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This study investigated the effect of economic vulnerability on unmet needs during the first wave of the coronavirus disease 2019 (COVID-19) epidemic in Europe among adults aged 50 years and older using data from the regular administration of the Survey of Health, Ageing and Retirement in Europe (SHARE) and the specific telephone survey administered regarding COVID-19 (SHARE Corona Survey). It addressed three main research questions: Did people who were in difficult economic situations before the epidemic face more barriers to accessing healthcare than others? If so, to what extent can these discrepancies be attributed to initial differences in health status, use of care, income or education between vulnerable individuals and non-vulnerable individuals or to differential effects of the pandemic on these groups? Did the effect of economic vulnerability with regard to unmet needs during the pandemic differ across countries? Unmet healthcare needs are characterised by three types of behaviours likely to be induced by the pandemic: forgoing care for fear of contracting COVID-19, having pre-scheduled care postponed and being unable to obtain medical appointments or treatments when needed. Our results substantiate the existence of significant differences in accessing healthcare during the pandemic according to economic vulnerability and of cumulative effects of economic and medical vulnerabilities: the impact of economic vulnerability is notably stronger among those who were in poor health before the outbreak and thus the oldest individuals. The cross-country comparison highlighted heterogeneous effects of economic vulnerability on forgoing care and having care postponed among countries, which are not comparable to the initial cross-country differences in social inequalities in access to healthcare. Supplementary Information The online version contains supplementary material available at 10.1007/s10433-021-00645-3.

Background We aimed to estimate the seropositivity to anti-SARS-CoV-2 antibodies in May–June 2020 after the first lockdown period in adults living in three regions in France and to identify the associated risk factors. Methods Between 4 May 2020 and 23 June 2020, 16 000 participants in a survey on COVID-19 from an existing consortium of three general adult population cohorts living in the Ile-de-France (IDF) or Grand Est (GE) (two regions with high rate of COVID-19) or in the Nouvelle-Aquitaine (NA) (with a low rate) were randomly selected to take a dried-blood spot for anti-SARS-CoV-2 antibodies assessment with three different serological methods (ClinicalTrial Identifier #NCT04392388). The primary outcome was a positive anti-SARS-CoV-2 ELISA IgG result against the spike protein of the virus (ELISA-S). Estimates were adjusted using sampling weights and post-stratification methods. Multiple imputation was used to infer the cumulative incidence of SARS-CoV-2 infection with adjustments for imperfect tests accuracies. Results The analysis included 14 628 participants, 983 with a positive ELISA-S. The weighted estimates of seropositivity and cumulative incidence were 10.0% [95% confidence interval (CI): 9.1%, 10.9%] and 11.4% (95% CI: 10.1%, 12.8%) in IDF, 9.0% (95% CI: 7.7%, 10.2%) and 9.8% (95% CI: 8.1%, 11.8%) in GE and 3.1% (95% CI: 2.4%, 3.7%) and 2.9% (95% CI: 2.1%, 3.8%) in NA, respectively. Seropositivity was higher in younger participants [odds ratio (OR) = 1.84 (95% CI: 1.79, 6.09) in Conclusions Seropositivity to anti-SARS-CoV-2 antibodies in the French adult population was ≤10% after the first wave. Modifiable and non-modifiable risk factors were identified.

ObjectiveAlthough 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.DesignRandom population-based prospective cohort.SettingFrom May to June 2020 in France.ParticipantsAdults included in the Epidémiologie et Conditions de Vie cohort (n=77 588).Main outcome measuresSelf-reported anosmia and/or ageusia in three categories: no symptom, during the first epidemic peak (in March 2020) or thereafter (during lockdown).ResultsIn 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.ConclusionThe 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.

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 possible COVID-19, 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 possible COVID-19 were reported during 62,099 person-months of follow-up. The cumulative incidences of possible COVID-19 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 possible COVID-19 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 possible COVID-19 in the general population remained high during the first two weeks of lockdown, and decreased significantly thereafter. Modifiable and non-modifiable risk factors were identified.

Objective We assess the existence of unfair inequalities in health and death using the normative framework of inequality of opportunities, from birth to middle age in Great Britain. Methods We use data from the 1958 National Child Development Study, which provides a unique opportunity to observe individual health from birth to the age of 54, including the occurrence of mortality. We measure health status combining self-assessed health and mortality. We compare and statistically test the differences between the cumulative distribution functions of health status at each age according to one childhood circumstance beyond people’s control: the father’s occupation. Results At all ages, individuals born to a ‘professional’, ‘senior manager or technician’ father report a better health status and have a lower mortality rate than individuals born to ‘skilled’, ‘partly skilled’ or ‘unskilled’ manual workers and individuals without a father at birth. The gap in the probability to report good health between individuals born into high social backgrounds compared with low, increases from 12 percentage points at age 23 to 26 at age 54. Health gaps are even more marked in health states at the bottom of the health distribution when mortality is combined with self-assessed health. Conclusions There is increasing inequality of opportunities in health over the lifespan in Great Britain. The tag of social background intensifies as individuals get older. Finally, there is added analytical value to combining mortality with self-assessed health when measuring health inequalities.

Background and purpose Access to evidence-based mental health care for children is an international priority. However, there are significant challenges to advancing this public health priority in an efficient and equitable manner. The purpose of this international colloquium was to convene a multidisciplinary group of health researchers to build an agenda for addressing disparities in mental health care access and treatment for children and families through collaboration among scholars from the United States and Europe engaged in innovative implementation science and mental health services research. Key highlights Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, presentations related to inner, outer, and bridging context factors that impact the accessibility and quality of mental health evidence-based practices (EBPs) for children and families. Three common topics emerged from the presentations and discussions from colloquium participants, which included: 1) the impact of inner and outer context factors that limit accessibility to EBPs across countries, 2) strategies to adapt EBPs to improve their fit in different settings, 3) the potential for implementation science to address emerging clinical and public health concerns. Implications The common topics discussed underscored that disparities in access to evidence-based mental health care are prevalent across countries. Opportunities for cross-country and cross-discipline learnings and collaborations can help drive solutions to address these inequities, which relate to the availability of a trained and culturally appropriate workforce, insurance reimbursement policies, and designing interventions and implementation strategies to support sustained use of evidence-based practices.

Background: To estimate the seroprevalence of SARS-CoV-2 infection in May-June 2020 after the lockdown in adults living in three regions in France and to identify the associated risk factors. Methods: Participants in a survey on COVID-19 from an existing consortia of three general adult population cohorts living in the Ile-de-France (IDF) or Grand Est (GE) - two regions with high rate of COVID-19, or in the Nouvelle-Aquitaine (NA) – with a low rate, were asked to take a dried-blood spot (DBS) for anti-SARS-CoV-2 antibodies.The primary outcome was a positive anti-SARS-CoV-2 ELISA IgG result against the spike protein of the virus (ELISA-S). The secondary outcomes were a positive ELISA IgG against the nucleocapsid protein (ELISA-NP), anti-SARS-CoV-2 neutralizing antibodies titers ≥40 (SN), and predicted positivity obtained from a multiple imputation model (MI). Prevalence estimates were adjusted using sampling weights and post-stratification methods. Findings: Between May 4, 2020 and June 23, 2020, 16,000 participants were asked to provide DBS, and 14,628 were included in the analysis, 983 with a positive ELISA-S, 511 with a positive ELISA-NP, 424 with SN≥40 and 941±31 with a positive MI. Adjusted estimates of seroprevalence (positive ELISA-S) were 10.0% (95%CI 9.1%;10.9%) in IDF, 9.0% (95%CI 7.7%; 10.2%) in GE and 3.1% (95%CI 2.4%; 3.7%), in NA. The adjusted prevalence of positive ELISA-NP, SN and MI were 5.7%, 5.0% and 10.0% in IDF, 6.0%, 4.3% and 8.6% in GE, and 0.6%, 1.3% and 2.5% in NA, respectively. A higher seroprevalence was observed in younger participants and when at least one child or adolescent lived in the same household. A lower seroprevalence was observed in smokers compared to non-smokers. Interpretation: At the end of the lockdown the prevalence of anti-SARS-CoV-2 IgG or neutralizing antibodies remained low in the French adult population, even in regions with high reported rates of COVID-19. Funding Statement: ANR (Agence Nationale de la Recherche, #ANR-20-COVI-000, #ANR-10-COHO-06), Fondation pour la Recherche Medicale (#20RR052-00), Inserm (Institut National de la Sante et de la Recherche Medicale, #C20-26). Additional cohort funding is listed in the manuscript. Declaration of Interests: Prof Fabrice Carrat reports grants from INSERM-ANRS, during the conduct of the study; personal fees from Imaxio, outside the submitted work. Mathilde Touvier, Prof Gianluca Severi, Prof Laurence Meyer, Prof Florence Jusot, Nathanael Lapidus, Delphine Rahib, Nathalie Lydie, Helene Blanche, Jean-Francois Deleuze, Marie-Aline Charles, Prof Pierre-Yves Ancel, Alexandra Rouquette, Claude Martin, Prof Xavier de Lamballerie, Prof Marie Zins, Nathalie Bajos declare no competing interest. The remaining authors have no competing interest to declare. Ethics Approval Statement: Ethical approval and written or electronic informed consent were obtained from each participant before enrolment in the original cohort. The SAPRIS survey was approved by the Inserm ethics committee (approval #20-672 dated March 30, 2020). The SAPRIS-SERO study was approved by the Sud-Mediterranee III ethics committee (approval #20.04.22.74247) and electronic informed consent was obtained from all participants for DBS testing.

Objective To evaluate the efficacy of financial incentives dependent on continuous smoking abstinence on smoking cessation and birth outcomes among pregnant smokers. Design Single blind, randomised controlled trial. Setting Financial Incentive for Smoking Cessation in Pregnancy (FISCP) trial in 18 maternity wards in France. Participants 460 pregnant smokers aged at least 18 years who smoked ≥5 cigarettes/day or ≥3 roll-your-own cigarettes/day and had a pregnancy gestation of Interventions Participants in the financial incentives group received a voucher equivalent to €20 (£17; $23), and further progressively increasing vouchers at each study visit if they remained abstinent. Participants in the control group received no financial incentive for abstinence. All participants received a €20 show-up fee at each of six visits. Main outcome measures The main outcome measure was continuous smoking abstinence from the first post-quit date visit to visit 6, before delivery. Secondary outcomes in the mothers were point prevalence abstinence, time to smoking relapse, withdrawal symptoms, blood pressure, and alcohol and cannabis use in past 30 days. Secondary outcomes in the babies were gestational age at birth, birth characteristics (birth weight, length, head circumference, Apgar score), and a poor neonatal outcome—a composite measure of transfer to the neonatal unit, congenital malformation, convulsions, or perinatal death. Results Mean age was 29 years. In the financial incentives and control groups, respectively, 137 (59%) and 148 (65%) were employed, 163 (71%) and 171 (75%) were in a relationship, and 41 (18%) and 31 (13%) were married. The participants had smoked a median of 60 cigarettes in the past seven days. The continuous abstinence rate was significantly higher in the financial incentives group (16%, 38/231) than control group (7%, 17/229): odds ratio 2.45 (95% confidence interval 1.34 to 4.49), P=0.004). The point prevalence abstinence rate was higher (4.61, 1.41 to 15.01, P=0.011), the median time to relapse was longer (visit 5 (interquartile range 3-6) and visit 4 (3-6), P Conclusions Financial incentives to reward smoking abstinence compared with no financial incentives were associated with an increased abstinence rate in pregnant smokers. Financial incentives dependent on smoking abstinence could be implemented as a safe and effective intervention to help pregnant smokers quit smoking. Trial registration ClinicalTrials.gov NCT02606227 .

Background The French health insurance system is universal but 95% of the population is also covered by a complementary private health insurance (CHI). The CHI take up is not uniform across the income distribution and health care access is partly conditioned by its coverage. The Complementary Universal Health Coverage (CMU-C) and the Health Insurance Vouchers Scheme (ACS) are mean tested programs providing CHI to the poor. The former is free while the latter takes the form of a voucher to buy private CHI. Our objective is to study and compare the evolution of health care use and consumption associated with the take up of the CMU-C or the ACS. Methods In a nationwide cohort of ACS and CMU-C beneficiaries we compute bi-annual expenditures, out of pockets expenditures and rates of use for different types of care: outpatient, inpatient, dental, optical and audiology. We use panel data regression methods to model the evolution of health care use and expenditures before, during and after the coverage periods of both programs. Results Our population is composed with about 10 million individuals benefiting at least once from either the ACS or the CMU-C on the 2012-2017 period. Preliminary results suggest that inpatient expenditures are increasing concomitantly with the take up of any program whereas outpatient expenditures tend to increase after. Results will be provided for the conference on the variations of the consumption according to the program (CMU-C or ACS), type of care, individual characteristics and health status. Conclusions Free or subsidized complementary health insurance may play an important role in the access to care for poor population, even in the presence of mandatory coverage. The take up of complementary health insurance for the poor population could be partly driven by the use of inpatient services but coverage may impact positively outpatient expenditures. Key messages Unlocking poor individuals financial constraint tends to increase their use of medical services. Generous insurance coverage targeting financially constrained individuals could be a tool to reduce health care use inequalities.

Recent developments in the analysis of inequality in health and healthcare have turned their interest into an explicit normative understanding of the sources of inequalities that calls upon the concept of equality of opportunity. According to this concept, some sources of inequality are more objectionable than others and could represent priorities for policies aiming to reduce inequality in healthcare use, access, or health status. Equality of opportunity draws a distinction between “legitimate” and “illegitimate” sources of inequality. While legitimate sources of differences can be attributed to the consequences of individual effort (i.e. determinants within the individual’s control), illegitimate sources of differences are related to circumstances (i.e. determinants beyond the individual’s responsibility). The study of inequality of opportunity is rooted in social justice research, and the last decade has seen a rapid growth in empirical work using this literature at the core of its approach in both developed and developing countries. Empirical research on inequality of opportunity in health and healthcare is mainly driven by data availability. Most studies in adult populations are based on data from European countries, especially from the UK, while studies analyzing inequalities of opportunity among children are usually based on data from low- or middle-income countries and focus on children under five years old. Regarding the choice of circumstances, most studies have considered social background to be an illegitimate source of inequality in health and healthcare. Geographical dimensions have also been taken into account, but to a lesser extent, and more frequently in studies focusing on children or those based on data from countries outside Europe. Regarding effort variables or legitimate sources of health inequality, there is wide use of smoking-related variables. Regardless of the population, health outcome, and circumstances considered, scholars have provided evidence of illegitimate inequality in health and healthcare. Studies on inequality of opportunity in healthcare are mainly found in children population; this emphasizes the need to tackle inequality as early as possible.

Early screening increases the likelihood of detecting cancer, thereby improving survival rates. National screening programs have been established in which eligible women receive a letter containing a voucher for a free screening. Even so, mammography use is often considered as remaining too low. We test four behavioral interventions in a large-scale randomized experiment involving 26,495 women. Our main assumption is that, due to biases in decision-making, women may be sensitive to the content and presentation of the invitation letter they receive. None of our treatments had any significant impact on mammography use. Sub-sample analysis suggests that this lack of a significant impact holds also for women invited for the first time and low-income women.

The study investigates the life cycle patterns of educational inequalities in smoking according to gender over three successive generations. Based on retrospective smoking histories collected by the nationwide French Health Barometer survey 2010, we explored educational inequalities in smoking at each age, using the relative index of inequality. Educational inequalities in smoking increase across cohorts for men and women, corresponding to a decline in smoking among the highly educated alongside progression among the lower educated. The analysis also shows a life cycle evolution: for all cohorts and for men and women, inequalities are considerable during adolescence, then start declining from 18 years until the age of peak prevalence (around 25), after which they remain stable throughout the life cycle, even tending to rise for the most recent cohort. This analysis contributes to the description of the “smoking epidemic” and highlights adolescence and late adulthood as life cycle stages with greater inequalities.

This study aims to analyse the impact of the measurement of health status on socioeconomic inequalities in health. A MIMIC model with structural equations is used to create a latent variable of health status from four health indicators : self-assessed health, report of chronic diseases, report of activity limitations and mental health. Then, we disentangle the impact of sociodemographic characteristics on latent health from their direct impact on each heath indicator and discuss their effects on the assessment of socioeconomic inequalities in health. This study emphasises differences in inequalities in health according to latent health. In addition, it suggests the existence of reporting heterogeneity biases. For a given latent health status, women and old people are more likely to report chronic diseases. Mental health problems are over-reported by women and isolated people and under-reported by the oldest people. Active and retired people as well as non manual workers in the top of the social hierarchy more often report activity limitations. Finally, highly educated and socially advantaged people more often report chronic diseases whereas less educated people under- report a poor self-assessed health. To conclude, the four health indicators suffer from reporting heterogeneity biases and the report of chronic diseases is the indicator which biases the most the measurement of socioeconomic inequalities in health.

In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists’ services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000–2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.

In France, access to health care greatly depends on having a complementary health insurance coverage (CHI). Thus, the generalisation of CHI became a core factor in the national health strategy created by the government in 2013. The first measure has been to compulsorily extend employer-sponsored CHI to all private sector employees on January 1st, 2016 and improve its portability coverage for unemployed former employees for up to 12 months. Based on data from the 2012 Health, Health Care and Insurance survey, this article provides a simulation of the likely effects of this mandate on CHI coverage and related inequalities in the general population by age, health status, socio-economic characteristics and time and risk preferences. We show that the non-coverage rate that was estimated to be 5% in 2012 will drop to 4% following the generalisation of employer-sponsored CHI and to 3.7% after accounting for portability coverage. The most vulnerable populations are expected to remain more often without CHI whereas non coverage will significantly decrease among the less risk averse and the more present oriented. With its focus on private sector employees, the policy is thus likely to do little for populations that would benefit most from additional insurance coverage while expanding coverage for other populations that appear to place little value on CHI.

International audience; Background: Even if health status of immigrants constitutes an important public health issue, the literature provides contradictory results on the existence of a ‘healthy migrant’ effect in Europe. This study proposes to explore the heterogeneity of the health gap between migrants and natives across four European countries. Data and methods: Based on several harmonized national health interview surveys, the association between migratory status and self-assessed health was firstly explored separately in Belgium, France, Spain and Italy. To explore whether differences in health gap between countries reflect differences in health status of immigrants between host countries or whether they are because of differences in health status of natives between host countries, the association between the host country and health was secondly analysed separately among a pooled sample of immigrants and one of natives, controlling for socio-economic status and country of origin. Results: After controlling for socio-economic status, immigrants report a poorer health status than natives in France, Belgium and Spain, whereas they report a better health status than natives in Italy, among both women and men. A North–South gradient in immigrants’ health status appears: their health status is better in Italy and in Spain than in France and Belgium. Conversely, health status of natives is poorer in Italy and in Belgium than in France and in Spain. Conclusion: Differences in health gap reflect differences in health status of both natives and immigrants between host countries. This suggests differences in health selection at migration and in immigrants’ integration between European countries.

International audience; Financial transfers from parents to their adult children are a growing trend in contemporary societies, and this study investigates the relation of those transfers to their beneficiaries' health in France. In the 2005 nationally representative Gender and Generation Survey, nearly 6% of the subjects aged 25–49 years reported having received financial transfers during the last 12 months. Subjects who had achieved intergenerational upward mobility as well as those who had remained in the upper class were more likely to receive transfers, suggesting that parents rewarded those of their children who achieved most social success. After adjusting for a wide range of socio-demographic factors, subjects who had been given large transfers were much more likely to report very good health than subjects who had not been given anything. Findings were interpreted within the framework of sociological research on intergenerational transfers and that of lifecourse epidemiology.

Background: Recent research shows that adverse experiences, such as economic hardships or exclusion, contribute to deterioration of health status. However, individuals currently experiencing adverse experiences are excluded from conventional health surveys, which, in addition, often focus on current social situation but rarely address past adverse experiences. This research explores the role of such experiences on health and related social inequalities based on a new set of ad hoc questions included in a regular health survey. Methods: In 2004, the National Health, Health Care and Insurance Survey included three questions on lifelong adverse experiences (LAE): financial difficulties, housing difficulties due to financial hardship, isolation. Logistic regressions were used to analyse associations between LAE, current socio-economic status (SES) (education, occupation, income) and health status (self-perceived health, activity limitation, chronic morbidity), on a sample of 4308 men and women aged ≥35 years. Results: LAE were reported by 20% of the sample. They were more frequent in low SES groups but concerned >10% of the highest income group. LAE increased the risk of poor self-perceived health, diseases and activity limitations, even after controlling for current SES [odds ratio (OR) > 2]. LAE experienced only during childhood are also linked to health. LAE account for up to 32% of the OR of activity limitations associated with the lowest quintile among women and 26% among men. Conclusions: LAE contribute to the social health gradient and explain variability within social groups. It is useful to take lifetime social factors into account when monitoring health inequalities.

Background In Western societies, a lower educational level is often associated with a higher prevalence of overweight and obesity. However, there may be important international differences in the strength and direction of this relationship, perhaps in respect of differing levels of socio-economic development. We aimed to describe educational inequalities in overweight and obesity across Europe, and to explore the contribution of level of socio-economic development to cross-national differences in educational inequalities in overweight and obese adults in Europe. Methods Cross-sectional data, based on self-reports, were derived from national health interview surveys from 19 European countries (N = 127 018; age range = 25–44 years). Height and weight data were used to calculate the body mass index (BMI). Multivariate regression analysis was employed to measure educational inequalities in overweight and obesity, based on BMI. Gross domestic product (GDP) per capita was used as a measure of level of socio-economic development. Results Inverse educational gradients in overweight and obesity (i.e. higher education, less overweight and obesity) are a generalized phenomenon among European men and even more so among women. Baltic and eastern European men were the exceptions, with weak positive associations between education and overweight and obesity. Educational inequalities in overweight and obesity were largest in Mediterranean women. A 10 000-euro increase in GDP was related to a 3% increase in overweight and obesity for low-educated men, but a 4% decrease for high-educated men. No associations with GDP were observed for women. Conclusion In most European countries, people of lower educational attainment are now most likely to be overweight or obese. An increasing level of socio-economic development was associated with an emergence of inequalities among men, and a persistence of these inequalities among women.

International audience; Heterogeneity in time and risk preferences has been proposed as one of the mechanisms involved in the educational gradient in smoking, but this mechanism has scarcely been explored empirically. Subjective scales were introduced in the 2008 French National Health, Health Care and Insurance Survey in order to elicit measures of time and risk preferences for a representative sample of 5188 men and 5684 women. Men and women were treated separately. First, logistic regressions were used to test the associations between preferences and education and between preferences and smoking. Second, nested logistic models were built to investigate the mediating role of preferences in the educational gradient in smoking, with an econometric treatment of the rescaling problem. Preference for the present and risk loving were found to be: inversely related to educational level; strongly related to each other, and; strongly associated to current smoking, even after adjustment for educational level. There was a weakening of the educational gradient after the control for preferences, which supports the role of these two preferences as partial mediators in the educational gradient in smoking. Among men, time preference was more strongly associated with smoking than risk aversion, while the reverse was found for women. We provide convincing evidence in favour of the mediating role of time preference and risk aversion in educational inequalities in smoking and highlight the connection between those two dimensions. Gender patterns are discussed and potential implications in terms of designing targeted anti-tobacco programmes are delineated.

Introduction Maternal smoking during pregnancy is associated with adverse perinatal and postnatal health outcomes. The efficacy of nicotine replacement therapies in helping pregnant smokers to quit is not clearly demonstrated; therefore new interventions should be proposed and assessed. Financial incentives rewarding abstinence from tobacco smoking is one of the promising options. Objective To assess the efficacy of financial incentives on smoking abstinence among French pregnant smokers. Methods and analysis Participants: pregnant smokers aged ≥18 years, smoking at least five manufactured or three roll-your-own cigarettes per day, and pregnant for

Context Several studies provide evidence of horizontal inequities in health care use in France, i.e. differences in health care utilization for equal needs in favor of the highest socioeconomic groups [1-3]. Similarly, significant social inequalities in mortality have been found in France in comparison with other European countries [4]. However, the contribution of inequity in access to care to health inequalities is disputable and the consequences in term of health status and future health care consumption of horizontal inequities in health care use have scarcely been explored.

The paper focuses on the long-term effects of early-life conditions with comparison to lifestyles and current socioeconomic factors on health status in a cohort of British people born in 1958. Using the longitudinal follow-up data at age 23, 33, 42 and 46, we build a dynamic model to investigate the influence of each determinant on health and the mediating role of education and lifestyles in the relationship between early-life conditions and later health. Direct and indirect effects of early-life conditions on adult health are explored using auxiliary linear regressions of education and lifestyles and panel Probit specifications of self-assessed health with random effects addressing individual unexplained heterogeneity. Our study shows that early-life conditions are important parameters for adult health, their contribution to health disparities increases from 17.8% to 23% when mediating effects are identified. They also shape other health determinants: the contribution of lifestyles reduces from 28% down to 22% when indirect effects of early-life conditions are distinguished. Noticeably, the absence of father at the time of birth and experience of financial hardships represent the lead factors for direct effects on health. The absence of obesity at 16 influences health both directly and indirectly working through lifestyles.

Background and objectives: Health selection into unemployment may be either direct or operate by reference to health-related behaviours rather than health per se (indirect selection). Panel data are desirable to investigate selection effects, and the two types of selection processes may be concurrent. We examine jointly the roles of health and health-related behaviours as precursors of unemployment, in order to disentangle direct from indirect selection processes. Design: The data of a multi-round nationally representative health survey in France were analysed longitudinally, based on three data collection rounds: 1992–5, 1996–8 and 2000–2. Following employees salaried in the private sector and aged 30–54 years at baseline, we explored through logistic regression the influence of non-optimal self-rated health, smoking and obesity on the risk of being found unemployed 4 years later. Results: After adjustment for self-rated health, obesity was found to be a significant precursor of unemployment in women, and heavy smoking had that role in men. After adjustment for smoking and obesity, poor health at baseline was found to be a significant precursor of unemployment in both genders. Conclusion: Those findings confirm the intrinsic role of poor health and of health-related behaviours as precursors of unemployment, with gender-specific patterns for the latter. Public policy prescriptions regarding employees’ protection from job insecurities should integrate appropriate accommodations of health limitations, and the personal factors underlying unfavourable work and health behaviours should be investigated, in order to thwart indirect selection phenomena.

The first stage of our analysis consisted of estimating the association between the probability of using each given service (Cij) and several individual explanatory variables (Xij: age, sex, education income, health status). The slope coefficients b of the individual explanatory variables were treated as fixed across countries. However, a random country intercept b0j was introduced in the model in order to take into account the differences between country in the average level of use a given health service. Across countries, the country intercepts b0j were assumed to be normally distributed with a mean b0 and a variance r . The estimate of the variance r provided then a measure of the differences in health care use across countries after controlling for compositional effect due to individual characteristics. If r was significantly different from zero, it indicated that the level of health services use significantly varies from one country to another. The second stage of the analysis aimed to establish the association between various health system features and the probability of service utilisation at the country level. In order to explain the variation in health care use across countries shown by the first stage of this analysis, health systems variables were introduced, in addition to individual characteristics. A random country intercept x0j (normally distributed) was also introduced in the model in order to control for unobserved country-level factors influencing preventive care use independently of health system characteristics.

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.