Disablement and the social context of daily activity

Revealing gendered identity and agency in dementia

As identity and agency are central to the well-being of people with dementia, this paper explores whether their dialogue conveys a gendered sense of identity and agency. The author discusses whether they demonstrate not just a subjective sense of being but also an understanding of their relational selves. Findings are presented from a qualitative study in the North of England which examined the everyday decisions made by married couples when one partner had dementia. Ethnographic methods were used, including participant observation and interviews. While dialogical analysis usually centres on the subjective self, it was also used to examine intersubjectivity. Comparisons are made between the dialogue of women and men in order to draw conclusions about the gendered nature of identity and agency. The study found that the women and men defined themselves according to their social and gender identities. The literature had suggested that agency might be a gendered concept and the study confirmed that men were somewhat individualistic and rational in their concerns, whereas women were more relational and even spiritual. Yet, women and men demonstrated emotional reflexivity. As national and international health policy prioritises living well with dementia, more systematic attention should be given to the role of gender in influencing well-being in dementia. Health and social care staff should recognise and facilitate the gender identity and related social roles of people with dementia (e.g. parent, carer and worker) in order to enhance their quality of life.

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.

Cultural, Linguistic and Contextual Factors in Validating the Mental Status Questionnaire: The Experience of Aboriginal Elders in Manitoba

This paper examines the impact of linguistic, cultural and contextual factors on the validity of mental status instruments through comparison of the performance of Native and non- Native respondents in a population-based survey of elderly Manitobans. Qualitative data describing potential biases associated with language, cultural and contextual factors are also drawn from observations of interviews using a culturally adapted instrument to screen for dementia among Cree speak ing Native elders living on Manitoba reserves and English speaking non-Native elders living in Winnipeg.

Disability Statistics, What We Count and What It Tells Us

This paper begins with four reinterpretations about the prevalence, trends, temporality, and spread of disability. Together they lead to a different view of disability as quite pervasive in terms of sheer numbers, length of disability experience, and domains of life, as well as organ systems affected. The denial of this reality is related to our attempt to make disability "fixed" and "dichotomous," whereas it is better conceived of as "fluid" and "continuous." The costs of maintaining the former position are traced in notions of disability's "real" numbers and measurement, as well as in research, policy, and advocacy arenas. A redirection is suggested in terms of a more multidimensional approach and a purging of the inherent negative elements in current conceptions and measurement of disability.

Value of measuring perceived problems in a stroke population

Functional status assessments mainly concentrate on difficulty in performance and/or dependency on other people. Very few assessments document the perceived problems of the patient regarding the assessed activities. This study evaluates the added value of measuring perceived problems using a parallel assessment method: the Rehabilitation Activities Profile. The study population consisted of 57 stroke patients living at home, six months after stroke. Thirty-three were receiving therapy (physiotherapy or rehabilitation day care). The patients indicated that they perceived a number of problems, especially on the items 'walking', 'using transport', 'leisure activities' and 'relation with friends/acquaintances'. The perceived problem scores did not relate in a uniform way to the disability scores. The perceived problem scores were dichotomized. The proportions of persons with perceived problems showed statistically significant differences between the therapy group and the nontherapy group for 15 out of 21 items (p <0.02). The cumulative relative frequency distributions showed that the therapy group indicated significantly more problems than the nontherapy group (p <0.01). It was concluded that it is at least as important to measure perceived problems as it is to measure disabilities.

'The old-fashioned way': conception and sex in serodiscordant relationships after ART

This paper explores heterosexual women's accounts of conception and sex within serodiscordant relationships in the period after the advent of Anti-Retroviral Treatment in Australia. It utilises Goffman's theory of stigma and narrative identity theory as a framework for analysis. Six women had planned and conceived pregnancies, four had an unexpected pregnancy and one was attempting to conceive. Accounts of conception usually consisted of a story that involved unprotected sex, once, for the purpose of conceiving. This included what they perceived to be an acceptable risk; one they were willing to take for the desired outcome. Two women gave accounts of artificial insemination. The conception story was usually constructed for the benefit of family and friends aware of the women's status thereby reinforcing the woman's identity as responsible and moral. However, most women revealed their partner did not like condoms and used them sporadically or not at all, directly contradicting the 'conception story'. To justify their actions as informed and responsible, women constructed accounts around low viral load and female-to-male transmission. But a consequence of limited or no condom use was that some women reported worrying about ensuing stigma from their partner's and their families if their partner did seroconvert.

Enhancing the conceptual clarity of the activity and participation components of the International Classification of Functioning, Disability, and Health

A key area left open in the International Classification of Functioning, Disability, and Health (ICF) is the distinction between activity and participation. This paper suggests characteristics to distinguish between the components in the ICF model which explicitly include the relationship of contextual factors to the different components. Ten distinguishing characteristics are presented which fall into three major groups: the construct of the component, individual effects, and contextual influences. Application of these suggests that there are four distinguishable components of functioning, disability, and health, which are labeled body functions and structures, acts, tasks, and societal involvement. The body functions and structures component is the same as the ICF component. Acts, tasks, and societal involvement are sub-components of the combined ICF components of activity and participation. Contextual influences operate both as facilitators or barriers (as suggested in the ICF) and as scene-setters. An enhanced model of the relationship between the components is presented, suggesting that there are reciprocal relationships between contextual factors acting as scene-setters, contextual factors acting as facilitators or barriers, societal involvement, tasks, and acts. Further research is needed to determine to what extent these characteristics can be operationalized to distinguish between items in the ICF combined activity and participation classification.

[Development of rheumatoid arthritis functional handicap assessment questionnaire: preliminary study]

OBJECTIVE

To construct a handicap assessment questionnaire for rheumatoid arthritis and to determine if the concept of "participation" can replace the one of "handicap".

METHODS

Selection of daily life domains and items was based on the International Classification of Impairment Disability and Handicap "ICIDH" and on some others handicap epidemiological studies. The questionnaire was tested among rheumatoid arthritis patients. The relation between handicap and participation was investigated. Statistics analysis was performed with Systat.9 program. Spearman's correlation coefficient between 2 quantitative variables was examined.

RESULTS

Six among the 7 "ICIDH" domains were included in the questionnaire. Each of them was explored with many items. Forty-six items were included; each item was explored in 4 chapters:participation assessment with VAS (Visual Analogical Scale) before rheumatoid arthritis and during the study; difficulties: need of help, environment accessibility, patient's satisfaction, feeling of devalorization; patient's propositions;handicap assessment with VAS; other questions were added in some particular items. Thirty patients were included in the study (23 women), the average age was 51 years. Five patients didn't understand the meaning of "Handicap".This study allows us to eliminate 2 items, to add 2 others and to ameliorate 1 of them. Correlation between handicap and participation was moderate to bad.

CONCLUSION

This questionnaire allows to explore rheumatoid arthritis handicap. Each domain of the daily life can be assessed separately. The main difficulties are the length and the impossibility to be self-administered. Handicap and participation probably assess different concepts or are differently understood by patients.

Older women's perceptions of independence versus dependence in food-related work

This qualitative study aims to explore the cultural meaning of accomplishing food-related work by older women, when disease has diminished their abilities and threatens to make them dependent. Seventy-two women with stroke, rheumatoid arthritis, and Parkinson's disease, as well as women without those diseases, were interviewed. All were living at home. Results showed that older women valued independence and feared dependence when declining ability threatened performance of food-related work. They also had strong beliefs about living a "normal life," managing by oneself as long as possible, and becoming their own masters again. To remain independent, participants used three kinds of strategies: Public Health Service Support, self-managing, and adaptation. Their beliefs about dependence included not becoming a burden, retaining self-determination, and maintaining order in life. Implications for nursing include supporting independent cooking, developing care plans with the care recipient, and demonstrating respect for the women's self-determination.

A tale of two countries: environmental impacts on social participation after spinal cord injury

STUDY DESIGN

Comparative analysis of survey data produced in two countries.

OBJECTIVES

To assess the degree to which environmental barriers impact social participation, and to identify the aspects of participation most affected.

SETTING

Community-dwelling individuals with spinal cord injury in the USA and Turkey.

METHODS

Subjects completed the Functional Independence Measure (FIM) motor score, the Craig Hospital Inventory of Environmental Factors (CHIEF), and the Craig Handicap Assessment and Reporting Technique (CHART). Analysis of co-variance was used to analyze CHIEF and CHART differences within and between country.

RESULTS

US subjects reported higher participation scores (CHART) and lower barriers (CHIEF), however, when controls for age, gender, time since injury and motor ability (FIM) were applied, country differences in reports of barriers were limited. Motor ability was the major predictor of participation, which was minimally affected by barriers.

CONCLUSION

Conceptualization and measurement issues may have been the reason for the minimal support for the hypothesis that environment affects participation. Suggestions for future research are made.

SPONSORSHIP

National Institute on Disability and Rehabilitation Research, Centers for Disease Control and Prevention.

Beyond disability: perceived participation in people with a chronic disabling condition

OBJECTIVE

To describe the impact of a chronic disabling condition on participation and to identify variables that may explain perceived restrictions in participation.

STUDY DESIGN

Cross-sectional.

SETTING

People were recruited from the outpatient clinics of two rehabilitation centres and the rehabilitation department of an academic hospital.

SUBJECTS

One hundred and twenty-six people from five diagnostic groups (neuromuscular disease, rheumatoid arthritis, spinal cord injury, stroke, fibromyalgia) participated in the study.

METHOD

The IPA (Impact on Participation and Autonomy) questionnaire was used to describe perceived participation. Explanatory variables were studied in terms of sociodemographic factors and health status variables.

RESULTS

Some restrictions in participation seem comparable among diagnostic groups, others are specific to one or two groups. People with stroke, rheumatoid arthritis or fibromyalgia perceived more restrictions in participation than people with spinal cord injury or neuromuscular disorders. Emotional distress was the most important factor contributing to restrictions in participation.

CONCLUSIONS

Perceived participation remains a complex concept in which many factors are involved. To make a contribution to meaningful participation of people with a chronic disabling condition, rehabilitation treatment should address physical, social, emotional and environmental aspects.

Intrinsicality: reconsidering spirituality, meaning(s) and mandates

Canadian occupational therapists have placed spirituality as the central core of their theoretical Model, depicting inner and outer selves that contradict simultaneous declarations concerning the integration of mind/body/spirit. Even the word spirituality has discrepant meanings and failure to articulate one chosen meaning leads to ambiguity. This paper argues that occupational therapists must agree upon a single definition of spirituality that is congruent with our professional mandate and philosophical perspective; and that prevention of misunderstandings between and amongst clients and other health care professionals demands recourse to our own terminology. It is proposed that intrinsicality be employed to articulate the personal philosophy of meaning with which we interpret our lives. Influenced by environmental context and in homeostatic relationship with the body and mind, intrinsicality constitutes the essence of the self and informs occupational choices based upon personal values and priorities. Acknowledgement of intrinsicality respects the uniqueness of individuals' meanings.

Cross-cultural validation of the London Handicap Scale in Hong Kong Chinese

STUDY OBJECTIVE

To investigate the cross-cultural validity of London Handicap Scale in Hong Kong Chinese.

DESIGN

Ratings of the utility of 10 hypothetical health scenarios were given by groups of HK Chinese subjects. Measured scores were compared with calculated scores from published scale weights of London Handicap Scale, which were based on utility ratings made by UK subjects.

SETTING

A rehabilitation hospital in Hong Kong.

SUBJECTS

A total of 164 HK Chinese, comprising doctors, medical students, nonmedical hospital staff, geriatric day hospital stroke and nonstroke patients, community day-care centre elderly, old age hostel elderly, young disabled inpatients and young community-dwelling disabled citizens.

MAIN RESULTS

There was a close correlation between the mean scores of HK subjects and the calculated scores derived from the published UK scale weights, apart from one scenario (Pearson's correlation coefficient r = 0.87 p = 0.001). The correlations were high for all subgroups, between which there was good consensus. Measured utilities were significantly different between subgroups for only one scenario. For this scenario of moderate to severe handicap in mobility, physical dependence, occupation and social integration, but with excellent orientation and economic self sufficiency: (1) older age groups gave better scores than younger age groups (p < 0.0005); (2) subjects with poor subjective health status gave better scores than those with good subjective health status (p = 0.002); (3) subjects related to the medical or hospital field, i.e. doctors, medical students and nonmedical hospital staff, gave worse scores than other subject groups (p < 0.0005).

CONCLUSION

The concept of handicap applies across cultures. Perception of severity of selected real life handicap scenarios by HK Chinese were well estimated using scale weights from UK populations developed for the London Handicap Scale. Significant differences in perception of certain handicap scenarios by different population subgroups deserve further study.

Negotiating spaces in home environments: older women living with arthritis

Within medical geography there has been a surge of interest in applying critical concepts in social theory to empirical settings, including those for persons with disabilities. The ways through which persons with disabilities negotiate space vary widely according to material and social experiences of being disabled. For older women, chronic illness as a type of disability shapes the way in which they approach their daily lives with respect to both the physical and social aspects of their home environments. In the first half of the paper, conceptually, I take a relational view of space and argue that household, as a narrow reading of domestic space, needs to be replaced by home environment which incorporates more fully age- and ablement-sensitive readings of the spaces constitutive of domestic space. This lays the basis for a contextualized socio-spatial understanding of the ways older women with chronic illness negotiate the spaces in home environments because it accounts for the disadvantaged positionings of access to power and resources as well as the uneven distributions of income based on gender, age, and (dis)ability. It also takes into account the material and social aspects of being disabled. In the second half of the paper, I present case studies of three older women diagnosed with rheumatoid arthritis to illustrate these arguments.

The context of measuring disability: does it matter whether capability or performance is measured?

This study assesses the differences between two methods of conceptually framing physical disability questions, using two scenarios (capability and performance). The relationship between capability and performance was explored on the basis of the literature and empirically tested by administering two versions of the Activities Scale for Kids (ASK) to 28 physically disabled children. The capability version asked children what they "could do," whereas the performance version asked what they "did do." Capability was found to exceed performance (p < 0.001) by approximately 18%. The difference may relate to a difference in environmental contexts between the two versions, with performance reflecting abilities in usual (or real life) circumstances and capability reflecting abilities in a defined situation apart from real life. Researchers must, therefore, consider carefully the environmental circumstances in which they wish to evaluate outcomes, and use this information to decide whether to measure capability, performance, or both.

Impact of patient with patient interaction on perceived rheumatoid arthritis overall disease status

To determine whether patient interaction impacts on perceived disease severity and ability to cope with rheumatoid arthritis (RA) forty RA patients were assessed using joint counts, clinician global assessment, patient global assessment (PGA), VAS pain scale and Health Assessment Questionnaire (HAQ). All participants had six one-on-one conversations about their disease activity and the effect of RA on their lives. Follow-up questionnaires asked about recall of pre-conversation PGA; post-conversation PGA; change in PGA; and change in ability to cope as a result of the conversations. 87.5% of the questionnaires were returned. Pre- and post-conversation PGA were statistically reliable; PGA score improved (P = 0.004); 60.0% of participants felt their ability to cope with their disease improved as a result of this interaction. RA patients benefit from sharing information with like patients. Support groups may be an integral part of treatment strategy in patients with RA.

Rehabilitation Activities Profile: the ICIDH as a framework for a problem-oriented assessment method in rehabilitation medicine

The Rehabilitation Activities Profile (RAP) is an ICIDH-based assessment method that covers the domains of communication, mobility, personal care, occupation, and relationships. Disabilities and handicaps in these domains are assessed on four-point Likert scales for severity. Problems perceived by the patient associated with these disabilities or handicaps are also assessed on four-point Likert scales for severity. High scores on perceived problems represent a patient's priorities. Information is gathered through a semi-structured interview with the patient; proxies and observations can be used as additional sources of information. Assessment can be performed at two levels. The first level is a global one, serving as a screening device. If disabilities or handicaps are identified, the second level provides for an in-depth assessment of those specific disabilities and handicaps as well as the related perceived problems. The method is designed to assist screening, goal-setting, and outcome evaluation of individual patients.

Hidden geographies: the changing lifeworlds of women with multiple sclerosis

This paper discusses the microgeographies of unemployed women with multiple sclerosis, as they manage the physical, social and economic consequences of their illness. Recent directions in the geography of health and health care draw attention to the relationships between space, place and health experience, and in this paper a focus on the everyday lives of women with Multiple Sclerosis reveals the complex interweaving of space, physical impairment and gender in how they experience place. In-depth interviews were used in the study to investigate how women occupied and used home and neighbourhood space after leaving the paid labour force. The majority of women were found to experience shrinking social and geographical worlds which rendered their lives increasingly hidden from view as patterns of social interaction changed and use of public space diminished. The paper discusses the women's residential and household changes, mediated by marital and socio-economic status, and presents two brief case studies to illustrate the remapping of the meanings of work and place as women renegotiate their lifeworlds. The focus of the study on the spatio-temporal settings of the women's everyday lives revealed an interplay of biomedical discourse, policy structures, sociocultural norms and local sets of social relations that shaped the strategies the women used in reconstructing their lives. The women showed a diversity of responses, but these were all characterized by a restructuring of home and neighbourhood space, a reordering of personal relationships and increasing interpenetration of the public sphere in their private lives. The findings suggest that attention to the body in its geographical as well as social context provides an avenue for investigating the links between subjective experience and the broader social relations and processes which shape the illness experience.

Tacit models of disability underlying health status instruments

In recent years much attention has been paid to the development of measures of subjective health status yet, although statistical criteria of reliability and validity have been quite rigourously tested, there has been little consideration of the different theories of disability which underlie the design. The sociology of disability may illuminate such tacit theories. It is suggested that the development of health status questionnaires has not been one of simple rational accumulation in response to methodological advances. Through an examination of the content of health assessment questionnaires, four distinct models of disability are identified. These are shown to influence not only the focus of the content and phrasing of the questions but also, crucially, the way that they perform and how responsive they are to change. The models (the functional, subjective distress, comparative and dependence) are illustrated and discussed in terms related to research design.

Community integration for persons with disabilities: working together to make it happen

In summary, the common themes for therapists working in these three areas are very evident. The content of each paper seemed relevant to all of the client populations. The current trends toward integration and increased consumer control are impacting on occupational therapy practice with all three groups. These trends have significant implications for service delivery and all health care professionals. Occupational therapy has already begun to recognize and value these trends (Canadian Association of Occupational Therapists, 1991; Law et al., 1991). Occupational therapists need to work together and align their efforts to promote the establishment of a comprehensive community service system that enables people to receive the support that they require in their home communities. Service approaches must be designed for empowerment and the full participation of persons with disabilities in all aspects of community living. Treatments that focus solely on minimizing an individual's disabilities will not be successful in achieving this stated goal. There is a need for approaches that creatively adapt environments and reallocate resources so as to enhance the formation of relationships and participation in typical community activities. Service providers must be prepared to respond with the assistance that individuals need to achieve their goals. This is only made possible by the participation of persons with disabilities in the decision making process and in the development of services to meet their needs. Such efforts are supported by government initiatives and strategic plans. The realization of full community participation of persons with disabilities is dependent on the quality of the partnerships that are formed between the community, the service providers, and (ABSTRACT TRUNCATED AT 250 WORDS)

The social dimension of health status measures in rheumatoid arthritis

Fifty-six patients with rheumatoid arthritis (RA) were assessed on two occasions three months apart. They completed two health status instruments--the Arthritis Impact Measurement Scales (AIMS) and the Nottingham Health Profile (NHP)--and the Beck Depression Inventory. In addition, clinical and serological data were gathered in order to calculate severity of disease according to the Mallya and Mace index. Health status instruments and the severity of disease index showed agreement in the assessment of mobility; similar agreement was found for different assessments of emotions. However, the two instruments provided social interaction scores with little agreement either cross-sectionally or in terms of change over time. It is argued that the generic NHP may be a valid instrument as an outcome measure in RA but the NHP and AIMS assess different aspects of social interaction. Care is needed in the selection of outcome measures to evaluate interventions.

Use of the 'extended activities of daily living scale' with depressed stroke patients

The 'extended activities of daily living scale' was given to 44 depressed stroke patients. All were more than 1 year after stroke. The completed forms were then Guttman scaled to find whether the ranking of the items was valid in this group of patients. The items were not passed in the order expected from the ranking. The results therefore suggest that all items should be assessed when using this scale with depressed stroke patients.

Coming to terms with chronic illness: the negotiation of autonomy in rheumatoid arthritis

This paper examines ways in which daily life is sustained in the face of chronic illness. Using data from interviews with people with rheumatoid arthritis, we try to capture the complexity of the interdependence between individuals with chronic illness and society. The main areas focused on cover the disordered body, disruption of relationships, and management of a deviant identity. What emerges is the relativities in everyday negotiations involved as people assimilate or come to terms with the circumstances of disablement. A great deal of research by rehabilitation specialists and advocates of independent living makes use of an abstract notion of the individual and a categorical definition of independence. We suggest that through the subtle relativities individuals in fact sustain considerably more self-determination than is suggested by prevalent notions of independence. This state of affairs is more appropriately referred to as autonomy. The implications of this perspective for health care professionals are discussed.

Managing symptoms in chronic disease: some dimensions of patients' experience

This paper is a review of strategies that patients use to manage their symptoms in chronic conditions, with particular reference to multiple sclerosis. It emphasizes the complex and socially conditioned process through which symptoms come to be recognized and managed by patients. This process is compared and contrasted with that of medical recognition of symptoms. A range of patient-based strategies and their implications is then discussed.