My place through my eyes: A social constructionist approach to researching the relationships between socioeconomic living contexts and physical activity

Abstract

Empirical research has shown that household and neighbourhood characteristics are significantly linked to particular health-behaviour profiles. Specifically, people living in lower socioeconomic living contexts tend to be associated with less active and healthy lifestyles. However, what is not yet fully understood is how living contexts work to produce and sustain common or shared behavioural patterns. To address this question, we employed Berger and Luckman's social constructionist conceptualisation of context to study a group of residents who had recently moved from poorer living contexts to a mixed-tenure, inner city, new urban village equipped with various resources promoting a physically active lifestyle. This framework was coupled with Charmaz’ social constructionist approach to grounded theory. An analysis of the qualitative data gave rise to the conceptual categories of “being flogged up something fierce”, “running away”, “sleeping with one eye open”, “you're just fat”, and “exercise as a dream” as the key contextual influences mediating poor living contexts and low physical activity levels. A core category of “identity management” was located. The selection of this case and the findings exhibited here draw attention to the need for a situated understanding of how particular lifestyles develop in socioeconomic living contexts. The insights need to be drawn from ‘insider perspectives’ in order to ensure more sensitive and effective interventions in the future.

• Socioeconomic
• urban
• physical activity
• social constructionism
• grounded theory

Introduction

Research has established that the socioeconomic position of households and neighbourhoods are reliable predictors of a range of health-related behaviours and outcomes (Ioannides & Zabel, 2007; Kavanagh et al., 2005; McCracken, 2001). However, questions remain about how the internal mechanisms, processes, and practices through which poorer living contexts produce and sustain less healthy lifestyles than wealthier ones (MacIntyre, McKay & Ellaway, 2005; Coen & Ross, 2006; Monden, Van Lenthe & Mackenbach, 2006; Cummins, Curtis, Diez-Roux & MacIntyre, 2007; Parkes & Kearns, 2006). While sophisticated statistical methodologies have been used to establish convincing links between contexts and health (Diez-Roux et al, 2000; Hou & Myles, 2005), further qualitative studies are needed to extend this knowledge to something beyond what statistics alone can capture. The nature of statistical analyses places limits on the insight that can be gained about the nature and the direction of the relationships linking poorer living contexts with poorer health. Thus, it is important to complement the epidemiological evidence base regarding “area-effects” on health with studies that allow an intensive focus on the situated relationships between context and practice.

Further to the lack of qualitative studies, there has been an associated lack of the theoretical development needed to understand and conceptualise the relationships between context and health-related behaviours. A key article by Frohlich, Potvin, Chabot and Corin (2002) makes special note of the lack of a useful conceptualisation of context for the study of health-related behaviours in urban neighbourhoods. They make the point that to study the “social contextuality of meaning”, methodologies are required that situate health-related behaviours within the context of the social relations and transactions or interactions of people's lives by tapping their subjective experience within their social location. They go on to refer to an article by Poland (1992) to emphasise the point that “not only is it a methodological issue requiring qualitative methods, but it is also a theoretical one in which the relationship between health-related behaviours, risk, and knowledge can be analysed in terms of the intersection of structure (norms, codes of conduct and institutions) and human agency (individual volition, action)”. (p. 1402.)

In this paper, we make the case that what is needed is a theorization of living contexts that lends itself to revealing the internal mechanisms that influence less healthy lifestyles, as well as qualitative instruments for extracting and analysing the data relevant to addressing this question. To illuminate, the main aim of the study was to gain insights into the everyday properties and processes underlying the empirical evidence depicting an association between lower socioeconomic living contexts and less physically active lifestyles (Mokdad et al., 2003; Lindstrom, Hanson & Ostergren, 2001). Importantly, we sought to unearth the key occurrences within poorer contexts that result in a particular construction or treatment of it there, conceptualise these within theoretical paradigm to both guide, and be tested in, future research.

In accordance with this aim, first, we adopted a theorisation of “contexts” from Berger and Luckman (1966) who understand it as a reflexive relationship between people's backgrounds and dispositions on the one hand, and the milieu and environments they inhabit on the other hand. Second, we describe the coupling of this conceptual and philosophical shift with the social constructionist approach to grounded theory as proposed and practised by Charmaz (2006) and others (Hjalmarson, Strandmark & Klassbo, 2007; Lesch & Kruger, 2005). Third, we outline data collection and analysis according to the principles that are typical of this qualitative approach. Fourth, we discuss the identification of the key processes and social interactions within participants’ housing and neighbourhood contexts which have affected their propensity to lead active and healthy lifestyles and develop these into conceptual categories. Fifth and finally, we identify a core category, and implications of these findings for future interventions.

Re-thinking context: A theoretical point of departure

This paper extends work oriented to capturing the relationship between living contexts and health practices by applying Berger and Luckman's philosophical framework devised in their 1966 work The social construction of reality to this empirical problem. Their conceptual framework emphasises the roles of agency, context, and subjectivity, in how particular human behavioural patterns arise over a period of time in particular social settings. Berger and Luckman offer a contextual, rather than a universal framework for thinking about and analysing patterns in human behaviour. In doing this, they illuminate contexts as powerful proponents of human behaviour, and theorise how norms, routines, and patterns of practice develop within them. For this reason, we propose that their work is directly suited to studying and analysing how living contexts work to give rise to particular behavioural and lifestyle profiles.

In Berger and Luckman's 1966 work, they proposed that people participate in social processes within a particular context over time to decide what things mean there, and what “the done thing” is amongst its occupants. They referred to this normalisation of procedures and responses over time as habituation and noted that over time, these habits become institutionalised in that context and taken for granted as “normal behaviour”. They further purported that the points of reference people use for assessing how to respond to something or somewhere and their interpretation of the behaviour of others there, depends on their personal and shared histories and experiences. They referred to this notion as historicity. The study applied the concepts of habituation, institutionalisation, and historicity to the problem of researching the responses of a particular socioeconomic group to a new urban environment, with particular attention paid to the amount of physical activity they became involved in. In line with this social constructionist perspective, we sought a subjective account of the world where physical activity has a low-priority status. A temporal account of poorer social contexts, and the dialectical tensions between human agency and social forces within them was undertaken.

Methodological design

Owing to the initiative in this study which sought to build the theory around the question of how physical activity is socially constructed within poorer living environments, Charmaz’ constructivist approach to grounded theory seemed to be most fitting with this particular conceptual approach, or “world view”. This is because constructivist grounded theory allows for a more flexible methodological approach (Mills, Bonner & Francis, 2006) and brings questions to the research process—with consequences for method and analysis—from the same school of thought as the Berger and Luckman philosophy. However, it must be noted that Charmaz did not specifically advocate using the Berger and Luckman framework, but takes a broader constructivist approach to grounded theory, in which the subjectivity inherent within analysis and theoretical development is acknowledged, and reflection on the role of the researcher in the production of data emphasised. Charmaz has taken a divergent, and yet increasingly accepted means of employing a grounded theory approach, which she refers to as a social constructionist approach to grounded theory, and emphasises the need for flexible guidelines, ‘not methodological rules, recipes and requirements’ (p. 20).

Charmaz (2006) reminds that taking a social constructionist approach to research means acknowledging that subjectivity applies also to the researchers, who are only able to interpret interpretations, and construct constructions provided by the participants. She argues that researchers bring their own histories, theories, values and ideas to the process of generating theory from data. Charmaz herself says, “Data do not provide a window on reality. Rather, the ‘discovered’ reality arises from the interactive processes and its temporal, cultural, and structural contexts” (Charmaz, 2000, p. 524). Thus, consideration must be given to both the researchers’ and participants’ backgrounds when data is being collected, selected, and analysed. A reflexive, interpretive approach to the data must be taken if there is an ongoing understanding of it being socially produced between the researcher and the participant. Further, she emphasises the need to keep returning to the study site to build concepts via the process of theoretical sampling, and to constantly compare and contrast data between individual cases, and to reflect on the relationship between researchers and participants as the theory is being developed.

While this study lies on the constructivist end of the Glaser-to-Charmaz approach to grounded theory (Hallberg, 2006), the unique methodological approach of this study is that it is guided by the specific version of social constructionism introduced by Berger and Luckman (1966) to build new theory around the relationships between poor living places and poor health. It acknowledges the iterative, and relatively subjective, process of theory building, but is primarily concerned with gaining insights into the perspectives of people who inhabit a poorer living context to tell us what physical activity—as a concept and practice—means there, and how this meaning was socially constructed over time. Importantly, it aims to use a social constructionist lens to build a theory with the capacity to hold explanatory power in relation to what has been described by McIntyre, Ellaway and Cummins (2002) as ‘a black box of mysterious influences on health’ (p. 125). Other studies on health-behaviours using Charmaz’ approach to grounded theory were located (Hjalmarson et al., 2007; Lesch & Kruger, 2005), however these authors made no reference to the conceptual framework of Berger and Luckman as a means of guiding the selection, collection or analysis of the data.

Location of the study: The Kelvin Grove Urban Village (KGUV)

This study investigated the residential population living within the four blocks of ‘affordable housing’ apartments within the Kelvin Grove Urban Village (KGUV; www.kgurbanvillage. com.au). KGUV is an AU-$800 million mixed-tenure, medium density, inner urban, master planned community based on the design principles of “new urbanism” located approximately two kilometres from the Central Business District (CBD) of Brisbane, Australia. It sits on approximately 16 hectares and contains approximately 2000 residential properties from both the public and private sectors. KGUV was designed according to the principles of new urbanism, thus promoting pedestrian mobility and activity through the provision of wide-pathways, bikeways, parks, and green recreational spaces. The KGUV provided a microcosm that generates aspects of human behaviour that are of interest in an investigation exploring the dynamics between lower socioeconomic living contexts and the propensity to be physically active. The case study of KGUV enabled an identification of the key relationships at stake in the adaptation of affordable housing residents to a “healthy environment”. Thus, the grounded theory techniques were applied within the KGUV context, because this particular neighbourhood site was seen to be theoretically representative of a development that encapsulated the relationships that were the focus of this study.

Study participants

Only the residents housed in the affordable housing—or government supported—housing options within the village participated in this study. Entry into this housing option is based on income-criteria, with only low-income singles, families, and pensioners qualifying for entry. They were all from disadvantaged backgrounds, on low incomes, and clustered together in a lower socioeconomic residential context within the broader context of the village, thus providing an opportunity to study this group of people, their low-income living context, and their perceptions and practices in relation to physical activity.

While a relatively heterogeneous mix of people within the affordable housing option at KGUV was recruited for the initial phase of data collection, the following two processes of participant recruitment were refined to seek out people who were most disadvantaged and the poorest in the group, in order to ascertain insight to experiences in their lives that prevented them from pursuing physical activity. Further, Charmaz (2006) refers to theoretical sampling more as a strategy than a process, and for our purposes, it worked well to not only develop categories that emerged in the first phase of data collection, but to fill in gaps that became evident in early phases of collection and analysis. Table I summarises the participants and data collection phases.

Table I.  Participants and data collection phases in the study.

Participants	Data collection
16	Blogging: An online mechanism known as a “blog” was appropriated as a means where residents wrote answers, stories, and opinions about KGUV in relation to healthy lifestyles. There were 214 responses posted on the blog in total. Blog address: http://theeffectsofanewurbancontextonhealth.blogspot.com/
8	Face-to-face interviews: One to two hours in-depth interviews were conducted with BHC residents in their apartments about how their living contexts affect their lifestyles and health.
6	Community focus group: Informal, opportunistic interviewing and observation notes were taken from BBQ in local park organized by researchers for BHC residents.

The researchers

The researchers were all of a higher socioeconomic background than the participants in the study were. The potential barriers created by the social and economic differences between the researcher and participants needs to be acknowledged and addressed in the research process (Charmaz, 2006; Lesch & Kruger, 2005). However, the background experience in counselling and home visiting in the area of housing services by the first author who conducted all the interviews helped develop a comfortable relationship with the participants. By sharing and swapping personal stories and comparative experiences in a few visits prior to each interview, trust was established and a sense of safety, and the ability to be open in conversation was established. Reflective notes were written on the constant divergence between the researcher's focus on physical activity, and the focus brought to the interviews by the participants on other aspects of their lives that were salient to them in shaping their current attitudes and beliefs in relation to health.

Entry into the field

The first round of participants was recruited via a survey, which was distributed in an earlier phase of this research project. Respondents returned their surveys, and agreed to participate in further research. Thus, this initial group was relatively accessible and enthusiastic to be involved with further study. However, the participants in phases two and three were the “hard-to-reach” group via whom we sought to tap into the processes giving rise to the evidence base depicting low activity levels amongst poorer populations. Invitations were posted in their mailboxes offering AU-$30 per interview, and AU-$10 for participation in the focus group. The affordable housing residents responded to this offer, primarily by contacting the researchers from the public telephones in the village. Participants in stages two and three were difficult to interview in the first instance as they were initially slightly mistrusting of the researcher; few had home telephones connected; and were often involved in court cases and social services, which made their daily schedules unpredictable. However, over time, a good rapport with the residents was established, and they benefited by receiving food parcels, children's clothing and referral to local welfare services.

Ethical clearance

An ethics application was approved by Queensland University of Technology (QUT) to conduct the study. Data was collected over a six-month period, including the online and face-to-face phases.

Data sources

1. Online blog entries

Sixteen residents in the affordable housing option at KGUV who had agreed to participate in further research following the completion of the survey were selected for the online qualitative data collection phase through a web log (“blog”). A blog is an online public forum traditionally used by a single author for writing a diary, and is often accompanied by photographic accounts to tell stories and share interests and viewpoints with others (Bachnik et al., 2005, p. 1). We chose this medium as it offers participants the opportunity to write their stories, opinions, and answers to the research questions in an online forum where they are able to view the anonymous input of other members of the community, and from where we could study their answers as a collective. Photographs of the neighbourhood were posted, as well as questions for participants to answer following these key themes:

• Self, health and space: What moves you?

• Social and psychological aspects of physical activity.

• Depth of engagement with neighbourhood resources for physical activity.

• Moving into a new urban environment.

• The effects of a new urban context on health.

Figure 1 is a sample from the blog to demonstrate its appearance on screen: 214 comments were made by participants on the blog. All data can be viewed at the blog site: http://theeffectsofanewurbancontextonhealth.blogspot.com/

Figure 1.  Social and psychological aspects of physical activity.

2. Interviews

One to two hour semi-structured, in-depth interviews with eight additional participants allowed an exploration of previous and current households and neighbourhoods as they related to the health and physical activity levels of participants. Questions were open-ended, and further questioning encouraged participants to talk at length about their previous experiences in households and neighbourhoods. Participants were left to emphasise what they felt was important to them, and raised topics, contextual characteristics, and past events that they recalled as being salient in terms of how it affected their propensity to be physically active. Notes and memos were written up both during and immediately after the interviews were conducted and recorded.

3. Outdoor community focus group

A further six affordable housing residents participated in an outdoor focus group held in one of the recreational areas in the village. In addition to the grocery vouchers, they were provided with a lunch during this interview phase. In this session, the interviewer focussed on the more notable similarities and differences that had emerged in the initial interviews regarding the nature of the urban village environment for pursuing physically active lifestyles, and directed the discussion around clarifying these points. This process of theoretical sampling allowed for the saturation of the emerging conceptual categories. The participants spent some time negotiating their perceptions of the village, their experiences in previous neighbourhoods, and their propensity to physical exercise, as a group.

Analysis: A social constructionist approach

According to Charmaz (2006), a core benefit of the social constructionist grounded theory approach, is gaining an insider perspective of the meanings behind the patterns of behaviour that can be observed in a particular context. This approach allows a focus on time, culture, and context; challenging concepts to examine using traditional, positivist methods (Hallberg, 2006). In an analytical sense, we adhered to the Berger and Luckman (1966) approach to studying human practice in context by noting the patterns of practice there, and then exploring the social influences involved in the construction of these over time. We explored the historicity of a particular social group to unearth the habituation of their conceptual relationship with physical activity as it evolved over time. We analysed the data for clues as to how this important health-related behaviour come to be institutionalised within their living contexts as a negative or low priority construct. Thus, concepts were built out of the stories told by the participants about their childhoods, their teenage years, their experiences in previous poor neighbourhoods, and their perceptions and practices around physical activity in their current neighbourhoods at this point in their lives.

The data from the blog and the transcripts from the interviews and focus group were transferred into NVivo software for coding and analysis. An inductive analysis fitting with the constructionist approach that emphasises the importance of respondents’ narratives of their experiences was used (Charmaz, 2006). In line with the emphasis Charmaz (1995) makes to focus on processes, actions and consequences we conducted a line-by-line coding procedure which provided subjective, temporal accounts of how physical activity as a concept was shaped and reinforced over time amongst these participants. The phrases and narratives they provided revealed how the different social and living contexts through which they travelled had ensured harsh and hostile barriers to feeling confident about both their body image and their ability to become physically active. We also used focussed coding, which is a more directive means of locating emerging themes and codes in the data, to identify the key processes mediating the people, place and health relationship in this case. Charmaz (2006) uses this focussed approach to develop the conceptual categories, which, according to Moghaddam (2006) become the “building blocks” for the theoretical development later in the process. This focussed, or conceptual coding, involves an abstraction of the data as it has been collected, organised and analysed into sets of shared phenomena underpinning the narratives (Charmaz, 2000). These analytic codes or categories allow us to develop a conceptualisation of the data as it is collected, recorded, and analysed. We developed a number of conceptual codes that appeared to underpin the collective experiences representing the evolution of the attitudes, beliefs and behaviours in relation to physical activity amongst that residential group.

This was followed by an exploration of how these conceptual categories relate to one another within the context of the groups’ experiences over time. In other words, while we could gather together key shared experiences and phenomena—such as abuse, neglect, early homelessness, or feeling afraid in one's neighbourhood—we then had to explore their connectedness to one another in order to develop the theory. In other words, how do these concepts tie together in a meaningful way and what is the core category mediating these subsets? To do this, we developed sub-categories, for example, “types of abuse” and “different experiences and contexts of abuse” that tied to this important category. The next important category of “leaving home early and homelessness” was analysed as relating to the previous category and a strategy, or consequence of the initial conditions of early childhood abuse and neglect. The key categories that typified their experiences growing up poor and how these related to one another in an almost catalytic sense were revealed in this part of the analysis.

Finally, a core category of identity management was located as the constant framing and reframing of self against others in poor contexts; the striving of participants to mould their identities as more palatable or less stigmatised than those around them, with strategies to do this often failing and resulting in even more unhealthy and harsh living situations. Theoretical coding was used to bring together the primary conceptual categories as they relate to the core category as a means of building theory and insight about how contexts affect physical activity levels. This process resulted in the production of a model for framing thinking and approaches in future research.

In addition to the analysis conducted on the data from the blog and the interviews, memos and observation notes were made to aid a reflection on the relationship between the goals of the research and the things that mattered most to participants in their living context. A consistent divergence from the topic of physical activity to “what matters to me here and now” was noted, and the events and reactions of salience to participants were categorised. Notes on the participants, such as smoking habits, weight, age, family dynamics, and the nature and contents of the households were also made.

Findings: Key conceptual categories mediating poor contexts and low physical activity levels

A model illustrating the results of the data analysis, the emergent key conceptual categories described above, and the core category of identity management are provided in Figure 2 below.

Figure 2.  Conceptual categories and core category emerging from a social constructionist grounded theory study into the relationships between poor living contexts and lower physical activity levels.

Figure 2 demonstrates the key categories that emerged as typical of experiences within poor contexts over the life-course that generate barriers to physical activity, as mediated by the core category of ongoing identity management in this process. It depicts the key conceptual categories that typified the experiences of the participants in this study from their childhood living environments to their current circumstances and experiences. The model indicates the catalytic chain of events that characterised the stories of all participants, and even if the abuse or neglect came in various forms, it was an ever-present trait of their childhood experiences. Their descriptions of their previous living contexts go some way to explaining their current perceptions, constructions and practices of physical activity and their experience of their body image in public spaces. The data analysis revealed that role of “context”—be it defined or measured socially, economically, or geographically—is a powerful factor influencing people's sense of identity and health-related practices such as physical activity. Their sense of self, place, and health appeared to be inextricably linked in the data, pointing to the need to intervene on a broad front to improve self-worth and health in these contexts.

The following quotes from the data demonstrate how the coding process developed, and how the conceptual categories formed from the stories told by participants about their previous living contexts, and their current attitudes and norms in relation to active and healthy living in their new neighbourhood environment.

Being flogged up something fierce: Conditions in childhood as catalysts for patterns in later life

An important historical theme that emerged in the data was how participants were treated by others over the various social and living contexts they traversed throughout their lives. Their sense of “self” had been greatly damaged in the first instance by spending their formative years in violent, neglectful, and psychologically and emotionally damaging places. It is important to ask of early scenarios that emerge in the data “What is happening in this data? What is the basic socio-psychological problem?” Each contextual scenario that participants described revealed a process wherein their sense of self and identity was being damaged by the various dimensions and properties of poverty. Further, their strategic responses for managing their circumstances and their sense of self meant that they were less able to focus on a health-related behaviour such as physical activity as a priority. For example, we began the interviews by asking participants about the extent to which being physical activity had been a priority in their childhood living environments, and the answers they provided all went similarly along the following tracks (I = Interviewer; P = Participant):

I: When you were growing up, how important was a healthy lifestyle in the family you grew up in? Were your parents or carers encouraging you to be fit and healthy or was it not really talked about that much. P: Not really talked about. We used to bring ourselves up. My mother was a real, you know. She wasn't a very nice person. We brung ourselves up and looked out for each other. I: So you had a lot of other things to worry about, besides health? P: Yeah, well my mum used to get flogged up somethin’ fierce, so … I: Can you tell me what you mean by that? P: She used to get, what's it called? Like, what do they call it on the TV? Like, domestic violence. I: Oh, your mum was beaten up? By your dad? P: Yeah, by my stepfathers. Not my real father, cause I didn't know who my real father was until I was 18. I've never met my father.

The relatively jarring re-orienting of the answers by participants that describe abusive and harsh childhood households from questions that inquired about health and physical activity, shed light on the powerful contextual influences in these early years that directed a priority from healthy living to sheer survival. The pictures painted for us by the participants of their roles as small, frightened child-figures in places that were meant to be safe, but were in fact filled with fear, darkness, and dread, go some way to answering questions about how poor contexts block pathways to physically active and healthy lifestyles. These rich narratives tell us that sexual, emotional, and physical abuse were powerful forces shaping their sense of self as children, and the extent to which they were able to feel confident about their identities and their bodies, as another story reveals:

I: When you were growing up, how important was it in the family you came from, or the household you grew up in to be healthy? Did your parents or carers emphasise this as a goal, or was it not so important? P: Um, I as a, well, growing up in my household, well there were lots of problems we faced on a daily basis. I: What kinds of problems? P: My stepfather abused us, um, my mum ended up staying with him for twelve years, which we in the end, just you know, got to the point where we were sick of it, cause we had enough. And my mum ended up carrying on a few of his traits, and me and mum clashed a lot, so … I: Right … P: I did have a weight problem when I was young, but I did something about it, I went and joined Jenny Craig and you know, and started losing weight, and you know, I dealt with it myself, because my mum used to call me horrible names about being overweight and that didn't help me.

Thus, in this example, we can see how the combination of abuse, household stress, and parental bullying held great implications for her perceptions of her body, her sense of self, and her general well-being.

The pertinent properties of lower socioeconomic contexts were identified in this study as abuse, neglect, alcoholism, violence, and parental bullying—often about participants’ weight or body images. Thus, it became evident that poverty was as much a property of these contexts as poor health practices were, with the psychosocial processes such as abuse and neglect being the powerful mediating these types of tangible “outcomes”. That is, the outcomes that are so often tended to in quantitative studies are merely the identifiable results of violent processes that diminish participants’ sense of self, and leaves them with the ongoing psychological battle of trying to improve this condition or perception in harsh and hostile contexts that constantly threaten their ability to feel positive about who they are and what they are capable of achieving. Abusive and neglectful early years meant that participants’ sense of self and personhood in the world remained in a constant state of risk, with the chain-reaction effect that ensured poverty, low physical activity levels, and poor sense of self ensued for the most part of the rest of their lives.

Running away: A strategy for surviving and starting again in hostile environments

In the descriptions of scenes in which abuse and neglect were the norm, participants struggled to find ways out of the conflict via their own resources. They all reported leaving home early, between the ages of eight and fourteen. This participant gave a vivid account of the conditions of her childhood, and the strategies she employed to deal with that living context:

P: Cause with alcoholism, I got molested by an uncle and I felt the best thing to do was to tell my mother. And I remember the guy saying, you can tell you and she's not going to believe you, and I told my mum and she would not believe me and I was really just hurt in the heart. I ran away. That was it, you know. She didn't believe me. Although before she died, before she died she knew that I was telling her the truth.

I: How old were you when this happened? P: Eight years old. I: Eight? And you ran away? P: Eight. And I kept on running away and running away.

All participants reported running away from home as a means of escaping contexts that were not a feasible option for them to continue inhabiting: “I ended up going into a homeless shelter …” The consequences of the strategy of escape or flight from these situations led in all of the cases to starting a “new family of their own” during their teen years, thus cementing their difficulties in relation to poverty due to limited options to develop further education, working skills or an earning capacity.

P: I didn't live at home, but I ended up falling pregnant. I was a runner. I: So where did you live, when you were 13, but still at school, and being a runner? P: I lived with Tom. They let me run for a couple more months, but then I ended up getting bigger and they said it would be too stressful. I: In year 9? P: Yeah, going into Year 10. I ended up getting out of school in year 10.

Further, many turned to drugs to cope during these teenage years: P: … then I ended up in rehab. I: So you got into some drug use and then rehabilitate? P: Yup and haven't been near it since I was sixteen. Nearly ten years.

Sleeping with one eye open: Living in poor neighbourhood contexts as young adults with children

Participants went on to describe living in and moving through neighbourhoods that were poor and unsafe. When we asked them to describe their relationship with these places, what they meant to them, and how they influenced their activity levels, participants reported high levels of danger and fear.

P: Before I was living in Fortitude Valley, and it was very unsafe there. I: OK, and what were the dangers? P: People robbing you of money, and stalking you.

And

P: Everythink. You can't even walk out your backdoor … I: For fear of? P: For fear of the kids, they can't ride their pushbikes 'cause they will get bashed and robbed for 'em. If you're out, after a certain time you will get rolled for shoes, your money, your wallet, different things like that. It was just … a lot of the areas aren't safe no more.

They describe living in fear due to the presence of a range of factors, such as discarded intravenous drug needles and crime, but also because of the relational dynamics that centre round intra and inter-household conflict and violence. For example, “I always had to sleep with one eye open, you know?” Another participant told many stories of crises occurring amongst neighbours, with police and ambulance call-outs:

P: But when the neighbours at night n that are having big arguments, and a lot of the time they come and there's the police or the ambulance and you can see the lights when the ambulance comes, and at times like that, I feel like I am in Once Were Warriors or something like that …

Importantly, one participant described the importance for her for needing to find a way out of her associations with poverty, danger, fear, and stigma. Her disapproval of being placed in government-supported housing with people in similar circumstances is clear here:

P: They think ‘Oh you live at that community housing place’. I: And do you think it reflects on you? P: Oh it does. Yeah. I think well they think I'm a drug addict just like everyone else is around here. And I … I feel like ‘I'm not one of them!’ And I don't want to be categorised into that.

And another stated: “ … but you haven't moved on, it's still housing commission”. As a result of the nature of these living environments, belief systems, attitudes, and norms developed around the importance of keeping to oneself and staying indoors to manage risks and stay safe—physically and emotionally. As one participant described her housing history: “It's a roof over your head and you keep to yourself.” While another explained her reasons for not wanting to socialise with neighbours:

P: That's just a personal thing for myself because I've been involved and been friends with neighbours and it doesn't turn out a good thing. I: Oh, OK? P: For myself, it always turns out it always seems to be a bad thing, and I dunno whether it's the people I meet or whether it's just myself, who knows? [Laughs.]

As a strategy of everyday risk-management in these contexts, participants expressed a preference for staying indoors. As one participant explained, she is not even comfortable being seen outside of her apartment:

“I'm not out here much. I very rarely venture out onto the balcony. Susie [her daughter] will come out here for fresh air to have her cigarettes. When you're out here, who knows who's watching you and from where.”

This relationship between sense of place and sense of self-being reflected in where you live, what is there, who is there, and what goes on there appeared to be salient in the data, with great implications for whether or not they are willing to leave their houses and feel safe, positive, or confident about engaging with the resources in the neighbourhood in ways that would ultimately improve their health.

You're just fat: Other intervening social interactions and influences on body image and physical activity

As is evident in this data, the contextual influences that shaped their relationship to managing their weight and being physically active are complex, and are comprised of a number of situational dynamics and environmental characteristics, which over time, have shaped their perception, or conceptual relationship with this particular health-related behaviour. The data reveals a psychosocial relationship between growing up in poor environments, experiencing difficulty with body weight and image, and a self-consciousness and general fear of others that then prohibits a propensity to be more physically active. Our data shows a connection between the characteristics and traits of poor households and neighbourhoods, such as violence, neglect, abuse and other dangers, and being less active, more over-weight, and consequently less likely to feel confident to engage in physical activity. One participant described the kinds of social challenges that arise from being overweight in public:

P: The thing that hit me the most in terms of my weight was when I went to the shopping centre just a couple of weeks ago, and I was putting on makeup because I was going for interviews for a job and I was with my girlfriend at the time and I said to her ‘Quick!’ cause she loves to try on all the make-up all the time, and I said ‘Quick! I gotta go to the toilet!’ and a lady turns around and says ‘Well that's what happens when you are expecting!’ And I was like ‘I'm not pregnant.’ And it just hit me like a ton of bricks, so I felt so horrible.

Another participant described her experience when she went to visit a doctor about trying to manage her weight:

“She [doctor] just turned around to me and said ‘Lay up on the bed’ and she grabbed my stomach and said ‘You're just fat, you need to lose some weight, can you do that?’ It shouldn't be like that.”

These kinds of social interactions and experiences deterred this group from wanting to be out in public too often, or from seeking assistance from health professionals to manage their weight better. There are clearly power differentials apparent in this last example that highlights the relationships between social status and feelings about body image, weight and exercise. This data also sheds light on potential reasons behind statistically proven weight differences between higher and lower socioeconomic demographics.

Exercise as a dream: The consequences of life-course contextual processes on the negative social construction of physical activity within this group.

The participants expressed the salience of the relationship between self or body image and their reluctance to engage publicly in physical activity for health and fitness reasons. They felt that the people who were able to do this must have had access to other means to looking as fit as they do, and that the participants were outside the realm of these recreational pursuits. Consider the following extracts:

P: If I see other people exercise I feel bad, as they are fitter and better looking than I am and I feel if people see me exercising I will just look fat and stupid, so it quietly motivates me to better myself but makes me feel bad …

Or:

P: I think, I would love to go for a jog or a run, but I dunno … I think when I look at them [other people running] that they've probably had liposuction … [laughs].

This self-consciousness seems to be contributing to a sense of “us” and “them” in terms of their own physical appearance or ability versus belonging to the social group that constitutes the “fit type”. “Yeah well we're really not a fit type like other people you see running around here and that [laughs]”.

While another participant has considered the potential of having community games organised in the local parks, she did not feel that she would automatically qualify for inclusion, as is expressed here: “Games in the park would be great. But I wonder if they would invite me … ” However, it is entirely not clear who the ‘they’ in her sentence is, aside from them having some kind of authority over the resources in relation to her requiring an invitation to participate. Further research is needed to unpack the relationship between the socioeconomic profile of co-located residents and their relative willingness or confidence to engage in the local neighbourhood to create more active lifestyles.

Primarily, participants expressed their sense of having a poor body image, or feeling overweight as a phenomenon that was incompatible with what they perceived physical activity to be about or associated with, as this participant explained: “My weight is a huge factor in my not wanting to exercise”. There seemed to be a relationship between looking and feeling good, and being prepared to be out and about and active, as is revealed to some extent here: “When I go into the bathroom now I don't even want to put make-up on because I just don't see the point. I only go out if I have to go out”.

The group generally felt that exercise was for people who had ideal body weights, or who looked like models and other celebrities, as this participant explained:

I: So what kinds of images or people come to mind when you think of physical activity? P: As soon as I think of exercise, I think of models. I: So for you it's mainly about body image and appearance? P: I think that that's the time we live in now, the bigger you are, the more down you get put.

Further, participants expressed that the pursuit of physical activity for health and fitness reasons was out of bounds for most of them, who did not perceive it as a realistic or accessible goal in a “real life” sense:

P: No, yeah, I would love to be fit. I walk past gyms and see fit people, and it really makes me think of going in, joining in …  I: Ah yeah, really? P: But as soon as I walk past it, I think it's just a dream.

In light of their negative (dis)associations with physical activity, body image and weight-control, we explored their relationship with media sources and health promotion on the topic of physical activity. There was a strong agreement amongst participants that neither commercial nor government sources of information or promotion of physical activity were to be trusted. As these participants stated:

• No. TV does not sell me on anything. I think there is too much said about diets and exercise.

• I am not usually prone to just accept because TV or papers tell me this or that will benefit me health wise or physically.

• I never act on advertising and am not influenced by other people's comments regarding becoming fitter.

• Jenny Craig, or the advertisements where they are selling all these gym products “You can look like this, just 20 minutes three times a day” and that is just like “Yeah right!”

Participants did, however, say that they enjoyed watching the show “Australia's Biggest Loser” as they could relate to the struggles of the people in the show to combat their obesity, and felt that these were just ordinary people like them, with similar weight issues and inhibitions regarding physical activity. They especially liked the attention given to participants on the show in terms of advice on their everyday diets, and expressed a desire for help from GPs to better manage their weight, as this participant explained:

“Yeah I don't want them to sit there and tell me you need to eat this on this day, and this on this day, but if they could just write down a list of what the most healthiest foods are, I could make my own list.”

The data unpacked a negative construction of physical activity in this context, and found that it was a concept that did not make them feel positive about themselves, and for which there were currently few avenues or trusted sources for seeking assistance for changing its awkward position in their lives. The stories told here describe links between structural features of poor environments, a decreased propensity to be physically active, an increased propensity to be overweight, and a negative social construction around the concept and promotion of physical activity by health professionals.

Discussion and conclusion

The aim of this study was to begin to unearth the properties and processes within poorer living contexts that give rise to less active and healthy lifestyles. Thus, the qualitative approach taken here allowed us to open up a microcosm of urban life to examine what goes on in these poorer contexts—both past and present—to equip socioeconomic contexts with powers to predict lifestyles and health, and in particular, physical activity. In the online and face-to-face stories told by the participants, these contextual factors were revealed as the social properties of poverty that were most harmful to participants’ sense of self and their chance of survival—let alone good health, and which provoked particular reactions to try and counteract the hostile aspects of these environments. As seen in the data, the ironic and invariable consequences of these various strategies resulted in worsening circumstances for the participants in a type of downward spiral effect. For example, child abuse leading to homelessness, leading to drug abuse and dependence, early pregnancies, and ongoing poverty and so on.

Participants had generally shared similar contextual experiences in relation to difficult and hostile physical and social experiences which formulated identities around being fat, unfit, and separate from people who had the luxury of looking good and being able to exercise in public. There are qualities attached to harsh socioeconomic environments that affect children from a young age in relation to their sense of place, their sense of self, and their identities in relation to health and healthy living. Aside from suffering from a poor body image and a “fat” identity, the kinds of social interactions within these contexts triggered an interesting psychosocial and behavioural response in participants. The high levels of neighbourhood conflict in poorer areas created a tendency to “stay indoors and keep to yourself”; these kinds of strategies of-course being counterproductive to staying fit and active and maintaining a healthy body weight. This essentially introverted response to the context had two key underlying motivations: first, physical protection, and second, identity protection.

What appeared paramount to participants in these contexts was defining “us” against “them” no matter how similar their circumstances were to that of their neighbours. This managing of identity in light of their poor individual circumstances within the broader context of an equally poor and disadvantaged context was a crucial part of their every day psychological survival there. The demarcation participants constantly made between themselves and the other occupants of poorer living environments shed light on high important it was to them to appear to have “moved on or up” and to somehow have shed the baggage of having grown up with and lived through similar hardships as those around them. Poorer contexts appear to act as powerful and unwanted mirrors of their pasts, their present and ongoing struggle with poverty, and their fear of a future wherein things do not improve, or perhaps get worse. It appears that poor “composition” (individual measures of socioeconomic position) is negatively compounded by poorer “contexts” (group measures of socioeconomic position), the latter or which acts as some kind of psychological maze of mirrors from which individuals feel unlikely to escape or move on from into environments that generate stronger, more positive, and ultimately healthier identities. Future studies need to consider socioeconomic position and contexts—however they are “measured”—as meaningful social properties and environments in which self is constructed and health is affected in a cyclic and reinforcing manner.

For our purposes, the Berger and Luckman premise laid the groundwork for investigating the social processes and dynamics via which the “treatment” of physical activity by a particular group is habituated and institutionalised in those contexts over time. It brought into question what physical activity as a concept or practice means in that setting, if anything, and why. The Berger and Luckman framework navigated a focus onto the context itself in order to try and understand what goes on there, and what happens to physical activity there. For example, whereas as health researchers and practitioners hold a behaviour, such as physical activity, high on their list of goals and priorities, and have a fervent interest in reducing the obesity epidemic, this is not necessarily the case in lower socioeconomic living environments. Nor does the simple provision of health-related resources for people living in poor contexts mean that they will immediately become more physically active, or interpret and engage with those resources in ways that improve their health. A linear relationship between access and use cannot be assumed. Researchers and practitioners need to understand where “health” is in poorer living contexts—and the processes by which it got there—in order to create more informed and insightful intervention responses.

The unearthing of the core category of identity in this study names a central psychosocial phenomenon mediating the relationships between people, place, and health. Identity is affected in an iterative and ongoing sense wherein people's sense of self is moulded and compounded by where they live, whom they live with, and how they perceive the composition of this context or environment. This development of self-in-place-in-society affects how people view themselves, how confident they are about their bodies, and their use or exhibition of their bodies in public space. Their consequent health-related behaviours and practices then feed back into their sense of identity, with the individual developing and living at the core of the people, place and health dynamic.

In a substantive sense, this data revealed that highly sensitive programs are needed for people who have experienced poor or hostile living contexts, and who have negative body images and associations with exercise. Affordable spaces that are socially, psychologically, and physically safe for them to become active within and achieve a greater sense of both health and self are needed. In an empirical sense, the research conducted here provides contextual depth or “background information” to the evidence established in social epidemiology that notes that people from lower socioeconomic backgrounds are more likely to be overweight than their wealthier counterparts (Mokdad et al., 2003), are less likely to engage in recommended physical activity levels (Lindstrom et al., 2001), as well as with findings from a study showing that people living in poor neighbourhoods are less likely to be physically active, even in cases where their access to facilities is superior to those living in wealthier areas (Giles-Corti & Donovan, 2002).

In a conceptual or theoretical sense, this qualitative study demonstrated how being poor or unhealthy or living in a poor place are all dimensions of context that comprise an individual's social and psychological experiences and construction of self over time; and that this process cannot be understood effectively in a linear, or causal sense. It pitches the concept of context as something people carry in their heads, and which develops over time to comprise their frames of reference, their boundaries, and their individual and social identities. Contexts in this sense are far more related to a person's outlook, perspective, and lifestyle than they are a measure of geographical region or socioeconomic position. While “poorer contexts” in a geographical sense exist for economic reasons, “unhealthy contexts” are generated by the social interactions and psychological processes that make unhealthy lifestyles the cultural property of poorer territories over time. We propose that a conceptualisation of “contextual effects” as the social and psychological constructions of self in place over time, with implications for health is likely to produce more insightful studies into socioeconomic health inequalities, and generate more sensitive and refined interventions amongst poorer groups in the future.

The substantive knowledge that has been unearthed brings implications for health promotion, health inequalities research, and urban design. The conceptualisation of contexts as socially constructed, and the attention paid to agency, time, and the human production of collective responses to a social context provided an abstraction or theoretical paradigm for thinking about poorer households and neighbourhoods as they pertain to health in future. We advocate the use of post-positivist approaches, such as the methodological framework devised by Charmaz (1995, 2006) that was followed here as a means of exposing in greater detail the mechanisms linking various measures of socioeconomic position, especially overtly social, contextual measures, such as area of residence and occupation, to unhealthy behaviours. Greater collaboration between quantitative and qualitative researchers is needed in order to understand and more effectively intervene in lower socioeconomic contexts in the future.

Reflections on methodological limitations

Theoretically, this case study allows us to propose that what we find out about this scenario may be relevant to other similar settings and urban environments. The knowledge produced via the investigation of this case study will be used for future testing to see how widely the theories or key concepts can be applied. The findings are valid within the case study, and cannot be generalised to all other urban environments and contexts. However, it does allow a case for producing knowledge for testing in other populations and areas.

Acknowledgements

This research was supported under the Australian Research Council's Discovery Projects funding scheme, project number DP0663854, New Media in the Urban Village: Mapping Communicative Ecologies and Socio-Economic Innovation in Emerging Inner-City Residential Developments. The authors thank the Brisbane Housing Company (BHC) and the project team of the Kelvin Grove Urban Village for allowing the research project to be undertaken. The authors also thank the men and women who participated in this research.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.