Design

A qualitative study designed according to the ethnoscience method22 was adopted to involve older citizens in the construction of a common vocabulary and in a shared taxonomy related to their health management experiences. This method assumes the importance of studying language (and the way language is used) to understand implicit meanings related to individual experiences. The linguistic choices made by speakers when describing their health management attitudes and behaviours may indeed uncover the social representations, emotional experiences and psychological attitudes of people towards their health. This may be particularly meaningful when the phenomenon under investigation is complex and ‘abstract’ (such as discussing about one's own engagement in health promotion) and when interviewees may find it difficult to reflect deeply on their related experiences. Ethnoscience is based on repeated semistructured interviews and Q-sorting tasks to allow the flexible investigation of the phenomena under investigation and to study the lexical expressions of participants when describing their experiences (see Data collection and procedure section).23 The Q-sorting technique is a general methodology used to gather and process a person's viewpoint as well as to categorise a complex phenomenon.24 By Q-sorting, people reveal their individual way of categorising a phenomenon and giving sense to a particular reality.25 ,26 In detail, all interviewees were interviewed twice. In the first round, they were required to reflect on their health promotion experiences following a semistructured guide of interview and a non-directive moderation style. In the second round of interviews, they were asked to engage in a participative analysis process aimed at drafting a shared vocabulary and taxonomy of health promotion experiences thanks to Q-sort tasks. In particular, the tasks involved selecting cards (which reported linguistic extracts from previous interviews) that reflected their health promotion experience, grouping the selected cards, assigning a name to each group, reflecting on the relationships among groups, and providing insights on the factors that are able to foster/obstruct older people's health promotion experiences (see the next paragraph for further details).

Data collection and procedure

Participants were involved in two sequential rounds of semistructured interviews. Two researchers conducted the interviews together. Both of them were psychologists trained in qualitative methods.

• The first round of interviews posed broad questions to collect data on the meanings and representations of health promotion, concrete daily habits, engagement in healthy lifestyles and situations that foster or obstruct active engagement in health promotion (see table 1 for details). Additional questions were asked, when needed, to elicit further details. Questions posed by researchers who adopt the ethnoscience method are usually broad and open-ended to elicit narratives from the participants and collect all possible statements, opinions and experiences from the respondents about the phenomenon under investigation.27 All interviews were fully transcribed, and selected recurrent linguistic expressions used by interviewees to describe their health promotion experience were reported verbatim on cards: one linguistic expression per card (see the Data analysis section for further details).

• All interviewees were reinterviewed after the first phase of the data analysis to construct a shared taxonomy of their health promotion experiences in collaboration with the researchers. In particular, this second round of interviews implied Q-sorting tasks. The first Q-sorting task asked participants to select the meanings and linguistic expressions reported on the cards that best represented their experience and engagement in health promotion (ie, please select the cards that mainly represent you) and to eliminate the cards which they felt were far from their subjective experience. In the second task, participants were invited to group and categorise the selected cards based on spontaneously agreed on homogeneity criteria (Among the cards you selected, can you identify group of cards that can be linked together?). This second task allowed the investigation of spontaneous categorisation and thus of individuals' representational domains. This task formed the basis of the first ‘taxonomies of meanings’ spontaneously created by participants during their interviews (How do the groups of cards relate among them? What is the reason of these linkages? What do this emerging taxonomy means to you?).

Each interview was completed in the individual's home or at the participant’s place of preference. The interviews ranged from 40 to 90 min, with an average duration of 60 min.

Participants

A purposive sample of 25 North Italian older adults was sequentially recruited to participate in the study.28 Potential participants were recruited through several means. First, citizens were recruited from different senior centres (eg, community centres, activity centres, recreation associations, community recreation centres), which were contacted by telephone or email, and invited to take part in the study. Individuals with the desired characteristics were then asked to recommend similar participants from their social networks, starting a ‘process analogous to a snowball rolling down a hill’.29 ,30 Thus, a snowball sampling technique was adopted,31 which is particularly useful to reach vulnerable or hard-to-reach groups in a more effective, pragmatic and culturally competent way.29

The inclusion criteria were:

1. Being 65–75 years of age (this range was selected because people who are younger than 75 years of age may particularly benefit from engaging in health-promoting behaviours in terms of prevention of future health problems; furthermore, this target population is more likely to engage in health promotion initiatives compared with individuals older than 75 years of age);

2. Being able to express themselves with well-articulated stories and to deeply reflect on their stories (eg, people with mental health problems or impaired physical conditions were excluded);

3. Being able to understand and speak Italian;

4. Being willing to participate in the study.

Data analysis

All interviews were transcribed verbatim and analysed using thematic analysis with an inductive approach.32 Two researchers analysed and coded the transcripts independently to identify the key words, phrases and expressions which the participants repeatedly used to describe their health promotion experiences. In a joint meeting, the researchers discussed and reached an agreement on a list of selected linguistic expressions. This process resulted in a shared ‘dictionary’ containing words/phrases that were then printed onto cards to be used in the second phase of the research process: the Q-sort tasks. These tasks were completed during the second round of interviews. The researchers kept track of card-sorting choices made by each participant during the second round of interviews. On the basis of spontaneous card sorting and grouping by each participant, researchers were able to draft a taxonomy of meanings and experiences (one for each participant), presenting the results of the card sorts in a tabular form. In a separate meeting, the researchers compared the taxonomies derived from the card-sort tasks to identify common thematic patterns and to develop a final, inclusive and synthetic taxonomy of older citizens' health promotion experiences. When disagreement emerged, the researchers reached a consensus through discussion.

The results are reviewed below, and they include some quotes extracted from the interviews to support our results. The researchers involved in the data collection and analysis translated the quotes selected for this article into English together with the assistance of an Italian-speaking and English-speaking translator.33 Finally, a professional native English translator corrected and checked the translations.33 Original quotes are available on request.

Ethical concerns

Each participant was free to participate and withdraw from the research and was informed about the procedures of the study. All participants consented to participate in the study (including audiotaping and transcription of the interviews) by signing a written consent form. Information that could identify participants was removed, and each interviewee was assigned an identification number to protect his/her anonymity.

Findings

Thirteen females and 12 males who met the inclusion criteria were included in the study. Most participants lived predominantly in Lombardy (68%) and in villages or small towns of suburban areas (60%) while only seven lived in Liguria (28%). The age ranged from 65 to 75 years (mean age of 67.8 years). The sample comprised primarily retired participants. Overall, 23 participants resided with a family member (in most cases with their spouse/partner) and 7 of them lived with two or more family members (generally the husband/wife and adult children). Two older adult participants lived alone but near a family member. For further details, see table 2.

Interviews conducted using the ethnoscience method allowed us to draw a taxonomy of older people's experiences of health promotion. In particular, this taxonomy featured three different types of health promotion experiences (ie, locked position; awakening position; climbing position), which represented four main experiential domains (ie, see figure 1). Each position reflects specific representations, emotions, behaviours and subjective meanings. First, we summarised the semantic areas and experiential domains related to health promotion experiences of the older North Italian adults enrolled in the study that emerged from the interviews (ie, see figure 2). Thereafter, the taxonomies related to the three types of health promotion experiences that emerged from working collaboratively with interviewees are presented below (ie, see figure 1).

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Figure 1

Taxonomy of older citizens' experiences of health promotion.

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Figure 2

Semantic areas and domains of subjective meanings of older citizens' experiences with health promotion.

Older citizens' experiences of health promotion: main domain of subjective meanings

The following four main semantic areas emerged from the older citizens' accounts of their health promotion experiences.

Physical care: For older participants, promoting health and well-being evoked experiences of care of their physical body. Thus, emotions related to becoming sick, being adherent to medical prescriptions and to health checks, and having in mind that managing one's own health and preventing future health problems is a daily and crucial effort were important experiential domains of taking care of their physical health.I’d name this group ‘contact with my health’, that is the contact with my body and with the awareness about the possibility that it could become sick.(Interview 14, male, 70 years old)

Daily lifestyle: Participants referred to this area when speaking about daily lifestyles, including factors such as physical activity, diet and risk behaviours (alcohol, smoke). In their words, “daily habits are the litmus test of my health, of my life” (interview 14, male, 73 years old). Participants also considered respect and awareness of limits, rules and boundaries as important when engaging in the suggested health-promoting behaviours and when effectively promoting health through physical care.This group speaks about activities of everyday life to manage my health, how to do sport, eat … how can we call it: lifestyle?(Interview 20, male, 68 years old)

Contact with ageing: Participants referred to ‘being in contact with ageing’ or ‘living and perceiving ageing’ to define the relationship with their age and their capacity to take the best from ageing. This domain of meanings also regards life objectives and the level of life satisfaction, the personal acceptance of ageing and the individual levels of self-esteem. Participants considered those factors as important in the successful ageing process and consequently in experiencing high levels of health and well-being.It is also important how you live your age: how do you enjoy the present days? Are you in contact with your ageing?(Interview 18, female, 65 years old)

Soul care: Finally, participants spoke about the importance of taking care of their mental health to support and promote their well-being. Participants described this area in terms of happiness, self-esteem and perceived control over life and health.This is more a question of head, mental. It's how I feel at this moment and it's more a mental fact to love and accept myself and feel that life is in my hands … of course, it takes a little bit of luck.(Interview 15, female, 68 year old)

Older citizens' experiences of health promotion: a taxonomy of experiences

The analysis of all individual taxonomies produced by interviewees during the Q-sort tasks (and related to their subjective experience of health promotion) helped draft a final inclusive taxonomy of older citizens' health promotion experiences featuring three main positions described in detail in the following paragraphs.

First position: ‘I feel locked’

Interviews revealed that the first experiential position of older citizens' health promotion was characterised by a blocked and frozen attitude towards health, which consequently leads to unhealthy lifestyles and habits. Lack of work and social network, emotional resignation, lack of purpose and unhealthy behaviours (ie, cigarettes, alcohol abuse) were found to characterise this position. Older participants often attributed the lack of healthy behaviours to a general lack of self-care and life purposes and used negative emotional words to refer to the relationship of this position with health. Participants reported a similar approach to health characterised by lack of love and self-acceptance, which often exemplifies the entire lifespan, although it is exacerbated by ageing-related issues (eg, retirement, death of loved ones, loss of a social role, menopause). Thinking about different ways to promote health during ageing was scary and anxiety provoking for people in this position; thus, ‘continuing the life as usual’, avoiding negative emotions and frightening thoughts that would emerge if health was in daily projects. This position was represented in terms of feeling ‘locked’ in an unhappy last part of life.After all, my life is ok for me, so I do absolutely nothing to change it … I’m fine by myself as well, so I don’t really look for particular situations to increase what I should do to feel better.(Interview 20, male, 65 years old)I have an identity issue in organizing my health, I get anxious to thinking about it and I prefer to continue my life as usual.(Interview 18, female, 65 years old)

Furthermore, the participants reported that health practices were inextricably linked to religious beliefs. Indeed, people in this position usually represented themselves as delegating their health management to others. Although this helped them avoid negative emotions, these beliefs contributed to the reduction of health promotion actions. Consequently, a fatalistic attitude with feelings of resignation and dissatisfaction with life was reported. These feelings also influenced the approach to risk prevention and health promotion. Regarding people in this position, the emergence of diseases could not be controlled; thus, following healthy lifestyles to prevent diseases would be useless.It is useless to worry about what may happen and what can be done to prevent mishaps … cancer or other diseases can occur also if you have an optimal lifestyle …(Interview 25, male, 68 years old)

Since the missing approach to health management was characterised by resignation, older participants reported that lack of purpose, worries and fears of losing autonomy or remaining alone were able to ‘upset’ and ‘awake’ them from the disengagement in health. The worries motivated them to seek sources of more positive feelings and hope towards future life trajectories.I absolutely do not follow prevention, but if any serious illness came, I would be forced to change to regain my health.(Interview 1, male, 65 years old)You can change in the event that a disease hits you, so you become scared, so your lifestyle changes.(Interview 20, male, 65 years old)I stopped smoking thanks to a book that made me aware that depending on cigarettes made me miserable and that convinced me that having fun would help me.(Interview 16, male, 73 years old)

Second position: ‘I'm awakening’

Some other citizens, mostly with a good social network but without strong and supportive relationships, described themselves as alternating in managing health between health awareness and a lack of motivation to improve their health during ageing, with the general adoption of a healthy lifestyle without the awareness of risks due to ageing. Unlike the ‘locked position’, in the ‘awakening position’, older citizens alternated between a fatalistic and a more active attitude towards health and life, perceiving some situations as being under their control. People in this position represented themselves as caring about their health only when sick but lacked motivation and perceived loss of control over their health when recovering from the disease.Obviously, I take care of my health when I'm sick to heal! But when I heal I do nothing to stay healthy: It's useless, it's not under your control!(Interview 10, female, 65 years old)

Although participants in this position were aware of the importance of engaging in healthy behaviours, engaging in physical activities, eating better and planning meaningful activities to feel healthier, they preferred to leave health out of daily plans. Thus, they were described as aware but often inactive in managing and promoting health. Accordingly, they were classified as having an ‘awakening’ status. They described themselves as having understood the importance of engaging in healthy behaviours at the ‘theoretical level’, but in practice they reported failure to translate this knowledge into concrete health-promoting and health-preventive behaviours (eg, doing more physical activity, paying attention to diet, going to health checks). Furthermore, these older citizens often failed to recognise their actual need to ‘do more’ to improve their lifestyle, particularly because ageing requires greater attention to physical limits and to global self-care. Focusing on preventing and modifying their lifestyles according to the limitations and barriers that emerge during the process of ageing was perceived as highly connected to the acceptance of growing old and thus to the participants' experiences of ageing. Finally, a sort of emotive ambivalence towards their ageing process characterised this position. On the one hand, feelings of guilt for doing the bare minimum and, on the other hand, the desire to avoid being concerned with health increased the disconnect between actions and thoughts. In this sense, social relationships were conceived as useful in fostering a more active health engagement and planning daily habits among individuals in this position.I know that I should do sport, in the past I used to go to the gym but in the recent years, I finally chose the oratory and not the gym, whereas I know that this is not the better choice for me.(Interview 23, female, 68 years old)Doing something with someone could help me to be more active.(Interview 18, female, 65 years old)Setting my own goals for the future and getting busy with daily commitment lead me to feel better…for example gardening or spending my time out, I’m sure that will bring benefit to my mind.(Interview 24, male, 65 years old)

Third position: ‘I'm aware that I'm climbing’

This experiential position was described in terms of a better integrated approach to health promotion. Important features of this position included being constantly aware of the importance of taking care of the self to remain healthy and feel good physically, mentally and socially. People in this position gave sense to their life and elaborated on the inevitability of death successfully, which allowed them to live fully every day. They were conscious that physical health influences well-being in all other spheres of human existence and that taking care of oneself increases wellness and happiness and fosters one's own sense of control over life trajectories. Thus, a strong sense of coherence, control and self-efficacy, as well as a greater motivation to feel aware and reflexive, emerged from the interviews as important factors of healthy ageing. In this sense, this position was defined as ‘climbing’ because of the constant efforts of participants to master their entire health status and well-being.As I do something, I think about the consequence of what I’m doing to prevent diseases and how I'm feeling.(Interview 3, male, 75 years old)At a certain age, you have to start thinking about your health and yourself, sooner or later something happens … there is an exponential curve between age and health, and I’m at the point in which something will happen … so I'm aware that I want to live the last years fully and peacefully!(Interview 22, male, 75 years old)Loving and accepting each other is the foundation of everything, it gives you a purpose of life, it makes you feel that it's you at the helm.(Interview 14, male, 73 years old)

People in this position were represented as having successfully managed critical events (such as the occurrence of health problems or the deaths of friends and relatives) by elaborating their sense within the whole spectrum of their existence and in the light of a positive approach to life. People in this position shared the personal objective of contributing to the wealth of the world to have a sense of life and die peacefully. According to participants, being at peace with life, ageing and death fosters well-being and positive engagement in a healthy lifestyle.Sooner or later, life ends. It is important to have the satisfaction of having done something, to have done things, to have left something … more than the fear of death, I’d rather end in a particular way.(Interview 22, male, 75 years old)The problem is not to avoid diseases but to live with them in a decent way and in line with your life.(Interview 18, female, 65 years old)

These participants were described as believing that their own actions determine their health. Perceptions of having control over health and life foster, as older participants said, proactive behaviours and a sense of power and agency. Being able to face anxiety related to taking responsibility for their health status, having control over all health dimensions and strengthening feelings of self-determination were also important features of this position.This is more a question of head, mental. It's how I feel at this moment and It's more a mental fact to love and accept myself and feel that life is in my hands … of course it takes a little bit of luck.(Interview 15, female, 68 year old)

Relationships also played an active part in the ‘climbing position’ because playing an active social role in the community was conceived as a way to have a purpose in life and to be part of something bigger, which can give sense to life and death.Sooner or later life ends, it is important to reach the satisfaction of having done something, of having left something, of having made a small contribution to other people …(Interview 22, male, 75 years old)

Additionally, participants explained their well-being as dependent also on “having the possibility to be free, also to exceed bounds sometimes” (interview 5, female, 67 years old). Indeed, engaging in bad habits is occasionally perceived as useful to maintain engagement in a balanced healthy lifestyle, avoiding the risk of becoming too obsessive about healthy behaviours and enjoying old age more fully.