Dissertations / Theses on the topic 'Poverty; Health inequalities; Low income'

This thesis reports on the gynaecological and mental health of low-income urban women in Thane, India. The research objectives were to study the women's perception and experience of gynaecological symptoms, their association with mental ill-health and the role of social support and social networks in these two morbidities. A combination of quantitative and qualitative research methods was used in the form of a survey questionnaire and in-depth interviews. Gynaecological morbidity was measured by women's perception of morbidity and prevalence was calculated on women's reporting of symptoms. The Self Response Questionnaire (SRQ-20) was used to calculate mental ill-health 'cases'. Social support and social networks were separately explored for the first time in an Indian community setting using an adapted version of the Close Persons Questionnaire (CPQ). There was a high reporting (50.6%) of gynaecological symptoms in the community with reproductive tract infections, menstrual problems, urinary infections and prolapse being most commonly reported. 17.9% of the women were 'cases' of mental ill-health. Gynaecological morbidity was associated with poor mental health and affected women's social life. Women's age and reporting of a major illness were associated with gynaecological and mental health, whereas unemployment was associated with mental ill-health. Levels of social support were not associated with either morbidity. Higher levels of negative support were received from spouses, by the women. An extensively used social network appeared to protect against mental ill-health. The study's conclusions point to the need to plan more appropriate (participatory) and culturally sensitive programmes for the identification and treatment of gynaecological and mental health at the community level. The research findings emphasize the need for integration of mental health services at the primary health level especially in low income urban communities and the recognition of social networks in maintaining positive health.

In 2011, an estimated 3 million children died in their first four weeks of life. The majority of these neonatal deaths are avoidable if effective low-cost interventions, such as clean delivery practices, exclusive breastfeeding, and newborn resuscitation are available. However, these interventions are clearly not reaching many of the women and newborns who need them most. A major challenge is how best to expand access to essential obstetric and newborn interventions, particularly among disadvantaged populations and in areas with poor access to health services. This requires an understanding of the social and geographical patterning of neonatal mortality rates (NMR) as well as evidence about which policies can reduce inequalities in access to essential maternal and newborn care. The three objectives of my thesis addressed these issues directly.First, we described socioeconomic inequalities in NMR across low- and middle-income countries (LMIC) and assessed changes in inequalities over the past decade. Using Demographic and Health Survey (DHS) data from 24 countries, we estimated absolute and relative socioeconomic inequalities using the Slope Index of Inequality and the Relative Index of Inequality, respectively. In most countries, absolute and relative inequality in NMR declined over the approximate 10-year period. There was, however, considerable heterogeneity both in the magnitude of NMR inequalities between countries and in how inequalities changed over time. Furthermore, there remained a substantial survival advantage for newborns born into wealthier and more educated households, which should be considered in global efforts to further reduce NMR. Next, we evaluated the impact of a policy that removes user fees for facility-based deliveries on health service utilization, neonatal mortality, and socioeconomic inequalities. Using DHS data from ten countries in sub-Saharan Africa, we employed a difference-in-differences regression approach to control for underlying secular trends in the outcomes that are common across countries and for time invariant differences between countries. Reducing fees for delivery services was associated with an increase in facility-based deliveries and a possible reduction in NMR. Furthermore, increases in facility-based deliveries occurred across all socioeconomic groups, with no indication that richer or more educated women benefited more from the policy change.Finally, we assessed the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality and examined whether proximity to services contributed to socioeconomic inequalities in early neonatal mortality. Using geographical coordinates collected in both surveys, we linked data from the 2011 Ethiopian DHS with comprehensive facility census data from the 2008 Ethiopian EmONC Needs Assessment. Closer proximity to delivery services and higher level of care were associated with lower early NMR. Distance to EmONC services was a main determinant of total inequality in NMR, although it did not make a significant contribution to socioeconomic inequality. In this thesis, we have identified several barriers that contribute to large and persistent inequalities in neonatal mortality and in the utilization of essential obstetric and newborn care in LMIC. The findings highlight the importance of a multipronged policy approach that addresses geographic accessibility and quality of obstetric and newborn services, affordability barriers, and socioeconomic inequalities to significantly reduce neonatal mortality. Further research examining the relative importance of various access barriers in different settings will help policy makers and planners adopt locally relevant approaches to improve newborn survival.
En 2011, environ 3 millions d'enfants sont morts au cours des quatre premières semaines de leurs vies. La majorité de ces morts néonatales peuvent être évitées si des interventions abordables, telles que des accouchements sanitaires, l'allaitement exclusif et la réanimation des nourrissons sont disponibles. Cependant, ces interventions ne sont pas accessibles aux femmes et aux nouveaux nés qui en ont le plus besoin. Un des défis majeurs à relever est de formuler la meilleure stratégie pour étendre l'accès des interventions obstétriques et des interventions aux nouveaux nés aux populations désavantagées et dans les zones qui manquent des services de santé. Cela nécessite une connaissance des dynamiques sociales et géographiques des taux de mortalité néonatale (TMN) et des données concernant les politiques pouvant réduire les inégalités d'accès aux soins essentiels aux mères et aux nouveaux nés. Les trois objectifs de ma thèse explorent directement ces sujets. D'abord, nous décrivons les inégalités socioéconomiques du TMN à travers les pays à bas et moyens revenus (PBMR). Basée sur les données du Demographic and Health Surveys (DHS) sur 24 pays, nous calculons les inégalités absolues et relatives. Dans la plupart des pays, les inégalités absolues et relatives du TMN ont diminué sur une période approximative de 10 ans. Il y a toutefois une hétérogénéité considérable quant à la magnitude des inégalités du TMN entre les pays et quant à leur fluctuation dans le temps. De plus, un avantage de survie substantiel pour les nouveaux nés des ménages riches et éduqués subsiste encore. Ensuite, nous évaluons l'impact des politiques supprimant les coûts des accouchements qui ont lieu dans des établissements de santé sur l'utilisation des services de santé, la mortalité néonatale et sur les inégalités socioéconomiques. Avec les données du DHS de dix pays sub-sahariens, nous utilisons l'approche de différence-en-différences dans des modèles de régression pour réguler les tendances séculaires des indicateurs communs à tous les pays ainsi que pour contrôler toute différence fixe dans le temps qui pourrait exister entre les pays. La réduction des coûts liés aux services d'accouchement est associée à une augmentation du nombre d'accouchements dans les établissements de santé et à une réduction potentielle du TMN. De plus, l'augmentation des accouchements en établissements de santé a eu lieu dans tous les groupes socioéconomiques.Enfin, nous évaluons l'effet de la distance entre le domicile et les centres des services obstétricaux et néonataux d'urgence (SONU) sur la mortalité néonatale. Dans ce projet, nous lions les données géographiques du DHS 2011 sur l'Éthiopie avec celles du recensement exhaustif des établissements de santé de 2008 sur l'Éthiopie. La proximité des services d'accouchement et un niveau élevé de soins sont associés à un plus faible taux de mortalité néonatale. La distance des services SONU est un déterminant principal des inégalités totales dans le taux de mortalité néonatale, malgré le fait qu'elle ne contribue pas significativement aux inégalités socioéconomiques. Dans cette thèse, nous identifions plusieurs obstacles qui contribuent aux inégalités larges et persistantes dans le taux de mortalité néonatale et de l'utilisation des soins obstétrique et néonataux essentiels dans les PBMR. Les résultats démontrent l'importance d'une approche politique multidimensionnelle qui prend en considération l'accessibilité géographique, la qualité des services obstétriques et néonataux, et l'accessibilité des coûts et des inégalités socioéconomiques afin de réduire sensiblement la moralité néonatale. D'autres recherches portant sur l'importance relative des obstacles à l'accessibilité dans différents contextes aideront les décideurs politiques et les administrateurs à adopter des approches locales appropriées pour améliorer la survie des nouveaux nés.

Thesis advisor: Lisa A. Goodman
As poverty rates in the United States increase, women continue to be disproportionately represented among individuals in poverty. As a result of their poverty, low-income women experience a range of acute stressors and chronic life conditions, within a sociopolitical climate that is highly stigmatizing. Not surprisingly, low-income women experience mental health issues at substantially higher rates than their higher-income counterparts. Despite the clear need for mental health services for this population, rates of access to treatment are low and attrition rates are high. The minimal research examining treatment outcomes for low-income women reveals mixed findings. Further, there is little research on low-income women's qualitative experiences of therapy; the role of their poverty and what they perceive to be meaningful and effective. The present study attempted to fill the gap in our understanding of low-income women's psychotherapy needs and experiences, in an effort to offer new insights about directions for research, training, and practice that can improve mental health services for this high-risk population. This study employed a qualitative descriptive methodology to explore low-income women's (n=10) experiences in traditional outpatient psychotherapy, with a particular focus on how poverty shaped their experiences and what they perceived to be most effective and meaningful. Six clusters emerged from data analysis: Awareness, Instrumental support and flexibility, Building strengths, Respect and dignity, Shared power, and Authenticity. These clusters, in turn, coalesced into three overarching themes: Awareness, Practices, and Relational Quality. Awareness pertains to participants' sense that their therapist understood the nature of poverty and was sensitive to the role of poverty-related stressors in their clients' lives. Practices reflects therapists' willingness to respond directly and actively to participants' poverty-related needs, as these are inextricably intertwined with their mental health. Relational quality refers to the participants' view of how therapists approached relational dynamics; in particular, how they negotiated issues such as power and transparency. Findings are discussed in the context of feminist theory and current research. Limitations are also presented along with recommendations for future research, training, and practice
Thesis (PhD) — Boston College, 2014
Submitted to: Boston College. Lynch School of Education
Discipline: Counseling, Developmental, and Educational Psychology

This dissertation consists of three essays examining the role of transfer-program interactions for families and households who participate in the social safety net. The safety net is comprised of many different programs, run by different agencies, governed by different rules, and often administered by disparate and secluded entities. However, many households participate in multiple programs, subjecting them to the milieu of administrative hurdles. In this dissertation, I try to untangle some of the intended and unintended effects of program participation that may be experienced by these households. In Essay 1, I examine the effect of the Patient Protection and Affordable Care Act of 2010 (ACA) on food hardship in US households, utilizing food security information from the Food Security Supplement of the Current Population Survey. Because states adopted the Medicaid expansions provided under the ACA at different times beginning in 2014, the cross-state, over time variation allows me to separate the impact of the ACA on food hardship using triple difference specifications. The richness of questions in the Food Security Supplement allows me to examine the effect of the ACA across different measures of food hardship, and also examine differential response for households participating in the Supplemental Nutrition Assistance Program (SNAP). Examining the mechanisms through which the ACA could affect food insecurity, I find the ACA not only increased average weekly food expenditure, but also the probability a household participates in SNAP. I employ a two-stage, control function approach to address reverse causality between SNAP and food insecurity. I find that the ACA reduced the probability that a household participating in SNAP falls into the two lowest food security categories by 6.5 percentage points and reduced the probability of being food insecure by 14.2 percentage points. Across specifications, I find strong evidence for increasing returns to program participation, and evidence of a differential impact of the ACA across the distribution of food hardship. In Essay 2, I examine how grant funding and fiscal structure affect program response over the business cycle. I compare child enrollment in Medicaid, a matching grant funding program, with enrollment the State Children's Health Insurance Program, a block grant funded program, utilizing the similarities in beneficiaries, program benefits, and administration to isolate the impact of fiscal structure. I utilize administrative enrollment records, along with individual level participation data, and find a one percentage point increase in the unemployment rate leads to a 7.6% decrease in the number of beneficiaries per person enrolled in block grant funded programs, and a 10% decrease in state expenditure per person decreases the probability of enrollment in a block grant program by 0.58 percentage points. I also find that enrollment is much more persistent among matching grant funded programs, and being enrolled in a block grant funded program the previous period increases the probability of enrolling in a matching grant program this period 75% more than remaining enrolled in the block grant funded program. Finally, in Essay 3 I explore the effect of the minimum wage on the self-reported value of public assistance program benefits, and the joint effect of the minimum wage and public assistance programs on the income to poverty ratio using data from the 1995-2016 Current Population Survey Annual Social and Economic Supplement. In the first stage, I estimate a Tobit model controlling for the censoring of received benefits from below at zero, and examine the effect of changes in the minimum wage on the self-reported dollar value of benefits received for food stamps/the Supplemental Nutrition Assistance Program (SNAP), Aid to Families with Dependent Children (AFDC)/Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), and the Earned Income Tax Credit (EITC), as well as the total sum of benefits. I find that the minimum wage reduces the value of means-tested benefits, but that this effect is strongest for programs with strong work requirements. Utilizing the residuals from the first stage, I employ a control function approach to estimate the joint effect of the minimum wage and program benefits on the income to poverty ratio. I find the own-effect of the minimum wage provides a small increase in the income to poverty ratio, but that the total effect, accounting for changes in benefits, attenuates by approximately 30%.

Oral caries is the most prevalent chronic disease among US children, and disproportionately impacts those of low socioeconomic status. Studies have shown that the Special Supplemental Nutrition Program for Women Infants and Children (WIC) improves access to dental care among Medicaid children. This study investigated the impact of WIC, Medicaid, and the State Children's Health Insurance Program (SCHIP) on the prevalence of dental caries among low-income children. The 1999-2000 and 2001-2002 NHANES data were utilized for this analysis. Children 2-4 years old who participated in WIC, Medicaid, or SCHIP, or who were uninsured, and for whom both interview and complete oral health exam data were available (n = 597) were included in the study. Multivariate logistic regression modeling was conducted to examine the effects of program participation on caries. There was no statistically significant association between dental caries and participation in public assistance programs. The risk of dental caries for children in MedicaidSCHIP only was comparable to the risk for children in WIC and MedicaidSCHIP (OR = 1.04; 95%CI = 0.622, 1.745) and also to uninsured children (OR = 0.96; 95%CI = 0.523, 1.773). Dental caries were not impacted if the child did not have a preventive dental visit in the past 6 months (OR = 0.68; 95% CI = 0.436, 1.063) or did not have a regular dental care provider (OR = 1.15; 95% CI = 0.646, 2.044). Participation in WIC and MedicaidSCHIP does not improve the oral health of low-income children. Because this population is a high-risk group requiring more specialized efforts, improving access to care is not sufficient to improve oral health. In addition to increased utilization of services, the program partnership between WIC and MedicaidSCHIP must provide targeted, educational interventions to prevent dental caries. It may also be necessary to increase the recommended number of preventive visits for low-income children.

Thesis advisor: Lisa A. Goodman
Those in poverty face myriad stressors, traumatic events, and ongoing hardships; and not surprisingly, struggle with a range of mental health issues. Yet, they are less likely to access mental health services than their middle-income counterparts, and when they do, they are more likely to drop out of treatment prematurely. Although researchers have found that when interventions are tailored to address poverty-related stressors outcomes are dramatically improved, the perspectives of those providing such treatment is rarely described. This qualitative descriptive study of twelve experienced psychologists working with clients in poverty aimed to fill this gap. The study explored the extent to which psychologists develop unique practices for working with low-income clients, as well as the personal and contextual factors that support or hinder these efforts. Findings can be distilled into three categories: Practices unique to working with low-income clients include strategies for addressing power dynamics, managing boundaries, and addressing external stressors as part of the therapeutic process. Therapist attributes key to working with low-income clients include possessing a values-based commitment to working with marginalized groups; possessing experience with, knowledge of, and empathy for the realities of living in poverty; possessing a high degree of self-awareness related to poverty; and possessing a willingness to be deeply affected by the work and cope with negative feelings. Contextual obstacles to working with low-income clients include agency-level and social service system-level challenges. Perhaps the most striking finding was participants' understanding of how conceptualizations of appropriate boundaries need to change in the context of work with this population. Many participants described, for example, giving food to their clients when they were hungry or giving them small amounts of money to help them take care of their most basic needs. The discussion section explores these findings in the context of ecological and feminist theoretical models and current research and describes the implications of the results for research, training, and practice
Thesis (PhD) — Boston College, 2014
Submitted to: Boston College. Lynch School of Education
Discipline: Counseling, Developmental and Educational Psychology

The collapse of the communist regimes in Central and Eastern Europe in 1989-1990 heralded the beginning of an economic transition from central planning to market economies. The subsequent period was marked by malfunctioning of these countries’ social sectors, including their health care systems, raising serious issues of equity. This thesis examines the impact of the transition period and the introduction of social insurance on equity in health care provision in Bulgaria. Equity in health care is investigated with respect to function - i.e. financing (according to ability to pay) and delivery (according to need) - and outcomes - i.e. health status, income inequality and poverty. Differences in health, health care financing and delivery are explored by income, education, ethnic, employment, marital status, age and sex groups. Furthermore, the thesis outlines the impact of health care provision, in particular social insurance, on poverty and health inequalities. The thesis employs empirical analysis based on household data. Its methodology includes concentration and decomposition analysis, and provides new ways of modelling health care financing and delivery, as well as the link between health and health care delivery. The thesis concludes that social insurance does not provide a uniform means of improving equity and that the root cause of the problem lies in the large proportion of out-of-pocket payments and the rather limited size of the health insurance sector. Inequity in health care provision leads to poverty and untreated illness. The data suggests that there are differences between socio-economic groups as regards their likelihood to seek treatment for their ill health, which result in differences in their health status. The social factors that have impacted the most on health are low education and low income.

Since 1999, there has been a significant increase in the number of food insecure individuals in the United States. The Great Recession (2007-2009) and slow economic recovery has led to additional increases in rates of food insecurity and the usage of emergency food assistance programs. Thirty qualitative interviews with individuals seeking emergency food assistance at a Tampa Bay food pantry were conducted. Interviews focused on collecting the life experiences of participants, the barriers they face in having food security, their strategies to cope with limited food budgets, and how food insecurity impacts their household's overall health and wellbeing. Recommendations for fulfilling the immediate need for food as well as addressing the larger issues that lead to and perpetuate food insecurity and hunger are presented in this paper. In collaboration with the food pantry, a booklet presenting personal experiences of hunger alongside broad institutional forces affecting food insecurity was disseminated in the community in hopes of increasing awareness of and support for combating this important social issue.

Thesis (Ph. D.)--Georgia State University, 2006.
Title from title screen. William L. Waugh, Jr., committee chair; Peter Lindsay, Allison Calhoun Brown, committee members. Electronic text (134 p. : ill. (some col.)) : digital, PDF file. Description based on contents viewed July 25, 2007. Includes bibliographical references (p. 128-134).

Depression is experienced at a higher degree in poor, female, and under-employed persons, as compared to the general population. A very large number of poor mothers have entered the workforce since the welfare reform of 1996. Poor mental health can prevent these women from achieving economic self-sufficiency because it can affect their ability to find and retain jobs. This study analyses the New Hope data of working and non-working poor in a Midwestern city to find if predictive relations exist between depressive symptoms and employment and income outcomes across a three-year span. A bi-directional predictive relation is found between depressive symptoms and household income. Also, a higher number of hours worked predicts declines in depressive symptoms, and a lower level of depressive symptoms predicts less AFDC receipt three years later.
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This ethnographic study explores diverse ways in which sexuality and social hierarchies and inequalities interact in the lives of low-income youth who were trained as peer-educators and sexual health and rights advocates in Ayacucho, Peru. It examines three central questions: 1) How are meanings about sexuality related to social hierarchies and social prestige among these youth? 2) How do quotidian manifestations of social inequity shape vulnerability of youth to sexual abuse and sexual risks, and their sexual agency to face these situations? and 3) What are the possibilities and limitations of existent sexual rights educational programs to diminish sexual vulnerability of youth facing diverse forms of inequality, such as economic, gender, ethnic and inter-generational disparities? I analyze what may be termed as the political economy of sexual vulnerability among low-income youth, and show the concrete ways in which it operates in their everyday life. Likewise, this research studies sexuality as a domain of reproduction, resignification and critique of social inequality and social hierarchies. The context is an Andean city, which in recent decades has experienced incomplete processes of democratization, and also a greater penetration of consumerism and transnational ideas and images. This study also reveals cultural logics of youth about sexual risks and complex dimensions of their sexual and gender agency. In terms of policies and programs, this research offers evidence and reflections about some challenges and limitations of a participatory sexual rights project within a context of poverty and social inequalities in urban low-income areas of Peru.

Yes
Recent research on health inequalities moves beyond illustrating the importance of psychosocial factors for health to a more in-depth study of the specific psychosocial pathways involved. Social capital is a concept that captures both a buffer function of the social environment on health, as well as potential negative effects arising from social inequality and exclusion. This systematic review assesses the current evidence, and identifies gaps in knowledge, on the associations and interactions between social capital and socioeconomic inequalities in health. Through this systematic review we identified studies on the interactions between social capital and socioeconomic inequalities in health published before July 2012. The literature search resulted in 618 studies after removal of duplicates, of which 60 studies were eligible for analysis. Self-reported measures of health were most frequently used, together with different bonding, bridging and linking components of social capital. A large majority, 56 studies, confirmed a correlation between social capital and socioeconomic inequalities in health. Twelve studies reported that social capital might buffer negative health effects of low socioeconomic status and five studies concluded that social capital has a stronger positive effect on health for people with a lower socioeconomic status. There is evidence for both a buffer effect and a dependency effect of social capital on socioeconomic inequalities in health, although the studies that assess these interactions are limited in number. More evidence is needed, as identified hypotheses have implications for community action and for action on the structural causes of social inequalities.

Obesity, being one of the most crucial health problems, affects an increasing part of the world population as it has severe health, social, psychological and economic consequences. Its main cause lies in today's obesogenic environment characterised by a passive lifestyle, easy access to energy- dense foods and their aggressive marketing strategies. Because of significant changes in both production and consumption, it is not possible to blame obesity merely on individual lifestyle choices. An important feature of today's obesity epidemic is its uneven distribution. Obesity prevalence is besides other things determined by education, income, gender, family status and age. Analysis of available data showed that also in the Czech Republic the occurrence of obesity has been increasing and the number of overweight and obese people is higher than the number of people with normal weight. The assumption that there be higher prevalence of excess weight among men was confirmed, however, the expected higher prevalence of obesity among women was disproved; both genders suffer from obesity equally, yet the tendency towards obesity increases more significantly among men. The hypothesis about negative dependence of education, income and BMI was confirmed only partially in the Czech Republic: contrary to expectations, groups...

The major goal of this study is to test the direction and strength of the relations of low-income single mothers’ depressive symptoms to their employment and income experiences over a time period following major welfare policy changes in the U.S. (2001 to 2003). The Panel Study of Income Dynamics provided data on 623 low-income, single mothers. The economic characteristics studied were: employment status, hours of work, wages, earnings, a job’s provision of personal control, family income, and welfare receipt. The mental health measure was the K-6 Non-Specific Psychological Distress Scale. The study adds to our understanding of the temporal relations between employment experiences and mental health by testing the social causation, social selection, and interactionist (bidirectional) perspectives. Specifically, this study tested the different perspectives with a wide range of economic indicators, tested mechanisms that may link mental and economic well-being, and combined multiple employment factors to see if patterns emerged that related uniquely to psychological distress. The findings supported social selection as earlier psychological distress predicted future employment, hours, wages, earnings, household income, and welfare receipt. The tested mediator of days of lost work affected by psychological distress indicated an indirect effect of poor mental health predicting diminished job productivity that, in turn, predicted reduced employment, hours, wages, and earnings. Results were similar for subgroups of mothers based on the age of their youngest child or prior welfare history. The single significant finding was that a longer span of welfare receipt predicted worse mental health as compared to mothers who reported a shorter period of welfare receipt. Latent class analysis identified three patterns of employment and welfare receipt across time: a) exchanged earnings for welfare, b) high employment and earnings growth with reduced welfare, and c) moderate employment growth. The groups that exchanged earnings for welfare (about 10% of the sample) evidenced increased psychological distress compared to mothers with high or moderate employment growth. Support for the social selection hypothesis suggests that policies and interventions that help low-income mothers improve their psychological well-being could also enhance their economic well-being. Implications for future research could explore the effects of such policies.
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Problématique : L’amélioration de l’accessibilité financière aux soins de santé est essentielle pour réduire la morbidité et de la mortalité infantile dans les pays à ressources limitées. Cependant, les preuves disponibles sur la relation entre un accès accru aux soins et l’amélioration la santé infantile, dans le long terme, demeurent insuffisantes et parfois inconnues. Dans le contexte spécifique de la région du Sahel au Burkina Faso où les niveaux élevés de morbidité et de malnutrition coïncident avec un faible recours aux soins, une intervention de santé publique associant la gratuité des soins à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté a été mise en œuvre en septembre 2008. Objectifs : En utilisant des approches statistiques et épidémiologiques appliquées aux données transversales et de séries chronologiques, cette thèse vise à apporter une meilleure compréhension de la façon dont la présence de l’intervention dans les communautés peut augmenter et maintenir l’utilisation des services de santé à long terme et améliorer la santé des enfants de moins de cinq ans. Les objectifs spécifiques sont : 1) évaluer le maintien à long terme des effets de l’intervention sur l’utilisation des services de santé chez les enfants de moins de cinq ans, 2) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur la probabilité de survenue d’une maladie et sur la probabilité d’utilisation des services de santé chez les enfants de moins de cinq ans, et 3) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur le retard de croissance chez les enfants de moins de cinq ans. Méthodes : Les données proviennent du système national d’information sanitaire, d’une enquête rétrospective sur les services de santé ainsi que d’une enquête de ménages réalisée quatre ans après le début de l’intervention dans 41 villages du district d’intervention et 51 villages du district de comparaison. Nous avons utilisé un plan quasi expérimental à séries temporelles interrompues avec groupe de comparaison pour évaluer les effets immédiats et à long terme de l’intervention sur les taux d’utilisation des services de santé. Ensuite, un plan d’étude transversale post-intervention avec un groupe de comparaison nous a permis d’évaluer l’effet contextuel de l’intervention sur la probabilité de survenue d’une maladie, sur la probabilité d’utilisation des services de santé et sur le retard de croissance chez les enfants de moins de cinq ans. La stratégie analytique a combiné la méthode de pondération par les scores de propension pour équilibrer les covariables entre les deux groupes, la modélisation binomiale négative à effets mixtes, les régressions linéaire et logistique multiniveaux. Résultats : L’intervention de gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté était associée à l’augmentation et au maintien de l’utilisation des services de santé au-delà de quatre ans (ratio des taux d’incidence = 2,33 ; IC 95 % = 1,98 – 2,67). En outre, comparativement aux enfants vivant dans le district de contrôle, la probabilité d’utiliser les services de santé était de 17,2 % plus élevée chez les enfants vivant dans le district d’intervention (IC 95 % = 15,01–26,6) ; et de 20,7 % plus élevée lorsque l’épisode de maladie était sévère (IC 95 % = 9,9–31,5). Ces associations étaient significatives, quels que soient la distance par rapport aux centres de santé et le statut socio-économique du ménage. Par ailleurs, alors que le contexte de résidence expliquait 9,36 % de la variance du retard de croissance (corrélation intraclasse = 9,36 % ; IC 95 % = 6,45–13,38), la présence de l’intervention dans les villages n’explique que 2 % de la variance du retard de croissance. Cependant, nous n’avons pas pu démontrer que la présence de l’intervention dans les communautés était associée à une réduction de la probabilité de survenue d’un épisode de maladie (Différentiel des probabilités = 4.4 ; IC 95% = -1.0 – 9.8), ni à une amélioration significative de l’état nutritionnel des enfants de moins de cinq ans (RC = 1,13 ; IC 95 % = 0,83–1,54). Conclusion : Cette thèse souligne que la gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté est efficace pour augmenter et maintenir l’utilisation des services de santé et réduire les inégalités géographiques de recours aux soins. Cependant, cette intervention n’était pas associée à une amélioration des résultats de santé infantile. Bien que des études longitudinales rigoureuses soient nécessaires pour comprendre pleinement l’influence potentielle de cette intervention sur la morbidité, cette thèse plaide pour la nécessité d’agir simultanément sur les autres déterminants sociaux de la santé et d’intégrer, de manière synergique, des interventions spécifiques à la nutrition pour plus d’impact sur la santé infantile.
Introduction: Improving financial access to health care is believed to be essential for reducing the burden of child morbidity and mortality in resource-limited settings, but the available evidence on the relationship between increased access and health remains scarce and the long-term issues are still unknown. In the specific context of the Sahel region in Burkina Faso where high levels of morbidity and malnutrition coincide with low health care use, a pilot intervention for free health care including quality of care improvement and management of malnutrition at the community level was implemented in September 2008. Objectives: Using statistical and epidemiological approaches applied to cross-sectional and time series data, this thesis aims to provide a better understanding of how the presence of intervention in communities can increase and maintain long-term use of health services and improve the health of children under five years. The specific objectives are: 1) to evaluate the long-term effects of the intervention on the use of health services in children under the age of five, 2) to estimate the contextual effect of intervention on the probability of occurrence of and the likelihood of health services being used by children under five, four years after the start of its implementation, and 3) to evaluate the contextual effect of the intervention on stunting in children under five, four years after the start of its implementation. Methods: The data for the analyses were provided from a variety of sources including the national health information system, a retrospective health services survey, and a household survey conducted four years after the intervention onset in 41 villages in the intervention district and 51 villages in the comparison district. We used a quasi-experimental controlled interrupted time-series design group to analyze the immediate and long-term effects of the intervention on the rate of health services utilization in children under five. Then, a quasi-experimental post-test-only design that included a control group allowed us to evaluate the contextual effect of the intervention on the probability of occurrence of a disease, on the probability of use of health services, and stunting in children under five. The analytic strategy combined the propensity score weighting method to balance the covariates between the two groups, two-level mixed-effects negative binomial, and linear and logistic regression models to account for the hierarchical structure of data. Results: The intervention for free health care including quality of care improvement and management of malnutrition at the community level was associated with an increased and maintained use of health services beyond four years after the onset of intervention (incidence rate ratio = 2.33; 95% CI = 1.98–2.67). In addition, compared to children living in the comparison district, the probability of using health services was 17.2% higher among those living in the intervention district (95% CI = 15.0–26.6); and 20.7% higher when the illness episode was severe (95% CI = 9.9–31.5). These associations were significant regardless of the distance to health centers and the socio-economic status of households. In addition, inequalities in the use of care were less pronounced in the intervention villages compared to those in the control village. Finally, the results also showed that the residence context accounted for 9.36% of the variance in stunting (intra-class correlation = 9.36% ; 95% CI = 6.45–13.38), and only 2% of the variance in stunting was explained by the intervention. However, we could not demonstrate that the intervention in these communities was associated with a reduced probability of an illness occurring (AME=4.4 (95% CI: -1.0 – 9.8), nor with a significant improvement in the nutritional status among children under five (OR = 1.13; 95% CI = 0.83–1.54). Conclusion: This thesis underlines the importance that affordable health care, including quality of care, as well as improving the management of malnutrition at the community level, are effective in increasing and maintaining the use of health services and reduce geographical inequalities in the use of care. However, this intervention was not associated with improved child health outcomes. Although rigorous longitudinal studies are necessary to fully understand the potential influence of this intervention on morbidity, this thesis highlights the need to simultaneously act on other social determinants of health and to synergistically integrate nutrition-specific interventions for greater impact on child health.