Versão portuguesa do CANE (Camberwell Assessment of Need for the Elderly) : desenvolvimento e dados preliminares

RESUMO - A avaliação de necessidades de cuidados é crucial no planeamento, monitorização e avaliação de serviços de psiquiatria e saúde mental, bem como na investigação e na clínica. Este princípio é obviamente aplicável aos serviços responsáveis por populações de pessoas mais velhas. O instrumento CANE — Camberwell Assessment of Need for the Elderly possibilita uma avaliação consistente das necessidades de utentes idosos, nomeadamente em situações de patologia neuropsiquiátrica. Procede-se a uma avaliação cruzada, entrevistando a pessoa em questão, o seu cuidador informal e o técnico responsável. Esta avaliação multidimensional abrange domínios da esfera biológica, psicológica e social, sendo aplicável na comunidade ou em internamento (regime parcial ou completo). A utilidade do CANE tem sido evidenciada em contextos clínicos, de investigação e de avaliação de serviços. Existem múltiplas traduções a nível internacional, a maioria das quais validada. Na área da epidemiologia psiquiátrica nem sempre estão disponíveis os dados relativos à qualidade das adaptações de instrumentos, pelo que se apresenta o processo de desenvolvimento da versão portuguesa (de acordo com as regras para validação transcultural, no processo de tradução-retroversão). A aplicabilidade da versão portuguesa foi satisfatória neste estudo-piloto, representando a primeira fase de um trabalho multicêntrico nacional. Nesta fase inicial, foram considerados casos de idosos com patologia neuropsiquiátrica (maioritariamente demência — 71,4%), em dois centros (Lisboa e Porto) (n = 21). A média de idades foi 73,9 (± 6,3) anos, sendo 76,2% do sexo feminino. A maioria vivia em casa, apresentava co-morbilidade somática e estava em contacto com um cuidador informal (em geral, familiares do sexo feminino). Os avaliadores identificaram necessidades, nem sempre cobertas, nas seguintes dimensões: cuidados com a casa, alimentação, actividades diárias, memória, saúde física, sofrimento psicológico, companhia e dinheiro/economias. Nem sempre a perspectiva de doentes, cuidadores, técnicos e avaliadores foi inteiramente coincidente. Estes resultados preliminares da aplicação da versão portuguesa do CANE são consistentes quanto à sua validade ecológica, facial e de conteúdo, estando em curso contributos adicionais para a validação efectiva numa amostra de maior dimensão.

A model of personality and health : coping styles as a moderator in the perfectionism-health connection

The purpose of this study was to examine a model of personality and health. Specifically, this thesis examined perfectionism as a predictor of health status and health behaviours, as moderated by coping styles. A community sample of 813 young adults completed the Multidimensional Perfectionism Scale, the Coping Strategy Indicator, and measures of health symptoms, health care utilization, and various health behaviours. Multiple regression analyses revealed a number of significant findings. First, perfectionism and coping styles contributed significant main effects in predicting health status and health behaviours, although coping styles were not shown to moderate the perfectionism-health relationship. The data showed that perfectionism did constitute a health risk, both in terms of health status and health behaviours. Finally, an unexpected finding was that perfectionism also included adaptive features related to health. Specifically, some dimensions of perfectionism were also associated with reports of better health status and involvement in some positive health behaviours.

Assessing the psychometric properties of dream content questionnaires

The present study was the first of its kind to systematically explore the psychometric properties of dream content questionnaires as measures of dream experience. One hundred and six University students filled out the Dream Content Questionnaire (DCQ) and kept a 14-day dream diary on two separate occasions, in addition to filling out the NEO-PI-R and Multidimensional Personality Questionnaire and measures of spatial ability and imaginativeness. The DCQ's reliability was acceptable, as was its discriminant and construct validity. Six of eight predicted relationships between trait personality and DCQ reported dream content were significant. In contrast, dream diaries showed instability over time and were unrelated to personality traits. The DCQ's concurrent validity could not be adequately appraised due to the inconsistency in dream diary content over time. The results suggest that questionnaires may be used to measure dream experience; however, the precise utility of dream questionnaires remains unclear. The findings raise important questions concerning measures of dream experience.

Identifying the psychosexual implications of radical radiation treatment in prostate cancer

The purpose of this study was to determine whether there was any evidence of psychosexual morbidity among men who experienced radical radiation treatment for prostate cancer. With relatively little known or available retrospective data on the psychosexual implications of radical radiation treatment in men with prostate cancer, this study posited eight research questions which provided the basis for the research. Fifty men from Southern Ontario, between the ages of 52 to 78 years, were included in the study. They had been previously randomized to a clinical trial comparing radical radiation therapy by external beam radiation, or radical radiation using a combination of a temporary iridium implant plus external beam radiation, for localized or locally advanced prostate cancer. Assessment of sexual functioning, drive, attitudes, body image, and sexual satisfaction was drawn from a multidimensional approach, since psychosexuality was viewed as having an impact on biological, psychological, and sociological domains of functioning. Medical chart reviews, semi-structured interviews, demographical profiles of each participant, and the Derogatis Sexual Functioning Inventory (DSFI) were the methods used to collect data over a four-month period. Both quantitative and qualitative research methods were incorporated in the design and evaluation of the study. Frequencies, contingency analysis, Pearson's coefficient of correlation, t-tests, and ANOVA comprised the quantitative analysis. Data obtained from audio-taped interviews were analyzed qualitatively, and used for offering further insight and for facilitating the quantitative aspect of the analysis. Overall, there was sufficient evidence to suggest psychosexual morbidity among men who were treated with radiation therapy for prostate cancer. As well,there were a number of significant findings available to answer all of the posited research questions. The most significant findings were noted in post-treatment erectile ability and sexual activity. A post-treatment change in erectile ability was reported by eighty percent of men. Sixty percent of men noted a decrease in their ability to achieve an erection by reporting some morning stiffness only, penile rigidity insufficient for penetration, decreased control of erection, and loss of spontaneous erection. Other contributing factors associated with change in erectile status were: pain or altering sensation of orgasm, blood in ejaculate, pain and decreased amount of ejaculate, and penile numbness or pain. Eighty-two percent of men experienced a post-treatment change in sexual function, primarily due to the impact of decreasing erectile status. Only seven men reported that they experienced a decrease in desire mentally, whereas the vast majority did not experience any change in desire. Changes in foreplay, stress with optimal sexual positioning, and reduced spontaneity of sex, were other factors reported with the changes in sexual activity. The findings in this study broaden our understanding of what middle- to later-aged men feel and experience as they venture onward following treatment. This was the first study that evaluated available prospective data on pre-treatment erectile status and sexual activity. As well, this study was the first (with participant compliance rates of 100 percent) to have included an interview format to capture the views of such a large number of men. This study concluded with recommendations and implications for future research and practice as we move in the direction of understanding what is necessary for preserving psychosexual well being and enhancing quality of life in men treated with radiation therapy for prostate cancer.

Wellness and balance: perceptions amongst female health care professionals negotiating career, family, and continuing education /

The purpose ofthis study was to explore the perceptions of wellness and bidance amongst female health care professionals negotiating career, family aiul continuing education commitments. Five women who met the criteria of having a family (with children), holding a full-time professional career in health care, and who were presently pursuing continuing education were interviewed. This paper begins with the introduction to the topic of research and the questions to be answered. The review of literature explores the theory and research A^ch precede this study and addresses the surrounding areas of: wellness, balance, multiple roles, stress and continuing education. < This study has assumed a qualitative, phenomenological approach. The data collected through the use of individual interviews were analyzed using a two-part process. Analysis using both (a) methodological interpretation and (b) The Listening Guide method has allowed for the uncovering of major themes, and the portrayal of each participant's unique experience. Some of the major themes which emerged from this research include: wellness as multidimensional and fluctuating, making personal sacrifices, the presence of stress, professional as a vital role, and continuing education as something for me. Perhaps the most significant finding this research has identified is the positive role continuing education can hold in the lives of women already negotiating multiple commitments. The notion that continuing education can act as a means of enhancing perceptions of wellness and balance holds a number of implications in theory, practice, and for future research.

Social comparison and body image in non or infrequent exercisers and exercisers

Body image refers to an individual's internal representation ofhis/her outer self (Cash, 1994; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). It is a multidimensional construct which includes an individual's attitudes towards hislher own physical characteristics (Bane & McAuley, 1998; Cash, 1994; Cash, 2004; Davison & McCabe, 2005; Muth & Cash, 1997; Sabiston, Crocker, & Munroe-Chandler, 2005). Social comparison is the process of thinking about the self in relation to others in order to determine if one's opinions and abilities are adequate and to assess one's social status (Festinger, 1954; Wood, 1996). Research investigating the role of social comparisons on body image has provided some information on the types and nature of the comparisons that are made. The act of making social comparisons may have a negative impact on body image (van den Berg et ai., 2007). Although exercise may improve body image, the impact of social comparisons in exercise settings may be less positive, and there may be differences in the social comparison tendencies between non or infrequent exercisers and exercisers. The present study examined the nature of social comparisons that female collegeaged non or infrequent exercisers and exercisers made with respect to their bodies, and the relationship of these social comparisons to body image attitudes. Specifically, the frequency and direction of comparisons on specific tal-gets and body dimensions were examined in both non or infrequent exercisers and exercisers. Finally, the relationship between body-image attitudes and the frequency and direction with which body-related social comparisons were made for non or infrequent exercisers and exercisers were examined. One hundred and fifty-two participants completed the study (n = 70 non or ill infrequent exercisers; n = 82 exercisers). Participants completed measures of social physique anxiety (SPA), body dissatisfaction, body esteem, body image cognitions, leisure time physical activity, and social comparisons. Results suggested that both groups (non or infrequent exercisers and exercisers) generally made social comparisons and most frequently made comparisons with same-sex friends, and least frequently with same-sex parents. Also, both groups made more appearance-related comparisons than non-appearance-related comparisons. Further, both groups made more negative comparisons with almost all targets. However, non or infrequent exercisers generally made more negative comparisons on all body dimensions, while exercisers made negative comparisons only on weight and body shape dimensions. MANOV As were conducted to examine if any differences on social comparisons between the two groups existed. Results of the MANOVAs indicated that frequency of comparisons with targets, the frequency of comparisons on body dimensions, and direction of comparisons with targets did not differ based on exercise status. However, the direction of comparison of specific body dimensions revealed a significant (F (7, 144) = 3.26,p < .05; 1]2 = .132) difference based on exercise status. Follow-up ANOVAs showed significant differences on five variables: physical attractiveness (F (1, 150) = 6.33,p < .05; 1]2 = .041); fitness (F(l, 150) = 11.89,p < .05; 1]2 = .073); co-ordination (F(I, 150) = 5.61,p < .05; 1]2 = .036); strength (F(I, dO) = 12.83,p < .05; 1]2 = .079); muscle mass or tone (F(l, 150) = 17.34,p < .05; 1]2 = 1.04), with exercisers making more positive comparisons than non or infrequent exercisers. The results from the regression analyses for non or infrequent exercisers showed appearance orientation was a significant predictor of the frequency of social comparisons N (B = .429, SEB = .154, /3 = .312,p < .01). Also, trait body image measures accounted for significant variance in the direction of social comparisons (F(9, 57) = 13.43,p < .001, R2adj = .68). Specifically, SPA (B = -.583, SEB = .186, /3 = -.446,p < .01) and body esteem-weight concerns (B = .522, SEB = .207, /3 = .432,p < .01) were significant predictors of the direction of comparisons. For exercisers, regressions revealed that specific trait measures of body image significantly predicted the frequency of comparisons (F(9, 71) = 8.67,p < .001, R2adj = .463). Specifically, SPA (B = .508, SEB = .147, /3 = .497,p < .01) and appearance orientation (B = .457, SEB = .134, /3 = .335,p < .01) were significant predictors of the frequency of social comparisons. Lastly, for exercisers, the results for the regression of body image measures on the direction of social comparisons were also significant (F(9, 70) = 14.65,p < .001, R2adj = .609) with body dissatisfaction (B = .368, SEB = .143, /3 = .362,p < .05), appearan.ce orientation (B = .256, SEB = .123, /3 = .175,p < .05), and fitness orientation (B = .423, SEB = .194, /3 = .266,p < .05) significant predictors of the direction of social comparison. The results indicated that young women made frequent social comparisons regardless of exercise status. However, exercisers m,a de more positive comparisons on all the body dimensions than non or infrequent exercisers. Also, certain trait body image measures may be good predictors of one's body comp~son tendencies. However, the measures which predict comparison tendencies may be different for non or infrequent exercisers and exercisers. Future research should examine the effects of social comparisons in different populations (i.e., males, the obese, older adults, etc.). Implications for practice and research were discussed.

Impact of social constructs on administrator understanding of social justice

Educational administrators are expected to relate social justice considerations to their actions and to the theoretical foundations of their practice. At the same time, social constructs-including those related to administrative practice, social justice, and societal norms-are important in helping administrators understand, frame, and describe administrative issues. Furthermore, as part of socially constructed language, these constructs represent discursive practices and accepted ways of knowing, valuing, and experiencing the world. Drawing on the multidimensional methods of critical discourse analysis as articulated in the writings of Michel Foucault, Norman Fairclough, and Allan Luke, and using deconstruction as a strategic device for reading and interpreting texts, this exploratory qualitative study examined how administrator knowledge, values, and experiences impact their understanding of social justice within the context of delivering social justice for students who experience bullying. Study findings reveal that school administrators interpreted social justice as equitable distribution, action, and results; fairness; and equity. Constructs embedded in these interpretations assumed common things such as universal acceptance of norms of social relations and conveyed administrator intent to secure the kind of social relations that enabled individuals to enjoy greater equality within existing social arrangements.

Actual and perceived coaches' sportspersonship behaviours and their relationship with young athletes' sportspersonship orientations

Hom' s (2008) model of coaching effectiveness provides a framework that outlines the antecedent factors that influence coaches' behaviours as well as the way in which coaches' behaviours can influence the psychosocial development of athletes. Perceived coaches" behaviours have been shown to predict the self-reported unsportspersonlike behaviours of young athletes (Shields et aI., 2007). However, very few studies have examined actual coaches' sportspersonship behaviours (Arthur-Banning et aI., 2009; Cote et aI., 1993; Trudel e t aI., 1991). The purpose of this exploratory study was to investigate the relationships between coaches' and athletes' sportspersonship orientations and behaviours. Participants included competitive male basketball coaches (N = 5) and their male athletes aged 10 to 13 (N= 48). Two investigators systematically observed coaches' sportspersonship behaviours. Subsequently, coaches and athletes completed questionnaires based on the Multidimensional Sportspersonship Orientations Scale (MSOS; Vallerand et aI., 1997). The results showed that coaches' self-reported sportspersonship orientations and athletes' perceptions of their coaches behaviours were consistent with coaches' actual behaviours for respect for the rules and officials as well as for social conventions. A series of multiple regressions were conducted in order to determine whether or not athletes' perceptions of their coaches' sportspersonship behaviours predicted the sportspersonship orientations of athletes. The only significant regression model was for athletes' negative approach toward sport participation. The results also suggest that the MSOS has reliability and validity issues.

The light and dark sides of perfectionism : implications for health and well-being

The present work presents two studies that examined the association of perfectionism, operationally defined by Hewi t t and Fl e t t ' s (1991) multidimensional mode l of perfectionism, with health and subjective well-being (SWB). The underlying question of this research was whether perfectionism could be beneficial as well as detrimental to health and well-being, as this is one of the mos t highly debated questions in the current literature. In samples of relatively healthy university students (n = 538) and community adults suffering from various chronic illnesses (n = 772), results from Study One indicated that socially prescribed perfectionism (SPP) is directly associated wi th poor e r he a l th and well-being. Results further showed f rom a personcentered perspective that there is a l a rge group of individuals wi th high levels of SPP and that i t is indeed these individuals who reported the poorest health and lowe s t levels of well-being. Other-oriented perfectionism was found to be unrelated to health and SWB. Findings revealed that when perfectionism is self-imposed (i.e., self-oriented perfectionism; SOP), i t is neither healthy nor unhealthy in an absolute sense. From the variable-centered perspective, this conclusion was supported by the f a c t tha t SOP was associated wi th both positive (e.g., be t t e r mental health and highe r levels of SWB in the student sample), and nega t ive correlates (e.g., higher levels of negative affect, stress, and neuroticism in both samples). Evidence f rom the chronically-ill sample further substantiated this conclusion by showing that there may be an optimal level of SOP, because mode r a t e levels of SOP we r e found to be associated with be t t e r health and highe r levels of SWB, whereas levels tha t we r e too low or too high we r e found to be associated with poor e r health and lowe r levels of SWB. Findings f rom the person-centered approach we r e particularly informative, in that they not only demonstrated tha t unique profiles of

Using GPS, GIS & remote sensing to understand Niagara Terroir : Pinot noir in the Four Mile Creek & St. David's Bench sub-appellations

The relationships between vine water status, soil texture, and vine size were observed in four Niagara, Ontario Pinot noir vineyards in 2008 and 2009. The vineyards were divided into water status zones using geographic information systems (GIS) software to map the seasonal mean midday leaf water potential (,P), and dormant pruning shoot weights following the 2008 season. Fruit was harvested from all sentinel vines, bulked by water status zones and made into wine. Sensory analysis included a multidimensional sorting (MDS) task and descriptive analysis (DA) of the 2008 wines. Airborne multispectral images, with a spatial resolution of 38 cm, were captured four times in 2008 and three times in 2009, with the final flights around veraison. A semi-automatic process was developed to extract NDVI from the images, and a masking procedure was identified to create a vine-only NDVI image. 2008 and 2009 were cooler and wetter than mean years, and the range of water status zones was narrow. Yield per vine, vine size, anthocyanins and phenols were the least consistent variables. Divided by water status or vine size, there were no variables with differences between zones in all four vineyards in either year. Wines were not different between water status zones in any chemical analysis, and HPLC revealed that there were no differences in individual anthocyanins or phenolic compounds between water status zones within the vineyard sites. There were some notable correlations between vineyard and grape composition variables, and spatial trends were observed to be qualitatively related for many of the variables. The MDS task revealed that wines from each vineyard were more affected by random fermentation effects than water status effects. This was confirmed by the DA; there were no differences between wines from the water status zones within vineyard sites for any attribute. Remotely sensed NDVI (normalized difference vegetation index) correlated reasonably well with a number of grape composition variables, as well as soil type. Resampling to a lower spatial resolution did not appreciably affect the strength of correlations, and corresponded to the information contained in the masked images, while maintaining the range of values of NDVI. This study showed that in cool climates, there is the potential for using precision viticulture techniques to understand the variability in vineyards, but the variable weather presents a challenge for understanding the driving forces of that variability.

Delineation of within-site terroir effects using soil and vine water measurements in Riesling vineyards within the Niagara Peninsula

The major focus of this dissertation was to explain terroir effects that impact wine varietal character and to elucidate potential determinants of terroir by testing vine water status (VWS) as the major factor of the terroir effect. It was hypothesized that consistent water status zones could be identified within vineyard sites, and, that differences in vine performance, fruit composition and wine sensory attributes could be related to VWS. To test this hypothesis, ten commercial Riesling vineyards representative of each Vintners Quality Alliance sub-appellation were selected. Vineyards were delineated using global positioning systems and 75 to 80 sentinel vines per vineyard were geo-referenced for data collection. During the 2005 to 2007 growing seasons, VWS measurements [midday leaf water potential ('l')] were collected from a subset of these sentinel vines. Data were collected on soil texture and composition, soil moisture, vine performance (yield components, vine size) and fruit composition. These variables were mapped using global information system (GIS) software and relationships between them were elucidated. Vines were categorized into "low" and "high" water status regions within each vineyard block and replicate wines were made from each. Many geospatial patterns and relationships were spatially and temporally stable within vineyards. Leaf'l' was temporally stable within vineyards despite different weather conditions during each growing season. Generally, spatial relationships between 'l', soil moisture, vine size, berry weight and yield were stable from year to year. Leaf", impacted fruit composition in several vineyards. Through sorting tasks and multidimensional scaling, wines of similar VWS had similar sensory properties. Descriptive analysis further indicated that VWS impacted wine sensory profiles, with similar attributes being different for wines from different water status zones. Vineyard designation had an effect on wine profiles, with certain sensory and chemical attributes being associated from different subappellations. However, wines were generally grouped in terms of their regional designation ('Lakeshore', 'Bench', 'Plains') within the Niagara Peninsula. Through multivariate analyses, specific sensory attributes, viticulture and chemical variables were associated with wines of different VWS. Vine water status was a major contributor to the terroir effect, as it had a major impact on vine size, berry weight and wine sensory characteristics.

METHOXYPYRAZINES AND LADYBUG TAINT IN WINES

Methoxypyrazines are aroma active compounds found in many wine varietals. These compounds can be of either grape-derived nature or can be introduced into wines via Coccinellidae beetles. Regardless of their origin, methoxypyrazines can have either a beneficial role for wine quality, contributing to the specificity of certain wine varietals (Cabernet sauvignon, Cabernet franc, Sauvignon blanc) or a detrimental role, particularly at higher concentrations, resulting in overpowering green, unripe and herbaceous notes. When methoxypyrazines of exogenous nature are responsible for these unpleasant characteristics, wines are considered to be affected by what is generally known as Ladybug taint (LBT). This is work is a collection of studies seeking to create a sensitive analytical method for the detection and quantification of methoxypyrazines in wines; to investigate the role of different Coccinellidae species in the tainting of wines with LBT and identify the main compounds in ladybug tainted wines responsible for the typical green herbaceous characteristics; to determine the human detection threshold of 2,5-dimethyl-3-methoxypyrazine in wines as well as investigate its contribution to the aroma of wines; and finally to survey methoxypyrazine concentrations in a large set of wines from around the world. In the first study, an analytical method for the detection and quantitation of methoxypyrazines in wines was created and validated. The method employs multidimensional Gas Chromatography coupled with Mass Spectrometry to detect four different methoxypyrazines (2,5-dimethyl-3-methoxypyrazine, isobutyl methoxypyrazine, secbutyl methoxypyrazine and isopropyl methoxypyrazines) in wine. The low limits of detection for the compounds of interest, improved separation and isolation capabilities, good validation data, as well as the ease of use recommend this method as a good alternative to the existing analytical methods for methoxypyrazine detection in wine. In the second study the capacity of two Coccinellidae species, found in many wine regions – Harmonia axyridis and Coccinella septempunctata - to taint wines is evaluated. Coccinella septempunctata is shown to be as capable as causing LBT in wines as Harmonia axyridis. Dimethyl methoxypyrazine, previously thought to be of exogenous nature only (from Coccinellidae haemolymph), is also detected in control (untainted) wines. The main odor active compounds in LBT wines are investigated through Aroma Extract Dilution Assay. These compounds are identified as isopropyl methoxypyrazine, sec- and iso- butyl methoxypyrazine. In the third study, the human detection threshold for dimethyl methoxypyrazine in wine is established to be 31 ng/L in the orthonasal modality and 70 ng/L retronasally. After wines spiked with various amounts of dimethyl methoxypyrazine are evaluated sensorally, dimethyl methoxypyrazine causes significant detrimental effects to wine aroma at a concentration of 120 ng/L. The final study examines methoxypyrazine (dimethyl methoxypyrazine, isopropyl methoxypyrazine, secbutyl methoxypyrazine and isobutyl methoxypyrazine) concentrations in 187 wines from around the world. Dimethyl methoxypyrazine is detected in the majority of the red wines tested. Data are interpreted through statistical analyses. A new measure for predicting greenness/herbaceousness in wines - methoxypyrazine “total impact factor” is proposed.

Aversion Analysis

In this paper : a) the consumer’s problem is studied over two periods, the second one involving S states, and the consumer being endowed with S+1 incomes and having access to N financial assets; b) the consumer is then representable by a continuously differentiable system of demands, commodity demands, asset demands and desirabilities of incomes (the S+1 Lagrange multiplier of the S+1 constraints); c) the multipliers can be transformed into subjective Arrow prices; d) the effects of the various incomes on these Arrow prices decompose into a compensation effect (an Antonelli matrix) and a wealth effect; e) the Antonelli matrix has rank S-N, the dimension of incompleteness, if the consumer can financially adjust himself when facing income shocks; f) the matrix has rank S, if not; g) in the first case, the matrix represents a residual aversion; in the second case, a fundamental aversion; the difference between them is an aversion to illiquidity; this last relation corresponds to the Drèze-Modigliani decomposition (1972); h) the fundamental aversion decomposes also into an aversion to impatience and a risk aversion; i) the above decompositions span a third decomposition; if there exists a sure asset (to be defined, the usual definition being too specific), the fundamental aversion admits a three-component decomposition, an aversion to impatience, a residual aversion and an aversion to the illiquidity of risky assets; j) the formulas of the corresponding financial premiums are also presented.

L’agrément : un agent moteur de développement des capacités, d’apprentissage collectif et de socialisation. Une étude de cas en profondeur dans un hôpital privé saoudien

Cette thèse vise à comprendre comment et dans quelle mesure l’agrément des établissements de santé est-il efficace pour développer les capacités des acteurs, nécessaires pour améliorer la qualité des soins et des services. Au cours des dix dernières années, il y a eu une croissance rapide, à l'échelle mondiale de la mise en œuvre de programmes d'agrément en santé pour l’amélioration de la qualité. L'expérience de la dernière décennie prouve que l'agrément est une technique valable pour l'amélioration de la qualité dans beaucoup d’organismes de santé. Il est également utilisé pour soutenir les réformes en santé. Malgré cela, les outils de gestion comme l’agrément sont souvent critiqués, car elles sont adoptées avec enthousiasme négligeant fréquemment une implantation favorisant la mise en place de comportements durables et la démonstration de meilleurs résultats. Le développement des capacités (DC) est un processus délibéré, multidimensionnel, dynamique dont le but est d’améliorer la performance des individus, des équipes, de l’organisation et d’un système. Le DC constitue une des trois assises de l’implantation d’une démarche institutionnalisée de la qualité, au même niveau que la communication et la reconnaissance. Cette recherche c’est déroulée dans un organisme d’Arabie Saoudite dans le cadre de leur première démarche avec le Conseil canadien d’agrément (CCASS) des services de santé. Une étude de cas unique d’implantation de l’agrément a été menée utilisant une approche mixte. Quatre niveaux d’analyse ont été étudiés en détail (individu, équipe, organisation et système) afin de mesurer 28 effets escomptés du DC puisés dans la littérature. Des entretiens semi-structurés, des groupes de discussion, une revue de la documentation ont été réalisés. Dans le but de mesurer trois des effets escomptés, un questionnaire sur le niveau d’implantation de la qualité (NIQ) a été administré pour la première fois en Arabie Saoudite dans cinq organismes. La performance du cas a été évaluée en relation avec les autres et en fonction de son positionnement dans le cycle d’agrément. Des analyses qualitatives et quantitatives utilisant la technique de polissage par la médiane ont été exécutées. Au niveau des individus, l’agrément a motivé la participation à de nouvelles formations. L’auto-évaluation est l’étape qui encourage l’apprentissage par l’autocritique. Le sentiment de fierté est le changement affectif le plus souvent répertorié. Les équipes ont amélioré leur communication par l’implantation d’une « chaîne de commandement ». Elle a introduit des notions de respect et de clarté des rôles telles qu’exigées par les normes. Au moyen de la mesure du NIQ, nous avons constaté que la majorité des organismes saoudiens se positionnent au niveau minimal d’implantation (assurance qualité). Le plus expérimenté avec l’agrément démontre les meilleurs résultats tout près du second niveau. Enfin, plus les organismes progressent dans la démarche d’agrément, plus les écarts de perception entre les 8 domaines mesurés par le questionnaire du NIQ et entre les différentes catégories d’emploi s’amincissent. En conclusion, l’agrément a démontré de l’efficacité à développer de nouvelles capacités par l’intégration des transformations des individus et par l’impact de l’acquisition des nouvelles capacités sur le changement des pratiques, majoritairement au niveau des individus, des équipes et de l’organisation. Le processus d’agrément a également fait preuve d’importants pouvoirs de convergence au niveau de l’adoption des pratiques édictées par les normes d’agrément qui contribuent positivement à l’amélioration de la qualité.

Variabilité Génétique des Populations Ouest-Africaines

Notre patrimoine génétique dévoile, de plus en plus, les passerelles démogénétiques d’une susceptibilité plus accrue de certains individus à des maladies infectieuses complexes. En vue d’une caractérisation de la variabilité génétique des populations ouest-africaines, nous avons analysé 659 chromosomes X au locus dys44 qui comprend, 35 SNPs et un microsatellite distribués sur 2853 pb en amont et 5034 pb en aval de l’exon 44 du gène de la dystrophine en Xp21.3. Les génotypes obtenus, par ASO dynamique et électrophorèse sur gel d’acrylamide, ont servi à la détermination des haplotypes. Des paramètres comme la diversité haplotypique (G) et l'indice de fixation (Fst) ont été calculés. Des analyses en composantes principales ainsi que multidimensionnelles ont été réalisées. Sur 68 haplotypes détectés, 26 sont nouveaux, et cette région, avec une diversité haplotypique moyenne (Gmoy) de 0,91 ± 0,03, se révèle beaucoup plus hétérogène que le reste du continent (Gmoy = 0,85 ± 0,04). Toutefois, malgré l’existence de disparités sous régionales dans la distribution des variants du marqueur dys44, l’AMOVA montre d’une manière générale, une faible érosion de l’éloignement génétique entre les populations subsahariennes (Fst = 1,5% ; p<10-5). Certains variants tel que l’haplotype eurasien B006 paraissent indiquer des flux transsahariens de gènes entre les populations nord-africaines et celles subsahariennes, comme l’exemplifie le pool génétique de l’une des populations ubiquitaires de la famille linguistique Nigéro-congolaise : Les Fulani. Nos résultats vont aussi dans le sens d’un héritage phylétique commun entre les Biaka, les Afro-américains et les populations de la sous-famille de langues Volta-Congo.