Avec le vieillissement démographique, le nombre de personnes âgées dépendantes augmente et les proches (ou "tierces personnes") sont de plus en plus sollicités à leur côté. Dans une visée de santé publique, il importe d'étudier la place des tierces personnes dans le vieillissement et la relation entre dépendance et accumulation de facteurs de risque accessibles à la prévention.Le premier axe de cette thèse s'intéresse à l'intervention des tierces personnes dans les études de cohorte avançant en âge. Le deuxième axe consiste à analyser l'association entre la dépendance et l'accumulation de déficits sensoriels ou de comportements de santé.Cette thèse se base sur les données des femmes de la cohorte E3Nnées entre 1925 et 1930 : celles auto-rapportées et celles recueillies auprès d'une tierce personne. La dépendance est définie comme la présence d'une limitation dans au moins une des huit activités de l'échelle des activités instrumentales de la vie quotidienne (IADL).Les tierces personnes corroborent globalement la perception des personnes âgées concernant leur capacité à réaliser les IADL, étayant ainsi l'intérêt de leur implication dans les études épidémiologiques portant sur le vieillissement. Nous montrons également qu'un double déficit sensoriel est associé à un risque accru de survenue de la dépendance à court terme. De plus, le non-respect des recommandations concernant cinq comportements de santé était associé à une augmentation du risque de dépendance une dizaine d'année plus tard, selon un schéma cumulatif.Cette thèse contribue à valoriser la place des tierces personnes dans les études épidémiologiques et à améliorer les connaissances sur les facteurs de risque modifiables de la dépendance. Elle ouvre des pistes d'actions ciblées permettant d'améliorer la qualité de vie des personnes âgées tout en augmentant leur durée de vie sans incapacité. / The number of people living with disabilities is rising with the ageing of the population, leading to an increased need in proxy' help (or from "third partie"). Preventive approaches to delay disability or increase disability-free life expectancy are needed. In that respect, it is essential to study proxies'role in ageing, to identify risk factors of disability, and to analyze the effect of combinations of risk factors on risk of disability.The first aim of this PhD thesis was to study the contribution of proxies in cohorts of older people. The second aim was to analyze the association between disability and cumulative sensory impairments or health behaviours.The study population consisted in a subpopulation of the E3N cohort of women born between 1925 and 1930. Data were self-reported and/or reported by a proxy. Disability was defined as a limitation in at least one of the eight instrumental activities of daily living (IADL) scale.Results supported the interest of proxy involvement in epidemiological studies, particularly in those dealing with ageing. Indeed, most proxies corroborated the perception of the elderly women about their ability to perform IADL. In the study of risk factors of disability, having a dual sensory impairment was associated with higher short-term incidence of disability. Moreover, not adhering to the recommendations in the five studied health behaviours was associated with an increased risk of disability ten years later, in a dose-dependent manner.This work contributes to highlight the usefulness of proxies in large epidemiological studies, and to enhance knowledge about risk factors of disability. It suggests tracks of targeted actions to improve the quality of life of older people, and to increase their disability-free life duration.

Emerging evidence indicates self-compassion can be beneficial for medical populations and for medical adherence; yet, research to date has not fully examined the reasons for this association. This study examined the association of dispositional self-compassion to adherence across five medical samples and tested the extent to which perceived stress accounted for this association. Five medical samples (total N = 709), including fibromyalgia, chronic fatigue syndrome, and cancer patients, recruited from various sources, completed online surveys. Self-compassion was positively associated with adherence in all five samples. A meta-analysis of the associations revealed a small average effect size (average r = .22, [0.15, 0.29]) of self-compassion and adherence and non-significant heterogeneity among the effects (Q (4) = 3.15, p = .532). A meta-analysis of the kappa2 values from the indirect effects of self-compassion on adherence revealed that, on average, 11% of the variance in medical adherence that was explained by self-compassion could be attributed to lower perceived stress. Overall, findings demonstrate that dispositional self-compassion is associated with better medical adherence among people with fibromyalgia, chronic fatigue syndrome, and cancer, due in part to lower stress. This research contributes to a growing evidence base indicating the value of self-compassion for health-related behaviours in a variety of medical populations.

Aims: The objective was to investigate if gender differences exist in the associations between periodontitis and type 2 diabetes. Disproportionate disparities by gender were found to exist in rates of both periodontitis and diabetes with respect to demographics and behavioural predictors that cannot be explained solely by the well-established association between these two diseases. Materials and methods: Multiple datasets were extracted from the National Health and Nutrition Examination Survey (NHANES) 2009–2014, which used a stratified multistage probability sampling to obtain samples from all civilian non-institutionalised people in the USA. Bivariate relationships between each explanatory variable and periodontitis level were assessed with odds ratios (OR) and their 95% confidence intervals (CI). A set of weighted logistic regression models was used to investigate the association differentiations between periodontitis and diabetes by gender. C-statistics measured the goodness-of-fit of weighted logistic regression models. Results: The prevalence of moderate–severe periodontitis was 36.39% and 22.71% among participants with type 2 diabetes and without diabetes, respectively. Type 2 diabetes was significantly associated with moderate–severe periodontitis OR (OR = 1.47, 95% CI: 1.18–1.82) among males even after adjusting for demographics, socioeconomic status and oral health behaviours. The aforementioned relationship was not found in females. Furthermore, different relationships of moderate–severe periodontitis with body mass index and the use of mouthwash were found between the males and females. Conclusions: The current findings suggest that important improvements in the development of gender-specific strategies in prevention, such as oral home-care, to reduce the high prevalence of periodontal disease and maintain good oral health are vital, and are especially important for male diabetic patients and those who are at high risk of developing diabetes, such as those who are obese.

Les différences de morbidité et de mortalité entre les groupes socioéconomiques constituent un des résultatsle plus cohérent de la recherche épidémiologique. Cependant, les mécanismes qui sous-tendent cetteassociation demeurent encore mal compris. Les données de deux grandes cohortes européennes ont étéutilisées pour décrire l'ampleur des différences socioéconomiques de mortalité toutes causes et spécifique, etexaminer le rôle des comportements de santé et du soutien social dans ces inégalités. Les indicateurs de lasituation socioéconomique dans l’enfance se sont révélés liés à la mortalité à l'âge adulte, même si toutefoisles trois mesures examinées – position socioprofessionnelle du père, niveau d’études et taille – étaientdifféremment liées à la mortalité. Les indicateurs de la position socioéconomique à l'âge adulte, catégoriesocioprofessionnelle et revenu, étaient associés à la mortalité toutes causes et cardiovasculaire dans les deuxcohortes. Dans l'étude Whitehall II, les comportements de santé étaient socialement distribués etexpliquaient une grande partie des inégalités sociales de mortalité, en particulier lorsque les changementsdans ces comportements au cours du suivi étaient pris en compte. Les mêmes comportements expliquaienttrès peu les inégalités sociales de mortalité dans l'étude GAZEL, leur répartition sociale étant faible danscette cohorte. Parmi les mesures de soutien social considérées, le statut marital expliquait également unepartie du gradient socioéconomique de mortalité dans l'étude Whitehall II, mais pas dans GAZEL, tandis quele rôle de la participation sociale et du réseau social était négligeable dans les deux cohortes. Différentsmécanismes semblent jouer un rôle dans les inégalités sociales de santé dans ces deux pays européensvoisins. Cela implique que des recherches comparatives visant à comprendre les déterminants communs etspécifiques des différences sociales de santé sont nécessaires. D’autres recherches visant davantage lescauses fondamentales des inégalités sociales de santé sont également souhaitables. / Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistentfindings of epidemiologic research. However, research on social inequalities in health has yet to provide acomprehensive understanding of the mechanisms underlying this association. Data from two large Europeancohorts were used to examine socioeconomic differences in all-cause and cause-specific mortality in twopopulations in early old age, as well as the role played by health behaviours and social support in shapingthose inequalities. Indicators of socioeconomic circumstances in early life were found to be related tomortality in adulthood, even though the association of the three measures examined, father’s occupationalposition, education and height, with mortality did not have the same shape and depended on the cause ofmortality being examined. Indicators of socioeconomic position in adulthood, occupational position andincome, were strongly associated with all-cause and cardiovascular mortality in both cohorts. In theWhitehall II study, health behaviours - smoking, alcohol consumption, diet and physical activity - werestrongly socially patterned, and were found to contribute to a large part of social inequalities in mortality,particularly when changes in these behaviours over time were taken into account. The same behaviourscontributed little to explaining social inequalities in mortality in the GAZEL cohort, as their socialpatterning was weak in this cohort. Of the measures of social support examined, marital status alsoaccounted for part of the socioeconomic gradient in mortality in the Whitehall II cohort but not in GAZEL,while the role of social participation and network size was negligible in both cohorts. Different mechanismsmay be driving social inequalities in health in two neighbouring European countries. This finding calls forfurther comparative research to understand the common and unique determinants of social differences inhealth within and between countries, and for additional research addressing the fundamental causes of socialinequalities in health.

Interventional technologies such as elective percutaneous coronary interventions (PCI)are increasingly used to manage the symptoms of coronary artery disease (CAD); however, this treatment approach is associated with poor risk factor management. The purpose of this study was to understand the factors that influence the health behaviors of elective PCI patients. A qualitative approach, using Interpretive Description, was used to explore the ten participants’ healthcare experiences, their perceptions of CAD, and the rationale for their health choices. This generated a profile of these individuals and their post-PCI health behaviours. Health behaviours were influenced by multiple factors and are reflected in the themes: what a relief – I’m better; uncertainty about their future health; the importance of relations; and barriers to lifestyle change. These findings not only extend our understanding of the elective PCI patients’ health behaviour choices but also provides insight into key areas to target for improving health service delivery.

Interventional technologies such as elective percutaneous coronary interventions (PCI)are increasingly used to manage the symptoms of coronary artery disease (CAD); however, this treatment approach is associated with poor risk factor management. The purpose of this study was to understand the factors that influence the health behaviors of elective PCI patients. A qualitative approach, using Interpretive Description, was used to explore the ten participants’ healthcare experiences, their perceptions of CAD, and the rationale for their health choices. This generated a profile of these individuals and their post-PCI health behaviours. Health behaviours were influenced by multiple factors and are reflected in the themes: what a relief – I’m better; uncertainty about their future health; the importance of relations; and barriers to lifestyle change. These findings not only extend our understanding of the elective PCI patients’ health behaviour choices but also provides insight into key areas to target for improving health service delivery.

Magister Public Health - MPH / Background: Alcohol consumption among adolescents is increasing due to the general availability of alcohol in many community settings. Binge drinking (defined as drinking 5 or more drinks per occasion) (Parry, 2000) is considered the most common type of harmful alcohol consumption among young people. The United States Youth Risk Behaviour Surveillance report proposes that patterns of health risk behaviours are established during youth (Centre for Disease Control and Prevention,2006). The abovementioned report highlights behaviours such as alcohol misuse, drug use and risky sexual behaviour that have the potential to undermine the health and development of youth. Adolescent developmental theories recognise risk behaviours as central to normal adolescent development but there are complex predisposing risk factors that can cause these behaviours to compromise the healthy development of our youth. In order to design and implement effective intervention schemes, we need to understand the dynamics of alcohol use among local youth better, as these play out in their specific social environmental and personal contexts.Aim: The aim of this study was to gain an understanding of what influences the patterns of alcohol use among adolescents in a peri-urban historically disadvantaged community in the Western Cape. The study identified some of the factors that promote and inhibit drinking within the study community from the perspective of the adolescents themselves and a few of the adults who work with adolescents. The study also determined some of the harmful consequences to drinking as described by the adolescents.Method: This was an exploratory study using qualitative research methods. Four focus group discussions were conducted with adolescents aged between 14 and 19 years that were both attending and not attending school. Three key informant interviews with adults who were involved with the youth were conducted.Convenience sampling was used for the non-school attending participants and snowball sampling was used for the school attending youth. The adults in the study were purposively sampled. The study was conducted within the study setting during March and April 2009. Thematic and content analysis was used to interpret the data.The descriptive data was coded and categorised according to themes that emerged during analysis.Results: In general the youth of this study are drinking on weekends. They spend their time on the streets and access alcohol from the many illegal taverns in their neighbourhood. Some of the reasons why adolescents drink include just for the fun of it and because their friends drink and to cope with stress or boredom (risk factors for problem behaviour). Those who don’t drink generally have strong parental role models, have observed some of the harmful effects of alcohol use and seem able to resist peer pressure (protective factors for problem behaviour). There were no significant differences between the perceptions of male and female adolescents regarding alcohol consumption. The black adolescents in general appeared to be more affected by poverty than the coloured adolescents, a factor that influenced their choices around alcohol use. Risky sexual behaviour, rape and fighting seem to be some of the harmful consequences to drinking that are described by the youth of this study. The social environment in which the adolescents of this study live seemed to play a significant role in their attitudes toward drinking. Factors such as a lack of infrastructure for leisure, poverty and a tolerance for public drunkenness are community factors that affect these adolescents but over which they have little or no control.Conclusion: The potential for problem behaviour as perceived by the participants is determined by the balance of risk and protective factors that emanate from their social environment, the community itself and their own personality. Those fortunate enough to have cohesive families with interested adults around them are more likely to be protected from problem behaviour due to drinking.Recommendations: Recommendations from this study include engaging with the youth directly when designing intervention programmes; using peer-led programmes to effect change and to help adolescents to clarify their values; equip them with skills to plan for the future in order to develop their self-efficacy to make the right choices when it comes to alcohol consumption. It is also recommended that intervention programmes address relationships within the community itself such as strengthening parent-child communication; building positive adult role models and empowering community members to challenge issues such as illegal tavern owners serving alcohol to minors.

Abstract General anaesthesia (GA) is a widely used sedation method in dentistry. It is usually used for patients with an extensive dental treatment need, most often related to dental caries, and limited coping skills to consider conventional dental care. These patients are often small children or persons with dental fear. Using dental general anaesthesia (DGA) is expensive, special equipment and trained staff are needed, and it is not without risks for patients. The aim of this study was to investigate factors associated with children’s DGA. In addition to dental caries and dental fear, general health status, oral health behaviours, family-related factors, as well as dental attendance after DGA were in focus. The thesis is composed of five independent studies. There were three different study populations ‒ one in specialised and two in primary health care. There was also an age- and gender-matched comparison group for one of the study populations. Questionnaires were used in three of the studies, and two of the studies were based on patient files. According to the results, DGA is more common among medically compromised children than among healthy children. Medically compromised children have more often a history of DGA treatments compared with their healthy peers. Dental caries and dental fear were the main reasons for DGA in all of the studies. Dietary and drinking habits, as well as oral hygiene behaviours were distinctly poorer among children undergoing DGA than among those treated in a normal dental setting. A history of DGA in the family, a large number of siblings and male gender were important background factors associated with DGA. Patients treated under DGA were prone to miss or cancel their upcoming appointments. In conclusion, DGA is necessary in some cases, but it could be avoided if factors associated with DGA were taken into account in treatment plans. DGA in itself does not have an enhancing effect on oral health over the long term. / Tiivistelmä Yleisanestesia on hammashoidossa yleisesti käytetty sedaatiomenetelmä vaikeahoitoisille potilaille. He ovat usein pieniä lapsia, hammashoitopelkoisia tai sellaisia potilaita, joiden hoidontarve on liian laaja ja haastava tavanomaiseen hammashoitoon. Tämän tutkimuksen tavoitteena oli selvittää lasten nukutushammashoitoon liittyviä tekijöitä. Karieksen ja hammashoitopelon lisäksi tutkimuksen kohteena oli yleisterveydellisiä seikkoja, suunterveystottumuksia, perheeseen liittyviä tekijöitä sekä hammashoitopalvelujen käyttö nukutushammashoidon jälkeen. Tämä väitöskirja koostuu viidestä erillisestä osajulkaisusta. Tutkimusjoukkoja oli kolme: yksi erikoissairaanhoidosta ja kaksi perusterveydenhuollosta. Yhdelle tutkimusjoukolle oli ikä- ja sukupuolivakioitu vertailuryhmä. Kyselylomakkeita käytettiin kolmessa osajulkaisussa ja kaksi osajulkaisua perustui potilaspapereihin. Nukutushammashoito oli yleisempää yleissairailla kuin terveillä lapsilla. Yleissairailla lapsilla oli myös useammin nukutushammashoitohistoriaa kuin terveillä lapsilla. Karies ja hammashoitopelko olivat pääsyyt nukutushammashoitoon kaikissa tutkimuksissa. Juoma- ja ruokatottumukset, kuten myös suuterveystottumukset, olivat selkeästi huonommat nukutushammashoidossa hoidetuilla lapsilla kuin niillä lapsilla, jotka hoidettiin normaalisti hereillä. Perheen nukutushammashoitohistoria, suuri määrä sisaruksia ja miessukupuoli olivat merkittäviä nukutushammashoitoon yhteydessä olevia tekijöitä. Nukutushammashoidossa hoidetut potilaat jättivät usein tulematta nukutushammashoidon jälkeisille hammashoitokäynneilleen tai peruivat aikansa. Nukutushammashoito on välttämätön tietyissä tilanteissa, mutta se voitaisiin välttää, jos siihen liittyviä tekijöitä huomioitaisiin paremmin hoitosuunnitelmissa. Nukutushammashoidolla sinänsä ei ole suunterveyttä parantavaa pitkäaikaisvaikutusta.

Health behaviors tend to occur together. However, the research on what factors define and regulate their coexistence within individuals is still limited. There is also no established methodology to investigate regulation mechanisms of multiple health behaviours. The objectives of the study were to explore: 1) co-occurrence of multiple health behaviours (smoking, alcohol drinking, physical activity, and healthy eating) in a sample of Canadian university students; 2) the role of motivational (e.g., controlled, autonomous and intrinsic motivations), cognitive (e.g., health attitudes and health empowerment), and social contextual (e.g., family and friends) components in these regulation mechanisms; 3) the strengths and limitations of integrating variable-based and case-based methodological approaches to study the coexistence and regulation of multiple health behaviours. The research was based on the theoretical underpinnings of Self-Determination Theory (SDT) and a critical realism paradigm. College students (N==238) from the University of Saskatchewan completed a survey in Study 1. Six participants, purposefully selected from the sample were interviewed in Study 2. The most frequent multiple health behaviour cluster was ‘alcohol drinking+physical activity+healthy eating’ (62%; n=143). The results of multiple regression analysis (Study 1) confirmed that intrinsic and autonomous motivations were the best predictors of the frequency of alcohol consumption, physical activity, and healthy eating. Interview analyses in Study 2 also suggested that multiple health behaviours were best self-regulated when motivations were harmonized with individuals’ cognitions and emotions, and supported by their social contexts. Such balance could be achieved by exercising more self-control, making up for one health behaviour via another, or avoiding cognitive dissonance by ‘splitting up’ a negative concept into positive and negative ones (e.g., occasional smoking to release stress versus harmful chain smoking). Both Study 1 and Study 2 results present motivation as a hierarchical structure and provide evidence that motivational regulations across multiple health behaviours are interrelated. The comparative analysis of Studies 1 and 2 demonstrates that the integration of two different methodological approaches and the consilience between their results added to the validity and generalizability of the common findings. Importantly, contradictions in findings highlighted limitations of each methodological approach and were discussed in terms of implications for their methodological refinement.

Darbo tikslas: Įvertinti asmens sveikatos priežiūros įstaigų pagrindinių žmogiškųjų išteklių būklę, pagrindžiant jų formavimo politikos pokyčių poreikį. Uždaviniai: Įvertinti Lietuvos gydytojų demografinę situaciją ir jų pasiskirstymo regioninius netolygumus, ištirti ligoninėse dirbančių gydytojų rizikos profilį susirgti lėtinėmis neinfekcinėmis ligomis, išanalizuoti ligoninėse dirbančių gydytojų dalyvavimo profilaktiniuose sveikatos patikrinimuose mastą. Tyrimo metodika. Siekiant įvertinti gydytojų demografinę situaciją ir jų regioninį pasiskirstymą, buvo atlikta iš Lietuvos sveikatos informacijos centro, Lietuvos statistikos departamento ir Valstybinės akreditavimo sveikatos priežiūros veiklai tarnybos prie Sveikatos apsaugos ministerijos gautų oficialių duomenų statistinė analizė. Gydytojų sveikatos būklės įvertinimui buvo pasirinkta po vieną ligoninę iš didmiesčio ir rajono (Vilniaus regione – Vilniaus miesto ir Ukmergės miesto ligonė, Kauno regione – Kauno miesto ir Marijampolės ligoninė). Visiems tose ligoninėse dirbantiems gydytojams buvo išdalintos anketos, suskirstytos į šešias dalis: I dalis – asmens duomenys ir darbinė veikla, II – pasitenkinimas darbu, III – klausimai apie sveikatą, IV – klausimai apie profilaktinius sveikatos patikrinimus, V – klausimai apie gyvenseną ir VI – nuomonė apie sveikatos priežiūrą. Dalyvauti tyrime buvo pakviesti visi tyrimo dieną dirbantys gydytojai. Anketinėje apklausoje dalyvavo 281 gydytojas (76 proc.). Sveikatos patikrinime... [toliau žr. visą tekstą] / Aim of the study: To evaluate the main human resources’ status in the health care institutions in support of their policy-making need to change. Objectives: To evaluate demographic situation of Lithuanian physicians and regional inequalities in the distribution of physicians; to assess the risk profile of chronic noncommunicable diseases of hospital-employed physicians; to analyse participation of hospital-employed physicians in screening programmes. Material and methods. The official statistical data obtained from Lithuanian Health Information Centre, Lithuanian Department of Statistics and the State Health Care Accreditation Agency under the Ministry of Health were used for evaluation of demographic situation of physicians and their regional distribution. The assessment of health status of physicians was carried out in four randomly selected hospitals from Vilnius and Kaunas regions. Two hospitals were selected from Vilnius and Kaunas cities, one hospital - from Ukmergė municipality and one hospital - from Marijampolė municipality. The questionnaire, which was distributed to physicians, consisted from six parts: I - personal data, and working activities, II - job satisfaction, III – health status, IV - preventive health check-up, V – health behaviours, and VI - opinion of health care. All physicians who were working in the hospital on the day of survey were invited to participate. Questionnaires were filled in by 281 physicians (response rate was 76%), and 242 physicians... [to full text]