European immigrant health policies, immigrants' health, and immigrants' access to healthcare.

OBJECTIVE: Evidence indicates presence of immigrant health disparities in the European Union (EU) and the United States (US). We examined the association between immigrant health policies and the gap in health status, unmet needs and service use between immigrants and citizens, in the EU and US. METHODS: We used the Migrant Integration Policy Index (MIPEX), European Health Interview Survey, and National Health Interview Survey for 2014. Our independent variables of interest were MIPEX Health strand score and citizenship. Our dependent variables were four measures of health status (self-reported poor health; severely limited in general activities; two or more comorbidities; one or more ambulatory care sensitive conditions) and four measures of health access and utilization (unmet need due to non-financial reasons; could not afford needed health care; one or more primary care visits last year; any hospitalization last year). We conducted linear probability models and presented the marginal effects of each outcome in percentage points. FINDINGS: We found that immigrant-friendly health policies were significantly associated with better health and less unmet need due to non-financial reasons. CONCLUSION: Our findings supported the promotion of immigrant-friendly and a 'Health-in-All Policies' (HiAP) approach to preserve the health of immigrants.

Burden of infectious diseases among undocumented migrants in France: Results of the Premiers Pas survey.

Introduction: An increase in migration rates to the European Union has been observed over the last few years. Part of these migrants is undocumented. This work aimed to describe the reported frequency of infectious diseases and their associated factors among unselected samples of undocumented migrants in France. Methodology: The Premier Pas survey is a cross-sectional epidemiological survey of a random sample (two-stage sample design) conducted among undocumented migrants recruited in Paris and the Bordeaux region, in places and facilities likely to be frequented by undocumented migrants. The percentages were weighted. The analysis was performed using Stata 15.1 software. Results: A total of 1,223 undocumented migrants were recruited from 63 places and facilities, with a participation rate of 50%. Most of them were between 30 and 40 years of age (36%), 69% were men, aged mainly 30-40 (36%) years old, from sub-Saharan Africa (60%) or North Africa (25%), and 60% had arrived <3 years earlier. Among the participants, 24.8% declared a poor perceived health status and 33.5% a chronic health condition. Dental infections concerned 43.2% of the participants. Apart from dental issues, 12.9% reported suffering from at least one infectious disease: HIV infection (3.5%), chronic hepatitis B virus infection (3.1%), upper respiratory tract infection (1.7%), skin mycosis (1.2%), skin and soft tissue infection (0.8%), chronic hepatitis C infection (0.8%), urinary tract infection (0.7%), lower respiratory tract infection (0.7%), scabies (0.3%), tuberculosis disease (0.2%), vaginal mycosis (0.6%), and herpes (0.1%). Regarding HIV, HBV, and HCV infections, 56, 71, and 89%, respectively, were diagnosed after their arrival. Chronic viral infections were more often reported by undocumented migrants from sub-Saharan Africa and Latin America. In multivariate analysis, a higher risk of reporting chronic viral infection was observed among people food insecure. Conclusion: This original study on a large random sample confirms the frequency of infectious diseases among undocumented migrants in France and the importance of integrating their screening during a health Rendezvous and their management into early access to care and inclusive medico-psycho-social management.

Impact of fees on access to dental care: evidence from France.

BACKGROUND: For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. METHODS: Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. RESULTS: Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35; P value = 0.024; 95% CI 1.04-1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. CONCLUSIONS: The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform.

Leveraging implementation science to reduce inequities in Children's mental health care: highlights from a multidisciplinary international colloquium.

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.

Economic Burden of the Out-of-Pocket Expenses for People with Multiple Sclerosis in France.

BACKGROUND: People with chronic diseases in France frequently incur out-of-pocket expenses (OOPE) related to their medical care. OBJECTIVE: The objective of this study was to evaluate OOPE incurred by people with multiple sclerosis (MS) with respect to direct non-medical and medical expenditure. METHODS: Data were collected through a web-based survey using an online patient community platform (Carenity). The survey questionnaire contained 87 questions (numerical response or Likert scale) and took less than 30 min to complete. Participants rated their disability on a ten-point scale. RESULTS: In total, 376 patients, with a mean age of 48.3 years (95% confidence interval [CI] 47.2-49.5), participated in the survey. Participants estimated that they spent an average of €127 each month on OOPE for their MS, principally on physician consultations (mean annual expenditure of €75 by 183 participants), non-physician consultations (€358 by 135 participants) and non-prescription medication (mean expense of €67 per pharmacy visit by 234 patients). In total, 77% of participants who needed adaptations to their home or vehicle because of their MS contributed to the cost. No obvious relationship between OOPE and self-rated disability was observed. A total of 61.4% of participants reported that they had to choose between spending money on MS care or on their family and social life. CONCLUSIONS: Most patients with MS incurred significant OOPE linked to consultations, non-prescription medications or home equipment and medical equipment. These outlays could lead to dilemmas when choosing between spending on MS care or family or social life.

Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform.

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.

Refugees in and out North Africa: a study of the Choucha refugee camp in Tunisia.

In recent years, North African (NA) countries ceased to be emigration-only countries and are now on the verge of becoming immigration as well as transit countries for economic migrants and refugees. Contextual as well as structural long-term factors are driving these changes. The ongoing crises in Africa and the Middle East are prompting strong outflows of refugees, which are likely to induce NA countries to share some common public policy and public health concerns with European countries in a near future. This article highlights some aspects of these changes, from the study of the consequences of the 2011 Libyan crisis in Tunisia. It addresses individual trajectories and health concerns of refugees in and out North Africa from a study of the Choucha camp in Tunisia. The camp opened to immigrants from Libya during the 2011 crisis and accommodated the bulk of the refugees flow to Tunisia until July 2012. The study includes a monographic approach and a qualitative survey in the Choucha camp refugees. We describe the crisis history and the health response with a focus on the camp. We then address refugees' trajectories, and health needs and concerns from the interviews we collected in the camp in April 2012.

The big crossing: illegal boat migrants in the Mediterranean.

This article explores illegal migration routes and groups across North Africa to Europe. We describe sub-Saharan and cross-Mediterranean routes, and how they changed during the years. We propose an analytical framework for the main factors for these migrations, from local to international and regulatory context. We then describe sea-migrants' nationalities and socio-economic and demographic characteristics, from studies undertook in Tunisia and Morocco. While boat migration represents only a fraction of illegal migration to Europe, it raises humanitarian as well as ethical issues for European and North African (NA) countries, as a non-negligible amount of them end up in death tolls of shipwrecks in the Mediterranean Sea. Moreover, existing statistics show that illegal trans-Mediterranean migration is growing exponentially. Ongoing crises in Africa and the Middle East are likely to prompt even larger outflows of refugees in the near future. This should induce NA countries to share closer public policy concerns with European countries.

Strengthening weak primary care systems: steps towards stronger primary care in selected Western and Eastern European countries.

European health care systems are facing diverse challenges. In health policy, strong primary care is seen as key to deal with these challenges. European countries differ in how strong their primary care systems are. Two groups of traditionally weak primary care systems are distinguished. First a number of social health insurance systems in Western Europe. In these systems we identified policies to strengthen primary care by small steps, characterized by weak incentives and a voluntary basis for primary care providers and patients. Secondly, transitional countries in Central and Eastern Europe (CCEE) that transformed their state-run, polyclinic based systems to general practice based systems to a varying extent. In this policy review article we describe the policies to strengthen primary care. For Western Europe, Germany, Belgium and France are described. The CCEE transformed their systems in a completely different context and urgency of problems. For this group, we describe the situation in Estonia and Lithuania, as former states of the Soviet Union that are now members of the EU, and Belarus which is not. We discuss the usefulness of voluntary approaches in the context of acceptability of such policies and in the context of (absence of) European policies.

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study.

BACKGROUND: Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors. AIM: To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level. DESIGN OF STUDY: INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France. METHOD: Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were 'mirrored', meaning that GPs and patients were presented with the same questions. RESULTS: The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained. CONCLUSION: This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.

Building bridges between health economics research and public policy evaluation.

The Institut de Recherche et Documentation en Economie de la Santé (IRDES) Workshop on Applied Health Economics and Policy Evaluation aims at disseminating health economic research's newest findings and enhancing the community's capacity to address issues that are relevant to public policy. The 2010 program consisted of 16 articles covering a vast range of topics, such as health insurance, social health inequalities and health services research. While most of the articles embedded theoretical material, all had to include empirical material in order to favor more applied and practical discussions and results. The 2010 workshop is to be the first of a series of annual workshops in Paris gathering together researchers on health economics and policy evaluation. The next workshop is to be held at IRDES in June 2011.

The preferred doctor scheme: a political reading of a French experiment of gate-keeping.

OBJECTIVES: Since 2006 France experiences an innovative version of Gate-keeping which aims at regulating access to outpatient specialist care. We describe the reform's initial objectives, the political pathway which lead to the implementation of a reshaped reform and discuss the first outcomes after 1 year implementation. In the conclusion, we try to catch a glimpse for future steps of the reform. METHODS: In order to observe the implantation and impact on the reform, we used national sickness fund databases and a sample of 7198 individuals from the 2006 French Health, Health Care and Insurance Survey (ESPS), including health, socio-economic and insurance status, questions relating to patient's understanding and compliance with the scheme, self-assessed unmet specialist needs since the reform. RESULTS AND DISCUSSION: 2006 results show that 94% chose a preferred doctor, in a vast majority their family doctor. Impact on access to specialist care appears significant for the less well off and those not covered by a complementary insurance. From the specialist's side, new constraints on access to care seem to have been offset by rises in fee schedules. CONCLUSION: Notwithstanding disappointing short terms results, the new scheme may however lead up to reinforced managed care reforms.

Patient-physician interaction in general practice and health inequalities in a multidisciplinary study: design, methods and feasibility in the French INTERMEDE study.

BACKGROUND: The way in which patients and their doctors interact is a potentially important factor in optimal communication during consultations as well as treatment, compliance and follow-up care. The aim of this multidisciplinary study is to use both qualitative and quantitative methods to explore the 'black box' that is the interaction between the two parties during a general practice consultation, and to identify factors therein that may contribute to producing health inequalities. This paper outlines the original multidisciplinary methodology used, and the feasibility of this type of study. METHODS AND DESIGN: The study design combines methodologies on two separate samples in two phases. Firstly, a qualitative phase collected ethnographical and sociological data during consultation, followed by in-depth interviews with both patients and doctors independently. Secondly, a quantitative phase on a different sample of patients and physicians collected data via several questionnaires given to patients and doctors consisting of specific 'mirrored' questions asked post-consultation, as well as collecting information on patient and physician characteristics. DISCUSSION: The design and methodology used in this study were both successfully implemented, and readily accepted by doctors and patients alike. This type of multidisciplinary study shows great potential in providing further knowledge into the role of patient/physician interaction and its influence on maintaining or producing health inequalities. The next challenge in this study will be implementing the multidisciplinary approach during the data analysis.

Access to psycho-social resources and health: exploratory findings from a survey of the French population.

We study the psycho-social determinants of self-assessed health in order to explain social inequalities in health in France. We use a unique general population survey to assess the respective impact on self-assessed health status of subjective perceptions of social capital, social support, and sense of control, controlling for standard socio-demographic factors (SES, income, education, age, and gender). The survey is unique in that it provides a variety of measures of self-perceived psycho-social resources (trust and civic engagement, social support, sense of control, and self-esteem). We find empirical support for the link between the subjective perception of psycho-social resources and health. Sense of control at work is the most important correlate of health status after income. Other important ones are civic engagement and social support. To a lesser extent, sense of being lower in the social hierarchy is associated with poorer health status. On the contrary, relative deprivation does not affect health in our survey. Since access to psycho-social resources is not equally distributed in the population, these findings suggest that psycho-social factors can partially explain of social inequalities in health in France.