This thesis is based on a population study conducted to explore ethnic inequalities in cardiovascular disease using Hospital Episode Statistics (HES). The Hospital Episode Statistics have significant potential for health studies for ethnic groups, due to the large number of events from minority ethnic groups, comprehensive clinical information, full England coverage and fine geographical scale. However, the percentage of Finished Consultant Episodes (FCEs) with invalid ethnicity codes is at a high level. This thesis starts by developing a record linkage method and a coding rate method to improve the data quality of ethnicity codes in the HES. This thesis then further examines ethnic inequalities in cardiovascular disease incidence in England at both national and local geographical scales. The patterns of ethnic inequalities in cardiovascular disease appear to have changed little in the last ten years. However, large variations of geographical relative risk of cardiovascular disease were observed for ethnicity-sex groups. The relationships between areal socioeconomic status measured at different geographical scales and ethnic inequalities in different types of cardiovascular disease were also explored. As there are very limited data on the mortality of minority ethnic groups in the UK, few studies have compared the incidence and outcome of cardiovascular disease from the same population. This thesis came up with some novel findings, for example, that people from minority ethnic groups, who generally have increased risk of cardiovascular disease incidence, have better cardiovascular disease survival than white people. The contribution of areal socioeconomic status, distance to treatment sites and cardiovascular disease severity and treatment to the ethnic inequalities in cardiovascular survival was examined. The relationships between socioeconomic status measured at different geographical scales and ethnic inequalities in cardiovascular disease severity and treatment were investigated in this thesis as well.

Urbane Gesundheit ist von globalem Interesse, da schon jetzt die Mehrheit der Menschen in Städten wohnt und dies zunehmend in Entwicklungsländern. Obwohl mentale Gesundheitsprobleme (z.B. Depressionen) in Entwicklungsländern stark verbreitet sind, wurden diese für die rasant anwachsenden Städte dieser Länder bisher nicht zufriedenstellend untersucht. Mit einem räumlich-epidemiologischen Ansatz werden in der vorliegenden Dissertation Faktoren identifiziert, welche das mentale Wohlbefinden der Slumbewohner Dhakas beeinflussen. Hierfür wurden Baseline Daten einer Kohortenstudie verwendet, welche Anfang 2009 in neun Slums in Dhaka durchgeführt wurde. Es wurden Daten von 1.938 Erwachsenen (≥15 Jahre) erhoben. Der WHO-5 Well-being Index wurde als Instrument zur Selbsteinschätzung des mentalen Wohlbefindens verwendet. Mentales Wohlbefinden war signifikant mit verschiedenen Faktoren der natürlichen Umwelt, der Sicherheit vor Überflutungen, sanitären Verhältnissen, sowie mit qualitativ hochwertiger, zufriedenstellender und beständiger Behausung assoziiert. Weitere mentale Gesundheitsassoziationen wurden in Bezug auf Bevölkerungsdichte, Zufriedenheit mit der Arbeitsstelle und mit der Einkommensgenerierung identifiziert, während für individuelle Faktoren wie Alter, Geschlecht, Krankheiten, Gesundheitswissen und Migrationshintergrund angepasst wurde. Räumliche Konzentrationen von gutem und schlechtem mentalem Wohlbefinden wurden festgestellt, welche auf massive Gesundheitsungleichheiten innerhalb der Slums hindeuten. Verschiedene Nachbarschaftskontexte wirken sich zudem in anderer Weise auf das Wohlbefinden aus als persönliche und Haushaltscharakteristika. In der Annahme, dass mentale Gesundheitsprobleme das Risiko physischer Krankheiten sowie die Unfallgefahr erhöhen, liefert diese Dissertation wichtige Informationen, um sowohl eine bessere Krankheitsversorgung als auch sinnvolle Krankheitspräventionsprogramme für die Slums von Dhaka und vergleichbarer Gebiete zu entwickeln. / Urban health is of global concern because the majority of the world’s population lives in urban areas, mainly in the global south. Although mental health problems (e.g., depression) in developing countries are highly prevalent, such issues are not yet adequately addressed in the rapidly urbanising megacities of these countries, where a growing number of residents live in slums. Little is known about the spectrum and burden of mental disease in urban slums. Using a spatial-epidemiological approach, this thesis identifies factors that contribute to mental well-being in the slums of Dhaka, the capital of Bangladesh, which currently accommodates an estimated population of more than 14 million, including 3.4 million slum dwellers. The baseline data from a cohort study conducted in early 2009 in nine slums of Dhaka were used. Data were collected from 1,938 adults (≥15 years). The WHO-5 Well-being Index was used as a measure of self-rated mental well-being. It was found that mental well-being was significantly associated with various factors such as selected features of the natural environment, flood non-affectedness, sanitation, and housing quality, sufficiency and durability. Further associations with population density, job satisfaction, and income generation were identified while adjusting for individual factors such as age, gender, diseases, health knowledge, and migration. Spatial clusters of poor and good mental well-being among different population groups were detected and point to severe health disparities both within and between the slums. Diverse neighbourhood conditions affected mental well-being differently from personal and household level characteristics. Given that mental health conditions could elevate the risk for physical diseases and contribute to injuries, this thesis may provide crucial information for developing better health care and disease prevention programmes in Dhaka’s slums and other comparable settings.

L’étude géographique des risques sanitaires hydriques à Antananarivo, capitale métropolitaine de Madagascar, pays tropical et au niveau de développement faible, s’articule à travers les conditions d’accès à la ressource, l’évaluation de la qualité de l’eau distribuée mais également à travers les pratiques domestiques accomplies jusqu’à sa consommation. Cette thèse cherche à illustrer via le déterminant hydrique combien les questions au croisement de la santé et de l’environnement sont, dans un milieu urbain en développement, des questions complexes. Cette complexité est engendrée par les différentes composantes du système pathogène à intégrer et les relations entre elles. À Antananarivo, nos analyses montrent que les disparités de santé en matière de risques hydriques sont le reflet d’une configuration sociale dichotomique héritée entre ville basse et ville haute et donc fortement imprégnée par les représentations. Comprendre les mécanismes à l’origine de ces disparités de santé, conduit à interroger les milieux de vie comme facteur risque, ici les quartiers précaires d’Antananarivo. Ces lieux sont soumis à des effets qui sont identifiés dans la littérature comme des effets de contexte (relatifs aux caractéristiques du territoire) et des effets de composition (relatifs aux caractéristiques des individus). À Antananarivo, l’approche quantitative confirme la prédominance des effets de contexte sur les effets de compositions. Pourtant, notre travail de terrain à travers la démonstration des pratiques et des compétences citadines mises en œuvre par les populations pour pallier, notamment les défaillances des services urbains de santé, de l’eau et de l’assainissement, nuance cette vision statique et déterministe des territoires enquêtés. En accord avec de récentes publications, cette recherche avec les difficultés que peuvent représenter les études un milieu urbain en développement, soutient qu’il existe une relation plus complexe et rétroactive entre les pratiques des populations et les territoires et que cette relation est en perpétuelle évolution. Les individus par leurs pratiques s’approprient et modifient la configuration des territoires et inversement. / The geographical study of the health risks related to water in Antananarivo, metropolitan capital of Madagascar, a tropical country with a low level development, is articulated through the access conditions to the water resources, the evaluation of supplied water quality and the domestic practices performed until its consumption. This thesis seeks to illustrate via the hydric determinant how complex are the issues at the intersection of health and environment in an urban developing area. This complexity is due to the integration of the various components of the pathogenic system and the connections between them. In Antananarivo, our analyses show that the disparities of health as regards hydric risks are the reflection of a dichotomic social configuration inherited between the lower and the upper city and thus strongly impregnated by the social representations. To understand the mechanisms at the origin of these disparities of health, life environment in the precarious districts of Antananarivo is studied as a risk factor. These places are subjected to effects which are identified in the literature like contextual effects (relating to the characteristics of the territory) and compositional effects (relating to the characteristics of the individuals). In Antananarivo, the quantitative approach confirms the predominance of the contextual effects over the compositional effects. However, our fieldwork moderates this static and deterministic vision of the surveyed territories through the observation of the coping strategies developed by the populations to mitigate the failures of the urban services of health, water and sanitation. In agreement with recent publications, this research, argues that it exists a more complex and retroactive relation between the practices of the populations and the territories. This relation is in perpetual evolution. The individuals by their practices adapt and modify the configuration of the territories and conversely.

L’accès aux soins est une préoccupation des pouvoirs publics, des patients et des médecins. Après avoir identifié le rôle et les différentes aspirations de ces acteurs de santé, une synthèse reposant sur la construction des concepts en sciences sociales est proposée afin de comparer les différentes approches de l’analyse et de la mesure de l’accès aux soins. En France, ce concept est principalement étudié à travers les difficultés financières ou la distance géographique, pourtant sa nature est multidimensionnelle. A partir de cette analyse, deux enquêtes ont été menées pour recueillir les perceptions de mille patients et cinq cents médecins libéraux afin de déterminer précisément la nature et la fréquence des difficultés d’accès aux soins. Les résultats montrent que les principaux obstacles sont le temps d’attente en cabinet chez les généralistes et le délai d’obtention d’un rendez-vous chez les spécialistes. Ces éléments sont également des facteurs de renoncement aux soins. L’enquête réalisée auprès des médecins identifie leurs perceptions concernant les difficultés d’accès aux consultations de leurs patients, leurs conditions de travail et les solutions privilégiées pour diminuer lesdélais de prise en charge des patients. Un vif intérêt pour le regroupement avec d’autres confrères est exprimé, en particulier pour les jeunes médecins. Ainsi, les deux principaux modes d’organisation émergents de l’offre de soins, les maisons de santé pluriprofessionnelles et la télémédecine, sont analysés et discutés à la suite de retours d’expériences et d’entretiens semi-directifs. A l’initiative des acteurs locaux, ces coopérations entre professionnels de santé favorisent la qualité et la durabilité des services de soins sur les territoires. / Access to health care is a concern for governments, patients and physicians. This study identifies the role and aspirations of health stakeholders and, based on the construction of social science concepts, it compares the previous conceptual frameworks analyzing and measuring access to health care. Access to health care is a multidimensional concept; however it was mainly analyzed through financial difficulties or geographical distance in France. Two surveys were conducted to collect the perceptions of one thousand patients and five hundred liberal doctors to determine the origin and frequency of problems of access to health care. The results show that the main barriers are the waiting time in the office of general practitioner and the waiting period to get an appointment with specialists. These previous factors lead also to health carerenunciation. Concerning the physicians, the survey identifies their perceptions of patient’s difficulties, their working conditions and their preferred solutions against the waiting period before patients care receiving. It appears that young doctors are particularly interested in group medical practices. Thus, the two main emerging organizations offering health care i.e., multidisciplinary health house and telemedicine are analyzed and discussed as a result of feedbacks and semi-structured interviews. At the initiative of local actors, cooperation between health professionals promotes the quality and sustainability of health care services in the territories.

Made available in DSpace on 2016-08-19T17:47:14Z (GMT). No. of bitstreams: 1 Dissertacao Marita.PDF: 1934711 bytes, checksum: 95583de2cf2048c15f954cbf5d816b26 (MD5) Previous issue date: 2004-04-11 / A geographical and historical analysis of helth-environment relation applied to the urban space of São Luis between 1854 and 1954, the main purpose is to discuss the binomial health-environment since the origin of Health Geography, showing how its presuppositions had been linked to the images of the maranhense environment and to the urban growth of São Luís, attending the economical priority of the social actors who investigated the urban diseases, The dialectic method of abordage and the historical procedure method were used, justapoing the qualitative aborgade through data interpretation, in the analysis of the contents of the researched texts, The origin and the development of the urban space as source of epidemic and endemic diseases are discussed, observing that the historical records indicate that this space was considered unhealthy, mainly, because of the populational concentration and because of the lack of basic infra-structure. As corollary of the insalubrity of the urban environment, the first sanitary rules were applied and regulated the use of it. The urban space is taken as an object to be medicated. As a scientific landmark to Health Geography of Maranhão it is considered the doctorate thesis Climate and most frequent diseases of the province of Maranhão , by César Augusto Marques, a doctor from Maranhão, presented in 1854. The historical aspects of the miasmatic and microbian theories are rescued, contextualizing in what way both of them gave priority or not to the relation health and envrironment, and their applicability to the movement of hygienist intervention of the urban space. From that dicussion it is done an analysis in which periods the miasmatic and microbian theories served as theorethical support to treat and attend the disorderly growth of the urban space of São Luís, and yet to discuss how the relation health-environment was priviledged and/or excluded in the actions of sanitary care which regulated the us and occupation of the same space. In spite of its theorethical and scientific restrictions, it is confirmed that the miasmatic theory was observed in the relation health and urban environment; as basic presupposition in the mitigating measures in promoting health, giving priority to the multicausality of factors vision which interfere in the population s health. The microbian theory, despite of contextualizing at first the relation health and urban environment of São Luís, gave more priority to the unicausality vision between the pathogenic agents and man. / O estudo faz uma análise geográfica e histórica da relação saúde-ambiente aplicada ao espaço urbano de São Luís, no recorte temporal de 1854 a 1954, e tem como principal escopo discutir o binômio saúde-ambiente a partir da origem da Geografia da Saúde e de que forma os seus pressupostos estiveram atrelados as imagens do ambiente maranhense e ao crescimento urbano de São Luís; atendendo assim as prioridades econômicas dos atores sociais que investigaram as doenças urbanas. Aplicou-se o método de abordagem dialético e método de procedimento histórico, justapondo-se a abordagem qualitativa através da interpretação dos dados, na análise de conteúdo dos textos pesquisados. Disserta-se sobre a origem e o desenvolvimento do espaço urbano como foco de doenças epidêmicas e endêmicas, observando que os registros históricos indicaram que esse espaço foi considerado insalubre, principalmente, em decorrência da concentração populacional e na ausência de infra-estrutura básica. Como corolário da insalubridade dos ambientes urbanos, as primeiras normas sanitárias foram aplicadas e disciplinaram o uso do mesmo. O espaço urbano passa a ser considerado um objeto a ser medicado. Como marco cientifico para a Geografia da Saúde no Maranhão considera-se a tese de doutorado Clima e moléstias mais freqüentes na província do Maranhão , de Augusto César Marques, médico maranhense, defendida em 1854.Resgata-se a historicidade das teorias miasmática e microbiana, contextualizando-as de que forma ambas priorizaram ou não a relação saúde e ambiente, e sua aplicabilidade junto ao movimento de intervenção higienista do espaço urbano.A partir dessa discussão analisa-se em quais períodos a teoria miasmática e microbiana serviram como suporte teórico para medicar e acompanhar o crescimento desordenado do espaço urbano de São Luís, e ainda discutir como a relação saúde e ambiente foi privilegiada e/ou excluída nas ações de cunho sanitarista que disciplinaram o uso e ocupação do mesmo espaço. Confirma-se, que apesar de suas restrições teóricas e científicas, a teoria miasmática foi observada na relação saúde e ambiente urbano; como pressuposto básico nas medidas mitigadoras em promover a saúde, priorizando a visão da multicausalidade de fatores que interferem na saúde da população. A teoria microbiana, apesar de contextualizar inicialmente a relação entre a saúde e o ambiente urbano de São Luís, priorizou mais a visão da unicausalidade entre os agentes patogênicos e o homem.

Les médecins généralistes libéraux sont inégalement répartis en France depuis longtemps. Ces inégalités se renforcent au détriment d’espaces moins attractifs. Des zones avec des difficultés d’accès aux soins, urbaines et rurales, apparaissent ou s’étendent. Depuis 2008, les pouvoirs publics accompagnent financièrement les maisons de santé pluriprofessionnelles en espérant qu’elles attirent et maintiennent des médecins dans ces espaces.Cette recherche étudie dans quelle mesure l’espace et le territoire participent à l’implantation de MSP, et en retour quels sont les effets de ces structures sur les espaces et territoires concernés. L’implantation des MSP et leurs effets seront étudiées à différentes échelles géographiques à partir d’approches quantitative et qualitative. Au plan quantitatif, l’analyse spatiale des MSP utilise plusieurs outils (typologies et SIG). Ceci est complété par plusieurs terrains dans lesquels il s’agit d’étudier la place des MSP dans des régions et territoires donnés, en recueillant les témoignages des principaux acteurs concernés. Les effets des MSP sur l’offre de soins sont étudiés sur le territoire métropolitain selon une approche nationale comparant l’évolution de la densité de généralistes libéraux dans des espaces avec MSP comparativement à des espaces « similaires » sans MSP. La conduite de terrains dans deux régions vient compléter et discuter les résultats.Mots clés : espace défavorisé, espace fragile, espace rural, évaluation de politiques publiques, géographie de la santé, maisons de santé pluriprofessionnelles (MSP), soins de premiers recours, médecins généralistes libéraux. / France faces an old and persistent problem, which is geographical imbalance of general practitioners. This uneven distribution grows at a steady pace due to less attractive areas. New urban and rural areas are emerging with limited access to primary health care, while existing ones grow even bigger. Since 2008, the liberal primary care team (PCT) are financially supported by the public authorities. They hope this structure will attract and retain general practitioner in the aforementioned areas.This study aims to explore how the space and the territory contribute to the localisation of PCT and how these structures affect spaces and territories. Localisation and impact of PCT are studied at different level, using quantitative and qualitative approaches. Spatial analysis of PCT is based on several tools such as SIG and typology in synergy with field investigation in two French regions. Effects of PCT on general practitioner density are studied on a national scale comparing the evolution of this density in space with PCT and similar space without PCT. The results are completed with field investigation.

Type 1 diabetes (T1D) is an autoimmune disease that destroys the bodies’ insulin producing beta-cells. The disease is understood to be triggered in genetically susceptible individuals by environmental factors. While the genetic side of the etiological model has to some degree been uncovered, there is no clear understanding of which environmental factors play a role in the disease process. Several hypotheses claim to explain the development of T1D, of which enteroviral infections show the most promise. According to this hypothesis high prevalence of enteroviral infections would also mean high incidence rates of T1D. This study focused on four Nordic countries (Denmark, Finland, Norway and Sweden) that as late as 2017 were found in the top 10 countries for incidence rate of childhood-onset T1D in the world. Incidence rates of T1D and prevalence of enteroviruses were mapped and geographically analyzed according to the principles of spatial epidemiology, after which correlation coefficients were calculated. In doing so the study tried to answer to which extent the prevalence of enteroviruses could explain the regional variations in T1D. For all countries no significant correlation was found, but increasing sample size, by grouping countries, showed considerably different outcomes with a small positive correlation in the case of Norway and Finland.

Health and reducing disparities in health between and within countries are among the principal global sustainable development objectives for the period 2016-2030. The incidence of Occupational Diseases (OD) is characterized by very distinct differentiation, both regional and sectoral, and has considerable dynamics in time and place. Given that Czechia is at the top among all EU member states in terms of employment in the automotive industry and production of new vehicles, new research on OD in the automotive industry acquires importance. The Ph.D. Thesis is conceived as an ecological correlation study focusing on the study of the determinants of OD in automotive industry. Its own core work is to analyze 32,646 cases of OD (in the past 20 years) and a set of data from a survey of 247 companies of the automotive industry (employing nearly 110,000 employees, i.e. 78 % of the economically active population working in this sector). In the present work are used available data from routine statistics, data from registers and basic sanitation data from a questionnaire survey. The study innovatively links research of Global production networks and medical-geographical approach. At the end of the Ph.D. Thesis, specific outcomes for praxis and discusses possible topics for further research in this area are...

Aedes aegypti est le vecteur principal de la dengue et du virus Zika. La surveillance et le contrôle vectoriels constituent des armes de première ligne pour lutter contre les arboviroses transmises par ce moustique. Dans ce cadre, cette thèse propose un modèle conceptuel (MODE) qui permet de reproduire in silico l'environnement dynamique d'Aedes aegypti aux échelles auxquelles sont organisées (échelle de la ville - MODE-macro) et menées (échelle du quartier -- MODE-micro) les campagnes de lutte anti-vectorielles. L'environnement ainsi généré peut (1) être intégré à un modèle à base d'agents qui permet alors de simuler le système pathogène complexe de la dengue ou du Zika (environnement - vecteur - hôte - virus) et (2) être utilisé pour cartographier l'aléa environnemental du risque vectoriel dans la ville. Le modèle conceptuel MODE repose sur une approche phénoménologique transposable dans le temps et dans l'espace : il peut être appliqué dans différents contextes urbains, à différentes périodes et à différentes échelles. Afin de garantir sa généricité spatio-temporelle, les modèles informatiques MODE-micro (échelle du quartier) et MODE-macro (échelle de la ville) ont été implémentés dans le but de générer des environnements dynamiques à partir de données libres ou aisément accessibles. Dans ce travail, les potentialités de MODE ont été évaluées à Delhi (Inde) et Bangkok (Thaïlande). Les connaissances issues de l'étude des relations dynamiques, multifactorielles et non-linéaires entre l’environnement et le vecteur devraient permettre d’améliorer les stratégies de surveillance et de contrôle. / Aedes aegypti is the main vector of dengue and Zika virus. Surveillance and vector control are frontline weapons in the battle against arboviruses transmitted by this mosquito. In this framework, the following thesis introduces a conceptual model (MODE) which can be used to recreate in silico the dynamical environment of Aedes aegypti at scales that match the ones at which vector control campaigns are organised (city scale - MODE-macro) and performed (neighbourhood scale - MODE-micro). The environment thus generated can be integrated with an agent-based model to simulate dengue or Zika complex pathogenic systems (environment - vector - host - virus) and can be used to map the environmental hazard of the vectorial risk in a city. The conceptual model MODE is based on a phenomenological approach that is transferable in time and space : it can be applied in different urban contexts, at different periods of time and at different scales. In order to ensure their spatio-temporal genericity, the computer models MODE-micro (neighbourhood scale) and MODE-macro (city scale) have been implemented for the purpose of generating dynamical environments using open or easily accessible data. In this thesis, MODE's potentials were assessed in Delhi (India), and Bangkok (Thailand).Knowledge resulting from the study of the dynamic, multifactorial and non-linear relationships between the environment and the vector should lead to the improvement of vector surveillance and control strategies.