This diploma thesis deals with the system of the informal long-term care for people with disabilities in the Czech Republic. The first aim of the diploma thesis is to describe this non-conceptually solved issue and confirm the European prevalent tendencies to refamilization and deinstitutionalization in the Czech Republic. Author tries to identify the main problems within the system of informal long-term care through interviews conducted with informal carers and workers from selected social services. The diploma thesis emphasizes the target population of informal carers, who face many obstacles, whether it is the cooperation between the systems of formal and informal care, lack of finances, deterioration of quality of life or insufficient recognition of the status of informal carers from the society and the state. Informal carers are presented on the basis of theoretical perspectives as well as the results of conducted research as the invisible stakeholders of the Czech public policy.

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Social contact is known to be vital for older adults' mental and physical health, but few studies of social interactions have taken place in long-term care settings. The current study investigated whether the psychological well-being of assisted living residents was influenced by factors associated with residents' social interactions involving humor. Specific aims of the present study were to develop and test a measure related to humor-related social exchanges, to examine how humor-related social exchanges affect residents' mental health, and to explore whether humor-related social exchanges mediated the effects of resident and facility characteristics on indices of mental health. One hundred and forty older adults residing in 14 assisted living facilities in the Portland, Oregon metropolitan area were interviewed about the frequency and types of social interactions they experienced with members of their facility-based social networks, as well as depression, mood, loneliness, self-esteem, and self-rated health. A 12-item, two-factor model of humor-related social exchanges was identified through confirmatory factor analysis, including both positive and negative humor-related social exchange factors. The newly developed scale displayed evidence of adequate reliability and validly in the current sample. Results indicated that both positive and negative humor-related exchanges were associated with various aspects of mental health, although negative humor-related exchanges appeared to be a stronger predictor of mental health than positive humor-related exchanges. Both positive and negative humor-related exchanges also served as mediators between resident and facility characteristics and indicators of mental health. Cultivating a better understanding of the relationships between humor-related social exchanges and mental health may be beneficial for researchers interested in the way humor impacts older adults' ability to cope with stress. This research may also be of value to long-term care providers who create interventions designed at improving residents' mental health and overall quality of life.

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Contexte : Partout dans le monde, la population âgée en hébergement a été la plus lourdement affectée par la pandémie de COVID-19, du point de vue des infections et des décès. Or, ces mêmes personnes ont été exclues d’une grande partie de la littérature scientifique. Ce mémoire décrit l’évolution des éclosions dans 17 CHSLD publics de Montréal, dont certains ont été fortement atteints alors que d’autres ont été épargnés pendant la première vague (23 février au 11 juillet 2020), en cherchant à élucider les facteurs associés à l’incidence et à la létalité de la COVID-19. Méthodes : Des données institutionnelles ont été recueillies sur les 17 CHSLD du CIUSSS Centre-Sud-de-l'Île-de-Montréal et des données individuelles ont été obtenues grâce à une révision des 1197 dossiers de patients atteints de la COVID-19 en première vague. Dans l’analyse ARIMA, des séries chronologiques ont été construites pour les cas incidents bruts chez les résidents en CHSLD et dans la ville de Montréal, afin d’évaluer l’impact de deux interventions, soit le port généralisé du masque de procédure et le dépistage élargi des résidents et des employés. Dans l’analyse des infections par CHSLD, des modèles de régression de type binomial négatif ont été construits pour estimer l’effet des facteurs de risque institutionnels sur l’incidence de la COVID-19 chez les résidents. Dans l’analyse de surmortalité, les excès de décès durant la période de février à juillet ont été évalués avec des tests t et des ratios de taux entre l’année 2020 et la moyenne des quatre années précédentes (2016-2019). Enfin, pour l’analyse de mortalité dans la cohorte rétrospective de résidents atteints de la COVID-19, des modèles de régression logistique à effets mixtes ont été utilisés pour évaluer les facteurs institutionnels et les traitements associés à la mortalité dans les 30 jours suivant un diagnostic de COVID-19, en contrôlant pour les facteurs de risque individuels. Résultats : Dans l’analyse de série chronologique ARIMA, chaque augmentation d’un cas incident quotidien par 100 000 à Montréal était associée avec une augmentation de 0,051 (IC95% 0,044 à 0,058) fois l’incidence quotidienne en CHSLD la semaine suivante, chez les résidents à risque. De plus, en contrôlant pour la transmission communautaire, chaque palier d’intensification du dépistage était associé à une diminution de l’incidence de 11,8 fois (IC95% -15,1 à -8,5) dans les deux semaines suivantes, chez les résidents à risque. Dans le modèle explicatif des infections au niveau des CHSLD, la pénurie sévère d’infirmières auxiliaires (IRR 3,2; IC95% 1,4 à 7,2), la mauvaise performance aux audits ministériels (IRR 3,0; IC95% 1,1 à 7,8) et un score moyen d’autonomie plus faible (IRR 2,1; IC95% 1,4 à 3,1) étaient associés au taux d’incidence par centre. En revanche, la présence de zone chaude dédiée aux patients COVID-19 (IRR; 0,56 IC95% 0,34 à 0,92) était protectrice. Pour l’ensemble des 17 CHSLD avec 2670 lits, l’excès de décès de février à juillet 2020 était de 428 (IC95% 409 à 447). Comparé aux quatre années précédentes, il y a eu plus que le double (IRR 2,3; IC95% 2,1 à 2,5) de décès en 2020 pendant la période de la première vague. Pour 12 CHSLD qui ont vécu des éclosions importantes, les excès de décès en 2020 variaient de 5,2 à 41,9 décès par 100 lits, avec une surmortalité par rapport aux années précédentes allant de 1,9 à 3,8. Selon l’analyse de mortalité dans la cohorte rétrospective, les facteurs individuels associés à la mortalité dans les 30 jours suivant le diagnostic de COVID-19 étaient l’âge (OR 1,58; IC95% 1,35 à 1,85 par tranche additionnelle de 10 ans), le sexe masculin (OR 2,37; IC95% 1,70 à 3,32), la perte d’autonomie (OR 1,12; IC95% 1,05 à 1,20 pour chaque augmentation d’un point à l’Iso-SMAF), le niveau d’intervention médicale C (OR 3,43; IC95% 1,57 à 7,51) et D (OR 3,61; IC95% 1,47 à 8,89) comparé au niveau A, ainsi que les diagnostics de trouble neurocognitif (OR 1,54; IC95% 1,04 à 2,29) et d’insuffisance cardiaque (OR 2,36; IC95% 1,45 à 3,85). Le traitement avec une thromboprophylaxie (OR 0,42; IC95% 0,29 à 0,63) et l’infection tardive après le 20 avril 2020 (OR 0,46; IC95% 0,33 à 0,65) étaient associés à la survie à 30 jours. Pour les facteurs institutionnels, la pénurie sévère de 25% ou plus d’infirmières auxiliaires (OR 1,91; IC95% 1,14 à 3,21 par rapport à une pénurie légère < 15%) et la taille du centre (OR 1,77; IC95% 1,17 à 2,68 pour chaque 100 lits additionnels) étaient associés au décès dans les 30 jours. Conclusion : Ce mémoire a relevé plusieurs facteurs de risque modifiables au niveau institutionnel associés aux infections et aux décès COVID-19, dont le dépistage, l’adhérence aux directives ministérielles de prévention et contrôle des infections, la pénurie d’infirmières auxiliaires et le nombre de lits par centre. Ces enjeux cruciaux devront être au cœur des futures orientations et politiques touchant les centres d’hébergement, pour cette pandémie et au-delà. / Background: In the midst of the COVID-19 pandemic, the population of long-term care residents has been the hardest hit by infections and deaths all around the world. Yet, these same individuals have been excluded from vast segments of the scientific literature. This thesis describes the evolution of outbreaks in 17 public long-term care facilities (“CHSLD”) in Montreal, some of which were severely affected and others were relatively spared during the first wave (February 23 to July 12, 2020), in search of risk factors associated with COVID-19 cases and deaths. Methods: Institutional-level data on the 17 CHSLDs were collected from relevant administrative departments within the establishment (CIUSSS Centre-Sud-de-l'Île-de-Montréal), and individual-level data was obtained from the chart reviews of 1,197 first wave COVID-19 patients. For the ARIMA analysis, time series were built using the crude incidence rates among CHSLD residents and in the city of Montreal, in order to assess the impact of two interventions – introduction of the mask-wearing policy and generalized testing among residents and staff. For the analysis of facility-level infection rates, negative binomial regression models were built to estimate the effects of several institutional risk factors on incident cases. As for the excess mortality analysis, excess death and relative mortality were estimated using one-sample t-tests and rate ratio tests to compare 2020 deaths with average deaths in the previous four years (2016-2019), for the period of February to July. Lastly, for the survival analysis of the retrospective cohort, mixed-effects logistic regression models were used to identify institutional factors and treatments associated with 30-day mortality after a COVID-19 diagnosis, while controlling for individual risk factors. Results: In the ARIMA time series analysis, each additional case per 100,000 per day in Montreal was associated with a 0.051 (95%CI 0.044 to 0.058) increase in CHSLD daily incidence a week later, among at-risk residents. In addition, while controlling for community transmission, increased testing intensity was associated with a 11.8 (95%CI -15.1 to -8.5) decrease in CHSLD daily incidence two weeks later, among at-risk residents. In the negative binomial regression model for facility-level COVID-19 infections, poor performance on ministry audits (IRR 3.0 95%CI 1.1 to 7.8), severe shortage of auxiliary nurses (IRR 3.2 95%CI 1.4 to 7.2) and lower average autonomy scores (IRR 2.1 95%CI 1.4 to 3.1) were associated with incident cases, while the presence of a COVID-19 unit or “red zone” (IRR 0.56 95%CI 0.34 to 0.92) was inversely associated with infections. For the 17 CHSLDs, excess deaths from February to July 2020 was 428 (95%CI 409 to 447). Compared to the same period in the previous four years, 2020 mortality during the first wave was 2.3 (IRR 95%CI 2.1 to 2.5) times higher. For a subset of 12 facilities that experienced substantial outbreaks, excess deaths in 2020 varied from 5.2 to 41.9 deaths per 100 beds, with significant excess mortality between 1.9 and 3.8, relative to previous years. According to the mortality analysis by mixed-effects logistic regression, individual risk factors associated with 30-day mortality after a COVID-19 diagnosis were age (OR 1.58 95%CI 1.35 to 1.85 per additional 10 years), male sex (OR 2.37 95%CI 1.70 to 3.32), loss of autonomy (OR 1.12 95%CI 1.05 to 1.20 per unit increase of Iso-SMAF profile), C-level (OR 3.43 95%CI 1.57 to 7.51) or D-level (OR 3.61 95%CI 1.47 to 8.89) medical intervention compared to A-level, as well as being diagnosed with a neurocognitive disorder (OR 1.54 95%CI 1.04 to 2.29) or congestive heart failure (OR 2.36 95%CI 1.45 to 3.85). Treatment with thromboprophylaxis (OR 0.42 95%CI 0.29 to 0.63) and diagnosis after April 20, 2020 (OR 0.46 95%CI 0.33 to 0.65) were associated with 30-day survival. As for institutional risk factors, severe shortage of auxiliary nurses (OR 1.91 95%CI 1.14 to 3.21) and facility size (OR 1.77 95%CI 1.17 to 2.68 per 100 beds) increased the odds of dying within 30 days. Conclusion: This study identified several modifiable risk factors at the institutional level associated with COVID-19 infections and deaths, including testing strategies, adherence to ministry directives for infection prevention, auxiliary nurse shortages, and number of beds per facility. Future policies and regulations targeting long-term care facilities will need to tackle these critical issues, for this pandemic and beyond.

[pt] O envelhecimento vem provocando mudanças significativas na vida das pessoas. De acordo com as Nações Unidas, o número de indivíduos com mais de 80 anos, no mundo, deve triplicar até 2050. Devem triplicar, também, os casos de demência. A longevidade é uma conquista, mas traz consigo o risco de que um maior número pessoas se mostrem incapazes de se cuidar sozinhas. No Brasil, a Constituição estabelece que o amparo ao idoso deve ser executado, preferencialmente, em seus lares. Todavia, cuidar de um idoso com limitações funcionais é complexo e as famílias nem sempre tem condições de fazê-lo. As Instituições de Longa Permanência para Idosos (ILPIs) podem oferecer o apoio que as famílias necessitam no cuidado de seus idosos. Contudo, enfrentam preconceito social e não estão consolidadas como um serviço capaz de ajudar a sociedade a lidar com os desafios do envelhecimento. Esta dissertação fundamenta-se na abordagem do design para a inovação social, de Ezio Manzini, segundo a qual designers devem criar as condições favoráveis para que pessoas sem conhecimento formal em design desenvolvam, de forma colaborativa, soluções adequadas às suas necessidades. A pesquisa teve como objetivo explorar o campo de possibilidades das ILPIs. Para tanto, ferramentas do design de serviços foram utilizadas para conhecer as ILPIs; identificar as principais demandas da família no cuidado do idoso e os principais desafios dos gestores de ILPIs na gestão do serviço. O estudo mostrou a pertinência e a urgência da contribuição do designer especializado no fortalecimento do serviço das ILPIs, via aplicação de métodos e ferramentas colaborativas junto aos diversos stakeholders deste serviço. / [en] Aging has been causing significant changes in people s lives. According to the United Nations, the number of individuals over 80 in the world is expected to triple by 2050. Dementia cases are also expected to triple. Longevity is an achievement, but it brings along a greater number of people in risk of becoming unable to take care of themselves. In Brazil, the Constitution establishes that support for the elderly must be carried out in their homes preferably. However, caring for an elderly person with functional limitations is complex and families are not always able to do so. Long-term care Institutions (LTCIs) can offer the support that families need to care for their elderly. However, they face social prejudice and are not consolidated as a service capable of helping society to deal with the challenges of aging. This dissertation is based on Ezio Manzini s approach to design for social innovation, according to which designers must create favorable conditions for people without formal design knowledge to develop, in a collaborative way, solutions appropriate to their needs. The research aimed to explore the field of possibilities of LTCIs. Therefore, tools of service design were used to get to know the LTCIs; to identify the main demands of the family in the care of the elderly and the main challenges of the LTCIs managers in service management. The study showed the relevance and the urgency of the contribution of the designer specialized in strengthening the service of ILPIs, through the application of collaborative methods and tools with the various stakeholders of this service.