Question

What is the health status of the French population?

Answer 1

The assessment of a population’s health status in its various dimensions (average life expectancy, frequency of disease and functional limitations, quality of life, etc.) requires the use of different data sources, the main ones being:

• Vital statistics (births, deaths). The life expectancy of a population (or the average lifetime of a fictional generation given mortality conditions of the moment) constitutes a simple and global dimension. A population is considered more or less healthy according to life expectancy. However, this measurement does not make it possible to evaluate the specific impact of various diseases in terms of mortality and morbidity or individuals’ quality of life.

• Death certificates that include medical causes of death. The analysis of the initial cause of death (i.e., the disease or trauma responsible for the morbid event leading directly to death and the circumstances of the accident or violence that resulted in a fatal trauma) makes it possible to measure the burden of different causes of death (pathologies, suicides, accidents in everyday life, etc.). Mortality indicators are the result of both the frequency of the health event causing death (incidence) and the quality of care (health system performance, therapeutic or diagnostic innovations). However, death sometimes occurs long after exposure to the risk factors. • Disease registers. A register is defined as a continuous and comprehensive collection of data related to one or more health events in a geographically defined population. Estimates of the incidence of cancers in children are based on data from these registers.

• Mandatory Notifiable Diseases (MND). In 2016, 33 diseases were subject to mandatory notification. Of these, 31 were infectious and 2 non-infectious (mesothelioma and lead poisoning in minor children).

A high life expectancy The french population have a high life expectancy. In 2015, it was 85.0 years for women, one of the highest in Europe, and 78.9 years for men, reflecting the European average. Between 2005 and 2015, life expectancy increased by 1.2 years for women and 2.2 years for men. However, a more marked increase was observed in the previous ten years. More specifically, it grew by 2.9 years in men and by 1.9 years in women between 1995 and 2005. Today, the gap between both genders is reducing, as is the case in most European countries.

Reduction in all-cause mortality, premature mortality (before age 65), and improved life expectancy for people with chronic diseases The very large reduction in all-cause mortality observed over the past several decades is continuing. Age-standardized mortality rates per 1,000 inhabitants decreased from 14.7 deaths to 11.4 in men and from 8.4 to 6.7 in women between 2000 and 2014. This decrease was across all age groups. For 2014, these rates were lower than the average rates observed in the EU-28 (12.7 for men and 8.4 for women).

The health status of people, especially women, who are currently under 65 (i.e., generation from the end of the baby boom) improved at a slower pace between 2000 and 2014 than for older age groups, and deteriorated for some diseases. In a generally favorable context of decreasing mortality and morbidity for several decades now, many factors shade this positive picture. The reduction in premature mortality (before 65) between 2000 and 2013 was lower in women: - 15% versus - 23% in men. This differing evolution between the sexes is even more noticeable when we analyze - over the same period - the evolution of avoidable premature mortality (-15% and -31%, respectively) and that of mortality associated with tobacco consumption (-27% in men but with a very strong increase in women (+ 38%). Among patients under 65 years, the decrease in the standardized incidence of hospitalized patients for ischemic heart disease (IHD) WAS lower in women than in men (-4.8% versus -15.6%) and IHD-related mortality in women under 65 years declined less rapidly than for men (-26% in women versus -42% between 2002 and 2014). Age standardized rates of hospitalizations and mortality for IHD increased with the level of social disadvantage and more markedly among those under 65 years of age. Hospitalizations rates for stroke ( mainly ischemic) are rising is rising sharply (+ 20% in both men and women under 65 between 2002 and 2014), while it is tending to stabilize among those aged 65 and over

A very large increase in the incidence of hospitalizations for COPD exacerbations has been observed for all ages, particularly among women under 65 (+ 134% between 2002 and 2014). COPD-related mortality almost doubled (+ 93%) for women under 65, whereas it remained more or less stable for adult men of all ages and for women aged 65 and over – Charts below). Since 2005, the incidence of lung cancer in women has accelerated. The standardized mortality rate has also risen, approaching that of breast cancer (12.9 per 100,000 for lung cancer, and 15.7 per 100, 000 for breast cancer) whereas incidence and mortality, although higher, are decreasing in men. These elements, which if analyzed individually could go unnoticed, reveal that the health of the youngest people in the population is improving less rapidly than in the oldest people, and that the least positive trends concern women in particular. While these mortality and morbidity indicators affect men more than women, their dynamics over the last 15 years have been more unfavorable for women. An important cause of these adverse trends is known: tobacco, whose consumption has not declined substantially in women over the past four decades. The proportion of «current smokers» (share of respondents who answered positively to the question «Do you smoke, even if only from time to time?») was 59.0% for men and 28.0% among women in 1974. This decreased to 38.8% in men in 2014, while it remained relatively stable at 29.9% among women. Indeed, among the latter, the most unfavorable evolutions concern diseases for which a particularly high percentage of cases are tobacco-related: lung cancer, COPD, ischemic cardiovascular diseases. Obviously, the deterioration or the slightest improvement in health status cannot be explained solely by the consumption of tobacco. Other known determinants play a part and can interact with one another. Thus, diet, sedentary behaviours, physical activity and corpulence also play a decisive role. The prevalence of people with obesity (BMI ≥ 30 kg / m2) continues to increase, even though this rise tended to slow down in the early 2010s, increasing in both men and women by approximately 10% (reported data) in the early 2000s to approximately 15% (reported data) in 2014.

Workers and employees are particularly affected by all the risk and exposure factors and their consequences in terms of occupational diseases (OD), work-related diseases (WRD) and occupational accidents

(OA). In 2012, in France, 676,700 OA and 90,100 commuting accidents were recognized by the CNAMTS and the MSA. Of these, 45,200 OA and 8,500 commuting accidents resulted in permanent partial disability (PPDI). The number and frequency of OA vary greatly according to the economic activity. OA are more frequent among men, young workers, and manual workers. Of the 56,100 occupational diseases recognized in 2012 (of which the vast majority were musculoskeletal disorders, occupational diseases due to exposure to asbestos and work-related deafness), 72% and 23%, respectively, affected workers and employees affiliated to the France’s general insurance scheme. The most serious diseases almost exclusively concerned manual workers, with 92% and 95% of recognized diseases in 2012 being asbestos and deafness related, respectively. In France, 12% of employees were exposed to a carcinogen (chemical or not) and approximately 30% of these were exposed to at least two. The exposure of men mainly due to chemical carcinogens, particularly affects construction and public-works laborers, and skilled workers ,in maintenance, car repair, metalworking and transport; The exposure of women to a carcinogen, is of a more varied nature (chemical agents, ionizing radiation, night work) and mainly affects the health (nurses, midwives, nursing aides, etc.) and service sectors . Similarly, 43% of workers and 25% of salespeople were exposed to arduous work factors, such as marked physical constraints (strenuous postures, manual handling of heavy loads, etc.). All categories combined, men, manual workers, and employees in the construction and manufacturing sectors remain the most exposed. Almost half of the workers carry out their duties in an aggressive physical environment (contact with chemicals or harmful noise, extreme temperatures), and 29% of manual workers and 24% of salespeople are affected by forced working schedules. Manual workers, especially unskilled manual workers, are more likely to be exposed to night work or repetitive gestures. In total, one manual worker in four is exposed to at least three hardship factors compared to less than 5% of managers or administrative employees. Women report the feeling of a lack of support and cooperation more often in particular by almost half of manual workers and employees, despite cooperation at work being a recognized factor of health protection. The feeling of economic insecurity expressed by 25% of the workforce concerned mostly workers (32%) and retailers (37%)

Social inequalities of health are present at all ages of life

Inequalities occur even before birth, during pregnancy, leading to a higher rate of preterm birth and lower birth weight in low-income households, as shown by national perinatal surveys. Similarly, children whose parents are unskilled workers and school-age children living in priority education areas or in rural areas have poorer dental health and are more often overweight than others. The proportion of children suffering from obesity is 5.8% for children whose parents are unskilled workers, compared with 1.3% for children whose parents are executives in the last grade of kindergarten, and 5.5% compared with 1.4% of children in fifth grade. Regardless of age, children of working class parents more frequently have caries than those of executives. In children as early as 5-6 years old, 31% with working class parents have at least one decayed tooth compared with 8% of those whose parents hold executive posts. In 5th grade, these percentages are, respectively, 40% and 27%, and 58% and 34% in 9th grade.

Scope • Whole France (excluding Mayotte before 2014), pupils enrolled in last year of GSM - grande section de maternelle - (nursery school), CM2 (5th grade) and 3e (9th grade). Sources • National Health Surveys in Schools (DREES-DGESCO). The majority of non-communicable diseases

demonstrate social gradients of incidence and mortality. This is the case of mortality due to alcohol-related illnesses, which is twice as high in the poorest quintile when compared to the wealthiest population quintile. For mortality due to tobacco-related diseases, the difference between the two quintiles is + 55%. Similarly, mortality and hospitalization rates for ischemic heart disease are, respectively, 50% and 16% higher in the poorest quintile when compared to the wealthiest quintile. For stroke these figures are 30% and 13%. For pulmonary embolism mortality in the poorest quintile is 30% higher when compared to the wealthiest quintile. With respect to pulmonary diseases, mortality and hospitalization rates for COPD are + 53% and + 65%, respectively, for the poorest quintile when compared with the wealthiest. The hospitalization rate for asthma is higher among those benefiting from the universal medical insurance than in does who do not (18.6 / 10,000 compared with 7.6 / 10,000). According to the social disadvantage index, it increases from 7.9 / 10,000 among residents of least disadvantaged municipalities to 10.6 / 10,000 among residents of most disadvantaged municipalities. The prevalence of diabetes is also 67% higher in women and 32% in men in the poorest quintile, this difference being related to the social gradient of obesity, which is a risk factor for diabetes, and which is more pronounced in women than in men. The same is true for high blood pressure, where the prevalence of people treated with antihypertensive drugs in the poorest quintile is 20.9% compared to 16.9% in the wealthiest quintile.

Health in “Overseas Departments and Regions” administrative areas (DROM)

The DROM are generally characterized by a higher birth rate, a lower maternal age at birth, and a more difficult socio-economic situation with higher unemployment rates than in metropolitan France. Nevertheless, there are also important differences between the DROM. More unfavorable perinatal indicators Preterm rates, stillbirth rates (number of stillborn children per 1,000 total births), perinatal and neonatal mortality (number of children who die during the first 28 days of life per 1,000 live births) are higher than those of metropolitan France in all the DROM. However, the situation is less favorable in Mayotte and Guyana and, for preterm births, in Reunion Island. Indicators for Martinique, although somewhat higher, are the closest to those observed in metropolitan France.

Infant mortality in the DROM (excluding Mayotte), averages 7.6 per thousand live births, in contrast to 3.3 for metropolitan France. Martinique, also has the lowest infant mortality rate in all the DROM (5.7 per 1,000). The rate of abortion is nearly twice as high in the DROM (26.5 per 1,000 women aged 15 to 49) when compared with Metropolitan France (14.4) and almost three times higher among women aged 15 to 17 years (20.0 and 7.6, respectively). On the other hand, the rate of breastfeeding in health facilities is much higher in the DROM: 85% on average compared with 66% in metropolitan France. An unfavorable evolution of certain risk factors for chronic diseases in the West Indies In the two Caribbean DROM Martinique and Guadeloupe, where a survey was carried out in 2013 on nutrition, the consumption of fruit and vegetables was far below the recommendations in both adults and children. Three-quarters of adults and 85% of children (11-15 years old) consume fewer than five portions of fruit and vegetables daily. Overweight and obesity in Martinique and Guadeloupe are high and are rapidly increasing: in women, the proportion of obesity measured was 33% and 31%, respectively, in 2013, while in Martinique it was 26% in 2003 and 21% in Guadeloupe in 2005. Although the data on overweight and obesity are older for metropolitan France (17% in 2007), most recent declarative surveys indicate that overweight and obesity in adults are higher in the two DOM than in Metropolitan France. Children are also more overweight and obese in these regions than in metropolitan France: in 2014, 4.8% of children in pre-school classes and 5.5% of children in fifth grade in the two DROM were obese compared to 3.5% and 3.6%, respectively, in metropolitan France. The burden of stroke and of diabetes and related main complications is greater in the DROM than in Metropolitan France Rates of hospitalizations and mortality caused by stroke are much higher in Guadeloupe, Guyana, and especially in Reunion Island. While in France the hospitalization rates vary between 147.6 and 191.6 per 100 000, depending on the region, these rates are respectively 210, 297.1 and 230.3 per 100 000 for these three DROM. Stroke mortality rates in metropolitan France range from 38.5 to 55.1 per 100,000, while they reach 73.6, 71.5, and 81.6 100 000 for these three DROM, respectively. Martinique has rates equivalent to those of the most disadvantaged French region (189 for hospitalization and 55 for mortality). Reunion has the highest rate of treated diabetes at 10.2%. The frequency of complications - and thus the severity of diabetes - also appears to be much greater in the DROM. Amputation rates in diabetics and especially the rates of end-stage renal disease are particularly high in comparison with metropolitan France. In addition, these complications appear to occur at a younger age: patients with end-stage renal disease are, depending on the DROM considered, 2 to 7

Premature mortality and avoidable mortality:

a regional map with stark contrasts Premature mortality is higher in the DROM than in Metropolitan France (225 deaths per 1,000 versus 200 in Metropolitan France in those aged under 65 in 2013). In Metropolitan France, the highest rates among women are found in Normandy, Grand Est and the Hauts-de-France regions, while the lowest are in the Île-de-France, Pays de la Loire and Auvergne-Rhône-Alpes regions. Among men, the highest rates are found in the Normandy, Brittany and Hauts-deFrance regions, and the lowest in Provence-Alpes-Côte d’Azur, Auvergne-Rhône-Alpes and Île-de-France regions. The regional differences are higher in men (ratio of 1.6 between Hautsde-France and Île-de-France). Unlike premature mortality, preventable mortality associated with primary prevention practices is lower in the DROM than in Metropolitan France. There are large differences between metropolitan regions: a ratio of approximately 2 between the Hauts-de-France region and the Ile-de-France region among men, and a ratio of approximately 1.6 between the Hauts-deFrance Auvergne-Rhône-Alpes regions among women. For women, the highest values are found in the Corsica, Brittany and Hauts-de-France regions and the lowest in the Occitanie, Île-de-France, and Auvergne-Rhône-Alpes regions With respect to avoidable mortality in relation to alcohol and tobacco consumption, four regions are particularly affected by the health consequences of excessive alcohol consumption, affecting women as much as men: Hauts-de-France, Brittany, Normandy, and Reunion (DROM). With an equal age structure and with the exception of Reunion, the DROM are less affected by preventable tobacco-related mortality than metropolitan France, as much for men and women. In women, mortality is highest in Corsica, Reunion Island and in the Grand Est and Brittany regions, whereas it is minimal in Martinique, Guadeloupe, Guyana and Pays de la Loire. In men, mortality is highest in Hauts-de-France, Grand Est, Reunion and Brittany, and lowest in Martinique, Guadeloupe, Guyana and Île-de-France. Regional differences are more pronounced among men. In the DROM, avoidable mortality, and especially alcohol and tobacco-related mortality, represents a lower proportion of premature mortality. This reflects a territorial specificity of the causes of mortality, which are more frequent during the perinatal and infantile period but also, in particular, because of the importance of infectious diseases. In Metropolitan France, for example, the Hauts-de-France region has the least favorable mortality indicators for both men and women. The highest rates of premature mortality, mortality and mortality are associated with alcohol and tobacco consumption: premature mortality (allcause mortality before the age of 65) is 366 per 100,000 for men and 159 per 100,000 for women (versus 276 and 129 per 100,000, respectively, in Metropolitan France); preventable premature mortality is 135 per 100,000 for men and 37.1 per 100,000 for women (versus 34 and 22 per 100,000 in Metropolitan France).

Report from WHO

Statistics

Total population (2015)	64,395,000
Gross national income per capita (PPP international $, 2013)	37
Life expectancy at birth m/f (years, 2015)	79/85
Probability of dying under five (per 1 000 live births, 0)	not available
Probability of dying between 15 and 60 years m/f (per 1 000 population, 2015)	104/51
Total expenditure on health per capita (Intl $, 2014)	4,508
Total expenditure on health as % of GDP (2014)	11.5