"We don't have the same bodies; we don't react the same way": mothers and adolescent girls' perceptions of the risks and benefits of HPV vaccination in France.

Human Papillomavirus (HPV) vaccination is one of the most publicly mistrusted vaccines in Europe, with countries such as France struggling with low vaccine uptake due to parental questioning of vaccine risks and benefits. However, limited evidence exists on adolescent girls' perceptions of the risks and benefits of HPV vaccination. The aim of this qualitative study was to provide an in-depth exploration and comparison of French mothers (n = 21) and adolescent girls' (n = 36) perceptions of the risks and benefits of HPV vaccination. A thematic analysis showed that adolescent girls and mothers perceived the risks and benefits of HPV vaccination differently, with girls reporting positive and beneficial views and emotions toward vaccination and mothers expressing concerns about possible risks. Adolescent girls also reported that both perceptions and actual risks and benefits may vary from one individual to another. Vaccine safety was also understood differently, with mothers reporting a widespread view that vaccines are unsafe and focusing on controversial side effects and girls discussing short-term consequences of vaccination (e.g. pain, fever) and administration and storage issues. Strategies to improve uptake of HPV vaccination should consider and address both the mothers' and daughters' perceptions and understandings of HPV vaccination.

'I trust them because my mum trusts them': Exploring the role of trust in HPV vaccination decision-making among adolescent girls and their mothers in France.

The success of vaccination programmes relies on high uptake and acceptance of vaccines, which is in part influenced by public trust in vaccines, providers, policy-makers and information. France is one of the countries in the world with the lowest confidence in vaccination, with parents expressing particular concerns about the human papillomavirus (HPV) vaccine. This qualitative study explored the role of trust in HPV vaccination decision-making among mothers and adolescent girls in France. Semi-structured interviews and focus groups were conducted with 15-16-year-old adolescent girls and their mothers in Paris. A thematic analysis based on deductive and inductive coding was conducted. HPV vaccination decision-making was described as a complex and uncertain process, a possible consequence of erosion of trust in the vaccine, in healthcare professionals and health authorities, and in information itself. Due to public criticism of the vaccine and conflicting advice received from medical professionals, the vaccine was perceived as controversial. The mothers' strong trust in doctors did not always increase HPV vaccine acceptance, as doctors themselves failed to recommend or recommended against the vaccine. Furthermore, the perceived mismanagement of previous health events tainted the mothers' trust in health authorities. Contrastingly, while adolescents expressed trust in doctors and health authorities, their trust in their own mothers was stronger. A lack of exposure to positive sources of information (e.g. from doctors, schools or media) contributed to low awareness about HPV vaccination among adolescent girls. While both mothers and girls discussed the importance of trusting themselves, they also acknowledged being influenced by others around them as well as information, often negative, from the internet. Adolescent girls also expressed mistrust about information in general, explaining that any information can be manipulated. Low confidence in HPV vaccination in France can be explained by broader trust issues, which will require long-term efforts to address.

The role of maturity in adolescent decision-making around HPV vaccination in France.

Mothers are often responsible for vaccination decisions in the household. However, their confidence in certain vaccines such as Human Papillomavirus (HPV) vaccines is eroding in some countries. France is one of the countries with the lowest HPV vaccine uptake in Europe, with parents delaying or refusing the vaccine for their adolescent daughters due to safety- and effectiveness-related concerns. Although parental consent is required for vaccination, adolescents' involvement in HPV vaccination decision-making could improve vaccine uptake, with self-consent procedures already introduced in some countries. Adolescents' capacity to engage in decision-making is influenced by their maturity and autonomy in health. This study explored the role of maturity in decision-making around HPV vaccination in France through qualitative interviews with adolescent girls (n = 24) and their mothers (n = 21) and two focus groups with adolescent girls (n = 12). A codebook approach to thematic analysis revealed that adolescent girls' involvement in HPV decision-making is a process that evolved with maturity. As adolescents progressed towards maturity at different speeds, some expressed childlike traits such as impulsive decisions and others described more rational, reflective decision-making. Despite these differences, most adolescents in this study described a passive role in HPV vaccination decision-making, following their parents' lead. However, their expressed desire for information and involvement in discussions indicates that their lack of engagement may not only be due to a lack of maturity but also a result of mothers and doctors excluding them from getting involved. Furthermore, as health behaviours are shaped during adolescence, the influence of vaccine hesitant mothers on their daughters' own views and beliefs could be significant, together with exposure to regular controversies in the mainstream media. Individualised approaches to engage adolescents in decision-making around their own health are needed, for example through strengthening discussions and information around HPV vaccination with parents and doctors.

The impact of the COVID-19 epidemic on primary care in South-eastern France: implementation of a real-time monitoring system based on regional health insurance system data.

BACKGROUND: The spring 2020 COVID-19 epidemic severely impacted France's healthcare system. The associated lockdown (17 March- 11 May 2020) and the risk of exposure to SARS-CoV-2 led patients to change their use of healthcare. This article presents the development and implementation of a real-time system to monitor i) private doctors' activity in South-eastern France, and ii) changes in prescription of drugs for people with diabetes, mental health disorders and for certain vaccines from Mars 2020 to October 2020. METHODS: Data extracted from the regional healthcare insurance databases for 2019 and 2020 were used to construct indicators of healthcare use. They were calculated on a weekly basis, starting from week 2 2020 and compared for the same period between 2019 and 2020. RESULTS: Private doctors' activity decreased during the spring 2020 lockdown (by 23 % for general practitioners and 46 % for specialists), followed by an almost complete return to normal after it ended until week 41. Over the same period, a huge increase in teleconsultations was observed, accounting for 30 % of private doctors' consultations at the height of the crisis. The start of the lockdown was marked by a peak in drug prescriptions, while vaccinations declined sharply (by 39 % for the measles, mumps and rubella (MMR) vaccine in children under 5 years old, and by 54 % for human papillomavirus vaccine in girls aged 10-14 years old). CONCLUSION: The ongoing COVID-19 epidemic may lead to health consequences other than those directly attributable to the disease itself. Specifically, lockdowns and foregoing healthcare could be very harmful at the individual and population levels. The latter issue is a concern for French public authorities, which have implemented actions aimed at encouraging patients to immediately seek treatment. However, the COVID-19 crisis has also created opportunities, such as the roll-out of teleconsultation and tele-expertise. The indicators described here as part of the monitoring system can help public decision-makers to become more responsive and to implement tailored actions to better meet the general population's healthcare needs.

[The impact of the COVID-19 pandemic on first-line primary care in southeastern France: Feedback on the implementation of a real-time monitoring system based on regional health insurance data]. / L'impact de l'épidémie de COVID-19 sur les soins de premier recours en région Provence-Alpes-Côte d'Azur : retour d'expérience sur la mise en place d'un dispositif de surveillance en temps réel à partir des données régionales de l'Assurance maladie.

BACKGROUND: Starting in spring 2020, the COVID-19 pandemic markedly impacted the French healthcare system. Lockdown and risks of exposure to the coronavirus induced patients to modify their ways of use. The objective of this article was to share feedback on the implementation of a real-time monitoring system concerning (a) the activity of private practitioners in southeastern France, and (b) the evolution of reimbursements for drugs prescribed to persons with diabetes, for treatment of mental health disorders, and for performance of some vaccines. METHODS: Data regarding 2019 and 2020 were extracted from regional health insurance databases. They were used to elaborate several indicators relative to the general health insurance scheme, which were calculated and updated each week, starting with week 2. RESULTS: We observed a drop in private physician activity during the lockdown (-23% for general practitioners; -46% for specialist doctors), followed by a return to a semblance of normalcy. Concomitantly, a boom in teleconsultations occurred: at the height of the crisis they represented 30% of medical acts. The initial stage of the lockdown was characterized by peak provisioning for drugs, whereas vaccination strongly declined (-39% regarding measles, mumps and rubella vaccine among children aged less than 5 years; -54% regarding human papillomavirus vaccine among girls aged 10 to 14 years). CONCLUSION: The COVID-19 pandemic could lead to health effects other than those directly attributable to the coronavirus itself. Renouncing care may result in healthcare delays highly deleterious for people and society. Public authorities are preoccupied with these questions; they have set up action plans aimed at encouraging patients to seek treatment without delay. That said, the COVID-19 pandemic crisis has also created opportunities, such as the expansion of telemedicine. Although partial, these indicators can provide useful information enabling public decision makers to be reactive and to implement specific actions to meet the health needs of the population.

Multi-trajectories of antidepressant and antipsychotic use: a 11-year naturalistic study in a community-based sample.

OBJECTIVE: To explore the temporal dynamic of antidepressant and antipsychotic co-prescribing in real-life conditions. METHODS: The study was performed using reimbursement data from the French Insurance Healthcare system in a cohort of 118 454 persons with at least one dispensing of antidepressants and/or antipsychotics over the period 2006-2016. Latent class analyses were used to identify homogeneous groups of persons following similar multi-trajectories of antidepressant and/or antipsychotic dispensing. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with distinct trajectories. RESULTS: Five multi-trajectories of antidepressant and/or antipsychotic dispensing were identified: more than half of the sample (58%) had very low antidepressant and antipsychotic use; two groups had chronic (12%) or decreasing (11%) antidepressant use with very low antipsychotic use; two groups used both antidepressants and antipsychotics simultaneously either in an increasing (12%) or chronic (7%) way. Persons with chronic antidepressant-antipsychotic use presented with markers of poor social and mental health conditions. CONCLUSIONS: Most persons using antipsychotics over the follow-up also used antidepressants over the same period. The benefit/risk ratio of these prescribing practices should be further explored as the long-term efficacy of antidepressant-antipsychotic polypharmacy is poorly documented, while this combination increases the risk of adverse effects.

Trajectory analysis of anxiolytic dispensing over 10 years among new users aged 50 and older.

OBJECTIVE: To identify temporal trajectories of anxiolytic benzodiazepine (A-BZD) use over 10 years among new A-BZD users aged 50 and older and describe treatment patterns and demographic and clinical characteristics associated with each trajectory. METHOD: A representative cohort of the French national health insurance fund users was tracked from 2006 through 2015. We used latent class mixed models to identify the trajectories. RESULTS: We observed four trajectories among new users (no A-BZD dispensing in 2005) plus one non-use trajectory. The proportion of occasional use among users was 60%; early increasing use, 10%; late increasing use, 17%; and increasing/decreasing use, 13%. Prevalence of occasional use decreased with age in women, but not men. Duration of treatment episodes and doses differed between trajectories. Multiple regression analyses with occasional use as the reference showed that the other three trajectories shared characteristics (age, coprescriptions of other psychotropic drugs, and more general practitioner consultations) but differed by the presence at inclusion or occurrence during follow-up of psychiatric, neurodegenerative, and somatic conditions. CONCLUSION: We found four different long-term temporal trajectories in new A-BZD users (occasional, early increasing, late increasing, and increasing/decreasing use). Difficulties quitting or reducing consumption may be very different for each trajectory, requiring tailored care approaches.

General practitioners and vaccination of children presenting with a benign infection.

PURPOSE: To assess the self-reported vaccination behavior of general practitioners (GPs) when asked whether they would recommend the vaccination of a child presenting with a febrile uncomplicated common cold. METHODS: We performed a cross-sectional survey in 2014 on a national sample of GPs. GPs were randomly assigned to one of eight clinical vignettes, all describing a child presenting with an uncomplicated febrile common cold, but differing by age (4 or 11 months), temperature (38°C or 39°C), and the mother's emotional state (calm or worried). GPs were asked whether they would recommend immediate vaccination of the child with a hexavalent vaccine (diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b, and hepatitis B), or postpone it. We investigated the relation between the GPs' recommendation to vaccinate, the clinical vignette's variables, and the GPs' perceptions, attitudes, and practices toward vaccination in a multivariate model. RESULTS: Among the 1582 participating GPs, 6% recommended immediate vaccination. This behavior was more frequent with a temperature of 38°C rather than 39°C (10% vs. 3%, P<0.001). GPs who felt comfortable giving explanations about vaccine safety were more likely to recommend immediate vaccination of the febrile child (P=0.045), but none of the other GPs' characteristics were associated with their vaccination behavior. CONCLUSIONS: Almost all GPs postponed the hexavalent vaccination of the febrile child presenting with an uncomplicated viral disease; fever being the major factor affecting their decision. More research is needed on vaccination responses in sick children, as well as clearer guidelines.

Discrepancies between general practitioners' vaccination recommendations for their patients and practices for their children.

OBJECTIVES: The objectives of our study were to describe the vaccination recommendations by general practitioners (GPs) for their patients and practices for their children, and to identify any discrepancies between them. METHODS: Applying multiple correspondence analysis and agglomerative hierarchical cluster analysis to data from a 2014 cross-sectional survey of a national sample of GPs, we constructed a typology based on the patterns of associations between GPs' vaccine recommendations to their patients and practices to their own children's vaccinations. RESULTS: This study includes the 1038 GPs who reported that they had at least one child aged 2-25 years. Nearly half (47%, 482/1021) reported that all of their children were vaccinated against hepatitis B but that they did not always recommend that vaccine to patients; the same discordance was observed among 36% (369/1027) for the measles-mumps-rubella vaccine, 19% (194/1013) to 28% (290/1019) for routine and catch-up meningococcal C vaccination, and 27% (136/496) for the human papillomavirus vaccine. Cluster analysis showed that 37% (95% CI 33%-39%) of GPs reported an above-average rate of systematic vaccine recommendations for their patients, and most reported that all their children were vaccinated (low level of discordance), whereas 60% (95% CI 58%-64%) had a high level of discordance, that is, most reported that their children were vaccinated, but did not always recommend the same vaccines to their patients. CONCLUSIONS: Many GPs do not report the same attitude concerning the vaccination of their children and their patients. The reasons underlying these discrepancies, possibly including vaccine hesitancy, should be investigated.

Papillomavirus vaccine coverage and its determinants in South-Eastern France.

OBJECTIVES: We wanted: (i) to assess vaccine coverage (VC) for papillomavirus (HPV) (one and three doses of the vaccine, VC1 and VC3) and compliance with the recommended vaccination regimen (3rd dose within 1 year after the 1st dose) among 14-16 year-old girls; and (ii) to identify the factors independently associated with VC and compliance with the recommended vaccination regimen. METHODS: We conducted a descriptive longitudinal study, using the National Health Insurance reimbursement database, for years 2007 to 2009, in South-Eastern France. We performed a multivariate analysis (Cox proportional hazards model). RESULTS: VC1 was 35.5%, with 68.8% of those who started vaccination having completed the 3-dose regimen, 64.1% within one year. VC1 and VC3 were positively associated with the girl's age. Girls covered by the complementary social welfare healthcare program and those living in rural areas had lower VC1 and VC3. Being covered by the complementary social welfare healthcare program was also associated with lower compliance with the recommended vaccination regimen. VC1 and VC3 were positively associated with the number of medical consultations during the study period. Important geographical variations were noted regarding VC1. CONCLUSIONS: Our study confirms that VC for HPV is insufficient in our region, and that there are socio-economic and geographical inequalities. Even though the vaccine is reimbursed for all girls, efforts must be made to improve VC, particularly for girls covered by the complementary social welfare healthcare program and those living in rural areas.

[Evaluation of hospital stays linkage quality to study health spatial variation. a feasibility study in three French regions]. / Évaluation de la qualité du chaînage des séjours hospitaliers pour l'étude des variations spatiales de santé à partir des données du PMSI. Étude de faisabilité dans trois régions françaises.

BACKGROUND: Since 2001, the French hospital stay databases (Programme de médicalisation des systèmes d'information, PMSI) have included a unique and anonymous identifier in order to cross-link discharge abstracts from a given patient, within and across hospitals. These data could be used to estimate prevalence for some diseases at a territorial level provided that linkage quality is good enough. Few morbidity data are available at this scale. This study analyzes the link between linkage quality and hospitalization rates in three French regions (Picardy, Brittany and Provence-Alpes-Côte d'Azur-Paca). METHODS: We studied short stays in medicine-chirurgical-obstetrical units for the 2004-2005 period (all stays, and stays with mention of cancer or asthma). To study linkage quality, the percentage of linkable stays (no error during the production of the anonymous identifier) was calculated at regional and territorial levels (areas used by regional health authorities). The interquartile range (IQR=third quartile-first quartile) of the percentage of linkable stays was calculated and the link between this percentage and standardized rates of people hospitalized at least once in 2004 or 2005 tested by Spearman correlation coefficients. RESULTS: For all stays, percentages of linkable stays were 94.4%, 96.6% and 97.0% in Picardy, Paca and Brittany respectively in 2004-2005. Geographical variation at the territorial level was higher in Picardy (IQR between 4 and 6) than in the two other regions (IQR between 1 and 2). The percentage of linkable stays was positively and significantly associated with the hospitalization rate for all stays and those with mention of cancer in Picardy only. CONCLUSION: According to these results, PMSI data earlier than 2006 should be used with precaution; linkage quality should be analyzed before making geographical or time comparisons of hospitalization rates. Comparisons cannot always be made. Other studies should be carried out in other regions, and to analyze recent trends in linkage quality.

Prevalence of treated diabetes: Geographical variations at the small-area level and their association with area-level characteristics. A multilevel analysis in Southeastern France.

AIM: This study estimated geographical variations in the prevalence of treated diabetes (TD) at the small-area level in Southeastern France to determine whether or not the characteristics of these areas (in particular, socioeconomic status or "SES") are associated with TD independent of person-level factors. METHODS: The study used drug reimbursement data for 2008 from the General Health Insurance Scheme in Southeastern France for beneficiaries aged 18 years or over. TD patients were defined as those to whom oral antidiabetic drugs or insulin had been dispensed at least three times within the year. Area (canton) characteristics associated with the prevalence of TD were studied using multilevel Poisson regression. RESULTS: In 2008, the crude prevalence of TD in adults in Southeastern France was 5.14%. In addition, TD prevalence was significantly higher in the more deprived and population-dense cantons independent of person-level factors (age, gender, low SES). CONCLUSION: This study found a positive association between area deprivation and TD, and adds further evidence to the scanty data so far available on this topic. This finding should contribute to pinpointing priority action areas for programmes of diabetes prevention. However, more research is needed to further elucidate the mechanism(s) linking area deprivation and diabetes.

Different reporting patterns for occupational diseases among physicians: a study of French general practitioners, pulmonologists and rheumatologists.

PURPOSE: Physicians can play an important role in the reporting of occupational diseases (ODs), which are still under-reported in many countries. We aimed to identify physicians' difficulties in recognizing and reporting ODs and to study the characteristics of the physicians that do report ODs. METHODS: We conducted a telephone study in 2006-2007 among general practitioners (GPs), pulmonologists and rheumatologists in south-eastern France, concerning their knowledge, attitudes and practice in occupational health. Simple and multiple logistic regressions were performed to study factors associated with the issue of medical certificates for the claim process. RESULTS: Three hundred and ninety-one GPs, 95 pulmonologists and 96 rheumatologists participated. GPs reported significantly less often than specialists that they questioned their patients on past occupational exposure. They more frequently reported difficulties in identifying the occupational origin of diseases, and lack of knowledge on the OD reporting system. Issue of medical certificates for OD reporting was significantly more frequent among specialists than among GPs, among physicians considering that ODs are a public health problem, among those acquainted with the forms required to establish certificates, using internet to obtain information, having trade union activities, or having contact with occupational physicians (OPs). CONCLUSION: Initial and continuing training should be developed to encourage physicians, in particular GPs, to question patients on their working conditions and to become better acquainted with claim procedures. Physicians should also be provided with tools for identification of ODs that are suited to their practices, and collaboration with OPs should be fostered.

[Occupational physicians and occupational cancers: attitudes, opinions, practices. A qualitative study in South Eastern France]. / Médecins du travail et cancers professionnels : attitudes, opinions et pratiques. Une recherche qualitative dans le Sud-Est de la France.

BACKGROUND: A qualitative study was conducted in 2008 of occupational physicians (OPs) in south-eastern France to document their attitudes, opinions and practices on prevention and screening of occupational cancers. This was done to provide elements to prepare the questionnaire of a quantitative study in 2009. METHODS: Semi-structured interviews were conducted using a structured interview guide with 20 OPs. The data collected were subjected to an analysis of thematic content type. RESULTS: The analysis revealed that OPs face many difficulties when preventing occupational cancers. For most of OPs, these difficulties appeared related to "external factors": lack of involvement of employers and minimization of risks by employers and employees. Lack of time, overload and, for some OPs, perceived lack of independence towards employers, were also mentioned as barriers to cancer prevention. This study also suggested hypotheses related to OPs themselves (internal factors): perceived lack of effectiveness and, trend to minimize the risks of occupational cancer in their geographical area. Finally, the results suggest a significant heterogeneity of OPs' practices regarding occupational cancer screening. CONCLUSION: These results raise several hypotheses that will be addressed further in the quantitative survey. They warn about the difficulties of a profession that seems to encounter a demographic and identity crisis.

[Impact of the estimation of the medically insured population on the pharmacological prevalence of diabetes at the regional and small area level]. / Impact de l'estimation de la population affiliée à l'assurance-maladie sur le calcul de la prévalence pharmacologique du diabète à l'échelle régionale et territoriale.

BACKGROUND: Data derived from Health Insurance databases are very useful for health observation. These data are however still underused, particularly for small local areas. This may be partly explained by the lack of reliable data on the number of insured people. Recent simplification of the Répertoire national interrégimes de l'assurance-maladie (RNIAM) indicator (French register of health insurance) gives the opportunity to improve the usefulness of these databases. This indicator specifies the beneficiaries' status towards the General Health Insurance Fund. This study aimed to select the population of beneficiaries, which could be most adequately used to calculate health indicators based on these data. METHODS: Data were collected from the outpatient database of the Southeastern France General Health Fund. We compared beneficiaries' characteristics according to the RNIAM indicator, calculated the annual unadjusted and age-adjusted regional and local prevalence of diabetes mellitus in two different populations: the whole initial beneficiaries database, and the population of "effective" beneficiaries (persons whose reimbursements were effectively managed by the General Health Insurance). RESULTS: The initial database included 4,817,871 beneficiaries. Almost 80% were in the "effective" population, 14% had left the General Health Insurance, or Southeastern France, and 4% were doubles. The annual unadjusted prevalence of diabetes mellitus was 3.31% in the initial database, and more than 20% higher when calculated among "effective" beneficiaries. Impact on aged-adjusted prevalence was less important (+9% at regional level), but the increase varied from 6 to 42% for the small local areas. Impact was much higher on age and gender specific rates. CONCLUSION: When Health Insurance databases are used to calculate health indicators at various geographical levels, only "effective" beneficiaries should be selected. The methodology for determining health indicators might be improved by updating databases (e.g. the date of the RNIAM indicator last update should be added).

Inequities in reporting asbestos-related lung cancer: influence of smoking stigma and physician's specialty, workload and role perception.

OBJECTIVES: To study physician barriers to workers' compensation claims for asbestos-related cancers, focusing on smokers' stigma and physicians' speciality and role perception. METHODS: Cross-sectional telephone study of 486 randomly-selected general practitioners (GPs) and pulmonologists in south-eastern France. Standardised questionnaires explored their behaviour, attitudes and practices in the field of occupational health and their responses to a case vignette of a lung cancer patient with long-term occupational asbestos exposure. Randomised subgroups of GPs and pulmonologists heard alternative versions varying only as regards the worker's smoking status. We studied factors associated with the recommendation that the case vignette patient file a compensation claim with simple and multiple logistic regressions. RESULTS: The response rate was 64.4% among GPs and 62.5% among pulmonologists. Recommending the filing of an occupational disease claim was significantly associated in multiple logistic regressions with speciality (OR 4.46; 95% CI 2.38 to 8.37, for pulmonologists vs GPs), patient's smoking status (OR 3.15; 95% CI 2.11 to 4.70, for non-smokers vs smokers), physician's workload (OR 1.83; 95% CI 1.17 to 2.88, for 25) and role perception (OR 2.00; 95% CI 1.22 to 3.27, for those who considered completing occupational disease medical certificates to be part of their role vs those who did not). CONCLUSIONS: The results of this French study appear applicable to various countries and contexts. To make physicians and especially GPs more aware of occupational health and smoking stigma, officials and educators must give these topics higher priority during initial training and continuing medical education. Tools and equipment that take time constraints into account should be developed and disseminated to help physicians manage occupational diseases.

[Physicians and occupational health: a qualitative study in south-eastern France]. / Les médecins face à la santé au travail: une étude qualitative dans le sud-est de la France.

BACKGROUND: Occupational health is a major public health problem in France. However, the level of investment of general practitioners and specialist physicians in this field is not well documented. We aimed at studying elements moving closer or differentiating groups of professionals (notably physicians) in the field of occupational health in terms of conceptions of their roles (prevention and care) and of practices (in particular detection and notification of occupational diseases and perceived barriers). METHODS: We conducted a qualitative study in south-eastern France which consisted of in-depth interviews of physicians and actors involved in the prevention of occupational hazards or in their indemnification. Then discourse analysis was carried out on the corpus collected. Content analysis grouped the data into themes. RESULTS: Several reasons could explain the low investment of physicians in the field of occupational health: insufficient detection of occupational causes of diseases, complexity of administrative procedures of declaration and bias of causal interpretation for the patients exposed to other risk factors such as smoking. The fear that notifying an occupational disease might have repercussions on patients' socio-professional situations places physicians in a situation of ethical dilemma: inducing a social risk on one side, ignoring his rights on the other. Physicians are not sufficiently prepared to deal with these situations, because they lack appropriate knowledge and support from specialists in the field, due to an important bulk-heading of actors and their practices. CONCLUSION: To sensitize and train physicians to occupational health and to support multi-field practices are essential.

[Evaluation of vaccine coverage in children from 2 to 4 years old in South-Eastern France]. / Estimation de la couverture vaccinale des enfants âgés de 2 à 4 ans en région Provence-Alpes-Côte d'Azur.

BACKGROUND: Few studies have evaluated vaccination coverage in early childhood in South-Eastern France and spatial and social factors associated to it. POPULATION AND METHODS: We carried out a study in children aged 3.5-4.5 years and attending 112 nursery schools randomly selected in South-Eastern France. Data were collected in 2002-2003 during a mandatory health assessment by physicians and nurses of the services of maternal and infant protection, who completed a new questionnaire developed to standardise these examinations in the whole region. RESULTS: Among the 2959 selected children, 2460 (83.1%) could be included in the study; out of them, 96.4% had been vaccinated against diphtheria and tetanus, 95.0% against poliomyelitis, 92.8% against pertussis, 89.3% against haemophilus influenzae type b and 96.5% against tuberculosis. Vaccination rates at the age of 18 months including the first booster were less important than vaccination rates for children aged 3.5-4.5 years. Only 24.3% of the children had been vaccinated against hepatitis B and 86.4% against measles-mumps-rubella. Vaccination rates at the age of 2, were significantly higher on the basis of the health certificates of the 24th month (CS24) than on the basis of our study. Vaccination rates were highest in urban areas and those with educational priority. CONCLUSION: Vaccination rates at the age of 3.5-4.5 years are satisfying but rates for the first booster should be improved. Vaccination rates against hepatitis B were low when those against MMR do not reach the WHO recommended level of 95.0%. Our results suggest that the analysis of data from the CS24 overestimates the real vaccination coverage at this age in South-Eastern France.

[The relationship between the rigorous practice of sports and addictions: results from a survey in south-eastern France]. / Pratique sportive intensive et addictions: une enquête en région PACA.

This study aimed to assess the prevalence of cigarette, alcohol and cannabis consumption among top-ranked French student athletes aged between 16-24 years old, and to identify correlating factors. Overall, 837 athletes participated in the study (82% response rate). Among females, the amount and duration of sporting activity in which they were engaged on a weekly basis had a negative correlation to cigarette smoking and the occasional use of cannabis. Among males, however, a positive correlation of these factors was observed for cigarette smoking. Other determinants of alcohol, tobacco and cannabis use were the level of athletic competition and whether the athlete practiced a team sport (as opposed to an individual one), with some gender variations. Two major risk factors for young adult athletes were the existence of high psychological distress (for both sexes) and a lack of family support (particularly in the case of males). Further research is needed to investigate the specific motives to use so-called "recreational" drugs among young athletes engaging in high-level competition.

Risk analysis of leukaemia incidence among people living along the Techa River: a nested case-control study.

Large quantities of radioactive materials released over time from the Mayak nuclear weapons facility caused significant internal and external exposure for people living along the banks of the Techa River (Southern Urals, Russia). We conducted a nested case-control study in the Extended Techa River Cohort to determine whether the risk of leukaemia incidence increased with protracted exposure to ionising radiation or with other non-radiation risk factors. The study included 83 cases identified over 47 years of follow-up and 415 controls matched for sex, age at diagnosis, age (within a 5 year age group), and date of initial residence in the riverside area. External and internal doses have been calculated using the Techa River Dosimetry System 1996 (TRDS96). Conditional logistic regression was used to calculate odds ratios per Gray (OR/Gy) and 95% confidence intervals (95% CI). After excluding cases of chronic lymphoid leukaemia, the OR/Gy of total, external, and internal doses were 4.6 (95% CI: 1.7-12.3), 7.2 (95%CI: 1.7-30.0) and 5.4 (95%CI: 1.1-27.2), respectively. A history of solid tumour, either malignant or benign, before the leukaemia diagnosis was associated with a 2.5-fold increase in the leukaemia risk (95% CI: 1.1-5.9). Even though the analysis of confounders was less useful than expected because of missing data, multivariate analyses that took the exposure dose into account confirmed the association between leukaemia incidence and tumour history.