PROBLEM INVESTIGATED: Methodological issues and policy implications arising from the application of interrupted time series (ITS) analyses to assess the impact of Pharmaceutical Benefit Scheme (PBS) subsidisation policies on drug utilisation in Australia. PROCEDURES FOLLOWED: A critical review of methodological issues relating to the application and analysis of ITS designs was undertaken. This included an examination of drug utilisation data sources in Australia. The PBS policies examined were: (i) the introduction of copayments in 1990; (ii) the introduction of re-supply limits in 1994 and (iii) the introduction of a form of reference pricing in 1998. Monthly aggregate drug utilisation data was obtained from the Australian Department of Health and Ageing. Segmented regression analyses incorporating autocorrelated errors were implemented and statistical diagnostics applied to ensure correct ITS model specification. Alternative seasonal modelling approaches were compared. RESULTS OBTAINED: The copayment ITS evaluation found that while these copayments produced a reduction in the utilisation of essential and discretionary medications, this effect was stronger for discretionary drugs. An unintended policy effect was a large anticipatory increase in drug utilisation during the month prior to the copayments. Repatriation PBS data was also utilised due to the limited number of pre-intervention data points in the Community series. The re-supply limit ITS evaluation found that the 20-day rule markedly reduced the size of the seasonal increase during the month of December. However, logistic regression analyses showed that the size of this reduction attenuated over time, highlighting the need to consider alternative analysis strategies when applying a ITS approach. The reference pricing ITS evaluation found that this policy had achieved its drug utilisation objectives for H2RAs and ACE Inhibitors. However with regard to CCBs, no increase in the utilisation of benchmark priced drug was apparent, which probably reflected clinical concerns at the time about the safety of these drugs. MAJOR CONCLUSIONS: Well implemented ITS analyses provide a valuable tool for evaluating the impact of PBS subsidisation policy change on drug utilisation in Australia. As with any methodology, however, different design and data integrity issues will affect the quality of information provided.

Background There is a widespread perception that the health status of rural Australians is poorer than that of urban Australians, characterised by higher mortality, lower life expectancies, and an increased incidence of some diseases. At present this perception is difficult to confirm or refute, in terms of mental illness, because of limited published data on the extent of mental illness in regional Australia. Australians from rural areas are also reported to have less access to appropriate health care compared to their urban counterparts; however, there is limited evidence to support such claims using large population-based epidemiological data. It is not known whether remoteness per se is an important determinant of health. Aim To determine if rural and remote South Australians were disadvantaged in terms of their mental health status and access to health care. The aims were to: 1) determine if prevalence of mental illness and comorbidity were associated with accessibility and remoteness; 2) examine the effects of accessibility and remoteness on health service utilisation; and 3) determine if remoteness per se was an important determinant of mental illness. Methods Prospectively designed, secondary analysis of data from a large cross sectional, population–based health survey, conducted in South Australia (SA) in 2000. In all, 2,454 adults, aged 18 years or more, were randomly selected and interviewed using the Computer Assisted Telephone Interview (CATI) system. CATI is a telephone monitoring system that is an efficient means of assessing self-reported aspects of population health, particularly in rural and remote areas. Psychological distress and depression were assessed using the Kessler 10 (K10) Psychological Distress Scale, the SF-12 measure of health status and self-reported, medically-confirmed mental illness, in the previous 12 months. Additional outcome measures included socio-demographic characteristics, a range of health services measures, psychosocial and health risk factors. Geographical variation in outcome measures was assessed using the Accessibility and Remoteness Index of Australia (ARIA). The data were analysed using SPPS and Stata statistical programs and weighted by region, age, sex and probability of selection in the household, using the 1999 total estimated resident population (ERP) figures supplied by the Australian Bureau of Statistics. Direct age-sex standardisation was applied to prevalence rates of mental illness, socio-demographic and health service utilisation data. Results Overall age-sex adjusted mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), depression (12.9%) and self-reported medically-confirmed mental illness (12.9%). For each measure, there was no significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the accessible category. There was also no significant difference in the median number of uses of four types of health services across ARIA categories. Significantly fewer residents of highly accessible areas reported never using primary health care services (14.4% vs. 22.2% in very remote areas), and significantly more reported high use (6 visits, 29.3% vs. 21.5%). Fewer residents of remote areas reported never attending hospital (65.6% vs. 73.8% in highly accessible areas). Frequency of use of mental health services was low and not significantly different across ARIA categories. Very remote residents were more likely to spend at least one night in a public hospital (15.8%) than were residents of other areas (eg 5.9% for highly accessible areas). After controlling for the joint effects of stressful life events, perceived control of life events, socio-demographic characteristics and health risk factors, odds of mental illness did not vary by ARIA category (highly accessible: reference category; accessible: OR 0.9, 95% CI 0.60-1.31; moderately accessible: OR 0.80, 95% CI 0.45-1.43; remote/ very remote: 0.70, 95% CI 0.44-1.03). The most important predictors of mental illness in the multivariate logistic model were female sex; smoking; low consumption of vegetables; low exercise; a physical condition; perceived lack of control with: life in general, personal life, job security or health; and major stressful events such as family or domestic violence and the death of someone close. Conclusions Prevalence rates of psychological distress, depression and medically-confirmed mental illness in SA were high. However, there was no evidence that the prevalence of these conditions varied substantially across ARIA categories. The frequency of use of a range of health services was also broadly similar across the state. Remoteness per se was not associated with mental illness, either directly or indirectly as an important confounder in stressful life event/mental illness associations. Psychosocial factors were more important determinants of mental illness. The data do not support existing stereotypes of a rural – urban mental health differential in SA and point to potential mechanisms that may be responsible for poorer mental health outcomes.

De par sa géométrie et sa situation géographique (2°N-13°N - 8°E-16°E ; ouverture sur l'océan Atlantique), le Cameroun offre l'avantage de proposer un ensemble représentatif des climats régionaux rencontrés en Afrique tropicale. La diminution des cumuls de précipitations enregistrée dans la région pendant la seconde moitié du XXe siècle, est associée à la récurrence de périodes anormalement sèches, essentiellement au coeur de la saison des pluies. Ces conditions ont amplifié la dégradation du couvert végétal au travers ses contraintes socioéconomiques et démographiques (déforestation, extension des surfaces d'activité). Les conséquences souvent dommageables de la variabilité climatique en général, et des sécheresses en particulier, sur les hommes et leurs activités suscitent l'intérêt de développer des études pour mieux comprendre comment le climat et les pressions naturelles et environnementales interagissent localement. Ainsi, l'objectif de cette thèse est de diagnostiquer la variabilité multiéchelle (saisonnière, interannuelle, intra-saisonnière, synoptique) des précipitations et les relations qu'elle entretient avec le couvert végétal au sens large qui, à ces latitudes, est associé directement ou non, à la dynamique d'occupation et d'utilisation du sol, particulièrement sur la période 1951-2002. A partir de données de précipitations observées (CRU/ponctuelles), les modes spatiaux de la variabilité ont été définis aux échelles annuelles et interannuelles, par Analyses en Composante Principale (ACP) et la Classification Ascendante Hiérarchique (CAH). Ces méthodes de classifications ont permis de discriminer cinq zones climatiques, différentes les unes des autres par l'intensité des cumuls et la saisonnalité (unimodal/bimodal). Pour chaque zone, l'attention a été portée sur les paramètres intrasaisonniers qui modulent la variabilité annuelle telle que, les séquences sèches (nombre, longueur, périodes d'occurrence) et les variations des dates de début et de fin des périodes végétatives. La répartition du couvert végétal dans l'espace et dans le temps (1982-2002) a été étudiée, en utilisant des méthodes de classification non supervisée (ISODATA) sur les données de NDVI (Normalized Difference Vegetation index) à 8km de résolution. Enfin, des méthodes statistiques et de télédétection ont permis d'évaluer l'impact des facteurs pluviométriques et anthropogéniques (croissance démographique et utilisation du sol) sur la dynamique du couvert végétal en utilisant des bases de données à plus fine résolution (NDVI/1Km ; Global Land Cover (GLC 2000/1Km)). Ces dernières investigations ont été menées dans le Nord-Cameroun (6°N-13°N - 11°E-16°E), qui est la région la plus sensible des points de vue climatique, économique et environnemental.

We all have a body: our own body and just one body. Through it, we move, we interact with the world and other persons, we perceive, basically we live. It's a unique essential object. If it is true that we have only one physical body, we also have many representations of it in the brain. There is little agreement about the exact number of body representations in the brain, but not on the fact that we have more than one. The multi-componential models of body representation are based on the notion, supported by scientific evidence that different activities demand and rely on specifically adapted representations. In my thesis, I studied one particular body representation that is used and involved in action planning and execution, i.e. the Body Schema. I have been able to describe and measure the plasticity of the Body Schema and its level of specificity in healthy individuals. In particular, using a tool-use paradigm, I showed that the Body Schema is quickly and efficiently updated once a change in the body configuration occurs. With a series of kinematic studies, I contributed unveiling the ingredients that rule the plasticity of the BS and the sensory information that is used to this purpose. As a result of my thesis, I suggest that a clearer definition and operational description of the Body Schema, as an action-devoted repertoire of effectors representations, is possible, particularly thanks to its plastic features.

L'information sectorielle est destinée à fournir aux investisseurs une information leur permettant de mieux anticiper le risque et les perspectives de rentabilité des entreprises diversifiées et/ou multinationales. Cette thèse constitue une contribution au développement et au perfectionnement de l'utilisation de cette information dans une perspective financière. L'étude des données sectorielles publiées par les entreprises montre que cette information peut être présentée sous plusieurs formes et que son contenu informatif peut être différent selon l'entreprise qui la publie. Nous mettons en évidence diverses caractéristiques de l'entreprise qui peuvent influencer ce contenu informatif : degré de diversification, organisation interne (structure organisationnelle et intégration verticale), profil (taille, intensité du financement par le marche, intérêts minoritaires, endettement, sensibilité politique et rentabilité des activités) et disponibilité des données. Nous proposons un cadre général d'utilisation de cette information qui intègre les différentes approches des utilisateurs et qui prend en compte la variabilité de ce contenu informatif. De plus, nous proposons une application de cette utilisation dans le cadre d'un modèle mécanique de prévision du résultat. Ces propositions sont ensuite confrontées aux études déjà réalisées sur l'utilité des données sectorielles en matière de prévision du rendement et d'évaluation du risque puis testées au travers de quatre études empiriques dont deux sont réalisées à l'échelle internationale. Ainsi, la démarche que nous proposons vise à donner des outils pour interpréter correctement des données dont de degré de pertinence dépend de divers facteurs. La caractérisation de ces derniers permet une utilisation optimale de l'information sectorielle qui peut apporter aux analystes une meilleure lisibilité des états financiers dans une vision prospective.

Les revêtements d'étain sont couramment utilisés en connectique automobile pour des utilisations peu sévères en température. Actuellement il n'existe pas de consensus sur la température limite d'utilisation des revêtements étamés. L'objectif de cette étude est d'étudier le vieillissement thermique des systèmes cuivre/étain utilisés en connectique, et d'évaluer leur durée de vie en fonctionnement, c'est-à-dire sous un courant moyen (produisant de l'effet Joule) et en régime vibratoire (fretting corrosion). L'interdiffusion cuivre/étain mène à la formation de phases intermétalliques de type Cu6Sn5 et Cu3Sn. La cinétique de croissance des intermétalliques est étudiée en fonction de la nature du revêtement d'étain, de la présence ou non d'une sous-couche de nickel (menant à la formation de l'intermétallique Ni3Sn4) et des types de substrats cuivreux différant par les éléments d'alliages. Le coefficient de croissance parabolique mesuré dans chaque système substrat/revêtement permet de comparer la rapidité de la croissance en fonction du système étudié. Les intermétalliques possèdent une dureté sensiblement plus élevée que celle de l'étain seul. Des essais d'échauffement par effet Joule et de fretting corrosion sont menés sur des éprouvettes vieillies et non vieillies. L'échauffement par effet Joule est directement lié à la surface de contact : la dureté du revêtement est donc un paramètre déterminant, qui conditionne l'élévation de température au point de contact. Mais l'aire de la surface de contact conductrice dépend également de l'oxydabilité du revêtement, car la présence d'oxyde peut la réduire. Le phénomène est accentué en régime vibratoire : la production d'oxyde est alors accélérée, et la formation de débris oxydés peut mener à l'apparition de microcoupures électriques. Différentes éprouvettes sont testées en fretting-corrosion, avec deux types d'expérience : des essais à débattement variables et des essais en durée de vie. Les essais en débattement variable permettent d'identifier la transition entre le glissement partiel (d'amplitudes faibles, pour lesquelles la durée de vie du contact est considérée comme infinie) et le glissement total (d'amplitudes plus élevées, pour lesquelles la durée de vie du contact est limitée). Les essais en durée de vie permettent de comparer la durabilité des éprouvettes testées. L'observation des traces de fretting permettent l'identification des modes de défaillance. La dégradation des contacts étamés est le fait d'une oxydation et d'une usure conjointes, menant à l'isolation électrique à cause de la présence de débris oxydés. La dégradation des contacts intermétalliques est le fait d'une fragilisation du revêtement, menant à son décollement : le mode de défaillance est alors la production de débris oxydés de cuivre, provoquant une isolation électrique au point de contact.

<p>The aims of this thesis are threefold: (1) To investigate cancer patients’ satisfaction with and utilisation of an Individual Psychological Support (IPS) intervention. (2) To evaluate the effects of Individual Support (IS), comprising IPS combined with Intensified Primary Health Care and Nutritional Support, on psychological distress and quality of life during the first year after diagnosis. (3) To explore to what extent aspects of quality of life and emotional functioning one year after diagnosis can be predicted by medical, psychological and socio-demographic factors at diagnosis. The analyses are based on data from the Support-Care-Rehabilitation project, using a prospective randomised design to compare four conditions: (1) Individual Support (IS) starting at diagnosis, (2) Group Rehabilitation (GR) starting three months later, (3) a combination of IS and GR, and (4) Standard Care (SC). The study sample consisted of patients newly diagnosed with breast cancer, colorectal cancer, gastric cancer or prostate cancer. A total of 481 patients were randomised and followed for 24 months.</p><p>The IPS was an individually tailored, problem-focused intervention based on psychosocial oncology and cognitive behaviour therapy. Half of the patients receiving IPS had more than 2 sessions. Patients reporting that they had problems to address received more IPS sessions and reported more benefits of the intervention. Receiving an extensive medical treatment, young age, and not having someone besides the family to rely on in times of difficulties increased the odds of receiving tree or more sessions of IPS. The IS had limited impact on psychological distress and quality of life in intention-to-treat analyses. Additional analyses with stratification for baseline anxiety and/or depression levels suggested that for IS patients with higher levels of anxiety and/or depression, these problems continued to diminish below those of Control patients during the first year after diagnosis.</p><p>Linear regression models were used to explore, one year after diagnosis, quality of life aspects indicative of rehabilitation needs. High levels of baseline anxiety and / or depressive symptoms were associated with lower levels of Emotional Functioning, and high self-rated well-being was associated with higher levels of Emotional Functioning. Extensive medical treatment and presence of comorbid conditions during the year before diagnosis predicted a low Global Quality of Life, whereas self-rated wellbeing predicted a high Global Quality of Life. Advanced disease, one or more comorbid conditions and high age were found to be associated with lower levels of Physical Functioning. A high level of activities outside the home during the year before diagnosis and high self-rated wellbeing were predictive of a better Physical Functioning. </p><p>In conclusion, a large proportion of cancer patients offered IPS in conjunction with diagnosis and primary treatments seized this opportunity to discuss their situation, and perceived the experience as beneficial. Thus, offering newly diagnosed cancer patients these psychosocial support services may facilitate their situation.</p>

<p>It has been suggested that persons with intellectual disabilities (ID) manifest the full range of mental health problems. The main purpose of this thesis is to adapt and evaluate two clinical assessment instruments and to investigate the occurrence of mental health problems as well as psychiatric care utilisation in persons with ID. </p><p>The psychometric properties of a Swedish version of the two instruments [Reiss Screen for Maladaptive Behaviour (RSMB) and the Psychopathology Inventory for Mentally Retarded Adults (PIMRA)] were investigated in a random, institutional and clinical sample of administratively defined (ADDEF) adults with ID (n = 199). The analyses suggest that the RSMB could be used as intended by staff as a primary screening device for the identification of mental health problems in persons with ID, and that the PIMRA had a potential to identify individuals with a specific mental disorder. The psychometric evaluation reveals that the Swedish versions of the RSMB and PIMRA measure a construct related to the diagnostic categories in the DSM-III-R and DSM-IV. This construct could be conceptualised as mental health problems.</p><p>The RSMB and PIMRA results show that the overall occurrence of mental health problems in ADDEF samples of persons with ID (175 men and 148 women) ranged from 34 to 64%.</p><p>The preliminary level of ID was mild (23%), moderate (39%) and severe (38%). The most common mental health problems were aggressive and self-injurious behaviours, depression, anxiety and adjustment disorders. In registered patients receiving out- or in-patient psychiatric care the occurrence of adults with an ICD-10 diagnosis of ID was approximately 1% (70 to 90% had a mild level of ID). </p><p>In contrast to the high frequency of mental health problems reported, psychiatric care was used infrequently. This tendency is particularly evident in persons with moderate and severe ID.</p>

<p>The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients.</p><p>Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged.</p><p>The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.</p>

<p><b>Objectives</b>. To study medication utilization and adherence to prescribed therapy in a female population in central Sweden. To study usage of hormone replacement therapy (HRT) in this population and to assess how HRT users compare to non-users regarding symptom reporting, general health and other variables. To evaluate symptom prevalence adjusted for potential symptom affecting variables. </p><p><b>Material and methods</b>. A cross-sectional postal questionnaire study was performed in 1995 in seven counties in central Sweden. A questionnaire was sent to a random sample of 4,200 women aged 35-64, of whom 2,991 responded (71.2%). The questionnaire contained questions on psycho-socio-economic background, quality of life, self-reported health, height and weight, climacteric symptom prevalence, and menopausal status and symptoms. It also comprised questions on medication prescribed during the past year. </p><p><b>Results</b>. 40% used prescribed medication and 12% took four drugs or more. Age, educational level, self-rated health, and BMI remained significantly correlated to drug use in multivariate analysis. Adherence ranged from 15%-98% depending on age, a scheduled check-up, perceived importance of medication, concern about medication, taking cardiovascular and respiratory disease drugs. The highest adherence was found for hormonal medication the lowest for musculoskeletal medication. </p><p>HRT was used by 15% of the women. 13 % used other symptom relieving therapy. HRT users reported higher score of vasomotor symptoms, except for sweating during the daytime. </p><p>Prevalence of general symptoms did not necessarily increase with age. Especially symptoms related to stress-tension-depression decreased with age. Four different symptom prevalence patterns were found. </p><p><b>Conclusions</b>. Age, health status, educational level and body mass index (BMI) appear to affect drug use. Adherence to therapy is highest among elderly women who regard their medication as important and have a scheduled check-up. HRT relieves some vasomotor symptoms but does not affect other symptoms or self-rated health. Prevalence of symptoms related to Stress-tension-depression appears to decrease with age.</p>