Contexte de genre, autonomie des femmes et utilisation des services de santé maternelle en milieu rural africain : analyse par modèles d’équations structurelles

La vie des femmes du continent africain et de leurs enfants continue d’être mise en danger lors de chaque accouchement car les risques de décès maternels et infantiles sont encore très élevés. Il est estimé chaque année à environ le quart du million le nombre de décès maternel et de près de quatre millions celui des enfants de moins de cinq ans. La comparaison de la situation sanitaire avec d’autres contextes permet de mieux cerner l’ampleur du problème : en Afrique sub-Saharienne, le risque de décès lié à la grossesse est de l’ordre de 1 pour 31, alors qu’il n’est que de 1 pour 4300 dans les pays industrialisés. Cette situation est évitable et, le plus souvent, résulte de la sous ou non-utilisation des services de santé maternelle, du manque de structures adéquates de soins ou de personnel de santé qualifié. Notre thèse cherche à comprendre la manière dont les inégalités de genre au sein du ménage et dans la communauté renforcent les inégalités quant à l’utilisation des services de santé maternelle, ainsi qu’aux relations empiriques qui lient les différents recours aux soins. Concrètement, elle vise à 1) proposer une mesure des normes de genre favorables à la violence contre les femmes et à analyser son influence sur leur prise de décision au sein du ménage, 2) analyser simultanément l’influence de ces normes et de l’autonomie des femmes sur le recours aux soins prénatals et à l’accouchement assisté et finalement, 3) cerner l’influence des soins prénatals sur le recours à l’accouchement assisté. Chacun de ces objectifs se heurte à un problème méthodologique substantiel, soit de mesure ou de biais de sélection, auxquels l’approche par modèles d’équations structurelles que nous avons adoptée permet de remédier. Les résultats de nos analyses, présentés sous forme d’articles scientifiques, s’appuient sur les données issues des Enquêtes Démographiques et de Santé (EDS) du Ghana, du Kenya, de l’Ouganda et de la Tanzanie et concernent les femmes vivant en milieu rural. Notre premier article propose une mesure des normes de genre et, plus exactement, celles liées à la violence contre les femmes en recourant à l’approche des variables latentes. Les cinq questions des EDS relatives à l’attitude des femmes sur la légitimation de la violence ont permis de saisir cette mesure au niveau contextuel. Les résultats suggèrent d’une part que cette mesure a de bons critères de validité puisque l’Alpha de Cronbach varie de 0.85 pour le Kenya à 0.94 pour le Ghana; les chi-deux sont non significatifs partout; le RMSEA est en dessous de 0.05; le CFI supérieur à 0.96 et les saturations sont pour la plupart supérieures à 0.7 dans tous les pays. D’autre part, à l’aide du modèle d’équations structurelles multiniveaux, nous avons trouvé qu’au-delà de leur propre attitude envers la violence contre les femmes, celles qui vivent dans un milieu où les normes de genres sont plus favorables à la violence ont plus de chances d’être de faible autonomie ou sans autonomie (comparativement à forte autonomie) dans l’ensemble des pays étudiés. Le second article documente l’influence des inégalités de genre, cernées au niveau contextuel par les normes favorables à la violence contre les femmes et au niveau individuel par l’autonomie de prise de décision au sein du ménage, sur la survenue des soins prénatals au cours du premier trimestre et sur les recours à au moins 4 consultations prénatales et à l’accouchement assisté. En utilisant également les modèles d’équations structurelles multiniveaux sur les mêmes données du premier article, nous constatons que chacune de ces variables dépendantes est fortement influencée par la grappe dans laquelle la femme vit. En d’autres mots, son lieu de résidence détermine le comportement de santé maternelle que l’on adopte. De même, en contrôlant pour les autres variables explicatives, nos résultats montrent que les femmes qui vivent dans un milieu où les normes de genre liées à la violence contre les femmes sont élevées ont, en moyenne, une plus grande chance de ne pas accoucher auprès d’un personnel qualifié au Ghana et en Ouganda, de ne pas débuter leurs soins prénatals dans le premier trimestre dans les mêmes pays, et de ne pas recourir à au moins quatre consultations prénatales en Tanzanie. Par contre, cette variable contextuelle n’influence pas significativement le recours aux soins de santé maternelle au Kenya. Enfin, les résultats montrent que les normes de genre favorables à la violence contre les femmes sont plus déterminantes pour comprendre le recours aux soins de santé maternelle dans les pays étudiés que l’autonomie de prise de décision de la femme. Dans le cadre du troisième et dernier article empirique de la thèse, nous nous sommes intéressés à l’importance des soins prénatals dans le processus de recours à l’accouchement assisté et à la place du contenu des soins reçus avant l’accouchement dans cette relation. Cet article met en exergue l’existence de biais d’endogénéité au Kenya et en Tanzanie, où sans sa prise en compte, l’effet des soins prénatals sur le recours à l’accouchement auprès d’un personnel qualifié serait fortement biaisé. De plus, il ressort qu’à l’exception du Ghana et dans une moindre mesure de la Tanzanie, cet effet est totalement médiatisé par le contenu des soins prénatals que les femmes reçoivent. L’article met ainsi en relief le rôle des prestataires de soins qui pour atteindre plus efficacement les populations doivent agir en tant que leaders au sein de leur communauté.

Le recours aux services de santé buccodentaire au sein de localités autochtones du Nord du Québec

Le mode de vie des Cris de la Baie James a changé radicalement au cours des dernières années. La carie dentaire est maintenant un problème de santé publique important, et des données montrent que les Cris utilisent les services dentaires en situation d’urgence plutôt qu’en prévention. Il apparaît donc important de savoir si les Cris sont satisfaits des services dentaires publics qui sont disponibles et de mieux comprendre leurs besoins. Ce projet aborde les deux questions suivantes : Quelles sont les attentes des résidants des localités cries pour les services dentaires? Est-ce que les services existants répondent aux attentes des gens? Nous avons mené une recherche qualitative descriptive basée sur des entrevues semi- structurées (n = 13). Les entrevues ont été enregistrées et transcrites. Nous avons ensuite procédé à une analyse inductive-déductive des transcriptions. Les résultats montrent que les participants ont des attentes très variées, mais que celles-ci sont rarement satisfaites. Premièrement, ils veulent accéder rapidement aux services lorsqu’ils en ressentent le besoin, par exemple en présence de douleur dentaire. Les participants désirent aussi transiger avec des professionnels dentaires attentionnés et expérimentés, ce qui n’est pas toujours le cas, selon eux. En conclusion, nous aimerions faire trois principales recommandations : améliorer l’accès aux services dentaires, en particulier en situation d’urgence; entraîner les professionnels dentaires en approches centrées sur le patient et pour en savoir plus sur la culture crie; et dialoguer avec les Cris pour développer, mettre en place et évaluer les services de santé dentaire.

Impact of the elderly on household health expenditure in Bihar and Kerala, India

Dans le contexte d’une population vieillissante, nous avons étudié l’impact de la présence de personnes âgées sur les dépenses catastrophiques de santé (DCS), ainsi que leur impact sur trois effets reliés (le fait d’éviter des traitements, la perte de revenu, et l’utilisation de sources de financement alternatives). Nous avons utilisé les données d’une enquête du National Sample Survey Organization (Inde) en 2004, portant sur les dépenses reliées à la santé. Nous avons choisi un état développé (Kerala) et un état en voie de développement (Bihar) pour faire une comparaison des effets de la présence de personnes âgées sur les ménages. Nous avons trouvé qu’il y avait plus de DCS au Kerala et que ceci était probablement lié à la présence accrue de personnes âgées au Kerala ce qui mène à plus de maladies chroniques. Nous avons supposé que l’utilisation de services de santé privés serait lié à une augmentation de DCS, mais l’effet a varié en fonction de l’état, du présence d’une personne âgée, et du type de service utilisé (ambulatoire ou hospitalisation). Nous avons aussi trouvé que les femmes âgées au Bihar utilisait les services de santé moins qu’elle ne devrait, que les ménages ayant plus de 4 personnes ont possiblement un effet protecteur pour les personnes âgées, et que certains castes et group religieux ont dû emprunter plus souvent que d’autres groupes pour payer les frais de santé. La présence de personnes âgées, les maladies chroniques, et l’utilisation de services de santé privées sont tous liés aux DCS, mais, d’après nos résultats, d’autres groupes retardent les conséquences économiques en empruntant ou évitant les traitements. Nous espérons que ces résultats seront utilisés pour approfondir les connaissances sur l’effet de personnes âgées sur les dépenses de santé ou qu’ils seront utilisés dans des discussions de politiques de santé.

Mental health service utilization among students and staff in 18 months following Dawson College shooting

The aim of this study was to investigate service utilization by students and staff in the 18 months following the September 13, 2006, shooting at Dawson College, Montreal, as well as the determinants of this utilization within the context of Canada’s publicly managed healthcare system. Methods A sample of 948 from among the college’s 10,091 students and staff agreed to complete an adapted computer or web-based standardized questionnaire drawn from the Statistics Canada 2002 Canadian Community Health Survey cycle 1.2 on mental health and well-being. Results In the 18 months following the shooting, there was a greater incidence and prevalence not only of PTSD, but also of other anxiety disorders, depression, and substance abuse. Staff and students were as likely to consult a health professional when presenting a mental or substance use disorder, with females more likely to do so than males. Results also indicated that there was relatively high internet use for mental health reasons by students and staff (14% overall). Conclusions Following a major crisis event causing potential mass trauma, even in a society characterized by easy access to public, school and health services and when the population involved is generally well educated, the acceptability of consulting health professionals for mental health or substance use problems represents a barrier. However, safe internet access is one way male and female students and staff can access information and support and it may be useful to further exploit the possibilities afforded by web-based interviews in anonymous environments.

Identifying job skills in commercial advisors in a health insurance company

The aim of this research was to identify the criticalcompetence of success of the commercial adviserin a company providing insurance and health services.For this research a sample of 34 commercialadvisers. The sample was divided into four groups(two per product and two per criterion of success).Systematic fi eld observations, interviews of criticalincidents, application of response tests and salesworkshops were used to evaluate the differentialcompetences that the successful advisers wereshowing in relation to the advisers de fi ned as average.The success criteria were based on the generatedcommission performance over the 10 months. Allin all, signi fi cant differences were found betweenthe “successful” and “average” groups. Furthermore,competences that correlate positively with atop sales performance were observed and competencesthat have major level of discrimination betweenthe “successful” and “average” groups wereestablished. Orientation to achievement, planningand management, information search, commercialaggressiveness and strategic vision are the competencesthat were considered to be key in the topperformance of a sales agent or commercial adviser.Additionally, the results in the response testswere analyzed in the four study groups, withoutobserving signi fi cant differences between them,which supports the theoretical framework of thepresent study.

Small-area variation in health care affecting the choice of cesarean delivery: the case of a Colombian health insurer

In the midst of health care reform, Colombia has succeeded in increasing health insurance coverage and the quality of health care. In spite of this, efficiency continues to be a matter of concern, and small-area variations in health care are one of the plausible causes of such inefficiencies. In order to understand this issue, we use individual data of all births from a Contributory-Regimen insurer in Colombia. We perform two different specifications of a multilevel logistic regression model. Our results reveal that hospitals account for 20% of variation on the probability of performing cesarean sections. Geographic area only explains 1/3 of the variance attributable to the hospital. Furthermore, some variables from both demand and supply sides are found to be also relevant on the probability of undergoing cesarean sections. This paper contributes to previous research by using a hierarchical model and by defining hospitals as cluster. Moreover, we also include clinical and supply induced demand variables.

The potential of digital interactive television for the provision of healthcare and wellness services

The potential of digital interactive television (iDTV) to promote original services, formats and contents that can be relevant to support personal health care and wellness of individuals, namely elderly people, has not been yet fully explored in the past. Therefore, in a context of rapid change of the technological resources, in which the distribution and presentation of content comes associated with new platforms (such as digital terrestrial TV and IPTV), it is important to perceive the configurations that are being developed for interactive digital TV (iDTV) that may result in relevant outcomes within the field of healthcare and wellness, with the aim of offering complementarity to the existing services and contents made available today via the traditional means and media. This article describes and discusses the preliminary results of the first part of the research project iDTV-HEALTH: Inclusive services to promote health and wellness via digital interactive television. These first results suggest that iDTV solutions may represent a real contribution to delivery healthcare and wellness to the target population, namely as a supplement to health services provision.

Global Acceleration and Dispossesion: Regression in the Right to Life and Public Health during Ecuador’s Neoliberal Decades

The present essay’s central argument or hypothesis is, consequently, that the mechanisms accelerating a wealth concentrating and exclusionary economy centred on the benefit and overprotection of big business—with a corresponding plundering of resources that are vital for life—generated forms of loss and regression in the right to healthcare and the dismantling of institutional protections. These are all expressed in indicators from 1990-2005, which point not only to the deterioration of healthcare programs and services but also to the undermining of the general conditions of life (social reproduction) and, in contrast to the reports and predictions of the era’s governments, a stagnation or deterioration in health indicators, especially for those most sensitive to the crisis. The present study’s argument is linked together across distinct chapters. First, we undertake the necessary clarification of the categories central to the understanding of a complex issue; clarifying the concept of health itself and its determinants, emphasizing the necessity of taking on an integral understanding as a fundamental prerequisite to unravelling what documents and reports from this era either leave unsaid or distort. Based on that analysis, we will explain the harmful effects of global economic acceleration, the monopolization and pillaging of strategic healthcare goods; not only those which directly place obstacles on the access to health services, but also those like the destructuration of small economies, linked to the impoverishment and worsening of living modes. Thinking epidemiologically, we intend to show signs of the deterioration of broad collectivities’ ways of life as a result of the mechanisms of acceleration and pillage. We will then collect disparate evidence of the deterioration of human health and ecosystems to, finally, establish the most urgent conclusions about this unfortunate period of our social and medical history.

Access, equity and the role of rights in health care

Modern health care rhetoric promotes choice and individual patient rights as dominant values. Yet we also accept that in any regime constrained by finite resources, difficult choices between patients are inevitable. How can we balance rights to liberty, on the one hand, with equity in the allocation of scarce resources on the other? For example, the duty of health authorities to allocate resources is a duty owed to the community as a whole, rather than to specific individuals. Macro-duties of this nature are founded on the notion of equity and fairness amongst individuals rather than personal liberty. They presume that if hard choices have to be made, they will be resolved according to fair and consistent principles which treat equal cases equally, and unequal cases unequally. In this paper, we argue for greater clarity and candour in the health care rights debate. With this in mind, we discuss (1) private and public rights, (2) negative and positive rights, (3) procedural and substantive rights, (4) sustainable health care rights and (5) the New Zealand booking system for prioritising access to elective services. This system aims to consider: individual need and ability to benefit alongside the resources made available to elective health services in an attempt to give the principles of equity practical effect. We describe a continuum on which the merits of those, sometimes competing, values-liberty and equity-can be evaluated and assessed.

Is NHS Direct meeting the needs of mental health callers?

Background: NHS Direct is a new service that offers 24-hour advice from trained nurses. The National Service Framework for Mental Health and the National Strategy for Carers both mention NHS Direct as an important source of support for people with mental health problems. Aims: This paper reports findings from an evaluation of the Department of Health's NHS Direct mental health initiative. This initiative was established to ensure that NHS Direct can meet the needs of callers with mental health problems by offering additional training to all staff and improving the database of mental health services. Method: The findings reported here are based on routine computer data provided by 12 out of 17 NHS Direct sites, 552 data forms completed by nurse advisers from the 17 sites, and 111 questionnaires administered over the telephone with callers to the 17 sites. Results: Mental health calls accounted for 3% of NHS Direct's workload, although these calls were often longer and more complex than other calls. The majority of callers to the service were in touch with other services for their mental health problems (59%), typically their GP. Most callers had 'moderate' mental health problems, as indicated by the Global Assessment of Functioning Scale. Generally callers were satisfied with the service they received, although satisfaction was lower in some areas than previous studies of NHS Direct. Conclusions: Improvements could be made in the mechanisms for referring callers on to other services, and training to increase nurse advisers' knowledge of mental health problems.

Provider diversity in the English NHS: a study of recent developments in four local health economies

Objectives: The overall objective of the research was to assess the impact of provider diversity on quality and innovation in the English NHS. The aims were to map the extent of diverse provider activity, identify the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organisations within the NHS, and the factors that affect the entry and growth of new private and TSOs. Methods: Case studies of four Local Health Economies (LHEs). Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and Third Sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results: Involvement of diverse providers in the NHS is limited. Commissioners’ local strategies influence degrees of diversity. Barriers to the entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS Trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions: There is scope to increase the participation of diverse providers in the NHS, but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Inequalities in dental services utilization among Brazilian low-income children: the role of individual determinants

Objectives: To assess the role of the individual determinants on the inequalities of dental services utilization among low-income children living in the working area of Brazilian`s federal Primary Health Care program, which is called Family Health Program (FHP), in a big city in Southern Brazil. Methods: A cross-sectional population-based study was performed. The sample included 350 children, ages 0 to 14 years, whose parents answered a questionnaire about their socioeconomic conditions, perceived needs, oral hygiene habits, and access to dental services. The data analysis was performed according to a conceptual framework based on Andersen`s behavioral model of health services use. Multivariate models of logistic regression analysis instructed the hypothesis on covariates for never having had a dental visit. Results: Thirty one percent of the surveyed children had never had a dental visit. In the bivariate analysis, higher proportion of children who had never had a dental visit was found among the very young, those with inadequate oral hygiene habits, those without perceived need of dental care, and those whose family homes were under absent ownership. The mechanisms of social support showed to be important enabling factors: children attending schools/kindergartens and being regularly monitored by the FHP teams had higher odds of having gone to the dentist, even after adjusting for socioeconomic, demographic, and need variables. Conclusions: The conceptual framework has confirmed the presence of social and psychosocial inequalities on the utilization pattern of dental services for low-income children. The individual determinants seem to be important predictors of access.

Analyses of cataract surgery performed by the Unified Health System in Brazil, 2006-2007

Objective. Estimate cataract surgical rates (CSR) for Brazil and each federal unit in 2006 and 2007 based on the number of surgeries performed by the Unified Health System to help plan a comprehensive ophthalmology network in order to eliminate cataract blindness in compliance with the target set by the World Health Organization (WHO) of 3 000 cataract surgeries per million inhabitants per year. Methods. This descriptive study calculates CSR by using the number of cataract surgeries carried out by the Brazilian Unified Health System for each federal unit and estimates the need for cataract surgery in Brazil for 2006-2007, with official population data provided by the Brazilian Institute of Geography and Statistics. The number of cataract surgeries was compared with the WHO target. Results. To reach the WHO goal for eliminating age-related cataract blindness in Brazil, 560 312 cataract surgeries in 2006 and 568 006 surgeries in 2007 needed to be done. In 2006, 179 121 cataract surgeries were done by the Unified Health System, corresponding to a CSR of 959 per million population; in 2007, 223 317 were performed, with a CSR of 1 179. With the Brazilian Council of Ophthalmology estimation of 165 000 surgeries each year by the non-public services, the CSR for Brazil would be 1 842 for 2006 and 2 051 for 2007. The proportions needed to achieve the proposed target were 38.6% in 2006 and 31.6% in 2007. Conclusions. Human resources, technical expertise, and equipment are crucial to reach the WHO goal. Brazil has enough ophthalmologists but needs improved planning and infrastructure in order to eliminate the problem, aspects that require greater financial investment and stronger political commitment.

Health in Brazil 2 Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5.5% a year in the 1980s and 1990s, and by 4.4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2.5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil`s progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women`s health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.