Life Course, HIV and Hepatitis B Among African Migrants Living in Ile-de-France
Condition: HIV Infection; Chronic Hepatitis B
MeSH terms: Hepatitis A; Hepatitis B; Hepatitis B, Chronic; Hepatitis
Study type: Observational

Summary: 
      Populations from Sub-Saharan Africa represent one of the most dynamic immigration flows in
      France and are among the most exposed to HIV infection and hepatitis B.

      The Parcours study aims to understand, among sub-Saharan African migrants, how social and
      individual factors combine in the course of migration and settlement in France, and influence
      the risk of infection, access to prevention and care, and the effectiveness of care for both
      HIV and hepatitis B diseases.

      The research was conducted in Ile-de-France, where 60% of sub-Saharan African migrants
      reside. It consists in a cross-sectional observational survey, using a life-event history
      approach that reproduces the sequence of different life and health events, and contributes to
      explain the present situation (type of disease management, patient's quality of life) in
      light of all the elements of the past trajectory (administrative, familial, socio-economic,
      professionals).

      A representative survey was conducted between February 2012 and May 2013 in health care
      facilities in Ile-de-France, among three groups of migrants from Sub-Saharan Africa: a group
      living with HIV, a group living with chronic hepatitis B and a group who has neither of these
      diseases. For each group, stratified random sampling was used. The survey was conducted in 24
      hospital services providing HIV care, 20 health care facilities providing hepatitis B care,
      and 30 primary health care facilities.

      Were eligible all patients attending these health care facilities, born in a Sub-Saharan
      African country and with Sub-Saharan African citizenship at birth, aged 18 to 59 years, with
      an HIV diagnosis (HIV group) or chronic hepatitis B diagnosis (hepatitis B group) more than
      three months prior or not diagnosed with HIV or chronic Hepatitis B (reference group).

      Among the patients offered participation, 926 HIV-infected patients, 779 patients infected by
      hepatitis B, and 763 patients without these two diseases participated in the study.

      For all participants, detailed information on socio-demographic characteristics; migration
      and life conditions in France; social, sexual and reproductive life history; and screening
      and care history were collected using a life-event history questionnaire administered
      face-to-face by a specialized interviewer. Health care professionals documented clinical
      information from the medical records. Data was collected anonymously.
    

Detailed description: 
      The PARCOURS study was conducted to study how health trajectories and social and migratory
      paths are interlaced for migrants from sub-Saharan Africa living in France. This
      retrospective quantitative life-event survey was conducted from February 2012 to May 2013 in
      health-care facilities in the greater Paris metropolitan area (Ile-de-France), among three
      groups of migrants born in sub-Saharan Africa: one group receiving HIV care, one group with
      chronic hepatitis B, and a third group of people visiting primary-care centres. Recruitment
      took place at facilities randomly selected from an exhaustive list of HIV outpatient hospital
      clinics (n=24), hepatitis treatment clinics (n=20) and general practice medical centres
      (n=30).

      Recruitment procedure for patients in each group:

      Within each health care facility selected for the study, all health care professionals
      providing outpatient care to patients born in sub-Saharan Africa were asked to participate in
      the study. They identified eligible patients during consultations based on medical records,
      and offered study participation to all eligible patients, except when the patient was deemed
      unable to be interviewed (for mental health or physical health reasons or because were unable
      to be interviewed in one of the languages spoken by the interviewer). When the patient agreed
      to participate in the study, health care professionals gave her/him an information leaflet on
      the study and obtained written consent. They also gave the participant a card bearing an
      identification number to ensure data collection anonymity and confidentiality, and referred
      her/him to the Parcours interviewer at the end of the consultation. The Parcours interviewer
      conducted the interview right after the consultation, in face-to-face mode, in a dedicated
      room, with closed door to ensure privacy.

      The health care professional could also suggest an appointment in the following days, always
      on site, to patients who agreed to participate in the study but were not immediately
      available.

      Consideration of non-Francophone participants:

      To take into account difficulties in participating in the survey due to poor or no knowledge
      of the French language, the patient questionnaire was available in French or English, and, by
      appointment, an interpreter could be made available to conduct the interview in an African
      language spoken by the respondent.

      Type of data collected

      Several data collection tools were used:

      Information register :

      In each service investigated, each health care professional participating in the study held
      an information register. Each page of the register had two parts, one with a detachable
      section specifying the correspondence between the identity of study patients and their
      identity number, and an anonymous one describing the main characteristics of eligible
      patients. During each consultation day, the health care professional listed in the register
      all eligible patients, their gender, age group, if the patient had worked at least one day in
      the previous month, a health indicator (last CD4 count for HIV + patients, last alanine
      transaminase (ALT) level for patients with hepatitis B, the fact of consulting in this
      facility for the first time for patients in the reference group), and participation in the
      survey (participant, not offered participation, refusal).

      Life-event history questionnaire

      Participants were interviewed using a standardized life-event history questionnaire
      administered by an interviewer face-to-face (average duration 55 minutes). The life-event
      questionnaire consisted of two parts:

        -  A list of questions associated with a life event calendar (or biographical grid), which
           allowed identifying, recording and dating (per year) events in the lives of the
           respondents, from birth to the date of the survey, and in the various themes explored in
           the study.

        -  A book of thematic modules, aimed at describing in-depth the events previously
           identified in the biographical grid (or some of them).

      The life-event calendar has a very graphic and visual form, which makes it easier to
      remember, record and date the events in the lives of the respondents. In particular, it
      encourages and easily adapts to the process of remembering that works by association of ideas
      and connections between life-event areas and as such optimizes data collection, in terms of
      completeness and reliability of the data collected.

      The themes explored in the life-event questionnaire were:

      Gender, age ; Residential biography and housing history ; Place of birth and places of
      residence. ; Work history - Education and Resources ; Marital and family history ; History of
      testing ; General health and history of disease ; Arrival in France and stay in France ;
      Sexual and reproductive health ; Social networks, support networks

      Medical questionnaire :

      The health care professional completed the medical questionnaire, from the patient's medical
      record. For the HIV and hepatitis B groups, this questionnaire documented the chronological
      landmarks and key parameters of the disease and its treatment. For the reference group, it
      informed the reason for consultation, potential diseases at the time of the survey, and
      current treatments.

      Anonymity of data:

      The identity number on the anonymity card given by the health care professional to the
      patient was the only participant identifier for the different survey questionnaires (thematic
      book and life-event calendar, medical questionnaire). The interviewer did not know the
      identity of the patient. No personally identifiable data was collected directly or indirectly
      for eligible individuals not offered participation or individuals refusing study
      participation. The general characteristics collected on the register among refusals were
      collected in the form of classes, and not precisely, thus not allowing for later
      identification.

      Ethical approvals :

      The survey was approved by the Advisory Committee for Data Processing in Health Research
      (CCTIRS) (approval on 13 April 2011) and by the National Commission on Informatics and
      Liberties (CNIL) (CD-2011-484 approval on 7 December 2011).

      Data collection :

      Between 30/01/2012 and 31/12/2012, 1,829 individuals infected with HIV and meeting the
      eligibility criteria presented at the participating services, among which 141 were not
      offered participation by their physician (111 for health reasons and 30 for language
      problems). Of the 1,688 individuals offered participation, 762 refused or abandoned during
      the questionnaire. In total, 926 individuals were included.

      Between 15/02/2012 and 31/05/2013, 1,169 individuals infected with hepatitis B and meeting
      the eligibility criteria presented at the participating services, among which 17 were not
      offered participation by their physician and 8 abandoned during the questionnaire due to
      language problems. In total, among the 1,135 individuals offered participation, 779 were
      included.

      Between 15/02/2012 and 31/05/2013, 1,184 meeting the eligibility criteria presented at the
      participating primary health care facilities. Among these, 124 were not offered participation
      by their physician (91 for health reasons and 33 for language problems). Among the 1,060
      individuals offered participation, 297 refused or abandoned during the questionnaire. In
      total, 763 individuals were included.

      Among all services and groups, the number of refusals due to language problems was 71 (30 in
      HIV group, 8 in Hepatitis B group and 33 in reference group), to which can be added 10
      interviews interrupted due to poor understanding of French (8 in hepatitis B group and 2 in
      reference group).

      Weighting :

      In order to take into account the sample design and non-participation, data was weighted
      according to each individual's probability of inclusion in the survey (i.e. considering the
      probability of inclusion in the sample for each health care facility, the number of half-days
      of weekly consultations in each facility included and the individual study participation per
      half-day of included consultations).
    

Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        Migrants from Sub-Saharan Africa living in Ile-de-France (Paris area) and visiting health
        care facilities: people living with HIV/AIDS (HIV group), people with chronic hepatitis B
        (hepatitis B group), and people who have neither of these conditions and consult within
        primary health care facilities in Ile-de-France (reference group).
      
Keywords: Life-event survey; observational survey among migrants in France