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.

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.

Depression prevalence and primary care among vulnerable patients at a free outpatient clinic in Paris, France, in 2010: results of a cross-sectional survey.

BACKGROUND: Data on the prevalence of depression and on how a depressive episode prompts the sufferer to seek primary care are not scarce, but the available evidence on the prevalence of depression among immigrants and poor people who frequent general practice facilities is scarce. The Baudelaire Outpatient Clinic at the Saint-Antoine Hospital in Paris provides free medical and social assistance to the poor and/or uninsured. The goal of our study was to estimate the prevalence of depression among these outpatients, to characterize this depressed population, and to analyze its demand for primary care for depressive episodes. METHODS: From September to December 2010, we conducted a cross-sectional, observational survey among users of the Baudelaire Outpatient Clinic. French-speaking patients attending the clinic between September 15 and December 30, 2010 who agreed to answer a questionnaire administered face-to-face before their consultation were included in the study. The chi-squared test (or Fisher's exact test for small samples) was used for the comparisons of proportions. Logistic regression models were estimated, along with the odds ratios (OR) and their 95% confidence intervals (95% CIs), for the multivariate analysis of factors associated with depression and healthcare-seeking. Models were estimated separately for men and women, since sex was an interaction factor. The statistical analyses were performed using Stata v. 10 software (StataCorp LP, College Station, Texas, USA). RESULTS: Of the 250 patients included (mean age: 45 years), 52.0% were men and 52.4% were immigrants. Close to 40% of them reported having no supplemental health insurance. The estimated prevalence of depression in this population was 56.7%. Depression was more prevalent among the women, immigrants, and people from the poorer socioeconomic groups. Only half of these depressed patients, mostly women, reported having discussed their depression with a physician. French nationality and complete health insurance coverage were associated with more-frequent healthcare-seeking. Few patients reported having been asked about their morale by the physician they consulted, and almost 80% would have liked to be asked about this more often. CONCLUSION: Depression is a real public health problem, particularly among people from disadvantaged backgrounds, and should be included in their overall management.

Causes of deaths data, linkages and big data perspectives.

The study of cause-specific mortality data is one of the main sources of information for public health monitoring. In most industrialized countries, when a death occurs, it is a legal requirement that a medical certificate based on the international form recommended by World Health Organization's (WHO) is filled in by a physician. The physician reports the causes of death that directly led or contributed to the death on the death certificate. The death certificate is then forwarded to a coding office, where each cause is coded, and one underlying cause is defined, using the rules of the International Classification of Diseases and Related Health Problems, now in its 10th Revision (ICD-10). Recently, a growing number of countries have adopted, or have decided to adopt, the coding software Iris, developed and maintained by an international consortium1. This whole standardized production process results in a high and constantly increasing international comparability of cause-specific mortality data. While these data could be used for international comparisons and benchmarking of global burden of diseases, quality of care and prevention policies, there are also many other ways and methods to explore their richness, especially when they are linked with other data sources. Some of these methods are potentially referring to the so-called "big data" field. These methods could be applied both to the production of the data, to the statistical processing of the data, and even more to process these data linked to other databases. In the present note, we depict the main domains in which this new field of methods could be applied. We focus specifically on the context of France, a 65 million inhabitants country with a centralized health data system. Finally we will insist on the importance of data quality, and the specific problematics related to death certification in the forensic medicine domain.

Cervical cancer screening among homeless women in the Greater Paris Area (France): results of the ENFAMS survey.

Little is known about the prevalence of cervical cancer screening (CCS) and its correlates among homeless women in France. The objectives of this study were to determine the prevalence of women who had never been screened for cervical cancer and to identify the associated factors. This cross-sectional study was based on data collected in the ENFAMS survey, which was conducted in 2013 among 764 sheltered homeless mothers in the Greater Paris Area. Robust Poisson regression models were used to estimate the association between no lifetime CCS and certain sociodemographic and health-related factors (selected from the behavioral model of vulnerable populations). Analyses were carried out separately for women with and without a regular gynaecological follow-up (RGF). The proportion of never-screeners was 33% among the women with an RGF versus 64% among those without an RGF (P<0.001). Among the latter, never having been screened for CCS was associated mainly with socioeconomic conditions, the length of time lived in France, a history of delivery in France and the duration of homelessness. In those with an RGF, the factors were mainly poor health service utilization and language difficulties. This first quantitative study of CCS among homeless women in the Greater Paris Area points to the need for it to be proposed and performed more systematically in primary care. Every contact between this hard-to-reach population and health services should be an opportunity to check their screening status and to ensure that those in need actually undergo a Pap test.

Prevention of Medical Events During Air Travel: A Narrative Review.

Prior to traveling, and when seeking medical pretravel advice, patients consult their personal physicians. Inflight medical issues are estimated to occur up to 350 times per day worldwide (1/14,000-40,000 passengers). Specific characteristics of the air cabin environment are associated with hypoxia and the expansion of trapped gases into body cavities, which can lead to harm. The most frequent medical events during air travel include abdominal pain; ear, nose, and throat pathologies; psychiatric disorders; and life-threatening events such as acute respiratory failure or cardiac arrest. Physicians need to be aware of the management of these conditions in this unusual setting. Chronic respiratory and cardiovascular diseases are common and are at increased risk of acute exacerbation. Physicians must be trained in these conditions and inform their patients about their prevention.

Views of general practitioners on indoor environmental health risks in the perinatal period.

BACKGROUND: Home is generally perceived as a safety place, whereas the concentration of pollutants, influenced not only by external pollution but also by human activities, the presence of domestic animals, construction and furniture materials, are sometimes greater than outside. OBJECTIVES: The aim of this study is to determine the general practitioners' (GPs) views on indoor environmental health risks in the perinatal period. METHODS: Four semi-structured focus group with 31 GPs were conducted in two French departments in November 2009, February, March, and April 2010. The focus group meetings were analyzed using a general thematic analysis. RESULTS: Perinatal care is a special health issue and a time of privileged sensitization. The attitude of health risks are well known in the case of "traditionally" toxic substances. In the case of "emerging" environmental exposure, these attitudes depend on the knowledge, beliefs, and experience specific to each practitioner. GPs are acquiring a new role in the field of environmental health, while at the same time coming to grips with its own strengths and limitations. The implementation of prevention depends on factors, which are not only specific to the practitioner but also related to the parents and the organization of the medical practice. CONCLUSION: The sensitization of GPs to environmental medicine, promotion of eco-citizen education, development of research, and the distribution of information are some of the means which need to be implemented to prevent harmful exposure of the infant.

Effects of Antenatal Maternal Depression and Anxiety on Children's Early Cognitive Development: A Prospective Cohort Study.

INTRODUCTION: Studies have shown that depression or anxiety occur in 10-20% of pregnant women. These disorders are often undertreated and may affect mothers and children's health. This study investigates the relation between antenatal maternal depression, anxiety and children's early cognitive development among 1380 two-year-old children and 1227 three-year-old children. METHODS: In the French EDEN Mother-Child Cohort Study, language ability was assessed with the Communicative Development Inventory at 2 years of age and overall development with the Ages and Stages Questionnaire at 3 years of age. Multiple regressions and structural equation modeling were used to examine links between depression, anxiety during pregnancy and child cognitive development. RESULTS: We found strong significant associations between maternal antenatal anxiety and poorer children's cognitive development at 2 and 3 years. Antenatal maternal depression was not associated with child development, except when antenatal maternal anxiety was also present. Both postnatal maternal depression and parental stimulation appeared to play mediating roles in the relation between antenatal maternal anxiety and children's cognitive development. At 3 years, parental stimulation mediated 13.2% of the effect of antenatal maternal anxiety while postnatal maternal depression mediated 26.5%. DISCUSSION: The partial nature of these effects suggests that other mediators may play a role. Implications for theory and research on child development are discussed.

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.

Renal thrombotic microangiopathy and FIP1L1/PDGFRα-associated myeloproliferative variant of hypereosinophilic syndrome.

We report a case of renal thrombotic microangiopathy (TMA) in a myeloproliferative variant of hypereosinophilic syndrome (HES) in a 24-year-old man which resolved with imatinib therapy. This is one of a few cases in the literature to date describing TMA in HES, suggesting that the pathogenesis of thrombosis is at least in part related to damage from activated eosinophils.