Navigating the time-space context of HIV and AIDS: daily routines and access to care

A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms

Background

Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.

Methods

This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.

Results

We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.

Conclusions

Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

Time-space constraints to HIV treatment engagement among women who use heroin in Dar es Salaam, Tanzania: A time geography perspective

Timely initiation and sustained adherence to antiretroviral therapy (ART) are essential to improving the health outcomes of people living with HIV and preventing onward HIV transmission. However, women who use heroin often face challenges to initiating and adhering to ART. In this paper we identify spatial, temporal, and social factors that affect HIV treatment engagement among women who use heroin, drawing from a time geography framework. We conducted in-depth interviews with 30 heroin-using women living with HIV in Dar es Salaam, Tanzania between January and March 2019. We found that unstable housing, high mobility, HIV-related stigma, and unpredictable daily paths due to heroin use and involvement in sex work spatially and temporally constrained women who use heroin from incorporating HIV treatment behaviors into daily routines. Some women, however, were able to overcome these time-space constraints to HIV treatment engagement through social support and social role performance. Time geography, including concepts of time-space constraints and daily paths, is a useful framework for identifying barriers to ART engagement. Structural, relational, and individual interventions aimed at eliminating time-space constraints hold the potential to improve HIV treatment engagement among particularly vulnerable and mobile populations.

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.

"Treatment is not yet necessary": delays in seeking access to HIV treatment in Uganda and Zimbabwe

We examined the logic that individuals use to account for delaying HIV testing and/or initiating HIV treatment. Our qualitative study, situated within the REALITY trial (Reduction of EArly mortaLITY in HIV infected adults and children starting antiretroviral therapy), was conducted in Uganda and Zimbabwe in 2015. Forty-eight participants (different age groups, sex and viral load/WHO disease stage) were included. Each participant had 2 interviews (1 after 4 weeks of participation in the trial the other after 12 weeks). If a person could manage presenting symptoms, they felt they had "more time" before starting antiretroviral therapy (ART). Their reluctance to have an HIV test (despite deteriorating health) arose from a belief that they were not "sick", that treatment was "not yet necessary". People in our study did not consider themselves as presenting "late", and treatment was not considered urgent as long as they considered their health to be "good enough".

Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study

INTRODUCTION

Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia.

METHODS

Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n = 2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted.

RESULTS

The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital.

CONCLUSIONS

Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system.

Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV

Our understanding of how community-level context impacts care of persons living with HIV (PLWH), including antiretroviral therapy (ART) adherence and retention in care, is limited. The objective of this study was to characterize the activity spaces of PLWH from an urban area in Southeastern U.S., where the epidemic is among the nation's highest, and to examine how such activity spaces are associated with daily mood and health behaviors. In this small, pilot study, 11 participants were tracked with a global positioning system (GPS)-enabled application on their smartphones for 2 weeks. Activity spaces were created by connecting GPS points sequentially and adding buffers. Contextual exposure data (e.g., alcohol outlets) were connected to activity spaces. Participants also completed daily diary entry through texts 3 times per day regarding outcomes of substance use behaviors, mood, and medication adherence. This yielded a total of 18,007 GPS polyline records that we aggregated into 258 person-days that captured discrete occasions of exposure to contextual factors and subjects' behaviors and moods. On average, the participants spent 19% of their time awake during the 2-week periods in their residential census tract. Exposure to social and built environment factors such as alcohol outlets was greater when participants were outside versus inside their residential census tract. Exposures on daily routes were also significantly associated with ART adherence, alcohol consumption, and mood. Findings suggest substantial differences between activity spaces and residential contexts. Activity spaces are relevant for PLWH and may impact HIV care and behavioral outcomes such as ART adherence and substance use.

Traveling with blindness: A qualitative space-time approach to understanding visual impairment and urban mobility

This paper draws from Hägerstrand's space-time framework to generate new insights on the everyday mobilities of individuals with visual impairments in the San Francisco Bay Area. While existing research on visual impairment and mobility emphasizes individual physical limitations resulting from vision loss or inaccessible public spaces, this article highlights and bridges both the behavioral and social processes that influence individual mobility. A qualitative analysis of sit-down and mobile interview data reveals that the space-time constraints of people with visual impairments are closely linked to their access to transportation, assistive technologies, and mobile devices. The findings deepen our understandings of the relationship between health and mobility, and present intervention opportunities for improving the quality of life for people with visual impairment.

Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease

In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.

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.

"Because everything changes that day; you don't do the routine": Alterations and activities chronically ill women undertake on days with health care provider appointments

OBJECTIVES

Research points to the importance of interactions with health care providers for chronically ill patients. Meanwhile, we know little about how visits to providers' offices are accommodated in these patients' lives. This analysis identifies the full scope of routine alterations and preparatory activities that require chronically will women's time and energy specifically on appointment days.

METHODS

55 semi-structured interviews were conducted with women with fibromyalgia syndrome living in Ontario, Canada. Interviews were transcribed verbatim and analyzed using the constant-comparative technique.

RESULTS

Two trajectories are identified: (1) alterations to daily routines on appointment days; and (2) activities to prepare for the provider-patient interaction. Factors such as wanting to minimize symptom exacerbation, desires to come across as informed patients, limited time afforded to interactions, and access to transportation explain why these particular routine alterations and preparatory activities were undertaken.

DISCUSSION

Findings demonstrate that the health care provider-patient interaction does not start or end in the space of the provider's office but is, rather, an event that is part of a larger process primarily focused on its successful negotiation. This suggests that the boundaries of the appointment need to be reconsidered, which holds implications for appointment-focused interventions aimed at chronically ill patients.

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

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

Neighborhood social environment and patterns of adherence to oral hypoglycemic agents among patients with type 2 diabetes mellitus

This study examined whether neighborhood social environment was related to patterns of adherence to oral hypoglycemic agents among primary care patients with type 2 diabetes mellitus. Residents in neighborhoods with high social affluence, high residential stability, and high neighborhood advantage, compared to residents in neighborhoods with one or no high features present, were significantly more likely to have an adherent pattern compared to a nonadherent pattern. Neighborhood social environment may influence patterns of adherence. Reliance on a multilevel contextual framework, extending beyond the individual, to promote diabetic self-management activities may be essential for notable public health improvements.

Neighborhoods and HIV: a social ecological approach to prevention and care

Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

The importance of place and time in translating knowledge about Canada's Compassionate Care Benefit to informal caregivers

Canada's Compassionate Care Benefit (CCB), an employment insurance program designed to allow Canadian workers time off to care for a dying relative or friend, has had low uptake since its inception. Due to their role in working with family caregivers, social workers are one group of primary health care professionals who have been identified as benefiting from a knowledge translation campaign. Knowledge tools about the CCB have been developed through social worker input in a prior study. This article presents the findings of a qualitative exploratory intervention. Social workers (n = 8) utilized the tools for 6 months and discussed their experiences with them. Data analysis revealed references to time and space constraints in using to the tools, and demonstrated the impact of time geography on knowledge translation about the CCB. The results suggest that knowledge translation about the CCB could be targeted toward caregivers earlier on in the disease progression before the terminal diagnosis, and knowledge tools must be disseminated to more locations. These results may be valuable to policymakers and palliative care providers, as well as theorists interested in ongoing applications of time geography in knowledge translation and the consumption/production of care.

Neighborhoods, daily activities, and measuring health risks experienced in urban environments

Studies of place and health often classify a subject's exposure status according to that which is present in their neighborhood of residence. One's neighborhood is often proxied by designating it to be an administratively defined unit such as census tract, to make analysis feasible. Although it is understood that residential space and actual lived space may not correspond and therefore exposure misclassification may result, few studies have the opportunity to investigate the implications of this issue concretely. A population-based case-control study that is currently underway provides one such opportunity. Adolescent victims of assault in Philadelphia, Pennsylvania, USA, and a control sample of adolescents drawn randomly from the community are being enrolled to study how alcohol consumption and time spent nearby alcohol outlets - individual-level and environmental-level risk factors for violence, respectively - over the course of daily activities relate to the likelihood of being assaulted. Data from a rapport-building exercise consist of hand-drawn sketches that subjects drew on street maps when asked to indicate the area considered their neighborhood. The main data consist of self-reported, detailed paths of the routes adolescents traveled from one location to the next over the course of one full day. Having noticed interesting patterns as the data collection phase proceeds, we present here an analysis conducted with the data of 55 control subjects between 15 and 19 years old. We found that hand-drawn neighborhoods and activity paths did not correspond to census tract boundaries, and time subjects spent in close proximity to alcohol outlets during their daily activities was not correlated with the prevalence of alcohol outlets in the census tract of their residence. This served as a useful example demonstrating how classifying subjects as exposed based solely on the prevalence of the exposure in the geographic area of their residence may misrepresent the exposure that is etiologically meaningful.

Population levels of psychological stress, herpesvirus reactivation and HIV

Nearly 40,000 Americans are newly infected with Human Immunodeficiency Virus (HIV) each year. Recently, studies have demonstrated associations between group-level characteristics and the prevalence and incidence of HIV/Acquired Immune Deficiency Syndrome (AIDS) and other sexually transmitted diseases. Two mechanisms previously posited to explain these associations are neighborhood effects on risk behaviors and social or institutional policies. In this paper, we hypothesize that adversity at the population level, such as neighborhood poverty, also influences HIV risk through stress-mediated aberrations in immunological susceptibility by reviewing existing data examining each of these pathways. In particular, we review the evidence showing that: (1) Neighborhood ecologic stressors influence neighborhood- and individual-levels of mental health, psychosocial stress, and HIV/AIDS risk, (2) Individual-level psychosocial stressors influence progression from HIV to AIDS through stress-related hormonal changes, and (3) Individual-level psychosocial stressors influence HIV acquisition via stress-related reactivation of latent herpesviruses, specifically EBV and HSV-2. Our review indicates that further studies are needed to examine the joint pathways linking neighborhood-level sources of psychosocial stress, stress-related reactivation of HSV-2 and EBV, and increased acquisition rates of HIV. We suggest using a multi-level framework for targeting HIV prevention efforts that address not only behavioral risk factors, but structural, political, and institutional factors associated with neighborhood disadvantage, levels of psychosocial stress, and prevention or treatment of HSV-2 and EBV.

Development and psychometric testing of the Scale of Older Adults' Routine

AIM

This paper is a report of a study to develop, test the reliability, convergent and criterion-related validity of the Scale of Older Adults' Routine, using measures of routinization and functional status.

BACKGROUND

The concept of routine needs a reliable and valid measure in order to allow for further expansion of research in this field.

METHODS

An instrument development procedure, followed by two studies, was conducted in 2004-2005. The validation study utilized a prospective, within-subject design. Testing took place in samples of independently dwelling residents in four retirement communities in an urban area in the Pacific Northwest of the United States of America (USA). A total of 90 participants took part in the studies. A pilot study (n = 10) allowed for feasibility testing, and a prospective three-time point longitudinal study (n = 80) assessed the instrument's reliability and preliminary validity.

RESULTS

The 42-item scale describes various aspects of older adults' routines and assesses routine stability across time. The scale has five dimensions (Basic, Instrumental, Social, Leisure and Rest Activities) and five scoring systems. The scale's content validity and feasibility were high. Reliability indices were acceptable, ranging from 0.56 to 0.90 for the subscales. Validity tests showed moderate correlations with both functional indices (r = 0.29-0.56; P < 0.01) and trait routinization (r = 0.30-0.38; P < 0.01).

CONCLUSIONS

Scale of Older Adults' Routine demonstrated acceptable psychometric properties for most of its subscales and scores. Although further research is needed, it can be applied in both research and practice for evaluating routine among older adults and its associations with various outcome measures.

Prevalence and predictors of poor antihypertensive medication adherence in an urban health clinic setting

Poor medication adherence may contribute to low hypertension control rates. In 2005, 295 hypertensive patients who reported taking antihypertensive medication were administered a telephone questionnaire including an 8-item scale assessing medication adherence. Overall, 35.6%, 36.0%, and 28.4% of patients were determined to have good, medium, and poor medication adherence, respectively. After multivariable adjustment, adults younger than 50 years and 51 to 60 years were 1.39 (95% confidence interval [CI], 0.56-3.42) and 1.53 (95% CI, 0.64-3.66), respectively, times more likely to be less adherent when compared with their counterparts who were older than 60 years. Black adults and men were 4.30 (95% CI, 1.06-17.5) and 2.45 (95% CI, 1.04-5.78) times more likely to be less adherent, respectively. Additionally, caring for dependents, an initial diagnosis of hypertension within 10 years, being uncomfortable about asking the doctor questions, and wanting to spend more time with the doctor if possible were associated with poor medication adherence. The current study identified a set of risk factors for poor antihypertensive medication adherence in the urban setting.

A concept analysis of routine: relevance to nursing

AIM

This paper reports a concept analysis identifying the attributes, antecedents and consequences of the concept of routine and examining the implications and applications of this concept in the field of nursing.

BACKGROUND

Routine may be a pivotal concept in understanding functional adaptation and wellbeing. Nurses in institutional settings work according to scheduled routines, patient care is largely orchestrated in routines set by organizations and regulations, and persons receiving care have their own life routines determining identity, capacities and frame of reference. However, to date, nursing has paid little attention to the relevance of routine and the role it may play in patient care.

METHOD

A concept analysis was conducted using Rodgers' guidelines. The literature search was based on the following databases: PsycInfo, CINAHL, MedLine, Social Services, and Social Work abstracts. To be included in the analysis, papers had to relate directly and essentially to the concept of routine. Seventy-four papers published from 1977 to 2005 were included in the final stage of the analysis. The analysis included target populations, disciplinary perspectives, type of manuscript, themes and definitions, theoretical models, antecedents and consequences, as well as related terms.

RESULTS

Routine is a concept pertaining to strategically designed behavioural patterns (conscious and subconscious) and is used to organize and coordinate activities along different axes of time, duration, social and physical contexts, sequence and order. It emerges from the literature as a strategy that serves adaptation, in general, especially in the face of change and stressful situations. The conceptual structure, relations with other concepts, antecedents and consequences are described.

CONCLUSION

The concept of routine is ill-defined and seldom used in the field of nursing, despite the promise it may hold for a better understanding of a wide range of health-related issues. This concept analysis offers an integrative view of routine and suggests directions for future research and practice.

Building Capacity for HIV/AIDS Prevention Among Asian Pacific Islander Organizations

This article has two goals: (1) to outline a conceptual model for culturally appropriate HIV prevention capacity building; (2) to present the experiences from a 3-year program provided by Asian Pacific AIDS Intervention Team to Asian Pacific Islander (API) organizations in southern California. The participating organizations were of two types: lesbian, gay, bisexual, transgender, and questioning (LGBTQ) social organizations and social service agencies not targeting LGBTQ. These organizations were selected for participation because of their commitment to HIV/AIDS issues in API communities. An organizational survey and staff observations were used to explore changes in capacity. The organizations were mostly small, targeted diverse populations, served a large geographic area (southern California as a region), and were knowledgeable about HIV. Organizations became more viable (more capacity in human resources, financial, external relations, and strategic management), but also more unstable (large growth in paid staff and board members), and showed more capacity in HIV knowledge environments (especially less stigma and more sensitivity to diverse populations). The results suggest that capacity can expand over a short period of time, but as capacity increases, organizational viability/stability and HIV knowledge environments change, meaning that different types of technical assistance would be needed for sustainability.

Mapping the social demography and location of HIV services across Toronto neighbourhoods

In this paper we map the location and distribution of HIV service providers across Toronto neighbourhoods. Our analysis identified an uneven distribution of services across Toronto and a number of communities that are less accessible to HIV-related services. We subsequently identified three neighbourhood-level characteristics of the populations living within these communities (i.e. concentrated economic disadvantage, concentrated immigration, and residential instability). Our findings suggest a significant overlap in the location of HIV service providers and the clustering of neighbourhood-level demographic and socioeconomic factors. Some inaccessible neighbourhoods overlap with clusters of neighbourhoods with higher levels of concentrated disadvantage, immigration and percentage of black Canadians. Accessible neighbourhoods are located within the downtown core of Toronto and overlap with clusters of highly dense, younger neighbourhoods (with a high proportion of 15- to 34-year-olds who are unmarried). Our findings point to the need for policy-makers to integrate spatial analytic techniques into their examination of the types of neighbourhoods, and subsequently the community members that live within those neighbourhoods, that are potentially underserved with respect to health and social services.

The social structural production of HIV risk among injecting drug users

There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. Drawing on a review of recently published literature, we seek to describe the social structural production of HIV risk associated with injecting drug use. We adopt an inclusive definition of the HIV 'risk environment' as the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to HIV. We identify the following factors as critical in the social structural production of HIV risk associated with drug injecting: cross-border trade and transport links; population movement and mixing; urban or neighbourhood deprivation and disadvantage; specific injecting environments (including shooting galleries and prisons); the role of peer groups and social networks; the relevance of 'social capital' at the level of networks, communities and neighbourhoods; the role of macro-social change and political or economic transition; political, social and economic inequities in relation to ethnicity, gender and sexuality; the role of social stigma and discrimination in reproducing inequity and vulnerability; the role of policies, laws and policing; and the role of complex emergencies such as armed conflict and natural disasters. We argue that the HIV risk environment is a product of interplay in which social and structural factors intermingle but where political-economic factors may play a predominant role. We therefore emphasise that much of the most needed 'structural HIV prevention' is unavoidably political in that it calls for community actions and structural changes within a broad framework concerned to alleviate inequity in health, welfare and human rights.

Family ties: constructing family time in low-income families

"Family time" is reflected in the process of building and fortifying family relationships. Whereas such time, free of obligatory work, school, and family maintenance activities, is purchased by many families using discretionary income, we explore how low-income mothers make time for and give meaning to focused engagement and relationship development with their children within time constraints idiosyncratic to being poor and relying on welfare. Longitudinal ethnographic data from 61 low-income African American, European American, and Latina American mothers were analyzed to understand how mothers construct family time during daily activities such as talking, play, and meals. We also identify unique cultural factors that shape family time for low-income families, such as changing temporal orientations, centrality of television time, and emotional burdens due to poverty. Implications for family therapy are also discussed.

Needle exchange programs. Delivery and access issues

OBJECTIVE

Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts.

METHODS

Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n = 59) of NEPs (n = 15) in Ontario. An iterative, inductive analytic process was used.

RESULTS

According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes.

DISCUSSION

NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.