Chapter 9 Understanding healthy ageing using a qualitative approach: the value of narratives and individual biographies JD Carpentieri and Jane Elliott 9.1 Introduction to understanding healthy ageing using a qualitative approach How can narrative methods be used inf course research on hay ageing, and in what ways can ey provide insights not rable throogh qntaive data? How can qualia and qu tuative tppreaches to studies ofthe Ife course be combined inorder to sl aldtional ligt on Telly ageing These quetions form te focus of this chapie, wich draws on mater fom cqsitanve biographical interviews with members ofthe MRC National Survey of Health and Development (NSHD) andthe Hertfordshire Cohet Study (HIS), to provide narative case stories This chapter highlights the methodological value Of ich narratives When sedking tne Rand older peoples own experiences of heath and ageing It des sy ft introducing key themes and concepts in narrative research and then dscising those themes in relation to thee individual case dle, ach of which hes been anonymated (Section 9.) 9.2 What is a narrative? ‘The most concise definition of narrative isa story with a beginning, a middle, and an erd—this ‘description has been traced back to Aristotle in his Poetics [1-3]. However, a successful narrative is more than justa sequence or chronicle of events. Indeed, Labov and Waletaky [4:p. 12] sug- ‘gested that although 2 sequence of actions is sufficient for a minimal narrative, such a narrative {s"abnormal: ii may be considered as empty or pointless:‘They argued that adetining feature of @ typical narrative is thatthe teller does not just list events or actions; he or she interprets them. The narrator makes sense of those experiences both for him or herself and for the audience. Given the spociic interest for many qualitative researchers in understanding the meanings of evenis and experiences from an individual’ perspective, itis clear why narrative can be seen asa powerful tnd useful tool for understanding healthy ageing from allfe course perspective. Narratives do not just tellus what hashappenec: they tell us what those events or happenings mean to thenamrator. They can therefore provide valuable information about older peoples diverse experiences of heath and ageing. 92.) Big stories and small stories ‘Within the field of narrative analysis, distinctions can be made between ‘big storie and ‘small sto- ries [5-7]. Big stories ae the grand, biographical narratives of lives; they tend to focus on major events, experiences and turning points. These events and experiences are connected to forma life story [7] n contrast, small stories tend to focus on mundane events and everyday occurrences. ‘Whereas big stories tend to be elicited by interviewers, small stories occur more naturally —these9.3 NAFRATIVES OF HEALTH, AGEING AND NLMESS | 119 ate the typeof anecdotes thet might occur in everyday conversation, Such anscdotes also occur in ‘open and semi-structured interviews, but are unlikely to appear inthe carefully structured inter ‘views most often used to collect quantitative data. Inthecontext othe research dicussed here, which involved qualtave biogrophicalntrvews with members of established cohort studies, researchers might expect congruence between the big story told by the interviewee, andthe information that could be derived ‘rom the prospective Jongtucinal data in constructing a case study ofa particular individual, For example, one of the ‘ease studies in this chapter centres on Patricia, 72 year-old woman. tn her qualitative interview, Patricia lf story includes the folowing key evens: geting married in her early fortis to a man \who was considerably older than her and who already had three chiléren; never having children of her own; enjoying successful working life; and rering inher erly stetes when her husband sutfereda stroke These key structuring elements ofthe Ife story areal ikely to have been recor din the cohort studs quantitative Jngtudinal data (although the meaning forthe individual more likely to be sared ina qualitative interview). In contrast, the smal stories ate those which provide insights into experiences of dally life andthe significance of those experiences, These are ‘very unlkely to be captured in the more structured quantitative longitudinal daca. The case tad ies below provide more examples of these small stores and exemplify how they might shed tight fn the Ive experiences of healthy ageing or, conversely, the impact of poor health and capability ‘onan individual's quay of life and welling. ‘A major advantage of conducting qualitative interviews with individuals who are already part ‘ofa large scalequanttative study is that is possibe to place these individual casesand narratives, in context. Each individuals big sory and small stories can be understood agains the backdrop othe detaed quantitative data collected from the larger sample. Therefore, foreach of the case studies we provide some brief information from thetr uanttative record. 9.3 Narratives of health, ageing and illness 9.3.1 Healthy ageing [Muh ofthe now considerable erature on healthy ageing draws on qualitative rscarch evidence [8-13], and some of this takes an explicitly narrative approach [8,14], Indeed, much ofthis is discussed dsewhere (Chapters 1 and 4). ‘Natrtve hes featured in ihe terature on heath behaviour ane ealh education [15.16], Within the feld of the sociology of health,there has been a focus on lay perspectives of disease and patients! ‘own experiences of il health. In particular, for those suffering from chronic disease, the idea ofan “ines career hasbeen a use analyte tol and ean be realy expressed inthe form oa marative In Chapter 1, heal ageing is defined as encompassing heallhybilogical ageing and high levels of psychological and social wellbeing: When looking at the key themes that older people themselves focus on as central o heathy ageing, qualitave researchers have found an emphasis on being engaged in meaningil activites, having the ably and resources io engage in at tnd having a postive atitude (Crapter 4), For example Bryant etal [9] found that sore older people conceptualized healthy ageing as ‘going and doing something meaning’ this in tara ‘equired a balance between'sblites and challenges Thishas clear resonances vith Lasts origi ‘al wor conceptualizing the tied age, which stresses the importance of ef-actualizaton [17} 9.3.2 Narrative identity ‘An interest in nazrative in qualitative research has clear resonances with theoretical work on the ‘concept of narrative identity [18-22] ‘The term ‘identity’ can be understood in two ways. On the120 | UvoeRsTaNDING HEALTHY AGENG Lista A QUALTATIVE APPROACH ‘one hand there ts the notion of identity as exactly the same, equivalent or identical (the Latin dem), Alternatively, identity can be used to refer to continuity or something that can be traced through time, The Latin ips or ‘se same’ (so%-méme in French) suggests this sense of identity 4s permanence without sameness through time [23]. Narrative fits with this conceptualization of Individual identity as self-same; ia that it provides the practical means by which a person can ‘undesstand themselves as living through time, a human subject with a past, present and future, made whole by the coherence ofthe narrative plot with a beginning, a mide, and an end 20}, ‘The narrative constitution ofthe self suggests that subjectivity is neither an incoherent stream of vents, nor fs itimmutabie and ineapabe of evolution [21], 9.33 Narrative gerontology Narrative gerontology and an emphasis on healthy o active ageing might be thought of by seme asthe ‘new’ gerontology (24), but its origins can be traced backtto at least the mid-1990« (25. le 's based on the concept, or metaphor, ofife as tory and therefore has siriarties with narrative Psychology, Much ofthe work that influenced by narrative gerontology is linked to qualitative or theoretical workon what it means to beold and on howto work with, and care for, older adults ‘There's therefore an emphasis on using narrative gerontology in practice and with practitioners. "Narrative getoniology puts an emphasis on the wisdom of the oldand the advantages in oldage of having greater life experience and more disposable time in which to reflect on and male sense of that life experience [26] t also encourages an awareness ofthe stereotypical discourses of decline and ageing that inform much of societal thinking about what it means tobe old [27]. Narrative serontology suggests that individuals need to have ‘narrative capital’ or ‘a good strong sory! in order to enable them to maintain levels of wellbeing. A central tenet of narrative gerontology ie {hat identity developmentis«lislong process; the selfs seen asa story that is continually devel- ‘ping [28-30], A key gal of active or healthy ageingis to avoid ‘narrative foreclosure’ or the sense ‘hat life is becoming hopeless and worthless [30-34]. Narativeforecosureis the ‘premature con Wiction that one} life story has effectively ended’ (35). The individual’ biographical development has stalled: the big stories have effectively ended, and only small stories remain. The narrator has moved into epilogue time’ [3:p. 193). Another way oflookingat this process is in terms of biographical disruption. Several rescarch- «ershave investigated the impact of chronic ill heath on individuals sense of identity [37-42]. In particular, Bury /43) showed unexpected chroniclinssas biographically disruptive: the sufferer’ narrative thread linking pas, present, and expected future is broken by poot health. However, ill health does not necessarily have the same impact on all sufferers’ (dentities. Bury’ original ‘work was with younger adults suffering from arthrtis—an unexpected condition for that age group. For older adults, serious health problems may be perceived as biographically reinforcing or continuous, Pourd and colleagues [44] found that elderly men and women in a working-claee section of London experienced stroke a a 'normel crisis one that, while unwanted, was not neo. ‘sarily unexpected. Likewise, Sinding and Wiernikowsk [45] found that many older people did ‘ot experience cancer as disruptive to the’story oftheir lf the disease was sen a¢ anormal, Hographically continuous part of the ageing process. 3.4 Collecting individual biographies and narr: cohort studies Cohort studies have some clear narrative properties [46,47,57]. They enable us to follow indi- viduals’ lives through time and allow for the estimation of models that focus on how earlier lie /e through125 HOW WERE THE NARRATIVE CASE STUDIES CHOSEN FOR THIS CHAPTER? | 121 ‘experiences and environments may impact on later outcomes. However, the quantitative data col lected as part ofa cohort study could be thought of as being closer to. chronicle than a narrative. Events, experiences and dates are recorded, but the individual respondents are not typically asked t0 make meaning out of this information, or to provide their own narrative acount of ther life. ‘Rather, narratives may be constructed by researchers, who aim to make sense of the detailed data from @ large sarnple within the framework oftheir wa research questions. A major advantage of these qualitative interviews over other collections of narrative biographical data, is that itis pos sible to locate individuals within the context ofa large representative sample and to understand 10 what extent their experiences may be shared by othe:s with siailar charactersils. By carrying ‘out qualitative Interviews with cohort members, t was Intended to give the individuals themselves ‘an opportunity to provide an accountof their life that would complement the quantitative data ‘tha had been collected from and about them ever since they were born. Qualitative biographical ‘interviews were carried out with small subsamples ofthe HES (30 interviews in total), the MRC NSH (30 imterviews),and the National Child Development Study (the 1958 British birth eohert) (220 interviews,not used in ths chapter), For further details ofthe sample selection and interview process see Eliot etal [48,43], 9.5 How were the narrative case studies chosen for this chapter? [Aste focus of this book:is on healthy ageing, the aim was to select cases from the interviewed subsample that could shed light on healthy ageing and barriers to it. Three variables were used 10 identify cases, with two focusing on physical health and one on wellveing Fist was self-rated health (SRI), asingle variable with five response categories ranging from excellent to poor. SRH_ {sasimple but reliable tool for assessing general heath and predicting future health issues, includ ing mortality [50]. "The second physical indicator was self-reported physical capability: a score ‘was derived from a series of six questions about capability in dail life ranging from being able to bathcand dress oncself to beingable to run fora bus, ‘Among the 69 interviewees in the NSHD and HCS, seven rated their health as excellent, 26 as “very good! 21 as good, and six.as Tai. None of those interviewed rated their health as poor. In total there were five individuals with excellent self-rated health and good physical espablity one from the H1CS and four from the NSHD) and four with fair’ self-rated health and poor physical ‘capability (two from the HCS and two from the NSH), ‘Third iotakeaccount of psychological and socal factors cohort members’ Warwick Edinburgh ‘mental wellbeing scores—possible range 14 (lowest) to 70 (highest}—were also considered [51] “There was considerable heterogeneity in wellbeing among these small groups of individuals, with wellbeing scores ranging from 38 to 70, However, individuals with excellent self-rated health and ‘good physical capability had wellbeing scores ranging from 52 to 70, and those with only fair? health and poor physical capability ranged from 38 to 46, There was no overlap between the two ‘groups. ‘Based om this inital analysis of the quantitative data, three eases were selected for detailed nar- ‘ative analysis in this chapter: two females from the HCS and one male from the NSHD. Doreen is2.76 year-old woman with only fir self-rated health, poor physical cpabiity and a wellbe- ing score of just 41. Patricie is a 72 year-old woman with excellent self-rated health and good physical capability and a wellbeing score of 52. Alan isa 64 year-old man with excellent self-rated health, high physical capability and a wellbeing score of 70. These cases are discussed in turn in ‘Sections9.5 to 9.7. Each case has been anonymized to avoid the possibility of identifying the indi- ‘duals concerned. Nemes have been changed, and afew blographical details have been altered to oy ewe122 | UNDERSTANDING HEALTHY AGENG USING A QUALITATIVE APPROACH ‘obscure individual identities. Written consent was provided by each individual for their interview to be recorded, and for extricted quotations to be teprodiced in publications, reports, web pages, and other research outputs, ‘These three case sudles provide examples of different narratives of heslth and ageing. One ‘ncerviewee telisatale of untelthy ageing. The second interviewees narrative is ofa good level of physical health but fower than expected psyshotogicaland socal wellbeing, The third narrative i of very healthy and active ageing. 96 Doreen: This unfortunate 76 year-old’: a narrative of decline Doreen is 76 and lives wit her husband, Doreen and her husband have been living in the same ‘house ina small town in Hertfordshire for nearly 40 years. They have three grown children who live firtynearty and three grandchildren. Doreen lft education atage 15, but enjoyed her subse- ‘quent career asa shorthand typist She was foresd by il health to retire at age 61, {tn the quantitative imerview, Doreen rated her own health as fair, and indicated that it had declined greatly over the as year. Indeeé, she was the only individual ofthe 30 interviewed fom the HCS whose health had decined greatly, with 20 of 30 individuals stating that their health was about the same, Doreen has a body mass index (BMI) of 35 kg/m? Le. Grade 2 obesity (BMI > 35), ‘which isassociated with higher all-cause mortality than Grade | obesity (BML of 30 ~ < 35) [52 Dorcens Warwick-Fdinburgh wellbeing sore is4I; this ismore thaa one standard deviation (SD) lower than the sample mean for the whole cohort (51,7, SD 8.02) [33], but is average for those in the sample with far heakh and poor physical capably. The health problems that Doreen cites include obesity, breast cance, diabetes, ‘gouty arthritis, an ovarian cyst, swollen hands and feet, and a recent knee replacement. Wher asked how she would describe her health, Doreen quotes hher doctor: [He] says 'm a very unfortunate 76 year-old, ‘cause ve had s0 muuch yo wrong with ime ito of complications, Doreeais physical problems means she struggles with many routine activities of dally living, such as geting up and down stairs and bathing herse, Her husband, in turn, suffers from Alzhelme’s disease, She fs physically reliant on him he is mentally reliant on her. As she observes, they are ‘mutually dependent: ‘Th hs brain moi of the time and he helps me o do the things that T can’t do Doreenls poor heath is the central theme of her interview: almost every narrative becomes an ness narrative. This s true no matter what the topic or time period. For example, when asked Ufshe had a sweet tooth asa chid, Doreen quickly brings the question back to her current health pproblems:"No more than average, {would say—no, not more than average. Ive got Type 2 diabetes, since Ie been in my ststtes: Health problems provide aform of global coherence to her interview [4], exerting a seemingly inexorable gravitational pull on her narratives, ‘This is perhaps unsurprising, given the vicous downward spiral she finds herself in: her health problems reduce her capability and her reduced capebilty in turn, makes itvery dlfcultto engage {in behaviours that would lesen her health problems. Her lackof health makes it nearly impossible ‘olive healthily. Fer example, Doreen understands that she should be more active and do more ‘exercise, but her weight, and problems with her swollen feet and ankles, make this extremely shllenging, As she explains: wish I was more mole that jor sure. Everybody keeps tling me F struld walk aid do this an all that, but when hurts, i very dificult. These problems are exac- exbated by her suscepubility to falling, which Doreen partly attributes to the antidepressants she Js taking, Her health, capabilty end psychological wellbeing all negatively influence each other. This troublesome spiral has had a strongly negative effect on her sense of sel In particular, dhe no longer views herself as a ‘coper While Doreen has suffered heakh problems for decades, she97 parmicus | 128 ‘had always viewed herself as someone who coped well with them. In Doreen’ narrative, there isa ‘sense that there was 2'past self” that was psychologically capable of tiumphing over health prob- Jems: ‘T ook—; having cancer very well. You know, I mean tt was serious, and ft frightens you, but {think Look «very welf. However, since her knee replacement a year ago, she fels she has gone ‘downhill rapidly, and is now much more easly overwhelmed, Instead of being incorporated into her sense of seit tl-health is now overwhelming i. In Doreens bigstory’ there isa major rupture between past and present. A key theme throughs ‘out Doreen narrative is the contrast between her former self and her current self the diference between then and now: In discussing her younger days, Doreen emphasizes her active engage- ‘ment with the world, whether through work—she siarts the life story section of the interview by saying, ‘T foved work, I loved my job’—or through play. She tellsa number of small stories ‘emphasizing activity:as. child, playing outside, building tree houses, tobogganingand throwing snowballs; 25 an adul, going dancing and shopping, These stories are contrasted with her lack of ‘capability and her immobility in her old age. She repeatedly begins small stories with the phrase, “Tused 10, emphasizing what she can no tonger accomplish ‘I wish we had dane a bit more really, she laments. Her big story seems to have come to an unexpectedly eatty end, replaced by a series ‘of small stories about the challenges of day-i0-day life. ‘The stark contrast between Doreen past selfand her current one fits with the once prevailing view of ageing asa decline imo decrepitude and incapability (as discussed by Laslet [17] and Gallete (53}), or narrative foreclosure. 97 Patricia: ‘I know what to watch for’: a narrative of control Patricia is age 72 and lives with her husband Donald, whois fifteen years older. Inthe quantitative interview, Patricia described her health as excellent, just as it was a year ago. She has a high level, of physical capability and a BMI of 26 kg/m, ie just lightly above the recommended range. Her Warwick Eiinourgh wellbeing score is 52, which is very close to the mean score for this cohort of 51.7 (SD: 8.02) [53], However, itis the lowest of anyone with excellent self-rated health and good physical capability. Piricia describes an active childhood in which she enjoyed playing, and swam regularly and with some skill. As an adul, she had an interesting career as an administrator, a job she loved. She had no children of her own, but has stepchildren through her husband, Like Doreen, Patricia, retired carlier than planned —not because of her own health problems but because of her hus: bands Since retirement, she has continued to lead an active life, playing bridge and bowis every week She also enjoys gardening and exercises regulary, As she says “feo tha (aetchng exercct) prety regular actualy 1Ve get all he video aa all he dics. Ive done Plats, Ive done yoga... ve dame al 1 do enydhing to heep ry wage down’ Patricia's quabtative interview provides indications why her wellbeing is lower than expected, sven her good physical health and active lif. Her husband had a stroke over 10 years ago and is ‘now in a wheelchairs his incapacity means that Patricia has major caring responsibilities, These responsibilities constrain her life in a number of ways, For example, the couple have recently ‘moved to house with a smaller garden, While the new house is better suted to their capabilites, the move has left Patricia feling socially isolated. As she says: “ave been so busy going tes tdng sored out and rep thunking. must phone Berbara, must phone Jean Fast et cat wit hem. nd hey sor ft me alone Fk, realy a wewmecus124 | UNDERSTANDING HEALTHY AGENG USING A QUALTATWE APRROACH ‘In contrast to Doreen, heath does not dominate Patrica narratives. However, it does play an ‘important role—particularly her hustandts health problems and their impact on her own life. In pertculr Patricia eis anumber of small stories that provide insights into the negativeimpacts of ‘er usband’ heath on her own wellbeing Inthe following extrac, for example, Patricia explains semewhat raefully that driving holidays used 19 be a major part of the couple’ life together, but te longer are: ‘ont know whether well go anymore dont particalany—, he ks to yo weken eny to hotel in England, ut al rive, dre, dive for me, Ihave to pack i scot hs wheelhat ht tot seat sen ‘is backrest: lf hat hasty, for about 3or 4s rive ala the M25, down the MG iyo going 401th up thet way and youve got— i ahaste and jt den’ realy want tod it anymore you know eri ot Haugh: A second key theme of Patricia narratives is her proactive approach to her own health as she ‘ages. Patricia is very candid sbout the fact that she would not expect her stepchildren to take care other in later lif. Seis therefore already planning to move into sheltered accommodation when she isolder: Prsby when | eto abou B0-ocd1 might move Io ene of hee completes forthe ede, because Uoaven gota der you ses Pe got stepehilren but ts nc he same as Your ov chien, end ‘fel that Tl ve looked efter that ay If tt getup i te morning someone wold wonder shy ‘would they 1s striking that Patricia uses the age of ‘about 80-odé as a benchmark for when she will need to more, in this way she underlines her rationality, realism and abity to lan, but also distances, ‘herself from being derly’ or inthe fourth age, the age of decrepitude and decline [17,36]. There ‘also, of cours, an implicit optimism herein expecting that she wil ive to beat least '@0-oddin comparison with her parents, who died in their mid-seventies ‘Thisplen highlights another powerful contrast between the lifecourse narratives of Doreen and. Patricia. Doreens disrupted biography’ is evident inher reluctance to lookahead. Whea asked 2 question about the future, she sidesteps the question. In contras, Patricia narratives focus not Juston the past and present, but on her plans forthe future. Implicit inthis planting is Patric’ desire to exert as much control as posible over her health, inorder to minimize decline. This con. trols manifested through planning, exercise and medical care. fn her narratives, Patricia's inde. pendence, capability and rationality is often constructed in contrast to other Ives that have been dominated by ill health and incapacity, For example, after briefly discussing her father’ sudden death, she provides a detailed narrative of her mother’s chronic ill health, which persisted from her fortiesunil she died in her mid- seventies. Likewise, Patricia tllsthe interviewer that like her husband, she sufers from eye problems, but implies that she has learned from his experiences: "Tanow what to wach Jor 10 that i thre problem 1x, jut ge stright and ge sen tc 9.8 Alan:'I usually get up and walk... about 3 miles’: striding on—a narrative of healthy ageing Alan is 64 and lives with his wife."They have a son and daughter and several grandchildren, who all lve in Canada, Despite this distance, they area close arly, speaking regulary onthe phone and through Skype, and visiting each other every year. Alan has recently retired after « uccesafl cateerasa teacher and then Head of Year. He enjoys avery active ie including chess chb, helping to run ayouth group at church, singing ina choir, and regularly walking for pleasure.oe aan | 125 {In the quantitative interview, Alan described his general health as excellent and as about the sameas. year ago. He alo was scored as having high capability. His Warwick-Edinburgh welbe- {ng score was the maximum possible score of 70, an unusually high score for this cohort (wo hhave a mean of 1.9 and SD of 7.85). He hasa BMI of 23 kg/m i.e. within the normal range. Alaris overarching narrative is one of enviable good health and high levels of physical sctivity. His body Is dys-appearing’ somewhat, making itself more apparent through aches, pains and otherassorted other indicators of ageing [57|—but he hasno serious health concerns ai is highly active. "Tn the morning’ he suys,'I usually getup and walk....for an hour oF 30... about 3 mies” He regularly goes on longer walks, as well—for example, Say hike in Northern England, He and bis wife, who is also in good health, ate very socially engaged: "We go out quitea lot visting! hhenotes, adding, ‘Wee «lo of riends in the arta Whilehisexcelent health and high levels of activity could in theory be atributed to his relative- |y young age compared to Doreen and Patrica it i worth noting that Alanis several years older than Doreen was when she was forced to retire due toll health. He appears to be on a markedly dlfferent health trajectory than she was at his age {In contrast to Doreen and Patricia, health and illness have barely any presence in Alan's nar tatives. Tis is particularly noteworthy given the cental place of physical activity in these narra tives. In contrat to Patri, thisactviy is presented not asa strategy for keepinghhis weight down and maintaining good health, but as enjoyable for its own sake. For example, when asked what hhegets out of walking, Alan highlights aesthetic, psychological and physical pleasures, but does not overly polnt to health just beautiful, natural the animals and birds that you see, ‘and it makes yo fol good: Throughout his interview, heath—and its corollary, llness—are inthe distant background if they have presence at all However in onesmall story about his chess clab, Alan does highlight his awarenes ofthe long term benefits of staying ative and engaged Fea "Lappe ts god for your mind, bat that’ nat the reason [tll When yu get oer you think wet jus continue with tha, Thera guy who naw 90 who plain the league you would’ think he wes 90. Hetilplays very high standard of ches He says without the ches, he wed have bee ke these other oes laughs Since retirement, Alan has, ifanything, grown more active and eagaged. Ashe observes his good health allows him to lia more dynamie, rewarding life, one that Is biographically continuous with his younger sal'[Goed health means] you can enjoy retirement more; t retire and ¢0 not be healthy would bea bit of «shame 1 don’t wat t stop doing the things that [im doing In par, his good physical and psychological health is due to maintaining his lilong interest in ‘walking. However, Alan has also taken advartage of the extra time availabe to him in setirement to take up new activities, eg, leading a local music group, Instead of facing nerrative foreclosure, like Doreen, he's ableto adda new chapter to his life" really loved teaching land] thou I would miss i, bat I don't he says, somewhat surprised.'Now In retired, [Ti] finding otker things to "This fits closely with Ricoeur’ [21] concept of individual identity developing through time, main= taining permanence witheut sameness, In some ways, Alané health has actually improved with age. In one ofthe few health-focused stories he tells, Alan mentions that he has had asthma sines he was an adolescent, and that it used to ‘bea prablem occasionally. Because of a new generation of medication, this is no longer the ‘case. Now, he says, ‘it dent stop me doing anything: This is useful reminder that individaal biographies unfold within a broader historical content; medical advances play a central role in Influencing healthy ageing26 UNDERSTANDING HEALTHY AGENG USING A QUALITATIVE APPROACH 9.9 Discussion “The igstries exemplifies in these three casestudies contain a amber of other artes and s number of key thers, Doreen story ia narrative of decine—reinforcing, perhaps the trad tonal view of old age ava period of phyoical decrepit and dsappearance from socal engage sent and publ life atic narrative sone of conto. She seckato masage Her health and sow any decline She seek to prepare for a predicted future when she wil be unable to care for ese She cannot top the ageing proces, bit she can manage oa certain degre, Alans narratives one of very active ageing the modern dea Iti striking that in none of these cave studs therea clear message, or narrative, about the ceilylfcexperienecs that might have influenced heli aie ife Nene these thre inv als flet on how pas experience or behaviours may have impacted on their current health and wellbeing. Rater, in Doreen's axe the egcing proces is conceptualized as having transformed her roman individual who copes well with i heals to scone who severely limited by health probit and lckof mobil. In contra both Patricia and Alan are current sil actively work: ing to mairain heath and capability. need, one way of characterizing the thre narratives isthe different wey that each individual mekes ink berween past, prevent and fare. Doreess poor bealin means that she focuses on looking bock at her past heher narrative focuses onthe past, ard has the ceurten theme off wd i The fst that Pari’ husband is signifcanly oer andin poor health encourages herto look forward, ao that her narrative focuses around the future ad the statement wis whereas Alan exelent hsalth allows him to fie inthe preset, com- Lining odo whatabways han, whil adding new actvties—his marae is mach more present focused and keeps retrnig tothe statement, I. “Thereare perhaps womain wap in which this more narrative approach to data collection and svalystscanbe seen o complement the quantitative longiadinalapproackes exemplified by other chapters Firs ia contrast to structured quantitative data collection, semi-structured and in-depth inter views provide cvidenee about the everyday lives and experiences of eer people. Doreen’ case study, in particular, provides good exemplar ofow we ean gain an inight int thedlflelies of dl lifethrough rll tris told in the conten of biographical inervew. Many of thes to- ries re habitual or exemplar narratives which help the interviewer to understand the challenges faced by the respondent In turn thiscan lead to an understanding of some ofthe mechanisms by which poor health and reduced capably can havean impact on wellbeing and quality of ie. Second, by cxaminingindividal casesholsiclly and allowing cohort members to provide the “big sory’ thee biography from thei own perspective remarchers can be alerted to important factors that influence individuals lives—facors that may not have been adequately capared in the structured quantiative interviews As dicused in Sections. and 946, for both Doreen and Patricia pouae' health san important factor cotebuting to indvidual wellbeing. (One ofthe key memage ofthese case tudes that healthy ageing cannot be locked at ony at the individual eve. Heath must be looked at fom fe course or iflong, perspective, but so froma fe wide’ pespeciveThe health of ne'spartercan sigan affect the quality of ne sagcing, Paticie has aged healthily as an individual bat despite her robust heath sid high level ‘of physical capability, Paris wellbeing i lative low for someone with good physical health, ‘Asher narrative indicates, this is ialuenced by the linitations placed on her ie by her partner’ poorhealth For example, she sno longer sble to enjoy valued pastimes such as traveling, and shehas grown somewhet slated frm her fren, Observing he older parteer'seath problems appears encourage Parca’ natural inclination tobe competent and in control and to makereferences plans to reduce the negative impacts of her own ageing on herselfand others. Dorsen, in contrast, {s co-dependent on her husband. Individually, nether could cope, but together, they have suffi. cient spability for most aspects of daly life, Narratively their life storieshave fused. Both the FICS and the NSHD include brief questions abeut sponses health status, but these casestudies suggest that as individuals get older, and restricted capability and health problems grow more common, ls important to ask more detailed questions about spouses’ health and caring rexpensibilities in lrder to understand more about factors influencing wellbeing and qualty of lf. “These three narratives are consistent with the sonceptuslization of healthy ageing provided by. Bryant and colleagues [9], namely that healthy ageing centres on the ability to go and do some. thing mesningful’ Hoth Patricia and Alan describe several groups and activites with which they are regulerly involved—chess, bridge, bowls, and walking provide social contact anda chance to exereise both body and mind, Even though Patricia is somewhat constrained by her disabled older husband she sill has excellent self-rated health and good physical capabilty. The amin this chapter has been to demonstrate the value of narrative data collection and narrative analysis for Aeveloping an understending of older people'sexperiences of ageing. Although there are just three case studies presented here, the quantitative studies from which they have been draven provide the contest within which they ean be understood. It is clear that Alan and Doreen are situated. car the extreme ends of the dimension spanning healthy and unhealthy ageing. 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