Este trabalho tem como objetivo avaliar o papel da autoridade estatal e do desenvolvimento na estabilidade dos Estados da África Subsaariana e a influência que têm nos processos de falência estatal e de eclosão de guerras intraestatais. Desde o fim da Guerra Fria, a corrente de pensamento que fundia segurança e desenvolvimento tornou-se predominante para analisar as causas e fornecer sugestões de políticas para impedir que os Estados sucumbissem a dinâmicas de violência, fomentadas por necessidade, ganância e agravo - todos gerados e intensificados em situações de subdesenvolvimento. Palco de boa parte dos países menos desenvolvidos (PMDs) do mundo e da grande maioria dos conflitos intraestatais que ocorreram nos últimos trinta anos, a África Subsaariana foi retratada como locus immutabilis, cujos problemas tinham poucas ou nenhuma solução possível. Desta forma, o subdesenvolvimento endêmico da região foi usado como guarda-chuva conceitual uma vez que intensificaria as consequências nocivas de certos tipos de regimes políticos, da distribuição desigual das riquezas e oportunidades econômicas e da incompatibilidade étnica que existiria em seus países. Seguindo esta linha de pensamento, bastaria resolver a situação do subdesenvolvimento nos Estados da África Subsaariana que seus processos de falência seriam revertidos e as guerras civis não mais aconteceriam. No entanto, é possível questionar esta relação entre segurança e desenvolvimento dado que países que têm o mesmo nível de subdesenvolvimento diferiram em seus destinos, tendo alguns sucumbido às dinâmicas violentas e outros não. Este trabalho pretende, portanto, identificar as causas das guerras civis e da falência de Estados na região. Este trabalho argumenta que é a baixa autoridade estatal (e não o subdesenvolvimento) a condição determinante para o advento de guerras civis e da falência de Estado na África Subsaariana. Para chegar a tal resultado, analisou-se os dados de 44 Estados da região fornecidos pelo Worldwide Governance Indicators do Banco Mundial e os mesmos dados utilizados pela ONU para classificar os PMDs. Também se utilizou análise qualitativa sobre a história dos países onde a paz imperou desde a independência para avaliar as fundações da autoridade estatal. / This thesis looks forward to assessing the role of state authority and development in the stability of Sub-Saharan African states and their influence on state failure processes and on the outbreak of intra-state wars. Since the end of the Cold War, the current of thought that merged security and development has become prevalent in analysing the causes and in providing policy suggestions to prevent states from succumbing to dynamics of violence fuelled by need, greed, and grievance - which are generated and intensified in situations of underdevelopment. As the stage for most of the world\'s least developed countries and the largest number of intrastate conflicts that have taken place over the last thirty years, Sub-Saharan Africa has been portrayed as locus immutabilis, whose problems had few or none feasible solutions. In this regard, the region\'s endemic underdevelopment was used as a conceptual umbrella since it would intensify the harmful consequences of certain types of political regimes, of the unequal distribution of wealth and economic opportunities, and the ethnic incompatibility that would exist in their countries. Following this line of thought, resolving the situation of underdevelopment in Sub-Saharan African states would suffice to reverse processes of state failure and civil wars would no longer happen. However, it is possible to question this relationship between security and development since countries that have the same level of underdevelopment had different outcomes, having some of them capitulated to violent dynamics and others not. This thesis therefore aims to identify the causes of civil wars and state failure in the region. It argues that it is the low level of state authority (and not underdevelopment) that is the determining factor for the advent of civil wars and state failure in Sub-Saharan Africa. In order to achieve this result data from 44 countries in the region provided by the World Bank\'s Worldwide Governance Indicators and the same data used by the UN to classify the LDCs were analysed. Qualitative analysis was also conducted about the history of countries where peace has prevailed since independence to assess the foundations of state authority.

En Afrique subsaharienne, le nationalisme « imagine » une identité nationale homogène enracinée dans la mythologie de la spécificité africaine qui représente la femme comme un symbole des racines culturelles (le trope de la « Mère Afrique »). Ce travail analyse comment la romancière subsaharienne (la femme objet culturel muet, extra-historique et apolitique) s’approprie le discours nationaliste africain (réimaginer la nation) pour définir une autre identité pour la femme. L’étude sonde l’hypothèse d’un sujet marginal qui se révèle dans des « lieux frontaliers » selon sa ressemblance et son altérité par rapport aux sujets dominants. Elle analyse la nationalité politique (citoyenneté), la nationalité culturelle (africanité), ainsi que leur enchevêtrement dans la nationalité féminine. And They Didn’t Die et Nehanda évoquent les mouvements de libération en l’Afrique du Sud et au Zimbabwe pour recontextualiser l’appartenance culturelle de la femme « pot de culture » entre la tradition de la modernité. Matins de couvre-feu et L’Ex-père de la nation révèlent la désillusion après les indépendances du Sénégal et la Côte d’Ivoire pour déstabiliser la dichotomie des espaces public et privé – un État centré sur l’homme (le « Père-de-la-nation ») et une sphère domestique féminine. Destination Biafra traite le nationalisme ethnique au Nigéria pour aborder la problématique de la nationalité au carrefour des nationalités politique et culturelle : Un Etat (espace géopolitique) définie par des frontières modernes et une Nation (« communauté imaginée ») supranationale définie par une culture précoloniale. / Nationalism in sub-Saharan Africa « imagines » a homogenous national identity embedded in the mythology of African uniqueness, which represents the woman symbol of cultural roots (the “Mother Africa “trope). This study analyses how the sub-Saharan female novelist (the woman as a mute, extra-historical and apolitical object of culture) appropriates African nationalism (re-imagines the nation) to define a new identity for African womanhood. The study tests the hypothesis that a marginal subject reveals itself in “border location” according to its similarity or difference to dominant subjects. It analyses political nationality (citizenship), cultural nationality (Africanness), and their interaction within the representation of female national identity. And They Didn’t Die and Nehanda evoke liberation movements in South Africa and Zimbabwe to recontextualise women’s cultural affiliation (the woman “pot of culture)” between tradition and modernity. Matins de couvre-feu and L’Ex-père de la nation depict the post-independence disillusionment of Senegal and the Ivory Coast to subvert the dichotomy of public and private spheres which construct a male centred State (the “Father of the Nation”) and the woman-centred “domestic” sphere. Finally, Destination Biafra highlights ethnic nationalism in Nigeria to illustrate the problematic of the intertwining of cultural and political nationalities resulting from the paradoxical construction of the African nation-state: A State (a geo-political space) defined by modern borders and a supranational nation (“imagined community”) delimited by the symbolic borders of a pre-colonial culture.

Magister Public Health - MPH / Sub-Saharan Africa is home to two thirds of the 33 million HIV infected individuals worldwide. In 2007 there were an estimated 1.5 million Kenyans infected with HIV, and 166 000 new infections in 2008. The introduction of antiretroviral therapy [ART] brought new hope to HIV patients. It has transformed a fatal disease to a chronic manageable condition. Kenya has made great strides in ensuring access to ART and by 2009, 308 610 patients in the country were receiving ART - which is the second highest number worldwide. The success of ART requires a sustained adherence rate to medication of more than 95% to prevent viral replication and the development of drug resistant HIV strains. Identifying the factors that influence adherence, is essential for the long-term success of public ART programmes. The current study explored patient, socio-economic, cultural, and religious and health systems factors that influence adherence to ART at the Coast Provincial General Hospital [CPGH] in Mombasa, Kenya. / South Africa

Magister Public Health - MPH / Aim: To obtain baseline data on adherence levels and the major determinants of adherence among patients on HAART at Rundu Hospital, Namibia. Results: Seventy-eight percent of the 97 participants included in the study were female, resulting in a female to male ratio of 4 :1. The mean age of the participants was 36.7 (SD: 9.00) years with 80% of the participants being in the 20-44 age group. The mean duration on ART treatment was 20 (SD: 10.3) months with 76% of the participants being on ART for 24 or less months. The average adherence rate reported by mean composite of the three measures was 95.1%, while the proportion of patients who achieved adherence levels of 95% and above was 64%. The main barriers to adherence to HAART reported by participants were forgetfulness (28%), lack of food (13%) and being away from the pills (11%): facilitators reported included counselling (19%) and treatment supporters (11%). Having knowledge of the consequences of failing to take HAART as prescribed was significantly associated with adherence (p = 0.03), as was being female (p = 0.04) while living further than 6 km from the hospital was significantly associated with non adherence (p = 0.018).

L’Afrique est confrontée à un vieillissement démographique sans précédent. L’âge étant le facteur principal dans la survenue des démences, l’Afrique devra affronter l’un des plus grands risques socio-sanitaire et économique du 21e siècle. Cette situation accentue la pression sur des systèmes nationaux de santé sollicités au-delà de leurs capacités. L’épidémiologie des démences est encore très peu connue en Afrique et la plupart des données existantes portent sur la prévalence. La démence étant une pathologie chronique et actuellement incurable, la prévention et l’amélioration de la qualité de la prise en charge des malades restent les meilleures armes pour la gestion de cette pathologie. Pour mieux aider les pays africains à bâtir des politiques de santé adaptées, il est important de fournir des données portant sur l’évolution (incidence et mortalité) de cette pathologie. L’objectif de nos travaux était d’estimer l’incidence des démences et le pronostic de ces pathologies en terme de survie. Notre travail a été réalisé à partir d’une cohorte de sujets âgés, habitant les zones urbaine et rurale de la République du Congo, recrutés lors de l’enquête de prévalence EPIDEMCA et suivis pendant deux ans entre 2012 et 2014. Dans un premier temps nous avons estimé la mortalité associée à la démence. La comparaison des taux de mortalité en fonction du statut cognitif a montré que les sujets déments avaient un risque de décès plus important. Ce risque était 2,5 fois plus élevé par rapport aux sujets normaux (HR= 2,53, IC95%: 1,42-4,49, p=0,001) et augmentait avec l’âge et la sévérité de la maladie. Concernant l’incidence, nous avons observé 23 (2,38%) nouveaux cas de démence et estimé une incidence brute de 15,79 (IC95% :10,25 – 23,32) pour 1000 Personne Année (PA). L’incidence standardisée à la population âgée d’Afrique Subsaharienne S était de 13,53 (IC95% 9,98 – 15,66). En tenant compte des différents facteurs analysés, l’âge (p=0,003) et un faible engagement social (p=0,028) (défini par un manque ou une faible participation aux activités communautaires) étaient les principaux facteurs associés à l’incidence de la démence en population congolaise. Globalement, nos résultats soulignent le fardeau que représente la démence pour l’Afrique et sont en parfaite adéquation avec ceux issus d’autres pays à faibles et moyens revenus et des pays à revenus élevés. Toutefois, il est difficile de généraliser nos résultats à la population africaine, car il s’agit d’un continent vaste avec des spécificités pour chaque population. La mise en place de programmes d’études multicentriques dédiés aux démences adoptant des méthodologies similaires serait souhaitable. Les politiques de santé relatives aux personnes âgées devraient intégrer la prise en charge des démences. / The African population is ageing at an unprecedented rate. In sub-Saharan Africa (SSA), the number of people aged 60 years and above is projected to rise to over 67 million by 2030 (representing a 100% increase in the 25 years since 2005). Incidence and mortality data help us understand the epidemiology and disease burden of dementia, and thereby improve policy planning. Although dementia prevalence have been reported for many countries of SSA, incidence and mortality related to dementia remain poorly described to date as only Nigeria had reported dementia incidence among older African adults. This study aimed to assess the dementia related incidence and mortality, and associated risk factors in Congolese people aged over 65 years recruited in EPIDEMCA survey. The baseline population was followed up during two years. Older participants were traced and interviewed annually in rural and urban Congo between 2012 and 2014. DSM-IV and NINCDS-ADRDA criteria were required for dementia and Alzheimer’s disease diagnoses. Data on vital status were collected throughout the follow-up. Cox proportional hazards model was used to assess the link between baseline dementia diagnosis and mortality risk. Risk factors for incident dementia were examined using a competing-risks regression model based on Fine and Gray methods. After two years of follow-up, 101 (9.8%) participants had died. Compared to participants with normal cognition at baseline, mortality risk was more than 2.5 times higher among those with dementia (HR= 2.53, 95% CI: 1.42-4.49, p=0.001). Among those with dementia, only clinical severity of dementia was associated with an additional increased mortality risk (HR=1.91; CI 95%, 1.23-2.96; p=0.004). Age (per 5-year increase), male sex and living in an urban area were independently associated with increased mortality risk across the full cohort. Among the dementia-free cohort, the crude incidence of dementia was estimated at 15.79 (95% CI 10.25 – 23.32) per 1000 Person Year. We estimated a standardised incidence (on the 2015 Sub-Saharan Africa population) of 13.53 (95% CI 9.98–15.66). Regarding baseline characteristics, old age (p=0.003) and poor social engagement (assessed by community activity) (p=0•028) at baseline were associated with increased dementia incidence among Congolese older adults.Our results, as previously described, support the ongoing demographic and epidemiologic transition in SSA. They highlight the need of longitudinal population-based studies dedicated to dementia incidence and mortality among African people. Given that Africa is a continent subject to unprecedented population ageing; our data highlight the need to address the burden of dementia in this region. Support should incorporate prevention plans based primarily on modifiable (cardiovascular) risk factors, education and social inclusion of the elderly, as well as support for patients and their relatives.

Doctorat en sciences sociales, politiques et économiques / info:eu-repo/semantics/nonPublished

Doctorat en sciences sociales, politiques et économiques / info:eu-repo/semantics/nonPublished

Cette thèse, inspirée des travaux sur le développement du jeune enfant en conditions de vie défavorisées (Zaouche Gaudron, 2005), traite de la subjectivation d’enfants d’Afrique subsaharienne dans leurs rapports à l’eau. La subjectivation est ici le procès par lequel les enfants produisent leur singularité subjective dans le rapport aux réalités objectives de leur environnement (Malrieu, 2003). Notre approche revient sur la question, classique en psychologie, de l’activité du sujet sur l’objet. L’alternative des objectivations nous permet de montrer que les objets ne sont pas seulement déterminants pour les sujets mais peuvent, dans et par la médiation sociale, devenir des sujets (Marx, 1867 ; Vygotsky, 1930 ; Wallon, 1945 ; Meyerson, 1948, Sève, 2008). Le processus de subjectivation chez l’enfant ne nous renvoie donc pas directement à l’activité des enfants, mais aux objectivations sociales à partir desquelles, dans leurs rapports aux objets, ils deviennent sujets singuliers. Notre échantillon d’étude est constitué de 68 enfants, âgés de 4 à 7 ans, qui vivent dans les localités rurales de Bogué et de Bakel proches du fleuve entre la Mauritanie et le Sénégal puis à Tomè au Togo près de la rivière Egbi. Notre recherche a été menée à partir d’entretiens semi-directifs à destination des parents ou adultes significatifs, et de planches figuratives destinées aux enfants et permettant, à partir de scènes d’eau, d’en faire l’objectivation en trois phases successives : en situations "naturelle", concertée et rémanente. Nos principaux résultats montrent que lorsque les adultes s’impliquent dans l’objectivation de l’eau, en situation concertée, l’eau devient un objet social dans le rapport auquel les enfants sont davantage en état de réaliser leurs subjectivations. Le rapport à l’eau propice au développement des enfants se révèle alors irréductible à l’effet des déterminations naturelles, c’est-à-dire de leur zone d’habitation. Néanmoins, nos résultats spécifiques, par localités, mettent en évidence des disparités entre celles-ci dans le rapport à l’eau indiquant que l’implication sociale nécessaire à un rapport à l’eau propice au développement des enfants, est encore à construire et à développer en Afrique subsaharienne. Les résultats obtenus permettent de proposer des perspectives de recherche et des pistes d’intervention quant au rapport des enfants aux objets, notamment ceux de première nécessité et en milieux défavorisés. / This thesis is inspired by the work on the development of children growing up in disadvantaged living conditions (Zaouche Gaudron, 2005). It treats the subjectification of the African Sub-Saharan children in their relationship with water. In this study, subjectification is the process by which children produce their subjective uniqueness based on the relationship with objective realities in their environment (Malrieu, 2003). Our approach comes back to the classical question in psychology, about the Subject’s activity on the Object. The alternative of the objectification allows us to show that Objects are not only determining factors toward Subjects but, through social mediation, they could become Subjects themselves (Marx, 1867; Vygotsky, 1930; Wallon, 1945; Meyerson, 1948, Sève, 2008). The process of child subjectification does not refer directly to children activity, but to their social objectification, allowing them, through their relationship to objects, to become singulars subjects. Our study sample consists of 68 children, between 4 and 7 years old, who are living in the rural communities of Bogué and Bakel close to the river between Mauritania and Senegal as well as in the rural community of Tomè in Togo close to the river of Egbi. Our research has been based on semi-structured interviews targeting parents or significant adults, and figurative boards targeting children that allow, through water scenes, to be exploited as objectification of three successive phases: “natural” situation, concerted and retentive. Our main results show that when adults are involved in water objectification, through the concerted situation, water becomes a social object intervening in the relationship enabling children more and more to realize their subjectification. The relationship between suitable water and children's development proves that is irreducible to the impact of natural determinations, for example the areas where they live. However, our specific results for each community, highlight the disparities between them regarding to water. These results indicate that the necessary social implication in the relationship between the suitable water and the children development is yet to be built and developed in Sub-Saharan Africa. The obtained results allow to open up research perspectives and intervention areas regarding to the relationship between children and objects, notably those of basic needs for children living in disadvantaged environments.

Magister Public Health - MPH / Background: Namibia is one of the Southern African countries hardest hit by the HIV epidemic, with an estimated one out of every five people infected (MoHSS, 2004). Approximately 80,000 of the infected population currently require antiretroviral treatment (ART). In order to prevent the progression of the HIV infection to AIDS, patients are required to take antiretroviral medicines lifelong. This lifelong use exposes patients to toxicities of these medicines and the only available options of managing the toxicities of ARVs are to treat the toxicity or substitute or switch the offending medicines. Aim: The current study aimed to describe the extent and reasons for substituting and switching HAART at the Katutura Intermediate Hospital in Windhoek, Namibia. Methodology: A descriptive retrospective case series study, in which medical records were reviewed to determine the extent and reasons for substituting and switching HAART was conducted. Random sampling was used to draw a sample of 500 from 3477 adult HAART patients who commenced treatment between 1 January 2002 and 31 December 2006. A prepiloted data collection tool was used to collect the data. The following information was collected: baseline CD4 count, weight, initial ARVs, first and second ARV substitutions, ART switch and the reasons for substituting ARVs or switching ART during the indicated period. Epi Info version 6 was used to analyse frequencies, means and medians of all important variables in the data set. Results: The sample was made up of 500 HAART patients; 60% were females. The median age of the sample was 34 years (Inter-quartile range (IQR) 30 – 40) and the median CD4 cell count was 153 cells/mm3 (IQR 96 – 212) at initiation of therapy. The median time on treatment before first substitution was 28 months (IQR 24 – 34), whereas the median time before second substitution was 10 months (IQR 6 – 15) from the time of the first substitution. The median time before switching was 31 months (IQR 24 - 39). A total of 31% of the study subjects underwent a substitution once, whereas 1.8% underwent a second substitution. Only six (1.2%) patients switched to a second line treatment after the modification of the treatment. The most commonly recorded reason for the first substitution was toxicity (19%). As in other studies, stavudine (D4T), nevirapine (NVP) and efavirenz (EFV) were the ARVs associated with most of the recorded toxicities. High viral load (50%) was the most reported reason for switching. In almost half of the substitution cases the reasons for substitution were not stated, and in a third of the switch cases the reasons for switching were not stated. Conclusion: The rate of substitution at 31% was similar to that found in other resource poor settings, however, the rate of switching (1.2%) was much lower than was found in similar settings. The main reason stated for substituting antiretrovirals was “toxicity”. / South Africa

Doctor Educationis / Background: In an attempt to avert the HIV/AIDS epidemic, more research has been conducted to determine why the epidemic is more devastating in Southern African countries than anywhere else in the world. Heterosexual transmission is believed to be driving the epidemic in many sub-Saharan African countries. Recent research has indicated that having concurrent sexual partners is one of the factors contributing to the fast spread of HIV transmission in this region.Aim: This study aimed to describe the level of knowledge about the risk of HIV transmission posed by concurrent sexual partnering as well as beliefs and practices about concurrent partnering among education students at the Rundu College of Education(RCE) in the Kavango region of Namibia. Concurrent partnering was defined as a situation where a person has more than one sexual partner at the same time, during the twelve months preceding the study.Methodology: There were 374 students registered for the 2009 academic year at RCE.All registered students were targeted for the study and 278 completed the questionnaire,yielding a response rate of 73.4%. The survey described prevalence of concurrent partnering, knowledge about risk posed by concurrent partnering as well as beliefs about concurrent partnering.Data collected was analyzed using Statistical Programs for Social Sciences (SPSS).Descriptive statistics were used to describe the prevalence of sexual concurrency,knowledge about risk posed by concurrent partnering and beliefs about concurrent partnering among the study population. Frequency of concurrency was cross tabulated with demographic variables like age group, sex and year of study as well as by knowledge and beliefs about sexual concurrent partnering.Results: The prevalence of concurrency in this sample was 9.4% with significantly higher prevalence (13.0%) among male students compared to females (5.3%). Males reported knowledge levels of 85.7% to 88.4% while females reported knowledge levels of 89.3% and 93.1%. More men (28.8%) than women (10.7%) agreed with the statement that sexual concurrency is a sign of manhood (p=0.00). Further, more male students(27.9%) compared to female students (6.1%) agreed with the statement that sexual concurrency is part of African culture and should continue (p=0.00).Conclusion: The study results show a high knowledge of risk posed by concurrency. It further reveals that a high number of people believe that concurrency is acceptable especially among men.HIV prevention activities promoting partner reduction and mutual fidelity should be implemented. Such activities should focus more on behavior change rather than on information giving. There is a need to create platforms for community members to debate on cultural beliefs about sexual concurrency.