Immigrants' health empowerment and access to health coverage in France: A stepped wedge randomised controlled trial.

Throughout Europe, migration-related health inequalities are mirrored by large inequalities in health coverage. There is a need to develop novel strategies to secure access to health insurance for immigrants in Europe, in order to meet the shared Sustainable Development Goal of universal health coverage. We evaluated the impact of an original health-related empowerment intervention on access to health coverage among vulnerable, mostly undocumented immigrants in France. As part of the MAKASI study, we adopted an outreach approach and developed a community-based intervention with and for immigrants from sub-Saharan Africa living in precarious conditions in the Greater Paris area. This participatory intervention was grounded in the theory of individual empowerment. Using a stepped wedge randomised design, we first conducted a robust evaluation of the effect of the intervention on access to health coverage at three and six months post-intervention. We then investigated whether the intervention effect was mediated by a health empowerment process. Between 2018 and 2021, a total of 821 participants - 77% of whom were men - were recruited in public spaces and followed up for six months. Participants had been living in France for four years on average, 75% of them had no residence permit, and 44% had no health coverage at the time of inclusion. The probability of accessing health coverage increased by 29 percentage points at six months post-intervention (p < 0.01). This improvement was partially mediated by a health empowerment process, namely a reinforcement of participants' knowledge of and capacity to access available social and health resources. A health empowerment intervention largely improved access to health insurance among vulnerable immigrants in France. Our findings may be transferred to other settings where immigrants are entitled to health insurance. This study offers promising perspectives - beyond information provision and direct referral - to reduce migration-related inequalities in health coverage.

Is empowerment in sexual health measurable? A scoping review of definitions and measurement indicators.

The concept of empowerment in sexual health is widely used in health promotion. This scoping review aims to identify how it is defined and measured. PubMed, Sage Journals, PsycInfo and the Web of Science are data sources. The inclusion criteria for studies were as follows: (1) an analysis of empowerment in sexual health, (2) quantitative evaluation and (3) publication in a peer-reviewed journal in French or English since January 1996. Data were extracted using a summary table of the definitions and indicators of empowerment in sexual health. Of the 2181 articles found, 29 met the inclusion criteria. Only 4 studies on 29 clearly defined empowerment in sexual health. Five dimensions emerged from the indicators used in the 29 studies in relation to sexual empowerment (social participation, participation in decision making, power to act, sexual health knowledge and gender norms), with two types of indicators: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Most studies concerned women and focused on individual empowerment, with a lack of measure of collective and structural levels of empowerment. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. This set could be systematically used in each study based on sexual empowerment concept, completed by supplementary indicators considering the specific context.

Empowerment is at the heart of health promotion. The concept of empowerment in sexual health has been increasingly used in the field of health promotion, but there is a lack of a consensual definition and great heterogeneity in the indicators used to assess that concept and measure it, according to targeted populations and cultural contexts. In this scoping review on how empowerment in sexual health is defined and measured, five dimensions emerged: social participation, participation in decision making, power to act, sexual health knowledge and gender norms. Through these dimensions, two types of indicators were collected: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. For future research, this set could be systematically used in each study based on sexual empowerment concept, and should be completed by supplementary indicators considering the specific context.

Does exposure to workplace hazards cluster by occupational or sociodemographic characteristics? An analysis of foreign-born workers in Australia.

BACKGROUND: Disparities in exposure to occupational hazards may be linked to social position as well as the type of job a person holds. This study aimed to describe the prevalence of exposure to workplace hazards among three migrant worker groups and to assess whether social disparities in exposure for these groups remain after adjusting for occupational characteristics. METHODS: Data were collected in 2017/2018 from 1630 Australian workers born in New Zealand, India, and the Philippines. Weighted estimated prevalence of exposure to 10 carcinogens and four psychosocial hazards (discrimination, job strain, vulnerability, and insecurity) was calculated for sociodemographics and occupation. Regression estimated the likelihood of exposure by sociodemographics after adjustment for occupational characteristics. RESULTS: Exposure to workplace hazards ranged from 11.7% (discrimination) to 61.2% (exposed to at least one carcinogen). Compared with workers born in India, New Zealand born workers were over twice as likely to be exposed to diesel engine exhaust (adjusted odds ratio [aOR] = 2.60) and 60% more likely to be exposed to at least one carcinogen (aOR = 1.60) but less likely to be exposed to any psychosocial hazard. Social disparities by country of birth, sex, age, education, and number of years in Australia, as well as company size, employment type, and hours, worked remained associated with greater likelihood of reporting one or more workplace hazards after adjusting for occupational characteristics. CONCLUSION: Examining sociodemographic as well as occupational characteristics helps to clarify groups most likely to be exposed to workplace hazards who can be hidden when examining occupational characteristics alone.

Finding the missing link: when community-based outreach in public space is key to engage migrants in health prevention programmes in Paris, France.

BACKGROUND: One of the classic challenges for prevention programmes is reaching the populations they serve. In France, a substantial number of African migrants living with HIV acquired their infection after migrating. The aim of this paper is to better understand the characteristics of the population reached by a community-based outreach approach. METHODS: We compared sociodemographic characteristics across three different groups in the Paris greater area: (1) the general African migrant population (Population census), (2) the African migrant population using either the regular healthcare system or the system for vulnerable populations (PARCOURS Survey) and (3) the African migrant population reached through a community-based mobile unit (Afrique Avenir). Comparisons were conducted according to sex, age, region of origin, duration of residence and occupational and legal statuses using χ2 tests. RESULTS: The migrants reached by the mobile unit were mostly men (69%), 52% of whom were younger than 35 years old. They more often lived in precarious situations than did the general sub-Saharan population (49% vs 35% were unemployed, respectively, p<0.001) and the ones accessing the regular healthcare system. Fewer of them lived in precarious situations than did migrants seeking healthcare consultations for vulnerable populations (42% in the mobile unit vs 54% in healthcare consultations were undocumented, p<0.028). CONCLUSION: Our study shows that the outreach approach can constitute a missing link in the prevention chain among sub-Saharan African migrants, reaching a group that differs from the general migrant population and from the migrant population in healthcare services-not only the newly arrived migrants who live in more precarious situations but also those who have been in France for several years and are still affected by social hardship.

Social and structural factors and engagement in HIV care of sub-Saharan African migrants diagnosed with HIV in the Paris region.

Migrants from sub-Saharan Africa (SSA) are often diagnosed at an advanced stage of HIV, and many of them have harsh living conditions. We aimed to evaluate the entry into care after HIV diagnosis and examine the related social determinants. The ANRS PARCOURS study is a life-event survey conducted in 2012-2013 in the Paris region among. Time between HIV diagnosis of SSA migrants living diagnosed HIV positive in France and HIV care and the determinants was assessed yearly by using mixed-effects logistic regression models. Among a total of 792 participants, 94.2% engaged in HIV care within the year of HIV diagnosis, 4.3% in the following year and 2.5% beyond the second year after diagnosis. The participants were more likely to engage in HIV care during years when they were effectively covered by health insurance and if the HIV test was carried out at the initiative of the doctor. Immigration for economic reasons or owing to threats in his/her country of origin was associated with delayed engagement in HIV care. Additionally, 4.3% of treated participants discontinued HIV care at least once at the time of the survey and more often if diagnosed at an advanced HIV disease stage and financially dependent.

[Residence permit for medical reasons: An obstacle to permanent residence status. Results of the ANRS Parcours Study]. / Le titre de séjour pour raison médicale, un obstacle à l'accès au titre de séjour pérenne : résultats de l'enquête ANRS Parcours.

OBJECTIVES: Various associations in France have denounced for a long time the difficulties encountered by foreigners with a residence permit for medical reasons to access permanent residence status (10-year resident's card or French nationality). The objective of this study was to determine whether there is a real discrimination towards foreigners with a residence permit for medical reasons, with all other things being equal. METHODS: This study was based on data from the retrospective quantitative ANRS Parcours survey, conducted in 2012-2013 among 1,705 Sub-Saharan immigrants with HIV/AIDS or Hepatitis B in Ile-de-France. This life-event survey reconstructed the immigrant's permit history. Discrete time logistic models were then used to model the factors associated with obtaining a permanent residence permit and the impact of a residence permit for medical reasons on this probability. Control variables were used to take into account the level of education, the reason for arrival in France, the period of arrival, the duration of stay. RESULTS: A residence permit for medical reasons has a negative impact on access to permanent residence status (aOr between 0.15 and 0.27 across subgroups, P < 0.01). Additionally, the time required to obtain permanent residence status has increased since 2005 compared to before 1996 for all foreigners participating in the survey. CONCLUSIONS: The results of this study suggest discrimination towards people with a residence permit for medical reasons in terms of access to permanent residence status, thereby placing their access to health care at stake.

Access to health insurance coverage among sub-Saharan African migrants living in France: Results of the ANRS-PARCOURS study.

BACKGROUND: Migrants' access to care depends on their health insurance coverage in the host country. We aimed to evaluate in France the dynamic and the determinants of health insurance coverage acquisition among sub-Saharan migrants. METHODS: In the PARCOURS life-event retrospective survey conducted in 2012-2013 in health-care facilities in the Paris region, data on health insurance coverage (HIC) each year since arrival in France has been collected among three groups of sub-Saharan migrants recruited in primary care centres (N = 763), centres for HIV care (N = 923) and for chronic hepatitis B care (N = 778). Year to year, the determinants of the acquisition and lapse of HIC were analysed with mixed-effects logistic regression models. RESULTS: In the year of arrival, 63.4% of women and 55.3% of men obtained HIC. But three years after arrival, still 14% of women and 19% of men had not obtained HIC. HIC acquisition was accelerated in case of HIV or hepatitis B infection, for migrants arrived after 2000, and for women in case of pregnancy and when they were studying. Conversely, it was slowed down in case of lack of a residency permit and lack of financial resources for men. In addition, women and men without residency permits were more likely to have lost HIC when they had one. CONCLUSION: In France, the health insurance system aiming at protecting all, including undocumented migrants, leads to a prompt access to HIC for migrants from sub-Saharan Africa. Nevertheless, this access may be impaired by administrative and social insecurities.

[Health care access of Sub-Saharan African migrants living with chronic hepatitis B]. / Accès aux soins des personnes originaires d'Afrique subsaharienne vivant avec une hépatite B chronique.

Objective: The objective of this study was to analyse health care access of Sub-Saharan African migrants living with chronic hepatitis B (CHB) in France. Methods: The ANRS-Parcours survey was a life-event survey conducted in 2012-2013 among Sub-Saharan African migrants recruited by health care facilities managing CHB in the Paris region. Data were collected by face-to-face interview using a biographical grid and a standardized questionnaire. Results: 96.4% of the 619 participants basic health insurance coverage with CMU universal health insurance coverage in 18.6% of cases and AME state medical assistance in 23.4% of cases. One-third of basic health insurance beneficiaries did not have any complementary health insurance and 75.7% had long-term disease status. The median time to acquisition of health insurance cover after arrival in France was one year. 22.0% of participants reported delaying health care for financial reasons since their arrival in France and 9.7% reported being refused health care usually due to refusal of CMU or AME. Health care access was effective within one year of the diagnosis. Delayed health care access was more common among people without health insurance coverage in the year of diagnosis. Patients lost to follow-up for more than 12 months were rare. Conclusion: Sub-Saharan African migrants living with chronic hepatitis B rapidly access health insurance coverage and health care. However, barriers to health care access persist for some people, essentially due to absent or incomplete health insurance cover and refusal of care for AME or CMU beneficiaries.