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Abstract Background We aimed to measure the variance due to examination conditions during the first sessions of objective structured clinical examinations (OSCEs) performed at a French medical school and identify factors associated with student success. Methods We conducted a retrospective, observational study using data from the first three OSCEs sessions performed at Paris-Saclay medical school in 2021 and 2022. For all sessions (each organized in 5 parallel circuits), we tested a circuit effect using a linear mixed-effects model adjusted for sex and the average academic level of students (according to written tests). Then, we studied the factors associated with student success at one station using a multivariate linear mixed-effects model, including the characteristics of students, assessors, and standardized patients. Results The study included three OSCEs sessions, with 122, 175, and 197 students and a mean (± SD) session score of 13.7(± 1.5)/20, 12.7(± 1.7)/20 and 12.7(± 1.9)/20, respectively. The percentage of variance due to the circuit was 6.5%, 18.2% (statistically significant), and 3.8%, respectively. For all sessions, the student’s average level and station scenario were significantly associated with the score obtained in a station. Still, specific characteristics of assessors or standardized patients were only associated with the student’s score in April 2021 (first session). Conclusion The percentage of the variance of students’ performance due to the examination conditions was significant in one out of three of the first OSCE sessions performed at Paris-Saclay medical school. This result seems more related to individual behaviors rather than specific characteristics of assessors or standardized patients, highlighting the need to continue training teaching teams. National clinical trial number Not applicable.

Objective In many countries, before COVID-19 vaccines became available, reluctance to get vaccinated was particularly prevalent among women, the most disadvantaged social groups and ethnoracial minorities, known to be at higher risk for the virus. Using a longitudinal perspective, we analyse the social determinants that are associated with the transition from attitudes towards vaccination to actual vaccination practices.Design Representative population-based prospective cohort.Settings From November 2020 to July 2021.Participants Adults included in the Epidemiology and Living Conditions (EpiCoV) cohort (n=86 701).Main outcome measures Attitudes towards vaccination in November 2020 before COVID-19 vaccines were available in France (in January 2021) and vaccination practices in July 2021.Results Among those who were initially reluctant in November 2020, the youngest, the poorest 10% (OR=0.68, 0.59–0.77), non-European immigrants (OR=0.72, 0.59–0.88) and descendants of non-European immigrants (OR=0.72, 0.61–0.86) were less likely to be vaccinated in July 2021, irrespective of trust in government and scientists. The same social factors were associated with non-vaccination among those who initially were undecided or who favoured vaccination.Conclusion Despite the fact that COVID-19 vaccines were relatively available and free of charge in France in July 2021, social inequalities in vaccination against the virus remained the same than those observed in vaccination reluctance in November 2020, before vaccines were available. While adjusting for trust, migration background, younger age and lower income were associated with lower vaccination uptake irrespective of initial intention. By neglecting to genuinely target specific groups that were initially reluctant to be vaccinated, vaccination policies contributed to strengthening pre-existing social inequalities around COVID-19 burden.

Abstract Several risk factors of children’s mental health issues have been identified during the pandemic of COronaVIrus Disease first appeared in 2019 (COVID-19). This study aims to fill the knowledge gap regarding the association between parents’ and children’s mental health issues during the COVID-19 school closure in France. We conducted a cross-sectional analysis of data collected in the SAPRIS-ELFE study during the COVID-19 pandemic in France. Using multinomial logistic regressions, we estimated associations between parents’ and children’s mental health issues. Symptoms of anxiety were assessed by the General Anxiety Disorder-7 (GAD-7) and depression by the Patient Health Questionnaire-9 (PHQ-9) for the parents. Hyperactivity/inattention and emotional symptoms in children were assessed by the Strengths and Difficulties Questionnaire (SDQ). The sample included 3496 children aged 8 to 9 years, of whom 50.0% were girls. During the school closure, 7.1% of responding parents had moderate to severe levels of anxiety and 6.7% had moderate to severe levels of depression. A total of 11.8% of the children had an abnormal hyperactivity/inattention score and 6.6% had an abnormal emotional symptoms score. In multivariate regression models, parental moderate to severe level of anxiety and moderate to severe level of depression were associated with abnormal hyperactivity-inattention score (adjusted Odds Ratio (aOR) 3.31; 95% Confidence Interval (CI) 2.33–4.70 and aOR 4.65; 95% CI 3.27–6.59, respectively) and abnormal emotional symptoms score in children (aOR 3.58; 95% CI 2.33–5.49 and aOR 3.78; 95 CI 2.47–5.78 respectively). Children whose parents have symptoms of anxiety and/or depression have an increased likelihood of symptoms of hyperactivity/inattention and emotional symptoms during school closures in France due to COVID-19. Our findings suggest that public health initiatives should target parents and children to limit the impact of such crises on their mental health issues.

Abstract Background Improving eHealth literacy (eHL) is one of the biggest challenges currently facing the global healthcare community. Indeed the use of digital services has the potential to engage patients in care as well as improve the effectiveness of chronic disease self-management, it remains highly dependent on a patient’s specific skills and experiences in the health care systems. Although eHealth literacy has gained momentum in the past decade, it remains an underresearched area, particularly eHealth literacy measurement. The aim of the review is to identify patient-reported outcome measures (PROMs) of eHealth literacy for adult populations and to summarize the evidence on their psychometric properties. Methods We will conduct a systematic literature review of the tools used to measure eHealth literacy for adult population. The search strategy aims to find published studies. A three-step search strategy will be used in this review. Published studies will be searched in CINAHL, PubMed, PsycINFO, and Web of Science from inception until end. Grey literature will be searched to find theses. Database search strategies will be formulated and tested with the assistance of an expert Health Sciences Librarian. The selection of studies will be done by two independent reviewers. Disagreements will be resolved through consensus, and a third reviewer will solve discrepancies. Furthermore, two reviewers will independently evaluate the methodological rigor of the instruments development and testing and assign a grade using the standardized Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Disagreements will be discussed with a third reviewer, expert in psychometrics. Extracted data will be aggregated and analyzed to produce a set of synthesized findings that will be used to develop evidence-informed recommendations in regard of eHL instruments. We will present a synthesis of all instruments, their psychometric properties, and make recommendations for eHL instrument selection in practice. Reporting will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and a PRISMA flow diagram. Discussion This systematic review will summarize the evidence on the psychometric properties of PROMs instruments used to measure eHL and will help clinicians, managers, and policy-makers to select an appropriate instrument. Systematic review registration PROSPERO CRD42021232765

BackgroundThe development of telehealth and telemedicine, in the form of increased teleconsultation and medical telemonitoring, accelerated during the COVID-19 health crisis in France to ensure continued access to care for the population. Since these new information and communication technologies (ICTs) are diverse and likely to transform how the health care system is organized, there is a need better to understand public attitudes toward them and their relationship with peoples’ current experience of health care. ObjectiveThis study aimed to determine the French general population’s perception of the usefulness of video recording/broadcasting (VRB) and mobile Health (mHealth) apps for medical consultations in France during the COVID-19 health crisis and the factors associated with this perception. MethodsData were collected for 2003 people in 2 waves of an online survey alongside the Health Literacy Survey 2019 (1003 in May 2020 and 1000 in January 2021) based on quota sampling. The survey collected sociodemographic characteristics, health literacy levels, trust in political representatives, and perceived health status. The perceived usefulness of VRB in medical consultations was measured by combining 2 responses concerning this technology for consultations. The perceived usefulness of mHealth apps was measured by combining 2 responses concerning their usefulness for booking doctor appointments and for communicating patient-reported outcomes to doctors. ResultsThe majority (1239/2003, 62%) of respondents considered the use of mHealth apps useful, while only 27.6% (551/2003) declared VRB useful. The factors associated with the perceived usefulness of both technologies were younger age (≤ 55 years), trust in political representatives (VRB: adjusted odds ratio [aOR] 1.68, 95% CI 1.31-2.17; mHealth apps: aOR 1.88, 95% CI 1.42-2.48), and higher (sufficient and excellent) health literacy. The period of the beginning of the COVID-19 epidemic, living in an urban area, and being limited in daily activities were also associated with perceiving VRB positively. The perceived usefulness of mHealth apps increased with the level of education. It was also higher in people who had 3 or more consultations with a medical specialist. ConclusionsThere are important differences in attitudes toward new ICTs. Perceived usefulness was lower for VRB than for mHealth apps. Moreover, it decreased after the initial months of the COVID-19 pandemic. There is also the possibility of new inequalities. Hence, despite the potential benefits of VRB and mHealth apps, people with low health literacy considered them to be of little use for their health care, possibly increasing their difficulties in accessing health care in the future. As such, health care providers and policy makers need to consider those perceptions to guarantee that new ICTs are accessible and beneficial to all.

BackgroundA higher risk of suicidal ideation associated with self-report of Coronavirus Disease 2019 (COVID-19)-like symptoms or COVID-19 infection has been observed in cross-sectional studies, but evidence from longitudinal studies remains limited. The aims of this study were 2-fold: (1) to explore if self-reported COVID-19-like symptoms in 2020 were associated with suicidal ideation in 2021; (2) to explore if the association also existed when using a biological marker of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in 2020.Methods and findingsA total of 52,050 participants from the French EpiCov cohort were included (median follow-up time = 13.7 months). In terms of demographics, 53.84% were women, 60.92% were over 45 years old, 82.01% were born in mainland France from parents born in mainland France, and 59.38% completed high school. COVID-19-like symptoms were defined as participant report of a sudden loss of taste/smell or fever alongside cough, shortness of breath, or chest oppression, between February and November 2020. Symptoms were self-reported at baseline in May 2020 and at the first follow-up in Autumn 2020. Serology-confirmed SARS-CoV-2 infection in 2020 was derived from Spike protein ELISA test screening in dried-blood-spot samples. Samples were collected from October 2020 to March 2021, with 94.4% collected in 2020. Suicidal ideation since December 2020 was self-reported at the second follow-up in Summer 2021. Associations of self-reported COVID-19-like symptoms and serology-confirmed SARS-CoV-2 infection in 2020 with suicidal ideation in 2021 were ascertained using modified Poisson regression models, weighted by inverse probability weights computed from propensity scores. Among the 52,050 participants, 1.68% [1.54% to 1.82%] reported suicidal ideation in 2021, 9.57% [9.24% to 9.90%] had a serology-confirmed SARS-CoV-2 infection in 2020, and 13.23% [12.86% to 13.61%] reported COVID-19-like symptoms in 2020. Self-reported COVID-19-like symptoms in 2020 were associated with higher risks of later suicidal ideation in 2021 (Relative Riskipw [95% CI] = 1.43 [1.20 to 1.69]), while serology-confirmed SARS-CoV-2 infection in 2020 was not (RRipw = 0.89 [0.70 to 1.13]). Limitations of this study include the use of a single question to assess suicidal ideation, the use of self-reported history of mental health disorders, and limited generalizability due to attrition bias.ConclusionsSelf-reported COVID-19-like symptoms in 2020, but not serology-confirmed SARS-CoV-2 infection in 2020, were associated with a higher risk of subsequent suicidal ideation in 2021. The exact role of SARS-CoV-2 infection with respect to suicide risk has yet to be clarified. Including mental health resources in COVID-19-related settings could encourage symptomatic individuals to care for their mental health and limit suicidal ideation to emerge or worsen.

Abstract COVID-19 limitation strategies have led to widespread school closures around the world. The present study reports children’s mental health and associated factors during the COVID-19 school closure in France in the spring of 2020. We conducted a cross-sectional analysis using data from the SAPRIS project set up during the COVID-19 pandemic in France. Using multinomial logistic regression models, we estimated associations between children’s mental health, children’s health behaviors, schooling, and socioeconomic characteristics of the children’s families. The sample consisted of 5702 children aged 8–9 years, including 50.2% girls. In multivariate logistic regression models, children’s sleeping difficulties were associated with children’s abnormal symptoms of both hyperactivity-inattention (adjusted Odds Ratio (aOR) 2.05; 95% Confidence Interval 1.70–2.47) and emotional symptoms (aOR 5.34; 95% CI 4.16–6.86). Factors specifically associated with abnormal hyperactivity/inattention were: male sex (aOR 2.29; 95% CI 1.90–2.76), access to specialized care prior to the pandemic and its suspension during school closure (aOR 1.51; 95% CI 1.21–1.88), abnormal emotional symptoms (aOR 4.06; 95% CI 3.11–5.29), being unschooled or schooled with assistance before lockdown (aOR 2.13; 95% CI 1.43–3.17), and tutoring with difficulties or absence of a tutor (aOR 3.25; 95% CI 2.64–3.99; aOR 2.47; 95% CI 1.48–4.11, respectively). Factors associated with children’s emotional symptoms were the following: being born pre-term (aOR 1.34; 95% CI 1.03–1.73), COVID-19 cases among household members (aOR 1.72; 95% CI 1.08–2.73), abnormal symptoms of hyperactivity/inattention (aOR 4.18; 95% CI 3.27–5.34) and modest income (aOR 1.45; 95% CI 1.07–1.96; aOR 1.36; 95% CI 1.01–1.84). Multiple characteristics were associated with elevated levels of symptoms of hyperactivity-inattention and emotional symptoms in children during the period of school closure due to COVID-19. Further studies are needed to help policymakers to balance the pros and cons of closing schools, taking into consideration the educational and psychological consequences for children.

Abstract Background The Patient Reported Outcome Measurement Information System profile instruments include “high information” items drawn from large item banks following the application of modern psychometric criteria. The shortest adult profile, PROMIS-29, looks set to replace existing short-form instruments in research and clinical practice. The objective of this study was to undertake the first psychometric evaluation of the Norwegian PROMIS-29, following a postal survey of a random sample of 12,790 Norwegians identified through the National Registry of the Norwegian Tax Administration. Confirmatory factor analysis was used to assess structural validity. Fit to the Rasch partial credit model and differential item functioning (DIF) were assessed in relation to age, gender, and education. PROMIS-29 scores were compared to those for the EQ-5D-5L and the Self-assessed Comorbidity Questionnaire (SCQ), for purposes of assessing validity based on a priori hypotheses. Results There were 3200 (25.9%) respondents with a mean age (SD) of 51 (20.7, range 18 to 97 years) and 55% were female. The PROMIS-29 showed satisfactory structural validity and acceptable fit to Rasch model including unidimensionality, and measurement invariance across age and education levels. One pain interference item had uniform DIF for gender but splitting gave satisfactory fit. Domain reliability estimates ranged from 0.85 to 0.95. Correlations between PROMIS-29 domain, SCQ and EQ-5D scores were largely as expected, the largest being for scores assessing very similar aspects of health. Conclusions The Norwegian version of the PROMIS-29 is a reliable and valid generic self-reported measure of health in the Norwegian general population. The instrument is recommended for further application, but the analysis should be replicated and responsiveness to change assessed in future studies before it can be recommended for clinical and health services evaluation in Norway.

Introduction : L’utilisation de services numériques en santé (e-santé) a le potentiel d’améliorer la participation des patients aux soins et à l’autogestion des maladies chroniques. Dès lors, les professionnels de la santé doivent tenir compte de la littératie en santé numérique (LSN) des patients lorsqu’ils dispensent des soins à l’aide de technologies d’e-santé. L’objectif de cette revue est d’identifier les instruments de mesure auto-rapportés de la littératie en santé numérique disponibles dans la littérature et rassembler les informations concernant leurs propriétés psychométriques pour aider les chercheurs et cliniciens à choisir un instrument. Méthode : Une revue systématique de la littérature des instruments de mesure de la LSN a été réalisée en appliquant la méthodologie COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments). Résultats : Dix instruments ont été identifiés à partir de 41 articles provenant de quatre bases de données (PubMed, CINAHL, PsycInfo et Web of Science). Le plus utilisé, le eHEALS, instrument unidimensionnel, a été développé avant l’essor de l’e-santé. Quatre instruments, le HLSI, le e-Health Literacy Scale 2.0, le e-HLS et le eHEALS-E ont démontré une validité du contenu (pertinence, exhaustivité et compréhensibilité) inadéquate. Les cinq instruments multidimensionnels développés reflètent le concept de littératie en santé numérique de façon plus large, mais les preuves de leurs qualités psychométriques sont insuffisantes. Discussion et conclusion : Il est fortement recommandé de mettre à jour le contenu des instruments afin de refléter les aptitudes des patients à utiliser les services numériques pour leur santé. En outre, l’étude des qualités psychométriques des instruments utilisés doit être réalisée de façon systématique.

ObjectiveTo examine the relationship between young adults' labor force participation and depression in the context of the COVID-19 pandemic.Design, setting, participantsData come from the nationally-representative EPICOV cohort study set up in France, and were collected in 2020 and 2021 (3 waves of online or telephone interviews: 02/05/2020–12/06/2020; 26/10/2020–14/12/2020; 24/06/2021–09/08/2021) among 2,217 participants aged 18–30 years. Participants with prior mental health disorder (n = 50) were excluded from the statistical analyses.ResultsUsing Generalized Estimating Equation (GEE) models controlled for participants' socio-demographic and health characteristics and weighted to be nationally-representative, we found that compared to young adults who were employed, those who were studying or unemployed were significantly more likely to experience depression assessed using the PHQ-9 (multivariable ORs, respectively: OR: 1.29, 95% CI 1.05–1.60 and OR: 1.50, 1.13–1.99). Stratifying the analyses by age, we observed that unemployment was more strongly associated with depression among participants 25–30 years than among those who were 18–24 years (multivariable ORs, respectively, 1.78, 95% CI 1.17–2.71 and 1.41, 95% CI 0.96–2.09). Being out of the labor force was, to the contrary, more significantly associated with depression among participants 18–24 years (multivariable OR: 1.71, 95% CI 1.04–2.82, vs. 1.00, 95% CI 0.53–1.87 among participants 25–30 years). Stratifying the analyses by sex, we found no significant differences in the relationships between labor market characteristics and depression (compared to participants who were employed, multivariable ORs associated with being a student: men: 1.33, 95% CI 1.01–1.76; women: 1.19, 95% CI 0.85–1.67, multivariable ORs associated with being unemployed: men: 1.60, 95% CI 1.04–2.45; women: 1.47, 95% CI 1.01–2.15).Conclusions and relevanceOur study shows that in addition to students, young adults who are unemployed also experience elevated levels of depression in the context of the COVID-19 pandemic. These two groups should be the focus of specific attention in terms of prevention and mental health treatment. Supporting employment could also be a propitious way of reducing the burden of the COVID-19 pandemic on the mental health of young adults.

ObjectiveTo assess whether lack of trust in the government and scientists reinforces social and racial inequalities in vaccination practices.DesignA follow-up of the EpiCov random population-based cohort survey.SettingIn July 2021, in France.ParticipantsEighty-thousand nine hundred and seventy-one participants aged 18 years and more.Main Outcome MeasuresAdjusted odds ratios of COVID-19 vaccination status (received at least one dose/ intends to get vaccinated/ does not know whether to get vaccinated/refuses vaccination) were assessed using multinomial regressions to test associations with social and trust factors and to study how these two factors interacted with each other.ResultsIn all, 72.2% were vaccinated at the time of the survey. The population of unvaccinated people was younger, less educated, had lower incomes, and more often belonged to racially minoritized groups, as compared to vaccinated people. Lack of trust in the government and scientists to curb the spread of the epidemic were the factors most associated with refusing to be vaccinated: OR = 8.86 (7.13 to 11.00) for the government and OR = 9.07 (7.71 to 10.07) for scientists, compared to vaccinated people. Lack of trust was more prevalent among the poorest which consequently reinforced social inequalities in vaccination. The poorest 10% who did not trust the government reached an OR of 16.2 (11.9 to 22.0) for refusing to be vaccinated compared to the richest 10% who did.ConclusionThere is a need to develop depoliticised outreach programmes targeted at the most socially disadvantaged groups, and to design vaccination strategies conceived with people from different social and racial backgrounds to enable them to make fully informed choices.

We aimed to analyze inequalities in social isolation among older adults in a time of COVID-19 social restrictions, using a gender perspective. A random population-based survey, including 21,543 older adults (65+) was conducted during and post COVID-19 lockdown in France. Our main outcome was a three-dimension indicator of social isolation based on living conditions, i.e., living alone (i) and not having gone out in the past week (ii), completed by an indicator measuring Internet use i.e., never using the Internet (iii). Logistic regressions were used to identify factors associated with isolation for women and men. Women were more likely to live alone (aOR = 2.72 [2.53; 2.92]), not to have gone out in the past week (aOR = 1.53 [1.39; 1.68]), and not to use the Internet (aOR = 1.30 [1.20; 1.44]). In addition to gender effects, being older, at the bottom of the social hierarchy, and from an ethno-racial minority was also associated with social isolation. Preventive policies should take into account these inequalities when addressing the issue of social isolation among older women and men, so as to enable all social groups to maintain social contacts, and access health information.

Abstract Background The Catquest-9SF questionnaire is a patient reported outcome measure that quantifies the visual benefits from cataract surgery. The purpose of this study was to translate and adapt the Catquest-9SF questionnaire for France, to assess its psychometric properties via Rasch analysis, and to assess its validity when completed using an electronic notepad. Methods The Catquest-9SF questionnaire was translated following the guidelines of the International Society for Pharmacoeconomics and Outcomes Research. Catquest-9SF and clinical data were collected from patients before and after routine cataract surgery. All questionnaire data were collected via an electronic notepad. Rasch analysis was performed to assess psychometric properties, and sensitivity to change was analysed for patients with complete paired pre- and post-operative questionnaires. Results A complete filled-in preoperative questionnaire was obtained for 848 patients. Rasch analysis showed good precision (person separation: 2.32, person reliability: 0.84), ordered category probability curves, no item misfit, and unidimensionality. The respondents were slightly more able than the level of item difficulty (targeting: −1.12 logits). Sensitivity was analysed on 211 paired questionnaires, and the postoperative questionnaires showed a clear ceiling effect. The effect size was 2.6. The use of an electronic notepad for completing the questionnaire worked out very well after some adjustments. Conclusions The French version of Catquest-9SF has good psychometric properties and is suitable for use in French-speaking patients. The use of the Catquest-9SF questionnaire in an electronic format showed good validity.

Abstract Background Our main objectives were to estimate the incidence of illnesses presumably caused by SARS-CoV-2 infection during the lockdown period and to identify the associated risk factors. Methods Participants from 3 adult cohorts in the general population in France were invited to participate in a survey on COVID-19. The main outcome was COVID-19-Like Symptoms (CLS), defined as a sudden onset of cough, fever, dyspnea, ageusia and/or anosmia, that lasted more than 3 days and occurred during the 17 days before the survey. We used delayed-entry Cox models to identify associated factors. Results Between April 2, 2020 and May 12, 2020, 279,478 participants were invited, 116,903 validated the questionnaire and 106,848 were included in the analysis. Three thousand thirty-five cases of CLS were reported during 62,099 person-months of follow-up. The cumulative incidences of CLS were 6.2% (95% Confidence Interval (95%CI): 5.7%; 6.6%) on day 15 and 8.8% (95%CI 8.3%; 9.2%) on day 45 of lockdown. The risk of CLS was lower in older age groups and higher in French regions with a high prevalence of SARS-CoV-2 infection, in participants living in cities > 100,000 inhabitants (vs rural areas), when at least one child or adolescent was living in the same household, in overweight or obese people, and in people with chronic respiratory diseases, anxiety or depression or chronic diseases other than diabetes, cancer, hypertension or cardiovascular diseases. Conclusion The incidence of CLS in the general population remained high during the first 2 weeks of lockdown, and decreased significantly thereafter. Modifiable and non-modifiable risk factors were identified.

Objective Although social inequalities in COVID-19 mortality by race, gender and socioeconomic status are well documented, less is known about social disparities in infection rates and their shift over time. We aim to study the evolution of social disparities in infection at the early stage of the epidemic in France with regard to the policies implemented.Design Random population-based prospective cohort.Setting From May to June 2020 in France.Participants Adults included in the Epidémiologie et Conditions de Vie cohort (n=77 588).Main outcome measures Self-reported anosmia and/or ageusia in three categories: no symptom, during the first epidemic peak (in March 2020) or thereafter (during lockdown).Results In all, 2052 participants (1.53%) reported anosmia/ageusia. The social distribution of exposure factors (density of place of residence, overcrowded housing and working outside the home) was described. Multinomial regressions were used to identify changes in social variables (gender, class and race) associated with symptoms of anosmia/ageusia. Women were more likely to report symptoms during the peak and after. Racialised minorities accumulated more exposure risk factors than the mainstream population and were at higher risk of anosmia/ageusia during the peak and after. By contrast, senior executive professionals were the least exposed to the virus with the lower rate of working outside the home during lockdown. They were more affected than lower social classes at the peak of the epidemic, but this effect disappeared after the peak.Conclusion The shift in the social profile of the epidemic was related to a shift in exposure factors under the implementation of a stringent stay-at-home order. Our study shows the importance to consider in a dynamic way the gender, socioeconomic and race direct and indirect effects of the COVID-19 pandemic, notably to implement policies that do not widen health inequalities.

BackgroundSeveral countries have implemented mobile apps in an attempt to trace close contacts of patients with COVID-19 and, in turn, reduce the spread of SARS-CoV-2. However, the effectiveness of this approach depends on the adherence of a large segment of the population. ObjectiveThe aims of this study were to evaluate the acceptability of a COVID-19 contact tracing mobile app among the French population and to investigate the barriers to its use. MethodsThe Health Literacy Survey 2019 questioned 1003 people in France during the COVID-19 pandemic on the basis of quota sampling. The survey collected sociodemographic characteristics and health literacy data, as well as information on participants’ communication with caregivers, trust in institutions, and COVID-19 knowledge and preventive behaviors. The acceptability of a mobile app for contact tracing was measured by a single question, the responses to which were grouped into three modalities: app-supporting, app-willing, and app-reluctant. Multinomial logistic regression analysis was performed to identify the factors associated with the acceptability of a mobile app during the COVID-19 pandemic. ResultsOnly 19.2% (193/1003) of all participants were app-supporting, whereas half of them (504/1003, 50.3%) were reluctant. The factors associated with willingness or support toward the contact tracing app included lower financial deprivation (app-willing: adjusted odds ratio [aOR] 0.8, 95% CI 0.69-0.93; app-supporting: aOR 0.7, 95% CI 0.58-0.84) and higher perceived usefulness of using a mobile app to send completed health questionnaires to doctors (app-willing: aOR 2.3, 95% CI 1.70-3.26; app-supporting: aOR 3.1, 95% CI 2.04-4.82). Furthermore, the likelihood of supporting the mobile app increased with age over 60 years (aOR 1.9, 95% CI 1.13-3.22), trust in political representatives (aOR 2.7, 95% CI 1.72-4.23), feeling concerned about the pandemic situation (aOR 2.2, 95% CI 1.47-3.32), and knowledge about the transmission of COVID-19 (aOR 2.0, 95% CI 1.39-2.96). ConclusionsThe most socioeconomically precarious people, who are at a higher risk of SARS-CoV-2 infection, are also the most reluctant to using a contact tracing mobile app. Therefore, optimal adherence can only be effective with a targeted discourse on public health benefits to adopt such an app, which should be combined with a reduction in inequalities by acting on structural determinants.

BACKGROUND:While patient-centered care is recommended as a key dimension for quality improvement, in case of serious illness, patients may have different expectations regarding information and participation in medical decision-making. In oncology, anticipation of disease worsening remains difficult, especially when patient's preferences towards prognosis medical information are unclear. Valid tools to explore patients' preferences could help targeting end-of-life discussions, which have been shown to decrease aggressiveness of end-of-life care. Our aim was to establish the validity and reliability of the French version of the Autonomy Preference Index (API) among patients with incurable cancer and in primary care setting. Three supplementary items were specifically developed to evaluate preparedness to anticipate disease deterioration among patients with incurable cancer. METHODS:The psychometric properties of the API translated into French were assessed among patients consecutively recruited from January to March 2017 in the waiting rooms of 19 general practitioners (N = 391) and in an oncology (N = 187) clinic in Paris. Relationships between the newly-developed items and the API subscale scores were studied. RESULTS:A three correlated factors confirmatory model (two factors related to decision-making and a factor related to information-seeking preferences) showed an acceptable fit on the whole sample and no measurement invariance issue was found across settings, age, sex and educational level. Internal consistency and test-retest reliability were acceptable for the information-seeking and decision-making subscales. One of the newly-developed items on patients' ability to anticipate a decision on the use of artificial respiration if a sudden deterioration of their illness occurred was not related to the API subscale scores. CONCLUSION:The French version of the API was found valid and reliable for use in general practice and oncology settings. The additional items on patient preparedness to anticipate disease deterioration can be of interest to ensure that patient values guide all end-of-life clinical decisions.

Abstract Background Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures. Methods A multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort. Results Among the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72–79%), specificity 79% (77–80%) and area under the receiver operating characteristic curve 0.83 (0.81–0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients. Conclusion The Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.

Abstract Background Health literacy is a key asset, defined as the capacity to acquire, understand and use information in ways which promote and maintain good health. Objectives To assess the reliability and validity of the French translation of the Functional, Communicative and Critical Health Literacy (FCCHL) scale. Methods/participants A cross-sectional survey using an online questionnaire was proposed to all members of Seintinelles association. Exploratory and confirmatory factorial analyses were conducted. Results Data from 2342 respondents (45.8% had cancer history) were analysed. The FCCHL scale was well-accepted (missing value by item ≤0.7%). Factor analysis revealed an acceptable fit of three-factor model (comparative fit index = 0.922, root mean square error of approximation = 0.065 and standardized root mean square residual = 0.052). The FCCHL showed satisfactory reliability (α = 0.77) and scalar invariance was reached for education and deprivation, but not for age. Known group validity was verified as mean scale scores differed according to education, deprivation and age, as expected. Conclusion The French version of the FCCHL provides a brief reliable and valid measure to explore the dimensions of health literacy. It could be used by health professionals to screen for health literacy level in order to develop this skill and to tailor health communication.

Abstract Based on evolutionary theory, a recent model in affective neuroscience delineated six emotional brain systems at the core of human personality: SEEKING, CARING, PLAYFULNESS, FEAR, ANGER, SADNESS. The Affective Neuroscience Personality Scales (ANPS) assess their functioning. Using a person-centred approach of the ANPS, this study: (i) examined the existence of latent personality profiles, (ii) studied their gender invariance, (iii) assessed their longitudinal (4 years) stability, and (iv) explored how they relate to several intrapersonal, interpersonal, and emotion regulation skills. Latent Profile Analysis in 2 samples (Canadian, longitudinal, N = 520; French, cross-sectional, N = 830) found that, qualitatively, 3 profiles characterized both populations and genders, with one distinction for the second profile where the French women endorsed slightly higher and lower scores for, respectively, the negative and positive emotions. Whilst not being quantitatively similar across genders, the personality profiles remained consistent across time in the longitudinal sample. Associations between profiles and intrapersonal (e.g. depression), interpersonal (e.g. empathy), and emotion regulation skills measures (e.g. emotional intelligence) offered concurrent validity evidence. This person centred approach to ANPS offers a holistic and parsimonious way to study affective personality dimensions. It opens promising avenues for future studies on the predictive value of ANPS profiles, and for personality-targeted interventions.

BackgroundTransporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).MethodsA retrospective cohort study was performed using 2015-2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records. Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality. Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3-1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12-0.19].ConclusionIn an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.

ObjectiveThe aims were to review practices concerning Differential Item Functioning (DIF) detection in composite measurement scales, particularly those used in health research, and to provide guidance on how to proceed if statistically significant DIF is detected.MethodsThis work specifically addressed the Rasch model which is the subject of growing interest in the field of health owing to its particularly advantageous properties. There were three steps: 1) Literature review to describe current practices; 2) Simulation study to determine under which conditions encountered in health research studies can erroneous conclusions be drawn from group comparisons when a scale is affected by DIF but which is not considered; 3) Based on steps 1 and 2, formulation of recommendations that were subsequently reviewed by leading internationally recognized experts.ResultsFour key recommendations were formulated to help researchers to determine whether statistically significant DIF is meaningful in practice, according to the kind of DIF (uniform or non-uniform) and the DIF effect size.ConclusionThis work provides the first recommendations on how to deal in practice with the presence of DIF in composite measurement scales used in health research studies.

Abstract Background A specific measurement issue often occurs in cohort studies with long-term follow-up: the substitution of the classic instruments used to assess one or several factors or outcomes studied by new, more reliable, more accurate or more convenient instruments. This study aimed to compare three techniques to deal with this issue when the substituted instrument is a questionnaire measuring a subjective phenomenon: one using only the items shared by the different questionnaires over time, i.e. computation of the raw score; the two others using every item, i.e. computation of the standardised score or estimation of the latent variable score using the Rasch model. Methods Two hundred databases were simulated, corresponding to longitudinal 10-item questionnaire data from three trajectory groups of subjects for the subjective phenomenon of interest (“increasing”, “stable-low” or “stable-high” mean trajectory over time). Three copies of these databases were generated and the subjects’ responses to some items were removed at some collection times leading to a number of shared items over time varying from 4 to 10 in the 800 datasets. The performances of Latent Class Growth Analysis (LCGA) applied to the raw score, the standardised score or the latent variable score were studied on these databases according to the number of shared items over time. Results Surprisingly, LCGA applied to the latent variable score estimate did not perform as well as LCGA applied to the standardised score, where it was the most efficient whatever the number of shared items. However, the proportions of correctly classified subjects by LCGA applied to the latent variable score were more balanced across trajectory groups. Conclusions The use of the standardised score to deal with questionnaire changes over time was more efficient than the raw score and also, surprisingly, than the latent variable score. LCGA applied to the raw score was the least efficient and exhibited the most unbalanced misclassifications across trajectory groups. As prospective longitudinal studies with long-term follow-up are more and more common, researchers should be aware of this phenomenon and should reconsider the use of the raw score when changes in the questionnaires used occurred during follow-up.

BackgroundShort versions of the European Health Literacy Survey (HLS-EU) questionnaire are increasingly used to measure and compare health literacy (HL) in populations worldwide. As no validated versions of these questionnaires have thus far appeared in French, this study aimed to study the psychometric properties of the French translation of the 16- and 6-item short versions (HLS-EU-Q16 and HLS-EU-Q6), including their measurement invariance across sex, age, and education level.MethodsA consensual French version of the HLS-EU-Q16 and HLS-EU-Q6 was developed by following the current recommendations for transcultural questionnaire adaptation. It was then completed by 317 patients recruited in waiting rooms of general practitioners in the Paris area (France). Structural validity was studied with the Rasch model for the HLS-EU-Q16 and confirmatory factorial analysis (CFA) for the HLS-EU-Q6. Concurrent and convergent validity, respectively, were assessed by scores on the Functional Communicative Critical Health Literacy (FCCHL) questionnaire and the physicians' evaluations of their patient's HL.ResultsThe 16 items of the HLS-EU-Q16 were Rasch homogenous but meaningful differential item functioning (DIF) was found across sex, age, and/or education level for eight items. The CFA model fit for the HLS-EU-Q6 was poor. The overall scores for both HLS-EU short versions correlated poorly with the FCCHL scores. Similarly, HL levels defined using either short-version score did not agree with physicians' HL assessments.ConclusionThe French version of the HLS-EU-Q16 has acceptable psychometric properties, despite meaningful DIF for age, sex and education level and a poor discriminative power among subjects with average to high HL level. We recommend its use to measure HL in populations with sufficient reading skills to discriminate between subjects with low to average HL. Also, sensitivity analyses should be performed to evaluate the potential measurement bias due to DIF. Our results did not demonstrate the validity of the HLS-EU-Q6.