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Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the alveoli accumulation of surfactants proteins and lipids, which diagnosis is confirmed by the presence of GM-CSF antibodies in serum. PAP can be evoked when its characteristic images on chest computed-tomography (CT) are present: bilateral and multifocal ground-glass opacities and crazy-paving appearance. Patients with PAP are at an increased risk of opportunistic infections caused by Nocardia, mycobacteria and fungal pathogens due to impaired processing of pulmonary surfactant. We here report a typical case of newly diagnosed autoimmune PAP, with initial indication to realize a whole-lung lavage. Despite this treatment the patient presented a marked clinical worsening, with increasing need for oxygen and finally the need for mechanical ventilation. The chest CT was controlled and found to be typical of PAP, while the search for opportunistic infections remained negative. Finally, SARS-CoV-2 PCR was performed on bronchoalveolar lavage fluid, and was positive, whereas it had previously been negative twice. Our case report highlights the difficulty of distinguishing SARS-CoV-2 infection in the context of PAP, as the chest CT features are similar. We believe that a SARS-CoV-2 RT-PCR should be systematically realized in case of respiratory deterioration in PAP patients.

Introduction The uptake of human papillomavirus (HPV) vaccination in France remains low. The aim of this study was to identify factors associated with the uptake of the HPV vaccine in girls aged 11–14 years in France. Methods We conducted a telephone survey among a quota sample of 1102 mothers of 11-14-year-old daughters residing in mainland France, using the French Survey Questionnaire for the Determinants of HPV Vaccine Hesitancy (FSQD-HPVH). The dependent variable was the uptake of at least one dose of the HPV vaccine in the daughter. The independent variables included the FSQD-HPVH item variables, the Global Vaccine Confidence Index item variables, the daughter’s age, and the mother’s socioeconomic status. Results Overall, 38.6% of the mothers indicated that their daughter received at least one dose of the HPV vaccine. The multivariate analysis revealed that agreeing with the statement that doctors/health care providers believe vaccinating girls against HPV was a good idea, and having asked questions to the attending doctor about HPV vaccines were associated with a higher HPV vaccine uptake (OR = 4.99 , 95% CI [2.09–11.89]; and OR = 3.44, 95% CI [2.40–4.92]). Mother’s belief that her daughter was too young to be vaccinated against HPV (OR = 0.16 , 95% CI [0. 09–0.29]) and lower daughter’s age (OR = 0.17 , 95% CI [0.10–0.28] for girls aged 11 compared to those aged 14) were found strongly inversely associated with HPV vaccination, followed by agreeing with the statement that the HPV vaccine was unsafe (OR = 0.42 , 95% CI [0.26–0.67]), identifying as true the statement that HPV was very rare (OR = 0.49 , 95% CI [0.31–0.77]), and the mother’s refusal of own vaccination (OR = 0.57 , 95% CI [0.40–0.80]). Conclusion We have identified important determinants associated with HPV vaccine uptake in France. Interventions designed to improve HPV vaccine uptake should be tailored to address these determinants.

The quality of online health information is cause for concern in general, and the spread of mis/disinformation on the benefits and risks of vaccines has certainly been fueling vaccine hesitancy. In the wake of the COVID-19 pandemic, we have entered an era of unprecedented “infodemic.” There has never been a more urgent time to address the long-standing question of how to overcome the deleterious influence of exposure to online mis/disinformation on vaccine uptake. eHealth literacy, a skill set including media literacy, is key to navigating the web in search for health information and processing the one encountered through social media. Studies assessing the impact of increasing eHealth literacy on behavioral attitudes and health outcomes in the general population are relatively scarce to date. Yet for many reasons, leveraging eHealth literacy skills, and more specifically, media literacy, could be of great value to help mitigate the detrimental effects of erroneous information on vaccination decision-making. In this paper, we make the case that eHealth and media literacies should be viewed as fundamental skills that have the potential to empower citizens to better recognize online mis/disinformation and make informed decisions about vaccination as any other health matters.

Abstract Background HIV, HBV and HCV infections continue to represent major health concerns, especially among key at-risk populations such as men who have sex with men (MSM), people who inject drugs (PWIDs), transgender women (TGW) and sex workers (SW). The objective of the ANRS-CUBE study was to evaluate the acceptability of a healthcare, community-based strategy offering a triple rapid HIV-HBV-HCV testing, and HBV vaccination, targeted at three priority groups (MSM, PWIDs and TGW/SWs), in three community centers, in the Paris area. Methods This longitudinal multicentric non-randomized study included all adult volunteers attending one of the three specialized community centers in Paris, between July 2014 and December 2015. HIV, HBV and HCV status and acceptability of HBV vaccination were evaluated. Results A total of 3662, MSM, 80 PWIDs and 72 TGW/SW were recruited in the three centers respectively. Acceptability of rapid tests was 98.5% in MSM and 14.9% in TGW/SWs, but could not be estimated in PWIDs since the number of users attending and the number of proposals were not recorded. User acceptability of HBV vaccination was weak, only 17.9% of the eligible MSM (neither vaccinated, nor infected) agreed to receive the first dose, 12.2% two doses, 5.9% had a complete vaccination. User acceptability of HBV vaccination was greater in PWIDs and TGW/SWs, but decreased for the last doses (66.7 and 53.3% respectively received a first dose, 24.4 and 26.7% a second dose and 6.7 and 0% a third dose). Fifty-three participants (49 MSM and 4 PWIDs) were discovered HIV positive, more than half with a recent infection. All but two HIV positive participants were linked to appropriate care in less than one month. Conclusions Rapid HIV-HCV-HBV screening showed a very high level of acceptability among MSM. Efforts need to be made to improve immediate acceptability for HBV vaccination, especially among MSM, and follow-up doses compliance. Our results show the important role of community centers in reaching targets, often fragile, populations, while also suggesting the need to reinforce on-site human support in terms of testing and vaccination, especially when addressing PWIDs.

Abstract Background Social and physical characteristics of the daily visited neighborhoods have gained an extensive interest in analyzing socio-territorial inequalities in health and healthcare. The objective of the present paper is to estimate and discuss the role of individual and contextual factors on participation in preventive health-care activities (smear screening) in the Greater Paris area focusing on the characteristics of daily visited neighborhoods in terms of medical densities and social deprivation. Methods The study included 1817 women involved in the SIRS survey carried out in 2010. Participants could report three neighborhoods they regularly visit (residence, work/study, and the next most regularly visited). Two “cumulative exposure scores” have been computed from household income and medical densities (general practitioners and gynecologists) in these neighborhoods. Multilevel logistic regression models were used to measure association between late cervical screening (> 3 years) and characteristics of daily visited neighborhoods (residential, work or study, visit). Results One-quarter of the women reported that they had not had a smear test in the previous 3 years. Late smear test was found to be more frequent among younger and older women, among women being single, foreigners and among women having a low-level of education and a limited activity space. After adjustment on individual characteristics, a significant association between the cumulative exposure scores and the risk of a delayed smear test was found: women who were exposed to low social deprivation and to low medical densities in the neighborhoods they daily visit had a significantly higher risk of late cervical cancer screening than their counterparts. Conclusions For a better understanding of social and territorial inequalities in healthcare, there is a need for considering multiple daily visited neighborhoods. Cumulative exposure scores may be an innovative approach for analyzing contextual effects of daily visited neighborhoods rather than focusing on the sole residential neighborhood.

Abstract Background Non-participation and attrition are rarely studied despite being important methodological issues when performing post-disaster studies. A longitudinal survey of civilians exposed to the January 2015 terrorist attacks in Paris, France, was conducted 6 (Wave 1) and 18 months (Wave 2) after the attacks. We described non-participation in Wave 1 and determined the factors associated with attrition in Wave 2. Methods Multivariate logistic regression models were used to compare participants in both waves with those who participated in the first wave only. Analyses were performed taking the following factors into account: socio-demographic characteristics, exposure to terror, peri-traumatic reactions, psychological support, perceived social support, impact on work, social and family life, and mental health disorders. Characteristics of new participants in Wave 2 were compared with participants in both waves using a chi-square test. Results Of the 390 persons who were eligible to participate in the survey, 190 participated in Wave 1 (participation rate: 49%). The most frequently reported reason for non-participation was to avoid being reminded of the painful event (32%, n = 34/105). In Wave 2, 67 were lost to follow-up, 141 people participated, of whom 123 participated in Wave 1 (re-participation rate: 65%) and 18 were new. Attrition in Wave 2 was associated with socio-demographic characteristics (age, French origin) and location during the attacks, but not with terror exposure or mental health disorders. Compared with those who participated in both waves, new participants declared less social and psychological support since the attacks. Conclusions Attrition at 6 months was not associated with exposure to terror or mental health disorders, which indicates that any bias in future analyses on IMPACTS on mental health outcomes will be limited. Our findings suggest the importance of adapting similar surveys for people of foreign origin and of improving strategies to avoid attrition of younger people, for example by using social media, peers, and the educational environment. The present study also revealed that a high level of exposure to terror and a lack of social and psychological support after a terrorist event could impede individuals’ participation in similar surveys in the short term.

The soluble form of the membrane hemoglobin scavenger receptor CD163 (sCD163), released by shedding, is a strong marker for macrophage activation. Serum sCD163 levels rise in several acute inflammatory states and some fibrosing diseases. Monocyte-derived macrophages (MoDM) differentiated by macrophage colony-stimulating factor (M-MoDM) contribute to the pathophysiology of idiopathic pulmonary fibrosis (IPF), an irreversible and rapidly fatal interstitial lung disease. Since M-MoDM express high membrane CD163 levels, we thus postulated that sCD163 could be a relevant biomarker for macrophage activation in IPF. We found that M-MoDM constitutively released higher amounts of sCD163 (49.5 ± 24.5 ng/ml) than monocytes (0.45 ± 0.32 ng/ml) or MoDM differentiated with granulocyte macrophage-stimulating factor (2.24 ± 0.98 ng/ml). The basal production of sCD163 by M-MoDM was increased following stimulation with lipopolysaccharide (123.4 ± 54.9 ng/ml) or ATP (168.9 ± 41.8 ng/ml). The sCD163 release was controlled by metalloproteases but not through ADAM17 activation. Moreover, CD163-positive macrophages and sCD163 were detected in pulmonary tissues and alveolar fluids of Caucasian patients with IPF, respectively. IPF alveolar macrophages constitutively secreted sCD163 amounts (67.6 ± 44.6 ng/µg RNA) which were significantly higher than those released by alveolar macrophages isolated from controls (19.2 ± 7.6 ng/µg RNA) or patients with other interstitial lung disease (31.5 ± 16.6 ng/µg RNA). However, the concentrations of sCD163 in blood serum collected from 155 patients with IPF did not correlate with the severity of their disease. In conclusion, our results show that M-MoDM constituted a pertinent model to study the regulation of sCD163 production. Yet, serum sCD163 values could not provide a prognostic biomarker for IPF in our cohort.

Abstract Background In France, with the growing scarcity of gynecologists and a globally low and socially differentiated coverage of cervical cancer screening (CCS), general practitioners (GPs) are valuable resources to improve screening services for women. Still all GPs do not perform Pap smears. In order to promote this screening among GPs, the characteristics of physicians who never perform CCS should be more precisely specified. Besides already-known individual characteristics, the contextual aspects of the physicians’ office, such as gynecologist density in the area, could shape GPs gynecological activities. Methods To analyze county (département) characteristics of GPs’ office associated with no performance of CCS, we used a representative sample of 1063 French GPs conducted in 2009 and we constructed mixed models with two levels, GP and county. Results Almost 35% (n = 369) of the GPs declared never performing CCS. GPs working in counties with a poor GP-density per inhabitants were more likely to perform CCS (odds ratio (OR) = 0.52 for each increase of density by 1 GP per 10,000 inhabitants, 95% confidence interval (CI) = 0.37–0.74). On the contrary, GPs working in counties with an easier access to a gynecologist were more likely not to perform CCS (OR = 1.06 for each increase of density by 1 gynecologist per 100,000 women, 95%CI = 1.03–1.10 and OR = 2.02 if the first gynecologist is reachable in less than 15 min, 95%CI = 1.20–3.41) as well as GPs working in areas with a poverty rate above the national average (OR = 1.66, 95%CI = 1.09–2.54). These contextual characteristics explain most of the differences between counties concerning rates of not performing CCS. Conclusions Specific programs should be developed for GPs working in contexts unfavorable to their involvement in CCS.

IntroductionEvacuation of infected fluid in pleural infections is essential. To date, the use of an intrapleural fibrinolytic agent such as urokinase and DNase has not yet been assessed in infections managed by repeated therapeutic thoracentesis (RTT).MethodsWe performed a retrospective comparative study of two successive cohorts of consecutive patients with pleural infections from 2001 to 2018. Between 2001 and 2010, patients had RTT with intrapleural urokinase (RTT-U). After 2011, patients received intrapleural urokinase and DNase with RTT (RTT-UD). Data were collected through a standardized questionnaire.ResultsOne hundred and thirty-three patients were included: 93 were men and the mean age was 59 years (standard deviation 17.2). Eighty-one patients were treated with a combination of intrapleural urokinase and DNase, and 52 were treated with intrapleural urokinase only. In the RTT-UD, RTT failure occurred in 14 patients (17%) compared to 10 (19%) in the RTT-U group (P = 0.82). There was no difference between the two groups in intensive care unit admission, surgical referrals or in-hospital mortality. RTT-UD was associated with faster time to apyrexia (aOR = 0.51, 95%CI [0.37-0.72]), a reduced length of hospital stay (aOR = 0.61, 95%CI [0.52-0.73]) and a higher volume of total pleural fluid retrieved (aOR = 1.38, 95%CI [1.02-1.88]). Complications were rare with only one hemothorax in the RTT-UD group and no pneumothorax requiring drainage in either group.ConclusionCompared to urokinase only, intrapleural use of urokinase and DNase in RTT was associated with quicker defervescence, shorter hospital stay and increased volumes of pleural fluid drained. Randomized controlled trials evaluating urokinase and DNase with RTT technique would be required to confirm these results.

Abstract Background Territorial differences in the access to innovative anticancer drugs have been reported from many countries. The objectives of this study were to evaluate access to innovative treatments for metastatic lung cancer in France, and to assess whether socioeconomic indicators were predictors of access at the level of the municipality of residence. Methods All incident cases of metastatic lung cancer hospitalised for a chemotherapy in public hospitals in 2011 were identified from the French National Hospital discharge database. Information on prescription of innovative drugs from an associated database (FICHCOMP) was crossed with the population density of the municipality and a social deprivation index based on national census data. Results Overall, 21,974 incident cases of metastatic lung cancer were identified, all of whom were followed for 2 years. Of the 11,486 analysable patients receiving chemotherapy in the public sector, 6959 were treated with a FICHCOMP drug at least once, principally pemetrexed. In multivariate analysis, prescription of FICHCOMP drugs was less frequent in patients ≥66 years compared to those ≤55 years (odds ratio: 0.49 [0.44–0.55]), in men compared to women (0.86 [0.79–0.94]) and in patients with renal insufficiency (0.55 [0.41–0.73]) and other comorbidities. Prescription rates were also associated with social deprivation, being lowest in the most deprived municipalities compared to the most privileged municipalities (odds ratio: 0.82 [0.72–0.92]). No association was observed between the population density of the municipality and access to innovative drugs. Conclusion Although access to innovative medication in France seems to be relatively equitable, social deprivation is associated with poorer access. The reasons for this need to be investigated and addressed.

BackgroundNEETs (young people not in employment, education or training) are at higher risk for poorer mental and physical health. In France, the Missions locales (MLs) are the only social structures dedicated to this population. We sought to determine whether the systematic offer of a social and preventive medicine consultation at a ML might increase NEET participants' access to training in the 12 months following the intervention.MethodsThis intervention research was a parallel randomised controlled interventional study conducted at five MLs in mainland France in 2011-2012. It included 976 NEETs aged 18 to 25 years who attended one of the five MLs. At inclusion, participants were randomly assigned (1:1:1) to three groups: those in the first group were invited to see a social worker (not studied in this paper), those in the second group were invited to see a doctor and a social worker (intervention group), and the third was a control group. The primary outcome was participation in at least one training session during the year following study inclusion.ResultsAmong the 976 participants, 504 were randomly assigned to the intervention group and 472 to the control group; 704 (72.1%) were included in the analyses. A significantly higher proportion of the participants in the intervention group participated in a training session in the 12 months following the intervention than of those in the control group (63.3% vs 55.6%; p = 0.04). This difference was significantly greater for women, those less than 21 years of age, those unstably housed and those with a lower level of education.ConclusionsSocial and preventive medicine consultations that are fully integrated into the social services for NEETs have an impact on their access to training and contribute to changing some of their health-related behaviours. This may improve their access to the labour market.

The present study aimed to assess socioeconomic inequalities in general and mental health, depression and substance use disorders (daily tobacco use, hazardous alcohol use). Data from the 2010 SIRS (French acronym for Health, Inequalities, and Social Ruptures) study, which is deemed to be representative of the French-speaking adult population living in the Paris Metropolitan Area, were analysed. Different socioeconomic position indicators were selected: education, income and perceived financial status. Absolute measures (the slope index of inequality (SII)) and relative measures (the odds ratio (OR) and relative index of inequality (RII)) of health inequalities were used. The OR, RII and SII were adjusted for age, household type and migration characteristics and all analyses were performed separately for men and women. The study included 3,006 adults. The results showed significant relative and absolute socioeconomic inequalities in general, mental health and depression for all socioeconomic position indicators considered (education, income, and perceived financial status). The absolute inequalities were greater for women than for men. Strongest inequalities were observed by perceived financial status for men and women. Education seemed to play a stronger role in inequalities for women, whereas, for men, income seemed to play a stronger role. Only few socioeconomic inequalities were found in daily tobacco use, while a reversed gradient was observed for hazardous alcohol use. We hope that these results will be regularly re-evaluated and compared across time in order to monitor socioeconomic inequalities in health.

Objective The relationship between food insecurity and obesity is discussed in the literature. The objective of this study was to determine whether food insecurity and obesity were associated in the Paris metropolitan area. Methods: We used data from third wave of the Health, Inequalities and Social Ruptures (SIRS) cohort study, a longitudinal population-based, representative health and socioepidemiological survey of the general population in the Paris metropolitan area. The participants' BMI (calculated using self-reported height and weight) was analyzed as a continuous variable, and a dichotomous variable (BMI 2/BMI ≥ 30 kg/m2) was constructed. Food insecurity was estimated using the Household Food Security Scale Module (HFSSM) and was treated as a trichotomous variable (food security / low food security / very low food security). Multilevel models were estimated for men and women separately. Results: Obesity (BMI ≥ 30 kg/m2) prevalence was 10.2%. The determinant of obesity differs according to gender. After adjustment for age, income and the sociooccupational group, very low food security was associated with obesity in women (OR = 2.01, 95%CI 1.05-3.82), and women with very low food security had a higher BMI (Coef. = 1.78, 95% CI 0.24-3.31). This association, however, was not significant for men (OR = 1.84, 95%CI 0.64-5.30). Conclusion: In times of economic crisis, it is increasingly essential to explore and understand the pathway through which very low food security is linked to obesity.

Despite their poor health status, homeless women encounter many barriers to care. The objectives of our study were to estimate the prevalence of unmet healthcare needs in homeless women and to analyse associated relationships with the following factors: financial and spatial access to care, housing history, migration status, healthcare utilisation, victimization history, caring for children, social network and self-perceived health status.We used data from 656 homeless women interviewed during the ENFAMS representative survey of sheltered homeless families, conducted in the Paris region in 2013. Structural equation models (SEM) were used to estimate the impact of various factors on homeless women's unmet healthcare needs.Among those interviewed, 25.1% (95%CI[21.3-29.0]) had at least one unmet healthcare need over the previous year. Most had given up on visiting general practitioners and medical specialists. No association with factors related to financial access or to health insurance status was found. However, food insecurity, poor spatial health access and poor self-perceived health were associated with unmet healthcare needs. Self-perceived health appeared to be affected by victimization and depression.The lower prevalence of unmet healthcare needs in homeless women compared with women in stable housing situations suggests that homeless women have lower needs perceptions and/or lower expectations of the healthcare system. This hypothesis is supported by the results from SEM. Strategies to provide better access to care for this population should not only focus on financial interventions but also more broadly on spatial healthcare access, cultural norms, and perceptions of health. Reducing their unmet needs and improving their access to healthcare and prevention must include an improvement in their living, financial and housing conditions.

The French healthcare system is a universal healthcare system with no financial barrier to access to health services and cancer drugs. The objective of the study is to investigate associations between, on the one hand, incidence and survival of patients diagnosed with lung cancer in France and, on the other, the socioeconomic deprivation and population density of their municipality of residence. A national, longitudinal analysis using data from the French National Hospital database crossed with the population density of the municipality and a social deprivation index based on census data aggregated at the municipality level. For lung cancer diagnosed at the metastatic stage, one-year and two-year survival was not associated with the population density of the municipality of residence. In contrast, mortality was higher for people living in very deprived, deprived and privileged areas compared to very privileged areas (hazard ratios at two years: 1.19 [1.13-1.25], 1.14 [1.08-1.20] and 1.10 [1.04-1.16] respectively). Similar associations are also observed in patients diagnosed with non-metastatic disease (hazard ratios at two years: 1.21 [1.13-1.30], 1.15 [1.08-1.23] and 1.10 [1.03-1.18] for people living in very deprived, deprived and privileged areas compared to very privileged areas). Despite a universal healthcare coverage, survival inequalities in patients with lung cancer can be observed in France with respect to certain socioeconomic indicators.

Oral health has improved in France. However, there are still inequalities related to the socio-economic status.The aim of this study was to measure the prevalence of dental care needs in an adult population and to identify the demographic, socio-economic and behavioral variables that may explain variations in this parameter.A cross-sectional analysis of the French SIRS cohort (n = 2,997 adults from the Paris region; 2010 data) was carried out to determine the prevalence of self-reported dental care needs relative to demographic, socio-economic and behavioral variables. A logistic regression model was used to identify the variables that were most strongly associated with the level of need.In 2010, the prevalence of the need for dental care in the SIRS cohort was 35.0% (95% CI [32.3-37.8]). It was lower in people with higher education levels (31.3% [27.9-34.6]), without immigrant background (31.3% [28.0-34.6]) and with comprehensive health insurance (social security + complementary health cover; 32.8% [30.2-35.4]). It decreased as the socio-economic status increased, but without following a strict linear change. It was also lower among individuals who had a dental check-up visit in the previous two years. In multivariate analyses, the socioeconomic variables most strongly associated with the need for dental care were: educational attainment (OR = 1.21 [1.02-1.44]), income level (OR = 1.66 [1.92-2.12]) and national origin (OR = 1.53 [1.26-1.86]).These results confirm that the prevalence of dental care needs is higher among adults with low socio-economic status. Education level, income level and also national origin were more strongly associated with the need for dental care than insurance cover level.

INTRODUCTION:Asthma remains poorly studied in homeless children. We sought to estimate the prevalence of asthma-like symptoms (ALS) and to identify the factors associated with ALS and healthcare service utilisation. MATERIALS AND METHODS:A cross-sectional survey of a random sample of sheltered homeless families was conducted by interviewing 801 parents of children (0-12 years) in 17 languages. ALS were defined as wheezing or night cough without fever during the previous year. Poisson regression models with robust error variance were used to compute prevalence ratios (PR) for factors associated with ALS and healthcare service utilisation for ALS. RESULTS:The prevalence of ALS among the children was 19.9%. Poor housing sanitation was significantly associated with ALS, as being born in the European Union. Most of the children with ALS had used healthcare services (85.4%). The main barriers to accessing such services were having lived in France for less than 49 months, having difficulties in French and living in poor housing conditions. CONCLUSION:ALS prevalence seemed lower than in the general child population, possibly because of the children's origins. Environmental factors associated with ALS point to the need to improve the indoor environment of family shelters. The relatively high rate of healthcare service utilisation should not overshadow existing barriers.

This interview was conducted with Pierre Chauvin, MD, PhD, Director of research at the French Institute for Health and Medical Researches (Inserm), and Director of the Social Epidemiology Research Center (ERES) of Pierre Louis Institute of Epidemiology and Public Health (UMRS 1136, Inserm & UPMC Sorbonne University) in Paris. Pierre Chauvin conducted research for nearly twenty years on health inequalities and social and territorial determinants of health and access to health care. Since 2005, he is the co-founder and main investigator of the SIRS cohort (which means Health, Inequalities and Social Disruptions) conducted in Paris region among 3,000 inhabitants within 50 neighborhoods. According to Chauvin, health behaviors, in the broad sense, are shaped and influenced by a large number of determinants, among which standards (collective and individual) and social interactions, that are all, or almost all, shaped to varying degrees by gender relations. Nevertheless, the gender issue remains largely understudied in social epidemiology and public health in France, although it is well recognized that it is a social determinant of health and that distinctive features related to gender are documented in France as elsewhere. To better take gender into account in epidemiology, it would require the development of multidisciplinary approaches, and to review findings from social sciences in the field of epidemiology and to try to translate these findings into concepts that could be use in quantitative analyses and in useful results for public health policy. The SIRS cohort was created especially to study the role of the living environment in individuals’ health and behaviors related to health (prevention, health care, etc.). From SIRS data, differences in daily mobility were observed by gender and socioeconomic status, probably emphasizing gendered territorial practices. Differences can be explained by the relationships with the neighborhood, especially with the gendered social roles and behaviors and the division of everyday tasks which remain largely assigned to women, or daily mobility, particularly related to commuting, which is known is unevenly distributed by socio-economic status, level of qualification and sectors and, thus, are largely dependent on gender. Therefore, women may be more sensitive than men to the effects of contextual characteristics of their environment on health, especially for the least mobile of them, which has been shown with SIRS data that it was usually the poorest ones.

While a great number of papers have been published on the short-term effects of air pollution on mortality, few have tried to assess whether this association varies according to the neighbourhood socioeconomic level and long-term ambient air concentrations measured at the place of residence. We explored the effect modification of 1) socioeconomic status, 2) long-term NO2 ambient air concentrations, and 3) both combined, on the association between short-term exposure to NO2 and all-cause mortality in Paris (France).A time-stratified case-crossover analysis was performed to evaluate the effect of short-term NO2 variations on mortality, based on 79,107 deaths having occurred among subjects aged over 35 years, from 2004 to 2009, in the city of Paris. Simple and double interactions were statistically tested in order to analyse effect modification by neighbourhood characteristics on the association between mortality and short-term NO2 exposure. The data was estimated at the census block scale (n=866).The mean of the NO2 concentrations during the five days prior to deaths were associated with an increased risk of all-cause mortality: overall Excess Risk (ER) was 0.94% (95%CI=[0.08;1.80]. A higher risk was revealed for subjects living in the most deprived census blocks in comparison with higher socioeconomic level areas (ER=3.14% (95%CI=[1.41-4.90], p

Meal times in France still represent an important moment in everyday life. The model of three rigorously synchronized meals is still followed by a majority of people, while meal frequencies have flattened in other European or North-American countries. We aimed to examine the "French model" of eating behavior by identifying and characterizing distinct meal patterns.Analyses were based on data from the SIRS cohort, a representative survey of the adult population in the Paris area. A clustering algorithm was applied to meal variables (number, time, location, with whom the meal is usually shared and activities associated with meals). Regression models were used to investigate associations between patterns and socio-demographic, social environment and perceived food quality variables.Five different patterns were identified among 2994 participants. The first three types (prevalence 33%, 17% and 24%) followed a three-meal pattern, with differences in locations and social interactions mainly related to time constraints and age. More marked differences were observed in the remaining two types. In the fourth type (prevalence 13%), individuals ate one or two meals per day, often with an irregular schedule, at home and in front of the television. They frequently were unemployed and had lower income. Breakfast skipping, increased snacking and a low adherence to dietary guidelines suggested that this behavior might have health consequences. In the fifth type (12%), people also ate two meals or less per day, possibly with the same consequences on food quality. However, meals were often taken outside the home, in social settings, and individuals following this pattern were typically active, integrated, young people, suggesting that this pattern might be an adaptation to a modern urban lifestyle.While a majority of the population still follows the three-meal pattern, our analysis distinguished two other eating patterns associated with specific sociological profiles.

OBJECTIVES: This study aims to compare breast cancer screening (BCS) and cervical cancer screening (CCS) practices of French women born to French parents with those of immigrants and nationals born to immigrants, taking their socioeconomic status into account. METHODS: The study is based on data collected in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For women with no history of breast or cervical cancer, multivariate logistic regressions and structural equation models were used to investigate the factors associated with never having undergone BCS or CCS. RESULTS: We confirmed the existence of a strong gradient, with respect to migration origin, for delaying or never having undergone BCS or CCS. Thus, being a foreign immigrant or being French of immigrant parentage were risk factors for delayed and no lifetime screening. Interestingly, we found that this gradient persisted (at least partially) after adjusting for the women's socioeconomic characteristics. Only the level of income seemed to play a mediating role, but only partially. We observed differences between BCS and CCS which suggest that organized CCS could be effective in reducing socioeconomic and/or ethnic inequities. CONCLUSION: Socioeconomic status partially explained the screening nonparticipation on the part of French women of immigrant origin and foreign immigrants. This was more so the case with CCS than with BCS, which suggests that organized prevention programs might reduce social inequalities.

To explore beliefs and apprehensions about disease and its treatment in patients with rheumatoid arthritis and spondyloarthritis.25 patients with rheumatoid arthritis and 25 with spondyloarthritis participated in semi-structured interviews about their disease and its treatment. The interviews were performed by trained interviewers in participants' homes. The interviews were recorded and the main themes identified by content analysis.Patients differentiated between the underlying cause of the disease, which was most frequently identified as a hereditary or individual predisposition. In patients with rheumatoid arthritis, the most frequently cited triggering factor for disease onset was a psychological factor or life-event, whereas patients with spondyloarthritis tended to focus more on an intrinsic vulnerability to disease. Stress and overexertion were considered important triggering factors for exacerbations, and relaxation techniques were frequently cited strategies to manage exacerbations. The unpredictability of the disease course was a common source of anxiety. Beliefs about the disease and apprehensions about the future tended to evolve over the course of the disease, as did treatment expectations.Patients with rheumatoid arthritis and spondyloarthritis hold a core set of beliefs and apprehensions that reflect their level of information about their disease and are not necessarily appropriate. The physician can initiate discussion of these beliefs in order to dispel misconceptions, align treatment expectations, provide reassurance to the patient and readjust disease management. Such a dialogue would help improve standards of care in these chronic and incapacitating diseases.

BACKGROUND:Cost containment policies and the need to satisfy patients' health needs and care expectations provide major challenges to healthcare systems. Identification of homogeneous groups in terms of healthcare utilisation could lead to a better understanding of how to adjust healthcare provision to society and patient needs. METHODS:This study used data from the third wave of the SIRS cohort study, a representative, population-based, socio-epidemiological study set up in 2005 in the Paris metropolitan area, France. The data were analysed using a cross-sectional design. In 2010, 3000 individuals were interviewed in their homes. Non-conventional multivariate clustering techniques were used to determine homogeneous user groups in data. Multinomial models assessed a wide range of potential associations between user characteristics and their pattern of healthcare utilisation. RESULTS:We identified four distinct patterns of healthcare use. Patterns of consumption and the socio-demographic characteristics of users differed qualitatively and quantitatively between these four profiles. Extensive and intensive use by older, wealthier and unhealthier people contrasted with narrow and parsimonious use by younger, socially deprived people and immigrants. Rare, intermittent use by young healthy men contrasted with regular targeted use by healthy and wealthy women. CONCLUSION:The use of an original technique of massive multivariate analysis allowed us to characterise different types of healthcare users, both in terms of resource utilisation and socio-demographic variables. This method would merit replication in different populations and healthcare systems.

OBJECTIVES: This study explored the pattern of associations between socioeconomic status (SES) and atherosclerosis progression (as indicated by carotid intima media thickness, CIMT) across gender. DESIGN: Cross-sectional analysis of a sample of 5474 older persons (mean age 73 years) recruited between 1999 and 2001 in the 3C study (France). We fitted linear regression models including neighborhood SES, individual SES and cardiovascular risk factors. RESULTS: CIMT was on average 24 µm higher in men (95% CI: 17 to 31). Neighborhood SES was inversely associated with CIMT in women only (highest versus lowest tertiles: -12.2 µm, 95%CI -22 to -2.4). This association persisted when individual SES and risk factors were accounted for. High individual education was associated with lower CIMT in men (-21.4 µm 95%CI -37.5 to -5.3) whereas high professional status was linked to lower CIMT among women (-15.7 µm 95%CI: -29.2 to -2.2). Adjustment for cardiovascular risk factors resulted in a slightly more pronounced reduction of the individual SES-CIMT association observed in men than in women. CONCLUSION: In this sample, neighborhood and individual SES displayed different patterns of associations with subclinical atherosclerosis across gender. This suggests that the causal pathways leading to SES variations in atherosclerosis may differ among men and women.