Un des défis de la promotion de la santé est de concevoir des outils théoriques et des interventions qui prennent en compte la façon dont les structures influencent le parcours de vie des individus tout en reconnaissant la capacité des individus à déterminer leur vie et à façonner, en retour, le monde dans lequel ils vivent. Le cadre d’analyse des mécanismes d’exclusion permet une telle intégration, particulièrement autour de la notion d’accès (Adam et Potvin, 2016). Ce cadre d’analyse conçoit les mécanismes d’exclusion comme un ensemble d’éléments de différents niveaux qui, en interaction, limitent l’accès aux droits, ressources et capacités pour vivre une vie en santé et mènent à des situations de vulnérabilité. Il propose de regarder les questions d’accès comme une fenêtre pertinente pour s’intéresser à l’interaction entre les individus et les structures. Partant de ce cadre d’analyse, le but de cette thèse est de comprendre comment les limites d’accès aux droits, aux ressources et aux possibilités de développer des capacités interagissent avec l’action des individus et le contexte dans lequel ils déploient cette action. Afin d’être en mesure d’examiner des contextes influencés par des mécanismes d’exclusion et d’étudier le déploiement de l’action des individus, cette recherche a pris appui sur deux postulats : 1) l’insécurité alimentaire est une manifestation de mécanismes d’exclusion limitant l’accès aux ressources financières nécessaires permettant de se nourrir en quantité et en qualité suffisante ou générant la peur de ne pas avoir la possibilité de se nourrir en quantité et en qualité suffisante; et 2) se rendre dans un organisme communautaire est une manifestation des individus de leur capacité à déployer des actions pour faire face aux obstacles qu’ils rencontrent. Partant de ces postulats, nous avons étudié, par voie d’entretiens de type récit de vie, le parcours de 12 individus en lien avec la fréquentation d’un organisme communautaire en sécurité alimentaire. Sur la base de l’analyse qualitative des récits de vie recueillis, le concept d’agir-en-contexte a été élaboré. Celui-ci comporte un système de cinq composantes : l’agentivité, les ressources, les capacités, les menaces et les opportunités. Ces composantes permettent de comprendre comment les mécanismes d’exclusion façonnent le contexte et interagissent avec la façon dont se déploie l’action des individus. En particulier, le concept d’agir-en-contexte suggère que les mécanismes d’exclusion modifient la configuration du contexte en augmentant les menaces, en diminuant les opportunités et en agissant sur les capacités et les ressources des individus et, par extension, leur agentivité. Partant de ce concept, trois types d’agir-en-contexte ont été élaborés : 1) l’agir-en-contexte motivé : les individus agissent en fonction de leurs désirs, souhaits, aspirations, valeurs et principes et font face à peu de menaces et beaucoup d’opportunités; 2) l’agir-en-contexte contraint : l’action est essentiellement orientée vers la gestion des menaces, laissant peu ou pas de place pour l’actualisation des désirs, souhaits, aspirations, valeurs et principes; et 3) l’agir-en-contexte synchronique : les individus tentent d’agir en fonction de leurs désirs, souhaits, aspirations, valeurs et principes, mais doivent déployer des actions pour faire face aux menaces qui limitent l’actualisation de leurs désirs, souhaits, aspirations, valeurs et principes. Cette thèse propose donc une nouvelle conceptualisation du contexte et donne de nouvelles clés analytiques pour comprendre l’action des individus. À terme, nos résultats suggèrent que l’intervention de promotion de la santé ayant pour finalité de renforcer la capacité d’agir des individus nécessite une analyse de la configuration de l’agir-en-contexte afin de réduire la densité des menaces et ainsi favoriser l’apparition d’opportunités, l’augmentation des capacités et de ressources et ultimement, permettre aux individus de déployer leurs actions en fonction de leurs désirs, souhaits, aspirations, valeurs et principes. / One of the challenges in health promotion is to design theoretical tools and interventions that take into consideration the way structures influence individuals’ life paths, while also recognizing individuals’ ability to make choices that shape their life and, in turn, have an effect on the world in which they live. The exclusionary mechanisms framework makes it possible to assimilate these two occurrences, particularly with regards to the notion of access (Adam & Potvin, 2016). This analytical framework conceives of exclusion mechanisms as a set of elements at various levels that, during interaction, limit access to rights, resources, and capacities for a healthy life and lead to situations of vulnerability. The framework proposes to look at issues of access as a relevant opportunity for addressing the interaction between individuals and structures. With this analytical framework as a starting point, the goal of this thesis is to understand how limited access to rights, resources, and possibilities for developing capacities interact with the context in which individuals evolve and their ability to act. In order to examine certain contexts that have been influenced by exclusionary mechanisms, as well as how individuals carry out their actions within these contexts, we postulated that: 1) Food insecurity is the result of exclusionary mechanisms that limit access to the financial resources necessary to feed oneself in sufficient quantity and quality, or that provoke anxiety that one will not be able to feed oneself in sufficient quantity and quality; and 2) Going to a community organization reflects individuals’ ability to act in the face of such adversities. Based on these postulates, and using life story interviews, we studied the paths of 12 individuals participating in a food insecurity community organization. The concept of acting-in-context has been developed based on the qualitative analysis of the life stories collected. This concept is composed of a five-part system: agency, resources, capacities, threats, and opportunities. These components make it possible to understand how exclusion mechanisms shape context and adjust individuals’ ability to act. More particularly, the concept of “acting-in-context” suggests that exclusionary mechanisms modify the context’s configuration by increasing threats, decreasing opportunities, and acting on individuals’ capacities, resources, and, by extension, agency. Based on this concept, three types of “acting-in-context” were developed: 1) motivated “acting-in-context”, in which individuals act according to their wishes, desires, aspirations, values, and principles while being faced with few threats, but many opportunities; 2) constrained “acting-in-context”, in which acting is essentially turned toward managing threats, leaving little or no room for wishes, desires, aspirations, values, and principles; and 3) synchronic “acting-in-context,” in which individuals attempt to act according to their wishes, desires, aspirations, values, and principles, but must also act otherwise in the face of threats limiting the possibility for them to realize their desires, hopes, aspirations, values and principles. This thesis therefore provides a new way of conceptualizing context and new analytical tools to understand individuals’ actions. In the end, our results suggest that a health promotion intervention that tries to strengthen individuals’ capacities needs to analyze the configuration of “acting-in-context” in order to reduce the density of threats. In this way, the intervention will increase opportunities, capacities, and resources, as well as enable individuals to act according to their wishes, desires, aspirations, values, and principles.

Introducción El presente estudio tuvo como objetivo evaluar los determinantes sociales que explican mejor la prevalencia de anemia infantil que continúa elevada en el Perú. Materiales y métodos Se incluyó datos registrados en la Encuesta Demográfica y de Salud Familiar (ENDES). Se calculó la desigualdad absoluta y relativa para cada año desde el 2004 al 2017 con datos consolidados. Además, se obtuvo los datos de hemoglobina sanguínea registrados a través de datos individuales para los años 2010 y 2017. Finalmente, se realizó un análisis descomposición de Oaxaca - Blinder para establecer que determinantes sociales explican la brecha de la desigualdad en la distribución del promedio de la hemoglobina entre ricos y pobres para estos dos años. Resultados El análisis de descomposición de Oaxaca identificó que la brecha entre el promedio de hemoglobina entre los ricos y pobres fue explicada por las diferencias en las variables educación materna (11%), región (14%), el grupo de edad (2%) y de otras variables no estudiadas (46%) en el año 2017. En el 2010 la brecha es explicada únicamente por la región (23%) y de otras variables no implicadas en el estudio (60%). Además, la desigualdad absoluta y relativa no se ha modificado sustancialmente ni antes ni durante la implementación del “Plan Nacional 2014-2016”. Conclusión La brecha de desigualdad sobre la prevalencia de anemia se mantuvo elevada durante el tiempo estudiado. La educación materna, la región y grupo etario explicaron la desigualdad en los promedios de hemoglobina. / Introduction The present study aimed to evaluate the social determinants that better explain the prevalence of childhood anemia, which is still high in Peru. Materials and methods Data registered in the Demographic and Family Health Survey (ENDES) were included. Absolute and relative inequality was calculated for each year from 2004 to 2017 with consolidated data. In addition, the blood hemoglobin data registered through individual data for the years 2010 and 2017 was obtained. Finally, a decomposition analysis of Oaxaca - Blinder was carried out to establish that social determinants explain the inequality gap in the distribution of the average of the hemoglobin between rich and poor for these two years. Results The decomposition analysis of Oaxaca identified that the gap between the average hemoglobin between the rich and the poor was explained by the differences in the variables maternal education (11%), region (14%), age group (2%) and of other variables not studied (46%) in 2017. In 2010 the gap is explained only by the region (23%) and of other variables not involved in the study (60%). Furthermore, absolute and relative inequality has not changed substantially either before or during the implementation of the "National Plan 2014-2016". Conclusion The inequality gap on the prevalence of anemia remained high during the time studied. Maternal education, region and age group explained the inequality in hemoglobin averages. / Tesis

Introdução - As perdas dentárias em adultos, configuram-se em um problema de saúde pública. Dada a relevância da problemática a Organização Mundial de Saúde propôs como meta para o ano 2000, que 75% dos adultos entre 35 e 44 anos de idade apresentassem 20 dentes ou mais funcionais. Objetivo Estudar a influência das variáveis de nível individual, familiar e de contexto na ocorrência de perdas dentárias superiores a 12 dentes em adultos de 40 anos de idade. Métodos Utilizando-se dados obtidos de um levantamento epidemiológico de saúde bucal realizado em 9 Unidades Básicas de Saúde, que desenvolvem a estratégia Saúde da Família, localizadas na zona leste do município de São Paulo, associados aos dados do Sistema de Informação da Atenção Básica (SIAB), foram desenvolvidas análises estatísticas pelo teste de associação do qui-quadrado, e análise multinível, tendo como variável dependente a ausência de mais de 12 dentes, baseando-se no componente P (perdido) do índice CPO-D (P 12 e P>12). As variáveis independentes foram obtidas de 3 níveis. As relativas ao nível I envolvem aspectos demográficos; socioeconômicos; características da família, dos domicílios, da ocupação, da saúde geral dos indivíduos e do núcleo familiar; hábitos e cuidados com a saúde bucal; autopercepção da saúde bucal; acesso a serviços odontológicos, e características relativas à saúde bucal. No segundo e terceiro nível, trabalhou-se com 23 indicadores, construídos a partir do banco de dados do SIAB de cada uma das Unidades de Saúde envolvidas na pesquisa. Tais indicadores referem-se às características das moradias, aspectos socioeconômicos, demográficos e relativos à saúde geral dos indivíduos cadastrados nas respectivas Áreas e Microáreas. O modelo multinível foi construído através do procedimento Stepwise Forward Selection Procedure. Resultados - A amostra foi constituída de 241 indivíduos, sendo que 58,9% apresentavam 20 dentes ou mais. Os fatores de risco independentes para a ocorrência de perdas dentárias superiores a 12 dentes foram: renda familiar mensal inferior à 170 dólares (OR=3,32 p= 0,001); densidade no domicílio superior a um indivíduo por cômodo (OR= 2,15 p=0,032); ser negro ou pardo (OR=2,07 p=0,032); nenhum membro da família ter plano de assistência médica (OR=2,20 p=0,046); residir em uma microárea onde 4,5% ou mais dos indivíduos com 15 anos ou mais são analfabetos (OR=2,45 p=0,012); residir em uma microárea com prevalência igual ou superior a 1,25% de alcoolismo entre os indivíduos com 15 anos ou mais (OR=2,30 p=0,020). Conclusão - Considerando que os dentes, ou a ausência deles têm o atributo de manter um registro permanente das ocorrências passadas, as perdas dentárias podem ser entendidas como seqüelas não apenas das doenças bucais, mas também do processo de exclusão social, econômica e cultural no decorrer da vida. Tal processo se materializa nas condições de vida, renda, moradia, trabalho, educação, entre outros, que só podem ser superadas mediante políticas sociais e econômicas que visem à redução do risco de doença e de outros agravos e ao acesso universal e igualitário às ações e serviços para sua promoção, proteção e recuperação (BRASIL, 1998), conforme determina o texto constitucional, de forma a garantir o direito à saúde / Introduction: The dental losses in adults are configured as a problem of public health. Given the relevance of the problem the World Organization of Health proposed as goal for the year 2000, that 75% of the adults between 35 and 44 years of age presented 20 teeth or more functional. Objective: to study the influence of the variables of individual, family level and of context in the occurrence of dental looses of more than 12 teeth in 40 year-old adults. Methodology: Through data obtained from an epidemical survey in oral health accomplished in 9 Basic care units of the Brazilian Public Health System located in the city of São Paulo, that develop the strategy of family health, associated to data of the Basic care National Data System of the national public health system, statistical analysis trough the qui-square test and multilevel analysis with a dependent variable the absence of more than 12 teeth based on M (missing) component of DMFT index ( M 12 and M > 12). Independent variables were obtained from 3 levels: level I are related to demographic aspects, socio-economical, family profile, housing, occupation, general health state of individuals and families, habits and oral health care; oral health self perception, access to oral health care and characteristics related to oral health. In second and third level 23 indicators were used based on the data of National Health System Data System from each care unit included in the research. These indicators are related to housing characteristics, socio-economical aspects, demographic and related to general health profile of individuals registered in the area and subareas. The multilevel model was set up through the Stepwise Forward Selection Procedure. Results - the sample was constituted of 241 individuals, and 58.9% presented 20 teeth or more. The independent risk factors for the occurrence of dental losses of 12 teeth or more were: monthly family income inferior to US$ 170 (OR=3.32 p = 0.001); demographic density in the home to an individual or more per room (OR = 2.15 p=0.032); belonging to black race or brown (OR=2.07 p=0.032); no member of the family to have private medical insurance (OR=2.20 p=0.046); to live in a micro region where 4.5% or more of the individuals with 15 years or more is illiterate (OR=2.45 p=0.012); to live in a micro region with percentile equal or superior to 1.25% of individuals with 15 old or more are alcoholic (OR=2.30 p=0.020). Conclusion - Considering that teeth or their absence has the attribute of maintaining a permanent record of previous incidents, the dental losses can be understood as the registration of the process of social, economical and cultural exclusion in elapsing of these people\'s life. Such process is materialized, in the life conditions, income, home, work and education that only can be overcome \"by social and economical politics that seek to the reduction of the risk of disease and of other grievances and to the universal and equalitarian access to the actions and services for it promotion, protection and recovery\"(BRASIL, 1998), as it determines the constitutional text, in order to guarantee the right to health.

Introdução - As perdas dentárias em adultos, configuram-se em um problema de saúde pública. Dada a relevância da problemática a Organização Mundial de Saúde propôs como meta para o ano 2000, que 75% dos adultos entre 35 e 44 anos de idade apresentassem 20 dentes ou mais funcionais. Objetivo Estudar a influência das variáveis de nível individual, familiar e de contexto na ocorrência de perdas dentárias superiores a 12 dentes em adultos de 40 anos de idade. Métodos Utilizando-se dados obtidos de um levantamento epidemiológico de saúde bucal realizado em 9 Unidades Básicas de Saúde, que desenvolvem a estratégia Saúde da Família, localizadas na zona leste do município de São Paulo, associados aos dados do Sistema de Informação da Atenção Básica (SIAB), foram desenvolvidas análises estatísticas pelo teste de associação do qui-quadrado, e análise multinível, tendo como variável dependente a ausência de mais de 12 dentes, baseando-se no componente P (perdido) do índice CPO-D (P 12 e P>12). As variáveis independentes foram obtidas de 3 níveis. As relativas ao nível I envolvem aspectos demográficos; socioeconômicos; características da família, dos domicílios, da ocupação, da saúde geral dos indivíduos e do núcleo familiar; hábitos e cuidados com a saúde bucal; autopercepção da saúde bucal; acesso a serviços odontológicos, e características relativas à saúde bucal. No segundo e terceiro nível, trabalhou-se com 23 indicadores, construídos a partir do banco de dados do SIAB de cada uma das Unidades de Saúde envolvidas na pesquisa. Tais indicadores referem-se às características das moradias, aspectos socioeconômicos, demográficos e relativos à saúde geral dos indivíduos cadastrados nas respectivas Áreas e Microáreas. O modelo multinível foi construído através do procedimento Stepwise Forward Selection Procedure. Resultados - A amostra foi constituída de 241 indivíduos, sendo que 58,9% apresentavam 20 dentes ou mais. Os fatores de risco independentes para a ocorrência de perdas dentárias superiores a 12 dentes foram: renda familiar mensal inferior à 170 dólares (OR=3,32 p= 0,001); densidade no domicílio superior a um indivíduo por cômodo (OR= 2,15 p=0,032); ser negro ou pardo (OR=2,07 p=0,032); nenhum membro da família ter plano de assistência médica (OR=2,20 p=0,046); residir em uma microárea onde 4,5% ou mais dos indivíduos com 15 anos ou mais são analfabetos (OR=2,45 p=0,012); residir em uma microárea com prevalência igual ou superior a 1,25% de alcoolismo entre os indivíduos com 15 anos ou mais (OR=2,30 p=0,020). Conclusão - Considerando que os dentes, ou a ausência deles têm o atributo de manter um registro permanente das ocorrências passadas, as perdas dentárias podem ser entendidas como seqüelas não apenas das doenças bucais, mas também do processo de exclusão social, econômica e cultural no decorrer da vida. Tal processo se materializa nas condições de vida, renda, moradia, trabalho, educação, entre outros, que só podem ser superadas mediante políticas sociais e econômicas que visem à redução do risco de doença e de outros agravos e ao acesso universal e igualitário às ações e serviços para sua promoção, proteção e recuperação (BRASIL, 1998), conforme determina o texto constitucional, de forma a garantir o direito à saúde / Introduction: The dental losses in adults are configured as a problem of public health. Given the relevance of the problem the World Organization of Health proposed as goal for the year 2000, that 75% of the adults between 35 and 44 years of age presented 20 teeth or more functional. Objective: to study the influence of the variables of individual, family level and of context in the occurrence of dental looses of more than 12 teeth in 40 year-old adults. Methodology: Through data obtained from an epidemical survey in oral health accomplished in 9 Basic care units of the Brazilian Public Health System located in the city of São Paulo, that develop the strategy of family health, associated to data of the Basic care National Data System of the national public health system, statistical analysis trough the qui-square test and multilevel analysis with a dependent variable the absence of more than 12 teeth based on M (missing) component of DMFT index ( M 12 and M > 12). Independent variables were obtained from 3 levels: level I are related to demographic aspects, socio-economical, family profile, housing, occupation, general health state of individuals and families, habits and oral health care; oral health self perception, access to oral health care and characteristics related to oral health. In second and third level 23 indicators were used based on the data of National Health System Data System from each care unit included in the research. These indicators are related to housing characteristics, socio-economical aspects, demographic and related to general health profile of individuals registered in the area and subareas. The multilevel model was set up through the Stepwise Forward Selection Procedure. Results - the sample was constituted of 241 individuals, and 58.9% presented 20 teeth or more. The independent risk factors for the occurrence of dental losses of 12 teeth or more were: monthly family income inferior to US$ 170 (OR=3.32 p = 0.001); demographic density in the home to an individual or more per room (OR = 2.15 p=0.032); belonging to black race or brown (OR=2.07 p=0.032); no member of the family to have private medical insurance (OR=2.20 p=0.046); to live in a micro region where 4.5% or more of the individuals with 15 years or more is illiterate (OR=2.45 p=0.012); to live in a micro region with percentile equal or superior to 1.25% of individuals with 15 old or more are alcoholic (OR=2.30 p=0.020). Conclusion - Considering that teeth or their absence has the attribute of maintaining a permanent record of previous incidents, the dental losses can be understood as the registration of the process of social, economical and cultural exclusion in elapsing of these people\'s life. Such process is materialized, in the life conditions, income, home, work and education that only can be overcome \"by social and economical politics that seek to the reduction of the risk of disease and of other grievances and to the universal and equalitarian access to the actions and services for it promotion, protection and recovery\"(BRASIL, 1998), as it determines the constitutional text, in order to guarantee the right to health.

La mise à l’échelle (scaling up) est un processus qui vise à accroitre l’impact et la pérennité des effets d’innovations jugées prometteuses. Les publications à ce sujet sont en progression importante dans le domaine de la santé depuis une vingtaine d’années. Toutefois, ces processus ont été étudiés de manière essentiellement technique malgré l’importance soulignée dans la littérature d’y prendre en compte des questions évolutives de sens et de valeurs. Ceci est particulièrement significatif pour les innovations de promotion de la santé, construites sur les capacités et collaborations de différents acteurs qui y partagent et négocient diverses vues sur les problèmes, les actions à entreprendre et leur but. Les contenus de ces innovations sont susceptibles d’évoluer de manière significative dans la mise à l’échelle, et d’affecter la fonction d’impact et pérennité du processus. Peu d’études, cependant, mobilisent des théories et méthodologies explicites à cet égard. Cette thèse s’inscrit dans une vision sociale de la mise à l’échelle et propose d’ajouter le concept de cadre interprétatif, ou « frame », à son outillage conceptuel ; elle vise à explorer l’utilité de cette notion au regard de la dynamique sociale de la mise à l’échelle d’innovations complexes de promotion de la santé. La thèse poursuit deux objectifs : 1) développer une articulation théorique de nature sociale pour la mise à l’échelle intégrant la notion de frame ; et 2) explorer l’utilité des frames comme ‘représentations’ pour documenter l’évolution du contenu des innovations au cours de leur mise à l’échelle. La réponse au premier objectif s’appuie sur une perspective de complexité des interventions en tant que réseaux dynamiques d’acteurs pour conceptualiser la mise à l’échelle comme une expansion de réseaux où le framing des questions de santé évolue au travers des relations entre acteurs. L’articulation théorique développée combine la sociologie de l’innovation - théorie de l’acteur-réseau - et les perspectives des frames pour envisager ceux-ci en tant que ‘représentations’ ou ‘interactions’. En réponse au second objectif, l’approche ‘représentationnelle’ aux frames est appliquée à l’étude d’un cas de mise à l’échelle d’innovation éducative à caractère intersectoriel concernant le développement de jeunes enfants socialement désavantagés. Sur la base de documents cadres qui balisent les phases ‘pilote’ et ‘programme à l’échelle’ de l'innovation, une analyse critique de frames est pratiquée au regard de la capacité du programme à grande échelle à supporter l’action sur les inégalités sociales de développement des enfants et l’équité. Les résultats illustrent des différences significatives de définitions du ‘problème’ du DJE et de la solution préconisée pour le programme à grande échelle, qui constituent des améliorations, mais aussi certaines ‘détériorations’ au regard des inégalités et de l’équité. En tant que constructions réalisées à partir des ‘produits’ du processus social qui s’opère dans le réseau intersectoriel des acteurs, les frames comme ‘représentations’ analysés de manière critique sont utiles pour expliciter et caractériser l’évolution des contenus des innovations et leurs conséquences pour la mise à l’échelle. Mobilisés dans un échange constructif avec les acteurs concernés, les frames pourraient constituer un outil intéressant pour favoriser la réflexivité à l’égard de ces processus et de l’impact et de la durabilité des effets des innovations portées à grande échelle. Cette thèse contribue de manière théorique à la littérature de santé publique en clarifiant l’utilité des frames et la manière dont ce concept peut être mobilisé pour documenter la dynamique de la mise à l’échelle d’innovations complexes de promotion de la santé. / Scaling up is a process that aims to increase the impact and sustainability of the effects of innovations deemed promising. Publications on this subject have markedly increased in the field of health over the past twenty years. However, these processes have essentially been studied in a technical way, despite the importance underlined in the literature to take into account their evolving meanings and values. This is particularly significant for health promotion innovations, built on the capacities and collaborations of different actors who share and negotiate various views on the problems, the actions to be taken and their goal. The contents of these innovations are likely to evolve significantly during scaling up, affecting impact and sustainability goals of the process. Few studies, however, mobilize explicit theories and methodologies in this respect. This thesis is part of a social vision of scaling up, and proposes to add the concept of ‘frame’ to its conceptual tools; it aims to explore the usefulness of this notion with regard to the social dynamics of scaling up health promotion innovations. The thesis pursues two objectives: 1) to develop a theoretical articulation of a social nature for scaling up, integrating the notion of frame; and 2) to explore the usefulness of frames as ‘representations’ to document the evolution of the content of innovations during their scaling up. The response to the first objective is based on a complexity perspective of interventions as dynamic networks of actors to conceptualize scaling up as an expansion of networks where the framing of health issues evolves through the relationships between the actors. The theoretical articulation developed combines the sociology of innovation - actor-network theory - and the perspectives of frames to consider them as 'representations' or 'interactions'. In response to the second objective, the 'representational' approach to frames is applied to the study of a scaling up case concerning an intersectoral educational innovation for the development of socially disadvantaged young children. On the basis of framework documents which mark out the 'pilot' and 'at scale program' phases of the innovation, a critical analysis of frames is carried out with regard to the capacity of the large-scale program to support action on the social inequalities in child development and equity. The results illustrate significant differences in definitions of the ECD ‘problem’ and of the recommended ‘solution’ for the at scale program, which constitute improvements, but also some ‘deteriorations’ with regard to inequalities and equity. As constructions made from the 'products' of the social process that takes place in the intersectoral network of actors, the frames as 'representations' critically analyzed are useful for explaining and characterizing the evolution of the contents of innovations and their consequences for scaling up. Mobilized in a constructive exchange with the actors concerned, the frames could constitute an interesting tool to promote reflexivity with regard to these processes and to the impact and sustainability of the effects of innovations carried out on a large scale. This thesis contributes theoretically to the public health literature by clarifying the usefulness of frames and the way in which this concept can be mobilized to document the dynamics of the scaling up of complex health promotion innovations.

Cette thèse a été réalisée en cotutelle Université de Montréal (UdeM) - Université Libre de Bruxelles (ULB). L'auteur a bénéficié de bourses doctorales provenant du Fonds national de la recherche scientifique (FNRS-Belgique), du Fonds de recherche du Québec-Société culture (FRQSC), et du Centre de recherche Léa-Roback sur les inégalités de santé de Montréal. / Les politiques de soutien au revenu des ménages se déclinent sous formes de mesures variées mises en place dans le cadre du système de protection sociale. Ces politiques influencent considérablement le revenu et les conditions de vie des ménages les plus vulnérables. Elles constituent un levier majeur pour réduire la pauvreté et les inégalités de revenu entre ménages. De ce fait, elles contribuent à améliorer la santé des populations et à réduire les inégalités sociales de santé (ISS) dès la naissance. L’évaluation de l’impact des politiques sociales sur les ISS dans différents contextes constitue une tâche complexe, du fait notamment de la difficulté, voire l’impossibilité, de mettre en place des études randomisées à grande échelle. Les variations des politiques sociales selon les pays constituent des opportunités pour mener des études comparatives sur base d’expériences naturelles. En partant d’un constat sur les limites des études comparatives habituelles, nous avons proposé une démarche de recherche visant à mieux étudier les spécificités des contextes afin d’expliquer les mécanismes par lesquels la combinaison des politiques de soutien au revenu influence la pauvreté des ménages et contribue aux ISS à la naissance à Bruxelles et à Montréal. Ce protocole de recherche a fait l’objet d’un 1er article. Le cœur de la thèse comprend trois parties. La première partie porte sur la comparaison des politiques d’aide sociale et d’allocations familiales en Belgique et au Québec et analyse les impacts sur l’intensité de la pauvreté des ménages à l’aide sociale dans les deux contextes. L’analyse se base sur la méthode des familles-types. Cette méthode consiste à calculer et comparer le revenu disponible de différents types de ménages. L’intensité de la pauvreté des ménages a été estimée selon le nombre d’enfants et la situation de couple. Pour chaque type de ménage, elle correspond à la différence relative entre le revenu disponible du ménage et le seuil de pauvreté relative. Les résultats montrent une intensité de la pauvreté plus marquée au Québec qu’en Belgique. Dans chaque contexte, on constate également que l’intensité de la pauvreté des ménages varie considérablement selon le nombre d’enfants et la situation de couple. Ce travail a fait l’objet d’un 2ème article. La deuxième partie porte sur la description des inégalités de santé à la naissance à Bruxelles et à Montréal. Les hypothèses de travail découlent des résultats obtenus à l’étape précédente. Deux études de cas ont été réalisées et analysées dans une perspective comparative. Les bases de données utilisées proviennent du couplage de données administratives issues des registres de naissance et des données de sécurité sociale. Les résultats ont donné lieu aux 3ème et 4ème articles. Le 3ème article concerne la population générale. Dans chaque région, des modèles de régression logistique ont été élaborés afin d’étudier l’association entre les issues défavorables de la grossesse (faible poids à la naissance, prématurité) et le statut socioéconomique (éducation de la mère et revenu). L’ampleur des inégalités de santé est plus marquée à Montréal qu’à Bruxelles et celles-ci diffèrent également selon l’origine de la mère. Le 4ème article porte spécifiquement sur la population bénéficiaire de l’aide sociale. Il compare l’association entre le faible poids à la naissance et la composition de ménage dans chaque région. On constate que les inégalités face au FPN varient selon le nombre d’enfants et la situation de couple entre les deux contextes, dans le même sens que les différences observées au niveau de la pauvreté. La troisième partie explore davantage les différences constatées à l'étape précédente selon l’immigration. Dans chaque région, elle compare l’impact du SES sur la santé périnatale chez différents groupes d’immigrés et les chez les mères nées en Belgique ou au Canada. Les résultats ont donné lieu aux 5ème et 6ème article de la thèse. L’analyse souligne l’importance de tenir compte des enjeux liés à l’immigration pour mieux expliquer la contribution des politiques de soutien au revenu aux ISS à la naissance. Cette thèse constitue une contribution unique. Dans deux régions où les taux de pauvreté et les prévalences des issues de la grossesse sont comparables dans la population générale, on constate des différences notables quant aux inégalités de santé à la naissance. Les politiques de soutien au revenu dans les deux contextes contribuent à expliquer ces différences. L’analyse démontre la nécessité de remédier aux insuffisances de ces politiques dans les deux contextes. Finalement, elle souligne les défis de la réduction de la pauvreté. Ces défis touchent à différents domaines, notamment la conciliation travail-famille, le marché du travail, l’immigration et les inégalités économiques. Mots-clés : Pauvreté, Inégalités sociales de santé, Politiques sociales, Etat-Providence, Evaluation d’impact en santé, Expériences naturelles, Inégalités de revenu, Faible poids à la naissance, Santé périnatale, Politiques de soutien au revenu. / Income support policies significantly influence the income and living conditions of the most vulnerable households. They constitute a major lever for reducing poverty and income inequalities between households. As a result, they contribute to improving the health of populations and reducing social inequalities in health (SIH) starting from birth. Assessing the impact of social policies on SIH in different contexts is a complex task, due in particular to the difficulty, if not impossibility, of setting up large-scale randomised studies. Varying social policies in different countries provide opportunities for comparative studies on the issue, based on natural experiments. Starting from an observation on the limitations of the usual comparative studies, we have proposed a research approach aiming to better study the specificities of contexts, which would allow us to explain the mechanisms by which the combination of income support policies influences household poverty and contributes to SIH at birth in Brussels and Montreal. This research protocol was the subject of a first article. This core of this thesis consists of three parts. The first deals with the comparison of welfare and family allowance policies in Belgium and Quebec and analyses their impact on the intensity of poverty of welfare households in both contexts. The analysis is based on the model family method, which consists of calculating and comparing the disposable income of different types of households. The intensity of household poverty was estimated according to the number of children and marital status. For each household type, the intensity of poverty corresponds to the relative difference between the household's disposable income and the relative poverty threshold. The results show a higher intensity of poverty in Quebec than in Belgium. It is also found that, in each context, the intensity of household poverty varies considerably depending on the number of children and marital status. This work was the subject of a second article. The second part of this thesis focuses on the description of health inequalities at birth in Brussels and Montreal. The working hypotheses are derived from the results obtained in the previous stage. Two case studies were carried out and analysed in a comparative perspective. The databases used come from a combination of administrative data from birth records and social security data. The results led to the third and fourth articles. The third article concerns itself with the general population. Logistic regression models were developed for each region to study the association between adverse pregnancy outcomes (low birth weight, prematurity) and socioeconomic status (mother's education and income levels). The magnitude of health inequalities is greater in Montreal than in Brussels and also differs according to the mother's origin. The fourth article focuses specifically on welfare recipients. It compares the association between low birth weight and household composition in each region. We can see that inequalities in LBW vary according to the number of children and marital status in both contexts, much like the differences observed in terms of poverty. The third part further explores the differences observed in the previous stage according to immigration. It compares the impact of SES on perinatal health among different immigrant groups and among mothers born in Belgium or Canada. The results led to the fifth and sixth papers of the thesis. The analysis underlines the importance of taking the specific issues linked to immigration into account to better explain the role that income support policies play in SIH at birth. This thesis is a unique contribution. There are notable differences in health inequalities at birth between two regions with similar poverty rates and levels of prevalence of unfavourable pregnancy outcomes among the general population. The impact of income support policies in Belgium and Quebec on the intensity of household poverty helps explain these differences. Our analysis demonstrates the need for public policies that address the inadequacy of the current income support measures in both regions. Lastly, it emphasises that the causes of poverty are interdependent and touch on various issues, including work-family balance, job insecurity, immigration and economic inequalities. Keywords: Poverty, Social inequalities in health, Social policies, Welfare state, Health impact assessment, Natural experiments, Income inequalities, Low birth weight, Perinatal health, Income support policies.

La question des infections sexuellement transmissibles (IST) en Afrique a longtemps été<p>négligée par des chercheurs africains spécialistes en sciences sociales, en raison notamment du tabou<p>qui entoure la sexualité dans ce continent. Toutefois, les dernières décennies ont donné lieu à plusieurs<p>recherches menées principalement par les Européens africanistes sur ces pathologies grâce à<p>l’émergence de la pandémie actuelle du Sida. La plupart des travaux réalisés sont axés sur les facteurs<p>de risque, les mécanismes de diffusion, les croyances et les attitudes populaires face à ces maladies, les<p>politiques de lutte, etc. Mais les études historiques consacrées aux IST sont très rares. Celles qui<p>existent ont surtout mis en évidence la dimension démographique axée sur le problème de la dénatalité<p>en laissant dans l’ombre le contexte socio-historique et les conditions socio-épidémiologiques de<p>propagation de ces affections. Au moment où le Sida fait des ravages dans le monde et tout<p>particulièrement en Afrique subsaharienne, l’intérêt d’une réflexion historique sur les IST au Congo<p>n’est plus à démontrer.<p>Contrairement à une affirmation classiquement admise dans la littérature, selon laquelle la<p>lutte contre les IST au sein de la population congolaise fut un franc succès pour les autorités coloniales<p>surtout après la Deuxième Guerre mondiale, cette thèse montre plutôt l’augmentation de la prévalence<p>des IST dans le temps. Les archives inédites et l’analyse des données révèlent que cette progression<p>continue est la conséquence de l'urbanisation accélerée et de la monétarisation de la société et de la sexualité entraînant des modes de vie propres à la société coloniale urbaine. Les villes issues de ce processus deviendront non seulement des espaces<p>d’acculturation et de modernité, mais aussi des lieux d’expansion de ces maladies. Le développement<p>de la prostitution et la multiplicité des partenaires sexuels, à travers les unions plus libres et<p>momentanées, sont les principaux facteurs explicatifs de cette observation.<p>On présente généralement de manière panégyrique l’oeuvre sanitaire coloniale de la Belgique<p>au Congo comme ‘‘modèle’’. Pourtant, aucune étude n’a déjà été menée pour examiner, de manière<p>chiffrée, les aspets liés aux différences de santé entre les Congolais et les Blancs. Cette<p>dissertation vient combler les lacunes existantes dans ce domaine. De ce point de vue, il en résulte de<p>fortes inégalités et des déséquilibres persistants de santé entre ces deux types de populations. Les Congolais beaucoup plus<p>nombreux, socialement défavorisés, ne bénéficient que d’une situation peu ou moins favorable ;tandis<p>que les Blancs, socialement plus favorisés, bénéficient en général d’une meilleure situation sanitaire.<p>Plusieurs indicateurs élaborés dans ce travail sont révélateurs de cette réalité coloniale, en termes<p>d’équipements sanitaires, d’accès et d’utilisation de soins et d’état de santé différencié./<p><p><p><p>The issue of sexually transmitted infections (STI) in Africa has long been neglected by<p>researchers African social scientists, particularly because of the taboo surrounding sexuality in Africa.<p>However, recent decades have resulted in several research conducted mainly by the European<p>Africanists on these diseases through the emergence of the current pandemic of AIDS. Most of studies<p>are focused on risk factors, distribution mechanisms, the popular attitudes about these infections,<p>control policies. But historical studies on STI are seldom examined. Those that exist are mainly<p>concerning the demographic dimension focuses on the problem of declining birth, leaving the socio-historical<p>and socio-epidemiological spread of such diseases. While AIDS is ravaging the world and<p>especially in sub-Saharan Africa, one thing to mention is that the interest of historical reflection on<p>STI in the Congo is obvious.<p>Contrary to an assertion conventionally accepted in the literature, that the fight against<p>gonorrhea and syphilis among the Congolese population was a success for the colonial authorities,<p>especially after the Second World War, our thesis shows rather the increasing prevalence of STI. The<p>archives and analysis of data indicates this continued progress is the result of special conditions of<p>industrialization and urbanization colonial that make people vulnerable. Cities from this historical<p>process will not only areas of acculturation and modernity, but also places for expansion of these<p>diseases. The development of prostitution and multiple sexual partners through free and temporary<p>unions are the main factors explaining this observation.<p>It has generally praises how the actions of Belgian colonial health in the Congo as 'model'.<p>However, no study has been conducted to establish or to compare quantitatively the health status<p>between Blacks (Congolese) and Withes (Europeans in majority). This essay shows the social health<p>inequalities among these two populations. The Congolese many in number, but more socially<p>disadvantaged have only less favorable conditions to health. While the white people, socially<p>privileged, generally have better health status. Several indicators developed in this study are revealing<p>of the colonial reality in terms of sanitation, access and use of care and health status differential. / Doctorat en Histoire, art et archéologie / info:eu-repo/semantics/nonPublished