This thesis aims to fill the gaps in the literature of the theory of constraints (TOC) in publicly funded health systems. While TOC seems to be a natural fit for this resource-constrained environment, there are still no reported application of TOC’s drum-buffer-rope tool and inadequate customizations with regards to defining system-wide goal and performance measures. The “Drum-Buffer-Rope for an Outpatient Cancer Facility” chapter is a real world case study exploring the usefulness of TOC’s drum-buffer-rope scheduling technique in a publicly funded outpatient cancer facility. With the use of a discrete event simulation model populated with historical data, the drum-buffer-rope scheduling policy is compared against “high constraint utilization” and “low wait time” scenarios. Drum-buffer-rope proved to be an effective mechanism in balancing the inherent tradeoff between the two performance measures of instances of delayed treatment and average patient wait time. To find the appropriate level of compromise in one performance measure in favor of the other, the linkage of these measures to system-wide performance measures are proposed. In the “Theory of Constraints’ Performance Measures for Publicly Funded Health Systems” chapter, a system dynamics representation of the classical TOC’s system-wide goal and performance measures for publicly traded for-profit companies is developed, which forms the basis for developing a similar model for publicly funded health systems. The model is then expanded to include some of the factors that affect system performance, providing a framework to apply TOC’s process of ongoing improvement in publicly funded health systems. The “Connecting Low-Level Performance Measures to the Goal” chapter attempts to provide a framework to link the low-level performance measures with system-wide performance measures. It is claimed that until such a linkage is adequately established, TOC has not been fully transferred to publicly funded health systems.

Trata-se de pesquisa quali-quantitativa que envolve observação participante, análise de documentos e realização de entrevistas com usuários de um hospital do SUS e um particular. O foco da investigação é o consentimento informado na assistência à saúde, entendido como o processo decisório compartilhado no qual há troca de informações, impressões e valores entre os usuários do serviço e os profissionais de saúde. Objetivou-se verificar sua prática no sistema de saúde brasileiro, com recorte para a área da oncologia. Para a análise estatística, as variáveis categóricas foram avaliadas por meio do teste exato de Fisher e, as variáveis numéricas, comparadas utilizando o teste t, com nível de significância de 5 por cento . Quanto aos termos de consentimento, os testes de Flesch e Flesch-Kincaid apontaram legibilidade inadequada segundo padrões internacionais, bem como diante dos níveis educacionais de fato encontrados nos hospitais. Mais de 70 por cento dos entrevistados do SUS não tinham escolaridade compatível com a exigida para a leitura dos documentos. Apesar de a quase totalidade dos usuários dos hospitais ter relatado satisfação com as informações recebidas sobre o procedimento que iria realizar, apenas 58 por cento souberam elencar ao menos um risco relacionado ao mesmo. Conforme o esperado, houve associação entre nível educacional e renda dos usuários com a compreensão de riscos dos procedimentos. Mesmo que não se tenha notícia da variável renda ter sido considerada em estudos anteriores, por meio de regressão logística múltipla, observou-se que teve peso muito maior do que a escolaridade em predizer a chance de a pessoa citar um dos riscos do procedimento, embora ambos os fatores sejam preditores independentes. Não houve relação entre a compreensão de riscos e se o hospital era SUS ou particular, e nem em relação ao tempo de tratamento. Diferentemente de pesquisas em outros países, tampouco houve associação entre nível educacional e leitura do termo de consentimento. Entretanto, quando foi o médico, dentre os profissionais de saúde, quem entregou o termo, este foi mais lido pelos usuários. Houve associação entre o usuário estar no hospital particular e acreditar que o termo de consentimento serve para proteger os médicos, em contraposição a servir à sua própria garantia. Pela análise qualitativa, os usuários do SUS tiveram maior habilidade que o esperado na compreensão do diagnóstico e histórico da doença. Acredita-se que o bom acolhimento conseguiu superar em parte o nível educacional e de renda que foram detectados como barreiras ao entendimento das informações, de forma que a humanização da saúde parece impactar positivamente na compreensão das informações pelos usuários. Contudo, em ambos os hospitais, apesar de conseguirem relatar bem os procedimentos pretéritos e futuros, muitos usuários pareciam não saber se contextualizar em seus tratamentos e nem entender os motivos e objetivos dos procedimentos realizados. Em geral, tanto usuários como profissionais mostraram não entender o que é o consentimento informado e a diferença deste para os termos de consentimento, comumente tratados como mera burocracia jurídica. Tudo isso pode estar prejudicando os objetivos do consentimento informado e são questões que necessitam ser repensadas no sistema de saúde / This qualitative-quantitative research includes participant observation, document analysis, and interviews with users from both SUS and private hospitals. It focuses the informed consent in the health care, understood as the shared decisionmaking process in which information, opinions, and values are exchanged between the service users and their health professionals. The goal is to analyze the practice of the informed consent within the Brazilian Health Systems oncology field. The evaluations of categorical variables associations used the Fisher\'s exact test, while the numerical variables were compared through a t-test, at the 5 per cent significance level. Through Flesch and Flesch-Kincaid methods, it was found that the hospitals informed consent terms are of inadequate readability according to international standards, and also inappropriate compared to the actual users literacy level: more than 70 per cent of the SUS interviewees do not match the required literacy standard for comprehending the documents. In addition, although almost all users reported satisfaction with the information they received about their procedure, only 58 per cent were able to name at least one related risk. As expected, there was an association between the educational and income levels of the participants and their ability to understand the risks of a medical procedure. It is noteworthy that previous studies, both national and foreign, do not seem to have considered income level as a variable. Although both factors were independent predictors, multiple logistic regressions showed that income level had a greater weight than educational level in predicting a person\'s chance of citing one of the procedural risks. Additionally, no matter the timing of the treatment, there was no relation between knowledge of risks and whether the hospital is SUS or private. Unlike results found in other countries, there appears to be no association between educational level and the reading of consent terms. Nevertheless, when the doctor is the health professional who applies the term, it is read more often by the users. The research demonstrated that there was an association between the user being in the private hospital and believing that the consent term exists to protect the rights of the doctor instead of their rights as health service users. Through qualitative analysis, this study found that the SUS hospital users had greater ability than expected to understand disease diagnosis and history. The hospitals effective patient care appears to have partly overcome the educational barrier that often prevents patients from understanding diagnostic and medical procedures information, so that humanization of healthcare seems to have a positive impact on users understanding of information. Despite of both hospitals users satisfactorily report past and future procedures, several of them appear not to contextualize their treatments either understand the performed procedures reasons and objectives. In general, users and health professionals in both hospitals do not seem to understand the informed consent concept, neither the difference between informed consent and informed consent terms, generally seen as mere legal bureaucracy. All of these issues may jeopardize the goals of informed consent, if they are not addressed properly at the health care

A tuberculose (TB) constitui a principal comorbidade a acometer as pessoas que vivem com HIV/aids (PVHA), sendo considerada a primeira causa de morte nesta população. Assim, a prevenção da coinfecção TB/HIV pelos Serviços de Atenção Especializada ao HIV/aids (SAE) se faz imprescindível. O estudo objetivou analisar a oferta e a integração das ações e serviços de saúde para a prevenção e o controle da TB nas PVHA pertencentes à rede de atenção ao HIV/aids do município de Ribeirão Preto-SP. Utilizou-se o conceito teórico da integralidade da atenção, tomando como eixo de análise a oferta e a integração das ações e serviços dentro das equipes de referência e junto a outros profissionais/especialidades/serviços. Trata-se de um estudo exploratório, do tipo inquérito, com abordagem quantitativa. Participaram 253 PVHA em acompanhamento nos cinco SAE sob gestão municipal, considerando-se os seguintes critérios de inclusão: indivíduos maiores de 18 anos, residentes no próprio município e não pertencentes ao sistema prisional. A coleta de dados foi realizada no período de janeiro/2012 a maio/2013, por meio de entrevistas com apoio de um instrumento específico. Os dados foram analisados por meio de distribuição de frequência, construção de indicadores e análise de correspondência múltipla. Quanto ao perfil dos sujeitos, identificou-se acometimento maior dentre o sexo feminino, faixa etária adulta, indivíduos casados/união estável e solteiros, baixa escolaridade, empregados e predomínio da classe econômica C. Tais características e especificidades sociais e demográficas expõem a complexidade que envolve a assistência às PVHA e, em contiguidade, o controle da TB nesta população. A oferta de ações e serviços para o controle da TB nas PVHA por todos os SAE do município foi considerada regular, reforçando a necessidade de melhor planejamento da assistência de forma integral, articulação dos profissionais nas equipes e entre estas e os demais serviços da rede, além da formação profissional e educação permanente. A integração, de modo geral, foi classificada como satisfatória, entretanto, identificou-se diferentes desempenhos entre os SAE, principalmente no que se refere à abordagem das condições sociais e encaminhamentos realizados, o que permite refletir sobre a complexidade da coordenação da assistência prestada às PVHA. O desafio que se coloca é pensar a integralidade da atenção que articule a oferta de ações e serviços de saúde para o controle da TB, sobretudo, destacando a necessidade de estratégias que favoreçam o desenvolvimento de ações compartilhadas e cooperadas dentro da equipe, entre os programas de TB e HIV/aids e entre os diferentes serviços, com o intuito de fortalecer a rede local de atenção visando a produção de um cuidado integral, singular e resolutivo. Para tanto, urge a necessidade de transformar os conceitos e práticas de saúde que orientam o processo de formação acadêmica no sentido de conceber profissionais capazes de compreensão e ação relativas à integralidade nas práticas de saúde / Tuberculosis (TB) is a major morbidity that affects people living with HIV/ AIDS (PLWHA), and it is considered the leading cause of death among this population. Thus, prevention of TB by HIV/AIDS Care Specialized Services is a prerogative. The study aimed to analyze the supply of health actions and the integration of health services for TB\' prevention and control among PLWHA in treatment at the HIV/AIDS care network in the city of Ribeirão Preto, SP. The theoretical concept of comprehensive care was used, by considering the supply and integration of programs and services within the reference teams and between other professionals/skills/services. This is an exploratory study, survey type, with a quantitative approach. A total of 253 PLWHA participated in the study. They were followed at the five municipal HIV/AIDS Specialized Assistance Services (SAS), and the following inclusion criteria were considered: patients over 18 years old, living in the study site and outside the prison system. Data collection was performed from January 2012 to May 2013, through interviews with the support of a specific instrument. Data were analyzed by frequency distribution, indicators development and multiple correspondence analysis. Regarding the subjects\' profile, we identified a higher prevalence of females, adult age, married/stable union or single, low education, employees and a predominance of economic class C. Such social and demographic characteristics expose the complexity involving the assistance to PLWHA, and, as a result, the complexity of controlling TB in this population. The availability of services for TB control in PLHIV in all five SASs was rated as regular, reinforcing the need for better planning focused on comprehensive care, coordination of professionals inside their teams, as well as between different teams and services, thinking beyond vocational training and continuing education. Although integration was generally rated as satisfactory, SASs presented different performances, especially with regard to addressing the social conditions and establishing referrals, allowing a reflection on the complexity of PLWHA care coordination. The challenge that arises is thinking about an integrated care that articulates the availability of health actions and services for TB control, e highlighting the need for strategies that favor the development of cooperative actions within health teams, between TB and HIV/AIDS programs and among different services in order to strengthen the local care network and develop unique, decisive and comprehensive care. Therefore, there is an urgent need to transform the health concepts and practices that guide the process of academic training to build professionals capable of understanding and acting for comprehensive health practices

<b>Background:</b> External Quality Assessment assesses the quality of the structures, processes and outcomes of health facilities using pre-determined standards. South Africa is introducing a national policy on External Quality Assessment, operationalised by a newly established External Quality Assessment agency: the Office of Health Standards Compliance. This thesis seeks to answer three research questions: What is the relationship between External Quality Assessment and patient outcomes (specifically Healthcare Associated Infections) at the specialist-care facility level in South Africa? What are the facilitators of and barriers to health facility performance (i.e. attainment of compliance with standards) in External Quality Assessment at the district hospital level in South Africa? What has been the experience of External Quality Assessment by frontline healthcare workers at the district hospital level in South Africa? <b>Methods:</b> Three systematic literature reviews are conducted that attempt to identify the existing evidence base for the above-mentioned research questions in the international literature. A convergent parallel mixed methods design is used to answer the research questions, comprising an Interrupted Time Series Analysis and a multiple embedded case study of two pairs of health facilities that had undergone External Quality Assessment by the Office of Health Standards Compliance. The Interrupted Time Series Analysis assesses whether an effectiveness relationship can be demonstrated between External Quality Assessment and the Healthcare Associated Infection Methicillin-resistant Staphylococcus Aureus (MRSA) in eight South African specialist-care hospitals using monthly MRSA data from 2004 to 2014. MRSA is used in this thesis as the proxy patient outcome indicator. In order to answer research questions two and three, I participated in a district hospital External Quality Assessment as a participant observer as well as conducted fifteen in-depth interviews with healthcare workers from two pairs of district hospitals and thirteen in-depth interviews with Office of Health Standards Compliance inspectors. These findings are triangulated with health facility External Quality Assessment reports. <b>Results:</b> No conclusive evidence is found of a relationship between implementation of External Quality Assessment and changes in MRSA. The major theoretical lenses drawn from in the analysis of the qualitative findings are systems thinking theory and regulatory theory. The qualitative research suggests that facilitators of performance in External Quality Assessment in South Africa include strong directional leadership within health facilities, a collaborative organisational culture, a whole systems approach, staff development, incentives, a robust information system and a supportive External Quality Assessment agency. The research also identifies poor alignment of External Quality Assessment standards, under-developed and limited human resources, inadequate decision-making space afforded to district hospital leadership, limited financial resources, the use of penalties and negative staff perceptions of External Quality Assessment as barriers to health facility performance in External Quality Assessment. In unpacking the experiences of South African healthcare workers of External Quality Assessment, this research finds that the work of the Office of Health Standards Compliance is valued by healthcare workers as a potential educational opportunity and is useful in providing the health system with a means to compare health facilities using a standardised tool. The implementation of the Office of Health Standards Compliance's External Quality Assessments requires significant improvement and, in their current form, they have potential unintended negative consequences on healthcare worker motivation as well as potentially, inadvertently encouraging the gaming of External Quality Assessment. <b>Conclusion:</b> The Office of Health Standards Compliance is being set up in such a way that once fully established it will be the primary regulator of quality of care in the South African health system. This thesis attempts to identify some of the strengths and weaknesses of this largely under-researched health system intervention and to contribute to strengthening its implementation.

<p>Predmet ovog istraživanja je uticaj sistema vrednosti i ličnih karakteristika<br />davaoca usluga na kvalitet usluga u zdravstvenim sistemima. Rezultati<br />istraživanja predstavljaju osnovu za planiranje aktivnosti kojima će se<br />unapređivati kvalitet rada pa i zadovoljstvo pacijenata kao glavni izlazni<br />rezultat.Cilj ovog istraživanja je da se sagleda koji je to uticaj sistema<br />vrednosti i ličnih karakteristika davaoca usluga na kvalitet usluga u<br />zdravstvenim sistemima, kao i faktori koji utiču na njihovo zadovoljstvo,<br />odnosno nezadovoljstvo. Na osnovu rezultata ovog istraživanja, sagledavajući<br />sisteme vrednosti zdravstvenih radnika i uvažavajući mišljenje korisnika,<br />mogu se jasnije definisati prioriteti za poboljšanje i unapređenje kvaliteta<br />rada.</p> / <p>The subject of this research is the influence of the system of values and personal<br />characteristics of the provider of services on the quality of services in health systems.<br />The results of the research are the basis for planning the activities that will improve the<br />quality of work and the satisfaction of patients as the main output. The aim of this<br />research is to examine what is the impact of the system of values and personal<br />characteristics of the provider of services on the quality of services in health systems,<br />as well as the factors that influence their satisfaction or dissatisfaction. Based on the<br />results of this research, looking at the systems of values of health workers and taking<br />into account the user&#39;s opinion, priorities for improving and improving the quality of<br />work can be clearly defined.</p>

Este trabalho se inscreve no campo da saúde pública em sua perspectiva interdisciplinar, pois mobiliza conhecimentos oriundos da epidemiologia, do planejamento e das ciências humanas e sociais. Nosso objetivo central foi analisar a viabilidade política do planejamento participativo na Terra Indígena Tirecatinga, DSEI Cuiabá, Estado de Mato Grosso, Brasil. A fundamentação teórica utilizada foi a Teoria do Jogo Social de Carlos Matus que visita e amplia duas outras teorias formuladas pelo autor: a Teoria das Situações e a Teoria da Produção Social. A estratégia metodológica escolhida foi o Estudo de Caso tendo em vista que a formulação de um plano local por meio do planejamento estratégico situacional tratou-se de um caso não significando que o processo e os resultados obtidos poderão ser generalizados para as demais comunidades indígenas do território nacional. Os depoimentos foram submetidos à Análise do Discurso segundo hipóteses de Dominique Mainguenau. Esperamos que o exercício do planejamento em território indígena amplie a compreensão da situação de saúde dos índios que vivem na Terra Indígena Tirecatinga, território adstrito ao DSEI Cuiabá; estenda a compreensão sobre as lógicas de ação que permeiam as práticas dos sujeitos nos espaços de participação social; que o planejamento seja um instrumento de reflexão e mudança para a organização fornecendo subsídios para a institucionalização do mesmo tendo em vista as necessidades dos sujeitos e, sobretudo, promova a reflexividade e a atividade crítica na comunidade indígena participante / This work falls within the field of public health from an interdisciplinary perspective as it mobilizes knowledge from epidemiology, planning and human and social sciences. Our main objective was to analyze the political viability of participatory planning within Tirecatinga Indigenous Territory, DSEI Cuiaba, Mato Grosso, Brazil. The theoretical framework used was the Theory of Social Game by Carlos Matus, created by visiting and extending two other theories formulated by the same author: the Theory of Situations and the Theory of Social Production. The selected methodological strategy was a case study with a view to formulate a local level situational strategic planning used to treat a case. Therefore the process and the results cannot be generalised to other indigenous communities within the national territory. All reports were submitted to Discourse Analysis according to Dominique Mainguenaus hypothesis. We hope that the exercise of planning within indigenous territories can expand the understanding of the health status of Indians living within Tirecatinga Indigenous Territorry, a territory attached to the DSEI Cuiabá; extend the understanding of the logic of action that permeates the practices of the subjects in the spaces of social participation; that planning can be used as a reflection tool and promote changes to the organization providing support for the institutionalization from a perspective which recognizes the needs of individuals and, above all, promote reflexivity and critical activity within the participating indigenous community

La chute des prix des technologies de séquençage de nouvelle génération (NGS) s'est accompagnée de leur utilisation accrue, en recherche et en clinique. L'interprétation toujours meilleure des génomes humains peut permettre le développement de meilleures stratégies de prévention, de diagnostic et de traitement des maladies. Des investissements significatifs ont vu le jour dans de nombreux pays industrialisés en vue de réaliser les promesses de la médecine personnalisée. Cependant, le séquençage du génome complet de patients n'est offert en tant que test clinique que dans un nombre très limité d'établissements de santé dans le monde. La France et le Québec ont investi de manière considérable dans la recherche en génomique. Cependant, des décisions stratégiques doivent encore être prises quant à l'implémentation clinique des technologies NGS dans ces deux juridictions. Dès lors, l'objectif de ce projet est de contribuer à l'ensemble des preuves et faits à la disposition des décideurs publics. Nous avons focalisé notre attention sur deux technologies, le séquençage de l'exome (whole-exome sequencing, WES) et du génome complet (whole-genome sequencing, WGS). Notre objectif était d'établir si l'utilisation efficace et responsable du WES/WGS pouvait être mise en péril par des lacunes dans les politiques publiques ou cadres règlementaires et normatifs applicables. A l'heure actuelle, l'interprétation clinique de la séquence génomique ou exomique d'un patient nécessite l'intervention de nombreuses parties prenantes, y compris des chercheurs qui utilisent des outils, procédés et normes développés dans le cadre de la recherche pour analyser les données NGS. En parallèle, les cadres normatifs existants ont été construits pour accommoder les données génétiques, mais n'abordent pas la question des données génomiques. Notre hypothèse est que ces éléments créent un besoin de standardisation, qui pourrait requérir des adaptations du cadre normatif. Nous avons répondu à trois questions de recherches: (1) Quels enjeux les utilisateurs de technologies NGS soulèvent-il à propos de leur utilisation en clinique ? Pour répondre nous avons fait une étude systématique de la littérature. (2) Comment les données NGS de patients sont-elles à l'heure actuelle par des institutions de santé en France et au Québec ? Pour répondre nous avons réalisé une étude de cas multiples. (3) Y a-t-il des lacunes dans les cadres normatifs qui devraient être comblées pour assurer l'utilisation responsable, efficace et standardisée des données NGS en clinique ? [...] / The decreasing cost of next-generation sequencing (NGS) technologies has resulted in their increased use in research, and in the clinical context. Indeed, the correct interpretation of a human genome can enable better prevention, diagnosis and treatment strategies. Significant public investments in NGS have been made in various developed nations to realise the promise of personalized medicine. Yet, today the sequencing and analysis of a patient’s exome or genome is only offered as a clinical test in a limited number of clinics around the world. France and Quebec have made sizable investments in genomics research, and France announced the launch of a genomic medicine plan in 2016. However, policy decisions still have to be made on the nation-wide clinical implementation of NGS technologies in both jurisdictions. Therefore, this project’s objective was to contribute to the body of evidence available to policymakers in France and Quebec on the clinical implementation of NGS technologies. We focused our attention on two specific NGS technologies, namely Whole Genome Sequencing (WGS), and Whole Exome Sequencing (WES). We specifically aimed to assess if the responsible and efficient use of WES/WGS data in the context of clinical care could be impeded by policy gaps. Currently, the clinical interpretation of a patient’s genome sequence data is done through the intervention of many stakeholders including basic science researchers. These researchers use bioinformatics tools, processes and norms developed for research to filter and analyse patients NGS data. In parallel, existing regulatory and normative frameworks have been developed for the use of genetic data, and include no clear definition of genomic data or genomic technologies. We hypothesised that these elements create a strong need for standardization of practices, and may require adaptations of current regulatory and normative frameworks to the context of NGS. We therefore aimed to answer three research questions: (1) What issues do technology users experience and foresee when using WES data to inform patient care? To answer this, we performed a systematic review of the literature. (2) How are patients’ NGS data currently managed (produced, analysed, interpreted and shared) in clinical institutions in Quebec and in France? We answered this by performing a case studies analysis, interrogating key stakeholders directly involved in managing patients’ NGS data in France and Quebec. (3) Are there gaps in the current regulatory and normative frameworks which should be addressed to enable a responsible and efficient standardized use of NGS data in the clinic? [...]

acase@tulane.edu

acase@tulane.edu

Background: Despite the contraceptive prevalence of 67.4% in Morocco, one woman out of 10 has unmet need for birth spacing or limiting and, only one woman out of two is using modern contraception. Although, Moroccan national family program [FP] was launched in the sixties and aimed to increase use of FP among married Moroccan women; the program is still facing some limits to improve couple’s contraceptive care. This paper examines to what extent women’s status, husband’s FP approval and mass media positive exposure to FP messages translate into increased modern contraceptive uptake. This study uses the socio ecological framework to assess factors that influence FP use among married women in Morocco. In this model factors from individual, interpersonal and programmatic levels were identified based on a review of the literature as having an effect on contraception use. Objectives: The main objectives of this study are to: (1) explore the effect of women’s status including their education, their occupation and, their FP decision making on women’s desire for more children, (2) examine if husbands’ FP approval impacts women’s fertility desire, (3) assess how positive mass media FP messages ‘exposure influences women’s desire for children, (4) explore the effect of women’s fertility desire on women’s FP approval and,(5) assess if women’s FP approval increases modern contraception adoption. Methods: This analysis is based on secondary data from the 2004 Demographic Health Survey and, 2011 Morocco National Survey on Population and Family Health which were conducted among married women aged between 15 and 49 years old. Data were collected using a two-stage sampling scheme and the study population was 8,106 women in 2004 and 9,317 women in 2011. Path analysis, using series of multiple regression modeling analyses, was conducted to investigate the relationship between women’s desire for more children and predictors related to women’s status, husbands’ FP approval and, women’s exposure to FP messages via mass media. Full models were fitted to test the relationships between women’s desire for more children and women’s FP approval; women’s approval of FP and modern contraception use. Results: Descriptive analysis between 2004 data and 2011 data analysis showed similar results for women’s and husbands’ predictors. Women in 2011 who used modern contraception were mostly aged more than 35 years old (51%), lived in urban areas (56%), mostly rich (40.3%), educated (46%), with no occupation (89%), did not decide FP use alone (73.3%), whose husbands discussed FP with them (62%) and, approved contraceptive use (98%). Positive exposures to FP messages on mass media were measured only in 2004 data and showed that among women who adopted modern contraception, only 2.9% read FP messages in newspapers, 12.6% heard them in the radio and 25.5% heard them on television. Path analyses showed some differences between 2004 data and 2011data. In 2011 data educated women were 1.42 (O.R. = 1.42, C.I. 1.26–1.6) more likely to desire more children than those with no education. Women with occupation were 1.25 (O.R. = 1.25, C.I. 1.01–1.47) times more likely to desire children than those with no occupation. However, women’s education and women’s occupation factors were not related to women’s fertility desire in 2004 data. Husbands’ FP approval was not significantly associated to women’s fertility desire in both 2004 and 2011 data analyses. Mass media exposure to FP messages was examined only in 2004 and showed no significant association with women’s fertility desire. Similar results were observed between 2004 data and 2011 data and showed that women who decided for FP were 0.75 (O.R. = 0.75, C.I. 1.01–1.47) times less likely to desire more children than those who were not FP decision makers. Moreover, in 2004 women who decided for FP were 2, 32 times more likely to use modern contraception than women who were not FP decision makers [O.R. 2, 31 (CI 1.79-3.01)]. In 2011 data analysis, women who approved FP were 5.72 (O.R. = 5.72, C.I. 3.06–10.7) more likely to use modern contraception than those who did not approve FP. Furthermore, women whose husbands approved FP were 2.55 times more likely to adopt modern contraception (O.R. = 2.55, CI 1.845-3.513). Conclusions: This study results indicated women’s and, husband’s factors affecting women’s fertility desire and women’s contraceptive use. The factors effects varied between 2004 data and 2011 data. In 2011 data women’s education, women’s occupation, women’s FP decision making and, husbands’ FP discussion variables, had a significant effect on women’s fertility desire. However, in 2004 data only husband’s FP discussion had a positive effect on women’s fertility desire which had a positive effect on women’s FP approval. Women’s exposure to mass media FP messages did not have a significant effect on both women’s fertility desire and women’s contraceptive outcomes. Husbands’ FP approval and husbands’ FP discussion with their wives were highly predictive for women’s contraceptive use and remained essential factors for which Moroccan health policy makers should take into consideration in order to reduce unmet needs and improve couple’s contraceptive care in Morocco. / acase@tulane.edu