Dissertations / Theses on the topic 'Epidemiology – Methodology'

Since the early 20th Century, epidemiological research has brought benefits and burdens to Aboriginal communities in Canada. Many First Nations, Métis, and Inuit continue to view Western research with distrust; quantitative study methods are perceived as especially inconsistent with indigenous ways of knowing. There is increasing recognition, however, that rigorous epidemiological research can produce evidence that draws attention, and potentially resources, to pressing health issues in Aboriginal communities. The thesis begins by introducing a framework for culturally safe epidemiology, from the identification of research priorities, through fieldwork and analysis, to communication and use of evidence. Drawing on a sexual health research initiative with Inuit in Ottawa as a case study, the thesis examines cognitive mapping as a promising culturally safe method to reviewing indigenous knowledge. Juxtaposing this approach with a systematic review of the literature, the standard protocol to reviewing Western scientific knowledge, the thesis demonstrates the potential for cognitive mapping to identify culturally safe spaces in epidemiological research where neither scientific validity nor cultural integrity is compromised. Modern epidemiology and indigenous knowledge are not inherently discordant; many public health opportunities arise at this interface and good science must begin here too.

Made available in DSpace on 2014-08-13T14:51:01Z (GMT). No. of bitstreams: 0 Previous issue date: 2014-02-20Bitstream added on 2014-08-13T17:59:35Z : No. of bitstreams: 1 000776589.pdf: 2857888 bytes, checksum: d897ae9d66a070240898f1eb97648046 (MD5)
Introdução: O melanoma cutâneo é o mais agressivo dos cânceres de pele. Sua incidência vem aumentando em todo o mundo e vários fatores têm sido atribuídos a este aumento. Estudos sobre o melanoma cutâneo com base em dados de registros populacionais são escassos no Brasil. Objetivos: Descrever os coeficientes de incidência (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: sexo, ano de diagnóstico, faixa etária, localização anatômica, estadio e tipo histológico. Descrever os coeficientes de mortalidade (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: sexo, ano do óbito e faixa etária. Analisar a tendência dos coeficientes de incidência (1996-2011), segundo: ano de diagnóstico, sexo e estadio. Analisar a tendência dos coeficientes de mortalidade (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: ano do óbito e sexo. Métodos: Foram analisados 162 casos novos de melanoma cutâneo diagnosticados no período de 1996 a 2011 fornecidos pelo Registro de Câncer de Base Populacional de Jahu e 39 óbitos por melanoma cutâneo ocorridos entre 1996 e 2011 fornecidos pelo Sistema de Informações sobre Mortalidade do Ministério da Saúde (SIM-MS). Foram calculados os coeficientes bruto e padronizado de incidência e de mortalidade, foi analisada a tendência destes coeficientes através do modelo de regressão. Resultados: O coeficiente médio de incidência (1996-2011) para o sexo feminino foi de 5,1 por 100.000 e para o sexo masculino foi de 4,8 por 100.000. Ambos não apresentaram tendência de crescimento ou queda no período (estabilidade). O coeficiente médio de mortalidade (1996-2011) para o sexo feminino foi de 1,4 por 100.000 e para o sexo masculino foi de 2,2 por 100.000, ambos também não apresentaram tendência de crescimento ou queda. Os coeficientes de incidência para os casos diagnosticados na fase inicial da doença, estadio 0, apresentaram tendencia de crescimento (r2=0,73; ...
Introduction: The cutaneous melanoma is the most aggressive of the skin cancers. Its incidence is increasing all over the world and many factors are being assigned to this increase. Studies on cutaneous melanoma based on population-based registries are scarce in Brazil. Objectives: Describe the incidence rates (1996-2011) by cutaneous melanoma in the city of Jaú, according: sex, year of the diagnosis, age, anatomic location, stage and histological type. Describe the mortality coefficients (1996-2011) by cutaneous melanoma in the city of Jaú, according: sex, year of death and age. Analyze the tendency of the incidence coefficients (1996-2011), according: year of diagnosis, sex and stage. Analyze the tendency of the mortality coefficients (1996-2011) by cutaneous melanoma in the city of Jaú, according: year of death and sex. Methods: 162 new cases of cutaneous melanoma diagnosed in the period from 1996 to 2011 were analyzed and they were provided by the Population-Based Cancer Registry of Jaú and 39 deaths by cutaneous melanoma occurred between 1996 and 2011 provided by the Mortality Information System of the Ministry of Health (SIM-MS). The crude and the standardized coefficients of incidence and mortality were calculated, the tendency of those coefficients were analyzed through the regression model. Results: The average incidence coefficient (1996-2011) for the feminine sex was 5.1 from 100,000 and for the masculine sex was 4.8 from 100,000. Both didn’t present tendency of increasing or decreasing in the period (stability). The average mortality coefficient (1996-2011) for the feminine sex was 1.4 from 100,000 and for the masculine sex was 2.2 from 100,000, both also didn’t present tendency of increasing or decreasing. The incidence coefficients for the cases diagnosed in the initial phase of the disease, stage 0, presented growing tendency (r2=0.73; p=0.03) and the cases of stage I and II, presented decreasing tendency (r2=0.98; ...

Orientador: Ana Gabriela Sálvio
Banca: Luciana Patrícia Abbade
Banca: Luiz Augusto Marcondes Fonseca
Resumo: Introdução: O melanoma cutâneo é o mais agressivo dos cânceres de pele. Sua incidência vem aumentando em todo o mundo e vários fatores têm sido atribuídos a este aumento. Estudos sobre o melanoma cutâneo com base em dados de registros populacionais são escassos no Brasil. Objetivos: Descrever os coeficientes de incidência (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: sexo, ano de diagnóstico, faixa etária, localização anatômica, estadio e tipo histológico. Descrever os coeficientes de mortalidade (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: sexo, ano do óbito e faixa etária. Analisar a tendência dos coeficientes de incidência (1996-2011), segundo: ano de diagnóstico, sexo e estadio. Analisar a tendência dos coeficientes de mortalidade (1996-2011) por melanoma cutâneo na cidade de Jaú, segundo: ano do óbito e sexo. Métodos: Foram analisados 162 casos novos de melanoma cutâneo diagnosticados no período de 1996 a 2011 fornecidos pelo Registro de Câncer de Base Populacional de Jahu e 39 óbitos por melanoma cutâneo ocorridos entre 1996 e 2011 fornecidos pelo Sistema de Informações sobre Mortalidade do Ministério da Saúde (SIM-MS). Foram calculados os coeficientes bruto e padronizado de incidência e de mortalidade, foi analisada a tendência destes coeficientes através do modelo de regressão. Resultados: O coeficiente médio de incidência (1996-2011) para o sexo feminino foi de 5,1 por 100.000 e para o sexo masculino foi de 4,8 por 100.000. Ambos não apresentaram tendência de crescimento ou queda no período (estabilidade). O coeficiente médio de mortalidade (1996-2011) para o sexo feminino foi de 1,4 por 100.000 e para o sexo masculino foi de 2,2 por 100.000, ambos também não apresentaram tendência de crescimento ou queda. Os coeficientes de incidência para os casos diagnosticados na fase inicial da doença, estadio 0, apresentaram tendencia de crescimento (r2=0,73; ...
Abstract: Introduction: The cutaneous melanoma is the most aggressive of the skin cancers. Its incidence is increasing all over the world and many factors are being assigned to this increase. Studies on cutaneous melanoma based on population-based registries are scarce in Brazil. Objectives: Describe the incidence rates (1996-2011) by cutaneous melanoma in the city of Jaú, according: sex, year of the diagnosis, age, anatomic location, stage and histological type. Describe the mortality coefficients (1996-2011) by cutaneous melanoma in the city of Jaú, according: sex, year of death and age. Analyze the tendency of the incidence coefficients (1996-2011), according: year of diagnosis, sex and stage. Analyze the tendency of the mortality coefficients (1996-2011) by cutaneous melanoma in the city of Jaú, according: year of death and sex. Methods: 162 new cases of cutaneous melanoma diagnosed in the period from 1996 to 2011 were analyzed and they were provided by the Population-Based Cancer Registry of Jaú and 39 deaths by cutaneous melanoma occurred between 1996 and 2011 provided by the Mortality Information System of the Ministry of Health (SIM-MS). The crude and the standardized coefficients of incidence and mortality were calculated, the tendency of those coefficients were analyzed through the regression model. Results: The average incidence coefficient (1996-2011) for the feminine sex was 5.1 from 100,000 and for the masculine sex was 4.8 from 100,000. Both didn't present tendency of increasing or decreasing in the period (stability). The average mortality coefficient (1996-2011) for the feminine sex was 1.4 from 100,000 and for the masculine sex was 2.2 from 100,000, both also didn't present tendency of increasing or decreasing. The incidence coefficients for the cases diagnosed in the initial phase of the disease, stage 0, presented growing tendency (r2=0.73; p=0.03) and the cases of stage I and II, presented decreasing tendency (r2=0.98; ...
Mestre

This work aims to contribute methodologically in the epidemiology of drug use, particularly estimation of incidence. No incidence figures of drug use in Spain had ever been published, prior to those appearing in these articles, and relatively little has been published for other countries. Since around 2000, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), which is an agency of the European Union, has been making a concerted effort to promote the determination and publication of drug use incidence figures, given their great importance in designing prevention policies. The approaches used and results obtained by our research have been presented in three EMCDDA meetings (years 2007, 2008 and 2012), at a monographic meeting on incidence promoted by the Norwegian Institute for Alcohol and Drug Research (SIRUS) in 2009, and in the framework of a European project on new methodological tools for policy and programme evaluation (JUST/2010/DPIP/AG/1410) which ran from 2010 to 2012. This work therefore contributes not only by presenting drug use incidence results for Spain, but also by describing the development of methods and sharing ideas that may be adapted for use in other countries.

Introduction: Low income, less educated and immigrant populations are notorious for having low response rates in research studies. Therefore, it is not surprising that when attempting to estimate food allergy prevalence in Canada, the SCAAALAR study (Surveying Canadians to Assess the Prevalence of Common food Allergies and Attitudes towards food LAbeling and Risk), which attained a response rate of only 34.6% , underrepresented several vulnerable populations (those of low socioeconomic status, non post-secondary graduates, new Canadians, residents of the territories and Aboriginals).Objective: The objective of this thesis is two fold: 1) to determine an effective methodology for obtaining high response rates in the vulnerable populations not adequately represented in SCAAALAR and 2) to attain food allergy prevalence estimates for these vulnerable populations.Methods: To increase response rates and adequately sample the desired populations, a pilot study was conducted to evaluate the effect of unconditional incentives in vulnerable populations for a telephone survey. Households in low income/high immigrant postal codes were randomly selected and randomly assigned to receive either an unconditional incentive or no incentive. The difference in response rate and 95% confidence interval was calculated using a normal approximation to the difference of two binomial distributions. The pilot study informed the methodology employed in the SPAACE study (Surveying the8Prevalence of Food Allergy in All Canadian Environments), which subsequently addressed the second objective of this Thesis. SPAACE then estimated the prevalence of food allergy for those of low socioeconomic status, non post-secondary graduates, new Canadians, residents of the territories and Aboriginals. Prevalence estimates among vulnerable populations were compared to their comparator populations (i.e., those of high socioeconomic status, post-secondary graduates, individuals born in Canada, residents of the provinces and non-Aboriginals); between population differences and 95% confidence intervals were calculated using normal approximations to the difference of two binomial distributions.Results: The response rates were 38.4% and 31.4% for the incentive and non-incentive groups respectively, with a between group difference of 0.070 (-0.013, 0.15). The cooperation rates, which exclude non-contacts from the calculation, were 47.3% and 40.0% for the incentive and non-incentive group respectively, with a between group difference of 0.073 (-0.023, 0.17). Prevalence estimates for those of low socioeconomic status, new Canadians and Aboriginals were lower than their comparator population's prevalence (between population differences respectively: -2.44% (95% CI: -3.52%, -1.35%); -2.66% (95% CI: -3.5%, -1.82%); -2.17% (95% CI: -3.18%, -1.16%)) .Discussion: Although wide confidence intervals preclude definitive conclusions, our results suggest that unconditional incentives are an effective means of9increasing response rates in vulnerable populations for telephone surveys. Additionally, the results of SPAACE demonstrate that socioeconomic status, birthplace and ethnicity are associated with the prevalence of food allergy. These findings are indicative of potential lifestyle, cultural, and genetic factors that may influence the development of food allergy.
Introduction : Les populations immigrantes, moins nanties and moins éduquées sont reconnues comme ayant des taux de réponses peu élevés lors d'études. Il est alors peu surprenant de constater que l'étude SCAAALAR (Surveying Canadians to Assess the Prevalence of Common food Allergies and Attitudes towards food LAbeling and Risk), qui a atteint un taux de réponse de seulement de 34.6%, ait sous-représenté plusieurs groupes de la population (ceux de statut socioéconomique moins élevé, de non-gradués postsecondaire, de nouveaux arrivants au Canada, de résidents des territoires et des amérindiens). Objectif : L'objectif de cette thèse est en deux parties : 1) déterminer une méthodologie efficace pour obtenir un haut taux de réponse au sein des populations vulnérables mal-représentées avec SCAAALAR et 2) obtenir des estimés de prévalences d'allergies alimentaires pour ces populations vulnérables. Méthodologie : Pour améliorer les taux de réponse et de sonder adéquatement les populations désirées, une étude pilote a été réalisée pour évaluer les effets des incitatifs inconditionnels sur les populations vulnérables lors d'un sondage téléphonique. Les ménages situés dans les codes postaux à faibles revenus et à haute présence d'immigrants ont été sélectionnés et assignés de manière aléatoire à recevoir un incitatif inconditionnel ou à ne pas en recevoir. La différence du taux de réponse et de l'intervalle de confiance à 95% a été calculé en utilisant une approximation normale jusqu'à 2 distribution binômes. L'étude pilote a informé la11méthodologie employée dans l'étude SPAACE (Surveying the Prevalence of Food Allergy in All Canadian Environments), qui a par la suite adressé le deuxième objectif de cette thèse. SPAACE a ensuite estimé la prévalence d'allergies alimentaires pour les populations non graduées d'études postsecondaire, les immigrants, les résidents des territoires et des amérindiens. Les estimés de prévalences au sein des populations vulnérables ont été comparés à leurs populations comparatives (i.e., celles de statut socioéconomique plus élevé, les gradués postsecondaire, les canadiens nés au pays, les résidents des provinces et des non-Amérindiens); les différences entre populations et les intervalles à 95% de confiance ont été calculés en utilisant des estimés normaux de différences entre 2 distributions binômes.Résultats : Les taux de réponse ont atteint 38.4% et 31.4% pour les groupes avec et sans incitatifs, respectivement, avec une différence entre groupes de 0.070 (-0.013, 0.15). Les taux de coopération, ce qui exclu les non-contacts des calculs, ont été de 47.3% et 40.0% pour les groupes avec et sans incitatifs, respectivement, avec une différence entre groupes de 0.073 (-0.023, 0.17). Les estimés de prévalences pour les populations de statut socioéconomique moins élevé, les immigrants, et les amérindiens étaient moins élevés que les prévalences de leurs populations comparatives (différences entre populations, respectivement : -2.44% (95% CI : -3.52%, -1.35%); -2.66% (95% CI : -3.5%, -1.82%); -2.17% (95% CI : -3.18%, -1.16%)).12 Discussion : Bien que de larges intervalles de confiance excluent des conclusions définitives, nos résultats suggèrent que des incitatifs inconditionnels sont une manière efficace d'augmenter le taux de réponse lors de sondages téléphoniques auprès des populations vulnérables. De plus, les résultats de SPAACE démontrent que le statut socioéconomique, le lieu de naissance et l'ethnie sont associés à la prévalence des allergies alimentaires. Ces découvertes indiquent que des facteurs culturels, génétiques et des habitudes de vie peuvent influencer le développement des allergies alimentaires.

Angiostrongylus cantonensis is a parasitic nematode endemic to tropical and subtropical regions and is the leading cause of human eosinophilic meningitis. The parasite is commonly known as rat lungworm because the primary host in its lifecycle is the rat. A clinical overview of rat lungworm infection is presented, followed by a literature review of rat lungworm epidemiology, risk factors, and surveillance projects. Data collected from previous snail surveys in Florida was considered alongside elevation, population per square kilometer, median household income by zip code territory, and normalized difference vegetation index specific to the geographic coordinates from which the snail samples were retrieved. The parameters of interest were incorporated as possible predictor variables in a Poisson probability regression model and a negative binomial regression model. NDVI and population density were determined to be positively associated with number of snail samples positive for A. cantonensis in a given Miami-based location. A surveillance project was conducted in Hillsborough County, Florida, U.S.A.. Snail samples were collected and tested for A. cantonensis DNA via polymerase chain reaction (PCR) and gel electrophoresis. None of the samples tested positive for A. cantonensis.

Made available in DSpace on 2014-06-11T19:30:22Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-07-31Bitstream added on 2014-06-13T19:19:07Z : No. of bitstreams: 1 000754767.pdf: 1885697 bytes, checksum: 2ed2ea03ad68b5ea2b12562ea9d0f63c (MD5)
A hanseníase é uma doença infecciosa crônica, que acomete pele e sistema nervoso periférico e tem como agente etiológico o Mycobacterium leprae, um patógeno exclusivamente intracelular, que tem predileção por macrófagos e pelas células de Schwann. É um traço complexo e fatores genéticos do hospedeiro têm sido repetidamente implicados com o risco para a doença. A região cromossômica 6p21 vem sendo sistematicamente envolvida com a hanseníase, não só pelos genes do HLA de classe II, como também pelos estudos envolvendo marcadores em genes como o TNF e a LTA. O gene TLR1 também é um importante candidato e polimorfismos deste já têm sido associados com hanseníase per se e com reação hansênica. O objetivo desta pesquisa foi conduzir estudo de associação de base populacional do tipo caso-controle em hanseníase testando marcadores do tipo tag SNPs em genes candidatos da região cromossômica candidata 6p21 e do gene TLR1. Oitenta e nove marcadores do tipo tag SNPs, localizados em trinta e seis genes foram genotipados. O presente trabalho envolveu 1718 indivíduos, 981 casos e 737 controles, provenientes de dois estados brasileiros: Mato Grosso e São Paulo. As genotipagens da população de Rondonópolis, MT foram realizadas em plataforma de médio rendimento (VeraCode GoldenGate Genotyping Assay – Illumina) e as genotipagens da população de São Paulo foram feitas usando discriminação alélica baseada na tecnologia TaqMan (Applied Biosystems). Para as análises estatísticas foi empregado modelo de regressão logística, com correção para as co-variáveis etnia e sexo, usando o software R, para Windows. Treze genes localizados na região 6p21 tiveram marcadores associados com hanseníase per se. O alelo S do polimorfismo N248S do gene TLR1 também foi associado com susceptibilidade para hanseníase per se. Estes dados ressaltam o papel destes genes na susceptibilidade genética para a...
Leprosy is an chronic infectious disease that attacks skin and peripheral nervous system. The causative agent is Mycobacterium leprae, an obligate intracellular pathogen that infects macrophage and Schwann cells. It is a complex trait and host genetic factors have been extensively implicated in leprosy susceptibility. The chromosomal region 6p21 has been involved with leprosy susceptibility due to HLA class II, and TNF and LTA genes, as well. The TLR1 gene is also an important candidate gene and polymorphisms at this locus have been associated to leprosy per se and leprosy reactions. This research is a population-based association study in leprosy which tested tag SNPs located at candidate genes in chromosomal region 6p21 and in TLR1 gene. Eighty-nine markers distributed in thirty-six genes were genotyped. The present work enrolled 1,718 individuals, 981 cases and 737 controls from Mato Grosso and São Paulo States, Brazil. The genotypes for Rondonópolis population were obtained using by medium-scale genotyping platform (VeraCode GoldenGate Genotyping Assay – Illumina), while to São Paulo samples the genotyping were done by allelic discrimination based on TaqMan technology (Applied Biosystems). Statistical analysis were performed by logistic regression models adjusted for the covariates sex and ethnicity, using R software. Thirteen genes located at 6p21 region presented markers associated to leprosy per se. The S allele for N248S polymorphism at TLR1gene was also associated to leprosy susceptibility. These data show the role of these genes in genetic host resistance and susceptibility to leprosy and suggest the necessity of replication and functional studies in order to better explain their involvement with the disease

Orientador: Ana Carla Pereira Latini
Banca: Alessandra Pontillo
Banca: James Venturini
Resumo: A hanseníase é uma doença infecciosa crônica, que acomete pele e sistema nervoso periférico e tem como agente etiológico o Mycobacterium leprae, um patógeno exclusivamente intracelular, que tem predileção por macrófagos e pelas células de Schwann. É um traço complexo e fatores genéticos do hospedeiro têm sido repetidamente implicados com o risco para a doença. A região cromossômica 6p21 vem sendo sistematicamente envolvida com a hanseníase, não só pelos genes do HLA de classe II, como também pelos estudos envolvendo marcadores em genes como o TNF e a LTA. O gene TLR1 também é um importante candidato e polimorfismos deste já têm sido associados com hanseníase per se e com reação hansênica. O objetivo desta pesquisa foi conduzir estudo de associação de base populacional do tipo caso-controle em hanseníase testando marcadores do tipo tag SNPs em genes candidatos da região cromossômica candidata 6p21 e do gene TLR1. Oitenta e nove marcadores do tipo tag SNPs, localizados em trinta e seis genes foram genotipados. O presente trabalho envolveu 1718 indivíduos, 981 casos e 737 controles, provenientes de dois estados brasileiros: Mato Grosso e São Paulo. As genotipagens da população de Rondonópolis, MT foram realizadas em plataforma de médio rendimento (VeraCode GoldenGate Genotyping Assay - Illumina) e as genotipagens da população de São Paulo foram feitas usando discriminação alélica baseada na tecnologia TaqMan (Applied Biosystems). Para as análises estatísticas foi empregado modelo de regressão logística, com correção para as co-variáveis etnia e sexo, usando o software R, para Windows. Treze genes localizados na região 6p21 tiveram marcadores associados com hanseníase per se. O alelo S do polimorfismo N248S do gene TLR1 também foi associado com susceptibilidade para hanseníase per se. Estes dados ressaltam o papel destes genes na susceptibilidade genética para a ...
Abstract: Leprosy is an chronic infectious disease that attacks skin and peripheral nervous system. The causative agent is Mycobacterium leprae, an obligate intracellular pathogen that infects macrophage and Schwann cells. It is a complex trait and host genetic factors have been extensively implicated in leprosy susceptibility. The chromosomal region 6p21 has been involved with leprosy susceptibility due to HLA class II, and TNF and LTA genes, as well. The TLR1 gene is also an important candidate gene and polymorphisms at this locus have been associated to leprosy per se and leprosy reactions. This research is a population-based association study in leprosy which tested tag SNPs located at candidate genes in chromosomal region 6p21 and in TLR1 gene. Eighty-nine markers distributed in thirty-six genes were genotyped. The present work enrolled 1,718 individuals, 981 cases and 737 controls from Mato Grosso and São Paulo States, Brazil. The genotypes for Rondonópolis population were obtained using by medium-scale genotyping platform (VeraCode GoldenGate Genotyping Assay - Illumina), while to São Paulo samples the genotyping were done by allelic discrimination based on TaqMan technology (Applied Biosystems). Statistical analysis were performed by logistic regression models adjusted for the covariates sex and ethnicity, using R software. Thirteen genes located at 6p21 region presented markers associated to leprosy per se. The S allele for N248S polymorphism at TLR1gene was also associated to leprosy susceptibility. These data show the role of these genes in genetic host resistance and susceptibility to leprosy and suggest the necessity of replication and functional studies in order to better explain their involvement with the disease
Mestre

BACKGROUND: Oral communication impairments (OCIs) are a common childhood problem with often long-term negative outcomes for both the child and society. Despite the growing body of knowledge about the epidemiology of this problem, the shift from traditional treatment approaches to population based approaches to management has been slow. One suggested reason for this is a lack of community based population data on such problems with which to plan services more broadly. AIM: The aim of this thesis is to contribute to the population knowledge of children with OCIs by developing and trialing a data collection method at a community level. LITERATURE REVIEW: One of the major issues in understanding OCIs from a population perspective is the disparate and often incongruent nature of epidemiological data reported in the literature. Five areas of epidemiological research were reviewed in order to critically evaluate the existing evidence base and identify gaps for further research. The five areas reviewed were: Prevalence (Regardless of the methodology used to collect prevalence data, OCIs have been described as a common childhood problem), Life Course (Children with OCIs often have ongoing communication problems and are at risk for poorer life outcomes in social, educational and occupational domains), Comorbidities (OCIs rarely occur in isolation and most children will have other developmental or health issues), Risk factors (There is no one easily definable cause of OCIs, however, genetic and environmental factors appear to increase the risk of OCI in the general population), and Service use (Only around half of children with recognised OCIs will access specialist intervention services).The review concluded that local community data measuring the 'burden', or impact, of the problem, comorbidities and service use in children with and without OCIs would assist in service planning. Therefore a methodology would need to be developed which addressed these issues.A further review of the literature considered this methodology development with specific reference to the issues of study design, sampling and identification of OCIs. The review concluded that a cross-sectional survey design of a community sample could provide the necessary data. Parent and teacher report was suggested as a method for identifying OCIs in surveys, however, a tool needed to be developed and trialed to ensure this method was effective, valid and reliable. PILOT STUDY: A survey tool for parents was designed which included the Child Health Questionnaire (PF - 28), questions relating to socio-demographic features, health and development conditions, service use and specifically developed questions regarding OCIs. The survey methodology was trialed in one school and one childcare centre. The results of the study were reviewed and suggestions made for methodological changes before a community trial was carried out. The reliability and validity of the questions designed to identify OCIs was assessed in a number of ways. Test-retest reliability of parent completed questionnaires proved to be good. Interrater reliability was examined by comparing parent and teacher responses. Parents and teachers agreed on identification of OCI in over 75% of cases for each of the OCIs studied. Criterion validity was assessed by comparing parent report to speech pathologist evaluation in a clinical sample and by comparing parent and teacher report to screening assessments of communication skills in a school sample. Both parents and teachers tended to over-identify children, however, when parent and teacher reports were considered together the validity approached that of the 'gold standard'. Construct validity was assessed by comparing reported OCIs with reports of other developmental conditions known to be commonly comorbid with OCIs. Once again using both parent and teacher report proved to be the most valid method of identifying OCIs using the developed tool. COMMUNITY STUDY: A targeted community survey of 3 to 7 year old children was conducted in a regional centre in Queensland, Australia. Children were sampled through schools and childcare centres. Information letters were distributed to the parents of 898 eligible children. Completed questionnaires were received for 397 children. Teachers completed questionnaires on 375 children which was 42% of the population sampled. Parents and teachers identified OCIs in 16% of the children. However, only 3% of the population were rated by parents or teachers as having severe problems. Over 70% of parents and teachers of children with a reported OCI rated the problem as having an impact on the child's life. Ratings of impact were not related to parent/teacher ratings of severity. Children with OCIs were reported to have significantly more health, developmental and behaviour problems than their peers. Children with OCIs were rated lower by their parents on most aspects of the Child Health Questionnaire (PF-28). In particular, parents reported impacts on their own time and family activities due to the child's problems. No significant differences were found between children with and without reported OCIs on any of the socio-demographic variables studied. Children with reported OCIs used more health and educational services than their peers. Around 60% of children with reported OCIs had seen a speech pathologist, but many parents had also sought advice from a range of other health and educational professionals. Those with two or more OCI conditions were more likely to have seen a professional, however socio-demographic variables did not generally predict service use. Parents reported that the type of service they chose was most commonly influenced by advice from a doctor or teacher. The limitations of this methodology for collecting this type of data are discussed. However despite these limitations data were collected which has major implications for the provision of population based services for children with OCI. CONCLUSION: This thesis has contributed to the understanding of children with OCIs by researching the development of a methodology to study this problem in a defined community sample. The information gained from the literature review and the community study were considered within two models of service provision. The models encompass service delivery from individualised to more population based approaches to the management of OCIs in children. From these models, specific suggestions for the community involved in the study were discussed. This thesis, therefore, provided a survey methodology that is resource efficient in the collection of community data useful in suggesting improved services for children with oral communication impairments.

Traffic-related injuries represent a global public health problem, and contribute largely to mortality and years lived with disability worldwide. Over the course of the last decades, improvements to road traffic safety and injury surveillance systems have resulted in a shift in focus from the prevention of motor vehicle accidents to the control of injury events involving vulnerable road users (VRUs), such as cyclists and moped riders. There have been calls for improvements to the evaluation of safety interventions due to methodological problems associated with the most commonly used study designs. The purpose of this licentiate thesis was to assess the strengths and limitations of the interrupted time series (ITS) design, which has gained some attention for its ability to provide valid effect estimates. Two national road safety interventions involving VRUs were selected as cases: the Swedish bicycle helmet law for children under the age 15, and the tightening of licensing rules for Class 1 mopeds. The empirical results suggest that both interventions were effective in improving the safety of VRUs. Unless other concurrent events affect the treatment population at the exact time of intervention, the effect estimates should be internally valid. One of the main limitations of the study design is the inability to identify why the interventions were successful, especially if they are complex and multifaceted. A lack of reliable exposure data can also pose a further threat to studies of interventions involving VRUs if the intervention can affect the exposure itself. It may also be difficult to generalize the exact effect estimates to other regions and populations. Future studies should consider the use of the ITS design to enhance the internal validity of before-after measurements.
Traffic-related injuries represent a global public health problem, and contribute largely to mortality and years lived with disability. Over the course of the last decades, improvements to road traffic safety and injury surveillance systems have resulted in a shift in focus from motor vehicle accidents to injury events involving vulnerable road users (VRUs), such as cyclists and moped riders. There have been calls for improvements to the evaluation of safety interventions due to methodological problems associated with the most commonly used study designs. The purpose of this licentiate thesis was to assess the strengths and limitations of the interrupted time series (ITS) design, which has gained some attention for its ability to provide valid effect estimates while accounting for secular trends. Two national interventions involving VRUs were selected as cases: the Swedish bicycle helmet law for children under the age 15, and the tightening of licensing rules for Class 1 mopeds. The empirical results suggest that both interventions were effective. These results are discussed in the light of some methodological considerations regarding internal and external validity, data quality and the ability to fully understand key causal mechanisms behind complex interventions.

Agriculture is a hazardous industry worldwide, and certain groups of agricultural workers are at increased risk of experiencing adverse health outcomes. Agricultural workforces are becoming increasingly transitional, as established and experienced workers exit the industry and new workers take their place. Limited occupational health surveillance exists among certain transitional agricultural workforces. In the US, beginning farmers, i.e., agricultural workers with 10 years or less experience operating a farm, may differ from established farmers in terms of their demographics, length of experience within the agricultural industry, and occupational exposures and health outcomes. Separately, South Indian tea harvesting workers are exposed to occupational physical demands that are risk factors for musculoskeletal health outcomes. However, few studies have examined associations between occupational demands and musculoskeletal pain among these workers. Furthermore, no studies have identified additional occupational health issues within the tea harvesting process. To address the lack of available knowledge on beginning farmers and tea harvesting workers, the goals of this mixed method study were to estimate the associations between musculoskeletal symptoms and occupational physical demands and occupational psychosocial stress among beginning farmers in the US and tea harvesting workers in South India. An additional goal was to identify occupational health issues within the tea harvesting process and to determine how tea harvesting workers conceptualize and prioritize these issues. An online survey was conducted among beginning farmers across the U.S. Participants answered questions about their demographics, personal health and farm characteristics, occupational physical demands, occupational psychosocial stress, and musculoskeletal symptoms of the low back, neck/shoulder, and elbow/wrist/hand. An interviewer-based survey was conducted among South Indian tea harvesting workers. Participants answered questions about their demographics, personal health, occupational physical demands, occupational psychosocial stress, and musculoskeletal symptoms of the neck/upper back, lower back, upper extremity region, and lower extremity region. A qualitative study was conducted using focus groups among South Indian tea harvesting workers and semi-structured interviews and structured interviews among South Indian tea harvesting workers and supervisors. Results from the cross sectional online survey concluded that musculoskeletal symptoms were common among beginning farmers. In addition, occupational physical demands were associated with musculoskeletal pain, particularly low back pain was associated with working in awkward and cramped positions, bending or twisting the back, and carrying, lifting, or moving heavy material by hand. Results from the cross sectional interviewer-based survey concluded that musculoskeletal symptoms were also common among South Indian tea harvesting workers. Musculoskeletal pain was associated with exposure to forceful exertions, awkward posture, and repetition. Finally, results from the qualitative study identified additional occupational health issues within tea harvesting, including the presence of animals and pelvic organ prolapse. The study further identified important influential stakeholders within the tea harvesting process. Findings from these three studies may be used to inform future health interventions among these transitional workforces.

Contrairement à la majorité des maladies chroniques qui s’aggravent progressivement, l’expression de l’asthme est variable au cours du temps. L’asthme peut apparaître, disparaître, s’aggraver ou s’améliorer au cours de plusieurs années, voire une décennie, à tout âge de la vie. Cette variabilité à long terme est particulièrement mal décrite chez l’adulte car les données sont rares. Par une approche épidémiologique, la thèse a pour objectif de mieux comprendre la variabilité de l’expression de l’asthme au long cours chez l’adulte dans deux cohortes françaises : E3N, l’Étude Épidémiologique auprès des femmes de la Mutuelle Générale de l’Éducation Nationale et EGEA, l’étude Épidémiologique des facteurs Génétiques et Environnementaux de l’Asthme. Le premier axe, méthodologique, porte sur la mesure de la variabilité de l’expression de l’asthme au long cours. Le second axe, environnemental, porte sur le rôle de la pollution atmosphérique sur cette variabilité. Concernant l’axe méthodologique, l’étude des réponses à une unique question sur l’asthme répétée 7 fois sur 13 ans dans le cadre de la cohorte E3N a montré qu’une succession incohérente de réponses (positives et négatives) reflétait une partie de la variabilité de l’activité de l’asthme à moyen terme, suggérant l’intérêt de cette approche pour affiner la caractérisation de l’expression de la maladie au cours du temps. Dans le contexte d’un intérêt croissant pour la santé perçue, l’étude d’une question portant sur l’auto-évaluation rétrospective du changement dans la santé respiratoire au cours des 10 dernières années a montré que l’information ainsi obtenue était complémentaire de celle d’outils épidémiologiques et cliniques existants pour décrire la trajectoire à long terme de l’asthme, et permettait de prédire en partie l’évolution de l’asthme.À la suite d’une récente méta-analyse regroupant 6 cohortes européennes (avec 23 000 participants) dont les résultats suggèrent le rôle d’une exposition chronique à la pollution atmosphérique dans l’incidence de l’asthme chez l’adulte, une analyse a porté sur l’évolution des traitements de fond et de secours de l’asthme sur une période de 4 ans en lien avec la pollution atmosphérique. Chez les femmes asthmatiques de la cohorte E3N, plus l’exposition chronique au dioxyde d’azote et aux particules était élevée, plus la consommation de corticoïdes inhalés augmentait au cours du temps, suggérant le rôle à long terme du dioxyde d’azote dans la progression de l’asthme. En conclusion, les résultats de la thèse montrent que des outils simples, tels que l’utilisation de réponses successives à une unique question sur l’asthme et l’auto-évaluation du changement dans la santé respiratoire sur 10 ans, peuvent être utilisés pour mieux caractériser la variabilité de l’expression de l’asthme au long cours, de façon complémentaire aux outils déjà existants. Associés à ceux de la littérature, les résultats de la thèse soutiennent le rôle délétère d’une exposition chronique à la pollution de l’air extérieur sur l’évolution de l’asthme au long cours et renforcent l’intérêt d’interventions de santé publique visant à diminuer la concentration des polluants atmosphériques
Unlike most chronic diseases, which tend to get progressively worse over time, the expression of asthma is variable over time. Asthma may onset at any age and is known to clinically persist, possibly resolve, or present any combination of remissions and relapses over several years, even decades. Such long-term variability has been difficult to describe in adults as data are scarce. Through an epidemiological approach, the aim of the thesis is to gain a better understanding of the variability of asthma expression over the long term in adults, in two French cohorts: the E3N study (l’Étude Épidémiologique auprès des femmes de la Mutuelle Générale de l’Éducation Nationale) and the EGEA study (the Epidemiological study on the Genetics and Environment of Asthma). The first axis is methodological and relates to the characterization of asthma expression variability over the long term. The second axis is environmental and related to the effect of air pollution on such long-term variability. Regarding the methodological axis, the in-depth analysis of answers to a single question on ever asthma repeated 7 times over 13 years in the E3N study has shown that apparently inconsistent succession of answers (positive and negative) could capture part of the medium-term variability of asthma activity, suggesting the usefulness of such approach to improve the characterization of asthma expression over time. In a context of growing interest for perceived health, a simple retrospective self-assessment of 10-year change in respiratory health has been shown to provide complementary insights to classical epidemiological and clinical tools to describe the long-term trajectory of asthma, and could predict part of the asthma evolution. Following a recent meta-analysis including 6 European cohorts (23000 participants), in which results suggest a deleterious effect of chronic ambient air pollution on asthma incidence in adults, an analysis investigated the evolution of asthma medication dispensations over 4 consecutive years, in relation with air pollution. Among the women with asthma in the E3N study, an increased estimated exposure to outdoor nitrogen dioxide and particles was associated with increased rate of controller dispensations over time, suggesting the long-term effect of air pollution on asthma progression. In conclusion, results of the thesis showed that simple tools such as several repeated answers to a single question on asthma and the self-assessment of long-term change in respiratory health may be useful in order to better characterize the variability of asthma expression over the long term, as a complementary approach alongside with classical tools. Combined with the literature, results of the thesis support the deleterious impact of chronic air pollution on progression of asthma and strengthen the need of public health interventions to reduce air pollutants concentration

L’épidémiologie d’intervention a pour objectif la détection précoce des situations d’alerte sanitaire afin d’apporter une aide à la décision pour le déclenchement d’une réponse visant à en limiter l’impact. Dans le domaine de la santé animale, l’épidémiologie d’intervention se développe sous l’influence d’enjeux sanitaires, économiques et de santé publique. La structuration des activités est nécessaire au développement performant de cette discipline.Dans ce contexte, un modèle pour la structuration opérationnelle de l’épidémiologie d’intervention a été développé selon les principes d’une méthode d’optimisation de la performance reconnue : l’approche processus. L’établissement de ce modèle a reposé sur l’identification des chaînes d’activités (processus) d’une épidémiologie d’intervention performante, adaptée à la santé animale, tout en capitalisant les acquis et les avancées de cette discipline dans le domaine de la santé publique. Ces chaînes d’activités ont été identifiées grâce à l’analyse qualitative rétrospective d’expériences en épidémiologie d’intervention dans différents domaines (santé publique, santé publique vétérinaire, santé animale), en réponse à des contextes variés.Ces analyses rétrospectives ont permis d’identifier des chaînes d’activités vectrices de performance en épidémiologie d’intervention. Ces activités ont été intégrées au modèle proposé pour la structuration opérationnelle de cette discipline.L’objectif serait désormais d’assurer la mise en œuvre des chaînes d’activités identifiées via un système intégré global, à même de détecter et de documenter toute maladie animale, ou menace liée aux animaux, et d’informer la prise de mesures adéquates pour son controle
Emerging disease surveillance and investigation aim at the early detection of any health threat in order to perform a comprehensive analysis of the disease situation to help target an appropriate response. Its expansion in the field of animal health is led by major health, economic, and public health drivers. In support of this ongoing development, a standard structure for improved emerging animal disease surveillance and investigation capacities was established. This structure was based on a Business Process Management (BPM) approach.The primary goal of this work was to identify chains of activities (processes) that can support the most successful implementation of emerging animal disease surveillance and investigation, while buidling on the achievements made in the public health area. These chains of activities were identified through a qualitative retrospective analysis of various experiences of emerging disease surveillance and investigation, in the domains of public health, veterinary public health and animal heath, in distinct contexts ranging from a routine investigation to a major sanitary crisis.These analysis resulted in the identification of standard chains of activities that can support a successful implementation of emerging disease surveillance and investigation. These chains of activities were integrated in a standard structure for enhanced emerging animal disease surveillance and investigation capacities.The goal should now be to set up an integrated global system that would routinely implement these chains of activities and allow for the detection and description of any animal disease or threat to help inform prevention and control strategies

L’objectif principal de la thèse était de comprendre le rôle complexe des facteurs nutritionnels dans l’asthme, avec une première partie portant sur l’alimentation et une seconde sur l’obésité. Alimentation – L’objectif était de comparer les typologies alimentaires obtenues par une analyse en composantes principales (ACP) à celles identifiées par une analyse factorielle confirmatoire (AFC) grâce aux données de l’étude E3N (étude épidémiologique auprès des femmes de la MGEN, 30589 femmes). En utilisant les ACP et les AFC, 3 typologies alimentaires ont été identifiées. Selon la méthode, des corrélations différentes étaient observées entre les typologies alimentaires et les groupes d’aliments, conduisant à des associations différentes avec les caractéristiques socio-économiques et l’incidence de l’asthme chez l’adulte. Obésité – Le premier objectif était de comprendre les rôles conjoints et indépendants, dépendants du temps, de l’activité physique et l’obésité sur l’asthme en utilisant des modèles marginaux structuraux chez 15352 femmes d’E3N. L’obésité était liée de façon causale à l’asthme actuel avec symptômes, indépendamment de l’activité physique. Le second objectif était de considérer le rôle modificateur du surpoids dans l’association entre l’exposition domestique aux sprays de nettoyage et l’asthme chez 304 femmes d’E3N. Parmi les femmes sans traitement anti-inflammatoire, le rôle délétère de l’utilisation de sprays sur l’asthme était plus fort chez les femmes en surpoids. L’AFC devrait être utilisée pour l’identification des typologies alimentaires en épidémiologie nutritionnelle. L’obésité pourrait causer de l’asthme indépendamment de l’activité physique, et pourrait augmenter l’effet délétère d’autres facteurs environnementaux de l’asthme
The general aim of the thesis was to assess the complex role of nutritional factors in asthma, with a first part focused on diet, and a second part focused on obesity. Diet – The objective was to compare dietary patterns based on principal component analysis (PCA) to patterns based on confirmatory factor analysis (CFA). The analysis was performed among 30,589 women from the E3N study (epidemiological cohort study among women of the Mutuelle Générale de l’Education Nationale). Whether PCA or CFA was used, 3 patterns were derived. For each pattern, we reported different correlations between food groups and dietary patterns when using PCA or CFA, leading to different associations between dietary patterns with socio-economic characteristics and adult-onset asthma. Obesity – The first objective was to assess the joint and independent, time-dependent, roles of physical activity and obesity on asthma using marginal structural models. Among 15,352 women from E3N, analyses showed that obesity was related causally to current asthma with symptoms independently of physical activity, whereas no association was reported for physical activity. The second objective was to assess the modifying role of overweight in the association between domestic exposure to cleaning sprays and current asthma. Among 304 women from E3N, analysis showed that among women without anti-inflammatory therapy, the effect of spray use on asthma was higher in overweight women. CFA should be considered for the assessment of dietary patterns in nutritional epidemiology. Obesity may lead to asthma independently of physical activity, and may increase the deleterious effect of other environmental factors of asthma

Background Mass screening for celiac disease (CD) as a public health intervention is controversial. Before implementation, a suitable screening strategy should be outlined, and the acceptability of the screening scrutinized. Also, the benefits of early detection and possible negative consequences should be explored and compared. The overall aim of this thesis was to evaluate different strategies for finding 12-year-olds with undiagnosed CD in the general population, and to explore the experiences of those receiving the diagnosis in a mass screening. Methods A school-based CD screening of 12-year-olds was conducted in five study sites across Sweden. Out of 10041 children who were invited, 7208 had a blood sample analyzed for CD-marker tissue transglutaminase of isotype IgA (tTG-IgA) and 7161 for total serum IgA (s-IgA). If the s-IgA value was low, tTG-IgG was also measured. Additional analysis of endomysial antibodies (EMA) was performed if borderline values of tTG were found. In total, 192 had elevated CD-markers, 184 underwent a small intestinal biopsy and 153 eventually had CD diagnosed. Before receiving knowledge about their CD status, children and their parents filled in questionnaires regarding symptoms and CD-associated conditions. Questionnaires were returned by 7054 children (98%) and 6294 parents (88%). Later, all adolescents who had been diagnosed with CD more than one year ago (n=145), and their parents, were invited to a mixed-method follow-up study in which they shared their experiences in questionnaires, written narratives and focus group discussions. In total, we have information on 117 (81%) of these adolescents, either from the adolescents themselves (n=101) and/or from their parent/s (n=125). Data were analyzed using a combination of descriptive and analytical quantitative and qualitative methodologies. Results We found that information on symptoms and CD-associated conditions were poor predictors for finding undiagnosed CD in the study population. Questionnaire-based case-finding by asking for CD-associated symptoms and conditions would have identified 52 cases (38% of all cases) at a cost of blood-sampling 2282 children (37% of the study population). The tTG-IgA test had an excellent diagnostic accuracy with the area under the receiver operating characteristic curve of 0.988. If using the recommended cut-off for tTG-IgA (>5 U/mL) 151 had fulfilled biopsy criteria and 134 CD cases had been identified. The strategy of lowering the cut-off to tTG-IgA>4 U/mL, and adding the EMA analysis in those with tTG-IgA between 2-4 U/mL, identified another 17 cases (a 12% increase) at the cost of performing 32 additional biopsies. Measuring total s-IgA in 7161 children discovered only two additional cases at the cost of performing 5 additional biopsies. The positive predictive value of our screening strategy was 80%.  Results from the follow-up study of the screening-detected CD cases illustrated that 54% reported health improvement after initiated treatment, but also that these health benefits had to be balanced against social sacrifices. We also found that although the screening-detected diagnosis was met with surprise and anxiety, the adolescents and their parents were grateful for being made aware of the diagnosis. A majority of parents (92%) welcomed a future screening, but both adolescents and parents suggested that it should be conducted earlier in life. Conclusion Obtaining information on symptoms and CD-associated conditions was not a useful step in finding undiagnosed CD cases in a general population. The serological marker tTG-IgA, however, had excellent diagnostic accuracy also when lowering the cut-off. The diagnosis had varying impact on adolescents’ quality of life, and their perceived change in health had to be balanced against the social sacrifices resulting from the diagnosis. Overall, CD mass screening seemed acceptable to most of those who were diagnosed and their parents.

Asthma and rhinitis epidemiology has wide variations around the world. The aim of this review was verify the prevalence of asthma and rhinitis in South America and report differences from other regions of the world. We reviewed studies with International Study of Asthma and Allergies in Childhood (ISAAC) methodology in South America, Phases I and III. In South America the ISAAC Phase I ranked four countries among top ten in prevalence of asthma and three countries among top ten in prevalence of rhinoconjunctivitis. ISAAC Phase III showed little changes in asthma and rhinitis prevalence in South American countries. The prevalence increases of asthma and rhinitis in South American centers indicate that the burden of both is continuing to rise, but the differences in prevalence are lessening.
Revisión por pares

La sclérose latérale amyotrophique (SLA) est une maladie neurodégénérative fatale. De récents travaux suggèrent une variabilité en termes d'incidence, de mortalité et de caractéristiques cliniques selon les régions géographiques et les populations. Cette thèse offre une mise à jour sur l'hétérogénéité de la SLA, accompagnée de deux études épidémiologiques et cliniques originales en Afrique et en Amérique latine. La première est une étude hospitalière multicentrique dans huit pays africains qui décrit et compare les caractéristiques sociodémographiques et cliniques, les traitements, les facteurs pronostics et la durée de survie chez les patients atteints de la SLA. Certaines caractéristiques sont plus spécifiques aux cas africains par rapport aux occidentaux, telles qu’une proportion plus élevée de patients masculins, un âge de début plus jeune, une proportion plus faible de début bulbaire et une survie plus courte que prévue. Le sous-continent et le traitement par riluzole sont des facteurs indépendamment liés à la survie du patient. La seconde étude en population générale a estimé les taux de mortalité en Équateur, pays composé d’une population majoritairement métisse. Ces résultats soutiennent l’hypothèse d’une survenue plus faible de cas SLA dans les populations métisses d’Amérique latine comparée aux populations caucasiennes d'Europe et d'Amérique du Nord. Les taux de mortalité standardisés ont été comparés entre les groupes ethniques, montrant des différences significatives entre le groupe métisse et le groupe comprenant les autres ethnies (indigènes, asiatiques et arabes). Ce travail fournit des données originales et fiables pour améliorer nos connaissances sur la SLA en Afrique et en Amérique latine. Une collaboration internationale et multidisciplinaire est cruciale pour comprendre la variabilité de la SLA dans différentes populations
Amyotrophic lateral sclerosis (ALS) is a rare neurodegenerative disorder with an invariable fatal outcome. Current evidence supports ALS variability in terms of incidence, mortality and clinical features between geographic areas and populations. This dissertation offers an updated review of ALS heterogeneity along with two original epidemiological and clinical studies in Africa and Latin America. First, a multicenter hospital-based study in eight African countries that described and compared the sociodemographic characteristics, clinical features, treatments, prognoses and survival times of patients with ALS. Certain specific characteristics were different in African cases compared to Western cases like higher proportion of male patients, younger age at onset, lower proportion of bulbar onset and shorter survival than expected. Subcontinental location and riluzole treatment are independently associated with survival. Second, a population-based study estimated ALS mortality rates in Ecuador, a predominant admixed population. The findings support a lower ALS occurrence in admixed populations from Latin America compared to European and Northern American populations. Standardized mortality rates were compared among ethnic groups with significant differences between admixed and other ethnic groups (Indigenous, Asians and Arabs). This work provides original and reliable data to improve our knowledge of ALS in Africa and Latin America. An international and multidisciplinary collaboration is crucial to understand ALS variability in different populations

Mental health in the United States is a rising concern. More concerning still is the growing number of children and adolescents with serious depression and other mental health disorders (SAMHSA, 2009; Merikangas et al., 2010). Despite a growing list of proven and best-practice prevention and intervention initiatives that have been made available to children and adolescents, 80 percent of children and adolescents with a diagnosable mental health disorder will not receive services for their associated mental health concerns (U.S. Department of Health and Human Services, 1999; Cummings 2014). Children and adolescents with mental health disorders are faced with an ever-increasing list of barriers that prevent them from accessing much needed mental health services. At a particular disadvantage are Black adolescents, who are even less likely than their non-minority peers to have access to or receive services for mental health concerns (Lindsey, Chambers, Pohle, Beall, & Lucksted, 2013). As result, this Q Methodology study was designed to understand the perspectives Black adolescents hold toward access to mental health care. The researcher first developed a naturalistic, 36-item Q Sample from participant responses to open-ended prompts designed to elicit distinct thoughts around perceptions of access to mental health care, including supports and barriers. Thirty Black adolescents sorted this 36-item Q sample in a forced distribution resembling a semi-normal curve ranging from “least like my perspective” (-4) to “most like my perspective” (+4) and also wrote explanations for why they sorted they ways they did. Subsequently, these 30 Q sorts were correlated and these correlations were factor analyzed, rotated, and extracted producing five factors. Based on an analysis of these five factors, or shared perspectives, they were named: Building My Own Barriers (Factor 1), I Don’t Talk About My Feelings! (Factor 2), I’m Looking For A Shift In My Perspective (Factor 3), Counseling When I Want It; Not Always From A Counselor (Factor 4), and Money Is The Least Of My Problems (Factor 5). These five factors represented distinct and diverse viewpoints toward the access to mental health counseling. A primary implication from this study was that school leaders and community leaders, educators, parents and caregivers, and policy-makers must find ways to decrease the barriers youth experience as they seek and attempt to participate in mental health counseling services, while working also to leverage the power of those things that support access.

碩士
開南大學
商學院碩士在職專班
105
Wearable artificial kidney(WAK), a novel product in the renal dialysis market, brings a hope with achievement in effectiveness, efficiency, and quality of life. However, before introducing such a high technology product, both government and firm would like to understand the economic scale and performance of the existing market. Therefore, the aim of this study was to evaluate the performance of Taiwan renal dialysis market, to investigate the difference between areas, and further to investigate the influence of those preceding risk factors of Ends Stage Renal Disease (ESRD) based on epidemiology methodology. The target population is consisted of all residents aged 45 or over in Taiwan. Secondary data analysis, accompanied with the methods of prevalence and Population Attributable Risk(PAR) was adopted. Our finding shows the difference in renal dialysis care between areas. Eastern area shows a worse performance. If hypertension and diabetes, two prevalent chronic diseases in the middle and old age, getting worse control, the risk of developing ESRD will increase rapidly.

The aim of this thesis is to demonstrate the importance of walking to public health. The first part is characterized by epidemiological research. First, a typology for the measurement of walking is developed. A systematic review is conducted of observational studies to determine the health benefits of walking in its own right. Studies consistently confirm that 30 minutes walking on most days of the week is sufficient to reduce the risk of cardiovascular diseases and non-communicable disease risk. Then, a series of epidemiological analyses describes the prevalence and correlates of walking, using multiple health and non-health surveillance data sets. Surveillance data indicate that the prevalence of walking at the above recommended levels is low across all domains. Between 1991 and 2001 an increase in walking occurred, and was the main contributor to reductions in leisure time physical inactivity; however, the proportion of the population who achieved the recommended amount of physical activity by walking did not change in leisure and transport domains. The next part of the thesis is characterized by health promotion research examining the impact of three population-based approaches to increasing walking among Australian adults. The first was an evaluation of a conversion of rail to trail, as an environmental change intervention; the second was a mass media campaign promoting walking to work, and the third was a targeted print media walking program. Providing environmental supports with minimal promotion had no effect on walking. A nation-wide mass media campaign promoting walking to work increased walking and other moderate intensity physical activity, but process evaluation indicated other promotional efforts contributed as well. The targeted print media randomised trial had the greatest effect on walking, but the increases were not greater than spontaneous change in the control. Increases in total physical activity were achieved only when the intervention was supplemented by the use of a pedometer. The expectation that broader approaches to the promotion of walking will bring about changes at the population level, were not corroborated by these case studies. There is a need for enhancement of walking-specific interventions to influence total PA at the population levels.

This thesis looks into the concept of the quality of life in women with epilepsy from a qualitative perspective. Epilepsy, as is a chronic neurological disease, affects not only everyday activities after the diagnosis, but also has its impact on the women's life regarding employment or family. By adapting the narrative analysis this thesis categorizes the influential factors of this concept into primary and secondary ones. Moreover, it explores in detail the issue of obtaining a driving license, which is one of the specifics of the people with epilepsy in Czechia. Also, it defines the respondents' attitudes toward the societal perception of epilepsy and fears that accompany it. In addition to that, the matter of motherhood and pregnancy for women with epilepsy is explored as one of the influential factors of the quality of life. Lastly, this thesis argues that the qualitative approach is essential for the initial examination of the selected sample for future investigations regarding the concept of the quality of life in epilepsy.

Indiana University-Purdue University Indianapolis (IUPUI)
Phytoestrogens that abound in soy products, legumes, and chickpeas can induce biologic responses in animals and humans due to structural similarity to 17β-estradiol. Although experimental studies suggest that phytoestrogen intake may alter the risk of cancer and cardiovascular disease, few epidemiologic studies have investigated this research question. This dissertation investigated the associations of intake of total and individual phytoestrogens and their urinary biomarkers with these chronic conditions using data previously collected from two US national cohort studies (NHANES and PLCO). Utilizing NHANES data with urinary phytoestrogen concentrations and follow-up mortality, Cox proportional hazards regression (HR; 95% CI) were performed to evaluate the association between total cancer, cardiovascular disease, and all-cause mortality and urinary phytoestrogens. After adjustment for confounders, it was found that higher concentrations of lignans were associated with a reduced risk of death from cardiovascular disease (0.48; 0.24-0.97), whereas higher concentrations of isoflavones (2.14; 1.03-4.47) and daidzein (2.05; 1.02-4.11) were associated with an increased risk. A reduction in all-cause mortality was observed for elevated concentrations of lignans (0.65; 0.43-0.96) and enterolactone (0.65; 0.44-0.97). Utilizing PLCO data and dietary phytoestrogens, Cox proportional hazards regression examined the associations between dietary phytoestrogens and the risk of prostate cancer incidence. After adjustment for confounders, a positive association was found between dietary intake of isoflavones (1.58; 1.11-2.24), genistein (1.42; 1.02-1.98), daidzein (1.62; 1.13-2.32), and glycitein (1.53; 1.09-2.15) and the risk of advanced prostate cancer. Conversely, an inverse association existed between dietary intake of genistein and the risk of non-advanced prostate cancer (0.88; 0.78-0.99) and total prostate cancer (0.90; 0.81-1.00). C-reactive protein (CRP) concentration levels rise in response to inflammation and higher levels are a risk factor for some cancers and cardiovascular disease reported in epidemiologic studies. Logistic regression performed on NHANES data evaluated the association between CRP and urinary phytoestrogen concentrations. Higher concentrations of total and individual phytoestrogens were associated with lower concentrations of CRP. In summary, dietary intake of some phytoestrogens significantly modulates prostate cancer risk and cardiovascular disease mortality. It is possible that these associations may be in part mediated through the influence of phytoestrogen intake on circulating levels of C-reactive protein.

Indiana University-Purdue University Indianapolis (IUPUI)
With effective antiretroviral therapy (ART), cardiovascular diseases (CVD), are emerging as a major cause of morbidity and death in the aging population with HIV infection. Although this increase in CVD could be partially explained by the toxic effects of combined anti-retroviral therapy (ART), more recently, HIV infection has emerged as an independent risk factor for CVD. However, it is unclear how HIV can contribute to CVD in patients on ART, when viral titers are low or non-detectable. Here, we provide several lines of evidence that HIV-Nef, produced in infected cells even when virus production is halted by ART, can lead to endothelial activation and dysfunction, and thus may be involved in CVD. We demonstrate that HIV-infected T cell-induced endothelial cell activation requires direct contact as well as functional HIV-Nef. Nef protein from either HIV-infected or Nef-transfected T cells rapidly transfers to endothelial cells while inducing nanotube-like conduits connecting T cells to endothelial cells. This transfer or transfection of endothelial cells results in endothelial apoptosis, ROS generation and release of monocyte attractant protein-1 (MCP-1). A Nef SH3 binding site mutant abolishes Nef-induced apoptosis and ROS formation and reduces MCP-1 production in endothelial cells, suggesting that the Nef SH3 binding site is critical for Nef effects on endothelial cells. Nef induces apoptosis of endothelial cells through both NADPH oxidase- and ROS-dependent mechanisms, while Nef-induced MCP-1 production is NF-kB dependent. Importantly, Nef can be found in CD4 positive and bystander circulating blood cells in patients receiving virally suppressive ART, and in the endothelium of chimeric SIV-infected macaques. Together, these data indicate that Nef could exert pro-atherogenic effects on the endothelium even when HIV infection is controlled and that inhibition of Nef-associated pathways may be promising new therapeutic targets for reducing the risk for cardiovascular disease in the HIV-infected population.

Indiana University-Purdue University Indianapolis (IUPUI)
Identifying spatial and temporal patterns of disease occurrence by mapping the residential locations of affected people can provide information that informs response by public health practitioners and improves understanding in epidemiological research. A common method of locating patients at the individual level is geocoding residential addresses stored in electronic medical records (EMRs) using address matching procedures in a geographic information system (GIS). While the process of geocoding is becoming more common in public health studies, few researchers take the time to examine the effects of using different address databases on match rate and positional accuracy of the geocoded results. This research examined and compared accuracy and match rate resulting from four commonly-used geocoding databases applied to sample of 59,341 subjects residing in and around Marion County/ Indianapolis, IN. The results are intended to inform researchers on the benefits and downsides to their selection of a database to geocode patient addresses in EMRs.