Nous avons souhaité accompagner des populations d’Afrique subsaharienne en France, sur une démarche de santé communautaire, afin d’agir sur les inégalités de santé. Ce travail permet une mesure des effets et conséquences sur le comportement de promotion de la santé sous l’angle des rapports interculturels. Cette démarche repose sur une méthodologie exploratoire constituée à la fois d’outils de recherche en psychologique, de protocoles d’intervention en santé publique et d’une problématique psycho-sociale d’interculturalité. Les évolutions de comportement en faveur d’actions de promotion de la santé sont liées de manière significative à cette démarche qui allie focus groupe et application de la théorie du comportement planifié (TCP). Une telle approche permet une réflexion sur les inégalités sociales en santé des communautés migrantes, et l’accompagnement vers les soins, en favorisant les relations entre habitants et professionnels de santé dans une démarche interculturelle. Les objectifs de l’étude étaient (i) de mieux comprendre l’intention des immigrants africains d’adopter une approche personnelle pour les problèmes de santé communautaire et (ii) d’évaluer la sensibilisation et le développement des compétences des membres de la communauté sur leur comportement de promotion de la santé. / We wanted to accompany sub-Saharan African population in France, on a community health approach, to act on health inequalities. This work allows to measure the effects and consequences of health behavior promotion from an inter-cultural relations angle. This approach is based on an exploratory methodology made up of both psychological research tools, protocols for intervention in public health with the psycho-social problematic of inter-culturality. Behavioral changes in favor of health promotion actions are significantly related to this approach, which will combine group focus and the application of planned behavior theory (PBT). Such an approach allows a reflection on the social inequalities in health of the migrant communities, and the accompaniment towards care, favouring relations between inhabitants and health professionals on an intercultural approach. The objectives of the study were (i) to better understand the intention of African migrants to adopt a personal approach to community health problems and (ii) to assess the influence of developing members’ awareness and skills of the community on their health promotion behavior.

Contexte Les programmes de promotion de la santé dans le milieu du travail sont des interventions complexes qui requièrent une compréhension des facteurs de risque pour l’identification des populations à cibler. Leur développement s’appuie souvent sur des méthodes de montage de projet qui ne tiennent pas compte de principes de promotion de la santé de la Charte d’Ottawa. Des approches méthodologiques adaptées sont nécessaires pour comprendre le fonctionnement de ces programmes. Objectifs Mener une réflexion autour de la promotion de la santé dans le milieu du travail à travers : (i) le développement de la « théorie de programme » d’une intervention de promotion de la santé intitulée « Plus Saine la Vie » réalisée à la Société Nationale des Chemins de Fer Français (SNCF) et (ii) l’identification des déterminants du diabète de type 2 et de l’hypertension artérielle que l’on peut mesurer en routine auprès d’une population de salariés en surpoids en milieu du travail. Méthodes L’outil de catégorisation des résultats de Promotion Santé Suisse a été utilisé pour développer la « théorie de programme » à l’aide d’une approche inductive fondée sur la documentation disponible sur l’intervention et l’observation de celle-ci sur le terrain. Vingt réunions itératives du comité de pilotage de l’intervention ont assuré la validation du processus qui a abouti au modèle final. Ensuite, nous avons utilisé la méthode de conception de programme proposée par Fry et Zask (2016) pour comprendre quels leviers d’action de la Charte d’Ottawa ont été mobilisés par l’intervention. L’identification des déterminants du diabète de type 2 et de l’hypertension artérielle a été réalisée par deux études transversales auprès des salariés en surpoids de la SNCF volontaires pour participer à un dépistage lors de la visite périodique de médecine du travail (janvier 2011- mars 2015). Résultats Une première « théorie de programme » a été développée avec des informations détaillées sur les activités, les résultats intermédiaires et les objectifs de l’intervention. Quatre axes stratégiques de la Charte d’Ottawa ont été mobilisés par l’intervention : création d’environnements favorables à la santé, renforcement de l’action communautaire, acquisition d’aptitudes individuelles et réorientation des services de santé. Dans la deuxième partie de notre travail, les quatre déterminants suivants ont été identifiés pour expliquer une hyperglycémie chez les salariés en surpoids : le sexe masculin, un âge ≥50 ans, une pression artérielle élevée (≥140/90 mm Hg), et une consommation quotidienne de produits sucrés. De plus, six déterminants ont été identifiés pour expliquer une pression artérielle élevée : le sexe masculin, un âge ≥40 ans, un indice de masse corporelle compris entre 27,5 et 29,9 kg/m², une hyperglycémie (mesurée par la glycémie capillaire ≥ 7 mmol/L), un risque élevé d'apnée du sommeil, et le travail de nuit. À l'inverse, être cadre au sein de la SNCF a été identifié comme un facteur protecteur de pression artérielle élevée. Discussion Notre travail propose un cadre conceptuel pour modéliser les programmes de promotion de la santé dans le milieu du travail et relève ainsi, par l’exemple concret de l’action « Plus Saine la Vie », comment certains des axes stratégiques de la Charte d’Ottawa ont pu être mobilisés dans le milieu du travail. Enfin, l’identification de déterminants du diabète de type 2 et de l’hypertension artérielle au cours d’une visite systématique de médecine du travail des salariés en surpoids montre la faisabilité d’interventions ciblées de promotion de la santé dans le milieu du travail. / Background Workplace health promotion programmes are complex interventions that need a wide understanding of risk factors to target high risk populations. The implementation of these programmes often requires the mobilization of classical methods of programme design and planning. However, these methods usually are not based on the Ottawa Charter five priority areas which provides a framework ensuring programme effectiveness. Understanding how a specific program is supposed to work is a crucial point in health promotion and could contribute to the appropriate programme planning and implementation. Thus, programme theory is a practical tool which captures the complexity of a programme by clarifying its objectives, activities and expected outcomes. Objective The aim of this work was to provide a deep insight about workplace health promotion by (i) developping the underlying programme theory of a health promotion programme entitled “Plus Saine la Vie” (“Healthier Life”) carried out in the French National Railways Company (SNCF) and (ii) identifying the factors that are associated with type 2 diabetes and hypertension and can be routinely measured in French overweight employees to develop targeted preventive strategies in the workplace. Methods The “Swiss Model for Outcome Classification in Health Promotion and Prevention” was used to develop the programme theory. Then, we used the design process proposed by Fry and Zask (2016) to understand which levers of action from the Ottawa Charter for Health Promotion had been mobilised in the programme. Secondly, two cross-sectional studies were conducted to identify the determinants of type 2 diabetes and hypertension among SNCF overweight employees who participated in a health screening conducted during their regular occupational health check-up (January 2011-March 2015). Results Our work provides a programme theory with detailed information regarding how this health promotion programme was supposed to work and what it was expected to be implemented in the workplace setting. Moreover, the programme design analysis showed that the programme had mobilised the following Ottawa Charter’s action areas in the workplace setting: “creating supportive environments”, “strengthening community action”, “developing personal skills” and “reorienting health services”. Significant predictors of hyperglycaemia were male sex, age ≥50 years, high blood pressure, and daily intake of sugary food. In addition, male sex, older age (age ≥40), body mass index between 27.5 and 29.9 kg/m², hyperglycaemia, high risk of sleep apnoea, and night work schedule were significantly associated with high blood pressure. Conversely, high job position was identified as a protective factor for high blood pressure. Discussion Our work provides an example of a programme theory which can be used as a framework to develop health promotion programmes in the workplace setting. Moreover, our work presents an analysis of the programme concerning the mobilisation of the Ottawa Charter’s action areas for health promotion in the workplace. Our findings could be used by occupational health professionals to design specific health promotion interventions in the workplace setting to target individuals at high risk for developing hypertension and type 2 diabetes.

The modern hospice movement emerged in the 1960s as a grassroots social movement that attempted to restore an holistic and contextualised approach to the care of people at the end of life. This approach embraced the lived experience of the dying person at the centre of care across physical, emotional, social and spiritual domains of life. To achieve this, the care of dying people was largely removed from mainstream health care systems to promote more holistic and socially contextualised dying. In recent decades, the evolution of palliative care demonstrates the gradual return of palliative care services to the mainstream. It has been asserted that, in this process, palliative care services have progressively abandoned the social context of dying people, increasing instead an emphasis on "physical care [while] simultaneously de-emphasizing psychological, social and spiritual care" (Kellehear, 1999a, p.76). Kellehear and others have proposed that the repositioning of palliative care within mainstream health care systems has increased a focus upon illness and disease at the expense of health and wellbeing. Subsequently, conventional palliative care services have been criticised for not adequately locating end of life care within the social contexts in which death and dying take place. In an attempt to address this problem, Australian sociologist Allan Kellehear proposed an approach to end of life care that brought together the core concerns of palliative care with the principles and practices of health promotion (Kellehear, 1999b). Whilst their congruence is not immediately apparent, these two fields have been increasingly examined for their potential benefits in the provision of end of life care. In the current policy climate in Australia, there is an imperative to consider how end of life support services might be improved through adopting a health promoting palliative care approach. The aim of this study has been to investigate the integration of health promotion principles and practice by a selected palliative care service by examining the qualitative impact of this change on the organisation. Specifically, it endeavoured to identify the factors that advanced or impeded this integration by examining how the structures and processes of, and outcomes for, the organisation reflected a health promoting approach. To meet these aims, this study undertook an in-depth examination of the implementation of a health promoting palliative care model by a community based palliative care organisation. Based in a constructionist-interpretivist paradigm, a mixed-method (QUAL+quant), instrumental case study research design was utilised to capture multiple perspectives of the implementation process. Data collection comprised examination of 127 organisational documents, 32 in-depth interviews with staff, volunteers and consumers, 5 focus groups with staff and volunteers, and 25 carer questionnaires. Qualitative data were subject to thematic analysis, with supplementary quantitative data analysed to generate descriptive statistics. The findings demonstrated a large number of complex and interrelated enabling and impeding factors to the implementation in the case study site. These factors have been grouped into four key themes which have been examined in light of the aims of this study and the issues identified in a comprehensive review of the literature. This study found that: ◦ Conceptual congruence between health promotion and palliative care was a fundamental starting point in the implementation of a health promoting palliative care model. ◦ Where conceptual congruence was clear, activities associated with the model that were regarded as beyond conventional approaches to palliative care core business were viewed favourably by stakeholders and were less likely to encounter resistance within the organisation. ◦ When systematic approaches to organisational change, such as quality improvement systems, were rigorously applied, the impact of the transition upon stakeholders was qualitatively less. ◦ Where this transition had been effectively made, consumers, staff, volunteers and members of the wider community were seen to benefit. This study adds to the current discourse regarding the intersection between end of life support and health promotion, and provides insight into how palliative care organisations might undertake the transition from conventional models to a health promoting palliative care approach.