Frontière d'empire, du nord à l'est : soldats coloniaux et immigrations des Suds

Les régions Nord-Pas-de-Calais, Lorraine, Alsace, Picardie, Champagne-Ardenne et Franche-Comté, de Lille à Strasbourg, ont tissé une relation unique avec les voyageurs, travailleurs, artistes, soldats, réfugiés, rapatriés et " sans-papiers " venus des Suds. Depuis le dernier tiers du XIXe siècle, le Nord-Est est une véritable frontière d'empire : il a reçu plus d'un million de combattants et travailleurs coloniaux lors des trois conflits qui opposèrent la France à l'Allemagne. Parallèlement, des dizaines d'expositions coloniales et ethnographiques contribuent à la formation d'une culture coloniale et accompagnent un premier flux d'originaires des colonies vers la métropole, notamment dans les mines du Nord. Durant tout le XXe siècle, venus des quatre coins de l'empire et du monde, recrutés et dockers chinois, soldats et étudiants d'Afrique noire, combattants, travailleurs et militants du Maghreb, migrants et ouvriers turcs, mobilisés indochinois et rapatriés vietnamiens ou d'Algérie, militants et enfants des deuxième et troisième générations, passent ou se fixent dans ces régions... Ce livre raconte leurs parcours et s'attache également au regard posé sur ces centaines de milliers de migrants, aujourd'hui composante importante de la société locale. A travers des images exceptionnelles et inédites, c'est l'histoire " aux confins d'un empire " qui se révèle ici. Histoire longue, complexe et étonnante, toujours en mouvement, constitutive en partie des mémoires et des identités locales.

Feasibility and clinical outcomes when using practice guidelines for evaluation of fever in returning travelers and migrants : a validation study.

BACKGROUND: Practice guidelines for examining febrile patients presenting upon returning from the tropics were developed to assist primary care physicians in decision making. Because of the low level of evidence available in this field, there was a need to validate them and assess their feasibility in the context they have been designed for. OBJECTIVES: The objectives of the study were to (1) evaluate physicians' adherence to recommendations; (2) investigate reasons for non-adherence; and (3) ensure good clinical outcome of patients, the ultimate goal being to improve the quality of the guidelines, in particular to tailor them for the needs of the target audience and population. METHODS: Physicians consulting the guidelines on the Internet (www.fevertravel.ch) were invited to participate in the study. Navigation through the decision chart was automatically recorded, including diagnostic tests performed, initial and final diagnoses, and clinical outcomes. The reasons for non-adherence were investigated and qualitative feedback was collected. RESULTS: A total of 539 physician/patient pairs were included in this study. Full adherence to guidelines was observed in 29% of the cases. Figure-specific adherence rate was 54.8%. The main reasons for non-adherence were as follows: no repetition of malaria tests (111/352) and no presumptive antibiotic treatment for febrile diarrhea (64/153) or abdominal pain without leukocytosis (46/101). Overall, 20% of diversions from guidelines were considered reasonable because there was an alternative presumptive diagnosis or the symptoms were mild, which means that the corrected adherence rate per case was 40.6% and corrected adherence per figure was 61.7%. No death was recorded and all complications could be attributed to the underlying illness rather than to adherence to guidelines. CONCLUSIONS: These guidelines proved to be feasible, useful, and leading to good clinical outcomes. Almost one third of physicians strictly adhered to the guidelines. Other physicians used the guidelines not to forget specific diagnoses but finally diverged from the proposed attitudes. These diversions should be scrutinized for further refinement of the guidelines to better fit to physician and patient needs.

Prevalence of overweight and obesity among migrants in Switzerland: association with country of origin.

Migrants tend to present higher overweight and obesity levels, but whether this relationship applies to all nationalities has seldom been studied. The present study aimed to assess the prevalence of overweight and obesity according to nationality in adults. Cross-sectional population-based samples. Five-year nationwide interview surveys (Swiss Health Surveys - SHS) from 1992 to 2007 (n 63 766) and a local examination survey (CoLaus Study in Lausanne 2004-2006, n 6743). Participants were separated into Swiss, French, German, Italian, Portuguese, Spanish nationals, those from the former Republic of Yugoslavia and from other European and other countries. Compared with Swiss nationals, German and French nationals presented a lower prevalence of overweight and obesity, whereas nationals from Italy, Spain, Portugal and the former Republic of Yugoslavia presented higher levels. Adjusting the SHS data for age, gender, education, smoking, leisure-time physical activity and survey year, a lower risk for overweight and obesity was found for German (OR = 0·80, 95 % CI 0·70, 0·92) and French (OR = 0·74, 95 % CI 0·61, 0·89) nationals, whereas higher risks were found for participants from Italy (OR = 1·45, 95 % CI 1·33, 1·58), Spain (OR = 1·36, 95 % CI 1·15, 1·61), Portugal (OR = 1·25, 95 % CI 1·06, 1·47) and the former Republic of Yugoslavia (OR = 1·98, 95 % CI 1·69, 2·32). Similar findings were observed in the CoLaus Study for Italian (OR = 1·63, 95 % CI 1·29, 2·06), Spanish (OR = 1·54, 95 % CI 1·17, 2·04) and Portuguese (OR = 1·49, 95 % CI 1·16, 1·91) participants and for those from the former Republic of Yugoslavia (OR = 5·34, 95 % CI 3·00, 9·50). Overweight and obesity are unevenly distributed among migrants in Switzerland. Migrants from Southern Europe and from the former Republic of Yugoslavia present higher prevalence rates. This suggests that preventive messages should be tailored to these specific populations.

La communication médicale avec les patients migrants allophones : difficultés de compréhension dans les consultations spécialisées centrées sur les douleurs musculo-squelettiques chroniques

Les suivis spécialisés de douleurs chroniques comportent des enjeux communicationnels sensibles liés notamment à la subjectivité des ressentis douloureux et aux fréquentes divergences de vue entre médecins et patients quant à l'origine du problème de santé et à son traitement. Centré sur ces suivis, ce travail de thèse a cherché à appréhender comment les situations sociolinguistiques des patients migrants allophones se répercutent sur la communication médicale et, plus particulièrement, sur la compréhension mutuelle dans les consultations. Il a emprunté une approche discursive s'appuyant sur l'analyse interactionnelle de consultations filmées et sur un riche corpus de données contextuelles recueillies dans des interviews de patients et de cliniciens. Les analyses réalisées ont, entre autres, mis en évidence que les difficultés de compréhension non résolues se concentrent dans les consultations des patients les moins à l'aise en français et que ces difficultés renferment pour la plupart une charge problématique certaine en termes de qualité des soins. Il apparaît également que lorsque des malentendus ou incompréhensions cliniquement pertinents ne peuvent être résolus, le caractère limité des compétences de français de base des patients migrants n'est jamais seul en cause. Des facteurs de complexité médicaux (ex. surestimations des connaissances médicales de base des patients), relationnels (ex. non-signalement de malentendus par les patients pour éviter de faire perdre la face au médecin) et discursifs (ex. nécessité de traiter de discours ou « voix » venant de l'extérieur de la consultation dans le cadre d'une polyphonie particulièrement marquée) jouent également des rôles de premier plan dans les difficultés non résolues les plus problématiques au plan clinique et sont généralement étroitement intriqués avec le langagier au sens strict. En termes pratiques, les résultats soulignent le rôle décisif de l'autoréflexivité chez les médecins, ainsi que de leur capacité à ajuster de manière flexible leurs styles communicationnels afin, par exemple, d'éviter le cumul de facteurs de complexités favorisant des malentendus ou incompréhensions problématiques. Les observations effectuées rappellent également l'importance du recours à des ressources d'interprétariat.

Risk factors for positive tuberculin skin tests among migrant and resident children in Lausanne, Switzerland.

SETTING: Ambulatory paediatric clinic in Lausanne, Switzerland, a country with a significant proportion of tuberculosis (TB) among immigrants. AIM: To assess the factors associated with positive tuberculin skin tests (TST) among children examined during a health check-up or during TB contact tracing, notably the influence of BCG vaccination (Bacille Calmette Guérin) and history of TB contact. METHOD: A descriptive study of children who had a TST (2 Units RT23) between November 2002 and April 2004. Age, sex, history of TB contact, BCG vaccination status, country of origin and birth outside Switzerland were recorded. RESULTS: Of 234 children, 176 (75%) had a reaction equal to zero and 31 (13%) tested positive (>10 mm). In a linear regression model, the size of the TST varied significantly according to the history of TB contact, age, TB incidence in the country of origin and BCG vaccination status but not according to sex or birth in or outside Switzerland. In a logistic regression model including all the recorded variables, age (Odds Ratio = 1.21, 95% CI 1.08; 1.35), a history of TB contact (OR = 7.31, 95% CI 2.23; 24) and the incidence of TB in the country of origin (OR = 1.01, 95% CI 1.00; 1.02) were significantly associated with a positive TST but sex (OR = 1.18, 95% CI 0.50; 2.78) and BCG vaccination status (OR = 2.97, 95% CI 0.91; 9.72) were not associated. CONCLUSIONS: TB incidence in the country of origin, BCG vaccination and age influence the TSTreaction (size or proportion of TST > or = 10 mm). However the most obvious risk factor for a positive TST is a history of contact with TB.

Health problems among detainees in Switzerland: a study using the ICPC-2 classification.

BACKGROUND: Little is known about the health status of prisoners in Switzerland. The aim of this study was to provide a detailed description of the health problems presented by detainees in Switzerland's largest remand prison. METHODS: In this retrospective cross-sectional study we reviewed the health records of all detainees leaving Switzerland's largest remand prison in 2007. The health problems were coded using the International Classification for Primary Care (ICPC-2). Analyses were descriptive, stratified by gender. RESULTS: A total of 2195 health records were reviewed. Mean age was 29.5 years (SD 9.5); 95% were male; 87.8% were migrants. Mean length of stay was 80 days (SD 160). Illicit drug use (40.2%) and mental health problems (32.6%) were frequent, but most of these detainees (57.6%) had more generic primary care problems, such as skin (27.0%), infectious diseases (23.5%), musculoskeletal (19.2%), injury related (18.3%), digestive (15.0%) or respiratory problems (14.0%). Furthermore, 7.9% reported exposure to violence during arrest by the police. CONCLUSION: Morbidity is high in this young, predominantly male population of detainees, in particular in relation to substance abuse. Other health problems more commonly seen in general practice are also frequent. These findings support the further development of coordinated primary care and mental health services within detention centers.

Perception of the damaging effects of smoking, and brief cessation counselling by doctors.

An open prospective study was conducted among the patients visiting an urban medical policlinic for the first time without an appointment to assess whether the immigrants (who represent more than half of our patients) are aware of the health effects of smoking, whether the level of acculturation influences knowledge, and whether doctors give similar advice to Swiss and foreign smokers. 226 smokers, 105 Swiss (46.5%), and 121 foreign-born (53.5%), participated in the study. 32.2% (95% CI [24.4%; 41.1%]) of migrants and 9.6% [5.3%; 16.8%] of Swiss patients were not aware of negative effects of smoking. After adjustment for age, the multivariate model showed that the estimated odds of "ignorance of health effects of smoking" was higher for people lacking mastery of the local language compared with those mastering it (odds ratio (OR) = 7.5 [3.6; 15.8], p < 0.001), and higher for men (OR = 4.3 [1.9; 10.0], p < 0.001). Advice to stop smoking was given with similar frequency to immigrants (31.9% [24.2%; 40.8%] and Swiss patients (29.0% [21.0%; 38.5%]). Nonintegrated patients did not appear to receive less counselling than integrated patients (OR = 1.1 [0.6; 2.1], p = 0.812). We conclude that the level of knowledge among male immigrants not integrated or unable to speak the local language is lower than among integrated foreign-born and Swiss patients. Smoking cessation counselling by a doctor was only given to a minority of patients, but such counselling seemed irrespective of nationality.

The health status of children without resident permit consulting the Children's Hospital of Lausanne.

OBJECTIVE: To assess social, economic and medical data concerning children without a resident permit taken into care by the Children's Hospital of Lausanne (HEL) in order to evaluate their specific needs. METHODS: Prospective exploratory study by a questionnaire including the socio-demographic, medical and education data of 103 children without a resident permit, who consulted the HEL for the first time between August 2003 and March 2006. These children were then recalled for a second check-up one year later in order to allow a regular monitoring. RESULTS: Eighty-seven percent of the children were native of Latin America, 36% being less than two years old. This population of children lived in precarious conditions with a family income lower than the poverty level (89% of the families with less than 3100 CHF/month). Forty-five percent of the children had a health insurance. The main reasons for consultation were infectious diseases, a check-up requested by the school or a check-up concerning newborn children. Most of them were in good health and the others were affected by illnesses similar to those found in other children of the same age. At least 13% of the children were obese and 27% were overweight. All children who were of educational age went to school during the year after the first check-up and 48% were affiliated to a health insurance. CONCLUSIONS: The majority of the children from Latin America lived in very precarious conditions. Their general health status was good and most of them could benefit from regular check-ups. Prevention, focused on a healthier life style, was particularly important among this population characterised by a high incidence of overweight and obesity.

Charges de travail et santé perçue de la "génération sandwich"

La coexistence des charges professionnelles, familiales, et d'aide à des ascendants expose la Génération Sandwich (GS) à des risques potentiels pour sa santé. Toutefois, les connaissances sur la GS sont insuffisantes pour permettre aux infirmières du secteur de la santé au travail de développer des interventions en promotion de la santé basées sur des preuves. Ce manque de clarté est préoccupant au vu de certaines tendances sociodémographiques. La présente étude vise à dresser le portrait des travailleurs de la GS en examinant les liens entre leurs caractéristiques, leurs charges co-existantes et leur santé perçue. Pour ce faire, nous avons développé un cadre de référence salutogénique. puis, nous l'avons utilisé pour conduire une recherche descriptive corrélationnelle transversale. un questionnaire électronique a permis de récolter les données de 826 employés d'une administration publique suisse. L'examen a montré que 23.5 % de l'échantillon appartenait à la GS. Cette appartenance ne dépendait pas du sexe. la charge de travail totale (70.5 h/sem) de la GS différait significativement de celle du reste de l'échantillon (62.8 h/sem). Nous n'avons pas trouvé de relation entre cette charge totale et la santé physique ou mentale des femmes. En revanche, il y avait une relation négative entre cette charge totale et la santé physique des hommes, et cette relation était proche du seuil de significativité pour la santé mentale de ces derniers. Grâce à une analyse soucieuse de faire évoluer favorablement les inégalités de genre (gender-transformative), cette étude fournit des pistes pour fonder des interventions préventives en faveur de la santé des membres de la GS.

Institutional legacies, employment and professional integration of non EU/EEA doctors in France

Internationally, policies for attracting highly-skilled migrants have become the guidelines mainly used by the Organisation for Economic Co-operation and Development (OECD) countries. Governments are implementing specific procedures to capture and facilitate their mobility. However, all professions are not equal when it comes to welcoming highly-skilled migrants. The medical profession, as a protective market, is one of these. Taking the case of non-EU/EEA doctors in France, this paper shows that the medical profession defined as the closed labour market, remains the most controversial in terms of professional integration of migrants, protectionist barriers to migrant competition and challenge of medical shortage. Based on the path-dependency approach, this paper argues that non-EU/EEA doctors' issues in France derive from a complex historical process of interaction between standards settled in the past, particularly the historical power of medical corporatism, the unexpected long-term effects of French hospital reforms of 1958, and budgetary pressures. Theoretically, this paper shows two significant findings. Firstly, the French medical system has undergone a series of transformations unthinkable in the strict sense of a path-dependence approach: an opening of the medical profession to foreign physicians in the context of the Europeanisation of public policy, acceptance of non-EU/EEA doctors in a context of medical shortage and budgetary pressures. Secondly, there is no change of the overall paradigm: significantly, the recruitment policies of non-EU/EEA doctors continue to highlight the imprint of the past and reveal a significant persistence of prejudices. Non-EU/EEA doctors are not considered legitimate doctors even if they have the qualifications of physicians which are legitimate in their country and which can be recognised in other receiving countries.