[Asthma: Adapting the therapeutic follow-up according to the medical and psychosocial profiles]. / Adapter l'accompagnement thérapeutique de l'asthmatique en fonction des profils médico-psycho-sociaux. Enseignements de l'enquête REALISE™ chez des patients asthmatiques adultes et repères éducationnels pour la pratique.

INTRODUCTION: This work is based on the data of REALISE™, a survey conducted among 8000 European patients to identify the profiles of adult asthma patients and how these are linked with treatment adherence behaviors. METHODS: A cluster analysis was performed by combining data in three ways: control of asthma, attitude towards the disease, compliance with treatment. A multidisciplinary group analyzed the results for the 1024 French survey respondents. RESULTS: Four patient profiles were identified: "rather confident" (28% of patients), rather young patients with a low level of concern about their asthma. "Rather committed" (23%) patients considering themselves to be mostly healthy, reporting better therapeutic declared. "Rather questing" (26%), patients poorly controlled, seeking to manage their asthma themselves. "Rather concerned" profile (23%), a bit older, with poor clinical control, considering their asthma to be severe. CONCLUSIONS: Cluster analysis provides a multidimensional approach to understand the therapeutic behavior of the different patient profiles better and so adjust communication by and education of healthcare professionals.

[Patients with asthma: Disease control, patients' perceptions and observance. Results of the French REALISE™ survey]. / Patient asthmatique : contrôle, ressenti et observance. Résultats français de l'enquête REALISE™.

INTRODUCTION: Poor adherence to treatment is a cause of inadequate asthma control and increased exacerbations. Better understanding of the factors associated with adherence could lead to recognition of appropriate solutions. METHOD: An online, quantitative, self-completed questionnaire-based survey was conducted among 1024 French adults with asthma (aged 18-50years). Data were collected on socio-demographic characteristics, asthma control, patient perception of the disease and adherence. RESULTS: Only 11% of asthma patients considered that their asthma is uncontrolled while 48% were uncontrolled according to the GINA criteria. More than half (56%) of respondents admitted not taking their maintenance therapy every day. The perception that asthma was well controlled and lack of impact of the disease on daily activities were the most common reasons cited (46% of respondents) for not taking maintenance therapy. The other main reasons cited were forgetting and use only during symptomatic periods (21% and 14% of respondents, respectively). CONCLUSION: Adult asthma patients tend to overestimate their level of asthma control. Improving the management of asthma requires systematic detection of respiratory symptoms, awareness of the patient that asthma is a chronic disease and improved physician assessment of patients' expectations and perception of their disease.

Malaria control among children under five in sub-Saharan Africa: the role of empowerment and parents' participation besides the clinical strategies.

CONTEXT: Child malaria remains a vital concern in sub-Saharan Africa in spite of major efforts to control it. The widely advertised best curative and preventive measures are not always accessible. ISSUE: This article examines the extent to which parents' perceptions and representations are considered, including their empowerment and participation in interventions aimed at controlling child malaria. The effect of this is examined through a content analysis of articles selected in the PubMed and Wholis databases over the period of 1996 to 2005. This analysis was performed according to three predefined categories consistent with the three main health promotion strategies used in the WHO-AFRO region: (1) development of knowledge and skills; (2) creation of supportive environments; and (3) advocacy. LESSONS LEARNED: Successful interventions met the health promotion strategies wholly or partly. Although these interventions were sometimes incomplete, the development took into account people's perceptions and representations. The authors acted on the belief that empowerment of parents and their participation in the development of interventions to control child malaria, is likely to yield better results and assist in reducing the prevalence of malaria morbidity and mortality in children under 5 years.

[First-generation immigrant adolescents' physical and mental health and behaviors]. / La santé physique, mentale et les comportements de santé des adolescents immigrants de première génération.

The objectives of this article are to: a) review literature about physical, mental health and behaviors of first generation immigrant adolescents and its evolution; b) compare first and second generations immigrant adolescents'health. Studies usually compare first generation and others adolescents groups: 1) first generation adolescents shows better physical health and behaviors than second generation; 2) first generation adolescents shows variable results for mental health compared to second generation and host adolescents according to the studies; 3) a degradation of physical health and behaviors is observed with the time passed in the host country. These results show necessity of a precocious evaluation of first generation adolescents' needs for a good planification of health promotion and prevention actions to preserve their health advantage at arrival.

[Newly immigrant adolescents health and quality of life in Belgium: screening and prevention in school medicine]. / Santé et qualité de vie des adolescents récemment immigrés en Belgique: dépistage et prévention en médecine scolaire.

OBJECTIVES: Little is known so far about the health of newly immigrant adolescents. The present study aimed to evaluate their health and quality of life (QoL) and to reinforce prevention and health promotion in school medicine. METHODS: One hundred and fifty-eight adolescents (mean age: 15,4 years) from 37 nationalities were included in the study in two health centers in Brussels. This study was carried out by medical records analysis and administration of a questionnaire about health and QoL (VSP-A) in several languages. RESULTS: The results showed adolescents in good physical health. Nevertheless their quality of life deteriorated over time in Belgium. The QoL was significantly lower for adolescents without social support: 48,0 (SD=13,5) vs 60,6 (SD=11,1) compared with adolescents with social support - i.e. with one resource person - on a scale from 0 to 100. Adolescents had many subjective health problems, like "the future" cited by half of them. CONCLUSION: This study shows the importance of developping a specific approach to newly immigrant adolescents health and the contribution of school medicine in the identification of biological, psychological and social needs and hightlights the preventive answers carried out by school medicine.

[Assessing adolescent's health in school medicine: quality of life as a complement to clinical indicators]. / Evaluer la santé des adolescents en médecine scolaire: la qualité de vie comme complément aux indicateurs cliniques.

UNLABELLED: Current medical practices of school health for adolescents are more based on the screening of specific physical problems than on psychosocial and subjective aspects of their health. OBJECTIVES: This study aimed at evaluating the usefulness of a quality of life (QoL) questionnaire during the consultations. POPULATION AND METHODS: Ninety-five adolescents (mean age: 16.9 years) present for the obligatory medical check-up in a health center in Brussels, were involved in the study. Data of the medical records were analysed and two questionnaires were administrated, one exploring the quality of life (VSP-A), the other the presence of depressive symptoms (CES-D). RESULTS: These adolescents were in good physical health and had a mean score of global quality of life of 62 (DS =11.2); 17% of the adolescents had significant depressive symptoms (score > or =24). There was a significant negative correlation between the scores of QoL and depression (R =-0.680, P <0.01), the QoL psychological dimension and depression (R =-0.656, P <0.01), the QoL energy-vitality dimension and depression (R= -0.763, P <0.01). CONCLUSION: An evaluation of the quality of life, approaching the mental health of the teenagers in a multidimensional and positive way, can be useful in school medicine for better identifying the medical and psychosocial adolescents needs. It can improve the relevance of the preventive consultation and the interventions of health promotion in schools.

Communication difficulties of healthcare professionals and family caregivers of HIV infected patients.

The family caregivers of HIV infected patients play a growing role in the support of the everyday life of their patient. Being more and more involved in different aspects of counselling and care-giving, they become the partner of the healthcare professionals who take care of the patient. It is nowadays well known that communication between healthcare professionals and patients is complex. So communication is between healthcare professionals and family caregivers, as our survey aims at demonstrating. Both the family caregivers and the healthcare professionals face difficulties and express needs and expectations that are important to meet in order to optimise the quality of care which is given to the patient.

[Role of patient associations in the development of therapeutic education in France]. / Le rôle des associations de patients dans le développement de l'éducation thérapeutique en France.

The aim of this survey conducted among patient associations is to define the role and the position that they have with regard to the development of therapeutic education in France. 124 associations were solicited (out of over 500 existing), and 68 replied. 17 indicated that the survey was not relevant for them. 51 answered the 43 questions related to the conception and implementation of educational programmes, their goals and objectives, the choice and selection of educational activities, the target audiences and pedagogical principles of reference. The results obtained demonstrate the predominance of informational activities and psychological support. The responding associations declared that sometimes they conduct educational activities which rather resemble informational activities. Only three associations declared having Implemented and managed formalised educational programmes based on pedagogical methods. The aims and objectives most frequently targeted were focused on increasing the patients' knowledge on their disease and its treatment. These educational programmes are usually delivered by members of the association's office staff. However, overall most of the responding associations indicated that it is relatively difficult to provide precise data on the pedagogical methods of the activities undertaken. In light of the results, it is therefore necessary to consider the totality of the activities conducted by the associations as a mechanism for building educational resources in which the place of formalised educational programmes remains marginal, even quasi-absent, for the moment. Associations believe that patient education is an important issue for their development. It is highly likely that the emergence of such programmes will only be possible if the associations show some degree of autonomy in relation to the health care sector and assert a point of view specific to patients, above and beyond that of health care users.

Patient education in Europe: united differences.

This issue of Patient Education and Counseling presents the state of the art of patient education in several European countries. It is based on papers presented at a meeting in Paris on the evolution and development of patient education in western, central and eastern Europe (May 1999). Also patient education in the US is presented in this issue. Patient education is defined as all the educational activities directed to patients, including aspects of therapeutic education, health education and clinical health promotion. Five important factors are identified in the development of patient education: (1) research and evidence based standards; (2) the organization of care; (3) training and methodological support; (4) professional values; and (5) acknowledgment, funding and place of patient education in health policy. Several of the discussed common orientations and priorities in the patient education in the reviewed countries are highlighted in this issue. And finally, an example of the possible integrated international practice in patient education in the field of diabetes is described in this issue. Several conclusions are drawn concerning future development of communication in health care within the framework of patient education in Europe.

A European perspective: common developments, differences and challenges in patient education.

In May 1999, a European meeting was held in Paris on the evolution and developments of patient education. The situation in different European countries and the factors influencing the development and improvement of patient education were discussed. Five categories of factors were identified: research and evidence based standards, the organization of care, training and methodological support, professional value and acknowledgement, funding and place of patient education in health policy. Several common orientations and priorities for the development of patient education have been presented, and are highlighted in this paper.

Patient education in Belgium: evolution, policy and perspectives.

Patient education started in Belgium in the late 70s. Tuberculosis and diabetes management and care were the first topics addressed. In the two main regions of the country (Flemish and French), the development of patient education has been very different. The Belgian French Ministry of Health and regional hospital associations appointed a non-profit resource center, the "Center d'Education du Patient", in order to help hospital departments and health care teams start and improve patient education work and programs. University training programmes were created in the 80s, and an inter-hospital network organized to facilitate collaborations. Later, patient education hospital committees and coordinators were appointed, and professional organizations (patient education nurses and coordinators organization) were set up. In 1999, 98% of French speaking hospitals state that they have patient education programmes (three per hospital, on average), a remarkable growth from 7% in 1983. Belgium has joined the WHO health promoting hospitals project in 1996. In private practice, due to the "payment on service" system that does not allow means for patient education work, patient education is still rare. In the Flemish region, patient education programmes exist in some hospitals, on private initiatives, without support from the Ministry of Health, nor from the health promotion agency. On the conceptual side, programmes have shifted from a "patient instruction" perspective focusing on the biomedical aspects of health and disease, and professional expertize and needs assessment, to "patient participation" dealing with biopsychosocial health and disease. Lay and subjective needs and "life projects" are more and more taken as a basis for patient counseling and therapeutic education. With the renewed involvement of the government in patients rights, and the possibility to start funding patient education as any other care work, new developments of patient education are expected in the next years.

Implementing health promotion in health care settings: conceptual coherence and policy support.

This article examines the level and conditions of development of the concept of "health promoting hospital (HPH)", in France and in Europe. Part of the literature on HPH was reviewed, looking at the kind of partnerships implemented within the HPH projects, and at the organisational strategies adopted by hospitals to be health promoting. The literature review is followed by an overview of the priorities defined by health policies in Europe. This research shows that there is still a lack of guidelines on how to put the health promotion concept into practice in health care settings. Moreover, it stresses that further research is needed in order to better define which personal skills ought to be developed through health education in health care settings, and how the development of such skills may be articulated to other priorities in health care settings.

[To better integrate prevention into general medicine in deprived milieus]. / Mieux intégrer la prévention en médecine générale dans les milieux défavorisés.

Generalists occupy a strategic position in the area of prevention within the general population, and among disadvantaged areas in particular. Yet, practice shows that this position is not a given, as the socio-cultural gap separating doctor and patient renders communication particularly difficult in this context. In order to analyse this situation, a review of the literature, surveys among generalists, and a European seminar were carried out. This article deals with the definition of "disadvantaged environments" by the practitioner, practices in prevention in disadvantaged environments and their related obstacles, and tracks for improving prevention in disadvantaged environments by visits with a generalist.

[Promoting health in health care organizations and hospitals? A survey of the French community in Belgium]. / Promouvoir la santé dans les milieux de soins et les hôpitaux? Une enquête en communauté française de Belgique.

Health promotion concept and practices have brought many significant changes even in disease management and care settings. In the Ottawa charter, health promotion is defined as "the process of enabling people to increase control over, and to improve, their health". However, care settings are in contradiction with this process on several levels (focus on disease and not enough on health, concern more on cure than on care, etc.). The emergence of health promotion practices has been deeply questioning these features. Care institutions start to reconsider their role and missions. However, changes are slow and there has been much resistance. What is the current situation of health promotion in French speaking Belgian care institutions in 1998? The WHO EUROPE HEALTH PROMOTING HOSPITALS' (HPH) project, which officially started in 1991, aims at "promoting positive health and well-being in hospitals and beyond that, in the community". For each participating hospital, the implications of membership have an important influence on the institution and care project, because it implies adherence to the principles of the Ottawa charter on health promotion, and to the philosophy and objectives of HPH. Belgium joined the WHO project and the HPH network in 1996. It was necessary to review the situation of health care institutions in the French speaking community of Belgium in order to understand the evolution over the last years, to assess health professionals expectations and the feasibility of some actions, and to provide political decision makers with information likely to influence future decisions and choices in a positive way. This article presents the descriptive results of a survey carried out on nursing and patient education departments in health care institutions. Half of 105 hospitals answered the questionnaires sent. Out of these answers, 150 projects and actions were identified and briefly described by the institutions, which had the possibility to present a maximum of five actions. The main topics addressed were chronic diseases, psychology (conflict management, aggressiveness, ill-treatment), maternity, screening, prevention and vaccination. Regarding perspectives, 78% of actions concern disease and/or risks of disease (therapeutic or preventive perspectives) and 22% concern the maintenance or improvement of health. 90% of listed and described actions are permanent, and only 10% are selective (limited), which suggests an evolution of projects and their integration in practices. Concerning the number of projects, two aspects were analysed: the number by institution and the evolution over the last twenty years. On average, there are 3.2 actions per institution. As for the evolution, 7% of hospitals said they had at least one education action/project in 1980, 60% in 1990 and 98% in 1998. This amazing and remarkable evolution occurred simultaneously to the development of education committees, of patient education co-ordinators and/or resource persons. In this field, there was also a remarkable evolution since the creation of the first committees in 1983. Amongst the elements encouraging the development of information and health education initiatives and actions mentioned by hospital managers, the first one is a demand from the public (and patients). It is the first time, since the existence of such surveys that this factor is mentioned as the most important.

[Evaluating quality and effectiveness in the promotion of health: approaches and methods of public health and social sciences]. / Evaluer la qualité et l'efficacité de la promotion de la santé: approches et méthodes de santé publique et de science humaines.

Health promotion and health education have often been limited to evaluation of the effectiveness of actions and programmes. However, since 1996 with the Third European Conference on Health Promotion and Education Effectiveness, many researchers have become interested in "quality assessment" and new ways of thinking have emerged. Quality assurance is a concept and activity developed in industry with the objective of increasing production efficiency. There are two distinct approaches: External Standard Inspection (ESI) and Continuous Quality Improvement (CQI). ESI involves establishing criteria of quality, evaluating them and improving whatever needs improvement. CQI views the activity or service as a process and includes the quality assessment as part of the process. This article attempts to answer the questions of whether these methods are sufficient and suitable for operationalising the concepts of evaluation, effectiveness and quality in health promotion and education, whether it is necessary to complement them with other methods, and whether the ESI approach is appropriate. The first section of the article explains that health promotion is based on various paradigms from epidemiology to psychology and anthropology. Many authors warn against the exclusive use of public health disciplines for understanding, implementing and evaluating health promotion. The author argues that in practice, health promotion: -integrates preventive actions with those aiming to maintain and improve health, a characteristic which widens the actions of health promotion from those of classic public health which include essentially an epidemiological or "risk" focus; -aims to replace vertical approaches to prevention with a global approach based on educational sciences; -involves a community approach which includes the individual in a "central position of power" as much in the definition of needs as in the evaluation of services; -includes the participation and socio-political actions which necessitate the use of varied and specific instruments for action and evaluation. With the choice of health promotion ideology, there exist corresponding theories, concepts of quality, and therefore methods and techniques that differ from those used until now. The educational sciences have led to a widening of the definition of process to include both "throughput and input", which has meant that the methods of needs analysis, objective and priority setting and project development in health promotion have become objects of quality assessment. Also, the modes of action and interaction among actors are included, which has led to evaluation of ethical and ideological aspects of projects. The second section of the article discusses quality assessment versus evaluation of effectiveness. Different paradigms of evaluation such as the public health approach based on the measurement of (epidemiological) effectiveness, social marketing and communication, and the anthropological approach are briefly discussed, pointing out that there are many approaches which can both complement and contradict one another. The author explains the difference between impact (the intermediate effects, direct or indirect, planned or not planned, changes in practical or theoretical knowledge, perceptions, and attitudes) and results (final effects of mid to long term changes such as changes in morbidity, mortality, or access to services or cost of health care). He argues that by being too concerned with results of programmes, we have often ignored the issue of impact. Also, by limiting ourselves to evaluating effectiveness (i.e. that the expected effects were obtained), we ignore other possible unexpected, unplanned and positive and negative secondary effects. There are therefore many reasons to: -evaluate all possible effects rather than only those lined to objectives; -evaluate the entire process rather than only the resources, procedures and costs; -evaluate the impact rather than results; -evalu

[Methods and perspectives of AIDS prevention among teachers of secondary schools in the village of Namur]. / Modalités et perspectives de prévention du sida parmi les enseignants des écoles secondaires de la ville de Namur.

In 1994, ASBL Namur-Entraide-Sida has been involved in a survey through questionnaires for teachers of the whole high schools in Namur (Belgium). Its purpose was to better notice what sort of viewpoints and modalities in preventing youngs from aids were developed or not during the school. From 2,435 questionnaires, 617 (25%) have been returned and analysed. Among the main results, the teachers' feeling was the professional training is adapted enough in order to response to this item in school and they also hope to improve the efficiency of the inside and outside collaborations. This survey has pointed out the teachers' prime perception of the risks for the pupils to be infected and that, in relation with their own exposition level. This last result leads us to wonder about the indicators which from the prevention from aids has been developed among the school children since the ten latest years. It has not to be forgotten that the urgency of the events is able to hide the stakes of the educative relation and ethic about the teenagers' prevention.

Teaching, training or educating patients? Influence of contexts and models of education and care on practice in patient education.

This paper presents the rationale, theoretical developments and operationalization of the role of contexts of care and education in practice, choice of methods and effects of patient education in chronic diseases. Starting from a review on the evolution of models of care, education and health education, and on the influence of characteristics of organization of care, it proposes an analysis model of contexts of care and education. A study carried out in 1993 in 10 Belgian and northern France hospitals, with 400 patients, is presented. Simultaneously, pre-post test evaluations of the effects of current patient education work on 40 compliance factors, and in-depth analyses of contexts of care and education were undertaken. The possible relationship between variety and number of effects of education and type of care and education is examined and discussed.