Care and rhythmanalysis: Using metastability to understand the routines of dementia care.

An increasing number of people living with dementia worldwide receive informal care from their family members. A key element of dementia care is maintaining a daily routine and familiarity, making caring an extremely rhythmic practice. To explore the rhythmic nature of informal care, we apply and advance Lefebvre's unfinished rhythmanalysis by developing an original typology of eurhythmia as a metastable equilibrium. Metastability, although appearing macroscopically stable, is a vulnerable state where a slight disturbance can result in deviation to another state (i.e., stable or unstable). Drawing upon interviews with informal caregivers, we discuss the rhythms and (dis)harmonies of caring practice, including the substantial rhythms of caring practice, the relational balance of rhythms between the caregiver and care recipient, and the various rhythmic disruptions that occur. We demonstrate how metastability provides an understanding of the ever-changing rhythms of every day and allows us to move beyond the immediacy of arrhythmic breaks and explore the subtle changes that occur in (poly)rhythms. Thus, eurhythmia as a metastable equilibrium allows us to explore the gradual and subtle development of, and changes to, dementia care and other routine practices in health geography.

The role of performativity in informal dementia carers' capability to be mobile.

Informal carers are and will remain a vital part of dementia care. Given the nature of their caring tasks, which focus on enabling the care recipient to engage in meaningful activities, informal dementia carers are affected in their everyday mobility. Expectations manifested by society, loved ones and the carers themselves play a critical role in how carers perform their caring role and how they perceive their opportunity, or capability, to be mobile. This article uses Butler's concept of performativity to understand informal dementia carers' capability to be mobile. In the spring and summer of 2021, we combined remote graphic elicitation with telephone interviews to gather the views of 17 informal dementia carers (aged 50+) living in England. Three key themes emerged from our analysis of the data. Firstly, participants perceived that becoming a carer changed their capability to be mobile. Secondly, the caring role in relation to the capability to be mobile resulted in an emotional toll and perceived loss of autonomy. Thirdly, the performativity of the caring role created feelings of guilt, selfishness and resentment due to the impact caring had on participants' capability to be mobile. Our study enriches the literature on informal dementia carers' mobility, as we suggest that performativity is a key factor in how this population experiences their everyday mobility. The findings suggest that existing ageing-in-place policies should take a more holistic approach by better including those ageing adults who provide the most support: informal dementia carers.

Perceptions and Experiences of Informal Caregivers of Breast Cancer Patients in South India: A Qualitative Study.

BACKGROUND: This study was conducted to explore the prevailing perceptions and experiences of caregiving burden among informal caregivers of women living with breast cancer in South India. METHODS: In-depth interviews were conducted among breast cancer care-receivers (n=35) and their informal caregivers (n=39) and a thematic analysis was used to analyze the data. Informal caregiver in the context of this study was defined as one who takes up the responsibility of an informal caregiving role, and were either self-identified or acknowledged by the care-receivers. RESULTS: Four main inductive themes in the domains of: emotional culpability, financial and workplace liability, psychosocial affliction, physical strain and health system demand were identified, that were associated with caregiver burden. CONCLUSION: Informal caregivers form an integral part of the cancer care continuum in India. It is recommended to factor in the identified themes while developing a caregiver needs assessment model in the context of caring for breast cancer patients in the Indian setting.

'We may be long in the tooth, but it makes us tough': exploring stillness for older adults during the COVID-19 lockdowns.

Following the outbreak of the SARS-CoV-2 across the world in 2020, millions of people were reduced in their mobility to hinder the spread of the disease. The lockdown was particularly difficult for older adults, who were deemed 'vulnerable' because many felt unsafe leaving the house and often forced to self-isolate. In this paper, we interpret the lockdowns as a period of prolonged stillness: breaks from everyday practices, including withdrawnness, inefficiency, and retreat. We extend ideas of stillness by integrating the capability approach, which shows how the opportunities and challenges that arise from moments of stillness are dependent on a combination of individual agency and the role of structural or contextual factors. Using the accounts of thirty-eight older adults in the Netherlands and England, we show how the COVID-19 lockdowns established and encouraged different types of stillness which had differing impacts upon the older adults' lives. The effect of the prolonged stillness on these different areas of everyday life is based on individual agency and contextual factors, such as choosing to volunteer or having an adequate internet connection. Thus, our findings contribute to discussions around active ageing and demonstrate that slowing down, and spending more time at home, can provide respite from an otherwise active everyday life.

Tras el brote del SARS-CoV-2 en todo el mundo en 2020, la movilidad de millones de personas se redujo para evitar la propagación de la enfermedad. El encierro fue particularmente difícil para los adultos mayores, a quienes se consideró 'vulnerables' porque muchos se sentían inseguros al salir de la casa y, a menudo, se vieron obligados a aislarse por sí mismos. En este artículo, interpretamos los encierros de emergencia como un período de quietud prolongada: rupturas con las prácticas cotidianas, que incluyen retraimiento, ineficacia y retirada. Extendemos las ideas de quietud integrando el enfoque de la capacidad, que muestra cómo las oportunidades y los desafíos que surgen de los momentos de quietud dependen de una combinación de agencia individual y el papel de factores estructurales o contextuales. Utilizando los relatos de treinta y ocho adultos mayores en los Países Bajos e Inglaterra, mostramos cómo los encierros de emergencia por el COVID-19 establecieron y alentaron diferentes tipos de quietud que tuvieron diferentes impactos en la vida de los adultos mayores. El efecto de la quietud prolongada en estas diferentes áreas de la vida cotidiana se basa en la agencia individual y factores contextuales, como elegir ser voluntario o tener una conexión a Internet adecuada. Por lo tanto, nuestros hallazgos contribuyen a las discusiones sobre el envejecimiento activo y demuestran que disminuir la velocidad y pasar más tiempo en casa puede brindar un respiro de una vida cotidiana que de otro modo sería activa.

À la suite de la flambée de la pandémie de SARS-CoV-2 dans le monde en 2020, des millions de personnes ont vu une réduction leur mobilité visant à limiter la propagation du virus. Le confinement s'est avéré particulièrement difficile pour les seniors, qui étaient considérés comme une « catégorie vulnérable ¼, parce que beaucoup d'entre eux ne se sentaient pas en sécurité en dehors de chez eux et étaient souvent forcés de s'auto-isoler. Dans cet article, nous interprétons les confinements comme une période d'immobilité prolongée: des interruptions du quotidien et de ses pratiques, contenant l'introversion, l'inefficacité et le repli. Nous enrichissons le concept d'immobilité en y intégrant la théorie de l'approche par les capacités, qui montre comment les opportunités et les obstacles qui surviennent de ces moments d'immobilité dépendent d'une combinaison d'agentivité personnelle et le rôle de facteurs structurels et contextuels. Nous avons utilisé les récits de trente-huit personnes âgées en Angleterre et aux Pays-Bas, nous exposons la manière dont les confinements dus à l'épidémie de COVID-19 ont établi et stimulé différentes sortes d'immobilités qui ont touché les vies des seniors de façons variées. L'effet de ces immobilités prolongées sur ces différentes parties du quotidien est fondé sur l'agentivité personnelle et les facteurs contextuels, par exemple le choix de faire du volontariat ou posséder une connexion Internet adéquate. Ainsi, nos observations contribuent aux débats autour du vieillissement actif et démontrent que ralentir et passer plus de temps chez soi peut apporter du répit dans une vie quotidienne habituellement remplie d'activités.

What happens behind doors? Exploring everyday indoor activities when ageing in place.

Engaging in social interaction and physical movement during everyday activities has a positive influence on wellbeing in later life. For older adults who age in place, the majority of activities occur indoors, yet studies typically focus on outdoors. Gender influences social and physical activities but is understudied in an ageing-in-place context. We aim to address these gaps by increasing insight into the indoor activities in later life, with a focus on gender differences in social interaction and physical movement. Through a mixed-methods approach, data were collected using global positioning system (GPS) trackers, pedometers and activity diaries. Twenty community-dwelling older adults (11 women and 9 men) who were living in Lancashire collected these data over seven days. An exploratory spatio-temporal analysis was conducted on the 820 activities they undertook. We discovered that our participants spend large amounts of time indoors. We also found that social interaction increases the duration of the activity and, conversely, decreases levels of physical movement. When zooming in to gender differences, men's activities took significantly longer than women's activities and were characterised by higher level of social interaction. Based on these results, we argue that there is a trade-off between social interaction and physical movement in everyday activities. We suggest establishing a balance between socialising and moving in everyday activities in later life, specifically because maintaining high levels of movement and social interaction at the same time seems unachievable. In conclusion, it is important to design indoor environments that facilitate choice between being active and resting, and between being social and being on one's own rather than assume they are mutually-exclusive and/or universally "good" or "bad" per se.

Canadian Older Adults' Intention to Use an Electronic Decision Aid for Housing Decisions: Cross-sectional Web-Based Survey.

BACKGROUND: Older adults with disabilities such as loss of autonomy face the decision of whether to stay at home or move to a health care facility such as a nursing home. Therefore, they may need support for this difficult decision. OBJECTIVE: We assessed the intention of Canadian older adults to use an electronic decision aid (eDA) to make housing decisions and identified the factors that influenced their intention. METHODS: We conducted a cross-sectional study using a web-based survey targeting older adults across 10 Canadian provinces and 3 territories. We included respondents from a web-based panel who were aged ≥65 years, understood English or French, had access to an electronic device with an internet connection, and had made a housing decision over the past few months or were planning to make a decision in the coming year. We based the web-based survey on the Unified Theory of Acceptance and Use of Technology (UTAUT). We adapted 17 UTAUT items to measure respondents' intention to use the eDA for housing decisions, as well as items measuring 4 intention constructs (performance expectancy, effort expectancy, social influence, and facilitating conditions). We also assessed eHealth literacy using both subjective and objective scales. We used descriptive statistics and multivariable linear regression analyses to identify the factors influencing the intention to use the eDA. RESULTS: Of the 11,972 invited panelists, 1176 (9.82%) met the eligibility criteria, and 1000 (85.03%) respondents completed the survey. The mean age was 72.5 (SD 5.59) years. Most respondents were male (548/1000, 54.8%), White (906/1000, 90.6%), English speakers (629/1000, 62.9%), and lived in Ontario or Quebec (628/1000, 62.8%) and in urban areas (850/1000, 85%). The mean scores were 27.8 (SD 5.88) out of 40 for subjective eHealth literacy and 3.00 (SD 0.97) out of 5 for objective eHealth literacy. In our sample, the intention score was 4.74 (SD 1.7) out of 7. The mean scores of intention constructs out of 7 were 5.63 (SD 1.28) for facilitating conditions, 4.94 (SD 1.48) for performance expectancy, 5.61 (SD 1.35) for effort expectancy, and 4.76 (SD 1.59) for social influence. In the final model, the factors associated with intention included mother tongue (ß=.30; P<.001), objective eHealth literacy (ß=-.06; P=.03), performance expectancy (ß=.55; P<.001), social influence (ß=.37; P<.001), and facilitating conditions (ß=.15; P<.001). CONCLUSIONS: Findings from this pan-Canadian web-based survey on Canadian older adults suggest that their intention to use the eDA to make housing decisions is similar to the findings in other studies using UTAUT. The factors identified as influencing intention were mother tongue, objective eHealth literacy, performance expectancy, social influence, and facilitating conditions. These will guide future strategies for the implementation of the eDA.

Hopeful adaptation after acquired brain injury: The case of late referrals in the Netherlands.

A substantial number of people with 'mild' acquired brain injury (ABI) suffer from cognitive impairments that are not immediately acknowledged as such. Some are eventually referred to multidisciplinary rehabilitation care after months or years of suffering, which is why we have labelled them 'late referrals'. The aim of this paper is to add to the discussion on hopeful adaptation by focussing on the diverse adaptive strategies of late referrals. Hope is typically discussed as a positive emotion that can contribute to transformative processes, but that is also mirrored by despair. We conducted in-depth interviews with ten late referrals in the Netherlands. Our findings demonstrate that the trajectories of late referrals are characterised by wandering and navigating. Wandering is predominantly associated with feeling lost, and not knowing where one is going. While navigating is more purposeful, we found that our participants sometimes navigated in directions that turned out to be dead-end streets. We conclude that hopeful adaptation encompasses a circuitous way of trying and adapting and trying again. As a key recommendation for practice, we suggest that people with cognitive problems due to mild ABI should be supported in reducing the complexities of their everyday lives by taking up challenges one place at a time.

Geographical life-space and subjective wellbeing in later life.

Geographical life-space is an important factor to consider when studying subjective wellbeing of older adults. The purpose of this article is twofold: to provide an in-depth understanding of 1) the geographical life-spaces in which the lives of older adults take place and 2) the relation between life-space and experienced levels of subjective wellbeing. Seventy-six older adults (aged 65 and older) participated in our qualitative study. We applied a qualitative research approach, through combining indepth-interviews with visual life-space diagrams. Our findings show that most older adults continue to experience a high level of subjective wellbeing, regardless of the extent of their life-space. We conclude that the possibility to fulfill one's needs, even in a restricted life-space, is more conducive to maintaining subjective wellbeing than the extent of life-space itself.

['I went for a short walk, so I'll run into people again'. Qualitative research on the participation of older adults with memory problems]. / 'Even een rondje wezen wandelen, want dan kom ik weer mensen tegen'. Kwalitatief onderzoek naar de participatie van ouderen met geheugenproblemen.

Many older adults who live at home face memory problems, which creates challenges for their participation in society. This may lead to social isolation and a lower wellbeing. In this qualitative study, we studied the physical and social participation of seven older adults with memory problems who live at home, to identify obstacles and coping strategies. Different research methods were adopted: 1) walking interviews, 2) travel diaries, and 3) in-depth interviews. Physical and social participation take place independently and in the immediate living environment. Participants experience several obstacles, which are highly impacted by the mode of transportation that they use: walking versus cycling. The results provide new insights on the strategies that participants develop to continue to participate. Fixed routes help them navigate, orientate and anticipate to traffic situations. Participating in activities for a short period of time is a strategy to make social participation less demanding. It is not the duration, but the experience of the activity that is important. The article concludes that older adults with memory problems exercise control in shaping their activities according to their personal needs, possibilities and surroundings. It is important that they are not only supported in avoiding risks, but also in developing suitable coping strategies.

Using Everyday Technology Independently When Living with Forgetfulness: Experiences of Older Adults in Barcelona.

Older adults living with forgetfulness encounter difficulties when engaging with changing and dynamic everyday technology (ET). The capability to use ET is important for independence in later life and is affected by the contextual and individual characteristics of older adults. Using the capability approach as a theoretical lens, this phenomenological study aims to explore the experiences of older adults living with forgetfulness, in order to identify contextual and individual factors that facilitate the use of ET in everyday life. A qualitative methodology was used to interview 16 community-dwelling older adults participating in memory and technology workshops at local community centres in Barcelona. Findings show that motivation and openness to learning played a facilitating role in our participants' use of ET. The presence of social support in the form of "technology experts" and community centres offering learning opportunities were also enhancing factors that encourage independence when engaging with ET. In conclusion, our study demonstrates the importance of expanding intergenerational ET learning opportunities, through the creation of age-friendly spaces.

Technology to Improve Autonomy and Inform Housing Decisions for Older Adults With Memory Problems Who Live at Home in Canada, Sweden, and the Netherlands: Protocol for a Multipronged Mixed Methods Study.

BACKGROUND: Understanding the mobility patterns and experiences of older adults with memory problems living at home has the potential to improve autonomy and inform shared decision making (SDM) about their housing options. OBJECTIVE: We aim to (1) assess the mobility patterns and experiences of older adults with memory problems, (2) co-design an electronic decision support intervention (e-DSI) that integrates users' mobility patterns and experiences, (3) explore their intention to use an e-DSI to support autonomy at home, and (4) inform future SDM processes about housing options. METHODS: Informed by the Good Reporting of A Mixed Methods Study (GRAMMS) reporting guidelines, we will conduct a 3-year, multipronged mixed methods study in Canada, Sweden, and the Netherlands. For Phase 1, we will recruit a convenience sample of 20 older adults living at home with memory problems from clinical and community settings in each country, for a total of 60 participants. We will ask participants to record their mobility patterns outside their home for 14 days using a GPS tracker and a travel diary; in addition, we will conduct a walking interview and a final debrief interview after 14 days. For Phase 2, referring to results from the first phase, we will conduct one user-centered co-design process per country with older adults with memory issues, caregivers, health care professionals, and information technology representatives informed by the Double Diamond method. We will ask participants how personalized information about mobility patterns and experiences could be added to an existing e-DSI and how this information could inform SDM about housing options. For Phase 3, using online web-based surveys, we will invite 210 older adults with memory problems and/or their caregivers, split equally across the three countries, to use the e-DSI and provide feedback on its strengths and limitations. Finally, in Phase 4, we will triangulate and compare data from all phases and countries to inform a stakeholder meeting where an action plan will be developed. RESULTS: The study opened for recruitment in the Netherlands in November 2018 and in Canada and Sweden in December 2019. Data collection will be completed by April 2021. CONCLUSIONS: This project will explore how e-DSIs can integrate the mobility patterns and mobility experiences of older adults with memory problems in three countries, improve older adults' autonomy, and, ultimately, inform SDM about housing options. TRIAL REGISTRATION: ClinicalTrials.gov NCT04267484; https://clinicaltrials.gov/ct2/show/NCT04267484. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19244.

The Role of Information and Communication Technology (ICT) for Older Adults' Decision-Making Related to Health, and Health and Social Care Services in Daily Life-A Scoping Review.

Information and communication technology (ICT) can potentially support older adults in making decisions and increase their involvement in decision-making processes. Although the range of technical products has expanded in various areas of society, knowledge is lacking on the influence that ICT has on older adults' decision-making in everyday situations. Based on the literature, we aimed to provide an overview of the role of ICT in home-dwelling older adults' decision-making in relation to health, and health and social care services. A scoping review of articles published between 2010 and 2020 was undertaken by searching five electronic databases. Finally, 12 articles using qualitative, quantitative, and mixed-method designs were included. The articles were published in journals representing biology and medicine, nursing, informatics, and computer science. A majority of the articles were published in the last five years, and most articles came from European countries. The results are presented in three categories: (i) form and function of ICT for decision-making, (ii) perceived value and effect of ICT for decision-making, and (iii) factors influencing ICT use for decision-making. According to our findings, ICT for decision-making in relation to health, and health and social care services was more implicitly described than explicitly described, and we conclude that more research on this topic is needed. Future research should engage older adults and health professionals in developing technology based on their needs. Further, factors that influence older adults' use of ICT should be evaluated to ensure that it is successfully integrated into their daily lives.

Using the concept of activity space to understand the social health of older adults living with memory problems and dementia at home.

Globally as the population ages, the prevalence of dementia will increase. Simultaneously, there is a trend toward people ageing at home. Therefore, more people will be ageing at home with dementia, as opposed to institutional environments. In this context, there has been a recent shift in research exploring ways that people can live well with the consequences of the disease. As a part of this emerging research, the social and spatial aspects of the lives of people living with memory problems are becoming increasingly of interest. The aim of this article is to use the concept of activity space to examine the social health of older adults with memory problems and dementia who live at home. Activity space data were collected from seven older adults experiencing memory problems and living at home in the Netherlands. Using a mixed-methods approach, insight into their activity spaces were gained through walking interviews, 14 days of global positioning system (GPS) movement data, travel diary entries and in-depth interviews. The GPS data, travel diary data and interview transcripts were analyzed using a grounded visualization approach. Our findings show that participants interact independently in routine activity spaces but depend on others to participate in occasional activity spaces. Interactions within both these spaces contribute to the social health of older adults with memory problems and dementia who live at home. Additionally, participants used coping strategies and decision-making to maintain autonomy in daily life. The findings can inform dementia-friendly initiatives and social health care planning.

Features of the social and built environment that contribute to the well-being of people with dementia who live at home: A scoping review.

This scoping review summarizes findings from 23 qualitative articles on how social and built environments contribute to the well-being of people with dementia who live at home. Through thematic analysis, two themes were identified: i) connection to society and supportive relationships and ii) interaction with natural environments and public space. Features of the social and built environment contribute to well-being both positively and negatively. Future research should explore how these features intersect in an urban-rural context as a basis to inform the development of dementia-friendly initiatives. Moreover, involving people with dementia in the design of features of built environments, such as infrastructure, will result in more inclusive communities.

Enduring rural poverty: Stigma, class practices and social networks in a town in the Groninger Veenkoloniën.

In the Groninger Veenkoloniën, a former peat region in the northeast of the Netherlands, persistent poverty is more prevalent compared to other rural regions in the country. Grounded in participant observations and supplemented by in-depth interviews capturing the social life history of 21 participants, this paper paints a detailed picture of the social networks and class practices of those experiencing persisting poverty in the examined town and surrounding region. In addition, we explore the relations between the rural context and lived experiences of class and poverty. Our findings highlight the complex experience as well as spatial embeddedness of persisting poverty. We find that, although the specific circumstances to which the participants are exposed vary greatly, the repercussions in terms of the characteristics of their social networks and practices are very similar. In general, the social networks of participants are fragmented and small, tightly knit, and characterized by clear power imbalances. The most formative experiences that result in the isolation of networks of poor are found to occur in the home and family situation during childhood years. We argue that poverty and the region's history are intricately interwoven resulting in a socio-spatial stigma which in turn contributes to the persistent and intergenerational character of poverty in the rural context of our study. Due to the long history of stigmatization, dismantling the socio-spatial stigma attached to the Groninger Veenkoloniën will presumably take multiple generations.

[Towards meaningful mobility]. / Naar betekenisvolle beweging.

This editorial is based on Towards meaningful mobility: a research agenda for movement within and between places in later life.

Health Literacy in the Everyday Lives of Older Adults in Greece, Hungary, and the Netherlands.

Health literacy (HL) encompasses someone's knowledge and abilities to access and use health information in order to make appropriate health decisions in life. HL is particularly valuable in later life when health challenges grow. An individual's HL is typically considered a fixed and skills-based characteristic, without taking into account how these are situated in the context of everyday life. Also, lay perspectives on health literacy are relatively scarce. Therefore, the aim of this article is to explore the context-specific perspectives of older adults and health professionals on HL in later life in Greece, Hungary, and the Netherlands. We adopted a qualitative methodology and conducted 12 focus groups: seven with 50 older adults and five with 30 health professionals to gain insight into individual perspectives on HL as situated in the health care and everyday life contexts. An informed grounded theory approach was used in analyzing the data. The results are structured in three themes: (1) interactions with health professionals, (2) perceived quality of the health care system, and (3) managing health in the context of everyday life. An overarching finding is that, for older adults, HL reflects the demands placed on them when managing their health. In the experience of older adults, these demands are placed upon them by healthcare professionals, the healthcare system, as well as their everyday lives. Our findings underscore the importance of Critical Health Literacy (CHL) as that concept foregrounds that HL is context specific. Also, CHL has been argued to be a community characteristic, which is why we call for community-based approaches to improve HL.

Implementation and Long-Term Outcomes of Organisational Health Literacy Interventions in Ireland and The Netherlands: A Longitudinal Mixed-Methods Study.

Organisational Health Literacy (OHL)-interventions are needed to overcome health inequality. OHL-interventions have successfully identified communication barriers at the organisational level, but evidence is limited on the extent to which this leads to sustainable organisational change. This study aims to assess the implementation fidelity, moderators (barriers and facilitators), and long-term impact of OHL-interventions in hospitals in Ireland and The Netherlands. We used a longitudinal mixed-methods approach to assess two similar OHL-interventions in one Irish and three Dutch hospitals. The OHL-interventions concerned the improvement of navigation and implementation of health literacy-friendly communication throughout organisations. Participants were 24 hospital employees and 40 older adults who use hospital services. At six, eight, and eighteen months, we assessed the level of implementation, barriers and facilitators, and impact through questionnaires and in-depth semi-structured interviews. After older adults and professionals had identified a number of communication problems, we found that professionals had successfully implemented OHL-interventions to promote navigation and comprehensible communication. Limited resources and variation in organisational structures and procedures were perceived as barriers to implementation. The participation of service users, leadership support, and a stepwise implementation of interventions were perceived to facilitate implementation. In the long term, the OHL-interventions led to system-wide improvements, as shown by better embedding of health literacy policies, enhanced patient engagement, provision of plain language training and comprehensible information. Findings were similar for the two countries. Embedded OHL-interventions resulted in sustainable and system-wide health literacy changes in all four hospitals. Following implementation, OHL-interventions have the potential to promote health equity and empowerment among health service users.

Re-engaging with places: Understanding bio-geo-graphical disruption and flow in adult brain injury survivors.

Acquired Brain Injury (ABI) is one of the most common causes of disability and death in adults worldwide. After a period of rehabilitation, many ABI survivors still face complex mind/body conditions when they try to take up their former life again. Besides lasting visible impairments such as weakness and loss of body balance, there are often less obvious disabilities such as extreme fatigue, hypersensitivity for stimuli, memory, concentration and attention problems or personality changes. The aim of this paper is to understand how ABI survivors and their significant others renegotiate their engagements with everyday places, using the concepts of bio-geo-graphical disruption and flow. We conducted in-depth interviews and did a place-mapping exercise with 18 adult ABI survivors and their significant others. The data were analysed according to the principles of thematic analysis, with use of Atlas.ti. In the struggles of ABI survivors' relations with place, our findings show diversity in personal experiences and strategies, as well as commonalities at a more general level. First, having access to meaningful places, old and new, and coming to terms with the fact that some places may not be accessible anymore, appeared to be vital in the participants' process of healing. Second, the interplay or, as we call it, reciprocity, between different places can contribute to wellbeing: for instance, the security and continuity found at home may enable ABI survivors to handle a trip to a crowded city centre. Thus, by framing mind/body problems of ABI survivors in terms of a network of meaningful places rather than as a body with lost functions, our study shows how the reciprocity between multiple places has a potentially positive effect on life post-ABI.

Developing and pilot testing a comprehensive health literacy communication training for health professionals in three European countries.

OBJECTIVE: Skills to address different health literacy problems are lacking among health professionals. We sought to develop and pilot test a comprehensive health literacy communication training for various health professionals in Ireland, Italy and the Netherlands. METHODS: Thirty health professionals participated in the study. A literature review focused on evidence-informed training-components. Focus group discussions (FGDs) explored perspectives from seventeen professionals on a prototype-program, and feedback from thirteen professionals following pilot-training. Pre-post questionnaires assessed self-rated health literacy communication skills. RESULTS: The literature review yielded five training-components to address functional, interactive and critical health literacy: health literacy education, gathering and providing information, shared decision-making, enabling self-management, and supporting behaviour change. In FGDs, professionals endorsed the prototype-program and reported that the pilot-training increased knowledge and patient-centred communication skills in addressing health literacy, as shown by self-rated pre-post questionnaires. CONCLUSION: A comprehensive training for health professionals in three European countries enhances perceived skills to address functional, interactive and critical health literacy. PRACTICE IMPLICATIONS: This training has potential for wider application in education and practice in Europe.