Le handicap est multifactoriel. Toutes ses composantes sont potentiellement sources d’obstacles et de désavantages. L’originalité de cette thèse est de tenir compte de la complexité de définition du handicap dans l’analyse du recours aux soins de santé primaires. L’objectif ultime des soins de santé primaires est une meilleure santé pour tous, passant par la réduction des exclusions et des inégalités sociales d’accès au système santé. Nous appréhendons le handicap de différentes manières jusqu’à intégrer les trois dimensions d’« une situation de handicap » (dimension fonctionnelle, dimension environnementale, et participation sociale) dans un même modèle explicatif. D’abord, nous analysons la dimension fonctionnelle en considérant les personnes handicapées comme physiquement limitées. Puis, nous investiguons la dimension environnementale par une étude chez les adultes vivant en institution. Enfin, nous adoptons une vision globale du handicap en intégrant simultanément toutes les dimensions par la mesure de capabilités latentes. Le modèle estimé s’approche d’une comparabilité inter-individus révélant, toutes choses égales par ailleurs, les niveaux sur lesquels agir pour pallier les inégalités. Les analyses suggèrent qu’un environnement favorable, sociétal et/ou socioéconomique, pourrait compenser les effets négatifs des limitations et des restrictions cognitives et physiques. Nous concluons sur plusieurs voies possibles afin d’améliorer le recours aux soins primaires : agir sur la dimension environnementale et sur la participation sociale. / Disability is multifactorial. All its components are potential sources of barriers and disadvantages. The originality of this thesis is to take into account the complexity of disability definition to analyze the use of primary health care. The ultimate goal of primary health care is better health for all, reducing exclusion and social inequalities in access to the health care system. We approach disability in different ways, ending with a model that includes the three dimensions of a “disability situation” (functional dimension, environmental dimension and social participation). First we analyze the functional dimension considering people with disabilities as physically limited. Then, we investigate the environmental dimension through analysis among adults living in institutions. Finally, we adopt a global vision of disability that integrates all the dimensions simultaneously through the measures of latent capabilities. The estimated model approximates a fundamental inter-individual comparability and reveals all things being equal, the levels on which to act to overcome inequalities. The analyses suggest that favorable environment, societal and/or socioeconomic could offset the negative impact of the limitations and cognitive and physical restrictions. We conclude on several possible waysto improve the use of primary care: acting on the environmental dimension and acting on social participation.

Ce travail de recherche a pour objectif de comprendre l’impact de la mise en place d’une approche relationnelle auprès de populations vulnérables sur les pratiques de dépistage du cancer. La problématique principale est la suivante : La mise en place d’une approche relationnelle en santé, via la présence de navigateurs auprès de populations vulnérables, permetelle d’améliorer la communication en prévention et son impact sur les pratiques de dépistage ? Ce travail fait suite au développement de dispositifs de prévention en santé visant à faire davantage participer au dépistage du cancer et réduire les inégalités sociales de santé. Ils testaient jusque-là la mise en place d’une approche relationnelle, prônant l’adaptation du profil du personnel en contact à une population vulnérable, sans toutefois tester l’effet des différentes caractéristiques de ce personnel. Les promoteurs de ces dispositifs, appelés « programmes de navigation », affirment que l’adaptation du profil du navigateur (chargé de prévention) à la population cible permet d’augmenter significativement la participation au dépistage. Cette adaptation se fait par le recrutement d’un chargé de prévention partageant des caractéristiques similaires avec la population cible (âge, genre, lieu d’habitation, etc.) et n’ayant pas nécessairement d’expertise en santé. Si l’efficacité des dispositifs mis en œuvre dans de précédentes expérimentations a été prouvée, rien n’est dit sur l’impact des caractéristiques des navigateurs. Un cadre théorique mobilisant les travaux en marketing des services et en marketing relationnel est proposé pour identifier les facteurs d’efficacité des programmes de navigation et, ainsi faisant, les caractéristiques des navigateurs. Pour cela, trois études empiriques sont menées. Les deux premières études (études 1 et 2) explorent la genèse d’un de ces dispositifs « ColoNav » afin d’en comprendre les tenants et les aboutissants. L’étude 1 mesure l’impact de ce dispositif sur la participation au dépistage du cancer colorectal et met en lien ces résultats avec le profil des personnels en contact recrutés. L’étude 2 analyse les données qualitatives de ce dispositif et met en lumière les différents facteurs ayant pu avoir un impact dans son efficacité. L’étude 3 (expérimentation) mesure le réel impact de l’adaptation du profil (similarité et expertise) du personnel en contact à une population vulnérable sur l’intention de participation au dépistage du cancer colorectal et sur l’intention de le recommander. L’étude 1 montre que la présence du navigateur pour promouvoir le dépistage du cancer colorectal semble avoir un effet sur la participation à celui-ci. Cependant, les conditions de l’étude ne permettent pas de conclure de façon satisfaisante au seul effet de l’adaptation du profil du chargé de prévention (étude 1). Ces résultats nous ont amenée à nous interroger sur le réel impact de cette adaptation et sur l’existence d’autres facteurs que le profil pouvant impacter les résultats de ce genre de dispositif. L’étude 2 nous a permis de constater l’existence de trois principaux facteurs et de les analyser en profondeur (étude 2). Ainsi, au profil du personnel en contact s’ajoutent son investissement dans la relation avec les personnes de la population cible (choix en matière de communication et capacité à s’adapter à son interlocuteur) et ses relations avec son environnement de travail (acteurs et population cible) qui viennent modérer son action (la faciliter ou la compliquer). Enfin, les résultats de l’étude 3 permettent de conclure à l’impact positif significatif de la similarité et de l’expertise sur l’intention de dépistage et de recommandation. Les conclusions de cette étude complètent celles faites pour le dispositif ColoNav. ... / The purpose of this research is to understand the impact of implementing a relational approach on vulnerable populations regarding cancer screening practices. The main issue was as follows: Does the implementation of a relational approach in health, through the presence of navigators with vulnerable populations, improve prevention communication and its impact on screening practices?This research is a follow-up to health prevention devices which aim was to increase participation in cancer screening and thus reduce social inequalities in health. Until now, they tested the implementation of a relational approach advocating the adaptation of the frontline employee’s profile to a vulnerable population, without however testing the effect of the different characteristics of this employee. These devices, called "navigation programs", claim that adapting the navigator’s profile (prevention officer) to a target population significantly increases the participation in screening. This adaptation is done by recruiting a prevention officer who shares similar characteristics with the target population (age, gender, place of residence, etc.) and does not necessarily have expertise in healthcare. If the effectiveness of the devices implemented in previous experiments has been proven, nothing is said about the impact of the navigators’ characteristics. A theoretical framework mobilizing research in Services marketing and Relationship marketing is proposed to identify the efficiency factors ofnavigation programs, thus, the characteristics of navigators. For that, three empirical studies have then been conducted.The first two studies (studies 1 and 2) explore the genesis of one of these devices, "ColoNav", in order to understand the reasons and outcomes. Study 1 measures the impact of this device on participation in colorectal cancer screening and links these results to the profile of the frontline employees recruited. Study 2 analyzes the qualitative data of this device and highlights the various factors that may have had an impact on its effectiveness. Study 3 (experimentation) measures the real impact of the adapting of the frontline employee’s profile (similarity and expertise) to a vulnerable population on the intention to participate to colorectal cancer screening and on the intention to recommend it. The first study shows that the presence of the navigator promoting colorectal cancer screening appears to affect participation to it. However, the conditions of the study do not allow to conclude satisfactorily on the only effect of the adaptation of the prevention officer’s profile (study 1). These results raise questions about the real impact of the adaptation of the frontline employee’s profile (similarity and expertise) and the existence of other factors than the profile that could impact the results of this kind of device. Study 2 allows us to find three main factors and analyzed them in depth (study 2). Thereby, the frontline employee’s profile complemented by his investment in the relationship with the target population (his communication choices and his ability to adapt to his nterlocutor) as well as by his relationship with his work environment (actors and target population), which moderates its action (facilitate or complicate it). Finally, the results of the experiment (study 3) allow us to conclude that there is a significant and positive impact of similarity and expertise on screening and recommendation intentions. The conclusions of study 3 complement those of the ColoNav device. They confirm the fact that in the context of the implementation of a relational approach, such as ColoNav, other factors than the frontline employee’s profile are to be considered in the effectiveness of a health prevention program.

Colonoscopy is used in colorectal cancer (CRC) screening either as an independent screening method (screening colonoscopy) or following a positive result of a primary screening test (eg. fecal occult blood test, FOBT). Preventive colonoscopy is the collective name for screening and FOBT+ colonoscopy. Due to the considerable variability in the detection of colorectal neoplasia between individual endoscopists, colonoscopy quality indicators were introduced. Adenoma detection rate (ADR) and polyp detection rate (PDR) are defined as the proportion of colonoscopies in which at least one adenoma (for ADR) or polyp (for PDR) was detected to the total number of colonoscopies performed. ADR is considered a key indicator of the quality of colonoscopy. Adenoma per colonoscopy (APC), defined as the total number of adenomas detected relative to the total number of colonoscopies performed, is the most accurate indicator currently available. However, APC limit values have not yet been set. Both ADR and APC are validated indicators, but their evaluation is time-consuming and personnel-intensive, which limits their use in clinical practice. The main purpose of the presented work is to simplify the monitoring of colonoscopy quality by introducing a more user-friendly indicator, which does not require histological...

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Cette thèse étudie les facteurs d’offre et de demande associés au recours au dépistage du cancer du sein. Parmi les facteurs d’offre, j’examine comment la coexistence du dépistage organisé au côté du dépistage individuel influence le contenu de l’examen de dépistage ainsi que le recours régulier au dépistage. En plus des facteurs de demande tels les caractéristiques socioéconomiques, une attention particulière est portée à la possibilité d’expliquer le recours régulier au dépistage par les préférences face au risque et temporelles ainsi que les perceptions. À partir de régularités psychologiques identifiées dans les travaux d’économie comportementale et de psychologie, trois interventions de type nudge sont testées dans le cadre d’une expérience randomisée sur le terrain visant à augmenter le taux de dépistage dans le programme national. / This thesis explores supply and demand factors associated with the use of breast cancer screening. Among the supply factors, I examine how the coexistence of organized and opportunistic screenings influences the content of the screening exam and screening regularity. Besides the usual demand factors such as socioeconomic characteristics, a special attention is being given to the possibility of explaining screening regularly by individuals’ risk and time preferences and perceptions. Based on psychological patterns identified in the literature in behavioral economics and psychology, three nudge interventions are tested in a randomized field experiment to increase the national program uptake rate.

In 2014, breast cancer was the second leading cause of death among Canadian women, with women over age 50 years making up 82% of the identified cases. To address this issue, the Ontario Breast Screening Program developed a media campaign that promoted the benefits of mammogram screening, but not the associated risks (i.e., false-positive, false-negative, radiation exposure, and overdiagnosis). This study was designed to determine whether there was a statistically significant relationship between knowledge of overdiagnosis and participation in mammogram screening. This cross-sectional, correlational study used schema theory supported by the effective health communication model. Forty-one women were invited to listen to a brief presentation on the benefits and risks of screening mammograms and then completed a modified Champion Health Belief Model Scale survey. Two sample t tests and logistic regression analyses of the survey scores showed that the data did not support any correlations with education and screening, but did indicate a correlation between overdiagnosis and participation. The less a participant felt that overdiagnosis was a negative consequence, the more likely they were to participate in breast screening. Survey participants also stated that promotions of mammograms should present balanced information about the benefits and risks of screening. The positive social change and policy implications of this study include providing women aged 50-69 years more information on overdiagnosis in mammograms so they are more informed participants in the decision-making process, and educating Ontario government policymakers with information about the barriers that women aged 50-69 years face in getting balanced information on mammography programs.

Breast cancer is the second leading cause of cancer death in women in the United States. Several factors have been identified that interfere with women's breast cancer screening practices, including lack of knowledge and confidence in the breast self-examination (BSE) technique, and lack of information provided by health care provider. One of the reasons nurses do not teach breast cancer detection could be the little emphasis given to breast cancer examination in nursing schools. The BSE is a measure of significant value in detecting cancer of the breast. However, less than half of the women in the United States are participating in breast cancer screening. The purpose of this quantitative study was to investigate the relationship between the freshman and senior nursing students' breast cancer knowledge (BCK) and breast self-examination technique confidence (BSE_TC). An online survey was administered to measure the students' BCK and their BSE_TC. The social cognitive theory guided this study. A sample 100 nursing students (54 senior and 46 freshman) were included for hypothesis testing. The study results indicate that senior nursing students had higher mean scores on the BCK and BSE_TC, as would be expected. However, senior nursing students' BCK_BSE_TC scores were also very low. This is a concern for the future of breast cancer detection. This study provides data showing breast cancer screening concepts are unclear to freshman students, and remain unclear with senior students. Nursing educational curricula in breast cancer screening should be revised to affect improvements in nurses' role in advising and educating patients.

Background: Shared decision-making (SDM) counseling for lung cancer screening is recommended by multiple professional societies and mandated by the Center for Medicare and Medicaid Services since lung cancer screening has both benefits and risks. However, uptake of SDM counseling as well as lung cancer screening itself remain low. We sought to develop educational text messages about lung cancer screening as an innovative implementation intervention tool to promote patient-provider discussion about lung cancer screening. Methods: After the study team drafted educational text messages about lung cancer screening, informed by existing decision aids, participants who had had lung cancer screening were recruited and asked to review and edit text messages. After that, participants eligible for lung cancer screening without the previous screening experience were recruited and were asked to select the messages to be included in this text message intervention. The final set of 14 text messages were delivered to the participants both with and without the previous lung cancer screening over a period of 14 days. Participants completed a telephone survey assessing their reactions to the messages after receiving the last message. Results: We successfully involved twelve participants with lung cancer screening experience and eleven lung cancer screening eligible participants without previous screening experience in the development of educational text messages about lung cancer screening. After one participant withdrew, 22 participants received text messages and completed the survey regarding the messages. Most participants (18 of 22) reported reading all 14 text messages, however most recommended sending fewer messages (median recommended number of messages = 10). Participants found the educational text messages informative. Only four participants reported the text messages triggered anxiety and two reported text messages disrupted their daily activities. Participants perceived the text messages would empower patients to discuss lung cancer screening with their providers. Conclusion: Participants generally supported the use of educational text messages about lung cancer screening to increase patients’ awareness and promote patient-provider discussion. Engaging patients in the development and evaluation of text messages elicited helpful feedback that will inform the content of the messages to be delivered via this lung cancer screening text messages intervention.

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