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Late adjuvant chemotherapy (aCT) administration after colectomy (56 d) is known to be associated with impaired prognosis. We aim to identify risk factors associated with late aCT, especially the travel time between patients' home and hospital.We performed a retrospective monocentre cohort study. Patients included had a colectomy for a stage III or high risk stage II colon cancer between 2009 and 2015 performed at a French university hospital. Risk factors for late aCT were identified using a fractional polynomial logistic regression.Ninety-four patients were included. The risk of late aCT was associated with travel time length, emergent colectomy, the need for scheduled care before aCT, and length of time between colectomy and postoperative multidisciplinary meeting advising aCT.Our study suggests that, in patients with colon cancer, factors unrelated to disease severity and complexity could be associated with a higher risk of late aCT.

International audience; Background: The spread of the coronavirus disease (COVID-19) led many countries to implement lockdown measures, which resulted in changes in dietary behaviours that could persist over the long term and have associated health consequences. Psychological traits may impact these changes given their known association with dietary behaviours. We aimed to investigate in a population-based study, whether positive psychological traits were associated with changes of snacking behaviour and food consumption observed during the first COVID-19 lockdown period.Design: In 2016, levels of optimism, resilience, self-esteem, satisfaction with life, mindfulness and mastery were assessed in 33,766 adults of the French NutriNet-Sante ' cohort. Snacking and food group consumption were assessed in April-May 2020. Association between psychological traits and changes (no change, increase, decrease) in snacking and food group consumption were assessed using logistic regressions. Multiple correspondence analysis followed by ascending hierarchical classification were used to derive clusters of dietary behaviours. Covariance analyses were used to compare mean scores of psychological traits between clusters. Analyses were adjusted for sociodemographic and lifestyle characteristics, anxiety and depressive symptomatology.Results: Participants with higher levels of optimism, resilience, self-esteem, satisfaction with life, mindfulness or mastery were less likely to change their snacking behaviour and food group consumption of various food groups. Individuals with lower levels were more likely to make changes, with either unhealthy (e.g., less fruits and vegetables, more processed meat) or healthy (e.g., more pasta/rice (whole-grain)) changes. Overall, individuals showed higher levels of positive psychological traits in the "no change" cluster, followed by the "healthy" and the "unhealthy" cluster (all P < 0.05).Conclusions: Individuals with higher levels of optimism, resilience, self-esteem, satisfaction with life, mindfulness or mastery were less impacted by the lockdown in terms of dietary behaviours.

EnglishCare arrangement for elderly people with disabilities: does the supply constrain the choices? This article examines the sensitivity of the demand of elderly people for care with respect to the supply. Based on a theoretical model, we estimated the probability of choosing a care arrangement using a multinomial model and data from the “Capacites, Aides et Ressources des Seniors” surveys. Theoretical out-of-pockets and densities are estimated for each alternative and individual in order to evaluate the effect of these two determinants on the decision to use a specific care arrangement. This article reveals that the choices are constrained by the out-of-pocket, the variety and the quantity of care supply, but that their effect is limited. francaisCet article s’interesse a la sensibilite de la demande de prise en charge de la perte d’autonomie vis-a-vis de l’offre. En nous appuyant sur un modele theorique, nous estimons la probabilite de choisir un mode de prise en charge grâce a une modelisation multinomiale utilisant les donnees des enquetes CARE (Capacites, aides et ressources des seniors). Des restes a charge et densites theoriques sont estimes pour chaque alternative et individu afin d’evaluer l’effet de ces deux determinants sur la decision de recourir a un mode de prise en charge specifique. Cet article revele que les choix sont contraints a la fois par le reste a charge de la prise en charge, sa variete et sa quantite mais que leur effet est limite. Classification JEL : D13, I11, I12, I14, J14.

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: Our main objective was to study the early social dynamics of the COVID-19 epidemic in France, taking into account gender, class, and ethnicity inequalities in living conditions. Methods: A random population-based survey was conducted in France in May 2020, during and post COVID-19 lockdown, in which 77,588 participants aged 18-64 were included in this study. We used multinomial regressions to identify changes in social position and exposure factors associated with symptoms of anosmia/ageusia during the first epidemic peak in late March and thereafter. Findings: In all, 2,045 (1.53% (95%CI 1.46%-1.61%)) participants reported anosmia/ageusia (1.13% during the epidemic peak and 0.40% after), with strong variations according to regions. Women and ethno-racial minorities remained at higher risk of anosmia/ageusia during and after the peak. Whereas senior executive professionals were more affected than lower social classes at the peak of the epidemic, this effect disappeared afterwards. Adjusting on key exposure factors substantially attenuated these associations, except for gender differences. While high density of the place of residence was associated with anosmia/ageusia during the peak, but no longer after, the opposite trend was observed for living in overcrowded housing. Having worked outside the home during lockdown was the most strongly associated exposure factor, and even more so after the peak. Interpretation: The shift in the social profile of the epidemic was related to a shift in exposure factors under the implementation of stringent collective prevention measures. Our results notably stress the importance of working outside the home, all the more so in essential occupations. Funding Statement: Inserm (Institut National de la Sante et de la Recherche Medicale). French Ministry for Research. Drees. Dr. Bajos has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No. [856478]) Declaration of Interests: None. Ethics Approval Statement: The survey was approved by the CNIL (French independent administrative authority responsible for data protection) on April 25th 2020 (ref: MLD/MFI/AR205138) and by the “Comite de protection des personnes” (French equivalent of the Research Ethics Committee) on April 24th. The survey also obtained an agreement from the “Comite du Label de la statistique publique”, proving its adequacy to statistical quality standards.

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.

Introduction Les etrangers en situation irregulieres en France sont inegalement touches par les maladies infectieuses en lien avec les pays d’origine mais aussi les mauvaises conditions d’accueil. Cependant, bien que les maladies infectieuses ressortent comme un des premiers motifs de consultations dans les structures d’accueil socio-sanitaire, aucune etude n’a a ce jour evalue la frequence de ces maladies infectieuses dans un echantillon non selectionne d’etrangers en situation irreguliere. Materiels et methodes L’enquete Premiers Pas est une enquete epidemiologique transversale realisee aupres d’un echantillon aleatoire (plan de sondage a 2 degres) d’etrangers en situation irregulieres recrutes a Paris et dans l’agglomeration de Bordeaux dans des lieux et structures susceptibles d’etre frequentes par des personnes sans titre de sejour. Les pourcentages ont ete ponderes. L’analyse a ete realisee a l’aide du logiciel Stata 15.0. Resultats Au total, 1223 etrangers sans titre de sejour ont ete recrutes dans 63 lieux et structures (selectionnes parmi 736 lieux et structures). L’entretien s’est deroule en francais dans 75 % des cas. L’echantillon etait compose d’hommes a 65 %, âges de 30 a 40 ans (36 %), originaires d’Afrique subsaharienne (63 %), d’Afrique du Nord (24 %) ou d’Amerique (6 %) ; 38 % etaient arrives en France depuis moins d’un an et 22 % depuis plus de 5 ans. Parmi les participants, 24,8 % declaraient un mauvais ou tres mauvais etat de sante percu, 33,5 % un probleme de sante chronique et 68,2 % un probleme de sante au moment de l’enquete. Mis a part les infections dentaires (caries, infection ou douleur) qui concernaient 43,2 % des participants, 12,9 % des repondants ont declare souffrir d’une maladie infectieuse : infection par le VIH (3,5 %), infection chronique par le VHB (3,1 %), infection de la sphere ORL (1,7 %), mycose cutanee (1,2 %), infection de la peau et des tissus mous (0,8 %), infection par le VHC (0,8 %), infection urinaire (0,7 %), infection bronchopulmonaire (0,7 %), gale (0,3 %), tuberculose maladie (0,2 %), mycose vaginale 0,6 % et herpes 0,1 %. Concernant les infections par le VIH, le VHB et le VHC, 56 %, 71 % et 89 % respectivement declaraient avoir ete diagnostiques apres leur arrivee en France. C’etait egalement le cas des quelques cas de tuberculose maladie. En analyse multivariee, le risque d’etre atteint d’une virose chronique etait plus frequent parmi les participants les plus jeunes, arrives en France depuis moins de 3 ans, originaires d’Afrique ou d’Amerique du Sud, en situation d’insecurite alimentaire et recrutes dans les associations ou les structures de soins primaires. Conclusion Cette etude originale aupres d’un echantillon tendant vers la representativite confirme la frequence des maladies infectieuses chez les personnes etrangeres sans papiers en France et l’importance d’integrer leur depistage et leur prise en charge dans une logique plus globale d’acces aux soins precoce et de prise en charge inclusive medico-psychosociale.

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.

While the health of young adults is a recognised public health issue in France, less atten-tion is paid to their use of healthcare. This article examines the existence of unequal opportunities in the use of healthcare for young adults using data from the National Survey on the Resources of Young Adults (Enquête nationale sur les ressources des jeunes - 2014). Using the framework of the philosophy of responsibility, a distinction is made between “unfair” inequalities linked to circums-tances beyond the control of young people – or unequal opportunity, and “fair” inequalities linked to characteristics for which they are responsible. Linear probability models are used to estimate the associations between the probabilities of non-use (non-utilisation and foregone health care) and parental characteristics (complementary health insurance, main activity, income, marital and vital status) on the one hand and those of the young person (education, main activity, whether living in the parental home or not, financial resources, complementary health insurance) on the other, reflecting the existence of unfair and fair inequalities respectively. Variance decomposition makes it possible to quantify these inequalities and suggests that unfair inequalities outweigh fair inequalities.; Alors que la santé des jeunes adultes est un enjeu reconnu de santé publique en France, moins d’attention est accordée à leur recours aux soins. Cet article s’interroge sur l’existence d’iné‑galité des chances dans le recours aux soins des jeunes adultes à partir des données de l’Enquête nationale sur les ressources des jeunes (2014). En mobilisant le cadre de la philosophie de la responsabilité, une distinction est faite entre des inégalités « injustes » liées à des circonstances en dehors du contrôle des jeunes et des inégalités « justes » liées à des caractéristiques relevant de leur responsabilité. Des modèles de probabilité linéaire sont mobilisés pour estimer les associations entre les probabilités de non‑recours (non‑utilisation et renoncement aux soins) et les caractéristiques parentales (assurance complémentaire santé, activité principale, revenu, situation familiale et statut vital) d’une part et celles du jeune (éducation, activité principale, cohabitation, ressources financières, assurance complémentaire santé) d’autre part, traduisant respectivement l’existence d’inégalités injustes et d’inégalités justes. La décomposition de la variance permet de quantifier ces inégalités et suggère que les inégalités injustes sont plus importantes que les inégalités justes.

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.

Les remises de fonds envoyees par les migrants ont-elles un impact sur la consommation de soins de leur famille au pays ? En assouplissant la contrainte budgetaire, ces transferts devraient ameliorer l’acces aux soins, en particulier dans les systemes avec de faibles depenses publiques de sante. Cependant, on peut soupconner les transferts d’etre endogenes, les besoins de soins pouvant inciter les migrants a envoyer davantage d’argent. Cet article etudie la question dans le cas du Tadjikistan, ou l’on observe a la fois des depenses directes de sante elevees et une forte dependance aux migrations. Il s’appuie sur les donnees du Tajikistan Living Standards Survey (2007). Les resultats montrent que les transferts ont un impact positif mais heterogene selon le niveau de la consommation de soins.

This chapter opens with a thorough review of the literature on the health effects of social capital in a large collection of countries, especially in developing countries such as Indonesia. The study includes many innovations and new findings. For example, it finds that inequalities in health opportunities account for 10 per cent of inequalities in health.

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.

In France, the horizontal equity principle is a founding principle of the social security. It is stated by the maxim “From each according to his ability to pay, to each according to his need”. However, the French health insurance system lets copay-ments for all health expense, in order to contain health expenditures and give incentives to patients. However, such copayments are financial barriers to health care access and sources of inequalities in use of health services. In order to improve equity in the financial access to health services, policies have been implemented in the last decades. This paper proposes an overview of the findings of these policies and provides new results on inequalities in access to health care in France. Most policies packages consis, in setting free access to certain types of care or to reduce health insurance premiums. Free care and free insurance have been demonstrated to be effective in reducing health care use inequalities, although such actions can diminish perceived quality of the service and lead to discrimination when physician fees are caped. By contrast, the literature has also shown the ineffectiveness of health insurance premium subsidy. More recent reforms of the health system, not assessed yet, are aiming at containing prices types of care which are poorly covered by the public health insurance. Despite those policies, we demonstrate that, controlling for need, inequalities in health care use subsist, particularly on specialist, dental, optical and preventive care. This suggests that the reduction in the financial barriers to health care access is a necessary condition but far from being sufficient for achieving equity in health., En France, le principe d’équité horizontale dans l’accès aux soins est au cœur du pacte de 1945, selon la maxime « De chacun selon ses moyens, à chacun selon ses besoins ». Pour autant, le système d’assurance maladie laisse depuis sa création une part du coût des soins à la charge des patients, afin notamment de les responsabiliser. Toutefois, ces instruments constituent des barrières financières à l’accès aux soins, qui sont autant de sources d’inégalités sociales de recours aux soins. Afin d’améliorer l’équité dans l’accès financier aux soins, diverses politiques ont été mises en œuvre au cours des dernières décennies. Cet article propose d’en tirer les leçons et de dresser le bilan des connaissances sur les inégalités de recours aux soins en France. L’essentiel des dispositifs ont consisté à introduire la gratuité de certains soins ou à réduire le coût de la complémentaire santé pour les ménages les plus modestes. Les évaluations disponibles démontrent l’efficacité de la gratuité, que celle-ci s’applique aux soins ou à l’assurance, même si elle peut conduire à une moindre qualité perçue ou à des discriminations lorqu’elle est assortie de tarifs plafonnés. La littérature converge également sur l’inefficacité des subventions à l’assurance. Les réformes les plus récentes, non encore évaluées, visent quant à elles à modérer les prix des soins mal couverts par l’assurance maladie. En dépit de ces dispositifs, il subsiste des inégalités de recours aux soins, à besoins de soins donnés, particulièrement importantes pour les soins de spécialistes, les soins dentaires et d’optique et les soins préventifs. La réduction des barrières financières est donc une condition nécessaire mais non suffisante pour atteindre l’équité en santé.

Notre pays — et la planète — traverse une crise épidémique majeure. Comme toute crise, elle peut être révélatrice des forces et faiblesses de la société, et de ses composantes : celles de son système de santé, de son système de recherche, du fonctionnement de la démocratie sanitaire… Cet article aborde la question des inégalités sociales au temps du Covid-19 : la crise sanitaire, la réaction politique et celle du système de santé les ont-elles amplifiées, atténuées ou les ont-elles laissées telles qu’elles étaient auparavant ? Ce numéro spécial de la revue Questions de Santé Publique apporte un éclairage sur cette question à partir de résultats originaux provenant de l’enquête « Épidémiologie et conditions de vie » (EpiCoV), permettant de documenter dans les meilleurs délais la situation exceptionnelle que nous traversons.

International audience

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 ANI reform mandates all private sector employers to offer sponsored Complementary Health Insurance (CHI) to all of their employees beginning on January 1st, 2016. This research simulates the likely effects of this mandate on the welfare of the population considering the Expected utility theory framework. The results show that the ANI reform may induce an increase in social welfare only if wages and CHI’s premiums remain the same. Assuming that premiums of individual CHI contracts increase because of the new risks segmentation, the reform may hardly impact the social welfare. The gain in welfare that benefit private sector employees is therefore offset by the loss of welfare that suffer the individuals insured by an individual CHI contract or who chose to be uninsured before the reform. Considering in addition that employers will include their subsidy amount into wages, the reform may greatly reduce the social welfare.; Depuis le 1er janvier 2016, les employeurs du secteur privé ont obligation de proposer et de financer partiellement une complémentaire santé à tous leurs salariés. Dans ce travail, nous simulons les gains et les pertes de bien-être à attendre de cette réforme sur l’ensemble de la population en mobilisant la théorie de l’utilité espérée. Les résultats montrent que la réforme augmente le bien-être collectif si et seulement si les salaires et les primes des contrats restent inchangés. En considérant que les primes des contrats individuels augmentent du fait de l’accord national interprofessionnel (ANI), l’impact de la réforme est quasi nul sur le bien-être collectif. Le gain en bien-être des salariés qui bénéficient de la réforme est alors contrebalancé par la perte de bien-être subie par les personnes couvertes en individuel ou que la réforme oblige à s’assurer. En considérant en sus que les employeurs intègrent le montant de leur subvention aux salaires, l’ANI réduit fortement le bien-être collectif.

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.

Peu de temps apres un numero special deja consacre a ce theme en 2012, la presente edition d’Economie et Statistique revient sur la question de la sante. Elle rassemble une selection d’articles issus des 35 Journees des economistes de la sante francais (JESF) qui se sont tenues a l’universite Paris‑Est Creteil en decembre 2013. Ces journees donnent regulierement lieu a publication d’un numero special consacre a la sante dans une revue a comite de lecture. Apres la Revue Economique et, a deux reprises, la revue Economie Publique, c’est au tour d’Economie et Statistique d’accueillir ces actes. Re‑aborder ce sujet, a des dates aussi rapprochees, s’explique evidemment par son importance, a la fois sociale et budgetaire, et nous allons y revenir dans un premier temps. Mais le precedent pour la revue ne se limite pas a ce numero special de 2012 : la thematique « sante » y a toujours eu une presence reguliere et importante. Apres un etat des lieux des donnees disponibles pour eclairer ce theme, on detaillera de quelle facon chacun des articles de ce numero est alle puiser dans cette masse de donnees, qu’elles relevent ou non du strict domaine de la statistique publique, et quels messages ont pu en etre tires.

This paper proposes a method to quantify the contribution of inequalities of opportunities and inequalities due to differences in effort to be in good health to overall health inequality. It examines three alternative specifications of legitimate and illegitimate inequalities drawing on Roemer, Barry and Swift’s considerations of circumstances and effort. The issue at stake is how to treat the correlation between circumstances and effort. Using a representative French health survey undertaken in 2006 and partly designed for this purpose, and the natural decomposition of the variance, the contribution of circumstances to inequalities in self-assessed health only differs of a few percentage points according to the approach. The same applies for the contribution of effort which represents at most 8%, while circumstances can account for up to 46%. The remaining part is due to the impact of age and sex.

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.

National audience; L’Aide à l’acquisition d’une complémentaire santé (ACS) est un dispositif, sous la forme d’une aide financière, mis en place en 2005 pour favoriser l’accès aux soins des personnes ayant un revenu juste au-dessus du plafond de l’éligibilité à la Couverture maladie universelle complémentaire (CMU-C). Malgré sa montée en charge, le non-recours à l’ACS estimportant, seules 22 % des personnes éligibles auraient fait valoir leur droit en 2011 (Fonds CMU, 2012). Comprendre les raisons du non-recours apparaît, dans ce contexte, essentiel pour améliorer l’efficacité du dispositif et permettre aux personnes aux revenus modestes d’accéder à une complémentaire santé. Suite à une expérimentation sociale, une enquête a été réalisée en 2009 à Lille auprès de personnes potentiellement éligibles à l’ACS afin de mieux connaître leurs caractéristiques et leurs motivations ou blocages à recourir au dispositif.Les résultats de cette enquête montrent que la population identifiée comme éligible à l’ACS à Lille est confrontée à des difficultés économiques et sociales et fait face à des besoins de soins importants. Le taux de recours à l’ACS est néanmoins faible puisque seules 18 % despersonnes ont entrepris des démarches pour l’obtenir. Les raisons les plus souvent invoquées pour expliquer ce non-recours sont : penser ne pas être éligible, le manque d’information, la complexité des démarches et, pour les personnes non couvertes, le prix de la complémentaire, même après déduction du chèque santé.

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.

The way to treat the correlation between circumstances and effort is a central, yet largely neglected issue in the applied literature on inequality of opportunity. This paper adopts three alternative normative ways of treating this correlation championed by Roemer, Barry and Swift and assesses their empirical relevance using survey data. We combine regression analysis with the natural decomposition of the variance to compare the relative contributions of circumstances and efforts to overall health inequality according to the different normative principles. Our results suggest that, in practice, the normative principle on the way to treat the correlation between circumstances and effort makes little difference on the relative contributions of circumstances and efforts to explained health inequality.