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Background: In France, differences in cardiovascular risk factor distribution have been observed which might be responsible for some disparities in cardiovascular mortality between social categories. The goal of the study was thus to assess the differences in coronary heart disease (CHD) and cerebrovascular diseases (CVD) mortality according to social category, and to determine their trends over the last 20 years in France.Methods: Mortality data for CHD, CVD, diseases of the circulatory system (CS) and all causes mortality (TM) were based on death certificates for 1970, 1980 and 1990, and categorized by sex, age group (35-44 and 45-54 years), region and social category.Results: Among active men, from 1970 to 1990, the overall decrease observed for all causes of death was significantly slower among employees and workers for CHD, CS and TM (P < 0.001), but not for CVD. In 1990, the highest mortality rates were observed among employees and workers for CHD, CVD and CS mortality. In women, no such trend was observed for CHD, CVD or CS mortality. No statistically significant difference between social categories was observed in 1990 for CHD and CVD. In the whole active population, a negative trend for the mortality rates was observed between 1970 and 1990 whatever the cause in both sexes. The ratio between mortality rates among non-active versus active people increased during the two decades in both sexes.Conclusions: In men, the inequalities have increased over the last two decades for CHD and have not been reduced for CVD. The category of employees and workers were found to be at special risk for premature cardiovascular disease mortality. Among women, the trends were less clear, although the tendencies were the same. An increasing disparity between active and non-active people suggests that a health-related selection process towards unemployment might have contributed to the decreasing mortality rates observed among employees and workers. [ABSTRACT FROM AUTHOR]

Introduction: As part of the National Health Strategy, the High Council for Public Health (HCSP) was tasked with leading a reflection on a &#8220;comprehensive and concerted child health policy&#8221;. Policy-making requires relevant knowledge and statistical benchmarks. It therefore seemed useful to examine the French statistical system and active research topics. This assessment is expected to provide a current portrait of the priorities and implicit health choices for the children. It also aims to reveal insufficiently explored aspects of children&#8217;s health., Methods: The inventory of this system was carried out on the basis of several methods, hearings, work of two documentalists, and analysis of the published and grey literature., Results: The emphasis is on pathologies, medical prevention and behaviors conceived primarily as individual. The idea that the health of tomorrow&#8217;s adults is built up behind this apparent good health and its inequalities does not appear, or only marginally. The elements on affective, cognitive or relational development are not sufficiently analyzed, for lack of data. The living conditions of children, especially poverty and violence in all its forms, are not sufficiently considered as health issues. Research is developing today with a hospital-centric vision, without a real strategy of research on children&#8217;s health., Discussion: Given the dispersion of data, publishing a summary report on children&#8217;s health on a regular basis is essential, as enriching the system with data on the environment, poverty and psychomotor, psychosocial and cognitive development. There is an urgent need to develop research on children&#8217;s health and to define a research strategy that does not exist today.

Objective: It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types., Methods: This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients' condition during ED visit was determined through the 'Clinical Classification of Emergency' score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures., Results: The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes., Discussion: It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The processes at play in the implementation of one program in different contexts are complex and not yet well understood. In order to facilitate both the analysis and transfer of interventions, a "key functions/implementation/context" (FIC) model was developed to structure the description of public health interventions by distinguishing their potentially transferable dimensions (their "key functions") from those associated with their translation within a specific context (their "form"). It was used to describe and compare preschool preventative nutrition interventions routinely implemented across three territories, in accordance with same national specifications., Methods: The interventions were independently described by researchers and intervention's implementers using the FIC model, during several workshops. Their key functions were then classified into 12 themes and compared to assess the extent to which the three interventions were similar., Results: Despite being produced from the same set of specifications and having similar objectives, the key functions of the interventions in the three departments mostly reflected the same major themes, they did not overlap and were in some cases very different. In one of the three departments, the intervention was markedly different from those of the other two departments. The historical context of the interventions and the specificities of the local actors appear highly determinant of the key functions described., Conclusions: For the interventions that we studied, some of the key functions varied greatly and translated different concepts of health education and modes of intervention to the population. It now seems vital to improve the description of interventions on the ground in order to highlight the key functions on which they are based, which still often remain implicit. The FIC model could be used to complement other models and theories focusing on the description of the implementation process, its determinants or its evaluation. Its interest is to provide a structure for joint reflection by various actors on the transferable aspects of an intervention, its form and its interactions with the context, in order ultimately to analyse or to improve its potential transferability.

Objectives: To analyse the association between patients' socioeconomic position (SEP) and the use of emergency departments (EDs)., Methods: This population-based study included all visits to ED in 2012 by inhabitants of the French Midi-Pyrénées region, recorded by the Regional Emergency Departments Observatory. We compared ED visit rates and the proportion of non-severe visits according to the patients' SEP as assessed by the European Deprivation Index., Results: We analysed 496,388 visits. The annual ED visit rate increased with deprivation level: 165.9 [95% CI (164.8-166.9)] visits per 1000 inhabitants among the most advantaged group, compared to 321.9 [95% CI (320.3-323.5)] per 1000 among the most disadvantaged. However, the proportion of non-severe visits was about 14% of the visits, and this proportion did not differ according to SEP., Conclusions: Although the study shows a difference of ED visit rates, the probability of a visit being non-severe is not meaningfully different according to SEP. This supports the assumption that ED visit rate variations according to SEP are mainly explained by SEP-related differences in health states rather than SEP-related differences in health behaviours.

Health is dependent on the living conditions and the socioeconomic environment of populations. The healthcare system tends to underestimate these aspects and thereby maintain, and even aggravate, the resulting social inequalities in health. It is essential that this situation is improved by adopting a global and interdisciplinary vision of healthcare and its social determinants., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: In aggregate studies, ecological indices are used to study the influence of socioeconomic status on health. Their main limitation is ecological bias. This study assesses the misclassification of individual socioeconomic status in seven ecological indices., Methods: Individual socioeconomic data for a random sample of 10,000 persons came from periodic health examinations conducted in 2006 in 11 French departments. Geographical data came from the 2007 census at the lowest geographical level available in France. The Receiver Operating Characteristics (ROC) curves, the areas under the curves (AUC) for each individual variable, and the distribution of deprived and non-deprived persons in quintiles of each aggregate score were analyzed., Results: The aggregate indices studied are quite good "proxies" for individual deprivation (AUC close to 0.7), and they have similar performance. The indices are more efficient at measuring individual income than education or occupational category and are suitable for measuring of deprivation but not affluence., Conclusions: The study inventoried the aggregate indices available in France and evaluated their assessment of individual SES.

Background: The failure to simultaneously address two objectives (increasing the average health of the population and reducing health inequalities) may have led to what has been observed in France so far: an overall decrease in mortality and increase in inequality., Objective: The Apprendre et Agir pour Réduire les Inégalités Sociales de Santé (AAPRISS) methodology is to analyze and modify interventions that are already underway in terms of their potential impact on health inequalities. It relies on partnership between researchers and actors in the health field, as well as policy makers. In this paper, we describe the program and discuss its feasibility and acceptability., Methods: This program is not a single intervention, but a process aiming at assessing and reshaping existing health programs, therefore acting as a kind of meta-intervention. The program develops scientific and methodological support stemming from co-construction methods aimed at increasing equity within the programs. Stakeholders from prevention policy-making and the health care system, as well as researchers, collaborate in defining interventions, monitoring their progress, and choosing indicators, methods and evaluation procedures. The target population is mainly the population of the greater Toulouse area. The steps of the process are described: (1) establishment of AAPRISS governance and partnerships; (2) inclusion of projects; and (3) the projects' process., Discussion: Many partners have rallied around this program, which has been shown to be feasible and acceptable by partners and health actors. A major challenge is understanding each partner's expectations in terms of temporality of interventions, expected outcomes, assessment methods and indicators. Analyzing the projects has been quite feasible, and some modifications have been implemented in them in order to take inequalities in health into account., (© The Author(s) 2015.)

L'Evaluation d'Impact sur la Santé (EIS) se développe au niveau international et est encore au stade émergent en France. Elle vise à évaluer les effets positifs et négatifs potentiels d'un projet, d'un programme ou d'une politique sur la santé. L'objectif est de produire des recommandations en direction des décideurs, afin d'en maximiser les effets positifs et d'en diminuer les effets négatifs. L'EIS est un moyen particulièrement intéressant d'action sur les déterminants de la santé au-delà des comportements individuels et du système de santé. Les politiques de logement, de transport, de solidarité, économiques, etc. ont, en effet, des impacts souvent non prévus sur la santé. Au-delà des effets sur la santé, l'EIS doit aussi permettre d'apprécier la distribution de ces effets dans la population.Si la préoccupation pour l'équité en santé est centrale dans l'EIS, elle reste cependant difficilement traduite en pratique. Face à cette difficulté, des démarches d'évaluation d'impact ont été développées pour renforcer la prise en compte de l'équité à chaque étape de l'EIS ou « Equity Focused Health Impact Assessment », ou prendre en compte les impacts sur les inégalités de santé de façon spécifique. Ainsi, l'Evaluation de l'Impact sur l'Equité en Santé (EIES) semble, par exemple, particulièrement intéressante pour évaluer l'impact sur les inégalités de projets dans le champ sanitaire.L'EIS et l'EIES posent de nombreuses questions de recherche, notamment autour de la réunion, dans une même démarche, du politique, du citoyen et de l'expert. La participation des populations vulnérables potentiellement affectées par la politique évaluée est une valeur centrale de l'EIS, mais pose des questions d'acceptabilité sociale. La collaboration avec les décideurs politiques est également un enjeu majeur. Les difficultés méthodologiques, notamment de quantification des impacts, peuvent constituer des freins à la promotion de la démarche auprès des décideurs., (© The Author(s) 2015.)

In mediation analysis between an exposure X and an outcome Y, estimation of the direct effect of X on Y by usual regression after adjustment for the mediator M may be biased if Z is a confounder between M and Y, and is also affected by X Alternative methods have been described to avoid such a bias: inverse probability of treatment weighting with and without weight truncation, the sequential g-estimator and g-computation. Our aim was to compare the usual linear regression adjusted for M to these methods when estimating the controlled direct effect between X and Y in the causal structure and to explore the size of the potential bias. Estimations were computed in several simulated data sets as well as real data. We observed an increased bias of the controlled direct effect estimation using linear regression adjusted for M for larger effects of X on M and larger effects of Z on M The sequential g-estimator and g-computation gave unbiased estimations with adequate coverage values in every situation studied. With continuous exposure X and mediator M, inverse probability of treatment weighting resulted in some bias and less satisfactory coverage for large effects of X on M and Z on M., (© The Author(s) 2012.)

An Illumina Infinium SNP genotyping array was constructed for European white oaks. Six individuals of Quercus petraea and Q. robur were considered for SNP discovery using both previously obtained Sanger sequences across 676 gene regions (1371 in vitro SNPs) and Roche 454 technology sequences from 5112 contigs (6542 putative in silico SNPs). The 7913 SNPs were genotyped across the six parental individuals, full-sib progenies (one within each species and two interspecific crosses between Q. petraea and Q. robur) and three natural populations from south-western France that included two additional interfertile white oak species (Q. pubescens and Q. pyrenaica). The genotyping success rate in mapping populations was 80.4% overall and 72.4% for polymorphic SNPs. In natural populations, these figures were lower (54.8% and 51.9%, respectively). Illumina genotype clusters with compression (shift of clusters on the normalized x-axis) were detected in ~25% of the successfully genotyped SNPs and may be due to the presence of paralogues. Compressed clusters were significantly more frequent for SNPs showing a priori incorrect Illumina genotypes, suggesting that they should be considered with caution or discarded. Altogether, these results show a high experimental error rate for the Infinium array (between 15% and 20% of SNPs potentially unreliable and 10% when excluding all compressed clusters), and recommendations are proposed when applying this type of high-throughput technique. Finally, results on diversity levels and shared polymorphisms across targeted white oaks and more distant species of the Quercus genus are discussed, and perspectives for future comparative studies are proposed., (© 2015 John Wiley & Sons Ltd.)

Objective: The AAPRISS intervention-research program (Apprendre et Agir Pour Réduire les Inégalités Sociales de Santé) aims to change prevention projects to improve the extent to which they take health inequalities into account. The goal is to assess a project's feasibility and its acceptability, from the viewpoint of the sponsors of the project in question, and to present its tools and potentially-transferable elements., Participants: Five cancer-prevention projects focused on nutrition have been included in the AAPRISS program: two projects conducted in school, one community-health project conducted in a disadvantaged neighbourhood and two hospital therapeutic-education programes. For each one, a workgroup was created bringing together the project sponsors and their team as well as researchers from various disciplines., Location: The study involves projects currently underway in the Midi- Pyrénées region of France., Intervention: AAPRISS is based on the exchange of knowledge among project sponsors and researchers and the co-construction of the analysis, reorientations and the assessment of the prevention projects included in the program. The validation of the program and its feasibility from the project sponsors' point of view is based on a questionnaire and presentations carried out during a symposium that took place in May 2014 in Toulouse., Results: Twelve key program functions have been described. They have been shown to be feasible and acceptable and concrete project modifications towards a better consideration of social inequalities of health (SIH) have been realized in most of the projects. Co-construction among the stakeholders raises many issues and difficulties that could have been overcome by the establishment of a relationship of trust between project sponsors and researchers., Conclusion: The complexity of the determinants leading to SIH calls for programs that revisit existing projects rather than a new intervention aimed at reducing them.

Objective: This study aimed to test longitudinal associations linking the work-unit-level psychosocial and organizational work environment and biomechanical constraints to workers' shoulder pain in the French multi-centre cohort ORSOSA study of registered nurses (RN) and nursing assistants (NA)., Methods: We analyzed 1896 female RN and NA, who were free of shoulder pain in 2006 and in the same position and work unit in 2008. Incident shoulder pain (SP) was defined as self-reported pain that persists for ≥ 4 days and/or increases during a lateral movement of the arm away from the midline of the body (abduction). Both cross-sectional and longitudinal models were built to test if work-unit-level features or their influences on both work tasks and individual perception of the work environment directly influence the risk of developing incident SP., Results: RN in work units with understaffing issues or poor relationships reported higher levels of biomechanical constraints in movements and postures and a lower level of perceived job security and stability. NA who experienced such issues reported higher levels of biomechanical constraints in indirect patient-handling activities only. The exposure to these latter factors was associated with higher two-year incident SP among workers., Conclusion: This study shows that the work-unit-level organizational characteristics may impact workers' musculoskeletal disorders by conditioning both work-task-related biomechanical exposures and individual perception of the working environment. In healthcare settings, primary prevention programs to reduce MSD would benefit from a focus on work unit level exposures.

To evaluate the incidence and risk factors of first-highly active antiretroviral therapy (HAART) modifications/interruptions and their causes in a cohort of newly-treated patients by using a competing risk model. In nine centers of the French cohort Dat'AIDS, in 1 year and 2 years of censorship, a competing risk analysis was implemented in HIV1 patients aged 18 years or older first-treated between September 2002 and March 2012. In 4669 patients, 3628 modifications (77.7%) were observed (median: 13.5 months). Cumulative incidence in 1 year: 46.8% [45.4-48.3]; in 2 years: 65.3% [63.8-66.8]. Intolerance (n = 1167; 32.3%): in 1 year, except first-treated from 2002 to 2005, modifications were not different: 2002-2003 (24.6%) 2004-2005 (26.1%), 2006-2007 (19.4%), 2008-2009 (18.8%) and 2010-2011 (15.7%). Women, AIDS patients, and those aged 50 years and older had an excess risk. Therapeutic simplification (n = 1037; 28.6%): in 1 year, except first-treated from 2002 to 2003, modifications were not different: 2002-2003 (9.0%), 2004-2005 (16.0%), 2006-2007 (11.0%), 2008-2009 (15.7%) and 2010-2011 (10.0%). Conversely to injecting-drug-users and AIDS patients, women and first-treated with non-nucleosides had an excess risk. Therapeutic failure (n = 189; 5.2%): contrary to first-treated between 2002 and 2003 or 2008 and 2009, in 1 year as in 2 years, modifications were not different. In 1 year, 1.9% for 2004-2005, 1.6% for 2006-2007 and 1.2% for 2010-2011. Maximum viral load ≥5.0 log10 copies/ml and CD4 <200 cells/mm(3) had a high probability. The study of first-HAART modifications suggests that in 1-year follow-up, intolerance incidence in the recent calendar year is still as frequent as the previous period which may constitute a limitation to the success of the seek, test, treat, and retain.

Objectives: This longitudinal study aimed to test the hypothesis that organizational work factors (OWFs) may be related to depressive symptoms through an increased effort-reward imbalance (ERI) ratio among registered nurses (RNs) and nursing assistants working in hospitals., Methods: We studied 2117 female RNs and nursing assistants who stayed in the same work unit and position during the follow-up from the ORSOSA (ORganisation des SOins-SAnté) longitudinal study. The work characteristics and workers' health were assessed in 2006 and 2008., Results: We confirmed our hypothesis of both direct and mediated effects of OWFs on workers' health. We showed that issues about patient-related information exchanges increased RNs' depressive disorders by increasing first a perceived ERI., Conclusions: Our results advocate integrating both the work organizational level and the individual level into preventive actions to improve workers' mental health.

The health of hospital workers, nurses and nurse-aids constitutes a public health challenge for three reasons: maintenance of personnel at work in a context in which many express their desire to quit their jobs, protection of their health, and maintenance of quality of care. ORSOSA (ORganisation des SOins et SAnté des soignants) is a multidisciplinary interventional population health research programme designed to improve quality of life in the workplace of healthcare workers. This programme is designed to develop a tool to diagnose psychosocial and organisational work factors (POWFs) and mechanical constraints (MC), and then to implement this method in primary prevention interventions. ORSOSA consists of two steps: research (ORSOSA 1) and intervention (ORSOSA 2). In ORSOSA 1, a prospective cohort of healthcare workers was developed to construct and validate the diagnostic tool of work-related constraints at the work unit level. ORSOSA 2 consists of using the tool to implement both a collective and consensual dynamic based on collective restitution of the strengths and weaknesses of the work unit in order to propose recommendations for better quality of life at work. ORSOSA is now deployed in 4 teaching hospitals (Lille, Bordeaux, Grenoble and Strasbourg), each with 5 peripheral hospitals. Evaluation and follow-up of the programme is ongoing.

Loci considered to be under selection are generally avoided in attempts to infer past demographic processes as they do not fit neutral model assumptions. However, opportunities to better reconstruct some aspects of past demography might thus be missed. Here we examined genetic differentiation between two sympatric European oak species with contrasting ecological dynamics (Quercus robur and Quercus petraea) with both outlier (i.e. loci possibly affected by divergent selection between species or by hitchhiking effects with genomic regions under selection) and nonoutlier loci. We sampled 855 individuals in six mixed forests in France and genotyped them with a set of 262 SNPs enriched with markers showing high interspecific differentiation, resulting in accurate species delimitation. We identified between 13 and 74 interspecific outlier loci, depending on the coalescent simulation models and parameters used. Greater genetic diversity was predicted in Q. petraea (a late-successional species) than in Q. robur (an early successional species) as introgression should theoretically occur predominantly from the resident species to the invading species. Remarkably, this prediction was verified with outlier loci but not with nonoutlier loci. We suggest that the lower effective interspecific gene flow at loci showing high interspecific divergence has better preserved the signal of past asymmetric introgression towards Q. petraea caused by the species' contrasting dynamics. Using markers under selection to reconstruct past demographic processes could therefore have broader potential than generally recognized., (© 2012 Blackwell Publishing Ltd.)

Background: Studying social disparities in health implies the ability to measure them accurately, to compare them between different areas or countries and to follow trends over time. This study proposes a method for constructing a French European deprivation index, which will be replicable in several European countries and is related to an individual deprivation indicator constructed from a European survey specifically designed to study deprivation., Methods and Results: Using individual data from the European Union Statistics on Income and Living Conditions survey, goods/services indicated by individuals as being fundamental needs, the lack of which reflect deprivation, were selected. From this definition, which is specific to a cultural context, an individual deprivation indicator was constructed by selecting fundamental needs associated both with objective and subjective poverty. Next, the authors selected among variables available both in the European Union Statistics on Income and Living Conditions survey and French national census those best reflecting individual experience of deprivation using multivariate logistic regression. An ecological measure of deprivation was provided for all the smallest French geographical units. Preliminary validation showed a higher association between the French European Deprivation Index (EDI) score and both income and education than the Townsend index, partly ensuring its ability to measure individual socioeconomic status., Conclusion: This index, which is specific to a particular cultural and social policy context, could be replicated in 25 other European countries, thereby allowing European comparisons. EDI could also be reproducible over time. EDI could prove to be a relevant tool in evidence-based policy-making for measuring and reducing social disparities in health issues and even outside the medical domain.

Objectives: The aims of this paper were (1) to analyze the prevalence of symptoms of post-traumatic stress disorder (S-PTSD) in a population of workers 1 year after an industrial disaster; and (2) to assess the role of factors of vulnerability such as the occupational impact of a disaster and economic conditions., Methods: A cross-sectional survey assessing the relationships between socio-occupational category, impact on employment and S-PTSD was conducted by the self-administered impact of event scale-revised., Results: The prevalence of S-PTSD in workers in the peripheral zone (<3 km around the explosion site) was 12% in men and 18% in women. Factors significantly associated with S-PTSD in men were non-managerial socio-occupational category: employees (ORa = 4.3; [2.3; 7.8]), factory workers/laborers (ORa = 3.7; [1.8; 7.6]), intermediate professions (ORa = 3.3; [1.9; 5.9]), and artisans (ORa = 3; [1.3; 7.7]); and layoff (ORa = 2.6; [1.5; 4.5]) or unusable workplace after the explosion (ORa = 1.8; [1.1; 2.8]). In women, factors significantly associated with S-PTSD were the socio-occupational categories of employees and factory workers (ORa = 2.2; [1.4; 3.5]), artisans (ORa = 2.7; [1.3; 5.7]) and intermediate professions, (ORa = 1.5; [1; 2.3]) and reporting of an occupational accident (ORa = 1.5; [1.1; 2.2])., Conclusion: Impact on the workplace and socioeconomic conditions were associated with S-PTSD. The epidemiological approach in disaster situations needs to be improved, particularly in the social and occupational dimension when economically active populations are involved. Vulnerable subgroups, defined by occupational impact and low socioeconomic category, should be taken into account.

Background: Our objective was to analyse the influence of education on the link between functional limitation (FL) and self-rated health (SRH) in two countries, France and the USA., Methods: The data of the North American NHANES study (n = 9254) and the French National Health Survey (n = 25 559) were used. FL was measured by the ADL and IADL scales. We constructed a logistic regression model with SRH as the outcome and included variables for education, FL and the interaction between education and FL. All results were adjusted for age., Results: Poor SRH was more frequently reported in France than in the USA (24.1% vs. 18.4% for men, 29.0% vs. 19.7% for women). The most highly educated persons in the USA had similar FL (25.4% for men, 32.9% for women) to the least educated French persons (22.8% for men, 31.8% for women). In the USA, FL was associated more strongly with poor SRH in the most educated men than in the least educated. In France, the same interaction was observed although the link was weaker than in the USA. FL was more strongly associated with poor SRH in the most educated women than in the least educated in both countries., Conclusion: Functional limitation had a greater impact on the most highly educated persons in both France and the USA. Using SRH as a measure of health for evaluating social inequalities could lead to underestimation of the true magnitude of functional health inequalities existing within and between countries.

Background: Self-rated Health (SRH) and health-related quality of life (HRQoL) are used to evaluate health disparities. Like all subjective measures of health, they are dependent on health expectations that are associated with socioeconomic characteristics. It is thus needed to analyse the influence played by socioeconomic position (SEP) on the relationship between these two indicators and health conditions if we aim to use them to study health disparities. Our objective is to assess the influence of SEP on the relationship between physical health status and subjective health status, measured by SRH and HRQoL using the SF-36 scale., Methods: We used data from the French National Health Survey. SEP was assessed by years of education and household annual income. Physical health status was measured by functional limitations and chronic low back pain., Results: Regardless of their health status, people with lower SEP were more likely than their more socially advantaged counterparts to report poor SRH and poorer HRQoL, using any of the indicators of SEP. The negative impact of chronic low back pain on SRH was relatively greater in people with a high SEP than in those with a low SEP. In contrast, chronic low back pain and functional limitations had less impact on physical and mental component scores of quality of life for socially advantaged men and women., Conclusions: Both SRH and HRQoL were lower among those reporting functional limitations or chronic low back pain. However, the change varied according SEP and the measure. In relative term, the negative impact of a given health condition seems to be greater on SRH and lower on HRQoL for people with higher SEP in comparison with people with low SEP. Using SRH could thus decrease socioeconomic differences. In contrast using HRQoL could increase these differences, suggesting being cautious when using these indicators for analyzing health disparities.

This study sought to ascertain whether disagreement between patients and physicians on the patients' health status varies according to patients' education level. INTERMEDE is a cross-sectional multicentre study. Data were collected from both patients and doctors via pre- and post consultation questionnaires at the GP's office over a two-week period in October 2007 in 3 regions of France. The sample consists of 585 eligible patients (61% women) and 27 GPs. A significant association between agreement/disagreement between GP and patient on the patient's health status and patient's education level was observed: 75% of patients with a high education level agreed with their GP compared to 50% of patients with a low level of education. Patients and GPs disagreed where patients with the lowest education level said that their health was worse relative to their doctor's evaluation 37% of the time, versus 16% and 14% for those with a medium or high education level respectively. A multilevel multivariate analysis revealed that patients with a low educational level and medium educational level respectively were at higher risk of being overestimated by GP's in respect of self-reported health even if controlling for confounders. These findings suggest that people with a lower education level who consider themselves to have poor health are less reliably identified as such in the primary care system. This could potentially result in lack of advice and treatment for these patients and ultimately the maintenance of health inequalities., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Through a national cohort of more than 4000 nurses and nursing assistants in 14 university hospital centres, a study has developed a tool to assess the health of nursing staff within nursing units. This tool enables the general health condition of caregivers, as well as their working conditions, to be gauged. On this basis, preventative measures in terms of work organisation can be drawn up.

Objective: Guidelines on cardiovascular prevention relying on common cardiovascular risk scoring could result in delayed drug therapy for patients with low psychosocial status because of underestimation of true cardiovascular risk. We aimed to assess the potential delay in drug therapy for subjects with adverse psychosocial factors., Method: The study population consisted of 6185 French men from the PRIME (Prospective Epidemiological Study of Myocardial Infarction) cohort study (1991-2003). The number of extra years to reach a risk threshold for subjects without adverse psychosocial factor compared to subject with adverse psychosocial factor was estimated using a coronary risk model including biomedical factors and a psychosocial variable (education, occupation, living conditions or a depression score)., Results: Coronary risk was significantly higher only for subjects with a high depression score (odds ratio=1.34; 95% confidence interval 1.04, 1.72) or low educational attainment (odds ratio=1.39; 95% confidence interval=1.07, 1.81). For a given risk threshold, subjects with high depression scores were 4.5 years (95% confidence interval=0.0, 15.4 years) younger than subjects with low depression scores. The age difference was 4.1 years (95% confidence interval=-0.5, 15.8 years) between subjects with low and high educational attainment., Conclusion: Clinical decision rules relying on classic cardiovascular risk scoring could result in delayed drug therapy for patients with depression or low educational attainment., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: On 21 September 2001, a huge explosion occurred in a chemical plant in Toulouse. The hypothesis of the study was that the level of depressive symptoms after an industrial disaster would be related to the intensity of exposure and the characteristics of the exposed population, as well as to the consequences of the disaster during the following months., Methods: A random sample of the population living close to the plant at the time of the explosion was included in a cross-sectional study, and 811 persons aged > 18 years were interviewed at home. The depressive symptoms score was analysed by gender in relation to characteristics of the population before the explosion, immediate exposure to the explosion and post-trauma factors., Results: The mean depressive symptoms scores (± SD) 18 months after the explosion were 17.8 (± 1) in women and 13.5 (± 1) in men. Age >  45 years and psychiatric treatment in the previous year; high immediate exposure (proximity to the site at the time of the explosion < 2500 m); and post-trauma factors such as financial difficulties or physical sequelae during the months after the disaster were related to a higher depressive symptoms score in both men and women., Conclusion: In the population living near the site of an industrial explosion, individual vulnerability, exposure and post-trauma factors were associated with depressive symptoms. All three sets of factors need to be taken into account when planning a response to a disaster and reducing the psychological aftermath.

Few studies have analysed the association between the organisational work environment and depression in hospital workers and we still have little understanding of how processes in the practice environment are related to depressive disorders. However, individual perception of an imbalance between efforts made and expected rewards has been associated with incident depression. The main goal of this study was to test the hypothesis that some organisational constraints at the work-unit level may be related to depressive symptoms in hospital workers, either directly or through individual perceptions of effort-reward imbalance (ERI). In 2006, 3316 female registered nurses and nursing aids working in 190 work units in seven French university hospitals, recruited from the baseline screening of an epidemiological cohort study (the ORSOSA study), responded in 2006 to valid self-report questionnaires (CES-D, ERI). The organisational work environment was assessed with the self-rated Nursing Work Index - Extended Organisation (NWI-EO) aggregated at the work unit level. Multilevel models were used. We found that poor relations between workers within work units were associated with higher CES-D score, independently of perceived ERI. Low level of communication between workers in the unit was associated with individual perceptions of ERI and indirectly associated with depressive symptoms. Understaffing and non-respect of planned days off and vacations were associated with perceived ERI but these organisational constraints were not associated with depressive symptoms. Our study allowed us to identify and quantify organisational factors that have a direct effect on hospital workers' depressive symptoms, or an indirect effect through perceived ERI. Better understanding of the effect of organisational factors on health through perceived ERI would provide targets for successful interventions. Organisational approaches may be more effective in improving mental health at work and may also have a longer-lasting impact than individual approaches., (Copyright 2010 Elsevier Ltd. All rights reserved.)

In France, more than 10 million people receive medications to treat hypotension. This simple figure underscores the dimension of hypertension for the country as a public health problem. Hypertension deserves careful attention not only for itself, but also because of the cardiac and vascular diseases which it may induce. Thus, renewed primary and secondary prevention strategies are needed. These must be based upon a better knowledge of the relationship between blood pressure level and cardiovascular diseases, upon new thresholds used to define hypertension, and upon an integrated approach to assess and reduce the overall cardiovascular risk in individuals. Eventually, low-cost population-based preventive strategies, still marginally used in our country, must receive a greater commitment from Public Health Authorities.

Objectives: Heart fatty acid-binding protein (h-FABP) and ischemia-modified albumin (IMA) have recently been evaluated, but to the best of our knowledge, no study has reported an analysis of these two markers for the detection of early myocardial infarction and myocardial ischemia in a large cohort of consecutive patients presenting to an emergency department (ED). This study evaluates the diagnostic accuracy and the clinical utility of h-FABP and IMA for non-ST-segment elevation acute coronary syndrome (ACS) diagnosis in the first hour of management in an ED., Methods: In a prospective 11-month study, 677 patients admitted to the ED with chest pain and suspected non-ST-segment elevation ACS were enrolled. On presentation, blood samples were obtained for the measurement of the biomarkers h-FABP (immunodetection with CardioDetect) and IMA (albumin cobalt-binding test). Two physicians, blinded to the results of the markers, independently categorized patients as having or not having non-ST-segment elevation ACS., Results: Of the 677 patients who were prospectively recruited, non-ST-segment elevation ACS was diagnosed in 185 (27.3%). While IMA was not predictive of the ACS diagnosis (odds ratio [OR] = 1.23; 95% CI = 0.87 to 1.81), h-FABP was predictive of ACS diagnosis (OR = 4.65; 95% CI = 2.39 to 9.04) with specificity at 96.8% (95% CI = 95.4% to 98.1%) and sensitivity at 13.5% (95% CI = 10.9% to 16.1%). However, h-FABP did not add significant additional information to a predictive model that included the usual diagnostic tools for non-ST-elevation ACS management (p = 0.40)., Conclusions: In this study on a large cohort of patients admitted to an ED for chest pain, IMA and h-FABP did not provide valuable information for ACS diagnosis., ((c) 2010 by the Society for Academic Emergency Medicine.)

Background: Arterial hypertension is managed mainly by general practitioners. The blood pressure level of most patients treated in a general practice setting is greater than or equal to 140/90 mmHg., Aims: To understand why a blood pressure level greater than or equal to 140/90 mmHg does not lead to a change of treatment., Methods: Over a 2-week period, 479 hypertensive patients were included in a cross-sectional study by 27 general practitioners. Consultation data were collected, as were reasons why patients with a blood pressure level greater than or equal to 140/90 mmHg did not have their treatment changed., Results: Blood pressure level was greater than or equal to 140/90 mmHg in 58% of patients; treatment was changed in 15% of these individuals. The lack of change in treatment was justified by the physicians as follows: the blood pressure measurements were not considered to be representative (about 30% of cases); the therapeutic result was considered to be satisfactory in the circumstances (about 30% of cases); change was not appropriate given the patient's specific context (the remaining third of cases). The proportion of uncontrolled hypertensive patients whose treatment remained the same was significantly higher among patients with a disease that affected their lifestyle or threatened their life expectancy., Conclusion: The disappointing therapeutic results observed in the management of arterial hypertension do not arise only from poor application of guidelines by general practitioners. Reluctance to rely on blood pressure measurements, a perception that guidelines are revised frequently and are not always clear, and consideration of the general practitioner's activity in the patient's specific context are the main factors involved.

Background: The way in which patients and their doctors interact is a potentially important factor in optimal communication during consultations as well as treatment, compliance and follow-up care. The aim of this multidisciplinary study is to use both qualitative and quantitative methods to explore the 'black box' that is the interaction between the two parties during a general practice consultation, and to identify factors therein that may contribute to producing health inequalities. This paper outlines the original multidisciplinary methodology used, and the feasibility of this type of study., Methods and Design: The study design combines methodologies on two separate samples in two phases. Firstly, a qualitative phase collected ethnographical and sociological data during consultation, followed by in-depth interviews with both patients and doctors independently. Secondly, a quantitative phase on a different sample of patients and physicians collected data via several questionnaires given to patients and doctors consisting of specific 'mirrored' questions asked post-consultation, as well as collecting information on patient and physician characteristics., Discussion: The design and methodology used in this study were both successfully implemented, and readily accepted by doctors and patients alike. This type of multidisciplinary study shows great potential in providing further knowledge into the role of patient/physician interaction and its influence on maintaining or producing health inequalities. The next challenge in this study will be implementing the multidisciplinary approach during the data analysis.

Objectives: To assess the association between social situation and disease progression among patients diagnosed with HIV infection since the advent of highly active antiretroviral therapy (HAART), taking late testing into account., Methods: Prospective cohort study of adults diagnosed with HIV since 1996 in six large HIV reference centres in France. Associations between social situation and death, disease progression and treatment initiation were assessed using Cox regression model. Analysis was restricted to 5302 patients (77.9% of the sample) for whom the status at HIV diagnosis (late or not late) was known., Results: 134 people (2.5%) died and 400 presented with a new AIDS defining event (7.5%). In multivariate analysis, probabilities of death (HR 3.75, 95% CI 2.11 to 6.66) and disease progression (HR 1.59, 95% CI 1.17 to 2.15) were higher for non-working patients and for late testers (HR 9.18, 95% CI 4.32 to 19.48 for death) and lower for treated patients (HR 0.18, 95% CI 0.08 to 0.41 for death and HR 0.29, 95% CI 0.20 to 0.42 for disease progression). The probability of receiving antiretroviral treatment was not associated with employment status but was higher for late testers, for those living in a stable relationship and lower for those diagnosed after 2000., Conclusion: Among patients diagnosed for HIV infection in the HAART era, poor social situation is an independent risk factor of mortality and morbidity, and is not explained by delayed access to diagnosis or treatment.

Objective: To analyse in the general population the prevalence and predictors of symptomatology consistent with post-traumatic stress disorder (S-PTSD) 18 months after an industrial explosion., Design: Cross-sectional survey., Participants and Outcome Measures: A random sample of 1191 city inhabitants, including an oversample of the immediate area (<3 km). S-PTSD was measured by the self-administered Impact of Event Scale-Revised. The relation between S-PTSD and individual vulnerability factors, immediate exposure and post-trauma factors was analysed by gender., Results: S-PTSD was more prevalent in the immediate area than in the peripheral area (women 19% vs 8%; men 8% vs 2%, p<0.01). In the immediate area, S-PTSD was independently associated with birth outside France (men: OR(a) = 13.9, 95% CI 3.7 to 52.8; women: OR(a) = 2.1, 95% CI 1.0 to 4.2), age more than 40 years (men: OR(a) = 4.3, 95% CI 1.01 to 18.2; women: OR(a) = 2.3, 95% CI 1.1 to 4.5), previous psychotropic treatment (men: OR(a) = 11.5, 95% CI 2.4 to 53.6), proximity to the explosion (less educated men only) (OR(a) = 9.3, 95% CI 1.9 to 44.7), rescue efforts (men: OR(a) = 5.2, 95% CI 1.5 to 18.2), temporarily uninhabitable home (men: OR(a) = 5.8, 95% CI 1.9 to 18.1), personal injury (women: OR(a) = 3.7, 95% CI 1.7 to 8.4), financial difficulties (men: OR(a) = 17.4, 95% CI 4.2 to 72.1; women: OR(a) = 3.4, 95% CI 1.7 to 7.1) and inconvenience due to closure of public services (women: OR(a) = 4.1, 95% CI 1.6 to 9.9)., Conclusions: Individual vulnerability, exposure and post-trauma factors were associated with S-PTSD. Vulnerable subgroups, defined by low socioeconomic characteristics may warrant focused screening after such disasters.

Objectives: Following the explosion of a chemical plant in France, a study was conducted to analyse the relationship between hearing thresholds and distance from the explosion based on post- and pre-blast audiometric data, and to describe the functional symptoms and visits for hearing problems., Methods: Audiometric tests with standard procedure of 511 workers of a company located near the explosion were proposed and conducted by the occupational medicine department after the explosion. Past occupational noise exposure, past medical history of ear problems, distance from the explosion, functional symptoms and visits for hearing problems following explosion and results of past audiometric tests if available were collected. Workers were classified as "exposed" or "less exposed" according to the distance from the explosion. Mean decibel threshold shifts for each ear were analysed by frequency with Student's t test and by multiple linear regression taking into account confounding factors., Results: Of a total of 425 (83%) of the firm's workers who participated in the study, 49% had received an audiometric test before the explosion. Hearing shift between pre- and post-explosion audiograms was significantly greater for the "exposed" group than for the "less exposed" one at 2,000 and 4,000 Hz (P < 0.05, P < 0.001, respectively) and borderline at 6,000 Hz (P = 0.09) for the right ear and at 2,000 (P < 0.01), 6,000 and 8,000 Hz (P < 0.05) for the left ear. Among those of the "exposed" workers who reported any functional symptom following the explosion, 45% did not visit an ENT specialist despite these signs., Conclusions: The study demonstrated statistically significant hearing shift from 2,000 to 6,000 Hz in relation with distance from the explosion and showed that even when functional symptoms were present, people did not necessarily seek medical advice. Screening for hearing loss should be recommended for people most exposed to excess acoustic pressure, in order to offer them prevention advice.

To develop new strategies aimed to reduce the delay in seeking HIV diagnosis, we proposed to identify correlates of late diagnosis of HIV infection in France. Late testing was studied among the 1077 patients diagnosed from 1996 and enrolled in the ANRS-EN12-VESPA, a representative sample of the French HIV-infected population. Patients were defined as 'late testers' if they had presented either clinical AIDS events or CD4 cell count <200/mm(3) at diagnosis. In all, 33.1% were classified as late testers, among whom 42.6% had discovered their HIV infection at the time of AIDS events. This proportion increased with age and was higher for heterosexual men and migrants. Among the non-migrants heterosexual population, late diagnosis was more frequent among people in longstanding couple, with children and conversely was less likely among individuals with large number of sexual partners. Being on welfare benefit before diagnosis was associated with a lower risk of late diagnosis. Among migrants, lack of recent steady partnership was associated with an increased risk, as being diagnosed during the first year of stay in France. Our results showed low risk factors of infection were risk factors of late testing. Public communication should aim at improving the awareness of HIV risk in longstanding couples with stable employment, both among homosexual and heterosexual populations. Among migrants, HIV testing with informed consent short after entry should be improved, especially towards individuals not in couple.

High prevalence and poor control of hypertension have been observed in populations with low-socioeconomic status. Comparing an unemployed population with another employed population sharing the same culture, and another employed population living in another environment might enlighten the effects of factors accessible to primary prevention on the one hand and access to health care on the other hand. The objectives are, first, to describe blood pressure (BP) prevalence and control in an unemployed Caribbean population benefiting from State financial support and good access to health care and second, compare the results in this population with those observed, with the same methodology in two employed populations, one in the Caribbean and one in metropolitan France. A cross-sectional study of 2420 consecutive unemployed subjects referred for check-up in the two health centres of Guadeloupe, a French Caribbean island. Hypertension prevalence was 25.2% in men and 22.1% in women. BP was controlled in 17.3% of men and 37.2% of women receiving antihypertensive medication. Among women, 58% were overweight and 29% obese. Prevalence of hypertension was higher among the unemployed and employed Caribbean population, than among an employed metropolitan French population. A high prevalence of obesity was observed in the two Caribbean populations suggesting the interest of primary prevention in the Caribbean. Burden of hypertension in a population relates to the development of hypertension (primary prevention) and control of hypertension (secondary prevention). Identifying hypertensive patients and controlling blood pressure are both important to reduce the disease burden.

Background: A major explosion occurred in the AZF chemical factory in Toulouse in September 2001. A comprehensive programme of epidemiological surveillance was set up., Objectives: To present an overview of the programme and discuss the methods and potential utility of post-disaster epidemiology. The programme had three objectives: (1) to analyse comprehensively the short-term and long-term effects of air, water and secondary soil pollution on health; (2) to identify health problems needing special attention; and (3) to investigate the long-term direct and indirect effects on the population's health., Methods: The programme was organised through three committees: (1) a scientific committee, (2) an executive programme committee and (3) an institutional committee which aimed to facilitate exchanges between the epidemiologists, the regional authorities, the population and the media. As the catastrophe was an industrial disaster that had a major effect on workers and companies, and also caused severe damage to many schools and buildings all over the city, routine and ad hoc surveillance systems were used and three specific ad hoc questionnaire surveys in workers, schoolchildren and the general population were planned., Results and Conclusions: Although the routine surveillance systems had limitations, several sources provided useful information for public health decisions and were found to be concordant with ad hoc epidemiological studies. Defining a victim was central to the choice of a programme design based on an approach either to victims of the disaster or to the entire population in the surrounding region. Anticipation and preparation for such disasters are thus required.

The aim of the study was to identify high-risk groups and the determinants of late HIV diagnosis in France in the era of highly active antiretroviral therapy (HAART), from January 1996 to June 2005. Informations were collected from an electronic medical record of all HIV- 1-infected patients who sought care in six HIV reference centers in France, constituting a prospective multicentric cohort. Patients were defined as "late testers" if they had presented with either symptoms of clinical AIDS or a CD4 cell count less than 200/mm(3) during the year of diagnosis, as "nonlate" if their CD4 count was above 200, and as "unknown" if CD4 cell count in the year at the time of diagnosis was not documented. Among the 4516 patients available for analysis, the percentage of late testing was 38% (n = 1718) and decreased after 2003 (31.5% in 2004-2005). This percentage was higher in heterosexual men (48.2%) than in homosexual men (31.7%) or heterosexual women (32.6%) and was higher for patients older than 30. Heterosexual men living in a couple with children had a higher risk of late testing (odds ratio [OR] = 1.65, 95% confidence interval [CI]: 1.03 to 2.66), while heterosexual women in a couple without children had a lower risk (OR = 0.46, 95% CI: 0.25 to 0.83). Among homosexual men, unemployment was associated with late testing (OR = 2.23, 95% CI: 1.14 to 4.36). The proportion of late testing was still high. Groups classically identified as low risk for HIV infection, particularly heterosexual men in a couple with children, were found to be at high risk for late testing. It seems necessary to improve HIV testing policy in the heterosexual population.

Objective: To describe characteristics of hypertension in French Caribbean regions., Design: A cross-sectional worksite study., Setting and Participants: A random sample of 6136 workers referred for annual check-up from Martinique, French Guyana and Guadeloupe. An average of three consecutive measurements was taken as the blood pressure (BP) level. An additional visit was required in subjects not taking antihypertensive medications with an average BP over 140/90 mmHg., Interventions: None., Main Outcome Measures: Hypertension prevalence, awareness, treatment and control., Results: The age-specific prevalence of hypertension, based on two visits, increased from 3.2% in men below 30 years to 46.9% in those older than 50 years. The corresponding values found in women were 1.8 and 42.6%. The overall prevalence was 19.5% in men and 18.9% in women. The rate of awareness remained low while age increased. The use of antihypertensive medications slowly increased with age, but overall the rate remained lower in men compared with women. Up to 71% of hypertensive women received antihypertensive medications. Compared with previous studies, a high proportion of adequately treated patients was found among women (44.9%). Only 30.4% of hypertensive men were treated, and as a result the control rate was lower (13.3%)., Conclusion: Major sex-related differences are found in the control of high BP, with an unexpected high rate observed among Caribbean women. Better awareness and higher treatment rates play an important role in explaining such results. This may be important, especially in developing countries, where poor control of hypertension is a major cause of cardiovascular diseases.

The Aims of Our Study Were: (i). to estimate the yearly incidence rates based on one vs two visits in a working population and (ii). to identify incident hypertension modifiable risk factors. A total of 21566 normotensive subjects were included in a 1-year cohort study. Blood pressure (BP) levels at inclusion and at the second year screening were measured on the basis of two visits, that is, if BP was over 140/90 mmHg in untreated subjects, they were invited to a control visit 1 month later. Height and weight were measured and behavioural risk factors were collected. Among the 17465 subjects who completed the entire protocol (9691 men and 7774 women), 17026 remained normotensive at a 1-year interval and 439 (325 men and 114 women) became hypertensive. Crude yearly incidence rates based on one visit were 6.21% in men and 3.06% in women, compared with 3.04% in men and 1.34% in women when incidence rates were based on two visits, a more than twofold difference. Age and body mass index at baseline were the two major independent determinants of incident hypertension in both genders. Smoking and alcohol consumption were significant risk factors in men but not in women, and a low educational level only in women. BP measurement on separate occasions is necessary to avoid overestimation of incidence. Weight in both genders and alcohol consumption in men were the main modifiable predictors of hypertension.

Objective: To explore the relation between risk factors (RF) and occupational mobility in working men., Setting: 20 000 volunteers working at the French National Electricity and Gas Company (GAZEL cohort)., Participants: Men aged 43 to 53 years in 1992., Design: Three designs were used for analysis. (1) The association between occupational mobility experienced before 1992 and RF reported at that date was analysed among 10 383 men. (2) The predictive role of RF on occupational mobility over 1992-1999 was studied in a subsample of 4715 men. (3) Reciprocally, occupational mobility in 1985-1992 was analysed in relation to RF changes over 1993-1999., Main Outcome Measures: Self reported smoking status, excessive alcohol consumption, arterial hypertension, and overweight. Occupational mobility defined by any upward transition between senior executives and professionals/middle executives/employees, and workers., Results: (1) Cross sectionally, non-mobile men as their entry into the company had a higher risk of being smokers, excessive alcohol drinkers, and overweight in 1992 than mobile men. (2) Longitudinally, smokers and excessive alcohol drinkers in 1992 had a higher risk of non-mobility than, respectively, non-smokers and non-excessive alcohol drinkers. (3) Non-mobile men in 1985-1992 had a higher risk of becoming smokers, excessive alcohol drinkers, and hypertensive in 1993-1999 than upwardly mobile men., Conclusion: These results suggest a complex relation between RF and occupational mobility. A high level of RF, particularly health behaviours, might account for a selection process reducing upward occupational mobility. In turn, a lack of upward occupational mobility might be associated with an increased incidence of RF.

Elderly patients with isolated systolic hypertension (ISH)--systolic blood pressure (SBP) > or =140 mmHg and diastolic blood pressure (DBP) <90 mmHg--have increased mortality and morbidity. The aim was to study the incidence of ISH in a younger population of between 15 and 60 years of age, and to measure pulse pressure (PP), mean arterial pressure (MAP) and heart rate (HR) in these subjects. The study population consisted of 27 783 subjects, aged 15-60 years, untreated for hypertension (HT) from a cohort of employees formed to study the incidence of HT in the French working population (AIHFP). BP and HR were measured with a validated, automatic device after 5, 6 and 7 min at rest. The prevalence of ISH was 6.9% in men, 2.3% in women. This prevalence was over 5% in young men and increased at 40-44 years; it was negligible in young women, but increased at 50-54 years to about 10% (ie to the same level as in men of the same age): PP in subjects with ISH (46.9 mmHg) was significantly higher than in the normotensive group (NT-40.9 mmHg); it was comparable in both young men (65.5 mmHg) and older men (66 mmHg); it was higher in men (63.1 mmHg) than in women (61.5 mmHg). HR was higher in ISH than in NT and it was higher in women ( approximately 5 bpm) in whom it decreased with age. The prevalence of ISH is not negligible in HT (30% men, 25% women), with a high prevalence in young subjects and elevated PP, MAP and HR values. These data should be taken into account as elevated ISH, PP and HR are considered as cardio-vascular risk factors.

In addition to conventional risk factors, environmental and occupational strain is an actor of the development and evolution of cardiovascular diseases. In industrialised countries, cardiovascular mortality is inversely correlated with the socio-economic level and type of occupation. In the French Ihpaf study, systemic hypertension and obesity were correlated with the socio-economic level. Among possible explanations for the importance of occupational environment, psychological stress at work, sedentary jobs, passive smoking and shift working may all play a role. Thus, beyond the conventional approach to individual risk factor management, it appears necessary to consider cardiovascular prevention through collective actions taking into account occupational environment.

To analyze the health disparities relative to the prevalence of arterial hypertension and its therapeutic control in the active French population, in relation to occupational categories (OC), a population of 17 359 men and 12 267 women was assessed from January 1997 to April 1998. The initial phase was a cross-sectional analysis of a cohort study designed to assess the incidence of arterial hypertension in a French working population. Information was collected by the worksite physician during the annual examination. Blood pressure (BP) was measured using a validated automatic device. Among subjects with a BP > or =140/90 mm Hg, patients not treated with antihypertensive drugs were invited to have an additional BP measurement, 1 month later. Overall prevalence was 16.1% for men and 9.4% for women. Both prevalence and therapeutic control of high BP were related to OCs in this study. Prevalence of hypertension was higher and maintenance of therapeutic control lower among lower OCs. In contrast, awareness of high BP and the proportion of hypertensive subjects under current treatment were not related to OCs. Educational level and low OC were significantly related to prevalence of high BP after adjustment for obesity, excessive alcohol consumption, and sedentary lifestyle in women only. A poor BP control under treatment was related to high alcohol intake and low OC in men. In women only, however, low educational level was related to high prevalence of hypertension and poor BP control under antihypertensive treatment. Inequalities in hypertension prevalence persist, with prevalence being higher among lower OCs. Social disparities were not observed, however, in awareness of their condition among hypertensive subjects and among patients for receiving versus not receiving any treatment for hypertension. In contrast, BP control under antihypertensive treatment was lower among lower OCs.