<p>Belonging to an indigenous group in Mexico is usually associated with poor health, mainly as the result of social isolation from the mainstream society. The Tarahumara are no exception. They constitute the largest indigenous group in northern Mexico and one of the most marginalized ethnic minorities in North America. Health conditions are precarious, yet very little data are available to facilitate the design and implementation of programs to prevent and manage the main public health problems affecting this people. This thesis aims at overcoming part of this information gap. It presents and discusses the results from studies focusing on the nutrition of women and children carried out between 1997 and 2002.</p><p>A survey in a representative district sample of Tarahumara women of reproductive age found the highest prevalence of anemia among pregnant women in their third trimester (38.5%) and those lactating during the first 6 months after delivery (42.9%), along with a high prevalence of iron deficiency. In this study a technique was developed to collect capillary serum samples spotted onto filter paper to measure serum ferritin in remote settings. In the same study, 52.5% of adult women were overweight, suggesting a process of ‘de-Indianization’ of their traditional diet and activity patterns. This issue was followed-up in a later study based on perceptions of food and body shape using cognitive anthropological methods. Speaking Spanish emerged as a clear indication of acculturation that could be associated with an increase in the prevalence of obesity and its consequences. A nutrition survey among Tarahumara children at boarding schools found evidence of zinc, vitamin B₁₂, iron, and iodine deficiencies but found similar anthropometric status to other rural Mexicans. Finally, a qualitative assessment was carried out to identify culturally accepted foods to redesign a food aid basket aimed at alleviating malnutrition among young Tarahumara children.</p><p>The results from this thesis provide relevant data for an improved design of interventions to combat and prevent some of the nutritional problems that affect the Tarahumara. These data could also constitute a baseline to which future changes can be compared if similar sampling strategies are used. Overall, the findings highlight the importance and challenge of achieving modernization in a way that not only improves health but at the same time supports, maintains and encourages traditional cultural values. These are not only the foundations of the Tarahumara society, but in some cases also contribute to a better diet and health.</p> / <p>Die Zugehörigkeit zu einer eingeborenen Volksgemeinschaft Mexikos wird gewöhnlich mit einem schlechten Gesundheitszustand, aufgrund sozialer Isolation von der allgemeinen Gesellschaft, verbunden. Die Tarahumara-Indianer sind dabei keine Ausnahme. Sie stellen eine der größten Eingeborenengruppen im Norden des Landes dar und sind eine der ausgeschlossensten ethnischen Minderheiten in Nordamerika. Der Gesundheitszustand ist prekär, da sehr wenige Daten existieren, um die Gestaltung und Einführung von Programmen zur Prävention und Handhabung der, diese Menschen betreffenden, hauptsächlichen Probleme im Gesundheitswesen, zu ermöglichen. Diese Dissertation beabsichtigt, Teil dieses Informationsdefizits zu beseitigen. Sie präsentiert und diskutiert die Ergebnisse von im Zeitraum 1997 bis 2002 durchgeführten Studien, welche die Ernährung der Tarahumarafrauen und -kinder fokussieren.</p><p>Eine Umfrage mit einer repräsentativen Stichprobe von Frauen im gebärfähigen Alter, im größten Tarahumara-Bezirk, ergab das höchste Vorkommen von Anämie bei schwangeren Frauen im dritten Trimester (38,5%) und bei solchen, die während der ersten 6 Monate nach der Geburt stillten (42,9%), bedingt durch Eisenmangel. Bei dieser Studie wurde eine Feldtechnik für weit entfernte Gebiete entwickelt, um die Ferritin-Konzentration in Kapillar-Serum auf Filter Papier zu messen. Dieselbe Studie zeigte eine Übergewichtsprävalenz von 52,5% bei erwachsenen Frauen, was auf einen Prozess einer „Entindianisierung“ ihrer traditionellen Diät und Aktivitätsmuster zurückzuführen ist. Dieses Thema wurde bei einer späteren Studie herangezogen, bei welcher der Eindruck von Nahrung und Körperumfang mit kognitiven anthropologischen Methoden evaluiert wurde. Spanisch zu sprechen erschien als eindeutige Indikation für Akkulturation, welche mit einer Zunahme des Vorhandenseins von Übergewicht und seiner Folgen assoziiert werden könnte. Eine Studie zu Schulkindern in Eingeboreneninternaten zeigte Beweise für Zink-, Vitamin B₁₂-, Eisen- und Jodmangel, fand aber ähnliche anthropometrische Status wie bei ländlichen Mexikanerkindern. Schließlich wurde eine qualitative Studie durchgeführt, mit dem Ziel, kulturell akzeptierte Lebensmittel für die Neuentwerfung eines Warenkorbes zu identifizieren, um den Ernährungszustand von Kleinkindern zu verbessern.</p><p>Die Ergebnisse dieser Dissertation liefern relevante Daten für eine Verbesserung der Gestaltung von Programmen zur Bekämpfung und Prävention von Ernährungsproblemen, welche die Tarahumaras betreffen. Diese Informationen können auch als „Baseline“ benutzt werden, mit der zukünftige Veränderungen verglichen werden könnten, wenn ähnliche Stichprobenstrategien angewandt würden. Vor allem betonen die Ergebnisse, die Wichtigkeit und Herausforderung, eine Modernisierung zu erreichen, die nicht nur eine Verbesserung der Gesundheit mit sich bringt, sondern gleichzeitig auch, traditionelle Werte unterstützt, aufrechterhält und anregt, da diese Werte nicht nur die Grundlagen der Tarahumara- Gesellschaft sind, sondern in vielen Fällen zu einer besseren Diät und Gesundheit beisteuern.</p> / <p>Att tillhöra en infödd folkgrupp i Mexiko associeras oftast med ett dåligt hälsotillstånd, framför allt på grund av social isolering från det konventionella samhället. Tarahumara indianerna utgör inget undantag. De utgör den största gruppen av infödda i norra Mexiko och är en av de mest utsatta etniska minoriteterna i Nord Amerika. Det finns anledning att oroa sig för de rådande hälsovillkoren då mycket lite information finns tillgänglig för att underlätta utformandet och tillämpningen av program för att förebygga och handskas med de huvudsakliga hälsoproblemen som drabbar denna folkgrupp. Denna avhandling syftar till att försöka täcka upp delar av den informations brist som råder. I den presenteras och diskuteras resultaten från de studier, som inriktar sig på näringstillståndet hos tarahumara kvinnor och barn, genomförda mellan åren 1997 och 2002. </p><p>En studie i ett representativt distrikt med ett representativt urval av Tarahumara kvinnor i fertil ålder fann man högst prevalens av anemi bland de gravida kvinnorna som befann sig i sista trimestern (38,5 %) samt i gruppen ammande kvinnor under de 6 första månaderna efter förlossning (42,9 %), detta tillsammans med en hög prevalens av järnbrist. I denna studie utvecklades en metod för insamling av kapillära serum prover som droppades på filter papper för att därefter analysera serum ferritin halten vid avsides liggande sättningar. I samma studie fann man även att 52,5 % av de vuxna kvinnorna var överviktiga, vilket skulle kunna antyda om en “avindianiserings-process” av deras traditionella diet och aktivitets mönster. Detta fynd följdes upp i en senare studie som grundade sig på föreställningar om mat och kroppsform, genom att använda kognitiva antropologiska metoder. Att vara spansktalande framträdde som ett tydligt tecken på kulturförändring som skulle kunna sammankopplas med en ökning i prevalensen av övervikt och dess konsekvenser. En skolbaserad nutritions studie bland Tarahumara barn vid internatskolor visade brist på zink, vitamin B₁₂, järn och jod, dock var dessa fynd likvärdiga med uppmätta värden bland barn på den mexikanska landsbygden. Slutligen genomfördes en kvalitativ studie med avsikt att identifiera kulturellt accepterade maträtter och därigenom kunna omforma regeringens rådande sammansättning av livsmedelsbistånd, med syfte att mildra undernäringen bland unga Tarahumara barn.</p><p>Resultaten från denna avhandling ger relevanta data för en förbättrad utformning av interventionsprogram för att bekämpa och förhindra en del av de nutritions problem som drabbar Tarahumara indianerna. Dessa data skulle också kunna utgöra en referenslinje med vilken framtida förändringar kan jämföras med såvida liknande provtagnings rutiner används. Generellt, belyser resultaten vikten och utmaningen att uppnå modernisering på ett sätt som inte enbart förbättrar hälsoläget men som samtidigt upprätthåller och uppmuntrar till att behålla traditionella värderingar. Dessa utgör inte enbart grunden för Tarahumara samhället utan bidrar även därigenom i en del fall till en bättre kosthållning och bättre hälsa.</p> / <p>La pertenencia a un grupo indígena en México se asocia frecuentemente a una salud pobre principalmente como resultado del aislamiento social de la sociedad Mexicana. Los Tarahumaras no son la excepción. Constituyen el grupo indígena más grande del norte del país y una de las minorías étnicas más marginadas de Norteamérica. A pesar de que sus condiciones de salud son precarias, existe muy poca información disponible que facilite el diseño e implementación de programas para prevenir y tratar los problemas de salud pública más importantes que les aquejan. Así pues, esta tesis tiene por objeto cubrir parte de esta falta de información. Presenta y discute resultados de estudios enfocados a la nutrición de mujeres y niños llevados a cabo entre 1997 y 2002.</p><p>Una encuesta en una muestra municipal representativa de mujeres Tarahumaras en edad reproductiva mostró la más alta prevalencia de anemia en las embarazadas en el tercer trimestre (38.5%) y las lactantes durante los primeros 6 meses después del parto (42.9%) paralelamente a una alta prevalencia de deficiencia de hierro. En este estudio, se desarrolló una técnica para la toma de muestras de suero capilar en papel filtro para medir los niveles de ferritina sérica en zonas remotas. Asimismo se encontró un 52.5% de sobrepeso en las mujeres adultas, sugiriendo un proceso de “deindigenización” de los patrones dietéticos y de actividad física tradicionales. Este tópico fue seguido en un estudio posterior sobre percepciones de la alimentación y apariencia corporal de la mujer Tarahumara utilizando métodos de antropología cognoscitiva. Hablar español emergió como un claro indicio de aculturación que podría estar asociado a un incremento en la prevalencia de obesidad y sus consecuencias. Una encuesta nutricional con niños Tarahumaras de albergues escolares mostró evidencia de deficiencia de cinc, vitamina B₁₂, hierro y yodo pero encontró un estado antropométrico similar al de otros niños mexicanos del medio rural. Finalmente, se condujo una evaluación cualitativa para identificar alimentos culturalmente aceptables para rediseñar una canasta de ayuda alimentaria con el objeto de aliviar la desnutrición infantil.</p><p>Los resultados de esta tesis ofrecen información relevante para el mejoramiento del diseño de intervenciones para combatir y prevenir algunos de los problemas nutricios que afectan a los Tarahumaras. De utilizarse estrategias muestrales similares, esta información podría además constituir el punto de comparación para evaluar cambios futuros. Pero sobre todo, los hallazgos apuntan a la importancia y el desafío para alcanzar una modernización que no solo mejore la salud de los indígenas, sino que además apoye, mantenga y promueva los valores culturales tradicionales, pues estos, además de conformar los cimientos de la sociedad Tarahumara, pueden en varios casos contribuir a una mejor nutrición y salud.</p>

Belonging to an indigenous group in Mexico is usually associated with poor health, mainly as the result of social isolation from the mainstream society. The Tarahumara are no exception. They constitute the largest indigenous group in northern Mexico and one of the most marginalized ethnic minorities in North America. Health conditions are precarious, yet very little data are available to facilitate the design and implementation of programs to prevent and manage the main public health problems affecting this people. This thesis aims at overcoming part of this information gap. It presents and discusses the results from studies focusing on the nutrition of women and children carried out between 1997 and 2002. A survey in a representative district sample of Tarahumara women of reproductive age found the highest prevalence of anemia among pregnant women in their third trimester (38.5%) and those lactating during the first 6 months after delivery (42.9%), along with a high prevalence of iron deficiency. In this study a technique was developed to collect capillary serum samples spotted onto filter paper to measure serum ferritin in remote settings. In the same study, 52.5% of adult women were overweight, suggesting a process of ‘de-Indianization’ of their traditional diet and activity patterns. This issue was followed-up in a later study based on perceptions of food and body shape using cognitive anthropological methods. Speaking Spanish emerged as a clear indication of acculturation that could be associated with an increase in the prevalence of obesity and its consequences. A nutrition survey among Tarahumara children at boarding schools found evidence of zinc, vitamin B12, iron, and iodine deficiencies but found similar anthropometric status to other rural Mexicans. Finally, a qualitative assessment was carried out to identify culturally accepted foods to redesign a food aid basket aimed at alleviating malnutrition among young Tarahumara children. The results from this thesis provide relevant data for an improved design of interventions to combat and prevent some of the nutritional problems that affect the Tarahumara. These data could also constitute a baseline to which future changes can be compared if similar sampling strategies are used. Overall, the findings highlight the importance and challenge of achieving modernization in a way that not only improves health but at the same time supports, maintains and encourages traditional cultural values. These are not only the foundations of the Tarahumara society, but in some cases also contribute to a better diet and health. / Die Zugehörigkeit zu einer eingeborenen Volksgemeinschaft Mexikos wird gewöhnlich mit einem schlechten Gesundheitszustand, aufgrund sozialer Isolation von der allgemeinen Gesellschaft, verbunden. Die Tarahumara-Indianer sind dabei keine Ausnahme. Sie stellen eine der größten Eingeborenengruppen im Norden des Landes dar und sind eine der ausgeschlossensten ethnischen Minderheiten in Nordamerika. Der Gesundheitszustand ist prekär, da sehr wenige Daten existieren, um die Gestaltung und Einführung von Programmen zur Prävention und Handhabung der, diese Menschen betreffenden, hauptsächlichen Probleme im Gesundheitswesen, zu ermöglichen. Diese Dissertation beabsichtigt, Teil dieses Informationsdefizits zu beseitigen. Sie präsentiert und diskutiert die Ergebnisse von im Zeitraum 1997 bis 2002 durchgeführten Studien, welche die Ernährung der Tarahumarafrauen und -kinder fokussieren. Eine Umfrage mit einer repräsentativen Stichprobe von Frauen im gebärfähigen Alter, im größten Tarahumara-Bezirk, ergab das höchste Vorkommen von Anämie bei schwangeren Frauen im dritten Trimester (38,5%) und bei solchen, die während der ersten 6 Monate nach der Geburt stillten (42,9%), bedingt durch Eisenmangel. Bei dieser Studie wurde eine Feldtechnik für weit entfernte Gebiete entwickelt, um die Ferritin-Konzentration in Kapillar-Serum auf Filter Papier zu messen. Dieselbe Studie zeigte eine Übergewichtsprävalenz von 52,5% bei erwachsenen Frauen, was auf einen Prozess einer „Entindianisierung“ ihrer traditionellen Diät und Aktivitätsmuster zurückzuführen ist. Dieses Thema wurde bei einer späteren Studie herangezogen, bei welcher der Eindruck von Nahrung und Körperumfang mit kognitiven anthropologischen Methoden evaluiert wurde. Spanisch zu sprechen erschien als eindeutige Indikation für Akkulturation, welche mit einer Zunahme des Vorhandenseins von Übergewicht und seiner Folgen assoziiert werden könnte. Eine Studie zu Schulkindern in Eingeboreneninternaten zeigte Beweise für Zink-, Vitamin B12-, Eisen- und Jodmangel, fand aber ähnliche anthropometrische Status wie bei ländlichen Mexikanerkindern. Schließlich wurde eine qualitative Studie durchgeführt, mit dem Ziel, kulturell akzeptierte Lebensmittel für die Neuentwerfung eines Warenkorbes zu identifizieren, um den Ernährungszustand von Kleinkindern zu verbessern. Die Ergebnisse dieser Dissertation liefern relevante Daten für eine Verbesserung der Gestaltung von Programmen zur Bekämpfung und Prävention von Ernährungsproblemen, welche die Tarahumaras betreffen. Diese Informationen können auch als „Baseline“ benutzt werden, mit der zukünftige Veränderungen verglichen werden könnten, wenn ähnliche Stichprobenstrategien angewandt würden. Vor allem betonen die Ergebnisse, die Wichtigkeit und Herausforderung, eine Modernisierung zu erreichen, die nicht nur eine Verbesserung der Gesundheit mit sich bringt, sondern gleichzeitig auch, traditionelle Werte unterstützt, aufrechterhält und anregt, da diese Werte nicht nur die Grundlagen der Tarahumara- Gesellschaft sind, sondern in vielen Fällen zu einer besseren Diät und Gesundheit beisteuern. / Att tillhöra en infödd folkgrupp i Mexiko associeras oftast med ett dåligt hälsotillstånd, framför allt på grund av social isolering från det konventionella samhället. Tarahumara indianerna utgör inget undantag. De utgör den största gruppen av infödda i norra Mexiko och är en av de mest utsatta etniska minoriteterna i Nord Amerika. Det finns anledning att oroa sig för de rådande hälsovillkoren då mycket lite information finns tillgänglig för att underlätta utformandet och tillämpningen av program för att förebygga och handskas med de huvudsakliga hälsoproblemen som drabbar denna folkgrupp. Denna avhandling syftar till att försöka täcka upp delar av den informations brist som råder. I den presenteras och diskuteras resultaten från de studier, som inriktar sig på näringstillståndet hos tarahumara kvinnor och barn, genomförda mellan åren 1997 och 2002. En studie i ett representativt distrikt med ett representativt urval av Tarahumara kvinnor i fertil ålder fann man högst prevalens av anemi bland de gravida kvinnorna som befann sig i sista trimestern (38,5 %) samt i gruppen ammande kvinnor under de 6 första månaderna efter förlossning (42,9 %), detta tillsammans med en hög prevalens av järnbrist. I denna studie utvecklades en metod för insamling av kapillära serum prover som droppades på filter papper för att därefter analysera serum ferritin halten vid avsides liggande sättningar. I samma studie fann man även att 52,5 % av de vuxna kvinnorna var överviktiga, vilket skulle kunna antyda om en “avindianiserings-process” av deras traditionella diet och aktivitets mönster. Detta fynd följdes upp i en senare studie som grundade sig på föreställningar om mat och kroppsform, genom att använda kognitiva antropologiska metoder. Att vara spansktalande framträdde som ett tydligt tecken på kulturförändring som skulle kunna sammankopplas med en ökning i prevalensen av övervikt och dess konsekvenser. En skolbaserad nutritions studie bland Tarahumara barn vid internatskolor visade brist på zink, vitamin B12, järn och jod, dock var dessa fynd likvärdiga med uppmätta värden bland barn på den mexikanska landsbygden. Slutligen genomfördes en kvalitativ studie med avsikt att identifiera kulturellt accepterade maträtter och därigenom kunna omforma regeringens rådande sammansättning av livsmedelsbistånd, med syfte att mildra undernäringen bland unga Tarahumara barn. Resultaten från denna avhandling ger relevanta data för en förbättrad utformning av interventionsprogram för att bekämpa och förhindra en del av de nutritions problem som drabbar Tarahumara indianerna. Dessa data skulle också kunna utgöra en referenslinje med vilken framtida förändringar kan jämföras med såvida liknande provtagnings rutiner används. Generellt, belyser resultaten vikten och utmaningen att uppnå modernisering på ett sätt som inte enbart förbättrar hälsoläget men som samtidigt upprätthåller och uppmuntrar till att behålla traditionella värderingar. Dessa utgör inte enbart grunden för Tarahumara samhället utan bidrar även därigenom i en del fall till en bättre kosthållning och bättre hälsa. / La pertenencia a un grupo indígena en México se asocia frecuentemente a una salud pobre principalmente como resultado del aislamiento social de la sociedad Mexicana. Los Tarahumaras no son la excepción. Constituyen el grupo indígena más grande del norte del país y una de las minorías étnicas más marginadas de Norteamérica. A pesar de que sus condiciones de salud son precarias, existe muy poca información disponible que facilite el diseño e implementación de programas para prevenir y tratar los problemas de salud pública más importantes que les aquejan. Así pues, esta tesis tiene por objeto cubrir parte de esta falta de información. Presenta y discute resultados de estudios enfocados a la nutrición de mujeres y niños llevados a cabo entre 1997 y 2002. Una encuesta en una muestra municipal representativa de mujeres Tarahumaras en edad reproductiva mostró la más alta prevalencia de anemia en las embarazadas en el tercer trimestre (38.5%) y las lactantes durante los primeros 6 meses después del parto (42.9%) paralelamente a una alta prevalencia de deficiencia de hierro. En este estudio, se desarrolló una técnica para la toma de muestras de suero capilar en papel filtro para medir los niveles de ferritina sérica en zonas remotas. Asimismo se encontró un 52.5% de sobrepeso en las mujeres adultas, sugiriendo un proceso de “deindigenización” de los patrones dietéticos y de actividad física tradicionales. Este tópico fue seguido en un estudio posterior sobre percepciones de la alimentación y apariencia corporal de la mujer Tarahumara utilizando métodos de antropología cognoscitiva. Hablar español emergió como un claro indicio de aculturación que podría estar asociado a un incremento en la prevalencia de obesidad y sus consecuencias. Una encuesta nutricional con niños Tarahumaras de albergues escolares mostró evidencia de deficiencia de cinc, vitamina B12, hierro y yodo pero encontró un estado antropométrico similar al de otros niños mexicanos del medio rural. Finalmente, se condujo una evaluación cualitativa para identificar alimentos culturalmente aceptables para rediseñar una canasta de ayuda alimentaria con el objeto de aliviar la desnutrición infantil. Los resultados de esta tesis ofrecen información relevante para el mejoramiento del diseño de intervenciones para combatir y prevenir algunos de los problemas nutricios que afectan a los Tarahumaras. De utilizarse estrategias muestrales similares, esta información podría además constituir el punto de comparación para evaluar cambios futuros. Pero sobre todo, los hallazgos apuntan a la importancia y el desafío para alcanzar una modernización que no solo mejore la salud de los indígenas, sino que además apoye, mantenga y promueva los valores culturales tradicionales, pues estos, además de conformar los cimientos de la sociedad Tarahumara, pueden en varios casos contribuir a una mejor nutrición y salud.

À partir des années 1980, la théorisation de la promotion de la santé et sa mise en place font partie de l’agenda des organisations internationales de santé et de plusieurs gouvernements. Cependant, une certaine tension est observable dans la compréhension de la promotion de la santé, et ce, dès ses débuts. En effet, elle est conçue en général selon une approche comportementale comme stratégie pour le changement de comportements individuels ou collectifs qui met l’accent sur les facteurs de risque et très peu fréquemment conçue selon une approche structurelle, incluant une action sur les déterminants structurels des sociétés responsables de l’état de santé des populations dans une mesure plus importante que les systèmes de soins. Cette recherche qualitative –étude de cas multiples- menée en Argentine et au Brésil, vise à analyser la place et la compréhension de la promotion de la santé dans les politiques nationales de santé de deux pays à travers l’analyse du processus d’élaboration des politiques publiques. Nous viserons à distinguer la promotion de la santé en tant que comportementale ou structurelle et à expliquer les raisons pour lesquelles elle est comprise de telle ou telle autre façon. Finalement, nous essayerons d’identifier les opportunités pour qu’une approche structurelle de la promotion de la santé soit adoptée dans la politique nationale de santé. Les données analysées proviennent d’entrevues semi-structurées (n=28) et de documents divers : sites gouvernementaux sur Internet, documents remis par les interviewés, documents officiels, soit gouvernementaux, soit des organismes de coopération et de financement. Notre cadre conceptuel s’est inspiré des trois modèles : celui du changement des politiques publiques de Sabatier et Jenkins-Smith (1999 ; 2009), celui des courants politiques de Kingdon (1984) et le cadre conceptuel proposé par Walt (1994) pour l’analyse du rôle des organisations internationales. Nous avons identifié deux niveaux d’analyse : l’organisation de l’État et le sous-système de santé. Nous avons aussi tenu compte de l’influence des événements externes et des organisations internationales de coopération technique et de financement. Notre démarche vise à observer, à analyser et à comprendre la façon dont ces niveaux influencent la place et la compréhension de la promotion de la santé dans la politique nationale de santé. La perspective temporelle de plus de douze années nous a permis de mener une analyse sur plusieurs années et de mieux comprendre le changement de la politique de santé à différents moments de son histoire ainsi que l’identification des acteurs et des coalitions les plus importants depuis l’origine des champs de la santé publique dans les deux pays. Les résultats de notre analyse montrent que la promotion de la santé – conçue selon une approche structurelle – ne fait pas encore partie du courant principal de la politique nationale de santé dans aucun des deux pays. Cependant, les explications diffèrent : En Argentine, on observe un sous-système de santé fragmenté avec prédominance du modèle médical ; les actions menées renforcent ce fonctionnement en ne permettant pas la discussion à propos des valeurs sous-jacentes à l’organisation du système de santé ni sur son changement en fonction des besoins de santé du pays. Au Brésil, la réforme sanitaire questionne le modèle préexistant et arrive à instaurer la santé comme droit au niveau de l’État. L’accent mis sur l’organisation des services réduit la compréhension de la promotion de la santé à une « politique nationale de promotion de la santé » qui vise le changement des comportements. L’analyse du rôle des organisations internationales montre deux situations différentes dans les deux pays : pour l’Argentine, il existe une dépendance majeure autant à l’agenda qu’au financement de ces organisations. Le manque d’un agenda national en matière de promotion de la santé fait que le pays adopte l’agenda international avec très peu des questionnements. Dans le cas du Brésil, la situation est bien différente et on observe une capacité importante à négocier avec la coopération internationale. Cela se fait aussi avec un intérêt du pays pour l’adoption de l’agenda des organisations internationales dans le but d’une reconnaissance et de sa participation à des instances internationales. Alors, pour des raisons différentes, les deux pays adoptent l’agenda international de la promotion de la santé avec une approche comportementale. À partir de notre recherche, nous considérons que cinq réflexions doivent guider l’analyse de la promotion de la santé en Amérique latine : 1) Les processus de réforme de l’État des années 1990 et ses conséquences actuelles (type de réforme, valeurs sociétales, arrangements constitutionnels) ; 2) Les processus de réforme des systèmes de santé avec un regard sur la composante de décentralisation (réforme sanitaire ou administrative ?, quel modèle prédomine dans le champ de la santé publique ?) ; 3) La revalorisation des soins primaires de santé de la fin des années 1990 (quel impact dans le pays ?) ; 4) La tendance à la réduction des propositions élargies autant des politiques que des programmes ; et 5) Les défis actuels des systèmes de santé (travailler avec d’autres secteurs pour produire de la santé, pour incorporer et pour mieux maîtriser les déterminants sociaux et structuraux de santé). Les résultats de notre analyse nous permettent d’identifier l’importance du rôle du gouvernement national par rapport au développement et à la compréhension de la promotion de la santé. De plus, cette recherche montre que même s’il existe une influence du contexte et de l’idéologie du gouvernement sur la compréhension de la promotion et l’inclusion des déterminants sociaux de santé, c’est l’organisation de l’État avec ces valeurs de base qui sera déterminante dans la création des conditions pour le développement d’une promotion de la santé structurelle. Alors que la littérature sur la promotion de la santé accorde encore très peu de place au rôle du niveau national et de l’État dans son développement, il est clair que ces derniers ont un impact fondamental sur la place de la promotion de la santé dans la politique et sur la façon de la comprendre et de la mettre en place. Les théories utilisées pour cette recherche nous ont aidée à modéliser notre cadre conceptuel et à mener une démarche d’analyse des politiques publiques. Cette démarche permet d’améliorer les connaissances sur le changement de la politique nationale de santé par rapport à la promotion de la santé en tenant compte des dynamiques gouvernementales, champ peu exploré encore. Ce cadre conceptuel, à la fois souple et rigoureux, pourrait s’avérer approprié pour mener d’autres recherches similaires portant sur la place et la compréhension de la promotion de la santé dans les politiques nationales de santé dans d’autres pays de l’Amérique latine. / From the 1980's, the theorization of health promotion and its implementation are part of the agenda of international health organizations and governments. However, from the beginning, there is a tension in its understanding. Indeed, health promotion in general is conceived from a behavioral approach as a strategy for changing individual or group behaviors, with emphasis on risk factors. It is rarely conceived from a structural approach that includes action on the social structural determinants of the societies. This qualitative research, a multiple case study conducted in Argentina and Brazil, aims to analyze the location and the understanding of health promotion in the national health policies of both countries through the analysis of the public policy development process. We aim to distinguish the approaches to health promotion, behavioral or structural, and explain the reasons why is understood in one way or the other. Finally, we try to identify opportunities for a structured approach to health promotion to be adopted in national health policy. The data analyzed come from semi-structured interviews (n = 28) and from the following sources: government websites, documents provided by the interviewees, and official documents from governments, cooperation agencies and funding organizations. Our conceptual framework was inspired by three models: the Model of Policy Change of Sabatier & Jenkins-Smith (1999, 2009), the Multiple Streams Model of policy-making defined by JW Kingdon (1984) and the conceptual framework proposed by Walt (1994) for analyzing the role of international organizations. We identified two levels of analysis: the organization of the State and the subsystem of health. We have also taken into account the influence of external events and of international organizations for technical cooperation and financing. We propose to observe, analyze and understand how these levels influence the place and the understanding of health promotion in national health policy. A time horizon of more than a decade allowed us to conduct a comprehensive analysis and get a better understanding of the health policy change in different historical moments of the countries studied, as well as identifying the most important actors and coalitions in the public health field. The results of our analysis show that health promotion, conceived according to a structural approach, is not yet part of the mainstream of national health policy in any of the two countries. However, the explanations are different; in Argentina we see a fragmented subsystem of health with predominance of the medical model, where the actions taken reinforce this functioning and do not allow for discussion, neither on the values underlying the organization of the health system, nor concerning their change according to the country's health needs. In Brazil, the health care reform of the 1980’s challenged the pre-existing model and achieved instituting health as a right at the State level. By putting emphasis on the organization of health services it reduced the understanding of health promotion to a "National Policy for Health Promotion" aimed at behavioral change. The analysis of the role of international organizations shows different situations in both countries: Argentina has a very strong dependence on both the agenda and the funding of these organizations; the lack of a national agenda on health promotion facilitates the adoption of the international agenda, almost without questioning. In the case of Brazil the situation is different and a strong capacity to negotiate with international cooperation is observable. The interest of this country to adopt the agenda of international organizations has the objective, among others, to gain recognition and participation in international bodies. Thus, for different reasons, we observe that the two countries adopt the international agenda of health promotion from a behavioral approach. In our research, we considered five considerations that should guide the analysis of health promotion in Latin America: 1) The processes of state reform of the 1990’s and the current consequences (type of reform, social values, constitutional arrangements), 2) the reforms of health systems with particular attention to the decentralization component (health or administrative reform?), which model dominates the field of public health?, 3) the revaluation of the APS of the late 1990’s (what impact did it have on the country?), 4) the tendency to reduce both the scope of policy and program proposals and, 5) current challenges facing health systems (collaboration with other sectors to improve health, incorporate and enhance the understanding of social and structural determinants of health). The results of our analysis allow us to identify an important role for the national government in regards to the development and understanding of health promotion. Our research shows that the organization of the State, with its basic values, will be crucial in creating the conditions for developing a structural health promotion, even when there is influence of context and government ideology on the understanding of promotion of health and the inclusion of its social determinants. While the literature on health promotion still dedicates very little attention to the role of national level and State for their development, our research shows that these two levels have a fundamental impact on the place of health promotion in national policy and on how to understand and implement it. The theories used for this research allowed us to build our conceptual framework and carry out a process of public policy analysis. This process improves the knowledge about the change in national health policy with regard to health promotion taking into account the relatively unexplored field of government dynamics. This conceptual framework is both flexible and rigorous, and may be appropriate to carry out similar research on the promotion of health in national health policies of other countries in Latin America.

Face aux pandémies, le droit international s'organise-t-il sous la forme d'un « système de sécurité sanitaire collective» (abandon des mesures unilatérales excessives - garantie offerte par la collectivité par le biais d'une action commune - sauvegarde du droit des États d'adopter les mesures individuelles nécessaires) ? L'étude des instruments adoptés au sein de l'OMS (Règlement sanitaire international et Cadre de préparation en cas de grippe pandémique), des actes unilatéraux de l'ONU (résolutions de l'Assemblée générale, du Conseil de sécurité et du Conseil économique et social), de la coopération entre organisations intergouvernementales et des accords de l'OMC (GATT, Accord SPS et Accord sur les ADPIC) révèle que chaque segment de la question reçoit une réponse positive. Pourtant, on ne peut ignorer le caractère largement imparfait du résultat de la lutte contre les pandémies. S'il existe indéniablement des indices en faveur de la thèse selon laquelle un système de sécurité sanitaire collective serait en formation, le droit international face aux pandémies se caractérise par un agglomérat de fragments aux antipodes d'un édifice juridique cohérent. / In the face of pandemics, is international law organized as a "system of collective health security" (foregoing excessive unilateral measures - guaranteed by the community through joint action - upholding State rights to adopt necessary individual measures)? The study of instruments adopted by the WHO (International Health Regulations, Pandemic Influenza Preparedness Framework), of unilateral acts of the UN (resolutions of the General Assembly, the Security Council and the Economic and Social Council), of cooperation between international organizations and of the WTO's Agreements (GATT, SPS Agreement and TRIPS Agreement) reveals that the answer to each segment of the question is positive. However, one cannot ignore the highly imperfect result of the fight against pandemics. If there are undeniable indices which illustrate the existence of a nascent system of collective health security, international law in the face of pandemics is nevertheless thus far characterized by an agglomerate of fragments at odds with a coherent legal edifice.

This diploma thesis on the theme:"The implementation of the International Health Regulations, 2005 in Czech Republic.", is divided into theoretical and practical part.The theoretical part focuses on the International Health Regulations 2005 capacity required, and the measures proposed in the Czech Republic. It describes the history of the International Health Regulations and the implementation of International Health Regulations 2005, in Czech Republic.I also deal, in this part of thesis, about highly contagious diseases.Data processing research for this study was collected in the district of Český Krumlov. The research was conducted by a qualitative method.The sample consisted of 8 respondents.The aim of the study was to determine whether practitioners know how to proceed in case of a patient with a highly contagious disease in their office.This diploma thesis could serve as a source of information, whether the Czech Republic meet the requirements formulated by the World Health Organization in the International Health Regulations 2005.

Rift Valley fever (RVF) is an emerging viral zoonosis that causes frequent outbreaks in east Africa and on the Arabian Peninsula. The likelihood of RVF global expansion due to climate change and human anthropogenic factors is an important issue. The causative agent, RVF virus, is an arbovirus that is transmitted by several mosquito species and is able to infect a wide range of livestock as well as people. The infection leads to mass abortions and death in livestock and a potentially deadly hemorrhagic fever in humans. RVF has severe socio-economic consequences such as animal trade bans between countries, disruption of food security, and economic disaster for farmers and pastoralists as well as for countries. Human behavior such as direct contact with infected animals or their fluids and exposure to mosquito bites increases the risk for contracting the disease. To better understand the challenges associated with RVF outbreaks and to explore prevention and control strategies, we used the One Health approach. The local community had to be involved to understand the interaction between the environment, animals, and humans. We focused on Sudan, Saudi Arabia, and Kenya. First, we systematically reviewed the literature and then we performed cross sectional community-based studies using a special One Health questionnaire. Climatic and remote sensing data were used in combination with statistics to develop a sub-region predictive model for RVF. For both Saudi Arabia and Sudan, the ecology and environment of the affected areas were similar. These areas included irrigation canals and excessive rains that provide an attractive habitat for mosquito vectors to multiply. The surveillance systems were unable to detect the virus in livestock before it spread to humans. Ideally, livestock should serve as sentinels to prevent loss of human lives, but the situation here was reversed. Differences between countries regarding further spread of RVF was mainly determined by better economic and infrastructure resources. In Sudan, there was a lack of knowledge and appropriate practices at the studied community regarding RVF disease symptoms and risk factors for both animals and humans. The community was hesitant in notifying the authorities about RVF suspicion in livestock due to the lack of a compensation system. The perceived role of the community in controlling RVF was fragmented, increasing the probability of RVF transmission and disease. In Kenya, our study found that better knowledge about RVF does not always translate to more appropriate practices that avoid exposure to the disease. However, the combination of good knowledge, attitudes, and practices may explain why certain communities were less affected. Strategies to combat RVF should consider socio-cultural and behavioral differences among communities. We also noticed that RVF outbreaks in Kenya occurred in regions with high livestock density exposed to heavy rains and wet soil fluxes, which could be measured by evapotranspiration and vegetation seasonality variables. We developed a RVF risk map on a sub-regional scale. Future outbreaks could be better managed if such relevant RVF variables are integrated into early warning systems. To confront RVF outbreaks, a policy is needed that better incorporates ecological factors and human interactions with livestock and environment that help the RVF pathogen spread. Early detection and notification of RVF is essential because a delay will threaten the core of International Health Regulations (IHR), which emphasizes the share of information during a transboundary disease outbreak to avoid unnecessary geographical expansion.

McMaster University DOCTOR OF PHILOSOPHY (2019) Hamilton, Ontario (Health Research Methods, Evidence, and Impact) TITLE: Measuring International Health Inequalities and Socioeconomic Status Using Household Survey Data AUTHOR: Mathieu J.P. Poirier, B.Sc., M.P.H. (McMaster University) SUPERVISOR: Dr. Michel Grignon NUMBER OF PAGES: xii, 231 / The methods underlying the quantification of health inequalities have profound consequences for measuring progress in achieving health for all. In Chapter two, associations between household wealth indices, income, and consumption were systematically compiled and different methods of wealth index calculation were evaluated for appropriateness of use in a variety of settings. Researchers are presented with a synthesis of existing evidence about the appropriateness of use of wealth indices in urban and rural areas, their robustness to changes in the asset mix, future applications, and advantages and disadvantages of primary competing methods of quantifying SES using household survey data. In Chapter three, international microdata were analyzed to evaluate how magnitudes of health inequality are affected by different methods of quantifying household socioeconomic status (SES), including income, consumption, and asset wealth. In Chapter four, the need for a transnational approach to measuring health inequalities was justified and the new method was developed using an empirical example. Substantively, these chapters develop the most complete evaluation of the association between the asset wealth, consumption, and income using both critical interpretive synthesis and microdata analysis, as well as the first meta-analysis evaluating changes in health inequality magnitudes according to the SES measure used over time and across country-income levels. The transnational analysis of health inequalities uncovered previously hidden health disparities in the island of Hispaniola, and detailed instructions for all methodological aspects of the new method were presented. The distribution of disease between nations, subnational regions, and urban-rural areas in Hispaniola were analyzed from 1994 to 2013, and the first relative geospatial wealth ranking between Haiti and the Dominican Republic was presented. Global health researchers should strive to measure the equity of health between people, and this sometimes requires analyzing populations that are not neatly contained by national boundaries. / Thesis / Doctor of Philosophy (PhD) / This thesis investigates social inequalities in health and how to measure socioeconomic status (SES) using household surveys in a way that is robust across jurisdictions. It examines how wealth indices compare to income and consumption, and develops a new method to calculate transnational health inequalities. Chapter two conducts a comprehensive evaluation of evidence surrounding the use of wealth indices in urban and rural areas, robustness to changes in assets, future applications, and the advantages and disadvantages of the primary competing methods for quantifying household SES. The third chapter systematically evaluates how health inequality magnitudes evolve over time and across country-incomes according to SES measure. Finally, a transnational measurement of health inequalities was calculated for the island of Hispaniola in chapter four, uncovering the distribution of disease between nations, subnational regions, and urban-rural areas. Detailed instructions for all methodological aspects of the new transnational method are presented.

The tax system in South Africa makes provision for every South African citizen to contribute to a greater or lesser extent to funding the National Health Insurance (NHI), either through VAT or PAYE. However, as a result of the high unemployment rate, a large gap exists between tax and non-tax contributors. The question can now be asked whether it is fair that just a small percentage of taxpayers are responsible for the total funding of the NHI. Furthermore, it could be asked whether the taxpayer is aware of the additional tax burden the NHI will impose on him/her. The purpose of this research was to investigate three countries, namely, Brazil, Spain and Germany, where some form of NHI is in operation, in order to find a possible appropriate funding model for South Africa's NHI and, ultimately, to make conclusions and recommendations based on the outcomes. It was subsequently found that, although the taxpayer should be more heavily taxed in order to fund the NHI, there are a few other possibilities for distributing the tax burden more evenly. However, the impact of the proposed adjustment to increase VAT could have a negative impact on the non-taxpayer and might contribute to greater poverty in South Africa. / MCom (South African and International Taxation), North-West University, Potchefstroom Campus, 2014

The tax system in South Africa makes provision for every South African citizen to contribute to a greater or lesser extent to funding the National Health Insurance (NHI), either through VAT or PAYE. However, as a result of the high unemployment rate, a large gap exists between tax and non-tax contributors. The question can now be asked whether it is fair that just a small percentage of taxpayers are responsible for the total funding of the NHI. Furthermore, it could be asked whether the taxpayer is aware of the additional tax burden the NHI will impose on him/her. The purpose of this research was to investigate three countries, namely, Brazil, Spain and Germany, where some form of NHI is in operation, in order to find a possible appropriate funding model for South Africa's NHI and, ultimately, to make conclusions and recommendations based on the outcomes. It was subsequently found that, although the taxpayer should be more heavily taxed in order to fund the NHI, there are a few other possibilities for distributing the tax burden more evenly. However, the impact of the proposed adjustment to increase VAT could have a negative impact on the non-taxpayer and might contribute to greater poverty in South Africa. / MCom (South African and International Taxation), North-West University, Potchefstroom Campus, 2014

This dissertation investigates the mutual life project of Signe (1896-1988) and Axel Höjer (1890-1974), a married couple who were key actors in the construction of the Swedish welfare state. It emphasises the ways in which they went about asserting a special public health expertise in different contexts. As starting points I take the malleability of the concept folkhälsa (people’s health or population health) and the centrality of expertise in the governance of modern societies. Theoretical concepts such as gender, policy transfer, biopower and governmentality are central to the analysis. The dissertation includes three parts. The first part investigates how the Höjers agreed to coordinate their work and how they, with reference to ideas picked up in France and England at the end of World War I, attempted to reform mother and child health care in Sweden. Their strategies where rhetorical but also practical, using Hagalund outside Stockholm as their experimental ground. The second part investigates, firstly, how Axel Höjer, as General-Director of the Medical Board of Sweden (1935-52) asserted a sociomedical expertise, integrating the emerging social sciences and universalist views on the organisation of the welfare state into the realm of medicine, in order to launch ideas of a thorough reorganisation and expansion of the Swedish health care system. His focus was on preventive medicine and health care, with the complete physical, mental and social health of the whole population as an explicit goal. Secondly, it explores how Signe Höjer at the same time tried to launch ideas on health and wellbeing as a social politician and a public committee member. She also tried to define family policy as a specific policy area. However, despite her training as a nurse and a social worker, she was largely confined to asserting a particularly ”female” expertise, which made her position rather ambiguous in terms of authority. The third part investigates how the Höjers, in the 1950s and 60s, worked with international health, Axel mainly for the WHO in India and Ghana, Signe as a policy entrepreneur, primarily in the fields of childcare and family planning. My findings partly confirm theories that see development aid as an extension of domestic social policy, but they challenge the view of aid as a simple one-way process. I demonstrate how the Höjers at least tried to adapt their projects abroad to meet local circumstances, and also show how they brought lessons from the third world to a domestic public. In the latter case they did not primarily act as experts of Swedish-style social policy, but as experts on the developing countries and on development aid.