Solicitud de envio de manuscrito como artículo científico. / Objetivo. Identificar si la migración interna de mujeres en edad fértil, considerando los flujos migratorios y tiempo de residencia, se asocia con mayor Violencia Física reciente por la Pareja (VFP). Metodología. Diseño transversal analítico secundario a la ENDES 2015 a 2017. La exposición fue Migración Interna Establecida en mujeres de 15 a 49 años, clasificándola en Migrante Rural-Rural, Urbano-Urbano, Urbano-Rural, Rural-Urbano y No Migrante. La variable resultado fue Violencia Física y/o Sexual reciente de pareja. Se utilizo un Modelo Lineal Generalizado de la familia y opción de enlace Log Poisson para estimar la asociación entre flujos de migración y la VFP en forma de PR. Resultados. En comparación con mujeres no migrantes, las mujeres migrantes Rural – Urbano tuvieron 14% más probabilidad de VFP (PRa 1.14 IC95 1.02 a 1.28 p=0.016), mientras la diferencia de probabilidades de VFP en mujeres migrantes Urbano-Rural, Rural-Rural y Urbano-Urbano no fue significativa (PRa 1.16 IC95 0.93 a 1.44 p=0.164, PRa= 0.94 IC95 0.83 a 1.05 p=0.309 y PRa 0.99 IC95 0.86 a 1.14 p=0.961 respectivamente). Residentes post-migración de 5 a 12 y de 13 a 20 años tuvieron 19% y 13% más de probabilidad de VFP que las no migrantes (PRc 1.19 IC95 1.07 a 1.31 p=0.001 y PRc=1.13 IC95 1.01 a 1.28 p=0.031 respectivamente). Conclusión. La migración rural-urbana en mujeres en edad fértil es un factor asociado a mayor probabilidad de VFP en los últimos 12 meses. El tiempo de residencia después de la migración estuvo relacionado a mayor VFP. / Background. In latest decades women internal migration in developing countries increased, mostly related to urbanization process: gender relations and IPV (Intimate Partner Violence) dynamics changed. The aim of this study was to identify whether women internal migration flows were related with recent IPV. Method. Analitical cross-sectional study based on peruvian DHS conducted from 2015 to 2017. The exposure was Intern migration established in women from 15 to 49 years old. The classification was set as Rural-Rural migrant, Urban-Urban migrant, Urban-Rural migrant, Rural-Urban migrant and Non-migrant. The outcome variable was Recent Physical and/or Sexual Intimate Partner Violence report. A generalized linear model of the family and a Log Poisson link option were used in order to estimate the association between migration flows and IPV by means of PR (Prevalence Ratio). Results. In contrast to non-migrant women, Rural-Urban migrant women had 14% higher probabilities of IPV (PRa 1.14 CI95 1.02 a 1.28 p=0.016), meanwhile the probabilities difference of IPV in Urban-Rural migrant women, Rural-Rural migrant women, and Urban-Urban migrant women was not meaningful (PRa 1.16 CI95 0.93 to 1.44 p=0.164, PRa= 0.94 CI95 0.83 a 1.05 p=0.309 and PRa 0.99 CI95 0.86 to 1.14 p=0.961 respectively) Post-migration residents from 5 to 12 years old and from 13 to 20 years old had 19% and 13% more probabilities of IPV than the non-migrants (PRc 1.19 CI95 1.07 to 1.31 p=0.001 and PRc=1.13 CI95 1.01 to 1.28 p=0.031 respectively) Conclusion. During the last 12 months, Rural-Urban migration in women during fertile age is an associated factor to a higher probability of IPV. The residence time after migration was related to a higher IPV. / Tesis

La plupart des immigrants qui arrivent au Canada s’installent d’abord dans les grands centres urbains. Ce phénomène a motivé des études sur la migration secondaire, qui cherchent à comprendre les raisons de cette concentration et les facteurs qui conduisent les immigrants à partir pour d’autres villes. Cependant, la majorité des études utilisent des méthodes quantitatives et peu d’entre elles cherchent à comprendre le point de vue des immigrants, ainsi que le processus d’adaptation vécu le long de cette trajectoire. À l’aide d’entrevues semi-dirigées, cette recherche vise à analyser l’adaptation des immigrants à Montréal et dans les villes d’une région du Québec, dans leurs communautés et dans leur milieu de travail. L’analyse et la présentation des résultats sont basées sur le modèle d’adaptation proposé par Young Yun Kim, qui considère la communication comme un aspect central du processus d’adaptation, résultant d’une interaction dynamique entre l’individu et l’environnement. Les résultats montrent que les immigrants cherchent à améliorer l’expérience d’adaptation tout au long de leur trajectoire. L’adaptation initiale facilite l’adaptation dans la deuxième ville, mais elle crée également de nouvelles attentes, car Montréal n’est pas en mesure de fournir tout ce dont les immigrants attendent. Bien que la présence d’immigrants et de services soit plus importante à Montréal, l’adaptation initiale représente un défi pour la plupart d’entre eux, qui ne connaissent pas les règles locales au début et ne se sentent pas intégrés à la communauté. Le multiculturalisme et le dynamisme économique favorisent toutefois l’insertion et l’adaptation sur le marché du travail. L’adaptation dans la deuxième ville s’avère finalement plus facile pour la plupart, qui font également état d’un plus grand sentiment d’appartenance et d’une meilleure qualité de vie. Cependant, l’intégration professionnelle représente un défi pour ceux qui quittent Montréal sans avoir planifié leur insertion au marché de travail. / Most immigrants who arrive in Canada initially settle in large urban centers. This phenomenon has motivated studies of secondary migration, which seek to understand the reasons for this concentration and the factors that lead immigrants to leave for other cities. However, most studies use quantitative methods, and few seek to understand the perspective of immigrants and the adaptation process experienced along this trajectory. Using semi-structured interviews, this research aims to analyze the adaptation of immigrants in Montreal and in cities in a region of Quebec, in their communities and in their workplaces. The analysis and presentation of the results are based on the adaptation model proposed by Young Yun Kim, who considers communication as a central aspect of the adaptation process, resulting from a dynamic interaction between the individual and the environment. The results show that immigrants seek to improve their adaptation experience throughout their trajectory. The adaptation in the first city facilitates adaptation in the second city, but it also creates new expectations, as Montreal is not able to provide everything that immigrants expect. Although there is a greater presence of immigrants and services in Montreal, the initial adaptation is a challenge for most of them, who are not familiar with the local rules at first and do not feel integrated into the community. However, the multiculturalism and economic dynamism of the city make it easier to integrate and adapt to the job market. Adaptation in the second city is ultimately easier for most and they report a greater sense of belonging and a better quality of life. However, professional integration is a challenge for those who leave Montreal without having planned their transition into the regional job market.

La migration interne est la principale forme de migration humaine et est sensible aux changements environnementaux, économiques et politiques. En Afrique de l'Ouest, les pressions environnementales et démographiques entraînent une précarité croissante pour les populations rurales dépendantes de l'agriculture pluviale, qui optent pour la migration temporaire vers les zones urbaines pour diversifier leurs moyens de subsistance. Ceci soulève deux questions : d’une part, il est important d’identifier les facteurs facilitant la migration et donc, la capacité d’adaptation des ménages vulnérables. Par ailleurs, dans les pays en pleine transition démographique, les écarts dans les niveaux de fécondité entre régions rurales et urbaines sont généralement élevés et les migrations entre ces milieux peuvent contribuer à la diffusion et l’homogénéisation de la fécondité. Ceci soulève la seconde question de comprendre si et comment la migration interne, surtout temporaire, s’associe à des changements dans les croyances et préférences de fécondité et de contraception chez les migrants. Malgré la pertinence de ces questions, nous constatons que la migration interne demeure le ‘parent pauvre’ en démographie et dans l’étude plus large des migrations; une position qui ne reflète pas son importance. Ainsi, pour contribuer à nos connaissances sur la migration interne dans le contexte de pays à faible et moyen revenu, cette thèse propose trois articles abordant les deux problématiques précédemment étalées. Pour y répondre, nous accordons une attention particulière au concept de réseaux sociaux; un concept central dans l’étude de la prise de décision de migrer et de la diffusion de la fécondité, mais qui fut mal intégré à l’étude de la migration interne et virtuellement absent du champ d’étude s’intéressant à la fécondité des populations migrantes. Nous utilisons un jumelage inédit de données, croisant les données longitudinales de l’observatoire de population de Niakhar, au Sénégal, à celles du projet Réseaux Sociaux et Santé à Niakhar. Conjointement, ces données permettent une analyse approfondie des trajectoires des migrants, leurs réseaux sociaux, ainsi que leur croyances et préférences de fécondité. Nos études se focalisent sur un seul village situé dans la zone d’étude de l’observatoire de population de Niakhar et s’intéressent aux migrants se dirigeant vers la capitale, Dakar. Dans le premier article, nous profitons des outils descriptifs et multivariés de l’analyse de survie afin d’explorer l’association entre l'exposition à du capital social migratoire dans les réseaux et la probabilité d’une première migration vers Dakar. Nous avons décomposé les réseaux de migrants selon les liens à des migrants de retour, des migrants actuels et des résidents non-migrants de la destination afin de capturer l'hétérogénéité du capital social lié à la migration. Nous testons également l'influence de la force des liens, évaluée subjectivement, et des liens structurellement faibles mesurés par les connexions de second ordre ("ami d'un ami"). Nous arrivons ainsi à revisiter certains des principaux postulats des théories de la causalité cumulative, du capital social (en migration) et de la force des liens. Par exemple, alors que les réseaux sont considérés être moins importants pour la migration interne, surtout dans des contextes où elle est généralisée, cette étude permet de revoir de tels constats en adoptant une définition élargie et plus complète du capital social migratoire, incluant des catégories de liens généralement sous-représentées ou absente dans la littérature empirique : les liens avec des non-migrants au lieu de destination et les liens faibles. Dans le second article, nous avons examiné comment la migration rurale-urbaine s’associe à des différences durables dans les croyances et les préférences en matière de fécondité et de contraception. À l’aide de quelques innovations méthodologiques et conceptuelles, nous avons distingué les effets d’adaptation et de sélection sur la fécondité des migrants temporaires à Dakar à l’aide de modèles de régression, malgré une approche transversale. Ceci fut notamment accompli grâce à l’inclusion d’un groupe de contrôle composé de futurs migrants et l’utilisation comme variables dépendantes de mesures idéationnelles de la fécondité, celle-ci étant moindrement affectées par les facteurs perturbants le calendrier génésique. Nous nous sommes également attardé aux migrants de retour, afin d’évaluer si l’adaptation persiste, une fois que les migrants réintègrent leur communauté d’origine. Enfin, nous avons ajouté une mesure des réseaux sociaux en ville, afin de tester son effet sur l’adaptation. Dans le dernier article, nous adoptons une approche ‘translocale’, mesurant les réseaux sociaux aux lieux de destination et d’origine, pour explorer à l’aide de modèles de régression, leur association avec la fécondité idéationnelle des migrants actuels à Dakar. L’analyse accorde une attention particulière aux liens maintenus avec la communauté du lieu d’origine, leur composition et leur structure, afin d’explorer la socialisation, ou l’influence des valeurs et normes acquises avant la migration, une hypothèse souvent peu approfondie dans l’étude de la fécondité des migrants. Plutôt que de concevoir la socialisation comme l’hypothèse nulle, nous l’identifions comme un phénomène continuant après la migration et s’opérant simultanément à l’adaptation. Dans l’ensemble, nos résultats confirment l’importance du rôle des réseaux sociaux comme déterminants de la migration interne, même dans des contextes où elle est généralisée. La migration semble aussi se placer comme un important vecteur de diffusion de la fécondité, par son influence sur les croyances et préférences des migrants actuels et de retour. Cette association est toutefois modérée par les relations maintenues au lieu d’origine. Plus largement nos résultats soulèvent quelques (re)questionnements théoriques et insistent sur l’importance d’adopter une approche centrée sur les réseaux sociaux multilocalisés dans l’étude de la migration interne. Enfin, nos résultats ont des implications substantielles sur le rôle potentiel des migrations rurales-urbaines dans les transformations sociodémographiques des pays du Sud et mettent en évidence les contradictions qui existent entre certaines politiques visant à limiter les migrations rurales-urbaines et celles voulant réduire la fécondité. / Internal migration is the main form of human migration and is sensitive to environmental, economic, and political changes. In West Africa, environmental stresses and rapid population growth are pressuring rural populations dependent on rain-fed agriculture into diversifying their livelihood strategies; this diversification largely depends on migration to urban areas. This raises two questions: firstly, it is important to identify the factors that facilitate migration and therefore the adaptation of vulnerable households. Secondly, in countries undergoing demographic transition, the gaps in fertility rates between rural and urban areas are generally high, and migrations between these regions can contribute to the diffusion and homogenization of fertility. This raises the second question of whether and how internal migration, especially temporary migration, is associated with changes in fertility and contraceptive beliefs and preferences among migrants. Despite the relevance of these questions, we find that internal migration remains the “stepchild” in demography and in the broader study of migration; a position that does not reflect its importance. Thus, to contribute to our understanding of internal migration in the context of low- and middle-income countries, this thesis proposes three papers addressing the two issues previously discussed. To answer them, we focus on the concept of social networks; a central concept in the study of the determinants of migration and the diffusion of fertility, but which was poorly integrated into the study of internal migration and virtually absent from the study of migrant fertility. We combine longitudinal data from the Niakhar Health and Demographic Surveillance System (NHDSS), in Senegal, with data from the Niakhar Social Networks and Health Project (NSNHP). Together, these data allow for an in-depth analysis of migrant trajectories, their social networks, as well as their fertility and contraceptive beliefs and preferences. Our studies focus on a single village located in the NHDSS study area and exclusively examine migrants to the capital, Dakar. In the first paper, we use descriptive and multivariate tools from survival analysis to explore the association between exposure to migratory social capital in networks and the probability of a first migration to Dakar. Taking advantage of our rich data, we disaggregated migrant networks into ties to returning migrants, current migrants, and non-migrant residents of the destination to capture the heterogeneity of social capital related to migration. We also tested the influence of the strength of ties, subjectively measured, and structurally weak ties measured by second-order connections ("friend of a friend"). We thus revisit some of the main hypotheses of the theories of cumulative causation, social capital (in migration), and strength of ties. For example, while networks are considered to be of lesser importance for internal migration, especially in contexts where it is widespread, this study allows us to reconsider such findings by adopting a broader and more comprehensive definition of migrant social capital, including categories of ties that are generally underrepresented or absent in empirical literature, such as ties to non-migrants at the destination and weak ties. In the second paper, we examined how rural-urban migration is associated with lasting differences in fertility and contraceptive beliefs and preferences. Using methodological and conceptual innovations, we distinguished the effects of adaptation and selection on the fertility of temporary migrants in Dakar through linear regression models, despite using a cross-sectional approach. This was achieved by including a control group consisting of future migrants and using ideational measures of fertility as dependent variables, which are less influenced by factors affecting the fertility calendar. We also focused on returning migrants to evaluate whether adaptation persists after migrants reintegrate into their community of origin. Additionally, we included a measure of urban social networks to test its effect on adaptation. In the last paper, we adopt a 'translocal' approach by measuring networks at both destination and origin to explore the association between social networks and the fertility ideation of current migrants in Dakar. The analysis pays particular attention to ties maintained with the community of origin and their composition and structure to explore socialization, or the influence of values and norms acquired before migration, an often-underexplored hypothesis in the study of migrant fertility. Rather than conceiving of socialization as the null hypothesis, we identify it as a phenomenon that continues after migration and operates simultaneously and interactively with adaptation. Our results confirm the importance of the role of social networks as a determinant of internal migration, even in contexts where it is widespread. Internal migration also appears to be an important vector for the diffusion of fertility, through its influence on the beliefs and preferences of current and returned migrants. However, this association is moderated by the relationships maintained at the place of origin. More broadly, our results raise some theoretical questions and emphasize the importance of adopting a multilocal social networks approach in the study of internal migration. Finally, our results have substantial implications for the potential role of rural-urban migration in sociodemographic transformations in the LMICs, highlighting the contradictions between public policies aiming to limit rural-urban migration and those aiming to reduce fertility.

Diese Dissertation umfasst drei Aufsätzen, die sich mit Erwartungen, Entscheidungen und deren Rückwirkung auf die Umgebung beschäftigen. Der erste Aufsatz untersucht die Binnenwanderung von Ost- nach Westdeutschland. Dabei wird der Zusammenhang von Variation in ökonomischen Disparitäten zwischen der Ursprungs- und der Zielregion und Bildungsniveau, Alter und Arbeitsmarktstatus der wandernden Bevölkerung untersucht. Mit Hilfe der SOEP Daten von 1993 bis 2011 gelangt die Untersuchung zu dem Ergebnis, dass regionale Disparitäten in Verbindung mit der Selbstselektion der Wandernden stehen. Während die Wandernden im Durchschnitt jünger und besser ausgebildet als die Bleibenden sind, verringert sich dieser Unterschied, wenn die Differentiale in den Arbeitslosenquoten zwischen den Regionen steigen. Im zweiten Aufsatz entwickle ich ein Modell zur Untersuchung von prosozialem Verhalten in Begegnungen mit Fremden. Durch das Abstrahieren von Möglichkeiten der Reputationsbildung oder des Bestraftwerdens, entfallen die wesentlichen strategischen Motive für prosoziales Verhalten. Die Entscheidung prosozial zu Handeln ist dann nicht mehr strategisch vorteilhaft sondern intrinsisch motiviert durch Altruismus und einer Neigung sich an das Verhalten anderer anzupassen. In einem zweiten Schritt untersuche ich, ob die Erkenntnisse des Modells mit dem empirisch beobachteten Verhalten übereinstimmen. Der dritte Aufsatz skizziert eine (mögliche) Verhaltensstruktur und notwendige Bedingungen auf Mikroebene, die zu den beobachteten Verhaltensunterschieden in prosozialem Verhalten zwischen dem ländlichen und städtischen Raum führen. Den Rahmen des hier entwickelten Modells bildet das bekannte Gefangenen Dilemma, das wiederholt mit zufällig zugeordneten Partnern einer großen Gesellschaft gespielt wird. Das Modell bezieht Merkmale ein, die sich häufig in realen Begegnungen wiederfinden: imperfekte Information, freiwillige Teilnahme und eine Neigung sich dem Verhalten anderer anzupassen. / This thesis consists of three essays that analyze choices and beliefs to explore how both lead to adaptive behavior. The first essay examines the positive net migration flow from the eastern to western parts of Germany. The migration decision is substantially based on expectations about future developments. With economic conditions changing substantially over the past 20 years in the eastern part of Germany, the incentives to migrate have also altered, so changing the composition of the east-to-west migrant body. This essay explores variations in economic disparities between the region of origin and region of destination, relating them to changes in the skill level, age and labor force status of the migrant population. Analyzing SOEP data from 1993-2011, the findings suggest that, with falling wage differentials, older migrants are less frequent job-to-job movers and are more likely to be non-working prior to migration. Furthermore, while migrants tend to be younger and better educated than stayers, the group of movers becomes partly less distinct from the group of stayers with respect to the skill and age composition when regional disparities in employment opportunities increase. The second and the third essay of this thesis model the decision making process in social interactions between strangers. In these situations, choices are often affected by beliefs about others behavior. In the second essay of this work, I develop a simple model of prosocial behavior for encounters between strangers. By abstracting from the possibility of reputation building and punishment between anonymous partners, I remove the main strategic motives for prosocial behavior so reducing it to a simple non-strategic decision. The principal motivation to behave prosocially is then intrinsic, based on altruism, with a taste for conforming to the behavior of others. In this way, individual decisions are conditional on the behavior of others. Emerging equilibria will then explain the occurrence of prosocial or cooperative behavior within a given society. In a second step, I analyze whether the model’s predictions are consistent with the empirical evidence on the link between beliefs and prosocial behavior using data on blood donations. The third essay outline a (possible) micro-structure and conditions which lead to the observed urban-rural differences in cooperative behavior using agent-based modeling. The model presented here adapts the familiar framework of a prisoners dilemma which is played repeatedly with randomly matched members of a large population. I introduce features that are often found in real world interactions: imperfect information, voluntary participation and a taste for conforming to majority behavior. In this analysis, peoples beliefs about the level of cooperation in the population and their resulting behavior are determined endogenously. Both are governed principally by the experience that they derive from interactions. I present results of an agentbased simulation in order to study the emerging dynamic relationships, to examine how cooperative behavior evolves over time under different circumstances, and to determine how urban-rural differences in behavior emerge. The factors that give rise to rural-urban differences are heterogeneity in individual loss aversion or risk taking, and limited migration possibilities between rural and urban areas.

INTRODUÇÃO: A hanseníase é uma doença infecciosa crônica granulomatosa, cujo agente etiológico é uma bactéria de vida intracelular obrigatória, o Mycobacterium leprae, que tem no homem seu principal reservatório. A doença possui distribuição universal, predominando atualmente, em latitudes tropicais e tem sido enquadrada entre as enfermidades negligenciadas, atingindo desproporcionalmente populações pobres e marginalizadas. O bacilo é altamente contagioso, de baixa patogenicidade e acomete primordialmente pele e nervos, com grande potencial incapacitante. A doença grassou no Velho Mundo durante a Idade Média e praticamente desapareceu da Europa ainda no início do século XX, antes que qualquer recurso terapêutico eficaz estivesse disponível. Introduzida com os primeiros colonizadores europeus, a hanseníase é doença endêmica no Brasil e um problema de saúde pública. A hanseníase é hiperendêmica em muitos municípios, notadamente nos estados das regiões Norte e Centro-Oeste, que abrangem biomas de cerrado, pântano e floresta amazônica, em vastas áreas de baixa densidade demográfica; estas áreas vêm sofrendo enorme pressão antrópica relacionada ao incremento de atividades agropecuárias e extrativistas, gerando preocupações em relação ao impacto ambiental sobre a saúde humana, decorrente de transformações na dinâmica territorial. OBJETIVO: O propósito desta pesquisa foi conhecer o efeito ecológico de fatores sociodemográficos na delimitação de espaços endêmicos de hanseníase e gerar hipóteses sobre a relação entre a constituição do território e a exposição ambiental ao agente biológico da doença. MATERIAL E MÉTODOS: Supondo que a variação dos fatores de risco para contrair hanseníase pudesse ser maior entre grupos populacionais do que entre indivíduos, foi empreendido um estudo epidemiológico de delineamento ecológico do tipo grupo múltiplo, envolvendo 203 municípios dos estados do Mato Grosso e Mato Grosso do Sul, que estão localizados na região Centro-Oeste do Brasil. Foram constituídas variáveis sociodemográficas de exposição e a variável de efeito foi representada pela taxa de detecção média anual de hanseníase entre os anos de 2000 e 2006. Foram aproveitados dados secundários provenientes do Instituto Brasileiro de Geografia e Estatística e do Ministério da Saúde. Para compor um modelo multivariado, 14 variáveis foram analisadas por regressão linear simples e selecionadas sete variáveis com probabilidade de p < 0,2 para o coeficiente de inclinação da reta de regressão. As variáveis independentes selecionadas foram passo a passo testadas, simultaneamente e analisada a associação da variável dependente, visando o ajuste de um modelo singular da variabilidade da taxa de detecção de hanseníase. RESULTADOS: As variáveis que restaram no modelo após o processo de ajuste foram: Proporção da população moradora em domicílios com seis ou mais pessoas; Proporção da população não natural do estado; e, Cobertura populacional da estratégia de Atenção Saúde da Família. Estas variáveis juntas explicam 24,1% da variação nas taxas de detecção de hanseníase. CONCLUSÕES: Fatores sociodemográficos representam um importante domínio na epidemiologia da doença. A associação positiva do desfecho com a cobertura da estratégia de Atenção Saúde da Família indica que deve haver melhora no acesso ao diagnóstico mediante a implantação de modelos de Atenção Primária à Saúde baseados em racionalidades preventivas. Doentes poderiam ter sua contagiosidade interrompida mais precocemente, uma vez melhorada a capacidade diagnóstica dos serviços de saúde. Como recomendação para melhorar o acesso ao diagnóstico nas áreas endêmicas, a adoção da estratégia de Atenção Saúde da Família deve ser encorajada. Aglomeração domiciliar como variável ecológica foi interpretada como sendo um indicador socioeconômico indireto, mais do que propriamente relacionada às condições de contato. A qualidade da moradia, talvez seja mais importante para controle da endemia, tanto quanto possa vir acompanhada de melhorias gerais no padrão de vida. Reservatórios do M. leprae constituídos por indivíduos que eliminam bacilos cronicamente são os que perpetuam a endemia, embora possam, em tese, serem suplementados por fontes secundárias representadas por portadores transitórios. Fatores ligados à formação da fronteira agrícola e à urbanização brasileira podem ter fomentado a endemia de hanseníase, ao predisporem a renovação de susceptíveis pelas migrações, que modificam a composição populacional quanto à experiência de contato com o bacilo. Migrações poderiam romper os focos de hanseníase que estivessem saturados de indivíduos resistentes ao redistribuir espacialmente a população susceptível, levar infectantes para áreas indenes ou instalar as premissas biológicas e territoriais para tornar o contágio recorrente na população, mesmo que o contingente demográfico proveniente de imigrações não seja predominantemente mais vulnerável à doença. Tecnicização rural e constrições na esfera do trabalho têm movimentado populações que procuram refúgio nas periferias das cidades, caracterizadas por escassa infraestrutura urbana e rápido crescimento demográfico, supostamente continentes de grupos humanos dotados de diferentes perfis de resistência ao M. leprae. O circuito inferior da economia, uma resposta social à escassez de meios de vida e um traço da territorialização brasileira, tem oferecido os predicados espaciais para a persistência da endemia de hanseníase nos bolsões de pobreza urbana, ao gerar uma multiplicidade de contatos em proximidade e alimentar suas relações sociais de uma massa de recém-chegados do campo e da cidade, sua principal e mais abundante variável. Se a geografia estuda as condições de vida sobre a terra, estes resultados sugerem que a topografia médica, para além da descrição dos aspectos demográficos e socioeconômicos dos lugares de surgimento de doenças, pode contribuir em muito ao conhecimento em saúde, ao considerar analisar tais fatores enquanto potenciais condicionantes de endemias / BACKGROUND: Leprosy is a chronic granulomatous infectious disease whose causative agent is an obligate intracellular bacterium of life, Mycobacterium leprae, which has its main reservoir in man. The disease has a worldwide distribution, currently prevailing in tropical latitudes and has been framed between neglected diseases, disproportionately affecting poor and marginalized populations. The bacillus is highly contagious, and low pathogenic primarily affects the skin and nerves, with great potential crippling. The disease raged in the Old World during the Middle Ages and still practically disappeared from Europe in the early twentieth century, before any effective therapeutic resource was available. Introduced with the first European settlers, leprosy is endemic in Brazil and a public health problem. Leprosy is hyperendemic in many cities, especially in the states of North and Midwest, covering biomes savannah, swamp and rainforest, in vast areas of low population density; these areas have suffered huge human pressure related to increased activity agricultural and extractive, generating concerns about the environmental impact on human health, due to dynamic changes in territorial. OBJECTIVE: The purpose of this research was to understand the ecological effect of sociodemographic factors in the delimitation of leprosy-endemic areas and generating concerns about the relationship between the constitution of the territory and environmental exposure to the biological agent of the disease. MATERIAL AND METHODS: Assuming that the variation of the risk factors for contracting leprosy could be higher among population groups than between individuals, an epidemiological study was undertaken to design ecological type group multiple, involving 203 municipalities in the states of Mato Grosso and Mato Grosso do Sul, which are located in the Midwest region of Brazil. Sociodemographic variables were recorded for exposure and effect was variable represented by annual average detection rate of leprosy between 2000 and 2006. We utilized secondary data from the Brazilian Institute of Geography and Statistics and the Ministry of Health to compose a multivariate model, 14 variables were analyzed by linear regression and seven variables selected with probability p<0.2 for the slope coefficient of regression line. The independent variables were tested step by step, and simultaneously analyzed the association of the dependent variable in order to fit a model of the variability of the detection rate of leprosy. The variables that remained in the model after adjustment process were: \"Proportion of population living in households with six or more people,\" \"Proportion of population unnatural state,\" and \"Coverage of Population Health Care Strategy Family \". These variables together explain 24.1% of the variation in detection rates of leprosy. CONCLUSIONS: Sociodemographic factors represent an important area in the epidemiology of the disease. The positive association with the outcome of the strategic coverage of Family Health Care indicates that there must be improved access to diagnosis by implementing models of primary care-based preventive rationales. Patients could have their contagiousness interrupted earlier, once improved the diagnostic capacity of health services. As a recommendation to improve access to diagnosis in endemic areas, the adoption of the strategy of the Family Health Care should be encouraged. Household crowding as ecological variable was interpreted as an indirect socioeconomic indicator, rather than strictly related to contact conditions. The quality of housing, perhaps most important for disease control, as far as can be accompanied by general improvements in living standards. Reservoirs of M. leprae consist of individuals who are chronically eliminate bacilli that perpetuate endemic, although, in theory, be supplemented by secondary sources represented by transient carriers. Factors related to the formation of the agricultural frontier and the Brazilian urbanization may have fostered endemic leprosy, predispose to the renewal of the likely migration, which modify the composition of the population as to the experience of contact with the bacillus. Migration could break outbreaks of leprosy that were saturated with individuals resistant to spatially redistribute the population likely lead to infective areas unaffected or install the territorial and biological assumptions to make the recurring infection in the population, even though the population from immigration quota is not predominantly more vulnerable to disease. Technicisation rural and constrictions in the sphere of labor are busy people seeking refuge on the outskirts of cities, characterized by poor urban infrastructure and rapid population growth, supposedly continents groups of humans with different resistance profiles to M. leprae. The lower circuit of the economy, a social response to the scarcity of livelihood and a dash of Brazilian territorialization, has offered the spatial predicates for the persistence of endemic leprosy in pockets of urban poverty, to generate a plurality of contacts in proximity and feed their social relationships from a mass of newcomers from the countryside and the city, its main and most abundant variable. If geography studies the conditions of life on earth, these results suggest that medical topography, beyond the description of the demographic and socioeconomic aspects of the places outbreaks of diseases, can contribute greatly to health knowledge, to consider examining such factors as potential determinants of diseases

INTRODUÇÃO: A hanseníase é uma doença infecciosa crônica granulomatosa, cujo agente etiológico é uma bactéria de vida intracelular obrigatória, o Mycobacterium leprae, que tem no homem seu principal reservatório. A doença possui distribuição universal, predominando atualmente, em latitudes tropicais e tem sido enquadrada entre as enfermidades negligenciadas, atingindo desproporcionalmente populações pobres e marginalizadas. O bacilo é altamente contagioso, de baixa patogenicidade e acomete primordialmente pele e nervos, com grande potencial incapacitante. A doença grassou no Velho Mundo durante a Idade Média e praticamente desapareceu da Europa ainda no início do século XX, antes que qualquer recurso terapêutico eficaz estivesse disponível. Introduzida com os primeiros colonizadores europeus, a hanseníase é doença endêmica no Brasil e um problema de saúde pública. A hanseníase é hiperendêmica em muitos municípios, notadamente nos estados das regiões Norte e Centro-Oeste, que abrangem biomas de cerrado, pântano e floresta amazônica, em vastas áreas de baixa densidade demográfica; estas áreas vêm sofrendo enorme pressão antrópica relacionada ao incremento de atividades agropecuárias e extrativistas, gerando preocupações em relação ao impacto ambiental sobre a saúde humana, decorrente de transformações na dinâmica territorial. OBJETIVO: O propósito desta pesquisa foi conhecer o efeito ecológico de fatores sociodemográficos na delimitação de espaços endêmicos de hanseníase e gerar hipóteses sobre a relação entre a constituição do território e a exposição ambiental ao agente biológico da doença. MATERIAL E MÉTODOS: Supondo que a variação dos fatores de risco para contrair hanseníase pudesse ser maior entre grupos populacionais do que entre indivíduos, foi empreendido um estudo epidemiológico de delineamento ecológico do tipo grupo múltiplo, envolvendo 203 municípios dos estados do Mato Grosso e Mato Grosso do Sul, que estão localizados na região Centro-Oeste do Brasil. Foram constituídas variáveis sociodemográficas de exposição e a variável de efeito foi representada pela taxa de detecção média anual de hanseníase entre os anos de 2000 e 2006. Foram aproveitados dados secundários provenientes do Instituto Brasileiro de Geografia e Estatística e do Ministério da Saúde. Para compor um modelo multivariado, 14 variáveis foram analisadas por regressão linear simples e selecionadas sete variáveis com probabilidade de p < 0,2 para o coeficiente de inclinação da reta de regressão. As variáveis independentes selecionadas foram passo a passo testadas, simultaneamente e analisada a associação da variável dependente, visando o ajuste de um modelo singular da variabilidade da taxa de detecção de hanseníase. RESULTADOS: As variáveis que restaram no modelo após o processo de ajuste foram: Proporção da população moradora em domicílios com seis ou mais pessoas; Proporção da população não natural do estado; e, Cobertura populacional da estratégia de Atenção Saúde da Família. Estas variáveis juntas explicam 24,1% da variação nas taxas de detecção de hanseníase. CONCLUSÕES: Fatores sociodemográficos representam um importante domínio na epidemiologia da doença. A associação positiva do desfecho com a cobertura da estratégia de Atenção Saúde da Família indica que deve haver melhora no acesso ao diagnóstico mediante a implantação de modelos de Atenção Primária à Saúde baseados em racionalidades preventivas. Doentes poderiam ter sua contagiosidade interrompida mais precocemente, uma vez melhorada a capacidade diagnóstica dos serviços de saúde. Como recomendação para melhorar o acesso ao diagnóstico nas áreas endêmicas, a adoção da estratégia de Atenção Saúde da Família deve ser encorajada. Aglomeração domiciliar como variável ecológica foi interpretada como sendo um indicador socioeconômico indireto, mais do que propriamente relacionada às condições de contato. A qualidade da moradia, talvez seja mais importante para controle da endemia, tanto quanto possa vir acompanhada de melhorias gerais no padrão de vida. Reservatórios do M. leprae constituídos por indivíduos que eliminam bacilos cronicamente são os que perpetuam a endemia, embora possam, em tese, serem suplementados por fontes secundárias representadas por portadores transitórios. Fatores ligados à formação da fronteira agrícola e à urbanização brasileira podem ter fomentado a endemia de hanseníase, ao predisporem a renovação de susceptíveis pelas migrações, que modificam a composição populacional quanto à experiência de contato com o bacilo. Migrações poderiam romper os focos de hanseníase que estivessem saturados de indivíduos resistentes ao redistribuir espacialmente a população susceptível, levar infectantes para áreas indenes ou instalar as premissas biológicas e territoriais para tornar o contágio recorrente na população, mesmo que o contingente demográfico proveniente de imigrações não seja predominantemente mais vulnerável à doença. Tecnicização rural e constrições na esfera do trabalho têm movimentado populações que procuram refúgio nas periferias das cidades, caracterizadas por escassa infraestrutura urbana e rápido crescimento demográfico, supostamente continentes de grupos humanos dotados de diferentes perfis de resistência ao M. leprae. O circuito inferior da economia, uma resposta social à escassez de meios de vida e um traço da territorialização brasileira, tem oferecido os predicados espaciais para a persistência da endemia de hanseníase nos bolsões de pobreza urbana, ao gerar uma multiplicidade de contatos em proximidade e alimentar suas relações sociais de uma massa de recém-chegados do campo e da cidade, sua principal e mais abundante variável. Se a geografia estuda as condições de vida sobre a terra, estes resultados sugerem que a topografia médica, para além da descrição dos aspectos demográficos e socioeconômicos dos lugares de surgimento de doenças, pode contribuir em muito ao conhecimento em saúde, ao considerar analisar tais fatores enquanto potenciais condicionantes de endemias / BACKGROUND: Leprosy is a chronic granulomatous infectious disease whose causative agent is an obligate intracellular bacterium of life, Mycobacterium leprae, which has its main reservoir in man. The disease has a worldwide distribution, currently prevailing in tropical latitudes and has been framed between neglected diseases, disproportionately affecting poor and marginalized populations. The bacillus is highly contagious, and low pathogenic primarily affects the skin and nerves, with great potential crippling. The disease raged in the Old World during the Middle Ages and still practically disappeared from Europe in the early twentieth century, before any effective therapeutic resource was available. Introduced with the first European settlers, leprosy is endemic in Brazil and a public health problem. Leprosy is hyperendemic in many cities, especially in the states of North and Midwest, covering biomes savannah, swamp and rainforest, in vast areas of low population density; these areas have suffered huge human pressure related to increased activity agricultural and extractive, generating concerns about the environmental impact on human health, due to dynamic changes in territorial. OBJECTIVE: The purpose of this research was to understand the ecological effect of sociodemographic factors in the delimitation of leprosy-endemic areas and generating concerns about the relationship between the constitution of the territory and environmental exposure to the biological agent of the disease. MATERIAL AND METHODS: Assuming that the variation of the risk factors for contracting leprosy could be higher among population groups than between individuals, an epidemiological study was undertaken to design ecological type group multiple, involving 203 municipalities in the states of Mato Grosso and Mato Grosso do Sul, which are located in the Midwest region of Brazil. Sociodemographic variables were recorded for exposure and effect was variable represented by annual average detection rate of leprosy between 2000 and 2006. We utilized secondary data from the Brazilian Institute of Geography and Statistics and the Ministry of Health to compose a multivariate model, 14 variables were analyzed by linear regression and seven variables selected with probability p<0.2 for the slope coefficient of regression line. The independent variables were tested step by step, and simultaneously analyzed the association of the dependent variable in order to fit a model of the variability of the detection rate of leprosy. The variables that remained in the model after adjustment process were: \"Proportion of population living in households with six or more people,\" \"Proportion of population unnatural state,\" and \"Coverage of Population Health Care Strategy Family \". These variables together explain 24.1% of the variation in detection rates of leprosy. CONCLUSIONS: Sociodemographic factors represent an important area in the epidemiology of the disease. The positive association with the outcome of the strategic coverage of Family Health Care indicates that there must be improved access to diagnosis by implementing models of primary care-based preventive rationales. Patients could have their contagiousness interrupted earlier, once improved the diagnostic capacity of health services. As a recommendation to improve access to diagnosis in endemic areas, the adoption of the strategy of the Family Health Care should be encouraged. Household crowding as ecological variable was interpreted as an indirect socioeconomic indicator, rather than strictly related to contact conditions. The quality of housing, perhaps most important for disease control, as far as can be accompanied by general improvements in living standards. Reservoirs of M. leprae consist of individuals who are chronically eliminate bacilli that perpetuate endemic, although, in theory, be supplemented by secondary sources represented by transient carriers. Factors related to the formation of the agricultural frontier and the Brazilian urbanization may have fostered endemic leprosy, predispose to the renewal of the likely migration, which modify the composition of the population as to the experience of contact with the bacillus. Migration could break outbreaks of leprosy that were saturated with individuals resistant to spatially redistribute the population likely lead to infective areas unaffected or install the territorial and biological assumptions to make the recurring infection in the population, even though the population from immigration quota is not predominantly more vulnerable to disease. Technicisation rural and constrictions in the sphere of labor are busy people seeking refuge on the outskirts of cities, characterized by poor urban infrastructure and rapid population growth, supposedly continents groups of humans with different resistance profiles to M. leprae. The lower circuit of the economy, a social response to the scarcity of livelihood and a dash of Brazilian territorialization, has offered the spatial predicates for the persistence of endemic leprosy in pockets of urban poverty, to generate a plurality of contacts in proximity and feed their social relationships from a mass of newcomers from the countryside and the city, its main and most abundant variable. If geography studies the conditions of life on earth, these results suggest that medical topography, beyond the description of the demographic and socioeconomic aspects of the places outbreaks of diseases, can contribute greatly to health knowledge, to consider examining such factors as potential determinants of diseases