The MAKASI empowerment randomized intervention and depression and loneliness among sub-Saharan immigrants living in the greater Paris area (preprint)

Purpose The MAKASI intervention aimed to empower sub-Saharan African immigrants living in precarious situations in the Paris metropolitan area. Because there are factors specifically related to immigration that may increase the risk for common mental disorders, the present study aimed to examine participants' levels of depression and loneliness and analyze the effect of the intervention on depression and loneliness.Methods The MAKASI study was designed as a stepped-wedge randomized intervention trial. Study participants were recruited through an outreach program led by a nongovernmental organization and randomly assigned to two groups, with an intervention delay of three months between groups. Both groups were assessed for six months after inclusion and the effect of the intervention on depression and loneliness was assessed using generalized linear mixed models. The study was conducted from 2018 to 2021 and we took in consideration whether being interviewed during one of the Covid-19 confinement had an effect on the results.Results A total of 821 subjects participated in the Makasi study. High levels of depression and loneliness were found in the study population. We found no effect of the intervention on depression [95%CI 0.77 to 2.40]. Similarly, no effect of the intervention was found on loneliness [95%CI 0.87 to 2.54].Conclusions The intervention we tested did not appear to improve the level of depression and loneliness among participants. However, the high prevalence of mental and emotional problems in the study population suggests a public health crisis among immigrants in the greater Paris area.Clinical Trial Registration Number: Trial registration Clinicaltrials.gov, NCT04468724 (July 13, 2020)

High screen time and internalizing and externalizing behaviours among children aged 3 to 14 years during the COVID-19 Pandemic in France (preprint)

Objective Children's screen time increased as a result of the COVID-19 pandemic. In summer 2021 we explored the association between high screen time over a period of one year since May 2020 and behavioural problems among children and adolescents. Methods The data was derived from the French EpiCov cohort study, collected in spring 2020, autumn 2020, and spring 2021. Participants (N=1,089) responded to online or telephone interviews about one of their children aged 3 to 14 years. Screen time was categorized as high if the daily mean screen time exceeded recommendations at each collection time. The Strengths and Difficulties Questionnaire (SDQ) was completed by parents to identify internalizing (emotional or peer problems) and externalizing (conduct problems or hyperactivity/inattention) behaviours in their children. Results Internalizing behaviours: No interaction was highlighted between children's age and high screen time. High screen time was not associated with internalizing behaviours (OR [95% CI]: 1.20 [0.90-1.59]) while it was associated with peer problems (1.42 [1.04-1.95]). Externalizing behaviours: there was an interaction of children's age in the relationship between high screen time and externalizing behaviours. High screen time was associated with externalizing problems (1.63 [1.01-2.63]) and conduct problems (1.91 [1.15-3.22]) only among older children aged 11 to 14 years. Conclusion This study found that persistent high screen time over one year after the onset of the pandemic was associated with peer problems among children aged 3-14 years and externalizing and conduct problems among 11-14-year-olds. Despite this very specific context, exposure to screens is not negligible.

COVID-19 illness, SARS-CoV2 infection, and subsequent suicidal ideation in the French nationwide population-based EpiCov cohort : a propensity score analysis of more than 50,000 individuals. (preprint)

Symptomatic COVID-19 appears to be associated with suicidal ideation but longitudinal evidence is still scarce. SARS-CoV2-induced neurological damages might underline this association, but findings are inconsistent. We therefore investigated the association between COVID-19 disease and subsequent suicidal ideation in the general population, using both self-reported symptoms and serology as well as inverse probability weighting to draw as near as possible to the direct association. Using data from the nationwide French EpiCov cohort, COVID-19 disease was assessed through 1) COVID-19 illness (self-reported symptoms of sudden loss of taste/smell or fever alongside cough, shortness of breath or chest oppression, between February and November 2020), and 2) SARS-CoV2 infection (Spike protein ELISA test screening in dried-blood-spot samples). Suicidal ideation was self-reported between December 2020 and July 2021. Inverse probability weighting with propensity scores was used as an adjustment strategy, leading to balanced sociodemographic and health-related factors between the exposed and non-exposed groups of both COVID-19 disease measures. Then, modified Poisson regression models were used to investigate the association of COVID-19 illness and SARS-CoV2 infection with subsequent suicidal ideation. Among 52,050 participants from the EpiCov cohort, 1.68% [1.54% - 1.82%] reported suicidal ideation in the first half of 2021, 9.57% [9.24% - 9.90%] had a SARS-CoV2 infection in 2020 and 13.23% [12.86% - 13.61%] reported COVID-19 symptoms in 2020. COVID-19 illness in 2020 was associated with higher risks of subsequent suicidal ideation in the first half of 2021 (Relative Riskipw [CI95%]= 1.43 [1.20 - 1.69]) while SARS-CoV2 infection in 2020 was not (RRipw = 0.88 [0.69 - 1.12]). If COVID-19 illness was associated with subsequent suicidal ideation, the exact role of SARS-CoV2 infection with respect to suicide risk has yet to be clarified. Psychological support should be offered to persons recovering from symptomatic COVID-19 in order to minimize suicidal ideation risk. Moreover, if such psychological support is to be implemented, serology status alone does not seem a relevant criterion to define persons who suffered from COVID-19 to prioritize.

Motives for COVID-19 vaccine hesitancy amongst marginalized groups, including homeless persons and migrants, in France: a mixed-methods study. (preprint)

Background: Persons experiencing unstable housing – including recently arrived migrants – are at elevated risk of contracting COVID-19 and suffer from high morbidity and mortality. In this context, the COVID-19 vaccine was foreseen as a promising way to control the pandemic and reduce social inequalities in this area. Understanding the motives of COVID-19 vaccine acceptability in people with unstable housing, including migrants, is therefore crucial to tailor public health communication and outreach. Thus, the main objective of our study was to investigate - both quantitatively and qualitatively – the motivations behind vaccine hesitancy in people experiencing unstable housing when vaccines became available in France. Methods: : A cross-sectional study was performed in Spring 2021, using convergent mixed-methods approach. Participants were recruited from homeless shelters and day centres and face-to-face interviews were offered, with help, where necessary, from phone-based interpreters. Factors associated with motives for COVID-19 vaccine hesitancy were explored using logistic regression models. Qualitative data – collected through semi-structured individual interviews - were analysed via an inductive thematic approach. Both quantitative and qualitative data were then integrated. Results: : Vaccine hesitancy was found to be at an elevated rate (58.0%). The three most reported motives of hesitancy were related to COVID-19 vaccine effectiveness, safety, and trust in information about the vaccine. Factors of elevated hesitancy comprised the interviewees’ age, level of education, French-language aptitude, feeling of worry about COVID-19, and time of residence in France. Generic distrust in official information was a shared associated factor for the 3 motives of hesitancy. This result was expanded upon by the interview data where participants described having differential trust depending on who is recommending the vaccination. Another emerging key theme related to hopes that the vaccine would release them from the burden of the pandemic. Conclusions: : Our mixed methods study provides a comprehensive understanding of COVID-19 vaccine hesitancy among persons with unstable housing in France in Spring 2021. Elevated levels of hesitancy remain a public health concern as “No one is safe until everyone is safe”. The already established role of trust in vaccine hesitancy is still to be adequately addressed as a potentially effective route of intervention.

Labor market position and depression during the COVID-19 epidemic among young adults (18 to 30 years): a nationally representative study in France. (preprint)

ObjectiveTo examine the relationship between young adults labor force participation and depression in the context of the COVID-19 pandemic. Design, Setting, ParticipantsData come from the nationally-representative EPICOV cohort study set up in France, and were collected in 2020 and 2021 (3 waves of online or telephone interviews) among 2217 participants aged 18-30 years. Participants with prior mental health disorder (n=50) were excluded from the statistical analyses. ResultsUsing Generalized Estimating Equation (GEE) models controlled for participants socio-demographic and health characteristics and weighted to be nationally-representative, we found that compared to young adults who were employed, those who were studying or unemployed were significantly more likely to experience depression assessed using the PHQ-9 (multivariate ORs respectively: OR: 1.29, 95% CI 1.05-1.60 and OR: 1.50, 1.13-1.99). Stratifying the analyses by age, we observed than unemployment was more strongly associated with depression among participants 25-30 years than among those who were 18-24 years (multivariate ORs respectively 1.78, 95% CI 1.17-2.71 and 1.41, 95% CI 0.96-2.09). Being out of the labor force was, to the contrary, more significantly associated with depression among participants 18-24 years (multivariate OR: 1.71, 95% CI 1.04-2.82, vs. 1.00, 95% CI 0.53-1.87 among participants 25-30 years). Stratifying the analyses by sex, we found no significant differences in the relationships between labor market characteristics and depression (compared to participants who were employed, multivariate ORs associated with being a student: men: 1.33, 95% CI 1.01-1.76; women: 1.19, 95% CI 0.85-1.67, multivariate ORs associated with being unemployed: men: 1.60, 95% CI 1.04-2.45; women: 1.47, 95% CI 1.01-2.15). Conclusions and relevanceOur study shows that in addition to students, young adults who are unemployed also experience elevated levels of depression in the context of the COVID-19 pandemic. These two groups should be the focus of specific attention in terms of prevention and mental health treatment. Supporting employment could also be a propitious way of reducing the burden of the Covid-19 pandemic on the mental health of young adults. Key PointsO_ST_ABSQuestionC_ST_ABSIs labor force participation associated with young adults likelihood of depression during the COVID-19 pandemic? FindingsIn a nationally-representative cohort study in France, compared to young adults who are employed, those who are studying or experience unemployment had elevated odds of depression in 2020 and 2021. MeaningYoung people are experiencing the highest burden of mental health problems in the context of the COVID-19 epidemic - our study implies that those who are studying or are unemployed are at especially high risk and should be the focus of attention in terms of prevention and treatment.

Coping with COVID: Risk and Resilience Factors for Mental Health in a German Representative Panel Study (preprint)

Background: The COVID-19 pandemic might affect mental health. Data from population-representative panel surveys with multiple waves including pre-COVID data investigating risk and protective factors are still rare. Methods: In a stratified random sample of the German household population (n=6,684), we conducted survey-weighted multiple linear regressions to determine the association of various psychological risk and protective factors with changes in psychological distress (PD; measured via PHQ-4) from pre-pandemic (average of 2016 and 2019) to peri-pandemic (both 2020 and 2021) time points. Control analyses on PD change between two pre-pandemic time points (2016 and 2019) were conducted. Regularized regressions were computed to inform on which factors were statistically most influential in the multicollinear setting. Results: PHQ-4 in 2020 (M=2.45) and 2021 (M=2.21) was elevated compared to 2019 (M=1.79). Several risk factors (catastrophizing, neuroticism, asking for instrumental support) and protective factors (perceived stress recovery, positive reappraisal, optimism) were identified for the peri-pandemic outcomes. Control analyses revealed that in pre-pandemic times, neuroticism and optimism were predominantly related to PD changes. Regularized regression mostly confirmed the results and highlighted perceived stress recovery as most consistent influential protective factor across peri-pandemic outcomes. Conclusions: We identified several psychological risk and protective factors related to PD outcomes during the COVID-19 pandemic. Comparison to pre-pandemic data stress the relevance of longitudinal assessments to potentially reconcile contradictory findings. Implications and suggestions for targeted prevention and intervention programs during highly stressful times such as pandemics are discussed.

Social and mental health risks faced by undocumented migrants during the COVID-19 pandemic: Evidence from three surveys in France (preprint)

Background The often-precarious life circumstances of undocumented migrants are likely to heighten the detrimental impact of the COVID-19 pandemic on their lives. Given the paucity of research exploring how undocumented migrants are affected by the COVID-19 pandemic, we set out to explore the association between being an undocumented migrant and a range of social and mental health measures. Methods Our study draws on three complementary surveys conducted among migrants in France between April 1st and June 7th 2020 (APART TOGETHER, MAKASI, ECHO; n = 716). We tested associations between eight outcome measures, covering health literacy, prevention behaviours, perceptions of government responses, livelihoods and mental health (PHQ-9 score), and the participants' legal status as either undocumented or documented. We modelled the probability of food insecurity increase, job loss, depression, and responses to SARS-COV-2 symptoms with logistic regression models, adjusted for age, gender and legal status. Results Undocumented migrants had a higher probability of experiencing food insecurity increase (aORs=10.40 [3.59, 30.16], and 2.19 [1.39, 3.50] in APART TOGETHER and ECHO), a higher probability of depression (aOR=2.65 [1.01, 6.97] in MAKASI). In all three surveys, undocumented migrants were more likely to lose their job (aORs=6.51 [1.18, 36.00], 8.36 [1.08, 64.70] and 3.96 [1.79, 9.16] in APART TOGETHER, MAKASI and ECHO respectively). Conclusion Our results suggest that the lives of undocumented migrants have been dramatically worsened by the COVID-19 pandemic, exposing and amplifying the inequalities facing this group. There is an urgent need for action to address these inequalities.

Children's Mental and Behavioral Health, Schooling, Sociodemographic and Socioeconomic Characteristics During School Closure in France Due To COVID-19: The SAPRIS Project. (preprint)

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

COVID-19 vaccine hesitancy among persons living in homeless shelters in France. (preprint)

COVID-19 vaccine hesitancy is frequent and can constitute a barrier to the dissemination of vaccines once they are available. Unequal access to vaccines may also contribute to socioeconomic inequalities with regard to COVID-19. We studied vaccine hesitancy among persons living in homeless shelters in France between May and June 2020 (n=235). Overall, 40.9% of study participants reported vaccine hesitancy, which is comparable to general population trends in France. In multivariate regression models, factors associated with vaccine hesitancy are: being a woman (OR=2.55; 95% CI 1.40-4.74), living with a partner (OR=2.48, 95% CI 1.17-5.41), no legal residence in France (OR=0.51, 95% CI 0.27-0.92), and health literacy (OR=0.38, 95% CI 0.21, 0.68). Our results suggest that trends in vaccine hesitancy and associated factors are similar among homeless persons as in the general population. Dissemination of information on vaccine risks and benefits needs to be adapted to persons who experience severe disadvantage.

Depression during the COVID-19 pandemic amongst residents of homeless shelters in France. (preprint)

BackgroundAccumulating evidence suggests that the COVID-19 pandemic has negatively affected global mental health and well-being. However, the impact amongst homeless persons has not been fully evaluated. The ECHO study reports factors associated with depression amongst the homeless population living in shelters in France during the Spring of 2020. MethodsInterview data were collected from 527 participants living in temporary and/or emergency accommodation following Frances first lockdown (02/05/20 - 07/06/20), in the metropolitan regions of Paris (74%), Lyon (19%) and Strasbourg (7%). Interviews were conducted in French, English, or with interpreters (33% of participants, [~]20 languages). Presence of depression was ascertained using the Patient Health Questionnaire (PHQ-9). ResultsAmongst ECHO study participants, 30% had symptoms of moderate to severe depression (PHQ-9[≥] 10). Multivariate analysis revealed depression to be associated with being female (aOR: 2.15; CI: 1.26-3.69), being single (aOR: 1.60; CI: 1.01-2.52), having a chronic illness (aOR: 2.32; CI: 1.43:-3.78), facing food insecurity (aOR: 2.12; CI: 1.40-3.22) and participants region of origin. Persons born in African and Eastern Mediterranean regions showed levels of depression comparable to those of French participants (30-33%) but higher than migrants from European countries (14%). Reduced rates of depression were observed amongst participants aged 30-49 (aOR: 0.60; CI: 0.38-0.95) and over 50 (aOR: 0.28; CI: 0.13-0.64), compared to 18-29-year-olds. ConclusionsOur results indicate high levels of depression among homeless persons during the COVID-19 pandemic. The value of these findings extends beyond the health crisis, as predicted future instability and economic repercussions could particularly impact the mental health of this vulnerable group.