Les personnes qui subissent une chirurgie pour un cancer de la tête et du cou sont souvent préoccupées par les changements dans l’apparence et les fonctions corporelles causés par le traitement et rapportent des problèmes d’image corporelle, des niveaux plus élevés d’anxiété et une diminution de la qualité de vie. La communication avec les professionnels de la santé peut affecter la façon dont les patients vivent avec ces changements, notamment en raison des différences dans la manière dont les patients et leur équipe médicale perçoivent le traitement et les aspects qu’ils jugent importants à discuter. Toutefois, peu d’études se sont penchées sur la communication entre les patients et leur équipe soignante autour des changements dans l’apparence et les fonctions corporelles lors de consultations cliniques. Cette étude répond à cette question en s’appuyant sur les recherches en oncologie psychosociale et sur les recherches en communication sur le cadrage. L’objectif est de mieux comprendre le processus de communication entre les patients et l’équipe interdisciplinaire de chirurgie cervicofaciale autour des changements dans l’apparence et les fonctions corporelles, ainsi que les impacts potentiels de cette communication sur l’expérience des patients au cours de leurs trajectoires de traitement. Une étude empirique sur la communication entre les patients et l’équipe médicale a été menée dans une clinique d’oncologie de la tête et du cou d’un grand hôpital universitaire au Québec, Canada. Vingt patients ont participé à l’étude pendant six mois et 88 visites pré-chirurgicales et post-chirurgicales ont été observées (totalisant 54 heures de données enregistrées par audio ou vidéo). Des entrevues semi-dirigées ont été réalisées avec les patients avant et après leur chirurgie (n=45), ainsi qu’avec les membres de l’équipe médicale (n=6) à la fin de l’étude. Tout d’abord, cette étude révèle les patterns d’interaction qui caractérisent les visites pré-chirurgicales : comment les changements corporels sont abordés dans les discussions en rapport avec la survie et la guérison, comment les changements corporels sont établis comme étant une préoccupation (ou non), et comment différents membres de l’équipe peuvent jouer des rôles différents pour discuter des changements corporels avec les patients. Deuxièmement, les patterns d’interaction qui caractérisent les visites post-chirurgicales sont décrits : comment les changements corporels sont abordés dans les discussions en rapport avec la guérison et le rétablissement physique, comment l’amélioration et le progrès sont mis en évidence dans les consultations, et comment les différences entre les points de vue des patients et des soignants sont résolues dans les interactions. Les données des entrevues complètent les analyses, montrant les impacts positifs et négatifs potentiels de ces patterns d’interaction sur l’expérience des patients. Plus précisément, l’analyse révèle comment les préoccupations psychosociales peuvent être mises en arrière-plan dans les interactions cliniques. Les résultats de l’étude contribuent à la recherche sur la communication patient-soignant en permettant de comprendre comment les préoccupations émergent dans les interactions cliniques et comment les changements dans l’apparence et les fonctions corporelles sont abordés lors des consultations avec différents membres de l’équipe médicale. Ces résultats pourront être utilisés pour développer des programmes de formation pour étudiants et professionnels, afin de favoriser la prestation des soins intégrés répondant aux besoins des patients tant sur le plan physique que psychosocial. / People who undergo surgery for head and neck cancer are often concerned about treatment-related changes in appearance and functional impairments, and report body image difficulties, higher levels of anxiety, and lower quality of life. Communication with health care professionals may impact patients’ experience of body changes, notably due to the differences between how patients and their medical team view the treatment and what aspects they find important to discuss. However, relatively little is known about how patients and providers discuss changes in body appearance and functioning during clinical consultations. This study addresses this question by combining insights from psychosocial oncology research with communication research on framing. The aim is to better understand the process of communication between surgical patients and the interdisciplinary Head and Neck Surgery team around changes in appearance and function, as well as how patients are experiencing such communication during their treatment trajectories. An empirical study of patient-medical team communication was conducted at the head and neck oncology outpatient clinic of a large university-affiliated hospital in the province of Quebec, Canada. Twenty patients participated in this study for a period of six months, and 88 pre-surgical and post-surgical visits were observed and audio or video recorded (54 hours of recorded data). Semi-structured interviews were conducted with patients before and after the surgery (n=45), as well as with medical team members (n=6) at the end of the study. First, this study reveals the communication patterns that characterize pre-surgical visits: how body changes are discussed in relation to survival and cure, how body changes are established as (not) being a matter of concern, and how different team members may play different roles in discussing body changes with patients. Second, the communication patterns that characterize post-surgical visits are described: how body changes are discussed in relation to cure and physical recovery, how improvement and progress are emphasized in consultations, and how differences between patients’ and providers’ perspectives are resolved in interactions. Interview data complements the analyses, showing the potential positive and negative impacts of these interaction patterns on patients’ experience. Specifically, the analyses reveal how psychosocial concerns can be silenced in clinical interactions. The results of this study contribute to research on patient-health care provider communication by providing insight into how concerns emerge in clinical interactions and how changes in appearance and function are discussed in patients’ visits with different medical team members. These results can be used to inform students’ and professionals’ training by providing guidance on integrated care addressing patients’ needs in both the physical and the psychosocial domain.

<p>This dissertation, broadly, examines how power dynamics manifest during clinical interactions related to vague and gendered medical symptoms, such as pelvic pain. To examine this issue, I approach my research questions through multiple methods including a critical discourse analysis of the medical discourse on pelvic pain, a survey experiment administered to healthcare workers in the US, and a narrative analysis of pelvic pain patient experiences. While the focus of this research is on pelvic pain, the analyses presented here reach far beyond ideas of power dynamics and pelvic pain. Rather, the findings from this research speak to theoretical discussions medical sociologists have been having for decades. Specifically, findings provide new insight on: 1) the limits of evidence-based medicine as a biomedical paradigm, 2) how fundamental causes of health inequality intersect with each other as well as other factors, such as gender, important in predicting health outcomes and 3) how discussions of metamechanisms in fundamental cause theory can inform our understanding of the accumulation of cultural health capital. In providing such insight, this dissertation uses the case of pelvic pain to integrate multiple perspectives and theories in medical sociology to drive the field forward in a way that acknowledges the many ways power is simultaneously constituted in the clinical interaction. From the role of gender, race, and class in power relations, to the ways medical knowledge, discourse, and authority dictate the clinical interaction, this research covers a wide range of sociological theories and concepts. In doing so, this dissertation sheds new light on current understandings of power in the clinical interaction and its relationship to inequitable health outcomes in the US.</p>

The purpose of this dissertation was to examine patterns of antenatal stressful life events (SLEs) experienced by women in the United States (U.S.) and their association with postpartum depression (PPD). It further explored the role of women's state-level socio-economic status (SES) on PPD; the racial/ethnic dispartites in SLE-PPD relationship; and the role of provider communication on perinatal depression. Data from 2009–11 Pregnancy Risk Assessment Monitoring System (PRAMS) and SES indicators published by the Institute of Women’s Policy Research (IWPR) were used. Latent class analysis (LCA) was performed to identify unobserved class membership based on antenatal SLEs. Multilevel generalized linear mixed models examined whether state-level SES moderated the antenatal SLE-PPD relationship. Of 116,595 respondents to the PRAMS 2009-11, the sample size for our analyses ranged from 78% to 99%. The majority (64%) of participants were in low-stress class. The illness/death related-stress class (13%) had a high prevalence of severe illness (77%) and death (63%) of a family member or someone very close to them, while those in the multiple-stress (22%) class endorsed most other SLEs. Eleven percent had PPD; women who experienced all types of stressors, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36, 5.51) of PPD. The odds of PPD decreased with increasing state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64, 0.88), with significant cross-level interaction between stressors and state-level SES. Among non-Hispanic blacks and non-Hispanic whites, husband/partner not wanting the pregnancy (aOR: 1.47; 95% CI: 1.14, 1.90) and drug/drinking problems of someone close (aOR: 1.37; 95% CI: 1.21, 1.55) were respectively associated with PPD. Provider communication was protective. That 1 out of every 5 and 1 out of every 8 women were in the high- and emotional-stress classes suggests that SLEs are common among pregnant women. Our results suggest that screening for antenatal SLEs might help identify women at risk for PPD. The finding that the odds of PPD decrease with increasing social/economic autonomy, could have policy implications and motivate efforts to improve these indices. This study also indicates the benefits of antenatal health care provider communication on perinatal depression.