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Background Although it is the moral duty of physicians to protect vulnerable patients, there are no data on how vulnerability is perceived in clinical practice. This study explores how physicians classify someone as “vulnerable”. Method Thirty-three physicians were initially questioned about resource allocation problems in their work. The results of these interviews were examined with qualitative study software to identify characteristics associated with vulnerability in patients. Data were conceptualized, classified and cross-linked to highlight the major determinants of vulnerability. The findings revealed the principal factors that make patients vulnerable in clinical practice, according to our definition of vulnerability: the likelihood of having one’s interests unjustly considered. Results Vulnerability can arise as a result of a mismatch between the characteristics of patients and physicians, the healthcare system, the treatment, or the communication between physicians and patients. Vulnerability appears as a gap between a patient’s needs and the means intended to meet them. Vulnerability can further be the result of doing too little or too much for patients. This result suggests that structures provided by healthcare systems are not as differentiated as they should be to cover all situations. Our initial definition of vulnerability was illustrated and supported by our results, showing that it encompasses all factors involved, not solely personal characteristics, indicating the need for a more pragmatic approach for use in clinical practice. Conclusion Vulnerability is not due to a single factor but appears under certain circumstances when there is a discrepancy between a patient’s interests and the care provided, despite existing compensation systems.

Context Approaches to priority‐setting for scarce resources have shifted to public deliberation as trade‐offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health‐care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care. Methods We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health‐care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio‐economic backgrounds in the three language regions. Findings Participants developed strategic arguments based on the importance of basic coverage for all, and of cost‐benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable. Conclusion The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade‐offs and setting priorities for complex health issues.

Background As universal health coverage becomes the norm in many countries, it is important to determine public priorities regarding benefits to include in health insurance coverage. We report results of participation in a decision exercise among residents of Switzerland, a high-income country with a long history of universal health insurance and deliberative democracy. Methods We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex healthcare allocation decisions into easily understandable choices, for use in Switzerland. We conducted CHAT exercises in twelve Swiss cities with recruitment from a range of socio-economic backgrounds, taking into account differences in language and culture. Results Compared to existing coverage, a majority of 175 participants accepted greater general practice gatekeeping (94%), exclusion of invasive life-sustaining measures in dying patients (80%), longer waiting times for non-urgent episodic care (78%), greater adherence to cost-effectiveness guidelines in chronic care (66%), and lower premium subsidies (51%). Most initially chose greater coverage for dental care (59%), quality of life (57%), and long-term care (90%). During group deliberations, participants increased coverage for out-of-pocket costs (58%) and mental health to current levels (41%) and beyond current levels for rehabilitation (50%), and decreased coverage for quality of life to current levels (74%). Following group deliberation, they tended to change their views back to below current coverage for help with out-of-pocket costs, and back to current levels for rehabilitation. Most participants accepted the plan as appropriate and fair. A significant number would have added nothing. Conclusion Swiss participants who have engaged in a priority setting exercise accept complex resource allocation tradeoffs in healthcare coverage. Moreover, in the context of a well-funded healthcare system with universal coverage centered on individual choice, at least some of our participants believed a fully sufficient threshold of health insurance coverage was achieved.

Swiss-CHAT’s playful approach to public rationing can be considered in terms of deliberative process design as well as in terms of health policy. The process’ forced negotiation of trade-offs exposed unexamined driving questions, and challenged prevalent presumptions about health care demand and about conditions of public reasoning that enable transparent rationing. While the experiment provided grounds for optimism that public deliberation can contribute to the design of fair insurance service-packages, it also left unanswered questions. What are the ethical and policy implications of non-consensuses? What is the presumed relationship between process and justice of outcome?

Contexte : Cet article s’inscrit dans une étude longitudinale contrôlée à travers laquelle nous avons émis l’hypothèse selon laquelle une éducation thérapeutique centrée sur la personne donnait plus de satisfaction aux professionnels de la santé qu’une éducation thérapeutique biomédicale centrée sur la maladie ou le traitement. Pour tester l’hypothèse, nous avions besoin d’un outil d’observation des interactions soignantes à domicile. Objectifs : Construire et valider un nouvel outil d’observation des interactions soignantes à domicile. Méthodes : Nous nous sommes inspirés du Roter Interaction Analysis System (RIAS) initié par Debra Roter, pour élaborer cet outil dont nous avons ensuite testé la fidélité à travers l’analyse de sa concordance interne. Résultats : Nous avons observé 25 soignants, 72 patients et 223 soins. La fidélité varie entre un α de Cronbach de 0,23 à 0,81 en fonction des dimensions analysées, avec une moyenne de 0,58. L’analyse de la régression entre les réactions des clients et les interventions des soignants corrobore une certaine validité de construit. Discussion : Bien que partiellement fidèle, cet outil nous semble un instrument pertinent pour analyser les interactions des soignants centrés sur la personne dans le cadre des soins à domicile. Son contenu doit encore être amélioré afin d’augmenter sa fidélité. Conclusion : Cet outil contribue à la mise en évidence d’interactions soignantes réellement centrées sur la personne à domicile tout en identifiant les méthodes et les éléments qui les favorisent.

Le risque infectieux observe en milieu hospitalier prend la forme d’un paradoxe : en effacant les frontieres entre soignants et patients, entre normal et pathologique, les infections nosocomiales menacent ceux-la memes qui sont censes les prevenir, a la fois dans leur integrite physique et dans leur identite professionnelle. Aux Hopitaux universitaires de Geneve, 38 professionnels de la sante temoignent de leurs resistances a observer le strict protocole de l’hygiene des mains lorsqu’il interfere avec le contact patient. La double contrainte qui met les soignants en demeure d’assurer a la fois un contact aseptique et une bonne relation au malade deplace le probleme de l’observance vers un espace plus social que medical, plus rituel que technique.

The 2009 H1N1 pandemic had considerable impact on risk perceptions, vaccination campaigns, and global health governance. In this context, risk communication issues have been probably the most puzzling and the least understood in retrospect. This article reviews the current knowledge on the following issues: risk and pandemic perceptions; vaccination perceptions and practices; rumors and rumor propagation; and health risk communication. It also highlights the research gaps in these areas that remain to be further explored in the future.

Le cas du diabète nous montre comment une personne qui est malade parvient au souci et au soin d’elle-même dans un quotidien très contraint, et comment elle acquiert une certaine sagesse au-delà du savoir médical. Le diabète est également philosophe en ce sens qu’il se trouve au centre des réflexions de Georges Canguilhem sur la maladie comme forme normale de la vie. Philippe Barrier, diabétique philosophe, lecteur de Canguilhem, crée le concept d’« autonormativité » pour décrire le processus de transformation d’une « blessure », l’atteinte par un diabète insulino-dépendant, en « force ». Lors d’une enquête sociologique, il se confronte à d’autres malades chroniques pour observer leur capacité à s’approprier leur maladie. Il donne ainsi une assise scientifique à sa démarche de refondation de l’éducation thérapeutique du patient. Le patient comme sujet entraîne une certaine déstabilisation du pouvoir médical puisque la pédagogie ainsi comprise s’échappe hors du champ de la médecine. The case of diabetes shows us how someone who is ill manages with worry and care in a daily life full of constraints, and how he acquires a certain wisdom beyond medical knowledge. Diabetes is also philosophical in as far as it is at the heart of Georges Canguilhem’s reflections on illness as a normal form of living. Philippe Barrier, a diabetic philosopher and reader of Canguilhem, has created the concept of “autonormativity” to describe the process of transformation of one’s wound into a strength. During a sociological study, he compared himself to other chronic patients to observe their capacity to take possession of their illness. He thus gives a scientific basis to his procedure of the refoundation of the therapeutic education of the patient. The patient as a subject destabilizes the medical authority as this pedagogy goes beyond the scope of the field of medicine.

Background The recommendation for seasonal flu immunization from the second trimester of pregnancy, adopted in summer 2010 in Switzerland, is situated within a social context characterized by reluctance toward some vaccinations, a relatively low vaccination coverage against flu in the general population, and still heated debates fuelled by vaccination campaigns organized around the A(H1N1)pdm09 flu pandemic in winter 2009 to 2010. This study examines Swiss pregnant women's representations of the risks associated with seasonal flu and its vaccination. Methods Semi-structured interviews were conducted with 29 women, while in the maternity unit in March 2011, 3 to 5 days after giving birth. The interviews addressed the risks associated with flu, modes of protection, motivations for, and obstacles to vaccination. Results The interviewees did not show major preoccupations regarding seasonal flu and they tended to distance themselves from the at-risk status. They did not directly challenge seasonal flu immunization; however, they were reluctant to do it. Their attitudes were supported by their personal experience and the experience of their social networks. Healthcare professionals, particularly medical doctors, gave very little direction, or even did not raise the issue with them. Conclusions Between the rather moderate positions of those who are against vaccination and those who support it, an intermediate grey zone, characterized by hesitation, was observed. Furthermore, the indecision of pregnant women is reinforced by doubts among the persons they are close to and also among the professionals they met during their pregnancy.

La Suisse, à l’instar d’autres pays, est la destination de migrants qui arrivent pour différentes raisons : économiques, politiques, professionnelles, études, regroupement familial… Parmi eux, un certain nombre sont considérés comme des « sans-papiers » : ils séjournent en Suisse sans documents de séjour valables du point de vue du droit des étrangers. Ces migrants sans papiers sont confrontés à des conditions de vie difficiles et, ne disposant pas d’assurance maladie, éprouvent des difficultés d’accès aux soins de santé. Cet article se base sur les résultats d’une recherche que nous avons menée auprès de patients migrants sans statut de séjour légal en consultation de physiothérapie à la Haute école de santé de Genève (HEdS-Genève). Plusieurs ont vécu des événements difficiles dans leur pays d’origine et de transit (traumatismes de guerre, violences…) ou en vivent dans leur pays d’accueil (problèmes de statut de séjour, séparations de leurs familles, chômage, problème de logement, etc.) et, souvent, lors des consultations, ont des demandes d’aide psychosociale qui dépassent le cadre physiothérapeutique. Dans cet article, nous abordons les enjeux psychosociaux et interculturels de leur prise en charge physiothérapeutique par les étudiants stagiaires de la HEdS-Genève.