Aujourd'hui, l'accumulation des risques associés à des facteurs comme l'urbanisation croissante, le changement et la variabilité du climat, le terrorisme, les épidémies ou pandémies animales et humaines ainsi que la mobilité accrue des personnes et des biens de par le monde, ont accru le potentiel perturbateur voire destructeur de divers types de catastrophes. Des plans de gestion de crises sont élaborés pour gérer au mieux la catastrophe engendrée voire l’éviter. L’objectif de ce travail de recherche est de développer des outils d’aide à la décision pour supporter les différentes phases du plan de gestion de crises dédiés aux établissements de soins à domiciles, notamment les phases de préparation et de réponse. Un ensemble de scénarios à étudier prioritairement en considérant les différentes sources de crises et les processus métier impactés, quant à leur fréquence et leurs impacts humain et matériel, a été défini. Une approche originale d’analyse de vulnérabilité basée sur la théorie des graphes et des matrices a été développée. Le but est de pouvoir mesurer l’impact des différentes crises sur la structure d’hospitalisation à domiciles en termes d’acteurs et de flux échangés. En se basant sur cette phase d’évaluation, nous avons proposé : une classification des acteurs de l’HAD, des méthodes pour la conception des stratégies et des contremesures de mitigation pour chaque classe d’acteurs. La problématique d’accès aux soins dans le cadre d’un scénario d’intoxication massive a été abordée. Un modèle de programmation linéaire a été proposé pour simuler le scénario étudié et évaluer ses conséquences. Il modélise l'infection d'origine alimentaire et la réponse médicale dans le cadre d’une collaboration HAD-Hôpital, c.-à-d., un plan blanc élargi. La problématique d’accès aux domiciles des patients a été investiguée dans le cadre d’un scénario de type crue, épisode neigeux etc. L'outil proposé fournit un plan d'évacuation pour les patients critiques à évacuer et un plan de soutien à domicile pour les patients à risque faible qui seront maintenus à domicile, ceci en utilisant des regroupements basés sur l'évaluation du risque de chaque patient. / Today, the accumulation of risks associated with factors such as increasing urbanization, climate change and variability, terrorism, animal and human epidemics or pandemics and enlarged mobility of people and goods have increased the disruptive and even destructive impact of various types of disasters. Crisis management plans are developed to better manage the crisis or even to avoid it. The purpose of this research is to develop decision aid tools to support the different phases of the crisis management plan for home health care (HHC) structures, mainly for preparation and response phases. A set of scenarios, considering the different sources of crises and the impacted business processes, with regard to their frequency and their human and material impacts, have been defined. An original approach of vulnerability analysis based on graph theory and matrix methods has been developed. The objective is to measure the impact of different crises on the HHC structure in terms of actors and exchanged flows. Based on this assessment phase we have proposed a classification of HHC actors. Different methods have been proposed for the design of mitigation strategies and countermeasures for each class of actors. The problem of access to care in the context of a scenario of massive intoxication is considered. A linear programming model has been proposed to simulate the studied scenario and evaluate its consequences. It models a foodborne infection and its medical response as part of a HHC-Hospital collaboration, in the framework of an extended white plan. The issue of access to patients' homes has been investigated in the context of a flood-like scenario. The proposed tool provides an evacuation plan for critical patients to evacuate and a home support plan for low-risk patients who will be kept at home, using clustering based on each patient's risk assessment.

Ce travail essaie d’identifier les enjeux rencontrés dans la pratique de la psychiatrie et de proposer des repères susceptibles d’éclairer une réflexion dans une perspective éthique. Dans une première partie, nous questionnons la démarche de la psychothérapie institutionnelle, mouvement humaniste d’ouverture des hôpitaux et de prise en considération du sujet, à la lumière des concepts de l’éthique médicale ; en retour nous tentons d’interpréter les principes éthiques dans le domaine de la psychiatrie. Cette approche met l’accent sur l’expérience vécue de la maladie, l’intersubjectivité et le contexte institutionnel. Dans un second temps, une étude par entretiens semi-directifs réalisée auprès de 12 psychiatres hospitaliers révèle que les pratiques collectives sont peu orientées vers la responsabilisation des patients. La troisième partie se situe du côté des personnes hospitalisées à travers deux enquêtes. Une étude qualitative explore la perception de l’isolement de 30 patients : prédominent des affects négatifs et un vécu de privation d’information. Ensuite, une enquête par questionnaire saisit l’opinion de 169 patients sur le déroulement et les effets du séjour hospitalier ; leur appréciation s’avère majoritairement favorable. La confrontation des points de vue des psychiatres et des personnes hospitalisées, à l’aune des trois principes fondamentaux, révèle la primauté d’une dimension bienveillante, à l’exclusion parfois de l’autonomie et de la non-malfaisance. La dimension éthique du soin doit être sans cesse interrogée et réaffirmée. A cet effet, nous discutons de la pertinence d’un outil de questionnement des pratiques qui validerait le point de vue des patients. / This work tries to identify the issues encountered in the practice of psychiatry, and to propose reference points likely to clarify thinking from an ethical perspective. We initially examined institutional psycho-therapy, an open and humanistic movement of hospitals, and deliberated the topic in light of ethical medical concepts ; in return, we hoped to interpret ethical principles in the field of psychiatry. This approach placed the accent on the experience inherent in the illness, inter-subjectivity and the institutional context. Secondly, a study conducted via semi-directed discussions among 12 hospital psychiatrists revealed that collective practices are not oriented towards the accountability of patients. The third part dealt with two surveys of hospitalized people. A qualitative study explored the perception of seclusion by 30 patients : they predominantly show negative affects and an experience of being deprived of information. Then, a questionnaire survey showed the opinion of 169 patients on the procedure and effects of a hospital stay ; their rating was over-whelmingly favourable. The confrontation of opinions by psychiatrists and hospitalized patients, compared with the three fundamental principles, revealed the primacy of a benevolent dimension, to the exclusion at times of autonomy and non-maleficence. The ethical dimension of care must continue to be queried and re-asserted unceasingly. To this end, we will continue to discuss and interrogate the pertinence of a questioning tool of practices that would validate the patient’s viewpoints.

This paper analyses mental patient’s rights. Mental patient has all political, economic, social and cultural rights. Mental patient with a mental illness has a right to appropriate, accessible and suitable medical aid provided free of charge at state health-care institutions. The paper further discusses such patients’ rights as the right to confidentiality with regard to information concerning their health. Involuntary hospitalization is studied in consideration of the constitutional right to liberty of an individual. Paper analyses criteria for involuntary hospitalization. The institute of guardianship is also discussed.

A hospitalisation experience is serious for every toddler, and implies physical and emotional trauma of one kind or another. The reaction of the toddler in terms of this trauma in effect is a normal reaction to an unnatural situation, through which he tries to be in control of himself and his unknown environment. His lack of experience, incomplete cognitive reasoning, and lack of insight cause anxiety and stress for the toddler. Misbehaviour because of account of his anxiety and fear which the form part of the toddlers attempts to control and get hold of this unknown situation. The research is primarily aimed at how the therapist, parents and hospital personnel can prepare, assess and support the toddler, in terms of handling the hospitalisation process. Seeing that there is normally no one to blame for the toddlers admission to hospital, the child directs his anger and anxiety at himself, resulting in inner conflict and intense feelings of guilt. The research project aims to focus on preparation of the pre-primary toddler for hospitalisation, by using playtherapeutic intervention, in order to lessen the fear and anxiety of the experience. This goal was achieved by a literature study, an empirical study with the aid of application of a preparatory intervention program, as well as an assessment and an evaluation of the program, in order to make recommendations, regarding the research. Optimal care, and preparation of sick toddlers for admission in hospital, includes more than satisfying the child’s physical needs. It also asks for gratification of the toddler’s psychosocial needs. Support and preparation of both the child and his/her parents form an integral component of the sanitary care process. Therapeutic activities with the child that is going to hospital, can, according to the goals of the research study, be instrumental in reducing fear, promote self-esteem, become acquainted with the medical setting and procedures, as well as providing in the toddlers physical, emotional, psychological and psychosocial needs. A complete and refined play therapeutic preparation program was developed and evaluated through the findings of the empirical and literature study. The process of intervention research was followed in the empirical study, where data was obtained with the aid of a purposive sample, of 20 hospitalised toddler respondents. Creswell’s dominant-less-dominant model was utilised. A dominant quantitative approach was being followed, through witch data was assembled by a self developed structured observation instrument, as a post-test for both the experimental as well as the comparative group. The less dominant, but equally important qualitative approach, that consisted of 9 playtherapeutic sessions with experimental group, field notes and interviews with parents, enrich and verified the quantitative data. According to the integration of the quantitative and qualitative findings, the conclusion can be made that the preparatory playtherapeutic program had a positive impact on the way fear and the toddlers handled anxiety during hospitalisation, with less misbehaviour. The findings show that the developed preparatory playtherapeutic program can be implemented with great success and confidence, with toddlers that are going to be hospitalised. It is recommended that further research can be done on development and evaluation of preparation programmes for toddlers from less fortunate communities. Seeing that individual sessions may due to financial difficulties be less tenable, group sessions and community work can be recommended to reach larger groups of children, as well as creating community awareness for the needs of toddlers, related to hospitalisation. / Thesis (DPhil (Play Therapy))--University of Pretoria, 2005. / Social Work / unrestricted

Les professionnels de l'analyse de la pratique et de l'organisation des soins interviennent dans un système complexe où interagissent des facteurs biologiques, culturels et sociaux. Ce travail de recherche porte sur les vécus du patient cardiovasculaire entrant dans un programme d'éducation thérapeutique, suite à un évènement aigu (infarctus du myocarde ou accident vasculaire cérébral). Il se justifie par la nécessité de comprendre le phénomène des récidives, rechutes et retours à l'hospitalisation malgré une prise en charge informative et éducative des facteurs de risques cardiovasculaires (tabagisme, sédentarité, mauvaise alimentation) durant l'hospitalisation initiale. Notre principal objectif est donc de comprendre ces récidives, rechutes et retours à l'hospitalisation des patients cardiovasculaires autrement que le résultat d'une non-observance. Cette recherche de type qualitatif est menée au Centre Hospitalo-Universitaire de Clermont-Ferrand (service de cardiologie court séjour) et à la clinique cardiopneumoloique de Durtol (centre de soins de suite et de réadaptation). La recherche est basée sur 22 situations d'observations de pratiques professionnelles, 9 entretiens centrés avec les professionnels dans ces 2 sites ci-dessus et 31 entretiens semi-directifs avec les patients. Ces enquêtes sont complétées par une analyse de la littérature française et anglo-saxonne, dans le domaine de l'éducation thérapeutique, de l'observance et du changement des comportements. En termes de résultats, la recherche présente les récidives, rechutes et retours à l'hospitalisation court séjour des patients comme le résultat d'une prise en charge inadaptée à leurs besoins. Des discordances de temps, de vécus et de ressentis entre professionnels de santé et patients durant l'hospitalisation initiale, l'inadaptation structurelle du court séjour, la discontinuité de la prise en charge et les ruptures de cohérence en fonction des différents niveaux de complexité (court séjour, centre de soins de suite et de réadaptation et chez les médecins traitants), mais surtout la confusion entre éducation du patient et information du patient, rendent les prescriptions médicales et soignantes en matière de changement des comportements à risques difficilement observables par les patients. Le format actuel de la relation et des interactions patients/professionnels de santé durant les soins, ne favorise pas l'implication et la participation active des patients dans leur prise en charge. En conclusion, nous retenons que les éléments qui influencent les comportements des patients vis-à-vis de leurs traitements ne relèvent pas seulement d'un apprentissage, mais de leur vécu et ressentis et également de leurs interactions avec les professionnels de santé. La prise en charge informative et éducative des facteurs de risques occulte parfois l'aspect relationnel de cette thérapeutique et les capacités cognitives et émotives des patients. Elle devrait suivre une double évolution : celle du patient (ses émotions, ses attentes, ses projets de vie…) et celle de la pathologie. Ce travail cherche également à répondre à la question suivante : en quoi et comment une approche socio-anthropologique permet-elle de comprendre les comportements des patients d'une part et des professionnels de santé d'autre part dans un contexte d'ETP en court séjour ? Il milite pour une reconnexion entre sciences sociales et sciences médicales et soignantes dans le système de soin et de santé français et montre l'apport considérable mais encore trop peu exploité des sciences sociales dans ce domaine. / The professionals of the practice analysis and care organization take part in a complex system where biological, cultural and social factors interact. This research task focuses on the experiences of the cardiovascular patient entering a therapeutic education program, after an acute event (myocardial infarction or stroke). It is justified by the need to understand the phenomenon of recurrence, relapse and hospitalization returns despite an informative and educational treatment in cardiovascular risk factors (smoking, physical inactivity, poor nutrition) during the initial hospitalization. Our main goal is therefore to understand these recurrences, relapses and hospitalization returns of cardiovascular patients other than the result of non-compliance. This qualitative research is carried out at the University Hospital Center of Clermont-Ferrand (Cardiology Department short stay) and at the cardio-pneumologic clinic of Durtol (follow-up and rehabilitation care center). The research is based on 22 observation situations of professional practices, nine focused interviews with professionals in these two sites above and 31 semi-structured interviews with the patients. These surveys are supplemented by an analysis of the French and Anglo-Saxon literature in the field of therapeutic education, compliance and behaviours change. In terms of results, the research presents the recurrences, relapses and returns to patients' short stay hospitalization as the result of an inappropriate care to their needs. Time discrepancies, experiences and felt between health professionals and patients during the initial hospitalization, inadequate structural short stay, the discontinuity of care and the inconsistencies in accordance with different levels of complexity (short stay, follow-up and rehabilitation care center and at the attending physicians', but mostly the confusion between the patient's education and the patient's information, makes medical and nursing requirements in terms of the change of risky behaviours hardly observable by patients. The current format of the relationship and the interactions patient/health professionals during the care doesn't promote the involvement and the active participation of patients in their care. In conclusion we retain that the elements which influence the patients' behaviours with respect to their treatments do not only depend on training, but on their experiences and felts and also on their interactions with health professionals. The informative and educational care of the risk factors sometimes conceals the relational aspect of this therapeutic and the cognitive and emotive capacities of the patients. It should follow a double evolution: that of the patient (his emotions, his expectations, his life plans) and that of the pathology. This work also seeks to answer to the following question: why and how a socio- anthropological approach allows us to understand the patients' behaviours on one hand and the health professionals on the other hand in a context of PTE (patient's therapeutic education) in short stay? It argues for a reconnection between social sciences and medical and nursing in the French health care system and shows the significant contribution but still too little used by social sciences in this area.

No / Increasing pressure on health care budgets highlights the need for clinicians to understand the true costs of wound care, in order to be able to defend services against indiscriminate cost cutting. Our aim was to develop and test a straightforward method of measuring treatment costs, which is feasible in routine practice. The method was tested in a prospective study of leg ulcer patients attending three specialist clinics in the UK. A set of ulcer-related health state descriptors were defined on the basis that they represented distinct and clinically relevant descriptions of wound condition ['healed', 'progressing'; 'static''deteriorating; 'severe' (ulcer with serious complications)]. A standardised data-collection instrument was used to record information for all patients attending the clinic during the study period regarding (i) the health state of the ulcer; (ii) treatment received during the clinic visit and (iii) treatment planned between clinic visits. Information on resource use was used to estimate weekly treatment costs by ulcer state. Information was collected at 827 independent weekly observations from the three study centres. Treatment costs increased markedly with ulcer severity: an ulcer which was 'deteriorating' or 'severe' cost between twice and six times as much per week as an ulcer which was progressing normally towards healing. Higher costs were driven primarily by more frequent clinic visits and by the costs of hospitalisation for ulcers with severe complications. This exercise has demonstrated that the proposed methodology is easy to apply, and produces information which is of value in monitoring healing and in potentially reducing treatment costs.

The purpose of the study was to describe factors contributing to mortality among HIVinfected people on Isoniazid Preventive Therapy (IPT) in Botswana. A quantitative, explorative, descriptive study was used and 80 records of deceased IPT respondents were reviewed through the use of a checklist. The demographic factors, baseline physical examination, hospitalisation and drug history were taken into consideration. Out of the deceased patients, 75% were female. The major findings showed that 100% (N=80), the most highly indicated causes of death were gastroenteritis (18.75%), cryptococcal meningitis (17.5%) andpneumonia (16.25%). Of the patients (28.75%) who died before completing the six months of IPT. The causes of death were gastroenteritis (21.7%), symptoms and signs of bacterial pneumonia (17.4%), cryptococcal meningitis (13%), Pulmonary Tuberculosis (PTB) (13%), septicaemia (13%), and murder (13%). It has been recommended that there should be reorganisation of services of care for HIV-infected persons, such as provision of Cotrimoxazole Prophylaxis Therapy (CPT) and Antiretroviral Therapy (ART) to ensure holistic approach care. The future study should include HIV-infected children on IPT using the same or modified objectives. The conclusion drawn was that disintegrated interventions of IPT, CPT and ART and lack of holistic care for PLHIV lead to opportunistic infections that caused mortality on patients on IPT. / Department of Health Studies / M.A. (Public Health)

No description available.

The purpose of the study was to describe factors contributing to mortality among HIVinfected people on Isoniazid Preventive Therapy (IPT) in Botswana. A quantitative, explorative, descriptive study was used and 80 records of deceased IPT respondents were reviewed through the use of a checklist. The demographic factors, baseline physical examination, hospitalisation and drug history were taken into consideration. Out of the deceased patients, 75% were female. The major findings showed that 100% (N=80), the most highly indicated causes of death were gastroenteritis (18.75%), cryptococcal meningitis (17.5%) andpneumonia (16.25%). Of the patients (28.75%) who died before completing the six months of IPT. The causes of death were gastroenteritis (21.7%), symptoms and signs of bacterial pneumonia (17.4%), cryptococcal meningitis (13%), Pulmonary Tuberculosis (PTB) (13%), septicaemia (13%), and murder (13%). It has been recommended that there should be reorganisation of services of care for HIV-infected persons, such as provision of Cotrimoxazole Prophylaxis Therapy (CPT) and Antiretroviral Therapy (ART) to ensure holistic approach care. The future study should include HIV-infected children on IPT using the same or modified objectives. The conclusion drawn was that disintegrated interventions of IPT, CPT and ART and lack of holistic care for PLHIV lead to opportunistic infections that caused mortality on patients on IPT. / Department of Health Studies / M.A. (Public Health)

Abstract Advances in perinatal treatment practices—such as antenatal corticosteroids, surfactant replacement therapy, and gentler ventilator modalities—have improved the survival of infants born preterm. Consequently, later morbidity and pulmonary outcome for survivors has attracted increasing interest. The incidence of bronchopulmonary dysplasia (BPD) remains high and the condition is manifesting in infants born at earlier gestational weeks than before. This so-called new BPD results from the arrest of alveolar development and is associated with less structural airway injury and interstitial fibrosis than previously. Long-term follow-up data on lung function, lung structure and respiratory morbidity of children treated with modern methods is insufficiently known. We performed a follow-up study of 88 preterm-born children and 88 matched term-born controls at school age. Children born preterm had lower values in lung function measurements than term-born peers. Reductions were most marked in those with a history of BPD. In accordance with the foetal origins hypothesis, children with intrauterine growth restriction (IUGR) had lower lung function than gestation-controls. This indicates that poor growth in utero is an additional burden on pulmonary health. Both IUGR and BPD predicted lower lung function independently. High-resolution computed tomography of the lung was obtained from 21 children with a history of BPD. Structural abnormalities were common, children with severe BPD being most affected. Preterm children were hospitalised more often than controls, mainly because of wheezing disorders. However, BPD did not influence the hospitalisations. According to the meta-analysis of the contemporary data available, the respiratory outcome of children who had only mild BPD may have improved in comparison to old follow-up data, whereas the results for those without BPD or moderate-to-severe BPD have remained remarkably stable despite progress in treatment practices during early life. In conclusion, preterm children had subtle impairments in lung function at school age. Although they were fairly asymptomatic, concern about the possible long-term effects of preterm birth on pulmonary health is justified. It has been proposed that BPD may predispose individuals to an early COPD-like disorder. Preterm children must be protected from any additional burden on respiratory health and should be monitored appropriately for early detection of lung disease. / Tiivistelmä Keskosten tehohoito on kehittynyt viime vuosikymmeninä merkittävästi, ja yhä epäkypsempänä syntyvät keskoset selviävät hengissä syntymän jälkeen. Keskosten pitkäaikainen keuhkosairaus, bronkopulmonaalinen dysplasia (BPD), on perinteisesti johtunut hengityskonehoidon ja happikaasun aiheuttamasta keuhkovauriosta ja johtanut keuhkokudoksen arpeutumiseen. Aiempaa ennenaikaisemmilla keskosilla esiintyy kuitenkin nykyään niin sanottua uutta BPD:tä, jonka ajatellaan johtuvan enemmän keuhkorakkuloiden kehityshäiriöstä kuin hoitojen aiheuttamasta keuhkovauriosta. Selvitimme, miten nykyaikaisilla menetelmillä hoidettujen keskosten keuhkojen rakenne ja toiminta kehittyvät kouluikään mennessä. Seurantatutkimukseemme osallistui 88 ennenaikaisena syntynyttä, kouluikään ehtinyttä lasta ja 88 täysiaikaisena syntynyttä, kaltaistettua verrokkia. Keskosena syntyneiden lasten keuhkofunktio oli kouluiässä huonompi kuin täysiaikaisena syntyneiden verrokkien. Alhaisin keuhkofunktio oli niillä keskosena syntyneillä lapsilla, jotka olivat sairastaneet vastasyntyneenä BPD:n. Myös kohdunsisäiseen kasvuhäiriöön (intrauterine growth restriction, IUGR) liittyi alentunut keuhkofunktio. BPD ja IUGR ennustivat alentunutta keuhkofunktiota toisistaan riippumatta. Tutkimuksessa tehtiin myös keuhkojen ohutleiketietokonekuvaus 21 keskoselle, jotka olivat sairastaneet BPD:n. Lähes kaikilla havaittiin poikkeavia löydöksiä – eniten niillä, joilla oli ollut vastasyntyneenä BPD:n vaikea tautimuoto. Keskosina syntyneet joutuivat kahden ensimmäisen vuoden aikana verrokkeja useammin sairaalahoitoon. Yleisimpiä syitä olivat hengityksen vinkumista aiheuttavat taudit kuten ilmatiehyttulehdus, ahtauttava keuhkoputkitulehdus tai akuutti astmakohtaus. Vastasyntyneenä sairastettu BPD ei kuitenkaan lisännyt todennäköisyyttä joutua sairaalahoitoon. Tutkimuksessa tehtiin myös meta-analyysi nykyaikaisilla menetelmillä hoidettujen keskosten keuhkofunktiosta: lievää BPD:tä sairastavien tulokset näyttävät parantuneen, kun taas keskivaikeaa tai vaikeaa tautimuotoa sairastavien ja ilman BPD:tä selvinneiden keuhkofunktio ei ole muuttunut uusien hoitojen myötä. Yhteenvetona voidaan todeta, että keskosten keuhkojen toimintakyky on jonkin verran alentunut täysiaikaisiin verrattuna. Lievästi alentunut keuhkofunktio ei kuitenkaan yleensä aiheuttanut koululaisille oireita. Keskosena syntyneiden lasten hengityselinten toimintaa on syytä seurata, sillä niin sanotun uuden BPD:n pitkäaikaisesta ennusteesta ei ole vielä tietoa.