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CONTEXTE : La France est caractérisée par l’existence de fortes disparités socioéconomiques et géographiquesde l’état de santé, le plus souvent objectivées par des indicateurs objectifs de morbidité et de mortalité. Ladistribution territoriale des mesures de santé perçue comme la qualité de vie liée à la santé (QdVLS) reste malconnue en population générale. Une meilleure connaissance de la répartition et des déterminants – en particuliercontextuels - de ces indicateurs subjectifs permettrait de mieux comprendre leur signification par rapport auxindicateurs objectifs et d’apprécier l’intérêt spécifique de leur suivi en population générale.OBJECTIFS : Les objectifs de cette recherche étaient [1] d’étudier l’existence de disparités spatiales de QdVLSdans la population française et d’analyser leur évolution dans le temps, [2] d’étudier les déterminants de laQdVLS à la fois individuels et contextuels dans le cadre d’une analyse multiniveau, et [3] d’évaluer lesassociations écologiques entre QdVLS et mortalité ultérieure à cinq ans d’intervalle.MATERIEL ET METHODES : Les données issues de deux enquêtes transversales nationales représentatives ont étéexploitées : l’enquête Décennale 2003 de l’Insee pour l’ensemble des travaux menés (N=22 743 [1 et 3] ; N=16 732 [2]) et l’enquête Sofres 1995 pour l’analyse de l’évolution temporelle de la QdVLS (N=3 243 [1]). Lequestionnaire utilisé dans les deux enquêtes était le SF-36. [1] Des modèles de régression linéaire multiple àeffets fixes avec recherche d’interactions ont été réalisés pour l’analyse de l’évolution temporelle. [2] L’analysemultiniveau des déterminants contextuels de la QdVLS s’appuyait sur des modèles à effets mixtes, afind’explorer une chaine causale incluant des déterminants aux niveaux individuel, du ménage, de l’unité urbaine etrégional, d’ordre démographique, socioéconomique ou intégrant la notion contextuelle plus complexed’attractivité (taux migratoire, désindustrialisation). [3] Les données de mortalité étaient issues de la statistiquenationale des décès élaborée annuellement par le CépiDc. Des modèles de régression binomiale négative ont étéréalisés pour l’analyse des associations écologiques au niveau régional entre QdVLS en 2003 et mortalitéultérieure (court terme [2003-2005] ; à 5 ans [2007-2009]) et en stratifiant sur le sexe, l’âge et les causesspécifiques de décès.RESULTATS PRINCIPAUX : [1] Une diminution significative de la QdVLS était observée entre 1995 et 2003affectant tous les groupes sociodémographiques et suggérant la possibilité d’un accroissement des disparités pourles catégories les plus fragiles de la population. [2] De fortes disparités régionales de QdVLS étaient retrouvées,persistant après ajustement sur les caractéristiques socioéconomiques individuelles. L’analyse multiniveaupermettait d’identifier des processus de médiation impliquant les variables contextuelles de désindustrialisation,le taux d’accroissement migratoire, le taux d’abstention aux élections, et les comportements liés à la santé. Desinteractions inter-niveaux et intra-régionales étaient identifiées. [3] Des associations écologiques significativesétaient retrouvées au niveau régional entre QdVLS et mortalité à cinq ans d’intervalle, persistant aprèsajustement sur le niveau socioéconomique. Des relations spécifiques étaient observées après stratification surl’âge, le genre, les causes spécifiques de décès ; le caractère prédictif de la QdVLS variait selon le délai plus oumoins court entre mesure de la QdVLS et mortalité. / BACKGROUND: Wide social and geographical disparities are reported in France for morbidity and mortalityindicators. Less is known regarding the spatial distribution in general population of self-rated health (SRH) andhealth-related quality of life (HRQoL). Improving the knowledge of the contextual determinants of HRQoLwould help towards a better understanding of their meaning and interest in general population when it comes tocompare with classical objective indicators.OBJECTIVES: The objectives were [1] to assess existing spatial disparities of HRQoL in French generalpopulation and to investigate their evolution in time, [2] to determine individual and contextual determinants ofHRQoL and [3] to explore the ecological associations between HRQoL and subsequent mortality five years later.METHODS: Data were drawn from two large representative cross sectional surveys: the Insee Decennial HealthSurvey led in 2003 (N=22 743 [study 1 and 3] ; N= 16 732 [2]) and the Sofres health survey led in 1995(N=3243 [1]).The MOS SF-36 questionnaire was used in both surveys. [1] Fixed effects linear models combinedwith interaction tests were used for assessing time trends. [2] Mixed effects linear models were used for themultilevel analysis, exploring a causal pathway including individual and macrolevel factors (household, urbanunit and region) assessing demographics, socioeconomics, and features related to the notion of areaattractiveness (deindustrialization, net migration rates). [3] Mortality data were drawn from the French nationalstatistics of mortality (CepiDc-Inserm). Negative binomial regression models were performed to identifyecological associations at the region level between HRQoL recorded in 2003 and subsequent mortality (shortterm [2003-2005]; 5-years later [2007-2009]), stratifying on age, gender and specific causes of death.MAIN RESULTS: [1] A significant decrease in HRQoL was observed between 1995 and 2003, affecting allsociodemographic categories and suggesting likely widening disparities in the most fragile categories. [2]Regional HRQoL disparities were found, persisting after adjusting on socioeconomic individual characteristics.Multilevel analysis showed some evidence for mediation involving contextual factors like deindustrialization,net migration rates, voter abstention rate and health-related behaviors. Cross-level interactions were found aswell. [3] Significant ecological associations were identified at the region level between HRQoL and mortalityfive years later, persisting after adjusting on deprivation. Specific relationships were observed after stratifying onage, gender, specific causes of death; the predictive ability of HRQoL for mortality was varying depending onthe mortality period considered for analysis.CONCLUSIONS: Our results highlight the interest in assessing HRQoL at the population level and in exploringthe contextual determinants at play. Systematic inclusion of validated and multidimensional HRQoLquestionnaires should be supported in national surveys, so as to improve our knowledge of long term temporaltrends in HRQoL, to promote an increased use of contextual multilevel analyses using such data, and eventuallyto help better identifying sub-groups at risk and optimizing public health interventions.

De-industrialisation and rising unemployment amongst the world's developed countries' manual labourers as well as continued economic stagnation in developing countries has resulted in many localities experiencing mounting economic hardships and uncertain futures. As a direct result, the time has come that localities are being called upon to take charge of their own futures using local resources for local solutions. Local development has appeared in various guises in different countries. Many agents in the developed North favour pro-business interventions that emphasise enterprise development, responsible local government, and investment in skills training. Stakeholders in developing nations however tend to favour bottom-up approaches focusing on participation in self-reliant activities, providing basic needs, and facilitating micro-enterprises. In addition to the actual nature of applied interventions, qualities such as commitment, innovation, co-operation, social capital and entrepreneurship are equally essential for over-all success. South Africa has recently devolved more autonomy to its localities to enable them to conduct local development as a way of coping with local socio-economic difficulties and is applying both pro-growth and pro-poor approaches. The Noordhoek Valley in the City of Cape Town is a locality where a community driven project seeks to promote both economic growth and poverty alleviation. The establishment of a skills training institution has equipped local residents with the skills to find jobs and become entrepreneurs. To date, over 1000 residents have received training and have earned over R5 million for the community. Although locality-based development is relatively new in South Africa, the activities and results achieved in the Noordhoek Valley indicate that with the appropriate approach and mentality local development and skills development are indeed possible.

科学研究費補助金 研究種目:基盤研究(C) 課題番号:07630022 研究代表者:木下 宗七 研究期間:1995-1996年度

The de-industrialisation process that was a common feature of North America and Western Europe in the 1970s, through into the 1980s has become an observable feature in African countries and South Africa in particular in the last two decades. Globally, hard hit areas include those associated with the early Industrial Revolution characterised by mass production and the agglomeration of iron and steel, coal and textile industries. General changes in the global market, especially the falling demand for extractive heavy minerals like coal and gold have also affected many countries region and localities. In the case of South Mrica, the previous high economic dependence on mined minerals like coal and gold has resulted in many once prosperous mining regions of the country being reduced to a shadow of their former selves. The worst affected areas in South Africa are those of the Klerksdorp Goldfields in the North West Province and Free State Goldfields, with the latter alone losing 100,000 jobs during the 1990s. This trend has also been acute in the coal-mining industry of the KwaZulu-Natal province since the late 1970s. The firms that had grown in the shadow of the major mining company supplyipg machinery, or who processed the semi-manufactured product are also severely affected by the closing down and restructuring in the mining and iron industries. These industries have often been forced to close down because of a break in the vital connections they developed with these mining industries. Such localised economic crisis has encouraged the universal trend towards the devolution of developmental responsibilities to the local governments and other local stakeholders to - empower them to respond to these changes. This study investigated the local economic initiatives which have been undertaken in the three municipalities of north-western KwaZulu Natal i.e. Utrecht, Dundee and Dannhauser to respond to the closures which have taken place in the mining industry of this region, which used to be among the most prosperous coal mining regions of South Africa. Using their new developmental mandate the local governments, in partnership with the communities and other external interveners have tried to respond to these localised economic crisis and also indirectly to the general poverty and underdevelopment, which characterises this region of KwaZulu-Natal. The effects of apartheid policies, and previous discriminatory rural development policies in, particular, and the Regional Industrial Development policy, which was intensively applied in the 1980s by the pre-1994 government regime, have further compounded the magnitude of the challenge. The lack of capacity in some municipalities has constrained successful implementation of Local Economic Development has led to some communities acting alone to face their situation with or without external intervention.