Combined influence of immigration status and income on cervical cancer screening uptake.

The regular performance of Pap tests for cervical cancer screening reduces this disease's incidence and mortality. Income inequalities have been reported for this screening, partly because in some countries women must advance or even pay out-of-pocket costs. Because immigrant status is also associated with low Pap test uptake, we aimed to analyze the combined impact of immigrant status and low income on cervical cancer underscreening. This study, based on the French CONSTANCES cohort, uses data from the cohort questionnaires and linked health insurance fund data about Pap test reimbursement. To measure income inequalities in screening, we calculated a Slope Index of Inequality (SII) by linear regression, taking into account the migration status of participants. The majority of the 70,614 women included in the analysis were not immigrants (80.2%), while 12.9% were second-generation immigrants, and 6.9% first-generation immigrants. The proportion of underscreening increased with immigrant status, from 19.5% among nonimmigrants to 23.6% among the second generation, and 26.5% among the first (P < 0.01). The proportion of underscreening also increased as income level decreased. The income gradient rose significantly from 14% among nonimmigrants to 21% in second-generation immigrants and 19% in the first generation (P < 0.01). Among first-generation migrants, the shorter the duration of residence, the higher the SII. Women who are first- or second-generation immigrants are simultaneously underscreened and subject to a more unfavorable economic gradient than native French women born to native French parents. The accumulation of several negative factors could be particularly unfavorable to screening uptake.

Impact of a patient reminder letter from their general practitioners on influenza vaccination: A quasi-experimental study in Paris, France.

BACKGROUND: Seasonal influenza vaccination coverage levels remain too low in many countries. OBJECTIVES: This study aimed to evaluate the impact of a reminder letter from their general practitioner (GP) on patients' influenza vaccination. METHODS: Eligible patients for this controlled non-randomised study were the vulnerable categories targeted by the 2019-2020 national health insurance fund (NHIF) vaccination campaign, on the lists of 14 GPs from three practices in Paris (France) and unvaccinated on January 2, 2020 (mid-campaign). The choice of practices and assigning five GPs to the intervention arm were made for convenience. At mid-campaign, GPs in the intervention arm sent a standardised letter reminding each eligible patient to be vaccinated. In the control arm, GPs worked as usual. The intervention effect, calculated from the NHIF databases, was estimated by the difference between the groups in their vaccination coverage at the end of the campaign, with a linear mixed model adjusted for age, sex, chronic disease (at the patient level) and medical practice (at the GP level). RESULTS: The vaccination coverage at the end of the campaign was 14.7% in the intervention group (n = 317) and 1.7% in the control group (n = 493): a difference of 13.1% points (95% confidence interval [9.0-17.2], number needed to send 7.7). At the campaign's end, vaccination coverage among patients from the lists of GPs in the intervention arm was 62.7%, and 46.2% among patients from the control-arm GP lists. CONCLUSION: Reminder letters could help increase influenza vaccination coverage.

Women with type 2 diabetes have LDL cholesterol levels higher than those of men, regardless of their treatment and their cardiovascular risk level.

BACKGROUND AND AIMS: Several works have shown that control of the principal cardiovascular risk factors, especially LDL-C, is poorer among women with type 2 diabetes than men with this disease. Our objectives were to compare the statin treatments and LDL-C levels between men and women with type 2 diabetes, according to the potency of the statin they take, while taking their cardiovascular risk level into account. METHOD AND RESULTS: This is a descriptive cross-sectional study within the French CONSTANCES cohort. At inclusion, each individual completed several self-administered questionnaires. Data were then matched to their health insurance fund reimbursement data. The study population comprises cohort members with pharmacologically treated type 2 diabetes. We identified 2541 individuals with type 2 diabetes; 2214 had an available LDL-C value. In the total sample, treatment by statins did not differ between men and women, while the women had a higher mean LCL-C level than men. The analyses stratified by cardiovascular risk showed that women at very high cardiovascular risk received significantly less frequent statin delivery than men (OR = 0.72 [0.56-0.92]; p = 0.01). At the same time, women received the same rate of high-potency statins as men. Women taking equivalently potent statins had significantly higher LDL-C levels than men did. CONCLUSION: For the same cardiovascular risk level and the same statin treatment, women had an LDL-C level higher than that of men. They thus present a residual cardiovascular risk that justifies intensification of their statin treatment if tolerance allows.

Women with obesity in cervical cancer screening. The double penalty: Underscreening and income inequalities.

The regular performance of Pap tests reduces the mortality of cervical cancer. Obesity is associated with low Pap test rates. We analyze the combined role of obesity and low income. We calculated a Slope Index of Inequality. Among the 28,905 women included, 23.1% were underscreened. The rate of underscreening increased with BMI. The income gradient increased significantly from 0.17 among normal-weight women to 0.19 in overweight and 0.23 in obese women (p = 0.047). Women who are obese are subject to a double penalty in cervical cancer screening: they are underscreened and subject to a more unfavorable economic gradient than normalweight women.

Level of agreement between physician and patient assessment of non-medical health factors.

Background: GPs need to consider assorted relevant non-medical factors, such as family or work situations or health insurance coverage, to determine appropriate patient care. If GPs' knowledge of these factors varies according to patients' social position, less advantaged patients might receive poorer care, resulting in the perpetuation of social inequalities in health. Objective: To assess social disparities in GPs' knowledge of non-medical factors relevant to patient care. Methods: Observational survey of GPs who supervise internships in the Paris metropolitan area. Each of the 52 enrolled GPs randomly selected 70 patients from their patient list. Their knowledge of five relevant factors (coverage by publicly funded free health insurance, or by supplementary health insurance, living with a partner, social support and employment status) was analysed as the agreement between the patients' and GPs' answers to matching questions. Occupational, educational and financial disparities were estimated with multilevel models adjusted for age, sex, chronic disease and GP-patient relationship. Results: Agreement varied according to the factor considered from 66% to 91%. The global agreement score (percentage of agreement for all five factors) was 72%. Social disparities and often gradients, disfavouring the less well-off patients, were observed for each factor considered. Social gradients were most marked according to perceived financial situation and for health insurance coverage. Conclusion: GPs must be particularly attentive toward their least advantaged patients, to be aware of the relevant non-medical factors that affect these patients' health and care, and thus provide management adapted to each individual's personal situation.

Are primary-care physician practices related to health behaviors likely to reduce social inequalities in health?

Our objective was to examine patients' health behaviors and the related practices of their primary-care physicians to determine whether physicians' actions might help to reduce the social inequalities in health behaviors among their patients. Fifty-two general practitioners, who were also medical school instructors in the Parisian area, volunteered to participate. A sample of 70 patients (stratified by sex) aged 40-70years was randomly chosen from each physician's patient panel and asked to complete a questionnaire about their social position and health behaviors: tobacco and alcohol use, diet, physical activity, and participation in breast and cervical cancer screening. Each physician reported their practices related to each such behavior of each patient. Mixed models were used to test for social differences. Questionnaires were collected in 2008-2009 from both patient and physician for 71% of the 3640 patients. Our results showed social inequalities disfavored those at the bottom of the social scale for all but one of the health behaviors studied among both men and women (exception: excessive alcohol consumption among women). Physicians' practices related to these health behaviors also appeared to be socially differentiated. Among men, this differentiation favored those with the lowest social position for all behaviors except physical activity. Among women, however, practices favored the most disadvantaged only for breast cancer screening. In all other cases, they were either socially neutral or unfavorable to the most disadvantaged. Physicians' practices related to their patients' health behaviors should focus more on those lowest in the social hierarchy, especially among women.

Time and feasibility of prevention in primary care.

BACKGROUND: Prevention is an essential task in primary care. According to primary care physicians (PCPs),lack of time is one of the principal obstacles to its performance. OBJECTIVE: To assess the feasibility of prevention in terms of time by estimating the time necessary to perform all of the preventive care recommended, separately from the PCPs and patient's perspectives, and to compare them to the amount of time available. METHODS: A review of the literature identified the prevention procedures recommended in France, the duration of each procedure and its recommended frequency, as well as PCPs' consultation time. A hypothetical patient panel size of 1000 patients, representative of the French population, served as the basis for our calculations of the annual time necessary for prevention for a PCP. The prevention time from the patient's perspective was estimated from data collected from a previous study of a panel of 3556 patients. RESULTS: For PCPs, the annual time necessary for all of the required preventive care was 250 hours, or 20% of their total patient time. For a patient, the annual time required for prevention during encounters with a PCP ranged from 9.7 to 26.4 minutes per year. The mean total encounter time was 75.9 minutes per year. Nearly 73% of patients had a prevention-to-care time ratio exceeding 15%. CONCLUSION: Feasibility thus differs substantially between patients. These differences correspond especially to disparities in the annual care time used by each patient. Specific solutions should be developed according to the patients' utilization of care.