published_or_final_version / abstract / toc / Clinical Psychology / Master / Master of Social Sciences

L’introduction de la télésanté dans l’offre des soins et services implique des changements et des transformations importants, attendus ou inattendus, de diverses natures, et ce à différents niveaux : sociopolitique, économique, organisationnel, clinique, professionnel, culturel, humain, légal, éthique et technologique. Certains enjeux sensibles associés à la télésanté révèlent le fossé existant entre une vision historique, dite techniciste (ou solutionniste), et les attentes, besoins et contextes des utilisateurs en ce qui a trait à sa vraie utilité et valeur ajoutée pour eux. Il est, en effet, à constater que dans l’histoire de l’évolution de la télésanté, notamment au Québec, les citoyens-patients sont les grands absents des décisions relatives au développement des services, alors que leur implication pourrait constituer un levier important pour éclairer la décision. De plus, il y a un manque important de travaux ayant questionné les conséquences multidimensionnelles et systémiques, attendues ou inattendues, négatives ou positives, de la télésanté sur les individus et groupes (ex. patients, communautés, professionnels), les organisations ainsi que sur les systèmes de santé. Cette thèse, composée de deux volets complémentaires, a pour finalité : 1) d’identifier les conséquences inattendues multidimensionnelles et multiniveaux de dix projets innovants et d’envergure de télésanté qui ont été implantés au Québec ; et 2) d’explorer la possibilité d’impliquer les citoyens-patients dans les décisions relatives au développement des services de télésanté selon la perspective croisée des différentes parties prenantes concernées au Québec. Pour le premier volet, soit l’étude des conséquences inattendues de la télésanté, nous avons effectué une analyse secondaire des données d’évaluation de 10 projets innovants et structurants ayant été implantés au Québec sur une période de 22 ans. Les données ont fait l’objet d’une analyse qualitative thématique en prenant pour assise le modèle des conséquences inattendues des technologies d’information en santé (adapté de Bloomrosen et al., 2011). Pour le deuxième volet, soit l’étude de l’implication des citoyens-patients dans le développement des services de télésanté au Québec, des entrevues semi-dirigées ont été menées auprès de 29 informateurs clés. Une analyse qualitative thématique des données a été effectuée en s’appuyant sur un cadre conceptuel intégrateur dérivé des théories de diffusion des innovations (adapté de Greenhalgh et al., 2004). Le premier volet a permis de constater que la télésanté requiert de nombreux ajustements, changements et négociations, souvent sous-estimés dans les étapes de planification des projets de télésanté. De plus, la télésanté peut être à l’origine de nombreuses conséquences inattendues, positives ou négatives, qui touchent aussi bien les individus, les groupes, les organisations que le système de santé dans sa globalité. Le deuxième volet démontre que l’implication des citoyens-patients dans le développement des services de télésanté se réfère davantage à une idée théorique qu’à une pratique réelle dans les organisations et le système de santé du Québec, ce qui lui confère encore un statut d’innovation pour de nombreux acteurs. Malgré les nombreuses incertitudes et les questionnements qui l’accompagnent, cette perspective est perçue comme pouvant éclairer la prise de décision et aider à implanter des services de télésanté harmonieux et socialement responsables, tout en impulsant l’innovation dans les organisations et le système de santé. Par ailleurs, les résultats ont montré que l’implication des citoyens-patients dans la prise de décision est fortement tributaire de nombreuses conditions organisationnelles et systémiques interdépendantes. Ils ont permis de constater un grand fossé entre le monde de la recherche sur la question et celui de la prise de décision, d’où le besoin d’un transfert soutenu des connaissances pour une meilleure traduction des connaissances dans l’action / The introduction of telehealth in the delivery of healthcare and services involves significant, attended or unintended, changes and transformations of various kinds and at different levels: socio-political, economic, organizational, clinical, professional, cultural, human, legal, ethical and technological. The sensitivity of certain issues associated with telehealth points to the gap between a historical vision, known as a technicist (or solutionist), and the actual expectations, needs and contexts of users with respect to its real usefulness and added value for them. It should indeed be noted that in the history of the evolution of telehealth, especially in Quebec, citizen-patients were the major absentees in decisions relating to the development of the services, whereas their involvement could constitute an important lever to inform decisions. In addition, there is a significant lack of research that has addressing the multidimensional and systemic, attended or unintended, negative or positive, consequences of telehealth on individuals and groups (e.g., patients, communities, and professionals), organizations, and health systems. This thesis, composed of two complementary components, aims to: 1) identify the multidimensional and multilevel unintended consequences of ten innovative and large scale telehealth projects that have been implemented in Quebec; and 2) explore the possibility of involving citizen-patients in decisions concerning the development of telehealth services in the cross-perspective of the different stakeholders concerned in Quebec. We used a predominantly qualitative approach. For the first part, the study of the unintended consequences of telehealth, we conducted a secondary analysis of the evaluation data of 10 innovative and structuring projects having been implemented in Quebec, over a 22-year period. The data were the subject of a thematic qualitative analysis based on the model of the unintended consequences of health information technologies (adapted from Bloomrosen et al., 2011). For the second part, the study of citizenpatient involvement in the development of telehealth services in Quebec, semi-structured interviews were conducted with 29 key informants. A thematic qualitative analysis of the data was carried out based on an integrative conceptual framework derived from the diffusion of innovation theories (adapted from Greenhalgh et al., 2004). The first part found that telehealth requires many adjustments, changes and negotiations, which are often underestimated in the planning stages of telehealth projects. In addition, telehealth could be the source of many unintended consequences, sometimes harmful, that affect individuals and groups, health organizations, and the health system as a whole. The second part helped show that citizen-patient involvement in the development of telehealth services is more of a theoretical idea than a real practice in Quebec's organizations and health system, which places it still at the stage of innovation for many shareholders. It remains that despite the many uncertainties and questions that accompany it, this perspective is seen as potentially informing decision-making and helping to implement harmonious and socially responsible telehealth services, this while driving innovation in organizations and the health system. In addition, the results showed that citizen-patient involvement in decision-making is highly dependent on many interrelated organizational and systemic conditions. The gap between research on the issue and decision-making has also emerged, pointing out the need for sustained knowledge transfer for a better translation of knowledge into action.

An estimated 9 to 14 million persons in the United States have latent tuberculosis infection (LTBI) and are therefore at risk for progression to active disease. Diagnosis and treatment for LTBI has been identified by the Centers for Disease Control and Prevention (CDC) and the Institute of Medicine as a major strategy for elimination of tuberculosis (TB) in the U.S. Approximately 200,000 - 300,000 Americans are treated for LTBI each year. This dissertation investigates patient characteristics that are associated with LTBI treatment completion and assesses the impact of a peer-based experimental intervention on adherence to, and completion of, LTBI treatment. A review of the literature (Chapter 2) demonstrates that LTBI treatment completion rates in the U.S. and Canada generally fall below established targets and have been reported to range from 20 to 65% for a 6-month course of self-administered treatment. Associations between patient factors, clinic facilities, or treatment characteristics and adherence to LTBI treatment were found to be inconsistent across studies. Additionally, adherence interventions have been developed but no single intervention has shown consistent effectiveness. This suggests that a 'one-size-fits-all' approach to LTBI treatment adherence is not likely to succeed across all settings. The remainder of the dissertation focuses on predictors of LTBI treatment completion and the impact of a peer-based experimental intervention on adherence to, and completion of, LTBI treatment in two separate randomized controlled trials. Data for these analyses are drawn from two sequential randomized controlled trials designed to compare a peer-based intervention to usual care for ensuring completion of treatment for LTBI in an urban clinic setting: the Pathways to Completion Study (recruitment from 1996 through 2000) as well as from the Tuberculosis Adherence Partnership Alliance Study (TAPAS ) (recruitment from 2002 through 2005). Chapter 3 describes the change in demographic, social, and behavioral characteristics between the two study populations. The first analysis (Chapter 4) examines predictors of LTBI treatment completion in this population. Our results suggest that foreign birth, homelessness, marriage, and alcohol or drug use all influence completion of TLTBI through complex interactions. Overall, married persons had better completion rates, but married foreign-born patients were substantially more likely to complete therapy than unmarried foreign-born patients. Similarly, alcohol users were less likely to complete therapy, but homeless alcohol users were more likely to complete treatment than other homeless patients. The latter is probably an artifact of our clinic population, which includes patients from alcohol and substance abuse rehabilitation programs. Residence in such programs may have a positive effect on treatment completion. Race/ethnicity did not appear to be associated with treatment completion, although the differences between the two study populations made this difficult to assess. Following from this, an analysis of the effectiveness of a peer-based experimental intervention on adherence to, and completion of, LTBI treatment in two separate randomized controlled trials (Chapter 5) finds peer support experimental intervention to be very effective in the Pathways population but not in the TAPAS population where completion rates increased substantially for both the intervention and control groups. The power for detecting an intervention effect in TAPAS was reduced by the higher than expected completion rates in both groups; however, the effect of the TAPAS intervention is statistically significant in the adherence model. Adherence analysis in TAPAS suggests that it is important to intervene early in the treatment as the first two months of treatment present a danger period where patients tend to default treatment. The most common reasons reported for not adhering to treatment were forgot, ran out of medications, and other priorities. Identifying reasons for missing medications can suggest possible foci for interventions in the early months, such as weekly reminders to take the medications and ensuring that prescriptions are refilled on schedule. Taken together, the findings of this research have significant implications for improving adherence to and completion of LTBI treatment. Currently, the primary intervention for improving LTBI adherence consists of educational programs to increase knowledge and modify attitudes. Our findings suggest that tangible assistance would be more effective in encouraging treatment completion. Additionally, adherence analysis in TAPAS suggests that it is important to intervene early in the treatment. Close follow-up of patients during the first two months of treatment, with prompt intervention to encourage completion among those stopping treatment, may yield better outcomes and reduce costs over the long term.

Thesis (M.Dev) --University of Limpopo, 2011

published_or_final_version / Social Work / Master / Master of Social Work

Breast and prostate cancers are the most commonly diagnosed forms of cancer in women and men in the United States. The federal government has played an active role in dedicating resources toward breast and prostate cancers since the early 1990s, when policy actors successfully lobbied Congress to adopt policies that increased awareness and spending. Using theories of social construction, I argue that the key to their success was the ability of these policy actors to socially construct the illnesses of breast and prostate cancers into politically attractive public issues that appealed to federal policymakers. Through the use of embedded collective case study and content analysis of newspaper coverage and congressional data, this dissertation demonstrates how the social constructions of these illnesses impacted the way that breast and prostate cancers were treated as they moved through the policy process. The way in which social construction influenced the types of policies that were adopted to deal with these illnesses is also examined. Because social construction is a multidimensional and dynamic process, several different elements of this process were examined in this dissertation: the ways that policy actors attracted attention to these illnesses, how gender influenced advocacy efforts, the symbolic aspects of these illnesses, and the way the illnesses were defined on systemic and institutional agendas. Since this dissertation examines two different policy issues, the similarities and differences in breast and prostate cancer policymaking were analyzed. I found that discussing breast and prostate cancers in relation to their social constructions provides support for the importance of symbolism and non-rational policy-making processes. / by Jocilyn Martinez. / Thesis (Ph.D.)--Florida Atlantic University, 2010. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2010. Mode of access: World Wide Web.

published_or_final_version / Social Work / Master / Master of Social Sciences

published_or_final_version / Social Work / Master / Master of Social Work

published_or_final_version / Social Work / Master / Master of Social Work

This is a sociological ethnography of nine people with dementia living in a private nursing home in central Scotland. It seeks to find an alternative way to view people in this situation, in a field that has been dominated by the medical modeL. By placing the people before the disease of dementia, they can be studied within the same framework as any people. For this study this framework is everyday life sociology with a focus on symbolic interactionism, ethnomethodology and dramaturgy. Additionally, by gaining the subjective perspective, we can get close to understanding meaning for these people. The ethnographic methods I use consist of participant observation and interviews. For analysis I employ NUDIST to structure the data and the thesis. The settng, Lavender Wing of Deer View Grange Nursing Home, provides context for the study. This is a culture of surveillance and routines, which can be restrictive, infantilizing and disabling for residents. Despite this culture research findings are of socially active participants. By examining relationships through an interactional framework three thematic areas developed concerned with emotions, interactions and classification. These thematic spheres demonstrate the emotional self, the interactional self and the generalized self of research informants. The emotional is concerned with the most inner and intimate self, often engaging in backstage intimacies and in thought. Significant others share with the interactional self, in frontstage performances, which are more ritualistic. The generalized self interacts with the generalized other, most often consisting of everyone in Lavender Wing and is concerned with classification and boundarydefinition. Within these spheres the described relationships are fluid and change according to the situation, and how participating actors define it. To engage in intimacies, rituals and form, and to shift between them requires social competence and active participation. People in this study demonstrate these. Despite restrictions they offer resistance to the environment and to dementia. They often make profound and metaphorical statements, to which this ethnography gives voice. Keywords Everyday life; interaction; nursing home culture; people with dementia; resistance; self and others; social competence; surveillance.