Substance abuse is the foremost health problem in the United States, with an estimated annual cost of over $400 billion and is linked to over 400,000 preventable deaths each year. Adolescents are among those abusing drugs and alcohol. Approximately one-half of high school students use alcohol and one-fourth smoke marijuana, and by their senior year of high school, over half will have used an illicit drug. Effective substance use interventions for young adults are important in preventing the progression toward other drug use disorders and harmful consequences of frequent drug use. Schools have been identified as a viable setting in which to conduct brief interventions to reduce adolescent substance use. However, a standard therapy for implementing motivational interventions in the school setting has not yet been established. The purpose of this study was to investigate the efficacy of a motivational intervention on substance use in a school-based adolescent population and to test the hypotheses that motivational interviewing, compared to assessment only, would result in a reduction of substance use and an increase in each participant's readiness to change. The proposed study utilized a randomized controlled design in which participants received one of two conditions, two 30-minute sessions of a motivational intervention or assessment only. Assessments were administered before and one month following the intervention. Results demonstrated that the intervention was effective in reducing daily cigarette use and symptoms of cigarette dependence for participants in the experimental group. These results are consistent with past research investigating the effectiveness of motivational interventions on reducing adolescent substance use, yet the current findings are unique because this is the first school-based motivational intervention delivered by school personnel to effectively reduce adolescent substance use. Results indicate that the current intervention could be implemented as a standard therapy for using motivational interventions to decrease adolescent substance use in the school setting.

The current study evaluated the initial feasibility, efficacy, and acceptability of a motivationally-tailored family-based intervention designed to promote the adoption of healthy lifestyle behaviors associated with physical activity and nutrition. Parents (N=132) of children 6 to 11 years old were randomly assigned to the intervention or control condition, and they completed a series of online questionnaires. Intervention participants (n=61) received a single motivationally-tailored feedback report via e-mail. Control participants (n=71) completed measures and immediately received information about a free online resource that provides information about healthy lifestyle behaviors (www.mypyramid.gov). Feasibility data indicate that an online feedback program has high dissemination potential (parents from 31 states participated). However, the current methodology is not sufficient in reaching families who are at greatest risk for developing chronic health conditions associated with obesity or low activity level. In general, the intervention was acceptable to parents. Outcome data revealed that the intervention and control groups did not differ significantly on most variables at one month follow-up. Exploratory analyses provided additional evidence for the importance of including parents and targeting parent-child interactions in the context of pediatric nutrition and physical activity interventions. Limitations and future directions are discussed.

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The aim of this dissertation is to examine the content and communicative strategies in texts used in a project on tobacco policy delegated by the Swedish government to the National Institute of Public Health (“The National Tobacco Assignment 2008–2010”). The study uses communicative strategies as an umbrella term for the way the texts fulfil the political assignment through adaptation to suit different receivers in a discursive practice with set guidelines for communication between experts and users, and how these strategies are visible in the studied texts. The material consists of six guides for care personnel and ten brochures for smokers. The study is a text-focused critical discourse analysis combining methodological tools from different linguistic traditions. These are chiefly taken from critical text linguistics, new rhetoric, and sociosemiotics. The main question posed in the study is how the public authority’s assignment to influence people through the texts is combined with ideas about smokers’ empowerment. The investigation problematizes how the content and form of the texts relates to the authority’s assignment to exert influence, and to motivational interviewing as a discursive practice with an empowerment perspective on lifestyle changes. The analyses show that controlling ideas and notions about smokers’ empowerment exist in parallel in the government texts about smoking cessation. Controlling elements are most prominent in the sections of the guides about groups who, in the encounter with care personnel, do not show any interest or desire to quit smoking. In the studied brochures the controlling elements are most prominent in those aimed at operation ­patients, adolescents, and parents-to-be. Both groups of material – the guides and the brochures – nevertheless give the impression of being designed to be compatible with a patient-cent­red discursive practice. This is noticeable, for example, in the occurrence of associative and dissociative argumentation strategies which legitimize or tone down controlling elements.

L’insuffisance cardiaque (IC), une maladie chronique caractérisée par un mauvais fonctionnement du muscle cardiaque, entraîne des symptômes comme l’essoufflement, l’œdème et la fatigue. L’IC nécessite l’adoption de comportements d’auto-soins pour prévenir les épisodes de décompensation. Le but de cette recherche est d’évaluer l’intervention infirmière motivationnelle selon les stades de changements (MSSC) sur les comportements d’auto-soins chez des patients IC. Afin de guider l’intervention MSSC, la théorie spécifique aux auto-soins chez les patients IC de Riegel et Dickson (2008) a été retenue ainsi que le modèle d’intervention de Bédard et al. (2006) combinant le modèle transthéorique (Prochaska & DiClemente, 1984) et l’entrevue motivationnelle (Miller & Rollnick, 2006). Il s’agit d’un devis expérimental randomisé (pré et post-test) avec groupe contrôle (N = 15/groupe). Les patients du groupe contrôle ont reçu les soins usuels et les patients du groupe intervention (GI) ont reçu l’intervention MSSC durant trois entretiens. Les mesures de résultats ont été collectées à un mois suite à la randomisation par une assistante de recherche aveugle à la randomisation. L’effet de l’intervention a été évalué par des analyses de covariance sur cinq mesures de résultats : la réalisation et la gestion (générale et spécifique à l’IC) des auto-soins, la confiance aux auto-soins (générale et spécifique à l’IC) et la conviction. L’acceptabilité et la faisabilité ont été évaluées. Les résultats indiquent un effet significatif sur la mesure de confiance à effectuer les auto-soins spécifiques à l’IC. La majorité des participants du GI ont progressé dans leurs stades de changement. Ces résultats soulignent le potentiel de cette approche pour favoriser l’adoption des auto-soins mais une étude à plus large échelle est proposée afin d’évaluer l’effet de cette approche dans un essai clinique randomisé. / Heart failure (HF) is characterized by the heart’s reduced capacity to pump, resulting in symptoms causing respiratory problems and reduced quality of life. HF patients are advised to adopt self-care behaviours to prevent frequent episodes of decompensation. While medication and behaviour change play a major role in maintaining physiological stability, patient adherence to self-care recommendations is not optimal. The goal of this pilot study was to evaluate a Motivational Intervention following the Stages of Change (MISC) on HF patients’ self-care behaviours. To guide the MISC, the situation-specific theory of heart failure self-care (Riegel & Dickson, 2008) was retained as well as Bédard et al. (2006) model of intervention, a combination of Motivational interviewing (MI) (Miller & Rollnick, 2006) and Transtheoretical model (TTM) (Prochaska & DiClemente, 1984). This was a randomized experimental pilot project (pre and post-test, with a control group) (n=15/group). Patients in the control group received usual care from the HF clinic while patients from the experimental group (EG) received 3 MISC interventions. Data were collected at one month post-randomization by a blinded research assistant. The effect of the intervention was assessed on five self-care outcomes using analysis of covariance models: self-care maintenance and management (general and specific to HF), confidence in self-care (general and specific to HF) and conviction. Acceptability and feasibility were assessed. Significant results were obtained regarding the confidence in performing self-care behaviours specific to HF. A majority of patient in the EG did progress in the stages of change. The results suggest that a MISC intervention has potential to improve self-care. A larger study is needed to evaluate the effects of the MISC intervention in a randomized controlled trial.

Abstract EXPLORING SUBSTANCE USE DISORDERS COMMUNITY OUTPATIENT COUNSELORS’ EXPERIENCES TREATING CLIENTS WITH CO-OCCURRING MEDICAL CONDITIONS. AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS Lauretta Anne Cathers, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2013 Major Director: Amy Armstrong, PhD, Chair, Rehabilitation Counseling The Interpretative Phenomenological Analysis study presents the findings from a qualitative study examining substance use disorders (SUD) community outpatient treatment counselors’ experiences treating clients with co-occurring medical conditions. Interviews from five SUD community outpatient treatment counselors resulted in four emerging super-ordinate themes. The findings illustrate the relationships between SUDs, medical conditions and other predisposing, enabling and need factors. In order to assist clients in focusing on therapy, counselors work to identify resources to treat the basic needs of the clients, including medical care. Challenges included limited resources, complex system processes, and client fear and apathy. In addition, various unique challenges related to medical conditions treated by potentially habit forming medications and traumatic brain injury were identified. Counselors discussed how their roles and responsibilities have expanded to include case management and additional responsibility for the overall well-being of the clients they serve. They encouraged SUD educators to include more education on counselor self-care, trauma, pain conditions and the assessment process. Implications from the study highlight the need for integrated behavioral and physical health care.

The aim of this dissertation is to examine empirically what Evidence-based practice (EBP) and its standardized procedures become when put into practice in social work. EBP builds on the idea that professional practice should be based on systematic and reliable knowledge of the interventions and instruments used in this work. This implies a standardization of both research and practice that has been highly contested. Inspired by works within science and technology studies (STS), this dissertation analyses the actual content of the standardized procedures and their uses in social work practice. The dissertation examines a ‘critical case’, a substance abuse social services agency that has worked extensively for several years at implementing EBP, and consists of four papers focusing on three standardized procedures used by the agency in order to enact EBP: 1) the Addiction severity index (ASI) assessment instrument; 2) the psychosocial intervention Motivational interviewing, and 3) the decision-making model Critical appraisal (CA). Ethnographic methods were employed to study the agency’s concrete uses of the standardized procedures in daily practice. MI was also followed in the research literature as it became established as an ‘evidence-based’ intervention. Fundamentally, the development of the standards of EBP can be a messy and paradoxical process. In the stabilization of MI, its differences and ‘fluidity’ have eventually been made to disappear and left a stable ‘evidence-based’ object. Findings from the ethnographic studies show that EBP, as enacted in the agency’s daily practice, is a bureaucratic project where the agency’s managers have decided on and control the use of a set of standards. Thus, what constitutes relevant evidence is based not on professional discussion within the agency but is ultimately determined by the managers. In practice, the standards introduce new logics that cause tensions within the agency, tensions which the social workers are left to handle. Main conflicts concern how the client work is ordered and contradictory organizational rationales. The three standards are used to varying extent, which can be understood by examining what they seek to standardize and how they are put to work. CA was not used at all, mainly due to its design. Disregarding organizational rationales that are unavoidable within the social services, it could not be adapted to the agency’s work. With ASI and MI the situation was different, mostly because of their organizational adaptability. ASI could be implemented in several phases of the agency’s work flow resulting in adjustments of both the instrument and the work flow. As a ‘fluid intervention’, MI was constrained by, but also adjustable to the organization. It was thus possible for both ASI and MI to transform and be transformed by pre-existing practices, in effect creating new practices. A major conclusion is that EBP and its standardized procedures is a more dynamic and multifaceted process than previously acknowledged in social work. Rather than a deterministic one-way path, there are different kinds, degrees, and mutual transformations of standardization processes, which must be appreciated in research and in practical efforts to implement EBP. Given the importance of the organization in professional social work, there is a need to move away from individualistic conceptions of EBP and to consider what evidence use might mean from an organizational perspective. / <p>At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Manuscript.</p>

L'obésité représente à l'heure actuelle un problème de santé publique majeur. Malgré le rôle essentiel de l'activité physique (AP) dans la gestion du poids, de nombreuses études rapportent les difficultés d'engagement des populations obèses dans un style de vie actif. Ce travail doctoral porte sur l'étude des déterminants psychosociaux de l'AP des personnes obèses. Une méta-analyse a tout d'abord été conduite afin de déterminer l'impact des interventions faisant la promotion de l'AP auprès des populations obèses. L'analyse des 49 études publiées à ce jour, a permis de conclure à un impact significatif, mais modéré (d = 0.44) des interventions, sur l'AP des participants. Si quelques variables (e.g., durée, type d'indicateurs d'AP, format des sessions) semblent moduler le poids des interventions, il n'a pas été possible de tirer des conclusions concernant les processus psychosociaux impliqués dans ces effets. Prenant appui sur la théorie de l'autodétermination (TAD, Deci & Ryan, 2002), un programme de recherche constitué de 3 études complémentaires a ensuite été réalisé, afin (1) d'améliorer la compréhension des mécanismes motivationnels associés à l'adoption d'AP chez des adolescents obèses, et (2) d'évaluer l'impact d'une intervention motivationnelle destinée à rendre cette population plus active physiquement. Suivant un plan corrélationnel transversal, l'étude 1 avait pour objectif d'identifier les patterns motivationnels spécifiquement associés à différents types d'AP (i.e., AP sportive, de loisir, domestique). Les résultats suggèrent que l'AP de loisir est associée à un niveau élevé de régulations identifiée et intégrée, et à un faible niveau d'introjection. La pratique sportive est quant à elle, associée à un niveau élevé d'introjection et un faible niveau de régulation externe. L'étude 2 a exploré, par l'intermédiaire d'une méthodologie qualitative, les facteurs motivationnels associés au succès ou à l'échec d'un programme de gestion du poids pour adolescents. Les résultats indiquent que les participants ayant réussi à perdre du poids semblaient bénéficier d'un plus grand soutien de la part de la famille, et manifestaient une plus grande motivation autodéterminée à maintenir leurs comportements de santé. Enfin, à partir d'un plan randomisé contrôlé sur 6 mois, l'étude 3 a cherché à déterminer si l'ajout de 6 entretiens motivationnels (EM, Miller & Rollnick, 2002) augmentait l'efficacité d'un programme cognitivo-comportemental de gestion du poids. Comparés aux participants n'ayant bénéficié que du programme de gestion du poids, les analyses multi-niveaux montrent que les adolescents qui ont bénéficié à la fois des EM et du programme de gestion du poids présentaient (1) une plus grande augmentation de leur AP (auto-rapportée et objective), (2) une plus grande hausse des régulations identifiée et intégrée, (3) un niveau supérieur de soutien de l'autonomie du personnel médical, et (4) une diminution plus importante du niveau d'amotivation. Pris dans leur ensemble, ces résultats soulignent à la fois l'intérêt de l'EM, comme une stratégie pertinente pour promouvoir l'AP des adolescents obèses, et celui de la TAD comme cadre explicatif des mécanismes motivationnels associés à l'adoption d'AP chez des adolescents obèses. / Obesity currently represents a major public health issue. Despite the fact that physical activity (PA) is recognized to play a key role in weight control, numerous studies tend to show that obese populations experience difficulties in the adoption of an active lifestyle. This doctoral dissertation deals with the psychosocial determinants of PA among obese populations. A meta-analysis was first conducted so as to determine the impact of interventions promoting PA among obese populations. Inclusion of 49 studies published to date enabled to conclude to the existence of a significant, but moderated (d=0.44), impact of interventions on participants' PA. Despite the fact that few variables (e.g., duration, type of PA indicator, format of sessions) modulated impact of interventions, few results appeared concerning the psychosocial processes implicated in those effects. Based on self-determination theory (SDT, Deci & Ryan, 2002), a program of research comprising 3 complementary studies was then conducted in order to (1) enhance the understanding of the motivational mechanisms associated with a PA adoption among obese adolescents, and (2) evaluate the impact of a motivational intervention aiming at helping this population to become more physically active. Using a cross-sectional methodology, study 1 aimed at indentifying the motivational patterns specifically associated with different type of PA (i.e., leisure time PA, sport, daily PA). The results suggest that leisure time PA is associated with high levels of identified and integrated regulations, as well as low levels of introjection. Sport participation was associated with high levels of introjection and low levels of external regulation. Study 2 explored with a qualitative methodology the motivational factors associated with the success or failure of a weight loss program for adolescents. The results indicate that participants who succeeded in losing weight expressed more support from their family and more autonomous reasons to maintain health behaviors. Lastly, study 3 consisted in a randomized controlled trial of 6 months aimed at determining to what extent the addition 6 motivational interviewing sessions (MI, Miller & Rollnick, 2002) would impact the efficacy of a cognitive-behavioral weight loss program. Compared to participants who only benefited from the weight loss program, multilevel analyses reveal that adolescents who received both MI and weight loss program reported (1) an higher increase of PA (self-reported and objective), (2) an higher increase of integrated and identified regulations, (3) an higher autonomy support from medical staff and (4) a more important decrease of amotivation. Taken globally, those results both suggest interest of MI as a pertinent counseling method to promote PA among obese adolescent population as well as interest of SDT as an explanatory framework of motivational processes associated with PA adoption among obese adolescents.

Inscription de la thèse. La présente thèse a fait l’objet d’une Convention Industrielle de Formation par la Recherche (CIFRE) entre le laboratoire de Psychologie EA-4139 Santé et Qualité de Vie de Bordeaux et l’Association pour le Dépistage du Cancer Colorectal (ADECA Alsace) à Colmar.Objectifs. L’objectif principal de la thèse était d’améliorer la participation des 50-75 ans au programme de dépistage organisé du cancer colorectal en Alsace, cela dans le respect de leur autonomie de décision. La thèse était aussi l’occasion de mieux cerner les facteurs d’adhérence aux recommandations de santé. Plan de la thèse. La thèse se compose en deux grandes parties. Dans une première partie, théorique, nous nous sommes interrogés sur la place de la prévention dans nos sociétés hypermodernes (Aubert, 2006) tout en proposant une lecture intégrative de l’adhérence à travers le concept de motivation (Carré et Fenouillet, 2009). Le modèle articule en particulier les apports de l’autorégulation (Hall et Fong, 2007), de l’autodétermination (Ryan et Deci, 2000) et de la dissonance (Festinger, 1957). Il adresse aux professionnels de santé un certain nombre de préconisations destinées à les aider à optimiser leur communication de prévention. Dans une seconde partie, empirique, nous présentons les études randomisées contrôlées mettant à l’épreuve des faits les éléments du modèle articulateur. Deux stratégies motivationnelles ont été testées. Toutes deux greffées sur le dépistage organisé du cancer colorectal en Alsace. La première étude (N=48 413) a fait l’objet d’un article publié dans la revue médicale Gastroenterology et de deux communications, dont une internationale à la Disease Digestive Week de San Diego. Elle évalue l’apport d’un conseil téléphonique ajusté guidée par une approche transthéorique de la motivation (Weinstein, 1988), en particulier l’entretien motivationnel (Miller et Rollnick, 2006). La deuxième étude randomisée contrôlée (N=22397) est une intervention motivationnelle postale axée sur l’autonomie et l’implication. Elle s’inspire du choix informé (Gøtzsche et al., 2008) et de la communication engageante (Girandola et Joule, 2008). Principaux résultats. Les résultats démontrent dans la première étude qu’un conseil téléphonique personnalisé décuple le retour des exclusions médicales (19,2%>1,8%) χ2 (1, N=26425) = 2,603E3 ; p=.000 et permet de doubler, voire tripler la participation par rapport au courrier (30,4%>9,2%) χ2 (1, N=22535) = 1,140E3 ; p=.000 quel que soit le type de conseil χ2 (1, N=2 182) =1,195 ; p=.274. La procédure témoigne en revanche d’un réel écueil de faisabilité par rapport au courrier (3,8%<9,2%) χ2 (1, N=46773) = 5,781E2 ; p.000. La deuxième étude montre un bénéfice du choix informé sur la satisfaction du sujet eu égard au processus d’information F (4, N=63) = 8,570 ; p=.000 mais aucun effet du type de courrier sur la participation en phase de première invitation χ2 (4, N=11470) = 3,012 ; p=.556 comme en relance χ2 (4, N=10610) = 4,352 ; p=.360. Discussion. Les résultats sont discutés et interprétés à l’appui des considérations théoriques du modèle articulateur. Des préconisations pour les professionnels et pour des recherches futures sont soumises en fin de thèse. / Context of the thesis: The present thesis is part of an Industrial Convention of Formation by Research (CIFRE) between the laboratory of Psychology EA-4139 Santé et Qualité de Vie of Bordeaux and the Association pour le Dépistage du Cancer Colorectal en Alsace (ADECA Alsace) in Colmar.Aims of the study: The main objective of the thesis was to improve the involvement of the 50-75 years old segment of the population of Alsace in the organized colorectal cancer screening, whilst respecting their personal decision. The thesis was also the opportunity to get a better understanding of the adherence factors to health recommendations. Structure of the thesis: The thesis is made up of two main parts. In a first theoretical part, we looked into the place of the prevention in our hypermodern societies (Aubert, 2006) while proposing an integrative reading of adherence through the concept of motivation (Carré & Fenouillet, 2009). The model underlines especially the contribution of self-regulation (Hall & Fong, 2007), self-determination (Ryan & Deci, 2000) and dissonance (Festinger, 1957). It provides health professionals with a wide range of recommendations to help them optimize their communication on prevention. In a second empirical part, we have put to the test the components of the articulator model by the randomized controlled studies and, in this way, tested two motivational strategies both related to organized colorectal cancer screening program in Alsace. The first study (N=48 413) resulted in an article published in the Gastroenterology medical review and two conferences, one of which in the international Disease Digestive Week in San Diego. It evaluates the contribution of an adjusted phone counselling guided by a transtheoric approach of motivation (Weinstein, 1988), amongst other things motivational interviewing (Miller & Rollnick, 2006). The second randomized controlled study (N=22397) is a postal motivational intervention focused on self-reliance and involvement inspired by the informed choice (Gøtzsche et al., 2008) and the engaging communication (Girandola & Joule, 2008). Main outcomes: The results of the first study demonstrate that an individualized phone counselling enables to get a tenfold increase in the return of medical exclusions (19,2%>1,8%) χ2 (1, N=26425) = 2,603E3 ; p=.000 and to double or even triple the participation compared to mail (30,4%> 9,2%) χ2 (1, N=22535) = 1,140E3; p=.000 whatever the type of advice χ2 (1, N=2 182) =1,195; p=.274. However, the procedure encounters barriers with regard to its feasibility compared to mail (3,8%< 9,2%) χ2 (1, N=46773) = 5,781E2; p.000. The second study shows a benefit of the informed choice on the satisfaction of the subject related to the information process F (4, N=63) = 8,570 ; p=.000 but no effects of the type of mail on the participation in the course of the phase of first invitation χ2 (4, N=11470) = 3,012 ; p=.556 and even in the relaunching process χ2 (4, N=10610) = 4,352 ; p=.360. Discussion: The results are discussed and interpreted with the support of the theoretical consideration of the articulator model. Recommendations for health professionals and further research projects are submitted at the end of the thesis.