Conditions for the effectiveness of health mediation in promoting healthcare utilization and prevention among populations who are disconnected from the healthcare system: a literature review
Conditions for the success and feasibility of health mediation to promote healthcare utilization among underserved populations: a scoping review
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Populations excluded from the healthcare system comprise a highly diverse group. They include all those underserved by the healthcare system due to their living conditions—particularly their material circumstances—as well as their socioeconomic vulnerability and their social status (housing, employment, education, income) and administrative status (access to rights and administrative status, health coverage). These challenges also demonstrate that the healthcare system, which is under significant strain, is ill-equipped to meet the specific needs of these populations.
These populations also face food insecurity, housing instability, discrimination, and insecurity, compounded for some by language barriers, a lack of social support, and low health literacy. Furthermore, their perception of their bodies and health results in a different standard of what constitutes good health compared to the general population and a tendency to underestimate the severity of illness.
In summary, these populations face a triple burden: greater exposure to disease, lower adherence to prevention messages, and reduced use of healthcare services. Interventions aimed at increasing healthcare utilization and prevention among these populations must support the ability of services to adapt their organizational structures, strengthen individuals’ capacity to make health-promoting decisions, and provide them with support while addressing structural determinants of health—by developing programs that promote access to and retention in healthy housing, employment for all, healthy diets, education for all, and the fight against discrimination and exclusion.
Health mediation is one such intervention. To date, no study has evaluated the effectiveness of health mediation and the conditions under which it is effective.
The article recently published in the journal BMJ Open [1], based on a scoping review (exploratory literature review), analyzes the conditions for the effectiveness of health mediation.
3 questions for Elodie Richard 1, Fnasat-GV, PHAReS, Inserm Center U1219, Bordeaux Population Health, University of Bordeaux, and Stéphanie Vandentorren, Scientific and International Directorate, Santé publique France, Inserm Center U1219, Bordeaux Population Health, University of Bordeaux
Health mediation refers to the role of acting as a local liaison between individuals who are disconnected from the healthcare system and the professionals involved in addressing their issues (social and healthcare professionals, government agencies, elected officials, etc.). Its purpose is to facilitate access to preventive care and treatment for individuals with one or more factors of social vulnerability: geographic, familial, or social isolation; health-risking practices or behaviors; a legal and health environment unfavorable to health; economic or administrative insecurity; lack of familiarity with the healthcare system in France; difficulties related to the French language or digital barriers; low health literacy; and discrimination.
It combines individual and/or collective actions focused on information, education, communication (i.e., “Working with”), and navigating the healthcare system for individuals (i.e., “Going to and bringing back to”), along with third-party mediation involving efforts to mobilize, engage, and foster collaboration among local stakeholders and between local populations and these stakeholders.
Health mediators may or may not come from the population they support, but have earned their legitimacy among them through in-depth knowledge of their local area, the challenges faced by the population, and local stakeholders.
Health mediation would help strengthen people’s capacities and support them in overcoming obstacles by empowering them to take action in their health journey. It would also help identify unmet social needs and the shortcomings of a system that remains ill-suited to everyone, bringing these to the attention of institutions and stakeholders to ensure better consideration and adaptation of health systems to the specific needs of these populations. Finally, it enables the development of access programs (rights, housing, employment, education) and the fight against inequalities in access to care and prevention, as well as the fight against discrimination and social exclusion.
Health mediation emerges as a promising intervention carried out by health mediators who play a pivotal role within the healthcare system to ensure the right to health for people in vulnerable situations.
Health mediation practices take many forms, although a common framework for intervention exists and has been formalized in a set of guidelines by the HAS. It must combine various practices to adapt to a changing social context and the characteristics of different populations. This is an intervention system.² Based on this systemic approach, we have mapped the conditions for the success and feasibility of health mediation within a conceptual framework that assumes their interrelationships.
In the first version of the conceptual framework for health mediation, the contextual conditions for success and feasibility (i.e., factors external to the mediation intervention that drive it) form the macro-system. These include political and financial commitment, the ability to influence structural and intermediate determinants of health, and ensuring the health mediator’s professional security.
The conditions for success and feasibility specific to the intervention are the principles of otherness and universalism with a holistic vision of health, as well as the functions of interfacing and intersectorality within a locally rooted network. Added to this is the formalization of actions into plans with adequate resources and health mediation activities that align with the ethical principles of all mediation according to Faget J.3: Going/Bringing Back to, Doing With, Being Together, and Doing Together.
The qualities required of a health mediator include a caring and attentive demeanor, great mental flexibility, perseverance while remaining true to oneself, a confident and non-judgmental attitude within a framework of shared power, positive feedback, and strong interdependence between the health mediator, local stakeholders, and the community.
The next steps to be taken to promote the implementation of health mediation are crucial, as health mediation is a cyclical process that combines knowledge transfer and empowerment from the individual to the societal level. Indeed, these interventions are carried out with the aim of empowering individuals who feel they have limited control over their environment; in this sense, they must address the structural determinants of health to achieve results, particularly among those who are marginalized from the healthcare system. Addressing access to rights, access to and retention of housing, healthy food, education, and employment are all levers that will enable access to care and prevention.
Many steps remain to be taken to facilitate the implementation of mediation on a large scale. One important step involves evaluation: identifying and funding promising interventions initially for evaluation purposes, promoting evaluations based on effectiveness criteria through research, and supporting research in this sector. A second key step is securing the professional framework for health mediators. Funding and securing positions for health mediators are crucial for ensuring the recognition and legitimacy of this profession among both social sector stakeholders and healthcare professionals. A recognized training framework that is professionalizing and incorporates the effectiveness elements highlighted by research would lead to greater recognition of the practices and actions carried out by health mediators.
Santé publique France has initiated and supported research on health mediation in collaboration with the University of Bordeaux. A special issue of the journal La santé en action is available to professionals, featuring numerous contributions from researchers and field practitioners to share knowledge and experiences in this field. The agency also supports and funds initiatives to develop skills and share best practices within the network of mediators as part of the national health mediation program led by FNASAT, as well as evaluations of health mediation (IKAMBERE project). At the regional level, in June 2022, the Provence-Alpes-Côte d’Azur Regional Health Agency decided to support a pilot health mediation project led by two associations, Sept and Corhesan, working in the most disadvantaged neighborhoods of Marseille (see box).
Health Outreach to Vulnerable Populations in Marseille
This health mediation project for vulnerable populations in Marseille follows on from the health mediation programs developed by associations as part of the fight against COVID-19 (Médilac Program). Health mediation interventions under the Marseille project began in October 2022. They primarily focus on cancer screening and vaccine-preventable diseases, and can be expanded to address the health needs expressed by the people encountered and to help them access their rights.
The project evaluation is being conducted as part of a partnership between Santé publique France, the ARS Paca, the CPAM, a joint research unit (UMR SESSTIM), and the two local associations, Sept and Corhesan. Its primary objective is to assess the effectiveness of field interventions by measuring their impact on vaccination coverage and screening rates. The evaluation focuses on several areas:
process evaluation (routine collection of activity and performance indicators);
quantitative evaluation aimed at providing evidence of the interventions’ effect;
qualitative evaluation.
The quantitative evaluation has three components:
repeated cross-sectional surveys assessing vaccine hesitancy and knowledge, attitudes, and practices regarding cancer screening,
an ecological survey measuring reimbursement volumes for medical procedures at the Iris level
a cohort survey individually assessing the provision of healthcare services.
These three surveys will be conducted using a “before-after” method in neighborhoods benefiting from the interventions and a “here-elsewhere” method by comparing the neighborhoods targeted by the interventions to control neighborhoods.
Article reference:
[1] Richard E, Vandentorren S, Cambon L. Conditions for the success and feasibility of health mediation for healthcare use by underserved populations: a scoping review. BMJ Open 2022;12:e062051. doi: 10.1136/bmjopen-2022-062051.
Other references:
1 This work was conducted as part of a Public Health doctoral thesis supported by a CIFRE partnership between the University of Bordeaux and FNASAT, under the supervision of Stéphanie Vandentorren (Santé publique France) and Linda Cambon (ISPED Prevention Chair, Inserm Center U1219, BPH, University of Bordeaux, Bordeaux University Hospital). This work received financial support from the National Cancer Institute and Santé Publique France.
2 Cambon L, Terral P, Alla F. From intervention to interventional system: towards greater theorization in population health intervention research. BMC Public Health. Dec 2019;19(1):339.
3 Faget J. Mediations: The Silent Workshops of Democracy. ERES. 2015;304.
Learn more about health mediation
HAS. Health mediation for people who are disconnected from prevention and care systems. 2017;70.
Health mediation: a new profession to remove barriers to care and prevention pathways. La Santé en Action. No. 460 - June 2022. 52p.
