The general question in this dissertation is whether the democracy of schools is carried out in a gender equal manner in Sweden’s gender segregated upper secondary school. Students’ experiences of school democracy are measured using the dimensions of influence, discussion and legal rights. Three different explanatory factors are considered: the significance of gender, gender context and the character of the school programmes for these experiences. The study is based on student responses to a poll conducted in the top form classes of Kronoberg County’s upper secondary schools during the school year 2008/2009. The results of a series of regression analyses show that neither gender, gender context or programme character alone had an affect on experiences of school democracy. However, the more males present in a teaching environment, the poorer the experiences of influence and discussion are when all of the three explanatory factors are controlled for. In addition, the school programmes having male-coded character content particularly stand out favourably regarding school democracy. The number of males is usually high in such programmes and therefore the negative effects of male representation cancel out the positive effects of programme affiliation unless an explicit division is made of both of these aspects. Thus, keeping gender context and programme character separate is very important with studies of school democracy, since significant effects otherwise remain hidden. The study demonstrates that school democracy is important for students. Those students who have good experiences of school democracy perceive the school environment as significantly better than those who have poor experiences of school democracy. Concerning secondary effects, it appears that experiences of school democracy have different implications for learning among female and male students. There is a negative relationship between male experiences of influence and their grades in Swedish and Maths, while female experiences of discussion seem to show a positive covariance with grades. There is no relationship found in the data between students’ daily experiences of school democracy and their thoughts on voting in the upcoming parliamentary election.

The overall aim of this thesis is to contribute to an understanding of the pathways through which structural and intermediary determinants influence child health in Colombia and how they operate through the context where children live in a more comprehensive way than has been determined to date. Colombia has made significant progress in child health in the last few decades and it is currently on track to meet the Millennium Development Goals (MDG). Nearly 90% of the goals on global malnutrition, infant mortality rate and under-five mortality rate have been achieved. However, despite the progress, national averages remain masking huge territorial disparities. While some regions present figures similar to those of a developed country, others report indicators similar to those of a very poor African country. Some municipalities, for example, record no stunted children, whereas in others, the prevalence of chronic malnutrition is greater than 50%. In this context, empirical research that enhances our understanding of socioeconomic determinants of child health and guide policy-making is crucial in order to reduce place-based health inequities in Colombia. This thesis is based on three research articles. The data used in these studies are drawn from the 2010 Colombian Demographic and Health Survey (DHS). The DHS is a large survey programme designed to collect high-quality nationally representative data on population, health and nutrition for developing countries. The DHS are widely recognised as the most important source of information for the analysis of health inequities in the developing world. Firstly, intermediary determinants of early childhood health have been analysed through the construction of a composite index (Chapter 3). The intermediary determinants are the most immediate mechanisms through which socioeconomic position influence child health inequities. Therefore, their identification should contribute to the drafting of intervention policies at this level, given the importance of these factors in programmes aimed at improving maternal and child care. The index allowed us to identify key immediate determinants of child health and their relative importance among Colombian departments (administrative subdivisions). The index was constructed using a more sophisticated methodological approach than that commonly used in the literature, termed polychoric principal component analysis (PCA). A hierarchical cluster analysis was also carried out in order to identify how departments cluster based on the health of their children rather than their geographic proximity. The results showed that the largest differences in intermediary determinants of child health are associated with health care before and during delivery. Furthermore, the departments that perform relatively better in the most immediate determinants of child health are located in the centre of the country. In contrast, those departments that perform worse are located in the peripheral region. This region has a per capita gross domestic product (GDP) well below the national average, little state presence, a hostile environment and a large proportion of the ethnic minorities. Our index provides very useful information in terms of public policy since it facilitates measuring, visualizing and monitoring of child health indicators, and may, therefore, help identify potential intervention strategies for improving the well-being of Colombian children. Secondly, this thesis examines the effect of individual, family and community socioeconomic conditions on different indices representing intermediary determinants of child health, using a coherent conceptual framework (Chapter 4). Using a weighted multilevel approach, the results indicate that whilst community socioeconomic context can exert a greater influence on factors linked directly to health, in the case of psychosocial factors and parent’s behaviours, the family context can be more important. In addition, the results indicate that a significant percentage of the variability in the overall index of intermediary determinants of child health is explained by the community context, even after controlling for individual, family and community characteristics. This study provides evidence that community socioeconomic context is a key component for improving child health in Colombia. However, the role played by context may vary according to the category of the intermediary determinants of child health analysed, highlighting the importance of distinguishing between community and family intervention programmes. Thirdly, the influence of education of other women in the community and family socioeconomic characteristics on child nutrition outcomes, as well as their interactions, was investigated (Chapter 5). The contextual effects of education on child health were studied using weighted multilevel models. This study takes into account important methodological issues such as sample weights and second level endogeneity in multilevel modelling, which have not been addressed in the empirical literature and can lead to biases in the estimates. Different ways through which community education can substitute for the effect of family characteristics on child nutrition were found, suggesting that child care programmes should focus not only on individuals but should also target the broader context of communities. In particular, those communities with less educated mothers and with low female autonomy are those that could benefit more from intervention policies that focus on encouraging female education. To conclude, previous studies on the social determinants of child health in Colombia are limited. Most of them have covered the issue from the perspective of the individual and little attention has been paid to the effect of context. In this vein, understanding the structural and intermediary determinants of child health inequities, as well as the role played by community socioeconomic context, is essential for the design, monitoring and tracking of public child care policies in Colombia. / El objetivo de esta tesis es contribuir a un entendimiento de los mecanismos a través de los cuales los determinantes estructurales e intermediarios de la salud influencian la salud de los niños en Colombia y como estos operan a través del contexto donde los niños viven, de una manera más completa que la que se ha hecho hasta ahora. Esta tesis se base en tres artículos de investigación. Los datos usados en estos estudios son de la “Demographic and Health Survey” (DHS) para Colombia en el año 2010. En primer lugar, los determinantes intermediarios de salud infantil se analizan a través de un indicador compuesto. El indicador permite identificar determinantes intermediarios claves de salud infantil y su importancia relativa entre departamentos colombianos. En segundo lugar, esta tesis examina el efecto de las condiciones socioeconómicas de la comunidad, la familia y los individuos sobre diferentes índices que representan determinantes intermediarios de salud infantil. Por último, se analiza la influencia de la educación de otras mujeres en la comunidad y de características socioeconómicas de las familias sobre la nutrición infantil, así como sus interacciones. Se utilizan diferentes enfoques metodológicos. Para la construcción de los indicadores compuestos se utiliza un análisis de componentes principales usando correlaciones policóricas, con el fin de analizar cómo se agrupan los departamentos de acuerdo a la salud de sus niños se hace un análisis de cluster jerarquico. Finalmente, con el fin de medir efectos contextuales se utilizan modelos multinivel de regresión lineal ponderados. Los resultados de esta tesis demuestran que el contexto de la comunidad es un componente clave en la determinación de determinantes intermediarios de salud infantil, así como de indicadores de nutrición de los niños, tanto en el mediano como en el largo plazo en Colombia. Por lo tanto, es necesario que los gobiernos municipales y departamentales involucren no sólo a los individuos, sino que también tengan en cuenta el contexto de las comunidades para el desarrollo, ejecución, monitoreo y evaluación de las políticas de cuidado infantil.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / Esta tese tem como foco os efeitos da desigualdade de renda na saúde bucal e as tendências em desigualdades socioeconômicas em saúde bucal. Qualquer injustiça social, pelo caráter moral é digna de estudo, porém nem toda desigualdade de renda é socialmente injusta. Ela se torna injusta quando as pessoas com menos recursos são aquelas que permitem que as desigualdades econômicas afetem direitos humanos, como o direito a um nível de vida que assegure ao indivíduo e a sua família uma vida saudável. As desigualdades de renda foram estudadas em duas vertentes:a) efeitos contextuais da desigualdade de renda na saúde bucal ; b) tendências na diferença de saúde bucal entre pessoas com maior e menor renda. A primeira parte contém quatro artigos originais que estudaram a associação e os mecanismos contextuais p elos quais a desigualdade de renda afeta a saúde bucal. Para isso, foram utilizados dados do inquérito em saúde bucal SBBrasil de 2002. Os resultados mostraram que: a) a associação entre desigualdade de renda e saúde bucal é mais forte em relação à cárie dental do que outras doenças bucais (e.g. doenças periodontais e maloclusões); b)seus efeitos estão mais fortemente associados à doenças bucais de menor latência; c) os efeitos associados à cárie dental afetam pobres e ricos igualmente; e d) a ausência de políticas públicas parece ser a melhor explicação para os efeitos da excessiva desigualdade de renda no Brasil. Ainda em relação às políticas públicas, foi encontrados que os ricos beneficiam-se mais de políticas públicas municipais do que os pobres. A segunda parte desta tese contém dois artigos originais que descrevem as tendências em saúde bucal e o uso dos serviços odontológicos em grupos de maior e menor renda, no Brasil e na Suécia. Para essas análises, foram usados dados dos inquéritos em saúde bucal no Brasil dos anos de 1986 e 2002, e para Suécia foram obtidos dados do "Swedish Level of Living Survey" para 1968, 1974, 1981, 1991 e 2000. As tendências relacionadas à prevalência de edentulismo mostraram que houve uma redução das desigualdade em percentuais absolutos nos dois países, porém, no Brasil houve um aumento das diferenças quando o desfecho foi a prevalência de nenhum dente perdido. As reduções das disparidades em edentulimo estiveram associadas à presença de uma diferença inicial significativa ,já o aumento das desigualdade na prevalência de nenhum dente perdido esteve relacionado a uma pequena desigualdade no início da coleta de dados. Em relação às desigualdades de uso dos serviços, ressalta-se que o grupo mais pobre permanece utilizando menos os serviços odontológicos em ambos os países e as diferenças continuam significantes através dos tempos. Entretanto, tanto no Brasil como na Suécia, essas diferenças reduziram levemente nas coortes jovens em função do declínio no percentual de pessoas mais ricas que visitam o dentista. Nossos dados permitem concluir que as desigualdades, em saúde bucal, mesmo em países altamente igualitários, como a Suécia. / This thesis focuses on the effect of income distribution on oral health and trends on socioeconomic disparities in oral health. Any social injustice, because of moral issues, is worth studying, though not all inequality of is unfair. Income inequality is unfair when people with less economic resources are penalized with poor health because of their condition of poverty. Unjust societies are those that allow economic inequalities to affect human rights as the right to a standard of living that ensures the individuals and their family a healthy life. Income inequalities were studied in two aspects: a) the contextual effects of income inequality in oral health, and; b) trends in the difference in oral health among people with higher and lower income. The first part contains 4 original articles that studied the association and the contextual mechanism by which income inequality affects oral health. For this we used data of the oral health survey SSBrasil in 2002. The results showed that: a) the association between income inequality and oral health is stronger in relation to dental caries than other oral diseases (e.g. periodontal diseases and malocclusions); b) the effects of inequality of income are more strongly associated with oral diseases of a shorter latency: c) that the effects associated with dental caries affect equally the rich and the poor. The second part of this thesis contains two original articles that described the trends in oral health and in the use of dental services into groups of higher and lower income, in Brazil and Sweden. For this analysis data were obtained from the Brazilian oral health surveys for the year 2002, while for Sweden were used data from the "Swedish Level of Living Survey" for the years 1968, 1974, 1981, 1991 and 2000. Trends in the prevalence of edentulismo showed a reduction in absolute disparities in both countries, but in Brazil trends in the prevalence of "no missing tooth" increased. Reductions in disparities in edentulismo were associated with the presence of a significant initiak difference, while the increase in inequality for outcome "no missing tooth" was related to small inequalities in the begining of data collection. Trends in the use of dental services highlighted that the poorer have been using less the dental services in both countries and the difference remain saignificant over time. however, in Brazil and Sweden, these differences decrease slightly in the cohort of young people because there was a decline in the percentage of rich people who visit the dentist. Our data show that income inequalities in oral health and use of dental serviceshave historically favored the more affluent population even in highly egalitarian countires as Sweden.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / Esta tese tem como foco os efeitos da desigualdade de renda na saúde bucal e as tendências em desigualdades socioeconômicas em saúde bucal. Qualquer injustiça social, pelo caráter moral é digna de estudo, porém nem toda desigualdade de renda é socialmente injusta. Ela se torna injusta quando as pessoas com menos recursos são aquelas que permitem que as desigualdades econômicas afetem direitos humanos, como o direito a um nível de vida que assegure ao indivíduo e a sua família uma vida saudável. As desigualdades de renda foram estudadas em duas vertentes:a) efeitos contextuais da desigualdade de renda na saúde bucal ; b) tendências na diferença de saúde bucal entre pessoas com maior e menor renda. A primeira parte contém quatro artigos originais que estudaram a associação e os mecanismos contextuais p elos quais a desigualdade de renda afeta a saúde bucal. Para isso, foram utilizados dados do inquérito em saúde bucal SBBrasil de 2002. Os resultados mostraram que: a) a associação entre desigualdade de renda e saúde bucal é mais forte em relação à cárie dental do que outras doenças bucais (e.g. doenças periodontais e maloclusões); b)seus efeitos estão mais fortemente associados à doenças bucais de menor latência; c) os efeitos associados à cárie dental afetam pobres e ricos igualmente; e d) a ausência de políticas públicas parece ser a melhor explicação para os efeitos da excessiva desigualdade de renda no Brasil. Ainda em relação às políticas públicas, foi encontrados que os ricos beneficiam-se mais de políticas públicas municipais do que os pobres. A segunda parte desta tese contém dois artigos originais que descrevem as tendências em saúde bucal e o uso dos serviços odontológicos em grupos de maior e menor renda, no Brasil e na Suécia. Para essas análises, foram usados dados dos inquéritos em saúde bucal no Brasil dos anos de 1986 e 2002, e para Suécia foram obtidos dados do "Swedish Level of Living Survey" para 1968, 1974, 1981, 1991 e 2000. As tendências relacionadas à prevalência de edentulismo mostraram que houve uma redução das desigualdade em percentuais absolutos nos dois países, porém, no Brasil houve um aumento das diferenças quando o desfecho foi a prevalência de nenhum dente perdido. As reduções das disparidades em edentulimo estiveram associadas à presença de uma diferença inicial significativa ,já o aumento das desigualdade na prevalência de nenhum dente perdido esteve relacionado a uma pequena desigualdade no início da coleta de dados. Em relação às desigualdades de uso dos serviços, ressalta-se que o grupo mais pobre permanece utilizando menos os serviços odontológicos em ambos os países e as diferenças continuam significantes através dos tempos. Entretanto, tanto no Brasil como na Suécia, essas diferenças reduziram levemente nas coortes jovens em função do declínio no percentual de pessoas mais ricas que visitam o dentista. Nossos dados permitem concluir que as desigualdades, em saúde bucal, mesmo em países altamente igualitários, como a Suécia. / This thesis focuses on the effect of income distribution on oral health and trends on socioeconomic disparities in oral health. Any social injustice, because of moral issues, is worth studying, though not all inequality of is unfair. Income inequality is unfair when people with less economic resources are penalized with poor health because of their condition of poverty. Unjust societies are those that allow economic inequalities to affect human rights as the right to a standard of living that ensures the individuals and their family a healthy life. Income inequalities were studied in two aspects: a) the contextual effects of income inequality in oral health, and; b) trends in the difference in oral health among people with higher and lower income. The first part contains 4 original articles that studied the association and the contextual mechanism by which income inequality affects oral health. For this we used data of the oral health survey SSBrasil in 2002. The results showed that: a) the association between income inequality and oral health is stronger in relation to dental caries than other oral diseases (e.g. periodontal diseases and malocclusions); b) the effects of inequality of income are more strongly associated with oral diseases of a shorter latency: c) that the effects associated with dental caries affect equally the rich and the poor. The second part of this thesis contains two original articles that described the trends in oral health and in the use of dental services into groups of higher and lower income, in Brazil and Sweden. For this analysis data were obtained from the Brazilian oral health surveys for the year 2002, while for Sweden were used data from the "Swedish Level of Living Survey" for the years 1968, 1974, 1981, 1991 and 2000. Trends in the prevalence of edentulismo showed a reduction in absolute disparities in both countries, but in Brazil trends in the prevalence of "no missing tooth" increased. Reductions in disparities in edentulismo were associated with the presence of a significant initiak difference, while the increase in inequality for outcome "no missing tooth" was related to small inequalities in the begining of data collection. Trends in the use of dental services highlighted that the poorer have been using less the dental services in both countries and the difference remain saignificant over time. however, in Brazil and Sweden, these differences decrease slightly in the cohort of young people because there was a decline in the percentage of rich people who visit the dentist. Our data show that income inequalities in oral health and use of dental serviceshave historically favored the more affluent population even in highly egalitarian countires as Sweden.

The dissertation employs laboratory experimental methodology to study decision-making when people face trade-offs between ethical and economic values. More explicitly, the three chapters investigate 1) consumer behaviour when a substantially equivalent version of a product is more expensive because it was produced without child labour, 2) the interaction between an expert advisor and an ignorant decision-maker, when the former may gain from lying and the latter has to decide whether or not to trust in the advice, and 3) fairness in divisions of an economic gain between two people who were both involved in creating the gain, but only one of them provided real effort. Here, a focus is on the impact of power structure, i.e. who decides, on divisions and fairness judgments. All studies discuss implications of experimental behaviour for market and business domains. In addition, the thesis emphasizes ethical theories as complementary to normative benchmark from economic and psychological theory. / La tesis utiliza una metodología experimental para investigar las decisiones de los individuos cuando hay un conflicto entre valores éticos y económicos. Mas específicamente, los tres capítulos investigan sobre 1) el comportamiento del consumidor cuando se enfrenta a dos versiones de un mismo producto, siendo una de ellas más cara por ser producida sin trabajo infantil, 2) la interacción entre un agente experto y un agente desinformado que debe tomar una decisión confiando o no en el consejo del experto, el cuál puede mentir para ganar más dinero, y 3) el reparto justo de una ganancia económica entre dos personas de las cuales sólo una ha contribuido trabajando en un ejercicio. Este último estudio se centra en el impacto de la estructura de poder, es decir quién decide, en el reparto y en los juicios de que es lo justo. Los estudios analizan las implicaciones del comportamiento experimental sobre los mercados y las empresas. Además, la tesis propone teorías éticas para complementar las teorías económicas y psicológicas.

La question démographique, occupant une place centrale au coeur du conflit qui sévit en Israël et en Palestine, a fait couler beaucoup d’encre. De nombreux chercheurs issus de disciplines telles que la sociologie, la science politique ou même la philosophie ont contribué à la compréhension des origines de ce conflit et de ses conséquences sur les populations humaines. Il va sans dire que les enjeux qui y sont associés sont nombreux et que, pour les comprendre de manière exhaustive, l’interaction de nombreuses disciplines est requise. Puisqu’il s’agit ici d’une thèse en démographie, nous nous limitons aux aspects démographiques du conflit israélo-palestinien. De nombreux ouvrages rigoureux dans d’autres disciplines sont disponibles pour une approche plus holistique. La fécondité exceptionnelle observée dans la région est souvent associée à une “guerre des berceaux” visant ultimement à obtenir la majorité sur le territoire. Plusieurs théories visant à lier fécondité et contexte politique ont émergé dans la littérature démographique mais aucune d’entre elles n’a été vérifiée empiriquement à la fois auprès des populations palestiniennes et juives (en Israël et dans les territoires palestiniens de la Cisjordanie et Gaza). Ainsi, dans la poursuite de cette thèse, nous souhaitons explorer des avenues qui nous permettraient d’enrichir la connaissance des dynamiques de fécondité dans la région et contribuer à l’effort collectif visant à mieux évaluer les conséquences d’un conflit endémique sur les comportements reproductifs. Le premier objectif de cette thèse par articles consiste à dresser un bilan de l’état de la fécondité chez les Juives et les Palestiniennes demeurant en Israël et dans les territoires palestiniens en accordant un intérêt particulier à certains déterminants de la fécondité tels que : la contraception, l’âge au mariage, l’origine ethnique et la religiosité. Tout en prenant en considération l’importante hétérogénéité des groupes d’intérêt, nous cherchons à établir certaines similitudes entre Palestiniennes et Juives d’Israël et des territoires palestiniens, qui sont exposées, à des niveaux variables, aux conséquences du conflit. Il s’agit d’une première tentative afin de regrouper ces individus dans une même étude à l’aide de données d’enquêtes. En second lieu, nous visons à faire la lumière sur les différents comportements de fécondité des Juives en Israël et dans les colonies des territoires palestiniens afin de départager les effets des principaux déterminants de la fécondité israélienne (nationalisme, religiosité et statut socioéconomique) dans les deux régions et leurs évolutions temporelles grâce à des données de recensement. Bien que de nombreuses études se soient penchées sur la fécondité israélienne au niveau national, peu se sont attardées à étudier la sous-population constituée par les colons juifs qui demeure, par conséquent, largement méconnue. Finalement, nous nous intéressons à l’influence exercée par des facteurs individuels et contextuels sur la fécondité des Palestiniennes en Cisjordanie et à Gaza. Nous tentons de quantifier les effets du contexte et du nationalisme sur la fécondité. L’objectif consiste principalement à analyser les facteurs liés à la fécondité palestinienne en mettant l’accent sur le rôle des variables contextuelles tout en prenant en compte les divers facteurs socioéconomiques et démographiques. Bien que le conflit soit régulièrement invoqué dans l’explication de la fécondité palestinienne, aucune étude n’a encore démontré empiriquement son rôle. Les conclusions de cette thèse apportent un éclairage important à la recherche sur la fécondité dans cette région. En effet, il en ressort que les déterminants habituels de la fécondité ne semblent pas avoir un impact majeur sur la fécondité. Cette relative inefficacité des déterminants “classiques” de la fécondité s’expliquerait en partie par des conséquences du conflit. Il en découle une religiosité accrue dans de nombreuses tranches de la population, un fort sentiment nationaliste et des institutions qui veillent à éliminer les obstacles à la fécondité grâce à de nombreux incitatifs fiscaux. Dans un climat social et politique incertain, les valeurs traditionnelles familiales procurent une certaine stabilité. / Demography is central to the Israeli-Palestinian conflict and the consequences of high Palestinian and Israeli fertility have interested many scientists, as population balance is a key determinant in a potential peace settlement. Many researchers from various disciplines such as sociology, political science, or even philosophy contributed to the general understanding of the origins of the conflict and of its consequences on human populations. It goes without saying that to fully understand the issues and consequences of the conflict, a multidisciplinary approach is required. However, because this is a thesis in demography, we limit ourselves to the demographic aspects of the Israeli-Palestinian conflict. For a more holistic approach, many important works are available. The exceptionally high fertility in the region is often described as a “war of the cradles” ultimately aimed at gaining majority over the land. Such theories implying a political fertility have never been tested empirically simultaneously on both Palestinian Arabs and Jews (in Israel and the settlements in the Palestinian territories). The objective of this thesis is thus to explore different avenues allowing to expand knowledge on fertility dynamics in the region and to contribute to the existing literature on the demography of conflict and more precisely, on the consequences of an endemic conflict on fertility behaviour. In the first of three articles, we are producing a descriptive portrait of fertility among Israelis and Palestinians living in Israel and the Palestinian territories of the West Bank and Gaza Strip with a particular interest for a number of fertility determinants such as contraception, age at marriage, immigration, and religiosity among others. Despite a clear heterogeneity between the subgroups, we aim at finding some resemblances among them, all exposed at different intensities to the consequences of the Israeli-Palestinian conflict. This represents the first attempt to analyze all groups in the same project using survey data. The aim of the second article is to highlight the differences in fertility behaviour of the Jewish population living in Israel and to that of the Jewish population living in the settlements of the West Bank and Gaza Strip and to distinguish the effects of various determinants of Israeli fertility (nationalism, religiosity, and socioeconomic status) in both regions and over time using data from the 1995 and 2008 censuses. Even though many articles have studied the impact of such determinants of fertility in Israel, none yet has put the emphasis on the largely unknown settler population that has a significantly higher fertility than their counterparts in Israel. In the last article, we are interested in quantifying the impact of individual and contextual factors on Palestinian fertility in the West Bank and Gaza Strip. We thus specifically evaluate the impact of contextual variables (number of checkpoints and year of violent uprising) and nationalism (proportion of Jewish settlers living in the same district) associated with the conflict while controlling for various socioeconomic and demographic variables often used in fertility studies. Even though the consequences of the conflict are often brought up as an explanation for the high Palestinian fertility, no research has tried to empirically test the validity of such hypotheses using survey data. This thesis brings important contributions to the literature on fertility in this region. Indeed, it appears a though the usual determinants of fertility change do not seem to have an important effect on these populations. The inefficiency of such determinants can be partly explained by the consequences of the conflict. They led to an increased religiosity among many population groups, to a strong nationalist sentiment, and to institutions trying to alleviate most of the obstacles to fertility by generous fiscal incentives. In an uncertain social and political climate, traditional values such as family provide stability.

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.