This thesis is concerned with plants, chronic illness and medicine in Oku, Northwest Region, Cameroon. I focus on patient strategies to obtain effective medical outcomes, and on how such outcomes may be obtained through seeking traditional medicine in Oku. I argue that biomedical notions of efficacy do not appropriately represent the central and diverse roles that plants play in traditional medicine nor do they correctly represent how people in Oku evaluate the efficacy of plant-based traditional medicine. I argue instead that efficacy must be understood in terms of the emic concept of power. This power is understood to be located in the Oku landscape, which is still uniquely forested and said to embody powerful ancestral spirits. With plants as the primary tangible material of power, and traditional doctors in Oku as those who claim exclusive rights to manipulate and disperse such power, I discuss traditional medicine in Oku as a system wherein power from the natural landscape is drawn upon to challenge harmful powers feared to derive from the social arena. Using the pragmatic and phenomenological approaches, I show how patients evaluate the efficacy of a medical treatment based on their bodily experiences, and how their actions, as revealed in their therapeutic trajectories, reveal their satisfaction or dissatisfaction with a given diagnosis and/or therapy. I discuss how enduring illness generates and exacerbates bodily, treatment-outcome, social, and psychological uncertainties. In this context, effective outcomes can be understood as those which address and limit these uncertainties and anxieties while offering ways to imagine hopeful prognoses. This thesis then outlines the major sources of uncertainty, people’s responses to such uncertainties, and what people might achieve in terms of limiting uncertainties by seeking traditional medicine in Oku.

健康相關生活品質越來越重視病人主觀的感受，然而將這個部分納入測量之後，許多研究結果卻出現殘疾悖論(disability paradox)的現象，也就是重度疾病病人的自評生活品質並不比程度輕微或甚至健康的人差。反應轉移理論認為，造成這個現象的原因在於個人的自評生活品質會受到個體對於生活品質定義的改變（重新構念）、內在測量尺度標準的改變（重新校準）、以及價值的改變（重新權重）的影響，到目前為止，反應轉移尚未發展出合適的測量工具。 SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life- direct weighting)做為一個生活品質測量個人化的代表，其評估分成三個步驟，分別是提名重要的生活領域、評估提名領域的滿意程度、以及評估提名領域的相對權重，許多研究者嘗試用SEIQoL-DW在兩點間的領域變化做為重新構念，權重變化做為重新權重，重新校準則需要搭配then test來測量，then test是在第二個測量點時邀請受試重新對第一個時間點的提名領域進行評估，然而這三個成分指標的操作型定義不一，then test也有使用上的不便，同時過去這些指標對生活品質的效用檢驗也都未達顯著。本研究分認為，若能解決上述的問題，將有助於解釋殘疾悖論，同時可以區辨不同類別病人的反應轉移模式，並運用在臨床來幫助病人進行調適。 本研究以立意取樣招募3期以上之慢性腎臟病患者、以及血液透析、腹膜透析未滿一年以上之三組病患共85名，除了背景和臨床資料外，在間隔三個月的兩點分別填寫SEIQoL-DW、ideal scale（評估期待）、生活滿意問卷、正負向情緒問卷，並在後測時填寫then test。研究結果顯示，三組病人的生活品質符合殘疾悖論，並無顯著差別。重新構念、重新校準、和重新權重當中，僅重新校準有助於生活品質的提升，並能夠顯著解釋生活品質的改變。 對腎臟病患者來說，期待越高，生活品質提升得越多，進一步的分析顯示，受試會捨棄相對權重較低的領域，新提名領域的滿意程度、期待、和相對權重都顯著高於捨棄的舊領域，這可以作為臨床上協助病人調適的策略。雖然then test的結果顯著，但實證結果和理論卻相當混亂，尚待未來研究釐清。 / Health-related quality of life (HRQoL) is increasingly recognized as being subjective, which emphasized patient-reported outcomes. Many HRQoL studies reported that people with serious illness perceived no less quality of life (QoL) than those without such illness. This phenomenon is labeled as disability paradox. Response shift theory provides an explanation for it and refers to a change in the meaning of one’s self-evaluation of QoL as a result of changes in internal standards (recalibration), values (reprioritization), and reconceptualization of QoL. It is these changes that will influenced perceived QoL. Current methods to detect Response Shift are still evolving. SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life- direct weighting) is one of individualized QoL instruments and measures three elements of QoL, including five important aspects of life, current satisfaction with each aspect, and relative importance of each aspect. Many researchers tried to use SEIQoL-DW to detect response shift. Changes in the content of aspects of life between two time points reflect reconceptualization. Changes in the relative weighting between two time points reflect reprioritization. Recalibration is measured by then test, which is a method by asking respondents at time two to provide a renewed rating of their aspects of life given at time one. However, there are no consensus operational definition of indices of reconceptualization , reprioritization, and recalibration. The examination between indices and improvements in QoL was not significant, either. Besides, then test with SEIQoL-DW has a disadvantage when aspects nominated between time one and two are different. This study tried to resolve issues above. If these issues are resolved, disability paradox will be explained. Response Shift will possibly differentiate patients of various disease, and provide ideas to help patients adjust to illness. 85 patients were recruited, including those with renal disease stage 3-5, and those undergoing hemodialysis or peritoneal dialysis within one year. All patients completed SEIQoL-DW, ideal scale, Satisfaction with Life Scale, the Positive And Negative Affect Scale at time one and three months after , except questionnaire on personal background and biological information (at time one) and then test (at time two). Results indicated that the QoLs of these three groups of patients showed no different, which confirmed disability paradox. Only recalibration showed helpful. Regression analyses also showed that recalibration indices were better predictors in QoLs. For End-stage Renal Disease patients, higher expectation suggested higher QoL improvement. Further analysis showed that patients would abandon lower-weighted aspect of life. Compared to the abandoned aspects, higher satisfaction, expectation and weighting were seen in new-nominated aspect. This finding could be useful in helping patients adjust. Although then test also reached significance, evidences was contradicted to its prediction. More research is needed in the future.

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Le système de santé est aujourd’hui marqué d’une complexité attribuable aux maladies chroniques, dont la hausse anticipée de la prévalence génère l’urgence d’une organisation et d’une approche différentes des services dispensés. Ce réaménagement des soins de santé fait appel à un changement de paradigme basé sur la collaboration interprofessionnelle et l’ouverture à l’incertitude, aptes à favoriser une mise en commun des connaissances. Dans cette perspective, les communautés de pratique (CdeP) semblent un moyen qui favorise le développement de la collaboration interprofessionnelle et le partage des connaissances. Elles apparaissent donc comme une formule qui mérite une investigation, à savoir si elles peuvent favoriser une telle collaboration et faciliter la co-construction de connaissances permettant une pratique évolutive, centrée sur le patient. Notre recherche s’inscrit dans cette optique et s’intéresse aux expériences, rapportées dans la littérature, de collaboration interprofessionnelle au sein de communautés de pratique centrées sur le patient atteint de maladie chronique. Pour ce faire, nous avons d’abord développé un cadre conceptuel visant à identifier les fondements théoriques et conceptuels de la notion de communauté de pratique. Ceci nous a amené à : 1) analyser l’évolution du concept de CdeP dans les principales œuvres de Wenger et de ses collaborateurs; 2) positionner les CdeP eu égard à d’autres formules de travail collaboratif (communauté, communauté d’apprentissage, communauté apprenante, organisation apprenante, communauté épistémique); 3) comparer le concept de collaboration avec d’autres s’en rapprochant (coopération notamment), de même que les notions d’interdisciplinarité et d’interprofessionnalité souvent associées à celle de CdeP; 4) étayer les dimensions cognitive et collaborative inhérentes aux expériences de CdeP; et 5) identifier les avancées et les limites attribuées à la mise en application du concept de CdeP dans le domaine de la santé. La métasynthèse (Beaucher et Jutras, 2007) dans une approche « compréhensive interprétative », s’est imposée comme méthode appropriée à notre intention de mieux saisir les expériences de collaboration interprofessionnelle menées dans le cadre des CdeP dans le domaine de la santé. La métasynthèse nous a ainsi permis d’obtenir une vue d’ensemble de la littérature portant sur les CdeP dans le domaine de la santé et de catégoriser les 194 articles rassemblés, pour ensuite retenir 13 articles traitant d’une réelle expérience de CdeP. Ainsi, dans une perspective contributoire, basée sur notre cadre conceptuel, l’analyse des principaux résultats de la métasynthèse, nous a permis 1) d’identifier les flous conceptuels liés aux expériences de CdeP rapportées, ainsi que 2) de dégager les retombées et les difficultés de leur mise en application dans le domaine de la santé et, enfin, 3) de démontrer la nécessité de mener des recherches visant l’étude du processus de développement de CdeP sur le terrain de la pratique de soins, notamment mais non exclusivement, lorsqu’il s’agit de maladies chroniques. / Today’s health system is increasingly complex due to the growth of chronic illnesses. The anticipated increase in the prevalence of chronic illnesses means there is an urgent need for a different type of organization and approach to providing services to the patient. This adjustment in health care delivery calls for a paradigm shift based on inter-professional collaboration and openness to uncertainty, which will in turn facilitate knowledge sharing. In this regard, communities of Practice (CoP) appear to be a way to facilitate the development of inter-professional collaboration and the sharing of knowledge, and therefore merit further investigation in order to determine whether or not they can foster such collaboration and facilitate the co-construction of knowledge leading to an evolving practice that is patient oriented and adapted to complexity. Our research is consistent with this view and is driven by an interest in the interprofessional collaboration experiences, as reported in litterature, that have taken place as part of communities of practice and have centred on patients suffering from chronic illnesses. In order to achieve this, we first developed a conceptual framework with the aim of identifying the theoretical and conceptual foundations of communities of practice. This has led us to 1) analyze the evolution of the concept of communities of practice in the major works of Wenger and of his collaborators; 2) position communities of practice by comparing them to other forms of collaborative work with which they are frequently associated and even substituted or mistaken for in the literature (such as community, learning community, learning organization, epistemic community); 3) compare the concept of collaboration with other similar concepts (including collaboration), as well as the notions of interdisciplinarity and inter-professionalism often associated with communities of practice; 4) support the cognitive and collaborative dimensions inherent to communitied of practice; and 5) identify the advances and limitations attributed to the implementation of the concept of communities of practice in the health field. Metasynthesis (Beaucher et Jutras, 2007) ), as part of a ‘‘comprehensive interpretative’’ approach, was determined to be the most appropriate research method for understanding the experiences of interprofessional collaboration as part of communities of Practice in the health field.. Metasynthesis provided us with an overview of the literature on the subject of CoP in the health field and allowed us to create a topology of the 194 collected articles. This overview led to the selection of 13 articles describing real experiences of CoPs. As such, in terms of contribution, this metasynthesis enabled us to 1) identify the reported conceptual vagueness associated with the implementation of CoPs; 2) identify the benefits and challenges of their implementation in the field of health; and 3) demonstrate that further research on the development process of communities of practice in the field of care practice, including but not limited to situations involving chronic illnesses, is necessary.

In this thesis, a phenomenological approach is taken as the purpose is to discuss how the healthcare experiences of Swedish patients with chronic illness are affected by political state reforms and governing technologies. The thesis compares the discourse of Swedish healthcare policy with the discourse of healthcare in practice. Swedish healthcare has gone through major changes during the past decades, which have affected the state-to-patient relationship. This shift involved a transfer of responsibility from the state to its citizens, enabled through patient empowerment. In this change, a new ideal patient-role emerged, which is the patient as an informed and active consumer. What this thesis shows is the existence of a discrepancy between the ideal patient-role in governmental writing and the same ideal patient-role in the reality of the healthcare system. The ethnography consists of a literature study of healthcare policy documents and interviews with ten informants about their experiences of healthcare, in connection with the chronic diseases that affected their lives. The aim has been to examine the governing qualities of healthcare policy and practice, implementing Foucault’s theory of governmentality and technologies of the self.

Made available in DSpace on 2016-04-28T20:39:23Z (GMT). No. of bitstreams: 1 Fernanda A C Gouveia Paulino.pdf: 1360933 bytes, checksum: d5b99823bc5f00a57167c68b294f0035 (MD5) Previous issue date: 2006-10-01 / Due to the increase of the chronic illness and the medical resources that generate survivors of acute physical illness, the purpose of this research is to understand the impact of chronic illness situations on middle-age, especially in cases of incapacitation that requires a familiar functioning reorganization. Because of the complexity of these cases, the choice of this work was to specially approach families with dependent children and that the carrier of the chronic illness is the member who supports the family. A qualitative inquiry was carried through on eight families. The data included interview , familiar genogram and part of the test Entrevista Familiar Estruturada (EFE). This data were discussed based on the systemic theory under a biopsycossocial perspective, with the survey of the main aspects that had allowed understanding of the interconnection among the biological, psychological and social sphere. Under the point of view of a familiar event, the results of this research allowed an understanding about the transformations that suffer a family with a middle-age adult with a chronic incapacity. The incapacity cases demands changes that reach the individual and familiar cycles of life and than alter insidiously in family s organization, relationship and functioning. Substitutions are required and changes are imposed that involves losses, with concomitant offering of care. When who fall ill is in middle age and centers the familiar responsibilities, the run down of the familiar system is intense and extensive. It involves post-pone, anticipation and cancellation of plans, intervenes on financial statements and it rearranges the relationships, being able to modify some familiar rules, leadership, hierarchies and cohesion between members. In this research, although the incapacity characteristics have been sufficiently notable to the configuration of the familiar organization, the quality of the previous relationship revealed the most significant factor for familiar flexibility and adaptation to the (new) condition. The characteristics of the familiar functioning and repercussions in the member who supports the family under a desenvolvimental approach had been argued. The results discussion pointed out to the necessity of psychological attention to the families with a chronic illness situation (member), considering the familiar structure and dynamics and still its vital cycle moment. The deeper understanding of each case with the apprehension of the meanings and beliefs, as well as the approach of the suffering of the families allowed the elaboration of a reflection about professional position, criterion for the clinical inquiry and the reach of the health psychology for providing interventions in the families that are living illness situations / Em razão do aumento da incidência de adoecimentos crônicos e dos recursos da área médica que geram sobreviventes de afecções físicas agudas, este trabalho teve por objetivo compreender o impacto das situações de cronicidade na meiaidade, especialmente nos quadros de incapacitação com necessidade de reorganização do funcionamento familiar. Optou-se por abordar especificamente famílias em que houvesse filhos dependentes e cujo portador de condição crônica desempenhasse previamente o papel de provedor e/ou cuidador familiar, dada a complexidade da substituição desses papéis. Foi realizada investigação qualitativa da qual participaram oito famílias. A coleta de dados incluiu entrevista semi-estruturada, genograma familiar e parte do instrumento Entrevista Familiar Estruturada (EFE). Os dados obtidos foram discutidos a partir da teoria sistêmica sob uma perspectiva biopsicossocial, com o levantamento dos principais aspectos que permitiram a leitura da interligação entre as esferas biológica, psicológica e social. Os resultados favoreceram a compreensão das transformações familiares diante de condições crônicas incapacitantes em adulto de meia-idade, sob o prisma de um evento familiar. Os quadros de incapacitação exigem transformações que atingem os ciclos de vida individuais e familiares e assim interferem de forma insidiosa na organização, relacionamentos e funcionamento da família. São requeridas substituições e impostas mudanças que envolvem perdas, com concomitante oferecimento de cuidado. Quando quem adoece está na meia-idade e centraliza as responsabilidades na família, a desestabilização do sistema é intensa e extensa. Envolve adiamento, antecipação ou cancelamento de planos, interfere no balanço financeiro e rearranja os relacionamentos, podendo modificar características como as regras, lideranças, hierarquias e coesão entre os membros. Neste estudo, embora as características da incapacitação tenham sido bastante relevantes para a configuração da organização familiar, a qualidade de relacionamento prévio mostrou-se o fator mais significativo para a flexibilidade familiar e adaptação à condição. Foram discutidas as características do funcionamento familiar e repercussões nos cuidadores sob um enfoque desenvolvimental. A discussão dos resultados apontou para a necessidade de atenção psicológica às famílias em situação de adoecimento crônico com a consideração da estrutura e dinâmica familiar e do momento de ciclo vital. A compreensão aprofundada de cada caso com a apreensão dos significados e crenças, bem como a aproximação do sofrimento das famílias permitiu a elaboração de reflexão sobre postura profissional, critérios para a investigação clínica e o alcance da psicologia da saúde no oferecimento de intervenções a famílias em situações de adoecimento

Individuals’ self-management styles are crucial for how they manage to live with illness. Commonly investigated factors include social support, self-efficacy, health beliefs, and demographics. There is a gap in the literature with regard to in-depth studies of how those factors actually influence an individual’s self-management.   The aim of this thesis was to investigate the underlying mechanisms of self-management from the perspective of individuals living with chronic illness.   Interviews were conducted with 47 individuals with various chronic illnesses, some of them repeatedly over two and a half years (a total of 107 interviews). The material was analysed with; constructive grounded theory, content analysis, phenomenography, and interpretive description.   The Self-management Support Model identified aspects that influenced participants’ self-management: economic and social situation, social support, views and perspectives on illness, attribution of responsibility, and ability to integrate self-management into an overall life situation. For example, individuals with a life-oriented or disease-oriented perspective on illness prioritized different aspects of self-management. People who attributed internal responsibility performed a more complex self-management regimen than individuals who attributed external responsibility. In conclusion, individuals who were creative and resourceful had a better chance of tailoring a self-management regimen that suited them well. People in more disadvantaged positions (e.g., financial strain, limited support, or severe intrusive illness) experienced difficulty in finding a method of self-management that fit their life situation.   These findings can inspire healthcare providers to initiate a reflective dialogue about self-management with their patients. / Exploring individuals’ conceptions as a way to understand self-management among people living with long term medical conditions

Diabetes mellitus ist mit die häufigste Volkskrankheit auf der Welt. 371 Millionen Menschen sind weltweit erkrankt und bis zum Jahr 2030 wird die Zahl auf ca. 552 Millionen ansteigen. Doch wie erleben PatientInnen ihre Welt mit Diabetes und wie bewältigen sie ihren Alltag? Mit Hilfe der systematischen Metaphernanalyse untersuchte ich qualitativ die subjektive Welt von Typ–1 DiabetikerInnen und vor allem ihre Sprache. Mit dieser Methode wollte ich Einblicke in das Denken und Handeln von Betroffenen gewinnen und Rückschlüsse zur Bewältigung ziehen.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

A child diagnosed with a life-threatening illness such as cancer, and is hospitalized for extensive periods of time, is faced with innumerable stressful and traumatic circumstances. This emotionally challenging life situation can bring on much emotional distress such as anxiety. Thus, it has become imperative that the oncology child is assisted and supported, in his individual struggle to cope with the harshness of his strained reality. In this study the hospitalized oncology child was provided with a means of support and intervention through the use of Gestalt play therapy. Gestalt play therapy was conducted to assist the child to express and work through feelings of anxiety and related emotional distress associated with his present life experience. Gestalt play therapy was presented with six case studies. The researcher explored and described the experiences of each case study from which, the researcher drew conclusions and made recommendations. / Social Work / M.Diac. (Play Therapy)