Introduction: The burden of road traffic injuries (RTI) is worsening globally, particularly in low- and middle-income countries (LMIC) and among the young and economically productive populations. A major barrier to improving road safety in India and other LMIC is that existing RTI data sources are severely limited by poor population coverage and data quality. This dissertation explores the reliability and feasibility of using a novel data source with verbal autopsy (VA) methods for the purposes of RTI surveillance in India. Methods: The reliability of the VA methods was assessed using physician agreement on the specific categories of injury death as the metric. Next, a nationally representative household mortality survey with VA methods was used to directly estimate the age- and gender-specific RTI death rates and to identify context-specific RTI risk factors in India. Finally, a national spatial database was constructed to quantify potential access to trauma care in relation to the spatial distribution of RTI deaths in India. Results: Across a broad array of application settings in India, the level of physician agreement was high indicating that the VA methods were reliable in distinguishing RTI deaths among other specific categories of injury deaths. The estimated 183,600 RTI deaths in 2005 from the mortality survey were over 50% more than the national police statistics. Of these RTI deaths, 65% were males between ages 15-59 years, 68% were pedestrians and other vulnerable road users, and over 55% occurred at the scene of collision, within minutes of collision, and/or involved a head injury. The existing community health centres and district hospitals in the Indian public health system had inadequate trauma care capacity but were suitably located to allow broad spatial access to timely trauma care for the majority of RTI deaths in India, which were most problematic in the northern states of Punjab, Haryana, Himachal Pradesh and in Tamil Nadu. Conclusions: Properly designed VA studies can provide accurate and reliable RTI surveillance data and assist in identifying context-specific road safety interventions.

The purpose of this study is to examine how the health care system in Babati meets the increasing need for control, treatment and prevention of diabetes and hypertension. By defining what kind of specific problems and obstacles that exists in this area, the result of the research can contribute to creation and adoption of improved policies and interventions. Field studies were conducted in Babati, Tanzania for three weeks in February and March 2014. This is a qualitative study with data collected through semi-structured interviews with informants from different levels of the health system, based on the pyramidal structure of Tanzania's health care system. The theoretical framework for the study is based on aspects that corresponding to critical functions of health systems. The type of problem being treated affects the adoption and diffusion of new health interventions and the extent to which they are integrated into critical health systems functions. The study shows that diabetes and hypertension is an increasing problem in Babati. In relation to the burden, resources are lacking at all investigated levels. Therefore it is difficult to meet the increasing needs for diabetes and hypertension. To meet the future challenges, a number of cost effective strategies with focus to improve the prevention, control and reduce modifiable risk factors is suggested. / Syftet med studien är att undersöka hur hälso-och sjukvården i Babati möter det ökande behovet för kontroll, behandling och förebyggande åtgärder för diabetes och högt blodtryck. Genom att definiera vilka typer av specifika problem och hinder som finns, kan resultat från studien bidra till att skapandet och antagandet av förbättrade strategier och åtgärder. Fältstudier genomföres i Babati, Tanzania under tre veckor i februari och mars 2014. Detta är en kvalitativ studie med data insamlat genom semistrukturerade intervjuer med informanter från olika nivåer inom sjukvårdsystemet baserat på den pyramidala struktur Tanzanias sjukvårdssystem bygger på. Det teoretiska ramverket för studien baseras på aspekter som motsvarar kritiska funktioner för sjukvårdssystem. Antagandet och spridning av nya hälsointerventioner och i vilken mån de är integrerade i kritiska hälso- systemfunktioner påverkas av den typ av problem som behandlas. Studien visar att diabetes och högt blodtryck är ett ökande problem i Babati. I relation till hur sjukdomsbördan ser ut, saknas det resurser på samtliga undersökta nivåer. Därför är det svårt att möta de ökande behov som finns för att hantera diabetes och högt blodtryck. För att möta de framtida utmaningarna i Babati har ett antal kostnadseffektiva strategier med fokus att förbättra förebyggande, kontroll och minska påverkbara riskfaktorer föreslagits.

Introduction: The burden of road traffic injuries (RTI) is worsening globally, particularly in low- and middle-income countries (LMIC) and among the young and economically productive populations. A major barrier to improving road safety in India and other LMIC is that existing RTI data sources are severely limited by poor population coverage and data quality. This dissertation explores the reliability and feasibility of using a novel data source with verbal autopsy (VA) methods for the purposes of RTI surveillance in India. Methods: The reliability of the VA methods was assessed using physician agreement on the specific categories of injury death as the metric. Next, a nationally representative household mortality survey with VA methods was used to directly estimate the age- and gender-specific RTI death rates and to identify context-specific RTI risk factors in India. Finally, a national spatial database was constructed to quantify potential access to trauma care in relation to the spatial distribution of RTI deaths in India. Results: Across a broad array of application settings in India, the level of physician agreement was high indicating that the VA methods were reliable in distinguishing RTI deaths among other specific categories of injury deaths. The estimated 183,600 RTI deaths in 2005 from the mortality survey were over 50% more than the national police statistics. Of these RTI deaths, 65% were males between ages 15-59 years, 68% were pedestrians and other vulnerable road users, and over 55% occurred at the scene of collision, within minutes of collision, and/or involved a head injury. The existing community health centres and district hospitals in the Indian public health system had inadequate trauma care capacity but were suitably located to allow broad spatial access to timely trauma care for the majority of RTI deaths in India, which were most problematic in the northern states of Punjab, Haryana, Himachal Pradesh and in Tamil Nadu. Conclusions: Properly designed VA studies can provide accurate and reliable RTI surveillance data and assist in identifying context-specific road safety interventions.

Submitted by Rey Buckman (rey.buckman@gmail.com) on 2016-01-10T15:01:59Z No. of bitstreams: 1 2015-Dec_MSc-Thesis_mHealth-Entrepreneurship-LMICs_Buckman.pdf: 5201516 bytes, checksum: 5c371c945ff66496fee5110423bd8cb8 (MD5) / Rejected by Ana Luiza Holme (ana.holme@fgv.br), reason: Dear Reymound, In the first page your name should appear before the title of your thesis. The number of the pages should appear in the introdution, they should count form the first page but only appear in the thesis in the introdution. and it can'T be as you put in the thesis ex: i of 149 pages You can't have a page in blank in your thesis. Ana Luiza Holme 3799-3492 on 2016-01-11T11:29:28Z (GMT) / Submitted by Rey Buckman (rey.buckman@gmail.com) on 2016-01-12T23:30:25Z No. of bitstreams: 1 2015-Dec_MSc-Thesis_mHealth-Entrepreneurship-LMICs_Buckman.pdf: 5038358 bytes, checksum: 4f2b04bebf79c72c1aa4664114581fb6 (MD5) / Approved for entry into archive by Ana Luiza Holme (ana.holme@fgv.br) on 2016-01-13T11:07:34Z (GMT) No. of bitstreams: 1 2015-Dec_MSc-Thesis_mHealth-Entrepreneurship-LMICs_Buckman.pdf: 5038358 bytes, checksum: 4f2b04bebf79c72c1aa4664114581fb6 (MD5) / Made available in DSpace on 2016-01-13T12:13:06Z (GMT). No. of bitstreams: 1 2015-Dec_MSc-Thesis_mHealth-Entrepreneurship-LMICs_Buckman.pdf: 5038358 bytes, checksum: 4f2b04bebf79c72c1aa4664114581fb6 (MD5) Previous issue date: 2015-12-14 / Tecnologias móveis na saúde (mHealth) representam há alguns anos a força de transformação para melhorar problemas de saúde em países de baixa e média renda (LMIC). Embora vários estudos tenham identificado evidências inconsistentes e novos quadros de avaliação tenham sido propostos, poucos trabalhos exploraram o papel do empreendedorismo para criar mudança disruptiva em um setor tradicionalmente conservador. Defendo que a melhoria da eficácia dos empresários mHealth pode aumentar a adoção de soluções mHealth. Assim, este estudo tem como objetivo propor um modelo de gestão para a análise de soluções mHealth do ponto de vista empresarial no contexto de LMIC. Identifiquei o ‘Khoja-Durrani-Scott (KDS) framework’ como base teórica para o modelo de gestão, devido ao seu foco explícito no contexto de LMICs. Na pesquisa exploratória introduzida a seguir utilizei entrevistas semi-estruturadas com cinco especialistas em mHealth, os sistemas de saúde locais e de investimento para identificar as necessárias adaptações ao modelo. Os resultados das entrevistas propuseram que especialmente a questão econômica deveria ser clarificada, assim como a questão empresarial deveria ser adicionada. Além disso, foi proposto um questionário de avaliação. Na segunda fase, apliquei o questionário a cinco start-ups, que operam no Brasil e na Tanzânia. Realizei entrevistas semi-estruturadas com os empresários para obter insights práticos para o desenvolvimento teórico. Três dos cinco empresários perceberam que os resultados correlacionavam com as expectativas dos pontos fortes e fracos das start-ups. As principais deficiências do modelo foram relacionadas com a ambigüidade de algumas questões. Além dos resultados para o modelo, os resultados das pontuações foram analisados. A análise sugeriu que entre os start-ups que participaram os resultados ‘comportamentais e sócio-técnicos’ foram os mais fortes e os resultados ‘política’ foram os mais fracos. O modelo de gestão integra várias perspectivas, estruturadas em torno do empresário. A fim de validar o modelo, a pesquisa futura pode vincular o desenvolvimento de uma start-up com a evolução das pontuações em estudos de caso longitudinais ou testes em grande escala. / Since some years, mobile technologies in healthcare (mHealth) stand for the transformational force to improve health issues in low- and middle-income countries (LMICs). Although several studies have identified the prevailing issue of inconsistent evidence and new evaluation frameworks have been proposed, few have explored the role of entrepreneurship to create disruptive change in a traditionally conservative sector. I argue that improving the effectiveness of mHealth entrepreneurs might increase the adoption of mHealth solutions. Thus, this study aims at proposing a managerial model for the analysis of mHealth solutions from the entrepreneurial perspective in the context of LMICs. I identified the Khoja–Durrani–Scott (KDS) framework as theoretical basis for the managerial model, due to its explicit focus on the context of LMICs. In the subsequent exploratory research I, first, used semi-structured interviews with five specialists in mHealth, local healthcare systems and investment to identify necessary adaptations to the model. The findings of the interviews proposed that especially the economic theme had to be clarified and an additional entrepreneurial theme was necessary. Additionally, an evaluation questionnaire was proposed. In the second phase, I applied the questionnaire to five start-ups, operating in Brazil and Tanzania, and conducted semi-structured interviews with the entrepreneurs to gain practical insights for the theoretical development. Three of five entrepreneurs perceived that the results correlated with the entrepreneurs' expectations of the strengths and weaknesses of the start-ups. Main shortcomings of the model related to the ambiguity of some questions. In addition to the findings for the model, the results of the scores were analyzed. The analysis suggested that across the participating mHealth start-ups the ‘behavioral and socio-technical’ outcomes were the strongest and the ‘policy’ outcomes were the weakest themes. The managerial model integrates several perspectives, structured around the entrepreneur. In order to validate the model, future research may link the development of a start-up with the evolution of the scores in longitudinal case studies or large-scale tests.

Smokefree environment created by smokefree policies is associated with smoking reduction; however, there is paucity of literature on the relationship between smokefree home rules and smoking intensity in low-and-middle income countries (LMICs), and how smokefree policy affects smoking behavior of smokers at different stages of smoking cessation. This study examined the relationship between smokefree home rules and average number of cigarettes smoked per day (CPD) among daily smokers at different stages of the transtheoretical model (TTM) of change. Data from 18,718 current daily cigarette smokers from the Global Adult Tobacco Survey (GATS) conducted from 2011 to 2017 in 20 LMICs were analyzed. Weighted multivariable linear regression analyses were conducted using the log of CPD as the outcome variable with smokefree home rules as the exposure variable, controlling for selected covariates. Approximately 15% of the participants were in precontemplation, 5% were in preparation, 15% lived in partial smokefree homes, and 30% lived in complete smokefree homes. The average number of CPD was 12.3, 12.0, and 10.6 among participants living in homes where smoking was allowed, partial smokefree homes, and complete smokefree homes, respectively. Compared to living in homes where smoking was allowed, living in complete smokefree homes were associated with 22.5% (95%CI = 18.4%–26.5%), 17.9% (95%CI = 8.4%–27.3%), and 29.3% (95% CI = 17.1%–41.5%) fewer CPD among participants in precontemplation, contemplation, and preparation stages, respectively. These findings suggest that complete smokefree home policy will benefit smokers in LMICs irrespective of their intention to quit smoking in addition to protecting non-smokers from secondhand smoke exposure.

Treatment outcomes of young patients with invasive breast cancer treated radically at Groote Schuur Hospital from 2013 to 2017: A single centre study Background: Breast cancer is the leading cause of cancer- related deaths globally, and the commonest cancer in women under 40 years. There is currently a lack of data relating to treatment outcomes of young women with breast cancer particularly in low-and middle-income countries. Aim: This study aims to evaluate the treatment outcomes of young patients (under 40 years) treated radically for invasive breast cancer in a low-and middle-income setting. Settings: Groote Schuur Hospital, Cape Town, South Africa Methods: A retrospective review of 101 women under 40 years, with invasive breast cancer treated radically, between 2013 and 2017 was conducted. Patient characteristics, tumour characteristics, disease stage, treatment, and follow-up were recorded. Primary objectives included evaluating overall and disease free survival, and analysing recurrence patterns and clinicopathological features. Results: The five-year overall and disease free survival for the entire cohort was 77% and 51%, respectively. Five-year overall survival by molecular subtype showed that Luminal A had the best survival, while triple negative breast cancer had the worst overall survival. Conclusion: Young women with breast cancer have poor survival outcomes despite early presentation. There is limited data regarding breast cancer treatment outcomes in patients under forty years.

Background: There is a strong association between exposure to intimate partner violence (IPV) and the development of negative mental health (MH) outcomes among women and their children. Given the high prevalence of IPV in low and lower-middle income countries (LLMICs) and its relationship with varying MH issues, it is essential to identify evidence-based interventions that reduce MH challenges, including interventions that remain effective under LLMIC resource, implementation, and scalability constraints. Objective: The proposed study involves a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating psychosocial interventions compared to a) no intervention, b) alternatively specified interventions, or c) waitlisted services to reduce MH impairment among women and children with IPV exposure and who live in LLMICs relative to those living in high income countries (HICs). Methods: Our methods and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically searched eight electronic databases for RCTs reporting the effects of psychosocial interventions on the well-being of women, and/or their children, who were exposed to IPV and who were living in LLMICs or HICs. Searches were completed on April 10, 2022. We implemented forward citation searching on February 19th, 2023, of the included studies to capture any missed or recently published papers. Title, abstract, full-text screening, and data extraction were completed independently, using Covidence. Primary and secondary outcome data extracted and analyzed from the included studies were: (a) MH disorder (depressive disorder, anxiety disorder, post-traumatic stress disorder (PTSD)), (b) clinical symptoms of mental illness (stress, emotion dysregulation, self-efficacy, self-esteem, externalizing symptoms, and suicidal thoughts and ideation) and (c) parent and child relationship and quality of life. Pooled effect estimates of the outcomes were synthesized on Comprehensive Meta-Analysis (CMA) and were reported using Hedge’s g. Risk of bias was also assessed, in duplicate, using the Clarity Risk of Bias Tool and the certainty of the available evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation Tool (GRADE). Where at least five studies were available for an outcome, three a priori subgroup analyses were completed for women and children on the basis of : 1) psychosocial intervention type (empowerment and advocacy, trauma-focused therapy, non-trauma focused therapy, counselling, and cognitive behavioural therapy (CBT), and parenting), income setting (LLMIC and HIC), and 3) length of follow-up (post-intervention, < 12-months follow-up, and ≥ 12-months follow-up). Lastly, sensitivity analyses explored the impact of the following on the outcomes (1) high-risk of bias ratings; (2) missing data, and (3) reporting on feasibility and pilot data. Results: A total of 33,257 articles were identified via database searches; 12,057 were removed using deduplication, resulting in 21, 200 articles for title and abstract screening. A total of 581 articles underwent full-text screening, of which 55 unique studies were included in the review. Across the included studies, enough data was available to analyze seven outcomes within the meta-analysis; this included the primary outcomes of depressive disorder, anxiety disorder, PTSD, and the secondary outcomes, stress, self-esteem, self-efficacy, and quality of life. Thirteen studies were completed in LLMIC settings, with 42 studies focused on HICs. Ten studies focused on women and children exposed to IPV, 43 studies focused strictly on women, and two studies focused strictly on children. With respect to the outcomes, the majority of studies examined intervention impacts on depression (k = 33, 60%), anxiety (k = 11, 20%), and PTSD (k = 26, 47%). After performing the meta-analyses, very uncertain evidence suggests that psychosocial interventions may lead to reductions in maternal depression (g = -0.222; 95% CI -0.353 to -0.090) maternal anxiety (g = -0.541; 95% CI -0.953 to -0.129), and child PTSD (g = -0.314; 95% CI -0.602 to -0.026). Additionally, very uncertain evidence suggests that psychosocial interventions may have little to no effect on child depression (g = 0.085; 95% CI -0.519 to 0.690), maternal PTSD (g = -0.193; 95% CI -0.339 to -0.047), maternal stress (g = -0.188; 95% CI -0.454 to 0.078), and maternal self-efficacy (g = 0.187; 95% CI -0.096, 0.469). As well, moderate certainty of evidence indicates that psychosocial interventions are likely to result in little to no difference in self-esteem (g = 0.196; 95% CI -0.009 to 0.401), and a low certainty of evidence indicates that psychosocial interventions may result in little to no difference in maternal quality of life (g = 0.121; 95% CI -0.090, 0.332), relative to controls. However, when considering these outcomes, trauma-focused therapy showed significant improvements in maternal depression in HICs and LLMICs, while maternal anxiety and PTSD showed significant improvements in LLMICs. Non-trauma focused therapy resulted in significant improvements in maternal stress specifically in LLMICs. Parenting psychosocial interventions were also effective in significantly improving child PTSD in LLMICs. Conclusion: The systematic review and meta-analysis found that psychosocial interventions may not be more beneficial compared to control groups for addressing MH outcomes amongst women and children exposed to IPV within LLMICs and HICs. While trauma-focused therapy, non-trauma focused therapy, and parenting interventions demonstrated significant positive impacts for maternal depression, anxiety, PTSD, stress and child PTSD, the evidence available was deemed to be uncertain. This review underscores the importance of equal resource distribution, fair research practices, investing in longer follow-up studies, comprehensive data analysis, and clear reporting. Future research should prioritize well-designed trials to understand the effects of specific psychosocial interventions. / Thesis / Master of Science (MSc) / Women's exposure to intimate partner violence (IPV) is a serious public health problem that often occurs in the presence of children and is linked to poor mental health; this is especially true among women and children living in low and lower-middle income countries (LLMIC) (Barada et al., 2021; García-Moreno et al., 2013; Silva et al., 2019). Given that intervening early can help reduce the mental health (MH) impacts of IPV exposure, there is an urgency to identify and disseminate evidence-based interventions in LLMIC settings. Here, we systematically review the literature evaluating psychosocial interventions that aim to reduce MH impairment among women and children exposed to IPV in LLMIC settings and examine how these findings compare to psychosocial interventions that reduce MH impairment among those living in high-income country (HIC) settings. In total, 55 unique studies were included in the systematic review. Findings are varied; however, overall, trauma-focused therapy, non-trauma focused therapy, and parenting psychosocial interventions significantly improved specific mental health outcomes within specific settings. In HICs, trauma-focused therapy demonstrated improvements in maternal depression. In LLMICs, trauma-focused therapy was effective in reducing maternal depression, anxiety, and post-traumatic stress disorder (PTSD). In addition, in LLMICs, only, non-trauma focused therapy improved maternal stress and parenting interventions improved child PTSD. We also narratively and statistically discuss factors specific to the psychosocial interventions that may improve MH following IPV exposure. Intervention factors include mechanism, type, delivery, setting, and modality, which should be targets for future evaluation. In sum, our review emphasizes the importance of tailoring interventions to address the unique needs of survivors in particular settings and calls for balanced, larger, and well-designed trials to better understand the effects of psychosocial interventions within and across contexts.

Rapid urbanization is taking place in Low-and middle-income countries (LMICs). Often there is not sufficient data monitoring the quick urban change. This study explores the use of machine learning classification within remote sensing to foster sustainable urban practices in a secondary city in an LMIC. The aim is to extract spatially detailed land cover data and investigate its temporal evolution from 2018 to 2021. Furthermore, targeted interviews with residents were conducted to gain an in-situ understanding of the land cover changes. The research reveals a trend of increased impervious surface in Sekondi-Takoradi, especially around the urban outskirts. Some patterns of densification can also be identified, predominantly in urban areas with a mix of impervious surfaces and vegetation. These findings reveal similar land cover change patterns as previous remote sensing studies, a decrease in vegetation, and an increase in impervious surfaces.  The used method can be applied at a larger scale to monitor the urbanization of secondary cities in LMICs, a field that often is neglected. These insights can contribute to achieving the UN's 11th Sustainable Development Sustainable Cities and Communities.

L’épidémie de tabagisme est responsable de la mort de millions de personnes et malgré cela, la consommation mondiale de produits du tabac ne cesse d’augmenter. La majorité des fumeurs vivent aujourd’hui dans les pays à revenu faible et intermédiaire, et les maladies non-transmissibles liées au tabac représentent un important fardeau pour ces systèmes de santé. L’Amérique du Sud n’y échappe pas et un fait très préoccupant est certainement la prévalence élevée chez les adolescents de cette région. La présente étude visait à évaluer l’effet du prix des cigarettes et de l’exposition à la publicité en faveur du tabac sur le tabagisme des adolescents d’Amérique du Sud, et ce à partir des données du Global Youth Tobacco Survey. Les niveaux d’exposition à la publicité et les prix auto-déclarés ont été utilisés pour modéliser ces relations, et les comportements tabagiques étudiés étaient l’expérimentation, la participation et la consommation. L’échantillon total comprenait 134 073 répondants provenant de 12 pays. Les résultats de l’étude ont montré que l’exposition à la publicité en faveur du tabac avait un effet positif sur le tabagisme des adolescents, mais contrairement au consensus établi dans la littérature, la relation négative entre le prix des cigarettes et le tabagisme n’a pas été observée de façon convaincante. Des lacunes inhérentes à la base de données utilisée pourraient expliquer ces résultats inattendus, et certains éléments méthodologiques du sondage sont remis en question. / The tobacco epidemic is responsible for the death of millions of people, and despite this fact the consumption of tobacco products is increasing globally. The majority of smokers now live in low-and middle-income countries, and non-communicable diseases linked to tobacco represent an important burden for these health systems. Such is the case for South American countries, and high smoking prevalence among teenagers of this region is also worrying. This study, based on Global Youth Tobacco Survey data, has examined the impact of cigarette prices and exposure to tobacco advertising on smoking among South American adolescents. Self-reported prices and levels of exposure to advertising have been used to model the relationships, and the smoking behaviors studied were experimentation, participation and consumption. The total survey sample included 134, 073 respondents from 12 countries. The results showed that exposure to tobacco advertising had a positive impact on smoking among adolescents. Although there is a clear consensus in the literature about the negative relationship between cigarette prices and smoking, it could not be demonstrated strongly in this study. Problems inherent to the database may explain these unexpected results and some methodological aspects are questioned.

Objetivo: i) Estudar os casos de tuberculose (TB) por transmissão recente em brasileiros e migrantes sul-americanos, quantificar a transmissão cruzada recente entre ambas as populações e estudar seus fatores associados; ii) Avaliar, isoladamente, os fatores associados à transmissão recente da TB e o impacto da migração e de outras vulnerabilidades nos casos da doença no município. Métodos: Estudo transversal em indivíduos brasileiros e migrantes de origem sul-americana, residentes de distritos centrais do município de São Paulo (MSP) com grande proporção de populações vulneráveis e elevada presença recente de migrantes. Estudaram-se os casos de TB pulmonar por M. tuberculosis (Mtb) notificados entre 2013 e 2014, confirmados por meio de cultura de escarro. Foram utilizados os dados do Sistema Estadual de Notificação (SINAN-TB), de unidades de saúde e do laboratório central do Instituto Adolfo Lutz. Analizaram-se as variáveis sociodemográficas, clínicas e a presença de clusters simples e mistos, obtidos pelo agrupamento dos isolados de Mtb por RFLP-IS6110. i) Descreveu-se a distribuição dos clusters mistos e outras variáveis em brasileiros e migrantes sul-americanos e, investigou-se os fatores independentemente associados à presença de clusters mistos na amostra por meio de regressão logística simples e múltipla; ii) Investigaram-se os fatores independentemente associados à ocorrência de clusters mediante regressão logística simples e múltipla e estimou-se o impacto da transmissão recente da TB por meio da Fração Atribuível Populacional (PAF). Resultados: Foram amostrados 347 indivíduos, 19 por cento dos casos na área estudada. Desses, 76 por cento eram brasileiros e 24 por cento migrantes sul-americanos. O primeiro estudo mostrou que a proporção de clusters foi de 40,5 por cento , sendo 28 por cento desses compartilhados por brasileiros e migrantes sul-americanos (clusters mistos). Clusters mistos foram mais frequentemente encontrados em migrantes sul-americanos do que em brasileiros (OR=6,05), porém sugeriu-se transmissão cruzada em ambas as direções. A análise de sensibilidade, removendo usuários de drogas, HIV positivos e alcóolicos, teve pouco efeito no número de clusters mistos porém reduziu o de clusters simples em vi brasileiros, sugerindo maior transmissão recente do Mtb entre indivíduos brasileiros e migrantes não pertencentes a esses grupos de risco. O segundo estudo sugeriu que o uso de drogas está independentemente e diretamente associados a clusters sugestivos de transmissão recente (ORaj=3,18) e o alcoolismo (ORaj=0,30) está inversamente associado à transmissão recente. Foi encontrada baixa prevalência de comorbidades e outros fatores de risco entre migrantes sul-americanos, tanto em clusters quanto em perfis únicos. A transmissão recente entre usuários de drogas foi atribuída a cerca de 15 por cento dos casos de TB em brasileiros. Conclusões: Verificou-se que a transmissão recente, tanto entre brasileiros quanto entre migrantes sul-americanos, desempenha um papel importante nas regiões centrais do MSP. No entanto, sugere-se que a migração possa desempenhar um papel menos importante na transmissão/reativação da TB do que o uso de drogas e outras condições de vulnerabilidade. Dessa forma, no contexto dos crescentes movimentos migratórios para grandes cidades de países de média e baixa renda, a migração se soma à vulnerabilidade social, reforçando a necessidade de políticas intersetoriais para controle da TB. / Objective: i) to study recent tuberculosis (TB) transmission in Brazilians and South-American migrants, to estimate the proportion of recent cross-transmission occurring between both populations and to study potential associated factors to cross-transmission; ii) to study associated factors to cross-transmission and to estimate the impact of South-American migration and other vulnerabilities on TB cases. Methods: we conducted a cross-sectional study with TB patients in a central area of São Paulo (MSP) with a strong presence of South-American migrants and vulnerable populations. We selected notified pulmonary TB (PTB) cases confirmed by sputum culture between 2013 and 2014 among Brazilians and South-American migrants. We used the Tuberculosis State Notification System (SINAN-TBWEB), health facilities and the State Reference Laboratory (Instituto Adolfo Lutz) as data sources. We typed M. tuberculosis isolates by IS6110-RFLP, which were clustered by similarity. Clusters were considered mixed when isolates from at least one Brazilian and one South-American migrant were similar; and were considered simple when the cluster contained isolates from patients of only one nationality. We study demographic and clinical variables from TB patients and the presence of clusters within the sample. i) We described the distribution of simple and mixed clusters and other variables amongst Brazilians and South-American migrants and study associated factors to cross-transmission using logistic regression; ii) we estimated the proportion of recent transmission in the sample and investigated the factors associated with the presence of clusters by multiple logistic regression. Results: We sampled 347 individuals, 19 per cent of cases that occurred in the study area. Nearly 76 per cent were Brazilians and 24 per cent South-Americans. The first study demonstrated that 40.5 per cent of cases were clustered, of which approximately 30 per cent were mixed. South-American migrants were more likely to have mixed clusters than Brazilians (OR=6.05) and the results suggest that TB transmission occurred in both directions. We conducted a sensitivity analysis removing drug users, HIV positive and alcoholics, which suggested higher transmission amongst Brazilian and migrants outside these groups. In the second study we demonstrated that drug users were more likely to viii belong to clusters (ORadj=3.18) while individuals who abuse alcohol were more likely to belong to unique profiles (ORadj=0.30). South American migrants had lower prevalence of comorbidities and other risk factors. Nearly 15 per cent of PTB cases among Brazilians were attributed to recent transmission among drug users. Conclusions: We conclude that general recent transmission of TB and cross-transmission between Brazilian and South American migrants play an important role in the central regions of MSP. Nevertheless, we suggest that social vulnerability and drug use in TB transmission may be more important than migration status itself. In the context of increasing migration to large cities of low- and middle-income countries, our findings add migration to other social vulnerabilities, reaffirming the need for inter-sectoral policies on TB control.