This thesis is an examination of the sex and gender differences in measures of relative deprivation for Winnipeg, Manitoba, and the value of these measures to predict health outcomes. Within theoretical frameworks of relative deprivation and intersectionality, principal component analysis was used to test nineteen different versions of a national area-based deprivation index using Census variables, for the total population and for males and females separately. Only one version of the deprivation index provided consistent factor scores, in keeping with the theoretical constructs, for the total, female-only and male-only populations for Winnipeg. Administrative health data were used to calculate area-level rates of select health outcomes and binomial negative regressions were then used to analyze whether the “best” index was predictive of health outcomes for the three populations. In regression models, only the “material” component of the deprivation index was predictive of the health outcomes, but results varied across the three populations. The application of the “best” deprivation index to health planning may depend on the health issue and the population in question. This thesis confirmed that examining the intersections of sex, gender and deprivation in population health research unmasks important differences that would otherwise be missed and could have implications in health planning.

This thesis is an examination of the sex and gender differences in measures of relative deprivation for Winnipeg, Manitoba, and the value of these measures to predict health outcomes. Within theoretical frameworks of relative deprivation and intersectionality, principal component analysis was used to test nineteen different versions of a national area-based deprivation index using Census variables, for the total population and for males and females separately. Only one version of the deprivation index provided consistent factor scores, in keeping with the theoretical constructs, for the total, female-only and male-only populations for Winnipeg. Administrative health data were used to calculate area-level rates of select health outcomes and binomial negative regressions were then used to analyze whether the “best” index was predictive of health outcomes for the three populations. In regression models, only the “material” component of the deprivation index was predictive of the health outcomes, but results varied across the three populations. The application of the “best” deprivation index to health planning may depend on the health issue and the population in question. This thesis confirmed that examining the intersections of sex, gender and deprivation in population health research unmasks important differences that would otherwise be missed and could have implications in health planning.

Significant efforts have been undertaken in medicine to identify hospital and primary care service areas (eg, the Dartmouth Atlas of Health Care) using patient origin information. Similar research in dentistry is nonexistent. The goal of this dissertation was to develop and refine methods of defining dentist service areas (DSAs) using dental insurance claims. These service areas were then used as spatial units of analysis in studies that examined relationships between utilization of oral health services, dentist workforce supply, and service area characteristics. Enrollment and claims data were obtained from the Iowa Medicaid program for children and adolescents ages 3-18 years during calendar years 2008 through 2010. The first study described rates of treatment by orthodontists in children ages 6-18 years. Orthodontic DSAs were identified by small area analysis in order to examine regional variability in utilization. The overall rate of utilization was approximately 3%; 19 DSAs were delineated. Interestingly, children living in small towns and rural areas were significantly more likely to have received orthodontic services than those living in metropolitan and micropolitan areas. The second study identified 113 DSAs using claims submitted by primary care dentists (ie, general and pediatric dentists). Characteristics of these primary care DSAs were then compared with counties. Localization of care was used as a measure of how well each region approximated a dental market area. Approximately 59% of care received by Medicaid-enrolled children took place within their assigned service area versus 52% of care within their county of residence. Hierarchical logistic regression was used in the final study to examine the influence of spatial accessibility and the importance of place on the receipt of preventive dental visits among Medicaid-enrolled children. Children living in urban areas were more likely to have received a visit than those living in more rural areas. Spatial accessibility assessed using measures of dentist workforce supply and travel cost did not appear to be a major barrier to care in this population. More studies are needed to explore the importance of spatial accessibility and other geographic barriers on access to oral health services. The methods used in this dissertation to identify service areas can be applied to other populations and offer an appropriate method for examining revealed patient preferences for oral health care.

Narrowing the gap in health inequality is vital not only from an equity point of view but also from an economic cost point of view. Small-area level investigations of health inequalities can play an important role in this effort. This research is an attempt to produce evidence of within-province social and health inequality. This cross-sectional, ecological study examines the geographical distribution of life expectancy at birth (LE) and its relationships with two domains of deprivation—material and social—at two time periods (1995-1999 and 2003-2007) across 182 ‘communities.’ The deprivation measures were derived from a set of indices now widely used in Quebec. Five community types assigned to the communities represented relative levels of rurality. A general pattern was observed that material deprivation became more prominent as ‘rurality’ increased. The pattern of social deprivation by rurality was more ‘flat’ where other levels of rurality than the most urban type had similar deprivation scores and rankings. LE was patterned by a relative degree of deprivation but not by rurality per se, though high socioeconomic deprivation tends to be observed in ‘rural areas.’ The gaps in LEs between the most and least deprived were wider for males than for females. Inequalities in LE by material deprivation of the communities appear to have widened over time. The regression models indicated the presence of an interaction effect—material and social deprivation together exacerbate the risk of low LE. The study also observed some regional clustering of unaccounted factors, which requires further investigation to determine what potential regional phenomena account for this effect. Lastly, the deprivation scores left more variations in LE in rural communities unexplained than variations in urban communities, leading us to suspect that the indices employed might be less sensitive for health inequalities in rural communities than in urban communities. Further research efforts are necessary to tackle many questions this research could not address, which would more fully inform policy related to the reduction of health and social inequality in Nova Scotia and elsewhere.

Introdução. A influência de fatores sócioeconômicos na epidemia pelo HIV/Aids tem sido discutida na literatura científica. Objetivo. Estudar a mortalidade por Aids segundo condições sócioeconômicas no município de São Paulo, no período de 1994 a 1999, entre homens e mulheres de 15 a 49 anos (15 a 24; 25 a 49). Método. Trata-se de um estudo ecológico tendo como unidades de análise os 96 distritos e 5 áreas homogêneas, classificadas segundo o índice social para cada distrito. Foram utilizados dados secundários do PROGRAMA DE APRIMORAMENTO DAS INFORMAÇÕES DE MORTALIDADE DO MUNICÍPIO (PRÓ – AIM), estimativas populacionais do censo de 1991 e os índices sociais do Mapa da exclusão/inclusão social para a cidade. Foram calculados os coeficientes de mortalidade por Aids por sexo e idade, em cada ano e área. Foi analisada a correlação entre o logarítmo dos coeficientes de mortalidade por Aids e os índices de exclusão/inclusão social nos 96 distritos. A tendência da mortalidade por Aids foi analisada na série histórica, nas 5 áreas homogêneas. Resultados. Foi encontrada correlação negativa estatisticamente significativa entre o log dos coeficientes de mortalidade por Aids e o índice de eqüidade entre homens e mulheres de 15 a 49 anos, ao longo de todo o período. Observou-se uma tendência à correlação positiva significativa entre o índice de qualidade de vida e a mortalidade masculina por Aids, entre 1994 e 1998, tornando-se negativa no ano de 1999. A redução da mortalidade por Aids observada após a introdução da moderna terapêutica anti-retroviral, entre 1996 e 1999, foi maior na área mais incluída: 60% entre os homens de 25 a 49 anos e 53% entre as mulheres da mesma idade. Os menores percentuais de queda foram observados nas áreas mais excluídas: 50% na AH5 entre homens de 25 a 49 anos, e 33% na AH3, entre as mulheres da mesma idade. Os percentuais de queda foram menores na população feminina em todas as áreas. Conclusões. A despeito da terapia anti-retroviral gratuita em todo município, a queda na mortalidade por Aids apresentou diferenças em relação às áreas geográficas. Essa redução foi menor na população vivendo em áreas de exclusão social e sendo mais lenta entre as mulheres em todas as áreas. Nos distritos onde foi maior a concentração de mulheres chefes de família não alfabetizadas observou-se também uma maior mortalidade por Aids, entre homens e mulheres. A vulnerabilidade feminina em relação ao HIV/Aids tem sido amplamente discutida na literatura científica. Alguns fatores como desigualdade no acesso aos cuidados de saúde e menor aderência ao tratamento podem estar relacionados com essas diferenças. A mortalidade por Aids nas diferentes áreas deve ser também estudada de acordo com a dinâmica da epidemia, a incidência e a letalidade nessas áreas, que podem explicar achados dessa mortalidade e diferenças entre áreas de inclusão e de exclusão. / Background. The role of the socioeconomic factors in the HIV/AIDS epidemic has been a subject of discussion in the scientific literature. Objective. The aim of the present study was to analyse AIDS mortality of persons aged 15-49 years old (15-24; 25-49) among men and women, in São Paulo city between 1994 and 1999, by socioeconomic conditions of geographic areas. Methods. Small area ecological study in the 96 districts and the five areas classified in level 1 to 5, better to worse socioeconomic conditions, drawn from city social exclusion map. Using 1991 population census, the city mortality information system (PROGRAMA DE APRIMORAMENTO DAS INFORMAÇÕES DE MORTALIDADE DO MUNICÍPIO) and socioeconomic indices for each district from city social exclusion map. We calculated the AIDS mortality rates by year, sex and age for each geographic area. The correlation between the rate of AIDS mortality and measures social exclusion was calculated for 96 districts over the period. The AIDS mortality trend was examined in the five areas. Results: The rate of AIDS mortality was correlated negatively with the equity index both males and females aged 15 to 49 years old over the period . Among men, a positive correlation was observed between the rate of AIDS mortality and the quality of life index. Reduction of mortality after the implementation of highly active antiretroviral therapy (1996-1999) was greater in the area of higher socioeconomic status (level 1) for both males (60%) and females (53%) aged 25-49. Whereas less decrease was observed in areas of lower socioeconomic conditions for both males and females. Mortality decrease more slowly for woman in all areas. Conclusions: Despite free antiretroviral therapy, differences in AIDS mortality are observed in relation to neighborhood-level socio economic conditions. The decrease in AIDS mortality was lowest in areas with disadvantaged socioeconomic status and among women. Inequalities in health-care access or poor adherence to treatment could explain the differences. These findings may also reflect, in part, differences in HIV/AIDS incidence in the geographic areas .

Introdução. A influência de fatores sócioeconômicos na epidemia pelo HIV/Aids tem sido discutida na literatura científica. Objetivo. Estudar a mortalidade por Aids segundo condições sócioeconômicas no município de São Paulo, no período de 1994 a 1999, entre homens e mulheres de 15 a 49 anos (15 a 24; 25 a 49). Método. Trata-se de um estudo ecológico tendo como unidades de análise os 96 distritos e 5 áreas homogêneas, classificadas segundo o índice social para cada distrito. Foram utilizados dados secundários do PROGRAMA DE APRIMORAMENTO DAS INFORMAÇÕES DE MORTALIDADE DO MUNICÍPIO (PRÓ – AIM), estimativas populacionais do censo de 1991 e os índices sociais do Mapa da exclusão/inclusão social para a cidade. Foram calculados os coeficientes de mortalidade por Aids por sexo e idade, em cada ano e área. Foi analisada a correlação entre o logarítmo dos coeficientes de mortalidade por Aids e os índices de exclusão/inclusão social nos 96 distritos. A tendência da mortalidade por Aids foi analisada na série histórica, nas 5 áreas homogêneas. Resultados. Foi encontrada correlação negativa estatisticamente significativa entre o log dos coeficientes de mortalidade por Aids e o índice de eqüidade entre homens e mulheres de 15 a 49 anos, ao longo de todo o período. Observou-se uma tendência à correlação positiva significativa entre o índice de qualidade de vida e a mortalidade masculina por Aids, entre 1994 e 1998, tornando-se negativa no ano de 1999. A redução da mortalidade por Aids observada após a introdução da moderna terapêutica anti-retroviral, entre 1996 e 1999, foi maior na área mais incluída: 60% entre os homens de 25 a 49 anos e 53% entre as mulheres da mesma idade. Os menores percentuais de queda foram observados nas áreas mais excluídas: 50% na AH5 entre homens de 25 a 49 anos, e 33% na AH3, entre as mulheres da mesma idade. Os percentuais de queda foram menores na população feminina em todas as áreas. Conclusões. A despeito da terapia anti-retroviral gratuita em todo município, a queda na mortalidade por Aids apresentou diferenças em relação às áreas geográficas. Essa redução foi menor na população vivendo em áreas de exclusão social e sendo mais lenta entre as mulheres em todas as áreas. Nos distritos onde foi maior a concentração de mulheres chefes de família não alfabetizadas observou-se também uma maior mortalidade por Aids, entre homens e mulheres. A vulnerabilidade feminina em relação ao HIV/Aids tem sido amplamente discutida na literatura científica. Alguns fatores como desigualdade no acesso aos cuidados de saúde e menor aderência ao tratamento podem estar relacionados com essas diferenças. A mortalidade por Aids nas diferentes áreas deve ser também estudada de acordo com a dinâmica da epidemia, a incidência e a letalidade nessas áreas, que podem explicar achados dessa mortalidade e diferenças entre áreas de inclusão e de exclusão. / Background. The role of the socioeconomic factors in the HIV/AIDS epidemic has been a subject of discussion in the scientific literature. Objective. The aim of the present study was to analyse AIDS mortality of persons aged 15-49 years old (15-24; 25-49) among men and women, in São Paulo city between 1994 and 1999, by socioeconomic conditions of geographic areas. Methods. Small area ecological study in the 96 districts and the five areas classified in level 1 to 5, better to worse socioeconomic conditions, drawn from city social exclusion map. Using 1991 population census, the city mortality information system (PROGRAMA DE APRIMORAMENTO DAS INFORMAÇÕES DE MORTALIDADE DO MUNICÍPIO) and socioeconomic indices for each district from city social exclusion map. We calculated the AIDS mortality rates by year, sex and age for each geographic area. The correlation between the rate of AIDS mortality and measures social exclusion was calculated for 96 districts over the period. The AIDS mortality trend was examined in the five areas. Results: The rate of AIDS mortality was correlated negatively with the equity index both males and females aged 15 to 49 years old over the period . Among men, a positive correlation was observed between the rate of AIDS mortality and the quality of life index. Reduction of mortality after the implementation of highly active antiretroviral therapy (1996-1999) was greater in the area of higher socioeconomic status (level 1) for both males (60%) and females (53%) aged 25-49. Whereas less decrease was observed in areas of lower socioeconomic conditions for both males and females. Mortality decrease more slowly for woman in all areas. Conclusions: Despite free antiretroviral therapy, differences in AIDS mortality are observed in relation to neighborhood-level socio economic conditions. The decrease in AIDS mortality was lowest in areas with disadvantaged socioeconomic status and among women. Inequalities in health-care access or poor adherence to treatment could explain the differences. These findings may also reflect, in part, differences in HIV/AIDS incidence in the geographic areas .

This work investigates births to white, African American and Hispanic adolescents in Hillsborough and Pinellas Counties, Florida, from 1992 to 1997 in two age groups - 13 to 17 year-olds and 18 to 19 year-olds - using spatial statistical techniques along with key informant interviews to provide insights into the utility of the research findings. The research developed a method for estimating the adolescent population in inter-census years, which was used to determine denominators for calculating teen birth rates. It also developed a composite deprivation index using socioeconomic indicators at the census block group level. The index provided context for hot and cold spot analysis, areas where expected teen birth rates were statistically higher or lower than expected. The association between socioeconomic deprivation in a neighborhood and rates of teen births was inconclusive, indicating a need for further research. Next steps include investigating individual-level risk and protective factors using multi-level modeling and cluster analysis as alternate analytic methods, and conducting ethnographic investigation to help provide context to the neighborhoods.

本研究提出一個兩階段的時空模型來分析空氣污染與健康的關係。我們選取在台灣的49個有設置空氣品質監測站的鄉鎮市區做為研究地區。資料包含這些小地區中1997-2001年的各地區每日因呼吸道疾病而就醫的門診人數與空氣污染物濃度與氣象監測資料。在第一階段中，對每一個月所有地區的每日因呼吸道疾病而就醫的門診人數與空氣污染配適時空模型，並利用氣象條件等因素做調整。在第二階段裡，利用線性混合效果模型將第一階段所獲得的60 個月空氣污染物係數估計值來獲得代表這五年全國整體污染物係數的估計。本文利用模擬研究來探討當季節因素與不可解釋的因素，例如像流行性感冒等存在時會對文獻上其他時空模型中參數的估計所造成的影響，同時與我們所提出的方法作一比較。 / We proposed a spatiotemporal model to investigate the association between the acute health effects and daily numbers of clinic visits for respiratory illness. The data include clinic records due to respiratory illness and environmental variables from air quality monitoring stations in Taiwan during 1997-2001. A small-area design and two-phase modeling were used for the analysis. In the first phase, we constructed a Poisson regression with autogressive residual process and spatial correlation to obtain the pollution coefficient of each single month. In the second phase, we combined the information from phase one model to improve estimates of the pollution coefficients of each month and to obtain an overall pollution coefficient across the temporal course. Simulation study was used to illustrate the bias of estimation when there are seasonal, spatial and the unexplained effects in the data.

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

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