Ce travail porte sur l’étude du traitement de la question sociale dans le domaine de la santé à l’hôpitalpublic au prisme des rapports de pouvoir et de l’organisation du système de santé. Ainsi, l’enquête sociologiquea porté sur les Permanences d’accès aux soins de santé (PASS) présentes au sein d’hôpitaux publics enFrance et dont l’accès est réservé aux personnes éloignées du système de santé, dont le cas emblématiqueest celui de l’étranger sans papier.La méthode a consisté à combiner des éléments sociohistoriques et une enquête empirique qui s’est dérouléesur trois années auprès de seize PASS implantées dans huit villes et au sein d’organismes en lien avecelles, telles des associations ou encore les tutelles institutionnelles. Des observations et des entretiens semidirectifsauprès de professionnels ont été réalisés (n=40).D’abord, l’étude de la généalogie de la question sociale en santé en France montre comment s’estprogressivement constitué à la fin du XXe siècle un espace du soin de la précarité visant à prendrespécifiquement en charge des groupes sociaux parmi les plus défavorisés. Cet espace de soin spécifique aconnu une institutionnalisation dans le système hospitalier public français au cours des années 1990,s’inscrivant à la fois dans le champ de la santé publique et dans celui de la lutte contre l’exclusion. Il remplitdes objectifs (bio-)politiques multiples : lutter contre l’exclusion sociale, garantir un droit à la santé, protégerla santé de la population générale. En second, l’étude des PASS dans l’organisation hospitalière conclut à leurmise en difficulté par les deux modèles dominants concurrents (spécialisation technique et néo-managérial).Face à cette situation, diverses stratégies (d’adaptation et d’autonomisation) sont déployées par différentsacteurs à l’intérieur et à l’extérieur de l’hôpital. Enfin un troisième résultat relève de l’analyse des catégoriesde patients produites lors des interactions avec les professionnels des PASS. Elle met en lumière le rôle qu’ellesjouent dans la stratification du système de santé à ses marges les plus basses. Les patients sont ainsi séparésen groupes plus ou moins légitimes selon des critères de citoyenneté et de solvabilité auxquels sont attribuéesdes valeurs de la vie différenciées. Cela se caractérise dans le quotidien des PASS, par une tension permanenteentre inclusion et exclusion du patient et une distribution différenciée des soins. Un gouvernement individualiséet flexible permet de poursuivre dans un tel contexte la multiplicité des objectifs (bio-)politiques. / This thesis explores how the “social question” (question sociale) is managed as an issue of health at publichospitals through the lens of power relations and health care structures. To this end, the sociological studyexamines the “healthcare access unit” (Permanence d’accès aux soins de santé, PASS) of public hospitals in France,which are reserved for persons who are excluded from the healthcare system – most notably irregular migrants.The employed methods combine a socio-historical analysis with ethnographic fieldwork — including participantobservation and semi-structured interviews (n=40) — conducted over the course of three years in sixteen PASSunits based at eight different hospitals, and in the broader structures within which they exist (i.e. associationsand institutional guardianships).In the first section, a genealogy of the “social question” in health in France demonstrates how space for thehealthcare of poverty has emerged at the end of the 20th century, which specifically targets social groups amongthe most destitute. This space of a particular type of care was increasingly institutionalized in the public hospitalsystem during the 1990’s, embedding itself in both the field of public health and in the fight against socialexclusion. This space fulfills several (bio)political objectives: fighting social exclusion, ensuring a right to health,and protecting the health of the population as a whole. Second, an analysis of PASS units in the organisation ofpublic hospitals exposes how they are weakened through two dominant and competing models (technicalspecialization and new public management). Faced with this situation, varied strategies (ex. of adaptation andempowerment) are employed by different actors inside and outside of the hospital. Lastly, a third section lays outthe categories of patients that are produced during interactions with professionals from PASS units. It exposesthe role of these categories in the stratification of the health care system along its lowest margins. Patients aredivided into more or less legitimate groups - based on criteria of citizenship and of solvency – each of which areafforded differentiated values of life. These dynamics are characterized by a permanent tension betweeninclusion and exclusion in the field, and by a differentiated distribution of health care. In such a context, anindividualized and flexible government allows for the pursuit of these multiple (bio)political objectives.

Using data gathered over the course of two months through participant observation and semi-structured interviews with health providers (n=19) and community members (n=20), this research analyzes patient access to health care resources and describes community members' and health care providers' perceptions of pressing health concerns in their area. The results of this research show the types of health care resources in the county, the similarities and differences between health providers' and community members' perceptions, and how the unique characteristics of this community influence health care access and health disparity.

This study aims to examine how the migration experience influences newcomer mothers’ young child feeding and care practices and their children’s overall health. The thesis comprises three separate manuscripts, each of which examines one of the three intermediate determinants of the nutritional status of young children (UNICEF 1990): access to healthcare, household food insecurity, and child feeding and care practices. The research was conducted in Toronto’s Jane-Finch neighbourhood, a suburban neighbourhood home to a high density of newcomers. Thirty-two participants (16 Sri Lankan Tamil and 16 Latin American) who had migrated to Canada within the past five years as refugee claimants or family sponsored immigrants participated in the study. Data collection consisted of semi-structured interviews with women from low-income households who had a child between the ages of 1 and 5 years. Spanish and Tamil speaking interviewers interviewed each participant two or three times. Data was analyzed using a mid-level approach in which broad analytical themes are determined prior to analysis and specific themes were then generated based on participants’ perspectives and are grounded in the data. The first manuscript examines newcomer mothers’ experiences accessing physicians for their children and identifies the major gaps between mothers’ expectations and their actual experiences that lead to barriers in communication and overall patient dissatisfaction. The second manuscript demonstrates that mothers’ past experiences with food insecurity affect two aspects of the construct of food insecurity: its managed aspect and its temporal nature. This finding has implications for the measurement of food insecurity in newcomer populations. The third manuscript reveals that newcomer mothers are exposed to several parallel and often conflicting systems of knowledge concerning health and nutrition for their children, and that their utilization of Canada’s Food Guide is impeded by its failure to acknowledge alternate parallel knowledge systems. These findings can be applied to the development of social and health policy aimed at improving cultural competency in healthcare and nutrition education and at ameliorating the income constraints leading to household food insecurity.

Wireless Sensor Networks (WSNs) have recently attracted much interest in the research community because of their wide range of applications. One emerging application for WSNs involves their use in healthcare where they are generally termed Wireless Medical Sensor Networks (WMSNs). In a hospital, fitting patients with tiny, wearable, wireless vital sign sensors would allow doctors, nurses and others to continuously monitor the state of those in their care. In the healthcare industry, patients are expected to be treated in reasonable time and any loss in data availability can result in further decline in the patient's condition or can even lead to death. Therefore, the availability of data is more important than security concerns. The overwhelming priority is to take care of the patient, but the privacy and confidentiality of that patient's medical records cannot be neglected. In current healthcare applications, there are many problems concerning security policy violations such as unauthorised denial of use, unauthorised information modification and unauthorised information release of medical data in the real world environment. Current WSN access control models used the traditional Role-Based Access Control (RBAC) or cryptographic methods for data access control but the systems still need to predefine attributes, roles and policies before deployment. It is, however, difficult to determine in advance all the possible needs for access in real world applications because there may be unanticipated situations at any time. This research proceeds to study possible approaches to address the above issues and to develop a new access control model to fill the gaps in work done by the WSN research community. Firstly, the adaptive access control model is proposed and developed based on the concept of discretionary overriding to address the data availability issue. In the healthcare industry, there are many problems concerning unauthorised information release. So, we extended the adaptive access control model with a prevention and detection mechanism to detect security policy violations, and added the concept of obligation to take a course of action when a restricted access is granted or denied. However, this approach does not consider privacy of patients' information because data availability is prioritised. To address the conflict between data availability and data privacy, this research proposed the Trust-based Adaptive Access Control (TBA2C) model that integrates the concept of trust into the previous model. A simple user behaviour trust model is developed to calculate the behaviour trust value which measures the trustworthiness of the users and that is used as one of the defined thresholds to override access policy for data availability purpose, but the framework of the TBA2C model can be adapted with other trust models in the research community. The trust model can also protect data privacy because only a user who satisfies the relevant trust threshold can get restricted access in emergency and unanticipated situations. Moreover, the introduction of trust values in the enforcement of authorisation decisions can detect abnormal data access even from authorised users. Ponder2 is used to develop the TBA2C model gradually, starting from a simple access control model to the full TBA2C. In Ponder2, a Self-Managed Cell (SMC) simulates a sensor node with the TBA2C engine inside it. Additionally, to enable a full comparison with the proposed TBA2C model, the Break-The-Glass Role Based Access Control (BTGRBAC) model is redesigned and developed in the same platform (Ponder2). The proposed TBA2C model is the first to realise a flexible access control engine and to address the conflict between data availability and data privacy by combining the concepts of discretionary overriding, the user behaviour trust model, and the prevention and detection mechanism.

Master of Public Health - MPH / Non-communicable diseases (NCDs) are the leading cause of death globally, affecting a significant proportion of the economically active population, the majority of these occurring in low- and middle-income countries (LMICs). In South Africa, over 40% of deaths are attributable to NCDs. The use of healthcare services by individuals who have NCDs is putatively high but has yet, not been adequately quantified. Furthermore, there is a paucity of research data on factors that influence healthcare services use among those experiencing NCDs in South Africa.

Indiana University-Purdue University Indianapolis (IUPUI) / In the United States, there is very little knowledge about the health of African immigrants. Although their population exceeds 2 million and still on the rise exponentially, a big gap exists regarding knowledge about health care access and outcomes for this population. Before relocating to the US, many African immigrants face health-threatening conditions, including civil wars and poverty, which are exacerbated by the lack of understanding and attention to their health care needs in the US. Methods: To examine the health care experiences of African immigrants in the US, two distinct studies were conducted. A scoping review examined literature between 1980 and 2016 using four databases, to identify knowledge-gaps concerning African immigrant in the US. A qualitative study comprising 33 semi-structured (one-on-one) interviews and 4 focus groups was conducted using Nigerian immigrant participants in Indianapolis, to assess how discrimination affects their health care experiences and quality of care, and the factors their influence their health care meanings, respectively. Results: For the scoping review, 14 articles were included. All the studies were focused on barriers to the health care access of African immigrants in the US. Along with religion and culture, lack of culturally-competent healthcare and distrust of the US health system, were identified as the major barriers. Both the one-on-one interviews and focus groups revealed provider attitudes, through implicit and open biases, were a key contributing factor to the participants’ health care meanings and healthcare utilization. Additionally, results showed an important intersectionality within the healthcare experiences of the participants, as a result of their perception as “black,” along with African Americans and other physically-related groups. Conclusion: African immigrants in the US grapple with the critical process of reconciling their original identities with their emerging realities, including negative provider attitudes and discrimination, and lack of identify in the US health system. This study highlights the importance of understanding African immigrant health in the US, through the examination of the role of the African framework of understanding of their health in their approaches to healthcare and well-being. / 2021-03-06

No description available.

No description available.

In the U.S., diabetes mellitus cases have been increasing, from 25 million in 2010 to 29 million in 2012. Healthy People 2020, the U.S. National Health Agenda, has established specific goals and objectives for diabetes. In the U.S., prevalence of pre-diabetes and diabetes for adult Hispanics was 38% and 12%, respectively, in 2012. The total estimated diabetes cost in the U.S. has been increasing, from $176 billion in 2007 to $245 billion in 2012. The current study had two research hypotheses; the formative phase was expected to demonstrate a need for a community-based Type 2 Diabetes Mellitus (T2DM) self-management intervention for Spanish-speaking Hispanics. Random Control Trial (RTC) was expected to demonstrate the potential impact in preventing and managing T2DM. Methods. A community-based lifestyle education curriculum was translated into Spanish, and adapted to Hispanic culture. This study includes three phases: 1) a formative phase; 2) a two-group pilot RCT with Hispanic Living with Diabetes (HBLD) and a delayed treatment condition; and 3) post-HBLD focus groups held with three participating groups of HBLD. Results. Of 60 participants screened in the formative phase, 62% had A1c > 5.7%, and 75% did not have medical insurance. Of 6 participants who completed the pilot, A1c decreased for all six participants. Of 67 participants screened in phase 2, 61% had A1c > 5.7%. Of 30 HBLD participants in the RCT, baseline versus 3-month mean A1c increased 0.2 for the delayed control group (n = 10) and did not experience any change for the intervention group (n = 11). The difference in A1c change from baseline to follow up between treatment groups was not statistically significant (Kruskal Wallis, p < 0.05). Diabetes knowledge and SCT variables change from baseline to follow-up between groups were not statistically significant. Major themes identified in focus group discussions included barriers to access to health and nutrition services, the value of having a Spanish-speaking Hispanic as a health educator, and barriers to recruiting community members as promotoras. Implications. HBLD has potential to reduce complications of diabetes among Hispanic participants by providing education to those who may not otherwise have access to it. / Ph. D.

The robustness and responsiveness of a country's health system predict access to a range of health services, including maternal and child health (MCH) services. The purpose of this cross-sectional study was to examine the influence of 5 health system characteristics on access to MCH services in Sierra Leone. This study was guided by Bryce, Victora, Boerma, Peters, and Black's framework for evaluating the scaleup to millennium development goals for maternal and child survival. The study was a secondary analysis of the Sierra Leone 2017 Service Availability and Readiness Assessment dataset, which comprised 100% (1, 284) of the country's health facilities. Data analysis included bivariate and multivariate logistic regressions. In the bivariate analysis, all the independent variables showed statistically significant association with access to MCH services and achieved a p-value < .001. In the multivariate analysis; however, only 3 predictors explained 38% of the variance (R� = .380, F (5, 1263) = 154.667, p <.001). The type of health provider significantly predicted access to MCH services (β =.549, p <.001), as did the availability of essential medicines (β= .255, p <.001) and the availability of basic equipment (β= .258, p <.001). According to the study findings, the availability of the right mix of health providers, essential medicines, and basic equipment significantly influenced access to MCH services, regardless of the level and type of health facility. The findings of this study might contribute to positive social change by helping the authorities of the Sierra Leone health sector to identify critical health system considerations for increased access to MCH services and improved maternal and child health outcomes.