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This dissertation analyses public health service delivery at the Sir Seewoosagur Ramgoolam National Hospital (S.S.R.N.H.) in Mauritius. Particular emphasis is laid on the historical development of public health service delivery at S.S.R.N.H. Public health service delivery has been approached from the view points of its nature and scope. The core components of the research survey have been on some major obstacles and flaws in effective public health service delivery at S.S.R.N.H. The measuring instrument used for the research survey was a self­ administered questionnaire. The main findings were discussed especially absenteeism, personnel turnover, stress, burnout, morale, sexual harassment, lethargy and disobedience, nepotism, shirking responsibility, alcohol and drug abuse, active political interference, bribery and corruption, dishonesty and retaliation and neglect of duty. Attention was also devoted on the current national health policy for improving public health service delivery at S.S.R.N.H., inter-alia, the National Policy for Public Heath Act 17 of 2000 and the White Paper on Health Sector Development and Reform of December 2003. The public health environment is constantly altering. Therefore, it is essential to adjust to the changing health environment. This dissertation has addressed the future challenges in the micro health environment and macro health environment of S.S.R.N.H. Ultimately, a holistic instead of a parochial approach to addressing shortcomings identified in public health service delivery at S.S.R.N.H. has been advocated in this dissertation. / Public Administration / M.Admin. (Public Admin)

[pt] Esta tese investiga a ação do designer que atua em contextos sociais de conflito e marginalizados para promover e potenciar processos locais de Inovação Social através de experiências participativas e da estratégia de Design. Por isto, em primeiro lugar, foi desenvolvida uma revisão teórica com relação ao âmbito da contribuição social do Design, às abordagens e práticas mais conhecidas e ao contexto selecionado. Este momento foi preparatório para a fase subsequente de pesquisa que consistiu na implementação de um projeto de Design participativo em uma favela carioca em colaboração com uma ONG local. Ao longo da pesquisa de campo foram coletados dados usando como estratégia a observação participante. Em seguida, os dados foram analisados, sendo identificadas duas macro categorias de investigação, que são fundamentais para o tipo de ação de Design considerada. Trata-se do tempo e dos parceiros de projetos e interesses locais. Ambas foram depois verificadas, compreendidas e detalhadas através de entrevistas com designers e de uma nova fase de revisão teórica. Tudo isso permitiu chegar aos resultados de pesquisa: foram levantadas duas questões que podem influenciar o processo de Design, obstaculizá-lo ou até impedi-lo. Em primeiro lugar, o tempo apresentou-se com um elemento determinante no desenvolvimento de um projeto, capaz de favorecê-lo ou obstaculizá-lo. De fato, podem ocorrer divergências temporais entre o designer e o processo de Design, o contexto e os parceiros de projeto. Em segundo lugar surgiu a influência das forças contextuais exercidas pelos atores locais - e baseadas em interesses e agendas internas - sobre as ações do designer e a sua relação com a estrutura da rede de projeto. Os resultados de pesquisa sugerem que: (1) os fatores contextuais podem influenciar o processo de Design no desenvolvimento de projetos participativos que visam promover processos locais de Inovação Social; (2) a ação do designer em experiências participativas que visam a Inovação Social pode se beneficiar de abordagens que consideram os fatores contextuais; (3) as metodologias e ferramentas desenvolvidas até então para a atuação do designer no âmbito social não são suficientes para a ação. Por fim, a partir disso, a tese promove uma reflexão sobre a proposta de um Design social eficaz e a atual formação em Design neste âmbito. / [en] The thesis investigates the designer s action in conflict and marginalized social contexts aimed at promoting and enhancing local Social Innovation processes through participatory experiences and the Design strategy. Firstly, a theoretical review of the social contribution of Design, of the best-known approaches and practices, and of the selected context was developed. This moment had been preparatory for a subsequent phase of applied research that occurred with the implementation of a participatory Design project inside a Rio de Janeiro slum in collaboration with a local NGO. During field research data were collected through participatory observation. Their later analysis led to identify two key research macro-categories - time, and Design partners and local interests – that were verified and better understood through some interviews with designers and a new phase of theoretical review. All this led to research results: two main issues that may influence, impede or hinder the development of this kind of project were identified. Firstly, time appeared as a fundamental element in project development, able to promote or prevent it. In fact, temporal divergences between the designer and the Design process, between the context and the Design partners may occur. Secondly, the influence of the forces exerted by local actors - and based on interests and inner agendas - on the designer s actions emerged as well as its relation to the project network structure. Research results indicate that: (1) contextual factors may influence the Design process in participatory projects aiming at promoting local Social Innovation processes; (2) the designer s action in participatory experiences may benefit of approaches that consider contextual factors; (3) the methodologies and tools that have been developed to support designer s work in the social field are not enough for action. Finally, this thesis promotes a reflection about the widespread idea of an efficient Social Design practice and about Design education in this area.

Many individuals with severe motor impairments are cognitively capable, but because of their physical impairments, unable to express their intention through conventional means of communication. Access technologies are devices that attempt to translate the intention of these individuals into functional activity by harnessing their residual physical or physiological abilities. The primary objective of this thesis was to design and develop a novel non-invasive and non-contact access technology based on infrared thermal imaging. This access technology translates the local temperature change associated with voluntary mouth opening to activation of a binary switch such as a mouse click or key press. To this end, an algorithm based on motion and temperature analyses, and morphological and anthropometric filters was designed to detect mouth opening activity in thermal video in real-time. The secondary objective of this thesis was to introduce a mutual information measure for objective assessment of binary switch users’ performance. A model was suggested, in which combination of cognitive and physical abilities of the human user of a binary access switch constitute a communication channel. The proposed mutual information measure estimates the rate of information transmission in the ‘human communication channel’ during stimulus response tasks. Using this measure, in a study with ten able-bodied participants, the infrared thermal switch was validated against a conventional chin switch. Impairments in body functions and structures that may contraindicate the use of the infrared thermal switch were explored in a study with seven clients, with severe disabilities. Potential hard and soft technological solutions to mitigate the effect of these impairments on infrared thermal switch use were recommended. Finally the infrared thermal switch was tailored to meet the needs of a young man with severe spastic quadriplegic cerebral palsy, who had no other means of physical access.

Many individuals with severe motor impairments are cognitively capable, but because of their physical impairments, unable to express their intention through conventional means of communication. Access technologies are devices that attempt to translate the intention of these individuals into functional activity by harnessing their residual physical or physiological abilities. The primary objective of this thesis was to design and develop a novel non-invasive and non-contact access technology based on infrared thermal imaging. This access technology translates the local temperature change associated with voluntary mouth opening to activation of a binary switch such as a mouse click or key press. To this end, an algorithm based on motion and temperature analyses, and morphological and anthropometric filters was designed to detect mouth opening activity in thermal video in real-time. The secondary objective of this thesis was to introduce a mutual information measure for objective assessment of binary switch users’ performance. A model was suggested, in which combination of cognitive and physical abilities of the human user of a binary access switch constitute a communication channel. The proposed mutual information measure estimates the rate of information transmission in the ‘human communication channel’ during stimulus response tasks. Using this measure, in a study with ten able-bodied participants, the infrared thermal switch was validated against a conventional chin switch. Impairments in body functions and structures that may contraindicate the use of the infrared thermal switch were explored in a study with seven clients, with severe disabilities. Potential hard and soft technological solutions to mitigate the effect of these impairments on infrared thermal switch use were recommended. Finally the infrared thermal switch was tailored to meet the needs of a young man with severe spastic quadriplegic cerebral palsy, who had no other means of physical access.

This dissertation analyses public health service delivery at the Sir Seewoosagur Ramgoolam National Hospital (S.S.R.N.H.) in Mauritius. Particular emphasis is laid on the historical development of public health service delivery at S.S.R.N.H. Public health service delivery has been approached from the view points of its nature and scope. The core components of the research survey have been on some major obstacles and flaws in effective public health service delivery at S.S.R.N.H. The measuring instrument used for the research survey was a self­ administered questionnaire. The main findings were discussed especially absenteeism, personnel turnover, stress, burnout, morale, sexual harassment, lethargy and disobedience, nepotism, shirking responsibility, alcohol and drug abuse, active political interference, bribery and corruption, dishonesty and retaliation and neglect of duty. Attention was also devoted on the current national health policy for improving public health service delivery at S.S.R.N.H., inter-alia, the National Policy for Public Heath Act 17 of 2000 and the White Paper on Health Sector Development and Reform of December 2003. The public health environment is constantly altering. Therefore, it is essential to adjust to the changing health environment. This dissertation has addressed the future challenges in the micro health environment and macro health environment of S.S.R.N.H. Ultimately, a holistic instead of a parochial approach to addressing shortcomings identified in public health service delivery at S.S.R.N.H. has been advocated in this dissertation. / Public Administration and Management / M.Admin. (Public Admin)

The present study is the first to examine the effect of first versus second language (L1 versus L2) speech production on specific temporal parameters of speech in bilingual speakers with neurogenic speech disorders. Three persons with apraxia of speech (AOS), three with phonemic paraphasia (PP) and five normal speaking participants were included as subjects in the study. Subjects were required to read phonemically similar L1 and L2 target utterances in a carrier phrase, five times each, at a normal and fast speaking rate, respectively. This rendered four speaking contexts that included speech production in L1 at either a normal (L1NR) or fast speaking rate (L1FR) and speech production in L2 at either a normal (L2NR) or fast speaking rate (L2FR). Acoustic analysis of on-target productions involved measurement of utterance onset duration, vowel duration, utterance duration and voice onset time. Results revealed that in normal speakers, speech production in L2 results in greater token-to-token variability than in L1. However, token-to-token variability in the experimental subjects did not tend to increase whilst speaking in L2, most probably because these subjects generally decreased their speaking rate in this context, resulting in more consistent production. The subjects with AOS and PP seemed to be influenced by the increased processing demands of speaking in L2 to a greater extent than the normal speakers, in that they more frequently experienced difficulty with durational adjustments (decreasing duration in the fast speaking rate) in L2 than in L1. Furthermore, the subjects with AOS or PP also exhibited a greater extent of durational adjustment in L1 than in L2. The durations of most of the subjects with either AOS or PP tended to differ from those of the normal group to a greater extent in L2FR that was hypothesized to be the most demanding speaking context for these subjects. The longer than normal durations and greater than normal token-to-token variability in the subjects with either AOS or PP imply the presence of a motor control deficit. The extent of the motor control deficit appears to be more severe in AOS than in PP as is evident from the finding that the subjects with AOS generally exhibited longer durations and greater token-to-token variability than the subjects with PP. The pattern of breakdown in respect of different parameters and utterance groups also differed between subjects with AOS and PP. The nature of the disorder in AOS and PP thus appears to be both quantitatively and qualitatively different. Regarding measurement of the different temporal parameters, voice onset time appears to be less subject to the influence of L2 than the other measured temporal parameters. The results of this study imply that bilingual AOS is as much a reality as bilingual aphasia. Furthermore, the results underscore the importance of taking contextual factors, specifically L1 versus L2, into account when compiling assessment and treatment procedures for persons with either AOS or PP, since speech production in L2 appears to be motorically more difficult than in L1 for persons with neurogenic involvement. The significance of the results is discussed with reference to the influence of speech production in L2 on temporal control and the underlying nature of AOS and PP with regard to theories of speech sensorimotor control. Copyright / Dissertation (DPhil (Communication Pathology))--University of Pretoria, 2004. / Speech-Language Pathology and Audiology / unrestricted

Cette thèse de doctorat tente de répondre à la question de recherche suivante :comment ont évolués les variations spatiales des comportements de fécondité en Europe depuis un demi-siècle ?Elle s’emploie donc plus à décrire les variations spatiales de la fécondité qu’à analyser comment et pourquoi la fécondité européenne à évoluée pendant cette période. Si cette question est principalement descriptive elle abordera toute fois des questionnements interprétatifs des variations spatiales observées. En effet décrire comment les variations spatiales ont évoluées mène indirectement à se demander pourquoi de telles évolutions ont eu lieu. Cette thèse adopte une méthodologie géographique, inductive, évolutive et à des échelles spatiales multiples, ce qui la distingue de la plupart des études qui abordent un sujet démographique. Elle recoure à plusieurs bases de données originales, certaines à la fois transversales, chronologiques, infranationales et couvrant un large espace transnational. Cela a imposé un important travail de récolte et prétraitement des données, mais confère aux résultats une originalité qui contribue à une meilleure compréhension globale de la fécondité en Europe, de ses variations spatiales et de ses évolutions récentes.Le corps de cette thèse est organisé en quatre chapitres ayant chacun fait l’objet d’une publication (soumise :chapitre 3, acceptée :chapitre 2, ou publiée :chapitre 4 et 5). Les deux premiers articles explorent chacun une des deux principales dimensions des comportements de fécondité que sont l’intensité (chapitre 2) et le calendrier de la fécondité (chapitre 3). Ils s’intéressent aux évolutions de ces dimensions sur environs un demi-siècle en Europe en utilisant principalement des données au niveau régional NUTS-2. Le quatrième chapitre considère ces deux dimensions de manière simultanée et s’intéresse aux différences spatiales locales (à une échelle équivalente au niveau communale en Belgique). Le cinquième chapitre considère les variations intra-urbaines à Bruxelles, en considérant à la fois les différences entre groupes sociaux et entre espaces, ce qui permet d’évaluer l’impact des variables contextuelles par rapport à l’influence de la composition de la population. En conclusion cette thèse expose les variations spatiales des comportements de fécondité en Europe ainsi que leurs évolutions depuis la seconde moitié du vingtième siècle. Elle propose aussi un ensemble de déterminants utile à l’interprétation les variations spatiales de la fécondité. Ces déterminants sont tantôt matériels tantôt du ressort des études abordant une position épistémologique plus post-matérialiste. L’approche géographique de cette thèse pousse à considérer ces deux ensembles de facteurs et à les structurer selon leur rayon d’action, soit l’échelle spatiale à laquelle ils influencent les comportements de fécondité. Il ressort que l’articulation de ces différents facteurs exerçant leur influence à des échelles différentes constitue un contexte géographique déterminant en partie les actions individuelles de la fécondité. / Option Géographie du Doctorat en Sciences / info:eu-repo/semantics/nonPublished

Contexte L'importance des stratégies nationales d'amélioration de la qualité est de plus en plus reconnue par les décideurs politiques des systèmes de santé et par les organisations internationales telles que l'OMS, l'OCDE et la Banque mondiale. À la suite de leur questionnement sur la manière de gérer l'amélioration systémique de la qualité, certains pays de l'OCDE, comme l'Allemagne, le Royaume-Uni, la France, le Canada, etc. ont stratégiquement adopté la stratégie systémique appelée « agence d'appui à l'amélioration de la qualité des soins et des services de santé ». Elle repose notamment sur des approches centrées sur le patient/usager et sur la collaboration des parties prenantes et encourage, entre autres, l'amélioration de la qualité à tous les niveaux de changement dans une juridiction : individuel, équipe, organisationnel et systémique, en assurant la cohérence de toutes les autres stratégies de la qualité. Cette thèse vise à examiner comment les stratégies nationales ont été façonnées dans certaines juridictions dans le monde et ensuite, en sélectionnant différentes juridictions ayant implanté une telle stratégie, elle en étudie deux cas en profondeur. Méthodes Dans un premier temps, une étude comparative en ligne des pratiques internationales de 13 juridictions de différentes régions du monde, sélectionnées selon un choix raisonné, a été réalisée. Cette étude s’est basée sur les sept principales fonctions de gestion de la qualité des soins et des services de santé dans une juridiction, proposées après avoir mobilisé plusieurs cadres dont le cadre d’action de l’OMS, et sur les indicateurs de qualité des soins, mis à disposition par l'OCDE sur son site Internet. Ensuite, deux agences de deux juridictions différentes, classées dans chacun des deux modèles proposés dans la première phase de la recherche, ont été sélectionnées afin de les étudier de manière approfondie en mobilisant un modèle d'analyse systémique. Il s'agit de la Haute autorité de santé (HAS) en France et de l'Institut national d'excellence en santé et services sociaux (INESSS) au Québec. Avec une approche déductive, dans le cadre d'une analyse d'implantation du type 2 et d’une approche inductive dans le cadre du type 3, plusieurs sources de données : une recherche documentaire approfondie, des entretiens semi-structurés, un groupe de discussion, et une observation ont été utilisées de manière itérative pour réaliser ce travail. Toutes les données ont été traitées et analysées de manière confidentielle à l'aide du logiciel QDA Miner 6.0.2 et validées par chaque agence étudiée. Résultats Les résultats du premier article ont révélé que les pays faisant partie du modèle 1 de notre taxonomie se classaient mieux pour la qualité des soins de santé avec, par exemple, 100 % (en Suède) à 21 % (en Allemagne) des principales fonctions de gestion de la qualité assurées par le "ministère de la Santé" et la plupart des fonctions modérément, voire pas du tout, concentrées dans une seule organisation. Parmi les deux agences contrastées étudiées, les résultats montrent que la HAS a un éventail d'activités plus large et que l'INESSS est plus concentré sur l’évaluation des médicaments, technologies et modes d’intervention en santé. Les résultats du second article ont, en effet, montré que ces deux agences d’appui à l’amélioration de la qualité disposent d'une autonomie relative et que chacune a eu un impact sur l'amélioration de la qualité des soins et des services dans les milieux de pratique de sa juridiction. Enfin, les résultats du troisième article ont fait ressortir deux grands groupes de facteurs contextuels : ceux liés au contexte interne des agences et ceux liés à leur environnement externe pouvant influencer les effets perçus de cette stratégie. Conclusion Cette recherche empirique internationale sur les stratégies systémiques d'amélioration de la qualité est l'une des premières. Elle vient enrichir la compréhension des différentes stratégies systémiques dans les juridictions et produit des connaissances aussi bien pour la pratique que pour la recherche. Nos conclusions peuvent être utilisées, non seulement, pour optimiser cette stratégie dans les juridictions que nous avons étudiées (France et Québec), mais aussi dans d'autres juridictions qui les ont également implantées. En outre, elles peuvent être utiles et inspirantes, à la fois, pour des pays développés, émergents et en développement qui n'ont pas encore implanté ce type de stratégie systémique. / Background The importance of national quality improvement strategies is increasingly recognized by policymakers in health systems and by international organizations such as the WHO, the OECD, and the World Bank. Following their questioning of how to manage the systemic quality improvement, some OECD countries, such as Germany, England, France, and Canada, etc. have strategically adopted the systemic strategy referred as the “Quality Improvement Support Agency for Health Care and Services (QISA)”. It is based on patient/user-centered approaches and stakeholder collaboration and promotes, among other things, quality improvement at all levels of change within a jurisdiction: individual, team, organizational and systemic by ensuring consistency across all quality strategies. This thesis aims to examine how national strategies have been shaped in some jurisdictions around the world and then, by selecting different jurisdictions that have implemented such a strategy, it studies two cases in depth. Methods First, an online comparative study of international practices in 13 jurisdictions in different regions of the world, selected according to a reasoned choice, was conducted. The study was based on the seven key health care and services quality management functions in a jurisdiction, proposed after mobilizing several frameworks, including the WHO's framework for action, and on the quality-of-care indicators made available by the OECD on its website. Next, two QISAs from different jurisdictions, classified in each of the two models proposed in the first phase of the research, were selected for in depth study with the mobilization of a systemic analysis model. These were the Haute autorité de santé (HAS) in France and the Institut national d'excellence en santé et services sociaux (INESSS) in Québec. Using a deductive approach in a type 2 implementation analysis and an inductive approach in the context of type 3, several sources of data: an extensive documentary research, semi-structured interviews, a focus group, and an observation were used in an iterative manner to complete this work. All data were processed and confidentially analyzed using QDA Miner 6.0.2 software. Finally, in a historical approach, a narrative was produced for each of the QISAs studied and validated by each studied. Results The results of the first article revealed that countries that are part of model 1 of our taxonomy ranked better for quality of care with, for example, 100% (in Sweden) to 21% (in Germany) of the key health care and services quality management functions performed by the "Ministry of Health" and most of the functions moderately, or not at all, concentrated in a single organization. Of the two contrasting QISAs studied, the results showed that the HAS has a broader range of activities and the INESSS is more focused on the assessment of drugs, technologies, and health interventions. The results of the second article showed that both have relative autonomy, and that each had an impact on improving the quality of care and services in the practice settings in its jurisdiction. Finally, the results of the third article highlight two main groups of contextual factors: those related to the internal context of the QISAs and those related to their external environment that can influence the perceived effects of this systemic strategy. Conclusion This international empirical research on systemic quality improvement strategies is one of the first. It adds to the understanding of different systemic strategies across jurisdictions and generates knowledge for both practice and research. Our conclusions can be used to optimize this strategy in the jurisdictions we studied (France and Québec), but also in other jurisdictions that have implemented them. Moreover, they can be useful and inspiring for developed, emerging, and developing countries that have not yet implemented this type of systemic strategy.