Accessibilité aux médecins généralistes en France : les méandres de la construction des zones sous-dotées

International audienceFacing geographical imbalances in primary care, French authorities have been defining under-served areas since 2005. They are used to implement several measures to attract and retain general practitioners (GPs). During this period, 4 waves of under-served areas were determined and new measures were deployed by different public authorities (local authorities, state, national health insurance). We aim to show how the succession of these different waves of areas and the intervention of numerous actors can lead to reduce the efficiency of a policy. To illustrate this point, we analyse the history of the definition of under-served areas in GPS in France. The presentation highlights that the mix of different areas and of different measures could diminish the visibility of the policy with GPs. This also raises the question of the effectiveness of this policy to attract and retain GPs in under-served areas.Face à l'inégale répartition géographique des médecins, les pouvoirs publics ont défini depuis 2005 des zones sous-dotées pour y déployer des mesures permettant d'attirer et de maintenir ces professionnels de santé. La définition de ces zones s'est complexifiée au fur et à mesure que les dispositifs s'étoffaient et que de nouveaux acteurs s'emparaient de cette question (collectivités territoriales, État, Assurance maladie). L'objectif est ici de montrer comment la montée en puissance d'une politique publique conduit, de par la multiplicité des acteurs et des territoires afférents mobilisés, à en réduire la portée. Nous nous appuyons dans cette communication sur l'historique de la définition des zones sous-dotées en médecins généralistes libéraux en France. L'enchevêtrement des zonages et dispositifs qui en résulte réduit la lisibilité de la politique auprès des médecins concernés et pose ainsi la question de son efficacité

Territorialisation sanitaire et décentralisation : état des lieux et enjeux à partir du cas français

Ces dernières décennies, les transformations des systèmes de santé dans le monde se traduisent par des processus de territorialisation, sous-tendus par trois tendances principales : la régulation financière, le développement des partenariats et le transfert des compétences. Dans ce papier, nous resituons tout d’abord le processus de territorialisation dans le cadre plus général des questions de décentralisation, de gouvernance et de gouvernement. En se focalisant sur le cas français, nous analysons ensuite l’articulation entre la décentralisation dite fonctionnelle en santé et les processus plus généraux de décentralisation des institutions. Pour conclure, nous questionnons les enjeux opérationnels et organisationnels qui en découlent.In this paper, we focus on the common trends of transformations of health care systems in the world. Based on the identification of three logics that root these evolutions (financial regulation, development of cooperation and skill/power transfers), we define territorialization as a process. It refers to projects of planning for which actors implement strategies to produce controlled and bounded spaces. In this process, scales, distances enacted through instruments are involved for putting public policy into practice and space. These actions give rise to different forms of territorialization in which different modes of governance, government and uses are embedded. In a second part, we focus on the case of France and the ways instruments have been used to develop public policies. We insist on the disconnections between the political and administrative decentralization with the evolution of the health sector. The general trend of decentralization of French administration during the eighties is characterized by a greater proximity of public decision with citizen, which involves more action for local authorities. A structured vision of decentralization appears only at the beginning of 2010s based on potential differentiation of standard on the territory and the possibility for regions to provide guidance to others local authorities. During these periods, health sector remains on the sidelines of the legislative evolution. Although regional level was defined as the structuring level of organization for health care in the hospital law of 1991, regionalization of public health policy really operated in 2009 with the Patients, Health and Territories Law (HPST) creating regional health agencies. These ones, with the legal personality are a type of functional decentralization, which are submitted to state monitoring. Concentrating the decision-making power at the regional level and breaking down barriers between sectoral policies, this law simplified local organization of health sector governance. It is operated in a regional health plan which relies on contractual partnerships with a lot of actors including local authorities which became a major actor to decline the plan at the local level. In a third part, we discuss the stakes, options and problems that actors have to face in the current stage of decentralization. Combined with deconcentration of others services, overlapping, cross-financing occurred and involved lower clarity of administrative organization. Two major stakes are identified. Firstly, the capabilities for actors to form a wide coalition sharing objectives and keeping up with changes in stakeholder’s dynamics, like political changeovers and budget cuts. Secondly, a better coordination of actors, in order to create favorable conditions for cooperation and complementarities

Experimental study of corrosion-induced degradation of reinforced concrete elements

Corrosion of steel reinforcement is the main cause of damage for reinforced concrete structures. Iron oxides produced during the corrosion process can induce concrete cracking, loss of adhesion at the steel-concrete interface, loss of reinforcing bar cross-section and even spalling of the concrete cover. In the presented research, the durability problems related to the corrosion of the reinforcement are investigated by combining experimental and numerical studies. However, this paper particularly focuses on the experimental methodology used for the time evolution of damages (steel corrosion products formation and crack patterns) induced by the accelerated corrosion test. The accelerated corrosion tests were carried out by applying a constant current between reinforcement used as an anode and a counter electrode. To control the corrosion process, electrochemical parameters (such as free corrosion potential, polarization resistance, electrical concrete resistance) were measured. The purpose of this paper is to determine the width and length of the cracks and their orientation according to the current density and time

Exploration by Shake-the-Box technique of the 3D perturbation induced by a bubble rising in a thin-gap cell

From Lagrangian measurements using the Shake-the-Box technique (Schanz et al. in Exp Fluids 57(5):70, 2016) we investigate the velocity field about a single bubble rising in a thin-gap cell and we discuss it in an Eulerian framework of analysis. The gap thickness is equal to 2.85 mm and the bubble-induced perturbation extends over at least 10 cm in the plane of the cell, so that a very flat volume of observation is required. At first validation of the technique is provided during an emptying of the cell. It allows to fix all methodological parameters to ensure accurate measurements and, indirectly, to measure precisely the gap thickness. Then, the velocity field about a confined high-Reynolds number bubble is investigated. This velocity field is discussed in comparison with a previous description obtained by two-dimensional Particle Image Velocimetry (2D2C-PIV) with volume enlightening of the whole cell (Roig et al. in J Fluid Mech 707:444–466, 2012; Filella et al. in J Fluid Mech 778:60–88, 2015). Velocity is first averaged over the gap and compared to the 2D2C-PIV measurement obtained from tomoreconstructed and projected frontal images. Then a 3D description of the velocity field is presented. It allows to discuss the quality and limitations of the 2D description of the wake with a velocity field integrated across the cell. In particular, the 3D description obtained from STB shows that the flow becomes mainly parallel to the cell plates at a distance of approximately one bubble diameter and that the wake is organised in slices parallel to the plates moving with their own dynamics that may vary their relative in-plane orientations, but all follow the general exponential viscous law of decay

Coopération agricole de production : quand l’activité agricole se distribue entre exploitation et action collective de proximité

L’agriculture est-elle toujours une affaire de famille ? Cet ouvrage analyse les transformations du caractère familial de l’agriculture en France, mises en perspective avec quelques éclairages de situations dans les pays du Sud. La première partie de l’ouvrage rend compte des recompositions de l’exploitation agricole et de ses enjeux, exploitation qui est de moins en moins familiale, tout en le restant. Elle propose des cadres d’analyse élargis pour les appréhender. Les transformations des formes familiales d’agriculture sont abordées dans une deuxième partie par l’étude des mutations qui s’opèrent dans le travail en agriculture. Ces mutations amènent à questionner le sens du travail et les interfaces avec le vivre en famille et les activités non-agricoles, au-delà des seules problématiques d’organisation et de performances technico-économiques. La troisième partie de l’ouvrage montre que les cadres structurant l’activité agricole dépassent le champ de la famille et se renouvellent, en particulier dans les formes d’insertion territoriale, dans les modalités des processus d’innovation et par des reconfigurations de l’action collective de proximité. Finalement, les transformations du caractère familial, saisies dans le temps long des trajectoires d’exploitations, sont aussi observées dans les formes et stratégies de pérennisation et de transmission, qu’il s’agisse de transmettre un statut, une activité, une entreprise, un patrimoine, un outil de production ou encore des savoir-faire. Une synthèse conclusive propose un renouvellement des questions de recherche et plaide pour un décloisonnement des études en agriculture. L’ouvrage rassemble des travaux de recherche récents de chercheurs issus du département Sciences pour l’action et le développement (Sad) de l’Inra et de ses partenaires scientifiques et professionnels. Il fait une large place à des travaux de jeunes chercheurs et à des thèses récemment soutenues. D’abord destiné aux chercheurs et enseignants-chercheurs, il s’adresse également aux organisations professionnelles (instituts techniques, réseaux associatifs, syndicats, chambres d’agriculture, etc.)

Readability of the Written Study Information in Pediatric Research in France

BACKGROUND: The aim was to evaluate the readability of research information leaflets (RIL) for minors asked to participate in biomedical research studies and to assess the factors influencing this readability. METHODS AND FINDINGS: All the pediatric protocols from three French pediatric clinical research units were included (N = 104). Three criteria were used to evaluate readability: length of the text, Flesch's readability score and presence of illustrations. We compared the readability of RIL to texts specifically written for children (school textbooks, school exams or extracts from literary works). We assessed the effect of protocol characteristics on readability. The RIL had a median length of 608 words [350 words, 25(th) percentile; 1005 words, 75(th) percentile], corresponding to two pages. The readability of the RIL, with a median Flesch score of 40 [30; 47], was much poorer than that of pediatric reference texts, with a Flesch score of 67 [60; 73]. A small proportion of RIL (13/91; 14%) were illustrated. The RIL were longer (p<0.001), more readable (p<0.001) and more likely to be illustrated (p<0.009) for industrial than for institutional sponsors. CONCLUSION: Researchers should routinely compute the reading ease of study information sheets and make greater efforts to improve the readability of written documents for potential participants

Observación de dinámicas colectivas de transición agroecológica en Francia

En el marco del proyecto de Observatorios de Dinámicas Territoriales (LABINTEX) se participa en 4 dispositivos de investigación participativa sobre diferentes situaciones territoriales con el objetivo de analizar la capacidad de dichos dispositivos de crear redes socio-técnicas con capacidad de agencia. Dos de estos dispositivos (CapVert y ObsTAE) están vinculados a situaciones de grupos de productores implicados en procesos de transición agroecológica. En ambos se realiza una caracterización de diferentes situaciones grupales y se hacen seguimientos de grupos seleccionados. En esta ponencia nos proponemos caracterizar estos dispositivos y mostrar algunos avances de los seguimientos realizados. Dos hipótesis principales guían esta presentación: 1) la pertenencia a un grupo facilita el proceso de transición agroecológica 2) Existe una correlación entre el avance en prácticas agroecológicas y la emergencia de nuevas formas de cooperación entre los productores y actores del territorio. Los primeros trabajos de terreno nos alientan a validar ambas hipótesis.In the framework of the project “Observatories of Territorial Dynamics” (LABINTEX) we participate in 4 devices of participatory research on different territorial situations in order to test the ability of these devices to create socio-technical networks with agency capability. Two of these devices (Capvert and ObsTAE) are linked to situations of farmers groups involved in processes of agroecological transition. In both cases the different group situations are characterized and monitoring of selected groups is made. In this paper we propose to characterize these devices and show some progress in the performed follow-ups. Two main hypotheses guide this presentation: 1) membership to a group facilitates the process of agroecological transition 2) There is a correlation between moving forward to agro-ecological practices and the emergence of new forms of cooperation between producers and actors of the territory. The first field works encourage us to validate both hypotheses.Eje A6: Desarrollo Rural, Movimientos Sociales, Estado y AgroecologíaFacultad de Ciencias Agrarias y Forestale

Insights Into the Complexity of Yeast Extract Peptides and Their Utilization by Streptococcus thermophilus

Streptococcus thermophilus, an extensively used lactic starter, is generally produced in yeast extract-based media containing a complex mixture of peptides whose exact composition remains elusive. In this work, we aimed at investigating the peptide content of a commercial yeast extract (YE) and identifying dynamics of peptide utilization during the growth of the industrial S. thermophilus N4L strain, cultivated in 1 l bioreactors under pH-regulation. To reach that goal, we set up a complete analytical workflow based on mass spectrometry (peptidomics). About 4,600 different oligopeptides ranging from 6 to more than 30 amino acids in length were identified during the time-course of the experiment. Due to the low spectral abundance of individual peptides, we performed a clustering approach to decipher the rules of peptide utilization during fermentation. The physicochemical characteristics of consumed peptides perfectly matched the known affinities of the oligopeptide transport system of S. thermophilus. Moreover, by analyzing such a large number of peptides, we were able to establish that peptide net charge is the major factor for oligopeptide transport in S. thermophilus N4L

Les paysages thérapeutiques de deux maternités d'Île-de-France

En mobilisant le concept de paysages thérapeutiques, nous proposons de nous interroger sur l’agencement des lieux de soins et leur appropriation par les professionnels de santé dans le contexte spécifique de la prise en charge de la grossesse en maternité. La méthodologie de cette recherche repose sur la visite commentée et collective de deux maternités franciliennes de statut différent : la maternité du Groupe Hospitalier Saint-Joseph, établissement de santé privé d’intérêt collectif et celle du Centre hospitalier intercommunal public de Montreuil. Les résultats de cette recherche montrent que l’entrée théorique par les trois versants de l’espace thérapeutique s’avère pertinente pour documenter les hôpitaux en tant qu’espace de bien-être. Si l’exercice soignant, et l’engagement qui l’accompagne, se retrouvent sur les deux sites, le bassin de population, le management et la mission de ces établissements diffèrent. Le soin ne peut être identique voire équitable selon les locaux, leur agencement et les symboles qu’ils portent.Thanks to the “cultural turn”, medical geography has produced a great deal of work on health, taking the health care places as an entry point (Gesler & Kearns, 2002, Curtis, 2004). The purpose was to give them a broad scope that questioned the place of identity, human experience, body, environment and culture. Thus, places that had a reputation for caring, affecting health, and healing, have been documented by researchers and conceptualized under the term of therapeutic landscapes (Gesler, 2002). English-speaking researchers have thus published extensively in this direction. They ask how the design of a care space can interact with the relational dimension of the caregivers. But also how the use of places could claim to have a therapeutic dimension, or even improve the quality of care and the quality of life of the sick people living in these places (Gesler et al., 2004). More: her

The therapeutic landscapes of two maternity hospitals in Ile-de-France

Thanks to the “cultural turn”, medical geography has produced a great deal of work on health, taking the health care places as an entry point (Gesler & Kearns, 2002, Curtis, 2004). The purpose was to give them a broad scope that questioned the place of identity, human experience, body, environment and culture. Thus, places that had a reputation for caring, affecting health, and healing, have been documented by researchers and conceptualized under the term of therapeutic landscapes (Gesler, 20..