La téléréadaptation, tout comme d’autres champs en télésanté, est de plus en plus interpelée pour la prestation de services. Le but de ce projet de thèse est d’enrichir l’évaluation de la téléréadaptation afin que les connaissances qui en découlent puissent venir soutenir la prise de décision d’acteurs impliqués à différents niveaux en téléréadaptation. Le premier article présente une revue systématique dont l’objectif était de faire synthèse critique des études en téléréadaptation. La revue rassemble 28 études en téléréadaptation, qui confirment l’efficacité de la téléréadaptation pour diverses clientèles dans différents milieux. Certaines des études suggèrent également des bénéfices en termes de coûts, mais ces résultats demeurent préliminaires. Cette synthèse critique est utile pour soutenir la décision d’introduire la téléréadaptation pour combler un besoin. Par contre, les décideurs bénéficieraient aussi de connaissances par rapport aux changements cliniques et organisationnels qui sont associés à la téléréadaptation lorsqu’elle est introduite en milieu clinique. Les deux autres articles traitent d’une étude de cas unique qui a examiné un projet clinique de téléréadaptation dans l’est de la province de Québec, au Canada. Le cadre conceptuel qui sous-tend l’étude de cas découle de la théorie de structuration de Giddens et des modèles de structuration de la technologie, en particulier de l’interaction entre la structure, l’agent et la technologie. Les données ont été recueillies à partir de plusieurs sources (groupes de discussion, entrevues individuelles, documents officiels et observation d’enregistrements) suivi d’une analyse qualitative. Le deuxième article de la thèse porte sur le lien entre la structure, l’agent et la culture organisationnelle dans l’utilisation de la téléréadaptation. Les résultats indiquent que les différences de culture organisationnelle entre les milieux sont plus évidentes avec l’utilisation de la téléréadaptation, entraînant des situations de conflits ainsi que des occasions de changement. De plus, la culture organisationnelle joue un rôle au niveau des croyances liées à la technologie. Les résultats indiquent aussi que la téléréadaptation pourrait contribuer à changer les cultures organisationnelles. Le troisième article examine l’intégration de la téléréadaptation dans les pratiques cliniques existantes, ainsi que les nouvelles routines cliniques qu’elle permet de soutenir et la pérennisation de la téléréadaptation. Les résultats indiquent qu’il y a effectivement certaines activités de téléréadaptation qui se sont intégrées aux routines des intervenants, principalement pour les plans d’intervention interdisciplinaire, tandis que pour les consultations et le suivi des patients, l’utilisation de la téléréadaptation n’a pas été intégrée aux routines. Plusieurs facteurs en lien avec la structure et l’agent ont contraint et facilité l’intégration aux routines cliniques, dont les croyances partagées, la visibilité de la téléréadaptation, le leadership clinique et organisationnel, la disponibilité des ressources, et l’existence de liens de collaboration. La pérennité de la téléréadaptation a aussi pu être observée à partir de la généralisation des activités et le développement de nouvelles applications et collaborations en téléréadaptation, et ce, uniquement pour les activités qui s’étaient intégrées aux routines des intervenants. Les résultats démontrent donc que lorsque la téléréadaptation n’est pas intégrée aux routines cliniques, elle n’est pas utilisée. Par contre, la téléréadaptation peut démontrée certains signes de pérennité lorsque les activités, qui sont reproduites, deviennent intégrées aux routines quotidiennes des utilisateurs. Ensemble, ces études font ressortir des résultats utiles pour la mise en place de la téléréadaptation et permettent de dégager des pistes pour enrichir le champ de l’évaluation de la téléréadaptation, afin que celui-ci devienne plus pertinent et complet, et puisse mieux soutenir les prises de décision d’acteurs impliqués à différents niveaux en téléréadaptation. / Telerehabilitation, like other telehealth applications, has been increasingly used to provide health services. The goal of this thesis is to enrich the field of telerehabilitation evaluation such that it can better contribute to informed decision making of those involved in telerehabilitation at different levels. The first article is a systematic review of telerehabilitation studies and it was conducted in order to provide a critical synthesis of the current telerehabilitation literature. The revue included 28 studies of telerehabilitation, which, overall, confirmed the efficacy of telerehabilitation when used with a variety of clienteles in different settings. Some of the studies also suggest that there may be some cost benefits associated with telerehabilitation although the findings remain preliminary. Such a synthesis of the literature can contribute to some decisions regarding the pertinence of introducing telerehabilitation. However, decision makers also need information regarding the clinical and organizational changes that are associated with telerehabilitation when implemented in a clinical setting. The next two articles contain the results of a single case study that was centered on a telerehabilitation clinical project implemented in the eastern part of the province of Quebec, in Canada. A conceptual model was developed to guide this study, and it was based on Giddens’ Theory of Structuration and on models of technology structuration, in particular drawing upon the notion of the interaction between structure, agent and technology. Data was collected from several sources (focus groups, interviews, official documents and observation of recordings) and was analyzed using a qualitative analysis approach. The second article in this thesis examined the relationship between structure, agent and organizational culture with respect to telerehabilitation use. The results indicate that differences in organizational culture between the centres are more visible when telerehabilitation is used, which can in some cases lead to conflicts, while in other cases create opportunities for change. In addition, organizational culture also played a role in shared beliefs linked to the technology. Lastly, the results suggest that telerehabilitation could be used to bring about changes in organizational culture. The third article examined how telerehabilitation became integrated into existing clinical practices, how it contributed to the development of new routines and explored the sustainability of telerehabilitation. The results indicate that some activities, namely interdisciplinary care plans were integrated into clinical routines, while consultations and patient follow-up were not. Several factors related to the structure and agent were found to facilitate or hinder the integration of telerehabilitation into routine practices, including shared beliefs, the visibility of telerehabilitation activities, the clinical and organizational leadership, the availability of resources and the existence of collaborations. Sustainability was also observed when telerehabilitation use became more generalized and novel applications were developed, although this was only found to occur for activities which had integrated into routine practice. The results therefore suggest that when telerehabilitation is not integrated into routine practices, it will not be used, but that, on the other hand, telerehabilitation may be sustainable for activities which are repeated and then integrated into routine day-to-day clinical activities. Together, these studies put forth findings which can be useful when implementing new telerehabilitation programs. They also help elucidate directions for future research in order to enrich the field of telerehabilitation evaluation so that it may become more pertinent and comprehensive to support decision-makers involved at all levels of telerehabilitation.

Made available in DSpace on 2016-06-02T20:39:19Z (GMT). No. of bitstreams: 1 5638.pdf: 3863541 bytes, checksum: 74ed5556a4774ead28ebb806dd347636 (MD5) Previous issue date: 2013-11-25 / Financiadora de Estudos e Projetos / Reports from IPCC (Intergovernmental Panel on Climate Change) call attention to the possibility of water shortages, to the collapse of the Amazon system, to the biodiversity crisis, and to the proliferation of extreme weather events. Anthony Giddens, British sociologist formulator of the theory of structuration, elaborates an analytical category appointing precisely the lack of concrete actions related to this environmental issue in the policy and in the daily practices. According to him, when practical measures for protecting the environment are put into practice, there will not be enough time to reverse the environmental collapse, setting the self-styled Giddens‟s Paradox. Such point of view of environmental question transforms in normative, abstract and universal, leaving to conceive it as eminently contextual - result of the interaction between individuals, groups and institutions. Precisely so it this research takes this analytical category as a starting point for a relational approach of environmental issues through his own theory of structuration. So, the environment and the nature are now considered as structural principles: as rules and resources mobilized in the reproduction and transformation of social life and, therefore, as objects of appointment disputes and discursive resignifications. In order to analyze sociologically the relational aspect the environmental issue through a qualitative research - theoretically and methodologically linked to the theory of structuration the county of Brotas (São Paulo/Brazil) was established as case study. Are used as research methods: semi-structured interviews, snowball technique, documental survey, photo documentation and socioeconomic questionnaire. This particular location shows a convergence between the multiple conceptions of the environmental issue, the professionalization of ecotourism and of the discursive resignification of the rural areas, allowing the visualization of multiple cognitive perceptions of the environmental issue. The critical debate from Giddens enabled the analysis of four social processes of resignification in the Brotas county: a) The Jacaré-Pepira River; b) From the "hole" to the tourist attraction; c) From Radical to Disneyland; and d) The Estrada do Patrimônio . In summary, the trajectory of the dissertation seeks to discuss sociologically that the environmental issue does not arise in everyday life in a universal and normative form, but eminently as cognitive perception linked to the complexity of knowingness agents. / Relatórios do IPCC (Painel Intergovernamental sobre as Mudanças Climáticas) alertam para a possibilidade de escassez de recursos hídricos, de colapso do sistema amazônico, de crise da biodiversidade, e de proliferação de eventos climáticos extremos. Anthony Giddens, sociólogo britânico formulador da teoria da estruturação, elabora uma categoria analítica que nomeia justamente a ausência de ações concretas em relação a essa questão ambiental nas práticas políticas e cotidianas. Segundo ele, quando medidas práticas de proteção ao meio ambiente forem postas em práticas, não haverá mais tempo suficiente de reverter o quadro de colapso ambiental, configurando o autodenominado Paradoxo de Giddens. Tal perspectiva da questão ambiental acaba por torná-la normativa, abstrata e universal, deixando de concebê-la como eminentemente contextual - fruto da interação entre indivíduos, grupos e instituições. Justamente por isso a pesquisa toma essa categoria analítica como ponto de partida para uma abordagem relacional da questão ambiental através da própria teoria da estruturação. Assim, meio ambiente e natureza passam a ser considerados como princípios estruturais: como regras e recursos mobilizados na reprodução e transformação da vida social e, portanto, como objetos de disputas de nomeação e de ressignificação discursiva. Para analisar sociologicamente o aspecto relacional da questão ambiental através de uma pesquisa qualitativa - teórica e metodologicamente vinculada à teoria da estruturação - estabeleceu-se o município de Brotas-SP como estudo de caso. São utilizados como métodos de pesquisa: entrevistas semiestruturadas, técnica de bola de neve, levantamento documental, fotodocumentação e questionário socioeconômico. Tal localidade específica apresenta uma convergência entre as múltiplas concepções da questão ambiental, a profissionalização do ecoturismo e a ressignificação discursiva do próprio espaço rural, possibilitando a observação de múltiplas percepções cognitivas da questão ambiental. O debate crítico a partir de Giddens permitiu a análise de quatro processos sociais de ressignificação no município de Brotas: a) O Rio Jacaré-Pepira; b) Do buraco ao atrativo turístico; c) Do Radical à Disneylândia e d) A Estrada do Patrimônio. Em síntese, a trajetória da dissertação procura debater sociologicamente que a questão ambiental não emerge na vida cotidiana de forma universal e normativa, mas eminentemente como percepção cognitiva vinculada à complexidade da cognoscência dos agentes.