Este é um estudo epidemiológico da mortalidade dos jovens (15 a 24 anos), nos municípios do Rio de Janeiro e São Paulo, no período de 1930 a 1991. Foram resgatados dados para referência histórica de interesse da saúde pública e para a construção de indicadores de saúde. Comparou-se a magnitude da mortalidade do grupo jovem, segundo sexo e causas, no tempo e entre as capitais. O coeficiente de mortalidade específico para a faixa etária de jovens declinou até 1970, em São Paulo e 1980, no Rio de Janeiro, sendo que este último município sempre apresentou níveis de mortalidade mais elevados do que o primeiro. Entretanto, São Paulo, de 1980 a 1991, sofreu um aumento relativo da mortalidade duas vezes maior do que o do Rio de Janeiro, aproximando os indicadores. A mortalidade dos jovens, embora baixa, em relação ao observado para as demais faixas etárias, não vem mais decrescendo. A elevação observada nas últimas décadas se dá às custas da mortalidade do sexo masculino. As doenças infecciosas e parasitárias apresentaram os coeficientes mais elevados nos dois municípios até 1950, sendo que os do Rio de Janeiro foram sempre maiores do que os de São Paulo. Dentre as doenças infecciosas destacou-se a importância da tuberculose como produtora de mortes, principalmente até 1950. A partir de 1960, as causas externas passaram a ocupar a primeira posição, com coeficientes elevados e crescentes. Dentre estas causas, os acidentes de trânsito e os homicídios se destacaram. Além das doenças infecciosas e parasitárias, outros grupos tais como o das doenças do aparelho circulatório e respiratório, e mais recentemente as doenças das glândulas endócrinas, da nutrição e do metabolismo e transtornos imunitários, principalmente pela AIDS, sempre estiveram entre os cinco primeiros grupos de causas de morte. As epidemias de doenças infecciosas e parasitárias, no caso dos jovens, pricipalmente do sexo masculino, foram sendo substituídas pelas violências, o que determinou um novo padrão de mortalidade, que deve ser abordado segundo a multiplicidade de elementos que o determinam. / This is an epidemiologic study of the youth (15 to 24 years old) mortality in Rio de Janeiro and São Paulo cities from the year 1930 to 1991. The main objective is to evaluate mortality related to sex and causes at the target population and to compare It between both cities and with other indicators. São Paulo city showed a rapid death rate decline to the group, up to 1970, as well as Rio de Janeiro city, up to 1980. The last city has always showed higher mortality rates. However, during the past decade a higher proportion of deaths happened in São Paulo, which means that their mortality slopes are closer. Young people mortality rates are not high when compared with other age groups, but they are not decreasing anymore. The rising tendency is caused by male mortality. Infectious diseases were responsable by the higher mortality during the first years studied, mainly up to 1950, in both ciites, and Rio de Janeiro has exhibited the higher levels. Among the diseases of the group, tuberculosis was distinguished. After 1960, violent deaths increased and occupied the main position. Traffic acidents and homicide are the most important death causes. Besides them cardiovascular diseases, respiratory affections and latter on, in 1991, the endocrinologic and metabolic diseases group became to a prominent position, because of AIDS. Infectious diseases epidemics in the early years ofthe century, mainly to the young male, were replaced by violence and this transition showed a new mortality pattern which must be approached according to Its multiple implications.

Este é um estudo epidemiológico da mortalidade dos jovens (15 a 24 anos), nos municípios do Rio de Janeiro e São Paulo, no período de 1930 a 1991. Foram resgatados dados para referência histórica de interesse da saúde pública e para a construção de indicadores de saúde. Comparou-se a magnitude da mortalidade do grupo jovem, segundo sexo e causas, no tempo e entre as capitais. O coeficiente de mortalidade específico para a faixa etária de jovens declinou até 1970, em São Paulo e 1980, no Rio de Janeiro, sendo que este último município sempre apresentou níveis de mortalidade mais elevados do que o primeiro. Entretanto, São Paulo, de 1980 a 1991, sofreu um aumento relativo da mortalidade duas vezes maior do que o do Rio de Janeiro, aproximando os indicadores. A mortalidade dos jovens, embora baixa, em relação ao observado para as demais faixas etárias, não vem mais decrescendo. A elevação observada nas últimas décadas se dá às custas da mortalidade do sexo masculino. As doenças infecciosas e parasitárias apresentaram os coeficientes mais elevados nos dois municípios até 1950, sendo que os do Rio de Janeiro foram sempre maiores do que os de São Paulo. Dentre as doenças infecciosas destacou-se a importância da tuberculose como produtora de mortes, principalmente até 1950. A partir de 1960, as causas externas passaram a ocupar a primeira posição, com coeficientes elevados e crescentes. Dentre estas causas, os acidentes de trânsito e os homicídios se destacaram. Além das doenças infecciosas e parasitárias, outros grupos tais como o das doenças do aparelho circulatório e respiratório, e mais recentemente as doenças das glândulas endócrinas, da nutrição e do metabolismo e transtornos imunitários, principalmente pela AIDS, sempre estiveram entre os cinco primeiros grupos de causas de morte. As epidemias de doenças infecciosas e parasitárias, no caso dos jovens, pricipalmente do sexo masculino, foram sendo substituídas pelas violências, o que determinou um novo padrão de mortalidade, que deve ser abordado segundo a multiplicidade de elementos que o determinam. / This is an epidemiologic study of the youth (15 to 24 years old) mortality in Rio de Janeiro and São Paulo cities from the year 1930 to 1991. The main objective is to evaluate mortality related to sex and causes at the target population and to compare It between both cities and with other indicators. São Paulo city showed a rapid death rate decline to the group, up to 1970, as well as Rio de Janeiro city, up to 1980. The last city has always showed higher mortality rates. However, during the past decade a higher proportion of deaths happened in São Paulo, which means that their mortality slopes are closer. Young people mortality rates are not high when compared with other age groups, but they are not decreasing anymore. The rising tendency is caused by male mortality. Infectious diseases were responsable by the higher mortality during the first years studied, mainly up to 1950, in both ciites, and Rio de Janeiro has exhibited the higher levels. Among the diseases of the group, tuberculosis was distinguished. After 1960, violent deaths increased and occupied the main position. Traffic acidents and homicide are the most important death causes. Besides them cardiovascular diseases, respiratory affections and latter on, in 1991, the endocrinologic and metabolic diseases group became to a prominent position, because of AIDS. Infectious diseases epidemics in the early years ofthe century, mainly to the young male, were replaced by violence and this transition showed a new mortality pattern which must be approached according to Its multiple implications.

This dissertation investigates the emergence and development of cause-of-death registration in nineteenth-century Massachusetts. I examine the historical, demographic, sociopolitical, and theoretical conditions that gave rise to the first state-implemented cause-of-death registration system in the United States, Massachusetts's vital registration system. Developments in almost every arena of social life during the nineteenth century were shaped in some fashion through disease. The disease ecology changed dramatically during this period shifting from acute infectious to chronic degenerative diseases, which marked the beginning of the epidemiological transition. Registration systems were key components in this transitional period, providing the raw data on which nineteenth-century public health policy emerged. The greatest challenge that public-health reformers faced in implementing and regulating cause-of-death registration was standardizing the language and practice of disease and cause-of-death reporting. I look closely at issues of implementation and regulation and examine the relative impact that standardized nomenclature and reporting practices had on cause-of-death registration in Massachusetts from 1850 through 1912. Efforts to standardize disease and cause-of-death terminology in the United States and internationally did not, however, successfully emerge until the late nineteenth century. While many disease terms were in common, their diagnostic applications were not. I argue that certain constitutive and regulative features of death registration did not match up with the institutional mandate of Massachusetts's vital registration system until forty years after its implementation. The institution-building process required the alignment of these features as normative practices, culminating in the organized efforts of European and American medical professionals to instruct physicians in proper nomenclature through explicit references and sanctions in the 1900 International Classification of Diseases. The pragmatic conditions out of which both Massachusetts' cause-of-death registration system and the International Classification of Diseases emerged did not consist of special circumstances or unique cultural practices. The social meanings of mortality in nineteenth-century Massachusetts reflected the public commitments of a diverse set of communities and practices that shared similar resources in working out the struggles and triumphs of communicating the language of death and disease.

ix, 88 p. A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / This dissertation addresses the high disease burden in developing countries today by examining the role of disease in economic development through its impact on productivity, fertility and human capital investment. In the second chapter of this dissertation, I model the impact on labor productivity of a change in disease susceptibility that results from intellectual property rights (IPR) reform. I develop a North-South model in which the disease environments differ between the rich and poor countries, and individuals consume innovated health goods to avoid the cost (labor time lost) of getting a disease. Southern welfare is shown to increase with the imposition of IPR protection when health needs in the South differ sufficiently from those in the North, and when health goods are accessible (in terms of adequate health care infrastructure) and effective (in counteracting disease). In the third chapter of this dissertation, I model the impact of child disease burden on fertility and human capital investment. The fertility response to a decline in child mortality depends on the morbidity effect of the disease, the level of disease burden, and whether prevalence rates or case fatalities decline. Fertility rates follow mortality and morbidity, but since mortality and morbidity do not always move in the same direction, the fertility response may be dampened or non-monotonic. Using a 20-year panel data set on malaria prevalence for 44 countries in sub-Saharan Africa, I find empirical support for the cases defined by the model; changes in malaria prevalence affect fertility more in non-endemic areas, where cases are more severe and more fatal relative to endemic areas. Historical and biological evidence suggest a link between (infectious) diseases early in life and (non-infectious) diseases later in life. In Chapter IV I model this link using a three-period overlapping generations model in which childhood disease outcomes affect longevity. Simulations in a general equilibrium framework duplicate the defining characteristics of the epidemiological-demographic transition as it occurred in many industrialized countries: as disease declines parents engage in a quantity-quality tradeoff for children, longevity rises and population declines after an initial jump. This dissertation includes unpublished co-authored material. / Committee in charge: Shankha Chakraborty, Chairperson, Economics; Bruce Blonigen, Member, Economics; Peter Lambert, Member, Economics; Laura Leete, Member, Planriing Public Policy & Mgmt; Jean Stockard, Outside Member, Planning Public Policy & Mgmt

Although the association between social inequality and poor adult health is well established, the mechanisms by which inequality is translated into poor adult health are less clear. Increasingly, evidence suggests that many adult health problems and health disparities have their origins in early life; the developmental origins of health and disease (DOHaD) hypothesis provides an explanatory mechanism linking adverse early life conditions with permanent structural or functional changes that increase the risk for disease. This hypothesis is consistent with bioarchaeological research noting reduced lifespan among individuals exhibiting signs of childhood stress. The principal aim of this dissertation is to contribute a bioarchaeological perspective to health disparities research by investigating how health disparities can be measured and understood in the past. This study focuses on early life conditions as a source of adult health disparity by examining a skeletal sample for the association between childhood stress and adult longevity; the relationship between childhood stress and the presence of adult health conditions; and sex, ancestry, and regional differences in these relationships. The study sampled 830 age-documented, U.S. born African American males and females and Euro-American males from the Terry and the Hamann-Todd anatomical collections, representing socially-marginalized individuals from the late 19th- to early 20th centuries. Enamel hypoplasia, femoral length, and vertebral neural canal diameters represented childhood stress; skeletal fractures, tibial periostosis, and the diseased, missing, and filled tooth index represented adult health. Longevity was modeled with Kaplan-Meier survival curves and adult health relationships were modeled with logistic regression. Additionally, cause of death data from historic health department publications and the study sample morgue records were examined for disparity in the epidemiological transition from infectious to degenerative cause of death. The study found mixed results for all analyses. There was no reduction in longevity for the presence of enamel hypoplasia, short femoral length, or reduced thoracic neural canal diameter. African American males had statistically significant reduced longevity for small lumbar vertebral neural canal diameters. African American males from the Hamann-Todd Collection and Euro-American males from both collections had significant relationships between vertebral neural canal diameters and adult conditions; these relationships varied among the groups but in most cases demonstrated reduced odds for having the adult condition for individuals with smaller canal diameters. African American females had no differential survival or relationships between variables over the lifecourse. All groups except for the Terry Collection Euro-American males continued to have more infectious disease deaths than degenerative disease deaths. The study results contribute to disparities research by demonstrating that the consequences of childhood stress varied by sex and ancestry and by demonstrating within-population variation in timing of the epidemiological transition. Additionally, the study results support the contention of greater male sensitivity to environmental conditions and contributes evidence supporting the DOHaD hypothesis.

Inequalities in levels of health between regions within a country are frequently regarded as a problem. Zimbabwe is characterised by poor and unequal conditions of health (both the state of people‘s health and health services). The health system of the country shows severe spatial inequalities that are manifested at provincial, district and even local levels. The current research therefore examines and analyses the spatial inequalities and temporal variation of health conditions in Zimbabwe. Composite indices were used to determine the people‘s state of health in Zimbabwe. Administrative districts were ranked according to the level of people‘s state of health. Cluster analysis was also performed to demarcate administrative districts according the level of health service provision. Districts with minimum difference were demarcated in a single cluster. Clusters were delineated using data on patterns of diseases and health and such clusters were used to demarcate the country‘s spatial health system according to the Adapted Epidemiological Transition Model. This was meant to evaluate the applicability of the model to Zimbabwe. It emerged from the research that generally the country‘s health conditions are poor and the health system is characterised by severe spatial inequalities. Some districts are experiencing poor health service provision and serious health challenges and are still in the age of pestilence and famine but others have good health service provision as well as highly developed health conditions and are in the age of degenerative and man-made diseases of the epidemiological transition model. It further emerged that the country‘s health has been evolving with signs of improvement since the 1990s. Some proposals are made in research for spatial development of health in the country. Recommendations were made regarding possible adjustment to previous strategies and policies used in Zimbabwe, for the development of the health system of the country. New strategies were also recommended for the improvement of the health system of the country. / Geography / Ph.D. (Geography)

INTRODUCTION: Epidemiological transition theory, first postulated by Omran in 1971, provides a useful framework for understanding cause-specific mortality changes and may contribute usefully to predictions about cause-specific mortality. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners due to lack of evidence from low- and middle-income countries. Therefore, understanding of the concept and development of epidemiological transition theory as well as population burden of premature mortality attributable to risk factors is needed. OBJECTIVES: This thesis aims to understand how epidemiological transition theory has been applied in different contexts, using available evidence on mortality transitions from high, middle- and low- income countries, as well as the contribution of risk factors to mortality transitions, particularly for premature mortality. METHODS: A Medline literature search from 1971 to 2013 was conducted to synthesise published evidence on mortality transition (paper I). A descriptive analysis of trends in cause of death using INDEPTH data was conducted, focusing on specific causes of death in 12 INDEPTH sites in Africa and Asia, using the INDEPTH 2013 standard population structure for appropriate comparisons across sites (paper II). A retrospective dynamic cohort database was constructed from Swedish population registers for the age range 30-69 years during 1991-2006, to measure reductions in premature non-communicable disease mortality using a life table method (paper III). Prospective cohort data from Västerbotten Intervention Programme from 1990 to 2006 were used to measure the magnitude of premature non-communicable disease mortality reductions associated with risk factor changes for each period of time (paper IV). FINDINGS: There were changes in emphasis in research on epidemiological transition over the four decades from 1971 to 2013, from cause of death to wide-ranging aspects of the determinants of mortality with increasing research interests in low-and middle-income countries, with some unconsidered aspects of social determinants contributing to deviations from classic theoretical pathways. Mortality rates declined in most sites, with the annual reductions in premature adult mortality varied across INDEPTH sites, Sweden, which now is at late stage of epidemiological transition stage, achieved a 25% reduction in premature mortality during 1991-2006. Overall downward trends in risk factors have helped to reduce premature mortality in the population of Västerbotten County, but some benefits were offset by other increasing risks. The largest mortality changes accrued from reductions in smoking, hypertension and hypercholesterolaemia. CONCLUSIONS: This thesis established patterns of current epidemiological transition in high, middle-and low-income countries (Asia and Africa), where the theory fits the transition patterns in some countries, but with some needs for further adjustments in other settings, as well as deviations from the classical ET theory in the last four decades. It highlights the need to identify the burden of mortality and morbidity, particularly for reducing mortality occurring before the age of 70 years and its attribution to risk factors, which are a major public health challenge. This informs shifting of public health priorities and resources towards prevention and control of chronic non-communicable disease risk factors.

Demographic and epidemiological change has resulted globally in changes in population and individual health, which, in turn, have resulted in changing care needs. Demographic change in South Africa, mainly through a confluence of declining fertility rates and pre-AIDS increases in life expectancy, has produced an ageing population that is expected to continue ageing for at least the next 10 to 15 years. Currently, South Africa’s older population (60 years+) has a much higher annual average percent growth rate than the total population. Having more older persons than ever before implies increased prevalence of frailty, chronic disease and disability through a tendency of declining physical, mental and cognitive functional capacities—hence meaning a larger demand for care. The changing age structure of a population is commonly associated with changes in health, disease and cause of death patterns. Recent research indicates an intensive, quadruple burden of disease, with the major addition of HIV/AIDS to persistent pre-transitional conditions, non-communicable conditions, and high rates of injuries—implying an extensive and diverse need for care. While demographic and epidemiological change have led to an increased demand for care, health system change, shortages in formal public health care delivery, and the spiralling costs of private care have led to decreased availability of formal care. Care-requiring persons therefore may need to rely increasingly on ‘informal care’, defined here as ‘care provided at home to another person who, because of frailty disability or ill-health, cannot manage on his/her own’. Research on informal care in developed nations is well-established and extensive, but has received very little attention in South Africa where it is not clear how many and who it is that are informal carers. The thesis study has hence been conducted to contribute to the limited research in the field of informal care, aiming to establish the national extent of informal care, and to present a demographic and socio-economic profile of informal carers. A multi-stage stratified area cluster probability sample of 2704 persons was drawn from free-living adults in a nationally-representative household survey in 2000. Field data were collected during 2611 individual face-to-face interviews. Basic univariate and logistic regression analyses were conducted. Of the adult population, 27% were found to be informal carers. Significant prevalence differences were found regarding sex, population group, geographic residence, education, employment status, and income. Adjusting for selected demographic characteristics, the significance status and levels of some relationships changed. It is concluded that informal caregiving is widespread in South Africa. While demographic and epidemiological evidence suggest that the reliance on informal carers is expected to increase, many informal carers are struggling to shoulder the physical, mental and financial burden. A national strategy to focus on informal carers is recommended, to raise awareness about their essential role and value in the health care system; to recognize their contributions to population and individual health; to comprehensively support them; and to assess their needs and concerns through ongoing research. / Dissertation (MA (Demography))--University of Pretoria, 2006. / Sociology / unrestricted

Inequalities in levels of health between regions within a country are frequently regarded as a problem. Zimbabwe is characterised by poor and unequal conditions of health (both the state of people’s health and health services). The health system of the country shows severe spatial inequalities that are manifested at provincial, district and even local levels. This research therefore examines and analyses the spatial inequalities and temporal variation of health conditions in Zimbabwe. Composite indices were used to determine the people’s state of health in Zimbabwe. Administrative districts were ranked according to the level of people’s state of health. Cluster analysis was also performed to demarcate administrative districts according the level of health service provision. Districts with minimum difference were demarcated in a single cluster. Clusters were delineated using data on patterns of diseases and health and such clusters were used to demarcate the country’s spatial health system according to the Adapted Epidemiological Transition Model. This was used to evaluate the applicability of the model to Zimbabwe. It emerged from the research that generally the country’s health conditions are poor and the health system is characterised by severe spatial inequalities. Some districts are experiencing poor health service provision and serious health challenges and are still in the age of pestilence and famine but others have good health service provision as well as highly developed health conditions and are in the age degenerative diseases of the epidemiological transition model. It further emerged that the country’s health has been evolving with signs of improvement since the 1990s. Recommendations were made regarding possible adjustment to previous strategies and policies used in Zimbabwe, for the development of the health system of the country. New strategies were also recommended for the improvement of the health system of the country. Some proposals are made for further research on the spatial development of health in the country. / Geography / D. Litt et. Phil. (Geography)

Il est actuellement bien établi que les facteurs nutritionnels sont les principaux déterminants de l’émergence des maladies chroniques. Au Maroc, il n’existe pas à ce jour de données étayant ces propos, bien que ce pays soit en pleine transition épidémiologique. L’objectif de la thèse était d’étudier la relation entre les facteurs nutritionnels et l’obésité ou surpoids chez un échantillon représentatif des adultes marocains âgés de 18 ans et plus obtenu par tirage au sort et stratification sur le sexe et l’origine. Au total, 2896 sujets ont participé à cette enquête transversale. L’obésité et le surpoids étaient très fréquents (13,5% et 29,9% respectivement) avec de grandes disparités socioéconomiques. Pour mieux décrire le comportement alimentaire des marocains, très probablement en rapport avec l’émergence de ce phénomène, plusieurs approches complémentaires ont été utilisées. D’abord, l’adhérence au régime de type méditerranéen, a été mesurée par un score construit selon une approche confirmatoire. Puis, l’identification des principaux profils de consommation spontanément observés par des méthodes exploratoires (analyse en composantes principales). Il s’avère que le régime méditerranéen n’était pas le régime communément suivi par toute la population marocaine. De plus, quatre principaux profils étaient identifiés et décrivent mieux le phénomène de transition nutritionnelle dont la spécificité au Maroc est le maintien de certains aliments traditionnels tels les céréales et légumes en plus de l’introduction des aliments occidentalisées tels les produits laitiers. Ces profils étaient associés aux caractéristiques sociodémographiques des individus. Une association significative a été notée entre l’obésité et les profils alimentaires occidentalisés mais pas avec le régime méditerranéen qui était, par ailleurs, associé au surpoids. / It is now well established that nutritional factors are the main determinants of the emergence of chronic diseases. In Morocco, there is currently no data to support this evidence, although this country is experiencing an epidemiological transition. The aim of the thesis was to study the relationship between nutritional factors and overweight or obesity in a representative sample of Moroccan adults aged 18 years and above. This sample was obtained by a simple random technique after stratification by sex and origin. In total, 2896 subjects have participated in this cross-sectional survey. Obesity and overweight were very frequent (13.5% and 29.9% respectively) with large socioeconomic disparities. To better describe the behavior of Moroccan food, most likely related to the emergence of this phenomenon, several complementary approaches were used. First, adherence to Mediterranean diet was measured by a score constructed using a confirmatory approach. Then, the identification of major patterns of consumption observed spontaneously by exploratory methods (Principal Component Analysis). Mediterranean diet was not the commonly diet followed by the entire Moroccan population. In addition, four major patterns were identified and describe better the nutritional transition in Morocco whose specificity is the maintenance of some traditional foods such as cereals and vegetables with some Westernized foods newly introduced such as dairy products. These profiles were associated with sociodemographic characteristics of individuals. A significant association was found between obesity and westernized dietary patterns but not with the Mediterranean diet which was associated with overweight.