Life course literature states that early childhood development (ECD) can influence most aspects of health throughout the life-cycle. Canada ranked last among 25 wealthy nations in meeting ECD objectives. Fewer than 5% of children born have clinically detectable shortcomings in developmental health, increasing to 26% by school age with emerging socioeconomic associations. Understanding how social determinants of health (SDH) influence ECD at the household and neighbourhood scales would help identify conditions for optimal developmental outcomes. The effects of SDH on ECD in the Kingston, Ontario area were studied. SDH were classified via marginalization (ONMarg) and deprivation (Pampalon) indices. ECD was measured via 2006 Early Development Instrument (EDI) scores for children most at risk upon school entry (Grade One). The basic spatial unit of analysis was 2006 Census of Canada Dissemination Areas, subdivided into quintiles of deprivation (Q1 being the least deprived and Q5 the most). EDI results from each of the quintiles within the two indices were compared and then combined. The socioeconomic health gradient assumes that EDI scores will directly correlate to material and social deprivation. Social deprivation had a slightly greater impact than material deprivation on children’s developmental vulnerability, with Q5 being the most vulnerable in all competencies. Surprisingly, emotional health and social competence were significant areas of vulnerability for children in Q1 and Q2. “Village effects” – when social determinants at the neighbourhood level have protective effects on ECD despite material deprivation at the household level – were present within the Q3 and Q4 groups for the domains of social competency and emotional health. While the highest proportions of early childhood developmental vulnerability are found within the most deprived households, the largest numbers of vulnerable children are spread throughout the middle-class in a variety of neighbourhoods. Canadian policy should focus on mediating avoidable risks within this critical time to avoid future deleterious health effects and costs. Mapping the effects of SDH at the neighbourhood level generates knowledge that informs intersectoral action by policy makers to provide the supports needed to foster healthy children. / Thesis (Master, Geography) -- Queen's University, 2013-05-04 10:36:25.165

L’objectif principal de cette thèse était de mettre en évidence l’évolution et l’orientation de la motivation intrinsèque et extrinsèque des élèves roumains tout au long du second cycle d’enseignement secondaire général. Depuis plusieurs années la théorie de l’autodétermination (Deci et Ryan, 1985b, 2000) a été utilisée afin de mieux comprendre le comportement des élèves en milieux scolaire. Ryan et Deci distinguent la motivation intrinsèque et la motivation extrinsèque qui diffèrent selon le type de récompense rattachée à l’activité. La théorie de l’autodétermination repose sur trois besoins psychologiques fondamentaux : l’autonomie, la compétence et la relation à autrui. Les déterminants psychologiques familiaux (parents), institutionnels (professeurs) et écologiques (système scolaire compétitif et évaluatif) sont aussi susceptibles d’influencer l’orientation motivationnelle de l’élève. Une première étude s’est attachée à analyser l’orientation et l’évolution de la motivation intrinsèque et extrinsèque. Les résultats présentent les élèves comme plus motivés extrinsèquement plutôt qu’intrinsèquement. De plus les deux formes de motivation diminuent tout au long de leur cursus scolaire. Une seconde étude s’est employée à mesurer le degré d’influence des trois besoins psychologiques sur la motivation intrinsèque des élèves. Les résultats ont montré que le besoin d’affiliation était le plus fortement corrélé positivement à la motivation intrinsèque. Les deux dernières études ont visé à mettre en évidence la relation entre le sentiment d’autonomie des élèves exercé par les parents et les professeurs et leur motivation intrinsèque. Les résultats confirment l’influence positive de ces deux déterminants sur la motivation intrinsèque des élèves. Enfin ces résultats seront discutés notamment sur le rôle des déterminants psychologiques dans cette recherche et dans le cadre des travaux sur la normativité de la motivation intrinsèque. / The main objective of this thesis was to highlight the evolution and direction of the intrinsic and extrinsic motivation of Romanian pupils throughout the second cycle of general secondary education. For several years the self-determination theory (Deci and Ryan, 1985b, 2000) was used to better understand the behavior of students in the school. Ryan and Deci distinguish intrinsic motivation and extrinsic motivation that vary by type of reward attached to the activity. Self-determination theory is based on three basic psychological needs: autonomy, competence and relatedness. The psychological determinants family (parents), institutional (college), and environmental (school system competitive and evaluative) are also likely to influence motivational orientation of students. A first study has sought to analyze the direction and evolution of the intrinsic and extrinsic motivation. The results show the students as more extrinsically motivated rather than intrinsically. In addition, both forms of motivation decrease throughout their school career. A second study aimed to measure the influence of the three basic psychological needs on the intrinsic motivation of students. The results showed that the need for affiliation was most strongly correlated positively to intrinsic motivation. Two recent studies have sought to highlight the relationship between perceived autonomy of students by parents and teachers and their intrinsic motivation. The results confirm the positive influence of these two determinants on the intrinsic motivation of students. Finally, these results will be discussed including the role of psychological determinants in this research and the work on the normativity of intrinsic motivation.

Entre 100 et 140 millions de femmes, de petites filles et d’adolescentes sont excisées (Andro et Lesclingrand, 2007). Les risques sanitaires de l’excision sont élevés et concernent la santé reproductive, physique et psychologique des femmes. Les nouvelles migrations et l’augmentation des pays qui légifèrent l’excision ont contribué à l’internationalisation de l’excision et à la modification de son processus. On constate actuellement une tendance de l’excision à devenir une pratique clandestine et une perte de sa signification rituelle. En même temps, les mouvements de lutte internationaux, régionaux autant que nationaux prennent de l’ampleur et connaissent une période de mutation afin de contrer la nouvelle figure de l’excision. Le Burkina Faso ne fait pas exception. Le gouvernement burkinabé s’est clairement positionné en faveur du mouvement de lutte contre l’excision et met en place de nombreux dispositifs juridiques, politiques et économiques afin d’en soutenir les initiatives. En 2003, 77 % des femmes burkinabè âgées de 15 à 49 ans se déclaraient excisées. Parallèlement, on assiste à une diminution de la pratique chez leurs filles entre 1998 et 2003 et à une augmentation du nombre de Burkinabè se déclarant contre la pratique. Pourtant en 2003, environ 40 % des femmes ont excisé ou souhaitent exciser leurs filles et environ 24 % des hommes et 26 % des femmes sont encore favorables à la perpétuation de l’excision. Ce mémoire s’intéresse d’abord aux changements de pratique, de connaissance et d’attitudes par rapport à l’excision entre 1998 et 2003. Il s’intéresse ensuite aux déterminants socioculturels, démographiques et économiques favorisant la persistance de cette pratique au sein de la société burkinabé et aux obstacles rencontrés par les intervenants pour combattre l’excision sur le terrain. Pour ce faire la recherche associe méthodes quantitatives et qualitatives. Elle combine analyses statistiques des données des enquêtes démographiques de santé de 2003 et de 1998 et analyse des données d’entretiens collectées auprès d’acteurs sur le terrain entre le premier et le 10 octobre 2005. / Between 100 and 140 million women, young and teenage girls have undergone feminine genital cutting (Andro and Lesclingrand, 2007). The medical risks of excision are high and relate to the reproductive, physical and psychological health of women. New migrations and the increase of countries legislating female genital cutting contributed to the internationalization of the practice and to the changes in its process. The loss of the ritual significance of excision and the increase as a concealed practice have clearly been noticed. In the meantime, the international movements fighting it, regional as well as national, amplify and put changes together in order to counter the new figure of female genital cutting. Burkina Faso does not make exception. The Government has clearly positioned itself in favour of movements fighting excision; and has set up many legal, political and economic devices in order to support their initiatives. In 2003, 77% of Burkina Faso women aged between 15 to 49 years old were declared excised. In parallel, a reduction in the practice for their daughter between 1998 and 2003 is noted as well as an increase in the number of Burkina Faso people declaring themselves against the practice. However in 2003, approximately 40% of women have performed or would like their daughter to undergo the cut; and approximately 24% of men and 26% of women are still encouraging the perpetuation of excision. This thesis’ first concern is the changes in the practice, and the knowledge and attitudes regarding excision between 1998 and 2003. Secondly, the attention is drawn on the socio-cultural, demographic and economic determinants indulging the doggedness of this practice within Burkina Faso people and on the concrete obstacles workers encounter on the ground. Therefore this research associates quantitative and qualitative methods. It combines statistic analysis of the Demographic and Health Surveys of 2003 and 1998 data; and analyzes data collected from talks made between October 1 st and 10th, 2005 with fields’ workers.

L’utilisation continue de corticostéroïdes inhalés est reconnue pour réduire le nombre d’hospitalisations, la morbidité ainsi que les décès liés à l’asthme. Cependant, l’observance à cette médication chez les enfants asthmatiques demeure sous-optimale. Objectif : L’objectif général de ce mémoire de maîtrise est d’identifier les déterminants de l’observance aux corticostéroïdes inhalés durant les 28 jours suivant une visite médicale d’urgence en raison d’une une exacerbation d’asthme. Méthodologie : Il s’agit d’une analyse de données secondaires provenant d’un essai randomisé conduit auprès de patients se présentant dans un département d’urgence pour une exacerbation d’asthme. L’utilisation de corticostéroïdes inhalés au cours des 28 jours suivant la visite à l’urgence a été mesurée à l’aide de compteurs de doses électroniques. Résultats : Deux cent onze enfants ont été inclus dans les analyses et 76,8% étaient âgés de moins de 7 ans. L’observance moyenne au cours des 28 jours suivant la visite à l’urgence était de 62% (±29%). Les déterminants associés à une meilleure observance étaient une durée de traitement prescrite plus courte, une scolarité maternelle universitaire, une plus grande consommation de médication de soulagement rapide, une crise d’asthme plus sévère, un plus jeune âge de l’enfant et être Caucasien. Conclusion : Cette étude se distingue par le fait qu’elle inclut une large proportion d’enfants d’âge préscolaire, une population d’asthmatiques sous-représentée dans la littérature médicale malgré sa morbidité élevée. Une prescription de corticostéroïdes inhalés de courte durée s’est avérée être le meilleur prédicteur d’une bonne observance et témoigne d’une pratique en milieu hospitalier qui va à l’encontre des lignes directrices en matière de gestion de l’asthme. / Inhaled corticosteroids are recognized to prevent asthma related hospitalizations, morbidity and mortality. However, inhaled corticosteroids adherence among children with asthma remains suboptimal. Objective: This master’s thesis aimed to identify predictors of inhaled corticosteroids adherence during the 28 days following an emergency department visit. Methods: This study is a secondary analysis of data collected during a randomized control trial conducted among children presenting at an emergency department for an acute asthma exacerbation. Inhaled corticosteroids use was electronically monitored during the 28 days following the hospital discharge. Results: Two hundred and eleven children were included in the analyses and 76.8% were aged less than 7 years old. Mean adherence over the 28 days observation period was 62% (±29%). Predictors of a better adherence were: shorter prescribed duration of treatment, maternal university degree, more frequent use of rescue medication, more severe index exacerbation, younger age and Caucasian ethnicity. Conclusion: This study distinguishes itself by including a large proportion of preschool aged children, an especially vulnerable population of patients with asthma that is understudied despite its high morbidity. A short duration of treatment prescribed was the strongest predictor of inhaled corticosteroids adherence. This result highlights a medical practice that is contrary to guidelines on asthma management.

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

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Background: Along with the austerity measures introduced in many countries, the economic crisis affecting Europe since 2008 seems to have impacted many aspects of the health of the Spanish population and has had a negative effect on the provision health services. An increasing body of knowledge has shown a clear impact of the current crisis on suicidal behaviour and mental health, and a less consistent effect on physical health and access to healthcare. However, little is known about the impact of the crisis on social inequalities in health and healthcare access, an area on which the present study seeks to shed light in the context of Spain, and specifically Andalusia, a region hit very hard by the crisis. Objective: To study the impact of the economic crisis starting in 2008 on health, health inequalities and health service utilisation in Spain and Andalusia and the roles of socio-demographic factors in these associations. Methods: Death rates were analysed to study the annual percent change in overall and cause-specific mortality in Spain between 1999 and 2011, and the Longitudinal Database of the Andalusian Population was used to study educational inequalities in overall mortality from 2002 to 2010 (study 1). To calculate suicide attempt rates, information from 2003 to 2012 on 11,494 men and 12,886 women provided by the Health Emergencies Public Enterprise Information System in Andalusia was utilised. The association between unemployment and suicide attempts was studied through linear regression models (study 2). Two waves of the Andalusian Health Survey (2007 and 2011–12) provided data for the third and fourth studies of this thesis. Educational and employment status inequalities in poor mental health in relation with the crisis were analysed through Poisson regression models (study 3). The change in inequalities (pre-crisis–crisis) in health care utilisation outcomes (general practitioner, specialist, hospitalisation and emergency attendance) was measured by the change in horizontal inequality indices. A decomposition analysis of change in inequality between periods was performed using the Oaxaca approach (study 4). Results: Study 1: Overall mortality in Spain decreased steadily during the period, with annual percent changes of -2.44% in men and -2.20% in women. An increase in educational inequality in mortality was observed in men in Andalusia. In women, the inequalities instead remained stable. Suicide mortality showed a downward trend in both sexes in Spain. Study 2: A sharp increase in suicide attempts in Andalusia was detected after the onset of the crisis in both sexes, with adults aged 35 to 54 years being the most affected. Suicide attempts were associated with unemployment rates only in men. Study 3: Poor mental health increased in working individuals with secondary and primary studies during the crisis compared to the pre-crisis period, while it decreased in the university study group. However, in unemployed individuals poor mental health increased only in the secondary studies group. Financial strain could partly explain the crisis effect on mental health among the unemployed. Study 4: Horizontal inequality in utilisation changed to a greater equality or a more pro-poor inequality in both sexes. In the decomposition analysis, socioeconomic position and health status showed greater contributions to the changes in inequalities. Conclusion: This thesis illustrates the complexity of the influences of the current economic crisis on health inequalities in a Southern European region. Specifically, no noticeable effects of the crisis on overall and suicide mortality were detected; instead, increasing educational inequalities in mortality in men and a large increase in suicide attempts in middle aged men and women were observed. The deterioration in poor mental health was mainly detected in those of intermediate educational level. Economic conditions such as unemployment and financial strain proved to be relevant. Finally, in the light of no increased inequalities in healthcare utilisation, the universal coverage health system seems to buffer the deleterious effect of the crisis and austerity policies in this context.

Abstract 1: A multi-level assessment of disproportionate population sex ratios and high-risk sexual behaviors among STD clinic patients Low male-to-female sex ratios in a population may influence high-risk sexual behaviors, such as multiple sex partners and inconsistent condom use, which facilitate the transmission of STDs. This study used multi-level modeling to assess whether population sex ratios were associated with these two individual-level behaviors. All analyses were stratified by gender. Interview data were collected from patients (N = 9,203, 48% male) attending participating STD clinics. Interviews included information on socio-demographics and sexual behavior, including number of sex partners in the previous 3 months and condom use at last sex. The sex ratio per census tract was obtained from the U.S. Census Bureau. There was no association between sex ratio and multiple sex partners or condom use for either men or women. That is, we found no evidence that a shortage of men in census tracts was associated with increased engagement in high-risk sexual behavior.   Abstract 2: A multi-level assessment of neighborhood vacancy rates and high-risk sexual behaviors among STD clinic patients The “broken windows” theory posits that physical neighborhood deterioration, and its association with reduced social cohesion, can lead to changes in individual behaviors. Thus individuals living in neighborhoods with high levels of deterioration may be more likely to engage in high-risk sexual behaviors. This study used multi-level modeling to evaluate the extent to which high residential vacancy rates increased the likelihood of individuals having multiple sex partners. Interview data, including data on patient demographics and sexual behaviors, were collected from patients (N = 6,347, 52% male) attending participating STD clinics in the Richmond, Virginia area from 2008-2010. Neighborhood vacancy rates were obtained from the U.S. Census Bureau. Fifty-one percent of men and 36% of women reported having 2 or more sex partners in the previous 3 months. Men who lived in census tracts with high vacancy rates were slightly more likely to report multiple sex partners (53.9%) compared to men who lived in low vacancy tracts (49.7%). In multi-level models, there was no association between high vacancy rates and having multiple sex partners among either women (OR = 0.98; 95% CI: 0.79, 1.20) or men (1.18; 95% CI: 0.99, 1.42). That is, we found no evidence that increased neighborhood deterioration, as measured by high residential vacancy rates, was associated with increased risk of having multiple sex partners among STD clinic patients.   Abstract 3: Residential segregation and gonorrhea rates in U.S. metropolitan statistical areas The residential segregation of black populations, often in areas of high economic disadvantage and low social status, may play a crucial role in the observed racial inequities in STD rates. An ecological analysis of 2005-2009 average gonorrhea rates was performed across 277 U.S. metropolitan statistical areas (MSAs). The black isolation index and Gini index of income inequality were used as proxy measures for racial and economic residential segregation respectively, derived from 2005-2009 U.S. Census estimates. We used logistic regression modeling to produce estimates of odds ratios (OR) and 95% confidence intervals (CI) for the association between a high black isolation index and Gini index, both independently and in combination, on gonorrhea rates in MSAs. Effect measure modification was assessed by calculating the relative excess risk due to interaction (RERI) between the two indices. Compared to MSAs with low levels of racial segregation, MSAs with high levels of racial segregation had increased odds of high gonorrhea rates (adjusted OR 5.54; 95% CI: 2.29-13.44). Adjustment for potential confounders did not noticeably impact the relationship between the Gini index and gonorrhea, with higher levels of income inequality predicting higher gonorrhea rates (adjusted OR = 2.47; 95% CI: 1.21-5.03). In combined models, the influence of racial residential segregation on gonorrhea rates was stronger than that of income inequality-based segregation; there was no evidence of additivity or a multiplicative interaction. Residential segregation by race or income equality may be a key component in the perpetuation of high rates of gonorrhea and other STDs among black populations in the U.S.

Context: Literature suggests that prenatal care and prenatal supplement use improves pregnancy outcomes. However, we do not know the factors associated with prenatal care and supplement use in Honduras.Objective: To identify characteristics of Honduran women who are the least and most likely to use prenatal care and supplements.Methods: Data from a 2001 Honduras cross-sectional survey of women was used to assess their use of prenatal care and supplements. All data was weighted, resulting in a sample size of n = 5647 women who had a live birth since January 1996. Bivariate and multivariate analyses were used to examine factors associated with prenatal care and supplement use.Results: Current education level was highly positively related to prenatal care and supplement use. Women who were 35 years or older at the time of their most recent birth, currently unmarried, of non-Catholic religious affiliation, and of low SES were significantly less likely to have used prenatal care and supplements. Women who reported the intentionality of their most recent birth as unwanted also were significantly less likely to have used prenatal care and supplements. Prenatal care was the most significant determinant of prenatal supplement use.Conclusion: There are significant differences between Honduran women who use prenatal care and supplements and women who do not. Efforts to increase prenatal health services among underserved women, especially women who are older, unmarried, with no formal education, of low SES, of a non-Catholic religious affiliation, and at risk for an unwanted pregnancy, may significantly improve pregnancy outcomes in Honduras.

This thesis uses data of more than 180 banks from CEE region to identify the main determinants of long term credit ratings assigned to these banks in period between 2010 - 2012. This is done by employing two frequently used classification methods - Multiple Discriminant Analysis and Ordered Logit Model. The main contribution lies in including explanatory variables from various areas which have impact on financial health of examined banks. Apart from standard spheres of banks' performance such as capital adequacy, asset quality or profitability we investigate relevance of macroeconomic and qualitative factors as well. Although our results suggest that all mentioned areas are relevant for credit risk and hence rating assignment process the bank specific variables, both quantitative and qualitative, still play the key role.