Karjeros valstybės tarnautojų motyvavimas dar nebuvo tiriamas sisteminiu požiūriu, nors šiuolaikinės aplinkos sąlygos neleidžia net paprastų reiškinių aiškinti redukcionalistiškai. Valstybės tarnybos tobulinimo koncepcijoje nurodoma, kad valstybės tarnautojų veikla nėra orientuota į rezultatus, darbo apmokėjimo sistema neskatina darbo kokybės ir nėra pakankamai skaidri. Šie du veiksniai sudarė prielaidas atsirasti šiam tyrimui. Kadangi sistemų teorija teigia, kad sistema yra kokybiškai vertingesnė, nei jos dalių suma, tyrime siekiama atskleisti karjeros valstybės tarnautojų motyvavimo sistemingumą. Šiuo tikslu iškeliama hipotezė h0 – karjeros valstybės tarnautojų motyvavimas nėra sistemingas ir hipotezė h1 – karjeros valstybės tarnautojų motyvavimas yra sistemingas. Hipotezei patikrinti pristatoma sistemų teoriją bei sistemų charakteristikos, atskleidžiama motyvavimo reikšmė modernioje žmogiškųjų išteklių vadyboje, sukuriamas sisteminis motyvavimo modelis ir jo pagrindu analizuojamas motyvavimo karjeros valstybės tarnyboje reglamentavimas. Tyrime naudojami mokslinės literatūros ir dokumentų analizės metodai. Tyrimas parodo, motyvavimo sistema yra chaotinės prigimties, todėl gali pasiekti itin didelį efektyvumą, jeigu yra valdoma. Taip pat, kad egzistuoja karjeros valstybės tarnautojų motyvavimo sistema, tačiau dėl reglamentavimo netobulumo ji yra chaoso būsenoje. Pasitvirtino h0 hipotezė – karjeros valstybės tarnautojų motyvavimas nėra sistemingas. / The motivation of state career servants haven’t been researched by taking a systemic approach, although now a days even the minor phenomenon couldn’t be explained by the reductionalistic approach because of the environment conditions we live in. In the State service improvement conception it is stated that the work of state career servants isn’t oriented towards results, salary system doesn’t stimulate work quality and isn’t transparent enough. These are the two reasons, which made the background for this research. Since systems’ theory suggests, that system is qualitatively superior that the sum of its elements, the research goal is to reveal the systematic of motivation of state career servants. Because of this goal there are two hypothesis formed: h0 - the motivation of state career servants isn’t systematic and h1 – the motivation of state career servants is systematic. In order to examine the hypothesis systems’ theory and systems’ characteristics are presented, the significance of motivation in the Modern human resource management is revealed, the systemic model of motivation is created and according to it the regulation of motivation of state career servants is analyzed. The methods of scientific theory analysis and document analysis are used in the research. The research shows that the nature of motivation system is chaotic, that’s why the system itself can reach a very high efficiency if controlled. It also shows the existence of motivation system of state career... [to full text]

A pesca artesanal tem significativa importância para o Estado de Santa Catarina, onde existem cerca de 25 mil pescadores artesanais em atividade, os quais são responsáveis por 30% da produção catarinense de pescado. Entretanto, verifica-se a existência de problemas em relação à atividade, como a dificuldade de manutenção das colônias de pescadores, a concorrência da pesca industrial, a poluição, dentre outros. Para estudar esse processo, a área delimitada é a Praia da Pinheira, no município de Palhoça, região de colonização açoriana, que até os anos 1970 ainda era caracterizada como uma comunidade de pescadores. Conforme foram se implantando melhorias na infra-estrutura da região, ocorreram significativas mudanças sócioeconômicas, principalmente a crescente presença do turismo. Soma-se ao contexto a criação de uma unidade de conservação, o Parque Estadual da Serra do Tabuleiro, em 1975, o que pode ser mais um obstáculo para a sociedade local, na medida em que restringe o uso dos recursos naturais. Assim, o contexto sócio-econômico também contribui para um processo de vulnerabilidade dos pescadores. Há diversos entendimentos a respeito da permanência de populações tradicionais e suas formas de relações sócio-econômicas, sendo importante uma reflexão sobre este grupo social que preserva características consideradas tradicionais na sociedade contemporânea. Além disso, é relevante compreender as relações do setor pesqueiro com outras atividades econômicas. Nesse sentido, este trabalho aborda a complexidade da atividade pesqueira, através de um enfoque sistêmico que permite conhecer a evolução e diferenciação dos sistemas pesqueiros da Praia da Pinheira. A pesquisa revelou quatro fases distintas: o sistema pesqueiro indígena; o sistema pesqueiro de subsistência dos açorianos; o sistema pesqueiro de salga; e o sistema pesqueiro comercial e de prestação de serviços. Igualmente, com base em dados qualitativos e quantitativos foram caracterizados os atuais sistemas técnicos de captura utilizados na Praia da Pinheira, bem como os atuais tipos de pescadores do local. / The artisan fishing is of great importance for the state of Santa Catarina, where roughly 25 thousand artisan fishermen are currently working, which represents 30% of the local fishing production. However, some problems related to this activity can be detected, as the difficulty to maintain the fishermen community, the industrial fishing competition, pollution, among others. In order to study this process, the delimited area is the Praia da Pinheira, in the municipality of Palhoça, region of Azorean colonization, which up until 1970s was predominantly a fishermen community. Whereas some infrastructure improvements were implemented in this region, important socioeconomic changes came into place, primarily the increasing tourism activity. In addition, the creation of a conservation unity, the Parque Estadual da Serra do Tabuleiro, in 1975, what may represent a further obstacle to the local society, in the extent that it restrains the use of natural resources. Thus, the socioeconomic juncture increases the fishermen vulnerability. There is a variety of interpretations about the resistance by traditional populations and its forms of socioeconomic relations, being important to analyze these social groups that preserve the so called traditional features in the contemporary society. Besides, it is important to understand the relationship between the fishing sector and the other economic activities. In this sense, this work comes up to the complexity of the fishing activity, through a systemic approach that allows us to understand the evolution and differentiation of the fishing systems in the Praia da Pinheira. The research revealed four different stages: the Indian fishing system; the Azorean subsistence fishing system; the salga fishing system; and the commercial fishing system and of services. By the same token, based on the qualitative and quantitative data, the contemporary technical systems of capturing used in the Praia da Pinheira were characterized, as well as the local fishermen types.

A realidade agrária da Bocacosta na Guatemala, área tradicionalmente cafeeira, sofreu modificações importantes nos últimos anos. As crise do café em princípios de 1990 e 2000, concomitantemente com a firmação dos Acordos de Paz em 1996, foram decisivos para a transformação produtiva e social da região. Atualmente, podemos encontrar, integrados aos latifúndios de café tradicionais do modelo agroexportador e às grandes fazendas de gado, associações compostas por pequenos produtores de café, assentamentos de ex-guerrilheiros do conflito armado, comunidades de camponeses que regularizaram as terras, entre outros. São estes grupos que, conscientes do perigo do monocultivo de café, estão diversificando a produção. Neste contexto, o presente trabalho tem por objetivo analisar as dinâmicas sociais e produtivas da Bocacosta, proporcionando um melhor entendimento do panorama agrário atual. A partir de uma metodologia fundamentada em um instrumental de cunho sistêmico, a pesquisa busca analisar e diagnosticar os sistemas de produção implementados pelos agricultores da Bocacosta. Este estudo permitiu identificar cinco (5) sistemas agrários, que evoluiram e diferenciaram-se ao longo do tempo, e sete (7) sistemas de produção predominantes, praticados atualmente na região. A análise aprofundada de cada sistema de produção foi operacionalizada por meio de estudos de caso, escolhidos intencionalmente, a partir da pesquisa de campo e das entrevistas com os informante-chave. Constatou-se que o café, apesar de ainda ser predominante na realidade agrária da região, encontra-se em regressão na maioria dos estabelecimentos rurais, em razão da baixa rentabilidade. Igualmente, destaca-se a heterogeneidade nas estratégias adotadas pelas novas formas sociais, responsáveis pelas novas dinâmicas produtivas. A análise das informações evidencia a necessidade de elaborar políticas públicas de caráter social que elevem as condições de vida da população rural, bem como medidas que permitam efetivar a transição produtiva para outros cultivos e criações ou a diferenciação do produto no mercado. / The agrarian reality at Bocacosta in Guatemala, a traditionally coffee area, underwent significant changes in recent years. The coffee crisis of early 1990 and 2000, concurrently with the Peace Accords signing in 1996, were crucial for the productive and social transformation in the region. Currently, we can find, integrated with traditional agro-export model coffee lands and large livestock farms, associations composed of small coffee producers, ex-guerrillas settlements of armed conflict, peasant communities that regularized the land, among others. Are these groups that, aware of the danger of coffee monoculture, are diversifying the production. In this context, the present study aims to examine the social and productive dynamics at Bocacosta, providing a better understanding of the current agricultural background. From a methodology based on a systemic instrument, the research seeks to analyze and diagnose the farming systems implemented by farmers of Bocacosta. This study allowed to identify five (5) agrarian systems, which evolved and differed over time, and seven (7) predominant farming systems, currently performed in the region. A detailed analysis of each farming system was carried out through case studies, intentionally chosen from the research field stage and interviews with key informers. We found out that coffee, despite still being dominant in the agricultural reality of the region, is declining in most of rural establishments, due to low profitability. Also, it can be highlight the heterogeneity of strategies adopted by the new social forms, responsible for new dynamic production. Analysis of the data illustrates the necessity to develop social-nature public policies that increase living conditions of rural population, as well as procedures to shift production to other crops and livestock or product differentiation on the marketplace.

A pesca artesanal tem significativa importância para o Estado de Santa Catarina, onde existem cerca de 25 mil pescadores artesanais em atividade, os quais são responsáveis por 30% da produção catarinense de pescado. Entretanto, verifica-se a existência de problemas em relação à atividade, como a dificuldade de manutenção das colônias de pescadores, a concorrência da pesca industrial, a poluição, dentre outros. Para estudar esse processo, a área delimitada é a Praia da Pinheira, no município de Palhoça, região de colonização açoriana, que até os anos 1970 ainda era caracterizada como uma comunidade de pescadores. Conforme foram se implantando melhorias na infra-estrutura da região, ocorreram significativas mudanças sócioeconômicas, principalmente a crescente presença do turismo. Soma-se ao contexto a criação de uma unidade de conservação, o Parque Estadual da Serra do Tabuleiro, em 1975, o que pode ser mais um obstáculo para a sociedade local, na medida em que restringe o uso dos recursos naturais. Assim, o contexto sócio-econômico também contribui para um processo de vulnerabilidade dos pescadores. Há diversos entendimentos a respeito da permanência de populações tradicionais e suas formas de relações sócio-econômicas, sendo importante uma reflexão sobre este grupo social que preserva características consideradas tradicionais na sociedade contemporânea. Além disso, é relevante compreender as relações do setor pesqueiro com outras atividades econômicas. Nesse sentido, este trabalho aborda a complexidade da atividade pesqueira, através de um enfoque sistêmico que permite conhecer a evolução e diferenciação dos sistemas pesqueiros da Praia da Pinheira. A pesquisa revelou quatro fases distintas: o sistema pesqueiro indígena; o sistema pesqueiro de subsistência dos açorianos; o sistema pesqueiro de salga; e o sistema pesqueiro comercial e de prestação de serviços. Igualmente, com base em dados qualitativos e quantitativos foram caracterizados os atuais sistemas técnicos de captura utilizados na Praia da Pinheira, bem como os atuais tipos de pescadores do local. / The artisan fishing is of great importance for the state of Santa Catarina, where roughly 25 thousand artisan fishermen are currently working, which represents 30% of the local fishing production. However, some problems related to this activity can be detected, as the difficulty to maintain the fishermen community, the industrial fishing competition, pollution, among others. In order to study this process, the delimited area is the Praia da Pinheira, in the municipality of Palhoça, region of Azorean colonization, which up until 1970s was predominantly a fishermen community. Whereas some infrastructure improvements were implemented in this region, important socioeconomic changes came into place, primarily the increasing tourism activity. In addition, the creation of a conservation unity, the Parque Estadual da Serra do Tabuleiro, in 1975, what may represent a further obstacle to the local society, in the extent that it restrains the use of natural resources. Thus, the socioeconomic juncture increases the fishermen vulnerability. There is a variety of interpretations about the resistance by traditional populations and its forms of socioeconomic relations, being important to analyze these social groups that preserve the so called traditional features in the contemporary society. Besides, it is important to understand the relationship between the fishing sector and the other economic activities. In this sense, this work comes up to the complexity of the fishing activity, through a systemic approach that allows us to understand the evolution and differentiation of the fishing systems in the Praia da Pinheira. The research revealed four different stages: the Indian fishing system; the Azorean subsistence fishing system; the salga fishing system; and the commercial fishing system and of services. By the same token, based on the qualitative and quantitative data, the contemporary technical systems of capturing used in the Praia da Pinheira were characterized, as well as the local fishermen types.

A realidade agrária da Bocacosta na Guatemala, área tradicionalmente cafeeira, sofreu modificações importantes nos últimos anos. As crise do café em princípios de 1990 e 2000, concomitantemente com a firmação dos Acordos de Paz em 1996, foram decisivos para a transformação produtiva e social da região. Atualmente, podemos encontrar, integrados aos latifúndios de café tradicionais do modelo agroexportador e às grandes fazendas de gado, associações compostas por pequenos produtores de café, assentamentos de ex-guerrilheiros do conflito armado, comunidades de camponeses que regularizaram as terras, entre outros. São estes grupos que, conscientes do perigo do monocultivo de café, estão diversificando a produção. Neste contexto, o presente trabalho tem por objetivo analisar as dinâmicas sociais e produtivas da Bocacosta, proporcionando um melhor entendimento do panorama agrário atual. A partir de uma metodologia fundamentada em um instrumental de cunho sistêmico, a pesquisa busca analisar e diagnosticar os sistemas de produção implementados pelos agricultores da Bocacosta. Este estudo permitiu identificar cinco (5) sistemas agrários, que evoluiram e diferenciaram-se ao longo do tempo, e sete (7) sistemas de produção predominantes, praticados atualmente na região. A análise aprofundada de cada sistema de produção foi operacionalizada por meio de estudos de caso, escolhidos intencionalmente, a partir da pesquisa de campo e das entrevistas com os informante-chave. Constatou-se que o café, apesar de ainda ser predominante na realidade agrária da região, encontra-se em regressão na maioria dos estabelecimentos rurais, em razão da baixa rentabilidade. Igualmente, destaca-se a heterogeneidade nas estratégias adotadas pelas novas formas sociais, responsáveis pelas novas dinâmicas produtivas. A análise das informações evidencia a necessidade de elaborar políticas públicas de caráter social que elevem as condições de vida da população rural, bem como medidas que permitam efetivar a transição produtiva para outros cultivos e criações ou a diferenciação do produto no mercado. / The agrarian reality at Bocacosta in Guatemala, a traditionally coffee area, underwent significant changes in recent years. The coffee crisis of early 1990 and 2000, concurrently with the Peace Accords signing in 1996, were crucial for the productive and social transformation in the region. Currently, we can find, integrated with traditional agro-export model coffee lands and large livestock farms, associations composed of small coffee producers, ex-guerrillas settlements of armed conflict, peasant communities that regularized the land, among others. Are these groups that, aware of the danger of coffee monoculture, are diversifying the production. In this context, the present study aims to examine the social and productive dynamics at Bocacosta, providing a better understanding of the current agricultural background. From a methodology based on a systemic instrument, the research seeks to analyze and diagnose the farming systems implemented by farmers of Bocacosta. This study allowed to identify five (5) agrarian systems, which evolved and differed over time, and seven (7) predominant farming systems, currently performed in the region. A detailed analysis of each farming system was carried out through case studies, intentionally chosen from the research field stage and interviews with key informers. We found out that coffee, despite still being dominant in the agricultural reality of the region, is declining in most of rural establishments, due to low profitability. Also, it can be highlight the heterogeneity of strategies adopted by the new social forms, responsible for new dynamic production. Analysis of the data illustrates the necessity to develop social-nature public policies that increase living conditions of rural population, as well as procedures to shift production to other crops and livestock or product differentiation on the marketplace.

Les systèmes de santé sont confrontés à l’heure actuelle aux défis que sont la demande croissante de soins, la diminution de la démographie médicale et les contraintes budgétaires de plus en plus importantes. La télémédecine apparaît comme une innovation majeure permettant de surmonter ces défis grâce à l’utilisation des nouvelles technologies de l’information et de la communication. Elle est définie comme une forme de coopération dans l’exercice médical mettant en rapport à distance, entre eux ou avec un patient, un ou plusieurs professionnels de santé. L’intégration de la télémédecine au sein du système sanitaire existant est envisagée dans ce travail de recherche comme l’incorporation d’un système technologique innovant au sein d’un système complexe organisationnel de santé. Notre problématique consiste alors à fournir une aide efficace à la réussite de cette intégration. Cette question sous-tend trois grandes interrogations : Comment construire de nouveaux processus permettant l’intégration d’une nouvelle technologie dans une organisation existante ? Comment concevoir les modèles de partage de la valeur économique pour réussir cette intégration ? Comment définir les stratégies à mobiliser pour déployer cette intégration ? Pour concevoir des processus en fonction de la création de valeurs souhaitées par chacune des parties prenantes du système de télémédecine, nous proposons la méthode OCSM (Organizational Complex System Modeling). Nous l’appliquons pour concevoir deux processus : un processus de téléexpertises dermatologiques et un processus de téléconsultations spécialisées avec une identification du parcours de soins des patients à travers différents types d’établissements d’une région. Pour concevoir de nouveaux modèles de partage de la valeur économique, nous préconisons la méthode FFM (Financial Flow Modeling). Nous avons conçu un outil adossé à cette méthode qui calcule le solde des marges de chacune des parties prenantes. Nous appliquons cette méthode pour modéliser les flux économiques entre les parties prenantes du système de télémédecine. Des hypothèses de partage de la valeur peuvent ainsi être testées. Ce travail a notamment permis de définir un exemple de modèle économique pérenne pour de futurs déploiements. Pour modéliser le comportement d’un système en lien avec son environnement nous utilisons la méthode SDM (System Dynamics Modeling). Nous proposons ainsi une modélisation en Dynamique des Systèmes de notre cas d’étude de la région Picardie. Différents scénarii de déploiement de processus y sont simulés et analysés. Ce modèle est réutilisable pour d’autres régions françaises. De ce fait, ce travail nous permet de formuler des recommandations à l’échelle nationale pour le déploiement de systèmes de télémédecine. Nous avons suivi une démarche de recherche-action pour répondre simultanément aux problématiques de terrain et à la nécessité de réaliser une contribution scientifique. Trois projets de télémédecine dans les régions Ile-de-France, Picardie et Centre ont alimenté et validé nos modèles démontrant leur généricité dans le milieu médical. Ce travail nous permet plus généralement de préconiser l’utilisation simultanée des méthodes OCSM, FFM et SDM pour intégrer efficacement un système innovant au sein d’un système complexe organisationnel. / Healthcare systems are currently facing intense challenges due to the growing demand for health care, the decreasing of medical demography and the increasing budgetary constraints. Telehealth appears as a major innovation to overcome these challenges through the use of new information and communication technologies. It is defined as a form of cooperation in medical practice by relating at distance, between them or with a patient, one or more healthcare professionals. Telehealth integration within the existing healthcare system is considered in this research as the incorporation of an innovative technological system within an organizational complex system. Thus, our problematic is to provide an effective help to the success of this integration. This underlies three major questions: How to design new processes for the integration of a new technology into an existing organization? How to design the suitable models to share the economic value in order to succeed in this integration? How to define the strategies to be mobilized to deploy this integration? To develop new processes based on the value creation desired by each stakeholder of the telehealth system, we propose the OCSM (Organizational Complex System Modeling) method. We apply it to model and analyze two processes: a process of teleexpertises in dermatology and a process of specialized teleconsultations with an identification of the patient path across different types of healthcare establishments. To develop new business models, we recommend the FFM (Financial Flow Modeling) method. We designed a specific tool to support it, which calculates the balances margins of each stakeholder. We apply this method to model the economic flows between the telehealth system stakeholders. Thus, hypotheses of shared value can be tested. This work identifies a particular example of sustainable economic model for future deployments. To model the behavior of a system in its environment we use the SDM (System Dynamics Modeling) method. We propose a System Dynamics model of our case study of the Picardie region. Different deployment scenarios of processes are simulated and analyzed. Our model can be used again for other French regions. Thus, this work makes recommendations at the national level for the deployment of telehealth systems. We followed an action-research process to solve practical telehealth problems and to address scientific contributions. Three telehealth projects in the regions Ile-de-France, Picardie and Centre fuelled and validated our models thus demonstrating their genericity in the medical community. More generally, this work recommends the simultaneous use of OCSM, FFM and SDM methods to effectively integrate an innovative system in a complex organizational system

ABSTRACT Introduction Caesarean practice as a major obstetrical intervention is widely recognized as an effective way to reduce maternal and perinatal mortality when used in appropriate way. Its rate is still low in many sub-Saharan African countries where there is still a considerable inequality in the access to caesarean section. In these countries, the policy of free caesarean practice has been initiated to solve the problem of unequal access. However, this policy of gratuity alone is not enough to reduce maternal and perinatal mortality. Having contribuated significantly to the high rate of caesarean practice, its decrease in maternal and perinatal mortality is left to be desired. It is therefore necessary that the debate on caesarean takes place not only in terms of quantity, but also in terms of quality. However, the literature review has focused on the caesarean rate but not on its quality. Since 2009, Benin, like other sub-Saharan African countries, has been implementing the policy of free caesarean practice. This led to an increase in the rate of caesarean section, but the quality of the caesarean has not been sufficiently documented. The objective of this thesis is to contribute to a better knowledge and understanding of the quality of caesarean section (in terms of accessibility, availability of resources, compliance with clinical standards and results) in Benin and to make available to the Agency for the management of free Caesarean section some criteria for the summary assessment of the quality of caesarean section with a view for better improvement.Method This research work has been carried out in three phases, namely literature review on the criteria to assess the quality of caesarean section, a cross-sectional study and the proposal of evaluation chart of the quality of caesarean practice. 1. Literature review on the criteria to assess the quality of caesarean section aimed at identifying the different models and criteria available in the literature for the assessment of the quality of cesarean section. The research conducted in five electronic databases, in the gray literature and follow-up by quotations, targeted all available studies published in French or English on the evaluation of the quality of caesarean section. 2. The aim of the cross-sectional study was to study the quality of caesarean section in the hospitals of Benin using the model of "quality caesarean practice" found in the literature review. This model has been chosen because it gives a systemic view of caesarean. It organizes the criteria for the quality of caesarean section into four pillars also called the determinants of the quality of the caesarean practice. The first pillar, access to health services, includes the reference system, financial, geographical and temporal accessibility, the acceptability of health services. The other three pillars correspond respectively to diagnosis, technical procedure and post-surgery follow-up. The study was conducted from December 18, 2013 to February 8, 2014, in 12 hospitals performing caesarean operation and chosen by simple random selection, with one hospital in each of the 12 departments of Benin. In each hospital, the study targeted the hospital manager, the mothers who gave birth through caesarean during the data collection period and their accompanying persons. The hospital managers and mothers were selected in an exhaustive way and the accompanying persons, by a rational method. Data collection was done in each hospital by two midwives, under our supervision. These midwives were external to the hospital, recruited on the basis of their experience in data collection and their understanding of the local language. The data were collected using the obstetrical records, through observation, by semi-structured individual interviews and by questionnaire surveys. They were processed using the Epi info 3.5.1 software. The study structured in four phases related respectively to "the quality of caesarean section in Benin hospitals", "the accessibility to caesarean section", "the results of caesarean section for the mother and the baby" and "the opinion on caesarean section of those who have delivered". Phase 1 aimed at assessing the quality of caesarean section using the Dujardin et al. model of "quality caesarean section". The variables mainly focused on the four pillars of the said model. The quality of caesarean section was considered "good" if at least 70% of the criteria were met and "bad" if not.  The objective of Phase 2 was to measure the accessibility to caesarean section in terms of geographical and financial accessibility and the functionality of the obstetrical emergency referral system. Geographical accessibility was measured by the estimation of the distance between the residence of the parturient and the hospital. This distance was estimated using the database of the Institute of National Geography of Benin, supplemented if necessary by the sanitary map of the health zones. The maximum distance deemed to be "accessible" was set at 15 kilometers. As financial accessibility, we considered the average direct cost of caesarean section which is the sum of the medical and non-medical costs incurred during the stay and calculated from the bills, cashier receipts and declarations by the accompanying persons. The functionality of the referral system was assessed on the basis of the referral conditions of the obstetrical emergencies (filling out referral form, taking a venous approach, means of transport used, and accompaniment of a health agent). Phase 3 was about the description of morbidity and maternal and perinatal mortality and about the identification of the factors associated with post-caesarean stillbirth in the hospitals of Benin. The dependent variable was stillbirth at the end of the caesarean section, defined as any "baby born by caesarean section, without spontaneous respiratory or cardiac movement", as mentioned in the obstetrical records and surgical protocols. The independent variables were the socio-demographic and gyneco-obstetric characteristics of the mothers, the baby and the medical data. The description was made with the parameters of dispersion and of central tendency. The associated factors were identified through unvariable analysis and "step-by-step descending" multiple logistic regression, at the significance level of 5%.  Phase 4 aimed at documenting the opinion of the women who gave birth through caesarean practice in Benin. The qualitative data from the semi-structured interview were manually processed by thematic analysis. The themes were identified during the analysis and not from a pre-existing list. 3. The proposal for a caesarean section quality assessment chart aimed at developing operational criteria for the summary assessment of the quality of the caesarean section. The criteria were selected from the "quality caesarean section" model and submitted to the appreciation of the experts through a Delphi survey. Consensus is met for a criterion when at least 80% of the experts agree or strongly agree with this criterion.Results 1. Literature review on the criteria to assess the quality of caesarean section: It helped select 12 studies of which 75 criteria to assess the quality of caesarean section were identified. These criteria could be divided into two assessment models, namely the "Inputs, processes and results" model and that of "quality caesarean section" of Dujardin et al.2. Cross-sectional study: A total of 579 women, of median age of 26 (15; 50) years old, who underwent caesarean section, were included. The average rate of caesarean section was 37.6%, ranging from 23.4 to 53.3%. The caesarean sections were 80.7% performed in emergency. The results according to the different phases are as follows:  Phase 1: The entrance examination was complete in 12.6% of the parturients. Among the 144 parturients followed for delivery labor, partograph was used in 32.6%. The average response time was 124 minutes (2h 04 minutes), ranging from 5 to 918 minutes (15h 18 minutes). The caesarean sections were 48.0% performed for absolute maternal indications, 84.2% performed under spinal anesthesia. In 98.3% of the cases, the anesthetists were nurses or midwives. Caesarean section was found to be of poor quality, with an average quality score of 60.0 ± 10.0%.  Phase 2: The average distance between the place of residence of the mothers and the hospital was 20.2 ± 22.3 kilometers (km), varying from 8.6 to 37.7 km depending on the hospital. Among the parturients coming from the hospital area, 36.0% were living at more than 15 km. There were 63.0% of women who underwent a caesarean section who have been referred from a peripheral structure, of which 46.0% were carried by motorcycle and 21.8% by an ambulance. For about half of the parturients referred from a peripheral structure to the hospital, the referral conditions had not been documented. The referral form has been filled out 34.4%, the venous approach was taken in 28.5% and the referral was accompanied in 1.7% of the cases. The direct cost of caesarean section for the families ranged from 0 to 200,000 Francs of the Financial Community in Africa (CFAF), with an average of 36,782 ± 30,859 CFAF. It was higher in case of eclampsia, suppuration of the surgery wound/release of wire and in case of hospital stay over 3 days. Phase 3: There were 8.6% maternal complications, including haemorrhage, surgical wound suppuration, puerperal infection and anesthetic complications. Intra-hospital maternal mortality was 1.7 ‰ and perinatal mortality was 74.3 ‰. Stillbirth was 66 per 1,000 births. For 58% of these stillbirths, fetal heart sounds were negative during the entrance examination of the mother's admission to the hospital. The risk factors for stillbirth were the referral of the mother with obstetrical complications (p = 0.0011), general anesthesia (p = 0.0371), low birth weight (p = 0.0001) retroplacental hematoma (p = 0.0083) and umbilical cord prolapse (p = 0.0229). On the other hand, acute fetal distress (p = 0.0308) and anesthesia administered by a nurse or midwife (p = 0.0337) resulted in a lower risk of stillbirth.  Phase 4: The quality of care was deemed good by 93.9% of the women who gave birth, the main reason being the improvement in their health state (92.8%). The cost of caesarean section was considered affordable by 58.9% of the beneficiaries. However, 16.6% of them found it still high due to additional prescriptions and parallel expenses. Nearly half of the women who gave birth through caesarean section were reassured of the success of subsequent deliveries, whatever the mode. 3. Development of criteria for summary assessment of the quality of caesarean section: The Delphi survey was conducted in two rounds, with the participation of 15 experts in the first round and 10 in the second. Out of 16 criteria submitted to the experts, 12 were validated by consensus. Among the validated criteria, nine were related to the technical quality of the caesarean section, one to the referral of the parturient and two to the outcome of the caesarean section for the mother and the newborn. The criteria related to the technical quality of the caesarean section are all based on clinical recommendations from the World Health Organization (WHO) and the National Institute for Clinical Excellence (NICE).Conclusion The research work showed a low level of the quality of caesarean section in the twelve hospitals, regarding the four pillars of our assessment model. Beyond the technical quality of caesarean section, the model of "quality caesarean section" used assumes the importance of the accessibility of caesarean section and the continuity of obstetrical and neonatal emergency care from the health center to the referral hospital. These results can guide decision-making for the effective implementation of the principles of the free policy. Moreover, caesarean section quality assessment chart proposed in this thesis is an operationalized tool which will help the Free Caesarean Section Management Agency initiate the process of improving the quality of caesarean practice in Benin. In this way, we hope to contribute to the reinforcement of the policy of free caesarean section, with a view to reducing maternal and perinatal mortality in Benin. / IntroductionLa césarienne est une intervention obstétricale majeure largement reconnue comme un moyen efficace pour réduire la mortalité maternelle et périnatale, quand son utilisation est appropriée. Son taux est encore bas dans de nombreux pays d’Afrique sub-saharienne où persiste une grande inégalité d’accès à la césarienne. Dans ces pays, la politique de gratuité de la césarienne a été initiée pour résoudre le problème d’inégalité d’accès. Or, cette politique de gratuité, à elle seule, n’est pas suffisante pour réduire la mortalité maternelle et périnatale. En effet, elle a contribué à une augmentation du taux de césarienne mais sans une baisse significative de la mortalité maternelle et périnatale. Il est donc nécessaire que le débat sur la césarienne soit mené non seulement en termes de quantité, mais aussi en termes de qualité. Toutefois, la littérature abonde de publications sur le taux de césarienne mais très peu sur sa qualité. Le Bénin, à l’instar des autres pays d’Afrique subsaharienne, applique depuis 2009, la politique de gratuité de la césarienne. Il s’en est suivi un accroissement du taux de césarienne mais la qualité de ces césariennes n’a pas été suffisamment documentée. L’objectif de la présente thèse est de contribuer à une meilleure connaissance et compréhension de la qualité de la césarienne (en termes d’accessibilité, de disponibilité des ressources, de respect des normes cliniques et des résultats) au Bénin et de mettre à disposition de l’Agence de gestion de la gratuité de la césarienne, des critères d’évaluation sommaire de la qualité de la césarienne en vue de son amélioration.MéthodeLes travaux de la présente thèse se sont déroulés en trois phases à savoir :une revue de littérature sur les critères d’évaluation de la qualité de la césarienne, une étude transversale et la proposition d’une grille d’évaluation de la qualité de la césarienne.• La revue de littérature sur les critères d’évaluation de la qualité de la césarienne visait à recenser les différents modèles et critères disponibles dans la littérature pour l’évaluation de la qualité de la césarienne. La recherche effectuée dans cinq bases de données électroniques, dans la littérature grise et par suivi des citations, a ciblé toutes les études disponibles, publiées en français ou en anglais, ayant porté sur l’évaluation de la qualité de la césarienne. • L’étude transversale visait à étudier la qualité de la césarienne dans les hôpitaux du Bénin avec le modèle de la "césarienne de qualité", recensé dans la revue de littérature. Ce modèle a été retenu parce qu’il donne une vue systémique de la césarienne. Il organise les critères de qualité de la césarienne en quatre piliers appelés aussi déterminants de la qualité de la césarienne. Le premier pilier, l'accès aux services de santé regroupe le système de référence, l’accessibilité financière, géographique et temporelle, l'acceptabilité des services de santé. Les trois autres piliers correspondent respectivement au diagnostic, à l’acte technique et au suivi post-opératoire. L’étude a été réalisée du 18 décembre 2013 au 8 février 2014, dans 12 hôpitaux pratiquant la césarienne et sélectionnés par choix aléatoire simple, à raison d’un hôpital dans chacun des 12 départements que compte le Bénin. Dans chaque hôpital, l’étude a porté sur le gestionnaire de l’hôpital, les mères ayant accouché par césarienne au cours de la période de collecte des données et leurs accompagnants. Les gestionnaires et les mères ont été retenus de façon exhaustive et les accompagnants, par choix raisonné. La collecte des données a été assurée dans chaque hôpital par deux sages-femmes, sous notre supervision. Ces dernières étaient externes à l’hôpital, recrutées sur la base de leur expérience de collecte des données et de la compréhension de la langue du milieu. Les données ont été collectées par exploitation des dossiers obstétricaux, observation et par enquête par questionnaire. Elles ont été traitées à l’aide du logiciel Epi info 3.5.1. L’étude a été structurée en quatre volets portant respectivement sur "la qualité de la césarienne dans les hôpitaux du Bénin", "l’accessibilité de la césarienne", "les résultats de la césarienne pour la mère et le bébé" et "l’opinion des accouchées sur la césarienne".- Le volet 1 visait à évaluer la qualité de la césarienne avec le modèle de "césarienne de qualité" de Dujardin et al. Les variables portaient essentiellement sur les quatre piliers dudit modèle. La qualité de la césarienne a été jugée "bonne" si au moins 70% des critères étaient respectés et "mauvaise" dans le cas contraire.- Le volet 2 avait pour objectif de mesurer l’accessibilité à la césarienne en termes d’accessibilité géographique et financière et de la fonctionnalité du système de référence des urgences obstétricales. L’accessibilité géographique a été mesurée par l’estimation de la distance entre la résidence des parturientes et l’hôpital. Cette distance a été estimée à l’aide de la base de données de l’Institut Géographique National du Bénin, complétée en cas de besoin par la carte sanitaire des zones sanitaires. La distance maximale jugée comme "accessible" a été fixée à 15 kilomètres. Comme accessibilité financière, nous avons considéré le coût moyen direct de la césarienne qui est la somme des coûts médicaux et non-médicaux engagés pendant le séjour et calculés à partir des factures, reçus de caisse et déclarations des accompagnants. La fonctionnalité du système de référence a été appréciée sur la base des conditions de référence des urgences obstétricales (remplissage de fiche de référence, prise d’un abord veineux, moyens de transport utilisés, accompagnement par un personnel de santé).- Le volet 3 portait sur la description de la morbidité et de la mortalité maternelle et périnatale, ainsi qu’à l’identification des facteurs associés à la mortinaissance post-césarienne dans les hôpitaux du Bénin. La variable dépendante était la mortinaissance à l’issue de la césarienne, définie comme tout "bébé né par césarienne, sans mouvement respiratoire ou cardiaque spontané", tel que mentionné dans les dossiers obstétricaux et protocoles opératoires. Les variables indépendantes étaient les caractéristiques socio-démographiques et gynéco-obstétricales de la mère, celles du bébé et les données médicales. La description de l’échantillon a été faite avec les paramètres de tendance centrale et de dispersion. Les facteurs associés ont été identifiés par analyse univariée et régression logistique multiple "pas à pas descendante", au seuil de signification de 5%.- Le volet 4 visait à documenter l’opinion des accouchées sur la césarienne au Bénin. Les données qualitatives issues des questions ouvertes du questionnaire des accouchées ont été traitées manuellement par analyse thématique. Les thèmes ont été identifiés lors de l’analyse et non à partir d’une liste pré-existante.• La proposition d’une grille d’évaluation de la qualité de la césarienne visait à élaborer des critères opérationnels pour l’évaluation sommaire de la qualité de la césarienne. Des critères ont été sélectionnés à partir du modèle de "césarienne de qualité" et soumis à l’appréciation des experts, à travers une enquête Delphi. Le consensus est déclaré pour un critère lorsqu’au moins 80% des experts étaient d’accord ou tout à fait d’accord pour ce critère. Résultats• Revue de littérature sur les critères d’évaluation de la qualité de la césarienne :Elle a permis de sélectionner 12 études dont 75 critères d’évaluation de la qualité de la césarienne ont été recensés. Ces critères pouvaient se répartir en deux modèles d’évaluation à savoir le modèle "Intrants, processus et résultats" et celui de la "césarienne de qualité" de Dujardin et al. • Etude transversale :Au total 579 césarisées, d’âge médian de 26 (15 ;50) ans ont été incluses. Le taux moyen de césarienne était de 37,6%, variant de 23,4 à 53,3%. Les césariennes étaient à 80,7% réalisées en urgence. Les résultats selon les différents volets se présentent comme suit :- Volet 1 :L’examen d’entrée a été complet chez 12,6% des parturientes. Parmi les 144 parturientes suivies pour travail d’accouchement, le partogramme a été utilisé chez 32,6%. Le délai moyen d’intervention était de 124 minutes (soit 2h 04 minutes), variant entre 5 et 918 minutes (15h 18 minutes). Les césariennes étaient à 48,0% réalisées pour indications maternelles absolues, à 84,2% effectuées sous rachianesthésie. Dans 98,3% des cas, les anesthésistes étaient des infirmiers ou sages-femmes. La césarienne a été jugée de mauvaise qualité, avec un score moyen de qualité de 60,0±10,0%. - Volet 2 :La distance moyenne entre le lieu de résidence des mères et l’hôpital était de 20,2 ± 22,3 kilomètres (km), variant de 8,6 à 37,7 km selon les hôpitaux. Parmi les parturientes provenant de la zone de desserte des hôpitaux, 36,0% résidaient à plus de 15 km. Il y avait 63,0% de césarisées référées d’une structure périphérique, dont 46,0% transportées à motocyclette et 21,8%, en ambulance. Pour environ la moitié des parturientes référées d’une structure périphérique pour l’hôpital, les conditions de référence n’avaient pas été renseignées dans les dossiers. La fiche de référence a été remplie chez 34,4%, l’abord veineux était pris chez 28,5% et la référence a été accompagnée dans 1,7% des cas. Le coût direct de la césarienne pour les familles variait de 0 à 200 000 Francs de la Communauté Financière Africaine (F CFA), avec une moyenne de 36 782 ± 30 859 F CFA. Il était plus élevé en cas d’éclampsie, de suppuration de la plaie opératoire/lâchage de fil et en cas de durée d’hospitalisation supérieure à 3 jours.- Volet 3 :Il y avait 8,6% de complications maternelles, dont l’hémorragie, la suppuration de la plaie opératoire, l’infection puerpérale et les complications anesthésiques. La mortalité maternelle intra-hospitalière était de 1,7‰ et la périnatale, de 74,3‰. La mortinaissance était de 66 pour 1000 naissances. Pour 58% de ces mort-nés, les bruits du cœur fœtal étaient négatifs lors de l’examen d’entrée à l’admission de la mère à l’hôpital. Les facteurs de risque de la mortinaissance étaient la référence de la mère présentant des complications obstétricales (p = 0,0011), l’anesthésie générale (p = 0,0371), le petit poids de naissance (p = 0,0001), l’hématome rétro-placentaire (p = 0,0083) et la procidence du cordon ombilical (p = 0,0229). Par contre, la souffrance fœtale aigüe (p = 0,0308) et l’anesthésie administrée par un anesthésiste infirmier ou sage-femme (p = 0,0337) exposaient à un moindre risque de mortinaissance.- Volet 4 :La qualité des soins a été jugée bonne par 93,9% des accouchées, avec pour principale justification, l’amélioration de leur état de santé (92,8%). Le coût de la césarienne était considéré comme abordable par 58,9% des bénéficiaires. Toutefois, 16,6% d’entre eux l’ont trouvé encore élevé, à cause des ordonnances supplémentaires et des dépenses parallèles. Près de la moitié des accouchées par césariennes était rassurée du bon déroulement des accouchements subséquents, quel qu’en soit le mode.• Elaboration des critères d’évaluation sommaire de la qualité de la césarienne :L’enquête Delphi s’est déroulée en deux tours, avec la participation de 15 experts au premier tour et de 10 au deuxième. Sur 16 critères soumis à l’appréciation des experts, 12 ont été validés par consensus. Parmi les critères validés, neuf étaient relatifs à la qualité technique de la césarienne, un, à la référence de la parturiente et deux, à l’issue de césarienne pour la mère et le nouveau-né. Les critères relatifs à la qualité technique de la césarienne sont tous basés sur des recommandations cliniques de l’Organisation Mondiale de la Santé et de "The National Institute for Clinical Excellence". ConclusionLes travaux de la thèse ont montré un faible niveau de qualité de la césarienne dans les douze hôpitaux, concernant les quatre piliers du modèle d’évaluation. Au-delà de la qualité technique de la césarienne, le modèle de la "césarienne de qualité" utilisé montre l’importance de l’accessibilité de la césarienne et de la continuité des soins obstétricaux et néonataux d’urgence, depuis le centre de santé jusqu’à l’hôpital de référence. Ces résultats pourront orienter la prise de décision en vue de la mise en œuvre effective des principes de la politique de gratuité. Par ailleurs, la grille d’évaluation de la qualité de la césarienne proposée dans la présente thèse est un outil opérationnalisé qui permettra à l’Agence de gestion de la gratuité de la césarienne d’initier le processus d’amélioration de la qualité des césariennes au Bénin. Nous espérons ainsi contribuer au renforcement de la politique de gratuité de la césarienne, en vue de la réduction de la mortalité maternelle et périnatale au Bénin. / Doctorat en Santé Publique / info:eu-repo/semantics/nonPublished

Cette thèse étudie les différentes formes d'étayage que les étudiants mettent en place dans un tandem par visiocoférence poste à poste afin de s'entraider dans leurs apprentissages des langues française et chinoise. Nous passons en revue différentes études s'étant penchées sur les questions de l'apprentissage, l'interaction, l'apprentissage des langues dans l'interaction, la compétence communicative, la multimodalité de la communication médiatisée par ordinateur. Pour les fins de notre recherche, nous avons compilé un corpus de vingt heures environ d'interactions télétandem. En adoptant un positionnement épistémologique constructiviste, complexe, transdisciplinaire et compréhensif, nous élaborons une perspective interactionniste et écologique dégageant plusieurs niveaux d'analyse, analysés avant tout séparément, ensuite en les reliant. Ainsi, nous étudions les positionnements discursifs d'expertise et différentes formes de séquences latérales d'étayage langagier. A l'aide de statistiques descriptives, nous dégageons les configurations et les attracteurs du système binôme télétandem et en analysons les potentialités pour le développement de la compétence communicative. / This thesis studies different forms of scaffolding that students provide in a tandem through desktop videoconference in order to help one another in learning French and Chines as foreign languages. I review studies on learning, interaction, language learning in interaction, communicative competence, the multimodality of computer-mediated communication.For my research, I compiled a corpus of about twenty hours of teletandem interactions. I adopt an epistemological posture which is constructivist, complex, transdisciplinary and comprehensive. I elaborate an interactionist and ecological perspective bringing out different levels of analysis, analyzed separately at first, then together. In this way, I study discursive positioning of expertise and different forms of scaffolding side sequences for language learning. Using descriptive statistics tools, I identify the configurations and attractors of the teletandem pair system and I discuss their potential for the development of communicative competence.

This document deals with the topic of mobile cellular networks, operating as a critical infrastructure, based on systemic approach, general risk analysis methods and specialized methods for diagnostics and analysis founded on technical praxis from running mobile cellular networks.

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