How Primary Healthcare Sector is Organized at the Territorial Level in France? A Typology of Territorial Structuring.

BACKGROUND: Most the Organization for Economic Co-operation and Development (OECD) countries are currently facing the challenges of the health transition, the aging of their populations and the increase in chronic diseases. Effective and comprehensive primary healthcare (PHC) services are considered essential for establishing an equitable, and cost-effective healthcare system. Developing care coordination and, on a broader scale, care integration, is a guarantee of quality healthcare delivery. The development of healthcare systems at the meso-level supports this ambition and results in a process of territorial structuring of PHC. In France, the Health Territorial and Professional Communities (HTPC) constitute meso-level organizations in which healthcare professionals (HCPs) from the same territory gather. We conducted a study to determine, in a qualitative step, the key elements of the territorial structuring of PHC in France and, then, to develop, in a quantitative step, a typology of this structuring. METHODS: A sequential-exploratory mixed-method study with a qualitative step using a multiple case approach and a quantitative step as a hierarchical clustering on principal components (HCPC) from a multiple correspondence analysis (MCA). RESULTS: A total of 7 territories were qualitatively explored. Territorial structuring appears to depend on: past collaborations at the micro-level, meso-level coordination among HCPs and multiprofessional structures, diversity of independent professionals, demographic dynamics attracting young professionals, and public health investment through local health contracts (LHCs). The typology identifies 4 clusters of mainland French territories based on their level of structuring: under or unstructured (38.6%), with potential for structuring (34.7%), in the way for structuring (25.3%) and already structured territories (1.4%). CONCLUSION: Interest in territorial structuring aligns with challenges in meso-level healthcare organization and the need for integrated care. Typologies of territorial structuring should be used to understand its impact on access, care quality, and medical resources.

Prevalence and socioeconomic factors associated with non-utilization of dental care in Lebanon: A nationwide cross-sectional survey.

OBJECTIVES: To assess the prevalence of non-utilization of dental care in Lebanon and associated socioeconomic factors and self-care behaviours. METHODS: A nationwide, quantitative, survey-based study was conducted by trained interviewers with Lebanese residents aged ≥18 years between July and September 2019. Univariate analyses were performed using Pearson Chi Square test or the Fisher's exact test followed by a binary logistic regression using the SPSS Version 25. RESULTS: Of the 1070 participants, 247 (23.1%) did not utilise any type of healthcare and 144/247 (58.3%) did not utilise dental care. The prevalence of non-utilization of dental care was estimated at 13.5%. Only 4.7% of the respondents consulted their dentist in the past year, among which 53% cited pain/emergencies as the reason for their consultation. Socioeconomic factors associated with the non-utilization of dental care were lack of social medical insurance (OR, 0.49 [95% CI, 0.31 to 0.79]) and long waiting time/patient time restriction (OR, 2.05 [95% CI, 1.26 to 3.35]). On the other hand, facilitators for utilization of dental care included ethical standards/personal qualities of the dentist (OR, 0.53 [95% CI, 0.32 to 0.88]) and convenient cost with respect to the individual's economic status (OR, 0.28 [95% CI, 0.18 to 0.43]). CONCLUSION: This study suggests that dental care practices in Lebanon, including the non-utilization of dental care, are suboptimal. Measures such as reducing sugar and tobacco consumption, providing information on oral hygiene, and using fluoride products are inexpensive; however, implementing these measures may take substantial time and input by multiple stakeholders.

Denormalization of tobacco and its industry by civil society: Implementation and evaluation of the "Pouvoir de vivre" campaign by ACT ­ Alliance Contre le Tabac (Alliance Against Tobacco) / Dénormalisation du tabac et de son industrie par la société civile : mise en œuvre et évaluation de la campagne « Pouvoir de vivre ¼ par l'ACT ­ Alliance contre le tabac

This article examines the "denormalization" approach, which has gradually gained ground in the field of tobacco control. This process encompasses a wide range of practices and aims to renew tobacco control by extending its scope beyond the usual individual and health considerations; it also considers smoking as a societal problem. This contribution illustrates the implementation of this approach, as embodied in France by the Alliance Contre le Tabac denormalization program launched in 2019, through campaigns addressing a diverse range of themes. The latest campaign, carried out in January 2023, demonstrates that smoking also exacerbates the social and economic difficulties of the most disadvantaged members of society. Its presentation illustrates the deployment of such a campaign, the methodology used, the tools mobilized, and the results obtained by carrying out a post-test.

Cet article présente l'approche dite de dénormalisation, qui s'est progressivement imposée dans le champ de la lutte contre le tabac. Cette démarche regroupe un ensemble varié de pratiques et entend renouveler les méthodes de la lutte contre le tabac en élargissant sa portée au-delà des considérations individuelles et sanitaires habituelles ; elle envisage le tabagisme en tant que problématique sociétale. Cette contribution illustre la mise en œuvre de cette approche, incarnée en France par les campagnes de dénormalisation de l'Alliance Contre le Tabac depuis 2019. La dernière campagne réalisée en janvier 2023 démontre que le tabagisme, au-delà de son impact sanitaire, aggrave aussi les difficultés financières quotidiennes des personnes les plus modestes. La présentation de ce dispositif permet d'illustrer le déploiement de ce type de campagne, la méthodologie utilisée, les outils mobilisés et les résultats obtenus, grâce à la réalisation d'un post-test.

Knowledge, attitudes and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France.

INTRODUCTION: Smoking remains a leading cause of preventable death in France, even among the elderly. Although smoking prevalence has decreased overall, it still affects a significant portion of older adults. This study investigates the knowledge, attitudes, and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France. METHODS: A cross-sectional study involved 300 primary care professionals (general practitioners, pharmacists, nurses) in the Ile-de-France region. Data collection occurred via telephone interviews in September and October 2019. The study employed a questionnaire focusing on knowledge (10 questions), attitudes (12 statements), and clinical practices (7 questions) related to tobacco dependence in older adults. Responses were scored based on correctness for knowledge and appropriateness for attitudes and practices. RESULTS: The surveyed professionals were predominantly female (57.7%), with a mean age of 53.0 years, and most were non-smokers or former smokers (85.3%). While 66.7% believed older smokers had lower cessation rates, only 64.3% knew it was safe to prescribe nicotine replacement therapy for the elderly. Attitude scores averaged 8.8/12, with pharmacists scoring highest (9.9) and nurses lowest (8.2). Practices scores averaged 2.8/7, with physicians scoring highest (3.8) and pharmacists lowest (1.9). CONCLUSIONS: Primary healthcare professionals have a relatively good knowledge of the management of tobacco dependence in the elderly and consider it to be part of their mission. However, their confidence in their abilities needs to be strengthened, and many opportunities to counsel and assist this population to quit smoking are still being missed. Preventive approaches to older smokers are essential, in keeping with the concept that 'every contact with the healthcare system counts'. Improving practice will require education and training that will not only build knowledge but also change perceptions, leading to better attitudes and practices in the management of smoking cessation among older adults.

Impact of the first COVID-19 epidemic wave in a large French network of nursing homes: a cross-sectional study.

BACKGROUND: Nursing homes (NHs) have been particularly affected by COVID-19. The aim of this study is to estimate the burden of COVID-19 and to investigate factors associated with mortality during the first epidemic wave in a large French NHs network. METHODS: An observational cross-sectional study was conducted in September-October 2020. 290 NHs were asked to complete an online questionnaire covering the first epidemic wave on facilities and resident characteristics, number of suspected/confirmed COVID-19 deaths, and preventive/control measures taken at the facility level. Data were crosschecked using routinely collected administrative data on the facilities. The statistical unit of the study was the NH. Overall COVID-19 mortality rate was estimated. Factors associated with COVID-19 mortality were investigated using a multivariable multinomial logistic regression. The outcome was classified in 3 categories: "no COVID-19 death in a given NH", occurrence of an "episode of concern" (at least 10% of the residents died from COVID-19), occurrence of a "moderate episode" (deaths of COVID-19, less than 10% of the residents). RESULTS: Of the 192 (66%) participating NHs, 28 (15%) were classified as having an "episode of concern". In the multinomial logistic regression, moderate epidemic magnitude in the NHs county (adjusted OR = 9.3; 95%CI=[2.6-33.3]), high number of healthcare and housekeeping staff (aOR = 3.7 [1.2-11.4]) and presence of an Alzheimer's unit (aOR = 0.2 [0.07-0.7]) were significantly associated with an "episode of concern". CONCLUSIONS: We found a significant association between the occurrence of an "episode of concern" in a NH and some of its organizational characteristics and the epidemic magnitude in the area. These results can be used to improve the epidemic preparedness of NHs, particularly regarding the organization of NHs in small units with dedicated staff. Factors associated with COVID-19 mortality and preventive measures taken in nursing homes in France during the first epidemic wave.

Prevalence of prediabetes and undiagnosed diabetes in a large urban middle-aged population: the CARVAR 92 cohort.

BACKGROUND: The aim of this study was to assess the prevalence of prediabetes and unknown diabetes and its long-term change in a large middle-aged urban population. METHODS: We conducted a screening campaign between 2007 and 2018 for cardiovascular risk factors in the western suburbs of Paris including subjects aged 40-70 (CARVAR 92). Among subjects who reported no previous diabetes, prediabetes and undiagnosed diabetes were defined as follows: fasting plasma glucose (FPG) ≥ 6.1 mmol/l (110 mg/dl) and < 7 mmol/l (126 mg/dl) for prediabetes according to WHO criteria (FPG between 5.6 and 6.9 mmol/l according to ADA criteria) and FPG ≥ 7.0 mmol/l for undiagnosed diabetes. RESULTS: Of the 32,721 subjects in the CARVAR 92 cohort, 32,675 were included in this analysis. The median age of the patients was 56 years [30, 94], 45.4% were male, 5.9% had known diabetes, 36.4% were overweight and 18.7% obese. Among patients without previously known diabetes (n = 30,759), 8.1% had prediabetes according to WHO criteria (27.2% according to ADA criteria) and 2.3% had diabetes. Subjects with prediabetes and unknown diabetes were more likely to be male, older, and overweight or obese than non-diabetic subjects. From 2007 to 2018, the prevalence of prediabetes, unknown diabetes, and known diabetes decreased, except for prediabetes which remained stable for people aged 55-64. CONCLUSION: The prevalence of prediabetes and unknown diabetes remains high but decreased during a 12-year period. About one-quarter of diabetes cases remain undiagnosed. Our results highlight that there is still a room for screening and cardiovascular prevention campaigns. TRIAL REGISTRATION: IRB00012437.

Dénormalisation du tabac et de son industrie par la société civile : mise en œuvre et évaluation de la campagne « Pouvoir de vivre ¼ par l'ACT ­ Alliance contre le tabac.

This article examines the "denormalization" approach, which has gradually gained ground in the field of tobacco control. This process encompasses a wide range of practices and aims to renew tobacco control by extending its scope beyond the usual individual and health considerations; it also considers smoking as a societal problem. This contribution illustrates the implementation of this approach, as embodied in France by the Alliance Contre le Tabac denormalization program launched in 2019, through campaigns addressing a diverse range of themes. The latest campaign, carried out in January 2023, demonstrates that smoking also exacerbates the social and economic difficulties of the most disadvantaged members of society. Its presentation illustrates the deployment of such a campaign, the methodology used, the tools mobilized, and the results obtained by carrying out a post-test.

Recours aux soins dentaires au Liban : de la perception vers la réalité.

INTRODUCTION: In the context of public health, seeking or not seeking dental care is a poorly documented topic. However, its control is essential for the establishment of effective prevention. PURPOSE OF RESEARCH: The main objective of our study is to explore the perceptions, attitudes, social representations and factors determining the behavior of the Lebanese population seeking oral care in two governorates, Beirut and Mount Lebanon.The method follows the descriptive qualitative approach. Semi-directed exploratory interviews were conducted with 20 beneficiaries and 7 dentists. The data was analyzed thematically in several stages according to the Kreuter and Green model. RESULTS: The results of our study showed that several factors hamper the beneficiaries’ use of dental care. The lack of knowledge about the association between dental health and general health, the negative perceptions of citizens towards prevention and dentistry as well as financial incapacity remain primordial factors obstructing the seeking of dental care. On the other hand, health education, changing perceptions as well as cost coverage or reimbursement would be factors that could promote the use of dental care. CONCLUSION: Not seeking dental care remains a worrying problem in a developing country like Lebanon. The impact is considerable on oral health and on general health with all its consequences on an already fragile health system.

The COVID-19 Pandemic and Responses in Nursing Homes: A Cross-Sectional Study in Four European Countries.

BACKGROUND: Studies comparing how the European nursing homes (NHs) handled the first wave of the COVID-19 pandemic remain scarce. METHODS: A cross-sectional study was conducted during the first wave in a private NHs network in Belgium, France, Germany and Italy. Mortality rates were estimated, and prevention and control measures were described by country. Data from the Oxford governmental response tracker project were used to elaborate a "modified stringency index" measuring the magnitude of the COVID-19 global response. RESULTS: Of the 580 NHs surveyed, 383 responded to the online questionnaire. The COVID-19 mortality rate was similar in France (3.9 deaths per 100 residents) and Belgium (4.5). It was almost four times higher in Italy (11.9) and particularly low in Germany (0.3). Prevention and control measures were diversely implemented: residents' sectorization was mainly carried out in France and Italy (~90% versus ~30% in Germany and Belgium). The "modified stringency index" followed roughly the same pattern in each country. CONCLUSION: This study, conducted in a European network of NHs, showed differences in mortality rate which could be explained by the characteristics of the residents, the magnitude of the first wave and the prevention and control measures implemented. These results may inform future European preparedness plans.

[Dénormaliser le tabac et son industrie, une approche gagnante ?] / Is de-normalizing tobacco and its industry a winning approach ?

IS DE-NORMALIZING TOBACCO AND ITS INDUSTRY A WINNING APPROACH? The so-called "denormalization" approach has progressively imposed itself in the field of tobacco control. This strategy is no longer limited to the health and individual implications of smoking but renews the fight against tobacco by considering it as a social problem. It is therefore a question of attacking the industry's influencing practices, and even appropriating them in campaigns linking the tobacco issue to contemporary struggles such as children's rights, climate change or gender equality. Denormalization is different from previous modes of action. Three American programs are considered to be the founders of this concept, which has recently been considered and practiced in France by ACT (Alliance contre le Tabac).

DÉNORMALISER LE TABAC ET SON INDUSTRIE, UNE APPROCHE GAGNANTE ? L'approche dite de « dénormalisation ¼ s'est progressivement imposée dans le champ de la lutte contre le tabac. Ensemble varié de pratiques d'influence, cette stratégie n'entend plus se limiter aux seules implications sanitaires et individuelles du problème tabagique, mais bien renouveler la lutte contre le tabac en considérant ce dernier comme un problème social. Il s'agit dès lors de contrecarrer les pratiques d'influence de l'industrie du tabac en mettant en lumière, par les mêmes outils, les conséquences sociétales de ses activités jusqu'alors méconnues du grand public : atteintes aux droits humains, dégradation de l'environnement et aggravation des inégalités économiques et sociales. La dénormalisation se distingue des modes d'action antérieurs. Trois programmes américains sont considérés comme fondateurs de ce concept qui est, depuis peu, également envisagé et pratiqué en France par l'Alliance contre le tabac (ACT).

A Restructured Hospital Into a One-Building Organization for COVID-19 Patients: A Resilient and Effective Response to the Pandemic.

The COVID-19 pandemic is a unique crisis challenging healthcare institutions as it rapidly overwhelmed hospitals due to a large influx of patients. This major event forced all the components of the healthcare systems to adapt and invent new workflows. Thus, our tertiary care hospital was reorganized entirely. During the cruising phase, additional staff was allocated to a one-building organization comprising an intensive care unit (ICU), an acute care unit, a physical medicine and rehabilitation unit, and a COVID-19 screening area. The transfer of patients from a ward to another was more efficient due to these organizations and pavilion structure. The observed mortality was low in the acute care ward, except in the palliative unit. No nosocomial infection with SARS-CoV-2 was reported in any other building of the hospital since this organization was set up. This type of one-building organization, integrating all the components for comprehensive patient care, seems to be the most appropriate response to pandemics.

Cross-sectional study on COVID-19 vaccine hesitancy and determinants in healthcare students: interdisciplinary trainings on vaccination are needed.

BACKGROUND: To ensure the success of COVID-19 vaccination, public authorities need to have the support of the entire population and build vaccine confidence. Identifying and understanding the determinants of vaccine acceptance is essential for conducting vaccine strategy. The aim was to estimate vaccine hesitancy among healthcare students in France and to investigate the associated factors. METHODS: A web-based cross-sectional study was conducted in a large French University in greater Paris area, among 4927 healthcare students from the different training courses such as medicine studies, midwifery studies, physiotherapy studies, nurse studies and others health studies. The study was conducted between January 21 and February 8, 2021 based on a questionnaire including 25 single or multiple-choice questions, made using the free software Limesurvey. The link of the questionnaire was distributed to the students by the teachers and the student associations. The SAGE group definition of vaccine hesitancy was used. All estimates were weighted using the gender and training courses category of all healthcare students registered for the 2020-2021 year. Crude and adjusted weighted odds ratio (wOR) and 95% confidence interval (95%CI) were estimated using logistic regression. RESULTS: A total of 1465 healthcare students answered. A proportion of 44.5% (95%CI = [41.7-47.3]) of them were considered as hesitant. Women were more hesitant (50.9, 95%CI = [48.0-53.9]) than men (21.6, 95%CI = [15.2-28.0]). Vaccine hesitancy was significantly associated with gender (wOR = 0.27, 95%CI = [0.18-0.39]) and training courses: medical students were less likely to be hesitant than students in the common and first year of several health studies (wOR = 0.48, 95%CI = [0.33-0.70]) while nursing students were more than 5 times more likely to be hesitant (wOR = 5.20, 95%CI = [3.71-7.28]). Students who did an internship during the epidemic (wOR = 0.53, 95%CI = [0.41-0.69]) and who downloaded the mobile contact-tracing mobile app "TousAntiCovid" (wOR = 0.34, 95%CI = [0.26-0.44]) were significantly less likely to be hesitant. CONCLUSIONS: Overall vaccine hesitancy among healthcare students was high, substantial differences were found between training courses. To reduce these disparities, interdisciplinary lectures on vaccines for all healthcare students may be implemented and evaluated.

Prevalence of familial hypercholesterolaemia in patients presenting with premature acute coronary syndrome.

BACKGROUND: Familial hypercholesterolaemia (FH) is responsible for severe hypercholesterolaemia and premature cardiovascular morbidity and mortality. The first clinical event is typically an acute coronary syndrome. Unfortunately, FH is largely underdiagnosed in the general population. AIMS: To assess the prevalence of clinical FH among patients with premature (aged≤50 years) acute myocardial infarction (MI) and compare it with FH prevalence in a control population. METHODS: We reviewed in our database all patients with premature MI (aged≤50 years) referred to Ambroise Paré Hospital from 2014 to 2018. FH prevalence was estimated via the Dutch Lipid Clinic Network score, based on personal and family history of premature cardiovascular disease and low-density lipoprotein cholesterol concentrations. FH was "possible" with a score between 3 and 5 points, "probable" with a score between 6 and 8 and "definite" with a score above 8. FH prevalence in young patients with MI was then compared with FH prevalence in a general population of the same age from the CARVAR 92 prospective cohort. RESULTS: Of the 457 patients with premature MI, 29 (6%) had "probable" or "definite" FH. In the CARVAR 92 cohort, 16 (0.16%) of 9900 subjects aged≤50 years had "probable" or "definite" FH. FH prevalence was 39 times greater among patients with premature MI than in the control population (P<0.0001). In multivariable analysis, FH was strongly associated with MI (adjusted odds ratio 38.4, 95% confidence interval 19.1-79.4). CONCLUSIONS: FH is>30-fold more common in patients referred for premature MI than in the general population; this highlights the need for FH screening after a first MI to enhance lipid-lowering therapy and allow early identification of family members.

Smoking and obesity among long-haul truck drivers in France.

INTRODUCTION: This study examines the health status of long-haul truck drivers (LHTDs) and more specifically smoking and obesity, in France. METHODS: A total of 373 French and other LHTDs were randomly interviewed at six highway rest stops. Variables recorded were self-reported sociodemographic characteristics (age, gender, marital status, and nationality), behavioral variables (consumption of sodas, daily exercise, smoking status), weight and height. Body mass index (BMI) was also calculated. Statistical analysis was conducted using chi-squared analysis and multiple logistic ordinal regression models (MLR) were developed. RESULTS: The mean age was 43.4 and the largest proportion (41.2%) of respondents were aged 40-50 years. Most respondents were French (70.3%), married (73.8%) and did not report having an active exercise routine (66.0%). Almost two-thirds of the drivers consumed daily 1-2 sodas (34.2%) or 3-4 sodas (33.2%). Based on the BMI, respondents were divided into normal (34.3%), overweight (39.8%), obese (19.5%) or morbidly obese (9.4%) categories. The mean BMI was 27.9 kg/m2 and 51.1% of LHTDs were current or active smokers. MLR analysis revealed that French LHTDs were more likely (OR=3.04; 95% CI: 1.62-5.69) to have a normal BMI compared to other drivers. Smokers were significantly more likely than non-smokers (OR=2.12; 95% CI: 1.26-3.58) to have an above normal BMI. CONCLUSIONS: These results confirm that French and other LHTDs are at high risk of non-communicable diseases. They also highlight the need to address the health risks associated with smoking and obesity among LHTDs using multifaceted strategies.

[Adolescents turning into smokers in France]. / Entrée des adolescents dans le tabagisme en France.

Adolescents turning into smokers in france .Tobacco kills more than 75,000 people in France each year. Among them, a large majority started their smoking history as an adolescent. More than half of 17-years-old have already tried tobacco and 25.1% of them report daily smoking. This is the lowest prevalence of daily smoking observed in France for 20 years. The daily consumption of 16-years-old decreased from 31% in 1995 to 12% in 2019, placing France in the European average. The initiation of regular tobacco consumption results from complex combinations of social (family, peers), environmental (passive exposure, accessibility, and marketing of products) and individual elements. Passive smoking in the family sphere and the influence of peers, which is most prevalent in adolescence, are two decisive determinants of future adolescent use of cigarette. The study of the entrance into smoking in adolescence should help to adapt preventive strategies to achieve a "tobacco-free generation".

"Entrée des adolescents dans le tabagisme en france. Le tabac tue en France chaque année plus de 75 000 personnes. Parmi elles, une très large majorité a commencé son histoire tabagique dès l'adolescence. Plus de la moitié des jeunes de 17 ans ont déjà essayé le tabac et 25,1 % d'entre eux déclarent fumer quotidiennement. Il s'agit de la prévalence de tabagisme quotidien la plus faible observée en France depuis 20 ans. La consommation quotidienne des jeunes de 16 ans est, quant à elle, passée de 31 % en 1995 à 12 % en 2019, plaçant la France dans la moyenne européenne. Le démarrage d'une consommation régulière de tabac résulte de combinaisons complexes entre des éléments sociaux (famille, pairs), environnementaux (exposition passive, accessibilité et marketing des produits) et individuels. Le tabagisme passif dans la sphère familiale et l'influence des pairs, majeure à l'adolescence, sont deux déterminants décisifs de la consommation future de l'adolescent. L'étude des modalités d'entrée dans le tabagisme à l'adolescence doit aider à adapter les stratégies préventives pour parvenir à une « génération sans tabac ¼."