Analyse organisationnelle et évaluation de la désinstitutionnalisation dans un hôpital psychiatrique

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal

Évaluation de la qualité de vie et des besoins des personnes itinérantes atteintes de troubles mentaux graves : perceptions d’une équipe itinérance-outreach

Ce projet, mis sur pied par l'équipe itinérance-outreach du CLSC des Faubourgs à l'automne 1998, étudie comment les membres de cette équipe perçoivent l'impact de leur intervention clinique auprès des personnes itinérantes atteintes de troubles mentaux. Un échantillon de convenance (n=52) a été sélectionné à partir de la clientèle de l'équipe. Les besoins de la clientèle ont été évalués à l'aide du Camberwell Assessment of Needs (CAN-F, Phelan et al., 1995). La qualité de vie a été mesurée à deux reprises, à l'aide du Questionnaire de la qualité de vie du Wisconsin (Version intervenant ; Becker et al., 1993). L'étude démontre que l'intervention clinique est associée à une amélioration de la qualité de vie des itinérants souffrant de pathologies mentales graves et ce, malgré l'existence de multiples autres besoins non comblés. L'étude suggère que la démarche de l'équipe itinérance-outreach touche les aspects cliniques et s'associe à l'amélioration des problèmes sociaux des personnes itinérantes atteintes de troubles mentaux graves.Assessment of quality of life and needs of homeless mentally ill people: perceptions of an outreach teamThis project established by an outreach team from the CLSC des Faubourgs in autumn 1998, studies how the members of this team perceive the impact of their clinical intervention with homeless people suffering of severe mental illness. A convenience sample (n=52) was selected within the team's clientele. The clientele's needs were evaluated with the Camberwell Assessment of Needs (CAN-F, Phelan et al., 1995). Quality of life was measured twice with the Wisconsin Quality of Life Questionnaire (Becker et al., 1993). The project shows that clinical intervention is associated with an improvement in quality of life of severely mentally ill homeless people and this despite the existence of numerous other needs that are not met. The study suggests the work done by the outreach team touches the clinical aspects and is associated with the improvement of social problems of severely mentally ill homeless people.Evaluación de la calidad de vida y de las necesidades de las personas itinerantes afectadas por desórdenes mentales graves: percepciones de un equipo itinerancia-outreachEste proyecto, puesto en marcha por el equipo itinerancia-outreach del CLSC des Faubourgs en el otoño 1998, estudia cómo los miembors de este equipo perciben el impacto de sus intervenciones clínicas con las personas itinerantes afectadas por desórdenes mentales. Un muestreo de conveniencia (n=52) fue seleccionado entre la clientela del equipo. Las necesidades de la clientela fueron evaluadas con la ayuda del Camberwell Assessment of Needs (CAN-F, Phelan Y al.,1995) En dos ocasiones, la calidad de vida fue medida con ayuda del Cuestionario de la calidad de vida de Wisconsin (Versión trabajador que interviene; Becker Y al., 1993) El estudio demuestra que la intervención clínica está asociada a un mejoramiento de la calidad de vida de los itinerantes que sufren de patologías mentales graves, y eso a pesar de la existencia de otra serie de necesidades no satisfechas. El estudio sugiere que el trabajo del equipo itinerancia-outreach aborda los aspectos clínicos y se asocia al mejoramiento de los problemas sociales de las personas itinerantes que sufren de desórdenes mentales graves

Which Target Population for Promotion Programs on Health Infant Feeding Practice in Laos?

One of the determinants of the poor improvement in child nutrition indicators observed in Laos is mothers’ feeding practices. These practices are influenced by many socio-environmental factors and are expected to be targets of public health programs against malnutrition. The purpose of this work is to examine how the Lao National Nutrition Strategy (NNS) incorporates the issue of the determinants of the behavior of mothers of young children in its recommendations. We argue that the little consideration brought in the NNS to key determinants of women’s behavior is a major explanatory factor for the poor performance in improving the nutrition status of Lao under-five-year-old children

Public telesurveillance service for frail elderly living at home, outcomes and cost evolution: a quasi experimental design with two follow-ups

BACKGROUND: Telesurveillance is a technologically based modality that allows the surveillance of patients in the natural setting, mainly home. It is based on communication technologies to relay information between a patient and a central call center where services are coordinated. Different types of telesurveillance systems have been implemented, some being staffed with non-health professionals and others with health professional, mainly nurses. Up to now, only telesurveillance services staffed with non-health professionals have been shown to be effective and efficient. The objective of this study was to document outcomes and cost evolution of a nurse-staffed telesurveillance system for frail elderly living at home. METHODS: A quasi experimental design over a nine-month period was done. Patients (n = 38) and caregivers (n = 38) were selected by health professionals from two local community health centers. To be eligible, elders had to be over 65, live at home with a permanent physical, slight cognitive or motor disability or both and have a close relative (the caregiver) willing to participate to the study. These disabilities had to hinder the accomplishment of daily life activities deemed essential to continue living at home safely. Three data sources were used: patient files, telesurveillance center's quarterly reports and personal questionnaires (Modified Mini-Mental State, Functional Autonomy Measurement System, Life Event Checklist, SF-12, Life-H, Quebec User Evaluation of Satisfaction with Assistive Technology, Caregiver Burden). The telesurveillance technology permitted, among various functionalities, bi-directional communication (speaker-receiver) between the patient and the response center. RESULTS: A total of 957 calls for 38 registered clients over a 6-month period was recorded. Only 48 (5.0%) of the calls were health-related. No change was reported in the elders' quality of life and daily activity abilities. Satisfaction was very high. Caregivers' psychological burden decreased substantially. On a 3 months period, length of hospital stays dropped from 13 to 4 days, and home care services decreased from 18 to 10 visits/client. Total cost of health and social public services used per client dropped by 17% after the first 3 months and by 39% in the second 3 months. CONCLUSION: The ratio of 0.50 calls per client to the call center for health events is three times higher than that reported in the literature. This difference is probably attributable to the fact that nurses rather than non-health professional personnel were available to answer the clients' questions about their health and medications. Cost evolution showed that registering older adults at a telesurveillance center staffed by nurses, upon a health professional recommendation, costs the health care system less and does not have any negative effects on the well-being of the individuals and their families. Telesurveillance for the elderly is effective and efficient

Implantation multisite du programme Integrated Psychological Treatment (IPT) pour les personnes souffrant de schizophrénie. Élaboration d’une version renouvelée

Le programme Integrated Psychological Treatment (IPT) de Brenner et al. (1992), d’approche cognitivo-comportementale, a été implanté dans neuf milieux cliniques offrant des services aux personnes souffrant de schizophrénie. Une étude a permis de suivre l’implantation du programme IPT dans chacun des milieux, plus particulièrement d’évaluer le niveau de satisfaction des participants et des intervenants et d’identifier les points forts et les améliorations souhaitées. Les résultats permettent de constater que l’implantation a été un succès pour l’ensemble des neuf milieux. Les intervenants et les participants ont apprécié non seulement la structure hiérarchique qui tient compte davantage des besoins en réadaptation des personnes souffrant de schizophrénie, mais aussi son cadre d’application privilégié qui permet le suivi régulier d’un même groupe de patients pendant une année. Les modifications et ajouts proposés ont permis de développer une version québécoise du programme favorisant davantage l’atteinte des objectifs, particulièrement ceux liés au maintien et à la généralisation des apprentissages dans le contexte de vie réelle des participants.Brenner’s Integrated Psychological Treatment (IPT) program (Brenner et al., 1992 ; Pomini et al., 1998), a cognitive-behavioural approach, was implemented in nine of Quebec’s clinical settings that treat people with schizophrenia. A study allowed an evaluation of the IPT program in each location, with emphasis on the level of satisfaction of both participants and professionals, the program’s strong points, and areas where improvements were needed. The results have shown that the implementation of the program has been successful in all nine clinical settings. Professionals and participants appreciated the IPT program not only for its hierarchic structure that considers the rehabilitation needs of people affected by schizophrenia, but also for its customised application framework, which allows a regular follow-up of a similar group of patients over the course of a one year period. As a result of this study, the modifications proposed and additions have enabled the creation of a Quebec version of the IPT program, which better achieves its objectives, particularly those relating to the maintenance and generalisation of social learning in the context of a participant’s real-life situation.El programa de Tratamiento Psicológico Integral (Integrated Psychological Treatment IPT) de Brenner (Brenner et al., 1992; Pomini et al., 1998), de enfoque cognitivo-comportamental, ha sido implantado en nueve medios clínicos quebequenses que ofrecen servicios a personas que sufren de esquizofrenia. Un estudio ha permitido dar seguimiento a la implantación del programa IPT en cada uno de los medios, en particular, evaluar el nivel de satisfacción de los participantes y de los interventores acerca del programa e identificar los puntos fuertes y las mejoras deseadas. Los resultados permiten constatar que la implantación del programa ha sido un éxito en los nueve medios. Los interventores y los participantes han apreciado el programa IPT no sólo por su estructura jerárquica, que toma más en cuenta las necesidades de readaptación de las personas que sufren de esquizofrenia, sino también por su marco de aplicación privilegiada, que permite el seguimiento regular de un mismo grupo de pacientes durante un año. Las modificaciones y adiciones propuestas en el momento de este estudio han permitido desarrollar una versión quebequense del programa IPT que favorece más el logro de los objetivos, particularmente aquellos relacionados con el mantenimiento y generalización del aprendizaje en el contexto de la vida real de los participantes.O programa Integrated Psychological Treatment (IPT) de Brenner (Brenner et al., 1992; Pomini et al., 1998), de abordagem cognitivo-comportamental, foi implantado em nove meios clínicos quebequenses que oferecem serviços às pessoas que sofrem de esquizofrenia. Um estudo permitiu acompanhar a implantação do programa IPT em cada um dos meios, mais precisamente, ele permitiu avaliar o nível de satisfação dos participantes e dos atores com respeito ao programa, e identificar os pontos fortes e as melhorias almejadas. Os resultados permitem constatar que a implantação do programa foi um sucesso em todos os nove meios. Os atores e os participantes apreciaram o programa IPT, não apenas por sua estrutura hierárquica, que leva mais em consideração as necessidades de readaptação das pessoas que sofrem de esquizofrenia, mas também por seu quadro de aplicação privilegiado, que permite o acompanhamento regular de um mesmo grupo de pacientes durante um ano. As modificações e acréscimos propostos durante este estudo permitiu desenvolver uma versão quebequense do programa IPT, que favorece mais o alcance dos objetivos, principalmente os relacionados com a manutenção e a generalização das aprendizagens no contexto de vida real dos participantes

Cost-effectiveness and accuracy of prenatal Down syndrome screening strategies: should the combined test continue to be widely used?

OBJECTIVE: We analyzed the cost-effectiveness (CE) and performances of commonly used prenatal Down syndrome (DS) screening strategies. STUDY DESIGN: We performed computer simulations to compare 8 screening options by applying empirical data from Serum, Urine, and Ultrasound Screening Study trials on the population of 110,948 pregnancies. Screening strategies outcomes, CE ratios, and incremental CE ratios were measured. RESULTS: The most CE DS screening strategy was the contingent screening method (CE ratio of Can$26,833 per DS case). Its incremental CE ratio compared to the second-most CE strategy (serum integrated screening) was Can$3815 per DS birth detected. Among the procedures respecting guidelines, our results identified the combined test as the screening strategy with the highest CE ratio (Can$47,358) and the highest number of procedure-related euploid miscarriages (n ϭ 71). CONCLUSION: In regard to CE, contingent screening is the best choice. The combined test, which is the most popular screening strategy, shows many limitations

Seroprotection at different levels of the healthcare system after routine vaccination with diphtheria-tetanus-pertussis whole cell--hepatitis B--haemophilus influenzae type B in Lao People’s Democratic Republic

Background The Lao People’s Democratic Republic continues to sustain a considerable burden of vaccine-preventable diseases because of incomplete vaccine coverage and weak vaccine responses. We have assessed seroconversion after routine vaccination with the pentavalent vaccine to capture weaknesses of vaccine management at the different levels of the healthcare system. Methods A total of 1151 children (aged 8–28 months) with 3 documented doses of the pentavalent vaccine delivered at central hospitals in Vientiane and the provincial hospital, 3 district hospitals, and 10 health centers in Bolikhamxay province were enrolled. Sociodemographic information was collected with a standardized questionnaire. Serum samples were analyzed for antibodies against vaccine components, and bivariate and multivariable analyses were performed to identify risk factors for low vaccine responses. Results Seroprotection rates at the provincial, district, and health center level were as high as in central hospitals, but seroprotection rates in areas covered by remote health centers were significantly lower. Protective levels also rapidly decreased with age at sampling. Seroprotection rates in Bolikhamxay against the different components reached 70%–77% and were up to 20% higher than in previous studies in the same region; 18.8% more children received the hepatitis B vaccine birth dose and the hepatitis B virus infection rate was 4 times lower. Conclusions Vaccine immunogenicity has dramatically improved in a central province, likely due to training and investment in the cold chain. Nevertheless, there remains a need to focus on the “last mile” in remote areas were most children are vaccinated through outreach activities

Perception of health risks in Lao market vendors

Wet markets are a critical part of South-East Asian culture and economy. However, their role in circulation and transmission of both endemic and emerging disease is a source of concern in a region considered a hotspot of disease emergence. In the Lao People's Democratic Republic (Lao PDR, Laos), live and dead wild animals are frequently found in wet markets, despite legislation against the bushmeat trade. This is generally considered to increase the risk of disease transmission and emergence, although whether or not wildlife vendors themselves have indeed increased incidence of zoonotic disease has rarely been assessed. In preparation for a future longitudinal study of market vendors investigating vendors’ exposure to zoonotic pathogens, we conducted a pilot survey of Lao market vendors of wildlife meat, livestock meat and vegetables, to identify demographic characteristics and potential control groups within markets. We also investigated baseline risk perception for infectious diseases among market vendors and assessed the association between risk perception and risk mitigation behaviours. The surveys conducted with 177 vendors revealed similar age, sex, ethnic background and geographical origin between vendor types, but differences in professional background and work history for livestock meat vendors. The perception of disease risk was very low across all vendors, as was the reported use of personal protective equipment, and the two appeared unrelated. Personal risk discounting and assumptions about transmission routes may explain this lack of association. This information will help inform the development of future research, risk communication and risk mitigation policy, especially in the light of the COVID-19 pandemic