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Rapports de Recherche

2008

Sirs Info n°4  Lettre d'information du programme "Santé, inégalités et ruptures sociales"

2007

Whist Enquête sur les habitudes de recherche d'informations liés à la santé sur Internet. Emilie Renahy

Sirs Info n°3  Lettre d'information du programme "Santé, inégalités et ruptures sociales"

Sirs Info n°2  Lettre d'information du programme "Santé, inégalités et ruptures sociales"

Enquête européenne sur l’accès aux soins des personnes en
situation irrégulière en Europe. 
Parizot I, Chauvin P. Rapport pour l’Observatoire 
Européen de Médecins du Monde

Les conditions de vie associées au surpoids et à l’obésité chez les adultes dans l’agglomération Parisienne en 2005. Catherine de Launay, Mémoire de Master sous la direction de Pierre Chauvin. Université Pierre et Marie Curie, Paris

2006

Sirs Info n°1  Lettre d'information du programme "Santé, inégalités et ruptures sociales"

Territoires, vulnérabilités et santé. Présentation au Conseil économique et social régional, Paris.

Anxiété et dépression chez les machinistes receveurs : enquête auprès des machinistes receveur du centre de bus de Vitry. Lesieur S, Bessis M, Anglaret I, Chauvin P. Rapport à la RATP. Paris

 

Les déterminants psychosociaux du recours aux soins Fabienne Bazin, Thèse de Doctorat, Université Paris 6

Application des modèles multiniveaux à l'étude des effets du contexte de résidence sur la survenue de cardiopathies ischémiques. Romain Silhol, rapport de stage de Master2

 

2005

Attitudes et comportements individuels liés à la prévention du cancer en Ile-de-France. Rapport pour la Direction Générale de la Santé

Santé, Inégalités et ruptures sociales à Antananarivo, Premiers résultats de l’enquête SIRS 2003 Rapport DIAL, IRD

Aider et être aidé : système et structure du soutien social informel à Antananarivo et à Paris Rapport DIAL, IRD

Enquête sur la santé et le recours aux soins dans les quartiers défavorisés d’Ile de France. Rapport pour la Délégation Interministérielle à la Ville.

Influence du contexte de résidence sur les comportements de recours aux soins : l’apport des méthodes d’analyse multiniveau et spatiale. Questions d’économie de la santé

Le "niveau de vie" un objet d'appréciation subjective ? Camille Mazé, mémoire DEA, ENS, EHESS

2004

Les déterminants contextuels et spatiaux des modes de recours aux soins  Rapport scientifique à l'Action Concertée Incitative "Terrains, techniques, théories ; travail interdisciplinaire en sciences humaines et sociales", Paris, Inserm

Enquête sur la santé et le recours aux soins dans les quartiers de la Politique de la Ville du 20ème arrondissement de Paris  Rapport pour la Mission Ville de la Préfecture de Paris. Synthèse du rapport (2pages)

Modélisation des effets du contexte sur la santé et le recours aux soins Basile Chaix, Thèse de Doctorat, Université Paris VI

Vivre dans un quartier disqualifié, Sylvain Péchoux, DEA de Sociologie, EHESS Les Zones Urbaines Sensibles , Mémoire complémentaire

Facteurs contextuels de la santé et du recours aux soins : de nouvelles approches méthodologiques. Pierre Chauvin, présentation au séminaire SIRS-IDF

2003

Santé, inégalités et ruptures sociales dans les zones urbaines sensibles d'Ile-de-France. Synthèse de recherche pour l'Observatoire National de la Pauvreté et de l'Exclusion Sociale

2002

Santé, inégalités et ruptures sociales, résultats de la pré-enquête conduite dans les cinq zones urbaines sensibles de l’Ile-de-France. Rapport à l’Observatoire national de la pauvreté et de l’exclusion sociale

 

2001

Les situations et trajectoires de précarité en milieu rural français et leurs impacts sur la santé et l‘accès aux soins. Rapport à l’Observatoire national de la pauvreté et de l’exclusion sociale. Paris, Institut de l’Humanitaire

1999

Précar : trajectoires de précarité, états de santé et accès aux soins Paris, Institut de l'Humanitaire

 

 

Our research hypothesis is grounded in the conviction that three complementary approaches to current courses of action can enhance this knowledge and clear the way for strategies that will be more effective in reaching (and then caring for) the people on the outskirts of health policies and the healthcare system

Our purpose is to broaden the model of health determinants to include social characteristics other than the standard ones (employment, resources and education) and take account of certain psychosocial and behavioural characteristics (specifically pertaining to health representations as well as to self-esteem and adaptability) and incorporate the level of individuals’ social integration (including the density of their social network, the magnitude of their social support and breaks in their life-history), and do so by studying a representative cohort of Ile-de-France residents and by conducting micro-local studies in city neighbourhoods (particularly in Paris). We aim also to use methods of contextual and spatial analysis to take account, simultaneously, of individual characteristics and contextual characteristics (pertaining to the individual’s socioeconomic environment, such as the city neighbourhood) in statistical models attempting to explain the individually observed health differences (perceived health, health attitudes and behaviours, health recourses).

Context

Research program

      Social inequalities in, and rationales for the recourse to care

  The SIRS cohort study

.       The social determinants of the recourse to screening

Uses and Practices for Health Information Search on the Internet

Effects of the residential, physical and social context on health: applications to coronary pathologies

The RECORD cohort study

Consequences of serious events experienced during childhood on psychosocial adjustment

Social determinants of diet, overweight and obesity

Migration and medical care

Health and recourse to health care of illegal foreigners in Europe

People of foreign descent and migrants’ health and recourse to healthcare

 

Context

Since the Nineteenth Century Hygienist Movement, numerous studies have reported the existence of a link between individuals’ health and their socioeconomic situation. Despite ongoing biomedical and technological progress over the past 50 years and despite the broader coverage of sickness protection, social inequalities in health have endured or even worsened comparatively throughout the social groups since the nineties, in all the developed countries, and specifically in our country. France has long lagged behind in the attention it has paid to health inequalities, even though, as early as the seventies, Insee studies clearly established the considerable differences in mortality according to social categories. After associations and health professionals mobilised against the phenomena of observable exclusion from care that affected the indigent, in the eighties, research in this field enjoyed renewed development, underscored by the publication of the Hcsp reports and several works by INSERM.,

Describing the inequalities is not enough to reduce them, the challenge is to explain them and move toward an understanding of the underlying mechanisms. However, whether focussing on mortality, morbidity, health behaviours, or people’s consumption of healthcare, the available social indicators (professional and social category, income bracket, level of education, public action beneficiaries such as the unemployed or RMI recipients) often only provide an approximate description of people’s socioeconomic position. The indicators provide an even poorer grasp of their living conditions and neo-material conditions (related to lifestyle in post-industrial societies: diet, leisure, ownership of certain consumer goods access to means of communication, and so on), and no grasp at all of their psychosocial characteristics.

Thus, the advantage of further in-depth studies is to renew the study of inequalities in health based on a better understanding of the interactions between social situations (in the broad meaning of the term) and health. The point is to measure the sanitary impacts of different forms of vulnerability during the entire course of the social continuum. We hypothesise that social situations detrimental to health do not only concern people experiencing precariousness. Indeed a growing number of recognised authors in social epidemiology underscore the relevance of studying new individual determinants. A growing number of public health research papers, overlapping the fields of social epidemiology and health sociology, are tackling the issue of the social determinants of health determinants. The research is based on conceptual models still under discussion, as are the chains of causality, which are obviously never direct, that link the reported psychosocial or socioeconomic characteristic of an individual and/or a group of individuals with a reported health differential (currently arguments of proof, and specifically experimental or biological arguments, have only been exceptionally demonstrated).

The following determinants should be mentioned: individuals’ representations of health, the care paid to their health and the ranking of health needs compared to other basic (or deemed basic) needs of the person, some psychosocial characteristics (such as self-esteem, adaptability, the aptitude to project oneself into the future, and so on), the internalisation of medical norms, and earlier or family experiences of disease and the recourse to care. Research on health related behaviours first got underway years ago (specifically research on health belief models). Since the fifties, the research has accumulated results demonstrating a close relation between health beliefs and recourse to care, therapeutic compliance, the use of prevention programmes, and the alteration of detrimental health behaviours (addictions, sexual behaviours, and so on). Research on family health behaviours (or the ‘family production’) should also be mentioned. As for the conditions of social integration, for the past twenty years numerous publications (also mainly Anglo-Saxon) have evidenced an association between a low level of social integration and increased frequencies of high-risk behaviours (tobacco addiction, alcoholism, eating disorders, lack of exercise, and so on). Other research, for instance, has observed strong associations between the size of an individual’s social network and the incidence and lethality of cardiovascular diseases. Some authors have proposed theoretical models of health social determinants that combine psychosocial characteristics as well as conditions of social integration, social support, and social capital. Research in life-course epidemiology clears the way for promising outlooks for characterising the medium and long-term impact on health of personal breaks and negative life events experienced during childhood or adulthood., Although the hypotheses were actually formulated some time ago (from French sociological research, such as Durkheim’s work), a large share of their statistical demonstration still has to be done in France. Indeed “ignoring social determinants of social disparities in health precludes adequate explanations for actual and changing population burdens of disease and death, thereby hampering efforts for prevention.”

All the preceding social determinants can be found - undoubtedly in a particularly acute manner - in France’s immigrant populations (among others, but not only, because racial discriminations structure certain social inequalities). Some studies show that immigrant populations experience worse living conditions more often than the French do (specifically in terms of resources, housing and work), conditions that are potentially detrimental to health. However, their morbidity and recourse to care are little studied in France (unlike other countries). The description of health disparities according to nationality, or to membership (or non membership) in an immigration group is still extremely sketchy in our country and epidemiological research on the topic is scarcer still. Furthermore, when measuring and understanding the role of ‘migratory descent’ and it contribution to reported social inequalities in health in France, the lack of available representative data on the population (including exclusively for research and within the framework provided for by law) is virtually absolute, to our knowledge.

Most studies in social epidemiology have conventionally focussed on health determinants measured at the individual level, following a long tradition of epidemiology that, thanks to the systematic collection of individual information, was forged in opposition to the scientifically dangerous and regularly criticised use of aggregate data and ecological analyses. More recently, a concern to ‘replace the individual in his or her context’ has emerged in the field, both because, as we have seen, results of the impacts of individuals’ social integration on their health have been amassed, and because, generally speaking, the reductionist outlook (handed down from the exact sciences) is, in turn, widely criticised in social epidemiology. Actually, the existence of context impacts on individuals’ health and their access to care is increasingly recognised in public health. The development of urban health research in the Anglo-Saxon countries (and specifically research on the impacts of the built environment) or the research on people living in underprivileged neighbourhoods should be mentioned, for instance. The flourishing literature on ‘contextual epidemiology’ deals with measuring jointly the effects of individual and contextual characteristics on health, using the appropriate statistical methods (specifically multi-level models). Numerous studies take account of the socioeconomic level of the neighbourhood. North European and North American research have shown that, aside from the effects linked to the individual’s socioeconomic level, the fact of residing in an underprivileged neighbourhood is associated with different health problems, such as low birth weight, some detrimental health behaviours,  overweight, cardiovascular diseases, and so on. However, the impacts of the residential context do no only refer to socioeconomic factors: social interaction characteristics (collective efficiency, and social capital, among others) or shared community standards (specifically in terms of health) are also studied in North America.

At the same time, observably, social inequalities in health are not automatically reduced by the quantitative and qualitative increase of the supply of curative care, as can be seen by the fact that inequalities endure despite the growing share of public healthcare spending. Also, the goal of equality pursued by European healthcare systems has not been fully reached,, including in countries where systematic health insurance (as in France with the Universal Health Coverage) theoretically ensures fewer financial hurdles to said care. Therefore, the issue of access to care cannot be reduced either to individuals’ financial and material resources or to the availability of supply. The behaviours of recourse to care, the modes of attendance and use of the healthcare system also depend on the above-mentioned factors. Thus, health inequalities and the inequalities in the recourse to care are not so much linked by a direct causal relation as by partly common determinants,  tracing a similar social gradient that should to be studied. For access to care and medical consumption, access channels and patient orientation and care are not the same for all, either. They may differ, or even reveal genuine discriminations, depending on the migratory origins of the people, their social situation, their sickness coverage or some of their practices or life habits, for instance. The ‘social distance’ toward care facilities, or the image that people have of the facilities, also induces symbolic deterrents that dissuade people from going to some facilities. The dissuasion works amongst the poorest as well as among people at the top of the social ladder, who little attend maternal and child welfare centres. Recourse to care, as a relation to a central institution of our society (medicine and its different facilities), comprises a vast set of factors encompassing standards, representations, identity and relational processes, and the relation the society as a whole., This is probably even more flagrant as the borders between the medical and social worlds and between health and the normative requirement to perform are blurred in our society.

These observable facts have prompted us to formulate four hypotheses for our research project:

·         The population cannot be divided into the ‘included’ and the ‘excluded’. These are two type-ideals that are the milestones of a continuum that comprises each person’s health an social situation (and health needs);

·         The determinants of health and the recourse to care describe a social gradient that cannot be exactly superposed on conventionally described socio-professional and economic gradients. On the contrary, they must take account of three innovative approaches: the study of social ties, the study of contextual characteristics, and the study of both within a life-course outlook, as much as possible;

·         The determinants may combine to impact negatively on health and are not sufficiently studied in the general population or recognised by health professionals and public policies;

·         Extant social inequalities in the access and recourse to (curative, preventive, and sociosanitary) care in France are probably at the root of a substantial share of reported health inequalities and/or sustain and emphasize them.

Research Project

The team’s research project is built on three tracks so that we can address the different determinants of health and the recourse to care from complementary outlooks: (1) The social and contextual determinants of the recourses to care; (2) The psychosocial and geographic determinants of health; (3) and a new topic that we plan to develop: Health, precariousness and migration.

Track 1. Social and Contextual Determinants of the Recourse to Care

1. Social inequalities in, and rationales for the recourse to care (P. Chauvin, I. Parizot)

Previous Research

Since 2002, we have been conducting several surveys of representative samples of urban populations. Aside from survey results per se, the investigations have served as preliminary surveys for the design of the SIRS cohort rolled out in 2005 (see infra). For instance, we have shown that foregone care for financial reasons was statistically associated with (after adjustment for different socioeconomic and health variables) serious events experienced in childhood and adulthood, the extent of patient’s acceptance of the disease, certain psychological characteristics such as self-esteem, and the priority given to health. The level of priority is extremely variable depending on the individual’s age, type of job and nationality, but also depending on their familial integration. Furthermore, we have observed a significant correlation between the lack of recourse to care and the weakness of the social network.

For her post doctorate at INSERM, I. Parizot working closely with ERIS analysed the issue of social identities for individuals in precarious situations in their relation to free clinics. She then conducted qualitative sociological research using non-directive interviews of the population in different Paris neighbourhoods. The comprehensive analysis underscores how much therapeutic approaches heavily depend on social processes, sometimes conflicting with the logic of searching for biomedical efficiency. Also, the decision to resort to care and the choice of which professional to consult appear to be very dependent on the way therapeutic care is integrated into the patient’s social and family life, symbolically and in terms of its (actual or supposed) material repercussions. The intensity of social ties – and chiefly the meaning they have for individuals – largely influence that way they experience and interpret their difficulties, define their expectations of the health system, decide whether or not to resort to the care system, and their modes of recourse. Her research helped pinpoint some aspects that had to be addressed in the SIRS cohort, specifically social roles and the size of the social network in the different spheres of socialisation (family, professional, friends and neighbours).

Our past research has also attempted to understand and assess to what extent (aside from their individual characteristics) people’s environment explains their modes of recourse to care and/or certain morbid disorders. The ‘contextual epidemiology’ research conducted mainly by B. Chaix for his doctorate took two approaches. One, certain structural characteristics of the environment are taken into account at different levels (household, neighbourhood, municipality, employment zone, and region), by using multi-level mixed models. Two, their spatial scope is also analysed in a more innovative approach, thanks to the use of geographic information systems and individual geocoding. We focussed on studying the impact of the family context, the economic characteristics, and the medical density on the recourse to different kinds of care (first recourse, specialist, and prevention), in a first set of second-tier data analyses: SPS survey (Irdes), permanent sample of the health insured (Cnam), Health Barometer (Inpes).

The SIRS cohort study

Since 2005, one of the team’s central projects has been the design of the SIRS (santé, inégalités et ruptures sociales dans l’agglomération parisienne, health, inequalities and social breaks in the greater Paris area) cohort that is a general survey (in the field of social epidemiology). During the last quarter in 2005, 3,000 household-individuals were included in the name-based cohort and questioned during face-to-face interviews the first time. The 3,000 individuals represent a random sample (3-stage randomised sampling: IRIS, household, household adult), representative of the French-speaking adult population living in Paris and in the near suburbs (départements: 92, 93, and 94), where households living in Zone Urbaine Sensible (ZUS, deprived urban areas) and underprivileged neighbourhoods are over-represented.

The SIRS cohort is a French first in the field of social epidemiology. To our knowledge, it is the first representative cohort of the general population. The cohort was put together on an ad hoc basis for the study of the social determinants of health, over-representing underprivileged neighbourhoods, geocoding respondents, and collecting a large number of social and sanitary characteristics during face-to-face interviews. It includes characteristics that have never been addressed in the general population (integration and social identity, social capital, health representations and beliefs, reasons for non-recourse to care, and so on). The longitudinal scope will help make future progress in interpretations, in terms of the causality of the associations highlighted transversally, and address new hypotheses concerning causal mechanisms during later surveys. The regional scope makes it possible to study the entire (Ile-de-France) social continuum and certain geographical and contextual aspects of health and recourse to care. The cohort designed in close collaboration with the research team on social inequalities (ERIS) headed by S. Paugam at the Maurice Halbwachs Centre (Cnrs-Ehess-Ens) and with Ined. The third in-depth wave scheduled for winter 2008/2009 will include an over-sampling of Paris, and be conducted in close collaboration with the Atelier parisien de santé publique (Apsp, Paris workshop for public health) with which we have decided to pool our human and financial resources to monitor the cohort.

Projects

We intend to continue analysing the social determinants of the recourse to care based on the SIRS cohort data, by exploring the three following aspects more thoroughly and systematically:

-          The analysis of social ties (specifically as sources of material, emotional, informative, symbolic and identity support), focussing on a better qualification of their intensities and combined impacts;

-          The living environment (supply of primary care and social services) but we also will be looking at the residential and employment areas as one of the aspects of individuals’ social integration where certain rationales of the recourse to care are devised; as places of social life where the relation to self and to others is built, where standards and values are internalised, and a relation with the future is forged;

-           The representations and attitudes toward health and medicine. We hypothesise that they mediate the relation between social situation and recourse to care, as do certain psychosocial characteristics such as self-esteem, locus of control, the ability to cope, or the feeling of personal efficiency. All these characteristics are likely to impact an individual’s ability to harness his or her social resources - in this case, cope with illness, manage or compensate for the negative consequences of potential recourse and, last, resort to care. The qualitative sociological analyses that will be conducted by I. Parizot in the team and at ERIS, and for Equalsoc, the European network of excellence she belongs to, will usefully complement the statistical analyses.

2. The social determinants of the recourse to screening (V. Massari, P. Chauvin)

Previous Research

In France, the Aids control policy is based on information, prevention, non-stigmatisation, and voluntary screening. Thus, the study of the circumstances surrounding the request for an HIV screening test in a non-selected population is vital. In her past research, V. Massari studied these as well as the circumstances surrounding HIV screening tests, in the physician base of the Sentinelles network. The study of the past fifteen years highlights that the number of tests peaked in 1993 then fell off sharply from 1995 to 2002. The frequency of positive tests, which had been steadily dropping since 1990, shifted slightly upward in 2002. Only 11% of the tested patient now belongs to a very high-risk group.

Projects

At the same time as the previous project (where the recourse to care is addressed in a fairly general manner, by typologies of the recourse modes), we intend to develop two complementary projects that will specifically attempt to understand the associations of the same factors on the recourse to HIV screening, on the one hand, and on the recourse to female cancer screening, on the other. We hypothesise that the three above-mentioned aspects are determining factors explaining reported insufficient recourse in (and from the standpoint of) public health.

Indeed the efficiency of the current French HIV screening system is imperfect, especially if one looks at the sizeable share of HIV infected patients who learn that they are HIV positive when they are diagnosed with Aids and of screened patients whose therapeutic care has been delayed overlong. This is why it would be particularly productive to draw on the assets of the SIRS cohort (Ile-de-France region, over-representation of underprivileged neighbourhoods, detailed data on people’s migratory origins, among others) to advance in the analysis of the social determinants of the recourse to screening.

For the recourse to female cancer screening, the SIRS cohort will address the methods and circumstances of the recourse to mammograms and cervical smears - both medically recommended screening procedures. In the first case, a “competition” between the recourse to individual screening and the organised screening programme exists in the Paris area and throughout France. Extant low re-attendance rate in the organised screening programme and quite sizeable social and geographic inequalities need to be characterised more precisely. For cervical smears, individual diagnosis is widespread but seems to leave a large share of women by the wayside (only 54% of 20 to 69 year-old women had at least one cervical smear taken within the past three years, from 1998 to 2000). Here too, the reasons or the social and geographic stratification are not precisely known. The project will be rolled out in collaboration with Apsp (E. Cadot) and with INSERM U822 (V. Ringa).

3. Uses and Practices for Health Information Search on the Internet (E. Renahy, P. Chauvin)

Previous Research

The project starts with the observable fact that the Internet provides access (for oneself, friends or relatives) to medical knowledge and information on the care system. Overall project goal is to describe the social stratification of Internet use when searching for health information and its consequences on health and care management. Based on a review of the literature [47] and qualitative interviews, a questionnaire was designed and integrated into the first SIRS cohort wave. Although our preliminary analyses showed that the Internet might be a useful media for health information dissemination to young adults, the ‘active’ search for health information on the Internet was usually done by people who already had access to other sources of information. We are now focussing on describing the social stratification of an accumulation of obstacles, to which the usual determinants of the digital divide, and the determinants associated with health information search in general should be added. We are also analysing to what extent such use is linked to individuals’ integration and social roles.

Projects

Another survey of only Internet users ha also been conducted (the WHIST study). In 2007, the online questionnaire was put on numerous French-speaking ‘general public’ websites, as part of INSERM partnerships. The purpose is to accurately describe the uses and (Internet user perceived) consequences of the health information search specifically on the use modes of the care system. The research is the subject of E. Rehany’s PhD thesis. For the call for contributions for second-tier processing issued by the Living Conditions Division at Insee, we plan to complete our analyses on the data from the Permanent Survey on Household Living Conditions (additional questionnaire on information and communications technologies).

Track 2. The Psychosocial and Geographic Determinants of Health

1. Effects of the residential, physical and social, context on health and influence mechanisms: applications to coronary pathologies (B. Chaix)

Previous Research

We have been able to assess the impacts of the country’s economic characteristics (first on a fairly large departmental scale) on a series of behaviours and/or risk factors, i.e., smoking, drinking, lack of physical activity and obesity, thanks to a contextual analysis of the data from the Inpes Health Barometer. Another example of analysis (conducted with Swedish georeferenced data) has highlighted the link between the socioeconomic level of the residential context and the incidence of mental disorders linked to the abuse of psychoactive substances. With the French and Swedish data, we have also shown the advantage of using models other than multi-level models (specifically geostatistical models) and of determining the scale of contextual impact maximisation (by defining growing ‘adaptive spatial areas’ systematically, for instance). The spatial approach, which models geographic variations and defines the explanatory factors of the context in a continuous space rather than in a space broken down into arbitrary zones, is a major methodological innovation in contextual analysis.

Projects

Project goals are to determine which characteristics of the residential context are associated with coronary disease and with its risk factor, by distinguishing the socio-demographic characteristics of the neighbourhoods (socioeconomic level, population density, and so on), physical environment (infrastructures and services, maintenance, pollution and noise exposure, built environment), and social interaction environment. An original project approach is to take account – at the individual level as well as characteristics of the residential context – of a wide range of lived experiences in the neighbourhood (attachment to the neighbourhood, social stressors, residential stigmatisation, residential captivity, social integration, social support and so on). Several analyses are underway on cardiovascular morbidity and risk factor incidence data from the LOMAS-2 base (Lund University, Sweden), the team’s data from the SIRS cohort, and the data (that was geocoded on this occasion) from the PRIME (INSERM U780) cohorts. Based on the data from the PRIME cohort, we use multi-level models and structural equations to show, for instance, that more than half of the negative impacts of neighbourhood poverty level on blood pressure are mediated by the strong prevalence of obesity in underprivileged neighbourhoods.

The RECORD cohort study

For a more accurate study of all these factors, we are developing a special cohort project called RECORD (Residential Environment and CORonary heart Disease) that matches the clinical, biological, psychological and medical data collected by the Paris Centre for Preventive and Clinical Investigations at its different Paris and suburban venues with the social and residential data collected specifically via self-questionnaire. The project also plans to monitor and detect prospectively the cardiovascular morbimortality of the participants through the National hospital based health information system (PMSI) and the National mortality surveillance system (Cépi-DC). The plan is to recruit 7,000 individuals, ranging from age 30 to 79 and residing in the 144 selected Ile-de-France municipalities, in 2007. The purpose is to have a large socio-geographic diversity in the sample. A second wave (by mail) is scheduled for 2008.

Similar to the SIRS cohort, participants will be geocoded and contextual data taken at different scales will be compiled in a huge database developed in the team’s geographic information system. The contextual data comes either from an aggregate of participant answers (ecometric approach), or from outside sources (Insee, General Tax Directorate, Paris Chamber of Notary Publics, CAF, Institute for Land and Urban Management of the Ile-de-France Region, Airparif, Regional Directorate for Infrastructures, the ministries for agriculture and for youth and sports, and Ign).

2. Medium and long-term consequences of serious events experienced during childhood on psychosocial adjustment (C. Roustit, P. Chauvin)

Previous Research

The team and the Quebec Institute of Statistics signed an agreement granting us preferred access to the data from the 1999 representative survey on Quebec teenage health (random sample of more than 2,000 teenagers and their parents). Thanks to this data, we have shown how parental separation is associated with 4 indicators of psychosocial maladjustment in children (internalised and/or externalised disorders, consumption of drugs and/or alcohol). For internalised disorders, the impact is largely explained by the existence of inter-parental violence whereas for the other 3 indicators, the family break-up and the different characteristics of the family modus operandi after the separation seem to have independent impacts. [65] We are now looking at these results more closely, analysing the links between anxiodepressive syndromes in the parent or parents and the psychosocial maladjustment of the children, and assessing the protective role of the (intra and extra familial) social support the children receive.

Projects

For the long-term consequences of events experienced in childhood, we will analyse the SIRS cohort data in which numerous serious events and social breaks experienced during childhood are collected retrospectively. We will attempt to distinguish the impacts of these early breaks on social integration (family and professional trajectories, breaks and social isolation in adulthood) and psychological health (perceived mental health, lifelong prevalence and yearly incidence of anxiodepressive syndromes, and self-esteem). We will focus on examining whether differences exist according to the individuals’ social origins (during childhood).

3. Social determinants of diet, overweight, and obesity (J. Martin, F. Grillo, P. Chauvin)

Projects

Preliminary analyses of the SIRS cohort highlight that obesity is associated with individuals’ socioeconomic status as well as with their conjugal and family situation and geographic origins, whereas certain contextual variables (food supply and sports facilities among others) are not determinant. This observable fact (and the limitation of the available data in the first waves of the cohort) has prompted us to develop a new project to take a closer look at the social inequalities of dietary behaviours and corpulence, and study their socioeconomic, psychosocial, and geographic determinants.

More precisely, 4 aspects of dietary practices will be distinguished (food supply, preparing, taking and eating meals). Questions on the four aspects will be asked during the next SIRS wave to test (through a qualitative and statistical approach) 4 main hypotheses: (1) diet is affected by the accumulation of social vulnerabilities (financial difficulties, social isolation, precarious employment, among others); (2) certain forms of the geographical relegation of unprivileged populations, and more broadly the features of the residential neighbourhoods, have consequences on dietary behaviours; (3) the perception of a relation – and its content – between people’s diet and health depends on their living conditions, psychological characteristics, and social ties and their responsiveness and reception of nutritional information messages; (4) in poor households, dietary practices are subject to, and reflect all the experienced difficulties. In this context, the diet does not ensure its structuring role but follows and strengthens individuals’ social and familial constraints.

The team-coordinated project is developed in collaboration with the Inra Laboratory for research on consumption (Corela) and ERIS.

Migratory origin has regularly been pinpointed as a factor that is often determinant (if not studied in itself) in numerous past works by the team.

Previous Research (B. Larouzé, V. Massari)

After several studies on the diagnosis of tuberculoses with negative baciloscopy [3, 53] and on the interactions between tuberculosis and HIV-2 in Subsaharan Africa [8], a multidisciplinary programme was rolled out in the prisons of Rio de Janeiro (in collaboration with the Oswaldo-Cruz Foundation and the Health Coordination of the Prisons of Rio de Janeiro) to detail the prevalence of tuberculosis (from 4 to 9% in the studied prisons), its determinants, and the most appropriate screening strategies [36, 43, 48]. The research-action programme in the prisons, in collaboration with the LCS (Paris 7) and HEC, involved the prisoners, prison guards, and other players of prison life. The purpose was to identify the obstacles to rolling out the tuberculosis control programmes. [68] The research was instrumental in getting the Brazilian State to issue new regulatory measures and served as the basis for nationwide discussions during a recent meeting on TB fighting strategies in prisons, under the aegis of the Global Fund to Fight Tuberculosis-Brazil and the Ministry for Health. The research will continue, process the huge amount of material that was collected during the research, and assess the impact of implemented strategies and their feasibility.

Another ANRS funded programme that was rolled out by G. Leloup (doctorate candidate) is dedicated to the HIV-Aids control policy in Brazil. It brings together 2 French research laboratories (ours and the GAPP/CNRS/Ecole Normale Supérieure de Cachan) and 2 Brazilian research laboratories (EBAPE/ Getulio Vargas Foundation and the Institute for Social Medicine at the State University of Rio de Janeiro). The research studies two very different Brazilian states in terms of resources and health system organisation. It uses the methods and approach of public policy analysis to study the response of the Brazilian health system to the evolution of the HIV-Aids epidemic and the problems accessing prevention and care that result from the said evolution.

Projects

This new research track addresses health and the recourse to care of immigrants in France. Its overall objective is to study whether – and to what extent – certain social determinants come in to play specifically in immigrants’ health and recourse to care, and whether the determinants are specifically linked to immigration (country of origin, immigration conditions: legal or not, personal or familial, old or recent, and so on) and/or commonly refer to the multiple aspects of social precariousness. The roles of health, disease, and care needs (its subjective and objective aspects) in the initial decision to emigrate and then stay in France will be studied. In the country of origin, the role of health determinants (diseases and medical care needs) and their interactions with other social factors – economic, financial, family, social or political factors among others – in the individuals’ migratory projects are still poorly known. Although it seems that, overall, the most healthy individuals are the most likely to emigrate (migration bias), on the other hand, ill people who do not find the appropriate care in their own country may want to emigrate (temporarily or definitively) to a country where the care is available. Such migrations obviously depend on the individuals’ resources (and not only their financial resources). In the host countries, morbid disorders – and/or merely ageing (see the mean age of the generations of migrant workers who arrived in France in the sixties) – may mean that any hope of returning to the country of origin has been put on hold or abandoned, if the required care is not available there, sometimes at the cost of extremely precarious living conditions. Some administrative indicators seem to suggest that the frequency of these situations is rising in France but their social and sanitary characterisation in terms of public health is still little studied.

All these issues arise in an international situation marked by 5 strong trends: (1) the general intensification of international human migrations; (2) the persistence of profound inequalities in the care supply between the North and South; (3) restrictive amendments to European (and specifically French) migratory policies; (4) recurrent discussions on the consequences and the social, political, economic, ethic and sanitary stakes of the three combined trends; (5) the questions of the development aid institutions concerning the impact of investments in the health sector on migratory flows.

1. Migration and medical care (J. Lebas, P. Chauvin)

We are developing a research programme in collaboration with the French Agency for Development (AFD) on the place of health and care needs in the South-North emigration processes. 

The multiyear programme will include an inventory of French and international public health and soft science literature on the topic and the set-up of a multidisciplinary network of researchers involved or interested in the issue, the inventory and analysis of extant French data, and the roll-out of surveys for comparing the processes at work in different pathologies (depending whether they are curable or not, their duration, survival, and prognosis for spontaneous cure or for cure following treatment, the availability of treatment in the countries of origin), and in the different countries of origin (according to the level of public spending for health but also to the size of their migratory flow to France). The goal is to combine qualitative and statistical surveys of migrants in France and of populations in the countries of origin.

In partnership with InVS and AFD, we are rolling out a representative survey of the general population on the social determinants of health and the recourse to care in the very specific context of Mayotte island. The geographic and cultural nearness of this French territory with some of the world’s poorest countries (namely the Comoros and Madagascar) generates extremely high migratory tensions. The survey will be reproduced in another French ‘border’ territory, French Guiana.

2. Health and recourse to health care of illegal foreigners in Europe (P. Chauvin, I. Parizot)

In 2006, we started working with the European Observatory of Médecins du Monde to measure and compare illegal foreigners’ state of health and access to care in different European countries. The first test survey of physicians treating illegal foreigners at 21 free clinics in 7 countries evidenced vast differences between countries in terms of the frequency and the nature of the (legal, administrative, linguistic, lack of information, care refused, and so on) hurdles encountered when attempting to access care, including for health problems that might have serious sanitary consequences for the individual or the community. In 2008, another survey has been planned with a larger sample of individuals, including more detailed questions on the circumstances of the migration, living conditions and social integration of the people in the host country and a medical assessment of the needs and delays in receiving care.

3. People of foreign descent and migrants’ health and recourse to healthcare (G. King)

Preliminary analyses based on SIRS cohort data highlight the existence of notable differences according to the nationality of the individuals and/or of their parents, with regards to perceived health, certain health behaviours, and the recourse to care. Our goal is to continue characterising the associations, determine to what extent they are mediated by other individual social characteristics, and conversely, whether the social gradients observed in the general population are or are not found in the different migratory groups. We will also take a closer look at certain explanatory hypotheses (specifically in terms of representations of health and medicine or lived experiences of discrimination in the health system). G. King, who has worked on the issue of disparities in health behaviours and studied their psychosocial and contextual determinants in the Afro-American minorities in the United States, will also conduct a comparative analysis of the individual and geographic inequalities of tobacco addiction between the Paris area and certain US cities, and the role of socioeconomic and ‘migratory’ (France) or ‘ethnic’ (United States) characteristics.

 

Date de dernière modification : 26 Juin 2008

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