From loss to repair. A study of body narratives in patient claims for medical injury.

In this article we examine the body's status in the complaints that patients filed with a compensation agency. Taking a corpus of letters, we analyse the way in which the patients mobilise their bodily experience from the angle of the damage for which they demand compensation. To this end, we articulate an approach in terms of the sociology of complaint with an approach rooted in the sociology of medicine, health and illness. To analyse the body narratives, we use the notion of loss. We highlight the manner in which patients approach their losses as 'losses in practice'. These losses are defined by the patients putting forward the concrete experience of a body harmed by the treatment received, and by their formulation of expectations in terms of compensation. We therefore identify four ways in which the reality of the damaged body is given a form in terms of expectations of repair: the 'body-producer', the 'body-ecological', the 'body-help' and the 'body-self-image'. Our analysis adds to studies on the status of the body in care and in complaint by showing: the specific influence of the enunciative situation, the plurality of patient evaluations and their temporal dynamic.

Why underserved patients do not consult their general practitioner for depression: results of a qualitative and a quantitative survey at a free outpatient clinic in Paris, France.

BACKGROUND: The prevalence of depression in the general population is 5 to 10% but can exceed 50% in the most socially vulnerable populations. The perceptions of this disease are widely described in the literature, but no research has been carried out in France to explain the reasons for not consulting a general practitioner during a depressive episode, particularly in people in the most precarious situations. The objective of this study was to describe the reasons for not seeking primary care during a depressive episode in a socially vulnerable population. METHODS: An exploratory sequential design with a preliminary qualitative study using a phenomenological approach. Subsequently, themes that emerged from the qualitative analysis were used in a questionnaire administered in a cross-sectional observational study at a free outpatient clinic in Paris in 2010. Lastly, a logistic regression analysis was performed. RESULTS: The qualitative analysis revealed four aspects that explain the non-consulting of a general practitioner during a depressive episode: the negative perception of treatment, the negative perception of the disease, the importance of the social environment, and the doctor-patient relationship. The quantitative analysis showed that close to 60% of the patients who visited the free clinic were depressed and that only half of them had talked with a care provider. The results of the statistical analysis are in line with those of the qualitative analysis, since the most common reasons for not seeing a general practitioner were the negative perception of the disease (especially among the men and foreigners) and its treatments (more often among the men and French nationals). CONCLUSIONS: Close to 50% of the depressed individuals did not seek primary care during a depressive episode, and close to 80% of them would have liked their mental health to be discussed more often by a health professional. Better information on depression and its treatments, and more-systematic screening by primary care personnel would improve the treatment of depressed patients, especially those in the most precarious situations.

Use of the internet as a health information resource among French young adults: results from a nationally representative survey.

BACKGROUND: The Internet is one of the main resources of health information especially for young adults, but website content is not always trustworthy or validated. Little is known about this specific population and the importance of online health searches for use and impact. It is fundamental to assess behaviors and attitudes of young people looking for online health-related information and their level of trust in such information. OBJECTIVE: The objective is to describe the characteristics of Internet users aged 15-30 years who use the Web as a health information resource and their trust in it, and to define the context and the effect of such use on French young adults' behavior in relation to their medical consultations. METHODS: We used the French Health Barometer 2010, a nationally representative survey of 27,653 individuals that investigates population health behaviors and concerns. Multivariate logistic regressions were performed using a subsample of 1052 young adults aged 15-30 years to estimate associations between demographics, socioeconomic, and health status and (1) the use of the Internet to search for health information, and (2) its impact on health behaviors and the physician-patient relationship. RESULTS: In 2010, 48.5% (474/977) of Web users aged 15-30 years used the Internet for health purposes. Those who did not use the Internet for health purposes reported being informed enough by other sources (75.0%, 377/503), stated they preferred seeing a doctor (74.1%, 373/503) or did not trust the information on the Internet (67.2%, 338/503). However, approximately 80% (371/474) of young online health seekers considered the information found online reliable. Women (P<.001) and people with higher sociocultural positions (OR 0.5, 95% CI 0.3-0.9 and OR 0.4, 95% CI 0.2-0.7 for employees and manual workers, respectively, vs individuals with executive or manager positions) were more likely to use the Internet for health purposes. For a subsample of women only, online health seeking was more likely among those having a child (OR 1.8, 95% CI 1.1-2.7) and experiencing psychological distress (OR 2.0, 95% CI 1.0-4.0). Finally, for online health seekers aged 15-30 years, one-third (33.3%, 157/474) reported they changed their health behaviors (eg, frequency of medical consultations, way of taking care of one's own health) because of their online searches. Different factors were associated with different outcomes of change, but psychological distress, poor quality of life, and low income were the most common. CONCLUSIONS: The Internet is a useful tool to spread health information and prevention campaigns, especially to target young adults. Young adults trust online information and consider the Internet as a valid source of health advice. Health agencies should ensure the improvement of online health information quality and the creation of health-related websites and programs dedicated to young adults.

The role of a lack of social integration in never having undergone breast cancer screening: results from a population-based, representative survey in the Paris metropolitan area in 2010.

OBJECTIVES: This study aims to investigate the association between social contact and social support and women's breast cancer screening (BCS) practices, taking their socioeconomic status (SES) into account. METHODS: The SIRS survey was conducted in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For the 784 women aged 50years or older with no history of breast cancer, multivariate logistic regressions and bootstrap methods were used to analyze the factors associated with never having undergone BCS. RESULTS: 6.5% of these women had never undergone BCS. In multivariate analysis, being older, having a low education level, having poor-quality health insurance, and having one or less than one social contact per 3-day period were significantly associated with never having undergone BCS during their lifetime, but the level of social support was not. The strength of the association with a low frequency of social contact tended to increase with age. CONCLUSION: This study analyzed the role of social contact in social inequalities in BCS practices in the Paris metropolitan area. Like SES, social integration and social isolation should be taken into consideration by public health professionals and practitioners when planning BCS programs and incentives.

Prevalence and socioeconomic and geographical inequalities of household food insecurity in the Paris region, France, 2010.

BACKGROUND: Food insecurity (FI) is the situation where people do not have, at all times, access to sufficient, safe and nutritious food that meets their dietary needs for an active and healthy life. The objectives of this study were to estimate the prevalence of FI in the Paris area by using, for the first time in France, a specific FI questionnaire and to identify the characteristics of food-insecure households, taking into account a potential neighbourhood effect. METHODS: This study is based on data from the third wave of the SIRS cohort study (a representative, population-based socioepidemiological study) that were analysed using a cross-sectional design. In 2010, 3000 individuals in the Paris metropolitan area (PMA) were interviewed. FI was investigated by means of the USDA's HFSSM. We used stratified multilevel models across three household income categories to identify populations at risk for FI. RESULTS: In 2010, 6.30% (95% CI = [4.99-7.97]) of the households in the PMA experienced FI (up to 13.59% in the most underprivileged neighbourhoods). About 2.50% of the households experienced severe FI and 2.85% of household living with an income above 1666 € experienced food insecurity, whereas the percentage raises to 23.38% among those living below the poverty threshold (< 791 €). Depending on the income level, different household characteristics emerged as being associated with FI. In the poorest households, the presence of a child under 3 years of age was associated with an increased risk of FI (OR = 2.11; p = 0.03). Among higher-income households, the household composition appeared to be strongly associated with FI. CONCLUSION: FI exists in several social groups in France. Its prevalence in the most underprivileged households should be considered an indicator of vulnerability, which could permit targeted social assistance policies.

Who still eats three meals a day? Findings from a quantitative survey in the Paris area.

In France, mealtimes constitute a strong cultural trait, especially the three-meal pattern. The aim of our study was to test whether this pattern is still prevailing and to what extent familial structure, gender, poverty and migration have an effect on meal frequency. This study is based on a cross-sectional analysis of data collected in 2010 in the SIRS cohort study among a representative sample of 3006 adults in the Paris metropolitan area. We developed simple logistic models and multinomial logistic models. Results confirmed that the three-meal pattern remains strongly rooted in food habits in the Paris area. For three meals a day, the presence of a partner was more significant than the presence of children in the household. However, the study highlighted that one out of four inhabitants declared eating two meals a day only. The results emphasized gender differences in eating two meals a day, as being less frequent but more distinctive for women than for men. For women indeed, it was mainly linked to economic and social vulnerability (women below the poverty line, foreigners, in single parent families). In this respect, the paper provides new insights into the social differentiation of meal patterns, and calls for further analysis.

Overweight according to geographical origin and time spent in France: a cross sectional study in the Paris metropolitan area.

BACKGROUND: For the first time in France in a population-based survey, this study sought to investigate the potential impact of migration origin and the proportion of lifetime spent in mainland France on body mass index (BMI) and overweight in adults living in the Paris metropolitan area. METHODS: A representative, population-based, random sample of the adult, French speaking population of the Paris metropolitan area was interviewed in 2005. Self-reported BMI (BMI = weight/height²) and overweight (BMI ≥ 25) were our 2 outcomes of interest. Two variables were constructed to estimate individuals' migration origin: parental nationality and the proportion of lifetime spent in mainland France, as declared by the participants. We performed multilevel regression models among different gender and age groups, adjusted for demographics and socioeconomic status. RESULTS: In women, a parental origin in the Middle East or North Africa (MENA) was associated with a higher risk of being overweight (especially before the age of 55) and a higher BMI (between 35 and 54 years of age), and so were women of Sub-Sahara African parental origin in the middle age category. Only in the youngest men (< 35 years of age) did we observe any association with parental nationality, with a higher BMI when having a MENA parentage. Regarding the association between the proportion of lifetime spent in France and overweight, we observed that, in women, a proportion of 50% to 99% appeared to be associated with overweight, especially after the age of 35. In men, having spent more than half of one's lifetime in France was associated with a higher risk of overweight among oldest men. CONCLUSIONS: Our results plea for potential cultural determinants of overweight in the migrant and migrants-born populations in the French context of the capital region. Taking into account the people' family and personal migration histories may be an important issue in public health research and policies on overweight and obesity prevention.

Gender, socio-economic status, migration origin and neighbourhood of residence are barriers to HIV testing in the Paris metropolitan area.

In France, numerous HIV patients still discover their HIV status as a result of AIDS-related symptoms. We investigated factors related to the absence of any HIV testing in men and women separately, using the data from the SIRS cohort, which includes 3023 households representative of the Paris metropolitan area in 2005. The failure to use HIV testing services was studied in relation to individual socio-economic and demographic factors as well as some psychosocial characteristics. The effect of the characteristics of the residential neighbourhood was also analysed using multilevel models. In multivariate analysis, the factors associated with no history of HIV testing in women were an age >44 years, the absence of any pregnancy during the previous 15 years, a low education level, unemployment, to have had no or only one steady relationship in one's lifetime, to have a religious affiliation and to live in a poor neighbourhood. In men, factors were age <30 or >44 years, to have had no or only one steady relationship during one's lifetime, to have a religious affiliation and to perceive oneself as being at low risk of HIV infection. An association according to the "migration origin" was observed among men: foreigners and French men born to (at least) one foreign parent were more likely not to have been tested than French men born to two French parents. We conclude that gender, social and territorial differences exist in HIV testing among people living in the Paris area. More systematic proposals of HIV test in primary care would be an effective policy to overcome these persistent social stratifications.

Family social environment in childhood and self-rated health in young adulthood.

BACKGROUND: Family social support, as a form of social capital, contributes to social health disparities at different age of life. In a life-course epidemiological perspective, the aims of our study were to examine the association between self-reported family social environment during childhood and self-reported health in young adulthood and to assess the role of family functioning during childhood as a potential mediating factor in explaining the association between family breakup in childhood and self-reported health in young adulthood. METHODS: We analyzed data from the first wave of the Health, Inequalities and Social Ruptures Survey (SIRS), a longitudinal health and socio-epidemiological survey of a random sample of 3000 households initiated in the Paris metropolitan area in 2005. Sample-weighted logistic regression analyses were performed to determine the association between the quality of family social environment in childhood and self-rated health (overall health, physical health and psychological well-being) in young adults (n = 1006). We used structural equation model to explore the mediating role of the quality of family functioning in childhood in the association between family breakup in childhood and self-rated health in young adulthood. RESULTS: The multivariate results support an association between a negative family social environment in childhood and poor self-perceived health in adulthood. The association found between parental separation or divorce in childhood and poor self-perceived health in adulthood was mediated by parent-child relationships and by having witnessed interparental violence during childhood. CONCLUSION: These results argue for interventions that enhance family cohesion, particularly after family disruptions during childhood, to promote health in young adulthood.

[Not Available]. / Recherche d'information en santé sur l'internet : une analyse contextuelle des données SIRS, une cohorte parisienne.

From a public healthcare point of view, the Internet rapidly emerged as a potentially useful tool for providing information to patients and for promoting healthcare. While the individual factors involved in the use of online healthcare information are now well known, the effect of the area of residence has been largely ignored. The object of this study is to assess the impact of contextual characteristics associated with the neighbourhood and area of residence on the use of internet for accessing healthcare information. Analyses of multilevel logistical regression were carried out on data drawn from the SIRS cohort, a representative sample of the population in the Paris metropolitan area in 2005. Variations between neighbourhoods were observed both in the general use of internet and, more specifically, in the search for information concerning healthcare. This variability tends to decrease when individual factors are taken into account, which points to an "effect of composition", and disappears altogether when the characteristics of the area of residence are added, indicating a "contextual effect". Individual inequalities of access to internet are even greater in the most underprivileged areas. By contrast, while individual obstacles are also reflected here, the probability of using the internet for issues of healthcare is higher in neighbourhoods that include a large proportion of unqualified people. From the point of view of reducing social inequalities in the realm of healthcare, an active promotion of internet access and training of both individuals and doctors are required both at an individual and at a social level in order that the internet may constitute a medium for publicizing prevention and the promotion of useful and widely used healthcare.

Association between unemployment and the co-occurrence and clustering of common risky health behaviors: Findings from the Constances cohort.

BACKGROUND: Unemployment is associated with a high prevalence of risky health behaviors. Mortality increases with the number of co-occurring risky behaviors but whether these behaviors co-occur with a greater than expected frequency (clustering) among unemployed people is not known. METHODS: Differences according to unemployment status in co-occurrence and clustering of smoking, alcohol abuse, low leisure-time physical activity and unhealthy diet (marked by low fruit and vegetable intake) were assessed in 65,630 salaried workers, aged 18 to 65, who were participants in Constances, a French population-based cohort. Among them, 4573 (7.0%) were unemployed without (n = 3160, 4.8%) or with (n = 1413, 2.1%) past experience of unemployment. RESULTS: Compared to the employed, unemployed participants without or with past experience of unemployment were similarly overexposed to each risky behavior (sex and age adjusted odds-ratios ranging from 1.38 to 2.19) except for low physical activity, resulting in higher rates of co-occurrence of two, three and four behaviors (relative risk ratios, RRR 1.20 to 3.74). Association between behavior co-occurrence and unemployment did not vary across gender, partnership status or income category. Risky behavior clustering, i.e., higher than expected co-occurrence rates based on the prevalence of each behavior, was similar across unemployment status. The same observations can be made in employed participants with past experience of unemployment, although overexposure to risky behaviors (ORs 1.15 to 1.38) and increased rates of co-occurrence (ORs 1.19 to 1.58) were not as pronounced as in the unemployed. CONCLUSIONS: Co-occurrence of risky behaviors in currently and/or formerly unemployed workers is not worsened by behavior clustering. Engagement in each of these behaviors should be considered an engagement in distinct social practices, with consequences for preventive policies.

Health information seeking on the Internet: a double divide? Results from a representative survey in the Paris metropolitan area, France, 2005-2006.

BACKGROUND: The Internet is a major source of information for professionals and the general public, especially in the field of health. However, despite ever-increasing connection rates, a digital divide persists in the industrialised countries. The objective of this study was to assess the determinants involved in: 1) having or not having Internet access; and 2) using or not using the Internet to obtain health information. METHODS: A cross-sectional survey of a representative random sample was conducted in the Paris metropolitan area, France, in the fall of 2005 (n = 3023). RESULTS: Close to 70% of the adult population had Internet access, and 49% of Internet users had previously searched for medical information. Economic and social disparities observed in online health information seeking are reinforced by the economic and social disparities in Internet access, hence a double divide. While individuals who reported having a recent health problem were less likely to have Internet access (odds ratio (OR): 0.72, 95% confidence interval (CI): 0.53-0.98), it is they who, when they have Internet access, are the most likely to search for health information (OR = 1.44, 95% CI = 1.11-1.87). CONCLUSION: In the French context of universal health insurance, access to the Internet varies according to social and socioeconomic status and health status, and its use for health information seeking varies also with health beliefs, but not to health insurance coverage or health-care utilisation. Certain economic and social inequalities seem to impact cumulatively on Internet access and on the use of the Internet for health information seeking. It is not obvious that the Internet is a special information tool for primary prevention in people who are the furthest removed from health concerns. However, the Internet appears to be a useful complement for secondary prevention, especially for better understanding health problems or enhancing therapeutic compliance.

Internet use for mental health information and support among European university students: The e-MentH project.

The aim of the present study was to describe the socio-demographic variables associated with the use of the Internet for mental health information-seeking by European university students, including participants' trust in the Internet, and their use of the Internet in comparison to traditional formal mental health care. A cross-sectional anonymous 25-item survey was conducted with 2466 students in three courses (Computer Science, Law, Nursing) from four European universities (France, Ireland, Italy, Spain). Participants were equally distributed in all four countries; they were mostly females (57.5%), with a mean age of 21.6 years. Overall, female, French and Nursing students were more likely to look for mental health information. The majority (69.7%) of students reported that information about mental health on the Internet was unreliable. Among all participants, Spanish students reported a higher trust in web content. The findings suggest that university students frequently use the Internet for mental health information-seeking but not for mental health support. Furthermore, they do not entirely trust the Internet for mental health-related issues. This should be considered in planning Internet-based programmes for mental health promotion and prevention in university students.

Spanish students' use of the Internet for mental health information and support seeking.

The Internet is a growing source of information for health in general, with university student being online almost daily. Evaluating their use of the Internet for mental health information and support can help understanding if online tools and websites should be used for mental health promotion and, to some extent, care. A survey was conducted with more than 600 students of Law, Nursing and Computer Science of the University of Cadiz in Spain to determine their general use of the Internet and their perceptions and trust in using this medium for mental health information. Data were collected using a 25-item-questionnaire and findings indicated that students had a strong distrust in online mental health information, notwithstanding their daily use of the Internet. The frequency and methods of their research on the Internet correlated with their health status, their medical consultations and with certain socio-demographic characteristics.

The moral career of poor patients in free clinics.

This paper explores the lived experiences and the identity processes attached to attendance at free clinics. It draws on a qualitative study of 94 patients and 37 professionals who were interviewed at four free clinics in France. Since these facilities are for the poor and for people without health coverage, attendance reflects a medical experience as well as an experience of assistance, both of which have an impact on healthcare utilisation. Nevertheless, the meaning attached to the recourse to free clinics and the patients' lived experiences change over time and depend on interactions with clinic staff. This study proposes a typology of care recourse modes (occasional, regular and inconsistent attendance) crossed with different types of lived experiences. Occasional attendance and distant patient-professionals relationships, often due to the humiliation that some people feel when they have to ask for social assistance, characterise the first time people have recourse to care. Patients commit to regular follow-ups only when they have come to terms with their position in the medical and assistance system, doing so by rationalising and adjusting their identity. Our aim in discussing our findings is to gain greater insight into the utilisation of healthcare by different population groups and in different contexts.

Is there still a French eating model? A taxonomy of eating behaviors in adults living in the Paris metropolitan area in 2010.

BACKGROUND: Meal times in France still represent an important moment in everyday life. The model of three rigorously synchronized meals is still followed by a majority of people, while meal frequencies have flattened in other European or North-American countries. We aimed to examine the "French model" of eating behavior by identifying and characterizing distinct meal patterns. METHODS: Analyses were based on data from the SIRS cohort, a representative survey of the adult population in the Paris area. A clustering algorithm was applied to meal variables (number, time, location, with whom the meal is usually shared and activities associated with meals). Regression models were used to investigate associations between patterns and socio-demographic, social environment and perceived food quality variables. RESULTS: Five different patterns were identified among 2994 participants. The first three types (prevalence 33%, 17% and 24%) followed a three-meal pattern, with differences in locations and social interactions mainly related to time constraints and age. More marked differences were observed in the remaining two types. In the fourth type (prevalence 13%), individuals ate one or two meals per day, often with an irregular schedule, at home and in front of the television. They frequently were unemployed and had lower income. Breakfast skipping, increased snacking and a low adherence to dietary guidelines suggested that this behavior might have health consequences. In the fifth type (12%), people also ate two meals or less per day, possibly with the same consequences on food quality. However, meals were often taken outside the home, in social settings, and individuals following this pattern were typically active, integrated, young people, suggesting that this pattern might be an adaptation to a modern urban lifestyle. CONCLUSIONS: While a majority of the population still follows the three-meal pattern, our analysis distinguished two other eating patterns associated with specific sociological profiles.

"No-fault" compensation for victims of medical injuries. Ten years of implementing the French model.

CONTEXT: For decades and in many countries, the issue of compensation for victims of medical injuries has led to lively debates. In 2002, a law set up a new model for compensation in France - based on the creation of a "no fault" compensation scheme and of an out-of-court settlement mechanism. This is one of the most recent models to have been adopted in European countries. This article analyses the choices made by the law and discusses the key figures of its ten years of implementation. METHODS: We conducted (1) a study of debates regarding compensation for victims of medical injuries in France; (2) a comparative analysis of the different models of compensation which had already been adopted in different countries; (3) a study of primary sources provided by the bodies in charge of the French new out-of-court settlement mechanism; and (4) a statistical analysis of the exhaustive list of 18,258 claims filed between 2003 and 2009. RESULTS: The article highlights the context which led to the adoption of the 2002 law on the quality of care and patients' rights. It analyses, from a comparative standpoint, the specificities of the new compensation model set up by the law. It shows how the opportunities for victims of medical injuries to be compensated had improved in France. Finally, we discuss the limits of the new model and what the next step might be to improve access to compensation for victims of medical injuries.

Applying multivariate clustering techniques to health data: the 4 types of healthcare utilization in the Paris metropolitan area.

BACKGROUND: Cost containment policies and the need to satisfy patients' health needs and care expectations provide major challenges to healthcare systems. Identification of homogeneous groups in terms of healthcare utilisation could lead to a better understanding of how to adjust healthcare provision to society and patient needs. METHODS: This study used data from the third wave of the SIRS cohort study, a representative, population-based, socio-epidemiological study set up in 2005 in the Paris metropolitan area, France. The data were analysed using a cross-sectional design. In 2010, 3000 individuals were interviewed in their homes. Non-conventional multivariate clustering techniques were used to determine homogeneous user groups in data. Multinomial models assessed a wide range of potential associations between user characteristics and their pattern of healthcare utilisation. RESULTS: We identified four distinct patterns of healthcare use. Patterns of consumption and the socio-demographic characteristics of users differed qualitatively and quantitatively between these four profiles. Extensive and intensive use by older, wealthier and unhealthier people contrasted with narrow and parsimonious use by younger, socially deprived people and immigrants. Rare, intermittent use by young healthy men contrasted with regular targeted use by healthy and wealthy women. CONCLUSION: The use of an original technique of massive multivariate analysis allowed us to characterise different types of healthcare users, both in terms of resource utilisation and socio-demographic variables. This method would merit replication in different populations and healthcare systems.

Are immigrants and nationals born to immigrants at higher risk for delayed or no lifetime breast and cervical cancer screening? The results from a population-based survey in Paris metropolitan area in 2010.

OBJECTIVES: This study aims to compare breast cancer screening (BCS) and cervical cancer screening (CCS) practices of French women born to French parents with those of immigrants and nationals born to immigrants, taking their socioeconomic status into account. METHODS: The study is based on data collected in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For women with no history of breast or cervical cancer, multivariate logistic regressions and structural equation models were used to investigate the factors associated with never having undergone BCS or CCS. RESULTS: We confirmed the existence of a strong gradient, with respect to migration origin, for delaying or never having undergone BCS or CCS. Thus, being a foreign immigrant or being French of immigrant parentage were risk factors for delayed and no lifetime screening. Interestingly, we found that this gradient persisted (at least partially) after adjusting for the women's socioeconomic characteristics. Only the level of income seemed to play a mediating role, but only partially. We observed differences between BCS and CCS which suggest that organized CCS could be effective in reducing socioeconomic and/or ethnic inequities. CONCLUSION: Socioeconomic status partially explained the screening nonparticipation on the part of French women of immigrant origin and foreign immigrants. This was more so the case with CCS than with BCS, which suggests that organized prevention programs might reduce social inequalities.

The role of daily mobility in mental health inequalities: the interactive influence of activity space and neighbourhood of residence on depression.

The literature reports an association between neighbourhood deprivation and individual depression after adjustment for individual factors. The present paper investigates whether vulnerability to neighbourhood features is influenced by individual "activity space" (i.e., the space within which people move about or travel in the course of their daily activities). It can be assumed that a deprived residential environment can exert a stronger influence on the mental health of people whose activity space is limited to their neighbourhood of residence, since their exposure to their neighbourhood would be greater. Moreover, we studied the relationship between activity space size and depression. A limited activity space could indeed reflect spatial and social confinement and thus be associated with a higher risk of being depressed, or, conversely, it could be linked to a deep attachment to the neighbourhood of residence and thus be associated with a lower risk of being depressed. Multilevel logistic regression analyses of a representative sample consisting of 3011 inhabitants surveyed in 2005 in the Paris, France metropolitan area and nested within 50 census blocks showed, after adjusting for individual-level variables, that people living in deprived neighbourhoods were significantly more depressed that those living in more advantaged neighbourhoods. We also observed a statistically significant cross-level interaction between activity space and neighbourhood deprivation, as they relate to depression. Living in a deprived neighbourhood had a stronger and statistically significant effect on depression in people whose activity space was limited to their neighbourhood than in those whose daily travels extended beyond it. In addition, a limited activity space appeared to be a protective factor with regard to depression for people living in advantaged neighbourhoods and a risk factor for those living in deprived neighbourhoods. It could therefore be useful to take activity space into consideration more often when studying the social and spatial determinants of depression.