In this chapter I present the core category derived from the study data, which involves exploring the way in which various personal, biographical and contextual factors contribute to the development of ‘unhealthy’ behaviours. The many
dimensions of context, including the biographical, social, economic, political, cultural, geographical and historical, are addressed primarily from the perspectives of service users. The influence of the organisational context is considered in the next chapter, which focuses more heavily on data from the health trainers and managers. Short vignettes and direct quotations from study participants are used to illustrate and support the analysis relating to the category ‘contextualising’ (see Appendix Q for a transcribing key). The chapter ends with a summary that draws together the main points to have emerged during the analysis.
Personal characteristics
Service user participants were asked at each interview to describe their current health status and the factors they felt impacted on their ability to live the life that they would like to lead. These questions were worded carefully in an attempt to avoid imposing ideas about a ‘normal’ or ‘healthy’ lifestyle. Participants were encouraged to provide their own definitions of health and wellbeing, which ranged from the ability to take part in regular physical activity to being able to leave the house. Most described a state of compromise and willingness to accept a certain level of ill-health. This is illustrated by the following quote from Cathy, a woman in her nineties who was housebound and needed daily care for multiple conditions, yet still described her health as good:
Cathy: I’ve been registered blind for four years now. Luckily my vital parts, you know... I’ve had lots of operations – don’t ask me what (laughs). But I’ve, my general health is pretty good up to now, with my heart and up to now my general health... If it wasn’t I keep breaking my bones a lot, I’d be fine. [...] Thank God I’ve still got this [indicates towards head]. If you’ve got your brain, you can put up with a lot.
Participants in this study identified age, disability status and various other personal factors that influence an individual’s health experiences and health-related
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Age
Age and the ageing process were identified as key contributors to the current health status of participants in this study, most of whom were over the age of 60 or had taken early retirement as a result of ill-health. Participants tended to report multiple physical conditions and expressed these as an inevitable aspect of the ageing process due to ‘wear and tear’ suffered over the years:
Kevin: It’s just crumbling of the spine – hard life you’ve had and it’s payback time now. This is the time it gets you. When you get over 50 it suddenly creeps up on you and it hits you, you know. But that’s life, isn’t it? It could be worse.
Losing a degree of mobility, slowing down and subsequently gaining weight were seen as accepted features of approaching old age. There was also felt to be a temptation to take the easy option and “vegetate”, by sitting at home and watching television every day. However, the participants were keen to identify themselves as responsible individuals who were making efforts to maintain their health and halt the decline, as illustrated by the quotes below. This was partly for their own benefit and partly due to a desire to avoid becoming a burden on others, including the state.
Kaye: I think when you reach a certain age, there’s a lot of people who I work with who are my age and they’re reaching the same point as I am. And your hormones change and you start putting weight on and it’s really hard to shift it, and all the things that you’ve tried in the past don’t work. And you can either accept it and think, “Well I’m just getting old”, or you can try to do something about it.
Int: I’ve kind of already asked about what you’re hoping to achieve in the longer term. Is it mainly preventative?
Peter: To live longer (laughs). To have as good a quality of life as I can as I get older, you know. I know I can’t run as fast as I was when I was a young man. I can’t do things as quickly as I can and I’m not as agile as I can. But I am more agile and run faster and do things better than most people of my age. And I have less illness.
As well as separating themselves from their less health-conscious peers, older participants were keen to distinguish their generation from younger people who were seen as being primarily concerned with vanity and consumption. This difference was attributed to wisdom gained with age, as well as having fewer demands on their time. The staff interviews largely reinforced this perception, although there were some barriers reported to working with older age groups, such as physical limitations and an initial resistance to new information. It was recognised
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that offering activities during normal working hours would be more likely to attract retired people who tend to be free during the day and are less likely to have
childcare responsibilities. This links to the influence of occupation on health-related lifestyle behaviours, as described in the next sub-section.
Occupation
A substantial body of literature documents the relationship between employment and health. On the whole, people who are in employment tend to have better physical and mental health than those who are out of work, partly due to increased status and economic independence. Participants in this study reported a decrease in access to financial resources following retirement due to reliance on state benefits, although most did not feel that money was a significant factor in their health. The primary concern was maintaining their pre-retirement lifestyle whilst on a fixed income, which involved making resource allocation decisions:
Terry: It [attending a private gym] boils down not to the convenience, it’s the expense. You know, when you retire, you're counting your pennies and looking at things like that.
For many, paid work represented a form of structured activity, whilst retirement initially represented a life without structure or routine. Employment had been the main source of physical activity for those involved in manual or non-manual roles. It was also associated with social activity and access to resources such as sporting teams or exercise facilities linked to the workplace. In this sense employment was seen as having both health promoting and protective effects:
Int: And so before that [retirement], was your… you hadn’t really had problems with your health or anything?
Sheila: No, nothing. No, I mean, I was on the go all the time. When you think, you had a routine. I mean, working full-time. [...] You used to sit at your desk maybe 10, 15 minutes, then you were up again and you never sat still. As soon as I retired, I sat down... I put the weight on and I’m convinced that’s what got the diabetes – putting the weight on. You know, once you’ve packed in work and then you’re just, you just slow down. You seem to just slow down to a nil and it just catches up on you.
In a minority of cases, employment was reported to have a negative impact on the ability to lead a healthy lifestyle, often due to the demands of a specific job. For example, Kevin described himself as a “fry-up merchant” whilst working as a long- distance lorry driver, whereas Brian “lived off the fat of the land” in hotels as a senior
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manager in the banking sector. Full-time and shift work act as barriers to attending health care appointments and services that are primarily open during office hours. Active work also places a strain on the body and can exacerbate existing health conditions, whilst work-related stress impacts negatively on mental health.
Kevin: I’ve never been a heavy smoker. I mean I haven't got a smoker’s cough or anything, you know. But it’s just something I’ve done for 40-odd years. You know, I can't give it up. Being a truck driver, long distance, you always smoke when you're driving.
Participants generally reported mental health benefits as a result of being in paid employment, which was felt to give them a sense of purpose, identity and increased self-esteem. For some female participants, paid work outside of the home was seen as a form of release from the stress of their caring responsibilities within the family. Boredom was identified as a major factor in the development of unhealthy eating patterns which, in turn, was associated with an unstructured lifestyle resulting from being out of work. To counteract this, participants had sought to reintroduce structure into their lives by taking part in regular, often health-related, activities:
Pam: I mean, if the hotel had been still open I would have still been [working] there. I would have still… I think it gives you a bit of purpose in life. I think that’s why I go to the gym and that. Rather than just, like, sit here.
Int: Work seems quite important to you.
Sian: Yeah. I think it’s just for self-respect and, like, esteem inside. And I think that’s part of the thing that keeps you ticking over, know what I mean? If you can go out and say, “I work”, even if it’s just part-time, you know. I work, I’m contributing. [...] For my own wellbeing, I think that’s important, you know. So I give myself a pat on the back and say, “I’m doing this” rather than just sitting at home, having everything being given to me.
Participants who were unable to work for health-related reasons reported a decrease in self-esteem and loss of independence, leading to boredom and other negative effects. This is illustrated by the following quote and explored further in the section on disability below:
Kevin: I haven’t worked since my brain haemorrhage in 2004. Basically, nobody would employ me as I am at the moment. Bit of a risk, you know. Bit of a liability. I miss work terribly, you know. [...] It does change your life. As well as losing that… your independence and losing your job. Thirty years behind the wheel of a big truck is a long time and I still want to do it but I can’t. It’s just not going to happen. So that’s when depression kicks in as well. Your whole life has got to change.
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Disability
The sample included a diverse mix of individuals with limiting physical conditions, mental health problems and physical or sensory disabilities, as well as relatively healthy participants. None of those recruited to the study described themselves as having a developmental or learning disability, and some staff identified this as an area of unmet need within the local community. Two participants were mothers of children with learning difficulties and their experiences as carers are described in the section on family below. Participants affected by some form of disability
encountered a number of challenges in attempting to lead a healthy, active lifestyle. These included a paucity of local services suited to their needs, practical access barriers and safety concerns. The following illustrative quote is from Frances, a woman in her early forties with progressive multiple sclerosis (MS):
Frances: [After writing to] the local MP, he got in touch with the PCT and he just said, “Oh well, the council gyms offer one-to-one support.” But in theory they might, not in practice. They haven’t got the staff to do it in practice. And I looked into a couple of private gyms but they’re not insured. So I can’t even join a private gym. And again they wouldn’t offer the help that I need. So that’s it, basically.
Int: And is it the one-to-one support you need, in terms of getting on and off machines and things like that?
Frances: That’s exactly it. It’s the getting on and off. And the weights I can’t do without being physically tied on to the machine. So I can’t go anywhere else. So it was a bit of kick in the teeth.
Frances spoke about an ongoing struggle to find ways to access services in order to meet her needs around engaging in activity and slowing the physical decline due to her condition. Over the course of our interviews, she spoke passionately about feeling shut off from an increasing number of avenues that would enable her to maintain a degree of dignity and independence. In part, this was due to her fear of exercising alongside able-bodied people and being subject to negative comments. Although Frances was speaking from her own personal experience, her comments are likely to be representative of many others with physical disabilities.
Frances: That’s what it’s like at a normal gym – you feel embarrassed and self- conscious because that’s the way they make you feel. Like you’ve got be ashamed because you don’t fit the stereotype, I suppose, of people that go to a gym. Fortunately they don’t make Lycra big enough
(laughs). But it’s like the gym thinks, like, all you should see in the gym is fit, healthy people and it’s a great advertisement for them. You see a disabled person or whatever and it doesn’t fit [that image]
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The staff also spoke of the difficulties experienced in attempting to support disabled people, mainly due to a shortage of appropriate follow-on services. There were particular challenges in working with wheelchair users, which can cause frustration for both the service user and health trainer. A situation where a wheelchair-bound user could not be given support to use her local library was described by one health trainer as “heartbreaking”. Deaf people were also felt to be particularly vulnerable to feelings of isolation and social exclusion. Staff reported challenges to working with these individuals that included the small size of the community, its diffuse nature, a lack of awareness amongst GPs, and language barriers:
HT: Within the Deaf community, information and access to information is way behind the access that hearing people have. They don’t just pick things up via, you know, sound, via radios or people speaking or overhearing things. [...] Deaf people as well find it difficult, when they’re on their own, to go into like a gym where it’s full of hearing people where there’s no communication. And so then, yes, I would go along to a gym and be there as a bit of company and support. It’s a language barrier, you know, that they face.
Ethnicity and religion
Similar communication barriers are experienced when individuals from black and minority ethnic (BME) communities attempt to access health and social services. These are often compounded by high levels of illiteracy, as well as specific cultural, religious and gender issues that may make it difficult for them to follow healthy lifestyles. For example, one of the health trainer teams identified a local need for advice and support around supari21 addiction that was not being met by existing smoking cessation services. Lack of awareness and understanding of health messages combined with low confidence levels were reported to be key issues in attempting to work with BME communities. However, the following quote from a Pakistani health trainer demonstrates that individuals from BME and White
communities may experience similar challenges resulting from a lack of confidence:
HT: I would say the biggest barriers are the culture and the language, in terms of Asian communities. But in terms of White communities, I’ve seen some of them… I used to think when I first came [to live in England], because they are English, they speak English, they have no problems, they know their... They are confident. But they’re not. I’ve seen so many White people with lower confidence and self-esteem than myself.
21
Supari is a mix of tobacco and betel nut that is chewed for its mild effect as a stimulant by members of some South Asian communities.
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People from similar ethnic or cultural backgrounds do not constitute a homogenous group; for example, there were differences reported between the experiences of Muslim women of Asian and Middle Eastern origins. This highlights the importance of considering the role of individual attitudes and beliefs towards health in shaping health-related behaviours, as described below.
Attitudes towards health
A key factor reported to influence an individual’s lifestyle was their attitude towards health and fitness. Maintaining a healthy, active lifestyle was often described as a “way of life”, particularly for those who had been involved in sport from a young age. Participants described themselves as having the ‘correct’ attitude in terms of “doing
as they should” and making health a priority; for example, allocating limited funds to
fitness classes rather than alcohol or bingo. The emphasis was on individual choice and personal responsibility, as indicated by the following quote:
Maxine: It’s up to the individual – if you want to do it, you do it. It’s the same as when you stop smoking – it’s got to be you and you alone. I mean, you do get help, but at the end of the day you don’t have to put that patch on your arm, you don’t have to chew that chewing gum.
These ideas were explored at the six-month follow-up interviews, when participants were asked to consider a series of prompts (see Appendix O) and discuss whether or not they felt these might act as barriers to leading a healthy lifestyle. The prompt that generated the strongest reaction was ‘Life is too short to worry about health’, as participants unanimously disagreed with this statement:
Sheila: ‘Life’s too short to worry about health’? That’s a good one (laughs). No, that’s stupid. You’ve got a sense of humour anyway. [...] ‘Don’t think I control my health’? Of course you do. You’re the only one that can control it really.
Terry: ‘Life is too short of worry about health’? I think life’s too short because you don't worry about your health. I think people – young ones now, you know – all they think about is drink [alcohol] and I don’t think they eat well and all that. And then it must have an effect as they get older but is it too late then? And I think you should look after your health from being taught at school.
People who do not worry about or prioritise their health were generally felt to be ignorant, lazy or lacking in self-control. One of the health trainers used the term “tunnel vision” to describe certain individuals who were unwilling to accept their
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help. Participants emphasised the importance of people having the freedom to do “what they want to do with their own body” and that any efforts to control the behaviours of others would be futile:
Jim: I can’t see where you could do any more. I mean, it’s the same old saying – you can lead people to water but you can’t make them drink.