published_or_final_version / Community Medicine / Master / Master of Philosophy

Shared characteristics and predictors of psychological distress are beginning to be identified in research on women seeking genetic testing for BRCA1 and BRCA2 gene mutations. This study further explored patterns of psychological distress for 51 community women waiting to receive such genetic test results. There was no significant relationship between psychological distress and family cancer history, personal cancer history, social support networks, and family environment. Women in this sample tended to rely more on females and relatives for support than males and friends. Social support satisfaction was not related to gender or number of relatives providing support. Thirty-four of the 36 women classified on the family environment type were from Personal Growth-Oriented families. Comparisons with normal and distressed family means revealed increased cohesion and expressiveness with decreased conflict, indicative of supportive family environments. Limitations and implications are discussed.

Background. In average hypertensive patients m China, approximately 3-4 major cardiovascular disease (CVD) events can be prevented in 100 treated with anti-hypertensive drugs for 5 years. Previous cross-sectional studies in healthy individuals showed that their willingness to payout of pocket for anti-hypertensive drugs dropped substantively after they were informed of the quantitative benefits, harms and costs of the treatment. These findings suggest, importantly, that patients should be provided with evidence and engaged in decision making for such conditions as hypertension in order to make decisions that will satisfy patients. This large effect of evidence-informed decision making found in the cross-sectional study has, however, not been confirmed in more rigorous studies and in diagnosed hypertensive patients in the country. We therefore conducted this randomized controlled trial to assess the effect of individualized, evidence-based counseling on medicine-using behaviors of hypertensive patients. / Methods. This is a randomized controlled trial with 210 patients with mild hypertension and free of CVD recruited in two primary care centers in Shenzhen, China. Individualized, evidence-based counseling on antihypertensive treatment and general counseling on lifestyle modifications (103 patients) were compared with general counseling alone (107 patients). The counseling was provided face-to-face and reinforced by a telephone call a week later. The key information provided in the intervention group included the lO-year CVD risk estimated based on an individual's risk factors, individualized benefit expressed in the absolute risk reduction, side effects, and costs of antihypertensive drugs. Medication use and good adherence at 6-month follow up were used as the primary outcomes. / Results. At baseline, the mean age of patients was 54.3 (SD=7.8) years, 49% were men, 62.4% were currently taking antihypertensive medicines which was all covered by health insurance. The overall attrition rate was 8.6%. At six months, the rate of medication use was marginally higher in the intervention group than that in the control group (65.0% vs 57.9%; odds ratio (OR) = l.35, 95% confidence interval (Cl): [0.77, 2.36]; P value= 0.290). The rate of good adherence in the intervention group was also slightly higher than that in the control group (43.7% vs 40.2%; OR= 1.15, 95% Cl: [0.67, 2.00]; P value= 0.607). The difference in medication use and good adherence between the intervention and control groups was however not statistically significant. The results remained unchanged in multivariate and sensitivity analyses. / Conclusions. The individualized, evidence-based counseling made little difference to the use of and adherence to anti-hypertensive medications in insured patients with mild hypertension in China. The lack of effect of informed decision making is likely a result of persistence of entrenched practice in particular for insured clinical conditions. The finding of this study raises important questions as to whether insurance policies and clinical guidelines reflect the true needs and opinions of the patients, and about the usefulness of informing and engaging patients in decision-making under such circumstances. / 背景：對100 例一般中國高血壓患者，進行持續5 年的降壓藥物治療，可預防心腦血管事件3-4 例。健康人群中進行的橫斷面調查結果顯示，研究對象在獲得降塵藥物治療量化的收益、副作用和花費的信息後，其支付意願明顯下降。此結果的重要提示是，應向患者提供此類信息，並且患者參與自身的醫療決策，使其能夠做出符合其價值觀等的決定。然而，目前尚未在中國開展相闊的隨機對照試驗。上述知情決策的顯著效果亦尚未在患者中得到證實。在此項隨機對照試驗中，我們蚣評價個體化、循證諮詢對高血壓患者服藥情況的影響。 / 方法：這是一項雙中心的隨機對照試驗。研究共納入輕度高血壓患者210例，這些患者均無心腦血管病。干預組患者(共103 例)接受關於降壓藥物的個體化、循證諮詢和生活習慣調整的一般諮詢，對照組患者(共107 例)僅接受一般諮詢。我們為每組患者均提供當面諮詢，並於一周後通過電話進行加強。為干預組患者提供的主要信息包括:基於每例患者危險因素評估的10 年心血管病風險，降塵藥物治療的收益、副作用及花費。其中收益以絕對風險降低表示。以諮詢結束後六個月時患者服藥和良好依從性作為主要結局指標。 / 結果：基線調查中，患者的平均年齡為54. 3 (標準差為7.8) 歲，有49% 的患者為男性， 62. 峭的患者目前正在服用降塵藥物，所有患者的降塵藥物花費均由醫療保險全部或部分支付。研究中總失訪率為8.6% 。諮詢結束後六個月，干預組患者整體服藥率較對照組患者稍高(干預組65.0% 對照組57.9%比值比:1.35，95%可信區問: [0.77 ，2.36];p=0.290) 。干預組患者中，良好依從性的比例亦稍高於對照組(干預組43.7%，對照組40.2%:比值比:1.15 , 95%可信區問: [0.67，2.00]; p= 0.607)。在多因素分析和敏感性分析中，上述結果均無顯著變化。 / 結論：個體化、循證諮詢並未明顯改變中國醫療保險覆蓋下輕度高血壓患者的服藥情況。知情決策無明顯效果很可能由固定化的醫療實踐導致，這種情況對醫療保險覆蓋的治療尤其突出。此研究的發現還引出了兩個重要問題:現行的醫療保險制度和臨床指南是否反映患者的真實需要和想法，患者知情並參與決策是否必要。 / Di, Mengyang. / Thesis Ph.D. Chinese University of Hong Kong 2015. / Includes bibliographical references (leaves 127-139). / Abstracts also in Chinese; some appendixes in Chinese. / Title from PDF title page (viewed on 06, October, 2016). / Di, Mengyang. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only.

This dissertation layers trauma studies theory with feminist theories of performance and autobiography to investigate how women's autobiographically based performances of illness experience disrupt and/or reinforce master discourses of medicine, identity, and knowledge. Feminist theories of performance and autobiography share with trauma studies the distrust of traditional frames and mechanisms of representation, and seek to discover new methods of interpreting experiences that lie "outside the realm" of normative discourse. These theories are further linked by their shared focus on agency and identity construction and an understanding of autobiography that emphasizes the limitations of language and memory which allows for aporia, contradiction, and dissonance, and the belief that testimony functions as a politicized performative of truth. Employing these theoretical perspectives, Carr investigates how these performances witness to radical reconfigurations of identity through the transference of trauma into conveyable life narrative -- even when those narratives falls outside the paradigm of traditional storytelling structures. Carr questions how the structures and content of these performances reveal what traumas are inflicted not only through illness, but also through treatment and care within the western medical model. Throughout the study Carr examines the moments when the cognitive structures of trauma are transmitted into performance through a variety of feminist and avant-garde performance techniques. Carr investigates the work of specific performers and contextualizes the performances within popular culture and medical discourse. Performances analyzed include; Robbie McCauley's Sugar, Susan Miller's My Left Breast, Brandyn Barbara Artis's Sister Girl, and Deb Margolin's bringing the fishermen home and Three Seconds in the Key. Carr questions how the formerly or currently ill female body performing in public disrupts notions of fixed and stable identity while examining the myriad identity constructions embedded within illness narrative. Rather than simplistic triumphant stories of individual cure and recovery, these complex expressions of traumatic experience reveal patterns of cultural oppression that keep the ill female body isolated and silenced. This study attempts to intervene in that silence by foregrounding these politicized performances.

The abstract on the file is incorrect, use the the one in the system as it summerizes the full text. / This attempted to describe factors contributing to sleep deprivation in the a multidisciplinary intensive care unit in KwaZulu-Natal Province. A quantitative, descriptive research design was adopted and structured interviews were conducted with 34 adult patients. Most factors contributing to these patients' sleep deprivation are basic physiological needs. Much can be done to enhance patients' abilities to sleep if noise (from alarms, monitors, televisions, telephones and footsteps) could be controlled, patients' pain would be managed effectively, doctors would visit the patients regularly, doctors and nurses use lay terms when talking to patients. Visible clocks and windows will help patients to maintain time orientation. Friendly, approachable and respectful nurses who introduce themselves to the patients help' to reduce patients' stress levels and improve their abilities to sleep. / Health Sciences / M.A. (Health Studies)

The focus of this study was on the problem of unwarranted demand for radiological imaging by patients in rural KZN of South Africa. Literature in the context of this topic is scarce. Consequently the aim of this study was to describe sociodemographic factors that might influence patients demand for x-ray examinations. A quantitative in the form of a cross sectional survey was done. A convenient sample of 110 patients was surveyed using a structured questionnaire. Results of the study indicate that age, and educational level might influence patients’ demand for x-ray examinations. The study also revealed that very few respondents 10.9% (n=12) had knowledge about x-rays. The study further revealed that there might be other factors such as patients’ perceived benefits of x-rays, beliefs, lack of public health awareness as well as lack of effective communication between patients and health care providers. / Health Studies / M.A. (Public Health)

Doctorat en sciences psychologiques / info:eu-repo/semantics/nonPublished

D.Litt. et Phil. / This research investigated the effectiveness of the treatment programme used by the South African Recurrent Coronary Prevention Project (SARCPP) in reducing the risk of not only recurrent heart disease, but also of original occurrence of heart disease. Heart disease can often be attributed to lifestyle factors such as obesity, high fat content diets and smoking (Friedman & Ulmer, 1995 and Richards & Baker, 1988). Another lifestyle risk factor of heart disease is Type A behaviour, as first discovered by Rosenman and Friedman (1959). Type A behaviour is made up of various components, such as hostility, time urgency and insecurity. The SARCPP has effectively reduced Type A behaviour in past studies (Venter, 1993; Viljoen, 1993; MacLennan, 1994 and Webster, 1994) and it has been found that reducing Type A behaviour through this programme increases high density lipoproteins and decreases total triglycerides, thus decreasing physiological risk factors of heart disease (Wolff, Thoresen, Viljoen, & Venter, 1994). The SARCPP thus far had only been used with Type A persons who had already suffered a form of heart disease, such as myocardial infarction and angina pectoris (here called "unhealthy" Type As). Other interventions have been used to decrease Type A behaviour in subjects who had not yet suffered heart disease (or "healthy" Type As). A leading researcher in this field is Ethel Roskies (1979-1990). Due to ineffective measurement and ineffective treatment programmes, her attempts were not successful, though. This research study applied the treatment used in the SARCPP to both "healthy" and "unhealthy" Type As and it was found that it was as successful in reducing Type A behaviour in both the "healthy" subjects as in the "unhealthy" subjects. Not only was global Type A behaviour as measured by the Videotaped Structured Interview decreased in the treatment groups, but so were the components of Hostility, Time Urgency and Insecurity (although Insecurity was not decreased in the "unhealthy" subjects). The tendency by the subjects to repress angry feelings was reduced in both "unhealthy" and "healthy" subjects, as was cynical hostility in the "healthy" subjects. It was found that the "unhealthy" subjects had significantly more State and Trait anxiety before the treatment took place than the "healthy" subjects and that the treatment reduced that anxiety in the "unhealthy" subjects significantly. Depression was decreased in both "healthy" and "unhealthy" subjects. Thus, the treatment programme of the SARCPP was effective in reducing coronary-prone behavioural factors and can be used as both prevention in recurrence and prevention in original occurrence of heart disease.

Acute lymphocytic leukemia (ALL) is one of the most common types of pediatric cancers. Improvements in treatment within the last 20 years have resulted in reduced mortality and a greater focus upon quality of life. Several researchers have documented neuropsychological impairments in children following treatment for ALL; however, there have not been any comparative studies documenting differences in neuropsychological functioning based upon treatment modality despite the documented effects of radiation therapy and combined radiation/chemotherapy upon the developing brain. In addition, past studies have focused on unitary measures, ignoring the hierarchical relationship between basic cognitive functions and more abstract skills. This study examined the neuropsychological functioning of 81 children who were treated for ALL at a metropolitan children's hospital. All children were tested a minimum of two years after the final treatment session and were administered the NEPSY. Results do not support any interactions or main effects with the exception of the age of the child at diagnosis. Children diagnosed prior to the age of 5 showed greater impairments on tasks measuring attention, memory, and visuospatial reasoning in comparison to peers diagnosed after age 6.

A forma de tratar os pacientes pode ser ensinada não somente pela teoria e prática formais, mas principalmente pelas atitudes do mestre e pela relação médico paciente que ele estabelece. O principal objetivo deste trabalho é avaliar os efeitos positivos ou deletérios da visita médica em grupo ao leito dos pacientes da Enfermaria da Clínica Médica Geral pois ela pode melhorar ou piorar a ansiedade e a depressão já contidas e instaladas no paciente e testar um modelo de visita médica hospitalar que priorize o paciente enquanto sujeito. Estudaram-se 95 pacientes com idades entre 16 e 65 anos, divididos em três grupos: um com 36 pacientes chamado G0 que passa visita na enfermaria mas não discute à beira do leito; outro com 34 pacientes chamado G1 que passa visita na enfermaria e discute à beira do leito e um novo, experimental, com 25 pacientes chamado G2, com visita na enfermaria e nova forma de discutir ao leito, com participação ativa do paciente em seu processo de recuperação . O Método utilizado foi: todos os pacientes, na véspera da visita, foram submetidos à escala HAD para medir ansiedade e depressão e à parte pré-visita do Questionário de Avaliação da Internação do Paciente da Clínica Médica Geral (QAIPCMG). No dia da visita, após a mesma, reaplicou-se aos três grupos a escala HAD, a parte pós-visita do QAIPCMG , a qual contém um quadro de Sentimentos e Sensações a serem escolhidos como tendo sido sentidos pelos pacientes durante a visita médica, o Teste de Apercepção Temática - TAT, pranchas 1 e 15 e o Questionário Desiderativo. Os critérios de inclusão foram: pacientes com doenças crônicas menores e agudas maiores internados há mais de uma semana e não mais do que duas. Para a análise estatística utilizaram-se os testes: Qui quadrado e Kruskal Wallis. As medidas de ansiedade e depressão da escala HAD pré e pós visita não apresentaram diferenças estatisticamente significantes. O grupo experimental G2, que se apresentou, propôs ao paciente que se sentasse, não usou termos técnicos para discutir o caso, explicou quais eram as medidas propostas para continuar o tratamento, pediu sua autorização para realizar novos exames e procedimentos, olhou e ouviu suas colocações, obteve referências de alegria (p= 0,0009) e tranqüilidade (p= 0,0058) por parte dos pacientes, estatisticamente significantes quando comparados às respostas dos outros dois grupos. O grupo G2 referiu um número maior de aspectos positivos observados na visita médica, (p = 0,0186) se comparados aos grupos G0 e G1. Os testes psicológicos projetivos possibilitaram medir e analisar as capacidades de abstração e elaboração mental de 52% da amostra, apontando que, nos 3 grupos 37,68% dos pacientes, mostrou boa capacidade para elaborar o impacto da internação e da doença, porém 40% apresentou pouca capacidade para conter aspectos negativos de suas personalidades. Conclui-se que, se não se cuidar do que e como se fala, não olhando e ouvindo o paciente, considerando-o como sujeito, a visita médica pode ser iatrogênica. / How to treat patients is something that can be taught not merely by theory and formal practices, but mainly through the teacher’s attitudes and how the physician-patient relationship is established. The main goal of this paper is to assess positive or deleterious effects of a group medical visit to patients’ bedsides at Internal Medicine Infirmary, as visits can improve or worsen anxiety and depression already existing in patients and test a model for hospital medical visits which allocates priority to patients as subjects. 95 patients with ages between 16 and 65 were studied, divided into three groups: one with 36 patients called G0, visiting patients with no discussion at the bedside; another with 34 patients called G1, visited in the infirmary with discussions, and a new, experimental group with 25 patients called G2, with infirmary visits and a new mode of discussion by the bedside, with the patient’s active participation in the recovery process. The method used was: the day before the visit, all patients underwent the HAD scale to measure anxiety and depression and the pre-visit part of the Questionnaire to Assess Hospitalization. On the day of the visit, after the call, the HAD scale was once again applied to the three groups, and the after visit part of the Questionnaire, using the chart on Feelings and Sensations that are selected to reflect patients feelings during the visit, the Theme Apperception Test - TAT, diagrams 1 and 15 and the Desiderative Questionnaire. Inclusion criteria included: patients with minor or greater chronic diseases extending for more than a week, not exceeding two weeks. The following tests were used for statistical analysis: chi square and Kruskal Wallis. The HAD scale measurements of anxiety and depression before and after the visits did not present significant statistical differences. The G2 experimental group introduced itself and proposed to the patient that he/she sit, avoided using technical terms to discuss the case, explained the measures being set forth to continue treatment and requested authorization to carry out new tests and procedures, heard the patient’s comments, obtained references on happiness (p= 0,0009) and calmness (p= 0,0058) expressed by patients that were statistically significant when compared to the responses of the other two groups. Group G2 referred to a greater number of positive aspects observed in the medical visits, (p = 0,0186) when compared to groups G0 and G1. The projective psychological enabled the measurement and analysis of the capacity for abstraction and mental elaboration of 52% of the sample, demonstrating that in the 3 groups, 37,68% of the patients had a good ability to elaborate on the impact of hospitalization and the disease, whilst 40% had little capacity when it came to containing or controlling negative aspects in their personalities. The conclusion therefore is that if no caution is taken on how to speak to patients, if physicians do not look at and listen to patients, considering them as subjects, medical visits may be iatrogenic.