Introduction
To continue to live an active and healthy life is recurrently described as an important goal for individual older persons as well as for ageing societies in general (Stenner, McFarquhar and Bowling Reference Stenner, McFarquhar and Bowling2011; Swedish National Institute of Public Health 2007; World Health Organization 2002). One way to support this goal has been the development of public health interventions that seek to enable older persons to maintain an active lifestyle and to participate in society through engagement in meaningful activities (Beswick et al. Reference Beswick, Rees, Dieppe, Ayis, Gooberman-Hill, Horwood and Ebrahim2008; Daniels et al. Reference Daniels, van Rossum, de Witte, Kempen and van den Heuvel2008; Gustafsson et al. Reference Gustafsson, Wilhelmson, Eklund, Gosman-Hedström, Zidén, Häggblom Kronlöf, Hojgaard, Slinde, Rothenberg, Landahl and Dahlin Ivanoff2012). Some of these interventions have shown significant effects on activity engagement (Fisher, Atler and Potts Reference Fisher, Atler and Potts2007), while others have shown little or no effect (Metzelthin et al. Reference Metzelthin, van Rossum, de Witte, Ambergen, Hobma, Sipers and Kempen2013), and there is to date no consensus as to what, how or when interventions should be offered. Thus, there is a need for systematic testing and refining to understand what constitutes the therapeutic mechanisms of successful interventions (Johnston and Case-Smith Reference Johnston and Case-Smith2009) and to provide new knowledge to support professionals who are involved in developing health-promoting interventions targeting older people (Behm, Dahlin Ivanoff and Zidén Reference Behm, Dahlin Ivanoff and Zidén2013; Whyte and Hart Reference Whyte and Hart2003).
There are, however, widely recognised problems involved in determining such mechanisms. For example, the effects of interventions are often dependent upon factors such as ‘the characteristics of participants, the setting for the intervention, and the way in which it is implemented’ (Blackwood, O'Halloran and Porter Reference Blackwood, O'Halloran and Porter2010: 512), which might make the mechanism behind the treatment's efficacy in rehabilitation appear ‘opaque and obscure’ even to the experts who are implementing the intervention (Whyte and Hart Reference Whyte and Hart2003: 650). For many scholars in the field, this recognition of the problem has been met by suggestions to further fine tune the methodologies of the interventions by systematically defining the dependent and independent variables and by specifying the measurable goals of the interventions (cf. Hart Reference Hart2009; Radomski Reference Radomski2011; Whyte and Hart Reference Whyte and Hart2003). Others have tried to go beyond what has been called the ‘impoverished ontology’ of positivism (Clark, MacIntyre and Cruicksbank Reference Clark, MacIntyre and Cruicksbank2007: 513; Houston Reference Houston2010: 89) by theorising on the complex relation between cause and effect from different perspectives. Many such studies have used aspects of critical realism (cf. Clark, MacIntyre and Cruicksbank Reference Clark, MacIntyre and Cruicksbank2007; Connely Reference Connely2007; Houston Reference Houston2010; McEvoy and Richards Reference McEvoy and Richards2003; Nairn Reference Nairn2012; Villar Reference Villar2012) as a way to avoid what Blackwood, O'Halloran and Porter (Reference Blackwood, O'Halloran and Porter2010: 518) have called the ‘constant conjunction between a determinist cause (the intervention) and its effect (the outcome)’.
There is also support for qualitative research that takes into consideration the sense-making that takes place in cultural contexts (Christiansen et al. Reference Christiansen, Backman, Little and Nguyen1999; Hannam Reference Hannam1997; Reed, Hocking and Smythe Reference Reed, Hocking and Smythe2010). Our analyses showed that one such context was the ways in which ‘preferred’ ageing was generally understood; norms of health and social participation permeated the material in a way similar to what has been called the paradigm of ‘successful ageing’ (Rowe and Kahn Reference Rowe and Kahn1997).
Constructivist studies of meaning-making primarily aim at understanding interventions from the perspective of the participants. Studies of meaning unanimously argue that activities hold rich meanings for individuals and that interventions become meaningful when they meet the interests of the individual (Hull Garci and Mandich Reference Hull Garci and Mandich2005; Shordike and Pierce Reference Shordike and Pierce2005). However, they also suggest that less is known about the kinds of meaning that are at stake (Reed, Hocking and Smythe Reference Reed, Hocking and Smythe2010). It is in line with this qualitative constructivist thinking that we approached the intervention studied in this article.
Aims and methods
In order to deepen the understanding of meaning-making in interventions, the aim of this article is to explore and describe how the participants of a group-based occupational therapy intervention with positive health outcomes created meaning of and around their experiences of the intervention. Inspired by Whyte and Hart's (Reference Whyte and Hart2003) suggestion to explore further the mechanisms involved in interventions, and influenced by studies that have highlighted the significance of meaning in occupational therapy (Christiansen Reference Christiansen1999; Hannam Reference Hannam1997; Reed, Hocking and Smythe Reference Reed, Hocking and Smythe2010), we wish to shed light on what stood out as specifically significant from the point of view of the participants. Our method allowed us to identify aspects of the intervention that were considered meaningful to the persons participating, and increased our understanding of what was at play that resulted in the increase in the participants’ self-rated health.
In the following sections we will describe the intervention, the interviews and our analytical strategies. We then describe the main findings before offering a critical reflection on how the material was dominated, but not determined, by a discourse on successful ageing.
The intervention
Inspired by the calls for further research on therapeutic mechanisms, and influenced by the Well Elderly Study (Clark et al. Reference Clark, Stanley, Zemke, Jackson, Carlson, Mandel, Hay, Josephson, Cherry, Hessel, Palmer and Lipson1997, Reference Clark, Jackson, Carlson, Chou, Cherry, Jordan-Marsh, Knight, Mandel, Blanchard, Granger, Wilcox, Lai, White, Hay, Lam, Marterella and Azen2012), a Swedish explorative study in the field of health promotion in older people was carried out. It was designed as a small randomised controlled trial to evaluate how three different intervention formats for occupational therapy services influenced the participants’ engagement in activities and their self-rated health, and it was conducted in a medium-sized city in Sweden (Zingmark et al. Reference Zingmark, Fisher, Rocklöv and Nilsson2014).Footnote 1 In the trial, three different intervention formats were compared with a control group. The target sample was older people between 77 and 82 years of age (born 1928–1933) at the time of the intervention. They were all living alone in their own housing in an urban area in northern Sweden, according to their self-report using no home care services and, based on the initial contact by telephone, having no apparent cognitive or communication problems. The recruitment was based on lists from the National Tax Board of Sweden.
One of the formats – the one studied in this article – was a group-based occupational therapy intervention with a health-promotion focus, and this group is referred to in this article as the activity group (Zingmark et al. Reference Zingmark, Fisher, Rocklöv and Nilsson2014, Reference Zingmark, Nilsson, Fisher and Lindholm2016). Those allocated to the activity group were in turn divided into six smaller groups of five to eight persons who met weekly over the course of eight weeks. Each meeting was around 1.5 hours. The group-based intervention was a mix of engagement in activities and discussions along with a small number of lectures, and the intervention was led by an occupational therapist with experience working with older people. The eight sessions were based on four themes (social activities, physical activities, meaningful participation and good eating habits) that are considered to be cornerstones for healthy ageing in Sweden (Swedish National Institute of Public Health 2007). In order to match the intervention to the needs of the participants, each theme could be adapted by the group members so that it became meaningful to them and suited their specific situation (e.g. Wallin et al. Reference Wallin, Talvitie, Cattan and Karppi2007). For example, the social activity theme was carried out through board games in one group, while another group decided to go to a café. For the quantitative evaluation of the trial before and after the intervention, base-line and follow-up data (after three and 12 months) were collected by a blinded raterFootnote 2 at each participant's home. Demographic data were collected along with the participants’ reported abilities to carry out daily life tasks, their ability to engage in leisure activities, their health-related issues and their use of health-care services. Positive effects in relation to the control group were seen for the activity group with regard to their ability to carry out daily life tasks (activities of daily living) and their self-reported health after three months. Some of these positive trends were maintained after 12 months (Zingmark et al. Reference Zingmark, Fisher, Rocklöv and Nilsson2014, Reference Zingmark, Nilsson, Fisher and Lindholm2016). To find out more about the participants’ perceptions of the intervention that they had taken part of, we conducted interviews with the participants, the results of which are presented in this article.
The interviews
The interviews were carried out after the intervention was completed and the quantitative data had been collected and evaluated. They were conducted by an occupational therapist who was not otherwise involved in the intervention. In order to get an understanding of how the participants had perceived and made sense of the intervention, the interviews were semi-structured (Kvale Reference Kvale1996) in the sense that the interviewer had a set of open questions that concerned the participants’ experiences and impressions of the intervention. How did they describe the intervention? What did they think had been good or bad? How had they perceived the group format? The participants were then free to talk about what they found relevant. The interviews lasted between 40 and 90 minutes and were audio-recorded and thoroughly transcribed in the sense that not only words but also stutters, pauses, emphasis and laughter were noted. We are aware that transcripts can never fully capture all of the details of an interview (Kvale Reference Kvale1996; but see Easton, McComish and Greenberg Reference Easton, McComish and Greenberg2000), but the chosen method of transcription gave us enough information to allow us to determine the meanings that were attached to the intervention. Our focus was less on how perceptions were communicated by the participants and more on the communicated perceptions themselves (Oliver, Serovich and Mason Reference Oliver, Serovich and Mason2005). Of the 49 persons who had taken part in the intervention, 19 agreed to be interviewed. Of these, three were men and 16 were women.
Analytical strategies
Our theoretical point of departure is constructivist in the sense that we assume the goals of the intervention – good health and engagement in meaningful activity – to be culturally constructed and related not only to the societal, cultural and individual contexts, but also to the interview situation in which the studied statements about the intervention were made. The constructivist understanding that older persons’ perceptions are constitutive and dependent on power/knowledge relations is well established (Cruikshank Reference Cruikshank1993; Gubrium and Holstein Reference Gubrium and Holstein2003). Individuals internalise the norms that surround them and ‘change the ways in which they construct and manage their selves and activities’ (Knight and Ricciardelli Reference Knight and Ricciardelli2003). Normative perceptions might thus well become self-fulfilling prophecies (Wurm et al. Reference Wurm, Warner, Ziegelmann, Wolff and Schüz2013).
Constructivist approaches to identity often acknowledge that identities are central when people narrate their experiences. For us, this meant that we viewed the participants’ identities as constituted in and through the very processes of participating in the intervention and talking about it in the interviews (Christiansen Reference Christiansen1999), but also that we recognised that the way they positioned their identities was central to how they talked about the intervention. In this pursuit, rather than only looking for the content of the intervention, we looked for how the intervention as a whole was negotiated and made meaningful when the participants talked about it.
Constructivist approaches have sometimes been criticised for being ‘a kind of postmodern empiricism where one is unable to say anything about an event, an object and occurrence of any kind for fear of imposing a definition on it that simply reflects a power/knowledge discourse’ (Nairn Reference Nairn2012: 11). However, individuals’ practices and self-understandings never just mirror discourses. Instead, they are always productive in the sense that they reproduce as well as disrupt and challenge discourses, and the many ways of employing discourses thus open up the possibility of discursive change (Butler Reference Butler1990, Reference Butler1993). This possibility to study the ongoing production of meaning is what decided our choice of a constructivist approach.
Because the data for this paper consisted of interviews carried out after the intervention was finished, i.e. after the completion of the initial self-rating, the group meetings and the final self-ratings, the quest to explore and describe how the participants perceived and created meaning of and around their experiences rested on the participants’ memories and reflected experiences of the intervention. In this sense, the concept of meaning becomes somewhat ephemeral (Hannam Reference Hannam1997). However, regardless of whether the informants had forgotten about things, chose not to tell about possibly important aspects or even lied during interviews, we argue that their statements still contribute to the construction of cultural significance. Through their narratives, notions of health and activity were negotiated and ascribed meaning. We thus define meaning as the significance ascribed to situations, practices and identities by articulating them in specific ways. Meaning-making, or sense-making which we use interchangeably, relate to the informants’ attempts to understand and define their experiences, but also emphasise the active as well as performative character of the studied articulatory practices.
We started our analysis of the material by identifying themes that occurred often in the interviews and/or that seemed to be retold with emphasis. Emphasis was defined as statements being accompanied by laughter, lengthy discussions, vocal emphasis or otherwise being singled out as important by the participants. Inspired by discourse theory (Laclau and Mouffe Reference Laclau and Mouffe1985), and thus working from the supposition that everything is meaningful, we chose from the transcribed statements the ones that were commonly repeated and that seemed particularly important for the participants. This did not mean that the participants themselves considered these themes to be ‘therapeutically effective’, but rather that they chose to highlight them often and/or as significant aspects of their experience. When the informants showed minimal interest in a topic brought up by the interviewer, we presumed that it was not interesting to the participant. It is, however, important to bear in mind that this presumption might be problematic (for discussions on silence in interviews, see Anderson and Jack Reference Anderson, Jack and Berger Gluck2013; Fivush Reference Fivush2010; Ryan-Flood and Gill Reference Ryan-Flood and Gill2013; Sue Reference Sue2015).
In the second phase of the analysis, we read the transcripts, trying to focus on how the identified themes were articulated, that is, how meaning was constructed around the themes by connecting them to certain words (Laclau and Mouffe Reference Laclau and Mouffe1985). For example, when analysing the first theme that had to do with the informants finding the intervention experience ‘nice’, we looked at how the word ‘nice’ was connected to other words. For example, ‘nice’ was often articulated with ‘pleasant’ or ‘unpretentious’. We also tried to be sensitive to whether the informants described the themes as being threatened by something. In cases where such threats could be identified, this gave us a deeper understanding of the discursive context from which the participants had comprehended the intervention. For example, ‘nice’ seemed threatened by ‘patronising’. We chose to analyse the totality of the articulated themes in terms of discourses, as ways of talking about and understanding the world that constitutes our conditions of possibility (Laclau and Mouffe Reference Laclau and Mouffe1985).
Finally, we looked at identity and how the participants positioned themselves in relation to the other participants in their group or to others in general. The reason for doing so was that we wanted to pinpoint how the discourses that were employed conditioned the positionings of the participants. How did they understand themselves in relation to the intervention? What kind of intervention narratives were evoked by the way the participants positioned themselves?
Results: the participants’ experiences
Five themes stood out in the interviews: the meaning of enjoyment, usefulness, togetherness, individuality and perspectives. The themes sometimes overlapped, but by articulating them in specific ways they constituted distinct ways of relating to the intervention, its goals and ageing in general.
‘It was so nice!’: meaning of enjoyment
We simply had a nice time, I can tell you that (laughter)!
One of the most emphasised words in the interviews was ‘nice’. In analysing how this word was discursively articulated, it became clear that it was put to use in a variety of contexts. Often it was the socialising or the other participants that were described as nice. Other times ‘nice’ was used to characterise the leader, the intervention as such or the different activities. For some, the word was used in a seemingly routine manner, as a way of being polite, but in most cases it was articulated with expressions of positive feelings such as laughter, smiles or complimentary words like ‘fun’, ‘rewarding’ or ‘a blast’. One woman even described the excitement of one of the group meetings in terms of becoming ‘like a child again’, while another told about her friend's jealousy when hearing about how much fun the intervention had been.
Almost all of the participants mentioned fika Footnote 3 when describing what was nice about the intervention. Not only was fika perceived as nice in itself and for the conversations that were connected to it, to be treated with fika seemed to confirm that the intervention and the participants were important.
I thought that the whole being together was nice every time, and she [the leader] had made coffee and bought biscuits and there was cold water for us while we talked.
Having a ‘nice’ time was thus often symbolised by talk about fika, and when fika had sometimes not been available this was described as disappointing in a way that suggests that fika was actually perceived as an immensely important part of – and maybe even a goal for – the participation in group meetings.
We thought we would have fika there, but there was nothing there, so that was the first time we didn't get fika and that was a bit disappointing.
Not getting fika was not the only thing that the participants found to endanger the niceness of the group meetings. They sometimes positioned other participants as a threat to the intervention's niceness. Specifically criticised were participants who were not perceived to be there enough for the group, for example, those who repeatedly expressed displeasure with the intervention or who were absent from group meetings without having given an acceptable excuse.
Similarly, problems with taxis not being on time were articulated as threatening the overall intervention, almost as if such failures to be on time signalled negligence on behalf of the organisation that might ruin the whole intervention. Such details clearly seemed to affect the participants’ views as they established how much value they placed on the intervention.
The perceived threats to the niceness of the intervention had primarily to do with actions and practices that the participants interpreted in terms of a lack of respect towards them and the intervention. Thus, it became clear that having a sense that the intervention and their participation in it were important and respected was essential to how the participants experienced the intervention.
The narratives describing the intervention's niceness primarily positioned the participants as both grateful for what was offered to them and as generally socially competent individuals. The things that were described as threats risked making the intervention seem less valuable and making the participants feel less important. The articulated niceness also successfully made the intervention seem less threatening by downplaying the associations to the academic occupational therapy domain.
‘We shared quite a few tips…’: meaning of usefulness
The more concrete content of the intervention was also mentioned, including recipes, physical exercises and information about nutrition, as well as ideas for social meeting places in the local area that one could visit. Such tips were shared both from the intervention (the leader and the material used) and between the participants themselves. Things that were articulated as tips by the participants were usually the same things that were regarded as important within the specific discourse of the intervention. These were described in information sheets distributed to the participants and were in line with general health policy (cf. Swedish National Institute of Public Health 2007), and what was considered ‘a tip’ tended to be articulated with social activities, physical activities, participation and food: ‘We shared quite a few tips in terms of food, exercise and balanced diet’.
The participants told about having gotten new tips and new food for thought while discussing the tips. Interestingly, the context of discussing the content together with other persons their age seemed especially significant.
Participant: You know how it is, you read of course in the newspapers and hear on the radio about that [health] all the time, so there was nothing new. But it's different when you're sitting next to your peers and hear this. Otherwise, it's like … Let's say that you read a diet chart or something in the papers, you don't embrace it the same way. That, I think, was better.
Interviewer: So it was better to have the opportunity to talk about it with others?
Participant: Exactly … You know you never meet … In this case we were all born in 1932, and of course it was fun when you knew that that man or woman is just as old as me.
Even though this person first says that ‘there was nothing new’, it was noted that ‘it's different when you're sitting next to your peers and hear this’. Although the content itself was considered important, it was the context of hearing it among peers that seemed to make the information stick, and this helped the participants embrace the wider implications of the information provided by the intervention.
Another example of the meaning of context was the way personal circumstances were put forth as reasons why certain elements of the intervention were specifically appreciated.
Then we talked about diet, and because I am a widower since last year, I became more interested in that. You don't learn [about food] so much in life, as long as you're two. My wife took care of all that, but now I'm very interested in trying to get some insights into what you should eat and should not eat. I think that was great, and we kept talking about that a couple of times I think.
This man explained his need for information about food and cooking by first referring to himself being a widower and then by situating marriage within a traditional gender system where – at least for his generation – cooking has been marked with femininity. Recognising such differences in experience seemed to help some participants justify their interest in an (in this case gendered) activity and to help others put up with an activity that they might otherwise find boring.
The most commonly perceived threat to the usefulness of the intervention was that the participants sometimes felt that the information was ‘old news’ to them. However, it could also be that they perceived the information to be insensitive to their age. The feeling that the information was intended for someone younger or someone older seemed to make it more difficult to take in the information. The participants were sensitive to not being recognised for their (perceived) age. They sometimes identified as ‘active’, and in relation to this they felt that some of the information positioned them as being older than they were. Other times they identified as ‘old’. For these participants, the information given was described as being given ‘too late’ and thus being of no use to them. However, many of the participants also took a position of being ‘grateful’ for having the opportunity to participate and to learn new things. These participants mostly meant that they could overlook the fact that they were already familiar with the content of the intervention. The participants seldom questioned the content as such, which may suggest that they were already invested in a similar ideological view on ageing as the intervention.
Doing (new) things together: meaning of togetherness
One aspect of what the participants appreciated with the intervention was doing things together with other people. Sometimes it was the interaction with others as such, while at other times it was the interaction with other persons their own age that was articulated with words like ‘nice’, ‘pleasant’ and ‘important’. Interacting with others within the groups was described as meaningful in itself and as something that added to the participants’ everyday lives.
Participant: Personally, I have no associations or anything that I'm part of or participate in, so for me it [the intervention] became, well, a bit like ‘all right, now it's Tuesday, so now I'll go and meet these people’, like that … Yes, it was something special.
Interviewer: It was something that you could look forward to?
Participant: Yes, definitely. Not in the beginning, but at the end. We all hugged each other when we finished bowling!
Interviewer: That was a lovely finale!
Participant: Yes, although none of us knew each other before! … A group like this was a great opportunity to meet people you didn't know before.
The social aspect was also described as a means for trying new things that the participants would not otherwise do on their own. Here it was not only the new activity that was articulated as meaningful, but also the fact that the new activity was approached together. Bowling, playing the parlour game Yahtzee or just taking a walk or having fika were examples of appreciated components of the intervention where the togetherness seemed to be just as important as the activity. Sometimes, this togetherness was articulated as a way to cure loneliness. Some of the participants even extended such interactions outside the scheduled intervention group meetings and continued the discussions in other places.
Participant: We laughed a lot and stuff like that, and that's really positive because you're quite alone, everyone was alone.
Interviewer: Single?
Participant: Yes, it's nice to meet more acquaintances.
Interviewer: What was it that you found fun? What was funny?
Participant: Just the things that came up and the things that we discussed. There were just three of us left after the activity ended, some disappeared very quickly afterwards … Yes, but the three of us went out to lunch afterwards and it was nice.
The participants who spoke well of the other participants in their groups and who appreciated the company also spoke well and were appreciative of the content of the intervention. Even when asked to do things that they already did in their everyday lives, they talked about the activities in a positive way. Some made it clear that some of the activities were ‘old news’ to them, but they emphasised that it might have been important to the other participants and that they enjoyed taking part in the activities anyway. A possible interpretation is that these participants also experienced a positive affirmation of themselves and how they led their lives and that this was also an important outcome of the group meetings.
Participants’ talk about the importance of doing things together positioned them as both social and active older persons, sometimes contrasting themselves to others who were not as active. In such cases, there was seldom any doubt that being social and active was seen as the norm, but the participants were mostly understanding of other people's situations, often arguing committedly that interventions like the one they were part of are specifically important to people who for different reasons have difficulties keeping a social life.
Despite the positive attitude of many of the participants, not everyone felt included in the community of their groups. Participants who expressed feelings of alienation also tended to be more critical of the content of the intervention as a whole and of the possibility that it would have any positive outcomes. These people focused on the intervention's activities as being pointless and aired what has been referred to as a ‘sense of disappointment’ with the intervention.
They were nice people, it wasn't that, but it didn't give me anything … The first time, we went out walking, and I do that every day and so did everyone else, so I think we agreed that it didn't do anything for us.
The woman in the quotation above had previously described feelings of alienation in relation to the others in her group, and it therefore seems reasonable to conclude that the social interaction of the activity was not enough to make up for what she found to be an otherwise useless activity. For others who also expressed similar views, feeling excluded from the social fellowship made it likely that the theme ‘doing (new) things together’ would not be an important component of the intervention experience. Importantly, this was a two-way street. Participants who enjoyed the social part of the intervention also felt that the joys of doing things together were threatened by participants who did not seem to like their company or whom they themselves did not like.
Not patronising: meaning of (respected) individuality
The participants seemed well aware of the dominant discourses on healthy living and ageing that promote diets, physical exercise and social contacts. In a few cases, this knowledge was described in relation to a critique of the content of the intervention being too basic or too shallow. Despite this, the participants highlighted how the familiar knowledge was not presented in a reprimanding way, and the intervention was applauded for not being patronising.
Interviewer: Were you told what to eat in this course?
Participant: We were given tips. Nobody said that ‘this is what you should do’, but we were given lists of what different foodstuffs contain, different things. About how far you must walk to get rid of a Danish pastry (laughter)!
Not being told what to do was articulated with words such as ‘important’ and ‘imperative’, and was described to maintain a sense of individuality and of being regarded as an adult. Some statements suggested that the participants had expected to be defined as inadequate, as ageing in the ‘wrong way’ and as being too unhealthy, too sedentary or too heavy, and they had prepared how they would react if such expectations came true.
I've said that ‘if they start talking about how you should lose weight and are too heavy, I'll leave’, for I think that … There's no point anymore, you will die soon anyway. Why should I do without all the good things in life?
It was much appreciated by the participants when the intervention did not judge but instead focused more on how factors like physical or social activities could be personally adapted and become a natural part of one's everyday life. From this perspective, the fact that the participants were treated to fika was of immense importance. This was perceived as a sign of recognition on the part of the intervention that health is more than just physical fitness. In contrast, the (expected) patronising stance was described as a potential threat to the intervention being effective and as potentially stealing the sense of enjoyment in life. Again, the intervention was articulated so as to downplay any potential threat that it may pose by virtue of belonging to a domain that is often associated with medical expertise, power and superiority.
The talk about the importance of not being reprimanded positioned the participants as ‘grown ups’ whose life choices were respected. Not being patronised made it possible for the participants to identify as successful rather than as failures. Healthy diets became something they could choose to follow rather than something others told them that they should follow. This also meant that the participants’ privacy was respected and protected from invasion in the name of the public good.
‘Maybe I'm not that bad’: meaning of having oneself put into perspective
Some participants talked openly about the significance of having one's life put into perspective, and the theme was still present in most interviews even if not reflected on explicitly. A few participants emphasised how parts of the intervention had helped them to put their own everyday practices into perspective, and they had come to realise that they were already doing things right:
I think that it was good to use these pedometers. You don't think about [how much] you walk when you are at home and places like that! This was a nice discovery, although I wasn't that good at using that thing [the pedometer].
Having the opportunity to try out a pedometer meant that this woman realised that she was in fact exercising although she had never thought of this before. In turn, this meant that the goal of taking a certain number of steps a day was not that far away, and this worked as an incentive to try to actually reach that goal. Similarly, interacting with others and being confronted with their lives was described by many of the participants as a way of suddenly seeing themselves. Such insights took different forms.
We have already mentioned that the intervention as such was sometimes criticised for being too shallow and for targeting people who were more impaired than the participants. One man talked about how the physical exercises they had been shown in a video featuring the well-known 90-year-old Swedish opera singer Kjerstin Dellert did not meet his level of physical ability:
Participant: [She] showed a few exercises, but it didn't do much for me because I get a lot more exercise than Kjerstin Dellert ever does. I play tennis throughout the winter and ski, and then I jog and play tennis in the summer.
Interviewer: You are very physically active?
Participant: Yes, so I wasn't that impressed, but I think the ladies embraced it more.
Although this man seemed quite aware that he led an active life, the articulation of this fact and the contrasting between him and ‘the ladies’ confirmed this awareness. He was ‘not very impressed’, but neither did he explicitly critique this part of the intervention. The presence of ‘the ladies’ concretised to him that he was unusually fit ‘for his age’. By making himself exceptional, he could be critical without undermining the significance of the intervention.
Comparing oneself with others could also result in a realisation that others were worse off and that the participant was actually quite fortunate:
Interviewer: Do you think this group has affected you in any way?
Participant: Well, I've come to understand that there are an awful lot of people who are alone. I live alone myself, but I think I'm still quite fortunate because I have the physical ability to walk for as long as I want, I can drive my car as much as I want, I can go away as much as I want. I have a son who lives in town who has a lot of time for me and all that. But I think there are … I understood from this [intervention] that there are those who are terribly alone.
Apart from emphasising the meaning of having oneself put into perspective by meeting people who were ‘worse off’, some participants also emphasised the significance of meeting persons their own age who were alert, healthy and happy. It was described as important that the group meetings did not focus on impairments, diseases and ailments, and meeting and talking to alert persons one's own age was sometimes described as having a positive effect. In this sense, the other group members were perceived to help the participants to self-reflect and appreciate what they had, as well as to act as role models or good examples for each other.
Discussion
The significance of context for understanding interventions has been repeatedly emphasised (Christiansen et al. Reference Christiansen, Backman, Little and Nguyen1999; Hannam Reference Hannam1997; Reed, Hocking and Smythe Reference Reed, Hocking and Smythe2010). One such context is constituted by understandings of what it means to age well. Below we will discuss the five themes that surfaced in the participants’ narratives and reflect on the way the intervention related to Rowe and Kahn's (Reference Rowe and Kahn1997) famous (biomedically invested) paradigm of successful ageing that has ‘set the frame’ for the discourse of contemporary research on ageing (Bülow and Söderqvist Reference Bülow and Söderqvist2014: 139).
Five themes that negotiated norms of health, activity and participation
In the narratives about the experience of taking part in the intervention, five related themes surfaced as particularly significant. The participants articulated the significance of the intervention with enjoyment, concrete usefulness, togetherness, respect and having gotten a sense of perspective on one's own life. Some of these themes were narrated as being discoveries that the participants had not expected from the intervention, supporting Spitzer's (Reference Spitzer2003) argument that meaning-making is not always a process of conscious reasoning, but is often embodied and defined in the moment of doing (see also Law Reference Law2002). Of the five themes, four were explicitly related to the social aspects of the intervention. Even the theme that highlighted the sense of concrete usefulness and the tips they had received did so in pronounced relation to the fact that the tips were shared between participants and the significance of discussing the tips with peers. This is consistent with what Bowling and Dieppe (Reference Bowling and Dieppe2005) write about lay views on successful ageing as often more comprehensive and multi-dimensional than biomedical views (see also Phelan et al. Reference Phelan, Anderson, Lacroix and Larson2004) and with research emphasising the meaning of context for the results of interventions (Blackwood, O'Halloran and Porter Reference Blackwood, O'Halloran and Porter2010).
Even though sometimes admitting to having some ailments, being too physically inactive or being ignorant in nutrition and cooking, the participants generally positioned themselves as quite independent, healthy, active and social, and what they deemed to constitute threats to the intervention being a positive experience were often incidents when these positions were at risk, such as when fearing being addressed in a patronising way (being told what not to eat), or when not being taken seriously (as when the taxi did not come). The view that the content was too basic sometimes gave rise to a ‘sense of disappointment’ (Wallin et al. Reference Wallin, Talvitie, Cattan and Karppi2007) and was mentioned as a serious threat to the perception of the intervention as being good, but the opportunity for reflection and developing a sense of perspective allowed the participants to relate to the needs of others in their groups, and this could make the content of the activity itself less important. In this sense, it seemed as though their positions as independent successful agers were something that had to be protected. This vulnerability might be interpreted as an indication of what discourse theorists call the contingency of life (Laclau and Mouffe Reference Laclau and Mouffe1985) or stemming from an experience or fear of being ageistly positioned as a stereotypical older person (Nelson Reference Nelson, Wiener and Wilborn2011). The latter supports Christiansen's (Reference Christiansen1999: 550) argument that life meaning is derived in the context of identity and that life meaning ‘is an essential element in promoting well-being and life-satisfaction’. If we do indeed interpret the events that we experience through our identities, then it is critical that our identities are included, confirmed and accepted in the events that we experience in order for them to be meaningful to us (cf. Hannam Reference Hannam1997; Reed, Hocking and Smythe Reference Reed, Hocking and Smythe2010).
On the one hand, the five themes in the interviews can thus be used to highlight how the social aspects of the intervention worked as important driving forces in pursuing intervention participation, and that it was the social aspects and aspects to do with identity that were the decisive focus for the participants (Hull Garci and Mandich Reference Hull Garci and Mandich2005; Shordike and Pierce Reference Shordike and Pierce2005). On the other hand, and from the perspective of discourse theory, the central meaning-making articulations of the five themes also worked to consolidate partly a discourse of successful ageing through accepting its central premises. Within each theme parts of the successful paradigm were taken for granted; social participation, physical exercise and healthy diets were seen as key to successful ageing.
But, importantly, while the discourse of successful ageing informed the participants’ meaning-making and positionings, it did not determine them. The intervention also seemed to evoke more reflective and understanding positions. The detours around fika, fun, togetherness and feeling respected opened up spaces for articulating one's own experiences with others and with people's different and unequal conditions and possibilities to live up to the norms of successful ageing. As individuals never just mirror discourses, but reproduce as well as disrupt and challenge them, the many ways of employing discourses may open up the possibility of discursive change (Butler Reference Butler1990, Reference Butler1993).
Through the five themes, the participants highlighted different meanings of social interaction in ways that seemed to go beyond the scope of Rowe and Kahn's (Reference Rowe and Kahn1997, Reference Rowe and Kahn2015) notion of successful ageing. The emphasis placed on enjoyment and laughter, as well as on socialising with peers rather than with society in general, pointed at values other than the ones that are usually connected to the successful ageing paradigm. Although the participants did not always practise solidarity when talking about other participants whom they thought had misbehaved during the intervention, they referred to their experiences of meeting these people as enlightening. Even though they had been annoyed at the time, they argued that in retrospect the experiences had still been meaningful to them because they had helped them to put their own lives into perspective as well as to get a better understanding of others who, for different reasons, could not live up to the norms. It is therefore possible to contend that although the successful ageing paradigm successfully surfaced as the participants’ primary goal, and relentlessly supported their identifications as active, healthy and responsible subjects, its normative positions and goals were partly challenged by the participants.
A norm critical perspective on the intervention and intervention experiences
The participants’ narratives were, of course, closely linked to and conditioned by the design of the intervention. It had as one prerequisite that participants were still relatively healthy physically and mentally. Such functioning was included in the intervention activities as something that was desirable in old age. The groups were asked to try new ways of exercising and engaging in physical activity, for example, by using pedometers. In this sense, Rowe and Kahn's component ‘good physical and mental functioning’ was partly a prerequisite for participation in the intervention.
Two of the central inclusion criteria were ‘living alone in their ordinary housing’ and ‘using no home care services’. This can be interpreted as a way of attracting participants who were not sick or impaired at the time of the intervention, thereby already, in a sense, living up to the norms of successful ageing. Villar (Reference Villar2012: 1089–90) has noted how the paradigm of successful ageing has tended to shift the focus of research away from ‘those who suffer illnesses and disabilities as they age and on to those who experience positive outcomes as they do so’. In a way, the intervention did just that, thus simultaneously complying with Rowe and Kahn's component of low probability of disease.
The intervention's explicit goal was to support engagement in activities (Zingmark et al. Reference Zingmark, Fisher, Rocklöv and Nilsson2014). It focused on concrete activities, and the participants were not only presented with how to do things, but they also got to try the things that were talked about. The very design of the intervention with group meetings required a certain amount of engagement, and participants had to relate to each other while doing things together. The intervention had a deliberately loose structure, and asking the participants themselves to come up with activities demanded – or at least elicited – active engagement. Although active engagement has been demonstrated to have a positive effect in ageing (e.g. Gustafsson et al. Reference Gustafsson, Wilhelmson, Eklund, Gosman-Hedström, Zidén, Häggblom Kronlöf, Hojgaard, Slinde, Rothenberg, Landahl and Dahlin Ivanoff2012), it has been pointed out that the inclusion of active engagement as a means and an end of successful ageing still has normative and political implications, for example, in the sense that it transfers responsibility to the individual (Bülow and Söderqvist Reference Bülow and Söderqvist2014). In this respect, the fact that the activities were partly chosen by the participants, and not imposed upon them by the intervention, suggests a transfer of responsibility where participants are made responsible not only for their ‘proper’ ageing, but also for the content of the intervention (Mol Reference Mol2008). Regardless, the intervention complied with Rowe and Kahn's component ‘active engagement with life’.
In this sense, the intervention seemed equipped to produce successful agers. It had the components for successful ageing as its selection criteria, as its methodological components and as its primary goal. Although the goal of the intervention was not explicitly stated as such, it can be interpreted in terms of ‘successful ageing’, and the goal was pursued within the intervention by focusing on the individual. Even though the primary method was to have people engage in group activities, in the long run the focus was on encouraging and stimulating older people to uphold or change their personal lifestyles in supposedly more ‘healthy’ and ‘active’ directions.
Focusing on lifestyle is common in many occupational therapy interventions, and often involves the teaching of strategies that participants are then encouraged to adhere to at home (Radomski Reference Radomski2011). Some of the appreciated aspects of the intervention also clearly worked in this way, e.g. when the participants borrowed pedometers. Even though the participants specifically emphasised the way that the pedometers had put themselves into perspective, it was clear that the pedometers were material objects that ‘followed the informants back home’ and continued to encourage or insist on certain physical practices outside intervention group meetings (Bennett Reference Bennett2013; Mol Reference Mol2008). Also, in cases when the participants admitted that they had not used the pedometers, it was evident that the material object as such continued their insistence and could lead to a persisting guilty conscience (Bryant Reference Bryant2011).
The teaching of strategies to adhere to can partly be seen as a way to empower the individual, suggesting that healthy ageing is reachable if only life is lived in certain ‘healthy’, ‘active’ and ‘participatory’ ways. It has been pointed out that such a focus suggests that loss and decline in later life might (and perhaps should) be individually prevented (Rozanova Reference Rozanova2010), that the normativity of the concept might marginalise people who age with disabilities (cf. Minkler and Fadem Reference Minkler and Fadem2002), and that it sees the individual as an important target for social savings (Bülow and Söderqvist Reference Bülow and Söderqvist2014; Katz Reference Katz2000; Martinson and Minkler Reference Martinson and Minkler2006; Sinding and Gray Reference Sinding and Gray2005). Thus, although rhetorically arguing for securing the welfare and empowering the individual (West and Lundgren Reference West and Lundgren2015), the kind of transformations towards ‘personalisation’ (West Reference West2013) or ‘consumer choice’ (Blomqvist Reference Blomqvist2004) that are common in present-day Europe must also be understood in terms of how they promote neoliberal ideals (Rose Reference Rose2007).
We argue that the kinds of intervention studied in this paper must similarly be understood not only for how they might improve older people's health, but also for how they simultaneously support and reproduce a normative understanding of ageing and who is to be held responsible for doing it successfully (Katz Reference Katz2000; Laliberte Rudman Reference Laliberte Rudman2006). Of course, the intervention as such cannot be held solely responsible for forcing the norms of successful ageing upon the participants. Such norms have had a pervasive influence in Swedish society, and the participants were, as we have seen, already very familiar with such a discourse. In fact, the discourse of successful ageing was broadly operative in their answers during the interviews and they articulated the intervention in relation to this specific ideology of healthy ageing. When commenting on the intervention, the participants also proved to be quite heavily invested in the subject positions offered by this discourse. They positioned themselves as active and aware of what they should do in order to stay healthy, and they aired a consciousness about being responsible for their own ageing, sometimes self-critically or self-ironically commenting on their own shortcomings in this respect.
Concluding remarks
The participants self-rated their health as having improved after the intervention (Zingmark et al. Reference Zingmark, Nilsson, Fisher and Lindholm2016). Based on this result, we assumed there must be some therapeutic components at work that had made a difference in the participants. It is, however, important to note that this ‘difference’ in health was not based on physiological measurements, but instead was a perceived change. Self-reported health has, however, shown to be an important indicator, predicting mortality (e.g. DeSalvo et al. Reference DeSalvo, Bloser, Reynolds, He and Muntner2006) and hospitalisation (e.g. Isaac et al. Reference Isaac, McLachlan, Baune, Huang and Wu2015). In the analysed interviews, the participants raised aspects of the intervention experience that were meaningful to them, and that we interpreted as having a therapeutic effect. Much more than the content of the intervention, these aspects had to do with the social aspects of the group intervention. It was communicated as immensely meaningful to meet new people, to talk together, to share experiences and to do new things together. Of equal importance was that the intervention as such was respected by all of the group members and intervention leaders, but also that the participants’ identities were treated with respect – that their perceived age was acknowledged and that they were neither treated as ‘children’ nor as ‘older than they were’. It was considered significant that information was not presented in a way that put blame on individuals who did not live up to communicated standards and expectations. In relation to this, the presence of fika during the group meetings was ever so important because it came to symbolise that the leaders of the intervention recognised that there is more to wellbeing than just strict diets. The emphasis on the social aspects of the intervention can thus partly be interpreted as a way to negotiate the power imbalance between the intervention and the participants. This shows how the totality of articulations produced a discourse about the intervention that comprised the handling of fears of becoming positioned as subordinate by downplaying the intervention's potential connotations to science and health-care professionalism, but also the intervention's underlying efforts to decide for the participants in what Bennett (2013) has referred to as ‘the name of the public good’.
While they were certainly meaningful to the participants, were these aspects of the intervention possible to view as therapeutic components that had affected the participants’ self-rated health and wellbeing? Our key finding is that the positive experience of participating in the intervention's group meetings itself made the participants feel healthier, and we believe that the identification of meaningful themes from the participants’ point of view contributes to the existing body of knowledge about occupational therapy interventions. Defined as a cultural construct, health is a relative concept that is made meaningful in social contexts. The group meetings with their room for joint meaning-making meant that the participants were confronted with other people's lives and possible ailments, and it is possible, but not determinately so, that this experience meant that the perception of one's own health was renegotiated. However, it has been suggested (Radomski Reference Radomski2011) that the meaning of context and individuality should be emphasised rather than universal fix-all solutions that might result when questions like ‘What works?’ are uncritically asked instead of more nuanced and context-sensitive questions like ‘What works for whom?’ Herein also lies one of the problems of the intervention, as well as a second key message and contribution of this study: social interaction is impossible to control since it involves ongoing constructions and negotiations of the participants’ identities and relations, and the participants who do not feel included are likely to miss out on the positive effects.
Early on in our analysis, we recognised that the initial intervention as well as the quest to find the therapeutic components rested on positivistic grounds, and that this was in contrast to our own thinking. Rather than just ‘taking part’ in the initial intervention project and having a desire to pinpoint its therapeutic components, we came to question reflexively its grounds and the ways in which the intervention project implicitly partook in the much-debated paradigm of successful ageing. For example, we highlighted how successful ageing surfaced as a normative ideal (Whyte and Hart Reference Whyte and Hart2003) in the participants’ answers during the interviews, but also, as it turned out, in the intervention. This exemplifies the impact of the discourse of successful ageing and how individual choice has become important in health promotion (Bülow and Söderqvist Reference Bülow and Söderqvist2014) but also in people's everyday thinking and talking.
In our attempts to describe what stood out as significant to the participants, however, we could also see how the discourse of successful ageing was also challenged. A third result of the interview study was that the participants were not totally positioned by the successful ageing paradigm but partly challenged the norm of individual responsibility by insisting on showing solidarity with others. This means that the results of this study might not be generalisable. In fact, we find it tremendously important to point out that they are not. Such generalising would probably strengthen the already strong paradigm of successful ageing and risk further obscuring what works for people who are not healthy, active and social, and who do not identify as such. However, it also means that we recognise the impact that dominant discourses may have in affecting, but not determining, people's perceptions of occupational therapy interventions.
Returning, then, to the introductory discussion about therapeutic mechanisms of successful interventions, we can conclude that while the intervention outcome may be a self-rated ‘healthier’ ageing, the way that the participants articulated their experiences into five themes suggests that the driving force for participating in the intervention as well as its most appreciated aspects were much more varied than just an eagerness to age healthily. Recognising this was one of the strengths of the intervention.
Acknowledgements
This study was supported financially by the Swedish Research Council's Linnaeus Grant (2006-21576-36119-66), the Swedish Research Council's Strategic Research Programme: Care Science, Umeå University and Forte: Swedish Research Council for Health, Working Life and Welfare. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
