Racial/Ethnic Disparities in Psychiatric Traits and Diagnoses within a Community-based Sample of Children and Youth: Disparités raciales/ethniques dans les traits et diagnostics psychiatriques au sein d'un échantillon communautaire d'enfants et de jeunes.

OBJECTIVE: Racial/ethnic disparities in the prevalence of psychiatric disorders have been reported, but have not accounted for the prevalence of the traits that underlie these disorders. Examining rates of diagnoses in relation to traits may yield a clearer understanding of the degree to which racial/ethnic minority youth in Canada differ in their access to care. We sought to examine differences in self/parent-reported rates of diagnoses for obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders after adjusting for differences in trait levels between youth from three racial/ethnic groups: White, South Asian and East Asian. METHOD: We collected parent or self-reported ratings of OCD, ADHD and anxiety traits and diagnoses for 6- to 17-year-olds from a Canadian general population sample (Spit for Science). We examined racial/ethnic differences in trait levels and the odds of reporting a diagnosis using mixed-effects linear models and logistic regression models. RESULTS: East Asian (N = 1301) and South Asian (N = 730) youth reported significantly higher levels of OCD and anxiety traits than White youth (N = 6896). East Asian and South Asian youth had significantly lower odds of reporting a diagnosis for OCD (odds ratio [OR]East Asian = 0.08 [0.02, 0.41]; ORSouth Asian = 0.05 [0.00, 0.81]), ADHD (OREast Asian = 0.27 [0.16, 0.45]; ORSouth Asian = 0.09 [0.03, 0.30]) and anxiety (OREast Asian = 0.21 [0.11, 0.39]; ORSouth Asian = 0.12 [0.05, 0.32]) than White youth after accounting for psychiatric trait levels. CONCLUSIONS: These results suggest a discrepancy between trait levels of OCD, ADHD and anxiety and rates of diagnoses for East Asian and South Asian youth. This discrepancy may be due to increased barriers for ethnically diverse youth to access mental health care. Efforts to understand and mitigate these barriers in Canada are needed.

We know that there is there are differences in the prevalence of childhood mental illnesses by race/ethnic group, which may be related to disproportionate access to mental health care. What is unknown is whether there this difference in prevalence is related to differences in the presence of symptoms for mental illness or whether children and youth from marginalized racial/ethnic groups have symptoms but are not getting diagnosed. This information is needed to understand the degree to which children and youth from marginalized race/ethnicity groups are accessing mental health care in Canada. We tested the differences in reported symptoms and diagnosis of three common and impairing childhood-onset disorders (obsessive-compulsive disorder­OCD), attention-deficit/hyperactivity disorder­ADHD and anxiety disorders) in children and youth (6­17 years of age) living in Canada that were from three racial/ethnic groups: White, South Asian and East Asian. East Asian and South Asian youth reported significantly higher levels of OCD and anxiety traits than White youth. However, East Asian and South Asian youth were significantly less likely than White youth to have a reported diagnosis of OCD, ADHD or anxiety even after accounting for symptom levels for each disorder. Our findings suggest that East and South Asian children are less likely than White children to get a diagnosis for common mental illness even if they have symptoms of that mental illness. This gap in receiving a diagnosis might be because of more barriers to mental health care for children and youth from marginalized racial/ethnic groups but we need more research to pinpoint the cause.

Economic analysis of a health system strengthening program in the Democratic Republic of the Congo / Analyse économique d'un programme de renforcement du système de santé en République démocratique du Congo.

INTRODUCTION: Due to the Democratic Republic of the Congo's (DRC) precarious health system that provides only limited access to health care, the European Union, via Memisa Belgium, implemented a program to strengthen provision of and access to health care (known as PRO DS) in the provinces of Kongo Central and Ituri. This program took a holistic approach, seeking to improve equitable access and combat malnutrition. METHODS: To measure the program's social return on investment and to estimate the cost per capita and effectiveness per euro invested (efficiency), a 61-month (1 July 2017 to 31 July 2022) cost-effectiveness evaluation with a societal perspective was carried out. The double-difference method was used to compare the results of PRO DS and non-PRO DS zones. The social return on investment was assessed via the ratio of effectiveness to costs. RESULTS: Analyses revealed the program cost between 3.72 and 3.96 euros per capita per year (2022) in Kongo Central, and between 3.12 and 3.36 euros in Ituri. Importantly, it was cost-effective in the areas of reproductive health, nutrition, and the use of health and nutrition services. CONCLUSIONS: The program's strong nutritional component and overall holistic vision may explain why it was so efficient. PRO DS stands out from other programs that focus solely on one specific problem or population. Although the program has some limitations, it would be worthwhile for the government to invest in it.

Introduction: Face à l'accès limité aux soins et à la précarité des structures sanitaires en République démocratique du Congo, l'Union européenne par l'intermédiaire de Memisa Belgique avait mis en œuvre le Programme de renforcement de l'offre et développement de l'accès aux soins de santé (PRO DS) dans les provinces du Kongo-Central et de l'Ituri. Ce programme se caractérisait par une approche holistique d'équité d'accès et de lutte contre la malnutrition. Méthodes: Pour mesurer le retour social sur investissement du programme et estimer son coût par habitant et son efficacité par euros investis (efficience), une évaluation coûts-efficacité avec une perspective sociétale de 61 mois (1er juillet 2017 au 31 juillet 2022) a été réalisée. La méthode de double différence, qui compare les résultats des zones PRO DS et des zones non PRO DS, a été utilisée. Le retour social sur investissement a été évalué par le biais du rapport entre l'efficacité et les coûts. Résultats: Les analyses ont montré que le programme coûtait par année et par habitant entre 3,72 et 3,96 euros (2022) au Kongo-Central, et entre 3,12 et 3,36 euros en Ituri. De plus, il était coût-efficace dans plusieurs domaines, telles la santé de la reproduction, la nutrition, l'utilisation des services de santé et nutritionnels. Conclusions: L'efficience du programme pourrait s'expliquer par sa vision holistique avec un fort volet « Nutrition ¼. PRO DS se démarque d'autres programmes qui agissent uniquement sur une problématique ou population spécifique. Malgré ses quelques imperfections, le gouvernement mériterait d'y investir.

[The Mission Migrants of the Samu social de Paris, a mobile healthcare service for exiles]. / La Mission Migrants du Samusocial de Paris, dispositif mobile d'accès aux soins pour les exilés.

Since its creation in 1993, Samusocial de Paris has been working with homeless people as part of its "outreach" approach. Mission Migrants, a mobile healthcare access service, works throughout the inner suburbs of Paris, helping precarious exiles wherever they are, and wherever they are at (in their pathways and access to healthcare). Its teams of nurses and mediator-interpreters visit camps, squats, shelters, day shelters and temporary accommodation centers to mediate, assess and guide them towards the care they need.

[Health has a cost]. / La santé a un coût.

Health has a cost, and in the face of declining purchasing power, many French people are forced to cut back on their healthcare spending, at the risk of damaging their health. For example, a chiropodist feels that some patients with a deforming forefoot pathology are depriving themselves of essential chiropody care, or are coming for consultations but at the expense of other leisure expenses. In this article, we present a study protocol designed to objectivize this phenomenon.

[The current state of healthcare provision: Between inequalities in access to care and new systemic measures]. / État des lieux de l'offre de soins : entre inégalités d'accès aux soins et nouvelles mesures systémiques.

Although France's healthcare system is rich in multi-faceted skills, both in the community and in hospitals, and implemented by a range of medical, paramedical and medico-social professionals, it is no longer able to meet the health needs of all. Today, these social inequalities in health require us to rethink our policies and redesign existing systems, in order to develop new alternatives that will make quality care and health maintenance accessible to all.

[Territorial health inequalities]. / Inégalités territoriales de santé.

Whether positively or negatively, an individual's geographical location has an impact on his or her state of health. Often described as a "catchword", the notion of territory is complex to define. To better understand its influence, we'll be looking at the different territorial scales, as well as the responses of populations to these issues. With this in mind, we'll take a look at how healthcare professionals are changing their practices.

[Evaluation of a referral protocol to primary health care for patients eligible for health service access points following hospitalization]. / Évaluation d'un protocole d'orientation vers le droit commun parmi des patients ayant été suivis en permanence d'accès aux soins de santé suite à une hospitalisation.

INTRODUCTION: PASS is a hospital care unit that provides access to health care for precarious persons and supports them as soon as they have obtained primary health care insurance. No details of this support had previously been described. A Hospital-to-Community protocol for referral to the public health system has been developed at the adult PASS unit of the Marseille public hospitals (AP-HM). The objectives of this study are to describe how this protocol is applied, to evaluate at six months the inclusion in general practice of patients having benefited (or not) from this protocol and to determine the key influencing factors. MATERIAL AND METHOD: This two-arm prospective observational study collected data on the primary care pathways of precarious patients six months after their having obtained health coverage, and found out whether or not the newly existing protocol had been effectively implemented. It was carried out on a cohort of people included in the PASS-MULTI study who had acquired complete health coverage. RESULTS: Sixty patients were included between November 2020 and August 2022, 35 of whom had availed themselves of the Hospital-to-Community protocol. Among them, 68.8% in the interventional group had consulted their referring general practitioner within six months, vs. 40% in the control group (p = 0.04). The initiation of follow-up in general medicine was associated with application of the protocol (p = 0.04). CONCLUSION: This study described an initial Hospital-to-Community protocol for referral to the primary healthcare system of patients followed up in the PASS unit and found an association between application of this protocol and initiation of follow-up in primary healthcare.

Health check-ups for the French under-consuming agricultural population: A pilot evaluation of the Instants santé MSA program.

BACKGROUND: The social protection scheme in charge of farmers and agricultural employees (MSA) in France has developed a two-step health promotion program with a nurse appointment followed by a consultation with a doctor of the participant's choosing to reach its under-consuming beneficiaries and enroll them back into a care pathway. Our objective was to carry out a pilot evaluation of this program. METHODS: The evaluation was carried out on the population invited during the second semester of 2017 using data from the program's service providers (date of invitation, of nurse appointment…), regional MSA bodies (consultation voucher), and reimbursement data (other care consumption). Participation rates were calculated overall and by participant characteristics. Medical needs were identified during the nurse appointment and new care pathways were assessed using reimbursement data. Multivariable regression models identified factors associated with participation. RESULTS: 2366 beneficiaries were included in the analysis. 1559 (65.89%) were men and mean age was 52.41 (standard deviation = 14.86). 409 (17.29%) attended the nurse appointment. There was a significant increase in participation with age, in farmers vs. employees (odds ratio = 1.905, 95% confidence interval = 1.393-2.604), and in people living in the most disadvantaged areas (odds ratio = 1.579, 95% confidence interval=1.079-2.312). Participation to the consultation following the nurse appointment was high (62.35%-73.11%). 87.53% of participants had at least one medical need, and new care pathways were more frequent among those who had attended the nurse appointment (55.50% vs. 34.80%, p < 0.0001). CONCLUSIONS: This pilot evaluation shows promising results which need to be confirmed with a national evaluation of the program and longer-term evidence.

Factors associated with the time from the first call to emergency medical services to puncture for mechanical thrombectomy for ischaemic stroke patients in Gironde, France, in 2017 and 2018.

BACKGROUND AND PURPOSE: When an ischaemic stroke due to a large vessel occlusion occurs, the sooner Mechanical Thrombectomy (MT) is performed, the better the functional prognosis. However, the organisation of care does not systematically allow rapid access to MT. The aim of our study was to determine the clinical and organisational factors associated with the time to access to MT. METHODS: We conducted a cohort study in Gironde County, France. Patients admitted for MT and regulated by the Gironde Emergency Medical Services (EMS) between 01/01/2017 and 31/12/2018 were included. The time to access to MT was the difference between the first call to EMS and groin puncture for MT. The main explanatory variables were: type of pathway (mothership (MS), drip and ship (DS) with cerebral imaging performed in the local hospital centre (LHC), and DS without imaging in the LHC); NIHSS score; driving distance to MT; time of stroke onset (weekend or holiday, school holidays, other); age and sex. Linear regression models were used to explain time to access to MT. Missing data were handled using a multiple imputation procedure (Full conditional specification, Mice R-Package) carried out in our multivariable linear regression model. A quantitative bias analysis was performed by weighing the imputed time to access to MT and identifying the weight changing the conclusions of our analysis. RESULTS: Among the 314 included patients, 152 were women (48.4%), and the mean NIHSS score was 16.4. Two hundred and two (64.3%) patients were managed through the MS pathway. The average time from onset to femoral puncture was 251 minutes. In the multivariate analysis, the time to MT was longer when patients were managed DS with imaging in the LHC pathway (+106 min, p = 0.03), and even longer in the DS without imaging in the LHC pathway (+197 min, p = 0.002), compared with MS. Time from onset to MT decreased with increasing NIHSS score (-6 min per NIHSS point, p <.0001). In our quantitative bias analysis, we multiplied the imputed time in access to MT in the DS pathways only (with or without imaging in the LHC) by weights varying from 0.9 to 0.2 (imputed delays reduced from 10% to 80%). With reduction of 40% or more, there was no longer any difference in time to access to MT between the three studied pathways. CONCLUSIONS: The DS pathway can be shortened by generalizing access to cerebral imaging in LHCs. Optimizing pre-admission orientation toward MT is a major issue in LVOS management.

[Barriers to access to care evaluation scale (bace-3) psychometric properties of the french version in a naturalistic ambulatory psychiatric community setting]. / Les barrières à l'accès aux soins : validation de la BACE-3 française.

OBJECTIVES: To translate into French and validate the BACE-3 scale (Barriers to Care Evaluation) and describe the barriers to access to care in mental health settings. METHODS: The instrument was translated into French with its author's authorisation and her supervision. Three outpatient consultation centres and two day hospitals in the same geographical region were involved. We included patients aged between 18 and 6years under regular follow-up with psychiatrists and diagnosed with a psychotic disorder, a bipolar disorder, a mood disorder, a personality disorder, an anxiety disorder or a somatoform disorder, all according to ICD-10 criteria. To be included subjects further had to have sought some health care support in the last twelve months or be be regularly treated in a continuous way at the time of inclusion. RESULTS: One hundred twenty-one patients were successively included during a regular consultation. The exploratory factor analysis of the 30-item BACE-3 yielded to a method factor (items that could only be answered by patients with a family and/or at work were recoded) and two clinically meaningful factors were named, Stigmatisation and Cognitive Bias and Denial. We found that the first factor was nicely in line with the factors we had extracted from the Internalized Stigma Mental Illness (ISMI) scale in the same sample. This provided an external validation of the BACE but it was difficult to conclude any further given the limited size of our sample. CONCLUSIONS: Barriers to care need to be addressed by clinicians. Internal and external validity properties of the BACE-3 scale show it can be used in French-speaking populations of outpatients suffering from mental health problems.

[Health simulation, access to somatic care for people with ASD]. / Simulation en santé et accès aux soins somatiques des personnes présentant un TSA.

The clinical characteristics of people with autism spectrum disorders can make it difficult for them to access care, including treatment and medical imaging examinations. Simulation-based learning can facilitate the performance of a CT scan, as in the case of Irène, who was able to adopt the expected body positions thanks to this intervention.

[The Pass, a medical and social device for vulnerable people]. / La Pass, un dispositif médico-social pour les personnes vulnérables.

The permanence of access to health care is a system that aims to facilitate access to ambulatory medical care for poor and vulnerable people who do not have social security or health insurance coverage, or who have incomplete social security coverage (neither mutual insurance, nor complementary health insurance from the primary health insurance fund). A health care team from the Ile-de-France region shares its know-how and expertise with the most disadvantaged.

[Asalée cooperation protocol, personalized support for chronic diseases]. / Protocole de coopération Asalée, un accompagnement personnalisé des maladies chroniques.

The permanent increase in the need for care and in the number of patients means that many general practitioners no longer have the time to accompany patients in need of therapeutic education. This is why the Asalée cooperation protocol has been developed in medical practices or health centres with nurses dedicated to this support. In addition to nursing skills in therapeutic education, the proper functioning of the protocol is based on the quality of the doctor-nurse pairing.

[From social medicine to the management of precariousness in health]. / De la médecine sociale à la prise en charge de la précarité en santé.

A review of the history leading from the creation of social medicine to the management of precariousness in the health field. We will define the main concepts (precariousness, poverty, social inequalities in health) and indicate the main barriers to access to care for people in precarious situations. Finally, we will give some guidelines for the healthcare community in order to improve care.

[What are the obstacles to drawing up a death certificate in a home setting ? A survey of doctors in Normandy]. / Quels freins à l'établissement du certificat de décès à domicile ? Enquête auprès de médecins sur le territoire de Normandie.

INTRODUCTION: Drafting a death certificate is an obligation for any physician called upon to note a death. It has a legal and epidemiological impact. The objective of this study is to highlight the obstacles encountered by professionals when this process takes place in a home setting. METHOD: A study was carried out by means of a questionnaire sent to doctors in the Normandy region. RESULTS: One fifth (20%) of the general practitioners (GPs), 25% of the SAMU practitioners (intervening in mobile emergency throughout the country), 27.3% of SOS doctors (intervening 24 hours a day in the deceased person's home in the absence of a GP) stated that they had at least once refused to establish a death certificate. Only 36.4% of SOS doctors, 62.5% of emergency physicians and 41% of GPs considered the drafting of a death certificate to be one of their mandatory missions. No less than 17% of GPs, 25% of SAMU doctors and 9% of SOS doctors stated that due to lack of time, they were occasionally unable to travel to fill out a death certificate, a factor causing delays that were detrimental, especially for the surviving relatives. We highlighted several other obstacles to the completion of death certificates: the difficulty of completing them accurately without knowledge of the deceased person's history, possible inability of professionals on tight schedules to deal with unforeseen requests and, more rarely, the issues raised by an absence of remuneration. CONCLUSION: Our study highlights major obstacles in the preparation of death certificates, obstacles that should be taken into consideration insofar as they affect the quality of the data collected, and entail ethical challenges.

[Experienced violence and enacted violence: The place of somatic expression]. / Violences subies, violences agies : la place de l'expression somatique du repérage à l'expertise.

Being a victim of violence and neglect during childhood can expose minors to significant health repercussions on the physical, psychological, psycho-affective and neuro-developmental levels.. Self- and hetero-aggressive violences in all age groups are now considered to be possible consequences of these severe adverse experiences. The place of the body is essential in this context. The body, often considered as the only tangible and opposable marker of violence, has a singular and integral place in the psyche and overall health. It is an important vector in order for professionals to have access to the child. The examination of the body allows the expression of violence and its formulation from a very young age, especially during clinical examinations in situations of possible danger. It also "speaks" in situations of malaise, growth disorder, self or heteroaggressive acts. During the adolescence, it can also be attacked by scarification, dietary restrictions, mutilations, early and risky sexual activity, prostitution.. By taking jointly both the body and the psyche, children and adolescents find a unity, are no longer fragmented. It is this unity that will allow the continuation of more specific care and more specifically child psychiatric support. This joint concern of paediatricians, general practitioners, child psychiatrists and psychologists will also ensure, particularly during adolescence, the continuation of health monitoring. It is essential to think about these collaborations from the first meeting with children and adolescents who are victims or perpetrators of violence. Encountering child and adolescent victims of violence confronts practitioners with a reality that is difficult to see and to conceive. Although the continuum between suffered violence and perpetrated violence seems to be better known today, these different situations remain difficult to understand and to manage. We believe that the violence that is perpetrated can be a screen for the causes of the violence and for the response to the needs of minors, particularly in terms of health. For practitioners, going to meet children and adolescents who are perpetrators of violence entails to be able to take a "step aside" from the classical representations of aggression or aggressiveness, whether they are directed towards third parties or towards the minor himself. Access to the somatic examination and medical history of these children or adolescents must be fully integrated from the first meeting. Associating health in all its aspects (somatic, psychic and social) then allows for specific care to be provided, regardless of their nature and place. This initial integrated practice allows us to take care of children and adolescents and highlights the notion of otherness that is undermined in situations of violence or neglect, particularly when they occur in the family environment. This initial joint somatic and psychological care in a single unit enables re-establishment of a dialogue with the minors and their parents. The shared competencies and the links that unite these different professionals together constitutes already therapeutic care. By reintroducing a dialogue about the children and adolescents and their overall health, the response to their needs can be perceived as a common and reachable objective that inscribes the minor in the temporality and extracts him or her from the immediacy of a punctually repressed act.

[Access to care service, a new city-hospital partnership]. / Le service d'accès aux soins, un nouveau partenariat ville-hôpital.

The access to care service is a joint regulation of calls to the Centre 15 and to the 116 117. The objective is to make the care pathway more fluid and to improve the orientation of the user through the collaboration of hospital and city health professionals to take care of emergencies and requests for unscheduled care.

[Territorial professional health communities in close proximity to patients]. / Les communautés professionnelles territoriales de santé au plus près des patients.

Territorial professional health communities have been set up by liberals healthcare professionals who, maneuvering this recent mechanism, are committed to improving care and coordinating patient care in their territories, at the crossroads of the city and the hospital. Feedback from a Breton team.

[Manage unscheduled care in a multidisciplinary team on the basis of cooperation protocols]. / Gérer les soins non programmés en équipe pluridisciplinaire sur la base de protocoles de coopération.

For primary care teams, cooperation protocols between health professionals can facilitate access to care, particularly in areas where there is a shortage of general practitioners. In the Ain, four protocols, including nurses, have been authorized to better manage access to certain unscheduled care. They are now authorized at the national level.

[Nurses at the heart of a cooperation protocol in rhythmology]. / Les infirmiers au cœur d'un protocole de coopération en rythmologie.

The cooperation protocol system allows healthcare professionals to engage in a cooperative approach to better meet patients' needs. The aim of these protocols is to offer a wider range of care by reducing access times and optimizing the patient's care pathway. Here is an example of an innovative approach taken in this context within a hospital rhythmology unit.