Enhancing lives through the development of a community-based participatory action research programme

Using Participatory Action Research to Redirect Tinnitus Treatment and Research-An Interview Study

Background: Chronic bothersome tinnitus is a prevalent tinnitus subtype placing a high burden on affected individuals, economies, and healthcare systems. Patient and professional perspectives seem to be partly misaligned on how to improve tinnitus research and treatments in the future. This qualitative interview study was aimed at exploring, comparing, and stipulating the perspectives of different tinnitus stakeholder groups on ways of redirecting research and treatments to reduce patients' suffering while accounting for challenges within these practices. Methods: This study used the participatory action research approach to facilitate the stakeholder involvement. Semi-structured online interviews including five participants (two tinnitus patients, two tinnitus researchers and medical specialists, one general practitioner) were conducted. Inductive grounded theory and the constant comparative method were used for data analysis. Results: Four categories for suggested research adaptations ((I) ethical patient involvement; (II) prioritising cure versus coping research; (III) funding; (IV) ethical publication) and six categories for suggested treatment adaptations ((I) ethical professional support; (II) patient involvement; (III) interdisciplinarity; (IV) professional tinnitus education; (V) clinical treatment guidelines; (VI) psychological treatment) were identified. Participants held partly similar priorities such as increasing pathophysiological and cure research. Differences between participants included, for instance, patients aiming for increasing patient involvement in tinnitus research and treatments compared to professionals arguing that the excessive focus on patients' conditions might reduce the patients' chances of habituating to their symptoms. Conclusions: Four action redirections for improving tinnitus research and treatment practices were defined: (I) facilitating communication between and within stakeholder groups, (II) increasing the reflective use of patient involvement, (III) increasing interdisciplinarity, and (IV) reducing barriers to receiving psychological treatment.

Sustainability Communication through Bio-Based Experiential Learning

Sustainability-related communication involving youth and children continues to be difficult to practice effectively and sustainably. This study examines how effective a particular approach to sustainability communication is at raising children’s environmental awareness through an educational program. Participatory action research and storytelling as a narrative paradigm were used to examine the effectiveness of bio-based experiential learning. A total of 74 students (ages 9 to 11) from Bandung, Indonesia, participated in the program. Twenty parents also participated in providing feedback for the campaign on how to change their children’s behavior towards the environment. The outcome demonstrates that the communication approach of bio-based experiential learning activities provides children with valuable education. The children are taught about urban farming, environmental awareness, and social responsibility. In the long run, it is hoped that children will be motivated to start an environmentally friendly business, particularly in biotechnology for the environment, to foster a sustainable city.

A participatory, farmer-led approach to changing practices around antimicrobial use on UK farms

Farmer-led, participatory approaches are being increasingly employed in agricultural research, with promising results. This study aimed to understand how a participatory approach based on the Danish stable schools could help to achieve practical, farmer-led changes that reduced reliance on antimicrobials in the UK. Five facilitated farmer action groups comprising 30 dairy farms across South West England met on farm at regular intervals between 2016 and 2018, and worked collaboratively within their groups to discuss how to reduce antimicrobial use. Qualitative data from group discussions and individual semi-structured interviews were collected and analyzed using thematic analysis to explore how the approach helped farmers address and deal with changes to their on-farm practices. Facilitator-guided reviews of antimicrobial use and benchmarking were carried out on each farm to assess any change in usage and help farmers review their practices. The pattern of antimicrobial use changed over the 2 yr of the study, with 21 participating farms reducing their use of highest-priority critically important antibiotics (6 farms were not using any of these critical medicines from the outset). Thirty practical action plans were co-developed by the groups with an average implementation rate of 54.3% within a year. All assessed farms implemented 1 recommendation, and many were still ongoing at the end of the study. Farmers particularly valued the peer-to-peer learning during farm walks. Farmers reported how facilitated discussions and action planning as a peer group had empowered them to change practices. Participants identified knowledge gaps during the project, particularly on highest-priority critically important antibiotics, where they were not getting information from their veterinarians. The study demonstrated that facilitation has a valuable role to play in participatory approaches beyond moderating discussion; facilitators encouraged knowledge mobilization within the groups and were participants in the research as well. Facilitated, farmer-led, participatory approaches that mobilize different forms of knowledge and encourage peer learning are a promising way of helping farmers to adapt and develop responsible practices.

Management of Chronic Daily Headache and Psychiatric Co-Morbidities by Lifestyle Modification: Participatory Action Research Combining New Communication Media

Background

Lifestyle modification has a significant role in chronic daily headache (CDH) management. Participatory action research (PAR) can play an important role in managing chronic medical conditions. However, it has been scarcely used in CDH management.

Objectives

This study aimed to empower patients with CDH to modify their lifestyle in order to reduce both their headache and related psychiatric co-morbidities in a multidisciplinary headache clinic at Baqiyatallah hospital, Tehran, IR Iran.

Methods

In the PAR plan, 37 patients (27 females) diagnosed with CDH were selected using purposeful sampling. Along with face-to-face group sessions, all available communication means such as phone calls, emails, short message system (SMS), and social media (Telegram) were used to facilitate the process. Questionnaires of health promotion lifestyle profile (HPLPІІ), visual analog scale (VAS), and depression-anxiety-stress scale (DASS21) were used to collect data. The data were analyzed using SPSS software.

Results

Mean age of the patients was 38.33 (± 9.7) years. Both “general pain” and “the worst imaginable pain” reduced (mean of reduction: 2.56 ± 2.7 and 2.3 ± 2.9, respectively, P < 0.001). > 50% of pain reduction occurred in “the worst imaginable pain" category (-1.45 ± 2.02, P < 0.001) and mean VAS score reduced to 5.20 (± 2.3) compared to the start of the study (7.50 ± 1.9, P < 0.001). Mean DASS-21 score also reduced significantly for depression (P < 0.016), anxiety (P < 0.026), and stress (P < 0.008). HPLPІІ score significantly improved (118.17 ± 14.8 vs. 160.83 ± 16.4, P < 0.001) and the highest increase was seen in the subscale of "stress management" (17.73 ± 2.8 vs. 25.53 ± 3.9, P < 0.001).

Conclusions

The empowering PAR plan combined with new communication tools helped the CDH patients better handle their lifestyle, reduce their headache, and lower their symptoms. Further studies with better use of currently available communication tools and social media are recommended for action research to be more applicable.

Culturally sensitive adaptation of the concept of relational communication therapy as a support to language development: An exploratory study in collaboration with a Tanzanian orphanage

BACKGROUND

Orphans and other vulnerable children (OVC) who grow up in institutional care often show communication and language problems. The caregivers lack training, and there are few language didactics programmes aimed at supporting communication and language development in OVC in institutional care in Tanzania.

OBJECTIVES

The purpose of the study was to adapt the German concept of relational communication therapy (RCT) as a support to language development in a Tanzanian early childhood education context in a culturally sensitive way. Following the adaptation of the concept, a training programme for Tanzanian caregiver students was developed to compare their competencies in language didactics before and after training.

METHODS

A convergent mixed methods design was used to examine changes following training in 12 participating caregiver students in a Tanzanian orphanage. The competencies in relational language didactics were assessed by a self-developed test and video recordings before and after intervention. Based on the results, we drew conclusions regarding necessary modifications to the training modules and to the concept of RCT.

RESULTS

The relational didactics competencies of the caregiver students improved significantly following their training. A detailed analysis of the four training modules showed that the improvement in relational didactics competencies varied depending on the topic and the teacher.

CONCLUSION

The results provide essential hints for the professionalisation of caregivers and for using the concept of RCT for OVC in institutional care in Tanzania. Training programmes and concepts should not just be transferred across different cultures, disciplines and settings; they must be adapted to the specific cultural setting.

Experiences of a PAR Intervention in Care for Older People

Participatory action research (PAR) is an approach for dealing with problematic areas in practice. Follow-up studies in which participants describe their participation in PAR in detail are rare. This follow-up study aimed to describe care providers' (CPs) experiences of having participated in a PAR intervention designed to assist them to constructively deal with troubled conscience. Twenty-nine CPs who participated in a PAR intervention were interviewed 2 to 4 months post-intervention. Content analysis was used to analyze the data. The analysis revealed three main categories: the importance of having a communal and collaborative meeting place, perceived changes in daily life, and "It has been good, but it has not solved all of our problems." Using PAR to deal with troubled conscience might be an important organizational investment for the future that can help prevent ill health among CPs and maintain or improve the quality of care.

Enhancing Research With Migrant Women Through Focus Groups

Recent systematic reviews of measurement strategies have identified a striking lack of data to support the validity of most questionnaires used with multiethnic, migrant populations. In the context of two ongoing research studies examining the reproductive health needs of migrant women in Canada, cultural validation was required for proposed study questionnaires and protocols in a total of 13 languages. Multilingual, multiethnic women with various migrant profiles were recruited from the community to review research materials in a series of focus groups. Recommendations by these women were made in relation to consent and interpretation procedures, development of trust in research, home visits after birth, approaches to sensitive topics, inclusion of discrimination as a research variable, and reimbursement of participants. Preliminary work applying focus-group methods to mixed ethno-cultural groups yielded valuable information on appropriateness of planned research.

A model for implementing guidelines for person-centered care in a nursing home setting

BACKGROUND

Systematic evaluations of knowledge translation interventions in nursing homes to improve practice are scarce. There is also a lack of studies focusing on creating sustainable evidence-based practice in the setting of residential dementia care.

METHODS

The aim of this paper is to describe a model for implementing national evidence-based guidelines for care of persons with dementia in nursing homes. The secondary aim is to outline the nursing home staff experiences during the first year of the implementation process. The intervention had a participatory action research approach. This included educational activities such as: (i) thematic seminars introducing national guidelines for dementia care, (ii) regular unit-based seminars; and (iii) later dissemination of information in reflective seminars and several days of poster-exhibitions. Areas of practice development were selected on each of the 24 units, based on unit-specific needs, and a quality improvement strategy was applied and evaluated. Each unit met ten times during a period of eight months. Data for this study were extracted from the reflective seminars and poster presentations, analyzed using a qualitative content analysis.

RESULTS

Findings showed that implementation of guidelines were perceived by staff as beneficial for both staff and the residents. However, barriers to identification of relevant sources of evidence and barriers to sustainable implementation were experienced.

CONCLUSIONS

One of our assumptions was that dementia nursing homes can benefit from becoming knowledge driven, with care practices founded in evidence-based sources. Our findings show that to be partly true, even though most staff units found their efforts to pursue and utilize knowledge adversely impacted by time-logistics and practical workload challenges.

Learning to Deal Constructively With Troubled Conscience Related to Care Providers’ Perceptions of Not Providing Sufficient Activities for Residents

The aim of this study was to illuminate an intervention process to assist care providers in municipal care of older people to constructively deal with their troubled conscience generated from their perceived shortcomings about not providing sufficient activities for residents. The study design was grounded in participatory action research. Twelve care providers and their manager participated in intervention sessions. Content analysis was used to analyze the transcriptions. By sharing their experiences with each other, care providers became aware of, and confirmed in one another, what types of activities were meaningful for residents and actions were taken to provide such activities. The importance of being attentive and relying on residents’ responses, that is, providing person-centered activities, was found to be satisfying to residents and eased the care providers’ troubled conscience. An enlightened conscience can be an important asset, which may prevent ill-health and improve quality of care.

From Practice to Praxis: Reconnecting Moral Vision with Philosophical Underpinnings

In this article, it is argued that in order to meet the profession's ethical and moral obligations, occupational therapists need to ensure that they are connected to the philosophical foundations of occupational therapy. By making occupational therapy practice occupation-focused, therapists guarantee that they provide a unique and valuable contribution to multidisciplinary teams and that they help to meet all the needs of patients. The findings from an action research study of 15 occupational therapists' practice in an urban Australian acute hospital setting are used to illustrate that occupational therapy practice can and should be occupation-focused.

Research data were gathered through audio-recording and transcribing individual interviews and research group meetings. The data were analysed qualitatively using non-linear formal and informal processes. The findings were as follows: having a clear professional vision increased the confidence of co-researchers; attending to patients' occupational needs increased the therapists' motivation to engage in more occupation-focused practice; and therapists felt increased satisfaction when their practice was occupation-focused. The article concludes by advocating that occupational therapists can be wiser and more ethical practitioners by engaging in praxis, a form of moral, reflective practice scholarship, particularly through participating in communities of practice that focus on understanding and developing ways of enabling occupation.

Hidden Heroines: Lone Mothers Assessing Community Health Using Photovoice

Between 2005 and 2007, a small group of lone mothers in Moncton, New Brunswick, carried out participatory action research within a university—community agency partnership. Applying the method of photovoice, the women took pictures within their community context on topics that they considered important to their health, health promotion, and quality of life. Eight themes that emerged from the process were represented with pictures and captions and presented in numerous public venues and conferences. Themes included finances, stress, support, personal development, violence and abuse, place, and transportation. The visual images and accompanying captions bring to the public arena the voices of those who are often most affected by public policy but have little, if any, input into its creation. Nurses and other health professionals can play a critical role in working toward gender and economic justice, while accompanying marginalized populations in ways that respect their beliefs, perceptions, and experiences.

Power brokering, empowering, and educating: the role of home-based care professionals in the reduction of HIV-related stigma in Kenya

In this article the authors report on how home-based care (HBC) professionals reduce stigmatizing behavior in Kenya. This study was part of an action research project that evaluated the introduction of HBC. HBC professionals coordinate the delivery of HIV/AIDS services at a district level and educate community-based health workers in HBC. Understanding how HBC professionals reduce stigma is crucial to reduce, prevent, and treat HIV/AIDS. Fifty HBC professionals participated in 27 focus group interviews over 18 months. Stigma featured strongly when they discussed barriers to the introduction of HBC. Using sociological theory, the authors organized the data into five themes: Power broking and mobilization, Stigma as a social construction, Community and structural interventions, Educating and training people, and Historical context. The HBC professionals appear to operate at mostly individual and community levels in their efforts to challenge stigma, and in spite of the difficulties they appear to be having some impact.

Feminist-informed participatory action research: a methodology of choice for examining critical nursing issues

Identifying a methodology to guide a study that aims to enhance service delivery can be challenging. Participatory action research offers a solution to this challenge as it both informs and is informed by critical social theory. In addition, using a feminist lens helps acquiesce this approach as a suitable methodology for changing practice. This methodology embraces empowerment self-determination and the facilitation of agreed change as central tenets that guide the research process. Encouraged by the work of Foucault, Friere, Habermas, and Maguire, this paper explicates the philosophical assumptions underpinning critical social theory and outlines how feminist influences are complimentary in exploring the processes and applications of nursing research that seeks to embrace change.

"It's like Tuskegee in reverse": a case study of ethical tensions in institutional review board review of community-based participatory research

Community-based participatory research (CBPR) addresses the social justice dimensions of health disparities by engaging marginalized communities, building capacity for action, and encouraging more egalitarian relationships between researchers and communities. CBPR may challenge institutionalized academic practices and the understandings that inform institutional review board deliberations and, indirectly, prioritize particular kinds of research. We present our attempt to study, as part of a CBPR partnership, cigarette sales practices in an inner-city community. We use critical and communitarian perspectives to examine the implications of the refusal of the university institutional review board (in this case, the University of California, San Francisco) to approve the study. CBPR requires expanding ethical discourse beyond the procedural, principle-based approaches common in biomedical research settings. The current ethics culture of academia may sometimes serve to protect institutional power at the expense of community empowerment.

The experience of fatigue for adults living with HIV

AIMS

The aim of this study was to go beyond objective clinical assessment and explore the experience of fatigue and self-care strategies with adults who live with HIV.

RATIONALE

This study responded to a perceived lack of available evidence to inform the practice of service providers about ways fatigue impacts on the lives of people with HIV. Prior understandings of fatigue are derived from survey or instrument-based tools or studies that do not consider the complexities of the personal experience that in-depth interviews can elicit. The focus remains generally on description, measurement or management from a biomedical perspective.

METHODS

A qualitative study using participatory action research methods was conducted during 2003 with 15 adults diagnosed with HIV who perceived fatigue was a problem in their lives. Data were collected by individual interviews, researcher's notes and two participatory action research groups.

RESULTS

Thematic analysis of data demonstrated that fatigue remains silent and invisible to participant's families, friends and employers. Fatigue experienced by people living with HIV generally also met with a lack of acknowledgement and understanding from health professionals. People developed self-care strategies over many years of trial and error.

RELEVANCE TO CLINICAL PRACTICE

People living with a HIV seek to be acknowledged that fatigue is a legitimate concern, not only by health care professionals, but also people with whom they live. It is imperative that nurses who work with people living with HIV-related fatigue consider the wider social aspects of the person's life as well as physical symptoms. Most importantly, there then needs to be a process of engagement and active listening to the individual's account of their experience of fatigue. Advocating that fatigue is a legitimate complaint to the person living with HIV as well as the wider public and professional community is imperative.

Core elements of programmatic research in nursing: a case study

In this invited paper Tina Koch and Debbie Kralik present the establishment of a research program outside the precincts of a university and we ask Gary Rolfe to provide a commentary from the perspective of an academic. We argue that a dedicated research unit, with a clearly articulated philosophy and in response to research questions from clients, community and practitioners, provides the focus to drive the program. Although we have infrastructure from the RDNS Foundation, obtaining external funding to support our program is a central activity. Discernable outcomes of our collaborative inquiries are described as participants with whom we research narrate aspects of their experience, leading to enhancement of self agency and quality of life. We illustrate the reform potential as groups of research participants develop sustainable people networks. Most importantly, theoretical development is ongoing describing transition (ways in which people are able to take a chronic illness into their lives and move on) and better understanding on ways in which health care professionals can facilitate transition. Evidence based news letters are written in collaboration with practitioners, however we ponder about ways to further our research findings in practice. Gary Rolfe speculates about intermural or extramural research programs. He frames his response using Brand's criteria to research program decisions. In order of importance he asks: (1) will it be fun? (2) will we learn anything from it? (3) will it make the world a better place? (4) will it earn enough money to pay for the first three? Gary argues that one of the luxuries of working within the university sector as an academic is that he can occasionally ignore question four.

Clinical application research: a hermeneutical approach to the appropriation of caring science

Clinical caring science researchers contribute, by means of various participatory research efforts, to bring clinical practice closer to the ideals of caring. These research efforts have in the main been developed from classical action research rooted in critical theory. In this article, the authors launch an alternative research approach called clinical application research, the basis of which can be traced to the interpretative paradigm, or hermeneutics. The basic cornerstones of this research approach are ontology, context, and appropriation as well as understanding, interpretation, and application. Using an example from ongoing clinical research, the authors demonstrate the utility of this approach. Their aim in this article is to contribute to the development of methods within clinical research.

Response to “Metrics of Rehabilitation Research Capacity”

This commentary responds to Dr. Allen Heinemann's paper on "Metrics of Rehabilitation Research Capacity." We follow his outline. Because Dr. Heinemann focuses primarily on training capacity, we take a panoramic view addressing the balance between training new researchers and the support of established investigators. We explore challenges, barriers, and solutions to enhancing research capacity in rehabilitation within contexts of the larger scientific enterprise. Our main premise is that the best way to build a strong and sustainable research capacity in the United States is to study and adopt component strategies developed by other medical disciplines and other nations. We propose a model referred to as the "dynamic cycle of research capacity-building" by adapting a framework for studying the eradication of infectious diseases in developing countries to concepts of disability recovery. The concept of career mapping is proposed as a means to measure research productivity among faculty according to "standardized" academic tracks with different balance among research, educational, and clinical activities. The first and most important step in building rehabilitation capacity is developing an understanding of and belief in the mission and the need for research to support it.

Practical suggestions for community interventions using participatory action research

Advanced practice nurses and nurse researchers with experience in clinical settings may encounter challenges in the initial development and implementation of community-based projects. Participatory action research methodology, a user-friendly framework for community-based research activities, provides a way for researchers and community members to work together to define a problem, take action, and evaluate their work. This article attempts to bridge the theory-implementation gap by describing background steps that researchers can use when conceptualizing and initiating a research project with community partners. Suggestions for initial steps and the planning and review cycles are presented, along with examples from the literature.

Chronic illness self-management: locating the 'self'

AIM

In this paper, we present the findings of a recent research project in which we explored self- management with older people who were diagnosed with asthma.

BACKGROUND

Asthma self-management literature has focused on the need for the patient to 'adhere' to prescribed therapies, in particular the taking of medications, monitoring of respiratory function or recognizing and avoiding triggers.

METHOD

Data were generated during a period of 9 months from three sources; in-depth interviews with 24 older participants, an open-ended questionnaire and two mixed-gender participatory action research groups.

FINDINGS

Based on current literature, our previous research findings which have 'unpacked' what is 'self'-management, and data generated in this project, we propose that three asthma management models are in operation: Medical Model of Self-management, Collaborative Model of Self-management and Self-Agency Model of Self-management. Locating the 'self' in self-management means acknowledging that many people living with a chronic condition are already self-determining and their expertise should be acknowledged as such.

CONCLUSION

Health care professionals can best facilitate people toward self-agency by embracing new understandings of self-management in long-term illness. This process is enhanced when the expertise a person brings to the management of their condition is given the respect it deserves. There needs to be a focus on providing people with the means to grow and learn in a participative relationship that cannot be fully realized with 'off the shelf' self-management solutions.

Community health development: what is it?

The Department of Health in Taiwan initiated community health development (CHD), a new approach to national community health care. Community-based research and evaluation approaches have recently been shifting from 'traditional' research to 'participatory' research. However, there is vagueness about the theoretical foundation of CHD and the appropriateness of using participatory action research (PAR) to evaluate CHD. This article explores theoretical concepts of CHD and discusses the compatibility of PAR and CHD in the theoretical and philosophical foundations. Community health development is a developing and changing process that involves both the social and the health contexts. It operates on the basis of three approaches to care: primary care, health promotion and community development. Partnership and empowerment between community health nurses and the community are concurrently involved in the entire process of CHD practice. The fundamental tenet of PAR focuses on the development of knowledge through partnership and empowerment between the researcher and the community, and the creation of critical consciousness leading to necessary action and effective change. Unlike empirical community-based research, PAR is flexible enough to capture an understanding of the complex social and health phenomena in the CHD framework. Furthermore, utilizing the PAR approach is appropriate not only for the methodological framework of the CHD evaluation, but also for the enhancement of the CHD actualization.

Community-based research: barriers to recruitment of African Americans

The elimination of health disparities for African Americans requires culturally relevant, empirical knowledge, which in turn requires including African Americans in research studies. However, power-difference barriers and conceptual barriers continue to inhibit the recruitment of African Americans. The purpose of this article is to define and discuss certain barriers to the recruitment of African Americans into research studies and to present culturally and contextually sensitive strategies to overcoming these barriers. Power-difference barriers reflect unequal authority and often generate mistrust. Conceptual barriers reflect researchers' need for better understanding about African Americans. Effective strategies include collaboration with the community through a community advisory board and conducting community-based participatory action research. Also, integrating alternative conceptual frameworks with mainstream frameworks may reduce researchers' ideological assumptions about African Americans. To promote optimal recruitment of African Americans, researchers must be aware of power-difference barriers and conceptual barriers and move toward active collaboration with African American communities.

Women's experiences of faecal incontinence: a study

Community nurses are often involved in the assessment of symptoms of incontinence and the provision of continence aids. However, it is less clear to what extent they can and do provide ongoing support and discuss with their patients the everyday experience of living with incontinence. This article focuses on what it means to live with faecal incontinence and, based on the findings from a small study, discusses the range of experience women with this chronic condition have.

Disaster down East: using participatory action research to explore intimate partner violence in eastern North Carolina

In the aftermath of Hurricane Floyd in 1999, a Community Advisory Committee requested assistance from its university partners (University of North Carolina) to address stress and increased risk for intimate partner violence (IPV). Collected from 12 study work sites, baseline data indicated that IPV rates were higher among blue-collar women in eastern North Carolina than national population-based rates suggest. IPV victims reported higher levels of perceived stress, psychological distress, somatic complaints, and post-traumatic stress disorder (PTSD) symptoms than did nonvictimized coworkers. As for the relationship of the flood to IPV, no significant increase in IPV incidence occurred after the flood. Regardless of their flood experience, however, IPV victims consistently reported greater stress, PTSD symptoms, and somatic and psychological problems. Moreover, IPV victims may be at higher risk for stress-mediated chronic illnesses and for using negative coping behaviors. This study uses an established trusting relationship between researchers and community members to explore community needs and inform intervention design.

Translating Research on Incontinence Into Practice

BACKGROUND

Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings.

OBJECTIVES

To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP.

METHODS

Existing literature on TRIP was analyzed to generate a plan for future research.

RESULTS

Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers.

CONCLUSIONS

Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

The (mis)estimation of neighborhood effects: causal inference for a practicable social epidemiology

The resurgence of interest in the effect of neighborhood contexts on health outcomes, motivated by advances in social epidemiology, multilevel theories and sophisticated statistical models, too often fails to confront the enormous methodological problems associated with causal inference. This paper employs the counterfactual causal framework to illuminate fundamental obstacles in the identification, explanation, and usefulness of multilevel neighborhood effect studies. We show that identifying useful independent neighborhood effect parameters, as currently conceptualized with observational data, to be impossible. Along with the development of a dependency-based methodology and theories of social interaction, randomized community trials are advocated as a superior research strategy, one that may help social epidemiology answer the causal questions necessary for remediating disparities and otherwise improving the public's health.

Chronic illness self-management: taking action to create order

BACKGROUND

This paper presents research that was framed by our early understandings about the ways that people incorporate the consequences of illness into their lives. The word 'transition' has been used to describe this process. We believed self-management to be central to the transition process but this assertion required further research, hence this paper.

AIM

The research aimed at understanding the way in which people who lived with chronic illness constructed the notion of self-management. While the participants of this study were living with arthritis, the focus was on understanding the meaning of self-management rather than the experience of living with the symptoms of arthritis.

APPROACH

Data were generated when nine people living with arthritis were invited to write an autobiography about their life and experiences of living with illness. Two telephone interviews were recorded with each participant and then the research group (researchers and participants) convened for a discussion meeting.

FINDINGS

In contrast to health professionals who identify self-management as structured education, participants identified self-management as a process initiated to bring about order in their lives. Creating a sense of order, or self-management, had four key themes (i) Recognizing and monitoring the boundaries, (ii) Mobilizing the resources, (iii) Managing the shift in self-identity, (iv) Balancing, pacing, planning and prioritizing

CONCLUSIONS

People learned about their responses to illness through daily life experiences and as a result of trial and error. They reconfigured their daily lives and reconstructed their self-identity by exploring their personal limitations or boundaries. Self-management of chronic illness has been considered as both structure and process, however it is the process of self-management that we contend is central to the experience of transition.

RELEVANCE TO CLINICAL PRACTICE

Clinical nursing intervention for people with a long term illness may be enhanced when self-management is approached from a broad, contextual perspective and self-management processes are integrated into clinical practice. The challenge is for nurses to embrace processes in nursing practice that will facilitate interactions with clients without obstructing the diversity of perspectives, create an environment conducive to learning and engage individuals in identifying self-management strategies that have meaning in their lives.

Considerations in participatory action research when working cross-culturally

Professionals from minority world nations are increasingly consulting with majority world nations to develop intervention and educational training programs, yet minority world programs cannot be simply transferred to majority world countries. Participatory action research (PAR) provides a methodology that can be used to facilitate the development of programs that are useful for and sustainable by the majority world communities. This article describes the principles of PAR and gives examples of the ways that cultural values and behaviors may influence interactions between minority and majority world persons. An understanding of these cultural variations in values is essential for the successful implementation of PAR and will reduce miscommunication and incorrect interpretations of behaviors.

The salience of the body: transition in sexual self-identity for women living with multiple sclerosis

AIM

The purpose of this paper is to outline understandings about the construction of sexuality and the impact of a changing body for women living with multiple sclerosis (MS). We suggest that the process of transition towards incorporating the experience of chronic illness into one's life is influenced by the (re)construction of self-identity.

DESIGN AND METHODS

A participatory action process guided the research. The women joined the authors for five group sessions that totalled 15 hours of contact time. In addition, we offered women the opportunity for one-to-one interviews at home. Nine women volunteered to participate. This allowed us to gain additional in-depth data about individual experiences. The interpretive framework was guided by the self-identity literature. When reading the transcripts we questioned: What is going on here? What does this say about the construction of self? What does this say about the construction of identity? What influence does the body have in the construction of self-identity? Analysis was collaborative (with the women) and the resultant emerging construction of sexuality is shared in this paper. Data generated during one-to-one interviews are privileged and we include two accounts from women who live with MS. The women's stories focus on sexuality, however, within this sexual context, we observed shifts in self-identity which we contend may shape the illness transition experience.

FINDINGS

The rationale for privileging only two accounts is to expand understanding of Ordinariness and Extraordinariness with particular focus on the salience of the body in the 'sexual' lives of the women. Self-identity was shaped by how they felt about themselves as sexual beings, how they experienced their body, how they felt about sexual activities and by the way others reacted to them. Importantly, we view the women's sense of self, identity and the relationship to the body and find that shifts in self identity shape the woman's transition towards Ordinariness.

CONCLUSIONS

This exploration of illness experiences is a reminder that our bodies are vehicles for our sense of self and identity. Cultural, educational, social, religious and family contexts all impact on women's capacity to shape the consequences of illness and the choices available to them. Facilitating women towards an awareness of the choices available in order to sustain or reclaim self may in turn expedite transition towards Ordinariness so that illness may become a part of their life.