Inégalités sociales de santé : quels impacts sur l’accès aux soins de prévention ?

En abordant la réduction des inégalités sociales et territoriales de santé sous l’angle exclusif de l’amélioration de l’accès aux soins des populations les plus « vulnérables », les politiques et programmes de santé considèrent une seule dimension de ces inégalités, alors qu’elles traversent l’ensemble de la hiérarchie sociale. Or, si les disparités d’accès aux soins préventifs ne constituent pas le déterminant principal des inégalités sociales de santé, dans un modèle de soins français essentiellement curatif, elles ne sont pas négligeables dans leur production. Cependant, les mesures visant à élargir l’accès aux soins de prévention ne sont pas les seules à mettre en oeuvre pour réduire les inégalités sociales de santé, qui traversent l’ensemble de la hiérarchie sociale.Seeking to reduce social and territorial inequalities of health by focusing exclusively on improved access to care for the most “vulnerable” population means that health policies and programmes take only one dimension of such inequalities into account, even though they are found throughout the social hierarchy. While access to preventive care is not the principal determinant of social inequalities of health, it is not a negligible factor in the production of such inequalities in a health care system such as France’s which focuses on cure

Pourquoi refuser de délivrer des soins ?

This article analyses social dynamics of care refusal by private practitioners towards patients covered by public funded complementary health insurance (CMU-C). The data are based on in-depth face-to-face interviews with physicians and dentists conducted between (2015-2016), and are analyzed from a socio-anthropological approach. The results show intertwining between economic logic and non-economic such as the social representations of those patients, the practitioners’ values, their relationship with the government and social insurance institution.Cet article vise à analyser les logiques sociales du refus de soins à l’égard des bénéficiaires de la Couverture maladie universelle complémentaire par des professionnels de santé de ville. Les résultats reposent sur une analyse socioanthropologique de discours d’une cinquantaine de médecins et dentistes, récoltés entre 2015 et 2016. Ils montrent l’intrication entre des logiques économiques et non économiques, telles que les représentations de cette catégorie de patients, les valeurs des praticiens et leur rapport à l’État et à l’assurance maladie

Stress perception among employees in a French University Hospital

Background Nantes University Hospital comprises 20 activity sectors.Aims To investigate the role of the work environment at the individual level, as well as the workplace level, in explaining the variability in employees’ perception of stress. Methods A self-administered enhanced Karasek Job Content Questionnaire was sent to employees. The main variables were the psychological job demand (PJD) score and the job decision latitude (JDL) score. Univariate and multivariate logistic regression analyses were conducted to estimate crude odds ratio (OR) and adjusted OR. Results One thousand eight hundred and sixty-eight workers were included. Nursing managers (25.9 ± 3.4), non-specialized nurses (25.6 ± 3.5) and physicians (25.3 ± 3.4) had the highest PJD. Cleaning staff (61.4 ± 11.4) and nurse aides (63.6 ± 8.8) had the lowest JDL. Items correlated with high PJD are: unacceptable work schedule, adjusted OR 2.16 (95% CI = 1.3–3.5); unsatisfactory workstation accessibility, OR 1.92 (95% CI = 1.1–3.2); getting from A to B, OR 1.67 (95% CI = 1.2–2.4); and heavy manual handling, OR 1.62 (95% CI = 1.1–2.3). Sleeping tablet use was linked to high PJD (P < 0.01), extra workload (P < 0.05) and tiredness (P < 0.05). Use of painkillers was correlated with musculoskeletal disorders (P < 0.05). Conclusions Our study highlighted women >40 years old, nurse managers, physicians, permanent and/or full-time workers having a high PJD. Nursing aides, medical secretary and nurses presented with high strain. Better control measures should be implemented for those socioprofessional categories to improve prevention measures. This study should be repeated in the future with a multi-centre approach to determine the generalizability of the findings

Surveillance épidémiologique des hernies discales opérées en lien avec l’activité professionnelle : Etudes en région Pays de la Loire

Introduction.– La hernie discale opérée (HDO) a été choisie comme indicateur de pathologie rachidienne pour déterminer l’association entre HDO et activité professionnelle et la contribution de celle-ci dans la survenue de cette pathologie. Méthodes.– Les patients furent sélectionnés à partir des bases régionales du Programme de médicalisation des systèmes d’information (PMSI) sur : âge 20 à 59 ans, acte d’HDO, en 2002 à 2003 au CHU de Nantes, pour l’étude pilote, et en 2007 à 2008 dans tous les centres chirurgicaux des Pays de la Loire, pour l’étude régionale. L’histoire médicale et professionnelle fut recueillie par auto-questionnaire postal. Le risque relatif ajusté sur l’âge (RR) permit d’estimer l’association entre HDO et activité professionnelle. La contribution des secteurs d’activité et professions au risque d’HDO fut quantifiée par la fraction de risque attribuable aux facteurs professionnels dans la population (Frap) et par la fraction de risque attribuable chez les exposés (Frae). Résultats.– L’étude pilote incluait 146 répondeurs à l’auto-questionnaire parmi les 272 patients éligibles. L’étude régionale comprenait 1870 répondants parmi les 3135 patients opérés en 2007 à 2008. Le RR d’HDO était, chez les hommes, de 5,1[2,6–10,1] dans les transports et, chez les femmes, de 2,7[1,6–4,5] dans la santé et de 10,2[4,4–23,3] dans l’hôtellerie restauration. Les fractions de risque attribuable les plus élevées étaient associées à l’hôtellerie restauration chez les femmes (Frap = 19 %, Frae = 90 %). Les professions à risque étaient, chez les hommes, les chauffeurs (Frap = 12 %, Frae = 79 %) et les ouvriers non qualifiés de l’industrie (Frap = 17 %, Frae = 80 %) et, chez les femmes, les employées de la fonction publique (Frap = 18 %, Frae = 66 %). Discussion et conclusion.– Ces études ont confirmé l’intérêt d’une surveillance de l’HDO fondée sur le PMSI et ont permis d’identifier les professions à risque d’HDO en population générale

Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study

Background: Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses’ influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents. Design and methods: An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016. Results: Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents’ infections.Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency

Impact of Home-Based Management of malaria combined with other community-based interventions: what do we learn from Rwanda?

Introduction: This study aimed to evaluate the impact of home-based management of malaria (HBM) strategy on time to treatment and reported presumed malaria morbidity in children aged less than 5 years in Rwanda. Methods: The study was carried out in two malaria-endemic rural districts, one where HBM was applied and the other serving as control. In each district, a sample of mothers was surveyed by questionnaire before (2004) and after (2007) implementation of HBM. Results: After implementation, we observed: i) an increase (P<0.001) in the number of febrile children treated within 24 hours of symptom onset in the experimental district (53.7% in 2007 vs 5% in 2004) compared with the control district (28% vs 7.7%); ii) a decrease in the reported number of febrile children in the experimental district (28.7% vs 44.9%, P<0.01) compared with the control district (45.7% vs 56.5%, P<0.05). Conclusion: HBM contributed to decrease time to treatment and reported presumed malaria morbidity.Pan African Medical Journal 2013; 14:5

Epidemiological surveillance of lumbar disc surgery in the general population: a pilot study in a French region.

OBJECTIVES: Disc-related sciatica (DRS) is a significant and costly health problem in the working population. The aim of this pilot study was to assess the feasibility of a surveillance system for DRS using hospital databases for lumbar disc surgery (LDS). METHODS: A total of 272 inpatients (119 men and 153 women) living in a French region and discharged in 2002-2003 from a spine center of a large University Hospital following LDS were compared with demographic and socioeconomic data on the population of the same region. Medical and occupational histories were gathered using a mailed questionnaire. The age-adjusted relative risks and population attributable fraction of risk (PAF) were calculated in relation to occupations and industries. RESULTS: Information on employment was available for the 75 women and 71 men. The risk of LDS varied according to occupations and industries. PAFs ranged between 30% (12-48) for male blue collar workers and 22% (4-40) for female lower white collar workers. PAFs ranged between 7 and 17% in the economic sectors at high risk. CONCLUSION: The surveillance of LDS can identify occupations and industries at risk

Population attributable risk of lumbar disc surgery according to occupation: a study in a French general population

Aims: Disc-related sciatica represents one of the most significant and costly health problems occurring in the working population. The aim of this study was to assess the work-related population attributable fraction (PAF) of lumbar disc surgery (LDS) for disc-related sciatica in occupational categories at high risk in the general population. Methods: Patients living in a French region in 2003 and discharged from a large University Hospital following LDS were compared with demographic and socioeconomic data from the population census. Medical and occupational histories from 75 women and 71 men were gathered using a mailed questionnaire. The ageadjusted relative risks and PAF of CTS were calculated according to occupational categories. Results: The PAFs of lumbar disc surgery was 37% [19-54] for the male blue-collar workers suggesting that about 37% of the cases occurring in this category of workers could be avoided if the excess risk of LDS could be eliminated. The PAF value for male and female lower-grade white collar workers and female intermediate occupations were 18%, 33% and 13%, respectively. Conclusion: The study suggested that 13–37% of LDS for disc-related sciatica might be avoided in the whole population if totally effective intervention programs were implemented in specific occupational categories or industries. However, these preliminary findings must be confirmed by a larger study conducted in the whole region to assess more accurately the proportion of avoidable cases of LDS in the population