Dissertationen zum Thema „Health Studies“

Aquesta tesi està formada per dues parts relacionades amb l'estudi de la salut d'una regió geogràfica dividida en un conjunt de zones (àrees petites). La primera part es basa en un estudi amb informació de salut agregada per cadascuna de les àrees que formen la regió d'estudi. En concret, es tracta d'una aplicació de mapes de salut (disease mapping), que utilitza mètodes Bayesians empírics per generar un Atles de mortalitat en àrees petites de Catalunya en el període 1984-1998. La segona part utilitza una nova perspectiva basada en la integració de les dades agregades i individuals de salut per cadascuna de les zones que formen la regió d'estudi, mitjançant equacions d'estimació (estimating equations). Aquesta nova perspectiva és una extensió de la regressió geogràfica.
L'elaboració de la primera part d'aquesta tesi està justificada per diferents raons. En primer lloc, els atles de salut i en general els mapes d'indicadors de salut, ens han mostrat la seva gran utilitat per identificar les localitzacions geogràfiques de les malalties, formular hipòtesis sobre les causes de la malaltia i monitoritzar intervencions en salut pública. En segon lloc, els atles de mortalitat en àrees petites presenten la distribució del risc relatiu per les causes de mortalitat més importants utilitzant mapes amb un alt nivell de resolució geogràfica.
El primer objectiu d'aquesta tesi va ser construir un atles de mortalitat en 289 àrees petites (municipis o municipis agregats) de la Comunitat Autònoma de Catalunya i 66 àrees bàsiques de salut de la ciutat de Barcelona (l'àrea petita analitzada amb una major població) per al període 1984-1998. Per obtenir els indicadors de salut en àrees petites s'han utilitzat mètodes Bayesians. Aquests mapes presenten, en un format de doble pàgina, els riscs relatius ajustats per edat, les àrees significatives d'alt i baix risc, el risc relatiu de la ciutat de Barcelona respecte a Catalunya i internament respecte a Barcelona, el risc relatiu per grups d'edat (0-64 i 65) i addicionalment l'evolució temporal del risc relatiu en cada àrea resumida en un únic mapa. En concret, per estudiar l'evolució del risc relatiu de mortalitat s'inclou: 1) l'evolució del risc relatiu en el període d'estudi de cada àrea comparada amb la tendència global de Catalunya i 2) l'evolució absoluta del risc relatiu a cada àrea. Segons el nostre coneixement, aquesta és la primera vegada que aquests dos tipus d'informació es combinen en un únic mapa. A més, aquest és el primer Atles que presenta informació sobre la distribució geogràfica de zones que formen àrees petites de gran població, com ciutats d'un país, i inclou l'esperança de vida obtinguda amb mètodes Bayesians empírics.
La segona part d'aquesta tesi és útil per estudis epidemiològics on s'inclouen variables d'exposició i confusió que poden tenir diferents fonts de variabilitat (variabilitat dins les poblacions i entre les poblacions). Específicament, els anàlisis individuals que valoren la relació entre la malaltia i l'exposició dins d'una població són útils quan l'exposició presenta variabilitat dins la població. Quan aquesta variabilitat és limitada, la força dels anàlisis individuals es debilita. En aquesta situació, un anàlisis de dades agregades de la malaltia entre poblacions, amb una mostra de dades individuals d'exposició, pot ser eficaç en l'estimació de l'efecte d'exposició si aquest presenta gran variabilitat entre poblacions. No obstant, encara que es pugui conèixer quina de les dues variacions domina en la variable d'exposició, es poden considerar conjuntament variables d'exposició i/o confusió amb diferents tipus de variació. El segon objectiu d'aquesta tesi va ser considerar una nova perspectiva, combinació dels anàlisis de dades individuals i agregades, basat en equacions d'estimació (perspectiva population-based estimating equation (PBEE)). En funció de la variabilitat que domina en la exposició, la anàlisis proposada pren força de la perspectiva basada en dades individuals i agrades de salut, per estimar els efectes d'exposició. Es van realitzar estudis de simulació en diferents escenaris per a mostrar el poder de la perspectiva proposada en l'estimació dels efectes d'exposició d'interès.
Finalment, esperem que els mètodes i els diferents aspectes utilitzats en aquesta tesi puguin ser d'utilitat per a aquells investigadors que vulguin millorar l'estudi de la salut a l'espai i temps.
Esta tesis esta formada por dos partes relacionadas con el estudio de la salud en una región geográfica dividida en un conjunto de zonas (áreas pequeñas). La primera parte considera un estudio con información de salud agregada para cada una de las áreas que forman la región analizada. En concreto, se trata de una aplicación de mapas de salud (disease mapping), consistente en el uso de métodos Bayesianos empíricos para generar un Atlas de mortalidad en áreas pequeñas de Cataluña en el periodo 1984-1998. La segunda parte considera un nuevo enfoque que realiza una integración de los datos agregados e individuales de salud para cada una de las zonas que forman la región en estudio, mediante ecuaciones de estimación (estimating equations). Se considera que este nuevo enfoque es una extensión de la regresión geográfica.
La elaboración de la primera parte de esta tesis esta justificada por diferentes razones. Primero, los atlas de salud y en general los mapas de indicadores de salud, han mostrado su gran utilidad para identificar localizaciones geográficas de las enfermedades, formular hipótesis sobre las causas de la enfermedad y monitorizar intervenciones en salud pública. En segundo lugar, los atlas de mortalidad en áreas pequeñas presentan la distribución del riesgo relativo para las causas de mortalidad más importantes usando mapas con un alto nivel de resolución geográfica.
El primer objetivo de esta tesis fue construir un atlas de mortalidad en 289 áreas pequeñas (municipios o municipios agregados) de la Comunidad Autónoma de Cataluña y 66 áreas básicas de salud de la ciudad de Barcelona (el área pequeña analizada con mayor población) para el periodo 1984-1998. Para obtener los indicadores de salud en las áreas pequeñas se han aplicado métodos Bayesianos. Estos mapas presentan, en un formato de página doble, los riesgos relativos ajustados por edad, las áreas significativas de alto y bajo riesgo, el riesgo relativo de la ciudad de Barcelona con respecto a Cataluña e internamente con respecto a Barcelona, el riesgo relativo por grupos de edad (0-64 y 65) y adicionalmente la evolución temporal del riesgo relativo en cada área resumida en un único mapa. En concreto, para estudiar la evolución del riesgo relativo de mortalidad se incluye: 1) la evolución del riesgo relativo en el periodo de estudio de cada área comparada con la tendencia global de Cataluña y 2) la evolución absoluta del riesgo relativo en cada área. Según nuestro conocimiento, esta es la primera vez que ambos tipos de información se combinan en un único mapa. Además, este es el primer Atlas que presenta información sobre la distribución geográfica de zonas que forman áreas pequeñas de gran población, como ciudades de un país, e incluye la esperanza de vida obtenida mediante métodos Bayesianos empíricos.
La segunda parte de esta tesis es útil en estudios epidemiológicos donde se incluyen variables de exposición y confusión que pueden tener diferentes fuentes de variabilidad (variabilidad dentro de las poblaciones y entre poblaciones). Específicamente, los análisis individuales que valoran la relación entre enfermedad y exposición dentro de una población son útiles cuando la exposición presenta variabilidad dentro de la población. Cuando dicha variabilidad es limitada el poder de los análisis individuales se reduce. En esta situación, un análisis de datos agregados de enfermedad entre poblaciones, con una muestra de datos individuales de exposición, puede ser eficaz en la estimación del efecto de exposición si este presenta gran variabilidad entre poblaciones. No obstante, aunque se pueda conocer cual de las dos variaciones domina en la variable de exposición, se pueden considerar conjuntamente variables de exposición y/o confusión con diferentes tipos de variación. El segundo objetivo de esta tesis fue considerar un nuevo enfoque, combinación de los análisis de datos individuales y agregados, basado en ecuaciones de estimación (enfoque population-based estimating equation (PBEE)). Dependiendo de la variabilidad que domina en dicha exposición, el análisis propuesto toma fuerza de los enfoques basados en datos individuales y agregados de salud, para estimar los efectos de exposición. Estudios de simulación bajo diferentes escenarios fueron realizados para mostrar el poder del enfoque propuesto en la estimación de los efectos de exposición de interés.
Finalmente, esperamos que los métodos y diferentes aspectos empleados en esta tesis puedan ser de utilidad para aquellos investigadores que quieran mejorar el estudio de la salud en el espacio y en el tiempo.
This thesis consists of two related parts based on the study of health in a geographical region divided in a set of zones (small areas). The first part considers studies based on health information aggregated for each area into which the region under study has been divided. Specifically, it is a disease mapping application, based on generation of an Atlas of mortality in small areas of Catalonia over the period 1984-1998, using empirical Bayes methods. The second part considers an innovative approach, based on an integration of aggregated and individual health data in each of the zones of the region under study, using an estimating equation approach. Specifically, we consider this new approach as an extension of geographical regression.
The elaboration of the first part of this thesis is justified for different reasons. First, health atlases and the mapping of health indicators in general, has demonstrated its great utility in identifying geographical localizations of health problems, in formulation of hypotheses about disease causes, and in monitoring public health interventions. Second, most atlases of mortality at the small area level present patterns of relative mortality risk for the most important causes of death using maps with a high level of geographical resolution. The first goal of this thesis was to construct a mortality Atlas involving a decomposition of the Autonomous Community of Catalonia into 289 small areas (municipalities or aggregates thereof) and 66 primary health areas of Barcelona city (being a small area but with a large population) for the period 1984-1998. For Catalonia as a whole, these maps presented, using a double-page format, the age adjusted relative risk, significantly high and low relative risk areas, relative risk in Barcelona City with respect to Catalonia and internally with respect to Barcelona, relative risk by age group (0-64 and 65) and additionally the relative risk evolution over time in each area summarized in an single map, using spatial and temporal information modeled through Bayesian methods. Specifically, the atlas uses a strategy to include both: 1) relative risk evolution throughout the study period of each area compared to the average trend for all Catalonia and 2) the absolute relative risk evolution of each area. To our knowledge, this is the first time that both types of information have been combined in a single map. In addition, this is the first Atlas that presents information about geographical patterns in zones within small areas having a large population such as the cities of a country and includes life expectancy obtained with an empirical Bayes approach.
The second part of this thesis can be useful in epidemiological studies where we include exposure and confounding variables that may have different sources of within and between-population variability. Specifically, analyses of individual disease-exposure data within a population are useful when exposure of interest varies sufficiently within the population. When the within-population variance of exposure is limited power of the individual-data analysis within a population is reduced. In such situations, aggregated-data analyses of disease data across populations, with a sample of individual exposure data from populations, can be powerful in estimating the exposure effect if between-population variation of exposure is large. However, although we may have knowledge of which variations dominate in each variable, exposure and/or confounding variables with different types of variation can be considered jointly. The second goal of this thesis was to consider a new analytical framework that is a combination of the individual- and aggregated-data analyses, based on an estimating equation approach ("population-based estimating equation" (PBEE) approach). The proposed analysis utilizes strengths from individual and aggregated health data approaches in the estimation of the exposure effect of interest, depending on which of the exposure variations (within- vs. between-population) dominates. Simulation studies under different scenarios were performed to show the strengths of the proposed approach in the estimation of the exposure effects of interest.
Finally, we hope that some of the methods and topics employed may be of use to researchers who want to improve the study of health in space and time.

This study examines the association between immigrant women's self-reported health and their employment status and occupation using data on 859 immigrant women aged 20--64 from the 1994--95 National Population Health Survey. Of this group, 502 were in paid employment, 107 assessed their global health as poor, and 158 reported one or more disability days in the previous two weeks. Distress scores ranged from 0--21 (mean 3.85). Logistic and multiple linear regression showed being employed (vs. not being in paid employment) was associated with better self-assessed global health when age, education, income, marital status, country of birth and time since immigration were controlled and women's care-giving role was accounted for. However, this protective association was weaker in women who also reported caring for their family as a main activity. Significant associations between work and disability days or mental distress did not occur. Among 476 immigrant women currently employed in their main occupation, manual workers had poorer self-reported health and higher mental distress scores than others.

The Kingdom of Swaziland is a small African nation with an HIV prevalence rate of 27.4% in adults and up to 39% in pregnant women (Global Health Observatory, 2014). In 2012, life expectancy for a woman in Swaziland was 55-years (World Health Organization, 2014). Health entails more than the absence of disease. Although considered a lower middle-income country, 69% of Swazi citizens live in poverty and nearly one-third live in extremely poor circumstances. The degree to which upstream factors such as social conditions and the cultural environment impact individuals tends to be minimized in Westernized models of health behavior. The purpose of this study was to examine the sociocultural factors that impact self-care and health maintenance of women in Swaziland. The goals related to this were to uncover the salient cultural values, beliefs and attitudes that affect the health of Swazi women, and to develop a deeper understanding of how strongly embedded cultural values are a determinant of health outcomes. Using Carspecken’s methodology of critical ethnography, which incorporates both observational and narrative methods, this study focused intensively on the life stories of four rural African women. The findings richly illustrate how social issues such as poverty and food insecurity impact the health of women and their children; and how traditional customs and practices both support and threaten the health of women and families. Women in this study experienced a loss of husband or extended family due to death or abandonment that resulted in losses in supports and resources. Additionally, they worried about the health and education of their children before personal health needs. They also reported chronic employment problems and mistrust in existing governmental agencies including the healthcare system. Application of the culturally sensitive Person-Environment-Neighborhood (PEN-3) model highlights areas of resilience, strengths, and resource targets and identifies the community as an appropriate entry level for health interventions.

Increasing interest in productivity, safety and environmental issues have highlighted the area of maintenance and reliability. The increasing cost of maintenance covers both preservation and sustainable exploitation of resources and awareness in maintaining equipment in a way to ensure return on investment both in the short and long run. The information obtained from condition monitoring of existing turbine, plant, rails and pumps can provide an important basis for dimensioning of future systems and components. The main objective of this research work is to develop and apply methods for efficient condition monitoring, and hence reduce maintenance costs and provide a framework for development and implementation of computer based decision tools. Furthermore, methods enabling existing process data and cost effective transducers to be used together with modern data analysis and diagnostic tools for condition monitoring of complex mechanical systems have been examined and prototypes developed. The areas of investigation covered in this work are hydropower turbines, rails and the main cooling pumps in a nuclear power-plant. The interest in diagnostics for hydropower turbines was driven by the obvious risk of contamination of water by oil leaks and expensive refurbishments caused by wear of the Kaplan turbine vane bearings. The intrest in risk analysis was motivated by Vattenfall's intrest in gaining knowledge about the state of all turbines in the company. The aim of this project was to develop a generic model of hydropower turbine behavior using physics-based models based on material properties, load tolerances, etc.. An important question was whether it was possible to predict the wear rate and plan predictive replacement or maintenance. A systematic approach to find failure modes, their effects, their causes and consequences in combination with Fault Tree Analysis was needed. The objective of this project was to examine a systematic approach to map failure modes and their causes in an hydropower turbine. We have restricted the study to turbine units of the Kaplan, Francis and tube types. The objective of the study concerning rail track was to develop methods and equipment for detection of surface damage in rail track rail in addition to the present system of practice of visual examination. The equipment developed has to be used to obtain objective statistical data for evaluating maintenance methods and efforts. We have restricted the study to spalling and headchecks on the rail head surface and running edge. The method developed enables measurements of different types of surface damage such as spalling and shelling to be made with inductive transducers sensitive to the distance to the measured object. The assumption here is that the damage being detected is characterized by the absence of material from rail surface. The main object of condition monitoring of the cooling pumps was to be able to detect bearing wear in order to be able to plan and carry out restoration well ahead of breakdown or bearing seizure. The study was restricted to the main cooling pump motor and its main bearings. Condition monitoring of the pumps was done using a method based on current measurements. Analysis of the currents on the main cooling pump of the power plant proved that it is possible to monitor the condition of the pump in spite of the presence of electronic frequency converters which distorts the signal.

Godkänd; 2002; 20070222 (ysko)

Research on the health effects of temperature has expanded greatly in recent years, mainly due to the occurrence of extreme weather events and predicted climate change scenarios. The development of appropriate statistical methodology has been an important component of this research, and standard approaches, primarily based on multi-city time series regression analysis, are now well established. However, particular aspects of temperature-health associations, such as the non-linear and delayed relationship and the joint handling of multi-city data, still pose important niet hodological problems. During my PhD research, I have contributed to the development of statistical methods that, address two particular limitations of traditional approaches, focusing on the development of two modelling frameworks: distributed lag non-linear models and multivariate meta-analysis. The former is a class of models that specify simultaneously non-linear and delayed exposure-response relationships in time series data, while the latter is an extension of traditional metaanalysis for the combination of multiple correlated outcomes across studies, that is also applicable to multi-parameter associations. These methods are placed within the traditional two-stage approach that, is adopted in tcuiperat, ure-health studies. The first stage is city-specific, with analyses deriving the estimated relationship within each city. The second-stage is meta-analytical procedure for combining the results from the first stage. I have implemented these modelling frameworks in two packages within the statistical environment R. In this PhD thesis I present a series of publications which summarize my research work. Their content focuses on three key aspects: the development of the statistical methodology, the implementation of the software, and the application of the methods to real data. The papers are preceded by an epidemiological and statistical introduction to the topic, and followed by a final discussion where I illustrate potential future developments and provide some conclusions. These methodological advancements contribute several improvements over standard methods that are applied to investigate temperature-health associations in time series data, and may be easily extended to other research fields and study designs.

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This thesis is a set of three studies concentrated on the antecedents and effects of users trust in online health groups on Facebook. People in Brazil are increasingly using these groups as a way to find health information and support from people who experience the same health challenges. There are several types of online groups addressing various topics of interest gathering together hundreds and thousands of individuals who can easily participate and interact with others. Their goal is to be able to improve their knowledge about their topic of interest, to manage their health condition better. Also many seek advice to better deal with the disease and alleviate its symptoms. Others are seeking support for behavior change to be healthier. The participation of people in such groups has the potential to address many health issues and positively influences health systems. So it is important to better understand about aspects that can contribute to the online group's sustainability and longevity, such as the activity of members, its inner workings and the relationship between members. These online groups are constituted by people who do not know each other personally. Thus, trust is an aspect that materializes from the interactions experienced and relationships constituted within the community. These experiences, result of the interaction of the individual with the other participants and the knowledge available, has the potential to increase or decrease their trust in the online groups. Which in turn impacts the way people engage in the community and contribute their knowledge as well as the adoption of knowledge available in the online group. The first study discusses aspects of the activity of members and the online group inner workings. These aspects imply the vitality of online communities, a crucial element for its success and development. Based on previous literature, we identified that there is no measure to assess the vitality of the community, although its dimensions have already been conceptualized. The main contribution of this paper is the development and validation of the Online Community Vitality scale, which can be measured by 20 items composed of five sub-dimensions: content quantity, content quality, interactivity, responsiveness, and atmosphere. The second study seeks to address the literature gap by exploring the determinants of individuals trust in online health groups. The main contribution of the second paper is the extension of the literature of trust in the context of social medias by testing and validating new variables as antecedents of trust: online community vitality, community support and perceived information credibility. The last study proposes that the participant's trust in online health groups have the potential to increase their engagement, knowledge adoption and contribution. Also, proposes that engagement positively influences the adoption of knowledge and knowledge contribution. The results support all prepositions. The findings contribute to the expand the literature about trust and engagement, considering the context of online health groups on Facebook.
Esta tese é um conjunto de três estudos sobre os fatores que impactam a confiança do indivíduo em grupos online de saúde no Facebook, bem como os efeitos da confiança nestes grupos. No Brasil as pessoas estão cada vez mais utilizando tais grupos como forma de acesso as informações de saúde e também para obter apoio de pessoas que enfrentam os mesmos desafios de saúde. Existem vários tipos de grupos online que tratam de temas diversos e reúnem centenas e milhares de pessoas, que facilmente participam e interagem com semelhantes. Estas pessoas buscam melhorar o seu conhecimento sobre o tópico de seu interesse, a fim de melhor administrar sua condição de saúde. Além disso, muitos procuram aconselhamento para melhor lidar com a doença e aliviar seus sintomas. Outros buscam suporte para que mudem seu próprio comportamento de modo a se tornarem mais saudáveis. A participação de pessoas em tais grupos tem potencial para ajudar na solução de muitos problemas de saúde e também influenciar positivamente os sistemas de saúde. Desta forma, é relevante a compreensão dos aspectos que podem contribuir para a sustentabilidade e longevidade do grupo online, tais como: as atividades dos membros, o funcionamento interno da comunidade e a relacionamento entre os membros. Os grupos on-line são constituídos por pessoas que geralmente não se conhecem pessoalmente, sendo assim, a confiança é um aspecto que se materializa a partir das interações vivenciadas e das relações constituídas dentro da comunidade. Essas experiências, resultado da interação do indivíduo com os outros participantes e do conhecimento disponível no grupo, têm potencial para aumentar ou diminuir sua confiança nos grupos on-line. O que por sua vez afeta a forma como as pessoas se engajam e contribuem com seus conhecimentos, bem como a adoção do conhecimento disponível no grupo on-line. O primeiro estudo discute aspectos relativos a atividade dos membros e o funcionamento do grupo online. Esses aspectos implicam a vitalidade da comunidade on-line, crucial para seu sucesso e desenvolvimento. Com base na literatura anterior, foi identificado que não há instrumento de medida para avaliar a vitalidade da comunidade, embora suas dimensões já tenham sido previamente conceituadas. A principal contribuição deste trabalho é o desenvolvimento e validação da escala de Vitalidade na Comunidade, que pode ser medida através de 20 itens distribuídos em cinco subdimensões: quantidade de conteúdo, qualidade do conteúdo, interatividade, capacidade de resposta e atmosfera. O segundo estudo trata de uma lacuna da literatura e explora os fatores determinantes da confiança dos indivíduos em grupos de saúde on-line. A principal contribuição do segundo artigo é a ampliação do arcabouço teórico de confiança no contexto das mídias sociais, por meio do teste e validação de novas variáveis como antecedentes de confiança, são elas: vitalidade da comunidade, suporte da comunidade e percepção de credibilidade da informação. O último estudo propõe que a confiança dos participantes em grupos on-line de saúde tem o potencial de aumentar seu engajamento, adoção e contribuição de conhecimento. Também propõe que o engajamento influencia positivamente a adoção de e contribuição de conhecimento. Os resultados suportam todas as proposições. Os achados contribuem para ampliar a literatura sobre confiança e engajamento, considerando o contexto dos grupos de saúde on-line no Facebook.

This research sets out to assess if the PHC system in rural Nigeria is effective by testing the research hypothesis: 'PHC can be effective if and only if the Health Care Delivery System matches the attitudes and expectations of the Community'. The field surveys to accomplish this task were carried out in IBO, YORUBA, and HAUSA rural communities. A variety of techniques have been used as Research Methodology and these include questionnaires, interviews and personal observations of events in the rural community. This thesis embraces three main parts. Part I traces the socio-cultural aspects of PHC in rural Nigeria, describes PHC management activities in Nigeria and the practical problems inherent in the system. Part II describes various theoretical and practical research techniques used for the study and concentrates on the field work programme, data analysis and the research hypothesis-testing. Part III focusses on general strategies to improve PHC system in Nigeria to make it more effective. The research contributions to knowledge and the summary of main conclusions of the study are highlighted in this part also. Based on testing and exploring the research hypothesis as stated above, some conclusions have been arrived at, which suggested that PHC in rural Nigeria is ineffective as revealed in people's low opinions of the system and dissatisfaction with PHC services. Many people had expressed the view that they could not obtain health care services in time, at a cost they could afford and in a manner acceptable to them. Following the conclusions, some alternative ways to implement PHC programmes in rural Nigeria have been put forward to improve and make the Nigerian PHC system more effective.

In response to the increased popularity and use of Traditional/Complementary Alternative Medicine, not only in less-developed countries where it is a first line of contact for the majority of people but also in developed countries, initiation of Integrative Medicine Clinics has been triggered particularly in Western countries. In addition, there are increased opportunities of research and associated criticism on the subject. Whereas such investigations have provided some interesting understandings on how the integrative clinics are managed, surprisingly, many of the investigations have been carried out in developed countries where biomedicine is affordable and accessible for the majority of people. There is a dearth of information about the opportunities and challenges for contemporary and traditional health practices to work together in less-developed countries where accessibility and affordability of modern medicine is a huge challenge. The objective of this thesis then was to offer some exploratory perceptions into how key stakeholders of health in Tanzania recognize the opportunities and challenges that are there for the two health practices to integrate under the National Health System. An ethnographic stance was utilised to explore the views of 35 participants from four regions in Tanzania, among whom were biomedical and traditional practitioners, policy-makers, and religious leaders; researchers of traditional medicine from two national research institutes, participants with multiple roles and clients of the two practices. In-depth, semi-structured interview was the main method of data generation. Data was analysed thematically, from which the study revealed that despite the potential opportunities for the two practices to work together, integration of the two practices cannot take place due to emergence of two schools of thought of traditionalism and modernity that were irreconcilable. Instead cooperation is possible under the framework of Negotiated Order Theory that feeds three processes of Integration and Differentiation, Hybridization of Traditional Medicine and Negotiating Modernity.

This small-scale study explores the concept of medical pluralism by looking at the health-seeking strategies of a selected group of residents in Stellenbosch's Kayamandi township. The study addresses the following three primary research questions: What are the health-seeking strategies of the target group? What factors significantly influence their health-seeking behaviour; and why are the respondents using more than one health-seeking strategy? We have used theoretical formulations derived from literature together with data we collected by questionnaires and interviews to respond to these questions. Our target group consisted of a mix of isiXhosa-speaking Christians, which fall into one of the following three groupings: Ecumenical, African Independent Zionists, and African Independent Non-Zionists. We applied a variety of methods to collect our data namely: survey questionnaire, in depth interviews and a focus group interview. Basic statistical and qualitative analysis techniques were used to analyze the data. We tested various potential variables before we concluded that Christian affiliation and gender are two major variables in this study that seem to influence our respondents' choices of strategy. The resulting data indicated that almost all of our respondents are mixing health seeking strategies. They are mixing in two ways: either in a complex way (multiple health seeking strategies for a single ailment), or a simple way (different strategies for different ailments). Even though Western Medicine is a dominant and the only legalized health-seeking strategy in South Africa this research suggests that there is a growing use of other health-seeking strategies, either alternatively or complementarily to Western Medicine. Reasons for this are discussed in this research report, and include firstly, conviction of experience and knowledge of health and illness among others. Secondly, we have established that these determinants transcend accessibility and availability of, particularly, Western medicine facilities. Respondents utilize three different health-seeking strategies selectively through 'border crossing' with minimal conflict.

Misclassification of disease and/or exposure is a common and potentially serious problem in epidemiologic studies. The impact of misclassification may be profound and may invalidate results. Despite the fact that there have been a number of articles published on the significance of misclassification bias, many epidemiologic studies are carried out with little attention paid to this issue either in the design or the analysis. The goal of this thesis is to provide clarifications on issues surrounding misclassification of exposure in case-control studies. Specifically, the conditions under which misclassification is likely to occur, the potential impact on effect measures and how misclassification can be prevented through design and corrected for in the analysis are discussed in detail.

Background: Cardiovascular disease (CVD) is the leading cause of death among all major racial and ethnic groups in the United States (US) and worldwide. Filipinos are the second largest Asian immigrant group in the US. Healthful lifestyle behaviors are cardioprotective factors, but have been under-, overestimated, or not studied among Asian American subgroups.

Objective: The purpose of this dissertation was to describe the cardiovascular health, cardiovascular mortality, cardiometabolic and lifestyle health behaviors, acculturation, and predictors associated with CVD in the Filipino American population.

Methods: A systematic review of the literature was conducted which focused on the cardiovascular mortality, disease and clinical and behavioral risks of Filipinos in the US. Two secondary analyses of the 2011-2012 California Health Interview Survey dataset were conducted which focused on the cardiovascular health, CVD, acculturation, metabolic and lifestyle health behavior of Filipino Americans (n = 555).

Results: The systematic review suggested that Filipino Americans are at high risk for developing cardiovascular disease, for having CVD-related clinical health risks, for engaging in unhealthy CVD lifestyle behaviors, and dying from CVD, as compared to White, non-Hispanic and other Asian Americans in general and by gender. The prevalence of CVD was 7.4% among Filipinos in California. Hypertension, diabetes, physical inactivity, being overweight/obese, and inadequate consumption of fruits and vegetables were prevalent among Filipinos. Multivariate logistic regression analysis indicated that only hypertension was a significant predictor of CVD, controlling for the effects of age, gender, being born in the US, and diabetes. When taking into consideration acculturation factors in chronic diseases and health behaviors, US-born Filipinos had a significantly lower proportion of chronic diseases as compared to Filipinos not born in the US. Filipinos who lacked English proficiency reported more hypertension as compared to Filipinos who reported proficiency in English. A higher proportion of several positive health behaviors were reported among Filipinos not born in the US and those who did not speak English at home ate the recommended 35 or more servings per week of fruits and vegetables compared to their counterparts.

Conclusions: Further research is needed for culturally-appropriate interventions, education, and prevention programs which focus on health behaviors and chronic diseases, such as CVD, for Filipino Americans.

Background. U.S. and other studies have established an inverse association between a variety of measures of income inequality and population health. Objectives. To describe income inequality (market income and income after tax) and population health (eight measures) in Canada and the provinces between 1981 and 1996; to establish associations between these variables; and to explore whether the associations are measure dependent. Method. Ecologic, analytic, mixed-design study, based on analysis of existing data. Results. The association between the Gini coefficient (market income) and total mortality was very weak in 1981 and 1986, but very strong in 1991 and 1996. Otherwise, associations between income inequality and different health outcomes were non-existent, weak, or sporadic. Conclusions. Income inequality depends on the income concept used. Associations between income inequality and health are measure dependent. Structural changes in Canadian society may account for the emerging association between income inequality and total mortality from 1991 onwards.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2013.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 59-63).
The Patient Protection and Affordable Care Act (PPACA) has set the tone for a radically revised health landscape in America that focuses on community-based care. Our health care system, however, has neither the infrastructure nor the vision to properly account for these demands. One possible solution is to redefine how established positions and organizations can be utilized to help accommodate the emerging needs. School-based health centers (SBHCs), for example, have traditionally provided general health services to students and members of the surrounding community. In many low-income neighborhoods, however, the needs of the community members far outpace the capabilities of the SBHCs and local community-based health centers. One promising answer to the need for community-based care is the integration of community health workers (CHWs) in SBHCs. The PPACA has identified CHWs as an integral component of health teams. They serve to connect people who have been historically marginalized to necessary health services and advocate on the behalf of community needs. This commentary proposes the integration of the CHW role into schools to provide comprehensive health-services to more students and community members than can be currently served. The argument begins with an examination of Massachusetts' CHW advocates' struggle to legitimize the field to gain the professional respect of other medical professions. Next, it explores the possibilities of a CHW in a school setting and makes recommendations to improve the viability and effectiveness of the role. It closes with an analysis of different views of community-based care and the role of planning in negotiating future workforce development challenges.
by Roy Jerome (RJ) Williams, III.
M.C.P.

The present dissertation includes four empirical studies, each of which focuses on specific aspects of children’s living conditions. Study I analyses the association between young people’s social relations and health complaints using Swedish nationally representative survey data on 10- to 18-year-olds. Both relations with parents and with peers are associated with health complaints. Relational content is more strongly associated with health complaints than is relational structure. With regard to relational content, strained relations are more strongly associated with health complaints than are supportive relations. Study II investigates how effort and reward in school are associated with pupils’ subjective health using data from the Stockholm School Survey. Both effort and reward are shown to be positively associated with subjective health, and in particular pupils who report to put in high effort in school have high levels of subjective health. Contextual variation in health is found for girls but not for boys. Study III is based on Swedish register data and analyses the association between family type and choice of programme in upper secondary school. Children in single-mother households less often choose the natural science/technology (NT) programme compared with children who live with two original parents. Having a resident or a non-resident parent with NT skills is positively associated with choice of the NT programme. Study IV analyses the association between family type and social support, health, and material resources in 24 countries. The data are derived from the international Health Behaviour of School-aged Children (HBSC) survey. In a majority of the countries studied, children in single-mother households report smaller resources compared with children living with two original parents. No clear pattern is found with regard to differences between countries.
At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 2: Submitted. Paper 4: Accepted.

Abstract The two universities in Oulu developed an interprofessional (IP) curriculum by implementing the theory and training periods for different undergraduate medical and health care students. The aim was to investigate how interprofessional education (IPE), use of collaborative learning methods and innovative learning environments will promote students’ IP competencies. Furthermore, the aim was to understand how the patients and families experienced the students’ receptions in the training periods. Students’ readiness and attitudes towards interprofessional learning (IPL) were investigated with the Readiness for Interprofessional Learning Scale (RIPLS) and their learning experiences after the courses and training periods with a structured questionnaire. The patients and families filled in the feedback questionnaire after the reception. The data was collected between 2007 and 2015. Almost all students indicated, according to RIPLS great importance towards teamwork and collaboration, and felt their professional identity promoted. The medical students evaluated their roles and responsibilities significantly lower than the other health care students. After the first semester, IP course students’ learning outcomes correlated linearly with their own activity and collaboration with the IP group in the e-learning platform. During the training periods in the out patients diabetes clinic, as well as in the preventive maternity and child health clinics, they performed well with IP competencies such as patient-centeredness, communication and teamwork. Students were well briefed to take responsibility as an IP team of the patients’ visit. The care plan was finalized with the facilitators. In the reflection session, learning outcomes were summarized. Students got an overview of primary and preventive services and their professional roles there. Patients and families were very satisfied with their experience with the students. IPE programs have positively changed the overall attitudes to IPL, both with students and the educators and professionals. In addition, students’ professional and IP clinical competencies have developed and the trust in working together has increased. Feedback from patients and families has been very positive. It showed the importance of IPE and the development of collaborative practice in the service system to stakeholders. IP teamwork experience benefits current and future health care professionals in organizing patient-centered care in collaboration with educational organizations and their working life partners
Tiivistelmä Oulun yliopiston ja ammattikorkeakoulun yhteistyönä kehitettiin lääketieteen ja terveydenhuollon eri perustutkinto-ohjelmille moniammatillinen opetussuunnitelma. Koulutus sisälsi teoriaopintoja sekä harjoittelua hyvinvointikeskuksessa. Tavoitteena oli tutkia, miten moniammatillinen oppiminen, osallistavien opetusmenetelmien käyttö sekä innovatiiviset oppimisympäristöt edistävät opiskelijoiden moniammatillisia taitoja. Tavoitteena oli myös kuvata potilaiden ja perheiden kokemuksia moniammatillisesti toteutetuista vastaanotoista harjoittelujaksoilla. Opiskelijoiden valmiuksia ja asenteita moniammatilliseen oppimiseen tutkittiin ”Valmiudet ja asenteet moniammatilliseen oppimiseen” (RIPLS) - mittarilla. Heidän oppimiskokemuksiaan koottiin opintojen ja harjoittelun päätteeksi strukturoidulla kyselymittarilla. Potilaat ja perheet täyttivät palautekyselyn vastaanoton päätyttyä. Aineisto kerättiin vuosina 2007-2015. Tarkasteltaessa opiskelijoiden asenteita RIPLS-mittarilla mitattuna suurin osa heistä piti erittäin tärkeänä tiimityötä ja vuorovaikutusta ja koki moniammatillisen oppimisen vahvistaneen heidän ammatillista identiteettiään. Lääketieteen opiskelijoiden arvio omasta ammattiroolistaan ja vastuistaan oli merkittävästi epävarmempi kuin muilla terveysalan opiskelijoilla. Opiskelijoiden oppiminen opintojen alkuvaiheen moniammatillisella kurssilla korreloi suoraan heidän omaan aktiivisuuteensa ja kommunikointiin moniammatillisen ryhmän kanssa verkkoalustan tehtävissä. Harjoittelujaksoilla sekä diabetesvastaanotolla että äitiys- ja lastenneuvolassa opiskelijat oppivat moniammatillisia taitoja, kuten potilaskeskeisyyttä, kommunikointia ja tiimityöskentelyä. He saivat kokonaiskuvan terveyskeskustyöstä ja ennaltaehkäisevistä palveluista sekä omista ammatillisista rooleistaan niissä. Potilaat ja perheet olivat erittäin tyytyväisiä saamaansa palveluun opiskelijavastaanotoilla. Opiskelijoiden asenteet moniammatillista oppimista kohtaan olivat positiivisia yhteisten opintojen alussa ja kehittyivät entistä positiivisemmiksi harjoittelujaksojen myötä. Samanaikaisesti opiskelijoiden ammattialakohtaiset sekä moniammatilliset taidot kehittyivät ja luottamus yhdessä työskentelyyn lisääntyi. Potilaiden ja perheiden antama erittäin myönteinen palaute on osoitus päättäjille ja palvelujärjestelmille moniammatillisen koulutuksen ja työkäytäntöjen kehittämisen merkityksestä. Moniammatilliset tiimityötaidot hyödyttävät sekä nykyisiä että tulevia terveysalan ammattilaisia toteuttamaan ja kehittämään asiakaslähtöistä työtä yhteistyössä korkeakoulujen ja työelämän palveluorganisaatioiden kanssa

This thesis explored the processes underlying interprofessional working relationships between midwives and health visitors in UK maternity services; using a multi method approach consisting of a systematic review, interviews, and focus groups. The systematic review synthesised the literature on midwife-health visitor collaboration, identifying barriers and enablers that are influential to successful interprofessional collaboration. Thus, the subsequent empirical studies attempted to explore these barriers and enablers in greater depth, from the perspectives of midwives and health visitors. Two studies utilised the Theoretical Domains Framework to explore the barriers and enablers to midwife-health visitor collaboration (Chapters 3 6). These are the first studies to examine midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration using a psychologically grounded theoretical framework. Midwives and health visitors identified barriers and enablers to interprofessional collaboration across each of the 12 theoretical domains, such as ‘Knowledge’ (e.g. awareness of processes involved in contacting midwives) and ‘Memory, attention, and decision processes’ (e.g. contacting health visitors when there is a concern). Chapter 6 compared midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration, and discussed its research and practice implications, including approaches to intervention development for improving interprofessional collaboration. For example, various behaviour change techniques can be integrated as part of interventions aiming to enhance interprofessional collaboration. The final empirical study attempted to address the gap in the interprofessional literature by involving service users’ views. Focus groups with recent mothers were conducted to gain explore their perspectives of interprofessional collaboration in maternity services. Findings suggest that women observe fragmentation between midwifery and health visiting. Participants recommended service changes including group based antenatal classes jointly provided by midwives and health visitors. In summary, the findings indicate that midwife-health visitor interprofessional collaboration is important to professionals and women, but will require health professional behaviour change along with service changes.

The aim of this PhD thesis was to expand the current knowledge of “traditional Sami” diet and lifestyle, and to test aspects of the Sami diet and lifestyle, specifically dietary pattern, macronutrient distribution and coffee consumption, in population-based epidemiological studies of mortality and incident cardiovascular disease and cancer in a general population. In Paper I, semi-structured interviews were conducted with 20 elderly Sami concerning their parent’s lifestyle and diet 50-70 years ago. Questionnaire data from 397 Sami and 1842 matched non-Sami were also analyzed, using non-parametric tests and partial least square methodology.  In Papers II-IV, mortality data and incident cancer data for participants in the Västerbotten Intervention Program (VIP) cohort were used for calculations of hazard ratios by Cox regression. In Paper II, a Sami diet score (0-8 points) was constructed by adding one point for each intake above the median for red meat, fatty fish, total fat, berries and boiled coffee, and one point for each intake below the median for vegetables, bread and fibre. In Paper III, deciles of energy-adjusted carbohydrate (descending) and protein (ascending) intake were added to create a Low-Carbohydrate, High-Protein (LCHP) score (2-20 points). In Paper IV, filtered and boiled coffee consumption was studied in relation to incident cancer. In Paper V, a nested case-control study of filtered and boiled coffee consumption and acute myocardial infarction, risk estimates were calculated by conditional logistic regression. Surprisingly, fatty fish may have been more important than reindeer meat for the Sami of southern Lapland in the 1930’s to 1950’s, and it is still consumed more frequently by reindeer-herding Sami than other Sami and non-Sami. Other dietary characteristics of the Sami 50-70 years ago and present-day reindeer-herding Sami were high intakes of fat, blood, and boiled coffee, and low intakes of bread, fibre and cultivated vegetables (Paper I). Stronger adherence to a “traditional Sami” diet, i.e. a higher Sami diet score, was associated with a weak increase in all-cause mortality, particulary apparent in men (Paper II). A diet relatively low in carbohydrates and high in protein, i.e. a high LCHP score, did not predict all-cause mortality compared with low LCHP score, after accounting for saturated fat intake and established risk factors (Paper III).  Neither filtered nor boiled coffee consumption was associated with cancer for all cancer sites combined, or for prostate or colorectal cancer. For breast cancer, consumption of boiled coffee ≥4 versus <1 occasions/day was associated with a reduced risk. An increased risk of premenopausal and a reduced risk of postmenopausal breast cancer were found for both total and filtered coffee. Boiled coffee was positively associated with the risk of respiratory tract cancer, a finding limited to men (Paper IV). A positive association was found between consumption of filtered coffee and the risk of acute myocardial infarction in men (Paper V). In conclusion, the findings of Paper I, in particular the relative importance of fatty fish compared to reindeer meat in the “traditional Sami” diet of the 1930’s-1950’s, suggest that aspects of cultural importance may not always be of most objective importance. The findings of Papers II-V generally did not support health benefits for the factors studied. The relatively good health status of the Sami population is therefore probably not attributable to the studied aspects of the “traditional Sami” lifestyle, but further investigation of cohorts with more detailed information on dietary and lifestyle items relevant for “traditional Sami” culture is warranted.
Syftet med denna avhandling var att beskriva livsstil och kostvanor hos samer. Det var också att undersöka hur en ”traditionell samisk” livsstil påverkar risken att insjukna av eller dö i cancer och hjärt-/kärlsjukdom i en norrländsk normalbefolkning. En majorietsbefolkning har alltså undersökts ur ett minoritetsperspektiv. Avhandlingen belyser framför allt kostvanor, fördelning av de näringsämnen som innehåller energi (kolhydrat, protein, fett) och konsumtion av kok- och bryggkaffe. Bakgrunden till undersökningarna var att samerna, till skillnad från de flesta andra urfolk i världen, kan förvänta sig ett lika långt liv som majoritetsbefolkningen. När det gäller hjärtkärlsjukdom finns inga stora etniska skillnader, men samiska män, särskilt renskötande, har lägre risk att drabbas av cancer än icke-samer. Det finns ingen entydig förklaring till samernas relativt goda hälsa, men det kan finnas ett samband med kostvanor och livsstil. Delstudie I var en intervjustudie med äldre samer och fungerade som bakgrund för de andra delstudierna. Tjugo äldre samer intervjuades om sina föräldrars livsstil och kostvanor för 50-70 år sedan. Dessutom analyserades kostdata från 81 renskötande och 226 icke-renskötande samer och 1842 matchade icke-samer för att se vilka skillnader som fanns mellan grupperna. Intervjuerna visade överraskande att fet fisk kan ha varit viktigare än renkött för samerna i södra Lappland under 1930-1950-talen. Fet fisk äts fortfarande i högre utsträckning av renskötande samer än av andra samer och icke-samer. Saker som har hög kulturell betydelse (i detta fall renkött) behöver alltså inte alltid ha lika stor betydelse ur ett objektivt, vetenskapligt perspektiv. Andra typiska särdrag hos den samiska kosten var en hög andel av fett, blod och kokkaffe och en låg andel av bröd, fibrer och odlade grönsaker. Det dagliga livet hos samerna på 1930-1950-talen präglades också mycket mer av fysisk aktivitet än vad det gör idag. De samiska männen arbetade oftast långt hemifrån, medan kvinnorna hade ansvaret hemmavid för fiske, jordbruk och trädgårdsskötsel (som introducerades under 1930-1950-talen). Kvinnorna tog även hand om hushållsarbetet och barnen. Delstudierna II-V handlade om olika aspekter av samisk kost i relation till dödlighet och sjuklighet. Till dessa användes huvudsakligen data från Västerbottens hälsoundersökningar, men i delstudie V även från MONICA-projektet, som är en del av ett multinationell forskningsprojekt om hjärt-/kärlsjukdom.  Totalt ingick på så sätt data från mer än 80 000 unika individer från en allmän, till största delen icke-samisk, normalbefolkning. Delstudie II byggde på en modell liknande den som använts för att undersöka hälsoeffekter av så kallad Medelhavsdiet.  En poängskala från 0-8 poäng, en så kallad ”Sami diet score”, skapades för att spegla likheter med ”traditionell samisk” kost. Den hälft av deltagarna som åt mest rött kött, fet fisk, fett, bär respektive kokkaffe, fick 1 poäng var, sammanlagt maximalt 5 poäng. Den hälft av deltagarna som åt minst grönsaker, bröd respektive fibrer fick också 1 poäng var, sammanlagt maximalt 3 poäng. Stora likheter med en ”traditionell samisk” kost, det vill säga höga ”Sami diet score” poäng, var förknippade med en svagt ökad dödlighet, särskilt hos männen. Det verkar därför osannolikt att den samiska kosten i sig förklarar den relativt goda hälsan hos samer. Denna fråga är dock mycket svår att undersöka, eftersom kostvanorna kan ha skiljt sig mellan olika samegrupper och över tid. Dessutom äter dagens västerbottningar mycket mindre av vissa livsmedel, jämfört med vad samerna gjorde förr i tiden. Det gäller till exempel fet fisk och bär.  För sådana livsmedel kan det därför vara extra svårt att påvisa samband med dödlighet. Syftet med kostenkäten i Västerbottens hälsoundersökningar är inte heller att spegla en ”traditionell samisk” kost. Det finns till exempel inga frågor om renkött och vilt, utan sådant kött räknas som en del av övrigt rött kött. Det här är första gången som någon undersökt betydelsen av ett ”traditionellt samiskt” kostmönster för hälsan på detta sätt. Fler liknande undersökningar i material med mer detaljerade frågor, som bättre fångar en samisk kost, är önskvärda. Lågkolhydratdieter, som har vissa likheter med den ”traditionella samiska” kosten, är både populära och kontroversiella. Eventuella långtidseffekter för hälsan är till stor del okända. I delstudie III speglades förhållandet mellan kolhydrater och protein i kosten med hjälp av så kallade LCHP (låg-kolhydrat, hög-protein) poäng. Högsta LCHP poäng fick de deltagare som åt minst kolhydrater och mest protein. Höga LCHP poäng påverkade inte risken att dö, eller att dö i cancer eller hjärt-/kärlsjukdom, efter att statistisk hänsyn tagits till intaget av mättat fett och de vanligaste riskfaktorerna. LCHP score användes i denna studie, istället för exempelvis en LCHF (low carbohydrate, high fat) variant. På så sätt kunde betydelsen av total fettmängd och av mättat fett också vägas in i analyserna. Dessutom innehåller kolhydrater och protein samma mängd energi per gram, vilket gör det lättare att byta ut dem mot varandra i en poängskala. Fett innehåller nästan dubbelt så mycket energi per gram som proteiner och kolhydrater. Inte bara olika sorters fett, utan även olika sorters protein och kolhydrater, kan spela roll för hälsan. Det är därför mycket svårt att skilja ut effekterna av mängd och kvalitet av kolhydrater, protein och fett i kosten. I delstudierna IV och V undersöktes risken att bli sjuk i cancer eller få en akut hjärtinfarkt hos västerbottningar som dricker mer respektive mindre kok- och bryggkaffe. De som drack mycket kaffe hade varken ökad generell cancerrisk, eller ökad risk för prostata- eller tjocktarmscancer. Kvinnor som drack kokkaffe ≥ 4 ggr/dag hade minskad risk för bröstcancer jämfört med kvinnor som drack <1 gång/dag.  Både totalt kaffeintag och intag av bryggkaffe var kopplade till ökad risk för bröstcancer hos yngre kvinnor och minskad risk hos äldre. Män som drack mycket kokkaffe hade ökad risk för cancer i luftvägarna. Dessa resultat visar att de som dricker olika sorters kaffe kan ha olika stor risk att drabbas av olika sorters cancer. I tidigare studier har inga starka samband hittats mellan kaffedrickande och cancer. Denna studie var den första att undersöka hur cancerriskerna ser ut hos människor som dricker olika sorters kaffe. När det gäller hjärtinfarkt, hade män som drack mycket bryggkaffe ökad risk, medan inga entydiga resultat kunde visas bland män som drack mycket kokkaffe. Tidigare studier har visat motstridiga resultat när det gäller kaffe och hjärt-/kärlsjukdom, även om kaffekonsumtion är vedertaget förknippat med en del faktorer som kan öka risken att drabbas av hjärtinfarkt, till exempel ökade halter av blodfetter. Betydelsen av kokkaffe har aldrig undersökts tidigare i en studie där uppgifter om kaffedrickande samlats in i förväg. Delstudierna II-V är alla så kallade observationsstudier. I sådana studier följer deltagarna ingen bestämd forskningsplan, utan lever sina normala liv och jämförs sedan med varandra.  I observationsstudier är det mycket svårt att ta hänsyn till alla möjliga störande faktorer som kan finnas i omgivningen. Därför är det i princip omöjligt att bevisa direkta samband mellan orsak och verkan i en observationsstudie. Delstudierna II-V hade emellertid den starkaste design som en observationsstudie kan ha. De byggde på en representativ normalbefolkning (= en befolkningsbaserad kohort), där data samlats in från ett stort antal personer (> 80 000 unika individer) medan de ännu var friska (= en prospektiv kohort).  Resultaten av enstaka observationsstudier har störst betydelse som underlag för att planera nya liknande, eller andra typer av mer riktade undersökningar. De är med andra ord hypotesgrundande. Om däremot flera observationsstudier visar på liknande resultat brukar man utgå från att resultaten är sanna, eller åtminstone sannolika.
(Nordsamiska) Guorahallama ulbmil lea muitalit sámi biepmu ja eallinvuogi birra ja iskat got árbevirolaš sámi borranvierut, makrobiebmama juogustus ja gáffegolaheapmi  váikkuhit jámolašvuođa  ja riskka oažžut borasdávdda dehe váibmo-/ suotnadávdda dábálaš davvi-ruoŧŧelaš ássiid luhtte. Guoktelogi sámi vuorrasa ledje jearahallon daid vánhemiid eallinvuogi  ja borramuša birra 50-70 jagi áigi (Oassedutkan 1). Dasa lassin  397 sámi ja 1842 ruoŧŧelačča biebmandata guorahallojuvvo eahpe-paramehtarlaš iskamiid ja partialalaš unnimus kvadráhta metoda (PLS) mielde. Dát golbma čuovvovaš oassedutkama, gait kohortdutkamat, isket jápminsiva dehe borasdávdabuohccivuođa oaseváldiid luhtte  Västerbottenis dearvas-vuohŧaiskkademiid hárrái (64 603-77 319 iskama) ja riskkaluoitimat leat rehkenaston Cox regrešuvnna  mielde. Oassedutkamis  2  árbevirolaš sámi biebman  lea speadjalaston čuokkesskála vuostá   0 rájes gitta 8 čuoggá.  Dát bealli oaseváldiin geat leat eanemus rukses bierggu, buoiddes guoli, buoiddi, murjiid ja vuoššangáfe borran, lea ožžon 1 čuoggá juohke áidna biebmanelemeanta ovddas, oktiibuot eanemus 5 čuoggá. Vel 3 čuoggá dát bealli oaseváldiin lea ožžon geat lea unnimus šattuid, láibbi ja fiberiid borran, eanemus oktiibuot 3 čuoggá. Oassedutkamis 3 speadjalastá oktavuođa kolhydráhtaid ja proteiinnaid gaskkas  biebmamis  LCHP (vuolit-kolhydráhta, alit-proteiidna) čuoggáid bokte. Alimus LHCP čuoggát (=20) dát oasseváldit leat ožžon geat leat borran unnimus kolhydráhtaid ja eanemus proteiinnaid  ja vuolimus čuoggát (=2)  dát oasseváldit leat ožžon geat leat borran eanemus kolhydráhtaid ja unnimus proteiinnaid. Oassedutkamis 4 riska borasdávdabuohccivuođa ektui guorahallojuvvo brygg- ja vuoššangáffejuhkkiid  luhtte. Oassedutkan 5 lei goallostuvvon dárkkástus-dutkan, gos riska fáhkkatlaš healladávdda oažžut gáffejuhkkiid luhtte rehkenasto logistihkalaš eaktuduvvon regrešuvnna bokte. Sáhttá leahkit nu ahte buoiddes guolli lea rievtti mielde leamašan deaŧaleabbo sámiide go boazobiergu lulli Lapplánddas  1930-1950-logus ja badjeolbmot ain dávjábut borret dan go iežá sámiid ja ruoŧŧelaččat. Iežá sierra erenomášvuohta sámi biebmamis lei alit oassi buoiddis, mális ja vuoššangáfes ja vuolit oassi láibbis, fiberiin ja šaddaduvvon  šattuin (Oassedutkan 1). Stuora seammaláganvuođat árbevirolaš sámi biebmamiin, rievtti mielde alit Sami diet score čuoggát, ledje čatnon veahá aliduvvon jámolašvuhtii  dievdduid luhtte muhto ii fal nissoniid luhtte (Oassedutkan 2). Biebman mas vuolit oassi kolhydráhtaid ja alit oassi proteiinnat, rievtti mielde alit LHCP čuoggát, ii váikkuhan riskka jápmit, maŋŋel go lea statistihkalaččat jurddašan ahte buoiddi borrat ja mat dát leat dát sajáiduvvon riskafáktorat (Oassedutkan 3). Gáffejuhkan ii lean čatnon eaneduvvon borasdávdariskii, iige eaneduvvon riskii oažžut prostata- gassačoalleborasdávdda. Nissoniin mat juhke vuoššangáfe ≥ 4 geardde/beaivái lei geahpeduvvon riska oažžut čižžeborasdávdda go nissonat mat juhke <1 geardde/beaivái.  Ollesgáffe ja brygg-gáffe ledje čatnon eaneduvvon riskii oažžut čižžeborasdávddá nuorat nissoniid luhtte ja geahpeduvvon riskii vuorrasiin luhtte. Dievdduin mat juhke ollu vuoššangáfe lei eaneduvvon riska oažžut borasdávdda (Oassedutkan 4). Dievdduin mat juhke olu brygg-gáfe lei eaneduvvon riska oažžut healladávdda (Oassedutkan 5). Vuorrasit sámiid muitalusat man olu guoli sin vánhemat leat borran boazobierggu ektui 1930-1950-logus, čujuhit ahte bealit main alit kultuvrralaš mearkkašupmi eai dárbbaš seamma nanu objektivalš mearkkašumi atnit. Oassedutkamiid 2-5 bohtosat čujuhit ahte guorahallon bealit árbevirolaš sámi biebmamis ja eallinvuogis eai váikkut gárrasit dearvvašvuođa ja buohccivuođa dábálaš davviruoŧŧelaš ássiid luhtte.
(Lulesamiska) Dán guoradallama ájggom lij sáme biebmov ja viessomvuogev tsuojgodit, ja åtsådit gåk árbbedábak sáme bårråmdábe, stuoräládusebna juohkem ja káffajuhkam nuorttalándak álmmugin, bájnná jábmemav ja bårredávddabalov ja tsåhke-/ varravárredávddabalov. Guoktalågev sáme gatjádaláduvvin sijá äjgádij viessomvuoge ja biebmo birra 50-70 jage dán åvddåla (Oasseåtsålvis 1). Biebbmodáhtá 397 sámes ja 1842 láttes guoradaláduvvin parametragahtes gähttjalimij ja muhtem miere unnemus kvadráhta vuoge (PLS) viehkijn. Gålmmå tjuovvo oasseåtsådime, gájkka kohorttaåtsådime, vuolggin Västerbottena varresvuohtaåtsådimj oassálasstij jábmemårijs jali bårredávddaskihpudagájs (64 603-77 319). Ballamoarremerustallamav dahkin Cox regressionijn.  Oasseåtsådibme 2 spiedjildij avtaárvojt árbbedábak sáme biebmon tjuokkesmåhtajn nållå rájes gávtse tjuoggáj. Dat lahkke oassálasstijs gudi bårrin ienemus ruoppsis biergov, buojdes guolev, buojdev, muorjijt ja máleskáfav, oattjoj avtav tjuoggáv juohkka avta bårråmoases, aktan 5 tjuoggá ienemusát.  Ájn 3 tjuoggá oattjoj dat lahkke oassálasstijs mij båråj binnemus ruonudisájt, lájbijt ja fiberijt, aktan ienemusát 3 tjuoggá. Oasseåtsådibme 3 spiedjilt vidjurijt kolhydráhtaj ja proteijnaj gaskan biebmon nåv gåhtjodum LCHP (vuolle-kolhydráhta, alla-proteijna) tjuoggáj viehkijn.  Alemus LCHP tjuoggájt (=20) oadtjun oassálasste gudi binnemus kolhydráhtajt ja ienemus proteinajt bårrin ja vuolemus LCHP tjuoggájt (=2) oassálasste gudi ienemus kolhydráhtajt ja binnemus proteijnajt bårrin.  Oasseåtsådimen 4 åtsådaláduváj bårredávddaballo brygga- ja máleskáffajuhkkijn. Oasseåtsådibme 5 lij aktijdum guoradim-åtsådibme, gånnå káffajuhkkij tsåhkedávddaballo merustaláduváj aktijdam vihkemáhtsadime baktu. Vuordedahtek lij buojdes guolle ájnnasabbo gå boatsojbierggo sámijda oarjje Lapplándan 1930-1950-lågojn ja ájn vilá ällosáme guolev ienebut bårri gå ietjá sáme ja látte. Ietjá sierra merka sáme biebmon lij alep oasse buojdes, máles ja máleskáfas ja unnep oasse lájbes, fiberis ja sáddjidum ruonudisájs (Oasseåtsådibme 1). Árbbedábak sáme biebmo muoduk biebbmo, alep Sami diet score tjuoggáj, aktijaneduváj lasse jábmemijn sierraláhkáj ålmmåj hárráj (Oasseåtsådibme 2). Biebbmo vuolep kolhydráhttaåsijn ja alep proteijnnaåsijn, alla LCHP tjuoggáj, ittjij jábmembalov bájne, maŋŋel gå statistijkalattjat gehtjadam buojddebårråmijt ja ieme ballovidjurijt (Oasseåtsådibme 3).  Káffajuhkam lij tjanádum juogu de lasse gájkkásasj bårredávddaballuj, jali lasse prostáhta- bahtatjoallebårredávddaj. Kujnajn gudi máleskáfav juhkin ≥ niellji bäjvváj lij binnep njidtjebårredávddaballo gå buohtastahttá kujnaj gudi < akti bäjvváj juhkin. Ålleskáffa ja bryggakáffa tjanáduváj lasse njidtjebårredávddaballuj nuorap kujnaj hárráj ja binnep vuorrasappoj. Ålmmåjn gudi juhkin edna máleskáfav lij lasse bårredávddaballo vuojŋŋamorgánajn (Oasseåtsådibme 4). Ålmmåjn gudi juhkin edna bryggakáfav lij lasse tsåhkedávddaballo (Oasseåtsådibme 5). Vuorrasap sámij tsuojggoma äjgádij guollebårråmis gå buohtastahttá boatsojbierggobårråmijn 1930-1950-lågo, vuosedi biele alla kultuvrak sisanos e agev dárbaha sämmi nanos objektijvak sisanov adnet. Oasseåtsådimij 2-5 båhtusa vuosedi åtsådum biele árbbedábak sámebiebmos ja viessomvuoges e varresvuodav ja skihpudagáv nuorttalándak álmmuga hárráj heva bájne.
(Sydsamiska) Dan goerehtimmien ulmie lea saemien beapmoem jïh jielemevuekiem buerkiestidh jïh dotkedh guktie aerpievuekien saemien beapmoevuekieh, makrobïepmehtimmiej juekeme jïh prïhtjhjovhkeme jaemedem jïh riskem dijpieh vaajmoe-/ jïh soeneskïemtjelassen muhteste noerhtesvöörjen sïejhmi årroji luvnie. Lea göökteluhkie saemien voeresh goerehtamme daej eejtegi jielemevuekien jïh beapmoen dïehre  50-70 jaepiej juassah (Stuhtjedotkeme 1). Dïsse lissine lea beapmoedaatam goerehtamme 397 saemijste jïh 1842 laedtijste ov-parametrihken gïehtjedimmiej jïh partiellen unnemes kvadraaten vuekien mietie (PLS).  Dah golme båetien stuhtjedotkemh, gaajhkh kohortdotkemh, leah dotkeme man gaavhtan jaameme jallh mïetskeåedtjieskïemtjelassh daej luvnie gïeh meatan Västerbottenen healsoedotkemi muhteste (64 603-77 319 dotkemh) jïh riskeryøknemh  dorjeme Cox  regresjovnen viehkine. Stuhtjedotkemisnie 2 lea mohtedamme guktie aerpievuekien saemien beapmoe vaestede låhkoeraajterasse 0 raejeste 8 raajan. Daate bielie daejstie gïeh meatan gïeh jeenemes rööpses bearkoem, buajtehks gueliem, buejtiem, muerjieh jïh voessjemeprïhtjegem byöpmedamme, leah aktem låhkoem åådtjeme fïere guhte beapmoeelementen åvteste, jeenemes 5 låhkoeh. Dïsse lissine 3 låhkoeh åådtje daate bielie daejstie gïeh meatan gïeh unnemes kruanesaath, laejpiem jïh fiberh byöpmedamme, jeenemes 3 låhkoeh. Stuhtjedotkemisnie 3 daelie mohtede kolhydraath jïh proteinh beapmosne LHCP (vuelehks-kolhydraath, jïlle-proteine) låhkoej viehkine. Jillemes LHCP låhkoem åådtjeme (=20) dah gïeh meatan gïeh vaenemes kolhydraath jïh jeenemes proteinh byöpmedamme jïh vueliehkommes LHCP låhkoem (=2) åådtjeme dah gïeh meatan gïeh jeenemes kolhydraath jïh vaenemes proteinh byöpmedamme. Stuhtjedotkemisnie 4 riskem goerehtamme mietskeåedtjieskïemtjelassem åadtjodh brygg- jïh voessjemeprïhtjegejovhkiji luvnie. Stuhjtedotkeme 5 lïj tjetskeme-dotkeme gusnie riskem ryöknoe logistihken regresjovnen baaktoe jis maahta  faahketji vaajmoedåeriesmoerh åadtjodh prïhtjhjovhkiji luvnie. Buajtehks guelie meehti vihkielåbpoe årrodh båatsoesaemide goh bovtsebearkoe åarjel Lapplaantesne 1930-1950-låhkosne jïh daamhtah båatsoesaemieh daam byöpmedieh jeenebe goh jeatjah saemieh jïh laedtieh. Jeatjah sïejhmi sjïere vuekieh saemien beapmosne lea jïlle stuhtje buejteste,  maeleste jïh voessjemeprïhtjegistie jïh vuelie stuhtje laejpeste, fiberistie jïh kruanesaatijste (Stuhtjedotkeme 1). Jeenh saemien aerpievuekien beapmoe, jïlle Sami diet score låhkoeh, provhki vuesiehtidh vaenie jeananamme jaemede ålmaj gaskemsh bene ij nyjsenæjjaj gaskemsh (Stuhtjedotkeme 2). Beapmoe man vuelehks stuhtje kolhydraath jïh stoerre stuhtje proteijnh, jeenh LCHP låhkoeh, ij leah dïjpeme riskem jaemedh, dan mænggan goh lea ussjedamme statistihken muhteste man jeene buejtiem byöpmedidh jïh sijjiedahteme riskefaktovrh ussjedamme. (Stuhtjedotkeme 3). Prïhtjhjovhkeme ij leah tjoelmesovveme jeananamme mïetskeåedtjieriskese, jallh jeananamme riskese prostaate-voeresbuejtiemïetskeåedtjiem åadtjodh. Nyjsenæjjah gïeh voessjemeprïhtjegem jovhkeme ≥ 4 aejkien/biejjesne unnemes riskem utnin njammamïetskeåedtjiem åadtjodh nyjsenæjjaj muhteste gïeh jovhkeme <1 aejkien/biejjesne. Ellies prïhtjege jïh bryggeprïhtjege lea tjoelmesovveme jeananamme riskese njammamïestkeåedtjiem åadtjodh noere nyjsenæjjah luvnie jïh unniedamme riskem voeresi luvnie. Ålmah gïeh jeenh voessjemeprïhtjegem juvhkieh jeananamme riskem utnieh mïetskeåedtjiem åadtjodh girsesne (Stuhtjedotkeme 4). Ålmah gïeh jeenh bryggeprïhtjegem jovhkeme jeananamme riskem utnieh vaajmoedåeriesmoerem åadjtodh (Stuhtjedotkeme 5). Dah saemien voeresi soptsestimmieh man jeeneh gueliem daej eejtegh leah byöpmedamme bovtsebearkoem muhteste 1930-1950-låhkosne, vuesehte ahte daate bielie man vihkeles kultuvren sisvege ij eejnegen seamma objektiven sisvegem utnieh. Illeldahkh stuhtjedotkemijstie 2-5 vuesiehtieh ahte  dah bielieh mejtie lea goerehtamme saemien aerpienvuekien beapmoen jïh jielemevuekien muhteste eah healsoem jïh skïemtjelassem dïjph jeenebe goh sïejme noerhtesvöörjen årrojh.
(Umesamiska) Dahte guoreteme suptseste saamien beäpmoen jah jielemevuökien  biire jah giehtjedie guktie aarpievuökien saamien beäpmoeh, oajviebeäpmoeh jah kaavoeh mietete jaameke vahkake jah  cancerenne jah vajmoen/ virreveättennea nuorthen  allmetjeih luunie. Guökteluhke saamieih boariesh gihtjedihke lie elltie eihtegeh jielemevuökien jah beäpmoen biire dann baelie 50-70 jaapieh (Oasie 1). Jieneh beäpmoe-dataede dahkedihke lie 397 saamieiheste jah 1842 ruotseiheste dennake viehketihenne ieh parmetriske giehtjedemeh jah  partiellen unnemes kvadraten vuökien miete (PLS). Dah gullme oasieh boatien kohort- luhkemeh, allkemme lie jaamemeste jall canceremeste mieteih Västerbottenen varaasgiehtjemeih luunie (64603-77319 ollu) vahkake-tsiehkesjeme dahkedihke Cox-enne regressione. Oasienne 2 vuöjnedihke leh akte laakatjenne aarpievuökien saamien beäpmoeh vuösstede akte tsiehkesjerairoe 0 – 8. Dahte bielie deistie gieh jienemes ruöpses beärrkoede, buöjteks guöliede, buöjtiede borrein jah vuossjeme kaavoede juukein, akte tsiehkie fierte beäpmoih outeste otjoin, jienemes 5 tsiehkieh.Vielie 3 tsiehkieh dahte bielie otjoin gieh unnemes jaamoede jah urhtsede, laipiede jah fiberede borrein, jienemes 3 tsiehkeh. Oasienne 3 vuöjnedihke aktevuotta gasske kolhydrateh jah proteieneh beäpmoenne LCHP-esne (vuöleke kolhydrateh, jylloeke-proteineh) tsiehkie. Jyllemes LCHP tsiehkieh (=20) dainie mietenne unnemes kolhydrateh jah ollomes proteineh borrein jah unnemes LCHP tsiehkieh (2) dainie mietenne ollomes kolhydrateh jah unnemes proteineh borrein. Oasienne 4 giehtjedihke vahkake cancerede brygg- jah vuossjeme kaavoe juukejenne. Oasie 5 tjohkenne lin kontrolle- giehtjedeme vahkake hiehke vaajmoe-narrenne kaavoe-juukejenne tsiehkiesjdihke logistiske regressionenne. Buöjteke guölieh borretdihke mahtein vieliebe buutsebeärrkoeste saamieihesne oarrjel  saamien eätname 1930-1950 jaapienne jah vieliebe borretdihke buutsesaamieiheste guh jeätja saamieh jah ruotse-allmetjeh. Jeätja siejhme sierreme saamien beäpmoesne lin akte jylloeke oasie buöjtie-, viire-, jah vuossjeme kaavoeste jah akte vuöleke oasie laipie-, fibere-, joamoe jah urhtseste (Oasie 1). Ollu aktelaaka aarpievuökien saamien beäpmoeh, ollu Sami diet score tsiehkieh tjohkan lin vieliebe jaameme ollmaihenne sierrelaaka (oasie 2). Beäpmoihenne unne kolhydrateh jah ollu proteineh, ollu LCHP tsiehkie, ieh vahkake lasste jaamet, dann mingjelen guh statistiske ussjede valltedihke leh borremmiean gallane buöjtieste jah vihties vahkake faktoreiheste (oasie 3). Kaavoejuukeminne lin ieh vielebe aarpievuökien cancer-vahkake tjohkenne, jall vielebe vahkake prostate-kolorektale-cancere. Nyesenejah guh vuossjeme kaavoe juukein ≥4  aikieh/biejvie  unnebe vahkake nitje-cancereb lin muhteste nyesenejanneh gieh  <1 aikie/biejvie juukein. Gaihkekaavoe jah brygg-kaavoe lie tjoahkan vielebe nitje cancereb nyesenejanne jah unnebe vahkake boariesh nyesenejaihenne. Ollma guh ollu vuossjeme kaavoeb juukein cancereste gonkelmesenne vieliebe vahkake otjoin (oasie 4). Ollma guh ollu brygg-kaavoe vajmoe-narreme vieleb vahkake otjoin (oasie 5). Dah boariesh saamieh suptsestemeh man jingje guöliede elltie eihtegeh buutsebeärrkoeh borrein 1930-1950-aikie, vuösiete dahte bielie veäksekes kulture miele ieh gaihke aikie darpesjedennake veäksekes objektive miele leh. Oasie 2-5 vuösiete dah giehtjedemes dahte bielie aarpievuökien saamien beäpmoen jah jielemen vuökien ieh varaas jah skieptjeme mietete ieh nuorthen almetejeh ollu.

Le récepteur du calcium (CaSR), exprimé par les cellules parathyroïdiennes, contrôle la calcémie en régulant la sécrétion d’hormone parathyroïdienne (PTH). Afin de comprendre le rôle extra-parathyroïdien du CaSR, nous avons utilisé un modèle de rat thyro-parathyroïdectomisé, recevant de manière prolongée une dose fixe de PTH exogène. Ainsi, l’inhibition chronique du CaSR était associée à une augmentation de la reabsorption tubulaire rénale du calcium et à une augmentation de la calcémie ionisée. . Par ailleurs, nous avons démontré que le CaSR était uniquement exprimé dans la branche large ascendante de l’anse de Henle (BLA). CaSR contrôlait spécifiquement et négativement la réabsorption rénale de calcium dans la branche large ascendante corticale, via une modification de la perméabilité paracellulaire au calcium, et ce, indépendemment de la PTH. Le CaSR est donc un déterminant majeur de l’homéostasie du calcium. L’hypercalciurie idiopathique (GHS) est la cause principale de lithiase urinaire chez l’homme. A l’état basal, le JCa était significativement plus bas chez le rat GHS que chez le rat témoin, alors que le JNa et le JCl n’était pas modifié. La mesure de la perméabilité paracellulaire au calcium (PCa) était significativement plus basse chez le rat GHS par rapport au rat témoin, alors que le voltage transépithélial n’était pas différent entre les deux groupes. En présence d’un inhibiteur du CaSR (NPS2143 1μM) ou d’un agoniste du récepteur de la PTH (PTH 300 pM) dans le bain de microperfusion, la réabsorption du calcium était significativement plus élevée chez le rat GHS et chez le rat témoin par rapport à l’état basal, mais augmentait de façon similaire dans les deux groupes. L’administration de calcitriol a induit une augmentation significative de la réabsorption de calcium dans la BLA corticale de rat témoin, alors qu’aucune différence significative n’est observée chez le rat GHS. Ceci suggère qu’il existe, chez le rat GHS, une anomalie de la voie de signalisation en aval du VDR, pouvant expliquer la diminution de la perméabilité paracellulaire au calcium. Au total, nous avons montré qu’il existait une diminution de la perméabilité paracellulaire au calcium au niveau de la BLA chez le rat GHS et qu’elle était associée à une résistance ces cellules au VDR. Le(s) mécanisme(s) moléculaire(s) à l’origine cette anomalie reste(nt) encore à déterminer
The Calcium sensing receptor (CaSR) expressed by parathyroid cells controls blood calcium concentration by regulating parathyroid hormone (PTH) secretion. We investigated the role of extraparathyroid CaSR using thyroparathyroidectomized, PTH-supplemented rats. Chronic inhibition of CaSR selectively increased renal tubular calcium absorption and blood calcium concentration independent of PTH secretion change and without altering intestinal calcium absorption and bone resorption. Kidney CaSR was expressed primarily in the thick ascending limb of the loop of Henle (TAL). As measured by in vitro microperfusion of cortical TAL, CaSR inhibitors increased calcium reabsorption and paracellular pathway permeability but did not alter NaCl reabsorption. We conclude that CaSR is a direct determinant of blood calcium concentration, independent of PTH, and modulates renal tubular calcium transport in the TAL via the permeability of the paracellular pathway. These findings suggest that CaSR inhibitors may provide a new specific treatment for disorders related to impaired PTH secretion, such as primary hypoparathyroidism. Idiopathic hypercalciuria (IH) is the principal risk factor for calcium (Ca) nephrolithiasis. Genetic hypercalciuric rats (GHS rats) model were developed to mimic the human idiopathic hypercalciuria. We observed, JCa was significantly lower in cTAL from GHS than from control rats, without alteration in NaCl reabsoprtion and transepithelial voltage. PCa was significantly lower in GHS than in control rats. CaSR and PTH pathway are functional in cTAL of GHS rats. Activation of VDR pathway by injection of calcitriol exhibited a significant difference in calcium flux in control rats whereas no significant difference in calcium flux observed in the similarly treated GHS rats. These results suggest that the primary defect in impaired calcium reabsorption comes from the defective VDR signaling pathway in cTAL of GHS rats. Further studies are warranted to explore the link of VDR signaling pathway to impaired paracellular pathway in cTAL of GHS rats

This thesis aims to investigate the extent to which work-related factors contribute to the health inequalities often observed between foreign-origin and native-origin persons in Sweden. Four empirical studies using survey data and population-based registers assessed the health impact of different labor market adversities among groups of foreign-origin persons who were both in and outside the labor market relative to native-origin Swedes. Studies I and II examined associations between different measures of working life quality, including adverse psychosocial and physical working conditions and educational mismatch, and self-reported health among the employed. Adverse psychosocial and physical working conditions minimally contributed to the excess risk of poor health found among workers from low- and middle-income countries. Over-education had a stronger association with increased risk of poor health, most notably among foreign-born workers from countries outside of Western Europe. Under-educated women from these countries also demonstrated an elevated risk of poor health.  There was no association between educational mismatch and poor health among native-born workers.  Studies III and IV focused on the health implications of labor market exclusion, and examined relationships between employment status and risk of all-cause mortality and suicide. The majority of foreign-origin groups that experienced unemployment showed an elevated risk of both mortality and suicide. The magnitude of excess risk varied by generational status and region of origin. Variations in patterns of suicide risk were also evident among migrants by age at arrival and duration of residence. Yet within many foreign-origin groups, health advantages were observed among the employed. The health of migrants is affected by the confluence of several different pre- and post-migration factors.  The extent to which health inequalities are found among persons of foreign-origin in Sweden is influenced by the degree to which they experience labor market adversities, as well as differential vulnerability to the negative effects of these adversities across foreign-origin groups.

At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript.

This study examined the relationship between health care leadership competencies as measured by the American College of Healthcare Executives Healthcare Executives Competencies Assessment Tool 2014 and leadership behaviors measured by the Path-Goal Theory Leadership Questionnaire among health care administrators and executives. The purpose of the study was to identify relationships between the 4 leadership behaviors (Directive, Supportive, Achievement-Oriented, and Participative) of the path-goal leadership theory with the 4 leadership competencies (Leadership Skills and Behavior, Organizational Climate and Culture, Communicating Vision, and Managing Change) from the health care sector as identified by the Leadership Domain of the American College of Healthcare Executives Healthcare Executive Competencies Assessment Tool 2014. Leadership competencies have been linked to increased performance and building professional development in individuals. For this study, quantitative methodology using survey administration was distributed to health care administrators and executives across the United States. Multiple linear regression design addressed the relationship among the Path-Goal Theory Leadership Questionnaire leadership behaviors variables and the health care leadership competencies identified by the Leadership Domain of the American College of Healthcare Executives Healthcare Executives Healthcare Executive Competencies Assessment Tool 2014. One hundred and fifty-three health care administrators and executives from across the United States were surveyed. The Path-Goal Theory Leadership Questionnaire was used to examine the impact of leadership behaviors on leadership competencies. The results of this study verified Directive and Supportive leadership behaviors were statistically significant predictors of health care leadership competencies in male subjects. Achievement-Oriented and Participative leadership behaviors were positive predictors of health care leadership competencies in female subjects. However, there was no statistical significance found between the organizational climate and culture health care leadership competencies in women.

Background: College settings are likely environments for Black women to contract STIs (including HIV) or experience unintentional/unwanted pregnancies. Effective prevention strategies for this population include dialogue and activities that focus on gender, maturity, cultural barriers, personal strength, and information needs. However, technological advancements (including virtual reality) and innovation are limited in prevention efforts.

Methods: Four 90-minute focus group sessions were conducted in a convenience sample of Black college females (ages 18 years or older) and a research-intensive public institution in the southeast. A series of surveys were distributed during each audio-recorded focus group session. A mixed-method approach to data analysis was based on applications of the Health Belief Model constructs to three principal research questions: (1) Q1: How do Black college females perceive the importance of sexual risk topics? (2) What are the experiences and attitudes of Black college females regarding the use of VR for education and training versus video game entertainment (i.e. “gaming)? and (3) Among Black college females, what sexual risk topics are considered most relevant to a VR education and training platform?

Results: Each of four study cohorts enrolled between 2-6 participants each (n=15). Participant ages ranged from 18-48 (x¯=28.6, σ=9.2) years within age groups of 18–24 years (60%, n=9), 25–34 years (26.7%, n=4), and 35 years or above (13.3%, n=2). The majority of participants (86.7%, n=13) were enrolled as full-time students, and resided in various off-campus locations (73.3%; n=11). Assessments of sexual risk topic importance were reported based on aggregated Survey 1 Lickert scale values. The majority of participants equally viewed the topics of HIV and STI status as important, mostly important, or very important. Other notable concerns include sex with drug/alcohol use, risk of intimate partner violence, and sexual communication (e.g. partners and peers. Despite the lack of formal virtual reality knowledge, the majority of participants reported experience with VF technology via “gaming” (e.g. SIMS). They also concluded that a virtual reality platform for sexual health education and training should involve comprehensive approaches to HIV/STI and unintentional pregnancy via use of barrier methods, including birth control, as well as facilitation of sexual communication.

Discussion: This research represents a unique approach to the identification of sexual health risk importance for HIV/STI transmission, as well as unintentional pregnancy, in Black college females. Although a successful demonstration of feasibility, this research is formative in nature—results should be interpreted as preliminary. However, methods and concepts presented in this thesis hold the potential for scientific contribution in prevention research, clinical practice, and other fields of study.

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2009.
Vita. Cataloged from PDF version of thesis.
Includes bibliographical references (p. 63-69).
This paper is based on ethnographic field research undertaken in a public health clinic in the periphery of São Paulo, as well as an examination of the "Humanisation of Childbirth Campaign". The Humanisation Campaign is a Brazilian public health initiative targeted at low-income women that aims to drastically lower country-wide caesarean rates. This paper will consider how pregnant women actively seek to be labeled 'at risk' during ante-natal care by doctors, nurses and health care technicians in order to ensure access to caesarean technology during their birthing process, in order to avoid the discrimination and physical abuse often associated with a vaginal delivery. I suggest that experiences of riscos, or riskiness, bear heavily on women's pragmatic adoption of interventionist birthing. Riscos, as it has been explained to me, is experienced both bodily and socially, as a physical threat to bodies that is experienced via physical and social violence within the clinic. In this paper, I plan to explore the phenomenology of risk, and how, for women from the periphery, risk to body and health is an embodied experience, and situated within the social and political context within which individual experience occurs. Ethnographic work suggests that women seek inclusion into 'expert' biomedical risk assessments and categories that ordinarily exclude or overlook them. This paper will be situated in an examination of the Humanisation of Birth Campaign, it will explore the conflicting meanings about what 'natural, normal and tradtional' means in Brazil, and the ongoing debate over birthing that is currently encapsulated in the narratives surrounding the Humanisation Campaign.
(cont.) This pragmatic desire to adopt risk labels offers a window into understanding a new range of questions about how public health narratives have direct implications for women's reproductive health, while at the same time reconfigure women's conceptions of, and negotiations with, bodily risk and flexibility.
by Laurie Michelle Denyer.
S.M.

Background: Low- and middle-income countries have been experiencing unprecedented rates of urbanization. Rapid urbanization has attributed to an upsurge in non-communicable diseases, such as diabetes, cardiovascular diseases, and cancers in these countries. Most low- and middle-income countries are also still struggling to control communicable diseases such as HIV/AIDS, tuberculosis, and malaria. This phenomenon, described as the double burden of disease, places greater strains on urban health systems and vulnerable urban populations, such as slum dwellers, who are likely to bear the brunt of any negative health outcomes. Given the potential impacts of urbanization and quality of health services on poverty and disease in the urban poor, there is urgent need to study urban health systems and the ways in which services can be made more available, accessible, and acceptable to socioeconomically disadvantaged and culturally/ethnically diverse populations.

Objectives: This dissertation is a case study that investigated the community-defined health system for Korogocho slum residents in Nairobi, Kenya. Specifically, the purpose of the research study was to (1) determine the readiness of health workers to provide HIV- and diabetes-related services, (2) define the components of the health system as perceived by Korogocho residents; that is, determine the community-defined health system, (3) assess the factors that affect health service utilization with respect to HIV/AIDS and diabetes prevention, care, and treatment, and (4) make recommendations for improving the availability, accessibility, and acceptability of health services for Korogocho residents.

Methods: The case study research employed both quantitative and qualitative methods. Three complementary peer-review quality manuscripts were developed. Manuscript 1 presents results from one of the first assessments of health provider readiness to provide HIV/AIDS- and diabetes-related services using data from the Demographic and Health Survey’s Kenya Service Provision Assessment. A cross-sectional quantitative study was conducted. Readiness was defined as health workers having the training to provide the minimum HIV/AIDS services as prescribed by key government policies. Data analysis was conducted using STATA version 13 to assess the readiness of health workers in terms of a weighted proportion of providers from facility levels 2-4 who were trained in essential HIV/AIDS- and diabetes-related services according to Kenya’s national guidelines. Manuscript 2 details the results of a qualitative inquiry to understand the community-defined health system and identify factors that influence Korogocho residents’ health utilization behavior, especially in relation to HIV/AIDS and diabetes services. Manuscript 3 utilized a qualitative assessment to determine the role of informal health providers (those who have not received a Western biomedical model of medical training) in health service delivery to the Korogocho community. In both Manuscripts 2 and 3, semi-structured interviews were conducted with community members and informal health providers, respectively. Qualitative sampling was conducted with the purpose of generating a conceptual model of the urban health system for slum residents. Analysis of semi-structured qualitative interviews with community members and informal health providers in Manuscripts 2 and 3 was completed through an iterative process using NVivo 11 for Mac.

Results: The results of this research demonstrate the complexity of urban health systems. Korogocho residents utilize health services from a variety of facilities and providers from both the formal and informal sectors. Their health utilization behavior is primarily influenced by the availability, accessibility, and acceptability of health services, health facilities, and health providers. Informal health providers play a critical role in terms of expanding the availability and accessibility of health services to Korogocho residents. The results of this case study also reveal that training levels of health providers in Nairobi for the delivery of HIV- and diabetes-related services are low. On average, 12% of health workers interviewed in the 2010 Kenya service provision assessment reported having training in the previous 2 years in the full complement of essential HIV-related services as prescribed by Kenyan Government policies. There were similar low proportions of training for the provision of diabetes-related services among the three health worker cadres included in this analysis of the 2010 Kenya service provision assessment. Moreover, the community’s perceptions of the availability and accessibility of diabetes services lagged behind HIV services.

Conclusions: The results of this research reveal key information that can impact the health systems strengthening agenda, particularly for improving the availability and accessibility of health services to the urban poor. It is also clear from this research that there is an urgent need to scale up the training of health providers to handle the current double burden of disease. Further, among socioeconomically disadvantaged populations, such as urban slums, the intentional incorporation of informal providers into the health system is a key step towards ensuring that much needed health services reach the urban poor.

This qualitative study focuses on the intersection of Organizational Studies and Public Health. Through the use of cross-sector work, the Public Health field coordinates work across multiple organizations to diagnose and prevent health issues. Interviewing several administrators from organizations who partake in the Healthy Ontario Initiative allowed me to examine how organizations of different types and sectors interact and connect around this project. This study will predominantly focus on the challenges they face, how they overcome them, and how they are evaluated. Highlighting the intersection of Public Health and Organizational Studies and the way a current Public Health initiative organizes and delivers services may impact the way in which the field evolves in the future.

The purpose of this study was to test a theoretical model of the process of health empowerment in women. The proposed model examined empowerment from a theoretical perspective based upon a Rogerian framework and Parse's simultaneity paradigm. The model examined interpersonal factors (social support and professional support) and contextual factors (age, income, years of education, number of children, and number of years currently married). Women's health empowerment was indexed using Power as Knowing Participation in Change Tool and Health Promoting Lifestyle Profile Instrument. A convenience sample of 133 women between the ages of 21 and 45 years with children were obtained from the Arizona State University College of Nursing sponsored Community Health Services Clinic to test the theory. Hierarchical multiple regression technique was used to explain women's health empowerment. Results indicated a 38% of the variance in health empowerment measured as knowing participation in change was explained by a significant beta weight for social support. In addition, a significant 43% of the variance in health empowerment, measured as lifestyle behaviors, was explained by significant beta weights for education and social support.

Mexican Americans constitute one of the fastest growing populations in the United States. Within Mexican American families, women are the primary caretakers and are responsible for managing family health. Many activities of health work fall within the household and domestic spheres. These activities include, providing a clean, safe environment providing nutritious foods, teaching hygienic practices, diagnosing and treating illnesses, and deciding when to seek outside health care. Until recently, household health work was not recognized as a factor in health knowledge and had been excluded from the discourse of health and healing. The purpose of this study was to describe health perceptions and health production among Mexican American women. This research was a descriptive ethnographic study of the health perceptions and health production of a sample of 13 English speaking Mexican American women. Informants participated in three in-depth interviews conducted over a two to four month period. The Household Production of Health was the conceptual model that guided this research and the World Health Organization definition of health was used to frame questions about health perceptions. Data analysis was directed towards identifying themes and sub-themes that were organized into categories that answered the three research questions. The informants integrated physical and mental health into an overarching concept of being healthy. Health included maintenance of the physical body, the mind, and the spirit. The informants identified a variety of health producing and help-seeking activities that were contextualized throughout their lives and were consistent with their health perceptions. In addition to outside employment, the informants took primary responsibility for health creation. Their roles were predominantly domestic in nature and included parenting, providing for health care, and managing and maintaining the household. This research has significance for nursing in three areas: (a) it explicates the importance of routine activities in health maintenance; (b) it provides a framework for community health nurses to analyze the entirety of health activities that occur within the household; and, (c) it suggests the importance of focusing health education on wellness behaviors such as stress reduction and coping strategies.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2008.
"June 2008."
Includes bibliographical references.
Many poor, segregated, urban neighborhoods are rife with risks to health, which contributes to stark racial and geographic disparities in health. Fighting health disparities requires buy-in from non-health professionals whose work directly impacts the way cities are designed and governed. This thesis provides a case study of one non-health initiative, assisted housing mobility, with clear relevance to health disparities. Research suggests that moving from high- to lower-poverty neighborhoods may confer a range of health benefits on individuals; however, assisted housing mobility programs are, to date, relocation-only interventions. Could these programs more deliberately promote health, and should they do so? Through interviews and a review of counseling materials, I examine. how nine assisted housing mobility programs are linked to health, how health is understood by program staff, and how managers might offer more health-conscious programming. Based on a review of pathways between health and housing and neighborhoods, I identified five areas of intervention around which managers could build healthful programs: housing units, neighborhoods, health behavior and awareness, social connectedness, and access to health services. For each area of intervention, I detail possibilities for active versus passive approaches, and document relevant practices from the profiled programs. I then explore practitioner attitudes towards integrating health into mobility programs. Although most practitioners see their work as disconnected from health, their programs actually play a promising mediating role. Concerns about mandate, privacy, legality, liability, and capacity hinder programs from exploring health. So does limited understanding of how to incorporate health appropriately.
(cont.) Yet, most staff members are encouraged that their work may improve client health, and many want to do more. I recommend steps programs could take to provide better health-related information and discuss health more openly throughout housing counseling so families can make deliberate choices. I provide a preliminary assessment of relative costs and benefits of each step. I note that program managers will require technical and collegial support in order to implement the suggested changes well. The Poverty & Race Research Action Council, which helped guide my research, could provide needed support.
by Mariana Clair Arcaya.
M.C.P.

Background and aims. Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) with potentially deleterious effects on well-being and daily-life functioning. A complete picture of health status in CD therefore comprises both disease activity (DA) and health-related quality of life (HRQL). Several measures of DA and HRQL in CD have been developed. Some have gained prominence as standard endpoints in clinical trials, but none has been validated in Swedish CD patients and their use in clinical practice has been limited. A conceptual health status model of five dimensions (Biological variables, Symptoms, Function, Worries, and Well-being) has been proposed for IBD health assessment, enabling the construction of the Short Health Scale (SHS), a four-item questionnaire intended to facilitate assessment and interpretation of HRQL in IBD. The aims of this thesis were: (1) to evaluate the Swedish versions of the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Rating Form of IBD Patient Concerns (RFIPC); (2) to evaluate the Short Health Scale; (3) to study the relationship between DA and HRQL variables by identifying determinants of DA outcome and by validating the SHS health status model; (4) to describe the spectrum of disease-related worries and repercussions on general HRQL in a context of social variables, sickness, and disability. Methods. The thesis is based on clinical variables and HRQL data measured in a population-based cohort of 505 CD patients, consecutively included in conjunction with their regular outpatient visits at three hospitals (Jönköping, Örebro, Linköping). The HRQL questionnaires were evaluated regarding construct validity, reliability, and responsiveness. Multivariate analyses were used to investigate the relationship between Crohn’s Disease Activity Index (CDAI) and physician-assessed DA. The SHS health status model was validated with structural equation modelling (SEM). Disease-related worries and concerns, general HRQL, social variables, sickness, and work disability were compared with data from background population or patients with ulcerative colitis (UC). Results. The IBDQ had good validity, reliability, and responsiveness, but the original dimensional structure was not supported. The RFIPC was valid, and reliable, but less sensitive to change in disease activity. The SHS had the highest completion rate and proved adequate psychometric properties. The CDAI correlated weakly with the physician’s appraisal of disease activity, being more influenced by subjective health perception than objective disease activity. SEM showed that the SHS model had a good fit to measured data, explaining >98% of the covariance of the variables. Worries and general HRQL impairment were greater in CD than in UC, especially for women. Disease complications and impaired life achievements elicited most worries. CD patients had lower educational level. Female patients were more often living single. The rates of long-term sickness and disability were doubled compared with background population, with worse outcome for women. Conclusions. The IBDQ, the RFIPC, and the SHS all demonstrated adequate psychometric properties. The SHS was easier to administer and provided a more comprehensive picture of subjective health status. The weak correlation between CDAI and physician-assessed DA was explained by a strong influence of subjective variables on CDAI, stressing the importance of assessing DA and HRQL separately. The SHS health status model was further supported by SEM. CD has tangible effects on subjective health perception, worries and work capacity, especially for women.

Trans* studies and issues have recently increased in coverage by the media and popular press. With recent changes in the DSM-5 (APA, 2000; APA 2013) and insurance law (HHS, 2014), trans* healthcare has been under increasing scrutiny. While a small number of studies (Bradford, Reisener, Honnold, & Xavier, 2013; Grant et al., 2011; Rounds, McGrath, & Walsh, 2013; Tanner et al., 2014) have documented discrimination and lack of cultural competencies from the perspective of trans* patients, little research exists that examines the training, support, and decision-making processes of medical professionals who treat trans* patients (Snelgrove et al., 2012, p. 2). The goal of this research study is to explore the training and cultural competencies of healthcare professionals in treating trans* patients by surveying and interviewing healthcare professionals about their experiences of trainings, familiarity with practices/protocols, and attitudes toward treating trans* patients. A survey of 35 health care professionals and nine interviews were conducted. These health care professionals, while generally accepting of trans* individuals, still had some reservations about working with trans* patients and suggested that there were many barriers and challenges to providing trans* health care. A majority of health care professionals had little or no familiarity with treatment protocols or diagnoses for trans* patients, and very few had received any type of training (formal or informal) before or after starting working in the health care about trans* patients. While there are many areas in which there perceived challenges and barriers to care, several participants did observe that there has been a shift in health care recently that is moving towards being more inclusive and responsive to trans* patients.

This study utilizes national household income and expenditure data from Honduras, collected by the Honduran Central Bank in 1998--99, to examine two distinct health issues. First a tobit censored regression model is estimated to identify the variables that affect monthly household expenditures on health. This analysis is then used to examine income elasticities for health goods. Secondly, a nested bivariate probit model is used to study the socio-economic and demographic variables that influence a Honduran household's decision to seek health services attention when a household member is acutely ill and, consequently, how they then choose between public and private health services.