Rebecca Dahm
email: rebecca.dahm@univ-tlse2.fr

Can pluralistic approaches based upon unknown languages enhance learner engagement and lead to active social inclusion?

Keywords: social inclusion, language learning, Pluralistic Approaches based upon Unknown Languages (PAUL), learning strategies, action research

Can pluralistic approaches based upon unknown languages enhance learner engagement and lead to active social inclusion?

Résumé

Migrants et langue d'instruction : la déficience des politiques européennes stimule-t-elle l'innovation dans l'inclusion sociale ? L'apprentissage linguistique est depuis longtemps considéré comme un outil décisif pour atteindre les cibles de l'Union européenne (UE) en termes d'inclusion sociale. Cependant, les instruments stratégiques classiques tels que le plan d'action sur l'apprentissage des langues et la diversité linguistique ou la Charte européenne des langues régionales ou minoritaires ont été minés ces dernières années par les répercussions de la crise financière mondiale. Celle-ci a contribué à la décimation généralisée des budgets sociaux dans un grand nombre d'États membres de l'UE. Ce phénomène s'est accompagné d'une influence croissante du discours « néolibéral » dans les politiques et pratiques des services sociaux et d'assistance. En conséquence, les gouvernements centraux, régionaux et locaux ont délégué la responsabilité de la prestation des services à des entreprises commerciales, à la société civile et finalement aux citoyens. Parallèlement, les lacunes dans les prestations de service résultant de cette « crise financière » ont ouvert de nouvelles opportunités aux innovateurs sociaux. De nouvelles formes d'organisations se développent aujourd'hui et appliquent de nouvelles approches qui exploitent l'apprentissage des langues pour dispenser des services innovants. Ceux-ci visent entre autres à favoriser

Introduction

Formal schooling in Europe has often been criticised for its monolingual habitus, even though recent changes in paradigm have been observed. Brigitta Busch contends that: languages and varieties are no longer seen as clear-cut bordered units, but rather conceived as a bundle of communicative means, shaped by specific practices and ideologies, which speakers draw on in situated interactions (Busch 2011, p. 544).

Busch is referring to the trend launched by, among others, the Council of Europe and its Common European framework of reference for languages (CoE 2001), which aims to develop not only linguistic competence but also plurilingual and pluricultural competence among European citizens. Therefore, language teaching and learning is considered to be an "interaction process in which learners draw on all available linguistic resources" [START_REF] Cathomas | Auf dem Weg zu einer intergralen (Mehr-)Sprachendidaktik [On the way to integral (multi)language didactics[END_REF]Carigiet 2006, cited by Busch 2011, p. 544). Teachers are encouraged to valorise the different language repertoires of all learners in order to help them develop their multilingual 1 competence which is considered to present positive cognitive aspects. Indeed, research over the past thirty years has confirmed the advantages related to bi/multilingualism. Ellen [START_REF] Bialystok | Words as things: Development of word concept by bilingual children[END_REF] was able to demonstrate cognitive advantages which can be ascribed to bilingualism such as the increased ability of bilingual children to solve problems. Bialystok (ibid.) describes metalinguistic skills as strategies which are applied, either consciously or automatically, to a linguistic message and allow one to think about language and to control language processing within a communicative culture. 1 The Council of Europe favours the use of the term "plurilingual", which refers to an individual's language repertoire, whereas "multilingual" is used to describe the range or the co-existence of different languages in a given society. However, the institutions of the European Union as well as many researchers, for more pragmatic reasons tend to use the term "multilingual" to cover both aspects, In this article, I have opted for the latter usage.

Four years later, Jim Cummins stressed the "interdependence of first-and secondlanguage proficiency in bilingual children" [START_REF] Cummins | Interdependence of first-and second-language proficiency in bilingual children[END_REF] in his theory of Common Underlying Proficiency (CUP). He found that the use of two or more languages develops metalinguistic skills which can be regarded as a comprehensive monitoring system related to all languages known by one multilingual speaker. Further research [START_REF] Bono | Quand je parle en langue étrangère, je parle anglais[END_REF][START_REF] Cenoz | Cross-linguistic influence in third language acquisition[END_REF][START_REF] Clyne | Dynamics of language contact[END_REF][START_REF] Ringbom | Cross-linguistic similarity in foreign language learning[END_REF]) has underlined that these advantages are related to the heightened ability of multilinguals to reflect upon languages belonging to their multilingual repertoire. First, Laurent [START_REF] Gajo | Immersion, bilinguisme et interaction en classe [Immersion, bilingualism and classroom interaction[END_REF], and then Philip Herdina and Ulrike Jessner (2002) determined the nature of this strategic advantage as being metalinguistic.

Despite the wide range of literature on the subject, bi/multilingual learners enrolled in French schools, especially those who have minority languages in their language repertoire, are rarely appreciated for their additional skills. Their non-French language(s) is/are not mentioned, and connections between languages are rarely made. Neither students nor teachers seem to be aware of existing research on the topic, and in cases where the teachers do know there might be a strategic advantage to multilingualism, they do not know how to help their students either develop this ability [START_REF] Dahm | Effets de l'introduction d'une approche plurielle fondée sur des langues inconnues sur le système didactique[END_REF] nor do they resort to using it in a positive way. That is why, instead of running a campaign to inform students or teachers about the advantages of multilingualism, I considered it more promising to raise their multilingual awareness, building upon their own experience. Prompting students to develop a curiosity for languages seemed likely to help them open up to the unknown, and therefore to others; and valorising the linguistic capital of multilingual learners (MLL) from an immigrant background was thought to have the potential of contributing to their personal development.

Both elements are crucial for social inclusion.

I therefore set up a small-scale study 2 including action research, during which nine volunteer teachers took part in the development of didactic tools and reflected upon the impact on their students. Five of the teachers taught English as a foreign language in 5° (seventh year of schooling) and the other four taught in 3° (ninth year of schooling) 3 My analysis, however, was only based on the results of the sessions held with the Year 7 students (n=136) aged 12-13 in the Limousin and Aquitaine regions (France). The small-scale study discussed in this article was not about teaching a language, but about helping students become aware of their metalinguistic skills. For the purposes of the study and within the context of 2 The design of the small-scale study is explained in more detail in the methodology section of this article. 3 In France, children start primary school (which lasts five years; from CP to CM2) at age 6. They proceed to lower secondary school (four years, from 6° to 3°) at age 11, and to upper secondary school (three years from 2nde to Terminale) at age 15, finishing at age 18.

their English lessons, the students were confronted with three unknown languages: Dutch, Italian and Finnish once a month, for the duration of one school year. None of their five teachers spoke the languages the sessions were about, so they were in the same position as their students. The instructional strategy, labelled "Pluralistic Approaches based upon Unknown Languages" (PAUL)4 was designed to make the students first try and understand a text in an unknown language (metasemantic tasks), then try and make up sentences in this language (metasyntactic tasks) and finally find ways to pronounce the language (metaphonological tasks).

Multilingual learners who are confronted on a daily basis with additional languages (not necessarily taught at school) unconsciously develop certain learning strategies (i.e. comparison, inferencing, deduction) when decoding and trying to use a new language. In order to explore whether the "quasi monolingual" population,5 whose daily experience did not include authentic multilingual situations, would be able develop such cognitive advantages, I grouped multilingual students separately from quasi monolinguals. Moreover, to prevent the involvement of any kind of preconceptions in the problem-solving tasks, none of the students were told which languages they would be working on. The expectation was that the combination of these two conditions (separation and non-disclosure) would evoke an attitude of curiosity and help to develop the students' self-esteem [START_REF] Dahm | Les « Approches Plurielles fondées sur des Langues Inconnues » ou comment valoriser la dimension affective de l'enseignement des langues[END_REF]). Out of this set-up, the following research questions then emerged:

(1) Do Pluralistic Approaches based upon Unknown Languages (PAUL) enhance learner engagement? (2) If so, can learner engagement improve learning outcomes, thus fostering a positive attitude towards "foreignness" and eventually facilitate social inclusion?

To examine these research questions, the research team got students engaged in nine PAUL sessions, three for each language. Michel [START_REF] Candelier | Approches plurielles, didactiques du plurilinguisme : le même et l'autre [Pluralistic approaches, didactics of plurilingualism: The same and the other[END_REF] defines pluralistic approaches as didactic approaches which use teaching/learning activities involving several varieties of languages or cultures. However, PAUL sessions take this one step further as they are conducted in a systematic and regular way, thus enabling both near and far transfer of learning 6 as well as providing comparable results (one session per month, over an entire school year). As noted before, students were confronted with a succession of metasemantic, metasyntactic and metaphonological tasks for each unknown language. To solve the problems they were presented with, they needed to build upon their prior knowledge of different linguistic systems, which for the quasi monolinguals would be their first language (L1),

French, and their school subject and second language (L2) English.

Taking into account the entire instructional approach, this article endeavours to assess the level of cognitive engagement PAUL sessions can elicit, analyse the effects of engagement on learning outcomes (for the quasi monolinguals in particular) and explore the potential of these to prepare the ground for active inclusion of learners from a migrant background.

Theoretical background

Before exploring the way PAUL sessions enable students to actively engage in their learning, it is essential to clearly define social inclusion and how learner engagement is considered.

After that, I will examine the importance of group work and its possible effects on social inclusion and then proceed to presenting the methodology of the small-scale study under discussion in this paper.

What is inclusion, and what is social inclusion through language learning?

Inclusion, in a general sense, is being part of a group. In social inclusion, this group is a society or a community. Language learning is often seen as a means to bridge the gap between communities. Indeed, the European Union policy agenda emphasises the value of mother-tongue and bilingual education, which can lead to social inclusion through language learning. As Barry van Driel, Merike Darmody and Jenniver Kerzil state:

Research findings also show immigrant languages tend to be least recognised, protected and/or promoted compared to other types of languages (e.g. national, foreign, regional languages) despite positive recognition in EU policy agenda (Extra and Yagmur 2012). This may be detrimental to the academic success of minority language students and negatively impact their self-esteem and sense of 6 Near transfer of learning refers to the ability of using skills learned during one particular situation for tackling another very similar situation. Far transfer of learning refers to the ability to apply such skills in an entirely different situation.

belonging. The evidence shows that recognition of the value and importance of migrants' linguistic heritage is critically important (Van Driel et al. 2016, p. 46). Research into social inclusion makes us become aware of the importance of identity. One of the ways for the European Union to enhance social inclusion is through lifelong learning.

However, this approach has often been seen as "a philosophy of identity where all humans are supposed to share common goals and motives" (Nordin 2008, p. 5). Richard Edwards, Paul

Armstrong and Nod Miller take this further, declaring:

What we wish to argue is that inclusion is primarily positioned within a philosophy of identity that denies difference. Within this stance inclusion and exclusion are described as binary opposites, in which the latter can be transcended to achieve the former (Edwards et al. 2001, p. 423 Andreas Nordin, who carried out an extensive literature review using the database of the Education Resources Information Center (ERIC), investigated the different approaches of inclusion/exclusion in educational research. He underlines that the stigmatisation of the others as abnormal becomes a powerful technique affecting the process of subjection. By adopting a dichotomist vocabulary using words like normal/abnormal and natural/unnatural, individual behaviour becomes strongly affected; not necessarily in any obvious way but in the way people talk, choose and act as active subjects (Nordin 2008, p. 10).

It therefore seems reasonable to ponder how it might be possible to value difference in a positive way, overcoming the dichotomist vocabulary and enabling people to feel included rather than integrated8 "into the normative group who have already accepted the lifelonglearning narrative" (Lindblad 2005, p. 44). This is one of the goals of PAUL sessions, since students participating in these not only learn to collaboratively build upon one another's knowledge; they are also enabled to overcome preconceived ideas about unknown languages, or the unknown/"foreignness" in general. However, to do so, they need to really engage in their learning.

How do students engage in learning?

Researchers have defined engagement in many different ways, but generally speaking, engagement refers to "the extent of a student's active involvement in a learning activity", as stated by James [START_REF] Wellborn | Engaged and disaffected action: The conceptualization and measurement of motivation in the academic domain[END_REF]. However, it is possible to consider engagement from different viewpoints, in terms of whether it is seen from a motivational, a behavioural or an emotional perspective. As Michelene Chi and Ruth Wylie put it, When engagement is discussed in motivational terms, it tends to mean the precursor attitude or interest in getting involved with the learning materials.

Behavioral engagement refers generally to the notion of participating and addresses large-grained measures, such as how often students attend class or do homework, whereas emotional engagement encompasses measures of positive and negative reactions to teachers, classmates, academics, and so on (Chi and Wylie 2014, p. 219; italics in the original).

Indeed, the distinction between behavioural and emotional engagement is also underlined by Johnmarshall Reeve (2012). However, he, describes four types of engagements: in addition to behavioural and emotional engagement, he also discerns cognitive engagement, which he defines as the "usage of sophisticated rather than superficial learning strategies", and agentic engagement, which refers to the extent to which the learner "tries to enrich the learning experience rather than just passively receive it as a given" (ibid., p. 150).

Even though PAUL sessions can be analysed according to the full spectrum of learner engagement, this article focuses on cognitive engagement, thus analysing the "overt behaviours that students can undertake and teachers can see" (Chi and Wylie 2014, p. 220).

Chi and Wylie's established taxonomy describing four modes of engagement is known as the Interactive-Constructive-Active-Passive (ICAP) framework. An overview (Table 1) of the ICAP taxonomy (Chi and Wylie 2014) seems helpful to better understand these four modes of engagement, their underlying knowledge-change processes, the expected changes in knowledge as well as the expected cognitive and learning outcomes.

The importance of group work

Group work fosters cohesion: when learners belong to a group in which they do not feel intimidated, they engage more in their learning and dare to take risks (e.g. getting the grammar wrong when they contribute to discussions within the group). Furthermore, allowing students to interact as part of a small group can, as John Dewey already mentioned in 1916 [START_REF] Dewey | Democracy and education. An introduction to the philosophy of education[END_REF][START_REF] Dewey | Democracy and education. An introduction to the philosophy of education[END_REF]), bring out certain capacities of an individual that are stimulated by the association with others. Working in groups provides an opportunity for students to increase the number of their interactions, to explore new ways without being under the teacher's assessing scrutiny, and to share knowledge and expertise.

Rod [START_REF] Ellis | Task-based language learning and teaching[END_REF] argues that group work results in cooperative learning through collaborative dialogue. For Merrill Swain, collaborative dialogue is a "dialogue in which stakeholders undertake problem solving and build up knowledge" (Swain 2000, p. 102). In our study, we were able to trace the cognitive operations carried out by the students by analysing both the results/learning outcomes of each group's work and the operations documented in transcripts of the interactions during the PAUL sessions.

Having established that group work is essential to the achievement of the proposed tasks, it was obvious to the research team that it would be vital to each session. This specificity of PAUL sessions led us to review the didactic situation. Starting out from the pedagogical triangle of Jean [START_REF] Houssaye | Le triangle pédagogique [The educational triangle[END_REF], which links the vertexes Teacher, Learner and Knowledge, we moved on to the pedagogical tetrahedron of Richard [START_REF] Faerber | Le groupe d'apprentissage en formation à distance : ses caractéristiques dans un environnement virtuel [The distance learning learning group: Its characteristics in a virtual environment[END_REF], which links the Teacher, Learner and Knowledge to a fourth vertex, the Group. Though Faerber is referring to distance learning groups, and our sessions were not embedded in a virtual learning environment, this tetrahedron is of great interest, since it introduces the element of the group. Indeed, as part of our study, the group obtained a legitimate status whose existence was confirmed by the students' use of the collective pronoun "we" instead of "I" when they were working on the metalinguistic tasks.

I chose to adapt this tetrahedron using a number of processes defined by [START_REF] Houssaye | Le triangle pédagogique [The educational triangle[END_REF] and [START_REF] Faerber | Le groupe d'apprentissage en formation à distance : ses caractéristiques dans un environnement virtuel [The distance learning learning group: Its characteristics in a virtual environment[END_REF] in order to reflect the specific nature of the teaching situation created by our PAUL strategy (see Figure 1). The adjustments I made to underline the importance of the "group" vertex were as follows:

-PAUL sessions become the mediating knowledge agent. The various processes involved depend on PAUL which is then at the centre of the tetrahedron. The session is more of a tool or a medium than a goal in itself.

-

The PAUL tetrahedron has six core processes, three of which are derived from Houssaye's pedagogical triangle (teaching, learning, training). The other three processes involve the "group" vertex (collaborating, solving, facilitating). The relationship established between the student and the group is a collaborative relationship: both observe the knowledge presented (through the unknown language) and work together to pool their resources. The problem-solving process is made possible by the exchange of ideas, the sharing of distributed knowledge [START_REF] Pea | Distributed intelligence and the growth of virtual learning communities over the global Internet[END_REF]. There is a shift from the "training" process characterising the dual teacher-student relationship to the "facilitating" process, representing the dialogue which takes place between the group and the teacher: his/her role is similar to that of a "facilitator" who guides the group in its reflection rather than that of a teacher trying to train the individual.

Figure 1 Pedagogic tetrahedron representing the didactic situation created in PAUL sessions

The PAUL tetrahedron (Figure 1) puts an emphasis on the group which is most probably one of the essential components of society. Indeed, as the Cambridge Advanced Learner's Dictionary puts it, society is "a large group of people who live together in an organized way, making decisions about how to do things and sharing the work that needs to be done" (McIntosh 2013). Thus, inclusion only seems possible if people work together, sharing ideas and values. Therefore, making students work in groups can be considered as one of the first steps to prepare the ground for social inclusion. Indeed, group work enables an improved behavioural and emotional engagement and increases the cognitive level of engagement. It is only through efficient engagement and social interaction that steps can be taken on the path towards social inclusion.

In the next two sections, I will present first the methodology and then the general results

of our small-scale study regarding the impact of students' active engagement on learning outcomes. The concluding section will explore how these PAUL sessions might be used to improve active social inclusion.

Methodology

The small-scale study under discussion here is part of a larger study which was carried out in the regions of Limousin and Aquitaine (France). It involved five lower secondary school teachers and 136 Year 7 students aged 12 to 13 from five classes at four schools, throughout one full school year. All five teachers also taught same level of English classes, which then became the control group (n=132): they benefited from the same teaching of the subject of English, but did not experience the PAUL sessions. Pre-tests and post-tests evaluating the ability to solve access-to-meaning problems and explaining the implemented strategies were administered to both the sample group and the control group. As mentioned earlier, in order to be able to assess the specific impact of the PAUL sessions on their learning strategies, I decided not to mix multilingual students with quasi monolingual ones. Out of the total sample of 136 students, 88 students were monolingual in their family environment. It was this subsample I was particularly interested in.

In a survey preceding the actual study, I asked students to provide information regarding their language use in the family environment and at school. Thus I was able to single out and observe 88 students who were all native speakers of French and who had only been learning English as a foreign language for four years.

In order to enhance learner engagement and to be able to monitor the implemented learning strategies, I set up 22 groups of 4 students (or "tetrads"). Peer-to-peer explanations of a linguistic feature are said to be beneficial for second language (L2) development [START_REF] Hulstijn | Grammatical errors as a function of processing constraints and explicit knowledge[END_REF]. It was therefore likely that the verbalisation of their understanding of the text in the unknown language would help the students become aware of the learning strategy they resorted to. However, in order to be able to assess the depth of the learning outcome, it was necessary to explore the extent to which the learners' engagement during this dialoguing activity is constructive or truly interactive.

In order to be able to compare the specific impact of PAUL sessions on engagement and learning strategies, we submitted a semantic pre-and post-test to both the control group (n=132) and to our participating sample group (n=88) described above. This "participating sample group" was composed of the 22 tetrads, set up according to various parameters (gender 9 , learner of Latin, other L2, willingness to learn other languages, interest in reflexive practice, own perception of grammar skills, results of pre-test) extracted from both the semantic pre-test and the pre-survey so as to be heterogeneous, yet of comparable structure.

Finally, a post-study survey was also set up to gather data about their use of strategies outside school. 9 The sample group was composed of 45 girls and 43 boys, and each tetrad was mixed-gender.

The small-scale engagement study discussed in this article is part of a larger study [START_REF] Dahm | Effets de l'introduction d'une approche plurielle fondée sur des langues inconnues sur le système didactique[END_REF] based on PAUL sessions, designed to confront students successively with three unknown languages, namely Dutch (NL; chosen because of its typological proximity to English); Italian (It; close to French) and Finnish (Finn), an agglutinative language, which presents no immediate similarity with any Indo-European language the students might know.

All sessions followed the same model to provide a certain systematicity in their regular exercise and to allow comparison of the results. They took place on a monthly basis. For each language, the set-up of the larger study included three successive sessions (S1-S3) of linguistic problem-solving tasks: (1) understanding the text (metasemantic tasks); (2) creating new sentences (metasyntactic tasks); and finally (3) trying to pronounce the unknown language (metaphonological tasks). As the nine sessions were spread across a school year, there was a gap of a month between each of the sessions. With the languages being treated one after the other (session 1 for e.g. Italian was held 3 months after session 1 for Dutch), it would be difficult for the students to simply remember and apply the skills learned during the first session. Therefore, it seemed likely that any heightened ability to solve linguistic problems would be related to a transfer of metalinguistic strategies.

This article focuses on the results of the metasemantic (session 1) and metasyntactic (session 2) tasks. In the first part of session 1, students were asked to reflect upon those elements of the language at hand which they understood or recognised, underlining the relevant items and writing down their ideas. This learning task was implemented individually, completed on a personal sheet and lasted five minutes. In the second part of session 1, students worked in their tetrad groups to share their findings and better understand the text.

They were asked to fill in an answer sheet collaboratively to explain what they understood and how they managed to understand these elements. In the third part of session 1, the groups' findings were discussed in class. During session 2, students were asked to create new sentences in the language they had explored during the previous session. To do so, they needed to carry out a grammatical analysis to be able to create new sentences as correctly as possible. As the students were conducting a dialogue and co-inferring new meaning and new sentences, they were undertaking the highest level of cognitive engagement.

I believed that comparing the students' individual findings with the group results should make it possible to gauge the extent to which these two modes of engagement (active and interactive) led to different learning outcomes. I began with a quantitative analysis of both the individual and collective worksheets, and then complemented this with a qualitative analysis, to understand exactly how new knowledge is created. In order to analyse the results with NVivo (a nodal analysis tool), I recorded all group discussions and saved them on mp3 recorders, then transcribed them whenever relevant. These qualitative data then enabled me to explore in what way PAUL sessions can lead to enhanced learner engagement.

Results and discussion

Do PAUL sessions enhance learner engagement?

According to Chi and Wylie, the process inherent to the interactive mode of engagement enables students to "co-create new knowledge that neither partner knew" (Chi and Wylie 2014, p. 220), which leads to the deepest understanding. To maximise learner engagement, it seemed plausible that through dialoguing, the students would co-infer new meaning.

However,

Co-inferring processes involve both partners taking turns mutually creating. This mutuality further benefits from opportunities and processes to incorporate feedback, to entertain new ideas, alternative perspectives, new directions, etc. (Chi and Wylie 2014, p. 214).

To be able to describe the overt activities, one cannot simply rely on the instructional design which is set up to have students engage interactively. It is necessary to carry out a qualitative analysis of the interactions going on to verify whether students manage to co-create new knowledge, either during metasemantic or metasyntactic PAUL sessions.

The analysis of the individual sheets10 revealed an affirmative answer rate of 31% for the session on Dutch, 38% for the session on Italian and 46% for the session on Finnish.

However, these answer rates do not take into account the accuracy of the answers; they only reflect the number of elements the students declared having understood. They reached an active level of engagement, since they manipulated (to use Chi and Wylie's term; see Table 1) the new knowledge. They were expected to be able to apply (transfer) the same processes to similar but non-identical situations. I did indeed find an increase in their learning outcome, but it seems difficult to state that this was merely due to their active level of engagement, since each individual reflection was followed by group work. Therefore, a qualitative analysis of the recorded interactions would enable me to check whether students were duly engaged and whether/how the dialogue led to the desired learning goal.

For the purposes of this article, I have chosen two excerpts from the transcriptions of the metasemantic session on Dutch 11 to underline the part played by the group and to analyse the role of the teacher. In Excerpt 1, the relationship established between the teacher and the group is a "facilitating" relationship, representing the dialogue set up between these two vertexes of the tetrahedron during one of the metasemantic PAUL sessions. The female teacher (P1) is helping group members to compare their ideas, creating a strong identity within the group through the negotiation she is encouraging.

Excerpt 1 Partial transcript of Dutch, session 1 (NLS1), group A4

Excerpt 1 reflects that this teacher plays a very limited role: her answers are reduced to the mirror technique and engage the students in a constructive exchange. She lets them compare their ideas so that they reach a consensus. She perfectly complies with the role of the teacher 11 Please report to Appendix 1 for the original text in Dutch.

Speaking turns

Speaker

Mais là ça ressemble parce que là il y a « O-U-D » et là il y a « E-R-S ».

Bt here it's similar because here it says "O-U-D" and there it says "E-R-S" 91 P1 Oui… Yes … as described by Ellis (2003, p. 271): this role can go from observation to intervention when a group has got stuck. However, the degree of intervention should be minimal, so as not to deconstruct the relationship within the group.

For a didactic mediation to be effective, the teacher must guide the student (or group, in our case) in the construction of their own knowledge of the language (Deyrich 2001, p. 143).

It comes down to "guiding" reflection so that students can build their meta-linguistic representation system by themselves. However, often the guidance is too deliberate, as is apparent in Excerpt 2. The exchange in Excerpt 2 is more of a dialogue between teacher and student than among students: P2, a female teacher, tries to guide one of them in his reflection, but the way she proceeds does not really encourage the construction of metalinguistic thought. The students are trying to find answers to please her, but end up randomly giving any kind of unsuitable answer, in an unreflective way. This teacher's "leadership" style [START_REF] Lewin | Patterns of aggressive behavior in experimentally created "social climates[END_REF] seems to be autocratic. As Zoltan Dörnyei and Angi Malderez put it, An authoritarian role, together with highly structured tasks, however, does appear to many teachers as safer and more efficient than leaving the students, to a certain extent, to their own devices -and indeed the [START_REF] Lewin | Patterns of aggressive behavior in experimentally created "social climates[END_REF] study did point to the greater productivity of autocratic groups (Dörnyei and Malderez 1999, p. 166).

Speaking turns

Speaker

Nonetheless, for maximum engagement to take place, it is important that the group vertex, as presented in the adapted version (Figure 1) of Faerber's tetrahedron, functions as an entity in which the students collaborate to solve the problem by themselves, whereas the teacher is merely facilitating the reflection.

It would therefore be interesting to compare the pre-and post-tests to find out whether P2's "autocratic" attitude reflected in Excerpt 2 had modified the effects of PAUL sessions on learning outcomes.

In what way does engagement in PAUL sessions impact learning outcomes?

Learning outcomes in metasemantic PAUL sessions (session 1) can be studied through the use of learning strategies. According to previous research on the strategic use of learning strategies during metasemantic PAUL sessions [START_REF] Dahm | Developing cognitive strategies through pluralistic approaches[END_REF]), it appears that the students mainly resort to comparison and translation strategies, while strategies of inferencing and deduction seem to be more difficult to implement. Comparison is the most frequently used strategy by the greatest number of groups, but the source language depends on a great number of factors (ibid., p. 59).

When comparing the pre-and post-tests, the most marked difference I observed between the results of the participant group and the control group concerned the inferencing strategy. The control group resorted to inferencing by 12%, whereas the participant group used this strategy in 18% of the cases to enhance their understanding of the post-test. However, these results merit further examination. The analysis of the evolution of the results between the pre-and post-test for the participant group showed an important teacher effect. It is remarkable indeed that the increase was 34% for the class of the first teacher, P1 (and about 26% for P4 and P5), while for P2 it was only 4% (and for P3 11%). I have already pointed out the differences in the teachers' attitudes: I described P1 as a "facilitator", while P2 functioned more according to an "autocratic" model. It therefore seems that spontaneous adoption of the inferencing strategies is fostered by group work in which the teacher has a limited role, a condition which leads to true co-inferring.

The effect of group work which leads to maximum engagement is also apparent during the metasyntactic PAUL sessions (session 2). Again, based upon Chi and Wylie's definition, a maximum level of engagement does seem to enable learners to co-create new sentences. To do so, they need to take risks and overcome their wariness of anything new. Here is an example of the risk-taking in the metasyntactic session on Finnish (last language introduced) where students created new sentences, building upon the original ones. To describe the way students created their sentences, I used the following code:

-0 designates the replacement of one element with another, without any real risk-taking.

An example from the Finnish sessions (FinnS2 B7) is: "Rakastatko Internetistä? Soitan Kitaraa?"[Do you love the Internet? I play the guitar?]. The original sentences were: "Rakastatko musiikkia?" "Soitan pianoa". Only the substantive was changed from the original sentence, without any other modification. It is a minimal creation where the group remains in its comfort zone.

-+ designates a change of at least two elements, entailing a more complete manipulation of the sentence. An example from another Finnish session (FinnS2 A1) is: "Lataan kitaraa musiikkia ja pianoa musiikkia. Soitan rap mutta ei soitan kitaraa. Sisareni rakastataa pianoa" [I download guitar music and piano music. I play rap, but I do not play the guitar. My sister love the piano]. The original sentences they built upon were: "Lataan paljon musiikkia Internetistä", "Soitan pianoa. Sisareni Eija ei soita pianoa, mutta hän soittaa kitaraa" [I download music from the Internet. I play the piano. My sister Eija doesn't play the piano, but she plays the guitar] Even if there are some mistakes, a real act of creativity took place: the group tried to set up new sentences building upon their previous observations, and took thoughtful risks.

-Abs means that no sentence was created.

Note

NL=Dutch; S2 = session 2; It = Italian; Finn = Finnish

Figure 2

Risk-taking during metasyntactic PAUL sessions

The results of the analysis speak for themselves (Figure 2): during the Dutch session (NLS2), 45% of the students had not created or not dared to create sentences (column Abs). For the Finnish session (FinnS2), the corresponding Abs result is only 14%. For risk taking (columns 0 and + respectively), Dutch is lowest at 18%/36%, and Finnish highest at 36%/50%. It therefore seems likely that the repetition of activities allowed students to change their attitude towards unknown languages. They "took possession" of the language (one cannot speak of ownership here) which they handled more easily. Similarly, the groups hesitated less and less to mobilise their knowledge or know-how, which also reflects a positive development in attitudes. Since these are three different languages, this shift cannot be attributed to increased language proficiency. It rather underlines the establishment of a strategic advantage (as defined by [START_REF] Herdina | A dynamic model of multilingualism[END_REF], usually specific to multilingual speakers. The distributed knowledge shared among the group led to a maximum level of engagement which enabled them to overcome their wariness of anything new and also enabled them to truly coconstruct new knowledge.

Through these PAUL sessions on languages the students were not studying as a subject, the participants built abstract and unconscious schemata enabling them to solve the problem and thus developed cognitive strategies. Most of these strategies were successfully transferred from one session to another, as students managed to establish connections between different linguistic situations (for more detailed results, see [START_REF] Dahm | Developing cognitive strategies through pluralistic approaches[END_REF].

Finally, some students consciously used the learning strategies they had developed during the PAUL sessions both inside and outside the school context. Indeed, the evaluation of the post-study survey underlines the fact that 35.8% of the students reflected upon other unknown languages by themselves, thus transferring to personal situations the strategies developed during PAUL sessions. Even though the questionnaire responses represent merely declarative "data", the effects of PAUL sessions do seem to exceed expectations since they appear to have changed the cognitive functioning of some students who are now on the lookout for any kind of multilingual situation.

Can learner engagement foster a positive attitude towards "foreignness" and eventually facilitate social inclusion?

A maximum level of engagement can also be achieved when students and teachers work together, co-elaborating new knowledge. However, it seems quite challenging to have a true interaction resulting in the creation of new knowledge none of the partners knew before, when one of them is the teacher and thus supposedly an expert. And yet, two teachers involved in our action research took PAUL sessions to the next level; they decided to explore the way PAUL sessions might contribute to including multilingual learners (MLL) from a migrant background.

Beyond the scope of the large-scale study, teacher P3 decided to try sessions with her three Turkish students and teacher P8 with her two Portuguese students. Once again, none of the teachers knew the languages which the sessions were going to be about. Both teachers met their multilingual students during a free period, and asked them to co-create a text similar to one of the texts that had been worked on during the PAUL sessions. They report having had exciting conversations with their students who had to meet the following requirements, related to the strategies to be implemented to understand the text: the text had to contain cognates12 (some could be repeated) enabling a certain number of comparison strategies, either with French (L1) or with English (L2). Clues allowing the use of inferencing strategies, bottom-up (e.g. capital letters or numbers) and top-down (general knowledge) deduction strategies were also required (see Table 2). The three Turkish students collaborated in creating one Turkish text, and the two Portuguese students created one Portuguese text together, without the presence of the teacher. They then asked their parents for help to ensure the final version of the text was correct.

When the two texts were ready, each teacher presented their MLLs' text to their class in the exact same way as during the previous metasemantic sessions: no announcement of the language, individual work for five minutes, then group work for twenty-five minutes followed by a class synthesis guided by the teacher. Finally, when the nature of the language was revealed, the authors of the text came forward and then read the text so that the other students could hear the language too.

The teachers report having observed a great deal of involvement and pride on the part of the MLLs and a very positive attitude on the part of the remaining students who genuinely took an interest in their classmates' language and pronunciation and wanted to know more about some cultural specificities. The teachers also underline the amount of work this operation required from their MLLs, some of whom had not been schooled in their mother tongue and therefore needed external advice. Despite this, they had volunteered to create such a session. Teacher P3 finally indicates having met the father of one of her MLL students, who was very happy to have been able to talk about the Turkish language with his son and to contribute to the session.

Not all MLL students however managed to create a text. Another student, an MLL speaking Arabic, had initially stated her interest in creating such a session, transcribing Arabic into the Latin alphabet. However, being on her own (no one else had volunteered) and the teacher not being able to help her, she finally abandoned the project.

Conclusion

As has been explored in this article, there is reason to believe that PAUL sessions enable students to increase their engagement in their learning, leading to maximum benefits, be it for the development of learning strategies or for their opening up to unknown languages.

Indeed, since none of the students knew the language they were confronted with (a main feature of PAUL sessions), they truly needed to collaborate in co-creating new knowledge.

This can only take place if the teacher plays the part of the facilitator and lets go of an autocratic (yet reassuring) attitude. But once the group functions efficiently, students actively engage in their learning and overcome their initial fears related to the unknown. They thus develop more challenging learning strategies (inferencing, for instance) which they are able to transfer to the learning of English (L2) or even to other linguistic situations (see [START_REF] Dahm | Developing cognitive strategies through pluralistic approaches[END_REF].

During metasyntactic PAUL sessions, they overcome their initial fears and together take more and more risks to create new sentences, in an efficient way. This is most probably one of the first attitudes which needs to be encouraged if we want students to set up a more tolerant society.

Even though the research design led me to observe multilingual and quasi monolingual students separately, it is likely to be beneficial for both monolingual and multilingual learners to be in mixed groups when discovering an unknown language. Students would most probably be able to benefit from the shared knowledge and might be able to increase further understanding. Asking MLLs to explain how they managed to understand the texts and/or create new sentences would most probably lead to a higher level of metalinguistic knowledge, which in turn might be beneficial to their mastery of the local L1 (in this case, French).

Even though the data we gathered in this study only enable us to underline the effects of PAUL sessions on learner engagement and the enhanced positive attitudes towards foreignness, it seems that setting up further PAUL sessions with students from a migrant background might be a means to bridge the gap between communities. PAUL-experienced students become used to discovering new languages and shed their initial pre-conceived ideas;

once they playfully discover the language of their peers, they want to know more about the other's culture.

Collaborating in order to solve the problems which confronted the group is the first step towards social cohesion. Furthermore, asking MLL students to contribute to the unfolding of such sessions can induce them to apply cognitive strategies, develop their knowledge of their own language and extend their pride by passing it on to their fellow classmates. It seems likely that involving students from a migrant background in setting up such sessions could enhance not only their linguistic abilities but also their feeling of inclusion and, finally, increase social cohesion among learners. However, further research is needed to scientifically explore this aspect.

Rebecca Dahm is a lecturer in language didactics at the University of Toulouse (France) and belongs to the laboratory CLLE-ERSS (CNRS-UMR 5263) researching linguistics, language didactics and psycholinguistics. She is also a teacher trainer at the Teacher training institution (ESPE) of the University of Toulouse-Jean Jaurès. She has been working on the benefits for monolingual learners and teachers of being confronted with artificial multilingual situations and is currently exploring ways to enhance social inclusion of multilingual learners from a migrant background.

Appendix1: Text in Dutch

  ).

7 The six founding organisations are: (1) Istituto per la Ricerca Sociale (IRS) -Italy; (2) Iniciativas Innovadoras S.A.L.(IN) -Spain; (3) Agenzia per l´Orientamento e la Formazione, Istruzione e Lavoro (APOF-IL) -Italy; (4) Université de Bordeaux-LACES -France; (5) Vytautas Magnus University -Lithuania; and (6) Arcola Research LLP -United Kingdom. For more information about the network, see http://www.includenetwork.eu/ [accessed 9 March 2017].

Table 1

 1 Overview Chi and Wylie's taxonomy suggests that engaging students in an interactive mode during which they co-infer knowledge, thus creating new knowledge none of the partners knew before, should lead to the deepest possible understanding.

	Modes of engagement	Descriptors	Knowledge-change processes	Expected changes in knowledge	Expected cognitive outcomes	Learning outcomes
					being able to
	Passive	receiving information	storing information	New knowledge is stored in an way. encapsulated	recall information verbatim in an transfer of context (near identical	minimal understanding
					learning)
					being able to
	Active	manipulating information	integrating information with prior knowledge	Existing schema is more complete, coherent, strengthened. salient, and	apply information to transfer of (extended similar but non-identical situations	shallow understanding
					learning)
				New inferences	being able to
	Constructive	generating new knowledge	inferring new knowledge	create new knowledge beyond what	transfer learned skill to novel context	deep understanding
				was encoded.	or distant

of the Interactive-Constructive-Active-Passive (ICAP) framework by

[START_REF] Chi | The ICAP Framework: Linking cognitive engagement to active learning outcomes[END_REF]

  Kyllä, minä soitan. Soitan pianoa. Sisareni Eija ei soita pianoa, mutta hän soittaa kitaraa. [Yes, I do. I play the piano. My sister Eija doesn't play the piano, but she plays the

	of music from the Internet]
	Päivi: "Soitatko musiikkia?" [Do you play music?]
	Timo: "guitar]
	Entä sisaresi Nina?" [And your sister Nina?]
	Päivi: "Sisareni Nina rakastaa rap-musiikkia. Rakastaako sisaresi Eija myös rap-musiikkia?"
	[My sister Nina likes rap-music. Does your sister Eija like rap-music too?]
	Timo: "Ei, hän ei rakasta." [No, she doesn't.]
	The original text was
	the following:
	Päivi: " Rakastatko musiikkia?" [Do you like music?]
	Timo: "Kyllä, minä rakastan. Lataan paljon musiikkia Internetistä." [Yes, I do. I download a lot

Table 2

 2 Required strategies and indicators to create a text

	Strategies	Comparison	Inferencing	Deduction Bottom-up Top-down
	Indicators	comparison with L1 (French) and/or L2 (English)	relying on several elements of the sentence to understand meaning	relying on capital letters or numbers (= input)	relying on general knowledge (= external input)

  Hello my friend, My name is Anneke and I'm 12. I live with my parents, Marijke and Geert, in Amsterdam. I have a big brother; his name is Hans and he is 20. He lives in Germany because he has a German girlfriend. I have also a younger sister; her name is Sara and she is 8. Write back to me soon and tell me about your family.Kind regards, AnnekeHallo mijn vriend! Mijn naam is Anneke en ik ben 12. Ik woon met mijn ouders, Marijke en Geert, in Amsterdam. Ik heb een grote broer; zijn naam is Hans en hij is 20. Hij woont in Duitsland want hij heeft een Duitse vriendin. Ik heb ook een kleine zuster; haar naam is Sara en zij is 8 jaar oud.Schrijf vlug terug en vertel mij over je familie.

	Beste groeten,
	Anneke
	Translation of Appendix 1

The study was carried out in French. The French term for the instructional design was Approches Plurielles fondées sur des Langues Inconnues (APLI).

For reasons of clarity, I have chosen to label those students "quasi monolingual" who had declared (in a survey preceding the actual study) that they had no contacts in their direct environment with languages other than their first language (L1), French, and the second language (L2), English, they were being being taught as a subject at school. This shortcut, while it only relies upon statements, enables me to distinguish between multilinguals and their non-multilingual peers which is useful for focusing my analysis on the latter. However, participants included both multilingual and non-multilingual students.

It is important to note that there is a difference in these two terms. While inclusion respects and fosters nonmainstream characteristics with the aim of including individuals on their own terms, integration refers to the aim of adjustment to mainstream characteristics.

Students were asked to underline and indicate what they understood, and then to count the number of elements they had managed to understand.

"Cognate languages and words have the same origin, or are related and in some way similar"[START_REF] Mcintosh | Cambridge advanced learner's dictionary (4th edn)[END_REF].

Acknowledgements This article draws on research done in the INCLUDE (EC Erasmus+) project, which is part of the European Commission's lifelong learning programme.


Marie Préau
email: preau@marseille.inserm.fr

PhD Fabienne Marcellin

Bruno Spire

MD Isabelle Ravaux

Bruno Msc

Spire

Pierre Dellamonica

M D Pr

Dominique Blanc

MD Maria Patrizia Carrieri

ANRS-QUALIPEP -Qualitative Study on access to PEP in one French region and acceptability of community-based PEP View project

Keywords: Anger, HIV/HCV coinfection, Interferon, Ribavirin, Quality of life

OBJECTIVE: To study the specific impact of treatments for chronic hepatitis C virus (HCV) infection on anger expression and control in adult patients coinfected with HIV and HCV receiving antiretroviral therapy. DESIGN: In 2005, a cross-sectional survey, collecting both clinical and sociobehavioral data, was conducted in two French clinical centers among adult patients coinfected with HIV and HCV.

METHODS: Participants were asked to answer anonymously a self-administered questionnaire aimed at obtaining sociodemographic, clinical and behavioral characteristics including self-reported treatments' side effects, quality of life (WHOQOL-HIV BREF), and irritability and anger (STAXI-2). Clinical characteristics were obtained from medical records. RESULTS: Among the 139 patients who were receiving antiretroviral therapy at the time of survey and who had complete self-reported data, 24 were being treated for their HCV infection, using either pegylated interferon (pegIFN) and ribavirin (RBV) or pegIFN alone.

Control of anger was significantly lower among treated patients than among untreated ones (STAXI-2 anger control-out dimension median scores of 18.5 versus 23 respectively, P = 0.02). Sociodemographic and clinical characteristics did not differ significantly between these 2 groups. Control of angry feelings was significantly correlated with psychological and social relationship dimensions of quality of life.

CONCLUSION: Treatment of HCV-HIV co-infected patients may require closer monitoring for anger control issues and adjustment of treatment as appropriate.

Impaired anger control as an underappreciated side effect of treatment(s) for chronic HCV infection in HIV-HCV coinfected patients

Introduction

With the dramatic improvement in treating many fatal complications of HIV infection, liver disease as a consequence of viral hepatitis C has emerged as a major cause of morbidity and mortality [START_REF] Tedaldi | Influence of coinfection with hepatitis C virus on morbidity and mortality due to human immunodeficiency virus infection in the era of highly active antiretroviral therapy[END_REF][START_REF]HIV/HCV coinfection cases require special attention. Experts discuss current treatments, concerns[END_REF]. As an estimated 15-30% of HIV infected patients are also infected with hepatitis C virus (HCV) [START_REF] Sherman | Hepatitis C Virus prevalence among patients infected with Human Immunodeficiency Virus: a cross-sectional analysis of the US adult AIDS Clinical Trials Group[END_REF][START_REF] Sulkowski | Perspectives on HIV/hepatitis C virus co-infection, illicit drug use and mental illness[END_REF], HIV-HCV coinfection has become a critical issue because of the interactions between the two viruses [START_REF] Piroth | Does hepatitis C virus co-infection accelerate clinical and immunological evolution of HIV-infected patients?[END_REF][START_REF] Greub | Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study[END_REF] which worsen the clinical course of HCV infection [START_REF] Sanchez-Quijano | Influence of human immunodeficiency virus type 1 infection on the natural course of chronic parenterally acquired hepatitis C[END_REF][START_REF] Soto | Human immunodeficiency virus infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis[END_REF]. Besides, in patients already being treated with antiretrovirals, HCV infection constitutes an additional burden associated with disabling symptoms, such as fatigue, which impair their quality of life (QOL) [START_REF] Kramer | Relative impact of fatigue and subclinical cognitive brain dysfunction on health-related quality of life in chronic hepatitis C infection[END_REF]. Pegylated interferon alpha (PegIFN) therapy in combination with ribavirin (RBV) is the most efficient treatment for HCV infection [START_REF] Soriano | Care of patients with hepatitis C and HIV co-infection[END_REF].

While anxiety and depression have been extensively described as common side effects of interferon therapy, data on the occurrence and management of other neuropsychiatric disorders such as anger remain scarce [START_REF] Constant | Mood alterations during interferon-alfa therapy in patients with chronic hepatitis C: evidence for an overlap between manic/hypomanic and depressive symptoms[END_REF][START_REF] Kraus | Psychiatric symptoms in patients with chronic hepatitis C receiving interferon alfa-2b therapy[END_REF][START_REF] Raison | Depression during pegylated interferon-alpha plus ribavirin therapy: prevalence and prediction[END_REF][START_REF] Nesic | Psychiatric adverse effects induced by recombinant interferon alfa in patients with chronic hepatitis C][END_REF]. However, anger has been identified as an independent predictor of progression to AIDS [START_REF] Leserman | Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors[END_REF] and its prevalence in older HIV-infected patients has been reported [START_REF] Singh | Psychological stress and depression in older patients with intravenous drug use and human immunodeficiency virus infection: implications for intervention[END_REF]. In this context, we aimed at investigating the specific impact of treatment for HCV infection on anger expression and control in adult HIV-HCV coinfected patients receiving antiretroviral therapy.

Patients and methods

In 2005, a cross-sectional survey was conducted among 223 coinfected patients being followed-up in two clinical centers located in the south of France (Nice, Marseilles). Participation in the survey was proposed to all adult HIV-infected patients who were co-infected with HCV virus, as documented by a positive HCV RNA detection test. Patients who agreed to participate were presented a self-administered questionnaire which included items on clinical status and history, sociodemographic characteristics and behavioral data, as well as self-reported side effects of antiretrovirals and QOL (WHO QOL-HIV BREF scale [START_REF]WHOQOL-HIV for quality of life assessment among people living with HIV and AIDS: results from the field test[END_REF]). This scale assesses six dimensions of QOL: physical QOL (bodily pain, sleep, tiredness), psychological QOL (satisfaction with cognitive capacity, self-esteem, self-image, positive and negative feelings), environmental QOL (satisfaction with physical security, home, accessibility and quality of health care, information, transport, pollution, noise, spare-time activities), level of independence QOL (mobility, employment), QOL concerning social relationship aspects (interpersonal relationships, social support, sexual activity, social integration in relation to seropositivity) and spirituality. Patients' irritability and anger were evaluated using the French adaptation of the 57-item State-Trait Anger Expression Inventory-2 (STAXI-2) of Spielberger [START_REF] Spielberger | Manual for the State-Trait Anger Expression Inventory[END_REF], which aims at exploring the different facets of anger simultaneously. This psychometric instrument measures the intensity of anger as an emotional state (State Anger, associated score ranging from 15 to 60) and the disposition to experiencing angry feelings as a personality trait (Trait Anger, associated score ranging from 10 to 40). It also contains a subscale evaluating anger expression and control. According to Spielberger's in-depth analyses concerning the factorial structure of the instrument, this subscale can be divided into four distinct dimensions: expressing anger towards other people or objects in the environment (Anger Expression-Out), holding in angry feelings (Anger Expression-In), controlling angry feelings by preventing the expression of anger towards other people or objects in the environment (Anger Control-Out), and controlling angry feelings by calming down or cooling off (Anger Control-In). Because of the correlations between Anger

Expression-In and Anger Expression-Out on one part, and between Anger Control-In and

Anger Control-Out on the other part, subscale scoring can be done either separately for each dimension (scores range: 8 to 32), or using a global anger expression and control score.

Higher scores denote more anger.

Statistical methods

Characteristics of patients being treated for their HCV infection and those who were not were compared using the Wilcoxon rank-sum test (continuous variables) and Fisher's exact test (categorical variables). Correlations between STAXI-2 and QOL dimensions were explored using Pearson's correlation coefficient. Significance level was fixed at α=0.05. Analyses were performed using SAS ® software version 9.1 for Windows (SAS Institute, Cary, NC, USA)

Results

A total of 223 patients agreed to participate in the survey, of whom 152 (68.2%) answered the self-administered questionnaire (respondents). Reasons most frequently given for nonresponse were lack of interest, desire or time. Respondents were not significantly different from non-respondents in terms of age, sex, HIV clinical status (HIV viral load, CDC stage C), and fibrosis stage 1 (results not shown). In order to isolate the specific effect of HCV treatment on patients' irritability and anger, we focused our analysis on patients already being treated for HIV infection at the time of the survey, as they constituted the majority of respondents (n=139, 91.4%). Characteristics of these patients are presented in Table 1. Most of them were men (64.0%), mean age (standard deviation) was 42.9 (5.4) years and mean time since HCV diagnosis was 10.9 (5.4) years. Seventy-three percent of patients had contracted HCV infection from IV drug abuse. Forty-eight patients were diagnosed with a fibrosis score 1 data on fibrosis stage (biopsy results or FibroTest TM score) were available for half of the patients exceeding F2 (METAVIR) and were therefore treated according to the existing recommendations for HCV treatment. Twenty-four patients were being treated for HCV infection at the time of survey, mainly using a combination therapy of pegIFN and RBV (n=21 patients) and, to a lesser extent, using pegIFN alone (n=3 patients). There was no significant difference between patients being treated for HCV and those who were not with respect to all considered socio-demographic and clinical characteristics, including CES-D global depression score (Table 1). Only one treated patient reported regular alcohol consumption during the previous six months (vs 27 untreated patients, P=0.05). Patients being treated presented significantly lower STAXI-2 scores for Anger Control-Out than those who were not, with median [interquartile range] scores of respectively 18.5 [17.5; 23] and 23 [18; 26] (P = 0.02) (Table 2). Anger Control-Out was positively correlated with three domains of QOL (psychological QOL: r = 0.42, P < 0.0001; social relationships QOL: r = 0.26, P = 0.01; environmental QOL: r = 0.25, P = 0.01).

Discussion

The data presented here suggest that anger control out is associated with pegIFN HCV treatment among patients co-infected with HIV. This result is consistent with literature on anger among HCV mono-infected patients [START_REF] Kraus | Psychiatric symptoms in patients with chronic hepatitis C receiving interferon alfa-2b therapy[END_REF][START_REF] Singh | Psychological stress and depression in older patients with intravenous drug use and human immunodeficiency virus infection: implications for intervention[END_REF][START_REF] Obhrai | Assessment of fatigue and psychologic disturbances in patients with hepatitis C virus infection[END_REF], and provides further information about the association between IFN therapy and neuropsychiatric disorders, as many other studies have focused only on depression. Besides, it underlines the necessity to take into account anger as a characteristic, which can have several implications on the management of HIV and HCV. Indeed, anger has already been shown to be associated with non adherence [START_REF] Kraus | Compliance with therapy in patients with chronic hepatitis C: associations with psychiatric symptoms, interpersonal problems, and mode of acquisition[END_REF] and depressive symptoms [START_REF] Obhrai | Assessment of fatigue and psychologic disturbances in patients with hepatitis C virus infection[END_REF] in the context of HCV infection and has also been shown to impact independently on HIV clinical progression [START_REF] Leserman | Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors[END_REF]. Our study identified an association between anger control-out and psychological and environmental aspects of QOL as well as social relationships. It can therefore be hypothesized that lack of anger control impairs patients' interactions with their close relations or occupational companions and also with their healthcare providers-interactions which have been shown to be of crucial importance in HIVinfected patients' QOL [START_REF] Preau | Healthrelated quality of life and patient-provider relationships in HIV-infected patients during the first three years after starting PI-containing antiretroviral treatment[END_REF]. All of these considerations underline the important role of anger among psychological disorders and difficulties of coinfected patients and highlight the necessity of adequate management of this problem.

It is interesting to note that no difference was detected in our study in terms of depression score between those patients being treated and those not being treated for HCV infection. As HIV-infected drug users are more likely to present depressive symptoms [START_REF] Chander | Substance Abuse and Psychiatric Disorders in HIV-Positive Patients : Epidemiology and Impact on Antiretroviral Therapy[END_REF], this result could be attributed to the fact that many of the study's patients may already have presented a depressive symptomatology, as more than 70% of them were HIV-infected through IDU.

In addition, our results show that anger control is the main characteristic of anger related to QOL and treatment. Again, this may be due to the high prevalence of patients infected through IDU in the study population. Indeed, a previous study indicated that drug users have a high risk of anger (related) hostility symptoms, are more likely to express anger towards other people or objects in the environment, and have less control over their angry feelings [START_REF] Moja | Anger and drug addiction[END_REF].

Besides, a cross sectional study based on data collected in the pre-HAART era in HIVinfected patients had demonstrated that patients HIV-infected through drug injection report more symptoms and higher overall and physical symptom distress than those belonging to other HIV-transmission categories [START_REF] Vogl | Symptom prevalence, characteristics, and distress in AIDS outpatients[END_REF], which can result in exacerbated angry feelings. In addition, these patients may not be adequately treated for their side effects including anger [START_REF] Breitbart | A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse[END_REF]. However, we pointed out a significant difference concerning angry feelings between HCV treated and not treated patients despite well-balanced proportions of former or active drug users in these two groups, which underlines the determinant impact of HCV treatment on anger.

The failure of the study to find differences on anger dimensions other than control-out between those patients being treated for HCV and those who were not may be due to limited statistical power. Besides, the use of a self-administered questionnaire to address anger issues may be limiting, as it does not take into account perceptions of the patients' environment regarding this problem. Therefore, studies including anger assessment of the patient's environment should be conducted for complementary information. Finally, studies among HCV-infected patients not infected by routes other than drug injection need to be developed in order to disentangle the impact of drug use on anger's dimensions.

Conclusion. Findings indicate that routine psychosocial assessment of patient's pattern of

symptoms should be integrated into HCV and HIV services in order to develop programs to reduce anger expression and to increase anger control ability. Indeed, anger behaviors can potentially be changed using group therapy [START_REF] Chan | Effectiveness of the anger-control program in reducing anger expression in patients with schizophrenia[END_REF]. Our results need to be taken into account when individualising treatment strategy in co-infected patients in order to minimise possible side effects and optimize patient's clinical outcomes and quality of life.

Table 1 -Socio-demographic, behavioral and clinical characteristics of HIV/HCV coinfected patients receiving antiretroviral therapy -comparison of those patients treated and those not treated for HCV infection (n=139, cross-sectional survey on HIV/HCV coinfected patients' QOL, France, 2005)

 1

		All patients	Patients treated	Patients not treated	P-value 1
			for HCV infection	for HCV infection
	Number of patients (%)	n=139	n=24	n=115
	Male gender	89 (64.0%)	13	76	0.35
	Mean age (SD) -years	42.9 (5.4)	43.6 (5.4)	42.7 (5.5)	0.73
	Mean time since HIV diagnosis (SD) -years	15.5 (4.4)	15.9 (3.4)	15.5 (4.6)	0.97
	HIV infection transmission category
	-sexual contact	24 (17.3%)	2	22	0.49
	-intravenous drug use	113 (81.3%)	22	91
	-other	2 (1.4%)	0	2
	Mean HIV viral load (SD) -log 10 copies/ml	2.26 (1.06)	1.89 (0.70)	2.34 (1.11)	0.23
	CD4 count -cells/mm 3
	-below 350	54 (39.7%)	13	41	0.14
	-between 350 and 500	31 (22.8%)	6	25
	-above 500	51 (37.5%)	5	46
	Mean duration of HIV treatment (SD) -years	9.4 (3.8)	10.6 (2.7)	9.1 (4.0)	0.09
	Mean time since HCV diagnosis (SD) -years	10.9 (5.4)	11.6 (4.8)	10.7 (5.6)	0.43
	HCV infection transmission category
	-sexual contact	25 (18.0%)	2	23	0.44
	-intravenous drug use	102 (73.4%)	20	82
	-other	12 (8.6%)	2	10
	Fibrosis stage 2
	-0 to 1	29 (37.7%)	7	22	1.00
	-2 to 4	48 (62.3%)	11	37
	Alcohol consumption
	during the previous six months
	-less than two times a week	111 (79.9%)	23	88	0.05
	-at least two times a week	28 (20.1%)	1	27
	Number of glasses consumed per day
	-less than 3 (2 for women)	107 (79.3%)	21	86	0.16
	-at least 3 (2 for women)	28 (20.7%)	2	26

Drug use 3 during the previous four weeks

  Wilcoxon rank-sum test for continuous variables) 2 data on fibrosis stage (biopsy results or FibroTest TM score) are available for half of the patients3 Use of at least one of the following products: cannabis, cocaine, heroin, crack, ecstasy, amphetamins, buprenorphine without medical prescription, LSD or other hallucinogens

	-
	n=121
	-none	95 (78.5%)	14	81	0.08
	-at least one	26 (21.5%)	8	18
	Depression global score (CES-D)
	median [IQR]	18 [11 ; 27]	20 [14 ; 27]	18 [11 ; 27]	0.22
	SD = standard deviation; IQR = interquartile range
	1 comparison of those patients treated and those not treated for HCV infection (Fisher's exact
	test for categorical variables,

Table 2 -State-Trait Anger Expression Inventory-2 (STAXI-2) scores in HIV/HCV coinfected patients receiving antiretroviral therapy: comparison of those patients treated and those not treated for HCV infection (n= 139, cross-sectional feasibility survey for the HEPAVIH project, 2005, French National Agency for AIDS and viral hepatitis Research -ANRS)

 2

		Patients treated	Patients not treated	P-value 1
	median	for HCV infection	for HCV infection
	[interquartile range]	n=24	n=115
	State Anger	[15; 30]	17 [15; 21]	0.07
	n=107
	Trait Anger	20.5 [13; 23.5]	17 [14; 21]	0.27
	n=109
	Anger Expression-Out	16 [11; 18]	14 [13; 17]	0.78
	n=108
	Anger Expression-In	18 [14.5; 21]	18 [15; 21]	0.83
	n=109
	Anger Control-Out	18.5 [17.5; 23]	23 [18; 26]	0.02
	n=110
	Anger Control-In	20 [18; 23]	22 [17.5; 25]	0.47
	n=103

1 nonparametric two-sided Wilcoxon rank-sum test

DÉPIST' HSH La question du recours This research was supported by the charity organisation ECS-SIDACTION (France).