AN ABSTRACT OF THE DISSERTATION OF MICHAEL A. STROUD, for Doctor of Philosophy degree in HEALTH EDUCATION, presented on MARCH 20, 2014, at Southern Illinois University Carbondale. TITLE: PHYSICAL THERAPISTS' CLINICAL PRACTICES REAGARDING INTRINSIC AND EXTRINSIC FALL RISK FACTORS AND THEIR ATTITUDES TOWARD THE USE OF EVIDENCE-BASED PRACTICE MAJOR PROFESSOR: Dr. Stephen Brown The phenomenon of falls among community-dwelling adults--coupled with an aging baby boomer generation and an increasing life expectancy--presents a significant concern for an increased number of unintentional deaths and injuries and their associated costs. The risk factors associated with falling are often categorized as intrinsic and extrinsic. Physical therapists have a unique opportunity to positively impact issues involving physical dysfunction and to educate their community-dwelling adult patients about the environmental risk factors and interventions that lessen their risk of falling. Abundant evidence-based research exists regarding interventions for the treatment and prevention of falls; however, this research indicates that physical therapists fail to consistently utilize evidence-based practice (EBP) in their daily clinical practices. The diffusion of innovations theory examines how innovations are adopted (Rogers, 2012). However, the innovation of EBP is not always adopted by physical therapists. Lack of time to conduct literature searches was the most common barrier noted by physical therapists for not adopting EBP (Jette et al., 2003; Fruth et al., 2010; Salbach, Jagial, Korner-Bitensky, Rappolt, & Davis, 2007). This study, which utilized a cross-sectional descriptive research design, provided insight into physical therapists' clinical practices regarding intrinsic and extrinsic fall risks in the treatment of community-dwelling adults aged 65 years and older. It examined physical therapists' attitudes and beliefs toward the use of EBP and identified the barriers to their adoption of it. The demographic data provided a descriptive overview of the study respondents. There were 3,523 potential physical therapist respondents, and the study's return rate was 9% (316 respondents. The majority of the respondents held doctoral degrees (49.4%), more than half (55.4%) worked in an outpatient physical therapy clinical setting, and approximately half indicated that they were American Physical Therapy Association (APTA)-certified instructors. The results of the study indicated that physical therapists who had more experience displayed a higher level of attention to clinical practices than those with less experience. The physical therapists who were APTA-certified clinical instructors demonstrated a higher level of attention to the intrinsic and extrinsic risks of falling than those who were not APTA-certified instructors. The physical therapists whose highest level of education was a doctorate placed greater importance on the utilization of EBP than respondents with a baccalaureate or master's degree. Although most physical therapists believe that the utilization of EBP holds significant value, they do not always access or apply it. Insufficient time for using EBP was the major barrier noted by most physical therapists. The results of this study concurred with those of previous studies regarding common barriers to physical therapists' adoption of EBP. Rehabilitation organizations may want to examine methods to promote the use of the most current physical therapy practices based on the evidence revealed in the literature and to explore options for improving staff access to and utilization of EBP research.

O objetivo deste trabalho é compreender e discutir alguns temas que atravessam o mundo contemporâneo para identificar elementos críticos e úteis à formação em psicologia, em especial, no campo das práticas clínicas. Por meio de uma metodologia qualitativa, fez-se um estudo teórico atrelado à análise de entrevistas concedidas por profissionais filiados a diferentes abordagens que atuam há pelo menos duas décadas no campo da clínica. Como questões ética e tecnicamente desafiadoras à clínica contemporânea, destacam-se a solidão, os processos de desenraizamento, a crise dos símbolos e papéis de autoridade, a banalização e a disseminação de violências (explícitas e sutis), a impaciência e a indiferença dos sujeitos, a perda da dignidade do sofrimento (que vem sendo sistematicamente patologizado e medicalizado), a mercantilização de valores, instituições, corpos e relações humanas, a terceirização de responsabilidades (a especialistas), a invasão da infância por valores e práticas do mundo adulto, os efeitos e as possibilidades da imersão no mundo virtual, o empobrecimento subjetivo associado à dificuldade de narrar e simbolizar experiências, o aumento de comportamentos compulsivos e irrefletidos, a privatização de bens e espaços públicos e a diminuição de experiências políticas e comunitárias / The main objective of this thesis is to comprehend and to discuss some topics in contemporary societies, in order to look for critical and useful elements for training and education in psychology, particularly regarding its clinical practices. Qualitative methods were used to carry out a theoretical study combined with the analysis of interviews made with professionals from different approaches, who have been working as psychologists for at least two decades. Ethical and technical issues which surfaced as particularly challenging to contemporary clinical psychology were: loneliness; uprooting processes; the crisis of authority symbols and roles; trivialization and spreading of violence (both explicit and subtle); peoples impatience and indifference; the loss of dignity to which suffering has been subjected (having been widely medicalized and pathologized); commercialization of values, institutions, bodies and human relations; outsourcing of responsibilities (to experts); takeover of childhood by adult values and practices; effects and possibilities of immersion in the virtual world; subjective impoverishment associated with the difficulties of symbolizing experiences and narrating them; increase in compulsive and unthinking behaviours; privatization of public assets and places; decrease in political and community experiences, among others

O objetivo deste trabalho é compreender e discutir alguns temas que atravessam o mundo contemporâneo para identificar elementos críticos e úteis à formação em psicologia, em especial, no campo das práticas clínicas. Por meio de uma metodologia qualitativa, fez-se um estudo teórico atrelado à análise de entrevistas concedidas por profissionais filiados a diferentes abordagens que atuam há pelo menos duas décadas no campo da clínica. Como questões ética e tecnicamente desafiadoras à clínica contemporânea, destacam-se a solidão, os processos de desenraizamento, a crise dos símbolos e papéis de autoridade, a banalização e a disseminação de violências (explícitas e sutis), a impaciência e a indiferença dos sujeitos, a perda da dignidade do sofrimento (que vem sendo sistematicamente patologizado e medicalizado), a mercantilização de valores, instituições, corpos e relações humanas, a terceirização de responsabilidades (a especialistas), a invasão da infância por valores e práticas do mundo adulto, os efeitos e as possibilidades da imersão no mundo virtual, o empobrecimento subjetivo associado à dificuldade de narrar e simbolizar experiências, o aumento de comportamentos compulsivos e irrefletidos, a privatização de bens e espaços públicos e a diminuição de experiências políticas e comunitárias / The main objective of this thesis is to comprehend and to discuss some topics in contemporary societies, in order to look for critical and useful elements for training and education in psychology, particularly regarding its clinical practices. Qualitative methods were used to carry out a theoretical study combined with the analysis of interviews made with professionals from different approaches, who have been working as psychologists for at least two decades. Ethical and technical issues which surfaced as particularly challenging to contemporary clinical psychology were: loneliness; uprooting processes; the crisis of authority symbols and roles; trivialization and spreading of violence (both explicit and subtle); peoples impatience and indifference; the loss of dignity to which suffering has been subjected (having been widely medicalized and pathologized); commercialization of values, institutions, bodies and human relations; outsourcing of responsibilities (to experts); takeover of childhood by adult values and practices; effects and possibilities of immersion in the virtual world; subjective impoverishment associated with the difficulties of symbolizing experiences and narrating them; increase in compulsive and unthinking behaviours; privatization of public assets and places; decrease in political and community experiences, among others

O objetivo dessa pesquisa é discutir o cenário de uso de crack no município do Rio de Janeiro contextualizado com a condição de vulnerabilidade e risco social, através do mapeamento das controvérsias entre os atores dessa rede. As percepções e experiências relatadas neste trabalho dizem respeito aos diferentes espaços profissionais voltados ao atendimento e prestação de serviço a este público. Inicialmente, é trazida a trajetória teórica e prática que levaram a construção desta dissertação. Foram relatadas experiências vividas nas ações conjuntas de abordagem com a SMDS (Secretaria Municipal de Desenvolvimento Social) e a prática como entrevistadora de usuários de crack na Pesquisa Nacional do Crack pela FIOCRUZ. No segundo momento, é feito um breve histórico da origem do crack e suas marcas pelo mundo. São trazidos também, dados sobre a droga no Brasil, em particular sua história no Rio de Janeiro. Ainda nesta sequência, é apresentada a política de Redução de Danos, mostrando de que maneira o sujeito é significado a partir dessa perspectiva, e suas principais contribuições pelo mundo e também no país. A dissertação é construída pela perspectiva das práticas profissionais do psicólogo SMDS pensada através da Teoria Ator-rede. Foi importante destacar as principais ações de política pública voltadas para essa temática, considerando os avanços na discussão da temática. Foram mapeadas e exploradas as relações entre os atores envolvidos nesta temática (usuários de crack, SMDS, SMS Secretaria Municipal de Saúde, Segurança Pública, Mídia, Sociedade), colocando em evidencia as controvérsias existentes nessas relações, como recolhimento compulsório. De maneira conclusiva, são trazidas as impressões tiradas ao final deste percurso, problematizando os papéis do poder público e daqueles que atuam para garantir a população que faz uso abusivo de crack e outras drogas o direito de acessar e exercia sua cidadania. / The objective of this research is to discuss the scenario of crack use in Rio de Janeiro city contextualized with the condition of vulnerability and social risk, by mapping the controversies between the actors of this network. The perceptions and experiences reported in this study concerns to the different professional areas related to assistance and service to this public. Initially, is introduced the theoretical and practice way that led to the framing of this dissertation. Experiences acquired in joint approach actions with MSDD (Municipal Social Development Department) and interviewing practice of crack users in the National Survey of Crack by FIOCRUZ were reported. In a second moment, is reported a brief historical about origin of crack and its effects worldwide. Data about crack in Brazil, particularly its history in Rio de Janeiro, are also shown. Subsequently, the harm reduction policy is introduced, demonstrating how the subject is understood from this perspective, and its main contributions in the country and worldwide. The dissertation is organized from the professional practice perspective of MSDD psychologists thought through Actor-Network Theory. Highlight key public policy actions focused on this theme, considering the advances in the discussion, was important. Relations between the actors involved in this issue (crack users, MSDD, MHD - Municipal Health Department , Public Security, Media, Society), putting in evidence the controversies in these relationships, such as compulsory internment . Conclusively, impressions taken at the end of this course are shown, questioning the roles of public power and those who work to ensure the population addicted to crack and other drugs the right to access and exercise their citizenship.

O objetivo dessa pesquisa é discutir o cenário de uso de crack no município do Rio de Janeiro contextualizado com a condição de vulnerabilidade e risco social, através do mapeamento das controvérsias entre os atores dessa rede. As percepções e experiências relatadas neste trabalho dizem respeito aos diferentes espaços profissionais voltados ao atendimento e prestação de serviço a este público. Inicialmente, é trazida a trajetória teórica e prática que levaram a construção desta dissertação. Foram relatadas experiências vividas nas ações conjuntas de abordagem com a SMDS (Secretaria Municipal de Desenvolvimento Social) e a prática como entrevistadora de usuários de crack na Pesquisa Nacional do Crack pela FIOCRUZ. No segundo momento, é feito um breve histórico da origem do crack e suas marcas pelo mundo. São trazidos também, dados sobre a droga no Brasil, em particular sua história no Rio de Janeiro. Ainda nesta sequência, é apresentada a política de Redução de Danos, mostrando de que maneira o sujeito é significado a partir dessa perspectiva, e suas principais contribuições pelo mundo e também no país. A dissertação é construída pela perspectiva das práticas profissionais do psicólogo SMDS pensada através da Teoria Ator-rede. Foi importante destacar as principais ações de política pública voltadas para essa temática, considerando os avanços na discussão da temática. Foram mapeadas e exploradas as relações entre os atores envolvidos nesta temática (usuários de crack, SMDS, SMS Secretaria Municipal de Saúde, Segurança Pública, Mídia, Sociedade), colocando em evidencia as controvérsias existentes nessas relações, como recolhimento compulsório. De maneira conclusiva, são trazidas as impressões tiradas ao final deste percurso, problematizando os papéis do poder público e daqueles que atuam para garantir a população que faz uso abusivo de crack e outras drogas o direito de acessar e exercia sua cidadania. / The objective of this research is to discuss the scenario of crack use in Rio de Janeiro city contextualized with the condition of vulnerability and social risk, by mapping the controversies between the actors of this network. The perceptions and experiences reported in this study concerns to the different professional areas related to assistance and service to this public. Initially, is introduced the theoretical and practice way that led to the framing of this dissertation. Experiences acquired in joint approach actions with MSDD (Municipal Social Development Department) and interviewing practice of crack users in the National Survey of Crack by FIOCRUZ were reported. In a second moment, is reported a brief historical about origin of crack and its effects worldwide. Data about crack in Brazil, particularly its history in Rio de Janeiro, are also shown. Subsequently, the harm reduction policy is introduced, demonstrating how the subject is understood from this perspective, and its main contributions in the country and worldwide. The dissertation is organized from the professional practice perspective of MSDD psychologists thought through Actor-Network Theory. Highlight key public policy actions focused on this theme, considering the advances in the discussion, was important. Relations between the actors involved in this issue (crack users, MSDD, MHD - Municipal Health Department , Public Security, Media, Society), putting in evidence the controversies in these relationships, such as compulsory internment . Conclusively, impressions taken at the end of this course are shown, questioning the roles of public power and those who work to ensure the population addicted to crack and other drugs the right to access and exercise their citizenship.

No description available.

Depuis 1994, l’ANRS mène en tant que promoteur des études cliniques dans les pays à ressources limitées. Ces études sur le Sida et les hépatites virales sont principalement menées dans les huit sites de l’agence en Afrique Subsaharienne, au Moyen Orient, en Asie du Sud-Est et en Amérique Latine. Les chercheurs dans les pays à ressources limitées font face à deux problématiques majeures : (i) les règles des Bonnes Pratiques Cliniques (BPC) n’intègrent pas leurs particularités fonctionnelles et culturelles ; et (ii) aucun outil n’existe dans la littérature pour évaluer l’adhésion des études cliniques à ces règles. Les objectifs de cette thèse sont premièrement d’identifier les particularités des études cliniques menées dans les pays à ressources limitées et développer par consensus des Indicateurs de Qualité (IQ) adaptés à leur contexte. Ensuite, d’appliquer ces IQ à des études cliniques menées dans les sites ANRS pour évaluer leur faisabilité et leur pertinence. Les IQ proposés ont couvert essentiellement huit processus : (i) rédaction du protocole et demande des autorisations ; (ii) inclusion et suivi des participants ; (iii) monitorage des sites ; (iv) gestion du médicament ; (v) examens biologiques ; (vi) gestion de l’archivage ; (vii) gestion de la base informatique ; (viii) clôture des sites cliniques. Le recueil des données a été réalisé dans neuf essais cliniques (2137 patients inclus) dans les six pays partenaires. Parmi les 58 IQ prédéfinis, 45 IQ ont été faisables et pertinents. Cette démarche originale a permis la mobilisation des acteurs des recherches financées par l’ANRS dans les pays à ressources limitées autour d’une véritable démarche qualité. Les résultats des IQ recueillis dans le cadre de ce programme ont montré que pour les notions essentielles les essais de l'ANRS sont conformes aux références BPC, ICH, et CIOMS. Le maintien et le suivi de cette démarche permettra à l’ANRS de veiller en permanence sur la qualité et la fiabilité des données des études et garantira la transparence des procédures et la sécurité des participants. / Since 1994, the ANRS has funded research sites in resource-limited countries (RLCs). Studies on AIDS and viral hepatitis are mainly conducted in the eight ANRS sites in Sub-Saharan Africa, the Middle East, Southeast Asia and Latin America. Researchers in RLCs face two major problems: (i) little guidance exists on how recommendations and regulations should be interpreted and applied in non-investigational new product trials and in the context of RLCs and (ii) in the literature there is not a standard tool assessing adherence of clinical studies to these guidelines. Objects of this thesis were firstly to identify specific considerations of clinical studies in RLCs and to develop by consensus methods Quality Indicators (QIs) adapted to their context. Then evaluate QIs feasibility and relevance through data collection in ANRS clinical trials. The proposed QIs covered eight main processes: (i) Protocol conception and seeking authorizations, (ii) participant enrollment and follow up, (iii) site monitoring, (iv) drug management, (v) biological investigations; (vi) records management, (vii) data management (viii) site close out. Data collection was carried out in nine trials (2137 patients) in the six participating sites. Of the 58 proposed IQ, 45 were feasible. This innovative program allowed ANRS sites located in resource-limited countries to share their GCP implementation experiences in order to build a list of relevant indicators for clinical trials. QI were able to assess the quality of all major processes of clinical trials and showed that major ethical and GCP requirements were respected in all nine ANRS trials. This permanent monitoring can be used to enable continuous practice improvement, ensure participants’ safety transparent procedures and guarantee data quality and reliability in all studies funded in resource-limited countries.

Les difficultés économiques qui affectent les systèmes de protection sociale, l’évolution des politiques publiques sous l’affirmation des principes du nouveau management public, et l’évolution des savoirs médicaux et soignants font peser sur de nombreux établissements de santé des menaces importantes pour leur survie ou à tout le moins sur la continuation de leur projet originel. Cette thèse s’intéresse à la question des facteurs de pérennité des organisations de santé. Elle repose sur l’étude de cas longitudinale d’un établissement psychiatrique privé fondé en 1943 qui assure la responsabilité de la psychiatrie publique du secteur de l’Est vaudois, alors qu’il pratique une politique de soins qui se réfère à la psychanalyse, à contre-courant des références actuelles en psychiatrie qui relèvent plutôt des neurosciences et des traitements cognitivo-comportementaux (TCC). Suivant les principes de la démarche clinique, une approche globale de l'organisation est réalisée pour comprendre la dynamique de fonctionnement de cette institution et son faire-ensemble particulier. Dans cet perspective, l’analyse se focalise sur les pratiques du quotidien, tant du point de vue des soins (les pratiques cliniques) que du management (les pratiques de gestion), en prenant également en compte la dimension historique de l’institution mais aussi de l’environnement et de la psychiatrie. Il ressort de cette analyse que 3 éléments fondent la pérennité de cet établissement dans une dynamique récursive :- une philosophie des soins affirmée et ancrée sur des valeurs humanistes,- l’homologie entre pratiques cliniques et pratiques de gestion,- La gestion de l’interstitiel, c’est-à-dire les espaces de marge de manœuvre et d’autonomie des acteurs instaurés en dehors de toute structure et de regards hiérarchiques dans des relations de confiance.Ces 3 éléments constituent l’esquisse d’un modèle organisationnel de pérennité qui devra être testé à plus grande échelle. / The economic difficulties affecting social protection systems, the evolution of public policies under the affirmation of the principles of the new public management, and the evolution of medical and nursing knowledge pose major threats to the survival of many health establishments or at least to the continuation of their original project. This thesis addresses the issue of sustainability factors in health organizations. It is based on the longitudinal case study of a private psychiatric establishment founded in 1943 which is responsible for public psychiatry in the eastern sector of the Canton of Vaud, while it practices a policy of care which refers to psychoanalysis, against the current references in psychiatry which are rather neurosciences and cognitive-behavioural treatments (CBT). Following the principles of the clinical approach, a global approach of the organization is realized to understand the dynamics of the functioning of this institution and its particular make-together. In this perspective, the analysis focuses on everyday practices, both from the point of view of care (clinical practices) and management (management practices), also taking into account the historical dimension of the institution but also of the environment and psychiatry. 3 inter-related elements emerge from this analysis as the basis of the sustainability of this establishment in a recursive dynamic:- an affirmed philosophy of care rooted in humanist values,- the homology between clinical and management practices,- Interstitial management, i.e. the spaces of autonomy of the actors that are set up outside any structure and hierarchical and are based on relationships of trust.These 3 elements constitute the outline of an organizational model of sustainability that will have to be tested on a larger scale.