This master thesis contributes to a growing body of literature analysing electronic health records (EHRs) and their importance to potentially optimization of the work flow in small medical practices. Additionally, general information about different health care systems is given, especially about the Canadian health care system. It gives a theoretical overview of information technologies used through health care providers. This thesis addresses the new technologies for communication and describes them. Problem: The "lack of clear channels of communication in patient transfer between care facilities leads to fragmentation in care." To prevent this, new communication channels need to be more effective in improving communication. Before trying to enhance communication channels used between care facilities, locally and nationally, the current focus needs to be on communication channels used within care facilities. This is of great importance especially for patients and other stakeholders who deem it as the most critical health care item. The slow implementation of EHRs in small medical practices makes it difficult to improve and evaluate performance and to ensure the confidence of patients in new technologies. On the other hand, the lack of implementation in this area has a negative effect on other health care providers, e.g. hospitals which already implemented the system. Through the existing gap the delivery of health care information is not complete possible and does not help to make the system safer for users. Research Question: The main goal is to obtain an understanding of individual physicians' attitudes and barriers to EHR. The thesis will show the advantages and obstacles as well as the pros and cons for small- and medium-sized practices to adopt EHRs. Result: It is not necessary anymore to discuss if EHRs should be implemented. It is more important to discuss how they should implement. The main problem for implementation is the financial barrier for small medical practices as well as personal attitudes connected with the age distribution of physicians and patients.

La présente thèse analyse le contrôle des pratiques médicales dans le royaume de Castille au XVIe siècle à travers, notamment, les procès des protomédicos. Le changement substantiel qui a lieu au sein des professions de santé se produit au moment où les protomédicos parviennent à obtenir le monopole légal sur le contrôle des pratiques médicales. Ce fait demeure en étroite relation avec la consolidation du pouvoir royal. Le processus d’institutionnalisation de la charge de protomédico n’est pas en progression régulière et n’est pas exempt de difficultés ; il touche non seulement ceux qui ont pour métier de soigner mais aussi le pouvoir municipal, le royaume et le pouvoir royal. Dans ce concert de forces, le protomédico est l’une des branches du pouvoir royal qui joue un rôle fondamental. Sa légitimité : être médecin de la Chambre du roi et son « alcalde examinador mayor ». Or son autorité est très contestée dans la pratique car il représente la mainmise royale sur des métiers qui autrefois furent sous l’autorité des autorités municipales. Ses actions sur le terrain sont ainsi une permanente source de conflits et controverses dans le royaume de Castille au XVIe siècle. / The present dissertation examines the control over medical practices in the kingdom of Castile during the XVIth century and, notably, the trials against protomédicos. An essential change that occurred in the medical profession during the period saw the protomédicos attempting to gain control of legal monopoly over the all medical practices. This issue was strictly linked to the consolidation of royal power in Castile. The establishment process of the office of the protomédico does not follow a regular progression and it was not created without struggles. This process does not only concern those that provide medical care but also the municipal authorities, the kingdom and the royal power. Thus, through this interplay, the protomédico became one of the branches of royal power that exercised a major role in the kingdom. The protomédico became the first official physician at the royal Chamber and the “alcalde examinador mayor”. However, his authority is highly contested in the practical field because he holds royal stranglehold over offices that were formerly subordinated to the municipal authorities. The protomédico’s activities on the ground were thus a permanent source of conflicts and controversies in 16th century Castile.

L’évaluation externe de la qualité (EEQ) est un outil indispensable qui permet au laboratoire d’analyse de biologie clinique de surveiller la qualité de ses analyses. Une analyse rétrospective sur 391 893 résultats appartenant à sept analytes fréquemment dosés (glucose, calcium, triglycérides, créatine kinase, hémoglobine, HbA1c et protéines urinaires) a été réalisée sur une période de douze ans, de 1996 à 2007. Pour trois analytes, les résultats accumulés par trois Centres européens suisse, français et belge organisant des EEQ ont été comparés. Une approche statistique simple non paramétrique a été utilisée afin de calculer les performances (CV % et pourcentages de résultats conformes interlaboratoires) en incluant tous les résultats des EEQ, y compris les valeurs aberrantes. Le travail a permis de calculer les performances des appareils en fonction des analytes, de comparer les performances entre les Centres et entre deux types d’utilisateurs – les laboratoires professionnels et les cabinets médicaux – et, enfin, de calculer l’évolution des performances dans le temps. Il en ressort que les performances entre les Centres sont comparables et les appareils des laboratoires professionnels obtiennent de meilleures performances par rapport aux petits analyseurs utilisés dans les cabinets médicaux.Concernant les POCT, les performances ne dépendent pas du type d’utilisateur mais du type de POCT : certains obtiennent des performances comparables aux appareils de laboratoire, d’autres inférieures. Globalement, une amélioration des performances est mesurée pour les deux types d’utilisateurs, pour la plupart des appareils et pour tous les analytes. / The external quality assessment (EQA) is an essential tool that allows medical laboratories to supervise the quality of their analyses. A retrospective analysis on 391.893 results originating from seven frequently measured analytes (glucose, calcium, triglycerides, creatine kinase, haemoglobin, HbA1c, and urinary proteins) was performed over a twelveyear period, from 1996 to 2007. For three analytes, the results accumulated by three European Centres – Swiss, French, and Belgian – organising EQA surveys were compared. A simple non-parametrical statistical approach was used to calculate the performances (inter-laboratory CV% and percentage of correct results) in order to include all EQA results, even aberrant values. The work allowed to calculate the performances of devices for the different analytes, to compare performances among the Centres and among two types of users – professional laboratories and medical offices – and, finally to calculate the evolution of performances over time. It turns out that performances among the Centres are comparable and that professional laboratory devices obtained better performances as compared with small laboratory devices used in medical offices. Concerning POCT devices, performances are not linked to the type of user but to the POCT type : certain types reach the same performances as laboratory devices, while others are below. A general improvement of performances is measured for both types of users, for most devices, and for all the analytes.

Submitted by Suelen Reis (suziy.ellen@gmail.com) on 2013-04-22T17:30:30Z No. of bitstreams: 1 Dissertacao Laura Santosseg.pdf: 1254768 bytes, checksum: c25346b91fb187552f76b18e86ea232a (MD5) / Approved for entry into archive by Rodrigo Meirelles(rodrigomei@ufba.br) on 2013-05-26T11:09:39Z (GMT) No. of bitstreams: 1 Dissertacao Laura Santosseg.pdf: 1254768 bytes, checksum: c25346b91fb187552f76b18e86ea232a (MD5) / Made available in DSpace on 2013-05-26T11:09:39Z (GMT). No. of bitstreams: 1 Dissertacao Laura Santosseg.pdf: 1254768 bytes, checksum: c25346b91fb187552f76b18e86ea232a (MD5) Previous issue date: 2008 / Nas primeiras décadas do século XIX no Brasil, verificou-se uma crescente institucionalização das práticas de cura e a busca pelo conhecimento e exploração econômica das riquezas naturais, que interagiram, num processo dinâmico. Os saberes e usos acerca das plantas medicinais, que ocorriam desde o início da colonização, tiveram notável destaque, fazendo parte da construção da ciência no Brasil, que ocorreu, nesse período, através da ação de Estado, cientistas, praticantes das artes de curar e viajantes naturalistas. Discutimos essas questões a partir da trajetória, atividades e escritos do viajante Antônio Moniz de Souza, que, no período citado, viajou por várias partes do Brasil, observando, catalogando e coletando drogas naturais, posteriormente fornecidas à profissionais de cura, estudiosos e instituições de ciência no país. Destacamos que, reconstruir sua trajetória e a difusão do uso de plantas medicinais no início do século XIX, fornece importante contribuição para o estudo das medicinas no Brasil e na Bahia, permitindo refletir sobre a dinâmica cultural entre diferentes segmentos sociais, tema fundamental nos estudos de História Social da Cultura, na qual o trabalho se insere, buscando problematizar o processo de formação e desenvolvimento da medicina e ciência brasileira. / Salvador

Cette thèse aborde l'histoire des enfants et adultes handicapés mentaux en France et en Allemagne entre 1890 et le milieu des années 1930. Ce travail prend pour objet les personnes atteintes de déficience mentale, qualifiées à l'époque de « débiles mentaux », « imbéciles », « idiots » ou du terme plus générique d' « arriérés ». Cette étude apporte un éclairage nouveau sur plusieurs thèmes, en adoptant une perspective transnationale pour éclairer la circulation et les résistances dans les pratiques médicales et pédagogiques destinées aux arriérés. Cherchant à mettre en valeur la part de construction qui est en jeu dans l'élaboration de ces catégories nosographiques, les critères aboutissant à créer la « faiblesse d'esprit » (Schwachsinnigkeit) sont étudiés à travers de points de vue variés (famille, instituteurs, psychologues et aliénistes). On montre ainsi comment la catégorie est forgée par ceux qui les observent au quotidien. A l'échelle des institutions étudiées, l'évolution des pratiques asilaires démontre une volonté progressive de rationaliser le tri entre ceux qu'on pense « éducables » et les « incurables » par l'emploi d'outils tels que les tests psychométriques. La thèse démontre aussi comment les arriérés sont envisagés peu à peu comme une charge, voire un danger à l'échelle nationale. Après la Grande Guerre, le coût de leur prise en charge est vu comme un fardeau dans les deux pays, justifiant une rationalisation des soins qui leur sont accordés. Ils sont surtout considérés comme porteurs de tares transmissibles héréditairement, soit des individus qu'il s'agit de sélectionner voire d'éliminer en tant que danger sanitaire. La thèse explore ces deux aspects observés en France comme en Allemagne, et leur part dans la légitimation de la stérilisation forcée des arriérés comme « Malades héréditaires » mises en place par la loi adoptée dès les premiers mois de l'avènement du IIIe Reich, ainsi que les réactions du milieu psychiatrique français. / The topic of this PhD dissertation is the history of mentally deficient children and adults in both France and Germany between 1890 and 1934. This work focuses on people who suffered from mental retardation although at that time they would have been referred to as "feeble-minded," "idiots" or "imbeciles." This study provides a new focus on different subjects. The various circulations of medical models are considered in a dynamic perspective. lt also provides an original vision of the construction of the category of feeblemidness, influenced by agents like doctors [psychiatrists], families or teachers, questioning what was done in practical terms. Mentally deficient people were shaped by the gaze of the people they interacted with. They are also examined in a social and economic context to which these individuals respond. The evolution of the characterization of feeble-mindedness and the use of intelligence tests highlight various attempts to classify those individuals in a more rational way. From a more specific psychiatrie point of view, this thesis shows how the emphasis on their classification as "unproductive persans" as well as the description of feeble-mindedness as a hereditary and "racial" disease transformed them into a social issue in the context of the rise of social Darwinism and eugenics, which led fo their sterilization in Germany from 1934 on.

Made available in DSpace on 2014-12-17T15:25:19Z (GMT). No. of bitstreams: 1 RodrigoOS_DISSERT.pdf: 3356802 bytes, checksum: 039b783a36874c8dd5c91b44a7d031f1 (MD5) Previous issue date: 2012-08-27 / This work has as object of study the Hospital de Caridade Juvino Barreto, nosocomial institution located in the city of Natal (RN), between the Praia de Areia Preta and the Monte Petr?polis, focusing on the period from 1909, the year in which the new hospital building was constructed and opened, and 1927, the date of the transfer of administration of the public domain to the newly created Sociedade de Assist?ncia Hospitalar (SAH). We study the conditions of possibility of the emergence of this hospital space in the urban environment of the capital of Rio Grande do Norte, seeking to understand the different tactics and strategies implemented by the historical subjects involved in the formation of this institution nosocomial. Starting from a corpus of documents consisting of medical memories (with Dr. Janu?rio Cicco as privileged observer), information present in newspapers (the Republic and the Christmas Journa l), photo collection and extensive administrative and legal material (Speeches, Exhibitions, Reports, Laws and Resolutions), we analyzed in detail the medical geography of HCJB, relating the discourses of medicine and geography in choosing the spatial location of the hospital as we examine the architecture of the hospital, its inner spat iality, divisions, forms of space control, and, finally, we discuss the medical practices that took place within it, leading us in this regard, from the experiences of clinical hospital chief, Dr. Janu?rio Cicco, especially the discussion on "ethics" in hospital work. The perception of HCJB as medical nosoespaciality always on the move, incorporated under taxonomic principles based on difference and dispersion forces, led us to articulate it theoretically from the conceptual-methodological arsenal of philosopher Michel Foucault, particularly his reflections of genealogical phase, focusing on the phenomenon of power, a position that allows us to enhance our space-hospital construction, invention, product of power relations, which give the unfinished aspect nosoc?mio, apparent, always at stake, perpetual non-modeling possibility has previously defined array, establishing it at the field of possible, of virtuality, of power: hospital that could have been and that it was not. Indeed, the investigation of various aspects/elements of hospital space Juvino Barreto revealed us new dimensions of hospital space, far more complex than the simple and the current idea of a place to shelter patients: plasticity and fluidity of space, which is not made to circumscribe the limits of empeiria, engraving up to strength relations fought between different subject; its Constitution as a transitional space, Heterotopic, doing live inside modern elements with premoderns (professional doctors working with religious thought, skeptical of positivist medicine living with the religious faith of the nuns of Santana); the impossibility of thinking hospital space of HCJB while homogeneous unit, static, transistoric, making the spatiality, without considering the profound differences, fractures and dislocations that animated his own existence, multiplying their expressions of identity / Este trabalho tem por objeto de estudo o Hospital de Caridade Juvino Barreto, institui??o nosocomial localizada na cidade do Natal (RN), entre a Praia de Areia Preta e o Monte Petr?polis, focalizando-o no per?odo compreendido entre 1909, ano em que o novo edif?cio hospitalar fora constru?do e inaugurado, e 1927, data da transfer?ncia de sua administra??o de dom?nio p?blico para a rec?m-criada associa??o m?dica da Sociedade de Assist?ncia Hospitalar (SAH). Estudamos as condi??es de possibilidade da emerg?ncia desse espa?o hospitalar no ambiente urbano da capital do Rio Grande do Norte, buscando compreender as diferentes t?ticas e estrat?gias implementadas pelos sujeitos hist?ricos envolvidos na constitui??o desse nosoc?mio. Partindo de um corpus documental constitu?do de mem?rias m?dicas (tendo o Doutor Janu?rio Cicco como observador privilegiado), informa??es presentes em jornais (A Rep?blica e O Di?rio do Natal), acervo fotogr?fico e extenso material de natureza administrativa e legal (Discursos, Exposi??es, Falas, Leis, Relat?rios e Resolu??es), analisamos detalhadamente a geografia m?dica do HCJB, relacionando os discursos da Geografia e da Medicina na escolha da localiza??o espacial do referido nosoc?mio hospitalar, bem como examinamos a arquitetura do hospital, sua espacialidade interna, divis?es, formas de controle do espa?o, e, por fim, abordamos as pr?ticas m?dicas que se desenrolaram no seu interior, conduzindo-nos, a esse respeito, a partir das experi?ncias do chefe de cl?nicas do hospital, o Dr. Janu?rio Cicco, destacando-se a? a discuss?o sobre a ?tica no trabalho m?dico-hospitalar. A percep??o do HCJB como nosoespacialidade m?dica sempre em movimento, constitu?da segundo princ?pios taxon?micos baseados na diferen?a e na dispers?o de for?as, levou-nos a articul?- lo teoricamente a partir do arsenal conceitual-metodol?gico do fil?sofo Michel Foucault, em especial suas reflex?es da fase geneal?gica, centradas no fen?meno do poder, posi??o que nos permite valorizar o espa?o noso-hospitalar como constru??o, inven??o, produto de rela??es de for?a, que conferem ao nosoc?mio aspecto inacabado, aparente, sempre em jogo, possibilidade perp?tua de modelagem que n?o tem matriz previamente definida, instaurando-o no campo do poss?vel, da virtualidade, da pot?ncia: hospital que poderia ter sido e que n?o foi. Com efeito, a investiga??o dos diversos aspectos/elementos do espa?o hospitalar do Juvino Barreto revelou-nos novas dimens?es da espacialidade m?dico-hospitalar, muito mais complexa do que a simples e corrente id?ia de um lugar para abrigo de doentes: a plasticidade e fluidez do espa?o, que n?o se deixava circunscrever aos limites da empeiria, plasmando-se ao sabor das rela??es de for?a travadas entre os diferentes sujeitos; sua constitui??o como espa?o de transi??o, heterot?pico, fazendo conviver no seu interior elementos modernos com pr?modernos (m?dicos profissionais trabalhando com religiosas, pensamento c?tico da medicina positivista convivendo com a f? religiosa das freiras de Santana); a impossibilidade de se pensar o espa?o noso-hospitalar do HCJB enquanto unidade homog?nea, est?tica, transist?rica, naturalizando essa espacialidade, sem se considerar as profundas diferen?as, fraturas e deslocamentos que animavam sua pr?pria exist?ncia, multiplicando as suas express?es identit?rias

Paul Ehrlich (1854-1915) était sans doute l'un des esprits les plus brillants en Europe de la fin du XIXème siècle. ses expériences variées et ses contributions théoriques ont inspiré toute une génération de chercheurs et ont également mené à de violentes disputes académiques. c'est ainsi que des champs entiers de recherche tels que celui de l'immunologie ont été définis à partir de ses découvertes.il semble qu'il existe un lien entre les travaux précoces de Paul Ehrlich sur les techniques de coloration et sur les colorants spécifiques pour certains tissus, qui lui ont permis de proposer ses nouvelles conceptions de l'immunité, et ses travaux systématiques tardifs qui culminèrent dans la découverte du salvarsan, le premier agent chimio thérapeutique pour le traitement de la syphilis.les efforts d'Ehrlich dans le champ des maladies vénériennes ne peuvent donc pas êtres conçus à part mais doivent en outre être mis dans le contexte de leur perception sociale au début du XXème siècle. il est également important de reconnaître que le développement de l'idée de la chimiothérapie est associé à une rupture conceptuelle en immunologie illustrée par la conception chimique d'ehrlich.dans ce projet de thèse on essayera d'analyser les différents aspects de l'œuvre académique de Paul Ehrlich. Cette tâche englobera d'un côté une perspective conceptuelle pour retracer l'émergence de la science de l'immunologie à la fin du XIXème siècle et de l'autre côté une approche d'histoire sociale en analysant les réseaux académiques, administratifs et industriels qui sont une partie intégrale de l'œuvre de Paul Ehrlich. / The overall aim of this work was to analyse transformations in Medicine and Science and the emergence of modern medical practices and cultures. For this aim we chose a dual approach in termsof social as well as of intellectual history. We gathered abroad range of themes stretching from bureaucratic authority over professionalizationin the health sector to legal change and industrialisation.Furthermore we considered the evolution of scientific cultures and practices in the field of experimental medicineand identified a number of leading themes stretching from observation practices overmeasuring and standardization practices to therapeutic intervention. Paul Ehrlich figured in a dual role as both paradigm of the triangular structure ofstate, science and industry that had a critical impact on the German health sector andalso as catalyst of emerging scientific cultures and practices in experimental medicine. His implication in both fields helped to demonstrate critical aspects of our study and further bridged the gap between approaches in terms of intellectual and social history. We found that the emergence of modern medical practice was intimately connected to the sum of elements that we developed between the late 19th and early 20th century. Social conditions allowed emerging therapeutic concepts to fortify through repeated practices. Its implication in concepts of therapy and disease was widespread and also acted on the evolution of social norms.With the spread of immunology and chemotherapy, the iatrochemical approach to medicine imposed itself and established a solid basis for its persistence during the 20th century. The conceptual as well as the social conditions for its success were intertwined and mutually fostered each other. Shortlly before the outbreak of the Great War Germany had become the testing field for a new kind of modern medicine.

With the advent of Highly Active Antiretroviral Therapy (HAART), people with the human immune deficiency virus (HIV) infection are increasingly enjoying longer and relatively healthy lives, particularly in developed countries. However, black Africans and African-Caribbean people in the United Kingdom and other developed countries are not yet enjoying the full benefits of HAART, essentially as a result of delayed diagnosis. Delayed diagnosis, in addition to affecting the health of infected individuals, also creates a community reservoir for the spread of the infection; thereby hampering prevention and control strategies by international and NHS guidelines. The delayed diagnosis may be grounded in individual, societal and health service factors that guide help-seeking behaviours of black African and African-Caribbean populations. This study set out to investigate the help-seeking behaviours to diagnose HIV and AIDS among UK based black African and African-Caribbean people, and to investigate the dynamics in those behaviours by place of origin (Africa vs. Caribbean) and by gender. A qualitative methodological approach involving semi-structured interviews was used to explore help-seeking behaviours to diagnose HIV and AIDS among black Africans and African-Caribbean populations in the UK and compared by gender. Thirty (30) purposively selected individuals from patients attending two sexual health clinics in the city of London were interviewed. These included 16 black Africans and 14 African-Caribbean people, and 16 men and 14 women. The symbolic interactionist perspective, and the concepts of broken narratives/silences, biographical disruption and biographical abruption guided the study and interpretation of findings. One main theme ‘Africanness’ and two sub-themes (“African way” and “African thing”) emerged from the findings. The “African way” embodies the risk factors involved in contracting or transmitting HIV and the “African thing” represents the HIV status itself. This is a cultural construction of HIV and AIDS within the acceptable context of participants which helped them to talk about HIV and AIDS without addressing it by the biomedical idiom. The notion of ‘Africanness’ provided a ‘marker’ for African identity. The “African thing” represented a new landscape for naming HIV without necessarily calling it by name and provided a comfortable platform for participants to seek help. The “African way” described the risk behaviours by participants that resulted in the “African thing”. Three sociological concepts; ‘broken narratives or silences, biographical disruption and biographical abruption were key issues in HIV and AIDS diagnosis at a late stage and have formed the basis for the development of a model of help-seeking for diagnosis by participants. Apparently, the main determinants of help-seeking for diagnosis of HIV and AIDS are dependent on cultural factors. Stigma is reinforced by the national health care system practices as well as health professionals themselves. This potentially increases the reluctance among black African and African-Caribbean populations to voluntarily test for HIV. An HIV diagnosis is seemingly a challenging experience because of the impending uncertainties associated with it. Seeking help for diagnosis may even be more difficult because of the anticipated and unpleasant experiences along the path to diagnosis. This may guide the individual to consider other alternatives outside the biomedical pathway, potentially; the biomedical path becomes the least likely choice, especially with black African and African-Caribbean populations. An insufficient cultural understanding is likely to result in inadequate recognition of alternative medical practices, insufficient attention to alternatives to biomedical health systems and potential distortion of the meaning of health messages linking them to practice.

English :Between 1870 and 1930, medicine on the heels of the Pastorian revolution underwent profound changes while the hospital – a charitable institution traditionally dedicated to the care of the poor – was fast becoming one of the central sites of Western health care. Yet, it was still decades away from the advent of "patient rights" and the rise to prominence of the ethics of patient autonomy. What moral culture, then, prevailed inside hospitals and shaped the encounter between patients and health care professionals? What logics underlay interactions between the former and the latter? These are the questions that this thesis aims to answer. Drawing from the archives of two public hospitals in Brussels as well as from a series of deontological, literary, religious and jurisprudential sources, this work sits at the intersection of the social history of medicine, the history of authoritarian institutions, the history of patients and the history of medical ethics. It offers an examination of therapeutics interactions that primarily focuses on the day-to-day practices of various groups of historical actors (patients, doctors, interns, catholic nuns, priests, administrators, etc.). With an eye on the larger social context, it attempts to give a new historical depth to topics borrowed from the field of medical ethics, such as medical authority, care relationships, experimentation, religious healing, truth and benevolent lies, etc. By mining a rich collection of letters written by patients and their family members to the hospital administration, this thesis also sheds light on the views and actions of hospital users. Ultimately, it reveals the hospital as structured by a complex moral economy that is the expression of the deep paternalistic outlook of western societies. In this economy, therapeutic interactions rest on an ambiguous system of moral reciprocity that encourages the simultaneous performance of charitable love and social domination, of docility and rebellion.------------Français :Entre 1870 et 1930, la médecine, enrichie par les nouvelles possibilités de l’anesthésie, exultant devant le miracle antiseptique et les promesses de la révolution pastorienne, subit une transformation profonde. L’hôpital public, institution charitable traditionnellement dédiée au soin des populations pauvres, est en passe de devenir un des sites centraux de la thérapeutique occidentale. Pourtant, cette période de formation décisive de la médecine moderne est encore à des décennies de l’avènement des « droits des patients » et de ce bouleversement majeur qui verra, au milieu du 20ème siècle, l’éthique médicale entièrement reformulée autour de la notion d’autonomie du malade. Quelle culture morale prévaut alors à l’intérieur des institutions hospitalières et détermine les formes de la rencontre entre les patients et les soignants? Quels logiques sous-tendent l’agir des premiers et des seconds, dans le cadre de toutes ces activités qui amènent ceux-ci à interagir ensemble ?Ce sont les questions auxquelles cette thèse a l’ambition de répondre. Le contexte hospitalier lui-même est abordé ici comme un révélateur des dynamiques sociales structurant plus largement non seulement la médecine de l’époque, mais aussi les sociétés occidentales avant la Seconde Guerre mondiale.Les archives des hôpitaux bruxellois St-Jean et St-Pierre, supplémentées par une série de sources déontologiques, littéraires, religieuses et jurisprudentielles, constituent le terrain d’étude à partir duquel s’élaborent les propositions nombreuses de cette thèse. L’objet central de celle-ci – les interactions en milieu hospitalier – se situe à la croisée de quatre courants historiographiques :l’histoire sociale de la médecine, le récit interactionniste des institutions autoritaires, l’histoire des patients et l’histoire de l’éthique médicale. Prêtant une attention particulière aux pratiques des acteurs historiques, Guérir, travailler, désobéir se structure autour de six chapitres. Ceux-ci abordent des thématiques aussi variées que l’autorité des acteurs hospitaliers, la communication entre patients et soignants, ou encore la relation soignante. La thèse interroge aussi la dimension « utilitaire » de la rencontre thérapeutique dans un contexte de médecine publique (usage des corps de malades pauvres pour la science, l’enseignement, etc), les pratiques de détournement de l’institution hospitalière par les malades, et la nature du dialogue mettant en lien ces mêmes malades et l’administration hospitalière en cas de plainte. Au final, ce travail de recherche met à jour une économie morale complexe, expression du paternalisme profond des sociétés occidentales, qui fait reposer les interactions thérapeutiques sur un système ambigu de réciprocité morale. / Doctorat en Histoire, histoire de l'art et archéologie / info:eu-repo/semantics/nonPublished

Le continuel développement des outils statistiques permet aujourd’hui la modélisation de nombreux phénomènes, toujours plus complexes. En combinant l’approche offerte par des modèles statistiques spécifiques, dit "multiniveaux", et leurs applications à différentes problématiques médicales, cette thèse s’inscrit à la croisée de divers domaines : celui des statistiques, de par la méthodologie sur laquelle reposent les résultats ; mais aussi, celui de l’économie de la santé et de la santé publique en général, au travers des applications présentées.La première partie de cette thèse s’intéresse aux aspects théoriques, et plus particulièrement à l’évolution des méthodologies, du modèle de régression linéaire simple aux modèles multiniveaux pour des liens non nécessairement linéaires. Le déroulé historique de la modélisation mais également les hypothèses, le principe, la stratégie d'analyse et enfin les limites y sont abordés.La seconde partie s’articule autour de deux applications multiniveaux distinctes. La première concerne les déterminants de l'observance et des interruptions de traitement, chez les personnes infectées par le virus du VIH/Sida suivant un traitement par antirétroviraux, dans le contexte du Cameroun. La seconde, quant à elle, s'intéresse au recours aux soins dentaires chez les personnes âgées de 60 ans et plus et vivant en domicile ordinaire. Ces deux applications sont comparables dans leurs méthodologies puisqu’il s’agit de déterminer les comportements étudiés par des variables individuelles habituellement retenues, mais aussi des variables de "contexte" (caractéristiques de l’offre de soins).La troisième partie est consacrée aux applications sur le panel de médecins généralistes et traite deux études autonomes. La première expose les réticences des médecins, et le rôle de leurs aprioris, face aux Recommandations de Bonnes Pratiques (RBP). Elle nous permet de déboucher sur quelques pistes pour améliorer l’usage des RBP en médecine de ville. La seconde analyse la similarité – ou parfois la dissimilarité – entre le cycle d’activité des médecins généralistes et la saisonnalité des épidémies, dans le but d’identifier les facteurs favorisant l’ajustement des médecins généralistes aux variations saisonnières des besoins des patients. Cette étude pourrait permettre, notamment, d’anticiper et de mieux gérer des situations de crise sanitaire, avec l’appui effectif de la médecine de ville. / The continual development of statistical tools allows the modelling of numerous phenomena, including the complex ones. Using a set of statistical techniques and applications, based on the so-called “multilevel” modelling, this thesis deals with different aspects related to the statistical methodology and applications as per health economics and public health.The first part reconsiders the evolution of methodology, starting from the simple linear regression techniques to the more complex multilevel modelling as applied to both the linear and non-linear relations. It addresses issues related to the historical development, the hypotheses, the strategy of analysis, and the scope of applications. The second part presents two distinct multilevel studies. The first concerns the determinants of observance and interruptions of treatment for persons infected by the HIV/AIDS and treated with antiretroviral in Cameroon. The second one focuses on the use of dental services for the elderly. The two studies are methodologically comparable in that, besides integrating the usually retained individual variables, the analyses examine health seeking behaviours, particularly, the utilisation of health care services, while accounting for contextual determinants such as the characteristics of health supply (clinic, department or region).The third part is dedicated to the applications on GPs' panel and contains two different studies. The first one explains the GPs’ behaviours and the role of their aprioris vis-à-vis Clinical Practice Guidelines (CPG), and suggests solutions to overcome their negative attitudes. The second study analyses the similarity – sometimes the differences – between the cycle of GPs’ activity and the seasonality of epidemics with the aim of better understanding determinants favouring the adjustment of the GP in the seasonal variations of the patients needs. This study helps anticipate and manage situations of sanitary crisis, with the effective support of general practitioners.