Facilitating barriers: Contextual factors and self-management of type 2 diabetes in urban settings

Urban environments create unique challenges for the management of type 2 diabetes (T2D). City living is associated with unhealthy occupational, nutritional, and physical activity patterns. However, it has also been linked to behaviours that promote health, such as walking and cycling for transportation. Our research is situated at the intersection of these contradictory findings. We ask: What aspects of urban living impact the ability of those living with diabetes to reach optimal health? What contextual and structural factors influence how barriers are experienced in the everyday lives of those living with T2D? We conducted semi-structured interviews with 29 individuals living in Toronto and Vancouver. Interviews were recorded, transcribed, and systematically coded for themes and sub-themes. In addition to affirming readily acknowledged barriers to diabetes management, such as accessing healthy, culturally appropriate food and the cost of management, our findings suggest that the unpredictable nature of urban living creates barriers to routinizing self-management practices. As large, cosmopolitan centres with an abundance of activities on offer, cities pulls people away from home, making adherence to self-management recommendations more difficult. Moreover, our findings challenge commonly held assumptions about the mutually exclusive and static nature of barriers and facilitators. Public transit, a readily acknowledged facilitator of healthy living, can be experienced as a barrier to diabetes management. Participants report intentional non-adherence to their medication regimens for fear of hypoglycemia in subway or traffic delays. While the stimulating nature of cities promotes walkability, it produces barriers as well: participants partake in more restaurant eating than they would if they lived in a rural area and were home to cook their own meals. Understanding how barriers are experienced by people living with diabetes will help mitigate some of the unintended consequences associated with various contextual factors. We recommend that healthcare professionals acknowledge and support people with T2D in routinizing self-management and developing contingency plans for the unpredictability and complexity that urban living entails. We suggest further research be carried out to develop contextually-tailored municipal policies and interventions that will support self-management and improve outcomes for individuals living with T2D in urban settings.

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.

Contextualising renal patient routines: Everyday space-time contexts, health service access, and wellbeing

Stable routines are key to successful illness self-management for the growing number of people living with chronic illness around the world. Yet, the influence of chronically ill individuals' everyday contexts in supporting routines is poorly understood. This paper takes a space-time geographical approach to explore the everyday space-time contexts and routines of individuals with chronic kidney disease (CKD). We ask: what is the relationship between renal patients' space-time contexts and their ability to establish and maintain stable routines, and, what role does health service access play in this regard? We draw from a qualitative case study of 26 individuals with CKD in Australia. Data comprised self-reported two day participant diaries and semi-structured interviews. Thematic analysis of interview transcripts was guided by an inductive-deductive approach. We examined the embeddedness of routines within the space-time contexts of participants' everyday lives. We found that participants' everyday space-time contexts were highly complex, especially for those receiving dialysis and/or employed, making routines difficult to establish and vulnerable to disruption. Health service access helped shape participants' everyday space-time contexts, meaning that incidences of unpredictability in accessing health services set-off 'ripple effects' within participants' space-time contexts, disrupting routines and making everyday life negotiation more difficult. The ability to absorb ripple effects from unpredictable health services without disrupting routines varied by space-time context. Implications of these findings for the deployment of the concept of routine in health research, the framing of patient success in self-managing illness, and health services design are discussed. In conclusion, efforts to understand and support individuals in establishing and maintaining routines that support health and wellbeing can benefit from approaches that contextualise and de-centre everyday human behaviour. Opportunities to support renal patients in managing illness and experiencing wellbeing outside the clinical setting lie in a space-time re-design of chronic care services.

Renegotiating environments to achieve participation: A metasynthesis of qualitative chronic disease research

BACKGROUND

Qualitative studies describe environmental influences on participation in adults with chronic disease, but translating these findings into practice can be difficult.

PURPOSE

This study sought to synthesize qualitative research findings regarding the influence of environmental factors on participation among adults with chronic disease.

METHODS

Searching revealed 31 I articles that describe the link between environment and participation for adults with osteoarthritis, rheumatoid arthritis, diabetes mellitus, heart disease, cancer, chronic obstructive pulmonary disease, and/or depression. Study findings were analyzed using metasynthesis methods to identify themes.

FINDINGS

For adults with chronic disease, renegotiating their environments and occupations to achieve, maintain, or rework their participation involves understanding support processes, being ordinary and able, navigating systems, and navigating physical environments.

IMPLICATIONS

Key areas that occupational therapy interventions can target are facilitating constructive collaboration between client and support person, fostering connections with others, recognizing cultural pressure to be ordinary and able, and advocating for supportive policy and practice.

Restructuring home care in the 1990s: geographical differentiation in Ontario, Canada

Through exploring the geographically differentiated effects of restructuring on the work of home care practitioners, labor process change is found to be spatially specific. It is through examining the spatiallity of labor process change that the differential impacts of health care restructuring on human health care resources can be determined. This has implications for human health care resource availability and service provision, which is particularly an issue for medically under-serviced regions. The restructuring approach, together with regulation theory, is used in this paper as tools for exploring the effects of health care reform on the local labor process. Both quantitative and qualitative data collected from home care practitioners in Ontario (Canada) show that the general trends in labor process change (work transfer down the home care hierarchy, increased time constraints, and enhanced job stress) are being similarly experienced, while shedding light on specific local differences. Findings show two working life factors to be differently experienced across the size of the place in which practitioners live and work. Two representative localities provide a closer examination of local differences in labor process change via the examination of local service cultures, local institutional practices, and local practitioner advocacy. The two sites are Sault Ste. Marie, located in northern Ontario's medically under-serviced northern health region, and Guelph, found in the province's well-serviced southern region.