Health Education Research, Vol. 15, No. 1, 13-24,
February 2000
© 2000 Oxford University Press
Autonomy, health and ageing: transnational perspectives
Department of Humanities and Applied Social Studies, and Health Research and Development Unit, Manchester Metropolitan University, Crewe and Alsager Faculty, Stoke-on-Trent ST7 2HL, UK
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Abstract |
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A comparative study was undertaken in Italy and the UK to explore elderly people's perceptions of old age and ageing, and to establish a ranking of factors which were seen to contribute to the maintenance or loss of autonomy. The results were collated with the expressed views of practitioners and others working with elderly people in a range of settings in eight different European Union Member States. These data informed the compilation of an educational programme, presented as a handbook for use by and with elderly people, the focus of which was life-skills development as a prerequisite for health education. Life-skills were defined in terms of the development of a positive self-image, a social `ease' and a feeling of `belongingness' in the context of old age. Assumptions underlying the framing of the educational programme were a transnationally accepted relationship between autonomy, empowerment, self-image and health, and the centrality of life-skills development as catalytic in this process. The paper, however, flags substantial conceptual and methodological issues which arose in moving towards transnationally, shared understandings within the project team at each of the three stages of the project, and offers some evaluative observations on the strengths, concerns and achievements offered by transnational research and collaborative activity.
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Introduction |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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The paper presents analysis and evaluative comment on a 10-year, transnational research and development project (1988–1998) in which the author acted as Director and one of the principal researchers. The project's focus was the role of health education in the prevention of loss of autonomy in elderly people, featuring the perceptions and activities of elderly people, together with those of researchers and practitioners, all of whom were linked to organizations (state-run, voluntary and private) in eight European Union (EU) Member States. For part of its life (those stages involving a survey of practitioners' views on autonomy in old age and the development of educational materials), funding was provided by the European Public Health Programme. The project was significant in terms of its nature, scope, purpose and output, and has given rise to a number of substantive themes worthy of scrutiny and debate. The paper selects two of these, developing them into a dual purpose:
- To discuss the relationship between autonomy and health, and to illustrate the role of life-skills work as a means of increasing autonomy among elderly people (and thus challenging the barriers to a positive self-image, to social ease and to feelings of `belongingness' in old age).
- To raise some conceptual and methodological issues associated with transnational research, and indicate areas for possible further exploration.
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Mapping boundaries and clarifying concepts |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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The project's first aim was to explore perceptions of age and ageing. The aim was based (1) on the assumption of the centrality of `autonomy' and `empowerment' both as shared transnational ideology and as key operational concepts, and (2) on a commitment to explore the inter-relationships between self-concept, world-view, health and life-skills development. In this context, health education as the over-arching concept was understood as a process for locating oneself confidently in the social world because of, or in spite of, images of old age and ageing. Autonomy, closely associated with well-being and empowerment, was held to imply control over one's life, opportunities to make choices, and feeling comfortable about developing and using one's personal resources (Heathcote, 1996
, 1997). These desirable processes or states, summarized as self-determination, self-government, a sense of responsibility and self-determination (Downie et al., 1990), demand an essential reference to others—their feelings, plans and understandings—and can only therefore be realized in a social context. Such defining theoretical principles provided the framework for the project's three stated objectives:
- As a preliminary, to conduct a small-scale study in the UK which had the same aims, sample and design features of an earlier study conducted in Italy which sought to (i) identify factors perceived by elderly people as enhancing or impeding autonomy and (ii) rank these factors in order of importance (nationally and transnationally) as a basis for comparison and further transnational investigation.
- Subsequently, to collect the views and experiences of health professionals and volunteers working with elderly people in a variety of related agencies in the two pilot study countries (Italy and the UK) and six additional EU Member States (Denmark, Greece, Ireland, Holland, Portugal and Spain).
- Having collated the data from (1) and (2) above, to produce a handbook of educational materials for health promoters, both professional and informal (e.g. elderly people themselves, facilitators, advocates, carers, family, friends), that offered strategies, activities and examples of good practice for enhancing self-esteem and developing those life-skills which increase control over everyday events.
The Italian and British research teams, who worked together in the first phase of the project, defined `elderly people' as those positioned in the 60–90 year age range. This consensus held firm following the subsequent enlargement of the project team to include health care workers and elderly people themselves from Denmark, Greece, Ireland, Holland, Portugal and Spain. In discussions throughout the life of the project, however, frequent reference was made to the sheer heterogeneity of this chronology in which the intersecting variables of class, education, gender, ethnicity, sexual orientation, marital status, religion, belief, culture, previous occupation, socio-psychological factors, physical health and environment—to name but some of the major sources of differentiation—were recognized as giving rise to substantially contrasting experiences in the daily lives of the elderly.
The diversity embraced by the term `elderly people' also prompted proposals for other operational sub-categories from some of the professionals and volunteers who contributed data to the survey of practitioners and users views (Stage II of the project). At one point in the project, for example, some of the practitioners wanted to categorize some of the data into `young-old', `old-old', `physically and mentally agile', `physically incapacitated', `mentally impaired', `house-bound', `recently retired' and `elderly widowed'. This, in the event, proved to be at best unhelpful and at worst empirically unworkable. It was, however, interesting to note that these sorts of categorizations (or perhaps characatures) of elderly people reflected some practitioners' perceptions of significant relational positions based not merely on chronology but also on perceived cross-cutting dimensions of health status, functionality and general relationship with the social and physical world. These attempts to `objectify' were promoted, in particular, by those practitioners whose medical training predisposed them to attach special significance to the variable of `functionality' and to oppose the `softness', even `sloppiness', of the socio-psychological approach favoured by other practitioners in the core project team whose training was non-medical. The dominance of the medical model of health and of positivistic views on appropriate methods of data collection were particularly marked among participants from Italy, Portugal and Spain who were all gerontologists. This observation should not claim a status beyond that of perception or, at most, insight. However, these professionals seemed to testify to the cultural influences on the construction and allocation of typologies, to the determining role of professional training and the distribution of professional power on these constructs, and to the near-certainty that associated ideologies support rather different orientations, policies and modus operandi in Southern Europe compared with Northern Europe.
Beyond the discernible professional differences, there was a sense among the majority of the project participants that, even accepting such operational categories, any attempt at grafting these onto an autonomy/absence or loss of autonomy continuum in a way that could win transnational approval would be a complex and probably hopeless undertaking. The dilemma was `solved' by an agreement (endorsed more reluctantly by the gerontologists from the South than by those with, for example, a social work background from the North) that, for a project professing autonomy, self-esteem and empowerment as foundational principles and using, as its key `organizer', elderly people's personal experiences, expressed needs and private hopes to substantially inform transnationally acceptable strategies for health education, all operational categories that tried to `slice up' too crudely elderly people's heterogeneity must be roundly rejected as `unhelpful', `degrading', `of no consequence', even `mythical' [sic]. Resisting, in this way, the (cultural) construction of operational categories (which, it must be said, are `real' to many who work with elderly people and, for that matter, for many elderly people themselves) was to deny important aspects of the relationship between, on the one hand, certain clusters of observable and subjectively experienced characteristics, and, on the other, manifestations of degrees of autonomy (and linked notions of well-being and health). Denying operational categories which may disempower the very people whose autonomy was sought, was rhetoric reflective of a desirable ideological position but, paradoxically, one which ran counter to the equally desirable practices of a research and development project informed by `sound scientific approaches' [sic] to data collection. This tension remained unresolved through the life of the project but for the sake of `entente cordiale' and for reasons of practical expedience, this problem was never fully confronted. Its effect was to create a disjunction between the research findings of the initial pilot study (which made some operational linkages between age, functionality, health status and social/physical relationships, and autonomy) and the content of the educational programme/handbook which was produced for facilitators in the final phase of the project (and which deliberately did not emphasize these differentiations).
Over time and particularly during the second phase of the project (when the core team was enlarged), this disjunction was mediated by an apparent consensus over key terms associated with `autonomy'. The transnational currency of `autonomy', `empowerment' and `positive self-image' proved surprisingly convertible, despite there being no word, other than the Anglo-American `empowerment', in the Dutch, Greek, Danish, Spanish, Portuguese or Italian languages at the time of the project's inception. Initially Northern European (but now increasingly Pan-European) theory and practice in the health, welfare and caring professions boast a rich, established but still burgeoning literature reflecting a broadly based stance concerning the dimensions mentioned earlier—self-determination, self-government, a sense of responsibility and self-development—and the idea of `strengthening the voice of older people on all issues which affect them' (Commission on the European Communities, 1995). Indeed, a definition which found particular favour with project participants as emblematic of the same set of values implied in autonomy was (Coventry Community Education Development Centre, 1996):
Empowerment implies self-determination and the ability and freedom to assume responsibility for oneself, to express ideas, to make decisions and to influence policy at all levels. It is concerned with all the dimensions of human existence—physical, mental, spiritual, cultural, social, economic and political.
In describing observable aspects of empowerment qua autonomy, this definition attracted support but again effectively precluded the genuine, in-depth discussion of the complexities of the project's key concepts, of their inter-relationship and, importantly, how in practice this may give rise to different orientations on the part of those working with elderly people. This omission was compounded not only by the absence of cultural construction and deconstruction, but also by the differential command of English (the working language of the project) on the part of the majority of the project team members. In this latter sense, the problematics of meaning in different linguistic contexts was inevitably glossed over. So, at a rhetorical level, the narrative of consensus over the representation and meaning of the project's key concepts was maintained. This was despite repeated uncomfortable evidence of different interpretations, perceptions and emphases in respect of empowerment as process—and hence the nature and scope of autonomy as a state which predisposes certain kinds of values, attitudes and behaviours. On the one hand, empowerment was often talked about as the rationale for framing interactions, arrangements and policies in self-consciously `empathetic' ways, aimed at encouraging the participation of elderly people but led by `experts' whose training entitled, indeed required them to take the directive. Alternatively, it was conceived as `finding a voice, demanding to be heard, creating opportunities for oneself and others, and removing obstacles to self-fulfillment in one's old age' (Coventry Community Education Development Centre, 1996) in a context where `experts' might be seen but certainly not heard.
This informal analysis of project team discussions illustrates vacillating meanings, and, at heart, some fundamental uncertainty about different cultural and linguistic connotations. Similarly the issue of agency and the extent of `alter' (usually practitioner) involvement in empowerment was often fluid. Understandably, varying views within the core team of the project participants were in part attributable to differences in professional background, in the mission of their employing organizations and the socio-economic context influencing arrangements and policies for elderly people in team members' countries of employment. Operationally, the problem was eventually `resolved' through compromise: because self- determination is inevitably shaped by structural and personal factors (e.g. material deprivation, frailty, mental instability) beyond total individual or collective control, elderly people, subjectively and objectively, locate different positions on the dependency–independence spectrum. This much was accepted, even by the anti-medical faction. In any case, autonomy and empowerment are relative and no-one had a problem with the over-riding aim of the project—to increase through life- skills work, the potential for optimal movement along this spectrum so as to maintain or increase autonomy in the elderly age group. The lingering anxiety, however, that we were somehow approaching the project's tasks from rather different ideological, cultural and power-related positions, was something which never quite receded. Transnational research inevitably embraces social and structural variables which in turn affect views, perceptions and activities. The dilemma is what to do about these. This is a theme which is revisited in the concluding remarks of this paper.
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Images of ageing in Italy and the UK |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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The first of the project's stated objectives—the conduct of a small-scale study of elderly people's perceptions of ageing in the UK—was staged in the Stoke-on-Trent area in 1994. The aims, sample and design features of this study intentionally matched those of an earlier study conducted by the late Dr Hugh Faulkner and two colleagues (clinical psychologists) 4 years earlier in the Chianti Health District of Italy (Florence and its suburbs). The aims of this Italian study were to:
- Explore elderly people's perceptions of old age and their experiences of the ageing process.
- Seek their views on the opportunities for, and barriers to, self-determination and increased autonomy.
- Identify and rank, in order of perceived importance to these elderly people, the factors which increase and decrease autonomy and feelings of empowerment.
- Discuss the findings with these elderly people and inform the relevant health, social and welfare agencies in the Chianti Health District with a view to improving services for the elderly.
Initially, three small same-sex groups comprising five or six people were encouraged to discuss with one of the researchers their perceptions and experiences in a free and open-ended way in a community hall setting. These social gatherings occurred three times. On the first occasion the purpose of the inquiry was explained and on the other two occasions data were recorded through the researchers' notes. The elderly people's ages were between 60 and 90, some lived in their own homes (alone or with a spouse), some in residential or sheltered accommodation and some with their family. They came from a variety of social backgrounds, had different health statuses, and expressed a range of views about old age and ageing. The sample was therefore intentionally varied, compiled through a mixture of volunteerism, and selection by health, welfare and caring personnel linked to the elderly people through state-run, religious and voluntary organizations. As a result of this preliminary activity, the researchers pulled out a number of recurrent themes which formed the basis of a short interview schedule comprising 10 semi-structured items. Interviews were then conducted individually with the original 26 who had taken part in the discussion groups, extended by a further 14 representative sample. In all, 21 men and 19 women were interviewed aged between 60 and 89 years in relation to the themes of activity/movement (mental and physical), home and neighbourhood (including family), financial security, health, and social services provision (state-run and voluntary).
The Stoke-on-Trent study conducted 4 years later replicated the Italian study as closely as possible in terms of sample size, gender balance, urban–rural origin, degree of functionality and social background. The characteristics of urban Stoke-on-Trent and its neighbourhood, and that of Florence and its surrounding villages were geographically, culturally and organizationally closer than would initially appear. The group discussions in Stoke-on-Trent, in common with those carried out in Florence, covered a range of social, physical, psychological and economic determinants of old age experience that included life-styles, hobbies, attitudes towards ageing, experiences of ageism, family relationships, friends and neighbours, personal finance, health, and housing. The follow-up interviews probed these issues in further depth on an individual basis. Ranking the factors in order of importance was organized according to the frequency with which they were mentioned.
The most significant cluster of issues for both the Italian and English groups of elderly people concerned the importance of social contact, emotional support, mental stimulation, `belongingness' and physical activity. Integral to these was the fundamental importance of positive self-image and of self-esteem, together with the ability and opportunity to take decisions and exercise control over their own lives. There was evidence of an associated underlying fear of impaired mental health, particularly Alzheimer's disease, depression, and a general inability to cope with isolation and loss in older age.
The second set of factors related to the home, family and neighbourhood. In the Italian sample, only six subjects lived alone in isolation, another seven lived by themselves but had daily contact with relatives or friends and 27 lived with family members. In contrast, the majority of the English group lived alone, with a minority living with their spouses. All subjects in both countries expressed the strong desire to stay in their own homes and avoid institutionalized care at all costs. Comments from the Italian group described such homes as `humiliating places, associated with the loss of independence, where the staff do not care enough for the welfare of their residents'. The predominant English view was of places `where independence and autonomy are lost and where the residents are treated like children'. Even in situations where staying in one's own home meant living alone, possibly in an unfriendly or unattractive environment (vandalism, litter and fear of attack often featured in the observations from the English sample), this was deemed preferable to the perceived dehumanizing effects of institutionalization. Sympathy and kindness to old people was essential, although only the Italian group considered that children should look after ageing parents.
The third most important cluster of issues related to material life: most participants in both country groups worried about money—the level of state pensions, the cost of living, the high costs of transport, and admission charges to places of recreation and entertainment (UK only), and the cost of household repairs and maintenance (again UK only). The Italian group was more concerned with the quality of medical and social services.
Retaining autonomy was the dominant theme across the three clusters of issues. From Italy, the voices claimed `...it is better to die than lose one's autonomy...', `...to stay autonomous, you need to love yourself...', `...to stay autonomous, you must always devise something new, dream, move outside yourself...', `...to stay autonomous, movement is important...', `...loss of health limits autonomy...'. From England, the messages were similar at one level and different at another; `...autonomy means retaining control over my life...' and `...retaining one's faculties, one's peace of mind, one's health and an interest in the world...'. The expression of autonomy was clearly culturally structured and differentiated. Family patterns and relationships often meant more social contact with and support from family and neighbourhood in the Italian experience and offered more examples of intergenerational living. The role of the Roman Catholic Church and of trade unionism in Italy (there is, for instance, a `union' for retired and elderly people) was a significant presence in the experience of old people, providing social and material support, strong links with previous work colleagues, leisure activities and social centres. Generally speaking, there was a sense of greater continuity with the past in Italy than in the UK where, in this latter case, relationships linking the elderly person's `earlier life' of family commitments and work to the present were more fractured and irregular. Thus, the different ways in which lifestyle patterns are constructed in Italy, compared with the UK, appears to change (at least to some extent) the range of perceived manifestations of autonomy. Whilst autonomy broadly represented a range of physical, mental, spiritual, cultural, financial and political `freedoms' to all the research participants, the social contexts in which these could be realized and enjoyed differed between the two countries. There was a sense in which, for the Italians, autonomy was a state, an `Elderado', whereas for the British, it was a series of (often challenging) processes through which one progressed as an on-going activity.
These observations must be tentative and, in formulating them, one is acutely aware of the possible accusations (no doubt justified) of national and cultural stereotyping. This links to a deeper anxiety about possible methodological differences in data collection within this study—and probably many other transnational studies. For example, in going back over the transcripts of the Italian research in translation for the purposes of writing this paper, two sentences were immediately arresting. One of the researchers, a clinical psychologist, commenting on his contact with his research subjects stated:
The elderly people felt useful and proud of being contacted by a social and public health organization. In particular, they were honoured to be asked personal questions about their experiences. It increased their self-esteem. One of them said, `I have become an interesting person even though I am old, cannot work any more and feel no longer useful to society'.
This account resonates with feminist researchers' preoccupation with the transformative influence of the researcher on the `researched'. Scott (Scott, 1992), for example, argues for the recognition of the way in which the experiences of others are not only transformed but are indeed distorted by the research process, resulting in a disjunction of two separate realities. The interpretation contained in the account of the Italian data collection makes no reference, however, to how the researcher in this particular case was transformed by the `researched' (the old man quoted above). It shows how knowledge is produced through relations of power; how one old man's experience was inevitably an interpretation which gave rise to a further (paradigmatic) interpretation on the part of the researcher/decoder; and how, in the quest to convert ethnographic data concerning experiences, perceptions, opinions, hopes and beliefs into quantifiable and rankable speech-acts inferring autonomy, one whole dimension, that of the researcher's reaction to and feelings about these old people as they presented their narratives, has been `laundered out' so as to provide `hygienic', `objective' data (Stanley and Wise, 1993). Here, the presence and interest of the researcher, it might be argued, interfered with the objective of `telling it as it really was', and instead, apparently, disturbed and (positively) transformed the way the old man saw himself. Logically, this colours and consequently casts doubt on the validity not only of all other `data' provided on this and subsequent research occasions—but also on the `data' offered by other old men in the same group as, inter-subjectively, they shared in the processes of interpretation, construction and reconstruction.
Of course, the other way of looking at this potentially disturbing phenomenon is to deny that the researcher `interfered' because the idea of `telling it as it really was' was never a possibility anyway. It actually does not matter that the Italian researcher created `objective' categories of data—any kind of research activity generates a type of co-construction in which the effect of questioning constructs the `story', rather than the story being already in situ, waiting to be detected. When, 4 years later, this research was replicated, the researcher, even though she used the same research design but organized the methodology differently (see later), necessarily exerted the same or similar researcher effect on her data too. On this ground, one should not reject the hypothesis of `common stimulus'. In any case, being listened to is a shared and common element of empowerment and self-esteem and therefore, arguably, defensible in this context.
Four years later, English `comparative' data was generated. Interestingly, and not by design, the activity was not presented as `research', neither was the `researcher' especially trained or `experienced'. The `research situation' was unselfconsciously considered to be `group discussions', the rationale was `to compare experiences of growing old in Italy and the UK for the purposes of exchange and mutual understanding' and the `researcher' was a woman of the same age as the `researched' who laid claim only to the status of being `recently retired'. This was not perceived as a dishonest manipulation of `the truth' but an opportunistic and commonsense use of the resources which were available at that time: the willingness and availability of a retired woman who shared many of the characteristics of the group she was working with and who was familiar with the activities of European projects (having worked on previous EU funded projects).
In a naturalistic and quite unplanned manner, many of the conditions advocated by feminist research methodology were either already in place or were generated in the course of this activity. The interpretation of the `data' and its collection process, spoken onto tape, made no attempt to exclude the `researcher' from the process, to deny her presence, her own experience of ageing and ideas about autonomy, her self-perceptions or her reactions to the experiences volunteered by others in the group. There was, of course, in the narrative, no attempt to `theorize', to use concepts from the social sciences, to count speech acts or impose meaning `from outside' by creating `research objects'. The account is presented as `we thought', `some of us felt', `the majority of us agreed'. This conveyed very much a sense of `research with', not `research into'.
However, here we confront another difference. The use of the first person plural in the British study has the effect of collectivizing views, of presenting commonality and generalizability. Data is treated normatively so as to realize clusters of consensus and differentiation. In contrast, in the Italian sample, the data is objectified as transparent truths—and the naturalistic fallacy which is arguably imposed through the everyday language of the narrative is screened out. In both studies, `data construction' is taking place but according to quite different rules. In (inadvertently) achieving the involvement and `vulnerability' of the `researcher' in the British study, this paradoxically ensured that the data was robbed of its unique richness and its personalized interpretation. Impressions were collected up and fashioned into the consensual, and the sometimes (it must be admitted) banal, to the extent that the emergent construct lost a potential sharpness of impact and—dare it be said—the shrewd analysis and insight of the `detached' observer.
The processes whereby research data is generated is an issue for discussion among all researchers and is obviously not necessary or inevitably an aspect of transnational research. It happened, however, that despite efforts to replicate the Italian study in terms of design and sample, the methodological and professional differences between the researchers in the two countries resulted in two sets of data that had been created in quite different ways. Whether this invalidates the implicit and explicit claims of a `comparative', in this case transnational study, is a question picked up in the final section of this paper.
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Promoting the health and autonomy of elderly people: multinational practitioner perspectives |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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The second phase of the project involved collecting the views and experiences of health professionals and volunteers working with elderly people. The rationale for seeking their views was:
- To triangulate the data from Italy and the UK.
- To extend participation into six more EU Member States.
- To elicit a multinational practitioner perspective on the issues around health, autonomy and health promotion with elderly people by (i) releasing practice-led experiences, and (ii) exposure to some of the more recent theoretical contributions to understanding autonomy, empowerment and associated concepts .
- By integrating these different sources of data and information, to develop a health education programme that offered strategies for empowerment using a life-skills development approach.
The practitioners came from a variety of different backgrounds that included medicine, nursing, teaching, social work, community development and health promotion.
The findings from the Italian–British study of elderly people were presented to these practitioners through a series of seminars, followed up by focus group discussions at a 3-day international meeting. During these discussions, the practitioners were encouraged to articulate, from their own professional experience and expertise, factors associated with autonomy, its retention and its loss in old age, and to confirm or disconfirm the general findings from the small-scale studies in Italy and Britain. Their emergent views broadly replicated the experiences and perceptions articulated by the elderly people in the comparative study. Common (transnational) factors seen as assisting the retention of autonomy were:
- Staying outside institutionalized care: staying in one's own home and enjoying an attractive, supportive, hazard-free environment.
- Recognizing the need for mental and physical activity, and for emotional fulfillment.
- Being committed to the need for regular social contact with others of all ages and for integrating elderly people into `mainstream' society.
- Recognizing the considerable heterogeneity among the elderly population.
In contrast, transnational factors of difference between the practitioners were reflected in:
- Differential (culturally-defined) designations of old age and images of old age (shaped by professional and organizational as well as national or regional cultures).
- Access to and availability of different forms of educational and recreational activities for elderly people.
- Loci of control in respect of resource allocation and policy.
- Existence and/or tradition of inter-agency work and multi-professional partnerships.
The practitioners, despite varying cultural and professional backgrounds, were entirely comfortable with the ideas emanating from the Italian–British work about the relationship between autonomy and health. There was also wide acceptance of the view that strengthening control over one's own life is inextricably linked to the multidimensionality of health and that life-skills development is foundational in contributing to a positive self-image and enhanced self-esteem. Decision making, political awareness and action, interpersonal relationships, communication, assertiveness and self-care (in the wider sense of coping skills) are life-skills which, they argued, promote autonomy and confront the fears of old age, particularly those of depression, isolation, loss, bereavement and survival in a potentially hostile environment (implicated with a loss of dignity, money crises, difficult access to transport, violence from younger people, closure of services and housing problems).
The practitioner group met together for two further transnational meetings in which they agreed upon a set of principles to inform a handbook for health promoters working with groups of elderly people in their own homes or in community settings. These were:
- Involve decision makers, resource holders and policy makers at all levels—local, regional and national—working on issues of interest and concern to elderly people.
- Broadly identify, but not stereotype, target groups within the elderly population for different forms of life-skills development, different approaches to maintaining and increasing autonomy, and be reflective in relation to the process of empowerment.
- Embody values of and strategies for empowerment, e.g. a positive self-image, retention of dignity, a desire to be independent, social inclusion, contact with all age groups, respect, self-respect, valuing by others, opportunities for self-(re)construction and self-reflection.
- Acknowledge transnational values and concerns as well as cultural, social and structural differences between and within EU Member States (e.g. use of time, access to new experience, transport networks, family structure, the role of religion, trade unions and other major `value systems', urban/rural experience, population density, and the role of work and work patterns).
- Recognize the complexity of cross-cutting variables which shape elderly people's lives and give rise to substantially different experiences and perceptions.
- Recognize the impact on elderly people of structural conditions associated with the economic, social and cultural, and their mediation by personality, temperament, a sense of self.
It was agreed too that a selection of the practitioners' current, most successful activities would be incorporated into the handbook, conceptualized by small case studies. These were categorized into chapters titled `interpersonal relationships', `communication', `political advocacy', `decision making', etc. Most of the practitioners acknowledged that prior to involvement in the project they were not working to a conscious or explicit model of life-skills development, but had assumed or intuited the relationship between life-skills development, well-being, health, social inclusion, autonomy and empowerment. However, the `grounded theory' which discussions about life-skills work generated within the project team is that genuine empowerment has to be `a transformational and communal process which seeks to rupture the structural constraints which entrap people's lives within rigid boundaries' (Heathcote, 1998). In this context, health education must address two dimensions of powerlessness which work to inhibit autonomy—the individual and the social.
The practitioners' conclusions regarding work with groups of elderly people in the different EU countries suggested a reinforcement of Wallerstein's (Wallerstein, 1992) view that Friere's dialogical approach can be used effectively as a model for health education activity because it achieves an appropriate exchange between two sets of skills, referred to as `community competence' and `individual effectiveness'. `Competence' among elderly people involves shared values and successful achievement of (their own) community-defined and -agreed outcomes. This was illustrated by the examples of group activity which the practitioners brought to the project and wished to see incorporated in the handbook. `Effectiveness' is about the development and use of a range of personal skills. Life-skills, it was agreed, offers the key to the otherwise problematic relationship (particularly for many elderly people who risk social exclusion and marginalization) between the self and society, and life-skills development is a powerful and demonstrably successful strategy for the pursuit of social justice and the principles of democratic societies.
The handbook was designed to be used flexibly in negotiation with the `users'/elderly people. It was finally launched in 1997/8 in a limited print-run as an illustrated educational text entitled Age Unlimited (Heathcote and Child, 1997). The programmes suggested in the text aim to develop skills, contextualized by examples of good and tried practice, strategies and approaches with recommendations about their suitability for different purposes, groups and occasions. It was designed for—and has subsequently been used with—facilitators from the professional, voluntary and informal sectors, including old people themselves, their friends and their families. Life-skills are developed through the expressive arts (drama, puppetry, video-making, singing, crafts, story- telling and narrative history), through physical activity (dancing, sport and walking), through social activity (voluntary work, advocacy, celebrations/fêtes and visits) and through other educative activity (providing and receiving information, help-lines, committee membership, lobbying, work in schools, etc.). There is a growing case history of achievement, success and changed biographies as a result of involvement in this life-skills programme. Regrettably though, a follow-on proposal to conduct a formal evaluation of the take-up and impact was unsuccessful in attracting funding from the EU's Public Health Programme (which has now moved on to target other priorities) although funding from elsewhere remains an option.
Some observations about the success of these last two phases of the project—practitioner involvement and the development of the health education materials—are appropriate here. What is particularly striking is the way in which the perceptions, orientations and organizing principles of the project participants changed over the time-scale of the project. The sharp ideological, professional and definitional differences regarding the key concepts which framed the project were blurred as project participants grew to know, like and respect each other, and as they were exposed to new and sometimes challenging ideas from theory, research and practice. In reviewing the joint declaration of shared principles upon which the handbook/health education programme was predicated, for example, it is significant to note that, in the final analysis, the necessity of recognizing operational categories of heterogeneity and differentiation among elderly people was actually achieved, despite the initial resistance and, in some cases, down-right rejection. These differences formed the basis of different conceptual and methodological approaches to developing empowerment and increasing autonomy through negotiated and customized programmes of life-skills development with groups of elderly people which were demonstrated in the handbook. Attitudes therefore changed perceptibly through the exchange of practice-led experience and through the exposure to more theoretical inputs concerning the link between autonomy, health and life-skills. In the end, the result was as good as one could have wished for—a complex multi-national project completed on time; its intended outcomes realized, its performance indicators met, and the bonus of increased cross-disciplinary and cross-cultural tolerance. These merits more than negated the anxieties that had lingered and niggled for (what seemed) so long.
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Concluding remarks on transnational research |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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Research and development projects have their own history, suspended between officially designated beginnings and ends. Within this history, working relationships must rapidly be established, codes of practice agreed, conceptual and operational boundaries mapped, and methodological issues quickly resolved. In a transnational initiative, these activities are coaxed into fast-motion against a backcloth of language difficulties, professional differences, cultural, political and social differentiation, and often varying personal motives for involvement. Inevitably, the questions which arise are `how useful and valid can work of this type really be?', `is it just another European project which, whilst interesting and informative for the participants, can only promote messages of such generality that they are inevitably tame and change nothing?', `are attempts at comparative research so fraught methodologically, conceptually and linguistically that their claimed `results' are meaningless?'. The literature on comparative research is ambiguous: this message is echoed in this paper too. Øyen (Øyen, 1990
), for example, in discussing comparative research, makes a distinction between those who see the difficult issues but `consciously ignore the many stumbling blocks of non- equivalence of concepts, a multitude of unknown variables interacting in an unknown context and influencing the research question in unknown ways' [(Øyen, 1990), p. 5] and `others who realize that comparative cross-national research is distinctive and frame their research questions accordingly' [(Øyen, 1990), p. 5]. The issues and the answers may be more complex than this. It will remain the case that European health education/promotion will continue to be constructed in ways which reflect the politico-economic priorities of nation states, and that health-promoting strategies will be culturally textured, reflecting different traditions, different conceptions of what is worthwhile, different ideas about the constituents of a healthy old age. Nevertheless, I believe that the three research stages described in this paper managed to produce what might be called a `Eurocentric resonance', and an insight that was recognizable not only to the elderly people and practitioners involved in this research and development project, but the many hundreds across Europe who have used the educational programme/handbook subsequently. This is because the project succeeded in achieving a social construction of epistemological similarity and (accepted) difference, despite its formidable challenges. Addressing life-skills development as a necessary prerequisite to and foundation for health has now, in 1999, a pervasiveness and a persuasiveness which is widely accepted transnationally, and chimes well with the now-formalized priority of life-long education in the UK and elsewhere. Finally, it can be claimed that joint action of the broadly political kind exemplified by this project which demonstrably benefits elderly people—the largest and most significant grouping in Europe—is what EU-funded, transnational research is justifiably about. This said, whether unacceptable compromises regarding the validity of comparisons and retreats from objectivity have been made, is for others to debate.
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Acknowledgments |
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I am grateful to my colleague Ian Stronach, Research Professor in Education, Manchester Metropolitan University, for helpful comments on a draft of the methodology section of this paper.
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References |
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TopAbstractIntroductionMapping boundaries and...Images of ageing in...Promoting the health and...Concluding remarks on...References |
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Commission on the European Communities (1995) Proposal for a Council Decision on Community Support for Actions in favour of Older People: Evaluation Report. Commission on the European Communities, Brussels.
Coventry Community Education Development Centre (1996) The Empowerment of Older People: Examples of Good Practice from European Countries. Coventry Community Education Development Centre, Coventry.
Downie, R. S., Fife, C. and Tonnahill, A. (1990) Health Promotion: Models and Values. Oxford University Press, Oxford.
Heathcote, G. (1996) Health in the community: contradictions posed by an `empowerment' model of health promotion. Journal of Community Studies, 3, 4–14.
Heathcote, G. (1997) Developing personal autonomy in continuing professional development. In Bridges, D. (ed.), Education, Autonomy and Democratic Citizenship: Philosophy in a Changing World. Routledge, London.
Heathcote, G. (1998) Empowerment for health: issues and experiences. In Proceedings of the World Conference for Health Promotion and Health Education. Health Authority for Puerto Rico, pp. 219–225.
Heathcote, G. and Child, M. (eds) (1997) Age Unlimited. European Commission and The Manchester Metropolitan University, Manchester.
Øyen, E. (ed.) (1990) Comparative Methodology. Aschehoug, Oslo.
Scott, J. (1992) Experience. In Butler, J. and Scott, J. (eds), Feminists Theorise the Political. Routledge, London.
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Wallerstein, N. (1992) Powerless, empowerment and health: implications for health promotion programs. American Journal of Health Promotion, 3, 4–14.
Received on March 31, 1998; accepted on March 15, 1999
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