LAY ENGAGEMENT WITH HEALTH CREATION AND MAINTENANCE Against the odds

The Jakarta Declaration on ‘Health Promotion into the Twenty-first Century’ identified as prerequisites for good health, ‘peace, shelter, education, social security, social relations, food, income, empowerment of women, a stable eco-system, sustainable resource use, social justice, respect for human rights and equity,’ and concluded, ‘Above all, poverty is the greatest threat to health’ (World Health Organisation (WHO) 1997: 1). At the local, personal level these necessities are reflected in the daily struggle most social work service users face in order to secure and maintain the money, housing, gas, electricity and water supplies, food and clothing and social support which underpin health. For many this is a struggle against inequitable conditions in the context of factors in the local, national and international social, physical and economic environment which are clearly beyond their control.

Nevertheless, for most individuals, the work to obtain such necessities and maintain health begins with self-care and care given to and received from those close to them. Lay people act to secure the essentials for health and take the hour-by-hour decisions which produce accommodation, meals, heating, relationships, advice and information. This lay work goes on throughout life. Mayall’s enquiries of primary school children showed that their understanding of the home as ‘the principal site for health care and for learning health knowledge and behaviour’ (1993: 482) was not just due to their parents’ (mainly mothers’) roles, but because these children perceived themselves as active workers for their own health. As one 9-year-old child said, ‘We’re keeping ourselves healthy by doing things ourselves. It’s my body so it’s my job’ (Mayall 1993: 473). At the other end of the age range, the Health and Lifestyle survey reported in Sidell (1995) found that as many people over 65 claimed that they made positive attempts to keep themselves healthy as did those in younger age groups, with over 60 per cent of both men and women acting positively to maintain their health. Graham’s work (1984, 1987 and 1993) has highlighted this duality – individual action taken within the context of unequal social relations – as characteristic of lay engagement with health creation and maintenance: ‘health-related behaviours are maintained within and against the constraining circumstances of everyday life’ (Graham 1996: 176–7).

Informed choices?

Within the confines of inequitable social conditions, what appear to be health-damaging attitudes and behaviours can make grim sense. First, for example, the barriers to healthy behaviour may be excessive. The benefits of attendance at clinics or of buying and preparing ‘healthy’ food may be outweighed by the costs in time, energy and material resources, particularly for people without transport, with limited income and/or heavy caring responsibilities. In the case of young women in social services residential care, negotiating for contraception was fraught with obstacles linked to the actual or anticipated attitudes of care and health staff, while the unpleasant sideeffects of contraceptive pills, injections or implants when finally obtained were often considerable (Corlyon and McGuire 1997). Second, other goals may be more important than promoting health, or different health objectives may conflict. For the young women in care, the risk of pregnancy was not of primary significance. As one put it, ‘Because people in care have such a shitty life they feel better if they’re going to bed with someone’ (Corlyon and McGuire 1997: 40). Third, many people – particularly women – are faced with choices in which their responsibility for the health of other people and limited resources conflicts with what they know about healthy behaviour.

A classic example is Oakley’s (1989) evidence that pregnant women who smoke often see themselves as carrying out a coping strategy for dealing with Stressors of various kinds, particularly when they lack adequate material resources. As one of Kempson’s respondents put it, ‘If my circumstances improved and I had less worry, I’d smoke less’ (1996: 22). Oakley described this as an example of ‘the rule that health-promoting work may be health-damaging for those who do it’ (1989: 327). For some of Corlyon and McGuire’s respondents, prioritising the health of others was reflected in their attitudes to abortion. ‘I made the mistake so why should somebody else [the baby] suffer for what I’ve done’ (1997: 64). Disadvantaged social circumstances also contributed to decisions to continue with pregnancies. As one young woman said, ‘I thought, “Well what have I got to lose if I keep it? There’s nowt else to do”’ (Corlyon and McGuire 1997: 65). Other evidence of Oakley’s ‘rule’ can be seen in a variety of situations.

For example, women on low incomes prioritised the needs of their male partners and their children for food, dealing with their own hunger and stress by getting by on cups of tea and cigarettes (Graham 1987). Parents who smoked also tried to protect their children from the financial costs of their smoking, for ‘while low income smokers had poorer diets than non-smokers, there was no difference in the diets of their children’ (Kempson 1996: 22). In a study of health and leisure in Hounslow, Asian women ‘cited pressurised lives and a primary duty to serve their family’ as key reasons for not exercising (Warren 1997: 26), and carers for adults have commonly provided care at the expense of physical, social and psychological damage to themselves (Anderson and Bury 1988; Atkin and Rollings 1996). Fourth, structural factors can place health prevention and promotion outside the control of individuals. Roberts et al. (1993) found that parents’ knowledge of environmental risks to their children in and outside homes on the Corkerhill estate in Glasgow was wider, more detailed and more specific than that of a group of professionals working in the area with some responsibility for accident prevention. While professionals were inclined to associate injuries with the characteristics of the families and to see education as a significant element in the solution, parents saw environmental hazards, such as gaps in balcony railings big enough for a baby to crawl through, hot water systems without thermostatic controls and lack of play space coupled with open access for cars, as accidents ‘waiting to happen’ (Roberts et al. 1993: 454). However, lack of resources (whether personal resources or resources available to the local authority) or the power to persuade others to take action meant that they experienced such hazards as out of their immediate control. The interaction between individual and structural factors in health creation and maintenance was also revealed in Davison et al.’s (1992) study of lay attitudes to heart disease in South Wales: could apparently ‘fatalistic’ attitudes explain the failure of many to follow healthy lifestyle advice?

Fatalism is the – implicitly wrong – assumption that control over a person’s health, lies externally; or that, at least, they cannot exercise such control. On examination, respondents had identified three sets of factors as affecting the likelihood of heart disease. These were:

• personal differences between individuals, for example, due to heredity or upbringing;

• factors in the social environment, for example (1992: 679) ‘relative wealth and access to resources, risks and dangers associated with occupation, loneliness’; and

• factors in the physical environment. In addition, respondents reported examples of people who, for no

apparent reasons, either behaved ‘unhealthily’ without the expected negative consequences, or else followed the rules but still got heart disease. They thus ascribed some element of chance or luck to the overall equation. However, this did not amount to a passive, irrational or culturebound ‘fatalism’, so much as to a recognition of the limits of knowledge. Lay beliefs about health protection or promotion placed actions which they could take as individuals in the context of external influences over which they had little control. Davison et al. concluded (1992: 683): ‘In our observation, popular belief and knowledge concerning the relationship of health to heredity, social conditions and the environment may be more in step with scientific epidemiology than the lifestylecentred orientation of the health promotion world.’