What is a missed dose? Implications for construct validity and patient adherence

The construct 'missed dose' is central to many assessments of medication adherence. However, few studies have investigated how patients or clinicians conceptualize missed doses or the extent of the concordance or discordance between clinicians and patients. To address this gap we conducted semi-structured interviews with 45 sero-positive African American adults taking HAART and 17 of their clinicians. Results reveal large variability in missed dose conceptions among both patients and physicians and significant differences between the two groups. Overall, patients reported a stricter definition of missed dose than did clinicians. Fifty-five percent of patients thought that a pill-taking delay of six hours beyond the prescribed dosing time constituted a missed dose, by comparison, only one physician agreed with this assessment. More than one-third of patients thought that the proper response to a missed dose would be to skip it altogether, but only about 12% of clinicians agreed. These findings have implications for the construct validity of self-report measures of adherence, for patient adherence behaviours based on missed dose conceptions and for patient-physician relationships and communication within the clinical environment.

Emerging concerns of older stroke patients about assistive device use

Assistive devices minimize limitations from physical impairment and are integral to rehabilitation. Little is known about older patients' concerns, perceptions, and beliefs about assistive devices. This study used a structured, qualitative approach to describe device perceptions of 103 stroke patients in rehabilitation. Six dimensions of patient concerns were identified, including the operation and utility of devices, social contexts and consequences, and attributions of cultural meanings of use. Initial device use posed cultural value dilemmas originating in discrepancies between sociocultural beliefs and conflicting normative expectations. Knowledge of these dimensions suggests new areas for social science research and refinements to clinical practice.

The process of self-report of impairment in clinical research

This paper examines how labels for impairment are negotiated by people with disabilities during clinical assessment. It builds on Robert Murphy's (1987) explanations of the disability experience as rooted in the individual's sense of having multiple past, present and intended future body-selves. Using transcripts of five consecutive daily clinical research assessments, it describes the conduct of clinical research assessments with an older man with stroke-related motor impairments and dysphoria. It also examines how the researcher as Other shapes a person's sense of identity, experience and quality of life by regulating the medical labels for personal experience, and by authoring socially authoritative scientific models of disabilities. Points of dissension (regarding identity, discourse and time perspectives) and collaboration are identified and then illustrated with excerpts from the transcripts. Analysis reveals how salient personal experiences are locally asserted in discourse, and selectively misrepresented in the clinical research record.

The romance with personal meaning in gerontology: cultural aspects of life themes

Life narratives have wide appeal because they promote the modern ideal of freeing people to reflect on their life and to share personal meanings and experience in public. Constructing a life story may aid adult development and well-being. This article explores how to enhance these benefits, but criticizes the idealization of stories and their benefits. Using life stories from 16 randomly selected clinically depressed and nondepressed elderly persons, this article examines the narrative structures and how these relate to mood and to ideal images for the self. Findings show that some normative styles for self-representation (i.e., personal themes) serve to express distress instead of positive well-being. The discussion points to cultural and historical forces shaping our ideas about themes in stories. Life stories do privilege personal meanings, but the settings and form constrain their value as research data and their effectiveness as vehicles for enhancing well-being.

Extending the critical gerontology perspective: cultural dimensions. Introduction

This introduction outlines how the emerging framework of critical gerontology (CG) may be enhanced by greater emphasis on understanding the cultural influences on research and practice in gerontology. CG pursues empirical insights into the historical and cultural forces shaping the sense of the problem for study, that is, the formulation of topics and ways of defining issues. Illustrations are drawn from a recent GSA symposium. The articles following this introduction document, in relation to two key constructs, the need to understand how cultural-historical contexts complexly inform the focus of core topics of attention, how these are operationalized for research and policy, and their role in shaping the course of American gerontology.