Automédication : l’influence du contexte local dans les perceptions et pratiques des médecins généralistes

Les pouvoirs publics français, dans un souci de maîtrise des dépenses de santé, encouragent le recours à l’automédication de la population. Les comportements d’auto-soin, qui consistent à consommer de sa propre initiative un médicament sans consulter un médecin, placent ce dernier au cœur d’un antagonisme entre la volonté d’autonomie des usagers confrontée à celle d’encadrement des pouvoirs publics et l’obligent à se positionner face à des pratiques dont par essence il est exclu par le patient. Cette étude cherche à comprendre, par la méthode de contextualisation des discours, l’influence du milieu géographique dans les positionnements et comportements des praticiens vis à vis de l’automédication. Elle a été réalisée à partir d’entretiens semi-directifs, selon des grilles élaborées conjointement avec des sociologues, des médecins et des géographes, auprès de 30 médecins généralistes et 19 pharmaciens des agglomérations nazairienne et nantaise. Les résultats de ce travail suggèrent l’importance de la prise en compte des données territoriales entourant soignant et soigné dans l’analyse des comportements des professionnels de santé et dans de nouvelles perspectives d’approche du recours à l’automédication.The French public authorities encourage the population to resort to self-medication to control health expenditure. Since risk may occur from this practice, general practitioners and pharmacists have been appointed to be the “guarantors” of a safe use for self-medication. Self-care behaviours, implying the consumption of medication without consultation, put the practitioner in an antagonistic situation between the patients’ will to be self-reliant in care use on the one hand, and the frame imposed by the public authorities on the other. This demands of the professionals that they adopt for themselves a position on such self-care practices in which they are excluded by the patient. This study aims at understanding the influence of the geographical environment on the professionals’ position and behaviour in relation to self-medication examined through the method of contextual speech. Semi-structured interviews have been conducted with 30 practitioners and 19 pharmacists from the Nantes and Saint-Nazaire areas based on questions defined by sociologists, doctors and geographers. The results of this study suggest that spatial data are salient to analyzing health professionals’ behaviour in relation to this concern of patient’s self-medication. The interviews aimed at determining the professionals’ perceptions with respect to the self-medication of their patients in terms of whether they have encouraged or on the contrary, attempted to prevent these behaviours through arguments in favour of the public policies promoting self-medication. The questions deal with the professionals’ career, the socio-economic characteristics of the patients and the motivations for their choice of place of work so as to link practices and behaviours with places. The simultaneous study of two different urban areas enables the analysis to distinguish the effects of context from geographical invariants. The main case study was Saint Nazaire with the case of Nantes used as a mirror to enable the identification of similarities or differences. Both case studies rely on a spatial analysis of data issued of the same program: the ANR Auto-med. The choice of Saint Nazaire as the main case study is based on two observations. First, the patients’ rate of self-medication declared in a survey conducted within the ANR Auto-med program appears to be lower in Saint Nazaire than that of the regional area. Secondly, an investigation of a panel of medical consultations on the frequency of self-medication mentioned by the doctor or the patient again indicates that the area of Saint Nazaire is below the average (tab.1). Local socio-economic conditions, culture and history influence the practices of the health professionals. The socio-economic status of the patients influences the attitude to them of the doctors, for example, in terms of their medical costs. The professionals located in the most deprived districts underline the inequalities in health generated by the de-listing of drugs known as “of comfort” from those whose costs will be reimbursed to the patient. In this context, the pharmacists seem to offer advice according to their customers’ supposed purchasing power. The health professionals located in a district concentrating a large number of poor workers express a certain concern with respect to the inequality of access to care. In this case, self-medication is an essential part of health-care behaviour because even if people provide a prescription, they are not necessarily reimbursed for certain kinds of drugs. The medical and social history of the Saint-Nazaire area has shaped the relations between patients and doctors such that a distinct community of professional practice has appeared in this area. This community is defined by a global approach towards the patient’s health, a broader concern with self-medication, and a significant emphasis given to listening and discussion during the consultations. Thus, the advice on drugs is simply part of the global relations between the patient and the GP or the pharmacist whereas in the mirror area of Nantes, this advice is delivered more as a recommendation of good practice from the “expert” to the non-expert. Interviews with pharmacists in Nantes suggest that self-medication offers a therapeutic alternative in response to a lack of listening that is prevalent among the doctors of the area. The doctors are influenced in their practices by perceived local beliefs about health. If the doctors are also native to their place of work and have always been embedded in such sets of beliefs, they are more tolerant than their fellow-doctors towards these beliefs and indeed will sometimes accept being guided by their patients when writing the prescription (although sometimes they may just add a placebo to seem to concur with the patient). The patients’ resort to self-medication is neither perceived nor accompanied in a homogeneous way from one city to another or from one district to another. In the area of Saint Nazaire, medical and social interventions have been anchored for a long time in a political and social tradition of solidarity, networking and proximity with a population weakened by the roughness and the liability of working conditions. Consequently, this situation strengthens even further the relationship between doctor and patient having thus a strong influence on self-medication. These results suggest the importance of taking into account the territorial context in the analysis of the health professionals’ behaviours opening new opportunities for studying self-medication

Refining the medical student safety attitudes and professionalism survey (MSSAPS): adaptation and assessment of patient safety perception of French medical residents

International audienceBACKGROUND:Implementing a patient safety curriculum for medical students requires to identify their needs and current awareness of the topic. Several tools have been developed to measure patient safety culture, but none of them have been developed in the French context. Our objective was to adapt and refine the psychometric properties of the MSSAPS, developed by Liao et al, to use it among general practice (GP) residents.METHODS:1-We conducted a translation and transcultural adaptation of the MSSAPS questionnaire (28 items, 5 dimensions: safety culture, teamwork culture, experiences with professionalism, error disclosure culture and comfort expressing professional concerns) in accordance with the international recommendations. 2-We studied the new questionnaire' psychometric properties on a sample of GP residency students in 2016. This validation comprised 2 steps: a confirmatory factor analysis (CFA) for each dimension of the MSAPPS to explore the adequacy of the structure of the questionnaire; an exploratory factor analysis to refine the instrument, using a principal component analysis and Cronbach's α-coefficients calculation. A final CFA examined the structure validity of the refined questionnaire. 3-We described the items and the safety cultural scores in our sample of residents.RESULTS:Among 391 eligible students, 213 responded (54%). The initial structure was not confirmed by CFAs, showing a poor fit for 3 of the 5 dimensions: safety culture, teamwork culture and professionalism. Exploratory PCA led to 3 dimensions: Safety culture (PVE: 18.5% and 7 of 8 initial items), Experiences with professionalism (PVE: 17.8% and 5 of 7 initial items) and Error disclosure culture (PVE: 13.6% and 3 of 4 original items). Cronbach's α-coefficients were 0.74, 0.78 and 0.76 respectively. The final CFA confirmed the existence of the 3 latent dimensions with a good fit to the and highly significant structural coefficients (P < 0.001). Mean scores were equal to 65.4 [63.6; 67.6] for the safety culture, 66.9 [63.8; 70.1] for the experience with professionalism, and 54.4 [51.6; 57.2] for the error disclosure culture.CONCLUSION:This study reports satisfactory psychometrics properties of the French version of the MSAPPS and provides evidence of important training needs for GP residents in the field of patient safety culture

Refining the medical student safety attitudes and professionalism survey (MSSAPS): adaptation and assessment of patient safety perception of French medical residents

International audienceBACKGROUND:Implementing a patient safety curriculum for medical students requires to identify their needs and current awareness of the topic. Several tools have been developed to measure patient safety culture, but none of them have been developed in the French context. Our objective was to adapt and refine the psychometric properties of the MSSAPS, developed by Liao et al, to use it among general practice (GP) residents.METHODS:1-We conducted a translation and transcultural adaptation of the MSSAPS questionnaire (28 items, 5 dimensions: safety culture, teamwork culture, experiences with professionalism, error disclosure culture and comfort expressing professional concerns) in accordance with the international recommendations. 2-We studied the new questionnaire' psychometric properties on a sample of GP residency students in 2016. This validation comprised 2 steps: a confirmatory factor analysis (CFA) for each dimension of the MSAPPS to explore the adequacy of the structure of the questionnaire; an exploratory factor analysis to refine the instrument, using a principal component analysis and Cronbach's α-coefficients calculation. A final CFA examined the structure validity of the refined questionnaire. 3-We described the items and the safety cultural scores in our sample of residents.RESULTS:Among 391 eligible students, 213 responded (54%). The initial structure was not confirmed by CFAs, showing a poor fit for 3 of the 5 dimensions: safety culture, teamwork culture and professionalism. Exploratory PCA led to 3 dimensions: Safety culture (PVE: 18.5% and 7 of 8 initial items), Experiences with professionalism (PVE: 17.8% and 5 of 7 initial items) and Error disclosure culture (PVE: 13.6% and 3 of 4 original items). Cronbach's α-coefficients were 0.74, 0.78 and 0.76 respectively. The final CFA confirmed the existence of the 3 latent dimensions with a good fit to the and highly significant structural coefficients (P < 0.001). Mean scores were equal to 65.4 [63.6; 67.6] for the safety culture, 66.9 [63.8; 70.1] for the experience with professionalism, and 54.4 [51.6; 57.2] for the error disclosure culture.CONCLUSION:This study reports satisfactory psychometrics properties of the French version of the MSAPPS and provides evidence of important training needs for GP residents in the field of patient safety culture

Association of socio-economic, environmental and health care factors with variation of prevalence of β-lactamase-producing escherichia coli community-acquired urinary tract infection

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Local characteristics associated with higher prevalence of ESBL-producing Escherichia coli in community-acquired urinary tract infections: an observational: cross-sectional study

International audienceObjectivesThe prevalence of ESBL-producing Escherichia coli (ESBL-E. coli) in community-acquired urinary tract infections (UTI) has been increasing worldwide since 2000, but with large geographical variations. The aim of this study was to determine whether the ESBL-E. coli rate in urine samples from individuals with community-acquired UTI was associated with the local socio-economic, environmental, agricultural and healthcare characteristics.MethodsThis was a cross-sectional study in western France using data on antibiotic susceptibility of E. coli isolated from urine samples of individuals with community-acquired UTI analysed in non-hospital laboratories from 2015 to 2017. The ESBL-E. coli rate was calculated for each laboratory. Data on socio-economic characteristics, human antibiotic consumption, hospital bed density, animal farming density and percentage of agricultural land and surface water were retrieved at the municipality level and aggregated by study area. Their association with ESBL-E. coli prevalence was quantified using multivariate linear regression models with a backward selection.ResultsFrom 358 291 E. coli isolates from urine samples tested in 92 laboratories, the mean ESBL-E. coli prevalence for the study period was 3.30%. In an adjusted model, the ESBL-E. coli rate was significantly (P 65 years old, third-generation cephalosporin use (DDD/1000 inhabitants), number of hospital beds/km2, poultry density, pig density and percentage of agricultural land. Lower deprivation was associated with a higher ESBL-E. coli rate.ConclusionsSeveral anthropogenic factors (primary care, hospitals and animal farming) are associated with the local ESBL-E. coli rate in community-acquired UTI. These results could contribute to improve risk management, including identification of at-risk patient groups

Risk Factors of Extended-Spectrum Beta-Lactamases-Producing <em>Escherichia coli</em> Community Acquired Urinary Tract Infections: A Systematic Review

International audiencePurpose: The prevalence of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) has been increasing worldwide since the early 2000s. E. coli is found in 70-90% of community-acquired urinary tract infections (CA-UTIs). We performed a systematic literature review to determine the risk factors for CA-UTI caused by ESBL-EC.Methods: We searched the MEDLINE, Cochrane Library, Embase and Web of Science databases without language or date restriction up to March 2019. Two independent reviewers selected studies with quantified risk factors for CA-UTI due to ESBL-EC, and assessed their quality using the Newcastle-Ottawa Scale.Results: Among the 5,597 studies identified, 16 observational studies (n=12,138 patients) met the eligibility criteria. The included studies were performed in various countries, and 14/16 were published after 2012. The most relevant risk factors for CA-UTI due to ESBL-EC identified were prior use of antibiotics (odds ratio (OR) from 2.2 to 21.4), previous hospitalization (OR: 1.7 to 3.9), and UTI history (OR: 1.3 to 3.8). Two risk factors were related to environmental contamination: travelling abroad, and swimming in freshwater.Conclusion: Our findings could allow adapting empiric antibiotic treatments according to the patient profile. Further studies are needed to quantify the relationships between CA-UTI due to ESBL-EC and the environment

Assessment of Factors Associated With Community-Acquired Extended-Spectrum β-Lactamase–Producing <i>Escherichia coli</i> Urinary Tract Infections in France

International audienceIMPORTANCE Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli is considered a leading pathogen contributing to the global burden of antimicrobial resistance. OBJECTIVE To better understand factors associated with the heterogeneity of community-acquired ESBL-producing E coli urinary tract infections (UTIs) in France. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study performed from January 1 to December 31, 2021, was based on data collected via PRIMO (Surveillance and Prevention of Antimicrobial Resistance in Primary Care and Nursing Homes), a nationwide clinical laboratory surveillance system in France. Strains of E coli isolated from community urine samples from January 1 to December 31, 2019, from 59 administrative departments of metropolitan France were included. MAIN OUTCOMES AND MEASURES Quasi-Poisson regression models were used to assess the associations between several ecological factors available on government and administration websites between 2010 and 2020 (demographic population structure, living conditions, baseline health care services, antibiotic consumptions, economic indicators, animal farming density, and environmental characteristics) and the number of ESBL-producing E coli strains isolated from urine samples of individuals with community-acquired UTI in 2019