Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach.

BACKGROUND: Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people. METHODS: This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms. RESULTS: Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities. CONCLUSIONS: The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

Respective healthcare system performances taking into account environmental quality: what are the re-rankings for OECD countries?

BACKGROUND: Efficiency analyses have been widely used in the literature to rank countries regarding their health system performances. However, little place has been given to the environmental aspect: two countries with the same characteristics could experience completely different healthcare system outcomes just because they do not face the same environmental quality situation, which is a major determinant of the health of inhabitants. METHODS: Using a stochastic frontier model, this paper analyses the effect of environmental quality on health system outcomes in OECD countries, measured by life expectancy at birth. RESULTS: We show that the healthcare system performance ranking of OECD countries changes significantly, depending on whether the environmental index is taken into account. CONCLUSIONS: These findings, once again, underline the critical importance of the environment when addressing population health issues. In general, our results can be aligned with the messages of the One Health approach literature.

United, can we be stronger? Did French general practitioners in multi-professional groups provide more chronic care follow-up during lockdown?

BACKGROUND: Given the importance of the continuous follow-up of chronic patients, we evaluated the performance of French private practice general practitioners (GPs) practicing in multi-professional group practices (MGP) regarding chronic care management during the first Covid-19 lockdown in Spring 2020 compared to GPs not in MGP. We consider two outcomes: continuity of care provision for chronic patients and proactivity in contacting these patients. METHODS: The cross-sectional web questionnaire of 1191 GPs took place in April 2020. We exploit self-reported data on: 1) the frequency of consultations for chronic patients during lockdown compared to their "typical" week before the pandemic, along with 2) GPs' proactive behaviour when contacting their chronic patients. We use probit and bivariate probit models (adjusted for endogeneity of choice of engagement in MGP) to test whether GPs in MGP had significantly different responses to the Covid-19 crisis compared to those practicing outside MGP. RESULTS: Out of 1191 participants (response rate: 43.1%), around 40% of GPs were female and 34% were younger than 50 years old. Regression results indicate that GPs in MGP were less likely to experience a drop in consultations related to complications of chronic diseases (- 45.3%). They were also more proactive (+ 13.4%) in contacting their chronic patients compared to their peers practicing outside MGP. CONCLUSION: We demonstrate that the MGP organisational formula was beneficial to the follow-up of patients with chronic conditions during the lockdown; therefore, it appears beneficial to expand integrated practices, since they perform better when facing a major shock. Further research is needed to confirm the efficiency of these integrated practices outside the particular pandemic setup.

When the messenger is more important than the message: an experimental study of evidence use in francophone Africa.

BACKGROUND: Epistemic injustices are increasingly decried in global health. This study aims to investigate whether the source of knowledge influences the perception of that knowledge and the willingness to use it in francophone African health policy-making context. METHODS: The study followed a randomized experimental design in which participants were randomly assigned to one of seven policy briefs that were designed with the same scientific content but with different organizations presented as authors. Each organization was representative of financial, scientific or moral authority. For each type of authority, two organizations were proposed: one North American or European, and the other African. RESULTS: The initial models showed that there was no significant association between the type of authority or the location of the authoring organization and the two outcomes (perceived quality and reported instrumental use). Stratified analyses highlighted that policy briefs signed by the African donor organization (financial authority) were perceived to be of higher quality than policy briefs signed by the North American/European donor organization. For both perceived quality and reported instrumental use, these analyses found that policy briefs signed by the African university (scientific authority) were associated with lower scores than policy briefs signed by the North American/European university. CONCLUSIONS: The results confirm the significant influence of sources on perceived global health knowledge and the intersectionality of sources of influence. This analysis allows us to learn more about organizations in global health leadership, and to reflect on the implications for knowledge translation practices.

RéSUMé: CONTEXTE: Les injustices épistémiques sont de plus en plus décriées dans le domaine de la santé mondiale. Cette étude vise à déterminer si la source des connaissances influence la perception de ces connaissances et la volonté de les utiliser. MéTHODES: L'étude suit un devis expérimental randomisé dans lequel les participant·es ont été assigné·es au hasard à l'une des sept notes politiques conçues avec le même contenu scientifique, mais avec différentes organisations présentées comme autrices. Chaque organisation était représentative d'une autorité financière, scientifique ou morale. Pour chaque type d'autorité, deux organisations étaient proposées : l'une nord-américaine ou européenne, l'autre africaine. RéSULTATS: Les résultats montrent que le type d'autorité et la localisation des organisations autrices ne sont pas significativement associés à la qualité perçue et à l'utilisation instrumentale déclarée. Toutefois, des interactions entre le type d'autorité et la localisation étaient significatives. Ainsi, les analyses stratifiées ont mis en évidence que pour la qualité perçue, les notes de politique signées par l'organisme bailleur (autorité financière) africain obtenaient de meilleurs scores que les notes de politique signées par l'organisme bailleur nord-américain / européen. Tant pour la qualité perçue que pour l'utilisation instrumentale déclarée, ces analyses stratifiées ont révélé que les notes de politique signées par l'université africaine (autorité scientifique) étaient associées à des scores plus faibles que les notes de politique signées par l'université nord-américaine/européenne. INTERPRéTATION: Les résultats confirment l'influence significative des sources sur la perception des connaissances en santé mondiale et rappellent l'intersectionnalité de l'influence des sources d'autorité. Cette analyse nous permet à la fois d'en apprendre davantage sur les organisations qui dominent la scène de la gouvernance mondiale en santé et de réfléchir aux implications pour les pratiques d'application des connaissances.

What drives the acceptability of restrictive health policies: An experimental assessment of individual preferences for anti-COVID 19 strategies.

The public acceptability of a policy is an important issue in democracies, in particular for anti-COVID-19 policies, which require the adherence of the population to be applicable and efficient. Discrete choice experiment (DCE) can help elicit preference ranking among various policies for the whole population and subgroups. Using a representative sample of the French population, we apply DCE methods to assess the acceptability of various anti-COVID-19 measures, separately and as a package. Owing to the methods, we determine the extent to which acceptability depends on personal characteristics: political orientation, health vulnerability, or age. The young population differs in terms of policy preferences and their claim for monetary compensation, suggesting a tailored policy for them. The paper provides key methodological tools based on microeconomic evaluation of individuals' preferences for improving the design of public health policies.

Comparing GPs' risk attitudes for their own health and for their patients' : a troubling discrepancy?

BACKGROUND: In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568). METHODS: Willingness to take risks in four different domains (daily life, financial matters, own health and patient health) was collected through a large-scale telephone interview of GPs using self-reported 11-point Likert scale questions. RESULTS: We uncover some specificities of the GPs population regarding their attitudes towards risk. In particular, we detect an important positive gap between their willingness to take risks in the domain of their own health and in the domain of the heath of their patients. This "patient-regarding" risk aversion is discussed with respect to its important consequences regarding medical behavior bias. CONCLUSIONS: We confirm the self-other discrepancy found in the medical literature on physicians' behaviors and emphasize the utility of the study and measures of personality traits such as "risk attitudes" for the medical professions and for the population they address.

Achieving universal health coverage in France: policy reforms and the challenge of inequalities.

Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France.

The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases.

BACKGROUND: The literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient's healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed. METHODS: The French Echantillon Généraliste de Bénéficiaires (EGB) database was used to assign all healthcare expenses for a representative sample of the population covered by the National Health Insurance. COIs were estimated in a bottom-up approach, through regressions on individuals' healthcare expenditure. Two-way interactions between the 10 chronic disease variables were included in the expenditure model to account for possible effect modification in the presence of comorbidity(ies). RESULTS: The costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity, demonstrating the pattern of super-additive costs in cases of diseases interaction. For instance, the cost associated with diabetes for people without comorbidity was estimated at 1776 €, whereas this was 2634 € for people with heart disease as a comorbidity. Overall, we detected 41 cases of super-additivity over 45 possible comorbidities. When simulating a preventive action on diabetes, our results showed that significant monetary savings could be achieved not only for diabetes itself, but also for the chronic diseases frequently associated with diabetes. CONCLUSIONS: When comorbidity exists and where super-additivity is involved, a given preventive policy leads to greater monetary savings than the costs associated with the single diagnosis, meaning that the returns from the action are generally underestimated.

Validation of a short-form questionnaire to check patients' adherence to antibiotic treatments in an outpatient setting.

Antimicrobial resistance challenge requests to be able to measure patient medication-adherence in outpatient setting, where more than 90% of antibiotics are prescribed. We take advantage of an original dataset where adherence to treatment has been measured through two alternative measurements: pills count and the Morisky scale. Considering the first measure as benchmark, we test the validity of each of the Morisky items and their composition in a synthetic scale. We show that the short-form version of the medication-adherence scale with three items has the best predictive properties in the domain of antibiotic treatments. Given its concision, this tool could even be used by clinicians to quickly assess patients' adherence and modify it in the course, when needed.

To count or not to count deaths: reranking effects in health distribution evaluation.

Populations' structures and sizes can be a result of healthcare policy decisions. We use a two-period theoretical framework and a dynamic microsimulation model to examine the consequences of this assertion on the appraisal of alternative health policy options. Results show that standard welfare-in-health measures are sensitive to changes in populations' sizes, in that taking into account the (virtual) existence of the dead can alter the ranking of policy options. Disregarding differences in the survivals induced by alternative policies can bias programmes' ranking in favour of less live-saving policies. The paper alerts on the risk of policy misranking by the use of ex-post cross-sectional analyses, neglecting deaths occurring in the past as well as counterfactual deaths in alternative policy scenarios.

Geographic variation in admissions for knee replacement, hip replacement, and hip fracture in France: evidence of supplier-induced demand in for-profit and not-for-profit hospitals.

INTRODUCTION: We sought to determine whether there was evidence of supplier-induced demand in mainland France, where health care is mainly financed by a public and compulsory health insurance and provided by both for-profit and not-for-profit hospitals. METHODS: Using a dataset of all admissions to French hospitals for 2009 and 2010, we calculated department-level age-adjusted and sex-adjusted per capita admission rates for hip replacement, knee replacement, and hip fracture for 2 age groups (45-64 and 65-99 y old), for-profit and not-for-profit hospitals. We used spatial regression analysis to examine the relationship between ecological variables, procedure rates, and supply of surgeons or sector-specific surgical beds. RESULTS: The large majority of hip and knee replacement surgeries were performed in for-profit hospitals, whereas the large majority of hip fracture admissions were in not-for-profit hospitals; nonetheless, we found approximately 2-fold variation in per capita rates of hip and knee replacement surgery in both age groups and settings. Spatial regression results showed that among younger patients, higher incomes were associated with lower admission rates; among older patients, higher levels of reliance on social benefits were associated with lower rates of elective surgery in for-profit hospitals. Although overall surgical bed supply was not associated with admission rates, for-profit-specific and not-for-profit-specific bed supply were associated with higher rates of elective procedures within a respective hospital type. DISCUSSION: We found evidence of supplier-induced demand within the French for-profit and not-for-profit hospital systems; however, these systems appear to complement one another so that there is no overall national supplier-induced effect.

Drug-specific quality indicators assessing outpatient antibiotic use among French general practitioners.

Quality indicators assessing the use of antibiotics among general practitioners (GPs) would be useful to target antibiotic stewardship interventions. We adapted to an individual GP level a set of 12 drug-specific quality indicators of outpatient antibiotic use in Europe developed by the European surveillance of antimicrobial consumption project. We performed a cross-sectional study analysing reimbursement data on outpatient antibiotic prescriptions in adults in south-eastern France in 2009. Substantial heterogeneity in antibiotic prescribing among French GPs was observed, and opportunity to improve antibiotic prescribing can be identified.

Appraising financial protection in health: the case of Tunisia.

Despite the remarkable progress in expanding the coverage of social protection mechanisms in health, the Tunisian healthcare system is still largely funded through direct out-of-pocket payments. This paper seeks to assess financial protection in health in the particular policy and epidemiological transition of Tunisia using nationally representative survey data on healthcare expenditure, utilization and morbidity. The extent to which the healthcare system protects people against the financial repercussions of ill-health is assessed using the catastrophic and impoverishing payment approaches. The characteristics associated with the likelihood of vulnerability to catastrophic health expenditure (CHE) are examined using multivariate logistic regression technique. Results revealed that non-negligible proportions of the Tunisian population (ranging from 4.5 % at the conservative 40 % threshold of discretionary nonfood expenditure to 12 % at the 10 % threshold of total expenditure) incurred CHE. In terms of impoverishment, results showed that health expenditure can be held responsible for about 18 % of the rise in the poverty gap. These results appeared to be relatively higher when compared with those obtained for other countries with similar level of development. Nonetheless, although households belonging to richer quintiles reported more illness episodes and received more treatment than the poor households, the latter households were more likely to incur CHE at any threshold. Amongst the correlates of CHE, health insurance coverage was significantly related to CHE regardless of the threshold used. Some implications and policy recommendations, which might also be useful for other similar countries, are advanced to enhance the financial protection capacity of the Tunisian healthcare system.

Mandatory membership of community-based mutual health insurance in Senegal: A national survey.

With the low adherence to voluntary mutual health insurance, Senegal's policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with a random composition method involving 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86%) over mandatory (70%) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p = 0.040), people under 35 (p = 0.033), and people with no health coverage (p = 0.011). Voluntary or compulsory membership was correlated (p = 0.000) to trust in current CBHIs and health systems. Lack of trust in the CBHI management has been more disadvantageous for acceptance of the mandatory than the voluntary membership. No particular preference emerged as the preferred administrative channel (e.g. death certificate, identity card, etc.) to enforce the mandatory option. The results confirmed the well-known challenges of building universal health coverage based on CBHIs-a poorly appreciated model whose low performance reduces the acceptability of populations to adhere to it, whether voluntary or mandatory. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.

Perceptions and attitudes of French general practitioners towards rapid antigen diagnostic tests in acute pharyngitis using a randomized case vignette study.

OBJECTIVES: This study had three objectives: (i) to assess the use of rapid antigen diagnostic tests (RADTs) and their impact on the antibiotic prescribing behaviour of general practitioners (GPs) for acute pharyngitis; (ii) to study the barriers to the use of RADTs; and (iii) to identify GPs' characteristics associated with non-compliance with French guidelines. METHODS: We conducted a cross-sectional survey of a representative sample of 369 self-employed GPs in south-eastern France using a randomized case vignette study. RESULTS: The availability of an RADT allowed a 44% relative reduction in the rate of antibiotic prescriptions. Of GPs for whom the test was available, 34% did not use an RADT in our acute pharyngitis vignette and 13% of those who used the test prescribed an antibiotic despite a negative RADT result. Non-compliance with French guidelines (i.e. not using an RADT and/or prescribing an antibiotic despite a negative RADT result) was independently associated with the following factors: less reading of medical journals, less benefits/risks discussion with patients about vaccinations and higher perception that clinical examination was sufficient to prescribe antibiotics. The three main declared barriers to RADT use were: time to perform the test, patient expectations regarding antibiotics and the perception that clinical examination was sufficient to decide to prescribe an antibiotic. CONCLUSIONS: RADTs are a useful but not sufficient tool to reduce antibiotic prescribing in general practice. The results of this study increase understanding of the factors underlying clinical decision making for acute pharyngitis and may contribute to the development of interventions to improve practice.

Individuals' willingness to provide geospatial global positioning system (GPS) data from their smartphone during the COVID-19 pandemic.

This study aims to evaluate people's willingness to provide their geospatial global positioning system (GPS) data from their smartphones during the COVID-19 pandemic. Based on the self-determination theory, the addition of monetary incentives to encourage data provision may have an adverse effect on spontaneous donation. Therefore, we tested if a crowding-out effect exists between financial and altruistic motivations. Participants were randomized to different frames of motivational messages regarding the provision of their GPS data based on (1) self-interest, (2) pro-social benefit, and (3) monetary compensation. We also sought to examine the use of a negative versus positive valence in the framing of the different armed messages. 1055 participants were recruited from 41 countries with a mean age of 34 years on Amazon Mechanical Turk (MTurk), an online crowdsourcing platform. Participants living in India or in Brazil were more willing to provide their GPS data compared to those living in the United States. No significant differences were seen between positive and negative valence framing messages. Monetary incentives of $5 significantly increased participants' willingness to provide GPS data. Half of the participants in the self-interest and pro-social arms agreed to provide their GPS data and almost two-thirds of participants were willing to provide their data in exchange for $5. If participants refused the first framing proposal, they were followed up with a "Vickrey auction" (a sealed-bid second-priced auction, SPSBA). An average of $17 bid was accepted in the self-interest condition to provide their GPS data, and the average "bid" of $21 was for the pro-social benefit experimental condition. These results revealed that a crowding-out effect between intrinsic and extrinsic motivations did not take place in our sample of internet users. Framing and incentivization can be used in combination to influence the acquisition of private GPS smartphone data. Financial incentives can increase data provision to a greater degree with no losses on these intrinsic motivations, to fight the COVID-19 pandemic.

Erratum: Author Correction: Individuals' willingness to provide geospatial global positioning system (GPS) data from their smartphone during the COVID-19 pandemic.

[This corrects the article DOI: 10.1057/s41599-022-01338-7.].

Does Self-Assessed Health Reflect the True Health State?

Self-assessed health (SAH) is a widely used tool to estimate population health. However, the debate continues as to what exactly this ubiquitous measure of social science research means for policy conclusions. This study is aimed at understanding the tenability of the construct of SAH by simultaneously modelling SAH and clinical morbidity. Using data from 17 waves (2001-2017) of the Russian Longitudinal Monitoring Survey, which captures repeated response for SAH and frequently updates information on clinical morbidity, we operationalise a recursive semi-ordered probit model. Our approach allows for the estimation of the distributional effect of clinical morbidity on perceived health. This study establishes the superiority of inferences from the recursive model. We illustrated the model use for examining the endogeneity problem of perceived health for SAH, contributing to population health research and public policy development, in particular, towards the organisation of health systems.

Estimation of Asthma Symptom Onset Using Internet Search Queries: Lag-Time Series Analysis.

BACKGROUND: Asthma affects over 330 million people worldwide. Timing of an asthma event is extremely important and lack of identification of asthma increases the risk of death. A major challenge for health systems is the length of time between symptom onset and care seeking, which could result in delayed treatment initiation and worsening of symptoms. OBJECTIVE: This study evaluates the utility of the internet search query data for the identification of the onset of asthma symptoms. METHODS: Pearson correlation coefficients between the time series of hospital admissions and Google searches were computed at lag times from 4 weeks before hospital admission to 4 weeks after hospital admission. An autoregressive integrated moving average (ARIMAX) model with an autoregressive process at lags of 1 and 2 and Google searches at weeks -1 and -2 as exogenous variables were conducted to validate our correlation results. RESULTS: Google search volume for asthma had the highest correlation at 2 weeks before hospital admission. The ARIMAX model using an autoregressive process showed that the relative searches from Google about asthma were significant at lags 1 (P<.001) and 2 (P=.04). CONCLUSIONS: Our findings demonstrate that internet search queries may provide a real-time signal for asthma events and may be useful to measure the timing of symptom onset.

Reassessing the demand for community-based health insurance in rural Senegal: Geographic distance and awareness.

Limited access to information is one of the main health insurance market imperfections in developing countries. Differential access to information may determine individuals' awareness of health insurance schemes, thereby influencing their probability of enrollment. Relying on primary data collected in 2019-2020 in rural Senegal, we estimate the uptake of community-based health insurance using a Heckman-type model to correct for awareness-based sample selection bias. Besides showing that health insurance awareness is a precondition for effective enrollment in community-based health insurance schemes, we also bring new evidence on the roles which geographic factors and individual risk preference play in health insurance uptake by rural dwellers. We show that geographic distance prevents individuals from accessing information on health insurance schemes, and discourage those who are informed from enrolling, because of the additional distance they must travel to benefit from covered healthcare services. Results also show that individual risk preference influences health insurance uptake, but only when information barriers are taken into account. Overall, our results could help decision-makers better shape the universal health coverage roadmap, as policies to improve health insurance awareness differ substantially from policies to improve the features of health insurance schemes.