higher doses.

Access to employment among African migrant women living with HIV in France: opportunities and constraints

HIV in France particularly affects sub-Saharan migrants as they accounted for 31% of the new diagnoses in 2013. The objective of this study is to investigate the access to and the experience of employment among migrant women living with HIV in France. We use a mixed-method approach. The quantitative data come from the ANRS Parcours study, a life-event survey conducted in 2012-2013 in 70 health centres which collected year-by-year detailed information on living conditions about 755 sub-Saharan women migrants in the greater Paris region (470 with HIV and 285 without HIV). The qualitative data have been collected independently in the same region through socio-ethnographic observations and interviews conducted in 8 HIV-positive migrant organisations and among 35 women-members from 2011 to 2013. Two main results are noteworthy. First, being HIV-positive unexpectedly gives sub-Saharan migrant women a quicker access to employment thanks to the social support they find in migrant organisations: in the third year in France in median (versus 5th year among HIV-negative group). This effect of being HIV-positive on the access to employment remains all things being equal in a discrete-time logistic regression (aOR [95% CI] HIV+: 1.4[1.1;1.8]). Second, their employment situation remains strongly shaped by the racial division of work existing in France and they develop individual strategies to negotiate this constraint: for example, temporary jobs and working as health mediators. The type of jobs they find, mainly in the care sector, force them to carefully hide their HIV status because they fear discrimination at work. Not only migrant women endure structural discrimination in a segmented labour market, but they also anticipate HIV-related discrimination related to caring activities. Thus, the design and implementation of programmes that address stigma should consider structural discrimination to improve PLWHA's working experiences.

Sub-Saharan African migrants living with HIV acquired after migration, France, ANRS PARCOURS study, 2012 to 2013

We estimated the proportion of migrants from sub-Saharan Africa who acquired human immunodeficiency virus (HIV) while living in France. Life-event and clinical information was collected in 2012 and 2013 from a random sample of HIV-infected outpatients born in sub-Saharan Africa and living in the Paris region. We assumed HIV infection in France if at least one of the following was fulfilled: (i) HIV diagnosis at least 11 years after arrival in France, (ii) at least one negative HIV test in France, (iii) sexual debut after arrival in France. Otherwise, time of HIV infection was based on statistical modelling of first CD4(+) T-cell count; infection in France was assumed if more than 50% (median scenario) or more than 95% (conservative scenario) of modelled infection times occurred after migration. We estimated that 49% of 898 HIV-infected adults born in sub-Saharan Africa (95% confidence interval (CI): 45-53) in the median and 35% (95% CI: 31-39) in the conservative scenario acquired HIV while living in France. This proportion was higher in men than women (44% (95% CI: 37-51) vs 30% (95% CI: 25-35); conservative scenario) and increased with length of stay in France. These high proportions highlight the need for improved HIV policies targeting migrants.