Inégalités sociales de santé : du modèle épidémiologique à l’intervention. Enchaînements et accumulations au cours de la vie

Usefulness of Home Screening for Promoting Awareness of Impaired Glycemic Status and Utilization of Primary Care in a Low Socio-Economic Setting: A Follow-Up Study in Reunion Island

BACKGROUND

Low socio-economic settings are characterized by high prevalence of diabetes and difficulty in accessing healthcare. In these contexts, proximity health services could improve healthcare access for diabetes prevention. Our primary objective was to evaluate the usefulness of home screening for promoting awareness of impaired glycemic status and utilization of primary care among adults aged 18-79 in a low socio-economic setting.

METHODS

This follow-up study was conducted in 2015-2016 in Reunion Island, a French overseas department in the Indian Ocean. Enrollment and screening occurred on the same day at the home of participants (N=907). Impaired glycemic status was defined as [glycated hemoglobin (HbA1c) ≥5.7%] OR [fasting capillary blood glucose (FCBG) ≥1.10 g/L] OR [HbA1c=5.5-5.6% and FCBG=1.00-1.09 g/L]. Medical, socio-cultural, and socio-economic characteristics were collected via a face-to-face questionnaire. A one-month telephone follow-up survey was conducted to determine whether participants had consulted a general practitioner (GP) for confirmation of screening results. A multinomial polytomous logistic regression model was used to identify factors independently associated with non-use of GP consultation for confirmation of screening results and nonresponse to the telephone follow-up survey.

RESULTS

Prevalence of glycemic abnormalities was 46.0% (95% CI = 42.7-49.2%). Among participants with impaired glycemic status (N=417), 77.7% (95% CI=73.7-81.7%) consulted a GP for confirmation of screening results, 12.5% (95% CI=9.3-15.6%) did not, and 9.8% failed to respond to the follow-up survey. Factors independently associated with non-use of GP consultation for confirmation of screening results were self-reported unwillingness to consult a GP (adjusted odds ratio [OR]: 4.86, 95% CI=1.70-13.84), usual GP consultation frequency of less than once a year (adjusted OR: 4.13, 95% CI=1.56-10.97), and age 18-39 years (adjusted OR: 3.09, 95% CI=1.46-6.57).

CONCLUSION

Home screening for glycemic abnormalities is a useful proximity health service for diabetes prevention in low socio-economic settings. Further efforts, including health literacy interventions, are needed to increase utilization of primary care.

[To analyse the transferability of an intervention : applying the functions/implementation/context model on a diabetes prevention programme]

INTRODUCTION

A type 2 diabetes primary prevention programme that was shown to be feasible and effective in 2003 was transferred to another vulnerable district of Reunion Island in 2004, but its short-term effectiveness could not be reproduced. Based on this example, this article analyses whether the key functions/implementation/context model can be useful to : 1- more accurately describe an evaluated intervention ; and 2- identify the factors involved in the transferability of this intervention.

METHODS

The causality model of the initial programme is described. We then identified the key functions (or theoretical processes) of this initial programme, implementation of these functions, and the context in which the intervention took place. Transfer was analysed by focusing on the differences between the initial programme and the transferred programme in terms of key functions, implementation and context.

RESULTS

The causality model involves individual, meso-social, and environmental health determinants. Our analysis of programme transfer highlights differences in : key functions (two key functions dropped, one key function added, one key function modified), implementation (failure to implement, loss/improvement of quality), and context (population and socioeconomic level of the district concerned).

CONCLUSION

This work supports the hypothesis that the key functions/implementation/context model can be useful to improve the description of an intervention, and analyse the factors involved in its transferability.

[The evaluation of pharmacological drugs, medical devices, and non-pharmacological or public health interventions: Experimental design limitations. Moving towards new methods?]

In the field of health, evidence-based medicine and associated methods like randomised controlled trials (RCTs) have become widely used. RCT has become the gold standard for evaluating causal links between interventions and health results. Originating in pharmacology, this method has been progressively expanded to medical devices, non-pharmacological individual interventions, as well as collective public health interventions. Its use in these domains has led to the formulation of several limits, and it has been called into question as an undisputed gold standard. Some of those limits (e.g. confounding biases and external validity) are common to these four different domains, while others are more specific. This paper describes the different limits, as well as several research avenues. Some are methodological reflections aiming at adapting RCT to the complexity of the tested interventions, and at overcoming some of its limits. Others are alternative methods. The objective is not to remove RCT from the range of evaluation methodologies, but to resituate it within this range. The aim is to encourage choosing between different methods according to the features and the level of the intervention to evaluate, thereby calling for methodological pluralism.

Evaluation d’impact sur la santé et évaluation d’impact sur l’équité en santé : éventail de pratiques et questions de recherche

L’Evaluation d’Impact sur la Santé (EIS) se développe au niveau international et est encore au stade émergent en France. Elle vise à évaluer les effets positifs et négatifs potentiels d’un projet, d’un programme ou d’une politique sur la santé. L’objectif est de produire des recommandations en direction des décideurs, afin d’en maximiser les effets positifs et d’en diminuer les effets négatifs. L’EIS est un moyen particulièrement intéressant d’action sur les déterminants de la santé au-delà des comportements individuels et du système de santé. Les politiques de logement, de transport, de solidarité, économiques, etc. ont, en effet, des impacts souvent non prévus sur la santé. Au-delà des effets sur la santé, l’EIS doit aussi permettre d’apprécier la distribution de ces effets dans la population.

Si la préoccupation pour l’équité en santé est centrale dans l’EIS, elle reste cependant difficilement traduite en pratique. Face à cette difficulté, des démarches d’évaluation d’impact ont été développées pour renforcer la prise en compte de l’équité à chaque étape de l’EIS ou « Equity Focused Health Impact Assessment », ou prendre en compte les impacts sur les inégalités de santé de façon spécifique. Ainsi, l’Evaluation de l’Impact sur l’Equité en Santé (EIES) semble, par exemple, particulièrement intéressante pour évaluer l’impact sur les inégalités de projets dans le champ sanitaire.

L’EIS et l’EIES posent de nombreuses questions de recherche, notamment autour de la réunion, dans une même démarche, du politique, du citoyen et de l’expert. La participation des populations vulnérables potentiellement affectées par la politique évaluée est une valeur centrale de l’EIS, mais pose des questions d’acceptabilité sociale. La collaboration avec les décideurs politiques est également un enjeu majeur. Les difficultés méthodologiques, notamment de quantification des impacts, peuvent constituer des freins à la promotion de la démarche auprès des décideurs.

A health equity impact assessment umbrella program (AAPRISS) to tackle social inequalities in health: program description

Background:

The failure to simultaneously address two objectives (increasing the average health of the population and reducing health inequalities) may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality.

Objective:

The Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) methodology is to analyze and modify interventions that are already underway in terms of their potential impact on health inequalities. It relies on partnership between researchers and actors in the health field, as well as policy makers. In this paper, we describe the program and discuss its feasibility and acceptability.

Methods:

This program is not a single intervention, but a process aiming at assessing and reshaping existing health programs, therefore acting as a kind of meta-intervention. The program develops scientific and methodological support stemming from co-construction methods aimed at increasing equity within the programs. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. The steps of the process are described: (1) establishment of AAPRISS governance and partnerships; (2) inclusion of projects; and (3) the projects’ process.

Discussion:

Many partners have rallied around this program, which has been shown to be feasible and acceptable by partners and health actors. A major challenge is understanding each partner’s expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in them in order to take inequalities in health into account.

Enabling the transferability of complex interventions: exploring the combination of an intervention's key functions and implementation

OBJECTIVES

Several public health interventions are not described, not evaluated and not transferred. The objective was to assess the feasibility and acceptability of using a description model making a distinction between interventions' transferable elements, and those that are more context-specific, to make their evaluation and transferability easier.

METHODS

The theoretical distinction between an intervention function and its form in a specific context has been empirically explored. A community-based intervention (named "Ciné-Ma-Santé") has been described, using a "key function/implementation/context" model. This process has been co-constructed through qualitative research and knowledge exchange process between project leaders and researchers from different disciplines.

RESULTS

The use of the model proves feasible and useful for both project leaders and researchers. Nine key functions were described, as well as their implementation and the features of the intervention context.

CONCLUSIONS

Rendering explicit key functions of public health interventions could constitute a useful step to their evaluation and transfer. It enables the formulation of hypotheses regarding the potentially standardizable elements of interventions, and elements that can be modified while maintaining the integrity of the intervention.

[The intervention mapping protocol: A structured process to develop, implement and evaluate health promotion programs]

BACKGROUND

Health promotion programs are expected to improve population health and reduce social inequalities in health. However, their theoretical foundations are frequently ill-defined, and their implementation faces many obstacles. The aim of this article is to describe the intervention mapping protocol in health promotion programs planning, used recently in several countries.

METHODS

The challenges of planning health promotion programs are presented, and the six steps of the intervention mapping protocol are described with an example. Based on a literature review, the use of this protocol, its requirements and potential limitations are discussed.

RESULTS

The intervention mapping protocol has four essential characteristics: an ecological perspective (person-environment), a participative approach, the use of theoretical models in human and social sciences and the use of scientific evidence. It comprises six steps: conduct a health needs assessment, define change objectives, select theory-based change techniques and practical applications, organize techniques and applications into an intervention program (logic model), plan for program adoption, implementation, and sustainability, and generate an evaluation plan. This protocol was used in different countries and domains such as obesity, tobacco, physical activity, cancer and occupational health. Although its utilization requires resources and a critical stance, this protocol was used to develop interventions which efficacy was demonstrated.

CONCLUSION

The intervention mapping protocol is an integrated process that fits the scientific and practical challenges of health promotion. It could be tested in France as it was used in other countries, in particular to reduce social inequalities in health.

[An intervention research program (AAPRISS) to reduce social inequalities in health: methods and validation]

OBJECTIVE

The AAPRISS intervention-research program (Apprendre et Agir Pour Réduire les Inégalités Sociales de Santé) aims to change prevention projects to improve the extent to which they take health inequalities into account. The goal is to assess a project's feasibility and its acceptability, from the viewpoint of the sponsors of the project in question, and to present its tools and potentially-transferable elements.

PARTICIPANTS

Five cancer-prevention projects focused on nutrition have been included in the AAPRISS program: two projects conducted in school, one community-health project conducted in a disadvantaged neighbourhood and two hospital therapeutic-education programes. For each one, a workgroup was created bringing together the project sponsors and their team as well as researchers from various disciplines.

LOCATION

The study involves projects currently underway in the Midi- Pyrénées region of France.

INTERVENTION

AAPRISS is based on the exchange of knowledge among project sponsors and researchers and the co-construction of the analysis, reorientations and the assessment of the prevention projects included in the program. The validation of the program and its feasibility from the project sponsors' point of view is based on a questionnaire and presentations carried out during a symposium that took place in May 2014 in Toulouse.

RESULTS

Twelve key program functions have been described. They have been shown to be feasible and acceptable and concrete project modifications towards a better consideration of social inequalities of health (SIH) have been realized in most of the projects. Co-construction among the stakeholders raises many issues and difficulties that could have been overcome by the establishment of a relationship of trust between project sponsors and researchers.

CONCLUSION

The complexity of the determinants leading to SIH calls for programs that revisit existing projects rather than a new intervention aimed at reducing them.

Barriers of access to oral health care among university students in southern Colombia, 2011. A multivariate analysis

<p>Background. The right to health is considered to be a fundamental human right. Therefore, it is a starting point from which to combat unjust and immoral inequalities. It is essential to study the process through which a need for attention is completely satisfied.</p><p><br />Objective. To analyze determinants of access to oral health<br />care among university students in municipality of Pasto.</p><p><br />Materials and methods. A sample of 338 university students<br />answered a confidential survey that was based upon previous<br />studies using a health care services utilization behavioral model.</p><p><br />Results. In terms of enabling factors, the students that responded as ‘having a bad health state’ were those that used oral health care services the most in last year, while those students that responded as “being dissatisfied with the appearance of their teeth’ used oral health care services less. In relation to need factors, the students whose quality of life was not affected by physical impairment and physical pain used oral health care services less. Predisposing factors were not statistically significant.</p><p><br />Conclusions. This study found that enabling and need factors<br />were associated with recent dental consultations by university<br />students in the municipality of Pasto.</p>

Lifecourse socioeconomic position and alcohol use in young adulthood: results from the French TEMPO cohort study

AIMS

The aim of the study was to examine the relationship between lifetime socioeconomic position and alcohol use in young adults.

METHODS

The participants (n = 1103, age 22-35 years in 2009) were the French TEMPO cohort, offspring of employees (all French nationals) of the French national gas and electricity company (GAZEL) who were in a previous cohort study. Alcohol use was assessed by the WHO AUDIT questionnaire (none, low or intermediate alcohol use, alcohol abuse). Childhood socioeconomic position was measured using parental income documented in the GAZEL study in 1989 (low: ≤ 2592€/month vs. intermediate/high: >2592€/month). Adult socioeconomic position was measured by participants' educational level (≤ high school degree vs. >high school degree). Combining family income and educational attainment, we ascertained participants' social trajectory (stable high, upward, downward and stable low). Data were analyzed using multinomial regression analyses controlled for demographic, social, psychological and family characteristics.

RESULTS

Compared with participants with a stable high social trajectory, those with an upward, downward or low social trajectory were more likely to abstain from alcohol (compared with a stable high social trajectory, sex and age-adjusted ORs: OR = 2.22, 95% CI 1.35-3.65 for an upward social trajectory; OR = 3.20, 95% CI 1.78-5.73 for a downward social trajectory; OR = 3.27, 95% CI 1.75-6.12 for a stable low social trajectory). Additionally, participants with a downward social trajectory were disproportionately likely to abuse alcohol (sex- and age-adjusted OR: 1.48, 95% CI 0.89-2.48). In multivariate analyses, social trajectory remained associated with alcohol use.

CONCLUSION

Lifelong socioeconomic position may shape patterns of alcohol use early in life.

[Toulouse, an "urban figure of public health". Dealing with public local struggles against health social differences]

When drawing up the portrait of "urban figures of public health", in 1998, Didier Fassin considered Toulouse to be one of the worthy "local experiments". Fifteen years after his precursory work, the recently developed local public policy against health social differences gives an opportunity to question ourselves about the effectiveness of such a quality then associated to the city. A cognitive analysis of the elaboration of the Toulousian health public policy meaning enables to notice that the process of health legitimization on a local scale takes the following forms. On the one hand, renaming health as a legitimate object of public policies sets it up as a common wealth. On the other hand, local public policy puts the emphasis on health education and tries to increase the standing of social appraisal coming from associative experiments and abilities of the inhabitants themselves. Finally, it calls for citizens' mobilization and solidarity in order to promote a "health democracy" able to struggle efficiently against health social differences.

[The qualitative research on social inequalities in health: the life courses]

OBJECTIVES

Adopting a lifecourse perspective is more and more frequent in the health inequalities research field. This article describes such an approach, as applied in a study on poverty and social exclusion.

METHODS

In this study, life histories were collected through open interviews and focused on the meaning of lived experiences. An original analysis table was used, in which words are grouped within categories identifying the different components of a lifecourse.

RESULTS

Whether it refers to experiences lived in childhood or adulthood, the life history enables the placing of these within the individual's lifecourse. The horizontal analysis of different individual stories makes it possible to identify experiences that have harmful, or conversely, beneficial effects. When transferring results, reporting the experiences lived by the populations using the same words they did to describe them can help those responsible for program development or implementation understand the genesis of social health inequities.

CONCLUSION

The analysis of life histories, based on the different components of a lifecourse, allows the identification of key moments in the interviewees' life evolution and, in an action perspective, to do so while taking health and social intervention fields into account. Such results make it easier to design actions to counter social health inequities - and above all their chronic nature - that are suited to the realities encountered.

Blind spots and adverse conditions of care: screening migrants for tuberculosis in France and Germany

Tuberculosis (TB) is an infectious disease that declined significantly throughout the 20(th) century. Large-scale TB screening of entire populations in France and Germany has thus been replaced by active screening of risk-groups, particularly migrants. The article engages with its problems and practices on three levels: by looking at the way information on migrants as an at-risk group is produced through disease surveillance data; by analysing how such at-risk group data influence local screening practices; and by showing which political and medical problems arise in the field. I overturn the discussion about screening and surveillance of migrants as a risk-group by showing that it is not the stigmatisation of migrants through disease risk that is most at stake, but the invisibility of the most vulnerable among them in disease surveillance data and the way restrictive national immigration policies interfere with and subvert local screening and treatment practices targeting them. The aim of my article is to promote a pragmatic sociology of screening, while paying attention to the practical complexities, political conditions and medical ambivalences of screening and follow-up care, especially when the migrant groups concerned are socially, politically and medically vulnerable.