Risk of pressure ulcers in tetraplegic people: a French survey crossing regional experience with a long-term follow-up.

Background: Pressure ulcer risk assessment provides an indicator of quality of care in French health establishments. The reliability and validity of assessment tools have been shown to be lower for people with spinal cord injury (SCI). We hypothesized that skin complications would be less frequent in people with traumatic SCI and tetraplegia (TSCIt), who were initially managed in French regions with a high level of specialized SCI rehabilitation experience. Methods: First, we used the most recent French territorial survey about SCI to determine a 'Level of Regional Experience (LRE) in Specialized Physical Medicine and Rehabilitation'. We then studied the individual variables reported in the Tetrafigap survey (which compiled a cohort of TSCIts people to assess their trajectory and life conditions following their return to community life by questionnaires) using univariate analysis according to these LREs (chi2 test using a significance threshold of P < 0.05). Finally, we performed a series of logistic regressions to determine the link between LREs and pressure ulcers. Results: Management in high-LRE regions was linked with a lower declaration of pressure ulcers during early treatment and in the long term (on average, 8 years post-trauma). Conclusions: Using pressure ulcers as a marker, our study showed the protective element of regional experience in the early management of TSCIts patients. A dilution effect between SCI specialized units and more polyvalent physical medicine and rehabilitation departments should be prevented within each region within the scope of a regional organization that would link referral centres and local health care networks.

Risk Analyses of Pressure Ulcer in Tetraplegic Spinal Cord-Injured Persons: A French Long-Term Survey.

OBJECTIVE: To identify the long-term clinical, individual, and social risk factors for the development of pressure ulcers (PUs) in traumatic spinal cord-injured persons with tetraplegia (TSCIt). DESIGN: Cohort survey with self-applied questionnaires in 1995 and 2006. SETTING: Thirty-five French-speaking European physical medicine and rehabilitation centers participating in the Tetrafigap surveys. PARTICIPANTS: Tetraplegic adults (N=1641) were surveyed after an initial posttraumatic period of at least 2 years. Eleven years later, a follow-up was done for 1327 TSCIt, among whom 221 had died and 547 could be surveyed again. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The proportion of PUs documented at the various defined time points, relative to the medical and social situations of the TSCIt, by using univariate analyses followed by logistic regression. RESULTS: Of the participants, 73.4% presented with a PU during at least 1 period after their injury. Four factors had an effect on the occurrence of PUs in the long-term. Protective features for this population were incomplete motor impairment (odds ratio, 0.5) and the ability to walk (odds ratio, 0.2), whereas a strong predictive factor was the development of a PU during the initial posttrauma phase (odds ratio, 2.7). Finally, a significant situational factor was the lack of a social network (odds ratio, 3.1). CONCLUSIONS: We believe that the highlighting of a motor incomplete feature of SCI (protective against the development of a PU) and of a medical risk factor, an early PU (which served as a definitive marker of the trajectory of TSCIt), together with a social situational factor, indicates the crucial role of initial management and long-term follow-up.

Disability, residential environment and social participation: factors influencing daily mobility of persons living in residential care facilities in two regions of France.

BACKGROUND: Despite the context of individualization of public policies and promotion of independent living, residential care facilities (RCFs) (called "établissements medico-sociaux" in France) still represent the main system used by disabled people. Through a study of their daily mobility, this article proposes a geographical approach to the examination of factors influencing the social participation of disabled persons with motor impairments who live in residential care facilities. METHODS: The data were collected in three stages from several sources. We first carried out 24 semi-directive interviews among supervisory staff in all the institutions in two regions of France (Greater Paris and Upper Normandy) to better understand the nature of services offered by medico-social facilities. We next did field work in greater detail in 10 of these institutions. We selected residents by random sampling. These first stages then allowed us to study the mobility of residents and record their perceptions. We conducted participant observation and interviews with 81 disabled residents within the 10 RCF. Data analysis enabled consideration not only of the role of the residential environment in people's daily mobility, but the role of the institutions as well. RESULTS: We identified three typical profiles of mobility practices depending on the facilities: "the islanders", living in isolated facilities far from public transportation, or in so-called "difficult" neighborhoods; people who alternate individual and group mobility in a more or less large area; and "the navigators" who have high mobility over a very large area, often living in facilities located in urban areas. The study also enabled an analysis of the obstacles and facilitators inside and outside the residential facilities. These place restrictions on social participation by disabled adults. However, possibilities for individual negotiation may enable bypassing some obstacles. CONCLUSIONS: The three ideal-type profiles of mobility analyzed constitute adaptations to the environment by residents and the institution. The research techniques used and the presentation of data (in the form of diagrams) enabled a better understanding of the mobility of severely disabled adults living in an institution, a population that is rarely studied.

Adherence to long-term medical follow-up: A qualitative, experience-focused study of people with spinal cord injury.

BACKGROUND: Scientific evidence indicates the presence of secondary conditions (such as pressure injuries) after spinal cord injury (SCI). Treatment methods focusing on the management of paraplegia and tetraplegia include systematic preventive follow-up. These advances have significantly improved the functional and vital prognosis of people with SCI, but some people may not have access to these specialized organizations or may not adhere closely to this medicalized vision. We used a narrative approach to explore the perceptions of people with SCI to better understand their adherence to follow-up. OBJECTIVES: We aimed to determine the "common denominators" that lead to adherence or non-adherence to long-term follow-up after SCI. METHODS: People with SCI who had completed their first rehabilitation period for > 1 year were included with regard to 2 variables: 1) an actual medical follow-up or not and 2) a history of pressure injury or not. A review of the literature was used as preparation for semi-directive interviews, which were prospectively analysed by using qualitative analysis software. Thematic saturation was reached at 28 interviews, and 32 interviews were ultimately completed. RESULT: Three main areas concerning participants' perceptions emerged: people's readiness, appropriation and modulation of the systematic follow-up. We developed a broad conceptual framework representing follow-up and the promotion of the long-term health of people with SCI from their perspectives. CONCLUSIONS: The medical environment should ensure that people with SCI are ready to actively consider the implementation of prevention strategies and should take into account their ability to establish their own truth, to integrate various life stages after SCI and to negotiate systematic follow-up. The implementation of data about functioning should be conducted using the concept of the Learning Health System.

The functioning of social support in long-term prevention after spinal cord injury. A qualitative study.

BACKGROUND: The impact of social support on the long-term condition after a spinal cord injury (SCI) varies across studies mainly involving self-report questionnaires. OBJECTIVE: We aimed to establish the common factors associated with social support leading individuals with an SCI to the effective prevention of secondary complications, including via adherence to medical follow-up. METHODS: Inclusion criteria were a history of acquired SCI of any etiology, wheelchair use, and age≥18 years at the time of the study. Participants should have completed their initial rehabilitation program in France≥1 year earlier and were also enrolled according to 2 related study variables: routine medical follow-up (patients were or were not followed up) and the medically supervised reporting of a pressure ulcer after the initial rehabilitation session (0 or≥1 pressure ulcers). We performed a preparatory quantitative and qualitative literature review to identify factors affecting long-term follow-up after SCI, then adopted a narrative design with semi-structured interviews, transcribed and analyzed progressively by using qualitative analysis software. RESULTS: We included 32 participants. We categorized our results based on the knowledge, attitudes, beliefs and practices of participants with respect to pressure ulcer prevention and long-term medical follow-up. Our narrative approach allowed us to identify 3 main domains relevant to social support: reciprocity, self-management and timing related to social support. CONCLUSIONS: Our study showed social support as a dynamic process, a reciprocal phenomenon evolving in variations over time. These findings should be central to short- and long-term therapeutic education programs for patients and for people providing social support. Effective changes should also be implemented through the concept of the Learning Health System.

[Definition, classification and epidemiology of disability]. / Définition, classification et épidémiologie du handicap.

How can we define disability and handicap? What are their different forms? What are the figures for the persons concerned? This paper reviews the key conceptual advances and classification developments as well as new French nationwide surveys on disability. Any attempt at defining what is handicap gives rise to heated debates. This layman word initially originating from the turf language has been prevailing in the medico-social field for the last fifty years. The French 2005 Law on disability has now provided a legal definition inspired by the recommendations of the World Health Organization (WHO). For thirty years, following the pioneering work of Wood, international classifications of disability have been an important activity within the WHO, thus revealing a growing interest for the consequences of health conditions. Following the ICIDH in 1980, WHO has moved towards an interactive model with ICF in 2001. Finally, disability issues open to new directions for epidemiology. In France, the investigations of the INSEE (National Institute on Statistics and Economic Studies), the HID survey "Disabilities-Impairments-Dependence", and tomorrow's "Disability-Health survey, bring issues of disabilities and loss of autonomy at the core of their concerns and allow for a better epidemiologic knowledge of the many faces of the disabled population.

Methods to assess the contribution of diseases to disability using cross-sectional studies: comparison of different versions of the attributable fraction and the attribution method.

BACKGROUND: This study aims to illustrate the differences between approaches proposed for apportioning disability to different diseases in a multicausal situation, i.e. the unadjusted attributable fraction (AF), the adjusted AF, the average AF and the attribution method (AM). This information is useful to better interpret results obtained from cross-sectional data and help policy makers decide on public health strategies. METHODS: Data for 29 931 individuals, representative of the French household population, who participated in the 2008-09 cross-sectional Disability-Health Survey, were included. Disability was defined as any limitation reported with the Global Activity Limitation Indicator. Unadjusted AFs were calculated using Levin's formula. Adjusted AFs were estimated for each disease by calculating predicted probabilities of disability for each individual in the dataset, under the assumption that the individual is unexposed to this specific disease (logistic model). Average AFs are based on the same methodology, but have the additional advantage that the average AFs for different diseases sum to the total AF associated with eliminating all diseases. AM accounts for competing risks and partitions total disability prevalence into additive contributions of different diseases and background disability (additive model). RESULTS: All methods obtained similar results with respect to the estimates of the disease contribution to disability prevalences and to ranking of the diseases, except unadjusted AFs, as the method ignores multimorbidity. Confounders other than diseases, such as age and gender, should be accurately taken into account. CONCLUSIONS: Conceptual differences, strengths and limitations of the different approaches were discussed.

Contribution of chronic diseases to educational disparity in disability in France: results from the cross-sectional "disability-health" survey.

BACKGROUND: This study aimed 1) to assess whether the contribution of chronic conditions to disability varies according to the educational attainment, 2) to disentangle the contributions of the prevalence and of the disabling impact of chronic conditions to educational disparities. METHODS: Data of the 2008-09 Disability Health Survey were examined (N = 23,348). The disability indicator was the Global Activity Limitation Indicator (GALI). The attribution method based on an additive hazard model was used to estimate educational differences in disabling impacts and in the contributions of diseases to disability. Counterfactual analyses were used to disentangle the contribution of differences in disease prevalence vs. disabling impact. RESULTS: In men, the main contributors to educational difference in disability prevalence were arthritis (contribution to disability prevalence: 5.7% (95% CI 5.4-6.0) for low-educated vs. 3.3% (3.0-3.9) for high-educated men), spine disorders (back/neck pain, deformity) (3.8% (3.6-4.0) vs. 1.9% (1.8-2.1)), chronic obstructive pulmonary diseases (2.4% (2.3-2.6) vs. 0.6% (0.5-0.7)) and ischemic heart /peripheral artery diseases (4.1% (3.9-4.3) vs. 2.4% (2.2-3.0)). In women, arthritis (9.5% (9.1-9.9) vs. 4.5%, (4.1-5.2)), spine disorders (4.5% (4.3-4.7) vs. 2.1% 1.9-2.3) and psychiatric diseases (3.1% (3.0-3.3) vs. 1.1% (1.0-1.3)) contributed most to education gap in disability. The educational differences were equally explained by differences in the disease prevalence and in their disabling impact. CONCLUSIONS: Public health policies aiming to reduce existing socioeconomic disparities in disability should focus on musculoskeletal, pulmonary, psychiatric and ischemic heart diseases, reducing their prevalence as well as their disabling impact in lower socioeconomic groups.

Demographics of wheelchair users in France: results of national community-based handicaps-incapacités-dépendance surveys.

OBJECTIVE: To highlight the prevalence of manual and/or powered wheelchair use within the general French population living at home or in institutions, to describe the users and to identify factors determining wheelchair use. METHODS: Data were obtained from national community-based Handicaps-Incapacités-Dépendance surveys on disability and dependency carried out on 2 representative samples of the French population in institutions (n = 15,288) and at home (n = 16,945). RESULTS: The prevalence of wheelchair use is 62 per 10,000 people living in France. Forty-three percent of users live in institutions. They frequently show multiple impairments and severe disabilities. They have a mean age of 70 years and 64% are women. After taking confounding factors into account, results show that wheelchair use is not sex-related and decreases slightly with age. On the other hand, wheelchair use is related to widowhood, to the extent of impairments and disabilities, to confinement, to exposure to environmental obstacles and to institutional life. CONCLUSION: Sociodemographic studies on the use of wheelchairs need to pay greater attention to people living in institutions. The prevalence of wheelchair use in France appears to be far lower than in other western countries, and this observation needs to be examined further with intercultural comparisons.

Socioeconomic differences in the impact of HIV infection on workforce participation in France in the era of highly active antiretroviral therapy.

OBJECTIVES: We sought to measure the difference in employment rates between HIV-seropositive and HIV-seronegative persons and to establish whether this difference varied according to the HIV-infected persons' socioeconomic position as defined by education level. METHODS: We used data from the VESPA (VIH: Enquête Sur les Personnes Atteintes) study, a large cross-sectional survey conducted among a nationally representative sample of 2932 HIV-infected patients in France. Age-, gender-, nationality-, and education-standardized employment rates were estimated with the French general population as the reference. The differences in employment rates with the general population were computed overall and according to education level. RESULTS: Compared with that of the general population, the overall employment rate was 25% lower (95% confidence interval [CI]=16%, 32%) among HIV-infected patients diagnosed before 1994 and 9% lower (95% CI = 5%, 16%) among HIV-infected patients diagnosed from 1994 onward. The difference in employment rates with the general population was significantly higher among patients with a low education level. The employment rate of highly educated HIV-infected patients diagnosed from 1994 onward did not differ from that of the general population. CONCLUSIONS: HIV infection was associated with decreased workforce participation among those with a low education level but not among highly educated individuals.

Associations of social and material deprivation with tobacco, alcohol, and psychotropic drug use, and gender: a population-based study.

BACKGROUND: The aim was to assess the relationships between social and material deprivation and the use of tobacco, excessive alcohol and psychotropic drugs by both sexes and in various age groups. Greater knowledge concerning these issues may help public health policy-makers design more effective means of preventing substance abuse. METHODS: The sample comprised 6,216 people aged > or 15 years randomly selected from the population in north-eastern France. Subjects completed a post-mailed questionnaire covering socio-demographic characteristics, occupation, employment, income, smoking habit, alcohol abuse and "psychotropic" drug intake (for headache, tiredness, nervousness, anxiety, insomnia). A deprivation score (D) was defined by the cumulative number of: low educational level, manual worker, unemployed, living alone, nationality other than western European, low income, and non-home-ownership. Data were analysed using adjusted odds ratios (ORa) computed with logistic models. RESULTS: Deprivation was common: 37.4% of respondents fell into category D = 1, 21.2% into D = 2, and 10.0% into D > or 3a re men than women reported tobacco use (30.2% vs. 21.9%) and alcohol abuse (12.5% vs. 3.3%), whereas psychotropic drug use was more common among women (23.8% vs. 41.0%). Increasing levels of deprivation were associated with a greater likelihood of tobacco use (ORa vs. D = 0: 1.16 in D = 1, 1.49 in D = 2, and 1.93 in D > or = 3), alcohol abuse (1.19 in D = 1, 1.32 in D = 2, and 1.80 in D > or = 3) and frequent psychotropic drug intake (1.26 in D = 1, 1.51 in D = 2, and 1.91 in D > or = 3). These patterns were observed in working/other non-retired men and women (except for alcohol abuse in women). Among retired people, deprivation was associated with tobacco and psychotropic drug use only in men. CONCLUSION: Preventive measures should be designed to improve work conditions, reduce deprivation, and help deprived populations to be more aware of risk and to find remedial measures.

Why is rehabilitation not yet fully person-centred and should it be more person-centred?

AIMS: It is a generally shared opinion that rehabilitation is not (yet) 'fully person-centred' and that it should be more. For a certain number of authors, this deficit in person-centredness has originated from the important weight of a 'medical framework' within rehabilitation. In this paper, we will discuss this criticism and its corollary: the idea that rehabilitation is bound to choose between a non-medical and a medical paradigm, since there is a fundamental contradiction between medicine and person-centredness. In the first section of the paper, we will examine the conceptual history of rehabilitation and question whether this history can really be summarized as a 'shift from a medical approach to a person-centred approach'. In the second section, we will question assumptions and suggestions that have been made to develop person-centredness in rehabilitation. In the third section, we will discuss what might be gained but also what might be lost by reinforcing person-centredness in rehabilitation. KEY FINDINGS AND IMPLICATIONS: (i) The history of rehabilitation is complex with several stages and paradigm shifts. Furthermore, these paradigms do not succeed one another but overlap. It would therefore be erroneous to reduce the history of rehabilitation to merely a shift 'from a medical approach to a person-centred approach'. (ii) Several proposals of how to make rehabilitation more person-centred are found within the literature. However, none of these appears satisfactory with each leading to theoretical and practical difficulties. (iii) Although person-centredness has unquestionably contributed to the overall progress of rehabilitation, it is not certain that more person-centredness is the solution to current challenges to rehabilitation. CONCLUSION AND RECOMMENDATIONS: In some ways, the challenge rehabilitation faces is the need to transpose and adapt a notion (person-centredness) that has emerged from fields that are in fact unrelated to disability such as, for example, clinical psychology. The difficulties encountered are therefore not so much related to the particular dominance of a 'medical model' in rehabilitation than they are to the complexities of the concept of disability. We argue that one way forward might be to clarify further the respective role of the medical and non-medical aspects of rehabilitation in ways that go beyond what has been already achieved in either the ICIDH or ICF but which is still unsatisfactory or incomplete in many respects.

Women with disabilities: general practitioners and breast cancer screening.

BACKGROUND: Because they undergo breast cancer screening (BCS) relatively infrequently, women with physical or mental impairments may be at higher risk of late-stage breast cancer than women without impairments. A panel of 600 general practitioners (GPs) in Provence (southeastern France) provided information from which barriers potentially associated with BCS practices for women with disabilities were evaluated. METHODS: In 2002, a telephone questionnaire collected data about GPs' personal and professional characteristics and their attitudes and practices regarding patients with disabilities. Analysis in 2003 used simple and multiple logistic regressions. RESULTS: More than a quarter of the GPs reported apparently inadequate BCS practices for people with disabilities. Feelings of discomfort when treating people with disabilities, lack of assistance, and communication difficulties were inversely associated with BCS for women with mental and physical impairments. General practitioners' information-seeking strategies were associated with BCS for women with mental impairments, and nursing home work experience was inversely associated with BCS for women with physical impairments. CONCLUSIONS: Appropriate training sessions should be made available to improve primary health care quality and prevention practices and to reduce GPs' misperceptions of people with disabilities.

General practitioners' attitudes towards patients with disabilities: the need for training and support.

PURPOSE: Some general practitioners (GPs) report discomfort in caring for people with disabilities. These feelings may impede the provision of quality health care to these patients. METHOD: A cross-sectional survey interviewed 600 GPs in southeastern France and assessed their personal and professional characteristics, their attitudes and opinions towards people with disabilities, and their knowledge and practices in this field. RESULTS: 21.3% of the GP reported discomfort in treating people with mental impairments and 8.2% people with physical impairments. Discomfort with either type of impairment was more frequent among GPs who perceived frequent communication problems with persons with disabilities (p < 0.05) or who did not belong to a professional network (p < 0.10). GPs who reported less experience with the disabled patients (p < 0.05), no medical training about disabilities (p = 0.04), a lack of assistance during consultations (p = 0.02), and inadequate consultation time (p = 0.09) expressed more discomfort in caring for patients with mental impairments. GPs' discomfort was associated with their assessment of the patient's level of disability among patients with physical impairments (p = 0.01). CONCLUSION: This study suggests that substantial obstacles related to GPs' attitudes impede the delivery of quality health care to patients with disabilities and that GPs need more support and guidance in dealing with them. These results raise also the issue of adequate time and remuneration for consultations with these patients.

Disability and a sense of community belonging. A study among tetraplegic spinal-cord-injured persons in France.

This article presents a study of the identity of persons with motor impairments with regard to the community of disabled persons. The authors used the Tetrafigap survey on the long-term outcome of Tetraplegic Spinal-cord-injured (TSCI) persons, in France, to study the sense of belonging to the community of disabled persons among 1356 TSCI persons in relation to factors of social participation (both sociological and disability-related) and subjective factors (subjective well-being, social perception of disability, perceived disability). The results show that 44% of TSCI persons felt that disabled persons do not constitute a community (the "no-community" group). Of those who recognised the existence of such a community, 34% said they belonged to it (the "in-community" group) and 22% declared they did not (the "out-community" group). People in the "no-community" group tended to be more socially integrated, whilst those in the "in-community" group tended to have greater social and clinical difficulties. The "out-community" group was more diverse, being made up of both autonomous persons and dependent persons suffering from complications. Factors related to the sense of community belonging were identified using bivariate analysis and multiple logistic regression. Subjective well-being appeared to be independent of any sense of community belonging. However, the authors found a gender difference: women in the "in-community" group described themselves as having a poorer level of well-being than women in the other two groups. The results are discussed in terms of two views on the social treatment of disabilities: universalism and assimilation vs. particularism and positive identity and the growth of the disability movement.

Relationships of job and some individual characteristics to occupational injuries in employed people: a community-based study.

This study assessed the associations of job and some individual factors with occupational injuries among employed people from a general population in north-eastern France; 2,562 workers were randomly selected from the working population. A mailed auto-questionnaire was filled in by each subject. Statistical analysis was performed with loglinear models. The annual incidence rate of at least one occupational injury was 4.45%. Significant contributing factors for occupational injuries were job category (60.8%), sex (16.2%), regular psychotropic drug use (8.5%), age groups (7.5%), and presence of a disease (7.0%). The men had higher risk than the women (adjusted odds-ratio 1.99, 95% CI 1.43-2.78). Compared to executives, intellectual professionals and teachers, labourers had the highest risk (6.40, 3.55-11.52). They were followed by farmers, craftsmen and tradesmen (6.18, 2.86-13.08), technicians (3.14, 1.41-6.70), employees (2.94, 1.59-5.48) and other subjects (3.87, 1.90-7.88). The young (< or = 29 yr) showed an increased risk. Similar odds-ratios were observed for regular psychotropic drug use (1.54, 1.16-2.05) and the presence of a disease (1.50, 1.11-2.02). Univariate analysis showed that smoking habit, overweight and excess alcohol use were also associated with injuries. The loglinear model results showed that there were associations between some of these independent factors. It was concluded that job, sex, young age, smoking habit, excess alcohol use, overweight, psychotropic drug use, and disease influenced the occupational injuries. Preventive measures concerning work conditions, risk assessment and job knowledge should be conducted in overall active population, especially in men, young workers, smokers, alcohol users, overweight workers and in individuals with a disease or psychosomatic disorders.

The burden of musculoskeletal conditions.

OBJECTIVE: Despite the burden of rheumatic and musculoskeletal diseases (RMDs), these conditions probably deserve more attention from public health authorities in several countries including developed ones. We assessed their contribution to disability. METHODS: Data on disabilities associated with RMDs were extracted from the national 2008-2009 Disability-Health Survey of 29,931 subjects representative of the population in France. We used the core set of disability categories for RMDs of the World Health Organization's International Classification of Functioning, Disability and Health for analysis. Diagnosis and disabilities were self-reported. We assessed the risk of disability associated with RMDs using odds ratios (ORs) and the societal impact of RMDs using the average attributable fraction (AAF). RESULTS: Overall 27.7% (about 17.3 million people) (95% CI 26.9-28.4%) of the population reported having RMDs. The most prevalent RMDs were low back pain (12.5%, 12.1-13.1) and osteoarthritis (12.3%, 11.8-12.7). People reporting osteoarthritis were more disabled in walking (adjusted OR 1.9, 1.7-2.2) than those without. People reporting inflammatory arthritis were more limited in activities of daily living (from 1.4, 1.2-1.8 for walking to 2.1, 1.5-2.9 for moving around). From a societal perspective, osteoarthritis was the main contributor to activity limitations (AAF 22% for walking difficulties). Changing jobs was mainly attributed to neck pain (AAF 13%) and low back pain (11.5%). CONCLUSION: RMDs are highly prevalent and significantly affect activity limitations and participation restrictions. More effort is needed to improve care and research in this field.

Respective contribution of chronic conditions to disability in France: results from the national Disability-Health Survey.

BACKGROUND: Representative national data on disability are becoming increasingly important in helping policymakers decide on public health strategies. We assessed the respective contribution of chronic health conditions to disability for three age groups (18-40, 40-65, and >65 years old) using data from the 2008-2009 Disability-Health Survey in France. METHODS: Data on 12 chronic conditions and on disability for 24,682 adults living in households were extracted from the Disability-Health Survey results. A weighting factor was applied to obtain representative estimates for the French population. Disability was defined as at least one restriction in activities of daily living (ADL), severe disability as the inability to perform at least one ADL alone, and self-reported disability as a general feeling of being disabled. To account for co-morbidities, we assessed the contribution of each chronic disorder to disability by using the average attributable fraction (AAF). FINDINGS: We estimated that 38.8 million people in France (81.7% [95% CI 80.9;82.6]) had a chronic condition: 14.3% (14.0;14.6) considered themselves disabled, 4.6% (4.4;4.9) were restricted in ADL and 1.7% (1.5;1.8) were severely disabled. Musculoskeletal and sensorial impairments contributed the most to self-reported disability (AAF 15.4% and 12.3%). Neurological and musculoskeletal diseases had the largest impact on disability (AAF 17.4% and 16.4%, respectively). Neurological disorders contributed the most to severe disability (AAF 31.0%). Psychiatric diseases contributed the most to disability categories for patients 18-40 years old (AAFs 23.8%-40.3%). Cardiovascular conditions were also among the top four contributors to disability categories (AAFs 8.5%-11.1%). CONCLUSIONS: Neurological, musculoskeletal, and cardiovascular chronic disorders mainly contribute to disability in France. Psychiatric impairments have a heavy burden for people 18-40 years old. These findings should help policymakers define priorities for health-service delivery in France and perhaps other developed countries.

Toll motorway accessibility for wheelchair users: a survey.

OBJECTIVE: To identify difficulties encountered by wheelchair users who travel on toll motorways, with the goal of defining areas for improvement. DESIGN: Survey. After observing a wheelchair user travelling on a toll motorway and using the associated services, we designed a self-questionnaire on perceptions by wheelchair users of toll motorway accessibility. SETTING: Toll motorway and rehabilitation hospital in France. SUBJECTS: We recruited 167 wheelchair users by advertisement and, to assess selection bias, 19 consecutive outpatients who visited our hospital's wheelchair showroom. INTERVENTION: None. RESULTS: Of the 186 included subjects, 91 (49%) were used to driving independently on toll motorways. Among them, only 16% used automatic toll booths and 32% reported difficulties at toll booths. Furthermore, 53% routinely asked for help at filling stations, and only 27% were aware of the availability of a free-of-charge assistance service for disabled people at some filling stations. Among the 186 toll motorway users, only 84 (45%) reported never encountering difficulties in lay-bys; 162 (87%) felt that toilet accessibility was the most important feature of lay-bys and 143 (77%) preferred the locked toilets reserved for disabled people. CONCLUSION: Wheelchair users reported difficulties on toll motorways that could be corrected fairly easily.

Knee arthroplasty: disabilities in comparison to the general population and to hip arthroplasty using a French national longitudinal survey.

BACKGROUND: Knee arthroplasty is increasing exponentially due to the aging of the population and to the broadening of indications. We aimed to compare physical disability and its evolution over two years in people with knee arthroplasty to that in the general population. A secondary objective was to compare the level of disabilities of people with knee to people with hip arthroplasty. METHODOLOGY/PRINCIPAL FINDINGS: 16,945 people representative of the French population were selected in 1999 from the French census and interviewed about their level of disability. This sample included 815 people with lower limb arthroplasty. In 2001, 608 of them were re-interviewed, among whom 134 had knee arthroplasty. Among the other participants re-interviewed, we identified 68 who had undergone knee arthroplasty and 145 hip arthroplasty within the last two years (recent arthroplasty). People with knee arthroplasty reported significantly greater difficulties than the general population with bending forward (odds ratio [OR] = 4.7; 95% confidence interval [CI]: 1.7, 12.6), walking more than 500 meters (OR = 6.0; 95% CI: 1.5, 24.7) and carrying 5 kg kilograms for 10 meters (OR = 4.6; 95% CI: 1.3, 16.4). However, the two years evolution in disability was similar to that in the general population for most activities. The level of mobility was similar between people with recent knee arthroplasty and those with recent hip arthroplasty. Nevertheless, people with recent knee arthroplasty reported a lower level of disability than the other group for washing and bending forward (OR = 0.3; 95% CI: 0.1, 0.6 and OR = 0.4; 95% CI: 0.1, 0.9, respectively). CONCLUSIONS/SIGNIFICANCE: People with knee arthroplasty reported a higher risk of disability than the general population for common activities of daily living but a similar evolution. There was no relevant difference between recent knee and hip arthroplasties for mobility.