Laboratoire Éducations et Promotion de la Santé (LEPS UR 3412)

Éducation pour la santé et Nutri-Score à destination des personnes ayant de faibles compétences en littératie en santé en Seine-Saint-Denis.

Health education and Nutri-Score for people with low health literacy skills in Seine-Saint-Denis.

Project overview Issues
The Nutri-Score was developed in 2014 by the Nutritional Epidemiology research team as a front-of-package display format to improve consumers' nutritional choices towards products of better nutritional quality. It is now in use in 7 European countries and is among the options selected by the European Commission to become the harmonized and mandatory front-of-package format for all EU countries. While the development of the Nutri-Score took into account the perceived needs of vulnerable populations by producing a simple, colorful format, and while studies on its effects have evaluated results according to social status (through income, level of education or knowledge of nutrition), very few studies have focused specifically on the most vulnerable populations, and on one of the determinants of health behaviors, including health literacy. Health literacy (HL) refers to the personal characteristics and social resources needed by individuals and communities to access, understand, evaluate, and use information and services to make health decisions. In Europe, nearly one in two people have a level of HLS described as limited8 . A low level of LS has a sufficiently large impact on health status that it must be taken into account when aiming to improve the overall health of the population. Social inequalities in health are also reflected in dietary behaviors, and it is therefore becoming urgent to adopt health promotion strategies that allow all populations, including those furthest from information, to improve their health. In this respect, it is important to ensure that the Nutri-Score can help these populations make better food choices and improve their sense of self-efficacy in making their daily choices.

Objectives
The objectives of this study are to:
1. Understand how vulnerable populations far from nutritional information understand and use the Nutri-Score system, and how health literacy plays a role in this understanding and the resulting intention to use it.
2. To construct an educational intervention for vulnerable, low LS individuals to: understand and use the Nutri-Score in daily nutrition choices.
3. Evaluate the effects of this intervention on:
a. sense of competence
b. participants' intention to use the Nutri-Score
c. actual use through food choices elicited in the context of an experiment

Method
Type of study
The project is based on a mixed method (quantitative and qualitative), with vulnerable populations participating in the interventions of associations acting in the 93 (Maison Martine Midy - located at the Avicenne hospital and the Aurore flowers).
It is an interventional research with a comprehensive aim on the one hand, and on the other hand, a quantitative experimental study of the before/after type on food choices.
Population and sampling
The sampling strategy will be based on networks via associations working in the Seine-Saint-Denis area, in particular the Maison Martine Midy and the association les fleurs d'Aurore. These two associations are identified as a priority because of their geographical proximity and their involvement in health promotion projects in the field of nutrition in the territory.
Inclusion criteria:
French-speaking people aged 18 to 65 years, volunteers. Basic socio-demographic data (age, gender, highest level of diploma attained) will be collected, but it is not envisaged to select subjects on the basis of their income or level of diploma.
Given the locations of inclusion, a strong assumption is made about the vulnerability of the audiences.
Non-inclusion criteria:
People under guardianship or people who do not speak French at all.
Procedure
The study will be conducted in two phases.
Phase 1
The first phase of the study will collect the perceptions, understanding and expectations of the participants regarding the Nutri-Score in the form of a focus group. The participants will then be asked to simulate food choices through a replica of a food display. The food choices will be made on the basis of a selection of products representative of the market of processed products sold in France, and from supermarkets, and corresponding to purchases for a meal or a snack. In order to be representative of the choices available in supermarkets, up to one hundred food products will be available. These choices will be made in the absence of any information on the front of the packaging. These choices will be discussed during the group interview.
The qualitative data obtained through the focus group will be transcribed and then processed according to a content analysis.
At the same time, participants will be asked to complete a short quantitative questionnaire on socio-demographic data and health literacy10.
Phase 2 (remote)
Based on the elements collected, a brief educational intervention (30 minutes to 1 hour) on Nutri-Score will be developed and offered to participants.
It will target the following learning objectives (which will be adjusted based on Phase 1):
- Understand how a product's score is obtained
- Use the Nutri-Score in their daily food choices
- Identify the products concerned by the logo
The evaluation of this intervention will be based on quantitative elements collected through short self-questionnaires or completed face-to-face on the feeling of competence and the intention to use, in pre and post educational intervention.
This part will be completed by an experimental approach, by which food choices will be elicited, according to a pre/post experimental design. In order to elicit realistic choices, participants will be given a fixed sum of 5€ at the beginning of the program to make their food choices for one consumption occasion (breakfast or snack). The choices available will be the same as in the previous phase, with products from supermarkets.
In the post phase, the same products will be offered, but this time bearing the Nutri-Score for the entire selection. Participants will be invited to modify their choices if they wish.
The associations between perception, understanding, feeling of competence, intention to use the Nutri-Score and health literacy will be explored using uni- and multi-variable logistic regression analyses.
Expected outcomes
This study will contribute to a better understanding of the nutritional choices of vulnerable populations in Seine-Saint-Denis; to the design of a Nutri-Score educational intervention aimed at people with a low level of health literacy; and to the evaluation of the effects of this intervention on the participants' feeling of competence and intention to use the Nutri-Score.
This study will provide valuable information on the motivations of food choices of people in vulnerable situations and the support measures that can be put in place to enable them to take advantage of them.

Research team

Aurore MARGAT

Maître de conférences en sciences infirmières Docteur en Sciences de l’éducation et de la formation

Nurse by training, I have been practicing since December 2019 as a Lecturer in the Laboratory of Education and Health Promotion (LEPS) UR 3412 of the UFR SMBH.

Activités récentes : The main objective of my research is to clarify the nature of the relationship between health education and health literacy in order to propose intervention models aimed at adapting health education programs to the specific needs of patients with low literacy skills, particularly those who are illiterate. In order to better understand this phenomenon and to design models or experiences that can be modeled, I link a discipline, nursing, a field of practice and study, health pedagogy, and a concept, that of a context of vulnerability. I thus study the learning that people develop to acquire health skills in contexts considered, at first glance, to be unfavorable to learning.

As for teaching, I coordinate or co-coordinate several training programs within the USPN: the 2nd year of the Bachelor of Science for Health (LSPS) health/city track; the DE IPA (emergency and stabilized chronic diseases track); the Master 2 of Public Health, Engineering and Training in Health (IFS) track; the Master 2 of Public Health track for the partnership between the USPN and the Institut de Formation des Cadres de Santé at Picpus (AP-HP).
I am also responsible for several teaching units within the Master of Public Health courses of the LEPS UR 3412 and the RSI Chair, the DE IPA, the Bachelor of Science in Health and Social Sciences, the Bachelor of Science in Health Sciences (2nd and 3rd year) and the APES class.

Publications récentes : Margat, A., & Gagnayre, R. (2021). L’éducation thérapeutique du patient chronique en situation d’illettrisme. Revue Education, Santé, Sociétés, Volume 8, Numéro 1, 41 64. https://doi.org/10.17184/eac.5347

Pétré, B., Servotte, J.-C., Piazza, J., Ghuysen, A., Margat, A., Gagnayre, R., & Leclercq, D. (2020). CEdRIC: Strategy for Patient Education During COVID-19 Triage. Western Journal of Emergency Medicine, 21(6). https://doi.org/10.5811/westjem.2020.7.47907
https://pubmed.ncbi.nlm.nih.gov/33052818/

Buscail, C., Margat, A. (co-first), Petit, S., Gendreau, J., Daval, P., Lombrail, P., Hercberg, S., Latino-Martel, P., Maurice, A., & Julia, C. (2018). Fruits and vegetables at home (FLAM) : A randomized controlled trial of the impact of fruits and vegetables vouchers in children from low-income families in an urban district of France. BMC Public Health, 18(1), 1065. BioMed Central. https://doi.org/10.1186/s12889-018-5908-5
https://pubmed.ncbi.nlm.nih.gov/30153820/

Margat, A., Gagnayre, R., Lombrail, P., Andrade, V. de, & Azogui-Levy, S. (2017). Interventions en littératie en santé et éducation thérapeutique : Une revue de la littérature. Santé Publique, 29(6), 811‑820. https://doi.org/10.3917/spub.176.0811

ORCID Resume Publication 1 Publication 2 Publication 3 Publication 4