Potential causes of ethnic group disparities in infertility:a hospital database study

Introduction - Lower success rates of in vitro fertilisation (IVF) in South East Asian countries compared to Western countries in informal studies and surveys was considered a reflection of variations in methodology and expertise. However, recent studies on the effects of ethnicity on success rates of infertility procedures in western countries have suggested other inherent contributing factors to the ethnic disparity but the evidence evaluating these is lacking. In our study we aim to investigate some of the comorbidities that might cause ethnic disparity to infertility and related procedures from hospital admissions data. Methods - Anonymous hospital admissions data on patients of various ethnic groups with infertility, comorbidities and infertility procedures from multiple hospitals in Birmingham andManchester, UK between 2000 and 2013 were obtained from the local health authority computerised hospital activity analysis register using ICD-10 and OPCS coding systems. Statistical analysis was performed using SPSS version 20.Results Of 522 223 female patients aged 18 and over, there were44 758 (8.4%) patients from South Asian (SA) community. 1156(13.4%) of the 8653 patients coded for infertility were SA, whichis a considerably higher proportion of the background SA population. For IVF procedures, the percentage of SA increased to15.4% (233 of the total 1479 patients). The mean age of SA codedfor infertility (30.6 ± 4.7 SD years versus 32.8 ± 4.9 SD years)and IVF (30.4 ± 4.3 SD years versus 32.7 ± 4.4 SD years) was significantly lower than caucasian patien ts (P < 0.001). A multivariate logistic regression model looking at patients with infertility, accounting for variations in age, showed that SA have significantly higher prevalence of hypothyroidism, obesity andiron-deficiency anaemia compared to caucasians but lower prevalence of endometriosis. Interestingly, psychiatric and psychological conditions diagnoses were seldom registered in infertility patients. Conclusion - Other studies suggest that various cultural, lifestyles, psychosocial and socio-economic factors may explain the disparities in IVF success rates between South Asians and caucasians. The fact that SA infertility and IVF patients, in ou rstudy, were significantly younger than caucasians and that their proportion is considerably higher than the background South Asian population suggests the influence of these factors. A significant psychiatric disease burden in other conditions and low numbers in our data suggest under diagnosis in this group.Despite the limitations of the coding data, from our study, we propose that hypothyroidism, obesity and/or iron-deficiency anaemia should be considered for the ethnic disparity. Further research in this topic is essential to fully investigate the reasons for such ethnic disparities.

Essays on the political economy of the Dominican reform process

This dissertation provides an analytical framework to study the political economy of policy reform in the Dominican Republic during the nineties. Based on a country study, I develop two theoretical models that replicate the mechanisms of policy approval in developing countries with weak democracies. The first model considers a pro-reform President who submits a tariff bill to an anti-reform Congress dominated by the opposition party. In between, two opposing lobbies try to get their favored policy approved. Lobbies act as Stackelberg leaders vis a vis a weak President. The behavior of the Congress is determined exogenously while the lobbies act strategically pursuing the approval of the reform bill and indirectly affecting the President's decision. I show that in such a setting external agents like the Press play an important role in the decision-making process of the political actors. ^ The second model presents a similar framework. However, the President, who is a Stackelberg leader, is allowed only two choices, total reform or status-quo. I show how a lobby reacts to an increase in its rival's or its own size. These reactions depend on the President's level of commitment to the reform. Finally, I discuss the effect of variations in the size of the lobbies on the President's choice. The model suitably explains real events that took place in the Dominican Republic in the mid-nineties. ^

Essays on the political economy of the dominican reform process

This dissertation provides an analytical framework to study the political economy of policy reform in the Dominican Republic during the nineties. Based on a country study, I develop two theoretical models that replicate the mechanisms of policy approval in developing countries with weak democracies. The first model considers a pro-reform President who submits a tariff bill to an anti-reform Congress dominated by the opposition party. In between, two opposing lobbies try to get their favored policy approved. Lobbies act as Stackelberg leaders vis a vis a weak President. The behavior of the Congress is determined exogenously while the lobbies act strategically pursuing the approval of the reform bill and indirectly affecting the President's decision. I show that in such a setting external agents like the Press play an important role in the decision-making process of the political actors. The second model presents a similar framework. However, the President, who is a Stackelberg leader, is allowed only two choices, total reform or status-quo. I show how a lobby reacts to an increase in its rival's or its own size. These reactions depend on the President's level of commitment to the reform. Finally, I discuss the effect of variations in the size of the lobbies on the President's choice. The model suitably explains real events that took place in the Dominican Republic in the mid-nineties.

Geochemistry of sediments from the continental slope of the Ross Sea, Antarctica

A sediment core, collected from the western part of the continental slope of the Ross Sea at 2380 m water depth, records events of the last two climatic cycles (250 kyr). A 230Thex-based chronology was obtained and boundaries of the isotope stages were set assuming that biological productivity was enhanced during periods of less ice cover. Then, 230Thex0, organic carbon, biogenic silica and biogenic Ba distributions were compared to the glacial-interglacial stage boundaries and corresponding ages of the delta18O record of Martinson et al. [Martinson et al., 1987, doi:10.1016/0033-5894(87)90046-9]. Sediment accumulation rates ranged between 1.2 cm kyr**-1 in the isotope stage 6 and 3.8 cm kyr**-1 during the Holocene. Variations in the concentrations and fluxes of organic carbon, biogenic Ba, biogenic silica and Mn gave information on palaeoclimate changes. Processes of sediment redistribution in the Ross Sea margin were enlightened from a comparison of the measured and expected fluxes of 230Thex. Calculation of the focusing-corrected accumulation rates of biogenic Ba enabled us to evaluate the export palaeoproductivity. Corrected accumulation rates of biogenic components and calculated palaeoproductivities were low, compared to the Antarctic Polar Front in the Atlantic sector, throughout the last two climatic cycles. Glacial-interglacial changes of sea ice cover and ventilation of the Ross Sea were probably major causes of variations in biogenic particle flux and distribution of redox-sensitive elements within the sediment column.

Nd, Sr and Pb isotopes and clay minerals in sediment cores from the Gulf of Cadiz and the Portuguese margin

The assemblages of marine sediments on the SW Iberian shelf have been controlled by contributions from distinct sources, which have varied in response to environmental changes since the Last Glacial Maximum (LGM). The rapid, decadal scale Mediterranean overturning circulation permits mixing of suspended particles from the entire Mediterranean Sea. They are entrained into the suspended particulate matter (SPM) carried by Mediterranean Outflow Water (MOW), which enters the eastern North Atlantic through the Strait of Gibraltar and spreads at intermediate depths in the Gulf of Cadiz and along the Portuguese continental margin. Other major sediment sources that have contributed to the characteristics and budget of SPM along the flow path of MOW on the SW Iberian shelf are North African dust and river-transported particles from the Iberian Peninsula. To reconstruct climate- and circulation-driven changes in the supply of sediments over the past ~23000 cal yr B.P., radiogenic Nd, Sr and Pb isotope records of the clay-size sediment fraction were obtained from one gravity core in the Gulf of Cadiz (577 m water depth) and from two gravity cores on the Portuguese shelf (1745 m, 1974 m water depth). These records are supplemented by time series analyses of clay mineral abundances from the same set of samples. Contrary to expectations, the transition from the LGM to the Holocene was not accompanied by strong changes in sediment provenance or transport, whereas Heinrich Event 1 (H1) and the African Humid Period (AHP) were marked by significantly different isotopic signatures reflecting changes in source contributions caused by supply of ice rafted material originating from the North American craton during H1 and diminished supply of Saharan dust during the AHP. The data also reveal that the timing of variations in the clay mineral abundances was decoupled from that of the radiogenic isotope signatures.

Data compilation on the biological response to ocean acidification: environmental and experimental context of data sets and related literature

The exponential growth of studies on the biological response to ocean acidification over the last few decades has generated a large amount of data. To facilitate data comparison, a data compilation hosted at the data publisher PANGAEA was initiated in 2008 and is updated on a regular basis (doi:10.1594/PANGAEA.149999). By January 2015, a total of 581 data sets (over 4 000 000 data points) from 539 papers had been archived. Here we present the developments of this data compilation five years since its first description by Nisumaa et al. (2010). Most of study sites from which data archived are still in the Northern Hemisphere and the number of archived data from studies from the Southern Hemisphere and polar oceans are still relatively low. Data from 60 studies that investigated the response of a mix of organisms or natural communities were all added after 2010, indicating a welcomed shift from the study of individual organisms to communities and ecosystems. The initial imbalance of considerably more data archived on calcification and primary production than on other processes has improved. There is also a clear tendency towards more data archived from multifactorial studies after 2010. For easier and more effective access to ocean acidification data, the ocean acidification community is strongly encouraged to contribute to the data archiving effort, and help develop standard vocabularies describing the variables and define best practices for archiving ocean acidification data.

Radiocarbon age of bottom sediments from the Yenisei Gulf and the Kara Sea

Sedimentation rates and bottom sediment ages were determined by 14C method in the Kara Sea and the Yenisei River marginal filter. Age of carbon supplied by the Yenisei River is estimated to be 6.9 ka. As supplied carbon mixes with young biogenic carbon under influence of plankton and benthos young carbon flux (planktogenic) sharply diminishes. This has been inferred from studies of organic matter in sedimentary traps deployed along sections from the Yenisei River mouth to 76°N. The major part (70-80%) of organic carbon in bottom sediments of the Kara and Laptev Seas is ancient (Holocene). Planktogenic part comprises only 20-30%. In the Central Arctic Basin percentage of planktogenic organic matter in bottom sediments is still lower, the major part being associated with supply of ancient terrigenous organic material of low nutritional value for organisms. Determinations of sedimentation rates and recent matter fluxes from sedimentary traps served as a basis for locating a sedimentary depocenter in the Yenisei River both for present time and for geological past. Regularities of variations of sediment matter fluxes in the marginal filter were studied.

(Table S1) Age determination of sediment core OCE326-GGC5

The Atlantic meridional overturning circulation is widely believed to affect climate. Changes in ocean circulation have been inferred from records of the deep water chemical composition derived from sedimentary nutrient proxies (Boyle and Keigwin, 1987, doi:10.1038/330035a0), but their impact on climate is difficult to assess because such reconstructions provide insufficient constraints on the rate of overturning (LeGrand and Wunsch, 1995, doi:10.1029/95PA01455). Here we report measurements of 231Pa/230Th, a kinematic proxy for the meridional overturning circulation, in a sediment core from the subtropical North Atlantic Ocean. We find that the meridional overturning was nearly, or completely, eliminated during the coldest deglacial interval in the North Atlantic region, beginning with the catastrophic iceberg discharge Heinrich event H1, 17,500 yr ago, and declined sharply but briefly into the Younger Dryas cold event, about 12,700 yr ago. Following these cold events, the 231Pa/230Th record indicates that rapid accelerations of the meridional overturning circulation were concurrent with the two strongest regional warming events during deglaciation. These results confirm the significance of variations in the rate of the Atlantic meridional overturning circulation for abrupt climate changes.

(Table 1) Chemical composition of Central Pacific manganese micronodules containing birnessite as a major component

Detailed mineralogical characterization of micronodules is given. The main regularities of variations in composition of micronodules from Central Pacific sedimentary rocks of different ages are revealed. New data on structure and structural features of manganese minerals are reported.

Biological and Physical Factors Affecting the Natural History and Evolution of Encapsulated Development

The evolution of reproductive strategies involves a complex calculus of costs and benefits to both parents and offspring. Many marine animals produce embryos packaged in tough egg capsules or gelatinous egg masses attached to benthic surfaces. While these egg structures can protect against environmental stresses, the packaging is energetically costly for parents to produce. In this series of studies, I examined a variety of ecological factors affecting the evolution of benthic development as a life history strategy. I used marine gastropods as my model system because they are incredibly diverse and abundant worldwide, and they exhibit a variety of reproductive and developmental strategies.

The first study examines predation on benthic egg masses. I investigated: 1) behavioral mechanisms of predation when embryos are targeted (rather than the whole egg mass); 2) the specific role of gelatinous matrix in predation. I hypothesized that gelatinous matrix does not facilitate predation. One study system was the sea slug Olea hansineensis, an obligate egg mass predator, feeding on the sea slug Haminoea vesicula. Olea fed intensely and efficiently on individual Haminoea embryos inside egg masses but showed no response to live embryos removed from gel, suggesting that gelatinous matrix enables predation. This may be due to mechanical support of the feeding predator by the matrix. However, Haminoea egg masses outnumber Olea by two orders of magnitude in the field, and each egg mass can contain many tens of thousands of embryos, so predation pressure on individuals is likely not strong. The second system involved the snail Nassarius vibex, a non-obligate egg mass predator, feeding on the polychaete worm Clymenella mucosa. Gel neither inhibits nor promotes embryo predation for Nassarius, but because it cannot target individual embryos inside an egg mass, its feeding is slow and inefficient, and feeding rates in the field are quite low. However, snails that compete with Nassarius for scavenged food have not been seen to eat egg masses in the field, leaving Nassarius free to exploit the resource. Overall, egg mass predation in these two systems likely benefits the predators much more than it negatively affects the prey. Thus, selection for environmentally protective aspects of egg mass production may be much stronger than selection for defense against predation.

In the second study, I examined desiccation resistance in intertidal egg masses made by Haminoea vesicula, which preferentially attaches its flat, ribbon-shaped egg masses to submerged substrata. Egg masses occasionally detach and become stranded on exposed sand at low tide. Unlike adults, the encased embryos cannot avoid desiccation by selectively moving about the habitat, and the egg mass shape has high surface-area-to-volume ratio that should make it prone to drying out. Thus, I hypothesized that the embryos would not survive stranding. I tested this by deploying individual egg masses of two age classes on exposed sand bars for the duration of low tide. After rehydration, embryos midway through development showed higher rates of survival than newly-laid embryos, though for both stages survival rates over 25% were frequently observed. Laboratory desiccation trials showed that >75% survival is possible in an egg mass that has lost 65% of its water weight, and some survival (<25%) was observed even after 83% water weight lost. Although many surviving embryos in both experiments showed damage, these data demonstrate that egg mass stranding is not necessarily fatal to embryos. They may be able to survive a far greater range of conditions than they normally encounter, compensating for their lack of ability to move. Also, desiccation tolerance of embryos may reduce pressure on parents to find optimal laying substrata.

The third study takes a big-picture approach to investigating the evolution of different developmental strategies in cone snails, the largest genus of marine invertebrates. Cone snail species hatch out of their capsules as either swimming larvae or non-dispersing forms, and their developmental mode has direct consequences for biogeographic patterns. Variability in life history strategies among taxa may be influenced by biological, environmental, or phylogenetic factors, or a combination of these. While most prior research has examined these factors singularly, my aim was to investigate the effects of a host of intrinsic, extrinsic, and historical factors on two fundamental aspects of life history: egg size and egg number. I used phylogenetic generalized least-squares regression models to examine relationships between these two egg traits and a variety of hypothesized intrinsic and extrinsic variables. Adult shell morphology and spatial variability in productivity and salinity across a species geographic range had the strongest effects on egg diameter and number of eggs per capsule. Phylogeny had no significant influence. Developmental mode in Conus appears to be influenced mostly by species-level adaptations and niche specificity rather than phylogenetic conservatism. Patterns of egg size and egg number appear to reflect energetic tradeoffs with body size and specific morphologies as well as adaptations to variable environments. Overall, this series of studies highlights the importance of organism-scale biotic and abiotic interactions in evolutionary patterns.

Avaliação do papel dos polimorfismos em enzimas metabolizadoras e enzimas transportadoras de fármacos em neoplasias hematológicas

O cancro é um dos maiores causadores globais de mortalidade e morbilidade, ocorrendo cerca de 14 milhões de novos casos por ano e 8,2 milhões de mortes anuais com esta patologia, números que tendem a aumentar 70% nas próximas duas décadas. A característica tumoral mais nefasta é a sua capacidade de metastização para outros órgãos, um mecanismo que pode ser despoletado pela falha dos mecanismos normais de controlo de crescimento, proliferação e reparação celulares, que facilita o processo de transformação de células normais em células cancerígenas. A oncogénese processa-se em três etapas, a iniciação, a promoção e a progressão e pode ter origem em células estaminais cancerígenas, que regulam as capacidades de propagação e recidiva do tumor. As neoplasias hematológicas resultam de alterações genéticas e /ou epigenéticas que conduzem à desregulação da proliferação, ao bloqueio da diferenciação e/ou à resitência à apoptose. Para além dos fatores de risco exógenos, como agentes carcinogénicos físicos, químicos e biológicos, existem também fatores endógenos, incluindo características genéticas, que podem alterar a predisposição para o aparecimento de neoplasias, bem como influenciar a resposta à terapêutica. Uma das terapêuticas aplicadas no tratamento do cancro é a quimioterapia. Os fármacos administrados a doentes oncológicos seguem normalmente o percurso de absorção, distribuição, metabolização e eliminação. Este curso pode sofrer alterações caso as proteínas transportadoras e metabolizadoras necessárias não atuem corretamente. Para um melhor conhecimento da influência das alterações provocadas por variações nos genes que codificam proteínas transportadoras de efluxo (MDR1, MRP1), proteínas de influxo (OCTN2) e proteínas metabolizadoras (UCK2), o objetivo deste trabalho consistiu na avaliação de polimorfismos nos genes MDR1, MRP1, OCTN2 e UCK2 e da sua relação com a predisposição para o desenvolvimento de neoplasias hematológicas. Para isto, foram utilizadas amostras de 307 doentes com neoplasias hematológicas, 83 de Síndrome Mielodisplásica (SMD), 63 Leucemia Mieloide Aguda (LMA), 16 de Síndrome Mielodisplásica/Neoplasias Mieloproliferativas (SMD/NMP), 77 de Mieloma Múltiplo (MM) e 68 de Gamapatia Monoclonal de Significado Indeterminado (MGUS) e 164 de controlos não neoplásicos e/ou indivíduos saudáveis. As amostras de ADN foram extraídas do sangue periférico com protocolo adequado. De forma a determinar os genótipos correspondentes a cada amostra, realizaram-se técnicas de RFLP-PCR e ARMS-PCR. Posteriormente, calcularam-se estatisticamente as frequências alélicas e genotípicas relativas às variantes polimórficas dos genes MDR1, MRP1, OCTN2 e UCK2 e verificou-se se estavam em Equilíbrio de Hardy-Weinberg. De seguida, avaliou-se a força de associação entre as formas polimórficas e o risco de desenvolvimento de neoplasias hematológicas, através do cálculo do risco relativo por análise de regressão logística. Avaliaram-se ainda os perfis genéticos e a possível relação com o desenvolvimento e progressão da neoplasia com recurso a regressão logística e análise de Kaplan-Meier. De um modo geral as frequências alélicas e genotípicas não se revelaram alteradas comparativamente ao esperado. A análise do odds ratio associado ao polimorfismo rs1045642 do gene MDR1 revelou que o genótipo CT pode constituir um fator de risco aumentado de 1,84x para o desenvolvimento de Gamapatias Monoclonais e 2,27x para o desenvolvimento de Mieloma Múltiplo. Por outro lado, a presença de genótipos portadores do alelo T têm um efeito protetor no desenvolvimento de MM (OR=0,41). O cálculo do risco associado ao polimorfismo rs4148330 do gene MRP1 revela que o genótipo AG é um fator protetor (OR=0,50) para o desenvolvimento de LMA, assim como o alelo G (OR=0,50). Além disso, verificámos que existe uma associação de risco de desenvolver neoplasia com o polimorfismo rs2185268 do gene UCK2. De facto, a presença dos genótipos CC e AC representam um fator de risco 4,59x aumentado para o desenvolvimento de SMD/NMP. O polimorfismo rs274561 do gene OCTN2 não apresenta relação com o risco relativo de desenvolvimento neoplásico. Da avaliação da influência dos polimorfismos em estudo na sobrevivência global dos doentes, podemos assumir que a presença do genótipo GG relativo ao polimorfismo rs2185268 do gene UCK2 representa uma diminuição da sobrevivência em 11 meses. Os resultados obtidos a partir do nosso estudo permitem-nos concluir que os polimorfismos podem ser fatores relevantes na predisposição para o desenvolvimento de neoplasias hematológicas e na progressão destas doenças.

Analysis of Self-Organization

The dissertation is devoted to the study of problems in calculus of variation, free boundary problems and gradient flows with respect to the Wasserstein metric. More concretely, we consider the problem of characterizing the regularity of minimizers to a certain interaction energy. Minimizers of the interaction energy have a somewhat surprising relationship with solutions to obstacle problems. Here we prove and exploit this relationship to obtain novel regularity results. Another problem we tackle is describing the asymptotic behavior of the Cahn-Hilliard equation with degenerate mobility. By framing the Cahn-Hilliard equation with degenerate mobility as a gradient flow in Wasserstein metric, in one space dimension, we prove its convergence to a degenerate parabolic equation under the framework recently developed by Sandier-Serfaty.

Fatalism, Attributions of Failure and Academic Performance in Mapuche and Non-Mapuche Chilean Students

This study investigated the role of fatalism as a cultural value orientation and causal attributions for past failure in the academic performance of high school students in the Araucania Region of Chile. Three thousand three hundred and fourty eight Mapuche and Non-Mapuche students participated in the study. Consistent with the Culture and Behavior model that guided the research, the test of causal models based on the analysis of structural equations show that academic performance is in part a function of variations in the level of fatalism, directly as well as indirectly through its influence in the attribution processes and failure-related emotions. In general, the model representing the proposed structure of relations among fatalism, attributions, and emotions as determinants of academic performance fit the data for both Mapuche and non-Mapuche students. However, results show that some of the relations in the model are different for students from these two ethnic groups. Finally, according to the results from the analysis of causal models, family SES appear to be the most important determinant of fatalism.

MORPHOLOGICAL DIVERSITY OF MANGO GERMPLASM FROM THE UPPER ATHI RIVER REGION OF EASTERN KENYA: AN ANALYSIS BASED ON NON- FRUIT DESCRIPTORS

Phenotypic variation in plants can be evaluated by morphological characterization using visual attributes. Fruits have been the major descriptors for identification of different varieties of fruit crops. However, even in their absence, farmers, breeders and interested stakeholders require to distinguish between different mango varieties. This study aimed at determining diversity in mango germplasm from the Upper Athi River (UAR) and providing useful alternative descriptors for the identification of different mango varieties in the absence of fruits. A total of 20 International Plant Genetic Resources Institute (IPGRI) descriptors for mango were selected for use in the visual assessment of 98 mango accessions from 15 sites of the UAR region of eastern Kenya. Purposive sampling was used to identify farmers growing diverse varieties of mangoes. Evaluation of the descriptors was performed on-site and the data collected were then subjected to multivariate analysis including Principal Component Analysis (PCA) and Cluster analysis, one- way analysis of variance (ANOVA) and Chi square tests. Results classified the accessions into two major groups corresponding to indigenous and exotic varieties. The PCA showed the first six principal components accounting for 75.12% of the total variance. A strong and highly significant correlation was observed between the color of fully grown leaves, leaf blade width, leaf blade length and petiole length and also between the leaf attitude, color of young leaf, stem circumference, tree height, leaf margin, growth habit and fragrance. Useful descriptors for morphological evaluation were 14 out of the selected 20; however, ANOVA and Chi square test revealed that diversity in the accessions was majorly as a result of variations in color of young leaves, leaf attitude, leaf texture, growth habit, leaf blade length, leaf blade width and petiole length traits. These results reveal that mango germplasm in the UAR has significant diversity and that other morphological traits apart from fruits can be useful in morphological characterization of mango.

Effets des variations dans l’implantation d’un programme sur le risque cardiométabolique dans six CSSS de Montréal sur les résultats chez les patients

En 2011, l’Agence de la santé et des services sociaux de Montréal (ASSSM), en partenariat avec les Centres de santé et services sociaux (CSSS) de la région, a coordonné la mise en œuvre d’un programme de prévention et de prise en charge intégré sur le risque cardiométabolique. Ce programme, s’inspirant du Chronic Care Model et s’adressant aux patients atteints de diabète et d’hypertension artérielle, est d’une durée de deux ans et comporte une séquence de suivis individuels avec l’infirmière et la nutritionniste, de cours de groupe et de séances d’activité physique. L’objectif de ce mémoire est d’évaluer, à l’aide d’un devis quasi-expérimental, l’impact de la variation dans l’implantation de certains aspects du programme dans les six CSSS participant à l’étude sur les résultats de santé des patients. Cinq aspects du programme ont été retenus : les ressources, la conformité au processus clinique prévu dans le programme régional, la maturité du programme, la coordination interne au sein de l’équipe de soins et la coordination externe avec les médecins de 1re ligne. Des analyses de différence de différences, incluant des scores de propension afin de rendre les groupes comparables, ont été effectuées dans le but d’évaluer l’influence de ces aspects sur quatre indicateurs de santé : l’hémoglobine glyquée, l’atteinte de la cible de tension artérielle et l’atteinte de deux cibles d’habitudes de vie concernant la répartition des glucides alimentaires et la pratique d’activité physique. Les résultats indiquent que les indicateurs de santé sélectionnés se sont améliorés chez les patients participant au programme et ce, indépendamment des variations dans son implantation entre les CSSS participant à l’étude. Très peu d’analyses de différence de différences ont en effet relevé un impact significatif des variables d’implantation étudiées sur ces indicateurs. Les résultats suggèrent que les effets bénéfiques d’un tel programme sont davantage tributaires de la prestation des interventions auprès des patients que d’aspects organisationnels liés à son implantation.