Hidden geographies: the changing lifeworlds of women with multiple sclerosis

Using the Knowledge to Action framework to improve housing and support for people with Multiple Sclerosis

Background People with Multiple Sclerosis (MS) have unique housing and support needs that are essential for maintaining independence at home; however, there is limited research to guide the design of community living options for this population. The aim of this study was to examine housing and support needs and preferences of people with MS with the intention to inform the planning of a co-designed intervention based on the study's findings. Methods Using the Knowledge to Action (KTA) framework, quantitative (n =79) and qualitative (n =6) data from people with MS were extracted and integrated from projects completed by the research team that explored the housing and support needs and preferences of people with disability. Results were synthesised and presented to a reference group for validation, contextualisation, and adaptation to the Australian context. Results High physical support needs were common across participants. People most commonly required home modifications to improve accessibility, such as ramps, equipment such as heating and cooling, and assistive technology. Many people required more than 8 hours per day of paid support. Moving into individualised housing facilitated independence and community reintegration. People reported gaps between what they wanted from support workers and what they received, citing individual and systemic barriers. Conclusion People with MS have support needs that require proactive and responsive funding arrangements, housing design and support provision. In line with KTA principles, findings will inform the planning of a co-designed intervention that involves people with lived experience of MS and other stakeholders to influence policy and improve home and living outcomes for this population.

Operationalizing the Consolidated Framework for Implementation Research to build and support the lived experience workforce in direct health service provision

BACKGROUND

The involvement of people with lived experience (LEX) workers in the development, design, and delivery of integrated health services seeks to improve service user engagement and health outcomes and reduce healthcare gaps. Yet, LEX workers report feeling undervalued and having limited influence on service delivery. There is a need for systematic improvements in how LEX workforces are engaged and supported to ensure the LEX workforce can fully contribute to integrated systems of care.

OBJECTIVE

This study aimed to operationalize the Consolidated Framework for Implementation Research (CFIR) using a rigorous scoping review methodology and co-creation process, so it could be used by health services seeking to build and strengthen their LEX workforce.

SEARCH STRATEGY

A systematic literature search of four databases was undertaken to identify peer-reviewed studies published between 2016 and 2022 providing evidence of the inclusion of LEX workers in direct health service provision.

DATA EXTRACTION AND SYNTHESIS

A descriptive-analytical method was used to map current evidence of LEX workers onto the CFIR. Then, co-creation sessions with LEX workers (n = 4) and their counterparts-nonpeer workers (n = 2)-further clarified the structural policies and strategies that allow people with LEX to actively participate in the provision and enhancement of integrated health service delivery.

MAIN RESULTS

Essential components underpinning the successful integration of LEX roles included: the capacity to engage in a co-creation process with individuals with LEX before the implementation of the role or intervention; and enhanced representation of LEX across organizational structures.

DISCUSSION AND CONCLUSION

The adapted CFIR for LEX workers (CFIR-LEX) that was developed as a result of this work clarifies contextual components that support the successful integration of LEX roles into the development, design, and delivery of integrated health services. Further work must be done to operationalize the framework in a local context and to better understand the ongoing application of the framework in a health setting.

PATIENT OR PUBLIC CONTRIBUTION

People with LEX were involved in the operationalization of the CFIR, including contributing their expertise to the domain adaptations that were relevant to the LEX workforce.

Choices are inevitable: A qualitative exploration of the lifecosts of systemic lupus erythematosus

OBJECTIVES

Individuals with systemic lupus erythematosus experience considerable economic challenges. The aim of this research is to qualitatively investigate experiences of the lifecosts (direct and indirect economic costs and beyond) to those with systemic lupus erythematosus in Canada.

METHODS

Using a biopsychosocial conceptual framework and integrated knowledge translation approach, qualitative semi-structured interviews were conducted with 3 physicians, 5 representatives from systemic lupus erythematosus advocacy groups, and 29 adult systemic lupus erythematosus patients. Themes emerged deductively and inductively, and the theme code set was used to code all transcripts.

RESULTS

Three dominant themes emerged: (1) impacts of systemic lupus erythematosus on quality of life, relationships, and health; (2) costs linked to healthcare; and (3) impacts of living with systemic lupus erythematosus on employment/economic standing.

DISCUSSION

Whereas previous work has focused almost exclusively on the direct, individual costs of systemic lupus erythematosus, the biopsychosocial approach taken here emphasizes not only the individual and intermediate factors (such as the workplace and family), but also the system-level factors (i.e. system-level policies) that influence quality of life, healthcare, and employment/economic experiences of those with systemic lupus erythematosus. Results indicate a need to target interventions beyond the individual and their immediate context, and recognize that lifecosts are shaped significantly by systems-level action.

The value of hackathons in integrated knowledge translation (iKT) research: Waterlupus

Background

Despite a growing movement toward a knowledge-user-driven research process, our understanding of the generation, implementation and evaluation of specific approaches in the integrated knowledge translation (iKT) toolbox that aim to engage health and healthcare knowledge users is limited. Health hackathons offer an innovative approach with potential to generate direct and indirect health-related outcomes benefitting participants, knowledge users and the broader population. In May 2019, our research team hosted Waterlupus, a health hackathon to improve the economic lives of individuals with systemic lupus erythematosus (SLE) in Canada. Waterlupus was held with a multi-stakeholder group of 50 participants that included advocacy organization representatives, policy-makers, researchers, physicians, individuals with lived experience and students. While the hackathon generated viable solutions with the potential to positively impact the lives of individuals with SLE, understanding how participants perceived the hackathon as an iKT tool is critical in the planning and implementation of future iKT research.

Methods

Semi-structured in-depth telephone interviews were conducted with Waterlupus participants (n = 13) between August and November 2019 to (1) explore participant experiences of the hackathon; (2) investigate participant-identified hackathon outcomes; and (3) elicit recommendations for future iKT research using health hackathons.

Results

Participants provided feedback on the format and organization of Waterlupus, and identified direct and indirect outcomes to knowledge users, students and researchers beyond the innovations generated at the event. While the majority (n = 11) had never participated in a hackathon prior to Waterlupus, all 13 stated they would participate in future hackathons. Positive outcomes identified include connecting with students and other SLE stakeholders, the formation of professional and support networks, increased awareness of SLE, as well as the innovations generated. Participant recommendations for future health hackathons include the addition of stakeholders from industry or technology, and the need for clear and designated roles for stakeholders to ensure efficient use of resources.

Conclusions

This work contributes to a limited literature regarding the use of health hackathons for social innovation, and offers knowledge-user suggestions relevant to the implementation of future iKT events, and hackathons specifically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00785-z.

Re-imagining world: From human health in the world to 'all-world health'

This article explores the concept of 'world' as it frequently appears across health studies; specifically largely humanistic and phenomenological variations in use of 'the world' and 'lifeworld' are considered as they have helped cast knowledge on health and care. Looking forward, it is argued that world might be reimagined post-humanistically and post-phenomenologically as a vital emergent material entity and property. This is a reimagination that pays dividends by drawing attention to all-world processes and productions, hence to 'all-world health'. On one level, all-world health involves consideration of the healths of all the world's material and biological entities (all parts of the world). On another level, all-world health involves understanding what an entity gains from its total surround as it moves through life (all parts of its world). Together these levels provide a more processual, relational and holistic understanding of health than that provided by traditional notions of human health states, determinants or meanings, and even by some environmental (ist) ideas on health. All-world health arguably provides a vision of interrelatedness on which greater unity, cooperation and care might be built.

Hand Injuries of Coal Miners in Southern West Virginia: A Pilot Study on Health-Care Resources in Southern West Virginia

Introduction:

Distance and other factors may play a significant role in both the implementation of care and the number of secondary health outcomes. The distance from an injury site can play a substantial impact on the mortality of different injuries and access to health-related services. Within this study, we sought to understand the effect of the site to treating center distance and access to relevant health-care services on effect and secondary injuries of coal mining-related injuries.

Methods:

We evaluated patient demographics, coal mining locations, and patient outcomes. This study is a retrospective review of patients with coal mining hand injuries included in our Level 1 trauma database as well as the amount of health-related resources defined by WV GIS Health Care (Hospitals). The sample consists of coal mine workers. All patients had to meet the study criteria and were admitted during the study period of January 1, 2005, through March 31, 2015. We then were able to locate the coal mines where these coal miners were injured based on information from their medical records and the availability of health-care resources (hospitals) around the zones of injury, as well as health-related resources from the WV GIS database. The sample size was n = 104. Data were collected in an Excel spreadsheet. Stata 11.2 was used to conduct a multinomial logistic regression. A hub analysis was performed to understand the overall distance associated with the injury site and care using Arch GIS 10.6. A hotspot analysis was also performed in order to understand the differences of different zones of concern of injury sites in Southern West Virginia, from January 1, 2005, to March 31, 2015.

Results:

Variables collected are as follows: a total number of coal miners were 104, with an average age of miners being similar in age demographics at 19–62. Coal mines are registered on the map with relevance to injury based on location; severity scale is presented. The most common injuries were fractures at 42.3% (47/104) followed by amputations at 26.9% (28/104). The index finger had an overall higher rate of injury at 28.8% (30/104). To understand the overall impact of specific injuries of coal miners based on the location, we peered into the number of injuries sustained at particular sites over the 10 years. Within this, the attached group, the average distance per injury to a medical center that was able to assist with hand injuries, was 46.1 miles. The shortest distance was within one mile of the center, and the most prolonged distance was 83.3 miles. The highest concentration of coal mining injuries were over 5 miles away from any health care organizations. The at-risk area of coal mining injuries was identified at (P = 0.001) and outside of health-care resources that can be seen within the hotspot analysis tested within this analysis.

Conclusion:

Specific injuries appear to be more at risk on different portions of the hand, as described in our initial data analysis. We also found that particular coal mines seem to harbor more coal mining hand injuries. Rural health care has the challenge of injuries occurring at extended distances and requires that treatment becomes as efficient as possible to maximize the chances of a full recovery.

Aim and Objectives:

The objective of this study is to understand if the distance between the location of injury and trauma center plays a role in the outcome of coal mines related to hand injuries treated at Charleston Area Medical Center.

Does Multiple Sclerosis Differently Impact Physical Activity in Women and Man? A Quantitative Study Based on Wearable Accelerometers

In people with multiple sclerosis (pwMS), fatigue, weakness and spasticity may reduce mobility and promote sedentary behavior. However, little is known about the existence of possible differences in the way MS modifies the propensity to perform physical activity (PA) in men and women. The present study aimed to partly close this gap by means of quantitative analysis carried out using wearable sensors. Forty-five pwMS (23 F, 22 M, mean age 50.3) and 41 unaffected age- and sex-matched individuals wore a tri-axial accelerometer 24 h/day for 7 consecutive days. Raw data were processed to calculate average number of daily steps, vector magnitude (VM) counts, and percentage of time spent in sedentary behavior and in PA of different intensities (i.e., light and moderate-to-vigorous, MVPA). Women with MS spent more time in sedentary behavior and exhibited a reduced amount of light intensity activity with respect to men, while MVPA was similar across sexes. However, in comparison with unaffected individuals, the overall PA patterns appear significantly modified mostly in women who, in presence of the disease, present increased sedentary behavior, reduced MVPA, number of daily steps and VM counts. The findings of the present study highlight the urgency of including sex as variable in all studies on PA in pwMS.

Spontaneity and serendipity: Space and time in the lives of people with diabetes

This article considers the relevance of non-representational theory to understanding the lived experience of diabetes. While non-representational theory has gained traction in the social sciences, especially Human Geography, its usefulness in extending our understanding of experiences of health and illness is often restricted to an idea of wellbeing that assumes an able and healthy body. This article draws on qualitative research on the everyday experiences of living with diabetes, to consider how non-representational theory can be applied to understanding the everyday experience of ill bodies. The analysis moves through ideas of mobility, routine, anticipation and adjustment to highlight the challenges of spontaneity and serendipity in the everyday lives of people with diabetes. The article concludes by considering some of the advantages of a non-representational approach for healthcare practice.

Benefits of Multiple Sclerosis Adult Day Program Participation for People with Multiple Sclerosis: A Qualitative Study

Background

Multiple sclerosis adult day programs (MSADPs) are nonmedical service programs that provide care and support to people with multiple sclerosis (MS) experiencing levels of impairment that interfere with employment and activities of daily living. The purpose of this study was to identify how program participants think MSADPs benefit them.

Methods

We conducted in-depth interviews with 95 people with MS who were MSADP participants. Interviews occurred as part of site visits to ten programs across the country. We supplemented participant interviews with interviews of program staff and ethnographic observation of activities at each site over 1 to 3 days.

Results

Participants reported several benefits from participating in an MSADP. Almost universally, participants explained that receiving and giving social support were the most important benefits. Other positive outcomes described included increased emotional well-being, better understanding and acceptance of MS, practical know-how for accomplishing ordinary tasks, and increased mobility and improved motor functioning.

Conclusions

Participants believe that MSADPs have a profound influence on their psychosocial health, much of which they attribute to membership in a socially cohesive community. Clinicians and policy makers should consider recommending these programs for people with MS who have unmet psychosocial needs and experience functional impairments.

Health information work and the enactment of care in couples and families affected by Multiple Sclerosis

Given the considerable emphasis placed on informed choice, the management of health information has become an increasingly important part of living with chronic illness. This paper explores the intra-familial dynamics of managing health information in the context of chronic illness. Drawing on 77 interviews with people affected by Multiple Sclerosis in the UK (patients, partners, family members and close friends), we show how families develop their own idiosyncratic information practices, including the careful, at times strategic, seeking, sharing and withholding of information. We describe how one individual, most commonly either the patient or their partner, often takes primary responsibility for managing growing quantities of health information. Doing this is a complex task, yet its dynamics within the family unit remain invisible and unacknowledged. In this paper we: (a) stress the importance of understanding information management in chronic illness as a collective process across all those affected, patients as well as carers; (b) conceptualise the process of managing health information in this context as 'health information work'; and (c) analyse it as part of the wider care practices families engage in and as a form of care in its own right.

The Relational Impact of Multiple Sclerosis: An Integrative Review of the Literature Using a Cognitive Analytic Framework

This integrative literature review uses cognitive analytic therapy (CAT) theory to examine the impact of a chronic illness, multiple sclerosis (MS), on relationships and mental health. Electronic searches were conducted in six medical and social science databases. Thirty-eight articles met inclusion criteria, and also satisfied quality criteria. Articles revealed that MS-related demands change care needs and alter relationships. Using a CAT framework, the MS literature was analysed, and five key patterns of relating to oneself and to others were identified. A diagrammatic formulation is proposed that interconnects these patterns with wellbeing and suggests potential “exits” to improve mental health, for example, assisting families to minimise overprotection. Application of CAT analysis to the literature clarifies relational processes that may affect mental health among individuals with MS, which hopefully will inform how services assist in reducing unhelpful patterns and improve coping. Further investigation of the identified patterns is needed.

The (un)habitual geographies of Social Anxiety Disorder

This article investigates experiences of Social Anxiety Disorder ('social anxiety') with reference to recent geographical debates on habit. It considers how habit simultaneously captures (un)reflective modes of being in the world and the foreboding disruptive capacity of uncertainty as people attempt to adapt to, negotiate and manage everyday life with social anxiety. Drawing on lived accounts from online questionnaires and online interviews with people diagnosed, or self-diagnosing, with social anxiety, it uncovers the relational and embodied practices-and the inherent spatialities of such practices-that enable individuals to (re)gain control of their socio-spatial surroundings. It also considers the capacity for habits to become disrupted and displaced through pervasive anxieties and persistent rumination and anticipation, situated within the context of participants' everyday lives. This analysis highlights the social, spatial and temporal dimensions of socially anxious experiences. Overall, by interpreting lived experience in this way, this article introduces a socio-spatial dynamic to otherwise extremely limited accounts of social anxiety found outside of the dominant biomedical framework.

Finding joy in poor health: The leisure-scapes of chronic illness

Globally, increasing numbers of people face the challenge of enjoying life while living with long-term illness. Little research addresses leisure participation for people with chronic illness despite its links with mental and physical health and self-rated quality of life. I use a space-time geographical approach to explore experiences with leisure in everyday life for 26 individuals with chronic kidney disease (CKD) in Australia. I examine ways in which the spatial and temporal characteristics of illness management and symptoms shape where, when, and how participants can enjoy leisure, focusing on: 1) logistical conflicts between illness and leisure; 2) rhythmic interferences with the force of habit in skilful leisure performance; and 3) absorbing experiences of encounter with self and place through leisure. Data were collected from 2013 to 2014. Participants kept diaries over two sample days and then participated in semi-structured interviews. Findings show that the voluntary nature of leisure offered participants important benefits in coping with and managing illness over the long-term, including opportunities to experience greater sense of control, an alternative experience of one's body to the 'sick body', and knowledge creation that supports adaptation to the uncertainties of illness trajectories. The ability to engage in meaningful leisure was constrained by the shaping forces of illness symptoms and management on participants' leisure-scapes. Illness treatment regimens should therefore be adapted to better accommodate leisure participation for chronically ill patients, and leisure should be explicitly incorporated into illness management plans negotiated between patients and health practitioners. Finally, greater understanding of the transformative capacity of habit in activities of experimentation and play may have wider-reaching implications for leisure's potential applications in public health. Leisure should be taken seriously as a vehicle for enhancing wellbeing and adaptation to life with long-term illness.

A qualitative investigation of lay perspectives of diagnosis and self-management strategies employed by people with progressive multiple sclerosis

This article explores how people with progressive multiple sclerosis give meaning to their experiences. It builds upon the self-management literature, which has captured the tension between the desire for retaining normalcy and the increasing burden of self-management associated with chronic disease progression. This repeat interview study is empirically grounded in 28 interviews with 14 people with progressive multiple sclerosis. We identified gender differences in diagnosis-seeking which impacted subsequent sense-making. Male respondents found a diagnosis of multiple sclerosis difficult to come to terms with, and an enduring sense of loss or anger could inhibit further sense-making. A diagnosis of multiple sclerosis was more difficult to obtain for women respondents, and any sense of certainty that diagnosis provided framed their subsequent sense-making strategies. The complex sequelae of multiple sclerosis require that self-management strategies are both contextual and timely, although even the most accomplished self-managers can lose their sense of self with neurodegeneration. Disease progression can be associated with suicidal ideation, suggesting the need for greater dialogue to ensure that people with multiple sclerosis are adequately supported to fulfil their quality of life at all stages of neurodegeneration. These lay perspectives emphasise the articulation of affect rather than the rendering of a medical diagnosis, although diagnosis may provide a degree of certainty in the short term. The ethos of self-management ensures people attempt to retain their sense of 'normality' and existent social roles for as long as possible, but this ethos can negate both one's ability to self-manage and the management of self.

Examining the role of patients’ experiences as a resource for choice and decision-making in health care: a creative, interdisciplinary mixed-method study in digital health

Background

Traditional health information has been based on facts and figures and not on patient experience (PEx). Websites featuring people’s accounts of their experiences of health and illness are popular as a source of information, support and much else. However, there are concerns that experiential information on the internet might have adverse effects on health.

Aims

To find out whether, when and how the NHS should incorporate PEx into online health information and elucidate the mechanisms through which PEx might influence health, develop a tool to measure the effects of online PEx, explore how PEx is used, and investigate the feasibility and acceptability of a randomised controlled trial of online PEx.

Methods

Mixed methods, including a conceptual literature review, qualitative secondary data analysis, the development of a new questionnaire, online ethnography, observational and experimental studies in an internet café environment, and finally feasibility trials to compare new websites based on PEx with those based on facts and figures.

Results

The review concluded that online PEx could affect health outcomes through seven domains (information, support, affecting relationships, providing ideas on how to use health services, influencing behaviour change, learning to tell the story and visualising illness). We developed the e-Health Impact Questionnaire, which demonstrates good psychometric properties and is suitable for use across different health groups and various styles of online information. Online ethnographic studies found three types of PEx on multiple sclerosis (MS) platforms: accounts of ‘living with MS’, self-expression and creativity, and experiences of health care and treatment. Observational and laboratory-based methods included studies of how people find and use PEx to inform health choices. We developed a three-stage model (gating, the engagement loop and outcomes) which guided the development of six prototype multimedia websites featuring either experiential information (intervention) or factual information (comparator) for three exemplar health issues. We evaluated the feasibility and acceptability of a trial of the prototype PEx websites, comparing self-report and process measures with a comparator. In the three conditions we randomised 87 (smoking cessation), 148 (asthma), and 42 (caring for someone with MS) participants. At final (2-week) follow-up, retention rates were 75%, 82% and 86%, for smoking cessation, asthma and MS carers, respectively. Usage of the allocated websites was low. The median number of logins to the websites over the 2-week period was two, two and four; the median number of page views was 10, 15 and 27.5, respectively, with a median total duration on site of 9 minutes, 17 minutes and 31.5 minutes respectively. There were no reported adverse events or harms. The qualitative interviews with 30 trial participants found that the trial methods were acceptable and not burdensome and that preferences for combinations of different types of information were both idiosyncratic and dependent on timing and need.

Limitations

This programme used a pragmatic, mixed-methods approach, in which we adapted some standard approaches (e.g. realist review). The conceptual review provided a framework for the whole programme but did not draw on a single overarching theoretically informed approach. Instead, we used relevant theory and methods from the work package leads, who represented a range of disciplines.

Conclusions

Online PEx is not seen as an alternative to facts, or to care from a health professional, but is used in addition to other sources of information, support and expression. This programme of work indicates how the sharing of online PEx may benefit people, and how this can be measured. A randomised controlled trial is feasible but an allocated ‘exposure’ to a ‘dose of information’ is far from from how online experiences are shared in everyday life. Future work evaluating online health interventions which incorporate personal experiences should aim to reflect ‘natural’ use of the internet and might include online ethnography and offline interviews. Studies might explore how and why people use online sources of experience-based health information, and the effects on subsequent behaviour and health and social outcomes in different conditions. Future intervention research evaluating online health interventions should examine and explain issues of engagement and use, and seek to identify how to increase engagement.

Trial registration

Current Controlled Trials ISRCTN29549695.

Funding

This project was funded by the Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 17. See the NIHR Journals Library website for further project information.

The Social Patterning of Work Disability Among Women in Canada

Although work disability is widespread among women with physical or mental impairment, little is known about its gendered nature. Drawing on the disablement and women's health literatures, it is argued that labor-market resources and participation in normatively structured social roles may be important in shaping women's work disability. Using data from a Canadian probability sample of community dwellers with disabilities, the paper examines the effects of functional limitation, labormarket resources, stage in the life course, and family roles on work disability. It also assesses the extent to which the relationship between social roles and disability depends on women's socioeconomic circumstances. Results indicate that younger individuals, married women, and those with high levels of homemaking responsibilities were less likely to report work disability than their counterparts without these social resources and roles. The impact of the parental role (children in the household) on work disability varied according to education.

Ménière's disease and biographical disruption: Where family transitions collide

People's lived experiences of chronic illness have garnered increasing research interest over the last 30-40 years, with studies recognising the disruptive influence of illness onset and progression, both to people's everyday lives and to their biographical selves. We extend this body of work, drawing on the experiences of people living with Ménière's disease; a long-term progressive vestibular disorder characterised by unpredictable episodes of debilitating vertigo, tinnitus and permanent sensorineural hearing loss. In response to calls for more critical examination of the wider biographical contexts in which chronic illnesses are encountered, we draw on 28 in-depth narrative interviews with Ménière's patients and their family members to discuss how personal chronic illness experiences may be closely entwined with, and deeply shaped by, the life transitions (illness-related and otherwise) of 'linked others'. Interviews were conducted in south west England from January to June 2015. Focusing on intersecting transitions of parenthood, caregiving and retirement, we explore how and why familial relationships can both facilitate and hinder adaptation to a lifetime of chronically disrupted normalities, contributing to fluctuating experiences of 'cherished time', 'anomalous time' and 'turbulent time'. In so doing, we suggest that the onset and progression of chronic illness could usefully be re-conceptualised as one of many 'biographical oscillations' encountered during the life course that serve to re-route us between continually shifting life trajectories. In recognising life's dynamism and challenging the identity-limiting and self-damaging nature of entrenched cultural life course constructions, we suggest value in recognising alternative ways of 'living well' when negotiating the wide-ranging biographical maps that life can follow.

Beyond the Clinic: Restructuring the Environment in Chronic Illness Experience

This article discusses research on the daily routines of women with chronic illness that focused on the relationship between body and environment. The analysis draws on insights from feminist theories of the body and human geography that explore the connections among the material or corporeal body, its representation in biomedical discourse and other dominant social ideas about the “able” body, and lived experience. The discussion, which is based on in-depth interviews with women about their daily lives in the spaces of home, neighborhood, and workplace, demonstrates the women's restructuring of their daily routines and environments as they respond to both the material changing of their body and its marking as “deviant.” The analysis emphasizes the powerful influence of dominant social norms about the body, which may cast certain bodies as “out of place,” not just physically but socially. The theoretical ideas are applied to case examples from occupational therapy, and implications for practice are suggested. Following from the analysis, an important focus of intervention is exploration of ways to restructure space and work with clients on issues of social identity.

Clinics and churches: lifeworlds and health-seeking practices of older women with noncommunicable disease in rural South Africa

Background

In this article we describe a phenomenological lifeworld study based on the theory of communicative action of 13 women with noncommunicable disease (NCDs) in a rural area in South Africa. The purpose of the study was to generate key concepts of health care access and the management of NCDs in a rural South African context.

Methods

The study employed a qualitative methodology with serial semistructured interviews. We used a content analytical approach to analyse key themes and patterns in participants’ narratives of NCDs and health care access.

Results

The findings are reported by theme and include analyses of narrative sequences related to 1) family environment, 2) experiences of NCDs, 3) understandings of the causes of NCDs, 4) accessibility of formal health care services, 5) experiences of formal health care services, 6) treating NCDs, and 7) experiences of informal health care services. The findings suggest that participation in the routines prescribed by formal health care services and reinforced by families and faith-based communities normalises the experience of NCDs to the extent that narratives of NCDs form the background, rather than the focus of broader illness narratives. Such narratives rather tend to focus on significant life events and relationships. The key features of the narratives include connections between social or autobiographical and biological understandings of NCDs, the appropriation of modern concepts of disease in illness narratives, and reflexive commentary on the modern features of NCDs. In the context of such narrative expertise formal health care services have a high level of acceptability in this rural area.

Conclusion

Lifeworld analysis of health care access based on the theory of communicative action places consensual understandings of NCDs and their treatment as central to the health care experience. Our findings suggest that such analyses can facilitate potential feedback processes between health care users and professionals which generate consensus as well as institutional reform within formal health care services.

Integrating paid work and chronic illness in daily life: A space-time approach to understanding the challenges

The upward trend of chronic illness in working age populations calls for better understanding of the difficulties chronically ill people face with workforce participation. Existing research focuses primarily on physical limitations and employer attitudes about chronic illness. Here we use a space-time approach to illuminate the importance of negotiating logistical challenges and embodied rhythms when balancing work and chronic illness. We draw from time geography and rhythmanalysis in analysing interviews from a qualitative case study of 26 individuals living with chronic kidney disease in Australia. Difficulties with paid work arise from: (1) competition for space-time resources by employers and health services; (2) arrhythmias between the body, work and health services; and (3) the absence of workplace rhythms on which to 'hook' health activities. Implications for workplaces and health services design are discussed.

Social identity in people with multiple sclerosis: a meta-synthesis of qualitative research

Purpose

– Many aspects of the self are lost as a consequence of having multiple sclerosis (MS). A person's identity can be altered by negative self-concepts, which are associated with poor psychological wellbeing and can lead individuals to reconstruct their sense of self. The Social Identity Model of Identity Change argues that previously established identities form a basis of continued social support, by providing grounding and connectedness to others to facilitate the establishment of new identities. Family support is a salient factor in adjustment to MS and may enable the establishment of new identities. The purpose of this paper is to investigate identity reconstruction following a diagnosis of MS.

Design/methodology/approach

– A meta-synthesis of the qualitative literature was conducted to examine the relationship between identity change and family identity of people with MS and other family members.

Findings

– In all, 16 studies were identified that examined identity change and the family following a diagnosis of MS. Coping strategies used by people with MS and their wider family groups, affect the reconstruction of people's identity and the adjustment to MS. Receiving support from the family whilst a new identity is constructed can buffer against the negative effects of identity loss.

Practical implications

– The family base is strengthened if MS-related problems in daily life are adapted into the individual and family identity using positive coping styles.

Originality/value

– This review provides an interpretation and explanation for results of previous qualitative studies in this area.

Understanding the Lived Experience of People with Multiple Sclerosis and Dysexecutive Syndrome

Introduction:

While evidence suggests that people with multiple sclerosis experience executive function impairment, there is a lack of understanding as to what this means for people within their occupational lives. This study attempted to explore the meanings constructed by individual participants who live with multiple sclerosis and dysexecutive syndrome on a daily basis.

Method:

Ten community-dwelling adults, diagnosed with clinically definite/probable multiple sclerosis and having performed within the ‘Impaired’ category of the Behavioural Assessment of Dysexecutive Syndrome, were invited to participate in semi-structured interviews. The data were analysed using interpretative phenomenological analysis.

Findings:

The reported changes in the occupational lives of the participants contributed to significant alterations in the roles they inhabited. There was a substantial cost to personal identity as the participants withdrew from former roles or perceived themselves to be failing within their existing roles, leading to a loss of self-worth and self-esteem.

Conclusion:

It is evident from the findings of this study that the actual cognitive deficits did not represent the main issue for people within their everyday lives; rather, the putative consequences of executive dysfunction were of much greater concern for them.

Graphic pathogeographies

This paper focuses on the graphic pathogeographies in David B.'s Epileptic and David Small's Stitches: A Memoir to highlight the significance of geographic concepts in graphic novels of health and disease. Despite its importance in such works, few scholars have examined the role of geography in their narrative and structure. I examine the role of place in Epileptic and Stitches to extend the academic discussion on graphic novels of health and disease and identify how such works bring attention to the role of geography in the individual's engagement with health, disease, and related settings.

Perceived Stigma Among People With Chronic Health Conditions

Objectives:

This study addresses whether age, functional limitation and other stressor exposure, and psychosocial coping resources influence variation in perceived stigma and the form this influence takes (i.e., independent and/or interdependent).

Methods:

Using data from two waves of a large community study of adults (age 20–93) with chronic health conditions ( n = 417), a residual change regression analysis considers direct and moderating factors influencing perceived stigma over a 3-year period.

Results:

Age, functional limitation, the experience of discrimination, and self-esteem independently account for variation in perceived stigma. Moderation tests reveal that age is associated with a greater increase in stigma in the context of greater functional limitation and increases in limitation. Functional limitation and stressor exposure are also associated with declines in stigma in the context of greater mastery and self-esteem.

Discussion:

Multiple processes bear on perceived stigma among people with chronic health conditions. Implications for stigma and stress research are discussed.

'I'm just a walking eating disorder': the mobilisation and construction of a collective illness identity in eating disorder support groups

The increasing visibility of support groups has prompted a flurry of sociological investigation, much of which explores how groups benefit participants. What researchers have failed to consider is the group itself. Bringing social movement theory to bear on the case of eating disorder support groups, this study seeks to explore how support groups attract and sustain adequate participation. Participant observation in an eating disorder support group reveals that broad diagnostic and prognostic frames, coupled with strong motivational framing and collective identification on the basis of a shared disordered self, promote support group participation. The very processes that enable support groups' successful mobilisation, however, simultaneously construct a collective illness identity, which in turn serves as the basis for participants' individual-level identity work. More specifically, support group mobilisation processes construct eating disorders as highly consequential, highly symptomatic, chronic, rooted in the self, and uncontrollable. Such findings suggest that support groups may have unanticipated and potentially adverse consequences for participants and thus build on previous work highlighting the unintended health consequences of framing processes. Such findings further contribute to our understanding of how macro-social forces shape illness experience.

Thinking through every step: how people with spinal cord injuries relearn to walk

In this article we explore how people with incomplete spinal cord injury (iSCI) create meaning out of their changing bodies as they undergo a therapeutic intervention called locomotor training (LT). Therapeutic interventions like LT are used to promote the recovery of walking ability among individuals with iSCI. The chronological nature of this study--interviews at three points throughout the 12-week intervention--enhances understanding of the recovering self after spinal cord injury. Drawing on a constructivist theoretical framework, we organize data according to three narrative frames. Participants interpreted LT as (a) a physical change that was meaningful because of its social significance, (b) a coping strategy for dealing with the uncertainty of long-term recovery, and (c) a moral strategy to reconstitute the self. We offer findings that lay the conceptual groundwork for generating new knowledge about what is important to people with iSCI as they relearn how to walk.

What Do People with Multiple Sclerosis Want from an Occupational Therapy Service?

Aim:

This study aimed to understand how people with multiple sclerosis (MS) experienced a local occupational therapy service and to identify what they would want from future services.

Method:

The data from this qualitative programme evaluation were generated through nine focus groups, including 30 people with a clinically definite diagnosis of MS, 10 partners/carers of people with MS and six occupational therapy staff.

Findings:

The findings evolved within four key themes: comprehension of occupational therapy; assessment and interventions; home visits; and levels of support. Although occupational therapy was not initially well understood, comprehension developed with greater use of the service. Nevertheless, significant challenges exist in providing therapeutic programmes that offer meaning and purpose within the lives of people with MS while ensuring flexibility and choice.

Conclusion:

This study suggests that there is a possible distinction between what occupational therapists believe people with MS want and what they and their partners/carers do want. People with MS and their partners/carers, therefore, have a meaningful contribution to make and should be involved in the future development of occupational therapy services.

Using GIS and perceived distance to understand the unequal geographies of healthcare in lower-income urban neighbourhoods

Geographers play important roles in public health research, particularly in understanding healthcare accessibility, utilisation, and individual healthcare experiences. Most accessibility studies have benefited from the increased sophistication of geographic information systems (GIS). Some studies have been enhanced with semi-structured in-depth interviews to understand individual experiences of people as they access healthcare. However, few accessibility studies have explicitly utilised individual in-depth interview data in the construction of new GIS accessibility measures. Using mixed methods including GIS analysis and individual data from semi-structured in-depth interviews, we offer satisfaction-adjusted distance as a new way of conceptualising accessibility in GIS. Based on fieldwork in a predominantly lower-income community in Columbus, Ohio (USA), we find many residents felt neighbourhood healthcare facilities offered low-quality care, which suggested an added perceived distance as they attempt to access high-quality healthcare facilities. The satisfaction-adjusted distance measure accounts for the perceived distance some residents feel as they search for high-quality healthcare in lower-income urban neighbourhoods. In moving beyond conventional GIS and re-conceptualising accessibility in this way, we offer a more realistic portrayal of the issues lower-income urban residents face as they attempt to access high-quality healthcare facilities. The work has theoretical implications for conceptualising healthcare accessibility, advances the mixed-methodologies literature, and argues for a more equitable distribution of high-quality healthcare in urban neighbourhoods.

MS and me: exploring the impact of multiple sclerosis on perceptions of self

PURPOSE

The aim of this qualitative study was to explore the impact of multiple sclerosis (MS) on perceptions of self as well as the emotional, social and practical implications of any self-reported changes.

METHOD

Twelve participants were interviewed and interpretative phenomenological analysis used to analyse the data. Participants were recruited from a MS hospital clinic in the north-west of England.

RESULTS

Four themes were identified although for reasons of space and novelty three were discussed, (i) 'my body didn't belong to me': the changing relationship to body, (ii) 'I miss the way I feel about myself': the changing relationship to self and (iii) 'let's just try and live with it': incorporating yet separating MS from self.

CONCLUSIONS

The onset of MS was seen to impact upon self yet impact did not necessarily equate with a loss of self but rather a changed self. Self-related changes did, however, carry the potential to impact negatively upon a person's mood and psychological functioning and consequently, clinicians are encouraged to consider issues relating to self as standard.

Meanings of feeling well for women with multiple sclerosis

In research concerning multiple sclerosis (MS), the factors that impact on people's well-being and quality of life have been studied, but little has been written about what it means to feel well for women with MS. Therefore, in this study our aim was to describe meanings of feeling well for women with MS. We interviewed 15 women with MS, and a phenomenological hermeneutic interpretation was utilized to analyze the interviews. Through this study it can be understood that finding a pace where daily life goes on means that women with MS feel well when the illness is kept in check and is not the dominant experience. The findings of this study can be used to confirm women's experiences of feeling well, despite living with the consequences of MS. Health care professionals will find the results of this study useful when they reflect on and formulate the care of women with MS when attempting to support the latter's desire to feel well in their daily lives.

Disparate routes through support: negotiating the sites, stages and support of informal dementia care

Worldwide people with dementia are usually cared for at home by informal carers who may themselves have poor health and/or live in social situations which intensify their needs. The scale of these needs continues to be underappreciated and they are exacerbated by the limited social, cultural and emotional resources that carers can draw upon. This paper looks at the disparities in support, and the complex negotiations made by carers, as they reconcile the everyday realities of informal care in the home. Appreciation of these issues is essential in understanding carers' coping strategies in an ageing population.

Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis

BACKGROUND

Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established.

OBJECTIVES

To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs.

SEARCH STRATEGY

Electronic searches included: Cochrane Central Register of Controlled Trials "CENTRAL" 2008 issue 3, MEDLINE (PubMed) (1966- 2008), EMBASE (1988- 2008), CINAHL (1982- 2008), PEDro (1990- 2008), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register.

SELECTION CRITERIA

Randomized and controlled clinical trials, including before - after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls.

DATA COLLECTION AND ANALYSIS

Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs.

MAIN RESULTS

Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)'competitive employment', in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labour force; (b) for altering 'work ability' by improving participants' confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness.

AUTHORS' CONCLUSIONS

There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.

What do people talk about during reflexology? Analysis of worries and concerns expressed during sessions for patients with multiple sclerosis

BACKGROUND

Our previous study evaluated the use of reflexology compared to progressive muscular relaxation in improving the psychological and physical profile associated with multiple sclerosis. In this paper audiotapes from the reflexology sessions have been analysed to give a picture of the nature of interaction between patients and therapists during treatment.

METHODS

A crossover design with two groups was chosen. Each participant received six sessions of both interventions. All reflexology sessions were recorded and the tapes transcribed and analysed.

RESULTS

Analysis of the available audiotapes (n=245) revealed that reflexology provided opportunities for 48 out of the 50 participants to share worries and concerns. Recurring disclosure themes related to physical symptoms and treatment, psychological concerns, home/family worries, and work/leisure issues. Explorative analysis revealed some differences in the amount of disclosure over the weeks, between for example the participant's type of MS and time living with the diagnosis.

CONCLUSIONS

Reflexology appears to have created a space for patients to talk about their worries and concerns, and to receive advice and support from the nurse therapists. This work contributes to the debate about the role of the therapeutic relationship within reflexology practice.

"It's like you are just a spectator in this thing": Experiencing social life the 'aspie' way

This study explores the experiences of people with Asperger syndrome (AS) from a sociological perspective using the theoretical approaches of ethnomethodology and symbolic interactionism. In-depth interviews were conducted with 16 people with AS and three key themes of feeling different, trying to fit in and safe spaces are considered here. We suggest that people with AS develop a different symbolic capacity to most people and have difficulties in making sense of social encounters. While these difficulties can be overcome, to some degree, by developing strategies to try to fit in, this learning remains at a superficial level and is not internalised through the process of socialisation. Without being able to derive a firm sense of reality from spontaneous involvement in social encounters, participants feel "unruled, unreal and anomic" (Goffman, 1967: 135) and experience intense autistic emotion (Davidson, 2007a,b).

'Restricting choices and limiting independence': social and economic impact of multiple sclerosis upon households by level of disability

OBJECTIVE

To examine the relationship between the social and economic impact of multiple sclerosis (MS) and levels of MS-related disability upon households in the following domains: household composition, housing modification, employment, standard of living, children, intimate and close relationships, and social life.

METHODS

A national sample of people with MS (pwMS) (n = 920), consisting of members of the MS Society and those accessing the MS Society website, completed a cross-sectional survey to generate quantitative and qualitative data.

RESULTS

Over three-quarters of the sample reported that MS had impacted on at least some areas of daily life. The reported impact increased significantly in a linear fashion in each domain with increasing disability, as measured by an activities of daily living index, although there was a discernible 'levelling off' in terms of impact in some domains among those at the higher levels of disability and dependency. Analysis of the qualitative data suggests that this impact can be conceptualized as a gradual process of 'restricting choices' and 'limiting independence' for both pwMS and their households.

DISCUSSION

MS restricts social and economic opportunities for pwMS and those who they live with. These findings extend the literature to households to illustrate the impact of MS not only on pwMS but also on their partners, children and other family members.

Experiencing and controlling time in everyday life with chronic widespread pain: a qualitative study

Background

Chronic widespread pain (CWP) affects 10% of adults and often causes significant disability in everyday life. Research on time in chronic conditions has focused on biographical disruption and perceptions of past and future. However, more mundane aspects of time are also disrupted in a condition such as CWP, which is uncertain on a minute-to-minute, day-to-day basis, as well as in the longer term. The results presented here are part of a wider study, the aim of which was to explore how people with CWP experience and give meaning to their 'condition'. This article focuses on how mundane, repetitive and taken-for-granted aspects of everyday life are disrupted for people with CWP.

Methods

Eight people aged 40–60 years living with CWP took part in multiple in-depth interviews, diaries and family interviews, exploring the meanings and interpretations of participants and individuals' experiences in a social context.

Results

The findings illuminate the ways in which the experience of time is changed by CWP: carrying out the tasks of everyday life takes longer, routines are disrupted, and changes are needed in how time is managed. Some strategies for managing these tasks rely on ability to control one's time. However, this is not always possible and, for some, the experience of CWP becomes characterised by lack of such control.

Conclusion

This study explored the concept of controllable time in the experience of CWP. Regaining control over time is an important element in coping with chronic pain, and helping patients to regain such control has potential as a target for health professionals involved in pain management.

Women's experiences of developing musculoskeletal diseases: employment challenges and policy recommendations

PURPOSE

To answer three specific questions: (i) How do women experience the workplace after the onset of a musculoskeletal disease; (ii) What employment policy and programme suggestions can they offer for ways to better support chronically ill women in their abilities to maintain workforce participation; and (iii) How are these women's employment policy and programme recommendations informed by their own lived experiences and desires?

METHOD

In-depth interviews were conducted with 18 women who had developed musculoskeletal diseases while involved in the labour market. Data were coded and analysed thematically.

RESULTS

Participants identified three common workplace barriers experienced and three types of workplace accommodations commonly requested. They offered four specific employment policy and programme recommendations for ways to better support women who develop musculoskeletal diseases in maintaining labour market participation. It is found that their employment policy and programme recommendations are informed by their own experiences in the workplace and desires for being supported in maintaining involvement in paid labour.

CONCLUSIONS

Creating employment programmes and policies that support chronically ill women in their attempts to remain involved in the workforce based on how much paid labour they are able to perform and where they are best able to work is of the utmost importance.

Biographical disruption associated with multiple sclerosis: Using propensity scoring to assess the impact

Chronic illness such as multiple sclerosis (MS) is often associated with 'biographical disruption', a concept that is derived from qualitative narrative analyses examining how people make sense of their illness in the context of their lives [Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182]. This paper attempts to operationalise the idea of disruption to one's life trajectory in quantitative analysis by examining the social, economic and emotional disruption associated with MS. A number of studies have suggested that it impacts negatively on employment, income and sexual relationships; however previous research has been based upon samples of people with MS (pwMS), with a dearth of studies comparing pwMS with the general population. This study reports a systematic comparison of MS and non-MS households to enable the impact of MS to be quantified in terms of household composition and marital status; household income; economic activity; and to determine whether biographical disruptions such as relationship breakdown or unemployment are more or less prevalent among those affected by MS compared to the general population. The MS sample came from randomly selected members of the UK MS Society (n=783) and those accessing the MS Society website (n=133). Data for the general population came from the 2001/02 British General Household Survey (GHS). Cases from the MS Society sample were matched using propensity scoring with cases from the GHS. The results of the matched analysis show that both men and women with MS are significantly less likely to be employed than those in the general population and are significantly more likely to have a 'below average' household income, despite the fact that they are in a higher social class and have higher educational levels than people in the general population. Differences between the MS and GHS samples in terms of marital status become non-significant when socio-demographic variables are controlled for using propensity scoring. This study provides robust evidence on how MS impacts on and disrupts the life of the person with MS and their household in terms of income and employment.

Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers

BACKGROUND

The NSF for Long-term Neurological Conditions highlights the need for vocational rehabilitation services. Although the barriers to work for people with MS (pwMS) have been clearly identified, there has been little research that identifies the type of support required.

OBJECTIVE

To identify what pwMS require from a vocational rehabilitation service in terms of content and service delivery.

DESIGN OF STUDY

Four focus groups of pwMS, currently in employment, were convened. These were audio-taped and content analysed using a constant comparison method.

RESULTS

People with MS identified two key needs; managing performance and managing expectations. Performance difficulties could be managed either by treating symptoms, by changing the environment, or by altering the demands of the job. PwMS highlighted the need for counselling to help them, and advocacy to help their employers have appropriate expectations.

CONCLUSION

PwMS need support in the workplace in two distinct ways. First, by managing the interaction between the impairments caused by MS, the physical environment, and the demands imposed by the work. Second, by providing expert knowledge about the employment environment and the needs of employers, an awareness of the relevant legislation and counselling in supporting people to adapt, adjust and resolve complex issues.

Experiencing chronic widespread pain in a family context: giving and receiving practical and emotional support

The impact of pain and chronic illness on the family has been documented, but there is little information about living with chronic widespread pain in the context of the family. This article uses data from a qualitative study of the experience of living with chronic widespread pain to examine the experience and meaning of support for people with this condition in the context of their families. It focuses on the varying, dynamic and reciprocal nature of practical and emotional support in the family. Family members may provide support but are also receivers of support from the person with chronic widespread pain. The factors mediating the provision of this support are also explored, including the nature of the pain and the needs of the person with pain, and the roles, responsibilities and characteristics of other family members.

Exploring the altered daily geographies and lifeworlds of women living with fibromyalgia syndrome: A mixed-method approach

In this paper I employ data triangulation in order to investigate the complex nature of the altered lifeworlds and daily geographies of women living with fibromyalgia syndrome (FMS). More specifically, I use the findings of in-depth interviews and a standardized test (the Sickness Impact Profile [SIP]) in a mixed-method approach to understanding how women's lives change after the onset of FMS and how their changing bodies and locations in society and space shape such altered lifeworlds. These data were collected from 55 women living with FMS in Ontario, Canada. The experiential evidence shared during the interviews is used to qualify or explain certain phenomena observed within the SIP dataset. I focus on four specific experiences in the women's lives; these are the: (1) onset of mental haziness and fatigue; (2) development of disrupted sleep/sleep disorders; (3) removal from paid labour; and (4) withdrawal from social and recreational activities. It is found that changes in the women's bodies precipitated some of the most significant life changes experienced, including altered identities and diminished incomes, and that altered bodily realities facilitated or denied access to socio-spatial life. At the same time, the women's changing locations in society and space also played a role in bringing about such changes.