[Professional practices and perceptions about job retention systems for the chronically ill: a qualitative study in south-eastern France]. / Pratiques et perceptions des professionnels vis-à-vis du dispositif de maintien dans l'emploi: étude qualitative en région Provence-Alpes-Côte d'Azur.

BACKGROUND: Continued employment of people with health problems that reduce their ability to work is a major social issue. The French measures to optimize job retention are characterized by a multiplicity of participants, and their efficacy depends largely on the capacity of these different participants to work together. The objective of this study was to document the perceived role, attitudes and practices of participants involved in these job retention measures and of general practitioners, as well as their difficulties in this domain. METHODS: In 2009, 15 semi-directive interviews were conducted in the region of Provence-Alpes-Côte d'Azur (PACA) of occupational physicians, general practitioners, and other participants involved in the occupational reclassification of workers no longer completely fit for their job. The data collected were analyzed from a thematic perspective. RESULTS: The different groups of professionals questioned agreed on the primacy of the role of the occupational physician, on the importance of early consideration of each worker's case, and on the need to work together as partners to optimize the prospects of job retention. This study nonetheless showed numerous communication difficulties between the various professionals: although informal exchanges have developed over time, the efficacy of the system seems to be limited by a lack of clarity about the role of each institution, divergences of opinions on some key points including the role of the physicians caring for the patient, and, more largely, lack of information about the tools for job retention. CONCLUSION: The distribution of homogeneous knowledge, the development of multidisciplinary collaborative practices and the pooling of the lessons of experience between the different groups of participants are essential for the success of job retention procedures.

Different reporting patterns for occupational diseases among physicians: a study of French general practitioners, pulmonologists and rheumatologists.

PURPOSE: Physicians can play an important role in the reporting of occupational diseases (ODs), which are still under-reported in many countries. We aimed to identify physicians' difficulties in recognizing and reporting ODs and to study the characteristics of the physicians that do report ODs. METHODS: We conducted a telephone study in 2006-2007 among general practitioners (GPs), pulmonologists and rheumatologists in south-eastern France, concerning their knowledge, attitudes and practice in occupational health. Simple and multiple logistic regressions were performed to study factors associated with the issue of medical certificates for the claim process. RESULTS: Three hundred and ninety-one GPs, 95 pulmonologists and 96 rheumatologists participated. GPs reported significantly less often than specialists that they questioned their patients on past occupational exposure. They more frequently reported difficulties in identifying the occupational origin of diseases, and lack of knowledge on the OD reporting system. Issue of medical certificates for OD reporting was significantly more frequent among specialists than among GPs, among physicians considering that ODs are a public health problem, among those acquainted with the forms required to establish certificates, using internet to obtain information, having trade union activities, or having contact with occupational physicians (OPs). CONCLUSION: Initial and continuing training should be developed to encourage physicians, in particular GPs, to question patients on their working conditions and to become better acquainted with claim procedures. Physicians should also be provided with tools for identification of ODs that are suited to their practices, and collaboration with OPs should be fostered.

[Occupational physicians and occupational cancers: attitudes, opinions, practices. A qualitative study in South Eastern France]. / Médecins du travail et cancers professionnels : attitudes, opinions et pratiques. Une recherche qualitative dans le Sud-Est de la France.

BACKGROUND: A qualitative study was conducted in 2008 of occupational physicians (OPs) in south-eastern France to document their attitudes, opinions and practices on prevention and screening of occupational cancers. This was done to provide elements to prepare the questionnaire of a quantitative study in 2009. METHODS: Semi-structured interviews were conducted using a structured interview guide with 20 OPs. The data collected were subjected to an analysis of thematic content type. RESULTS: The analysis revealed that OPs face many difficulties when preventing occupational cancers. For most of OPs, these difficulties appeared related to "external factors": lack of involvement of employers and minimization of risks by employers and employees. Lack of time, overload and, for some OPs, perceived lack of independence towards employers, were also mentioned as barriers to cancer prevention. This study also suggested hypotheses related to OPs themselves (internal factors): perceived lack of effectiveness and, trend to minimize the risks of occupational cancer in their geographical area. Finally, the results suggest a significant heterogeneity of OPs' practices regarding occupational cancer screening. CONCLUSION: These results raise several hypotheses that will be addressed further in the quantitative survey. They warn about the difficulties of a profession that seems to encounter a demographic and identity crisis.

General practitioners and patients with psychological stress at work.

INTRODUCTION: Identifying patients with psychological stress at work (PSW) and managing them are complex tasks. We studied the frequency of PSW as perceived by general practitioners (GPs), their practices in such situations, and the factors associated with these perceptions and practices, especially drug prescription. METHODS: Cross-sectional telephone study of GPs in southeastern France with a questionnaire about knowledge, attitudes, behavior, and practices in occupational health. We explored the management of PSW with a case-vignette of a 45-year-old supermarket cashier consulting for psychological stress that he or she attributes to the job. RESULTS: In all, 391 GPs participated; 87.2% reported that they encountered PSW often in their practice. GPs reported that they would treat the case-vignette patient by prescribing anxiolytics (66.5%) or sick leaves (65.7%) or referral to an occupational physician (80.3%) or a mental health specialist (44.8%). A multiple logistic regression showed that GPs reported prescribing an anxiolytic most frequently for the vignette-patient when they saw a high number of patients daily, asked patients about working conditions, suggested a sick leave or a referral to a specialist to the case-vignette patient and perceived more obstacles to reporting an occupational disease. CONCLUSION: Our study suggests that PSW is perceived by GPs as one of the principal work-related health problems and that in such situations, most GPs say they would prescribe drugs and sick leave and refer the patient to an occupational physician. Initial and continuing education programs and good practice guidelines would be useful to help them deal with these problems.

Inequities in reporting asbestos-related lung cancer: influence of smoking stigma and physician's specialty, workload and role perception.

OBJECTIVES: To study physician barriers to workers' compensation claims for asbestos-related cancers, focusing on smokers' stigma and physicians' speciality and role perception. METHODS: Cross-sectional telephone study of 486 randomly-selected general practitioners (GPs) and pulmonologists in south-eastern France. Standardised questionnaires explored their behaviour, attitudes and practices in the field of occupational health and their responses to a case vignette of a lung cancer patient with long-term occupational asbestos exposure. Randomised subgroups of GPs and pulmonologists heard alternative versions varying only as regards the worker's smoking status. We studied factors associated with the recommendation that the case vignette patient file a compensation claim with simple and multiple logistic regressions. RESULTS: The response rate was 64.4% among GPs and 62.5% among pulmonologists. Recommending the filing of an occupational disease claim was significantly associated in multiple logistic regressions with speciality (OR 4.46; 95% CI 2.38 to 8.37, for pulmonologists vs GPs), patient's smoking status (OR 3.15; 95% CI 2.11 to 4.70, for non-smokers vs smokers), physician's workload (OR 1.83; 95% CI 1.17 to 2.88, for 25) and role perception (OR 2.00; 95% CI 1.22 to 3.27, for those who considered completing occupational disease medical certificates to be part of their role vs those who did not). CONCLUSIONS: The results of this French study appear applicable to various countries and contexts. To make physicians and especially GPs more aware of occupational health and smoking stigma, officials and educators must give these topics higher priority during initial training and continuing medical education. Tools and equipment that take time constraints into account should be developed and disseminated to help physicians manage occupational diseases.

[Physicians and occupational health: a qualitative study in south-eastern France]. / Les médecins face à la santé au travail: une étude qualitative dans le sud-est de la France.

BACKGROUND: Occupational health is a major public health problem in France. However, the level of investment of general practitioners and specialist physicians in this field is not well documented. We aimed at studying elements moving closer or differentiating groups of professionals (notably physicians) in the field of occupational health in terms of conceptions of their roles (prevention and care) and of practices (in particular detection and notification of occupational diseases and perceived barriers). METHODS: We conducted a qualitative study in south-eastern France which consisted of in-depth interviews of physicians and actors involved in the prevention of occupational hazards or in their indemnification. Then discourse analysis was carried out on the corpus collected. Content analysis grouped the data into themes. RESULTS: Several reasons could explain the low investment of physicians in the field of occupational health: insufficient detection of occupational causes of diseases, complexity of administrative procedures of declaration and bias of causal interpretation for the patients exposed to other risk factors such as smoking. The fear that notifying an occupational disease might have repercussions on patients' socio-professional situations places physicians in a situation of ethical dilemma: inducing a social risk on one side, ignoring his rights on the other. Physicians are not sufficiently prepared to deal with these situations, because they lack appropriate knowledge and support from specialists in the field, due to an important bulk-heading of actors and their practices. CONCLUSION: To sensitize and train physicians to occupational health and to support multi-field practices are essential.

[Risks linked to mobile phone use and how they are portrayed in the media: examples from three daily newspapers]. / Les risques liés à l'usage du téléphone portable et leur représentation médiatique: l'exemple de trois quotidiens français.

This study analyses how three French daily newspapers (Liberation, Le Monde, Le Figaro) convey information on the risks associated with mobile phone use in the period from 1995 to 2002. Quantitatively, the physical risks inherent to the low-intensity, electro-magnetic waves are most frequently reported, followed by those linked to mobile phone use while driving. "Social" risks, such as those related to noise or uncivil behaviour, are amongst the most rarely communicated. In general, the media present two types of physical risks connected to mobile phone use: the collective ones, which cover the low-intensity electro-magnetic waves which are emitted from the antennas on signal base stations, and the individual ones, which concem the waves produced by the mobile phone itself, and the danger associated with its use by a driver while operating a motor vehicle. Controversy surrounding the current scientific studies and the uncontrollable character of the risks linked to the low-intensity, electro-magnetic waves instill much more fear and debate than around those related to the combination of driving while talking on the telephone. While this latter point is scientifically proven, it is also subjectively under control.

Prophylactic use of cotrimoxazole against opportunistic infections in HIV-positive patients: knowledge and practices of health care providers in Côte d'Ivoire.

We present here the results of a survey conducted in Côte d'Ivoire, Africa, among healthcare providers, on the knowledge of prophylactic use of cotrimoxazole to prevent opportunistic infections in HIV-infected persons. The survey was conducted in 15 health centres, involved or not in the 'initiative of access to treatment for HIV infected people'. Between December 1999 and March 2000, 145 physicians and 297 other health care providers were interviewed. In the analysis, the health centres were divided into three groups: health centres implicated in the initiative of access to treatment for HIV-infected people with a great deal of caring for HIV-infected people, health centres implicated in this initiative but caring for few HIV-infected people, and health centres not specifically involved in the care of HIV-infected people. Six per cent of physicians and 50% of other health care providers had never heard of cotrimoxazole prophylaxis. The level of information about this prophylaxis is related to the level of HIV-related activities in the health centre. Among health care providers informed, knowledge on the exact terms of prescription of the cotrimoxazole is poor. In conclusion, it appears that the recommendations for primary cotrimoxazole prophylaxis of HIV-infected people did not reach the whole health care provider population. Most physicians are informed but not other health workers, even if the latter are often the only contact of the patient with the healthcentre. The only medical staff correctly informed are the physicians already strongly engaged in the care of HIV-infected people.

French general practitioners' attitudes toward therapeutic advances in HIV care: results of a national survey.

We aimed to assess attitudes to French primary care providers towards recent advances in HIV care. Telephone surveys in a random sample of French general practitioners (GPs) were carried out in April 1996 (response rate=70.3%; n=1186). Only 40.5% of the sample had participated in the regular medical follow-up of HIV-infected patients during the previous year. Among these 480 respondents, only a few (13.3%) declared that they would take care of an asymptomatic patient with a high (>500 cells/mm3) CD4 count as the unique provider. A majority (66.2%) had referred at least one HIV-infected patient to a hospital specialist in the previous year. A total of 31.4% declared that they considered it appropriate for an antiretroviral treatment to be initiated to an asymptomatic patient with 300 CD4 cells/mm3, and only 23.5% were already in favour of combination therapies rather than zidovudine monotherapy as treatment of choice. GPs with the most experience with HIV care tended to be the most reluctant to modify their attitude in favour of earlier initiation of antiretroviral therapies and of the switch from monotherapy to combination therapies. The survey suggests there is a gap between attitudes of GPs and those of AIDS specialists toward preliminary reports of therapeutic advances in HIV care. Whether or not such a gap may create problems for an appropriate diffusion of new antiretroviral therapies should be carefully monitored, in the context of current reforms emphasizing the key role of primary providers in most health-care systems.

French general practitioners' attitudes toward maintenance drug abuse treatment with buprenorphine.

AIMS: To assess attitudes of general practitioners (GPs) toward buprenorphine maintenance drug abuse treatment just after its introduction in French ambulatory care (February, 1996). DESIGN: Cross-sectional survey by telephone interviews in a national random sample of French GPs (n = 1,186; response rate = 70.3%) carried out in April 1996. MEASUREMENTS: GPs' experience with care for IDU patients and HIV infection during the last 12 months. Logistic regression model to identify GPs' characteristics associated with readiness to prescribe buprenorphine for maintenance treatment. FINDINGS: A minority (24.0%) of GPs took care of IDU patients and 30.8% of these were prepared to prescribe buprenorphine (vs. only 7.5% in the rest of the sample). A positive attitude toward buprenorphine was related to GPs' experience with care for IDUs and with prescription of opiates for pain management and palliative care, tolerance toward drug use and personal characteristics such as tobacco use and interest in psychoanalysis. CONCLUSIONS: Giving general freedom of prescription of buprenorphine (rather than methadone) to all GPs did not lead to widespread acceptance of the drug's use in treating IDUs. The development of organized networks between specialist services for drug abuse treatment and motivated GPs may be necessary to maximize appropriate prescribing practices.

[Observance during clinical trials in HIV infection. A discontinuity between patient history and trial logic]. / L'observance au cours des essais thérapeutiques dans l'infection à VIH. Une discontinuité entre l'histoire des patients et la logique des essais.

OBJECTIVES: Describe and analyze the processes which lead to patient compliance or non-compliance in HIV treatment trials and to develop a model for strategies aimed at improving compliance and facilitating inclusion (adherence) of these patients. METHOD: First, 12 members of the health care teams at two day care clinics (Internal medicine unit, Sainte-Marguerite Hospital, Marseille and Hematology unit, Cimiez Hospital, Nice) were interviewed. In addition, 40 patients involved in the Delta trial (known compliance in 22, non compliance in 7, trial refusal in 7 and eligibility in 5 who were not invited to participate) responded in semi-directive discussions. RESULTS: The physicians found that the responses were a priori in agreement with patient compliance for those who had participated. Physicians tended to introduce "unofficial" criteria to select patients on the basis of "psychosociological" patterns. Patient agreement to begin the trial or to refuse inclusion and their compliance to medical prescriptions depended in part on their personal opinion concerning AIDS treatment. Patients who presevered in following medical prescriptions in the long-term trial adapted their lifestyle to the new care system (participation in the trial) and discussed their "adaptation" with the physician. The importance of the patient-physician relationship is of prime importance in the behavior of compliant patients. CONCLUSION: A communication strategy, reinforcing patient adherence at inclusion and favoring compliance during the trial should be part of the "basic rules" for controlled regulation of compliance in clinical trials.

Ethical dilemmas in care for HIV infection among French general practitioners.

A survey was carried out in May-June 1992, in the city of Marseille (South-Eastern France), to analyze attitudes towards ethical issues associated with the care of HIV-infected patients in a random sample of general practitioners (GPs) (telephone interviews; answer rate = 78.6%; n = 313). A total of 70.6% were consulted by HIV carriers and 48.9% regularly took care of these patients over the past year. Multi-dimensional analysis showed that support for HIV mandatory screening was related to lack of knowledge and experience with HIV infection, high perception of risks associated with HIV care, and the individual characteristics of GPs, such as religious beliefs and intolerance to uncertain situations. GPs with experience of regular care of HIV carriers had the same opinions than the rest of the sample about 'creation of specialized hospitals for AIDS patients' and similar attitudes toward HIV testing 'without patients' consent' or breaching of confidentiality of HIV diagnosis. Debates on ethical issues among GPs cannot be reduced to a simplistic division of a 'liberal group' highly involved in prevention and HIV care and a 'conservative' majority more or less inclined to stigmatize HIV-infected patients. Ambiguous messages on these issues from health authorities and professional ethical bodies may have very negative impacts on the attitudes of primary care physicians regarding the acceptability of HIV-infected patients.

Commitment, value conflicts and role strains among French GPs in care for HIV positive patients.

A survey was carried out on a random sample of GPs in the city of Marseille. 18.5% had been involved during the past year in a regular follow-up of HIV patients. They were in charge with 79.8% of all ambulatory care of HIV+ patients. Those informally 'specialized' professionals were connected to health networks (not only hospital structures but also associations dealing with commitment in care). Socio-biographical factors, training and environmental opportunities and ideological orientations would positively relate with commitment in care. GPs who were not involved with care, would worry more about personal risk of contamination; would not believe that wearing gloves could be a sufficient protection when doing invasive procedures; would feel less at ease with HIV patients, would be more strongly in favor of coercive measures with IVDU's. Most GP's would agree to avoid drug users HIV+ patients. They would attribute to them more guilt and responsibility than to other patients. Uncertainty concerning relevant knowledge, negative attitudes towards some patients like IVDU's and anticipated difficulties to deal with ethical and relational dilemmas keep limiting GPs interest and positive motivation in care for HIV patients.