Préoccupations et attentes en réadaptation physique dans des contextes pluralistes : vers un cadre théorique interculturel

Cette thèse porte sur les dynamiques interculturelles et la réactivité des institutions dans les contextes pluralistes. Le contexte clinique, un exemple parmi tant d’autres, sert à saisir les enjeux des rencontres entre personnes d’origines différentes. Le milieu de la réadaptation physique apparaît particulièrement intéressant pour étudier les enjeux induits par les rencontres interculturelles, car les interventions y sont d’une durée relativement longue en comparaison avec les soins aigus, et ce type de pratique demande une grande collaboration de la part des clients. Cette recherche sollicite trois acteurs essentiels dans ce contexte : clients immigrants, intervenants et agents tiers payeurs (CSST) ont pris la parole lors de groupes de rencontre (focus group). La recherche d’un cadre théorique pertinent en anthropologie interculturelle revisite les courants moderniste et postmoderniste, à partir d’une approche critique, et propose une épistémologie interactionniste. Ces courants qui traversent l’anthropologie sont étudiés à la lumière de la clinique, ce qui engendre un dialogue entre les intervenants et les anthropologues. Le contexte ethnographique permet de cerner différents enjeux concernant les politiques de santé dans les contextes pluriethniques, ce qui permet de saisir, à partir de la gestion, des rapports d’emboitement entre le macro et le micro. Le fonctionnement de la réadaptation physique au Québec sert de toile de fond pour comprendre les discours des acteurs sollicités par cette recherche. L’ethnographie met en lumière les convergences et les divergences entre ces trois acteurs dans les contextes pluriethniques. Selon une méthode caractéristique des relations interculturelles, je présente d’abord l’intervention dans les institutions de réadaptation. Les clients immigrants sont mis en scène avec l’intervention dans les contextes pluriethniques. Les discours de tous ces acteurs mettent en lumière des barrières dites objectives et des facteurs liés à la culture. L’analyse s’intéresse à la communication et à la circulation de l’information dans les contextes pluriethniques; elle étudie les rapports entre l’information, la connaissance et les préjugés. L’analyse offre quelques pistes qui aident à comprendre l’imperméabilité du système de santé dans les contextes pluralistes. La conclusion propose une approche complémentariste pour établir un dialogue entre les modèles de discrimination et l’interculturel. Les anthropologues sont alors interpellés en vue de répondre aux nouveaux défis générés par le néolibéralisme.This thesis is based on the intercultural and institutional dynamics of health care in pluralistic contexts. The clinical context makes it possible to understand what is at stake in encounters between people of different ethnic and religious backgrounds. The field of physical rehabilitation is a particularly interesting context for understanding these dynamics because interventions require long-term assessment and sustained collaboration on the part of clients. The current research examines three types of actors in this context: immigrant clients, health care specialists (or practitioners), and third party payers (CSST). In order to elaborate an intercultural theoretical framework, the thesis critically examines modernist and postmodernist orientations in anthropology, and through an epistemological approach proposes an interactionist orientation. These differing epistemological orientations are studied from a clinical standpoint and, the resulting analysis prepares the way for a dialogue between practitioners and anthropologists. The ethnographic context sheds light on various themes concerning the politics of healthcare in pluralistic contexts, but also the policies that influence different relationships between macroeconomics and local-level encounters in organizational settings. The system of physical rehabilitation in Quebec serves as a canvas to understand concerns and expectations of the different types actors solicited by this research. The ethnographic data presented here highlights the convergence and divergence between those who are involved in administering and receiving care. After describing the conditions and terms of intervention in the field of physical rehabilitation, there is a discussion of the specificity of immigrant clients and healthcare in pluriethnic contexts. Data collected from different actors highlights the difference between objective barriers to adequate services and factors which can be linked to culture. Analysis of the data focuses on communication in an intercultural or pluriethnic context and the flow of information, carefully examining the relationship between information, expertise and prejudice. The analysis also offers certain pathways to better understand the lack of reactivity in pluralistic contexts. The conclusion proposes a complementary approach which is intended to facilitate a dialogue between models based on discrimination and those on interculturalism. Anthropologists are presented as being particularly well positioned to answer new challenges generated by intercultural situations in an era of neoliberalism

The community structure of functional brain networks exhibits scale-specific patterns of inter- and intra-subject variability

The network organization of the human brain varies across individuals, changes with development and aging, and differs in disease. Discovering the major dimensions along which this variability is displayed remains a central goal of both neuroscience and clinical medicine. Such efforts can be usefully framed within the context of the brain\u27s modular network organization, which can be assessed quantitatively using computational techniques and extended for the purposes of multi-scale analysis, dimensionality reduction, and biomarker generation. Although the concept of modularity and its utility in describing brain network organization is clear, principled methods for comparing multi-scale communities across individuals and time are surprisingly lacking. Here, we present a method that uses multi-layer networks to simultaneously discover the modular structure of many subjects at once. This method builds upon the well-known multi-layer modularity maximization technique, and provides a viable and principled tool for studying differences in network communities across individuals and within individuals across time. We test this method on two datasets and identify consistent patterns of inter-subject community variability, demonstrating that this variability - which would be undetectable using past approaches - is associated with measures of cognitive performance. In general, the multi-layer, multi-subject framework proposed here represents an advance over current approaches by straighforwardly mapping community assignments across subjects and holds promise for future investigations of inter-subject community variation in clinical populations or as a result of task constraints

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Actes du Colloque de Mai 2011

Titre de l'écran-titre (visionné le 22 mars 2012)Comprend des réf. bibliogr

L’atelier de situations interculturelles : une méthodologie pour comprendre l’acte à poser en contexte pluriethnique

Depuis une dizaine d’années, une série d’évènements donnent l’impression que le Québec cherche à mieux définir son modèle d’intégration basé sur la notion d’interculturalisme. Mais comment définir l’approche interculturelle et comment savoir si elle favorise véritablement l’inclusion des nouveaux arrivants ? Dans le cadre du partenariat de recherche « Vers une ville interculturelle » nous avons organisé une série d’ateliers pratiques afin de faciliter la mise en commun de ce que les différents acteurs du milieu urbain voient comme situations interculturelles problématiques. Les « ateliers de situations interculturelles » ont donné des réponses préliminaires aux trois questions suivantes : 1) Quelles situations problématiques voyons-nous sur le terrain ? 2) Quels outils sont à notre portée pour répondre à ces situations ? 3) Sur quels cadres d’analyse nous appuyons-nous pour orienter nos actions ? Pendant cet atelier, qui a été organisé dans différents milieux professionnels et institutionnels, les participants ont travaillé en équipe afin d’identifier et d’analyser un nombre limité de situations qui proviennent de leurs milieux d’intervention respectifs. Les résultats préliminaires des ateliers démontrent la difficulté de distinguer entre les situations interculturelles et les préoccupations par rapport aux situations, mais aussi la difficulté de la centration sur les normes et les valeurs de la société d’accueil. L’analyse de plusieurs contextes d’intervention fait ressortir les différences individuelles et organisationnelles et démontre, entre autres, que les intervenants sont souvent pris entre les exigences contradictoires du multiculturalisme et de l’interculturalisme

Actes à poser en contexte interculturel : quelle place pour l’intervention?

Nous proposons un cadre théorique qui porte sur l’acte à poser en contexte pluriethnique, et ce, sous toutes ses formes : donner une information ou en obtenir une, donner un soin ou en recevoir un, enseigner ou se faire enseigner. Dans un sens plus large, l’agir s’imagine et se réalise selon le modèle de ses propres traditions ou selon celles de l’autre. Notre cadre invite à concevoir l’acte à poser dans les rencontres interculturelles d’un point de vue épistémologique, en nous forçant à tenir compte de la subtilité des pratiques qui s’inscrivent forcément dans un cadre institutionnel, méthodologique, organisationnel et déontologique. Ce collectif a ainsi pour thème les manifestations empiriques de l’interculturel, avec une attention particulière aux dynamiques d’interaction dans différents contextes d’intervention. On y analyse notamment les conditions de reproduction de la discrimination qui mène à l’exclusion des minorités ethniques et visibles en contexte d’immigration