Full text of DOI:10.1111/1467-9566.00315

Sociology of Health & Illness Vol. 24 No. 6 2002 ISSN 0141–9889, pp. 714–733
BS©2610OCJ u140lHoxraBl40iciflgIcaoL1l2i akionr–Ldwcl iao9sak, elgi8wUnlAy8l gteKrpo9olt lnuti fhcPbHleelui esfbuhal itilsunt hrge&Lr stI dl lLn t ed s/ Es ditorial Board 2001
Colonising the future: temporal perceptions and
health-relevant behaviours across the adult
lifecourse
Julia Lawton
Research Unit in Health, Behaviour and Change, University of Edinburgh
Abstract Health promotion is premised upon a proactive approach to
health and its management, one that requires a future-orientated
outlook, in which the threats of (future) ill-health can be
anticipated and thereby mitigated. Despite this, little is known
about the extent to which concerns about morbidity and mortality
actually feature in people’s present and future perceptions of self,
and whether such perceptions have any influence upon their
present health-relevant behaviours. By drawing upon interviews
with 55 people aged 26–81, this article highlights the central role
that embodiment plays in the mediation of health promotion
messages. The embodied experience of ill-health, it will be shown,
is an important, underlying prerequisite for perceiving a future in
which (further) ill-health is anticipated. This pivotal finding will
be used to illuminate the observation that, when lifestyles are
changed to concur with professional recommendations, these
changes tend to be reactive in nature.
Keywords: embodiment, risk perceptions, health-relevant behaviours, per-
ceptions of the future, health promotion
Introduction
This article reports some of the findings of a qualitative study conducted in
England in 2000 in which semi-structured, in-depth interviews were con-
ducted with 55 participants. In this, a lifecourse approach was employed to
explore the ways in which people of different ages, and from different back-
grounds, had – or had not – actively thought about, and planned for, their
futures. This focus was considered important because, within the supposed
‘
risk society’ of late modernity, increasing onus is being placed upon indi-
viduals to take responsibility for all aspects of their present and future lives
Giddens 1991, Beck 1992). One arena in which this cultural shift has
(
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Colonising the future 715
become apparent is that of health and its management. Whereas historically
disease and its causation were understood in fatalistic ways (Brandt 1997),
within the contemporary Western context, responsibility for health and its
maintenance has been set firmly within the hands of individuals (Lupton
1
995, Brandt 1990). Indeed, the past few decades have seen a significant
upsurge in health promotion activities sponsored by governmental and
other agencies. Health promotion advocates a proactive approach to health,
in which individuals are encouraged to adopt and/or maintain a range of
‘healthy’ lifestyle behaviours in the present in order to lessen their risks of
developing various acute and chronic conditions in the future (Blaxter 1990,
Department of Health 1999).
One of the most notable achievements of health promotion to date has
been the extent to which its messages have been successfully disseminated to
the lay population. As Blaxter (1990) has found, most people can compet-
ently cite what they (and others) should be doing to lessen their risks of
future ill-health. Yet herein lies the paradox: while most age and social
groups are well-acquainted with the messages of disease prevention, few
people, in practice, enact ‘healthy’ lifestyles either entirely or in part (Blaxter
1
990, Backett and Davison 1995, Dean 1989, Hunt and MacLeod 1987).
As Williams suggests, the translation of health promotion messages into
actual practice ‘remains a fundamental stumbling block for those concerned
with the promotion of “positive change” to a “healthier lifestyle” ’ (1995: 578).
This article will consider a body of work that has already greatly
enhanced our understanding of why health promotion activities have been,
in the main, remedial rather than radical in their impact. By drawing upon
the findings of the interview study, it will also develop an area of enquiry
and explanation that has received surprisingly little attention. In spite of the
fact that health promotion – and ‘risk management’ in general – require a
future-orientated outlook, one in which individuals can see themselves as
vulnerable to the threats of ill-health and ultimately death (Lupton 1999:
2
1), few studies have paid explicit attention to the ways in which people, in
their daily lives, actually anticipate their futures with regard to these emerg-
ing realities. As the findings described in this article suggest, the manner in
which people ‘imagine’ their futures varies according to their position in the
adult lifecourse, and, in particular, according to their current health status.
While it is common for younger people to perceive a long-term future for
themselves in which the potential constraints of morbidity and mortality are
often absent, for older people – especially those experiencing poor health –
future morbidity, and death, are often viewed as impending certainties.
These shifting experiences and perceptions, it will be shown, are highly rel-
evant to whether people are overtly ‘health conscious’ or not. As this article
will further suggest, the presence, or absence, of ‘health consciousness’,
‘morbidity consciousness’ and ‘death consciousness’ often appear to have a
direct bearing on people’s motivation to adopt behaviours aimed explicitly
at lessening their risk of future ill-health. Such observations will be used
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16 Julia Lawton
to raise pertinent questions about the likely (future) impact of predictive
genetic susceptibility testing for common, adult-onset disorders with a multi-
factorial aetiology.
Study background, design and methods
The study was commissioned by Age Concern England, to explore the
extent to which people from different age, gender and socioeconomic groups
had actively thought about future eventualities such as ill-health and death,
and whether these perceptions influenced their current health behaviours
1
and planning for their futures . Although there is already some relevant
research within this area, only limited insights can be gained from this body
of work. For example, while some studies have explored perceptions of risk
of susceptibility to future illness (for example, Davison et al. 1991, Ponder
et al. 1996, Glik et al. 1999), these have generally only focused on spe-
cific conditions such as coronary heart disease, and/or have rarely explored
the relationship between risk perceptions and actual health-relevant beha-
viours (Hunt et al. 2001). This situation also applies to the research that has
examined variations in death attitudes and anxieties across the lifecourse,
without actually exploring their impact on provisioning for the future (for
comprehensive overviews of these studies, see Fortner and Neimeyer 1999,
Gesser et al. 1987).
Thus, as the present study was essentially exploratory, it lent itself well to
a qualitative design, one that would enable themes to be identified and tested
during the study period, rather than simply assessing those formulated prior
to data collection (Britten et al. 1995). An interview schedule was designed
that allowed perceptions of morbidity and mortality to be identified, and
their effects on present health-relevant activities and future planning to be
examined. The interviews began by exploring the general state of health of
participants’ family and friends, thereby creating opportunities for them
to share information about the deaths of people who were important to
them, and any concerns they might have about the health of others. This
was considered an important line of enquiry because some studies have
suggested that the experience of death and ill-health within one’s circle of
significant others may have some influence upon one’s own existential
awareness (see, for example, Hallowell et al. 2001, Tokunaga 1985, Yalmon
and Lieberman 1991). The second part of the interviews contained a series
of questions about participants’ perceptions of their own general state of
health in the present and the past, and also if they had any concerns about
their future health. This question was further explored by asking if any
behaviours had been consciously adopted in the recent or distant past to
improve and/or maintain health, and, if they had, what factors had
prompted these changes. The interviews then went on to explore experiences
and perceptions of later life, and if any proactive plans had been made for
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Colonising the future 717
these events. They concluded with a series of open-ended questions about
hopes and expectations, in which participants were invited to talk about
their perceptions of self at various points in future time.
A flexible, open-ended approach was achieved by using an emergent study
design informed by grounded theory research (Glaser and Strauss 1967).
Data collection and analysis occurred concurrently, and systematic efforts
were made to check and refine developing categories of data (see Charmaz
1
983). The ongoing process of data collection and analysis directed further
literature reviews, investigation topics, sample selection, and interview ques-
tions. Thus, while some themes were formulated at the study’s outset, others
emerged during data collection. These emerging themes were explored with
respondents in later interviews, and, when necessary, were subjected to fur-
ther revision. Analysis also continued after data collection, when individual
transcripts were repeatedly re-examined and cross-compared using manual,
iterative methods. Although some revisions were made to the interview
schedule, its core structure remained essentially the same. Hence, it was
possible for comparisons to be drawn between different interviews and
clusters of interviews, as well as for points of similarity to be identified.
The sample
2
The study was conducted within tight time constraints . Despite this, it was
possible to interview 55 people within the allocated period of five months.
Recruitment was achieved through snowballing techniques, in which people
were drawn from four distinct geographical localities in England (one rural,
three urban). As one of the central aims of the study was to explore possible
variations across the adult lifecourse, people of a wide variety of ages were
involved in the study. The youngest interviewee was 26 and the oldest 81,
with the ages of the others falling more or less evenly on a spectrum between
these two extremes. Roughly equal numbers of men and women were inter-
viewed (27 men, 28 women) to allow possible gendered variations to be
identified. Likewise, potential class variations were accommodated through
the recruitment of people from a wide range of occupational backgrounds.
While social class is notoriously difficult to classify, the study followed
Blaxter (1990) in using the conventional Registrar General’s social class
method, which is based on occupation, or previous occupation in the case
of the retired, or husband’s occupation in the case of married women. The
social classes of the participants are as follows: classes I/II (professional,
employers and managerial families) (n = 20), class III non-manual (IIIN)
(
other non-manual occupations) (n = 15), class III manual (IIIM) (skilled
manual occupations and own account tradesmen) (n = 8), and classes IV/V
service occupations, semiskilled and unskilled) (n = 12). Hence, particip-
(
ants from classes IV/V are slightly under-represented in the final sample.
Only one participant came from a minority ethnic background.
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18 Julia Lawton
Data collection
The interviews were conducted between February and June 2000, and varied
in duration from 15 minutes to two-and-a-half hours. Most participants were
interviewed in their own homes, although some chose to be interviewed at
their place of work. With their permission, the interviews were tape recorded.
All participants completed a form in which they provided information about
their age, (former) occupation, education and ethnic status. Field notes were
written immediately after the interview had taken place. These were used to
record information that had been shared after the tape recorder had been
switched off.
All aspects of the research were guided by, and conformed to, current
BSA ethical guidelines. For example, confidentiality was assured and main-
tained throughout the study, and participants’ identities have been protected
through the use of pseudonyms.
Outline of findings
The interviews evoked a wide variety of responses. Whilst some participants
talked extensively about health issues and voiced concerns about future
morbidity and mortality, for others, health-related concerns did not seem to
feature prominently in their daily thinking and activities, let alone in their
perceptions and planning for their futures. While some modest gendered and
class variations were identified when the data were analysed, the strongest
distinctions emerged when the responses of people from different age groups
were compared. Older participants, as a general rule, appeared to be much
more ‘health conscious’ than those of younger ages, and were more likely to
perceive the prospect of future ill-health and death as certainties as opposed
to possibilities.
At first sight, the findings appeared to resonate with those of other studies
which have pointed to the role of increasing age in precipitating thoughts
of finitude (for example, Kalish and Reynolds 1977). Such a phenomenon,
Kalish and Reynolds suggest, stems from a general ‘recognition of the real-
ity that older people are more likely to die than people of any other age’
(
1977: 212), combined with the fact that older people are much more likely
than others to have been exposed to ill-health and death amongst their
family and peers (see also Keith 1982, Field 2000, Stillion 1995). ‘Com-
monsense’ explanations such as these, however, were thrown into question
in this study because important differences occurred between interviews
3
with participants of similar ages. For example, not all older participants
appeared to be concerned about their health, let alone with the prospect of
death; similarly, some people in the middle-aged groups claimed to be attent-
ive to health issues in ways that distinguished them from many of their
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Colonising the future 719
contemporaries, as well as most younger and some older participants. When
the transcripts were re-examined to take account of these variations within
particular age groups, it became apparent that it was the experience of
embodied ill-health, rather than increasing chronological age per se, that
prompted people to perceive themselves as directly vulnerable to the threats
of future morbidity and mortality. This general shift in perceptions and
experiences with increasing age could thus be accounted for by the fact that,
as people grow older, they become more prone to degenerative diseases and
4
multi-morbidity . The over-riding importance of health status over chrono-
logical age was amplified in a second, pivotal finding: when participants in
all the age groups reported that they had changed their lifestyles with
long-term health goals as their motivation, their accounts suggested that
these changes (with almost no exceptions) had been reactive rather than
proactive.
The following sections have been structured to highlight these key find-
ings. They begin with the perspectives of those participants (predominately
in the younger age groups) for whom good health was taken for granted,
and conclude with those for whom the experience of embodied ill-health had
become central to their daily activities and future perceptions. Gendered and
class-based issues are also briefly highlighted in some places. The article
ends by providing some reflections upon the implications of the findings for
future health promotion activities.
Taking good health for granted: absent bodies, immortal selves
Up to forty you don’t give a bugger. Do you, you know? You don’t really
think about it at all (Howard, 55, IIIN).
A substantial number of interviewees appeared to take basic good health
for granted, an experience that was most common amongst younger par-
ticipants, but also extended to some in the middle and older age groups for
whom no obvious health problems had featured in their lives. Importantly,
when these people were asked about their current state of health, and also
if they had any concerns about their future health, such lines of questioning
often elicited terse and dismissive responses:
It’s not something that plays on my mind; it’s not something I think about
(
Kate, 30, IIIM).
I wouldn’t say really I’ve given it any thought to be honest (Michael, 38,
IIIN).
The failure of health-related questions to strike a responsive chord suggests
that, for these participants, health held the status of an experiential absence,
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20 Julia Lawton
one displaced from the realms of conscious attention. Indeed, it was often
only after they were forced by the interviewer’s questioning to qualify com-
ments such as those made above, that participants described ‘states of being’
from which underlying, long-term health complications were absent:
I don’t think I’ve ever had a day’s sickness in my life (Elizabeth, 42, IIIN).
Well, I suppose because I’ve not been particularly ill, I’m not really
concerned about it (Lucy, 46, I/II).
As the above responses suggest, for as long as it can be take for granted,
health – to borrow an insight from the phenomenologist Leder (1990) – is
experienced as ‘an absent presence’. As van Hooft similarly suggests: ‘Inso-
far as we are living our lives more or less successfully, our health is not an
issue for us, and is not directly experienced as a state of our being’ (1997:
2
7). Importantly, while health retained a background quality for particip-
ants, the possibilities of imagining a self in sickness, and in death, also
appeared to be absent. When these participants talked about their hopes and
expectations for the future, virtually all projected their lives forward in ways
characterised by what has been termed an ‘unrealistic optimism’ (Segal
et al. 2001, Weinstein 1982). Not only was an extended period of longevity
taken for granted in their accounts (many participants, for example, made
reference to what they would be doing in their 80s); importantly, the ways
in which they described their futures precluded any references to ill-health,
let alone death. While some talked about their hopes of continuing to work
on a part-time or voluntary basis after they had reached retirement age, the
majority spoke with great enthusiasm about their plans to travel extensively
in later life. In all cases, their comments revealed an implicit assumption that
they would retain the corporeal and mental capabilities to pursue these
goals, an assumption that finds resonance in broader postmodern discourses
of ageing. In these, as Gilleard and Higgs (2000) observe, positive images of
ageing, in which later life is perceived as presenting opportunities for leisure
activities and personal development, are increasingly jostling for prominence
with those in which ageing is seen as involving inevitable deterioration and
dependency.
I want to travel round the world to some remote and amazing continent,
that’s what I’m contemplating (Catherine, 26, I/II).
There’s another thing I shall do when I’m old, too, is I’ll become a
connoisseur of fine wine . . . Well, I really would like to have a nice cellar.
So when I’m older and have more time, I think I would like to go
backwards and forwards to France buying wine . . . [and] . . . I might as
well have a pad in New York, so when I’m 80 I can be actually going to
the opera and the ballet and things like that (Elizabeth, 42, IIIN).
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Colonising the future 721
Whilst these participants demonstrated a clear capacity to ‘look forward’,
significantly, none of them claimed to have either adopted or changed
aspects of their lifestyles with the aim of promoting longevity. This could not
be explained by an ignorance of the messages of health promotion: indeed,
a general awareness of the current orthodoxies of preventative medicine (e.g.
don’t smoke, don’t drink to excess, exercise regularly, adopt a low-fat diet) was
frequently alluded to in these interviews. When, however, participants talked
about their own health-relevant behaviours, their comments often indicated
a perception that health-promotion activities lacked any relevance to them-
selves. This did not necessarily mean that these participants reported lifestyles
that might be characterised as uniformly ‘unhealthy’: as Blaxter (1990) has
similarly observed, patterns of health-relevant behaviours within this group
tended to be mixed, consisting of both ‘good’ and ‘bad’ components. None-
theless, when they were encouraged to explore the motives underlying the
supposedly ‘healthy’ components of their lifestyles, it became apparent
that long-term health considerations were not of central, if any, salience to
them. For example, the high cost of cigarettes, rather than a concern about
future health, was a frequently-cited reason for smoking cessation. Physical
and other sporting activities were pursued ‘more for the pleasure . . . than
necessarily because it’s keeping me healthy’ (John, 42, I/II). Dieting was
also commonly reported amongst members of this group, although this
was largely a gendered phenomenon. Whilst weight management is known
to lessen the risks of developing conditions such as cardio-vascular disease
and diabetes, such an agenda did not appear to have influenced these par-
ticipants’ actions. Instead, they articulated their motivations in terms of
current discourses centring upon the aesthetics of the body, those in which
the appearance of a youthful, slim, outer body has become a culturally revered
symbol of a successful social self (Bordo 1993, Shilling 1993). Indeed, this
immediate desire to ‘look good’ rather than to promote longevity was
reflected in the smoking behaviours of two women currently on diets. They
described how their fears about gaining weight, and of becoming ‘ugly and
unsexy’ (Elizabeth, 42, IIIN), had acted as a significant barrier to stopping
smoking, a situation that also finds resonance in Monaghan’s (2001) study of
male and female body-builders. To achieve their goal of changing ‘one’s bodily
appearance so that it more or less approximated idealised images of health,
youth, fitness and beauty’ (2001: 337), a significant proportion of Monaghan’s
informants took physique-enhancing drugs which, like cigarettes, are known
to have potentially serious, long-term health damaging effects.
Whilst the dieting and bodybuilding examples can be understood in the
context of contemporary Western notions of individualism, as Williams (1998),
drawing upon the work of Crawford (1984, 1998), rightly reminds us, the
pursuit of a socially sanctioned self in this cultural setting is inherently contra-
dictory. At the same time as ideals of individualism are expressed and played
out through regimes of bodily regulation and self-constraint (of which health
promotion activities are one component), consumerist society exalts powerful,
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22 Julia Lawton
oppositional values such as ‘ “letting go”, indulging one’s desires and enjoying
the corporeal excesses that follow’ (Williams 1998: 442). The latter, Williams
suggests, are pleasurable, thus making them important to contemporary
wellbeing, a perspective which goes some way to explaining why ‘excesses of
corporeality’, such as heavy drinking, smoking, and/or eating junk food,
were also a commonly reported feature of these participants’ lifestyles:
I think the guilt that people associate with not drinking, not smoking, not
eating the wrong things, is actually worse in very many cases than actually
committing the sins. Because people get so obsessive. And you’re probably
getting more benefit from getting enjoyment out of life and your friends
than you would if you abstained from everything (Catherine, 26, I/II).
I smoke, I smoke a lot. I’ve given up a few things, but not for long. It’s
always in the back of my mind to give up [for financial reasons] but it’s
either lack of will power or the fact that I really enjoy smoking, so I’ve not
really thought about giving it up properly (Andrew, 32, IIIM).
Williams’ work forms part of a broader trend in which studies have
attempted to ‘bring back culture’ (Milburn 1996: 42) into their analyses
and, in so doing, have highlighted the ways in which health-relevant beha-
viours that may seem ‘irrational’ from the standpoint of health promotion are
in fact reasonable, and in some cases, eminently sensible when considered
from a lay perspective (Backett and Davison 1992, Frankel et al. 1991,
Graham 1993). Yet, Williams’ article also highlights an additional theme
of key analytic import, that of the lived experience of the body. As he points
out, the ‘healthy body’ is the site from which ‘corporeal transgressions’
and ‘excesses’ are most likely to occur, because: ‘We take our bodies for
granted to a far greater degree when healthy than sick’ (1998: 451), an
observation well supported by the data presented here. However, an
important dimension missing from Williams’ account is the way in which
this ‘taken-for-grantedness’ of the body can also impact upon future concep-
tualisations of self. As the data above have vividly highlighted, participants
who took the embodied experience of ‘good health’ for granted did not
appear to anticipate (and, by implication, perceive themselves as being vul-
nerable to) future ill-health and death, a phenomenon which adds a crucial
dimension to understanding why they did not regard disease prevention
activities as having any immediate salience. Indeed, such a situation became
very apparent in the interview with Andrew, the heavy smoker quoted above,
who offered the following response when asked if he ever worried about the
possible effects of his smoking on his future health:
I don’t think about getting old and any heart attacks and stuff, or being
crippled. When you’re healthy you don’t think about it and don’t plan for
it or worry.
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Colonising the future 723
The central importance of embodiment to both present and future con-
ceptualisations of self is a key theme that runs through the remainder of this
article. Indeed, as the final findings section illustrates, it is one that is thrown
into particularly stark relief in cases where the embodied experience of ill-
health had become a central feature of participants’ lives. For now, however,
I will briefly consider the experiences of an intermediary group, for whom
subtle, but discernible, shifts had taken place in their attitudes towards their
future health, but not in terms of their actual health-relevant behaviours.
The ageing body: health-related intentions, but not actions
Once you start getting the odd muscle ache you try and start thinking about
doing some exercise, but I’m not too serious about it (William, 54, I/II).
For some participants, a point had been reached in the lifecourse at which
they claimed to have become aware of some subtle and gradual alterations
in their bodies. Whilst some pointed to specific changes in this regard – for
example, declining eye-sight, stomach problems and ‘the odd muscle ache’ –
most described a more generalised and periodical awareness of the ageing
process, of sometimes being conscious of ‘being a bit slower’ (Sarah, 42,
IIIN); of ‘your body telling you that you’re not sixteen’ (Louise, 31, IV/V)
(
see also Cunningham-Burley and Backett-Milburn 1998). The age at which
this awareness set in varied considerably between different participants.
Louise, for example, described how she had started to become mindful of
the effects of ageing in her late 20s, an experience she put down to a past in
which she had lived on the streets and had been a heavy drug user. The vast
majority, however, indicated that it was only in their late 30s, 40s, or some-
times even 50s, that they had become periodically aware of the ageing proc-
ess. One woman identified the onset of the menopause – with its ‘occasional
and embarrassing bodily reminders’ such as ‘hot flushes’ – as being a trigger
in this regard (Alice, 55, IIIN).
When these participants talked about their hopes and expectations for the
future, their conceptualisations revealed both points of similarity to and
difference from those described earlier. While many retained a positive and
forward-looking outlook (travel plans, for example, continued to feature
significantly in these interviews) their perceptions of later life often also
indicated a slightly more realistic and pragmatic view of the future:
I would like to think that I was mentally and physically active to work and
also to do the things I wanted – to travel and do things with our house
and family (Guitta, 46, I/II).
I would like to think that I’ll still be living here and still liking what I like
now: music and ballet and having the odd drink and going out for a meal.
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24 Julia Lawton
No great change really. I’m quite content – unless I get very ill, which I
hope I don’t (Bryan, 58, IIIN).
Hopefully I’ll have the health to enjoy it [retirement]. I do dread old age if
I am not going to be able to get around (Sarah, 42, IIIN).
What is salient here is that, while participants did articulate some apprehen-
sions about future morbidity, these concerns were framed as possibilities
rather than certainties, as ‘ifs’ rather than ‘whens’. Indeed, participants often
went on to describe how, within the context of their daily lives, such thoughts
about future ill-health and its effects tended only to be ‘fleeting’ or ‘periph-
eral’, and thus did not impinge significantly on their thinking and planning
for their futures. Relatedly, whilst the majority suggested that they had now
started to become more attentive to the messages of health promotion – that
they had begun to ‘think about’ doing more to keep themselves healthy –
few were able to point to instances in which they had actually made changes
to their lifestyles. Whilst many spoke of their intentions to take more exer-
cise, to give up smoking, or to change their diet, they also described how the
more ‘pressing’ and ‘immediate’ requirements created by work and family
responsibilities (Backett 1992, Backett and Davison 1995, Calnan and Wil-
liams 1991, Watson 2000), had led to postponement of these activities:
I plan to do a lot more to keep myself healthy than I do now. But, at the
moment, I literally get up in the morning, get in the car to the station,
train to London, the bus to the office and I sit in the office and then
repeat it round the other way (Penny, 53, I/II).
Clearly, time constraints and other practical factors (for example, not
having safe and easily accessible public spaces in which to exercise (Green-
halgh et al. 1998, Ross 1993) ) can act as barriers to the implementation of
(
health-relevant) lifestyle changes. Additional (albeit less explicit) barriers
are also created by the ‘habituated’ and ‘routinised’ nature of most behaviour
in everyday life. By drawing upon Bourdieu’s concepts of ‘habitus’ and the
‘logic of practice’, Williams (1995) highlights the complex ways in which
practices and behaviours (including those relevant to health) can become
such an ‘unthinking’ part of daily life (1995: 598), that their existence
becomes, to some extent, exterior to individuals to which they supposedly
belong. This perspective enhances understandings of why ‘unhealthy’
behaviours may persist even when people do appear sympathetic to the
messages of health promotion.
However, the wholesale currency of explanatory factors such as these was
thrown into question in this study by virtue of the fact that some particip-
ants reported that they had made conscious – and often successful – attempts
to reconfigure their behaviours in line with professional recommendations.
Their experiences are now considered.
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Colonising the future 725
(
Ill)-health: an omnipotent presence
It’s all your health when you get older, because if you haven’t got that,
you’ve got nothing (May, 73, IV/V).
Not all participants took their present and future health for granted;
indeed, as the quote above suggests, there were some for whom health-
related concerns appeared to have become a predominant feature of their
lives. As other studies have similarly found (for example, Calnan and Wil-
liams 1991), explicit attention to health issues only appeared to surface after
health ‘problems’ had set in: health became a subject of thematic awareness
by virtue of its absence. Importantly, a diagnosis of acute or chronic disease
was not always sufficient to bring about a conceptualisation of self as ‘ill’
(see Radley 1997). The disease also had to become manifest in tangible
ways. George (74, I/II), for example, described how, when he was first told
that he had type II diabetes following a routine medical check-up, ‘I
honestly and truthfully was not aware that it was a serious complaint’. It
was only after he had started to experience secondary complications that
he actually began to see himself as ‘sick’. As he suggested:
I think the emphasis I would make about it [diabetes] as a disease is that
if you’ve got a heart disease, or you’ve got a liver complaint or your
kidneys are all congested, it hits you hard; it doesn’t seem to be with
diabetics. . . . And it isn’t until your eyes go, or partially go, and just
recently I’ve had a lot of electric current in my toes, that you realise
that it’s very very serious.
Participants thus tended only to become overtly health-conscious after
they had experienced episodes of acute and chronic ill-health that had had
apparent and long-lasting bodily effects. These included heart attacks (with
consequent problems of breathlessness and lethargy), diabetic complications,
pleurisy, and painful, crippling arthritis, which limited mobility, and thus
impeded an independent lifestyle. In all such cases, a heightened awareness
of embodiment, and of bodily betrayal, was indicated by participants, an
experience brought about by the constant reminders that their bodies no
longer performed in ‘unthinking’, ‘pre-reflexive’ ways (see Leder 1990):
I keep trying to plod along, thinking that I can still do the things I used
to do, like gardening and housework, but my body says ‘no’. That tells me
you’re not 50, you’re 80-odd sort of a thing (Bill, 81, IV/V).
Not only was the body (and by implication health) rendered thematic by
virtue of these experiences of bodily dysfunction (see Leder 1990, Williams
1
996), the bodily effects of ill-health also appeared to have brought about a
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26 Julia Lawton
reconceptualisation of self as being inherently vulnerable and contingent
Lawton 2000), one which ‘involves a recognition of the worlds of pain and
(
suffering, possibly even of death, which are normally only seen as distant
possibilities or the plight of others’ (Bury 1982: 169). This situation became
apparent when participants referred to their own futures. As the following
quotes illustrate, a key conceptual shift appeared to have taken place, one in
which further morbidity (and sometimes also death) were viewed as certain,
impending threats to the self, as ‘whens’ rather than ‘ifs’:
We are anxious about what is going to happen to us. We haven’t actually
dealt with what will happen to us when we are no longer physically
capable of caring for ourselves (Frances, 56, I/II).
We have our holidays now while we can. There will come a time when
neither or both of us won’t want to or won’t be able to. It’s the same with
driving. I’ve told my oldest son, I said ‘when I get to the stage where you
don’t think I’m fit to drive, take my car away, because I won’t realise how
bad I’ve got’ (Arthur, 71, IV/V).
Indeed, it was due to these tangible future concerns, and the constant
bodily reminders that triggered them, that many participants claimed that
they had begun to ‘consciously think and act healthily’ (Gordon, 55, I/II).
Such conceptualisations often led to active efforts being made to follow the
recommendations of health promoters, participants’ reported motivations
being to ‘lengthen that life that diabetes would shorten’ (Melissa, 56, IIIM),
‘to live as long as possible, keep as fit as possible, to live till I die’ (Arthur,
7
1, IV/V). For example, two participants who had had heart attacks
described how they now paid very careful attention to their diet and levels
of alcohol consumption. Many, likewise, suggested that they now tried to
take regular exercise in order to maintain or improve their future health. As
Frances, 56, I/II, who was suffering from arthritis, described:
I walk at lot, although it’s painful if I walk very far. I always push myself
because I work on the principle that if you don’t use it, you lose it.
Generally speaking, I’m very aware of further deterioration, so I make
sure I exercise.
Smoking cessation – explicitly for health reasons – was also notable within
this group: one man had stopped after he developed a circulation problem
in his left leg which had caused him considerable discomfort, another after
he had developed pleurisy.
These findings illuminate broader trends identified elsewhere, namely, that
the adoption of health promoting behaviours tends to be most prominent
amongst those who are already experiencing (embodied) ill-health. As Blax-
ter has observed, smoking cessation is most likely to occur amongst those
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Colonising the future 727
with poor health (1990: 192). Calnan and Williams, in a related fashion,
have found that health-related dietary changes most often take place in
response to actual health problems such as heart disease (1991: 522; see also
Dean 1989), and various commentators have observed that compliance to
diabetes therapies generally increases after the onset of complications (Diet-
rich 1996, Maclean and Goldman 2000).
Somewhat ironically, however, the very factors that may motivate the
adoption of health-promoting behaviours can sometimes also act as sig-
nificant barriers to the realisation of these aims. Such a situation became
evident in the interview with Roger (64, IIIM) who described how the stroke
he had experienced two years previously had left him ‘so weak’ that he had
had to take early retirement from his building job. He spent a considerable
part of the interview talking about his worries about the future, in particular,
of ‘having to sell the house to pay for old age care’. Indeed, this was one of
the central issues he pointed to in explaining his determination to do every-
thing he now could to preserve ‘what remains of my health’. Whilst he had
successfully adopted a low-fat diet, his inability to exercise was a source of
considerable frustration:
I get too tired. When I try to walk any distance, I have to sit down. We
have a dog and I can just about manage to walk him up the street and
down the other side, but then I have to sit down, and I’m shot through for
the rest of the day.
Discussion and concluding remarks
In a theoretical contribution to studies of health and lifestyles, Williams
(
1995) pointed to an urgent need for empirical research that can inform and
enhance current analytical understandings of why people adopt, maintain
and/or change their lifestyles in ways that are relevant to their long-term
health. By drawing upon the views of people from a wide variety of age and
social groups, this study has provided an array of data that has allowed
meaningful comparisons to be drawn between participants who had actively
changed their lifestyles with health goals as their motivation, and those for
whom health was essentially taken for granted. In so doing, it has high-
lighted the complex ways in which dominant health and risk discourses
are mediated – and often muted by – people’s everyday, lived experiences of
embodiment (see Watson 2000). Health promotion is premised upon a
proactive attitude to health and its management, a ‘colonisation of the
future’ (Giddens 1991) wherein the possibilities of illness and death can be
anticipated and thereby mitigated. As the findings described in this article
indicate, however, the embodied experience of ill-health is an important,
underlying prerequisite for perceiving the future in this way. Indeed, it is one
that explains the somewhat ironic observation that, when participants did
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28 Julia Lawton
intentionally change their behaviours to concur with professional recom-
mendations, these changes tended to be reactive.
Some reservations might be expressed about these findings by virtue of the
study being cross-sectional rather than longitudinal. As Strauss and Howe
(
1991) suggest, the possibility of cohort effects should be taken seriously in
any study that attempts to compare the experiences of members of different
generational groups. In this respect, there are potentially valid grounds for
arguing that some of the differences observed between older and younger
participants could be accounted for by the different cultural/historical con-
texts into which they were socialised. For example, whereas older people
grew up at a time when medical sovereignty was rarely challenged, younger
people, as a consequence of being socialised into consumerist society, are
more likely to question the knowledge and authority of medical and other
professionals (McKinstry 2000). This observation might partly explain why
older people are more likely to comply with health-promotion advice than
those of younger ages. Some commentators, likewise, have pointed to the
role of shared historical experiences – such as living through one or both
World Wars – to explain the general propensity of older people to talk more
openly and pragmatically about ill-health and death than members of junior
generations (Field 2000, Stillion 1995).
There is, however, good reason to think that cohort effects did not have
a substantial impact on the study’s central findings, because there was a
substantial overlap in the responses of participants from different age/
generational groups. As has been illustrated, participants’ current state of
embodiment appears to be the central experience that united or distin-
guished them from one another. Indeed, in line with other studies (for ex-
ample, Kastenbaum et al. 1981), this article has highlighted the importance
of analysing people’s perspectives across the lifecourse through a theoretical
lens in which functional age takes precedence over chronological age.
In highlighting these issues, this article has sought to enhance current
understandings of why health-promotional activities have been, in the main,
remedial in their impact. The findings, however, can also be used to raise
pertinent questions about the effects of developments in health-promotion
activities in the future. Advancements in the new genetics bring with them
the likelihood that it will soon be possible to provide widespread, predictive
genetic susceptibility testing for a whole range of common, adult-onset dis-
orders with a multi-factorial aetiology, such as heart disease, type II diabetes
and Alzheimer’s disease. Whilst the knowledge that these diseases have a
hereditary component is already well established within lay and medical
circles (Davison et al. 1989, Hunt et al. 2000, 2001, Ponder et al. 1996), the
introduction of predictive genetic testing (PGT) offers the potential for
genetic risk information to be provided to greater numbers of people than
can be achieved through a knowledge of their family histories alone
(
Marteau and Lerman 2001). Consequently, the geneticisation of medicine
has been viewed with considerable enthusiasm by some commentators (for
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Colonising the future 729
example, Summers 1993), and it is likely that professional efforts targeted
towards primary prevention through lifestyle changes will become even
more intensive in the future (Davison 1996).
This article’s findings can be used to contribute to the small body of work
(
for example, Marteau and Lerman 2001) that has begun to question the
potential of the risk information provided by PGT actually to facilitate
proactive, health-beneficial lifestyle changes. As Davison has observed, pre-
dictive genetic testing for late onset, multi-factorial disorders can only pro-
vide ‘possible rather than defined futures’, futures that involve ‘ “ifs” rather
than “whens” ’ (1996: 318). Importantly, as has been shown here, the prospect
of ill-health often needs to be perceived in more concrete and absolute
terms – as a ‘when’ rather than an ‘if’ – before people are actually motivated
to change their lifestyles. Indeed, the insights gained from other studies are
very illuminating in this respect. As Marteau and Lerman (2001) have
observed in their review of the limited evidence base that is currently avail-
able, people who are known to be at genetic risk of conditions such as breast
cancer, bowel and prostate cancer, and heart disease, do not appear to differ
in highly significant ways from others in terms of their screening (e.g.
mammography) and (health-relevant) lifestyle behaviours (e.g. smoking and
physical activity).
It is becoming increasingly recognised that, for health promotion messages
to be effective, they must tap into an existing corpus of meaning, fitting into
‘a self-image already at least partially formed’ (Lupton, 1994: 115). By look-
ing at the perspectives and experiences of those for whom health promotion
messages do indeed appear to strike a responsive chord, this study’s findings
are very telling: namely, that it is amongst those for whom secondary
prevention is pertinent, that health promoters have had – and are likely to
continue to have – their most receptive and sympathetic audience. This is an
observation that policy makers may wish to consider seriously when they
make decisions about the targeting of scarce resources in the future.
Address for correspondence: Julia Lawton, Research Unit in Health,
Behaviour and Change, The University of Edinburgh, Medical School, Teviot
Place, Edinburgh EH8 9AG
e-mail: J.Lawton@ed.ac.uk
Acknowledgements
I am very grateful to Nina Hallowell, Kathryn Backett-Milburn, Odette Parry and
Steve Platt for their helpful comments on an earlier version of this article. Particular
thanks go to Ann Pyatt who assisted with the data collection. Age Concern England
funded the study in 2000. The Scottish Executive Health Department and the Health
Education Board for Scotland jointly fund the Research Unit in Health, Behaviour
and Change. All opinions expressed in this article are those of the author and not
necessarily those of the funding bodies.
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30 Julia Lawton
Notes
1
2
3
One component of the study was concerned with the financial provisions people
had made for later life and is reported elsewhere – see Lawton and Pyatt (in press).
This was an exploratory study, its aim being to identify themes and to open areas
of enquiry that could be pursued by more in-depth research in the future.
While the imposition of ‘age-determined’ categories provides a convenient way of
organising the data, it is important to acknowledge that the labelling of some
people as ‘young’, ‘middle-aged’ and ‘old’ may be incongruent with the ways in
which they actually perceive themselves (see Thompson 1992).
4
It is now widely recognised that people age physically at different rates (Anstey
et al. 1996, Gilleard and Higgs 1998, Renner et al. 2000). The findings of various
studies indicate that, whilst women within most Euro-American countries have
higher life expectancies than men, non-fatal morbidity appears to be higher
amongst the former (Kirby et al. 1999, Verbrugge 1985). Significant socioeco-
nomic inequalities in health have also been reported (Smith et al. 1990).
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