The science of psychotherapy is reliant on various research designs to provide evidence for and bolster the efficacy of therapeutic interventions, techniques, and packages. Among the therapeutic orientations with ample evidence of support is Acceptance and Commitment Therapy (ACT; Hayes et al., 1999). The creators of ACT propose targeting psychological flexibility, broadly defined as engaging with personal values with no regard of the presence of unwanted and undesired experiences. The Life Skills Modules protocol was developed to provide graduate student trainees with a simple and accessible tool to provide effective ACT treatment clients from the local community seeking treatment at the Southern Illinois University Clinical Center. The results of the study indicates that the clients improved in psychological flexibility, inflexibility, and symptoms of anxiety and depression, though this improvement is not explained by number of sessions nor completion of the protocol. Additionally, improvement in flexibility and inflexibility accounted for a significant portion of the variance in the improvement in symptoms as well. Flourishing did not improve within the clients. This study, while being marred with significant limitations, supports the ACT model of change of targeting psychological flexibility and inflexibility as being important towards improvement in treatment. The results of the study do not indicate the use of the protocol is the explicit cause of improvement. Discussion of the results and limitations are provided.

Dupuytren's contracture (DC) is a fibromatous disease of the palmar fascia of unknown etiology. The present study was undertaken in order to assess pathophysiological mechanisms and consequences. In a cohort study of 2,375 patients operated for DC at the Department of Hand Surgery, Uppsala there was a male: female ratio of 5.9:1. Women had a higher mean age at first operation than men. One-third of the men and one-quarter of the women required repeated surgery. Early age at first operation was associated with recurrent disease. The risk of cancer was determined in 15,212 patients operated on for DC in Sweden. The overall relative risk was increased by 24%. There was a significantly increased risk for buccal, oesophageal, gastric, lung and pancreatic cancers, which indicates that smoking and alcohol abuse are probable risk factors for DC. Furthermore, there was an increased frequency of fibrosarcoma and malignant fibrous histiocytoma, the cause of which is unexplained The causes of death were evaluated in a national cohort of 16,517 patients operated for DC. There was an overall increased mortality (SMR=1.06), inversely related to age and significant for both sexes, in patients under 70 years. The risk estimate was highest for endocrine-, gastrointestinal-, and respiratory diseases, and accidents. There was also an increased SMR for cardiovascular diseases in younger patients more than 10 years after surgery. The most probable mechanism is related to smoking and other lifestyle factors. Outcome after surgery was not related to the immunohistochemical expression of connective tissue activation markers, such as collagen type IV, integrin α5, laminin, smooth muscle α-actin, procollagen type I, and desmin, in surgical specimens in a prospectively investigated group of patients. Furthermore, there were no associations between gender, age at onset of DC, number of operations, heredity, diabetes mellitus, or medication for cardiovascular disease, and the expression of the different markers. The individual characteristics that place a person at high risk are, thus, not obviously related to ongoing connective tissue production at time of surgery or to connective tissue activity in its conventionally used sense.

This study addresses the hitherto limited research on sexually abusive children and youths in New Zealand (NZ). It encompasses children (12 years or younger) and youths (13 to 19 years) referred to the three largest specialised community sexual offender treatment programmes in Auckland, Wellington, and Christchurch over a 9½ year period. Additionally, three special populations are considered: female sexually abusive youth, youth with ‘special needs’ and children (12 years and under). To increase our understanding of the individual, offending and family characteristics of these children and youths in specialised community treatment programmes in New Zealand Study One audited client’s clinical files (N = 702). Consistent with international research, New Zealand children and youth who engaged in sexually abusive behaviours not only presented with sexually abusive behaviour(s) but also had other psychological and behavioural issues. These included a history of childhood sexual and physical abuse (38%, n = 263 and 39%, n = 272 respectively), behavioural (63%, n = 442) and mental health problems (65%, n = 457), drug and alcohol misuse (22%, n = 156) and a history of suicide ideation or deliberate self-harm (27%, n = 187). They often had poor social skills (46%, n = 326) and had struggled to establish appropriate peer relationships (44%, n = 306). Many of the children and youth came from multi-problem and chaotic family backgrounds (e.g., 55%, n = 387 of parents were divorced or separated, 38%, n = 267 were exposed to domestic violence and 32%, n = 222 had family member(s) with a substance abuse problem) and had experienced numerous out-of-home placements (57%, n = 389). Factors associated with resiliency were also investigated. It was found that children and youth primarily victimised male and female children (12 years or younger) (70%, n = 1407), who were acquaintances (57%, n = 1295) or relatives (32%, n = 730). Very few victimised strangers (7%, n = 86 of victims were strangers). They engaged in both ‘hands on’ (e.g., penetrative acts) and ‘hands off’ offences (e.g., voyeurism). Study Two was a naturalistic treatment outcome study to explore treatment outcomes and involved 682 sexually abusive children and youth who attended three specialised community treatment programmes in New Zealand. The main outcome of interest was sexual recidivism (prevalence rate of re-offending during the follow-up period) with secondary outcome variables of general and violent recidivism. The follow-up period ranged from 1 year to 10 years (mean 4.5 years, SD = 2.2). Three groups were compared: the ‘Comparison’ group (referral or assessment only, n = 300), ‘Treatment Dropout’ group (those who prematurely terminated their involvement in treatment, n = 165) and the ‘Treatment Completer’ group (those successfully completing treatment, n = 217). To allow for triangulation of offences that were dealt with through the youth and adult justice system’s recidivism data were collected from multiple sources (Child, Youth and Family , Youth Court, and Police criminal charges and convictions data). Post-treatment sexual, general (nonsexual and non-violent) and violent recidivism are reported from each data source as well as overall sexual, general and violent recidivism. Sexual, general and violent re-offending that occurred while the children and youths were attending treatment are also presented. Changes in behavioural problems and the psychological functioning of sexually abusive children and youth between assessment and the end of treatment (as assessed by the Child Behavior Checklist, Youth Self Report and Millon Adolescent Clinical Inventory) contribute additional outcome measures. This naturalistic outcome study found that the treatment programmes were effective in reducing sexual recidivism amongst sexually abusive children and youth who completed treatment compared with those who did not complete treatment. Less than 3% (2.8%, n = 8) of Treatment Completers sexually re-offended compared with 6% (n = 17) of the Comparison group and 10% (n = 16) of the Treatment Dropout group. Treatment Dropouts were found to be at highest risk of sexual, general and violent recidivism. Recidivism for the three special populations (children, females and ‘special needs’ youth) are also presented. The results from the psychological measures indicate a general pattern of reduction in behavioural and psychological problems between assessment and end of treatment. Logistic regression analysis was used in Study Three (N = 682) to explore factors associated with the risk of sexual and nonsexual (violent and general offending) re-offending post-treatment and dropping out of treatment. The factor predictive of sexual recidivism risk was having three or more victims and was associated with a decreased risk of sexual recidivism. Older age at first known sexual offence was associated with increased chance of nonsexual recidivism. Dropping out of treatment and having a history of nonsexual offending were associated with a decreased risk of nonsexual recidivism. Older age at referral and having no external mandate to attend treatment were associated with increased risk of youth dropping out of treatment. A history of mental health problems was associated with a decreased risk of treatment dropout. Conclusions This is the first study of the characteristics and treatment outcomes of sexually abusive children and youth in New Zealand. Its strengths include the large sample size, length of the follow-up period, use of a comparison group and data triangulation to determine recidivism. This study, therefore, compares favourably with international studies. This research enhances understanding of the individual, family and offending characteristics of sexually abusive youth in New Zealand as well as children, females and special needs youth. The Cognitive Behavioural Theory (CBT) based approach of the community programmes in New Zealand was found to be effective in reducing recidivism amongst children and youths who completed treatment. Specific recommendations relevant to treatment programmes and statutory agencies around programme development, referral processes and identification of sexually abusive children and youth are made. Directions for future research are also discussed. These include research exploring outcomes, other than recidivism, for those attending the Maori programmes, possible exploration of typologies within New Zealand sexually abusive children and youth, and subsequent follow-up research. / University of Auckland Doctoral Scholarship

This study addresses the hitherto limited research on sexually abusive children and youths in New Zealand (NZ). It encompasses children (12 years or younger) and youths (13 to 19 years) referred to the three largest specialised community sexual offender treatment programmes in Auckland, Wellington, and Christchurch over a 9½ year period. Additionally, three special populations are considered: female sexually abusive youth, youth with ‘special needs’ and children (12 years and under). To increase our understanding of the individual, offending and family characteristics of these children and youths in specialised community treatment programmes in New Zealand Study One audited client’s clinical files (N = 702). Consistent with international research, New Zealand children and youth who engaged in sexually abusive behaviours not only presented with sexually abusive behaviour(s) but also had other psychological and behavioural issues. These included a history of childhood sexual and physical abuse (38%, n = 263 and 39%, n = 272 respectively), behavioural (63%, n = 442) and mental health problems (65%, n = 457), drug and alcohol misuse (22%, n = 156) and a history of suicide ideation or deliberate self-harm (27%, n = 187). They often had poor social skills (46%, n = 326) and had struggled to establish appropriate peer relationships (44%, n = 306). Many of the children and youth came from multi-problem and chaotic family backgrounds (e.g., 55%, n = 387 of parents were divorced or separated, 38%, n = 267 were exposed to domestic violence and 32%, n = 222 had family member(s) with a substance abuse problem) and had experienced numerous out-of-home placements (57%, n = 389). Factors associated with resiliency were also investigated. It was found that children and youth primarily victimised male and female children (12 years or younger) (70%, n = 1407), who were acquaintances (57%, n = 1295) or relatives (32%, n = 730). Very few victimised strangers (7%, n = 86 of victims were strangers). They engaged in both ‘hands on’ (e.g., penetrative acts) and ‘hands off’ offences (e.g., voyeurism). Study Two was a naturalistic treatment outcome study to explore treatment outcomes and involved 682 sexually abusive children and youth who attended three specialised community treatment programmes in New Zealand. The main outcome of interest was sexual recidivism (prevalence rate of re-offending during the follow-up period) with secondary outcome variables of general and violent recidivism. The follow-up period ranged from 1 year to 10 years (mean 4.5 years, SD = 2.2). Three groups were compared: the ‘Comparison’ group (referral or assessment only, n = 300), ‘Treatment Dropout’ group (those who prematurely terminated their involvement in treatment, n = 165) and the ‘Treatment Completer’ group (those successfully completing treatment, n = 217). To allow for triangulation of offences that were dealt with through the youth and adult justice system’s recidivism data were collected from multiple sources (Child, Youth and Family , Youth Court, and Police criminal charges and convictions data). Post-treatment sexual, general (nonsexual and non-violent) and violent recidivism are reported from each data source as well as overall sexual, general and violent recidivism. Sexual, general and violent re-offending that occurred while the children and youths were attending treatment are also presented. Changes in behavioural problems and the psychological functioning of sexually abusive children and youth between assessment and the end of treatment (as assessed by the Child Behavior Checklist, Youth Self Report and Millon Adolescent Clinical Inventory) contribute additional outcome measures. This naturalistic outcome study found that the treatment programmes were effective in reducing sexual recidivism amongst sexually abusive children and youth who completed treatment compared with those who did not complete treatment. Less than 3% (2.8%, n = 8) of Treatment Completers sexually re-offended compared with 6% (n = 17) of the Comparison group and 10% (n = 16) of the Treatment Dropout group. Treatment Dropouts were found to be at highest risk of sexual, general and violent recidivism. Recidivism for the three special populations (children, females and ‘special needs’ youth) are also presented. The results from the psychological measures indicate a general pattern of reduction in behavioural and psychological problems between assessment and end of treatment. Logistic regression analysis was used in Study Three (N = 682) to explore factors associated with the risk of sexual and nonsexual (violent and general offending) re-offending post-treatment and dropping out of treatment. The factor predictive of sexual recidivism risk was having three or more victims and was associated with a decreased risk of sexual recidivism. Older age at first known sexual offence was associated with increased chance of nonsexual recidivism. Dropping out of treatment and having a history of nonsexual offending were associated with a decreased risk of nonsexual recidivism. Older age at referral and having no external mandate to attend treatment were associated with increased risk of youth dropping out of treatment. A history of mental health problems was associated with a decreased risk of treatment dropout. Conclusions This is the first study of the characteristics and treatment outcomes of sexually abusive children and youth in New Zealand. Its strengths include the large sample size, length of the follow-up period, use of a comparison group and data triangulation to determine recidivism. This study, therefore, compares favourably with international studies. This research enhances understanding of the individual, family and offending characteristics of sexually abusive youth in New Zealand as well as children, females and special needs youth. The Cognitive Behavioural Theory (CBT) based approach of the community programmes in New Zealand was found to be effective in reducing recidivism amongst children and youths who completed treatment. Specific recommendations relevant to treatment programmes and statutory agencies around programme development, referral processes and identification of sexually abusive children and youth are made. Directions for future research are also discussed. These include research exploring outcomes, other than recidivism, for those attending the Maori programmes, possible exploration of typologies within New Zealand sexually abusive children and youth, and subsequent follow-up research. / University of Auckland Doctoral Scholarship

This study addresses the hitherto limited research on sexually abusive children and youths in New Zealand (NZ). It encompasses children (12 years or younger) and youths (13 to 19 years) referred to the three largest specialised community sexual offender treatment programmes in Auckland, Wellington, and Christchurch over a 9½ year period. Additionally, three special populations are considered: female sexually abusive youth, youth with ‘special needs’ and children (12 years and under). To increase our understanding of the individual, offending and family characteristics of these children and youths in specialised community treatment programmes in New Zealand Study One audited client’s clinical files (N = 702). Consistent with international research, New Zealand children and youth who engaged in sexually abusive behaviours not only presented with sexually abusive behaviour(s) but also had other psychological and behavioural issues. These included a history of childhood sexual and physical abuse (38%, n = 263 and 39%, n = 272 respectively), behavioural (63%, n = 442) and mental health problems (65%, n = 457), drug and alcohol misuse (22%, n = 156) and a history of suicide ideation or deliberate self-harm (27%, n = 187). They often had poor social skills (46%, n = 326) and had struggled to establish appropriate peer relationships (44%, n = 306). Many of the children and youth came from multi-problem and chaotic family backgrounds (e.g., 55%, n = 387 of parents were divorced or separated, 38%, n = 267 were exposed to domestic violence and 32%, n = 222 had family member(s) with a substance abuse problem) and had experienced numerous out-of-home placements (57%, n = 389). Factors associated with resiliency were also investigated. It was found that children and youth primarily victimised male and female children (12 years or younger) (70%, n = 1407), who were acquaintances (57%, n = 1295) or relatives (32%, n = 730). Very few victimised strangers (7%, n = 86 of victims were strangers). They engaged in both ‘hands on’ (e.g., penetrative acts) and ‘hands off’ offences (e.g., voyeurism). Study Two was a naturalistic treatment outcome study to explore treatment outcomes and involved 682 sexually abusive children and youth who attended three specialised community treatment programmes in New Zealand. The main outcome of interest was sexual recidivism (prevalence rate of re-offending during the follow-up period) with secondary outcome variables of general and violent recidivism. The follow-up period ranged from 1 year to 10 years (mean 4.5 years, SD = 2.2). Three groups were compared: the ‘Comparison’ group (referral or assessment only, n = 300), ‘Treatment Dropout’ group (those who prematurely terminated their involvement in treatment, n = 165) and the ‘Treatment Completer’ group (those successfully completing treatment, n = 217). To allow for triangulation of offences that were dealt with through the youth and adult justice system’s recidivism data were collected from multiple sources (Child, Youth and Family , Youth Court, and Police criminal charges and convictions data). Post-treatment sexual, general (nonsexual and non-violent) and violent recidivism are reported from each data source as well as overall sexual, general and violent recidivism. Sexual, general and violent re-offending that occurred while the children and youths were attending treatment are also presented. Changes in behavioural problems and the psychological functioning of sexually abusive children and youth between assessment and the end of treatment (as assessed by the Child Behavior Checklist, Youth Self Report and Millon Adolescent Clinical Inventory) contribute additional outcome measures. This naturalistic outcome study found that the treatment programmes were effective in reducing sexual recidivism amongst sexually abusive children and youth who completed treatment compared with those who did not complete treatment. Less than 3% (2.8%, n = 8) of Treatment Completers sexually re-offended compared with 6% (n = 17) of the Comparison group and 10% (n = 16) of the Treatment Dropout group. Treatment Dropouts were found to be at highest risk of sexual, general and violent recidivism. Recidivism for the three special populations (children, females and ‘special needs’ youth) are also presented. The results from the psychological measures indicate a general pattern of reduction in behavioural and psychological problems between assessment and end of treatment. Logistic regression analysis was used in Study Three (N = 682) to explore factors associated with the risk of sexual and nonsexual (violent and general offending) re-offending post-treatment and dropping out of treatment. The factor predictive of sexual recidivism risk was having three or more victims and was associated with a decreased risk of sexual recidivism. Older age at first known sexual offence was associated with increased chance of nonsexual recidivism. Dropping out of treatment and having a history of nonsexual offending were associated with a decreased risk of nonsexual recidivism. Older age at referral and having no external mandate to attend treatment were associated with increased risk of youth dropping out of treatment. A history of mental health problems was associated with a decreased risk of treatment dropout. Conclusions This is the first study of the characteristics and treatment outcomes of sexually abusive children and youth in New Zealand. Its strengths include the large sample size, length of the follow-up period, use of a comparison group and data triangulation to determine recidivism. This study, therefore, compares favourably with international studies. This research enhances understanding of the individual, family and offending characteristics of sexually abusive youth in New Zealand as well as children, females and special needs youth. The Cognitive Behavioural Theory (CBT) based approach of the community programmes in New Zealand was found to be effective in reducing recidivism amongst children and youths who completed treatment. Specific recommendations relevant to treatment programmes and statutory agencies around programme development, referral processes and identification of sexually abusive children and youth are made. Directions for future research are also discussed. These include research exploring outcomes, other than recidivism, for those attending the Maori programmes, possible exploration of typologies within New Zealand sexually abusive children and youth, and subsequent follow-up research. / University of Auckland Doctoral Scholarship

This study addresses the hitherto limited research on sexually abusive children and youths in New Zealand (NZ). It encompasses children (12 years or younger) and youths (13 to 19 years) referred to the three largest specialised community sexual offender treatment programmes in Auckland, Wellington, and Christchurch over a 9½ year period. Additionally, three special populations are considered: female sexually abusive youth, youth with ‘special needs’ and children (12 years and under). To increase our understanding of the individual, offending and family characteristics of these children and youths in specialised community treatment programmes in New Zealand Study One audited client’s clinical files (N = 702). Consistent with international research, New Zealand children and youth who engaged in sexually abusive behaviours not only presented with sexually abusive behaviour(s) but also had other psychological and behavioural issues. These included a history of childhood sexual and physical abuse (38%, n = 263 and 39%, n = 272 respectively), behavioural (63%, n = 442) and mental health problems (65%, n = 457), drug and alcohol misuse (22%, n = 156) and a history of suicide ideation or deliberate self-harm (27%, n = 187). They often had poor social skills (46%, n = 326) and had struggled to establish appropriate peer relationships (44%, n = 306). Many of the children and youth came from multi-problem and chaotic family backgrounds (e.g., 55%, n = 387 of parents were divorced or separated, 38%, n = 267 were exposed to domestic violence and 32%, n = 222 had family member(s) with a substance abuse problem) and had experienced numerous out-of-home placements (57%, n = 389). Factors associated with resiliency were also investigated. It was found that children and youth primarily victimised male and female children (12 years or younger) (70%, n = 1407), who were acquaintances (57%, n = 1295) or relatives (32%, n = 730). Very few victimised strangers (7%, n = 86 of victims were strangers). They engaged in both ‘hands on’ (e.g., penetrative acts) and ‘hands off’ offences (e.g., voyeurism). Study Two was a naturalistic treatment outcome study to explore treatment outcomes and involved 682 sexually abusive children and youth who attended three specialised community treatment programmes in New Zealand. The main outcome of interest was sexual recidivism (prevalence rate of re-offending during the follow-up period) with secondary outcome variables of general and violent recidivism. The follow-up period ranged from 1 year to 10 years (mean 4.5 years, SD = 2.2). Three groups were compared: the ‘Comparison’ group (referral or assessment only, n = 300), ‘Treatment Dropout’ group (those who prematurely terminated their involvement in treatment, n = 165) and the ‘Treatment Completer’ group (those successfully completing treatment, n = 217). To allow for triangulation of offences that were dealt with through the youth and adult justice system’s recidivism data were collected from multiple sources (Child, Youth and Family , Youth Court, and Police criminal charges and convictions data). Post-treatment sexual, general (nonsexual and non-violent) and violent recidivism are reported from each data source as well as overall sexual, general and violent recidivism. Sexual, general and violent re-offending that occurred while the children and youths were attending treatment are also presented. Changes in behavioural problems and the psychological functioning of sexually abusive children and youth between assessment and the end of treatment (as assessed by the Child Behavior Checklist, Youth Self Report and Millon Adolescent Clinical Inventory) contribute additional outcome measures. This naturalistic outcome study found that the treatment programmes were effective in reducing sexual recidivism amongst sexually abusive children and youth who completed treatment compared with those who did not complete treatment. Less than 3% (2.8%, n = 8) of Treatment Completers sexually re-offended compared with 6% (n = 17) of the Comparison group and 10% (n = 16) of the Treatment Dropout group. Treatment Dropouts were found to be at highest risk of sexual, general and violent recidivism. Recidivism for the three special populations (children, females and ‘special needs’ youth) are also presented. The results from the psychological measures indicate a general pattern of reduction in behavioural and psychological problems between assessment and end of treatment. Logistic regression analysis was used in Study Three (N = 682) to explore factors associated with the risk of sexual and nonsexual (violent and general offending) re-offending post-treatment and dropping out of treatment. The factor predictive of sexual recidivism risk was having three or more victims and was associated with a decreased risk of sexual recidivism. Older age at first known sexual offence was associated with increased chance of nonsexual recidivism. Dropping out of treatment and having a history of nonsexual offending were associated with a decreased risk of nonsexual recidivism. Older age at referral and having no external mandate to attend treatment were associated with increased risk of youth dropping out of treatment. A history of mental health problems was associated with a decreased risk of treatment dropout. Conclusions This is the first study of the characteristics and treatment outcomes of sexually abusive children and youth in New Zealand. Its strengths include the large sample size, length of the follow-up period, use of a comparison group and data triangulation to determine recidivism. This study, therefore, compares favourably with international studies. This research enhances understanding of the individual, family and offending characteristics of sexually abusive youth in New Zealand as well as children, females and special needs youth. The Cognitive Behavioural Theory (CBT) based approach of the community programmes in New Zealand was found to be effective in reducing recidivism amongst children and youths who completed treatment. Specific recommendations relevant to treatment programmes and statutory agencies around programme development, referral processes and identification of sexually abusive children and youth are made. Directions for future research are also discussed. These include research exploring outcomes, other than recidivism, for those attending the Maori programmes, possible exploration of typologies within New Zealand sexually abusive children and youth, and subsequent follow-up research. / University of Auckland Doctoral Scholarship

No description available.

No description available.

La presente Tesis Doctoral sigue el formato por compendio de publicaciones, en la que se han incluido cuatro artículos, tres de ellos publicados en revistas de alto factor de impacto Journal Citations Report; JCR Q1, y un artículo en proceso de revisión en una revista también de alto factor de impacto JCR Q1. La transmisión del Virus de la Inmunodeficiencia Humana (VIH) sigue siendo un problema de salud pública. En los últimos años se ha visto incrementado el porcentaje de nuevos casos de personas infectadas por este virus, llegando a desarrollar el Síndrome de Inmunodeficencia adquirida (SIDA), lo que conlleva una disminución de la Calidad de Vida Relacionada con la Salud (CVRS) de aquellas personas que lo padecen. Dicho aumento en la transmisión de este virus se ha visto incrementado en mayor medida entre la población joven, por lo que es de gran relevancia indagar e identificar aquellos factores de riesgo que propician la adquisición del VIH en este colectivo. Es por todo ello, que la presente tesis doctoral se dirige al estudio de los factores de riesgo y protección relacionados con variables biopsicosociales y del estilo de vida para el contagio del VIH, así como en la evaluación y asociación del estilo de vida con la Calidad de Vida Relacionada con la Salud en población que convive con la infección por VIH. Para ello, en el primer estudio se contó con una muestra de 335 estudiantes universitarios españoles y se evaluaron factores sociodemográficos, estilos de vida y variables de riesgo de transmisión del VIH. Se establecieron diferencias respecto a las características sociodemográficas (edad, sexo, estado civil, situación laboral, situación económica y orientación sexual) y estilo de vida (dieta, ejercicio físico, tabaquismo, consumo de alcohol y estrés). Los resultados obtenidos indicaron que, en general, ser mayor, estar en pareja y estar empleado son factores relacionados con un alto riesgo de transmisión del VIH. En cuanto al estilo de vida, la mala alimentación, una menor intensidad en la práctica de ejercicio físico, la mayor ingesta de alcohol y el tabaquismo se asociaron significativamente con un mayor riesgo de transmisión del VIH, a través de un menor uso del preservativo y una mayor frecuencia de conductas sexuales de riesgo. En este sentido, los participantes que desarrollan un estilo de vida poco saludable tienen el doble de probabilidad de tener un alto riesgo de transmisión del VIH, especialmente con respecto a estos comportamientos previamente indicados. Con el objetivo de analizar en mayor profundidad la relación entre los estilos de vida y el riesgo de transmisión de VIH, en el segundo estudio se analizó la relación entre la adherencia al Estilo de Vida Mediterráneo (EVM), caracterizado por establecer una adherencia a la dieta mediterránea, un alto nivel de socialización y comunicación durante el cocinado o consumo de los alimentos, realización de actividad física regular y buena calidad del sueño, con el funcionamiento y conductas de riesgo para la salud asociadas a la transmisión del VIH. Para ello, se evaluó la asociación entre la adherencia al EVM con el funcionamiento cognitivo, principalmente síntomas prefrontales, y conductas de riesgo para la transmisión del VIH. La muestra estuvo compuesta por 328 estudiantes universitarios españoles con un rango de edad entre 18 y 30 años. Los resultados obtenidos mostraron una asociación significativa entre el EVM, los síntomas prefrontales y conductas de riesgo para el contagio de VIH. Los participantes con una alta adherencia al EVM mostraron un menor riesgo de contagio de VIH, ya que presentaron más información sobre el virus, conductas sexuales más seguras y una mayor frecuencia de uso de del preservativo. Los síntomas prefrontales en el dominio ejecutivo mediaron la relación entre EVM y las actitudes y la autoeficacia hacia el uso del preservativo. De esta manera, una mayor adherencia al EVM se relacionó con un menor número de síntomas prefrontales, y, por tanto, con una mayor autoeficacia y actitud positiva hacia el uso del preservativo. Una vez analizada la influencia de los estilos de vida sobre el riesgo de transmisión del VIH en población general, se hacía necesario analizar los estilos de vida en población con VIH, y de la misma manera, analizar la relación de estas variables con el riesgo de transmisión del virus y con el estado de salud. Dada que la transmisión del VIH ha aumentado y con ella, el número de personas infectadas, es importante evaluar aquellos factores del estilo de vida, fundamentalmente relacionados con las prácticas sexuales, y su relación con la CVRS en este grupo de población. Tras la realización de una exhaustiva revisión bibliográfica, se encontró que el cuestionario Medical Outcome Study - HIV Health Survey (MOS-HIV) es uno de los instrumentos más utilizados para la evaluación de la CVRS en personas que viven con el VIH, tanto en contextos clínicos como en estudios de investigación. Por ello, en el tercer estudio de esta tesis doctoral, se estimó la fiabilidad promedio de las puntuaciones del cuestionario MOS-HIV y se evaluaron las características de los estudios que podrían explicar la variabilidad entre las estimaciones de fiabilidad. Además, se estimó la tasa de inducción de la fiabilidad del MOS-HIV. Para ello, se realizó una revisión sistemática de la literatura previa, que incluyó estudios que informaron de coeficientes α y/o test-retest con los datos disponibles para la puntuación total del MOS-HIV y sus diferentes subescalas. Se incluyeron 50 estudios (N= 14.132) en el metanálisis de generalización de la fiabilidad. El coeficiente α promedio para la puntuación total de MOS-HIV fue de .91 y superior a .80 para todas las subescalas, excepto para el RF (funcionamiento de rol), que obtuvo un coeficiente de fiabilidad promedio de .76. Además, se encontró que la inducción de fiabilidad en los diferentes estudios analizados era del 76,1%. Los resultados obtenidos en el presente estudio indicaron que el MOS-HIV es un instrumento fiable para la evaluación de la CVRS en personas que conviven con el VIH, con fines clínicos y de investigación. Una vez que se identificó que el cuestionario MOS-HIV es un instrumento válido y fiables para la evaluación de la CVRS en población con VIH, el cuarto estudio se dirigió a analizar los efectos de los estilos de vida, fundamentalmente relacionados con las prácticas sexuales, sobre la CVRS en población con VIH. En este sentido, en los últimos años no solamente ha aumentado la transmisión de VIH, sino que también han aparecido nuevas prácticas sexuales que favorecen dicha transmisión. Una de estas nuevas prácticas es el Chemsex, es decir, un nuevo comportamiento sexual de riesgo que implica la participación en relaciones sexuales bajo la influencia del efecto de diferentes drogas. Estas nuevas prácticas sexuales de riesgo han mostrado un aumento significativo durante los últimos años, lo que conlleva un grave problema de salud pública, especialmente cuando el Chemsex es practicado por personas con un diagnóstico de VIH. Por ello, se analizaron las características de las prácticas de Chemsex, las prácticas sexuales asociadas y los resultados de salud en una muestra de 101 hombres con VIH que tienen sexo con hombres que acudían al Servicio de Enfermedades Infecciosas del Hospital General Universitario de Alicante (España). Además, también se analizó la asociación entre la práctica de Chemsex y la CVRS. El Chemsex y las prácticas sexuales se evaluaron empleando un cuestionario aplicado ad hoc. La CVRS se evaluó mediante el cuestionario MOS-HIV. En total, el 40,6% de los participantes había practicado Chemsex durante el último año. Cuando se compararon las prácticas sexuales entre los individuos que practicaban Chemsex y los que no, los primeros presentaron un mayor nivel de conductas sexuales de riesgo, especialmente con parejas sexuales ocasionales y múltiples. En cuanto a la CVRS, aquellos individuos que practicaron Chemsex presentaron una peor CVRS en la mayoría de los dominios, especialmente aquellos participantes que lo practicaban con mayor intensidad. La presente Tesis Doctoral aporta información relevante acerca del VIH, su transmisión y su afectación sobre la CVRS en las personas que lo presentan. Se destaca la relevancia de las características sociodemográficas y los estilos de vida en la propensión a desarrollar conductas de riesgo para la infección por VIH, así como la importancia del estilo de vida mediterráneo en la prevención de estas conductas de riesgo, especialmente a través de un adecuado funcionamiento cognitivo. Además, se ha identificado al cuestionario MOS-HIV como “gold estándar” para la evaluación de la CVRS en personas con VIH. Finalmente, se destaca la alta prevalencia de la práctica de Chemsex entre hombres con VIH que tienen sexo con hombres en España y se especifican los efectos negativos que tienen estas prácticas sobre la CVRS, probablemente debido a los efectos mixtos de niveles más altos de conductas sexuales de riesgo y las consecuencias del consumo de drogas.

La méthodologie de l’évaluation en psychothérapie s’est longtemps limitée aux résultats issus d’essais cliniques comparatifs de groupes. L’objectif, engagé dans les années 2000, de comprendre ce qui cause son efficacité a engagé un renouvellement méthodologique. Son application concrète est peu documentée. La première partie présente, à partir d’une revue de la littérature centrée sur l’introduction de la recherche sur le processus associée aux résultats, comment le paradigme interactionnel multifactoriel de la psychothérapie a stimulé le développement de méthodes adaptées à la complexité et à l’observation en conditions naturelles. La seconde partie introduit autour de cinq axes principaux les questions méthodologiques générales et spécifiques de cette nouvelle orientation : 1. une épistémologie interactionnelle et transactionnelle ; 2. Un recentrage sur les études mixtes intensives de cas ; 3. Une investigation clinique et théorique multifocale des processus et mécanismes de changement ; 4. une forte relation clinicien-chercheur ; 5. une approche statistique innovante. La troisième partie expose l’expérience et les questions soulevées par la mise en œuvre de ce programme dans le cadre d’un réseau de recherche clinique centré sur les pratiques, du recueil des données jusqu’à l’analyse des processus et mécanismes de changement, et les résultats qui en sont issus. La quatrième partie présente une revue détaillée de la littérature. Ce travail devrait favoriser les collaborations avec les disciplines connexes et l’efficience des traitements par une meilleure connaissance des conditions et des mécanismes de changement associée au développement d’une base de données issue d’études de cas. / The methodology of assessment in psychotherapy has long been limited to results from comparative group clinical trials. The objective, expressed in the 2000s, to understand what is causing its effectiveness has involved a methodological renewal. Its concrete application is poorly documented. The first part presents, from a review of the literature focusing on the introduction of research on the process associated with outcomes, how the multifactorial interactional paradigm of psychotherapy has stimulated the development of methods adapted to the complexity and observation in natural conditions. The second part introduces the general and specific methodological questions of this new orientation around five main axes: 1. an interactional and transactional epistemology; 2. A refocusing on intensive mixed case studies; 3. A multifocal clinical and theoretical investigation of the processes and mechanisms of change; 4. a strong clinical-researcher relationship; 5. an innovative statistical approach. The third part presents the experience and issues raised by the implementation of this program as part of a practice-oriented clinical research network, from data collection to analysis of processes and mechanisms of change, and results. The fourth part presents a detailed review of the literature. This work should foster collaborations with related disciplines and treatment efficiency through a better understanding of the conditions and mechanisms of change associated with the development of a case study database.