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

The aim of this thesis was to find out how much and in what way children are prepared for surgical procedures. For the research were selected children at the Department of Paediatric Surgery of the Kolín Regional Hospital, from February to June 2018. In the theoretical part, risk factors for developing anxiety disorders in childhood are described. In particular, anxiety and nervousness, fear, phobia, situational anxiety and mental resilience are defined. A mixed method was used in the research. The main tool was a written questionnaire. In the case of unclear answers, an oral interview was used. In the practical part, two types of questionnaires were used. One is for hospitalized children aged 7-15 and the other for their parents. The research found that seventeen children, out of seventy, were not informed at all, or immediately before surgery. All these children were restless, or even hysterical, they were screaming and crying. The children who were informed of the operation in some way tolerated it quite well. So we can say that most of the children were prepared. Mostly it was only by conversation with parents. The educational material was not used because there is not currently appropriate one.

This study examines the design, implementation and evaluation of a communication skills training programme for adherence counsellors in a paediatric HIV clinic. Effective communication is a pre-requisite skill for any counselling interaction. For both prevention and treatment, counselling is a critical component of the healthcare team response to the HIV epidemic. Given the shortages of healthcare workers in sub-Saharan Africa, task-shifting of the counselling role to less-trained cadres of workers is commonplace. In the multilingual, multicultural South African context, taskshifting coupled with the complexity of the message in paediatric HIV presents enormous challenges. In-service support for counsellors is lacking. Counsellor burn-out and fatigue is commonplace affecting the quality of counselling interactions. Measuring the quality of communication in a multilingual context poses ethical and methodological challenges and is a neglected area of research. Traditional communication and counselling assessments appear to be largely taxonomic; lack cultural and linguistic sensitivity; and fail to acknowledge communication as a dynamic, two-way process. Mindful of these issues, this study utilized a non-taxonomic approach. Verbal and non-verbal communication was analysed before and after the implementation of in-service training which was tailored to the specific research context. The training comprised a two day multidisciplinary team workshop followed by individual training. This consisted of video feedback and analysis of counsellors’ own sessions and was attended by four counsellors. Results were recorded over an eighteen month period. Twenty-two consultations between counsellors and caregivers were video-recorded, transcribed verbatim and analysed using a hybridized form of linguistic analysis. Findings that demonstrated consensus, substantiation and cross-consultation occurrence were triangulated with thematically analysed interview data, patient questionnaires and researcher reflections. These methods are more sensitive to process than checklist approaches and individualised, complex dynamics emerged. Communication barriers and facilitators were identified before training. Variations in communicative competence between counsellors appeared to be unrelated to prior training. After training, counsellors asked more open-ended questions, encouraged caregivers more, provided simpler explanations of treatment regimens and checked understanding more effectively. In response, caregivers initiated more questions. These findings suggest that communication training improves treatment literacy and results in interactions that are more patient-centered. Despite this evidence, the results suggest limitations to the impact of communication training given the lack of agency of women in South Africa. Interactions included frank and open discussion about cultural beliefs. However, this benefit may be lost due to poor healthcare team cohesion. In their roles as mothers and caregivers themselves, counsellors are effective patient advocates and bring their own lifeworld experience to the counselling interaction. These shared stories are testimonies to the resilience of women living in poverty. Whilst allowing for greater exploration of patients’ cultural beliefs and explanatory models, communication training has limited impact in assisting counsellors with dealing with issues such as disclosure, non-adherence and scepticism about biomedicine. Results indicate conflict between patient-centeredness and perceived desired medical outcomes. Caregivers and counsellors appeared to engage in ritualistic dialogue when discussing certain topics suggesting that a shared lifeworld between caregiver and counsellor is insufficient to overcome barriers from the meso (institutional) and macro (broader socio-political) context. An awareness of the impact of context is critical to our understanding of communication in a clinical setting. The results from this research have implications for the role of the counsellor within a multidisciplinary team and establish a need for communication specialists to work in a clinical setting within the HIV epidemic.

>Magister Scientiae - MSc / Background: Plaster models form an integral part of the traditional orthodontic records. They are necessary for diagnosis and treatment planning, case presentations as well as for the evaluation of treatment progress. The accuracy of the measurements taken for space assessment is crucial prior to treatment planning. The introduction of digital models overcomes some problems experienced with plaster models. Digital models have shown to be an acceptable alternative for plaster models. Aim: The aim of the study was to determine the accuracy of traditional measurement techniques when compared to the CAD/ CAM measurements in the assessment of tooth widths and arch perimeter from plaster models. Method: The mesio-distal tooth widths and arch perimeter of thirty archived plaster models were measured using a digital caliper to the nearest 0.01 mm and divider to the nearest 0.1 mm. Corresponding digital models were produced by scanning them with a CAD/CAM (InEos X5) and space analysis completed by measurements using InEos Blue software. Measurements were repeated after 1 week from the initial measurement. The methods were compared using descriptive analysis (mean difference and standard deviation). Results: The operator reliability was high for digital models as well as the plaster models when the measurement tool was the digital caliper (analyzed using the Pearson correlation coefficient in the paired t-test). The mean values of tooth widths measurements of CAD/CAM, digital caliper and divider were 6.82 (±0.04), 6.94 (± 0.04) and 7.11 (± 0.04). There was a significant difference between the measurements made by the CAD/CAM and the divider. Additionally significant differences between the measurements by digital caliper and divider measurements (p < 0.05) were observed. No significant difference was found when comparing CAD/CAM to digital caliper. Positive correlation was displayed between CAD/CAM, digital caliper and the divider, but the measurements completed with the digital caliper had the highest correlation with the CAD/CAM. The difference was not significant between the aforementioned measurement tools (p > 0.05). Arch perimeter measurements showed no statistical significant difference between CAD/CAM, digital caliper and divider (p < 0.05). Conclusion: Archived plaster models stored as records can be converted to digital models as it will have the same accuracy of measurements. The value of doing a space analysis with the CAD/CAM system can be performed with similar reliability on the digital models as a caliper on plaster models.

Multiple breath washout (MBW) of inert gas for assessment of airway disease in children is an emerging technique. In many studies Lung Clearance Index (LCI), derived from multiple breath washout of SF6, is more able to detect early or mild lung disease than standard lung function measurements. It is also able to detect very early lung disease in progressive conditions such as Cystic Fibrosis (CF). Where infants born with this condition were thought to have minimal lung disease activity, LCI is higher in these children than healthy controls. Lack of available commercial devices has hampered expansion of this technique to centres other than specialist research teams. Innocor (Innovision, Dk), a photoacoustic mass spectrometer capable of performing multiple breath washout, was adapted within this research group for use in adults. This thesis describes the setup, adaptation and validation of Innocor for use in children. In 4 studies, healthy controls, children with asthma and children with CF were recruited to perform MBW. In one study, 29 healthy controls and 31 children with asthma were recruited. Healthy controls performed 1 set of washouts, establishing a normative range. Children with asthma performed measurements before and after bronchodilator. Results showed increased LCI in children with asthma even though they were clinically stable as defined by symptoms. LCI stayed high even following bronchodilator suggesting evidence of residual airway disease in well controlled asthmatics despite adequate symptom control. To investigate short term variability of MBW measurements, two other studies recruited 18 children with CF in each. They performed measurements before and after standard physiotherapy manoeuvres and during sitting and lying posture. LCI did not change significantly after airway clearance physiotherapy, compared with children who did no intervention. Variability was high in both groups however suggesting CF lung disease is a complex interaction of changing ventilation in adjacent lung units. Lying posture induced greater changes in lung function in children with CF than controls. LCI appears to be more sensitive to this change than standard lung function measurements (spirometry). In another study 32 children with CF were recruited to perform serial lung function measurements over 18 months. These were data collected as part of the UK Cystic Fibrosis Gene Therapy Consortium (CFGTC) clinical studies in preparation for planned gene therapy trials. LCI appears comparable to FEV1 and may be able to detect another aspect of airway disease. All initial studies were performed in older children (>5yrs). The basic Innocor device is unsuitable for testing of younger patients with low breath volume and high respiratory rate. In-house adaptations following detailed lung model experimentation led to a faster analyser response, potentially capable of MBW in younger children. The second part of this thesis concerns lab experiments and an in-vivo comparison with the current gold-standard MBW device, a respiratory mass spectrometer. 16 healthy volunteers and 9 children with CF were recruited. Ages ranged from 0.4 yrs to 49 yrs. Innocor values for lung volume estimation compared favourably with the mass spectrometer. No evidence of bias caused by Innocor error was seen, however intra-test variability was rather high, reducing the precision of the results. These studies indicate Innocor is a robust, simple to use device with potential as a commercial lung function system. Modifications were made to make it suitable for use in all ages. Further development will need to focus on the patient interface and software, which is the domain of the manufacturers. The experiments contained in this thesis are therefore of interest to the wider respiratory research community as well as manufacturers of MBW devices.

Introduction: In previous years, Occupational Therapy relied on the parents and caregivers’ perspectives about their children’s activity capacity, performance, and participation. The shift to a more child and family-centred practice has led to the creation of a variety of self-reported assessments for children and adolescents. This study reviewed articles containing paediatric self-report assessments, available for use within the Occupational Therapy area, and critically appraised them. Method: A systematic review in seven databases with the use of 22 search terms was conducted. Inclusion criteria was articles containing paediatric and adolescent reported assessments available to Occupational Therapists, published up to 20 years old and written in the English language. Exclusion criteria included articles containing impairment-based measures and proxy reported measures. The initial literature search took place between March 1st, 2018 and April 30th, 2018. Eighty-two articles met criteria, and, from these articles, 21 assessments were found and appraised using the COSMIN checklist Results:. Twenty-one assessments were found to measure children’s and adolescents’ perceptions on their activity capacity, performance and/ or participation. All their characteristics and technical details are mentioned in depth in this research. When applicable, clinimetric properties were appraised and found quite a few with good or excellent reliability and validity. Few assessments had not any research regarding their clinimetric properties. Conclusion: Most found assessments measured activity capacity and performance. The need for more participation-based measures emerged. Few assessments showed good or excellent reliability and validity which need to be considered if used within clinical practice.

It is of crucial importance to identify and disseminate effective treatments for paediatric obsessive-compulsive disorder (OCD). OCD is time-consuming and distressing, and can substantially disable functioning at school, at home, and with peers (Piacentini, 2003). Children who do not receive treatment are at risk of psychological difficulties in adulthood, including continued OCD, clinical anxiety and depression, personality disorders, and social maladjustment (Wewetzer et al., 2001). Two-thirds of adult cases of OCD develop in childhood, and adults with OCD have lower employment, poorer academic achievement, and lower marital rates compared to non-OCD adults (Hollander et al., 1996; Koran, 2000; Lensi et al., 1996; Steketee, 1993). The distressing nature of OCD in childhood, accompanying psychosocial impairment and risk of future psychopathology, underscore the need to identify effective treatments. The primary aim of this thesis was to expand knowledge of evidence-based treatments for paediatric OCD. A mixed-methodology approach was employed to examine key issues in this area. The first study used meta-analytic methodology to determine the evidence supporting available treatments for paediatric OCD. An extensive literature search revealed over 100 published reports of treatments, encompassing a broad array of theoretical approaches and treatment strategies. Examples of treatments used for paediatric OCD included psychodynamic therapy, pharmacotherapy, cognitive-behavioural therapy (CBT), hypnosis, family therapy, immunotherapy, and homeopathy. / Study 1 comprised the first known meta-analysis of randomised, controlled treatment trials (RCTs) for paediatric OCD. Included studies were limited to RCTs as they are the most scientifically valid means for determining treatment efficacy and provide a more accurate estimate of treatment effect by removing error variance associated with confounding variables. The literature search identified 13 RCTs containing 10 pharmacotherapy to control comparisons (N = 1016) and 5 CBT to control comparisons (N = 161). Random effects modelling yielded statistically significant pooled effect size (ES) estimates for pharmacotherapy (ES = 0.48, 95% CI = 0.36 to 0.61, p < .00001) and CBT (ES = 1.45, 95% CI = 0.68 to 2.22, p =.002). The results support the efficacy of CBT and pharmacotherapy, and confirm these approaches as the only two evidence-based treatments for paediatric OCD. Implications and suggestions for future research are discussed. The effectiveness of CBT provided impetus to further examine this treatment. Group CBT is an understudied treatment modality among children with OCD. It was hypothesised that group CBT would possess efficacy because of the effectiveness of individual CBT for children with OCD, the demonstrated effectiveness of group CBT among adults with OCD, the practical and therapeutic advantages afforded by a group treatment approach, and the embeddedness of the approach in robust psychological theory. The aim of the second study was to evaluate the efficacy of group CBT. The study comprised the largest known conducted randomised, placebo-controlled trial of group CBT for paediatric OCD. / Twenty-two children and adolescents with a primary diagnosis of OCD were randomly assigned to a 12-week program of group CBT or a credible psychological placebo. Children were assessed at baseline, end of treatment, and at 1 month follow-up. Outcome measures included the Children’s Yale-Brown Obsessive-Compulsive Scale, global measures of OCD severity, Children’s Depression Inventory, and parent- and child-rated measures of psychosocial functioning. An intention-to-treat analysis revealed that children in the group CBT condition had statistically significantly lower levels of symptomatology at posttreatment and follow-up compared to children in the placebo condition. Analysis of clinical significance showed that 91% of children that received CBT were ‘recovered’ or ‘improved’ at follow-up, whereas 73% of children in the placebo condition were ‘unchanged’. Effect size analysis using Cohen’s d derived an effect of 1.14 and 1.20 at posttreatment and follow-up, respectively. These effects are comparable to results from studies of individual CBT. This study supported group CBT as an effective treatment modality for paediatric OCD and demonstrated that the effect extends beyond placebo and nonspecific treatment factors. In addition to treatment efficacy, the inherent worth of a treatment lies in its adoption by the relevant clinical population. Children with OCD are known to be secretive and embarrassed about symptoms, and there is often a long delay between onset of symptoms and treatment-seeking (Simonds & Elliot, 2001). An important observation during the course of conducting the RCT was that a high rate (39%) of eligible families declined participation. / This led to the question, "What barriers prevent participation in group CBT for paediatric OCD?" Qualitative methodology was employed to address this research question. Eligible families that had declined participation in the RCT were contacted and invited to participate in semi-structured interviews that explored reasons for non-participation and positive and negative perceptions of group CBT. The average time between non-participation and interview was 1.33 years (SD = 3 months). Data were collected from nine families and thematic analysis methodology was utilised to identify emergent themes. Failure to participate was predicted by practical and attitudinal barriers. Practical barriers included a lack of time, distance, severity of OCD symptoms, financial, and child physical health. Attitudinal barriers included child embarrassment about OCD symptoms, child belief that therapy would be ineffective, fear of the social aspect of the group, lack of previous success with psychology, lack of trust in strangers, parental concern about the structure of the group, denial of a problem, and ‘not being ready for it’. Attitudinal barriers more frequently predicted treatment non-participation. Positive and negative perceptions of this treatment modality were informative. Parents showed no differences in preference for individual or group CBT. An important finding was that 56% of the children had not received treatment since parental expression of interest in the group CBT program. Application of the findings to methods that promote service utilisation is discussed.

Family centred care is a concept espoused to be fundamental to achieving excellence in paediatric nursing. Although it is recognised that family centred care includes the child's rights to self determination the focus of this study is parental participation in the decision making and care of their hospitalised child at a partnership level. This is based on negotiation and requires frequent, effective communication between parents and nurses and for each to respect the other's knowledge and appreciate the other has something to offer in the relationship which will benefit the child. The purpose of this study was to identify whether family centred care was occurring in paediatric settings in rural Western Australia and explored parents' and nurses' perceptions of the concept. A questionnaire was designed based on the literature and common themes identified from focus groups. Convenience sampling was used and 15 rural hospitals facilitated participation of 243 parents who had a child under ten years of age hospitalised and 108 nurses who cared for children. Exploratory factor analysis identified four subscales from the parents' questionnaire and three subscales from the nurses' questionnaire which measured separate concepts of family centred care. Descriptive statistics were generated for each subscale, and independent t-tests, ANOVA and correlations were examined between independent variables and subscales of family centred care. There was a statistically significant difference in scores for parents' perceptions of `child friendly environment' between regional and district hospitals. Those parents who did not have social support scored a statistically significantly lower mean score for `respect as parent'. Nurses in district hospitals generated statistically significantly higher mean scores for `family focussed hospital' than those who worked in regional hospitals. / Parents and nurses both perceived that parents wanted to continue parenting their hospitalised child, however parents wanted to provide more nursing care than was perceived by nurses. Nurses' perceptions of delivering family centred care were greater than the perceptions of parents receiving it, however they were consistent in items that were scored low. Nurses did ask parents about the amount of participation they wanted in their child's care on admission however, it was not done on a regular basis. Parents perceived that nurses were unaware of other things that parents needed to attend to while their child was hospitalised and therefore did not enable parents to attend to these needs. More frequent negotiation of roles between parents and nurses by communicating each shift, or at least daily, could narrow the gap between differing perceptions in care provision and also enable parents to attend to their other roles thereby reducing their levels of physical and emotional stress.

Doctor of Philosophy (PhD) / This study was conducted to increase our understanding of children and young people’s experience of a hospital environment and to identify the salient attributes of the physical environment in their experience. There were three specific aims: to describe children and young people’s experience of a hospital environment and identify what constitutes a supportive paediatric environment; to examine the role of the physical environment in patients’ feeling of well-being; and to highlight the capacity of participatory research with children and young people to inform evidence-based paediatric design. At this stage, there has been very little healthcare design research carried out with populations of children and young people. Well-being research with children and young people in paediatric environments that identifies the potential supportive attributes in this environment is also very limited. Historically research on children’s health and well-being has been dominated by a focus on the prevalence of disorders, problems and disabilities. More recently, in response to the change to health promotion, positive attributes have been included in well-being and satisfaction measures. At this stage, there are still many fewer positive measures. Within the body of literature that exists in healthcare, healthcare design research, and well-being research, there are only a small number of participatory studies that focus on children and young people’s experience of hospitalisation, and an even smaller number that include children and young people’s experience of hospital environments. The picture that is created by the research that exists is patchy. There is a need for a more holistic understanding of children and young people’s experience of hospitalisation and of hospital environments from their own perspectives. Based on these gaps in current knowledge, two research questions were developed. The first was concerned with describing children and young people’s experience of the sociophysical environment of a paediatric hospital. The second question was concerned with understanding the role of the physical environment in children and young people’s feeling of well-being in a hospital environment. In addressing these questions, the intention was to identify attributes within the hospital setting which collectively comprise a supportive environment for children and young people and which contribute to children and young people’s feeling of well-being in a paediatric setting. The current study was conducted as an exploratory qualitative case study and carried out at the Children’s Hospital at Westmead, in Sydney, Australia. Using participatory research techniques, the sequence of the study included two pilot studies and the main study. The focus was on understanding the experiences of longer-term patients of a paediatric hospital environment. In the main study 25 children and young people, aged between 9-18 years, who had been in hospital for at least a week completed semi-structured interviews in which they talked about their response to the environment of the hospital and their experience of hospitalisation. Data analysis was completed using a combination of concept mapping and thematic analysis techniques. Preliminary findings were used as the basis of a further member-checking task carried out with a further six children and young people before conclusions were reached. The findings reveal that children and young people’s experience of a paediatric setting involves a number of major areas of influence including their personal situation, their social experience, their interaction with the physical environment, opportunities and characteristics of the organisation, and the effect of time. The findings also reveal that children’s feeling of well-being within this experience is linked to their ability to feel comfortable in the environment, to maintain a positive state of mind, and to remain positively engaged with the experience and the environment. This research reveals a dynamic relationship between children and young people and a paediatric environment that children and young people actively manage and shape. It reveals some of the key considerations in children and young people’s experience of hospitalisation. It also reveals why these considerations are important and what role they play in patients’ experience and feeling of well-being. These findings provide the basis for further research and they have implications for future design and research practice in paediatric healthcare settings.

<p>Identifiering av fysisk barnmisshandel är en komplicerad uppgift och många misshandelsfall upptäcks inte av sjukvården. Det har skett en attitydförändring i samhället över tid, vilket har bidragit till en ökad anmälningsfrekvens av barnmisshandel. Fysisk barnmisshandel är när en vuxen vållar ett barn skada med eller utan tillhygge. Syftet med denna litteraturstudie var att belysa vilka kännetecken sjuksköterskan ska uppmärksamma vid kontakt med familjer för att upptäcka om barnet har utsatts för fysiskt våld. Med hjälp av tretton artiklar och en avhandling formades litteraturstudien. Resultatet visar att det finns ett stort antal varningssignaler som sjuksköterskan ska vara observant på vid misstanke av barnmisshandel. Dessa kännetecken varierar och kan vara allt från somatiska skador på barnet till föräldrarnas beteende i sociala sammanhang. Genom erfarenhet och utbildning inom området barnmisshandel, underlättas sjuksköterskans arbete i att särskilja situationer där ett barn blir misshandlat från en situation där ett barn skadas i samband med lek. Vidare forskning i ämnet barnmisshandel krävs för att stärka sjuksköterskeprofessionen och därmed fånga upp fler utsatta barn.</p> / <p>The disclosure of physical child abuse is a complex task for the medical care. A great number of cases are never revealed. There is a trend of an increased reporting frequency of child abuse, since the general attitude in the society has changed. Physical child abuse is defined as: An adult physically harming a child with or without an object. The purpose of this literature study was to summarize what nurses on the field should look for to discover physical child abuse. This paper was formed as a result of a literature study which included 13 articles and 1 thesis. The literature study resulted in identification of a large number of relevant warning signals of child abuse, for example somatic injuries and parental behaviour in social groups. To simplify the nurses' work of separating cases of child abuse from cases of normal accidents during play, existing experience within this area must be disseminated by education. Also, further research within this area is required to improve the nursing profession and help a larger fraction of exposed children.</p>