Interaction between patient and general practitioner according to the patient body weight: a cross-sectional survey.

OBJECTIVE: To analyse whether patient-general practitioner (GP) interaction, measured by their disagreement, varies among overweight or obese patients compared with normal-weight patients. METHODS: Twenty-seven GPs and 585 patients participated in the quantitative phase of the multidisciplinary INTERMEDE project and answered "mirrored" questionnaires collecting both GPs and patients' perceptions on information and advice given at the end of the consultation. Multilevel logistic regressions were performed to explore associations between patient body mass index (BMI) and patient-GP disagreement on information and advice given during the consultation. RESULTS: Disagreement increased with the patients' excess weight, and it was particularly pronounced for advice given by GPs on weight and lifestyle issues. Compared with patients with a "normal" BMI, overweight patients were more likely to disagree with their GP regarding advice given on weight loss (odds ratio [OR] = 10.7, 95% confidence interval [CI] = 4.1-27.3), advice given on doing more physical activity (OR = 1.9, 95% CI = 1.1-3.4), and nutritional advice (OR = 2.9, 95% CI = 1.5-5.6). CONCLUSION: These disagreements could degrade the quality of patient-physician relationship. Our study provides an opportunity for GPs to reflect on how they communicate with overweight and obese patients, particularly with regard to lifestyle and weight-related advice and interventions taking into account the patient's representations.

L'impact de la COVID-19 sur la santé des enfants, groupe « protégé ¼ de l'infection.

OBJECTIVE: This article underlines that a viral epidemic and strategies to deal with it 1) have a major impact on groups that are a priori spared by the disease itself, in this case children, and 2) can generate health problems beyond the disease and lead to major social, economic and educational difficulties and an increase of social inequalities in health. METHOD: The observations presented are based on the scientific literature available in the first half of 2020 and on discussions with actors in the field, experts and heads of institutions, conducted by a working group of the Haut Conseil de la Santé Publique reflecting on a global and concerted policy for children's health. RESULTS: The health crisis and its management have had an impact on children's development and their quality of life. They have been more exposed to sedentary lifestyles, screens, accidents, and violence at home. The closure of schools and leisure facilities has led to difficulties in school, socialization, psychological well-being and mental health. Curative or preventive care has been postponed. These effects occurred with significant social and territorial inequalities. CONCLUSION: Any health crisis management requires an assessment of the overall impact of the epidemic and the proposed measures on health, economic, social, and educational indicators. This crisis shows the need for a coordinated children's policy, which is not currently the case in France.

Tackling social inequalities in health: acceptability and feasibility of a systematic approach toward health impact assessment of urban projects.

INTRODUCTION: The general objective of this research project was to explore the feasibility and acceptability of an original method intended to systematically identify urban planning projects whose potential impacts on health and social inequalities in health (SIH) would be most damaging. An approach based on a short meeting and a tool would help to discuss whether or not to engage in a more comprehensive health impact assessment. METHODS: A tool was developed by the research team based on various tools reported in the literature and modified with urban planners. Meetings were organized for each development project with the volunteer planners, who were working on the projects selected. Reviews of six projects at different stages of design made it possible to assess the acceptability and feasibility of this approach to identify public health and social equity issues in health. RESULTS: The process and the use of the tool were found to be feasible. The tool was easily understandable, adapted to the practices of planners and usable without real training other than a quick introduction to tool usage. It was also found to be acceptable. Despite an interest in the inclusion of SIH, the integration of the relationship between SIH and urban development was not easy for most of the urban planners. CONCLUSION: This exploratory work suggests that a systematic approach to assessing the impact of urban projects on health and SIH is feasible and acceptable. Dealing with SIH was not found to be easy by the urban planners.

Troubles mictionnels et accès aux toilettes chez les enfants scolarisés : enquête dans l'Académie de Toulouse.

Not urinating regularly, voluntarily restraining oneself at school promotes the occurrence of voiding disorders. AIM: To determine the prevalence of such disorders in elementary schools (students from 1st to 5th grade) and analyze the role of access to school toilets on voiding habits. METHOD: Observational, descriptive epidemiological study during the 2017-2018 school year by electronic questionnaire with parents of pupils attending elementary school. RESULTS: 2119 questionnaires were analyzed. The graders sex ratio was 1.07 (1087 boys). 410 families (19%) were classified as "popular" class. First, second and third graders represented 60% of the enrollment (N = 1273). Overall use of school toilets was 87% and 69% of students had appropriate use for urine. The main obstacles to their use were lack of hygiene and comfort (51%), lack of security or privacy (33%), limited accessibility (28%). The overall prevalence of urinary elimination disorders was 9%. Girls had more inappropriate use of the toilet for urine (36% vs 27%, OR 1.5, P = 0.0004). The factors associated with urinary elimination disorders were: not using the toilet (13% vs 9 %, OR 1.5, P = 0.04), being a girl (14% vs 5%, OR 3.5, P < 0.0001), belonging to the working class (14% vs 8% OR 1.8, P = 0.0008). CONCLUSION: This situation, which is a long-denounced major public health problem, mainly affects girls and also reveals social inequalities in the use of school toilets.

Comparison of smoking reduction with improvement of social conditions in early life: simulation in a British cohort.

BACKGROUND: Health care evaluation models can be useful to assign different levels of priority to interventions or policies targeting different age groups or different determinants of health. We aimed to assess early mortality in counterfactual scenarios implying reduced adverse childhood experience (ACE) and/or improved educational attainment (childhood and early life characteristics), compared with a counterfactual scenario implying reduced smoking in adulthood. METHODS: We used data from the 1958 National Child Development Study British birth cohort, which initially included 18 558 subjects. Applying a potential outcome approach, scenarios were simulated to estimate the expected mortality between ages 16 and 55 under a counterfactual decrease by half of the observed level of exposure to (i) ACE, (ii) low educational attainment (at age 22), (iii) ACE and low educational attainment (a combined exposure) and (iv) smoking at age 33. Estimations were obtained using g-computation, separately for men and women. Analyses were further stratified according to the parental level of education, to assess social inequalities. RESULTS: The study population included 12 164 members. The estimated decrease in mortality in the counterfactual scenarios with reduced ACE and improved educational attainment was close to the decreased mortality in the counterfactual scenario with reduced smoking, showing a relative difference in mortality of respectively -7.2% [95% CI (confidence interval) = (-12.2% to 1.2%)] versus -7.0% (-13.1% to +1.2%) for women, and -9.9% (-15.6% to -6.2%) versus -12.3% (-17.0% to -5.9%) for men. CONCLUSIONS: Our results highlight the potential value of targeting early social characteristics such as ACE and education, compared with well-recognized interventions on smoking.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium.

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

[Voiding dysfunction and access to toilets among elementary school children: A Toulouse school district study]. / Troubles mictionnels et accès aux toilettes chez les enfants scolarisés : enquête dans l'Académie de Toulouse.

Not urinating regularly, voluntarily restraining oneself at school promotes the occurrence of voiding disorders. AIM: To determine the prevalence of such disorders in elementary schools (students from 1st to 5th grade) and analyze the role of access to school toilets on voiding habits. METHOD: Observational, descriptive epidemiological study during the 2017-2018 school year by electronic questionnaire with parents of pupils attending elementary school. RESULTS: 2119 questionnaires were analyzed. The graders sex ratio was 1.07 (1087 boys). 410 families (19%) were classified as "popular" class. First, second and third graders represented 60% of the enrollment (N = 1273). Overall use of school toilets was 87% and 69% of students had appropriate use for urine. The main obstacles to their use were lack of hygiene and comfort (51%), lack of security or privacy (33%), limited accessibility (28%). The overall prevalence of urinary elimination disorders was 9%. Girls had more inappropriate use of the toilet for urine (36% vs 27%, OR 1.5, P = 0.0004). The factors associated with urinary elimination disorders were: not using the toilet (13% vs 9 %, OR 1.5, P = 0.04), being a girl (14% vs 5%, OR 3.5, P < 0.0001), belonging to the working class (14% vs 8% OR 1.8, P = 0.0008). CONCLUSION: This situation, which is a long-denounced major public health problem, mainly affects girls and also reveals social inequalities in the use of school toilets.

La santé des enfants en France : un enjeu négligé ?

INTRODUCTION: As part of the National Health Strategy, the High Council for Public Health (HCSP) was tasked with leading a reflection on a “comprehensive and concerted child health policy”. Policy-making requires relevant knowledge and statistical benchmarks. It therefore seemed useful to examine the French statistical system and active research topics. This assessment is expected to provide a current portrait of the priorities and implicit health choices for the children. It also aims to reveal insufficiently explored aspects of children’s health. METHODS: The inventory of this system was carried out on the basis of several methods, hearings, work of two documentalists, and analysis of the published and grey literature. RESULTS: The emphasis is on pathologies, medical prevention and behaviors conceived primarily as individual. The idea that the health of tomorrow’s adults is built up behind this apparent good health and its inequalities does not appear, or only marginally. The elements on affective, cognitive or relational development are not sufficiently analyzed, for lack of data. The living conditions of children, especially poverty and violence in all its forms, are not sufficiently considered as health issues. Research is developing today with a hospital-centric vision, without a real strategy of research on children’s health. DISCUSSION: Given the dispersion of data, publishing a summary report on children’s health on a regular basis is essential, as enriching the system with data on the environment, poverty and psychomotor, psychosocial and cognitive development. There is an urgent need to develop research on children’s health and to define a research strategy that does not exist today.

Why are people increasingly attending the emergency department? A study of the French healthcare system.

OBJECTIVE: It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types. METHODS: This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients' condition during ED visit was determined through the 'Clinical Classification of Emergency' score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures. RESULTS: The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes. DISCUSSION: It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

Do the key functions of an intervention designed from the same specifications vary according to context? Investigating the transferability of a public health intervention in France.

BACKGROUND: The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a "key functions/implementation/context" (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their "key functions") from those associated with their translation within a specific context (their "form"). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications. METHODS: The interventions were independently described by researchers and intervention's implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar. RESULTS: Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described. CONCLUSIONS: For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

[Social environment, biological embedding and social inequalities in health]. / Environnement social, incorporation biologique et inégalités sociales de santé.

The social gradient in health refers to the fact that the higher individuals rise in the social hierarchy, the better is their health. Understanding the construction of this gradient is a major challenge in social epidemiology. An original approach consists in looking at how the different exposures (chemical, physical, behavioural, psychosocial…) associated with the social environment are ultimately expressed at the biological level influencing health positively or negatively, referring to the concept of biological embedding. Data from animal models and life course epidemiology have shed new light on the biological mechanisms potentially at play. Recent discoveries from the field of epigenetics provide a better understanding of how the social environment, especially the early environment, can influence biological functioning over the long term or even over several generations. The work on the biological embedding of the social environment in connection with epigenetics still needs to be very largely consolidated, but could constitute a change of perspective in human biology, particularly by reconsidering the influence of the environment on biological functioning, which is not without consequences in terms of public health interventions.

Expectations and boundaries for Big Data approaches in social medicine.

It seems no longer possible to produce knowledge, even biological knowledge regardless of social, cultural and economic environments in which they were observed. Therefore never the term "social medicine" or more generally "social biology" has appeared more appropriate. This way of linking the social and the biological exceeds the sole social medicine by involving also other medical disciplines. As such, forensics, whose an important activity is represented by clinical forensics in charge of types of violence (physical, psychological, sexual, abuse) and persons held in custody could see its practice heavily modified through the use of various data describing both the clinical situation of patients but also their context of life. A better understanding of mechanisms of violence development and potentially a better prevention of these situations allow forensics not to be restricted (or seen as limited to) a "descriptive medicine", but to be seen also as a preventive and curative medicine. In this evolution, the potential contribution of Big Data appears significant insofar as information on a wide range of characteristics of the environment or context of life (social, economic, cultural) can be collected and be connected with health data, for example to develop models on social determinants of health. In the common thinking, the use of a larger amount of data and consequently a multiplicity of information via a multiplicity of databases would allow to access to a greater objectivity of a reality that we are approaching by fragmented viewpoints otherwise. In this light, the "bigger" and "more varied" would serve the "better" or at least the "more true". But to be able to consider together or to link different databases it will be necessary to know how to handle this diversity regarding hypotheses made to build databases and regarding their purposes (by whom, for what bases have been made). It will be equally important to question the representativeness of situations that led to the creation of a database and to question the validity of information and data according to the secondary or tertiary uses anticipated from their original purpose. This step of data validity control for the anticipated use is a sine qua non condition, particularly in the field of public health, to guarantee a sufficient level of quality and exploit in the best way the benefits of Big Data approaches.

Is the use of emergency departments socially patterned?

OBJECTIVES: To analyse the association between patients' socioeconomic position (SEP) and the use of emergency departments (EDs). METHODS: This population-based study included all visits to ED in 2012 by inhabitants of the French Midi-Pyrénées region, recorded by the Regional Emergency Departments Observatory. We compared ED visit rates and the proportion of non-severe visits according to the patients' SEP as assessed by the European Deprivation Index. RESULTS: We analysed 496,388 visits. The annual ED visit rate increased with deprivation level: 165.9 [95% CI (164.8-166.9)] visits per 1000 inhabitants among the most advantaged group, compared to 321.9 [95% CI (320.3-323.5)] per 1000 among the most disadvantaged. However, the proportion of non-severe visits was about 14% of the visits, and this proportion did not differ according to SEP. CONCLUSIONS: Although the study shows a difference of ED visit rates, the probability of a visit being non-severe is not meaningfully different according to SEP. This supports the assumption that ED visit rate variations according to SEP are mainly explained by SEP-related differences in health states rather than SEP-related differences in health behaviours.

Diabetes mellitus and obesity in the French Caribbean: A special vulnerability for women?

The objective of this study was to analyze the prevalence, awareness, treatment, and control of diabetes and its risk factors among French Caribbean adults. This cross-sectional study included 18-74-year olds (N = 2252; 56.5 percent women) who underwent a heath examination in Guadeloupe during July-December 2014. Diabetes was defined as using antidiabetic treatment, or fasting glucose ≥7 mmol/l, and glycated hemoglobin (HbA1c) ≥6.5 percent; diabetes control was defined as HbA1c < 7 percent. Multilevel logistic regression was used. Diabetes prevalence was 8.2 percent for women and 5 percent for men (age-adjusted odds ratio [aOR] for women = 2.0; 95 percent confidence interval [CI]: 1.4-2.9). The proportion of women with diabetes who were aware of it was 84.5 versus 67.3 percent in men (aOR = 2.7; 95 percent CI: 1.2-6.2). Nearly, all diagnosed participants were being treated. In less than a third of diabetics in both sexes was diabetes control obtained. Most women (55.3 percent) had a waist circumference at or above the National Cholesterol Education Program thresholds versus 14 percent of men (aOR = 9.3; 95 percent CI: 7.5-11.7), which wholly accounted for excess diabetes in women. In women, obesity and diabetes were associated with low education and income. In this French Caribbean sample, abdominal obesity and diabetes affected more women. Diabetes was rarely controlled. A comprehensive women's health policy for the prevention of abdominal obesity and diabetes is needed.

[To analyse the transferability of an intervention : applying the functions/implementation/context model on a diabetes prevention programme]. / Analyser la transférabilité d'une intervention : application du modèle fonctions clés/implémentation/contexte à un programme de prévention du diabète.

INTRODUCTION: A type 2 diabetes primary prevention programme that was shown to be feasible and effective in 2003 was transferred to another vulnerable district of Reunion Island in 2004, but its short-term effectiveness could not be reproduced. Based on this example, this article analyses whether the key functions/implementation/context model can be useful to : 1- more accurately describe an evaluated intervention ; and 2- identify the factors involved in the transferability of this intervention. METHODS: The causality model of the initial programme is described. We then identified the key functions (or theoretical processes) of this initial programme, implementation of these functions, and the context in which the intervention took place. Transfer was analysed by focusing on the differences between the initial programme and the transferred programme in terms of key functions, implementation and context. RESULTS: The causality model involves individual, meso-social, and environmental health determinants. Our analysis of programme transfer highlights differences in : key functions (two key functions dropped, one key function added, one key function modified), implementation (failure to implement, loss/improvement of quality), and context (population and socioeconomic level of the district concerned). CONCLUSION: This work supports the hypothesis that the key functions/implementation/context model can be useful to improve the description of an intervention, and analyse the factors involved in its transferability.

New insights into experimental visceral leishmaniasis: Real-time in vivo imaging of Leishmania donovani virulence.

Visceral leishmaniasis is an insidious neglected disease with worldwide distribution. It is caused by parasites from the Leishmania donovani complex, which are able to be transmitted by different species of phlebotomine sand flies and to infect numerous mammal hosts. Despite the high number of people infected or at risk, and the remarkable quantity of studies focusing on this disease, a proper experimental model to efficiently decipher the infectious process of visceral leishmaniasis taking into account the nuances of parasite's virulence and the duration of the infection is still lacking. Therefore, using golden Syrian hamsters and BALB/c mice, state-of-the-art genetic manipulation applied on a fully virulent L. donovani strain and in vivo imaging approaches, we describe herein three benefits for experimental visceral leishmaniasis: (i) the development of a double transfected bioluminescent (firefly luciferase) and fluorescent (E2-crimson) virulent strain of L. donovani (Ld1S_luci_E2-crimson), favoring a wide range of both in vivo and in vitro investigations, (ii) the establishment of a non-invasive mouse model to evaluate the infectious process during visceral leishmaniasis and the parasite's virulence in real time, allowing longitudinal studies with the same animals, and (iii) the elaboration of a suitable method to reinstate (and verify anew) the virulence in a population of attenuated parasites, by recovering persistent parasites from chronic infected mice. Consequently, these results open up new perspectives on the study of visceral leishmaniasis, especially in the fields of therapeutics and vaccinology, since the model described herein renders now possible long-lasting follow up studies, with easy and accurate day-by-day verifications of the infection status along with a reduced number of laboratory animals. TRIAL REGISTRATION: ClinicalTrials.gov 2013-0047.

Unveiling Cerebral Leishmaniasis: parasites and brain inflammation in Leishmania donovani infected mice.

Visceral leishmaniasis (VL) is a systemic disease with multifaceted clinical manifestations, including neurological signs, however, the involvement of the nervous system during VL is underestimated. Accordingly, we investigated both brain infection and inflammation in a mouse model of VL. Using bioluminescent Leishmania donovani and real-time 2D-3D imaging tools, we strikingly detected live parasites in the brain, where we observed a compartmentalized dual-phased inflammation pattern: an early phase during the first two weeks post-infection, with the prompt arrival of neutrophils and Ly6Chigh macrophages in an environment presenting a variety of pro-inflammatory mediators (IFN-γ, IL-1ß, CXCL-10/CXCR-3, CCL-7/CCR-2), but with an intense anti-inflammatory response, led by IL-10; and a re-inflammation phase three months later, extremely pro-inflammatory, with novel upregulation of mediators, including IL-1ß, TNF-α and MMP-9. These new data give support and corroborate previous studies connecting human and canine VL with neuroinflammation and blood-brain barrier disruption, and conclusively place the brain among the organs affected by this parasite. Altogether, our results provide convincing evidences that Leishmania donovani indeed infects and inflames the brain.