Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Osteoarthritis (OA) is the leading cause of disability in North American and has major economic consequences for society. People with knee OA experience the worst quality of life, among musculoskeletal conditions, with function and mobility being influenced by symptoms such as pain and stiffness. However, the impact of OA symptoms varies due to intrinsic and extrinsic factors, leading many researchers to employ biopsychosocial and other population health frameworks to study the disease. These population health approaches have not been adopted when studying knee OA outcomes in bioarchaeology, where a limited biological lens prevails due to the sole reliance on skeletal remains. The purpose of this research was to explore methods for identifying the impairment potential of knee OA in archaeological populations using a clinical sample and population health approaches. Clinical studies have the advantage of assessing not only the biological implications of knee OA but also the functional outcomes. By creating a knee OA grading system applicable for both MRI and dry bone femora samples (Clinical Archaeological Osteoarthritis Score) a link between clinical and archaeological populations was proposed. Using this link to infer functional deficits onto archaeological populations using population health frameworks, a theoretical analysis was performed with two populations; the 17th century Huron and the 19th century Inuit from the Igloolik region of Nunavut. The results demonstrated the increased impairment potential of knee OA in the Inuit population versus the Huron population, produced by contrasting factors captured by the determinants of health, including social and physical environments.

This research contributes to the social work understanding of mental competency assessments with older adults in healthcare settings. Utilizing a narrative research methodology, this qualitative research study analysed nine face-to-face interviews with social workers with experience assessing competency of older adults in the following Winnipeg, Manitoba healthcare settings: hospitals, personal care homes, and a number of community settings (home care, geriatric specialty programs, and private practice). Drawing from systems and ecological theories, as well as the social determinants of health, the results of this study revealed several key concerns such as the motivation behind what triggers an assessment, the specific tests and methods used to determine competency, inequitable treatment of the patient throughout the assessment depending on their cultural or socioeconomic background, and depending on the setting whether the social worker felt their role on the assessment team was valued or dismissed. Recommendations outlined implications for: enhancing the quality of the competency assessment process; expanding the role of social work in interdisciplinary settings; examining the use of methods and tests for assessment; and exploring opportunities for change in legislation, education and early detection. Potential areas of further study are discussed.

Bakgrunn: Det er avdekket at pasienter med komplekse behov og kroniske lidelser har behov for mer integrerte helsetjenester en de har fått. Samhandlingsreformen fremmer at dagens helsevesen må desentraliseres for å gi integrerte tjenester til denne pasientgruppen. Hensikt: Formålet med denne studien var å avdekke hva som er avgjørende for en bærekraftigbehandlingskjede til personer med komplekse og langvarige lidelser. Metode: Forskningen er et multiple case study med to case; diagnosegruppene Schizofreni ogKOLS. Undersøkelsen ble gjennomført i to middels store norske kommuner og deres respektive regionale sykehus. Det ble gjenomført 10 semi-strukturerte intervju med påfølgende innholdsanalyse. Funn fra intervjuene og dokumentanalysen ble triangulert. Resultat: Avgjørende for bærekraftige behandlingskjeder er: Organisasjonsstruktur: Interorganisatorisk behandlingskjede, med minimum nivå av lenket interaksjon, fundamentert på samarbeidsavtale. Interaksjonsnivået og bruk av IP var høyest innen for psykisk helse sektoren. Ingen av behandlingskjedene har multidisiplinære team som har myndighet til situasjonstilpasning avtjenestene; Organisasjonskultur: Det var ett multidisiplinært grenseoverskridende team, som var utenlederstøtte relatert til felles målsetninger og felles styrende idéer og løsning på samhandlingsutfordringer eller fokus på utvikling av helhetlige behandlingskjeder, spesielt fellesoppgavene; Utviklingsmulighet gjennom støttende nasjonal policy og statlige virkemidler; og Utviklingsfokus Det manglet avklaring på lederansvar for utvikling av behandlingskjeder og prioritering av ressurser til utvikling i form av personell, økonomi og tid. Konklusjon: Studien viser at det er avgjørende med adekvat organisasjonsstruktur med samhandlingssoner for både multidisiplinære grenseoverskridende team med tilstrekkelig interaksjonog myndighet til å gi situasjonstilpassede tjenester, og et ledernivå med fokus på lederstøtte for de multidisiplinære teamene. En altruistisk holdning i lederskapet kan bidra til støttende strukturer somfelles styrende ideer og målsetninger. Det er nødvendig med et tydelig fokus på utvikling av tjenester der det er tjenestetomme rom, og spesielt på fellesoppgaver og løsing av samhandlingsutfordringer,.Det er også viktig for behandlingskjedens bærekraft at ledere prioriterer tilstrekkelig ressurser til utviklingen av behandlingskjeder og bruker mulighetene gjennom de statlige virkemidlene.En integrert helsetjeneste er ennå ikke et faktum i de undersøkte behandlingskjedene, men viktige steg er tatt i retning av å oppfylle Samarbeidsreformens målsetning. / Background: Evidence shows that patients with complex and chronic illnesses need greater coordination of their healthcare services. The Coordination Reform claims that health care services must be decentralized to give integrated care to these patients Purpose: This study aimed to determine the crucial factors for sustainable chains of care for persons with complex and chronic diseases. Method: This study was organized as a multiple case study involving two diagnosis groups for schizophrenia and chronic obstructive pulmonary disease. Research was conducted in two mid-sized Norwegian municipalities, each connected to separate regional hospitals. It was conducted 10 semistructured interviews. Findings from interviews and document analysis were triangulated. Result: Integrated chains of care depend on four factors. Organizational structure needed organizational chains of treatment with a minimum level of linked interaction, based on contracts.The level of interaction was higher, and the use of Individual Plans was more common within the mental health sector. In our study, neither chain of care had a mandate to adjust services according tochanging needs. In organizational culture, we identified one inter-organizational team, which lacked necessary leadership support to identify common goals, and lacked governing ideas or leadership to solve the challenges or focus on developing integrated chains of care. Supporting policies andgovernmental incentives enabled development opportunities. Finally, we identified a lack of development focus (i.e., appointed responsibility for the development of integrated health care and the allocation and management of resources for personnel, time, and economy). Conclusion: We determined that an adequate organizational structure for interaction is crucial to creating zones of interaction for multi-disciplinary teams with adequate interaction and authority to adjust health services according to need. We also determined a need for leadership to focus on supporting multidisciplinary teams. Leadership with altruistic attitudes may inspire and strengthen supporting structures such as common governing ideas and goals. When voids exist in the chain of care, clearly focused service development and problem solving is crucial, especially for interorganizational treatment. Sustainability of the chain of care requires leaders prioritize development regarding the allocation of adequate resources, using the possibilities within the national regulations and incentives. An integrated chain of care was not yet in place for the cases studied here, butimportant steps have been taken towards fulfilling the goals of the Norwegian Coordination reform. / <p>ISBN 978-91-982282-1-2</p>

Background: Drug utilisation among the elderly is complex due to multiplemorbidities, extensive drug utilisation and an increased sensitivity to drugs. One of the most common drug groups utilised in this population is psychotropic drugs, which include antipsychotics, anxiolytics, hypnotics, and antidepressants. In appropriat eutilisation of drugs among the elderly is an issue of great public health importance. Aims: The overall aim of this thesis is to assess and analyse potentially in appropriat eutilisation of psychotropic drugs among the elderly in Sweden. The specific aims are to assess to what extent the indicator “concurrent use of three or more psychotropic drugs”captures the utilisation of Potentially Inappropriate Psychotropics (PIP) among theelderly, and to analyse potentially inappropriate utilisation of psychotropic drugs inrelation to time, mental disorders, institutionalisation, and socioeconomic determinants among the elderly in Sweden. Methods: Data from individual-based registers on dispensed drugs and socioeconomic determinants in 2006, the Gothenburg 95+ Study (1996-1998), and aggregated drug sales statistics from 2000-2008 were used. The agreement between the two indicators“concurrent use of three or more psychotropic drugs” and PIP was assessed. Utilisationof psychotropic drugs and PIP was assessed in relation to mental disorders and institutionalisation among the 95-year olds, and in relation to socioeconomic determinants among individuals aged 75 years and older. Further, trends over time inutilisation of PIP and recommended drugs were analysed. Results: During 2006, about half of the elderly aged 75 years and older utilised psychotropic drugs and one fifth of all elderly utilised PIP. One fourth of individualsutilising PIP were captured by the indicator “concurrent use of three or morepsychotropic drugs”. In 1996-1998, less than one tenth of the 95-year olds with depression utilised antidepressants, while hypnotics and anxiolytics were more common. Individuals with low income and the non-married were more likely to utilise PIP compared to those with high income and the married, respectively. During 2000-2008, utilisation of PIP decreased and utilisation of recommended psychotropic drugs increased. Conclusions: There are substantial problems in the utilisation of psychotropic drugsamong the elderly. This thesis found that the agreement between two indicators of inappropriate psychotropic drug utilisation was poor, which emphasises the importance of choosing relevant indicators. The findings also show socioeconomic inequities inpsychotropic drug utilisation among the elderly, a low utilisation of antidepressants among 95-year olds diagnosed with depression, and a trend towards the utilisation of recommended rather than inappropriate psychotropic drugs among the elderly / Bakgrund: Användning av läkemedel bland äldre är komplicerat på grund avmultisjuklighet, användning av flera läkemedel och en ökad känslighet för läkemedel.En av de vanligaste läkemedelsgrupperna hos äldre är psykofarmaka, som inkluderarantipsykotika, ångestdämpande, sömnmedel och antidepressiva läkemedel. Olämpliganvändning av läkemedel bland äldre är ett betydande folkhälsoproblem. Syfte: Det övergripande syftet med avhandlingen är att beskriva och analyserapotentiellt olämplig användning av psykofarmaka bland äldre i Sverige. De specifikasyftena är att undersöka i vilken utsträckning indikatorn ”samtidig användning av treeller fler psykofarmaka” fångar användningen av potentiellt olämpliga psykofarmaka(PIP) bland äldre och att analysera potentiellt olämplig användning av psykofarmaka irelation till förändring över tid, psykiatriska diagnoser, boendeform och socioekonomiska determinanter bland äldre i Sverige. Metod: Avhandlingen baseras på data från individbaserade register över läkemedelsköp och socioekonomiska determinanter under 2006, Göteborg 95+ studien (1996-1998)samt aggregerade data över läkemedelsförsäljning under 2000-2008. Överensstämmelsen mellan de två indikatorerna ”samtidig användning av tre eller flerpsykofarmaka” och PIP undersöktes. Användning av psykofarmaka och PIP studerades i relation till psykiatriska diagnoser och boendeform hos 95-åringar och i relation till socioekonomiska determinanter hos de som var 75 år och äldre. Vidare analyseradesförändring över tid i användning av PIP och rekommenderade psykofarmaka. Resultat: Hälften av alla äldre som var 75 år och äldre använde psykofarmaka under2006 och en femtedel av alla äldre använde PIP. En fjärdedel av individerna somanvände PIP fångades av indikatorn ”samtidig användning av tre eller flerpsykofarmaka”. Bland 95-åringarna med depression år 1996-1998 använde färre än enav tio antidepressiva läkemedel, medan sömnmedel och ångestdämpande läkemedel varvanligare. PIP var vanligare hos de äldre med låg inkomst och bland de som inte vargifta, jämfört med individer med hög inkomst och de gifta. Under 2000-2008 minskade användningen av PIP medan användningen av rekommenderade psykofarmaka ökade. Slutsatser: Det finns fortfarande stora problem i äldres användning av psykofarmaka.Avhandlingen visar en låg överensstämmelse mellan två indikatorer för olämpliganvändning av psykofarmaka, vilket pekar på betydelsen av att välja relevantaindikatorer. Avhandlingen visar också på socioekonomiska ojämlikheter i användningenav psykofarmaka hos äldre, en låg användning av antidepressiva läkemedel bland 95-åringar med depression och en ökning i användningen av rekommenderade istället förolämpliga psykofarmaka bland äldre

Darbo tikslas – įvertinti Tauragės miesto darželio vaikų mitybą ir jos sąsajas su tėvų socialine-ekonomine padėtimi. Tyrimo metodika. Apytikslio registravimo metodu vaikų mitybos tyrimas atliktas 2012 m. liepos 9, 11 ir 14 dienomis lopšelyje-darželyje ,,Žvaigždutė“. Tyrime dalyvavo aštuonių grupių vaikai, iš viso 124 tiriamieji (44,4 proc. berniukų ir 55,6 proc. mergaičių), kurių amžius – 3 - 6 metai. Vaikų mityba darželyje stebėta dvi darbo dienas, o vieną dieną mityba tirta namuose neanoniminiu anketiniu būdu apklausiant vaikų tėvus apie suvartotus maisto produktus ir jų kiekius. Šiame darbe analizuojami tik tų vaikų duomenys, kurie dalyvavo tyrime visas tris dienas. Atsako dažnis – 67,4 proc. Statistinė duomenų analizė atlikta naudojantis SPSS 16.0 for Windows programa. Rezultatai. Išanalizavus trijų parų maisto davinio energinę vertę ir maisto medžiagų sudėtį, nustatyta, kad 1 - 3 metų amžiaus grupės vaikų vidutinė paros maisto davinio energinė vertė buvo 1587,4 kcal, o 4 - 6 metų – 1940,0 kcal. Abiejose amžiaus grupėse daugiausia energijos gauta iš angliavandenių (atitinkamai 50,1 ir 50,3 proc.). Tačiau tiriamųjų suvartota angliavandenių, skaidulinių maisto medžiagų dalis buvo nepakankama. Baltymų dalis ikimokyklinio amžiaus vaikų maisto davinyje – pakankama. Maisto davinyje buvo per daug riebalų, ypač sočiųjų riebalų rūgščių. 1 - 3 ir 4 - 6 metų amžiaus grupių vaikų maisto davinyje riebalai viršijo maksimalią rekomenduojamą normą atitinkamai 7,5 proc. ir 7 proc... [toliau žr. visą tekstą] / Aim of the study – to assess dietary intake of children in Taurage kindergarden and its links between parental socioeconomic status. Research methodology. An approximate recording method was used in July 9, 11, 14, 2012, to carry out dietary intake of children in a nursery-kindergarten “Žvaigždute”. Children from three groups, i. e. 124 respondents (44.4 percent of boys and 55.6 percent of girls), aged 3 - 6 years participated in the research. Dietary intake of children was observed for two days and one day it was observed at children’s homes – parents were provided with non-anonymous questionnaires which had to be filled with the data about food products and their quantities their children had that day. In this study it is analyzed the data of those children who participated in the research for all three days. Response rate – 67.4 percent. Statistical analysis of the data has been carried out using SPSS 16.0 Windows Programme. Results. Analysis of the three-day food intake energy value and nutrient composition determined that the energy value of the food ration of the group of 1 - 3 years old children was 1587,4 kcal and 1940,0 kcal of the group of 4 - 6 years old children. Both age groups got the most energy from carbohydrates (respectively 50.1 and 50.3 percent). However, part of investigated carbohydrates and fiber nutrients was insufficient. The part of proteins in pre-school children’s food ration was sufficient. Also, there was too much fat, especially saturated fatty... [to full text]

Abstract Type 2 diabetes mellitus is a disease that has trebled in incidence over the last 25 years, affecting both adults and increasingly children. The rapid increase of the disease mirrors the gradients of social position and income distribution, and parallels the accelerated environmental changes witnessed with the rise of neoliberal capitalism. This research situates neoliberal capitalism as a collection of political and economic policies that form an ideology suited to protect discrete elite interests. The current ideology has permeated all social aspects of society, including education and healthcare. Therefore, it is argued that the practice of healthcare and the education of healthcare students are shaped by the sociopolitical environment in which they exist. Ten best-selling postsecondary textbooks in pathology, pathophysiology, and disease processes were selected for content analysis to determine if the interpretation of type 2 diabetes in pathophysiology textbooks reflects neoliberal thinking. The data were interpreted within the tradition of critical discourse analysis and theoretically enriched using Foucault’s descriptions of governmentality, biopolitics, and discursive formations. The results indicate that notions consistent with neoliberal capitalism permeate pathology textbooks in the understandings of type 2 diabetes. Consistent with how neoliberal thought embodies and explicates social conditions, type 2 diabetes is described in a way that stresses iii self-responsibility and culpability for falling ill. The texts also impart the importance of biomedical industry interventions for the treatment of the sick and the surveillance of the healthy. Finally, in a way that substantiates the degradation of the environment and retrenchment of social welfare policies, the textbooks fail to make any reference to the ecological factors that contribute to type 2 diabetes, including urbanisation and the propagation of food deserts, environmental toxins, income inequality, the steepening of the social gradient, and the deleterious effects of globalisation on human nutrition.

Abstract Type 2 diabetes mellitus is a disease that has trebled in incidence over the last 25 years, affecting both adults and increasingly children. The rapid increase of the disease mirrors the gradients of social position and income distribution, and parallels the accelerated environmental changes witnessed with the rise of neoliberal capitalism. This research situates neoliberal capitalism as a collection of political and economic policies that form an ideology suited to protect discrete elite interests. The current ideology has permeated all social aspects of society, including education and healthcare. Therefore, it is argued that the practice of healthcare and the education of healthcare students are shaped by the sociopolitical environment in which they exist. Ten best-selling postsecondary textbooks in pathology, pathophysiology, and disease processes were selected for content analysis to determine if the interpretation of type 2 diabetes in pathophysiology textbooks reflects neoliberal thinking. The data were interpreted within the tradition of critical discourse analysis and theoretically enriched using Foucault’s descriptions of governmentality, biopolitics, and discursive formations. The results indicate that notions consistent with neoliberal capitalism permeate pathology textbooks in the understandings of type 2 diabetes. Consistent with how neoliberal thought embodies and explicates social conditions, type 2 diabetes is described in a way that stresses iii self-responsibility and culpability for falling ill. The texts also impart the importance of biomedical industry interventions for the treatment of the sick and the surveillance of the healthy. Finally, in a way that substantiates the degradation of the environment and retrenchment of social welfare policies, the textbooks fail to make any reference to the ecological factors that contribute to type 2 diabetes, including urbanisation and the propagation of food deserts, environmental toxins, income inequality, the steepening of the social gradient, and the deleterious effects of globalisation on human nutrition.

中國在經濟發展的過程中，由於面臨著資金不足和技術落後的問題，以致於在1978年確立改革開放政策後，企圖透過外商直接投資來加速工業化及促進產業升級。然而一直到1992年鄧小平南巡，宣布將堅持中國的改革開放政策後，外商直接投資才開始大量流入中國。本文的研究目的即是鎖定外商直接投資開始大量進入中國後，影響世界各國對中國直接投資的因素。 本文利用24個國家（地區）在1993年至2003年期間的資料，採固定效果模型研究外商對中國直接投資的原因為何。結果顯示在1993到1996年間，顯著的決定因素為相對國內生產毛額、相對每人國內生產毛額，以及相對工資率。而在1997到2003年間，顯著的變項轉變為相對國內生產毛額、相對借貸成本、以及相對國家風險。此外，兩階段的外商直接投資都有增加的趨勢，但1997到2003年間增加的速度有趨緩的現象。另由固定效果的分析中得知，地理距離與對中國的自發性直接投資具有負相關的關係，此可由引力模型和地理距離影響文化的擴散和交流解釋之。最後，為了降低實證模型發生錯誤的機會，並使研究過程更為嚴謹，於是對本文模型和估計結果使用更多的方法加以檢定。 / Since 1978, China has adopted the so-called “open door policy”, attracting foreign direct investment(FDI) has become one of the most important methods to facilitate its economic growth. However, foreign countries didn’t invest large amount toward China until Deng Xiaoping’s southern trip in 1992. The purpose of this study is thus to investigate the determinants of FDI from different foreign countries in China after foreign countries started to invest tremendous amount toward China. This study adopts fixed-effect model to investigate the determinants of FDI in China with 24 countries’ (regions’) data during the period of 1993-2003. The result shows relative GDP, relative GDP per capita, and relative wage are the most important factor in attracting FDI in China during 1993-1996. However, during 1997- 2003, the important factors change into relative GDP, relative borrowing cost, and relative country risk. In addition, the FDI at two periods both have a increasing trend, but the increasing speed during 1997-2003 isn’t increase so quickly as 1993-1996. Furthermore, from the analysis of the fixed effect knows the geographical distance has a negative relationship to FDI in China, and it can be explained by gravity equation and geographical distance influences the diffusion and exchange of culture. Finally, in order to reduce the mistakes occurred in positive models and enable the study more rigorous, then uses more methods to test the models and the result.

2009年中國大陸正式超越德國，成為全球最大出口國，顯示中國大陸在國際貿易市場的重要地位，而天津市以16.4%經濟成長速度成為2011 年中國大陸各省區中，經濟增長最快速的城市。同時，也為英國《經濟學人智庫》2012年公布全球最具經濟競爭力城市。中國大陸傳統產業升級，天津市經濟轉型成功，以及天津市具有沿海的外貿地緣及資源優勢，外貿帶動經濟發展前景不容小覷。 本研究針對天津市外貿及觀察各類出口產品結構變化，以SITC國際貿易標準分類，以顯著性比較利益法及波士頓矩陣分析，探討天津市各項出口產品的比較利益分析。 此外，本研究利用實證模型分析影響天津整體出口額之因素中，將各項自變數分類為要素因素、外部拉動因素以及金融因素之三大影響因素，研究方法先以進行單根檢定（unit-root test），確定變數資料成為定態(stationary)，再以迴歸分析方式，藉此檢驗各項變數與天津外貿之間因果關係為何。 / China overtaken Germany as the world's top merchandise exporter in 2009 from WTO data, demonstrates trade status of China in the international trade market. Tianjin posted the fastest growth rates of 16.4 percent among the provinces in China in 2011 as well as ranked as top city in 2012 of economic strength in the global competitiveness by EIU. Trade transition from traditional industry in China transformed the impetus of foreign trade successfully bringing economy prospects in Tianjin with superiority of geography and resources. The research utilized RCA and BCG analysis to observe significance and comparative advantage of each kind of Tianjin’s export products classified by SITC international trade standard method. Moreover, the research selected several affects factors categorized as fundamental element、global propelling and financial factor to examine each variable would be influential and the relation on foreign trade in Tianjin by regression analysis.