WORK IN PROGRESS- NOT FOR CITATION · WORK IN PROGRESS- NOT FOR CITATION ... Flis Henwood School of Applied ... „living in the city of Brighton and Hove‟ and „aged 16 or over‟.

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WORK IN PROGRESS- NOT FOR CITATION

‘Preventing obesity through self care? Ageing, technology and ‘healthy living’

Paper prepared for the Social Policy Association Conference, University of Lincoln,

July 5-7th 2010.

Flis Henwood

School of Applied Social Science

University of Brighton

[email protected]

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Abstract

In recent government policy on obesity (Healthy Weight, Healthy Lives (2008), we can see

the beginnings of a shift of focus from individual responsibility, Body Mass Index measures

and weight management, to a recognition of the multi-causal nature of obesity and the

concomitant need for a cross-government approach to change. It is now accepted that a

balance needs to be struck between individual behaviour change and much wider social and

environmental changes that tackle the „obesogenic society‟. But how do those who see

themselves as overweight experience this tension, what are their own personal strategies for

self care and healthy living, and what social and environmental factors do they experience

as facilitating or inhibiting these?

A parallel set of developments in policy focused on older people (see, for example, Shaping

the Future of Care Together, 2009), indicates a renewed interest in low level „prevention‟

strategies that can help promote independence and well-being, whilst reducing demand on

health and social care services. Key to the prevention agenda are access to information and

advice on exercise, diet and healthy living and on low intensity practical support services.

But what does healthy living mean in the context of ageing and older people‟s diverse and

complex bodies and lives? What kinds of intervention and prevention strategies are

employed in the everyday lived experience of growing old and trying to stay fit and healthy?

This paper will draw on a Department of Health-funded study of the potential of information

and communications technologies (ICTs) to support self care in the context of obesity

management. The study was based in one city in order to enable obesity and overweight to

be explored „in place‟, to facilitate a participatory research approach and enable a mapping

of local health and information providers and explore their relationship with the local

community. 84 per cent of study participants were women and 57 per cent were aged 45 and

over. All were engaged in some form of weight management and/or attempts at living a

healthier lifestyle.

Drawing on data collected via a survey, focus groups, participatory learning workshops, and

a set of reflective interviews, this paper explores how discourses of ageing are mobilised in

engagements with both technologies and the healthy living agenda and how understanding

the lived experience of attempts at active ageing can contribute to improved design for

interventions aimed at the prevention of obesity amongst older people.

Introduction

Recent policy focused on older people (see, for example, Shaping the Future of Care

Together, 2009), indicates a renewed interest in low level „prevention‟ strategies that can

help promote independence and well-being, whilst reducing demand on health and social

care services. Key to the prevention agenda are access to information and advice on

exercise, diet and healthy living and on low intensity practical support services. Also integral

to, if not always explicit within, this prevention agenda, is the notion that self care is a central

means by which well-being can best be promoted. But what does healthy living mean in the

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context of ageing and older people‟s diverse and complex bodies and lives? What kinds of

self care strategies are employed in the everyday lived experience of growing old and trying

to stay fit and healthy?

In recent government policy on obesity (Healthy Weight, Healthy Lives, 2008), we can see

the beginnings of a shift of focus from individual responsibility, Body Mass Index (BMI)

measures and weight management, to a recognition of the multi-causal nature of obesity and

the concomitant need for a cross-government approach to change. This emerging approach

argues that a balance needs to be struck between individual behaviour change and much

wider social and environmental changes that tackle the „obesogenic society‟. But how do

those who see themselves as overweight experience this tension, what are their own

personal strategies for self care and healthy living, and what social and environmental

factors do they experience as facilitating or inhibiting these?

The e-health agenda positions information and communication technologies (ICTs) as key

tools for the empowerment of patients and the public, providing access to information that

can help them make appropriate healthy life choices (Department of Health 2004a and b).

But how do those seeking to live healthy lifestyles engage with information and ICTs? What

role does the internet play in supporting healthy living? And how does age intersect with

internet use in the context of healthy living practices?

A recently completed study that explored self care in the context of obesity enables us to

begin to address these questions and, in so doing, to engage more critically with the concept

of „prevention‟ when used in the context of healthy living and active ageing agendas. The

Net.Weight study1 explored the potential of information and communications technologies

(ICTs) to support self care in the context of obesity management. The study was based in

one city in order to enable obesity and overweight to be explored „in place‟, to facilitate a

participatory research approach and to enable a mapping of local health and information

providers and explore their relationship with the local community. The majority of participants

were over 45 and all were engaged in some form of weight management and/or attempts at

living a healthier lifestyle. Drawing on data from this study, this paper makes the case for

understanding the lived experience of attempts at healthy living and active ageing, arguing

1 The study’s formal title is ‘Supporting the self-management of obesity: the role of information and

communication technologies’. For full report, see http://research.cmis.brighton.ac.uk/netweight/. This is an

independent report commissioned and funded by the Policy Research Programme in the Department of

Health. The views expressed are not necessarily those of the Department.

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that this understanding is crucial not only for the design of appropriate interventions, but for a

more critical engagement with the whole notion of „prevention‟ when applied in the context of

older people.

The Net.Weight study participants

Inclusion criteria for the Net.Weight study was: „over the recommended weight for your

height‟, „trying to do something about it‟, „living in the city of Brighton and Hove‟ and „aged 16

or over‟. There were many different elements to the study, several of which are drawn upon

in this paper. The main sources of data for the analysis presented here are: survey of

people‟s self care practices which focused on overall health, weight management,

information and technology practices (385 respondents); 4 focus groups (average of 7

participants each); 3 sets of participatory learning workshop groups (39 participants in all);

and a set of reflective interviews for those who attended workshops (18 participants).

57% of the user survey respondents were aged 45 or over, although the workshop

participants were an older group, with 85% in this age group2. Women made up 84% of the

survey sample and 79% of the workshop participants.

In policy discourse, „healthy lives‟ are strongly associated with „healthy weights‟ (Department

of Health, 2008) and „healthy weights‟ are measured, most commonly, using the Body Mass

Indicator (BMI) scores, where a BMI in the range between 18.5 and 24.9 is considered as

normal, between 25 and 29.9 is overweight, and 30 or above is obese (Department of Health

2006). Using the BMI, 95% of the Net.Weight user survey sample was either overweight

(45%) or obese (50%)3. The average BMI in this sample was 30.7. The workshop

participants were a slightly heavier group, with average BMI of 31.8. Many survey

respondents lived with one or more chronic health condition associated with being

overweight, including high blood pressure (23%), breathlessness (19%), high cholesterol

(13%), osteoarthritis (11%), type 2 diabetes (7%) and „other‟ conditions (22%). 30% lived

with more than one chronic condition. Workshops participants had a similar health profile.

2 This difference may well reflect the fact that older respondents to the survey were less confident in the use

of computers and the internet and were keen to learn new skills and assess the relevance of these technologies for their everyday healthy living practices. It may also reflect the fact that older people have more time to attend such workshops. Of the 3 workshop groups, the group with the highest average age (67, Group B) met in the day time; Group A (average age 58) also met in the day time; Group C, with the youngest average age (46) met in the evening.

3 This reflects the sampling approach which sought to recruit participants who were overweight or obese, as

measured by the BMI. A few ‘normal weight’ people did respond to the survey and were included because they were deemed to be engaged in self care related to the prevention of weight gain.

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High blood pressure, high cholesterol and osteoarthritis were significantly more prevalent in

the older age groups. These conditions, and the „lived experiences‟ of managing them,

provides important context for understanding participants‟ self care and healthy living

strategies, and may point to the redundancy of the more generic „preventative‟ healthy living

messages for many older people and people with complex health problems.

Several participants drew on their experiences of age-related health problems to resist a

simple conflation of health and weight and emphasise a broader definition of „keeping well‟:

Lianne was concerned about her weight but had a more pressing health issue to address:

Yes, and I mean I am overweight, but with kidney failure, I do have to follow a special diet, so it‟s not that easy to lose weight (Lianne, aged 64).

She continued:

being on dialysis now I have to be careful that I‟m not missing things, before I was on dialysis I had a very strict diet, now I have to make sure I eat enough because I could be missing protein or vitamins… the doctor is, you know, says I‟ve got to be careful to eat enough, and eat enough protein, so that‟s why I don‟t worry too much about my weight (Lianne).

Amanda, recently diagnosed with diabetes, stated that her priorities had had to change:

when I dieted before, I would actually cut down on the carbohydrates, but as a diabetic, I can‟t do that. So I‟ve actually had to change and learn different, different ways… (Amanda, aged 60)

With complex co-morbidities, there is, of course, also the problem of not knowing for sure

what is causing what. As Esther expressed:

... I‟d got to the heaviest I‟d ever been, and I was having more and more twinges of backache and knees and thinking „is this old age and arthritis, or is this overweight and could I ease it…? (Esther, age not given).

Esther‟s predicament neatly encapsulates the complex relationship between health, weight

and age in older people‟s lives where bodily constraints imposed by co-morbidities interact

with discourses of self care to raise questions about the responsibility for „prevention‟ of

unhealthy bodies and lives.

Self care as ‘prevention’?

The prevention discourse encompasses concerns about an ageing population and ever

increasing demands on the health service caused by people living longer, often with long

term and chronic illnesses and associated disabilities. For example, the 2009 Green Paper

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Shaping the Future of Care Together, which set out a vision for a new National Care

Service, focuses on how to meet the care needs of the ageing population in the context of

rising demand and limited resources. In this context, „prevention‟ becomes a powerful and

seemingly rational concept to employ:

Money could often be better invested in prevention, rehabilitation and keeping people active and healthy (HM Government, 2009, p.9, emphasis added)

However, insofar as self care is seen as key to „prevention‟, we need to start thinking more

critically about self care. The self care agenda is seen as a key component of the model for

Supporting People with Long Term Conditions (Department of Health, 2005a), linked to both

improved health outcomes and the empowerment of patients (Department of Health, 2005b)

The Department of Health states that self care is about putting people in control of their

health, and that:

[T]he NHS cannot do self care to people, but what it can do is create an environment

where people feel supported to self care. 4

A number of innovative national initiatives have been introduced to showcase this self-care

agenda, including the Expert Patient Programme (EPP) and the „patient trainers‟ initiative,

where patients and the public are trained in self care skills to improve health (Department of

Health, 2004a).

As I have argued elsewhere (Henwood et al, forthcoming), the UK government‟s self care

agenda can been understood as part of the neo-liberal agenda encompassing the new

public health (NPH) and the new „healthism‟ (Peterson and Lupton, 1996). As such, „self

care‟ might be differentiated from „self –help‟. As Bella (forthcoming) argues, early self-help

movements worked with a „collective‟ model of empowerment that was overtly „political‟, and

„intended to achieve broadly based social change‟ (p.**), an agenda that has arguably been

subverted by formal self-management programmes and health promotion approaches which

promote „state-sanctioned‟ objectives‟ (p**). However, the situation may not be as clear-cut

as this. For example, recent research on self-management programmes in the UK, whilst

remaining critical of the policy emphasis on the individual and on efficacy, and whilst

claiming that self-management programmes may represent an abdication of state

responsibility for health (Kendall and Rogers, 2007), also acknowledge that such

programmes do, at times, seem to trigger a new consumer health movement built not on the

medical paradigm but on the subjective experience of living with a chronic condition (Wilson

et al, 2007; Kennedy et al, 2004). Thus, it may be more useful to think not of the state

4 (http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_4128529

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approach to self care subverting self-help approaches but as the two approaches existing in

tension with one another. Veinot, in her study of the UK‟s Expert Patient Programme (EPP),

describes this in terms of two „co-existing discourses‟- „self help‟ and „managerial

effectiveness‟ (Veinot, forthcoming).

Obesity is challenging from a self care point of view and illustrates these tensions well.

Despite the beginnings of a shift in government policy from a focus on individual

responsibility to a recognition of the wider, environmental causes of obesity (Department of

Health, 2008), Webb‟s argument - that obesity policy tends to position the individual as

„normatively responsible for the onset of obesity and, in part, its management‟ (Webb, 2009,

p855) - still has relevance. Despite the fact that both the causes and consequences of the

condition are complex and beyond the scope of individual self management alone, NHS

weight management and healthy living programmes are typically aimed at individuals and

may, therefore, be understood as representing just the type of abdication of state

responsibility for health that Kendall and Rogers speak of. This focus on individuals may

also, of course, lead to attributions of blame that undermine the very practices of self care

such programmes aim to promote.

What is the lived experience of self care in the context of overweight and obesity for older

people? How do older people, many of whom have struggled with their weight all their lives,

understand and manage the tension between individual responsibility and wider, social

determinants of unhealthy lifestyles? Is there evidence of the co-existing discourses of self

help and self care?

The user survey asked specifically about what people did to manage their weight. Physical

exercise and dieting were the most common ways in which people has sought or were

seeking to manage their weight, with more than 95% of respondents having tried one or both

means to manage their weight. More than 60% of the sample said that weight management

was important to them (particularly true for women) but 60% had not been successful in over

the preceding year and, whilst more than 60% wanted to lose 1, 2 or more stone in the next

year, almost 50% were not confident about their ability to do so. Responses to the survey

open question „what do you find hardest about managing your weight?‟ suggest a number of

reasons why weight management is difficult for our sample with „temptations‟ of food,

„comfort eating‟ and a „lack of will power‟, related to both food and exercise, being key.

However, unsurprisingly, given the health conditions with which many of our participants

lived, ill-health and bodily constraints (for example, knee pain, making exercise difficult;

prescribed drugs (steroids, HRT); kidney failure; multiple sclerosis; heart condition; slipped

disc) were also mentioned frequently as either causing weight gain and/or mobility problems.

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Asked „what would help you most with managing your weight?‟, support was paramount

(„help from doctor and more support from family‟, „someone overseeing me‟, „support from

other dieters‟, „greater motivational support‟ etc.). However, again, there were responses that

suggested a wider context for weight management and attempts at living healthier lifestyles.

Many talked about the need to reduce stress which often led to over-eating and under-

exercising, creating a negative cycle („finding work that is no stressful‟; ‟less stress‟; „finding

another way with dealing with emotions‟; „a balanced lifestyle‟; „having a job that was less

stressful‟). Women, in particular, mentioned their role in food provision within the family in

this context: („not having to cook for children‟; „not having to cook for the rest of my family‟;

„to be able to concentrate entirely on myself- difficult with a family to cook for‟).

Others key suggestions for support for lifestyle change were affordable food and exercise

options and accessible local services: („finding a diet that lets me eat the food I can afford to

buy‟; „cheaper forms of exercise‟; „free gym membership‟; „better access to leisure centres‟;

„accessible exercise at reasonable cost…and being able to find it locally‟; „nicer

swimming/gym facilities‟; „to keep going to slimming club (but expensive)‟; „finding a sport or

activity that I enjoy and is fun, without being expensive‟; „affordable healthy food at work‟ ;

„safe bicycle lane in Brighton‟).

Age was articulated strongly in responses to the question „what would help you most with

managing your weight?‟ with many expressing a need for the support of a group of older

people („a group exercise with people my own age would be good‟; „a class or group of

people that are the same age/weight‟).

Others resisted an individualised approach more explicitly and expressed a clear desire for

the need for wider social changes – again, expressed in relation to age:

resources that cater for my age group that acknowledge many of us over 60 are neither elderly/olds loaded with money and would like to continue to be interested in how we look, what we wear; encouraging incentive to remain lively and feel good about ourselves (survey response)

One response neatly encapsulates the range of exclusions (based on cost, age and size)

from existing resources felt by many of our participants:

I have only ever been successful in weight loss when I have been able to attend a gym and had help. I can‟t afford this anymore and I think I am too old and too big now anyway (survey response)

Interviews also revealed a tension between individual responsibility and the wider, social

determinants of unhealthy weights and/or lifestyles. By participating in the Net.Weight study,

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all participants can be understood at some level as taking individual responsibility for their

weight and health and their responses demonstrate this clearly, often relating the need for

action directly to age:

… being over 50 and reading the information that‟s out there it‟s vitally important that I get some of this weight down for cardiac reasons really, to get rid of it, because I am at high risk (Alexander, aged 63).

What am I? I‟m 72 and I‟m fairly...well, quite overweight. And I‟m diabetic, so I really do need to get my weight down (Claire).

However, there were also very clear resistances to the self care agenda that prioritises

individual responsibility and often blame. Many of these resistances involve the mobilisation

of ideas about age and the ageing body. For women, menopause was a time of significant

change in relation to their bodies, their weight and, for some, their approach to weight

management. Two responses to the open question „what do you find hardest about

managing your weight?‟ illustrate this point well:

My metabolism seems to have changed since going on HRT. I put on a stone and have not been able to shift it (survey response)

I have struggled to lose weight since menopause - feel my problem exacerbated by hormones (survey response)

In interview, Isabelle, aged 67, who had had a hysterectomy, related her weight and body

size directly to this mid life event:

... the annoying thing was I wasn‟t always like this but people only know me as I am now, you know, and I mean, until I was 47 and I had my hysterectomy, I was only a size 10 or 12 and then, you know, now I‟m nearly 11 stone and I‟m only five foot and you know people only see me as I am now, you know, that annoys me that they judge you by what you are now, not what I can do or what I‟ve done, but what I look like and I find that very, very upsetting (Isabelle)

Asked if she started to put weight on gradually after her hysterectomy, she replied:

Yeah, it sort of came on very quickly, I suppose, with my age as well but, yes, I did find that I‟d put a lot of weight on after I had that (Isabelle)

Here, participants can be understood a resisting the idea that individuals can always

„manage‟ their way out of poor health and related weight gain, implicitly taking issue with

notions of „prevention‟ as found within self care discourse. Their accounts also point to the

inappropriateness of generic healthy living messages in the context of the mid-life to older

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women and their ageing bodies. In the next section, we explore, more critically, the role of

information in self care.

Information as prevention?

Information is considered an essential component of self care, a point that can be illustrated

well in the case of obesity. In December 2004, a year or so before the Net.Weight study was

devised, the then Public Health Minister, Melanie Johnson, spoke about the obesity problem

in the UK:

Obesity has rapidly become a serious problem, with over half of the population recorded as either overweight or obese. It is essential that people eat healthily and stay active if they are to stave off the threat of killer diseases like cardiovascular disease, type II diabetes and cancer. But we can‟t force people to be healthy nor tell them how to lead their lives. What we can do is provide them with the information, advice and support to make their own choices (Department of Health, 2004c) (emphasis added).

This message encapsulates, neatly, the policy context within which the Net.Weight study

was undertaken. Heavy emphasis is placed here on the importance of information, advice

and support for „self management‟ or „self care‟ in relation to obesity and a seemingly

unproblematic link between information, empowerment and choice. The Net.Weight study

took a more critical approach to the concept of „information‟ and its relationship to

empowerment and choice in the context of self care.

In contrast to policy discourse and much of the practice-based literature, where information

is understood as a neutral resource to be collected, organised, communicated and used, a

more critical social science approach might understand information as „situated knowledge‟,

a distinction that, following Haraway, can be characterised as a „view from nowhere‟, versus

a „view from somewhere‟ (Haraway,1991). Suchman makes a similar distinction between a

view of objective knowledge as „a single, asituated, master perspective that bases its claims

to objectivity in the closure of controversy‟, and „multiple, located, partial perspectives that

find their objective character through ongoing processes of debate‟ (Suchman, 2002, p. 92).

As I have argued elsewhere (Henwood et al, forthcoming), information is often „black-boxed‟

but this does not mean it is neutral; it simply means that its knowledge roots and the type of

expertise it represents are obscured from view. Medical knowledge is particularly susceptible

to this form of black boxing when it is re-packaged as „health information‟. In e-health

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discourse, information is associated with empowerment but, as has been suggested

elsewhere (Henwood et al 2008), information cannot be empowering if its knowledge roots

are obscured, if the „user‟ is unable to assess its provenance and its overall accuracy and

validity, as well as its relevance for the particular local and social circumstances of use.

Access only to such „informational knowledge‟ (Lash, 2002) restricts opportunities for critical

engagement with that information and, arguably, positions people as agents of „self-care‟

rather than „self-help‟.

How do older people seeking to live healthier lifestyles engage with healthy living

information? What normative assumptions about bodies and health are being communicated

in healthy living information and how relevant is generic healthy living advice in the context

of ageing and older people‟s diverse and complex bodies and lives?

Responses to an open question in the user survey about information and support needs

generated an interesting set of responses, many of which suggested that information was

not the main issue or inhibiting factor („Information? Sure, but losing weight is hard

work!!!!!!!!!!!!!!!!!!‟; „Information is not the problem, will power is!‟; „I already feel confident

about finding information but I fail to use the information correctly‟; „I'm confident enough

about this - it's putting all the information and my knowledge into practice, that's the

crunch‟). Thus, participants do not give primacy to information in the way that self care

discourse does but they are still positioning themselves firmly within this discourse when

they emphasise their own inadequacies in „using‟ the information correctly to make

behaviour changes- the „healthy choices‟.

In interview, Olga (77) expressed frustration at the generic level of much of the health

information which she experienced as having been „pushed‟ at her throughout her life. Asked

if and where she looks for health information now, she replied:

Well I really and truly haven‟t looked at that much. I just feel now having got to the age I have I know what I should do, which is near starve, and then it would work…but I'm constantly bombarded by Tesco diets on the email (Olga)

There was a strong feeling amongst participants that, insofar as information was deemed

important, it needed to be age-appropriate. Amanda (60) had lived with a weight goal of 65

kilos for many years. Asked if this was still her goal, she replied:

It still is my goal. Actually, it might be, it might, it might be, aghh.. I don‟t know, 65, I mean that‟s 63, 65 was my weight when I was 25 and working at the Folies Bergère (she was a dancer), so may not be. Maybe I can put it up to 68. I‟m not really sure

Later, she drew on the idea of an aging body to argue for resistance to cultural norms and

for being more „realistic‟ about one‟s goals:

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I think, you know, there‟s, there are realities that we have to sort of think about and, you know, being in, in reality… I am 60, I‟m not going to have a 25 year old body…and so forth. Once you get that kind of information, sort of self assessment, I think it makes it easier.

Interestingly, Amanda had ideas about how the internet might open up access to a wider

range of knowledges about body weight:

What would help would be, would be a site that was real, and not trying to make you into a 60 kilo stick insect! I think internet could help with that if we, you know, if we weren‟t fed this sort of „You should be such and such a weight‟ etcetera and so forth, and, and fed the healthy aspect, as opposed to, you know, sort of the idealistic „Let‟s all conform‟ (Amanda)

Age- and health-appropriate, local information was also a major theme when participants

were generating ideas for the content of workshops:

More information for people with health problems- I have osteoarthritis, sciatica and

don‟t know what exercises to do

Where can people in wheelchairs take exercise?

Participants‟ accounts of engaging with information about weight management show that

there are resistances to the „view from nowhere‟ and that lived experiences have produced

alternative „views from somewhere‟. These „somewhere‟ experiences include the embodied

experience of ageing and the desire for local, accessible and age-appropriate activities and

services also suggest the importance of the design and planning of services for „active

ageing in place’.

Technologies of prevention?

As in the case of self care, policy agendas have tended to link the implementation of ICTs

with the development of a patient-centred health service and the empowerment of patients,

without the mechanisms by which this link works being fully explicated. For example, the

development of health information services offered via NHS Direct and digital interactive

television (DiTV) in the late 1990s were said to widen access to information in ways that

support the development of self care and patient empowerment (Nicholas et al 2002 and

2003). More recent research has looked at the potential of Web 2.0 as an enabling

technology in healthcare (Boulos and Wheeler, 2007; Deshpande & Jadad, 2006;

Eysenbach, 2008; Hardey, 2008) and at how it is currently being used in self care through

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blogging (Sundar et al, 2007) and online communities (Blank & Adams-Blodnieks, 2007;

Leimeister et al, 2006) . However, there is no necessary or straightforward correlation

between the implementation and use of ICTs and improved services, health care

experiences or health outcomes because social outcomes are not determined by technology

alone. We have already seen that information, as understood within the discourse of self

care, is experienced by older people as too generic, too imbued with inappropriate cultural

values and norms, and as being „pushed‟ at them in ways that imply individual responsibility

and induce feelings of blame. With Web 2.0 offering more interactivity and the potential for

patient and citizen feedback on health services, interesting new questions arise about the

extent to which such technologies can be used to support new forms of governance, as well

as individual choice. The Net.Weight study sought to contribute to a better understanding of

these important socio-technical factors.

„Users‟ have become an important focus for researchers working in the socio-technical

tradition in recent years (see, for example, the collection Users Matter by Oudshoorn and

Pinch, 2003). Following Latour, who argued that „the fate of…. machines is in later users‟

hands‟ (Latour, 1987, p259), and Bijker, who argued that neither technology nor society

determines the other but rather they both „emerge as two sides of the same coin, during the

construction processes of artifacts, facts and relevant social groups‟ (Bijker, 1995, p.274),

much emphasis has been placed on how users shape technologies through the process of

„design-in-use‟. This socio-technical approach recognizes that technologies are not simply

„adopted‟ and „used‟ in an unproblematic sense. As Suchman argues, there are many

activities, and often much hard work, currently „glossed under the notion of technology

adoption‟ and that these involve „appropriating the technology so as to incorporate it into an

existing material environment and set of practices‟ (Suchman, 2002, p 93). Strauss (1985)

referred to this work as „articulation work‟.

It is this idea of technology being embedded into everyday life through processes of

„appropriation‟ and „articulation work‟ that we took into the Net.Weight study. As people

engaged in self care for over-weight and obesity management, our participants were

positioned as potential „users‟ of digital technologies such as the internet, to support their

self care practices. But how did this group of largely older people engage with technology

and appropriate it into their everyday lives and self care practices? What happened when

these „users‟ were engaged in a process of „design-in use‟?

In policy discourse, older people are typically defined as „digitally excluded‟ and interventions

offer access and training, often in public places. However, as the critical social science

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literature has shown, the picture is more complex than this. Early work by Wyatt et al (2002)

and Selwyn (2003) pointed to the importance of understanding agency with respect to non-

use of technologies. Selwyn (2003), in his analysis of those who stand „apart from

technology‟, emphasised the importance of different „readings‟ of technologies for

understanding different types and levels of engagement. Developing these themes, Wyatt

and Henwood (2005) and Henwood and Wyatt (2009) have explored gendered and aged

meanings attached to the internet and have argued for the importance of understanding

„relational‟ aspects of internet use and the ways in which the internet can be understood as a

site of both gender and age construction. Bose (2010), in her study of computer technologies

and embodiment in later life, and drawing on people‟s „technobiographies‟ (Henwood et al,

2001), has drawn attention to the generational significance of technologies, both in terms of

embodied competencies and cultural meanings where computer and internet technologies

are „coded as the domain of “youth” ‟ (Bose, 2010, p15). Gender and age are combined by

Loe (2010) in her study of women in their 90s and their engagement with everyday

technologies and routines of self care when she found that „Lifelong gender roles and

expectations‟ (including care work, relationship work and health work) continue to „organize

elders‟ lives and technology use in old age‟ (Loe, 2010, p322).

The Net.Weight survey showed that digital exclusion – if inclusion is deemed to have been

provided via access - was not a problem in the Net.Weight survey sample, with 84% having

access at home. However, people aged 60 or over were less likely to use the internet than

younger ones and, although lack of skill, knowledge, confidence and enthusiasm were not

reported as a problem for the majority, older people felt less confident than younger ones

and were more likely to agree with the statement that „the internet is not useful or interesting‟

than their younger counterparts. The internet was not widely used to support weight

management or to access local health information and services, with just under half of

respondents using it „sometimes‟ to access information about diets and exercise. Use of

social networking sites and other forms of potential support for weight management were

rarely used, especially by those in the older age groups.

In the participatory learning workshops and the reflective interviews held six months

afterwards, we learned much more about how age relates to computer and internet use. Age

was mobilized in participants‟ accounts as a way of making sense of their relationships to

computers and the internet- especially their non-use:

you gave us a lot of positive things to interact and not to be scared of computers, and not to be scared of really anything to do with the future where (we‟re??) not being of the computer age, you know. (Sandy, 54)

Olga (77) was asked about her interest in blogs, a topic covered in the workshops:

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It's terribly (pause), you‟re shooting something off into the ether, aren't you? I think a personal one-to-one, I mean, I did get, in the past, in groups, I've belonged to quite a lot, from that you know, which is a much more eye-to-eye contact, more personal…probably a generation thing (Olga, 77)

Georgia, one of the younger workshop participants at 54, summed up why she wasn‟t really

interested in going further with computers and the internet:

Maybe it's because of my age and I wasn‟t brought up on the computers so it's more, it's not like a natural thing that I do regularly… (Georgia)

Engagements with the internet were also shown to be relational, with gender and generation

being closely intertwined for many women, as this focus group extract suggests:

Female participant 1: ….I don‟t even know, I can just about put a video in…my

husband used to do it all and I never…

Female participant 2: Yes, but I don‟t use it – I make my grand-daughters use it.

Interviewer: You said that earlier you „weren‟t allowed‟ to use the internet?

Female participant 3: No. Because I went on it once and I lost the whole blinking lot –

twice I done it. [They] got an old one for me to play with.

Here, women make sense of their lack of confidence with computers and the internet, by

characterising them as technologies with which their male partners or children in the family

are more skilled and, perhaps, more entitled.

Sandy (54) was heavily reliant on her husband and son to help her with computers and the

Internet before the workshops. Her account suggests that her relationship to these

technologies was shaped by both gendered and generational relationships:

I mean the one day, I don‟t know what I did and the whole screen went black, and I said to [husband], „I‟ve finished with this computer‟, and I went and sat down you see, so he said to me, „did you switch it off?‟ I said, „I think I did, you know‟, but I hadn‟t! [laughs] So I‟d done something that the whole screen went black, because I mean, John, my son, gave me a computer to play with, and then I phoned him and I said to him „I don‟t know what‟s wrong but the computer‟s not working anymore!‟ So he said, „now what have you done?’

However, like many participants, Sandy gained experience and confidence in the

workshops:

I said to John the other day, „oh, I know what I haven‟t done in a long time, I must do my blog, update it, you know, tell people what‟s been going on and things like that‟. He said to me, „no, you just want to show off to [granddaughter]!‟ So I said to him, „yes..‟. (Sandy)

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Here, Sandy can be seen as using the technology to communicate both „what‟s been going

on‟ and a new sense of digital confidence, to the younger generation who are seen to „own‟

the technology.

Practice with computers and the internet was deemed important as participants embedded

technology into their everyday lives- a process of embodiment that Bose (2010), following

Mauss (1979) refers to as „body technique‟. Again, Net.Weight participants made sense of

this practice in terms of age and generation. Virginia (60) explained why she preferred to

work with people her own age:

I‟ve got some younger friends that sort of say „oh you just do this, this, and this‟, and that is so intensely annoying... They‟ve got to stand back and let me do it and if I get stuck, you know, it‟s my learning style...and them leaning over my shoulder and pressing some buttons and arriving at where I want to be just doesn‟t help...My older friends...they know about these things…they understand that you have to go through the process yourself and at your speed. (Virginia)

Virginia‟s experience was shared by others and may well be one of the reasons why

participants felt able to share their experiences with others in workshops where older people

were in the majority. However, participants wanted to go further than simply sharing their

individual experiences and improve their own individual skills and confidence in a mutually

supportive environment. They were keen to explore ways in which both healthy living

strategies and the information and technologies often heralded as tools for the prevention of

unhealthy living, could build on their collective experience and be appropriated in ways that

were more meaningful for the older people living in the city.

Like others in the workshops, Olivia enjoyed using her new found knowledge and skills in

blogging to support and motivate others, informing them, via Net.Weight Community5 about

swimming classes for older people and about a local radio host with whom one could

exercise „at a distance‟:

I don‟t know what she looks like, but she does this buttock clenching. You do it to a record, you have to sit there and clench your buttocks. It sounds like it‟s a good idea actually. I do it, if I‟m there with the radio on and I‟m at the computer……I told people about that, because I think you should listen to that. It‟s sort of quite motivating if you‟re indoors (Olivia, age not given).

Others shared recipes or blogged about their preferred healthy living approaches. For

Alexander (63), this was gardening with his dog (Let’s get gardening to burn the fat off), and

5 Net.Weight Community is a website set up as a prototype community-based resource where participants

could share experiences and information in an online environment in ways that reflected their interests and concerns. http://research.cmis.brighton.ac.uk/net.weight.community/

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for Amanda, this was keeping fit with her grandson (Weight loss with George), both sets of

activities grounded very much in their everyday lives and loves.

In engaging in an exercise to come up with ideas to re-design the local Active for Life

website (run by the PCT and the city council), participants again sought to bring their

experiences of age and ageing in the city to bear. Many felt that the site‟s use of „50 and

over‟ group didn‟t make sense as „life doesn‟t end at 49‟ and whereas „if you‟re over 70, you

don‟t want aerobics‟, the younger old may well do. In seeking an appropriate image and

slogan for their re-designed sites, participants wanted positive images of age and ageing.

One suggested: „How about two racing grannies and “Go for it”? ‟

Conclusion

In so far as self care is seen as key to the „prevention‟ strategy for older people, it is

important to think critically about self care. This paper has drawn on a study that explored

self care in relation to weight management and healthy living, where the majority of

participants were over 45. Their accounts illustrate how they negotiate between two co-

exiting discourses – self-care and self-help. While participants did, at times, position

themselves within self care discourse, taking individual responsibility for weight and health

and their management (often leading to feelings of inadequacy and self-blame which

undermined their attempts at self care), there were also very clear signs of resistance to the

idea that poor health and/or overweight is something that can be prevented by good

„management‟ alone. Both their resistances and their alternative positionings drew heavily on

their experiences of age and ageing, often alongside gender, suggesting the limitations of

generic healthy living messages and a simple causal relationship between information and

healthy choices and behaviours.

Participants‟ accounts of engaging with information about weight management show that

there are resistances to the „view from nowhere‟ and that lived experiences have produced

alternative „views from somewhere‟. These „somewhere‟ experiences include the embodied

experience of ageing and the desire for local, accessible and age-appropriate activities and

services also suggest the importance of the design and planning of services for „active

ageing in place’.

The study‟s participative approach facilitated the opening up of a space where participants

could engage with information and technologies often said to facilitate self care. It

demonstrated clearly that there was an interest not simply in improving individual skills and

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confidence in information and technology „use‟ to support self care, but in engaging critically

to appropriate and shape technologies in ways that support collective as well as individual

goals, thereby facilitating self-help as well as self care in the prevention of „unhealthy

ageing‟.

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