Contexte De nombreuses études, utilisant des indicateurs de qualité variés, ont démontré que la qualité des soins pour la dépression n’est pas optimale en première ligne. Peu de ces études ont examiné les facteurs associés à la réception d’un traitement adéquat, en particulier en tenant compte simultanément des caractéristiques individuelles et organisationnelles. L'association entre un traitement adéquat pour un épisode dépressif majeur (EDM) et une amélioration des symptômes dépressifs n'est pas bien établie dans des conditions non-expérimentales. Les objectifs de cette étude étaient de : 1) réaliser une revue systématique des indicateurs mesurant la qualité du traitement de la dépression en première ligne ; 2) estimer la proportion de patients souffrant d’EDM qui reçoivent un traitement adéquat (selon les guides de pratique clinique) en première ligne ; 3) examiner les caractéristiques individuelles et organisationnelles associées à l’adéquation du traitement pour la dépression ; 4) examiner l'association entre un traitement minimalement adéquat au cours des 12 mois précédents et l'évolution des symptômes dépressifs à 6 et 12 mois. Méthodes La littérature sur la qualité du traitement de la dépression a été examinée en utilisant un ensemble de mots-clés (« depression », « depressive disorder », « quality », « treatment », « indicator », « adequacy », « adherence », « concordance », « clinical guideline » et « guideline ») et « 360search », un moteur de recherche fédérée. Les données proviennent d'une étude de cohorte incluant 915 adultes consultant un médecin généraliste, quel que soit le motif de consultation, répondant aux critères du DSM-IV pour l’EDM dans la dernière année, nichés dans 65 cliniques de première ligne au Québec, Canada. Des analyses multiniveaux ont été réalisées. Résultats Bien que majoritairement développés à partir de guides de pratique clinique, une grande variété d'indicateurs a été observée dans la revue systématique de littérature. La plupart des études retenues ont utilisé des indicateurs de qualité rudimentaires, surtout pour la psychothérapie. Les méthodes utilisées étaient très variées, limitant la comparabilité des résultats. Toutefois, quelque soit la méthode choisie, la plupart des études ont révélé qu’une grande proportion des personnes souffrant de dépression n’ont pas reçu de traitement minimalement adéquat en première ligne. Dans notre échantillon, l’adéquation était élevée (> 75 %) pour un tiers des indicateurs de qualité mesurés, mais était faible (< 60 %) pour près de la moitié des mesures. Un peu plus de la moitié de l'échantillon (52,2 %) a reçu au moins un traitement minimalement adéquat pour la dépression. Au niveau individuel, les jeunes adultes (18-24 ans) et les personnes de plus de 65 ans avaient une probabilité moins élevée de recevoir un traitement minimalement adéquat. Cette probabilité était plus élevée pour ceux qui ont un médecin de famille, une assurance complémentaire, un trouble anxieux comorbide et une dépression plus sévère. Au niveau des cliniques, la disponibilité de la psychothérapie sur place, l'utilisation d'algorithmes de traitement, et le mode de rémunération perçu comme adéquat étaient associés à plus de traitement adéquat. Les résultats ont également montré que 1) la réception d'au moins un traitement minimalement adéquat pour la dépression était associée à une plus grande amélioration des symptômes dépressifs à 6 et à 12 mois; 2) la pharmacothérapie adéquate et la psychothérapie adéquate étaient toutes deux associées à de plus grandes améliorations dans les symptômes dépressifs, et 3) l'association entre un traitement adéquat et l'amélioration des symptômes dépressifs varie en fonction de la sévérité des symptômes au moment de l'inclusion dans la cohorte, un niveau de symptômes plus élevé étant associé à une amélioration plus importante à 6 et à 12 mois. Conclusions Nos résultats suggèrent que des interventions sont nécessaires pour améliorer la qualité du traitement de la dépression en première ligne. Ces interventions devraient cibler des populations spécifiques (les jeunes adultes et les personnes âgées), améliorer l'accessibilité à la psychothérapie et à un médecin de famille, et soutenir les médecins de première ligne dans leur pratique clinique avec des patients souffrant de dépression de différentes façons, telles que le développement des connaissances pour traiter la dépression et l'adaptation du mode de rémunération. Cette étude montre également que le traitement adéquat de la dépression en première ligne est associé à une amélioration des symptômes dépressifs dans des conditions non-expérimentales. / Background Numerous studies, using a variety of quality indicators, highlight an important gap in the quality of care for depression in primary care. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The objectives of this study were to i) systematically review indicators used to measure the quality of depression treatment in primary care, ii) estimate the proportion of primary care patients with a MDE who receive adequate treatment, iii) examine the individual and organizational characteristics associated with the receipt of minimally adequate treatment for depression, iv) examine the association between receiving minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6 and 12 months. Methods The literature on the quality of depression treatment was reviewed using a set of keywords (depression, depressive disorder, quality, treatment, indicator, adequacy, adherence, concordance, clinical guideline and guideline) and « 360search », a federated search engine. Data were obtained from a cohort study including 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for previous-year MDE, and nested within 65 primary care clinics in Quebec, Canada. Multilevel analyses were conducted. Results Though mostly based on recommendations from clinical practice guidelines, a great variety of indicators were observed. Most studies used rudimentary indicators to measure the quality of depression treatment, especially for psychotherapy. Studies also differed greatly with respect to the methods used, thus limiting the comparability of results. However, whatever the chosen method, most studies reveal that a large proportion of people with depression do not receive minimally adequate treatment in primary care settings. In our sample, adherence to guidelines was high (> 75 %) for one third of the quality indicators that were measured but was low (< 60 %) for nearly half of the measures. Just over half of the sample (52.2 %) received at least one minimally adequate treatment for depression. At the individual level, young adults (18-24) et older people (>65) had a lower probability of receiving at least one minimally adequate treatment. This probability was higher for people with a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and a more severe depression. At the clinic level, the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration perceived as adequate were associated with more adequate treatment. Results also showed that i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months. Conclusions Our findings suggest that interventions are needed to increase the quality of depression treatment in primary care. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration. This study also shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions.

O bullying escolar é um importante problema de saúde pública que vem sendo extensivamente estudado em países de alta renda. Nos países de baixa e média renda, características individuais e contextuais associadas ao bullying são pouco conhecidas. A presente tese é composta por três estudos. O estudo 1 objetivou realizar revisão sistemática sobre fatores contextuais associados ao bullying escolar. A busca utilizou as bases de dados MEDLINE, PsychInfo, Web of Knowledge e SciELO. Trinta e um estudos foram incluídos. Resultados sugerem associação entre maior desigualdade de renda em classes, escolas e países e maior risco de bullying. A relação entre tamanho da classe e da escola com bullying foi inconclusiva; escolas sem normas anti-bullying, com menor apoio e pior gestão da classe pelo professor tiveram maior risco de bullying. O estudo 2 visou identificar características individuais e contextuais associadas ao bullying verbal na escola, entre adolescentes brasileiros. Utilizou-se dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) 2009, com estudantes do 9º ano escolar. Realizou-se modelos de regressão logística multinível para identificar associações com variáveis de três níveis (indivíduo, escolas, cidades). A prevalência de bullying verbal em adolescentes brasileiros foi 14,2%. Somente 1,8% e 0,3% da variância do bullying verbal ocorreu nos níveis de escola e capital, respectivamente. Nenhuma característica das cidades se associou ao bullying. Escolas privadas apresentaram mais bullying que escolas públicas. Desigualdade de renda não se associou ao bullying. Meninos, os mais jovens, os que não moravam com pai e mãe, os expostos à violência doméstica, os com baixo peso ou sobrepeso sofreram mais bullying. O estudo 3 objetivou identificar padrões de comportamento relacionados a saúde, incluindo bullying, entre adolescentes brasileiros. Utilizou-se dados da segunda edição da PeNSE, coletados em 2012. Realizou-se análise fatorial exploratória e confirmatória, além de regressão linear para descrever características socio-demográficas associadas a cada padrão. Identificou-se três padrões de comportamento: o padrão \"comportamento problema\", compreendeu comportamento agressivo (incluindo bullying), consumo de álcool, cigarro e drogas e sexo não seguro; o padrão \"comprometedor da saúde\" incluiu indicadores de alimentação não saudável e comportamento sedentário; e o padrão \"promotor da saúde\" incluiu indicadores de alimentação saudável e atividade física. Os padrões \"comportamento problema\" e \"comprometedor da saúde\" se associaram aos mais velhos e aos residentes em regiões mais desenvolvidas, sendo o primeiro associado a escolas públicas e ao sexo masculino, enquanto o segundo ao sexo feminino. O padrão \"promotor da saúde\" se associou ao sexo masculino e aqueles com mães com maior nível educacional. Concluiuse que contextos de desigualdade parecem mais propícios à ocorrência de bullying de acordo com a revisão. Entretanto, dados do Brasil não corroboram essa hipótese para bullying verbal. Ambiente escolar com adoção de regras anti-bullying e professores mais solidários devem ser estimulados. As características das escolas e cidades estudadas explicaram pouco o bullying verbal. Características individuais sugerem sub-grupos de maior risco, podendo subsidiar políticas anti-bullying. Perpetrar bullying compôs o padrão de \"comportamento problema\", indicando que as intervenções devem ser mais amplas e direcionadas a múltiplos comportamentos / School bullying is an important public health problem, which has been extensively studied among high-income countries. In low- middle-income countries, there is a lack of information about associations between both individual-level and contextual-level characteristics with bullying. The aim of Study 1 was to carry out a systematic review of contextual factors associated with school bullying. Searches were performed in MEDLINE, PsychInfo, Web of Knowledge and SciELO. 31 studies were included. Results suggested that greater income inequality in schools, classes and countries is associated with increased risk of bullying. The influence of class and school size on bullying was inconclusive; schools without anti-bullying rules, with less support and poorer classroom management by the teacher had a higher risk of bullying. The aim of study 2 was to identify individual and contextual characteristics associated with verbal bullying, among Brazilian adolescents. We used data from the National Survey of School Health (PeNSE 2009) on students in 9th grade. We performed multilevel logistic regression models to identify associations with variables from three levels (individual, school, city). The prevalence of verbal bullying among Brazilian adolescents was 14.2%. Only 1.8% and 0.3% of the bullying variance occurred at school and capital levels, respectively. No city characteristic was associated with bullying. Private schools showed more bullying than public. Income inequality was not associated with bullying in Brazil. Boys, those of younger age, those not living with both parents, those exposed to domestic violence, those underweight or overweight suffered more bullying. The aim of Study 3 was to identify health-related behavior patterns, including bullying, among Brazilian adolescents. We used data from the second edition of PeNSE, carried out in 2012. We conducted exploratory and confirmatory factor analysis to identify behavior patterns, and linear regression models to describe sociodemographic characteristics associated with each pattern. We identified three behavior patterns; the problem-behavior pattern, which comprised aggressive behavior (including bullying), alcohol drinking, smoking, drugs use and unsafe sex; the health-compromising pattern, which included unhealthy diet indicators and sedentary behavior; and the health-enhancing pattern, which included healthy diet indicators and physical activity. The problembehavior and health-compromising patterns were associated with older age and from more developed regions. The former was associated with male gender and attending public school, while the latter was associated with female gender and more educated mothers. The health-enhancing pattern was associated with male gender and more educated mothers. In conclusion, the review suggested that bullying is more likely to occur in unequal contexts, but we could not confirm this hypothesis for verbal bullying in the Brazilian setting. Schools should be encouraged to adopt anti-bullying rules and to train teachers in bullying prevention. Among Brazilian adolescents the school and city variables explained litle of verbal bullying victimization. Individual characteristics indicated high risk sub-groups, which could be used to support anti-bullying policies. Bullying perpetration comprised part of the problem behavior pattern, suggesting that interventions should be more broaden

In der Dissertation wurden Effekte der zuwanderungsbezogenen Klassenzusammensetzung auf verschiedene Leistungsmaße und psychosoziale Schülermerkmale im Rahmen von drei Zeitschriftenbeiträgen untersucht. In Teilstudie eins wurden Effekte der sozialen und zuwanderungsbezogenen Zusammensetzung auf das Leseverständnis im Verlauf der neunten Klasse und deren Vermittlung durch Merkmale der Unterrichtsqualität analysiert. Der Klassenanteil von Heranwachsenden mit Zuwanderungshintergrund war unter Kontrolle des mittleren sozioökonomischen Status nicht mit der Leseleistung assoziiert. Es zeigten sich Hinweise einer partiellen Vermittlung des Effekts sozialer Zusammensetzung durch das Ausmaß herausfordernden Sprachunterrichts. Teilstudie zwei beschäftigte sich mit Effekten der Zusammensetzung auf die Lernmotivation im Verlauf der neunten Klasse und deren Vermittlung durch das Ausmaß schülerorientierten Unterrichtsklimas. Heranwachsende mit Zuwanderungshintergrund berichteten höhere Motivation, wenn sie Klassen mit einem höheren Anteil von Heranwachsenden mit Zuwanderungshintergrund besuchten. Es zeigten sich keine vermittelten Effekte durch Merkmale des Unterrichtsklimas. In Teilstudie drei wurden der Anteil von Kindern mit Zuwanderungshintergrund und Maße zuwanderungsbezogener Heterogenität in ihrer Assoziation mit Mathematik- und Leseleistung sowie dem Verbundenheitsgefühl mit Peers von Kindern der vierten Klasse verglichen. Es bestanden stärkere negative Effekte des Klassenanteils im Vergleich zu Heterogenitätsmaßen. Bei simultaner Berücksichtigung von Klassenanteil und Heterogenitätsmaßen waren Heterogenitätseffekte größtenteils nicht mehr signifikant. Es zeigten sich jedoch leicht positive Heterogenitätseffekte auf die Mathematikleistung. Es bestanden keine Effektunterschiede zwischen Heterogenitätsmaßen. Die Befunde verweisen auf die Bedeutung der Schulklasse für die akademische Entwicklung sowie für die Erklärung zuwanderungsbezogener Disparitäten im Bildungssystem. / The thesis at hand explored effects of the language-related and ethnic makeup of classrooms on several achievement outcomes as well as psychosocial outcomes in three research articles. The first article investigated effects of socioeconomic and language minority classroom composition on ninth graders’ reading achievement across two measurement points and explored the mediating role of instructional quality. The proportion of minority students had no effect on achievement after controlling for the socioeconomic composition. The results suggest that the effect of the socioeconomic composition on achievement may be mediated partially by the teacher’s focus on language during instruction. The second article focused on effects of the proportion of language minority students on the development of ninth graders’ motivation and the mediating role of a student-oriented climate. The analyses revealed that minority students were increasingly motivated in classrooms with a higher proportion of minority students. The compositional effect was not mediated by the instructional climate. The third article explored various measures of the ethnic makeup of classrooms and their relationship with student outcomes. The proportion of minority students and measures of diversity were compared in their prediction of fourth graders’ achievement in math and reading as well as the feeling of belonging with one’s peers. The proportion of minority students showed stronger negative effects on student outcomes than the diversity measures. Including diversity measures and the proportion of minority students, the diversity effects mostly lost their significance. However, students showed slightly higher levels of math achievement in more diverse classrooms. The various measures of diversity led to similar results. The findings add to the evidence indicating that the classroom learning environment affects students’ academic development and contributes to ethnic disparities in the education system.

CONTEXTE : La France est caractérisée par l’existence de fortes disparités socioéconomiques et géographiquesde l’état de santé, le plus souvent objectivées par des indicateurs objectifs de morbidité et de mortalité. Ladistribution territoriale des mesures de santé perçue comme la qualité de vie liée à la santé (QdVLS) reste malconnue en population générale. Une meilleure connaissance de la répartition et des déterminants – en particuliercontextuels - de ces indicateurs subjectifs permettrait de mieux comprendre leur signification par rapport auxindicateurs objectifs et d’apprécier l’intérêt spécifique de leur suivi en population générale.OBJECTIFS : Les objectifs de cette recherche étaient [1] d’étudier l’existence de disparités spatiales de QdVLSdans la population française et d’analyser leur évolution dans le temps, [2] d’étudier les déterminants de laQdVLS à la fois individuels et contextuels dans le cadre d’une analyse multiniveau, et [3] d’évaluer lesassociations écologiques entre QdVLS et mortalité ultérieure à cinq ans d’intervalle.MATERIEL ET METHODES : Les données issues de deux enquêtes transversales nationales représentatives ont étéexploitées : l’enquête Décennale 2003 de l’Insee pour l’ensemble des travaux menés (N=22 743 [1 et 3] ; N=16 732 [2]) et l’enquête Sofres 1995 pour l’analyse de l’évolution temporelle de la QdVLS (N=3 243 [1]). Lequestionnaire utilisé dans les deux enquêtes était le SF-36. [1] Des modèles de régression linéaire multiple àeffets fixes avec recherche d’interactions ont été réalisés pour l’analyse de l’évolution temporelle. [2] L’analysemultiniveau des déterminants contextuels de la QdVLS s’appuyait sur des modèles à effets mixtes, afind’explorer une chaine causale incluant des déterminants aux niveaux individuel, du ménage, de l’unité urbaine etrégional, d’ordre démographique, socioéconomique ou intégrant la notion contextuelle plus complexed’attractivité (taux migratoire, désindustrialisation). [3] Les données de mortalité étaient issues de la statistiquenationale des décès élaborée annuellement par le CépiDc. Des modèles de régression binomiale négative ont étéréalisés pour l’analyse des associations écologiques au niveau régional entre QdVLS en 2003 et mortalitéultérieure (court terme [2003-2005] ; à 5 ans [2007-2009]) et en stratifiant sur le sexe, l’âge et les causesspécifiques de décès.RESULTATS PRINCIPAUX : [1] Une diminution significative de la QdVLS était observée entre 1995 et 2003affectant tous les groupes sociodémographiques et suggérant la possibilité d’un accroissement des disparités pourles catégories les plus fragiles de la population. [2] De fortes disparités régionales de QdVLS étaient retrouvées,persistant après ajustement sur les caractéristiques socioéconomiques individuelles. L’analyse multiniveaupermettait d’identifier des processus de médiation impliquant les variables contextuelles de désindustrialisation,le taux d’accroissement migratoire, le taux d’abstention aux élections, et les comportements liés à la santé. Desinteractions inter-niveaux et intra-régionales étaient identifiées. [3] Des associations écologiques significativesétaient retrouvées au niveau régional entre QdVLS et mortalité à cinq ans d’intervalle, persistant aprèsajustement sur le niveau socioéconomique. Des relations spécifiques étaient observées après stratification surl’âge, le genre, les causes spécifiques de décès ; le caractère prédictif de la QdVLS variait selon le délai plus oumoins court entre mesure de la QdVLS et mortalité. / BACKGROUND: Wide social and geographical disparities are reported in France for morbidity and mortalityindicators. Less is known regarding the spatial distribution in general population of self-rated health (SRH) andhealth-related quality of life (HRQoL). Improving the knowledge of the contextual determinants of HRQoLwould help towards a better understanding of their meaning and interest in general population when it comes tocompare with classical objective indicators.OBJECTIVES: The objectives were [1] to assess existing spatial disparities of HRQoL in French generalpopulation and to investigate their evolution in time, [2] to determine individual and contextual determinants ofHRQoL and [3] to explore the ecological associations between HRQoL and subsequent mortality five years later.METHODS: Data were drawn from two large representative cross sectional surveys: the Insee Decennial HealthSurvey led in 2003 (N=22 743 [study 1 and 3] ; N= 16 732 [2]) and the Sofres health survey led in 1995(N=3243 [1]).The MOS SF-36 questionnaire was used in both surveys. [1] Fixed effects linear models combinedwith interaction tests were used for assessing time trends. [2] Mixed effects linear models were used for themultilevel analysis, exploring a causal pathway including individual and macrolevel factors (household, urbanunit and region) assessing demographics, socioeconomics, and features related to the notion of areaattractiveness (deindustrialization, net migration rates). [3] Mortality data were drawn from the French nationalstatistics of mortality (CepiDc-Inserm). Negative binomial regression models were performed to identifyecological associations at the region level between HRQoL recorded in 2003 and subsequent mortality (shortterm [2003-2005]; 5-years later [2007-2009]), stratifying on age, gender and specific causes of death.MAIN RESULTS: [1] A significant decrease in HRQoL was observed between 1995 and 2003, affecting allsociodemographic categories and suggesting likely widening disparities in the most fragile categories. [2]Regional HRQoL disparities were found, persisting after adjusting on socioeconomic individual characteristics.Multilevel analysis showed some evidence for mediation involving contextual factors like deindustrialization,net migration rates, voter abstention rate and health-related behaviors. Cross-level interactions were found aswell. [3] Significant ecological associations were identified at the region level between HRQoL and mortalityfive years later, persisting after adjusting on deprivation. Specific relationships were observed after stratifying onage, gender, specific causes of death; the predictive ability of HRQoL for mortality was varying depending onthe mortality period considered for analysis.CONCLUSIONS: Our results highlight the interest in assessing HRQoL at the population level and in exploringthe contextual determinants at play. Systematic inclusion of validated and multidimensional HRQoLquestionnaires should be supported in national surveys, so as to improve our knowledge of long term temporaltrends in HRQoL, to promote an increased use of contextual multilevel analyses using such data, and eventuallyto help better identifying sub-groups at risk and optimizing public health interventions.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

台灣民主轉型的成功除執政菁英的主動變革外，公民參與政治和支持改革亦有其重要性。有鑑於逐年下滑的投票率和工具性社團參與率，本研究主要從制度變遷與社會資本論點來進行探討，以縣市層次制度變項為自變項，三類型社會資本為中介變項，投票與競選活動參與為依變項，目的在了解於民主鞏固時期前後，社會資本的分佈狀況和影響社會資本、政治參與的因素，以提升民眾的社會和政治參與。中介變項與依變項資料來自1993年與2005年台灣社會變遷調查資料(TSCS)，自變項資料整合自臺灣地區社會意向調查、各縣市社福資訊與政大選研中心資料庫，主要採用多層次迴歸與邏輯迴歸分析模型來分析資料。 在社會資本分布變化上，結合式社會資本與工具性社參未有顯著改變，情感性社參則顯著增加。相較於情感性社團參與，工具性社團參與的比例較高，在兩個年代中，民眾參與工具性社團比例約在22%左右。在社團內異質性資源分佈上，不同社團的年齡異質性與性別異質性隨不同時期而有所變化。相對地，各類社團在成員的教育、收入與族群組成上反而較為穩定。由於在2005年，民眾教育與收入顯著較1993年為高，意謂著在民主鞏固時期，團體參與者可接觸的社團內異質性資源較多。 並非所有社會資本皆受外在制度所影響，研究結果顯示出國家制度較難影響立基於儒家文化的結合式社會資本。在民主鞏固時期前，縣市執政評價氛圍與生活扶助資源如理論所預期，可影響民眾的情感性社會參與，但其影響力似乎亦有減弱情形。一致性社福資源雖對工具性社團參與有跨期影響力，但卻產生資源排擠效果，而非是資源溢注效果。 政治態度論與社會資本論皆能部份說明為何民眾要參與兩類傳統政治活動，但相較於投票，參與競選活動屬於較耗費成本的參與行為，因此個體資源論較能解釋競選活動的參與。以多層次中介分析步驟檢視縣市制度變項對政治參與的作用後，證實了制度論的作用。在制度變項可能透過社會資本影響政治參與的三條中介路徑，僅一條路徑得到實證上支持。在2005年，縣市急難救助資源可透過工具性社團參與進而影響競選活動參與。 制度變遷的觀點能說明不同時期情感性社團參與和投票的變化。傳統文化價值觀的現代化改變了縣市執政評價氛圍對情感性社團參與的作用。隨著非正式制度環境的改變，情感性社團參與對競選活動參與的作用亦可能隨之改變。而隨著社會福利政策綱領的施行，人均生活扶助資源量的提升，則促進個人的投票行為。總言之，中央政府應注意自身的施政效能，並透過社福資源的適度分配，來促進民眾的社會參與與政治參與行為。 / The success of the transition to democracy in Taiwan should attribute not only to the active reform of the ruling party' cadre, but also to citizens’ participation and political support for the political reformer. In view of the gradual declining turnout rate and instrumental group participation rate, the study tends to describe the distribution of social capital, and explore the potential factors influencing social capital and political participation before and after democratic consolidation period. The paper’s framework from the perspective of institutional change and social capital treats institutional change as the independent variable, three kinds of social capital as the mediated variable, and voting and electoral campaign participation as dependent variables. The study mainly applies the multilevel linear regression and logistic regression model to analyze the mediated and dependent variables from the Taiwan Social Change Survey in 1993 and 2005, separately. As for independent variables, the data is integrated from the Social Image Survey, the social welfare report across counties, and online database of election study center in national Chengchi University. As far as the distribution of social capital is concerned, the results show that the distribution of bonding social capital and instrumental group participation do not have significant change between 1993 and 2005. Compared with participation in 1993, in 2005, the increase of this emotional group participation is apparent. In both year, the instrumental group participation rate is about 22% and is higher than the emotional group participation. In the distribution of diverse resources within groups, age diversity and sex diversity change a lot as the time went by. In contrast, education diversity, income diversity and ethnicity diversity stay stable between groups. In comparison with 1993, people in 2005 have higher education and income level, resulting in the increase of group members’ education and income level. It means that in the democratic consolidation period, it is probable for group participators to approach more diverse resources existing within groups . The effect of institutional variables on the three kinds of social capital is not as same as previous literatures report. Bonding social capital based on confucianism is difficult to be enhanced by the national institutions. Before the democratic consolidation, the effect of living assistance resources, and the atmosphere where people are satisfied with the central government performance which is consistent with theoretical prediction affects people’s participation in the emotional group. However, the effect seems to weaken gradually at the later period. Universal social welfare resources influence the instrumental group participation across different periods, but the negative effect belongs to the crowing out effect rather than the crawling back effect. Political attitudes theory and social capital theory both can partly account for why people participate in these two kinds of traditional political activities. Individual resources theory is suitable for explaining the participation of electoral campaign in that it takes people much more time and cost to engage in the electoral campaign participation than in voting. After examing the effect of institutional variables at the county-level on the political participation through the procedure of multilevel mediation analysis, the findings proven the argument of institution theory. Among the three potential mediation paths in which the institutional variables impact on the political participation through social capital, just one path is supported by the data. In 2005, emergent assistant resources can affect the electoral campaign through the instrumental group participation. The perspective of institutional change can explain the change of the emotional group participation and voting between 1993 and 2005. With the modernization of individual’s traditional attitudes, the county-level effect of evaluation of the central government on the participation in the emotional group is abated. It is probable that the effect of the emotional group participation on the electoral campaign participation differs according to the different environment of the informal institution The increase of living assistant resources per capita, because of the execution of the guiding principle of the social welfare policy, promote people’s voting significantly. In sum up, the attention should be paid by the central authority to strengthen the efficiency of the administration and distribute the social welfare resources appropriately based on the contemporary social condition, in order to improve people’s social participation and political participation.

O bullying escolar é um importante problema de saúde pública que vem sendo extensivamente estudado em países de alta renda. Nos países de baixa e média renda, características individuais e contextuais associadas ao bullying são pouco conhecidas. A presente tese é composta por três estudos. O estudo 1 objetivou realizar revisão sistemática sobre fatores contextuais associados ao bullying escolar. A busca utilizou as bases de dados MEDLINE, PsychInfo, Web of Knowledge e SciELO. Trinta e um estudos foram incluídos. Resultados sugerem associação entre maior desigualdade de renda em classes, escolas e países e maior risco de bullying. A relação entre tamanho da classe e da escola com bullying foi inconclusiva; escolas sem normas anti-bullying, com menor apoio e pior gestão da classe pelo professor tiveram maior risco de bullying. O estudo 2 visou identificar características individuais e contextuais associadas ao bullying verbal na escola, entre adolescentes brasileiros. Utilizou-se dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) 2009, com estudantes do 9º ano escolar. Realizou-se modelos de regressão logística multinível para identificar associações com variáveis de três níveis (indivíduo, escolas, cidades). A prevalência de bullying verbal em adolescentes brasileiros foi 14,2%. Somente 1,8% e 0,3% da variância do bullying verbal ocorreu nos níveis de escola e capital, respectivamente. Nenhuma característica das cidades se associou ao bullying. Escolas privadas apresentaram mais bullying que escolas públicas. Desigualdade de renda não se associou ao bullying. Meninos, os mais jovens, os que não moravam com pai e mãe, os expostos à violência doméstica, os com baixo peso ou sobrepeso sofreram mais bullying. O estudo 3 objetivou identificar padrões de comportamento relacionados a saúde, incluindo bullying, entre adolescentes brasileiros. Utilizou-se dados da segunda edição da PeNSE, coletados em 2012. Realizou-se análise fatorial exploratória e confirmatória, além de regressão linear para descrever características socio-demográficas associadas a cada padrão. Identificou-se três padrões de comportamento: o padrão \"comportamento problema\", compreendeu comportamento agressivo (incluindo bullying), consumo de álcool, cigarro e drogas e sexo não seguro; o padrão \"comprometedor da saúde\" incluiu indicadores de alimentação não saudável e comportamento sedentário; e o padrão \"promotor da saúde\" incluiu indicadores de alimentação saudável e atividade física. Os padrões \"comportamento problema\" e \"comprometedor da saúde\" se associaram aos mais velhos e aos residentes em regiões mais desenvolvidas, sendo o primeiro associado a escolas públicas e ao sexo masculino, enquanto o segundo ao sexo feminino. O padrão \"promotor da saúde\" se associou ao sexo masculino e aqueles com mães com maior nível educacional. Concluiuse que contextos de desigualdade parecem mais propícios à ocorrência de bullying de acordo com a revisão. Entretanto, dados do Brasil não corroboram essa hipótese para bullying verbal. Ambiente escolar com adoção de regras anti-bullying e professores mais solidários devem ser estimulados. As características das escolas e cidades estudadas explicaram pouco o bullying verbal. Características individuais sugerem sub-grupos de maior risco, podendo subsidiar políticas anti-bullying. Perpetrar bullying compôs o padrão de \"comportamento problema\", indicando que as intervenções devem ser mais amplas e direcionadas a múltiplos comportamentos / School bullying is an important public health problem, which has been extensively studied among high-income countries. In low- middle-income countries, there is a lack of information about associations between both individual-level and contextual-level characteristics with bullying. The aim of Study 1 was to carry out a systematic review of contextual factors associated with school bullying. Searches were performed in MEDLINE, PsychInfo, Web of Knowledge and SciELO. 31 studies were included. Results suggested that greater income inequality in schools, classes and countries is associated with increased risk of bullying. The influence of class and school size on bullying was inconclusive; schools without anti-bullying rules, with less support and poorer classroom management by the teacher had a higher risk of bullying. The aim of study 2 was to identify individual and contextual characteristics associated with verbal bullying, among Brazilian adolescents. We used data from the National Survey of School Health (PeNSE 2009) on students in 9th grade. We performed multilevel logistic regression models to identify associations with variables from three levels (individual, school, city). The prevalence of verbal bullying among Brazilian adolescents was 14.2%. Only 1.8% and 0.3% of the bullying variance occurred at school and capital levels, respectively. No city characteristic was associated with bullying. Private schools showed more bullying than public. Income inequality was not associated with bullying in Brazil. Boys, those of younger age, those not living with both parents, those exposed to domestic violence, those underweight or overweight suffered more bullying. The aim of Study 3 was to identify health-related behavior patterns, including bullying, among Brazilian adolescents. We used data from the second edition of PeNSE, carried out in 2012. We conducted exploratory and confirmatory factor analysis to identify behavior patterns, and linear regression models to describe sociodemographic characteristics associated with each pattern. We identified three behavior patterns; the problem-behavior pattern, which comprised aggressive behavior (including bullying), alcohol drinking, smoking, drugs use and unsafe sex; the health-compromising pattern, which included unhealthy diet indicators and sedentary behavior; and the health-enhancing pattern, which included healthy diet indicators and physical activity. The problembehavior and health-compromising patterns were associated with older age and from more developed regions. The former was associated with male gender and attending public school, while the latter was associated with female gender and more educated mothers. The health-enhancing pattern was associated with male gender and more educated mothers. In conclusion, the review suggested that bullying is more likely to occur in unequal contexts, but we could not confirm this hypothesis for verbal bullying in the Brazilian setting. Schools should be encouraged to adopt anti-bullying rules and to train teachers in bullying prevention. Among Brazilian adolescents the school and city variables explained litle of verbal bullying victimization. Individual characteristics indicated high risk sub-groups, which could be used to support anti-bullying policies. Bullying perpetration comprised part of the problem behavior pattern, suggesting that interventions should be more broaden

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Depuis le retour de la démocratie l’Amérique Latine a expérimenté une série de transformations importantes. Les premières, furent économiques et se caractérisent principalement par une grande vague de libéralisation économique qui a signifié entre d’autres choses, un type de changement fluctuant, des réductions des dépenses publiques, ainsi que, la privatisation des entreprises et des services de l’État qui ont fini pour réduire considérablement leur rôle. Les secondes, furent politiques et ont été marquées par l’arrivée des partis de gauche au pouvoir et la mise en œuvre d’une série de politiques sociales visant à réduire la pauvreté et les inégalités, qui ont permis d’améliorer significativement les conditions de vie de millions de Latino-américains. Tous ces changements, en plus de la fréquente alternance entre l’autoritarisme et la démocratie vécue durant les dernières années ont inévitablement eu un effet sur la confiance que les individus ont envers les institutions. Dans ce sens, comment le niveau de confiance institutionnelle en l’Amérique Latine a-t-il évolué au cours des dernières années? Spécifiquement, comment l’alternance au pouvoir des partis de gauche et de droite qui ont gouverné en Amérique Latine durant les derniers trente ans, a-t-il impacté sur les niveaux de confiance que les Latino-américains ont envers leurs institutions? Utilisant un modèle statistique multiniveau longitudinale de mesures répétées, cette recherche a comme premier objectif, de comprendre l’évolution historique du niveau de confiance institutionnelle en Amérique Latine entre 1995 et 2021, à partir de la combinaison des données incluses dans les sondages réalisées par Latinobarómetro, LAPOP et l’Enquête Mondiale des Valeurs (WVS), et comme deuxième objectif, d’estimer l’impact de l’orientation idéologique des individus et des partis au pouvoir sur le niveau de confiance institutionnelle. Les résultats montrent que quand le parti au pouvoir est de gauche, le niveau de confiance moyen envers les institutions est significativement plus élevé. Ils montrent également que la confiance institutionnelle se renforce positivement chez ceux qui déclarent avoir la même orientation que le parti au pouvoir. L’évolution de la confiance institutionnelle dans la région s’explique donc en partie, par l’orientation idéologique des individus et du parti au pouvoir. / Desde el retorno de la democracia América Latina ha experimentado una serie de importantes transformaciones. Las primeras, fueron económicas y se caracterizaron principalmente por una gran ola de liberalización económica que significó, entre otras cosas, un tipo de cambio fluctuante, recortes en el gasto público, la privatización de las empresas y servicios públicos que terminaron por reducir considerablemente el papel del Estado. Las segundas, fueron políticas y estuvieron marcadas por la llegada de los partidos de izquierda al poder y la implementación de una serie de políticas sociales dirigidas a reducir la pobreza y la desigualdad que permitieron mejorar significativamente las condiciones de vida de millones de latinoamericanos. Todas estas experiencias más la frecuente alternancia entre el autoritarismo y la democracia vivida durante los últimos años inevitablemente han ejercido un efecto en la confianza que los individuos tienen sobre las instituciones. En este sentido, ¿Cómo ha evolucionado el nivel de confianza institucional en América Latina los últimos años? Específicamente, ¿Cómo la alternancia en el poder de partidos de izquierda y de derecha que han gobernado en América Latina durante los últimos treinta años, ha impactado en los niveles de confianza que los latinoamericanos tienen de sus instituciones? A través de un modelo estadístico multinivel longitudinal de medidas repetidas, esta investigación tiene como objetivo en primer lugar, comprender la evolución histórica del nivel de confianza institucional en América Latina entre 1995 y 2021, a partir de la combinación de datos incluidos en las encuestas realizadas por Latinobarómetro, LAPOP y la Encuesta Mundial de Valores (WVS), y en segundo lugar, estimar el impacto de la orientación ideológica de los individuos y de los partidos gobernantes sobre el nivel de confianza institucional. Los resultados muestran que cuando el partido gobernante es de izquierda, el nivel de confianza medio hacia las instituciones es significativamente más alto. Por otra parte, muestran que la confianza hacia las instituciones se refuerza positivamente en aquellas personas que declaran tener la misma orientación que el partido gobernante. Por lo tanto, la evolución de la confianza institucional en América Latina se explica en parte, por la orientación ideológica de los individuos y del partido en el poder. / Since the return of democracy, Latin America has experienced a series of important transformations. The first, were economic and were mainly characterized by a big wave of economic liberalization that meant, among other things, a fluctuating exchange rate, curs in public spending, the privatization of public organizations and services that ended up considerably reducing the role of the State. The second, were politics and were marked by the arrival of left-wing parties to power and the implementation of a series of social policies aimed at reducing poverty and inequality that allowed to significantly improved millions of Latin Americans’ life conditions. All those experiences, plus the frequent alternance between authoritarianism and democracy in recent years, have inevitably had an effect on the trust that individuals have in institutions. Therefore, how has the level of institutional trust evolved in Latin America in recent years? Specifically, how has the alternance in power of left and right parties that have governed in Latin America during the last thirty years, had an impact on the levels of trust that Latin Americans have in their institutions? Through a longitudinal multilevel statistical model of repeated measures, this research aims, first, at understanding the historical evolution of the level of institutional trust in Latin America between 1995 and 2021, from the combination of data included in the surveys carried out by Latinobarómetro, LAPOP and the World Values Survey (WVS), and secondly, to estimate the impact of the ideological orientation of individuals and of the ruling parties on the level of institutional trust. The results show that when the ruling party is from the left, the average level of trust towards the institutions is significantly higher. They also show that trust in institutions is positively reinforced in those people who declare that they have the same orientation as the ruling party. Therefore, the evolution of institutional trust in Latin America is explained in part by the ideological orientation of individuals and the party in power.

Problématique : L’amélioration de l’accessibilité financière aux soins de santé est essentielle pour réduire la morbidité et de la mortalité infantile dans les pays à ressources limitées. Cependant, les preuves disponibles sur la relation entre un accès accru aux soins et l’amélioration la santé infantile, dans le long terme, demeurent insuffisantes et parfois inconnues. Dans le contexte spécifique de la région du Sahel au Burkina Faso où les niveaux élevés de morbidité et de malnutrition coïncident avec un faible recours aux soins, une intervention de santé publique associant la gratuité des soins à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté a été mise en œuvre en septembre 2008. Objectifs : En utilisant des approches statistiques et épidémiologiques appliquées aux données transversales et de séries chronologiques, cette thèse vise à apporter une meilleure compréhension de la façon dont la présence de l’intervention dans les communautés peut augmenter et maintenir l’utilisation des services de santé à long terme et améliorer la santé des enfants de moins de cinq ans. Les objectifs spécifiques sont : 1) évaluer le maintien à long terme des effets de l’intervention sur l’utilisation des services de santé chez les enfants de moins de cinq ans, 2) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur la probabilité de survenue d’une maladie et sur la probabilité d’utilisation des services de santé chez les enfants de moins de cinq ans, et 3) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur le retard de croissance chez les enfants de moins de cinq ans. Méthodes : Les données proviennent du système national d’information sanitaire, d’une enquête rétrospective sur les services de santé ainsi que d’une enquête de ménages réalisée quatre ans après le début de l’intervention dans 41 villages du district d’intervention et 51 villages du district de comparaison. Nous avons utilisé un plan quasi expérimental à séries temporelles interrompues avec groupe de comparaison pour évaluer les effets immédiats et à long terme de l’intervention sur les taux d’utilisation des services de santé. Ensuite, un plan d’étude transversale post-intervention avec un groupe de comparaison nous a permis d’évaluer l’effet contextuel de l’intervention sur la probabilité de survenue d’une maladie, sur la probabilité d’utilisation des services de santé et sur le retard de croissance chez les enfants de moins de cinq ans. La stratégie analytique a combiné la méthode de pondération par les scores de propension pour équilibrer les covariables entre les deux groupes, la modélisation binomiale négative à effets mixtes, les régressions linéaire et logistique multiniveaux. Résultats : L’intervention de gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté était associée à l’augmentation et au maintien de l’utilisation des services de santé au-delà de quatre ans (ratio des taux d’incidence = 2,33 ; IC 95 % = 1,98 – 2,67). En outre, comparativement aux enfants vivant dans le district de contrôle, la probabilité d’utiliser les services de santé était de 17,2 % plus élevée chez les enfants vivant dans le district d’intervention (IC 95 % = 15,01–26,6) ; et de 20,7 % plus élevée lorsque l’épisode de maladie était sévère (IC 95 % = 9,9–31,5). Ces associations étaient significatives, quels que soient la distance par rapport aux centres de santé et le statut socio-économique du ménage. Par ailleurs, alors que le contexte de résidence expliquait 9,36 % de la variance du retard de croissance (corrélation intraclasse = 9,36 % ; IC 95 % = 6,45–13,38), la présence de l’intervention dans les villages n’explique que 2 % de la variance du retard de croissance. Cependant, nous n’avons pas pu démontrer que la présence de l’intervention dans les communautés était associée à une réduction de la probabilité de survenue d’un épisode de maladie (Différentiel des probabilités = 4.4 ; IC 95% = -1.0 – 9.8), ni à une amélioration significative de l’état nutritionnel des enfants de moins de cinq ans (RC = 1,13 ; IC 95 % = 0,83–1,54). Conclusion : Cette thèse souligne que la gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté est efficace pour augmenter et maintenir l’utilisation des services de santé et réduire les inégalités géographiques de recours aux soins. Cependant, cette intervention n’était pas associée à une amélioration des résultats de santé infantile. Bien que des études longitudinales rigoureuses soient nécessaires pour comprendre pleinement l’influence potentielle de cette intervention sur la morbidité, cette thèse plaide pour la nécessité d’agir simultanément sur les autres déterminants sociaux de la santé et d’intégrer, de manière synergique, des interventions spécifiques à la nutrition pour plus d’impact sur la santé infantile. / Introduction: Improving financial access to health care is believed to be essential for reducing the burden of child morbidity and mortality in resource-limited settings, but the available evidence on the relationship between increased access and health remains scarce and the long-term issues are still unknown. In the specific context of the Sahel region in Burkina Faso where high levels of morbidity and malnutrition coincide with low health care use, a pilot intervention for free health care including quality of care improvement and management of malnutrition at the community level was implemented in September 2008. Objectives: Using statistical and epidemiological approaches applied to cross-sectional and time series data, this thesis aims to provide a better understanding of how the presence of intervention in communities can increase and maintain long-term use of health services and improve the health of children under five years. The specific objectives are: 1) to evaluate the long-term effects of the intervention on the use of health services in children under the age of five, 2) to estimate the contextual effect of intervention on the probability of occurrence of and the likelihood of health services being used by children under five, four years after the start of its implementation, and 3) to evaluate the contextual effect of the intervention on stunting in children under five, four years after the start of its implementation. Methods: The data for the analyses were provided from a variety of sources including the national health information system, a retrospective health services survey, and a household survey conducted four years after the intervention onset in 41 villages in the intervention district and 51 villages in the comparison district. We used a quasi-experimental controlled interrupted time-series design group to analyze the immediate and long-term effects of the intervention on the rate of health services utilization in children under five. Then, a quasi-experimental post-test-only design that included a control group allowed us to evaluate the contextual effect of the intervention on the probability of occurrence of a disease, on the probability of use of health services, and stunting in children under five. The analytic strategy combined the propensity score weighting method to balance the covariates between the two groups, two-level mixed-effects negative binomial, and linear and logistic regression models to account for the hierarchical structure of data. Results: The intervention for free health care including quality of care improvement and management of malnutrition at the community level was associated with an increased and maintained use of health services beyond four years after the onset of intervention (incidence rate ratio = 2.33; 95% CI = 1.98–2.67). In addition, compared to children living in the comparison district, the probability of using health services was 17.2% higher among those living in the intervention district (95% CI = 15.0–26.6); and 20.7% higher when the illness episode was severe (95% CI = 9.9–31.5). These associations were significant regardless of the distance to health centers and the socio-economic status of households. In addition, inequalities in the use of care were less pronounced in the intervention villages compared to those in the control village. Finally, the results also showed that the residence context accounted for 9.36% of the variance in stunting (intra-class correlation = 9.36% ; 95% CI = 6.45–13.38), and only 2% of the variance in stunting was explained by the intervention. However, we could not demonstrate that the intervention in these communities was associated with a reduced probability of an illness occurring (AME=4.4 (95% CI: -1.0 – 9.8), nor with a significant improvement in the nutritional status among children under five (OR = 1.13; 95% CI = 0.83–1.54). Conclusion: This thesis underlines the importance that affordable health care, including quality of care, as well as improving the management of malnutrition at the community level, are effective in increasing and maintaining the use of health services and reduce geographical inequalities in the use of care. However, this intervention was not associated with improved child health outcomes. Although rigorous longitudinal studies are necessary to fully understand the potential influence of this intervention on morbidity, this thesis highlights the need to simultaneously act on other social determinants of health and to synergistically integrate nutrition-specific interventions for greater impact on child health.