Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach.

BACKGROUND: Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people. METHODS: This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms. RESULTS: Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities. CONCLUSIONS: The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

Respective healthcare system performances taking into account environmental quality: what are the re-rankings for OECD countries?

BACKGROUND: Efficiency analyses have been widely used in the literature to rank countries regarding their health system performances. However, little place has been given to the environmental aspect: two countries with the same characteristics could experience completely different healthcare system outcomes just because they do not face the same environmental quality situation, which is a major determinant of the health of inhabitants. METHODS: Using a stochastic frontier model, this paper analyses the effect of environmental quality on health system outcomes in OECD countries, measured by life expectancy at birth. RESULTS: We show that the healthcare system performance ranking of OECD countries changes significantly, depending on whether the environmental index is taken into account. CONCLUSIONS: These findings, once again, underline the critical importance of the environment when addressing population health issues. In general, our results can be aligned with the messages of the One Health approach literature.

What drives the acceptability of restrictive health policies: An experimental assessment of individual preferences for anti-COVID 19 strategies.

The public acceptability of a policy is an important issue in democracies, in particular for anti-COVID-19 policies, which require the adherence of the population to be applicable and efficient. Discrete choice experiment (DCE) can help elicit preference ranking among various policies for the whole population and subgroups. Using a representative sample of the French population, we apply DCE methods to assess the acceptability of various anti-COVID-19 measures, separately and as a package. Owing to the methods, we determine the extent to which acceptability depends on personal characteristics: political orientation, health vulnerability, or age. The young population differs in terms of policy preferences and their claim for monetary compensation, suggesting a tailored policy for them. The paper provides key methodological tools based on microeconomic evaluation of individuals' preferences for improving the design of public health policies.

[A behavioral economics approach for individual decisions in the face of COVID-19: Successes and disappointments]. / Les attendus d'une approche d'économie comportementale pour les décisions individuelles face à la pandémie de COVID-19 : succès et déceptions.

Title: Les attendus d'une approche d'économie comportementale pour les décisions individuelles face à la pandémie de COVID-19 : succès et déceptions. Abstract: Dans le cadre du premier appel à projet « Flash-COVID-19 ¼ de l'Agence nationale de la recherche, nous avons mobilisé des méthodes récentes de l'économie comportementale afin de mieux comprendre les décisions des individus face à la crise sanitaire due à la pandémie de COVID-19 (coronavirus disease 2019) et d'identifier les paramètres pouvant influencer le respect des mesures sanitaires. Cet article introduit brièvement l'économie comportementale, présente un compte rendu des attendus du projet CONFINOBS (Observance et observation des mesures barrières et du confinement : une approche d'économie comportementale) et de ses méthodes, puis il propose une synthèse des résultats obtenus.

Reassessing the demand for community-based health insurance in rural Senegal: Geographic distance and awareness.

Limited access to information is one of the main health insurance market imperfections in developing countries. Differential access to information may determine individuals' awareness of health insurance schemes, thereby influencing their probability of enrollment. Relying on primary data collected in 2019-2020 in rural Senegal, we estimate the uptake of community-based health insurance using a Heckman-type model to correct for awareness-based sample selection bias. Besides showing that health insurance awareness is a precondition for effective enrollment in community-based health insurance schemes, we also bring new evidence on the roles which geographic factors and individual risk preference play in health insurance uptake by rural dwellers. We show that geographic distance prevents individuals from accessing information on health insurance schemes, and discourage those who are informed from enrolling, because of the additional distance they must travel to benefit from covered healthcare services. Results also show that individual risk preference influences health insurance uptake, but only when information barriers are taken into account. Overall, our results could help decision-makers better shape the universal health coverage roadmap, as policies to improve health insurance awareness differ substantially from policies to improve the features of health insurance schemes.

Assessing the future medical cost burden for the European health systems under alternative exposure-to-risks scenarios.

BACKGROUND: Ageing populations and rising prevalence of non-communicable diseases (NCDs) increasingly contribute to the growing cost burden facing European healthcare systems. Few studies have attempted to quantify the future magnitude of this burden at the European level, and none of them consider the impact of potential changes in risk factor trajectories on future health expenditures. METHODS: The new microsimulation model forecasts the impact of behavioural and metabolic risk factors on NCDs, longevity and direct healthcare costs, and shows how changes in epidemiological trends can modify those impacts. Economic burden of NCDs is modelled under three scenarios based on assumed future risk factors trends: business as usual (BAU); best case and worst case predictions (BCP and WCP). FINDINGS: The direct costs of NCDs in the EU 27 countries and the UK (in constant 2014 prices) will grow under all scenarios. Between 2014 and 2050, the overall healthcare spending is expected to increase by 0.8% annually under BAU. In the all the countries, 605 billion Euros can be saved by 2050 if BCP is realized compared to the BAU, while excess spending under the WCP is forecast to be around 350 billion. Interpretation: Although the savings realised under the BCP can be substantial, population ageing is a stronger driver of rising total healthcare expenditures in Europe compared to scenario-based changes in risk factor prevalence.

How French general practitioners respond to declining medical density: a study on prescription practices, with an insight into opioids use.

Disparities in physicians' geographical distribution lead to highly unequal access to healthcare, which may impact quality of care in both high and low-income countries. This paper uses a 2013-2014 nationally representative survey of French general practitioners (GPs) matched with corresponding administrative data to analyze the effects of practicing in an area with weaker medical density. To avoid the endogeneity issue on physicians' choice of the location, we enriched our variable of interest, practicing in a relatively underserved area, with considering changes in medical density between 2007 and 2013, thus isolating GPs who only recently experienced a density decline (identifying assumption). We find that GPs practicing in underserved areas do shorter consultations and tend to substitute time-consuming procedures with alternatives requiring fewer human resources, especially for pain management. Results are robust to considering only GPs newly exposed to low medical density. Findings suggest a significant impact of supply-side shortages on the mix of healthcare services used to treat patients, and point to a plausible increased use of painkillers, opioids in particular.

Inequity in access to personalized medicine in France: Evidences from analysis of geo variations in the access to molecular profiling among advanced non-small-cell lung cancer patients: Results from the IFCT Biomarkers France Study.

In this article, we studied geographic variation in the use of personalized genetic testing for advanced non-small cell lung cancer (NSCLC) and we evaluated the relationship between genetic testing rates and local socioeconomic and ecological variables. We used data on all advanced NSCLC patients who had a genetic test between April 2012 and April 2013 in France in the frame of the IFCT Biomarqueurs-France study (n = 15814). We computed four established measures of geographic variation of the sex-adjusted rates of genetic testing utilization at the "départment" (the French territory is divided into 94 administrative units called 'départements') level. We also performed a spatial regression model to determine the relationship between département-level sex-adjusted rates of genetic testing utilization and economic and ecological variables. Our results are the following: (i) Overall, 46.87% lung cancer admission patients obtained genetic testing for NSCLC; département-level utilization rates varied over 3.2-fold. Measures of geographic variation indicated a relatively high degree of geographic variation. (ii) there was a statistically significant relationship between genetic testing rates and per capita supply of general practitioners, radiotherapists and surgeons (negative correlation for the latter); lower genetic testing rates were also associated with higher local poverty rates. French policymakers should pursue effort toward deprived areas to obtain equal access to personalized medicine for advanced NSCLC patients.

Who bears the burden of universal health coverage? An assessment of alternative financing policies using an overlapping-generations general equilibrium model.

In their quest for universal health coverage (UHC), many developing countries use alternative financing strategies including general revenues to expand health coverage to the whole population. Unless a policy adjustment is undertaken, future generations may foot the bill of the UHC. This raises the important policy questions of who bears the burden of UHC and whether the UHC-fiscal stance is sustainable in the long term. These two questions are addressed using an overlapping generations model within a general equilibrium (OLG-CGE) framework applied to Palestine. We assess and compare alternative ways of financing the UHC-ridden deficit (viz. deferred-debt, current and phased-manner finance) and their implications on fiscal sustainability and intergenerational inequalities. The policy instruments examined include direct labour-income tax and indirect consumption taxes as well as health insurance contributions. Results show that in the absence of any policy adjustment, the implementation of UHC would explode the fiscal deficit and debt-GDP ratio. This indicates that the UHC-fiscal stance is rather unsustainable in the long term, thus, calling for a policy adjustment to service the UHC debt. Among the policies we examined, a current rather than deferred-debt finance through consumption taxation emerged to be preferred over other policies in terms of its implications for both fiscal sustainability and intergenerational inequality.

How will the main risk factors contribute to the burden of non-communicable diseases under different scenarios by 2050? A modelling study.

BACKGROUND: The future burden of non-communicable diseases (NCDs) depends on numerous factors such as population ageing, evolution of societal trends, behavioural and physiological risk factors of individuals (e.g. smoking, alcohol use, obesity, physical inactivity, and hypertension). This study aims to assess the burden of NCDs in Europe by 2050 under alternative scenarios. METHODS: This study combines qualitative and quantitative forecasting techniques to examine how population health in Europe may evolve from 2015 to 2050, taking into account future societal trends. Four scenarios were developed (one business-as-usual scenario, two response scenarios and one pessimistic scenario) and assessed against 'best' and 'worst'-case scenarios. This study provides quantitative estimates of both diseases and mortality outcomes, using a microsimulation model incorporating international survey data. FINDINGS: Each scenario is associated with a different risk factor prevalence rate across Europe during the period 2015-2050. The prevalence and incidence of NCDs consistently increase during the analysed time period, mainly driven by population ageing. In more optimistic scenarios, diseases will appear in later ages, while in the pessimistic scenarios, NCDs will impair working-age people. Life expectancy is expected to grow in all scenarios, but with differences by up to 4 years across scenarios and population groups. Premature mortality from NCDs will be reduced in more optimistic scenarios but stagnate in the worst-case scenario. INTERPRETATION: Population ageing will have a greater impact on the spread of NCDs by 2050 compared to risk factors. Nevertheless, risk factors, which are influenced by living environments, are an important factor for determining future life expectancy in Europe.

The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases.

BACKGROUND: The literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient's healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed. METHODS: The French Echantillon Généraliste de Bénéficiaires (EGB) database was used to assign all healthcare expenses for a representative sample of the population covered by the National Health Insurance. COIs were estimated in a bottom-up approach, through regressions on individuals' healthcare expenditure. Two-way interactions between the 10 chronic disease variables were included in the expenditure model to account for possible effect modification in the presence of comorbidity(ies). RESULTS: The costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity, demonstrating the pattern of super-additive costs in cases of diseases interaction. For instance, the cost associated with diabetes for people without comorbidity was estimated at 1776 €, whereas this was 2634 € for people with heart disease as a comorbidity. Overall, we detected 41 cases of super-additivity over 45 possible comorbidities. When simulating a preventive action on diabetes, our results showed that significant monetary savings could be achieved not only for diabetes itself, but also for the chronic diseases frequently associated with diabetes. CONCLUSIONS: When comorbidity exists and where super-additivity is involved, a given preventive policy leads to greater monetary savings than the costs associated with the single diagnosis, meaning that the returns from the action are generally underestimated.

Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol.

INTRODUCTION: Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). METHODS AND ANALYSIS: This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). ETHICS AND DISSEMINATION: This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network. PROSPERO REGISTRATION NUMBER: CRD42015020558.

The expected and unexpected benefits of dispensing the exact number of pills.

BACKGROUND: From November 2014 to November 2015, an experiment in French community pharmacies replaced traditional pre-packed boxes by per-unit dispensing of pills in the exact numbers prescribed, for 14 antibiotics. METHODS: A cluster randomised control trial was carried out in 100 pharmacies. 75 pharmacies counted out the medication by units (experimental group), the other 25 providing the treatment in the existing pharmaceutical company boxes (control group). Data on patients under the two arms were compared to assess the environmental, economic and health effects of this change in drug dispensing. In particular, adherence was measured indirectly by comparing the number of pills left at the end of the prescribed treatment. RESULTS: Out of the 1185 patients included during 3 sessions of 4 consecutive weeks each, 907 patients experimented the personalized delivery and 278 were assigned to the control group, consistent with a 1/3 randomization-rate at the pharmacy level. 80% of eligible patients approved of the per-unit dispensing of their treatment. The initial packaging of the drugs did not match with the prescription in 60% of cases and per-unit dispensing reduced by 10% the number of pills supplied. 13.1% of patients declared that they threw away pills residuals instead of recycling-no differences between groups. Finally, per-unit dispensing appeared to improve adherence to antibiotic treatment (marginal effect 0.21, IC 95, 0.14-0.28). CONCLUSIONS: Supplying antibiotics per unit is not only beneficial in terms of a reduced number of pills to reimburse or for the environment (less pills wasted and non-recycled), but also has a positive and unexpected impact on adherence to treatment, and thus on both individual and public health.

Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region.

Evidence suggests that the effect of health expenditure on health outcomes is highly context-specific and may be driven by other factors. We construct a panel dataset of 18 countries from the Middle East and North Africa region for the period 1995-2012. Panel data models are used to estimate the macro-level determinants of health outcomes. The core finding of the paper is that increasing health expenditure leads to health outcomes improvements only to the extent that the quality of institutions within a country is sufficiently high. The sensitivity of the results is assessed using various measures of health outcomes as well as institutional variables. Overall, it appears that increasing health care expenditure in the MENA region is a necessary but not sufficient condition for health outcomes improvements.

Achieving universal health coverage in France: policy reforms and the challenge of inequalities.

Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.

Socioeconomic inequalities in informal payments for health care: An assessment of the 'Robin Hood' hypothesis in 33 African countries.

In almost all African countries, informal payments are frequently made when accessing health care. Some literature suggests that the informal payment system could lead to quasi-redistribution among patients, with physicians playing a 'Robin Hood' role, subsidizing the poor at the expense of the rich. We empirically tested this assumption with data from the rounds 3 and 5 of the Afrobarometer surveys conducted in 18 and 33 African countries respectively, from 2005 to 2006 for round 3 and from 2011 to 2013 for round 5. In these surveys, nationally representative samples of people aged 18 years or more were randomly selected in each country, with sizes varying between 1048 and 2400 for round 3 and between 1190 and 2407 for round 5. We used the 'normalized' concentration index, the poor/rich gap and the odds ratio to assess the level of inequality in the payment of bribes to access care at the local public health facility and implemented two decomposition techniques to identify the contributors to the observed inequalities. We obtained that: i) the socioeconomic gradient in informal payments is in favor of the rich in almost all countries, indicating a rather regressive system; ii) this is mainly due to the socioeconomic disadvantage itself, to poor/rich differences in supply side factors like lack of medicines, absence of doctors and long waiting times, as well as regional disparities. Although essentially empirical, the paper highlights the need for African health systems to undergo substantial country-specific reforms in order to better protect the worse-off from financial risk when they seek care.

The true impact of the French pay-for-performance program on physicians' benzodiazepines prescription behavior.

OBJECTIVES: The French pay-for-performance (P4P) contract CAPI implemented by the national health insurance included a target-goal which aims at reducing benzodiazepines prescriptions. In this investigation, we would like to assess whether: (1) the general practitioners (GPs) having signed P4P contract obtain better results regarding the target-goal than non-signatories; (2) (part of) this progression is due to the CAPI contract itself (tentative measurement of a "causal effect"); (3) (part of) the money spent on this P4P incentive can be self-financed with the amount of pharmaceuticals saved. METHODS: We matched cross-sectional and longitudinal data including 4622 French GPs from June 2011 to December 2012. A treatment effect model using instrumental variables was performed to take into account potential self-selection issue in signing. After having identified the NET impact of the P4P, we calculate the cost of an avoided benzodiazepines treatment. RESULTS: In our study, GPs who have signed the CAPI contract (36 % of the sample) are more numerous in achieving benzodiazepines target goal than non-signatories: 90.7 vs. 85.5 %. After controlling for the self-selection bias, the propensity of GPs to achieve the benzodiazepines target is only 0.31 % higher for signatories than for their non-signing counterparts-estimate for June 2012, which yields a statistically significant gap. Our economic analysis demonstrates that the CAPI contract does not allow savings, but presents in 2012 a NET cost of 93.6€ per avoided benzodiazepines treatment (291€ in 2011). CONCLUSIONS: The P4P contract has a positive but modest impact on the achievement of GPs regarding benzodiazepines indicator.

Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison.

BACKGROUND: Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume. METHODS: We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries. RESULTS: The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined. CONCLUSIONS: Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.