Search

Objectives This study aimed to quantify the relative importance of barriers to better secondary prevention of osteoporotic fractures and of care expectations expressed by patients with osteoporotic fractures in France. Methods A qualitative exploration of potential barriers to care and expectations was undertaken through a systematic literature review and in-depth patients interviews. A list of 21 barriers and 21 expectations was identified. These were presented to 324 subjects with osteoporotic fractures, identified in a representative sample of the French population, in the form of best-worst scaling questionnaires. Patients rated the relative importance of the attributes, and arithmetic mean importance scores were calculated and ranked. A Bayesian hierarchical model was also performed to generate a relative importance score. Latent class analysis was performed to identify potential subgroups of patients with different response profiles. Results A total of 7 barriers were rated as the most important, relating to awareness of osteoporosis and coordination of care. The highest-ranked barrier, “my fracture is not related to osteoporosis,” was significantly more important than all the others (mean importance score 0.45; 95% confidence interval 0.33-0.56). A similar ranking of attributes was obtained with both the arithmetic and the Bayesian approach. For expectations, no clear hierarchy of attributes was identified. Latent class analysis discriminated 3 classes of respondents with significant differences in response profiles (the educated environmentalists, the unaware, and the victims of the system). Conclusions Better quality of care of osteoporosis and effective secondary fracture prevention will require improvements in patient education, training of healthcare professionals, and coordination of care.

International audience; Background: The contemporary crisis of trust in vaccines has severely impaired acceptance of the HPV vaccine, especially in France, where its uptake culminated at 23.7% in 2018 (complete course at age 16). Physicians’ recommendations strongly influence its acceptance/refusal. Our study sought to understand the decision processes leading physicians to recommend this vaccine (or not). Methods: Qualitative interviews of French physicians (general practitioners, gynecologists, and pediatricians). We first randomly selected doctors in a national register of medical professionals and then resorted to snowballing to build a convenience sample. We coded the interviews in a thematic analysis built both inductively and deductively from our research questions and data. Results: Two thirds of the participants (19/28) were favorable to HPV vaccination, some (4) opposed it, while the others were hesitant about recommending it. In explaining their opinions, most participants mentioned that they trusted the stakeholders within the vaccination system: the less trust they had, the more critical they were of the vaccine and the more importance they attributed to patients’ opinions. We identified three different ways they interacted with patients on this topic: informing and convincing; adapting to patients’ opinions; refusing compromise about vaccination. Crossing these various themes, we found 5 types of physicians: dissidents (mistrustful of the healthcare system and HPV vaccine), hesitant (finding it difficult to make up their minds about this vaccination), laissez-faire (letting patients decide by themselves, but very favorable to HPV vaccination), educator (very favorable), and uncompromising vaccinators (refusing debate). Pediatricians were overrepresented among the latter two types. Conclusions: Physicians’ judgment was influenced by their trust in the stakeholders involved in designing and implementing the HPV vaccination strategy. In this sense, doctors did not differ substantially from laypeople. They were, nonetheless, strongly influenced by their professional style and ethos. © 2020 Elsevier Ltd

Background Vaccination is expected to change the epidemiology and management of SARS-CoV-2 epidemics. Methods We used an age-stratified compartmental model calibrated to French data to anticipate these changes and determine implications for the control of an autumn epidemic. We assumed vaccines reduce the risk of hospitalization, infection, and transmission if infected by 95%, 60%, and 50%, respectively. Results In our baseline scenario characterized by basic reproduction number R0=5 and a vaccine coverage of 70–80–90% among 12–17, 18–59, and ≥ 60 years old, important stress on healthcare is expected in the absence of measures. Unvaccinated adults ≥60 years old represent 3% of the population but 43% of hospitalizations. Given limited vaccine coverage, children aged 0–17 years old represent a third of infections and are responsible for almost half of transmissions. Unvaccinated individuals have a disproportionate contribution to transmission so that measures targeting them may help maximize epidemic control while minimizing costs for society compared to non-targeted approaches. Of all the interventions considered including repeated testing and non-pharmaceutical measures, vaccination of the unvaccinated is the most effective. Conclusions With the Delta variant, vaccinated individuals are well protected against hospitalization but remain at risk of infection and should therefore apply protective behaviors (e.g., mask-wearing). Targeting non-vaccinated individuals may maximize epidemic control while minimizing costs for society. Vaccinating children protects them from the deleterious effects of non-pharmaceutical measures. Control strategies should account for the changing SARS-CoV-2 epidemiology.

Background—We aimed to identify the knowledge producers, the knowledge that they produce and the main areas of interest for health services research (HSR) in France, which is one of the priorities for public health research planning.Methods—A two-phase approach comprising a bibliometric analysis and semi-structured interviews with 20 researchers and 13 staff members of public health bodies was used.Results—In France today, interdisciplinary research teams are being organized in the main cities despite a lack of critical mass. The interviews showed that the term ‘health services research’ is vague with fuzzy boundaries between research, scientific expertise and evaluation. A keyword cluster analysis showed that French HSR is more hospital-centric compared to those countries that publish most frequently. The analysis also revealed a lack of research on methodological aspects.Conclusions—We analyzed the structure of HSR in France and the specificity of the French publications in this field, compared with other countries. The results indicate the obstacles faced by researchers and decision-makers and offer insight into how these barriers may be removed.

Measuring Influence? A Quantified Method for Evaluating the Political Activities of Agri-Food Companies in France. Starting from the example of the food industry in France, this article proposes a method to give an overview of the social space where the political activities of companies take shape. Simple from a processing point of view, this approach makes it possible to distinguish and represent, based on quantified data, the strategies implemented by the main economic actors to influence public decisions and policies. This approach is of interest not only in terms of classifying the individual and collective actors involved in various political practices, or characterising the institutional field and network formed by these actors. It also makes it possible to draw some more general lessons on the work of influencing companies.; En partant de l’exemple de l’industrie agroalimentaire en France, cet article propose une méthode permettant de donner une vision d’ensemble de l’espace social où les activités politiques des entreprises prennent forme. Simple du point de vue du traitement, cette démarche permet de distinguer et de représenter à partir de données quantifiées les stratégies mises en œuvre par les principaux acteurs économiques pour peser sur les décisions et les politiques publiques. Cette démarche n’a pas seulement un intérêt en matière de classification des acteurs individuels et collectifs impliqués dans diverses pratiques politiques ou de caractérisation du champ institutionnel et du réseau que forment ces acteurs. Elle permet aussi de dégager quelques enseignements de portée plus générale sur le travail d’influence des entreprises.

The French contribution to global public health over the past two centuries has been marked by a fundamental tension between two approaches: State-provided universal free health care and what we propose to call State humanitarian verticalism. Both approaches have historical roots in French colonialism and have led to successes and failures that continue until the present day. In this paper, the second in The Lancet's Series on France, we look at how this tension has evolved. During the French colonial period (1890s to 1950s), the Indigenous Medical Assistance structure was supposed to bring metropolitan France's model of universal and free public health care to the colonies, and French State imperial humanitarianism crystallised in vertical programmes inspired by Louis Pasteur, while vying with early private humanitarian activism in health represented by Albert Schweitzer. From decolonisation to the end of the Cold War (1960-99), French assistance to newly independent states was affected by sans frontièrisme, Health for All, and the AIDS pandemic. Since 2000, France has had an active role in development of global health initiatives and favoured multilateral action for health assistance. Today, with adoption of the 2030 Sustainable Development Goals and the challenges of non-communicable diseases, economic inequality, and climate change, French international health assistance needs new direction. In the context of current debate over global health as a universal goal, understanding and acknowledging France's history could help strengthen advocacy in favour of universal health coverage and contribute to advancing global equity through income redistribution, from healthy populations to people who are sick and from wealthy individuals to those who are poor.

International audience; Since 1945, the provision of health care in France has been grounded in a social conception promoting universalism and equality. The French health-care system is based on compulsory social insurance funded by social contributions, co-administered by workers' and employers' organisations under State control and driven by highly redistributive financial transfers. This system is described frequently as the French model. In this paper, the first in The Lancet's Series on France, we challenge conventional wisdom about health care in France. First, we focus on policy and institutional transformations that have affected deeply the governance of health care over past decades. We argue that the health system rests on a diversity of institutions, policy mechanisms, and health actors, while its governance has been marked by the reinforcement of national regulation under the aegis of the State. Second, we suggest the redistributive mechanisms of the health insurance system are impeded by social inequalities in health, which remain major hindrances to achieving objectives of justice and solidarity associated with the conception of health care in France. ; Depuis 1945, les politiques de santé en France s’appuient sur une conception sociale s’inspirant de deux principes : l’universalisme et l’égalité. Le système de santé français repose en effet sur un système de sécurité sociale obligatoire et fortement redistributif, financé par les contributions sociales et co-administré par les organisations patronales et salariales, sous le contrôle de l’Etat. Ce système est fréquemment désigné comme le « modèle français ». Dans cet article, le premier du numéro spécial du Lancet sur la France, nous remettons en question quelques idées reçues sur l’accès à la santé en France. Dans un premier temps, nous ouvrons la réflexion sur les transformations politiques et institutionnelles qui ont affecté la gouvernance de la santé au cours des dernières décennies. Nous montrons d’une part que le système de santé, loin d’être uniforme, repose sur une diversité d’institutions, mécanismes et acteurs des politiques de santé, d’autre part que la gouvernance de la santé a été marquée par une tendance au renforcement du rôle régulateur de l’Etat. Dans un second temps, nous suggérons que les mécanismes de redistribution du système d’assurance maladie sont bien actifs, mais que leur efficacité reste entravée par les inégalités sociales de santé, lesquelles constituent des obstacles majeurs à la réalisation des objectifs de justice et de solidarité qui sont au cœur de la conception sociale de la santé en France.

L'hopital a traditionnellement beneficie d'une certaine autonomie organisationnelle, qui resultait de la conjonction de l'autonomie des professionnels de sante et de logiques politiques territoriales (Moisdon & Tonneau, 1996). L'hopital est desormais engage dans un processus d'integration bureaucratique tout a la fois diffus, transversal et relativement puissant. Nous proposons d'illustrer les manifestations de ce processus dans les contextes hospitaliers locaux, a partir d'une enquete sur l'introduction des indicateurs nationaux de qualite hospitaliere en Aquitaine, premiere region a avoir experimente ces indicateurs, des 2008, avant leur generalisation a l'ensemble du territoire dans le cadre des procedures nationales de certification.

The reimbursement of health care expenses by the Social Security is slightly dwindling in France. In recent years, a significant level of health expenditures has been transferred to private insurance companies or to patients. This article explores the growing role of French private health insurance in two different contexts: In the 1980s, the role of insurance companies in this sector was highly topical, while their actual expansion in the 2000s was much more discrete. This paradox is explained by the positions of key actors. Between these two periods, both public and private insurers on one side, and the economic experts on the other, came closer together in a set of new institutions built for this purpose. The social proximity between these key actors limited the potential for controversy. Nurtured by administrative actors within a public institutional framework, the soaring role of private actors finally appears as a rather bureaucratic from of privatization, the effects of which remain unclear: would the bureaucratic aspect of such a privatization in health care eventually ease or contain its consequences?; Depuis quelques années, la prise en charge des dépenses de santé par la Sécurité sociale se réduit sous l’effet d’un transfert de charges vers les assurances complémentaires et les assurés sociaux. Cet article compare le contexte dans lequel est intervenu un recours accru aux acteurs privés en matière d’assurance maladie au cours de deux périodes, caractérisées par un débat controversé dans les années 1980 et par un débat plus discret dans les années 2000, alors même que le recours aux acteurs privés est alors plus net. Ce paradoxe est expliqué à partir des positions relatives des principaux acteurs impliqués dans ces débats, notamment les acteurs publics et privés de l’assurance maladie et les experts économiques, qu’ils soient administratifs ou académiques. Le rapprochement de ces différents acteurs dans un nouveau complexe institutionnel réduit l’espace des différends, auparavant moins circonscrit. Engagé par des acteurs administratifs et développé dans un cadre institutionnel à dominante publique, le recours aux acteurs privés apparaît en définitive sous la forme d’une privatisation bureaucratique, dont il reste à savoir si le caractère bureaucratique favorise ou contient au contraire les effets d’une privatisation en clair-obscur.