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Cette thèse part de la proposition d’une rencontre possible entre psychanalyse et génétique médicale par le biais des soins offerts aux enfants porteurs de syndromes génétiques, notamment le syndrome de l’X fragile. Nous avons trouvé dans les recherches en épigénétique une voie de rapprochement de ces différents champs du savoir. L’idée selon laquelle l’environnement est capable de modifier l’expression des gènes représente la rupture d’un certain déterminisme génétique autrefois accepté, et ouvre un espace où penser la singularité. Notre travail propose d’élargir le concept d’environnement, en y considérant la relation de l’enfant avec l'Autre, lieu du langage, comme opérateur de marques sur son corps : marques symboliques, constituées dès le tout début de la rencontre de l’infans et de ceux qui s’occupent de lui. C’est justement dans cet espace d’échange avec l'Autre qu’a lieu l’émergence d’un sujet. Nous avons opté pour les concepts de sujet et de transfert pour soutenir l’articulation de la clinique psychanalytique et de la génétique médicale en ce qui concerne le traitement. Nous avons donc exposé trois cas cliniques issus de notre pratique, d’enfants traversés par le diagnostic de l’X fragile afin d’illustrer de quelle manière les conceptions de sujet et de transfert se reflètent dans la clinique. Tenant compte que la psychothérapie est également prise comme objet d’étude de l’épigénétique, et qu’elle est donc considérée comme un environnement capable de provoquer, voire de renverser des marques épigénétiques, l’enjeu de notre travail repose sur la proposition suivante : et pourquoi pas la psychanalyse également ? La psychothérapie psychanalytique, ancrée sur le transfert, ne peut-elle pas, elle aussi, laisser des marques sur le petit patient ? / The current thesis assumes a possible encounter between psychoanalysis and medical genetics based on the treatment applied to children carrying genetic syndromes such as the Fragile X Syndrome. Epigenetic studies are a way to approximate different knowledge fields. The assumption that the environment is able to change gene expression strays from the genetic determinism we once believed and opens the way for us to reason about singularity. The proposition in the present study lies on expanding the concept of environment, by taking into consideration the relation between the child and the Other in the environment in question, as well as the place of language as the operator marking the child’s body. These symbolic marks start emerging in the first encounter between the infans and caregivers. The subject emerges precisely within an environment of exchanges that is set with the Other. The concepts of subject and transference were chosen to support the treatment articulation between psychoanalytic clinic and medical genetics. Thus, the present study reports three clinical cases followed by the authors, which involved children diagnosed with fragile X syndrome. These cases illustrate how the aforementioned concepts affect the clinical practice. Since psychotherapy has also been taken as the object of epigenetic studies, and as it is considered an environment able to cause, and even reverse, epigenetic marks, the current study relies on the following proposition: why not psychoanalysis as well? Can the psychoanalytic psychotherapy, anchored in the concept of transference, leave marks on the little patient too? / Esta tese parte da proposição de um encontro possível entre psicanálise e genética médica através do tratamento oferecido às crianças com síndromes genéticas, notadamente a Síndrome do X Frágil. Encontramos nas pesquisas em epigenética uma via de aproximação entre os distintos campos de saber. A ideia de que o ambiente é capaz de alterar a expressão dos genes quebra com um certo determinismo genético outrora acreditado, abrindo espaço para se pensar a singularidade. Nosso trabalho propõe a ampliação do conceito de ambiente, considerando nele a relação da criança com o Outro, lugar da linguagem, como operadora de marcas no seu corpo: marcas simbólicas, constituídas desde os primórdios do encontro do infans com seus cuidadores. É justamente nesse ambiente de trocas com o Outro que se dá a emergência de um sujeito. Os conceitos de sujeito e transferência foram escolhidos para sustentarmos a articulação da clínica psicanalítica com a genética médica no que concerne o tratamento. Assim, expusemos três casos clínicos oriundos de nossa prática, de crianças atravessadas pelo diagnóstico de X frágil no intuito de ilustrar de que forma as concepções de sujeito e transferência incidem na clínica. Levando-se em conta que a psicoterapia tem sido igualmente tomada como objeto de estudo da epigenética, sendo, desta forma, considerada como ambiente capaz de provocar e até mesmo reverter marcas epigenéticas, a aposta de nosso trabalho repousa na seguinte proposição: e por que não a psicanálise também? Será que a psicoterapia psicanalítica, ancorada na transferência, não pode ela também provocar marcas no pequeno paciente?

Outpatient physical therapy clinics (OPTC), like many other healthcare organizations, face an array of challenges in meeting the needs of the growing elderly population. The leadership behavior of OPTC managers is a key component to secure employee loyalty, accommodate increased patient demand, and implement positive organizational change. The purpose of this nonexperimental quantitative survey designed study was to investigate the relationship between the leadership styles perceived by OPTC healthcare managers and nonmanagerial employees, as measured by the Multifactor Leadership Questionnaire Short. The primary research question examined the difference between the OPTC managers' self-perceived leadership style and the nonmanagerial subordinates' perceptions of the manager's leadership style. The theoretical framework was the transformational and transactional leadership theory by Bass. Sampling was random and comprised of a minimal sample of 89 respondents. Data analysis included both descriptive and inferential statistics. Multiple regression analysis and correlations statistical models were used to predict the relationship of the dependent and independent variables. The results of the present study indicated a statistically significant relationship between the leadership style of OPTC managers and job effectiveness. All leadership styles of the OPTC managers were moderately correlated with job effectiveness, whereas passive/avoidant was negatively related to job effectiveness. This study is significant for OPTC leaders in their quest to create a leadership environment that fosters a positive influence on overall job performance and satisfaction among nonmanagerial staff, a formula for growth, and positive social change.

<p>The thesis examines the privatisation of China's health care since the 1980s, focusingon the privatisation of primary health care at the county level. The research choosesprivate clinics as research objects, includes a brief historical description of privatehealth care evolution and the existing health care system in China; based on theempirical data collected in the field work, it provides a current picture of private clinicand its privatisation process in a Chinese city, discusses the problems in privatemedical practice and challenges private clinic faces, and the influence of privatisationon health sector performance.The thesis notes the privatisation of primary health care by private clinics supplies analternative way for health care services. It plays a significant role in compensatingpublic system and promotes more equal health access, although the radicalprivatisation of all health sectors undermines the accessibility and quality of healthservices in general. Currently the private health sector in China is still small and yet toform a mature market, and there are multiple challenges for its further development,but it can be expected that the private sector in the health care area will expand rapidly,and China could hopefully find a suitable way of public/private mix under the newhealth reform.</p>

<p>In South Africa, governance structures in the form of clinic committees, hospital boards and district health councils are intended to provide expression to the principle of community participation at a local and district level. They are meant to act as a link between communities and health services and to provide a conduit for the health needs and aspirations of the community to be represented at various local, districts, provincial and national levels. This study aimed to assess the functioning of health governance structures in the form of clinic committees. Specifically, the study sought to ascertain the number of clinic committees associated with public health facilities in three provinces in South Africa namely the Eastern Cape, Free State and KwaZulu Natal and to identify the factors that are perceived by clinic committee members to either facilitate or impede the effective functioning of clinic committees.</p>

<p>Teenage pregnancy is one of the major public health problems facing teenage girls in Zambia (Webb, 2000 / Warenius, 2008). Teenage girls‟ access to and utilization of adolescent&nbsp / reproductive health (ARH) services is important for the prevention of teenage pregnancies and sexually transmitted infections (STIs) amongst teenagers.High incidence of teenage pregnancies has been noted in the district despite availability of ARHservices. Teenage pregnancy is a major contributing factor to the high school drop-out rate amongst the girls and is one of the challenges faced by non-governmental organizations (NGOs) that support girl child education, such as the campaign for female&nbsp / education (CAMFED) as well as for government agencies such as the Ministry of Education. The high incidence of teenage pregnancies could be an indication of poor access to&nbsp / and utilization of ARH services and therefore an assessment of the accessibility and utilization of the ARH services was done to explore the reasons for this.This research aimed to explore the factors affecting teenage girls‟ access to and utilization of ARH services in the Mpika district, Zambia. The research was a qualitative, descriptive and exploratory study using individual interviews with ten in-school teenage girls, four key informants rendering ARH services and a focus group discussion (FGD) with ten pregnant teenage girls. By exploring these particpants‟ perceptions and experiences, appropriate interventions to improve accessibility to and utilization of ARH services could be designed that would be appropriate for the local context in order for them to be effective. Thematic analysis with categorizing and coding methods was used to analyze the data. The study used the theory of planned behaviour (TPB) which stipulates that an individual‟s attitude,subjective norms and perceived behavioural control influence behaviour as a framework to explain the findings of the results of the study. The findings of the study indicated that physical, psychological and social barriers hindered adolescents from accessing and utilizing ARH services. The findings also suggested that high levels of knowledge about RH services do not necessarily translate into accessibility and utilization of ARH services. Accessibility to and utilization of ARH services by adolescents can also be determined by an individual‟s attitude, subjective norms, and perceived behavioural control as illustrated by the TPB. Adolescents need to feel comfortable using ARH services. Therefore the three variables of TPB should be taken into consideration when designing comprehensive ARH programmes in order to accommodate the unique reproductive health needs of the adolescents. There is need to encourage participation in and involvement of adolescents in planning and&nbsp / &nbsp / implementation of ARH programmes. The participants also made recommendations which included strengthening information and education on ARH, strengthening adolescent-friendly services, improving staffing levels and promotion of school health services.</p>

Objetivos: Describir y comparar las características epidemiológicas, clínicas e inmuno-virológicas de la población inmigrante y autóctona VIH+. Pacientes y Métodos: Estudio de cohortes retrospectivo que analiza y compara las principales variables clínicas, epidemiológicas, inmuno-virológicas y los principales aspectos relacionados con el TARGA en la población inmigrante y autóctona. Resultados y Conclusiones: El modo de transmisión del VIH más prevalente en inmigrantes fue la vía heterosexual (70.5%) y en autóctonos el consumo de drogas intravenosas (54.7%). No se hallaron diferencias clínicas e inmuno-virológicas significativas en ambas poblaciones tanto en la visita basal como al final del seguimiento clínico. La adherencia al TARGA fue buena (>95%) en inmigrantes y autóctonos (80.2% vs 76.2%, p=N.S). La frecuencia de defunciones por SIDA fue similar en inmigrantes y autóctonos (33.3% vs 31.2%) y las pérdidas de seguimiento de causa no filiada fueron mayores en sujetos inmigrantes (45% vs 36%). / Objectives: To describe and compare the epidemiological, clinical and immuno-virological features in immigrant and native HIV + populations. Patients and Methods: A retrospective cohort study that analyzes and compares the main clinical, epidemiological, immuno-virological aspects and the main issues that relate to HAART in the immigrant and native population. Results and Conclusions: The mode of transmission of HIV most prevalent in immigrants was heterosexual (70.5%) and indigenous injecting drug use (54.7%). We found no significant differences in immuno-virological parameters in both populations in the baseline visit and at the end of clinical follow-up. Adherence to HAART was good (> 95%) in immigrant and native HIV+ patients (80.2% vs 76.2%), without significant differences. The frequency of AIDS deaths was similar for immigrant and native patients (33.3% vs 31.2%) and the losses to follow-up due to unknown causes were higher in immigrant patients (45% vs 36%).

The thesis examines the privatisation of China's health care since the 1980s, focusingon the privatisation of primary health care at the county level. The research choosesprivate clinics as research objects, includes a brief historical description of privatehealth care evolution and the existing health care system in China; based on theempirical data collected in the field work, it provides a current picture of private clinicand its privatisation process in a Chinese city, discusses the problems in privatemedical practice and challenges private clinic faces, and the influence of privatisationon health sector performance.The thesis notes the privatisation of primary health care by private clinics supplies analternative way for health care services. It plays a significant role in compensatingpublic system and promotes more equal health access, although the radicalprivatisation of all health sectors undermines the accessibility and quality of healthservices in general. Currently the private health sector in China is still small and yet toform a mature market, and there are multiple challenges for its further development,but it can be expected that the private sector in the health care area will expand rapidly,and China could hopefully find a suitable way of public/private mix under the newhealth reform.