This thesis is a subset of a larger “parent” project under the direction of my supervisor, Dr. Cecilia Benoit. The purpose of the larger project is to seize an unique research opportunity that has emerged with the development and implementation of the HerWay Home (HWH) program, a community-based initiative for pregnant and early parenting women who face substance use and other challenges in the Greater Victoria Area. My research has capitalized on the pre-implementation phase of the HWH program between 2010-2011. Thirteen in-person semi-structured interviews were conducted with women who would likely be clients for the HWH program, based on their pregnancy experiences, substance use concerns and other life challenges. The goal of this research has been to explore these women’s pregnancy and postpartum narratives and investigate what, in their view, should be crucial components of the HWH intervention in the short and longterm. My findings indicate that, consistent with the literature on pregnant and early parenting women facing substance use and other life challenges, a range of complex, intertwined disadvantages exist in their lives that translate into multiple barriers to accessing continuous health and social care during their pregnancy and after the birth of their child. An adapted model of the Health Lifestyle Theory is used to frame the analysis of the data collected from this research. The results from this research support the argument that the life choices of the participants are constrained by structural life chances and socially determined inequities that systematically disadvantage and disempower them. The findings also reveal an implicit sense of agency in the women’s narratives, as well as key specifics about what they view as the main gaps in care and their desired program services. The findings will be relayed to HWH organizers, and used to inform the development and implementation of the program’s services. / Graduate

This thesis explores employment among people who inject drugs (IDU). It seeks identify what differentiates IDU who work from those who do not, barriers to labour market participation, and how employment is perceived and experienced by IDU. Using longitudinal data from the Vancouver Injection Drug User Study (VIDUS), it conducts this research through a detailed examination of the implications of missing data, quantitative analyses of transitions into employment and qualitative, in-depth interviews. Missing data analyses identified differences between those that those that do and do not have missing data, as well as predictors of observation gaps and how individuals end their study participation (either right-hand censorship, attrition, or death). Differences were observed along individual, behavioural and contextual dimensions. Analytical approaches to the relationship between data structure and content gleaned useful information for longitudinal studies with marginalized populations. Discrete time event history analyses of work transitions revealed complex relationships between drug use, drug-related activities, situational risk factors, and transitions into employment. While most IDU did not make transitions into employment, some did, and while some statistical relationships were expected, others were surprising. Novel findings included mode-specific addiction treatment impacts on employment (methadone vs. non-methadone) and the importance of the broader risk environment over and above even high-intensity substance use. Finally, qualitative interviews identified heterogeneity in individual motivations toward and experiences of work. Those who maintained concurrent drug use and formal labour market involvement utilized strategies to spatially and temporally separate the two activities. Individual capacities to employ these strategies were facilitated by material, vocational and temporal motivations, and interfered with by health conditions, catastrophic events and institutional relationships that operated as barriers to employment. This study provides insight into what is a known social determinant of health in the general population among injection drug users.

Extant literature has documented well that people seek health information via the internet as patients and consumers. Much less, however, is known about interaction and creation behaviors in the development of new online health information and knowledge. More specifically, generalizable sociodemographic data on who engages in this online health behavior via social media is lacking in the sociological literature. The term “social e-health” is introduced to emphasize the difference between seeking behaviors and interaction and creation behaviors. A 2010 dataset of a large nationally representative and randomly sampled telephone survey made freely available from the Pew Research Center is used to examine social e-health behavior according to respondents’ sociodemographics. The dependent variable of social e-health behavior is measured by 13 survey questions from the survey. Gender, race, ethnicity, age, education, and income are used as independent variables. Logistic regression analysis was used to determine the odds of engagement in social e-health behavior based on the sociodemographic predictors. The social determinants of health and digital divide frameworks are used to help explain why socioeconomic variances exist in social e-health behavior. The findings of the current study suggest that predictable sociodemographic patterns along the dimensions of gender, race, age, education, and income exist for those who report engaging in social e-health behavior. This study is important because it underscores the fact that engagement in social e-health behavior is differentially distributed in the general U.S. population according to patterned sociodemographics.

Purpose: The primary objective of this study was to estimate the prevalence of vaccination and HBV infection status of adults and to evaluate the trend in self reported vaccination and seroprevalence for Hepatitis B for this population. Additionally, this study sought to assess the association between vaccination rates, seroprevalence (HBsAg, anti-HBc, and anti-HBs), demographic (age, gender, location of birth, race/ethnicity), and socioeconomic (annual household income, education level, insurance coverage and access to care, marital status) characteristics. Methods: Eight years, 1999-2006, of the National Health and Nutrition Examination Survey (NHANES) data were used. NHANES participants aged 20-59 years who contributed data via the household interview and laboratory component were eligible for this study. Two sources of vaccination status were available. The vaccination status was identified through self-report. Those who answered yes to “less than three doses” and “at least three doses” were classified as vaccinated. Vaccination status was also verified through serologic markers. All analyses were weighted to consider the complex weighting scheme and adjusted to the 2000 US census population. Vaccination rates were calculated for both low and high risk populations. 95% confidence intervals (95% CI) of each estimate were also calculated. The association between potential predictors of vaccination (demographic variables, socioeconomic status, high risk, and health care access and utilization variables) and vaccination status was assessed using bivariate analysis. We used logistic regression model to obtain odds ratios and their 95% confidence intervals for the association between predictor variables and vaccination status after adjusting for all potential confounding factors. Results: Vaccinated adults were more likely to be female, younger (20-29), Non-Hispanic white, married, born in the United States, have some education beyond high school, have a household income greater than $20000, health insurance coverage, a source of usual medical care, report a health status of good or higher, be non-smokers, and have no history of alcohol abuse. High risk adults comprised about 16% of adults who had received at least one dose of the Hepatitis B vaccine. Unvaccinated adults were more likely to be male, over the age of 40, Non-Hispanic white, born in the United States, married, have some education beyond high school, have a household income greater than $20,000, live in a household of 6 or fewer people, have health insurance coverage, and a source of usual care. When comparing the self reported vaccination status with serologic status, almost half of the adults who reported receiving all three doses of the vaccine tested negative for immunity. For all adults the prevalence increased from 23.4% to 39.1%. Compared to adults in 1999-2000, adults were twice as likely to report vaccination in 2005-2006 (OR=2.1 95% CI [1.77, 2.49]). Conclusions: Although, hepatitis B vaccination rates are rising, only 32% of high risk adults are vaccinated. The rise in vaccination rates in young adults is mostly related to childhood immunization strategies and not strategies aimed at adults. Older males, those with less than high school education, without health insurance coverage and a source of usual care were least likely to be vaccinated. More targeted interventions are needed to educate and vaccinate the adult population and to create a means for identifying those at risk and those already vaccinated.

Os catadores de materiais recicláveis, cuja profissão é reconhecida pelo Ministério do Trabalho desde 2002, têm a necessidade de assegurar a sua própria sobrevivência bem como a dos seus familiares. Os Determinantes Sociais da Saúde (DSS) buscam analisar as condições econômicas e sociais que afetam a saúde. Os DSS envolvem cinco níveis superpostos: comportamento e estilo de vida; redes sociais e comunitárias; condições de vida e trabalho, macrodeterminantes e condições de saúde. Todos influenciam na ocorrência de problemas de saúde e nos fatores de risco da população. O objetivo deste trabalho é caracterizar os Determinantes Sociais da Saúde dos catadores de materiais recicláveis, através da análise de dados secundários obtidos no Sistema Único de Assistência Social-SUAS e delimitados geograficamente ao município de Serrana. A população de catadores de material reciclado revelou uma prevalência acentuada de homens com idade média de 40 anos, a maioria solteiros e autodeclarados como pardos. Dentro da avaliação dos DSS, 93,75% dos indivíduos declaram não praticar esportes, 75% são fumantes, não possuem acesso à TV e internet e 69% são analfabetos. Por outro lado, os indivíduos possuem moradias dignas com infraestrutura de água e esgoto. As condições de saúde desses indivíduos também foram analisadas e uma parcela apresentou alterações em exames de sangue, como: colesterol (37,5%), glicemia (12,5%) e nível de plaquetas (6,25%). Outra variável analisada foi o ambiente de trabalho, com 37,5% de notificações de algum tipo de acidente, como corte de mão, braço ou pé durante a coleta de lixo. Concluímos que avaliar esses fatores é importante para identificar os riscos que o grupo de catadores de materiais recicláveis é exposto e compreender a intervenção sobre os mecanismos de estratificação social. Os DSS são ferramentas importantes para que a gestão pública conheça a realidade dos catadores de recicláveis e consiga apresentar políticas públicas eficazes, melhorando, assim, a qualidade de vida dessas pessoas extremamente vulneráveis e de função social importante, pois são essenciais à conservação do território e na redução da quantidade de resíduos / Waste recyclers, whose profession has been recognized by the Brazilian Ministry of Labor since 2002, have a need to ensure their own survival, as well as their family members\' maintenance. Social Determinants of Health (SDHs) are used to analyze economic and social conditions affecting a population\'s health. SDHs consist of five superimposed levels: behavior and lifestyle, social and community networks, life and work conditions, macrodeterminants, and health conditions. All of them have a relationship with health problems and risk factors in a population. This study aimed to characterize the SDHs of recyclable waste collectors living in the city of Serrana - SP (Brazil), through secondary data taken from the Unified Social Assistance System (SUAS). This group consisted mainly of men with a mean age of 40 years, most of whom were single and self-reported as brown or \'pardo\' (a mixture of white, black, and Amerindian races). Results of the SDH assessment showed that 93.75% of the individuals reported not playing sports; 75% declared being smokers, not having TV and internet access; and 69% were illiterate. However, these individuals live in decent housing with water and sewage infrastructure. The health conditions of these workers were also analyzed, and blood examination revealed alterations in the levels of cholesterol (37.5%), blood glucose (12.5%), and platelets (6.25%). We also assessed the work environment and noted that work accidents such as hand, arm, or foot cutting during waste collection represented 37.5% of the cases. Thus, we conclude that these factors are important to identify risks to which recyclable waste pickers are exposed, as well as to understand social stratification mechanisms. In short, SDHs are of paramount importance for public administrators to know the reality of recyclable waste collectors and elaborate effective public policies to improve their quality of life, since they are extremely vulnerable people and play a major social role contributing to the environmental conservation and waste reduction

Despite decreasing cardiovascular disease mortality rates, these diseases are still the most common cause of death in a number of economically advanced countries, including the Czech Republic. This thesis deals with prevalence of myocardial infarction (the most common forms of ischemic heart disease) and selected risk factors of this disease, using the database of the international project SHARE (The Survey of Health, Aging and Retirement in Europe). The first part describes the development of mortality on circulatory system diseases and the risk factors of myocardial infarction are discussed in the context of the literature. The empirical part of this work analyzes the infarction prevalence and the relationship between infarction prevalence and risk factors in SHARE respondents, both in the group of respondents from European countries and in the subset of respondents from the Czech Republic, using the binary logistic regression method. The analysis showed, among other things, that the main risk factor for myocardial infarction of SHARE respondents was low physical activity among respondents in European countries, so did male respondents in the Czech Republic. In the group of Czech women, the main risk factor was underweight. Out of the social determinants, the impact of education attained in both...

A tuberculose (TB) ainda se destaca como uma emergência global, apresentando elevada magnitude, transcendência e vulnerabilidade. Assim, objetivou-se investigar os determinantes das internações por tuberculose e sua distribuição espacial e tendência temporal. Estudo ecológico, cujos dados primários foram obtidos a partir de entrevistas com os profissionais da saúde da Atenção Primária à Saúde (APS) no ano de 2014 e os dados secundários das internações por TB entre 2006 e 2015 registrados no Sistema de Informação Hospitalar do Sistema Único de Saúde (SIH/SUS). Além disso, recorreu-se ao Índice Paulista de Vulnerabilidade Social - versão 2010 para mensurar a vulnerabilidade social nos territórios. Procedeu-se inicialmente às análises dos dados por meio da estatística descritiva, realizadas no Statistica 12.0. Para análise espacial realizou-se a geocodificação das internações no TerraView versão 4.2.2. Considerou-se como unidades de análise as 46 áreas de abrangência da APS, classificadas segundo suas modalidades. Estimou-se a taxa bruta e bayesiana empírica das internações evitáveis por TB, sendo suavizada pelo Método Bayesiano Empírico. Recorreu-se, ainda, à regressão linear múltipla pelo método dos mínimos quadrados e à regressão espacial para verificar a relação de dependência espacial das internações evitáveis por TB com a capacidade da APS de coordenar as Redes de Atenção à Saúde (RAS) e ao Índice de Vulnerabilidade Social. Mapas coropléticos foram construídos no ArcGis 10.2. Das 46 unidades de APS, apenas cinco foram classificadas na condição regular para coordenar as RAS. Em relação aos atributos, nenhuma das áreas foi classificada na condição insatisfatória e apenas uma, na condição ótima. Na modelagem espacial, não se observaram atributos que fossem significativamente relacionados às internações evitáveis por TB. Foram identificados 265 casos de internações evitáveis por TB. As taxas variaram de 1,24 a 10,66 internações por TB por 100.000 habitantes/ano. O Distrito Norte apresentou as taxas mais altas (> 6,57); os Distritos Sul, Oeste e Norte apresentaram taxas moderadas (3,70 - 6,56); os Distritos Leste e Central apresentaram as taxas mais baixas (< 3,69). Houve uma maior concentração de internações em regiões mais densas e entre os anos de 2008 a 2009 e 2014 a 2015. Referente ao IVS, os Distritos Sul, Leste, Oeste e Central foram classificados em sua maioria no Grupo 2 (vulnerabilidade muito baixa); os Distritos Norte e Oeste, no Grupo 3 (vulnerabilidade baixa) e uma área foi classificada com vulnerabilidade muito alta (Distrito Norte). Na modelagem espacial também não se observou relação estatisticamente significativa do IVS com as internações evitáveis por TB. O estudo, identificou as áreas da APS mais deficientes quanto à coordenação das RAS e cartografou as áreas mais vulneráveis às internações por TB, possibilitando à gestão local um planejamento em saúde mais direcionado àqueles grupos mais vulneráveis, a fim de diminuir o número de internações evitáveis e injustas e avançar na melhoria da qualidade e fortalecimento de um sistema de saúde orientado pela APS sob a conformação de Redes / Tuberculosis (TB) still stands as a global emergency and presents high magnitude, transcendence and vulnerability. Thus, the aim was to investigate determinants of tuberculosis hospitalizations, their spatial distribution and temporal trend. An ecological study whose primary data were obtained from interviews with Primary Health Care (PHC) professionals in the year 2014 and secondary data of hospitalizations for TB were collected between 2006 and 2015 and recorded in the Hospital Information System of the Health Unique System (SIH/SUS). Also, it was possible to use the Paulista Social Vulnerability Index, 2010 version, to measure social vulnerability in the territories. Initially, data analyses were carried out through descriptive statistics and performed by Statistica 12.0. For spatial analysis, it was carried out hospitalizations geocoding through TerraView, version 4.2.2. The 46 areas covered by the APS were considered as analyses units and classified according to their modalities. It was possible to estimate the gross and empirical Bayesian rate of avoidable hospitalizations by TB and smoothed by the Bayesian Empiric Method. It was also used the multiple linear regression through the method of least squares and spatial regression to verify the spatial dependence relation of avoidable hospitalizations by TB, with the APS capacity to coordinate the Health Care Networks (RAS) and Index of Social vulnerability. Coropletic maps were constructed in the ArcGis 10.2. Of a total of 46 APS, only five were classified in the regular condition to coordinate the RAS. Regarding the attributes, none of the areas was classified as unsatisfactory condition and only one of them was categorized in the optimal condition. In the spatial modeling, there were no attributes significantly related to avoidable hospitalizations for TB. A total of 265 cases of preventable hospitalizations for TB were identified. Rates ranged from 1.24 to 10.66 hospitalizations for TB per 100,000 inhabitants a year. The Northern District had the highest rates (> 6.57); The South, West and North Districts presented reasonable rates (3.70 - 6.56); The Eastern and Central Districts had the lowest rates (<3.69). There was a greater concentration of hospitalizations in denser regions between the years 2008-2009 and 2014-2015. Regarding the IVS, South, East, West and Central Districts were classified mostly in the Group 2 (very low vulnerability). North and West Districts in Group 3 (low vulnerability) and one area was ranked with very high vulnerability (Northern District). In the spatial modeling, there was no statistically significant relationship between the IVS and avoidable hospitalizations for TB. The study identified the most deficient areas of APS in the coordination of RAS and mapped the most vulnerable areas to hospitalizations for TB. Thus, it was possible for the local management to plan a health care more targeted to the most vulnerable groups to reduce the number of avoidable and unjust hospitalizations and advance in quality and strengthening improvement of a health system oriented to the APS, under the formation of Networks

Introdução: A tuberculose (TB) se configura como um grave problema de saúde pública, estando entre as principais doenças infecciosas que mais matam no mundo. Objetivo: Investigar se as variações espaciais das iniquidades sociais afetam as mortes por tuberculose. Métodos: Trata-se de um estudo ecológico analítico de medidas múltiplas de análise, desenvolvido na área urbana de Manaus, o qual utilizou como unidade de análise as Unidades de Desenvolvimento Humano (UDHs). A população do estudo foi composta de casos de óbito por TB como causa básica, registrados no Sistema de Informações sobre Mortalidade no período de 2006 a 2015. A geocodificação dos endereços foi processada no TerraView versão 4.2.2. Posteriormente, Taxas brutas, padronizadas e bayesianas empíricas globais de mortalidade foram calculadas. A existência de autocorrelação espacial da mortalidade por TB foi verificada pelos índices de Moran Global e Local. Aplicou-se Regressão Linear Múltipla (OLS), optando pelo modelo que apresentasse o menor AIC (Critério de Informação de Akaike), conforme técnica de stepwise. Os resíduos da regressão linear foram investigados quanto à existência de autocorrelação espacial por meio do Teste Global de Moran. Após, recorreu-se a uma análise multivariada espacial local utilizando modelo de Regressão Ponderada Geograficamente (GWR). Na GWR foram incorporadas como variáveis exploratórias aquelas que se apresentaram como melhor modelo conforme critério de R², R² ajustado e valor de AIC no modelo linear (OLS). Para as análises foram considerados os softwares Statistica versão 12.0, R versão 3.2.2 e ArcGIS versão 10.2.2. Em todos os testes estatísticos foi fixado o nível de significância em 5% (p< 0,05). Resultados: Foram identificados 731 óbitos, 692 seguiram para a etapa de análise espacial, e 666 (96,24%) foram geocodificados. Houve predominância de casos no sexo masculino e na etnia parda. Observou-se que a maioria apresentou idade entre 15 e 59 anos e possuía ensino fundamental e médio e ocupação ignorada. Observou-se maior taxa de mortalidade na região sul do município, onde as taxas anuais variaram entre 1,6 a 7,7 casos por 100.000 habitantes. Na análise da correlação espacial da variável dependente (taxa padronizada dos óbitos por tuberculose), o índice de Moran global (I) encontrado foi de 0,177 (p=0,01). O modelo final OLS pode explicar 0,06 (R²) da variação das taxas de mortalidade por TB, obtendo R² ajustado 0,044 e AIC 1189,19. O modelo OLS permitiu a seleção das variáveis a serem testadas no modelo GWR, tais como: Taxa de analfabetismo da população de 18 anos ou mais de idade; Proporção de pobres; Proporção de vulneráveis à pobreza; Percentual da renda total apropriada pelos 20% da população com menor renda domiciliar per capita e Taxa de desocupação da população de 18 anos ou mais de idade. O modelo final GWS apresentou parâmetros de R2 0,093, R2 ajustado 0,037 e AIC 1178,36. Conclusão: O estudo avança no conhecimento ao evidenciar diferenças entre as áreas em termos dos determinantes sociais. Neste sentido, são fundamentais reformulações políticas e intervenções em saúde nas áreas identificadas de maior risco em Manaus / Introduction. Tuberculosis (TB) is a serious public health problem, being among the main infectious diseases that kill more people worldwide. Aim: To investigate whether spatial variations in social inequities affect tuberculosis deaths. Methods: This was an ecological analytical study of multiple measures of analysis, developed in the urban area of Manaus, in which the Human Development Units (HDUs) were used as the unit of analysis. The study population was composed of cases of death due to TB as the basic cause, recorded in the Mortality Information System from 2006 to 2015. The geocoding of the addresses was processed using the TerraView version 4.2.2 software. Subsequently, gross, standardized, and Bayesian global empirical mortality rates were calculated. The existence of spatial autocorrelation of TB mortality was verified through the Global and Local Moran indices. Multiple Linear Regression (OLS) was applied, choosing the model that presented the lowest AIC (Akaike Information Criterion), according to the stepwise technique. Residues of linear regression were investigated for the existence of spatial autocorrelation through the Global Moran Test. Subsequently, a local spatial multivariate analysis was employed using the Geographically Weighted Regression (GWR) model. In the GWR, those variables that presented the best model according to the R² criterion, adjusted R² and AIC value in the linear model (OLS) were incorporated as exploratory variables. The Statistica version 12.0, R version 3.2.2 and ArcGIS version 10.2 programs were used for the analyses. In all statistical tests, the level of significance was set at 5% (p<0.05). Results: A total of 731 deaths were identified, with 692 used in the spatial analysis stage and 666 (96.24%) geocoded. There was a predominance of cases in males and in people of brown skin color. It was observed that the majority was aged between 15 and 59 years, had elementary and high school education and did not report an occupation. A higher mortality rate was observed in the southern region of the city, where annual rates ranged from 1.6 to 7.7 cases per 100,000 inhabitants. In the analysis of the spatial correlation of the dependent variable (standardized rate of deaths due to tuberculosis), the global Moran index (I) found was 0.177 (p=0.01). The final OLS model explained 0.06 (R²) of the variation of mortality rates due to TB, obtaining 0.044 adjusted R² and 1189.19 AIC. The OLS model allowed the selection of the variables to be tested in the GWR model, such as: Illiteracy rate of the population aged 18 years or over; Proportion of poor people; Proportion of people vulnerable to poverty; Percentage of total income appropriated by the 20% of the population with the lowest per capita household income and the unemployment rate of the population aged 18 years or over. The final GWS model presented the following parameters, 0.093 R2, 0.037 adjusted R2 and 1178.36 AIC. Conclusion: The study advances knowledge by highlighting differences between areas in terms of the social determinants. Accordingly, political reformulations and health interventions are fundamental in the areas of greater risk identified in Manaus

Submitted by Verena Pereira (verenagoncalves@uefs.br) on 2018-07-17T21:43:39Z No. of bitstreams: 1 DISSERTA??O PPGSC CANDISSE ALVES DE ALMEIDA VERS?O FINAL PDF.pdf: 1292449 bytes, checksum: a4006dd589548bd88e4b06311531dacc (MD5) / Made available in DSpace on 2018-07-17T21:43:39Z (GMT). No. of bitstreams: 1 DISSERTA??O PPGSC CANDISSE ALVES DE ALMEIDA VERS?O FINAL PDF.pdf: 1292449 bytes, checksum: a4006dd589548bd88e4b06311531dacc (MD5) Previous issue date: 2017-06-08 / Funda??o de Amparo ? Pesquisa do Estado da Bahia - FAPEB / The objective of this study was to analyze the quality of life (QoL) of people with sickle cell disease (DF) from the perspective of the social health determination model (MDSS). A scientific paper entitled "Quality of life of people with sickle cell disease and the model of social determination of health" was constructed. The study of the QoL assessment of people with DF is considered a tool to reach the social and scientific visibility of this illness in the national scenario. The study of the evaluation of QoL in chronic diseases, like DF, is extremely important, since the impact of the disease on QoL strongly influences the way the subject faces his illness. It was a challenging study that sought to understand QOL in people with FD as a phenomenon of great complexity, on which individual and collective conditions are linked, considering not only biological and hereditary conditions, but also social and cultural, capable of influencing the perception of the individual and determining their health condition and these characteristics illustrate the social determinants of health. In view of this complex scenario, we suggest the development of specific instruments to evaluate the QoL of people with FD, considering all the peculiarities inherent to this disease so prevalent in the northeastern territory / O objetivo deste estudo foi analisar a qualidade de vida (QV) das pessoas com Doen?a falciforme (DF), na perspectiva do modelo de determina??o social da sa?de (MDSS). Para isso foi constru?do um artigo cient?fico intitulado: ?Qualidade de vida de pessoas com Doen?a Falciforme e o modelo de determina??o social da sa?de?. Considera-se o estudo da avalia??o da QV das pessoas com DF uma ferramenta para alcance da visibilidade social e cient?fica deste adoecimento no cen?rio nacional. A realiza??o de estudos sobre a avalia??o da QV em adoecimentos cr?nicos, a exemplo da DF, ? de extrema import?ncia, visto que o impacto exercido pela doen?a sobre a QV influencia intensamente a forma como o sujeito enfrenta o seu adoecimento. Tratou-se de um estudo desafiador, que buscou entender a QV em pessoas com DF como um fen?meno de grande complexidade, sobre o qual est?o atreladas as condi??es individuais e coletivas, considerando n?o somente as condi??es biol?gicas e heredit?rias, mas tamb?m as quest?es sociais e culturais, capazes de influenciar a percep??o do indiv?duo e de determinar a sua condi??o de sa?de e estas caracter?sticas ilustram os determinantes sociais da sa?de. Diante deste cen?rio complexo, sugere-se o desenvolvimento de instrumentos espec?ficos para avalia??o da QV de pessoas com DF, considerando todas as particularidades inerentes a este adoecimento t?o prevalente no territ?rio nordestino

Contexte: De récentes études ont explicitement démontré que les communautés d’immigrants doivent affronter des difficultés particulières afin d'accéder aux services de santé et font face à des disparités sanitaires significatives, subissant l'effet de déterminants sociaux sous-jacents de la santé (DSS). Les immigrants représentant un pourcentage grandissant de la population dans de nombreux pays développés, mieux comprendre et supprimer ces barrières est une des grandes priorités. En se fondant sur l'utilisation d'une structure DSS, cette thèse contribue aux recherches actuelles concernant l'accès aux services de santé parmi les populations d'immigrants bangladais dans trois villes internationales : Lisbonne (Portugal), Bruxelles (Belgique) et Boston (Massachusetts, U.S.A.). À cet effet, elle apporte des précisions sur les données qualitatives limitées disponibles concernant les communautés immigrantes bangladaises qui vivent sur les sites de recherche mentionnés ci-dessus.Résultats: Les résultats obtenus ont montré que les immigrants bangladais vivant sur ces trois sites de recherche possèdent une vision généralement holistique de la santé et du bien-être. Les pressions de l'acculturation et l'isolement social constituent deux des DSS pertinents ayant une influence sur la santé et l'accès aux services sanitaires. Parmi les principaux enjeux de santé et besoins en soins de cette communauté, les problèmes de santé mentale et l'isolement social, l'alimentation et les habitudes alimentaires, le manque d'activité physique, des niveaux élevés de diabète et de maladies cardiovasculaires ont été identifiés comme facteurs influençant. Certaines valeurs culturelles associées à des motivations d'ordre économique peuvent conditionner l'importance que les individus accordent à leur santé. A titre d'exemple, l'obligation envers la famille, profondément ancrée dans la culture bangladaise, se traduit souvent chez les immigrants travaillant à l'étranger par un sentiment de pression économique et se manifeste par un stress chronique et un déséquilibre entre vie professionnelle et vie personnelle. La communication et les barrières linguistiques apparaissent comme étant les principaux freins à l'engagement des immigrants bangladais avec les prestataires de soins. Enfin, le type ainsi que le contexte de l'immigration joue un rôle important dans l'utilisation des services de santé par les immigrants bangladais: le sentiment d’être dans une situation transitoire sur le lieu où ils se trouvent tel qu'à Lisbonne et Bruxelles, en opposition à une perspective d'établissement plus permanent tel qu'à Boston, semble influencer l'utilisation active de soins de santé continus.Conclusion: Les problèmes de santé de chaque individu, la situation de leur statut d'immigrant et les circonstances familiales ont joué un rôle sur la manière dont les membres de la communauté bangladaise ont accédé et utilisé les services de santé sur chaque site de recherche. Bien que les liens sociaux au sein des communautés bangladaises vivant à l'étranger soient forts, tous les individus ne se trouvaient pas nécessairement en contact avec les membres de leur communauté. Ceci met en exergue le besoin d'un engagement et d'une sensibilisation auprès des immigrants susceptibles de ne pas bénéficier de la protection du capital social de leur communauté. Cette dissertation a permis de dresser le profil des déterminants sociaux influençant l'accès aux services de santé de la communauté immigrante bangladaise, avec pour objectif d'informer les professionnels travaillant avec cette population. A cet effet, les conclusions de cette recherche seront partagées avec les participants et intervenants de chaque site d'études afin de renforcer la compréhension des communautés immigrantes bangladaises et accroître les ressources mises à leur disposition. / Background: Recent studies clearly identify that immigrant communities experience specific challenges in accessing health care services, and face significant health disparities, that are impacted by underlying social determinants of health (SDH). As immigrants comprise an increasing percentage of the population in many developed nations, a better understanding and eliminating of these barriers is a major priority. Using an SDH framework, this dissertation contributes to the current research regarding access to health services among Bangladeshi immigrant populations in three international cities: Lisbon (Portugal), Brussels (Belgium), and Boston (MA-USA). In doing so, it expands upon the limited qualitative data available that concerns Bangladeshi immigrant communities living in these aforementioned research sites.Methods: This dissertation utilized a qualitative descriptive research design to comprehend issues from the perspective of both immigrant community members and service providers. The findings presented in this study, therefore, focus on data analyzed from 45 original in-depth interviews with Bangladeshi immigrant community members (n=32) and service providers (n=13) across Lisbon, Brussels, and Boston. Data was collected primarily using a semi-structured interview guide.Results: Bangladeshi immigrants living across the three research sites possess an overall holistic view of health and well-being according to results. Relevant SDH affecting health and accessing health services included pressures of acculturation and social isolation. The following were identified as some of the key community health issues and care needs: mental health and social isolation, food and dietary habits, lack of exercise, high levels of diabetes and cardiovascular disease. Certain cultural values coupled with economic motivators may influence the way individuals prioritize their health. For example, the obligation towards family that is deeply embedded in Bangladeshi culture often translated to feelings of economic pressure by immigrants working abroad and manifested as chronic stress and a work-life imbalance. Communication and language barriers emerged as the most prominent issue of engagement between Bangladeshi immigrants and service providers. Finally, the type and context of immigration played in important role in health service utilization by Bangladeshi immigrants: a transitory outlook on their current location such as in Lisbon and Brussels, as opposed to a more permanent outlook in Boston, appeared to influence the active uptake of continuous health care.Conclusion: Individual health priorities, immigration status, and family circumstances affected how Bangladeshi community members accessed and utilized health services at each research site. Although social networks in Bangladeshi communities abroad were strong, not all individuals were necessarily connected with their fellow community members. This underlines the need to initiate engagement and outreach to immigrant individuals who may fall outside of the protection of social capital in their community. This dissertation has established a profile of social determinants impacting access to health services for Bangladeshi immigrant communities, with the purposes of informing professionals working within this population. As such, results will be shared with participants and stakeholders at each of the study sites in order to strengthen the understanding of and resources available to Bangladeshi immigrant communities.