The (De)normalisation of Smoking Among Apprentices: Plurality of Settings, Norms and Vulnerability Levels.

When it comes to smoking, apprentices are considered a 'vulnerable' population. They have been the subject of targeted approaches based on the assumption of common characteristics. In contrast to most public health studies, that assume homogeneity of vulnerable groups, this article, based on Lahire's 'theory of the plural individual', aims to examine inter- and intra-individual variability in relation to tobacco exposure. It is based on a secondary analysis of 30 interviews with apprentices in France on the stigma attached to their use in their different living environments. Our study confirms that the family and the Centre de Formation des Apprentis, as a whole, encourage smoking. It also provides a better understanding of the mechanisms by which inequalities are perpetuated (permissive rules, loans and gifts of cigarettes, spillover effects, lack of incentives to quit). Nevertheless, it allows us to observe that, in some families and in some companies, smoking is denormalised, even stigmatised. Several apprentice profiles emerge: those who are protected from tobacco and seem to be able to quit easily; those who are permanently confronted with it and for whom it is difficult to consider quitting or reducing; and those who are confronted with a plurality of norms, who seem ambivalent and whose consumption varies significantly. These results will allow us to adapt the interventions according to the profile of the apprentices and by including their entourage. In particular, it will be necessary to propose a 'go-to' approach that goes beyond the school setting and involves the family and the workplace.

Use of qualitative methods to optimize collaborative practices by highlighting differences in perceptions between professionals: an example of patient education.

Interprofessional working must be approached within health promotion interventions using systematic methods to identify areas of suboptimal collaboration. We designed a qualitative study with a purposive sample of seven French therapeutic patient education programs. Semi-structured individual interviews were conducted with 14 healthcare providers and seven clinician leaders (coordinators) involved in patient education. We used the same interview guide and thematic grid regardless of the professional's profile to compare their perceptions on elements affecting outcome, participation and sustainability of programs. Healthcare providers and coordinators addressed non-convergent issues at both ends of a continuum from a micro-level nested in the program delivery to a macro-level corresponding to the structured implementation and sustainability of the program. Meso-level issues featured convergent perspectives. Our methodology could be used at the level of health services in a health system to provide a complete recovery of stakeholders' perspectives (without "blind spots" from one stakeholder or another). In our study, we focused on patient education in the French health system and pointed out possible considerations to optimize the functioning of programs. Such considerations include specific training plan development, encouraging reflection on the content and use of initial assessment, leading sessions in pairs to save on work time, and communication on the ins and outs of organizational imperatives that require healthcare providers' contributions.

Strengthening students' well-being and nutritional balance in Grand Est (France): "Lycéen Bouge" program intervention logic / Renforcement du bien-être et de la nutrition des lycéens : la logique d'intervention du programme « Lycéen Bouge ¼

Introduction: As part of a national health policy to fight excess weight and obesity, the "Lycéen Bouge" program aims to fight against social inequalities in health among adolescents by improving their well-being and nutritional balance. The aim of this article is to present the intervention logic of this program and to identify the key functions that are essential for the project to function properly and to be transferable. Method: Data was collected through interviews with project officers, observation sessions in several high schools. A documentary analysis was also carried out. The data was then analyzed thematically, in a collaborative process with the project leader, in order to develop the program logic model. Results: The analysis and development of the logic model identified the program's objectives and components, as well as six key functions. The key functions identified concern the format and co-construction of activities, local partnerships, high-school volunteering, social skills training and project length. Conclusion: In some respects, the program differs from the literature and the evidence and could therefore draw on it for improvement. These include the involvement of beneficiaries and the implementation of a comprehensive approach and a gender-sensitive approach, which would make it possible to reach more students.

Introduction: Dans le cadre d'une politique nationale de lutte contre le surpoids et l'obésité, le programme « Lycéen Bouge ¼ vise à combattre les inégalités sociales de santé chez les adolescents, en améliorant leur bien-être et leur équilibre nutritionnel. Cet article a pour objectif de présenter la logique d'intervention de ce programme, et d'en identifier les fonctions clés, indispensables au bon fonctionnement du programme et à son éventuelle transférabilité. Méthode: Les données ont été recueillies à travers des entretiens auprès des chargés de projet et des séances d'observation des activités au sein de plusieurs lycées. Une analyse documentaire a également été réalisée. Les données ont ensuite été analysées par thématiques, dans une démarche collaborative avec le porteur de projet, afin d'élaborer le modèle logique du programme. Résultats: Le travail d'analyse et d'élaboration du modèle logique a permis d'identifier les objectifs et les composantes du programme, ainsi que six fonctions clés. Les fonctions clés identifiées concernent le format et la co-construction des activités, les partenariats locaux, le volontariat des établissements, la formation aux compétences psychosociales (CPS) et la durabilité du projet. Discussion: Sur certains points, le programme se démarque de ce que l'on trouve dans la littérature et les données probantes, et pourrait donc s'en inspirer pour s'améliorer. Il s'agit notamment de l'implication des bénéficiaires et de la mise en place d'une approche globale et sensible au genre, qui permettraient de toucher plus d'élèves.

Tailored patient therapeutic educational interventions: A patient-centred communication model.

BACKGROUND: Tailoring therapeutic education consists of adapting the intervention to patients' needs with the expectation that this individualization will improve the results of the intervention. Communication is the basis for any individualization process. To our knowledge, there is no guide or structured advice to help healthcare providers (HCPs) tailor patient education interventions. OBJECTIVES: We used a data-driven qualitative analysis to (1) investigate the reasons why HCPs tailor their educational interventions and (2) identify how this tailoring is effectively conducted. The perspective aimed to better understand how to individualize therapeutic patient education and to disentangle the different elements to set up studies to investigate the mechanisms and effects of individualization. DESIGN: Individual semistructured interviews with 28 HCPs involved in patient education were conducted. The present study complied with the COREQ criteria. RESULTS: Why individualization is necessary: participants outlined that the person must be thought of as unique and that therapeutic education should be adapted to the patient's personality and cognitive abilities. The first step in the individualization process was formalized by an initial patient assessment. Several informal practices were identified: if needed, giving an individual time or involving a specific professional; eliciting individual objectives; reinforcing the relationship by avoiding asymmetrical posture; focusing on patients' concerns; leading sessions in pairs; and making the patient the actor of decisions. CONCLUSION: From our thematic data analysis, a model for tailoring patient education interventions based on the Haes and Bensing medical communication framework is proposed. The present work paves the way for evaluation, then generation of recommendations and finally implementation of training for individualization in educational interventions. SHORT INFORMATIVE: Tailoring in therapeutic education consists of an adaptation to patients' needs. Communication is the basis for any individualization process. There is no model of patient-centred communication in educational interventions. From semistructured interviews with HCPs, we propose a patient-centred communication model for tailoring patient education intervention.

Accompagnement à la parentalité en Protection maternelle et infantile : co-construction de la logique d'intervention PERL.

INTRODUCTION: In the Greater Eastern region of France, a primary prevention intervention in perinatal care has shown promising results on child development. In order to make this intervention transferable and sustainable outside a research context, it was adapted into a universal family health program. The PERL (Petite Enfance Recherche-action en Lorraine: early childhood research-action in Lorraine) research-action aimed to evaluate the effects of this new intervention. METHOD: The objective of the article was to present the intervention logic of the PERL program, based on the evaluation of processes and mechanisms (2018-2019). The method was based on 18 semi-structured interviews with actors involved in the construction and implementation of PERL, and a consultation process. RESULTS: Supported by the Maternal and Child Protection services (PMI), PERL is a program based on home visits by nurses, analysis of practices and supervision. In contrast to a standardized or an injunctive perspective, the approach recognizes and supports the parent as an expert of his or her own child. The importance of supervision in facilitating the adoption of an unconditional benevolent posture and the professional development of nurses confronted with complex situations is one of the cornerstones of the system. CONCLUSIONS: PERL is a structured and non-standardized parenting support program, based on strong health promotion concepts. This evaluation underlines the importance and challenges of having a shared vision of the intervention logic. In the perspective of the deployment and transfer of PERL, it will be necessary to adapt the system to the contexts and territories. In this perspective, an implementation guide has been produced.

Stigmatisation et santé publique : le côté obscur des interventions anti-tabac.

Tobacco control strategies, considered legitimate and effective, are rarely the subject of critical analysis in France. This is specifically true with regard to their potentially harmful effects, particularly against people who continue to smoke. This article introduces this debate, focusing on the potentially stigmatizing effects of anti-smoking policies. It has been attested by numerous international studies, and by a study in France, that the general process of tobacco denormalization has led to the stigmatization of smokers who then may be subject to discrimination. To the extent that smoking is now concentrated in the most disadvantaged socio-economic populations in France, the latter are thus more exposed to stigma. While underscoring the need to develop targeted interventions against them, this article also warns and calls for vigilance regarding the potential iatrogenic effects of these interventions. It is therefore necessary to develop research and evaluations on this subject in order to accurately measure the effects of these interventions, particularly in terms of stigmatization and self-stigma, and to ensure that public health actors do not generate more problems than they solve.

Postponing vaccination in children with an infection: a qualitative study among general practitioners and pediatricians.

BACKGROUND: Vaccination postponement is an important contributing factor to low vaccination coverage. The causes of vaccine postponement are numerous, but the presence of viral infection, whether febrile or not, is the most frequent cause. OBJECTIVE: The objective was to explore the factors motivating the practice of vaccination postponement in a child with an infection by general practitioners (GPs) and paediatricians. METHODS: An exploratory qualitative study using semi-directive individual interviews was carried out among GPs and paediatricians in a French region between November 2015 and January 2018. After the interviews were fully transcribed, an analysis of the data was performed using an inductive method derived from the grounded theory. RESULTS: Fourteen GPs and four paediatricians participated in the study. Vaccination postponement during infection in children is rooted in doctors' practices; it is considered a low-risk habit that is shared with parents, and vaccine hesitancy reinforces this practice. In children presenting with an infection, the presence of uncertainty about vaccine safety and effectiveness seems to justify postponing vaccination. The organization of a consultation dedicated to vaccination catch-up was cited as the best tool to limit the effects of vaccination delay on vaccination coverage. DISCUSSION: In children presenting with an infection, vaccination postponement is widely used by GPs and paediatricians. Simplification of the vaccination catch-up process and clear and consistent recommendations on the indications and modalities for vaccination postponement would be useful.

Patients and relatives coping with inflammatory arthritis: Care teamwork.

OBJECTIVE: To explore how patients and relatives experience and talk together about their life with inflammatory arthritis. DESIGN: Qualitative research. SETTING: A convenience sample was used. Participants were recruited in seven rheumatology departments in France. PARTICIPANTS: Patients with rheumatoid arthritis or spondyloarthritis, agreeing to participate in the study with a relative, age at least 18 years. DATA COLLECTION AND ANALYSIS: Two psychologists conducted face-to-face interviews with 20 patient-relative dyads (40 individuals). A thematic analysis followed a general inductive approach. RESULTS: Saturation was reached after interviews with 20 dyads. The analysis revealed four main themes: (a) disease 'lived' together: a new role for the relative (providing help in physical tasks, emotional support, acting as a driving force, having a role in medical care) and communication around the disease (not focusing on the disease); (b) impact of the disease on the relationship; (c) social impact of the disease on the dyad (social isolation); (d) difficulties and needs of the relative (need to better know the disease). CONCLUSION: This study has highlighted the importance of recognizing the role of the relative in the management of inflammatory arthritis disease, especially when medical decisions are shared with professionals. A joint approach to treatment is a basis for coping with the disease. This approach supposes (a) discussions about relatives' new roles to clarify them, (b) patients' and relatives' communication skills and (c) a good understanding of each other, which can be improved by providing information on the disease and coping strategies for both the patient and the relative.

[Stigmatization and public health: The dark-side of anti-smoking interventions]. / Stigmatisation et santé publique : le côté obscur des interventions anti-tabac.

Tobacco control strategies, considered legitimate and effective, are rarely the subject of critical analysis in France. This is specifically true with regard to their potentially harmful effects, particularly against people who continue to smoke. This article introduces this debate, focusing on the potentially stigmatizing effects of anti-smoking policies. It has been attested by numerous international studies, and by a study in France, that the general process of tobacco denormalization has led to the stigmatization of smokers who then may be subject to discrimination. To the extent that smoking is now concentrated in the most disadvantaged socio-economic populations in France, the latter are thus more exposed to stigma. While underscoring the need to develop targeted interventions against them, this article also warns and calls for vigilance regarding the potential iatrogenic effects of these interventions. It is therefore necessary to develop research and evaluations on this subject in order to accurately measure the effects of these interventions, particularly in terms of stigmatization and self-stigma, and to ensure that public health actors do not generate more problems than they solve.

Which design to evaluate complex interventions? Toward a methodological framework through a systematic review.

BACKGROUND: Evaluation of complex interventions (CI) is challenging for health researchers and requires innovative approaches. The objective of this work is to present the main methods used to evaluate CI. METHODS: A systematic review of the scientific literature was conducted to identify methods used for the evaluation of CI. We searched MEDLINE via PubMed databases for articles including an evaluation or a pilot study of a complex intervention, published in a ten-year period. Key-words of this research were ("complex intervention*" AND "evaluation"). RESULTS: Among 445 identified articles, 100 research results or protocols were included. Among them, 5 presented 2 different types of design in the same publication, thus our work included 105 designs. Individual randomized controlled trials (IRCT) represented 21.9% (n = 23) of evaluation designs, randomized clinical trials adaptations 44.8% (n = 47), quasi -experimental designs and cohort study 19.0% (n = 20), realist evaluation 6.7% (n = 7) and other cases studies and other approaches 8.6% (n = 9). A process/mechanisms analysis was included in 80% (n = 84) of these designs. CONCLUSION: A range of methods can be used successively or combined at various steps of the evaluation approach. A framework is proposed to situate each of the designs with respect to evaluation questions. The growing interest of researchers in alternative methods and the development of their use must be accompanied by conceptual and methodological research in order to more clearly define their principles of use.

[Therapeutic patient education practices in Ivory Cost: investigation among health professionals] / Pratique de l'éducation thérapeutique du patient en Côte d'Ivoire : enquête auprès des professionnels de santé.

INTRODUCTION: Patient education is an important component in the management and monitoring of chronic diseases. It plays an important role in the decline of the disease severity, mortality and socioeconomic burden and the complications of these chronic diseases. In Côte d'Ivoire, there are few studies to evaluate the reality of this activity. OBJECTIVE: To explore the practice of patient education in Ivory Coast. METHOD: This qualitative study has been carried out by means of semi-structured interviews with 24 healthcare professionals including 14 health managers for individual interviews and 10 care providers for focus group discussion. RESULTS: There are various representations of therapeutic patient education among health professionals. There was no real distinction between patient education and the broader concept of health education. Absence of national patient education policy, the lack of training in TPE and lack of experience of educational practice lead health professionals to realize an unstructured educational activity. CONCLUSION: These results show the need for Côte d'Ivoire to have a national policy of patient education to educate patients in accordance with international recommendations.

[Complexity: concept and challenges for public health interventions]. / La complexité : concept et enjeux pour les interventions de santé publique.

Introduction: Since 2000, the notion of "complex interventions" has been emerging in the health research field. "Complex interventions" and "complexity" are commonly used terms, but they are generally not defined. Conceptual ambiguities persist concerning the notion of complexity. The objective of this exploratory review is to characterize the notion of complexity: What is complexity? Where does this notion come from and what does it cover? What are the consequences of complexity in the health field?Methods: To clarify the concept of complexity, a narrative review was conducted in the fields of humanities and social science, managerial economics, psychology and healthcare.Results: The concept of complexity, that can be attributed to Edgar Morin, has been the subject of appropriations, adaptations, and operations in multiple areas. Complexity consists of understanding the factors influencing individual decisions. In the field of healthcare, the concept of complexity is used more pragmatically and is defined by objective characteristics of interventions (defined as complex) or their contexts for the practical purposes of evaluation.Discussion: The notions of complexity and complex interventions have implications for researchers and users of the results of research. In particular, the notion of complexity is designed to provide a better understanding of the mechanism of effectiveness of interventions, support transferability and use by actors and decision-makers.

Telemedicine in rural areas: general practitioners' representations and experiences / La télémédecine en zones rurales?: représentations et expériences de médecins généralistes.

Introduction: Telemedicine is a rapidly growing new mode of healthcare practice. It is particularly used and needed in remote areas in Lorraine (North East of France) that currently face a shortage of general practitioners and specialists. The objective of this study was to analyse general practitioner's representations of telemedicine and teleconsultation. The study also identified the advantages and disadvantages of this new mode of medical practice. Methods: A qualitative research was led: 5 focus groups were conducted with 32 doctors in areas faced with the problems of health professional shortages between June 2014 and July 2015. Results: This study reveals a general ignorance of telemedicine. Doctors want to play a central role in this new form of medical practice which must remain optional. Their reluctance essentially concerns financial and legal aspects that constitute obstacles to the development of telemedicine. Finally, this new mode of medical practice must comply with a legal framework regarding medical responsibility and personal data protection. Discussion.More than 100 medical procedures are delivered by telemedicine in Lorraine each month. This new technology is a solution to provide healthcare services in medically underserved areas. However, general practitioners want to preserve the "doctor-patient" relationship and do not wish to change their practice.

[Reflections on the evaluation and funding of complex public health interventions]. / Pistes de réflexion pour l’évaluation et le financement des interventions complexes en santé publique.

In France, in a context of growing health inequalities, the need for action on life settings and, more broadly, on the social determinants of health (SDH), requires a contribution from health promotion research. Today's challenge is not only to design interventions tailored to contexts and actively targeting SDH, but also to develop innovative evaluation strategies of these complex interventions. A group of researchers and representatives from funding agencies met in Paris on june 2nd, 2014 to discuss current experiences conducted in France. The debates yielded five conclusions: (i) the context of the intervention must be considered as one of its active ingredients, (ii) evaluation must be guided by a sound intervention logic (iii) randomized controlled trials cannot capture the complexity of the environment and evaluation must be designed using alternative models, including process evaluation, (iv) interventional research should be collaborative, or co-constructed, (v) public health training should cover the diversity of evaluative methods. The conclusions described here, in the context of France, stress that to address these challenges, funding agencies, researchers and stakeholders should further engage in discussions concerning the conduct of interventional research, evaluation and implementation of complex public health interventions.

Stakeholders' perceptions of transferability criteria for health promotion interventions: a case study.

BACKGROUND: The effects of health promotion interventions are the result not only of the interventions themselves, but also of the contexts in which they unfold. The objective of this study was to analyze, through stakeholders' discourse, the characteristics of an intervention that can influence its outcomes. METHODS: This case study was based on semi-structured interviews with health promotion stakeholders involved in a regional program (PRALIMAP). General hypotheses on transferability and on how the intervention is presumed to produce its effects were used to construct an interview guide. Interviews were analyzed using thematic coding. RESULTS: Twenty-three stakeholders were interviewed. Results showed stakeholders made few references to population and environment characteristics. Three themes emerged as significant for the stakeholders: implementation modalities and methodology, modalities used to mobilize actors; and transferability-promoting factors and barriers. CONCLUSION: Our work contributes to a better understanding not only of transferability factors, but also of stakeholders' perceptions of them, which are just as important, because those perceptions themselves are a factor in mobilization of actors, implementation, and transferability.

What contextual features affect the outcome and sustainability of therapeutic patient education interventions?

BACKGROUND: Therapeutic patient education interventions are influenced by contextual factors. Therefore, describing the context is crucial to understanding how it can affect therapeutic patient education interventions and contribute to outcomes. We aimed to identify the contextual features that may affect the outcome and sustainability of therapeutic patient education interventions from a healthcare professional perspective. METHODS: Semi-structured individual interviews were conducted with healthcare professionals involved in 14 therapeutic patient education interventions covering different chronic conditions (e.g., kidney and cardiovascular diseases, chronic pain, diabetes, obesity). Interviews were recorded and fully transcribed. We followed a general inductive approach to identify themes from healthcare professionals' discourse to properly capture their perception. RESULTS: Saturation was achieved with 28 interviews with 20 nurses, 6 dieticians, one physiotherapist and one psychologist. The average therapeutic patient education experience was 7 years. Identified contextual features clustered in 5 main themes: 1) conditions for the development of the intervention (genesis of the program: Who and what prompted it?; supports; content development; legislative framework); 2) integration of the program (in the healthcare pathway or the environment, relationship with the institution or local environment); 3) teamwork cohesion, interaction and integration with the environment (exchanges, cohesion of the team); 4) sustainability of the program; and 5) patient and healthcare professional contextual factors. CONCLUSION: New insights into contextual features that may be involved in therapeutic patient education interventions are represented in a framework based on the Medical Research Council evaluation framework. These features need to be addressed in studies of therapeutic patient education interventions and could help healthcare professionals build more effective interventions within the context. However, describing a list of elements of the context is not enough; analyses should also focus on how the contextual elements might affect an intervention and how they interact.

[Benchmarks for interdisciplinary health and social sciences research: contributions of a research seminar]. / Jalons pour une recherche interdisciplinaire en santé et en sciences humaines et sociales: apports d'un séminaire de recherche.

This article proposes a reflection on an interdisciplinary seminar, initiated by philosophy and sociology researchers and public health professionals. The objective of this seminar was to explore the mechanisms involved in setting up and conducting interdisciplinary research, by investigating the practical modalities of articulating health and human and social sciences research in order to more clearly understand the conditions, tensions and contributions of collaborative research. These questions were discussed on the basis of detailed analysis of four recent or current research projects. Case studies identified four typical epistemological or methodological issues faced by researchers in the fields of health and human and social sciences: institutional conditions and their effects on research; deconstruction of the object; the researcher's commitment in his/her field; the articulation of research methods. Three prerequisites for interdisciplinary research in social and human sciences and in health were identified: mutual questioning of research positions and fields of study; awareness of the tensions related to institutional positions and disciplinary affiliation; joint elaboration and exchanges between various types of knowledge to ensure an interdisciplinary approach throughout all of the research process.

Patient Satisfaction and Perspectives on Self-Management Education Programs: A Qualitative Study.

Purpose: According to the Centre for Disease Control and Prevention, "Self-management education (SME) refers to programs that help people who have ongoing health conditions learn how to live life to the fullest". Most studies to date have focused on SME outcomes, such as the acquisition of predefined knowledge or skills or quality of life. However, no study has yet investigated patients' satisfaction with SMEs. The aim of the present study was therefore to explore participants' subjective appreciation of SME programs using qualitative methods and formulate propositions based on patients' preferences to improve ultimately clinical outcomes. Patients and Methods: Twenty-five participants from five French SME programs to conduct focus groups were recruited. An inductive approach using grounded theory as an overall methodology orientation for the thematic analysis process has been followed. The study was reported in compliance with the consolidated criteria for reporting qualitative research criteria (COREQ). Results: Patients expressed great satisfaction concerning the effective delivery of SME sessions. They appreciated the considerations for their concerns and needs, the adaptation of sessions' content to their interests and questions, and learning to take care of themselves. Moreover, patients had a positive opinion on the quality of their relationship with health care providers. However, the major point of improvement of SMEs was the opportunity to repeat the program if needed, as this opportunity was not offered. This consideration was particularly salient when patients did not consider themselves autonomous for disease management at the end of the program, ie, when they had low levels of perceived self-efficacy. Conclusion: While patients expressed great satisfaction regarding SME programs, our results suggest that some changes might be needed to make the endpoint of SME interventions coincide with the patient's perception of self-efficacy in disease self-management and ultimately improve clinical outcomes.

Healthcare providers perception of therapeutic patient education efficacy according to patient and healthcare provider characteristics.

OBJECTIVES: Therapeutic patient education improves numerous health and psychological outcomes in patients with chronic diseases. However, little is known about what makes a therapeutic patient education intervention more effective than another one. This study aims to identify in healthcare professionals the perceived determinants of therapeutic patient education efficacy at the individual level. METHODS: Semi-structured individual interviews have been conducted with healthcare professionals (HCP, n=28, including 20 nurses) involved in therapeutic patient education programs (n=14) covering various chronic conditions (kidney and cardiovascular diseases, chronic pain, diabetes, etc.). A thematic content analysis following an inductive approach was used (Nvivo.11 software). RESULTS: Five themes were retrieved for patient characteristics: understanding and education, personality, readiness and motivation, social environment, and misinformation and beliefs. Four themes were retrieved for healthcare professionals' characteristics: medical knowledge, appropriate attitude and relational skills, pedagogical skills, and training. DISCUSSION: Patient personality is rarely discussed in the literature. Patients who are introverted, lack curiosity, or are not compliant might benefit from specific therapeutic patient education practices or formats. All these potential determinants regarding patients and healthcare professionals should be routinely assessed in future studies about therapeutic patient education efficacy to understand precisely what makes an intervention successful.