Fatalism and short-termism as cultural barriers to cardiac rehabilitation among underprivileged men

Authors


Abstract

Cardiovascular diseases are a leading cause of death and disability in Canada, and individuals of low socioeconomic status appear particularly vulnerable to such disorders. Although many health-related institutions have promoted cardiovascular health and have created cardiac rehabilitation programmes, they have not attained their desired outcomes, especially amongst socioeconomically deprived men. Drawing on Pierre Bourdieu's sociocultural theory, this qualitative study aims to understand the social mechanisms underpinning the lifestyles and health practices of men who had suffered a cardiovascular incident requiring hospitalisation. In all, 20 interviews were conducted with francophone men aged 40 to 65 years living in the province of Québec, Canada. The analysis strongly suggests that the respondents' living conditions and disease were significant obstacles to their adoption of a healthy lifestyle. Their despair and pessimism, apparently originating in the harshness of their financial realities, physical limitations and social networks, led them to believe that they could do little to control their lives, thereby limiting the fulfillment of any long-term ambitions. Therefore, the adoption of a habitus characterised by fatalistic and short-term perceptions of health influenced their lifestyle choices, leading them to maintain lives that were in stark contrast with the recommendations made by health promotion experts.

Many studies have documented the link between social inequality and health. While research on this subject is abundant, many specific questions remain on the connection between socioeconomic conditions and lifestyles. Drawing chiefly on Pierre Bourdieu's social cultural theory of practice, this qualitative study focuses on fatalism and short-termism as key considerations involved in the adoption of ‘unhealthy lifestyles’ by underprivileged francophone men who had suffered a cardiovascular incident requiring hospitalisation. While these attitudes have a bearing on health, they have yet to be applied together in an empirical study on lifestyle dispositions. It is argued here that social and material deprivation do not provide individuals with many incentives to adopt recommended forms of cardiac rehabilitation; through a combination of increased concern for short-term necessities and reduced perceptions of self-control over health, low socioeconomic status appears to compromise an individual's personal investments in future health and wellbeing.

Social inequality and cardiovascular health

Epidemiological and sociological studies have documented the extent of health inequalities and consistently indicate that, in economically advanced societies, socially and materially deprived groups die younger and suffer more from every major disease than more affluent groups (e.g., Marmot et al. 1984, van Rossom et al. 2000). Cardiovascular diseases (CVD) are a significant contributing factor both in overall mortality rates and in the social gradient of health (Wilkins et al. 2002). Preceded by the legacy of the Whitehall study, research on the social variation of heart disease clearly shows the impact of socioeconomic status on health and related outcomes.

In spite of the country's universal health-care system, a recent government report in Canada identified a 5.4 year difference in life expectancy between men in the lowest socioeconomic quintile and those in the highest quintile, and an 8.4 year difference compared with women from the highest quintile (Greenberg and Normandin 2011). In fact:

[O]nly 51 per cent of men in the poorest one-fifth of the income distribution were expected to survive to the age of 75, compared with 72 per cent of those in the richest one-fifth of the income distribution. (Statistics Canada 2008)

More particularly, in the province of Québec there are indications that 94 per cent of premature deaths are attributable to social and/or material deprivation and that CVD are a significant component of these health inequalities. Pampalon et al. (2008) estimate that 31 per cent of this province's population's potential years of life lost due to income inequality are related to premature mortality caused by CVD. Between 1999 and 2003 the mortality rates of those in Québec who died prematurely because of CVD show striking social and gender inequalities: men in the lowest income quintile are represented 3.4 times more than men and 10.4 times more than women in the highest income quintiles, respectively (Pampalon, Hamel, and Gamache 2008)

Many factors contribute to this social gradient in health (for an overview, see Marmot 2004). As suggested by several studies, in addition to the adverse effects of experiencing long-term stress, the adoption of an unhealthy lifestyle (e.g., sedentary behaviour, diets high in fat and salt and tobacco consumption) is one of the most important factors explaining a higher prevalence of CVD among underprivileged men (e.g., Heart and Stroke Foundation 2003, Johansson et al. 1999, Marmot 2001; Wannamethee et al. 1998).

While socioeconomically deprived men appear to adopt more unhealthy lifestyles than those in the general population, they also tend to maintain them after experiencing a cardiovascular incident (Chamberlain and O'Neill 1998, Wheatley 2006). Such men are also less likely to survive 1-year post disease-related surgery (Alter et al. 1999). This group's lack of adherence to formal and informal cardiac rehabilitation protocols has led to their identification as a priority for health promotion activity (Chan et al. 2008, Harlan et al. 1995, Lane et al. 2001, Worcester et al. 2004). Although this particular issue has been frequently highlighted, very little research has been done to attempt to understand the social mechanisms leading underprivileged men to adopt and maintain such unhealthy lifestyles during cardiac rehabilitation (Emslie and Hunt 2009).

Key concepts: short-termism and fatalism

Sociologist Pierre Bourdieu's sociocultural theory of habitus has provided an intricate framework of analysis and has often been applied by researchers to establish the connection between class culture and lifestyles. It was used by Bourdieu to explain an individual's schemes of perceptions, appreciations and actions (Bourdieu, 1984, 2000). According to the theory, the habitus is shaped by an individual's living conditions and engenders practices adapted to these conditions. Its formal application to the field of health has shown that precarious living conditions fashion attitudes that lead individuals to adopt anti-normative lifestyles (Boltanski 1971, Cockerham et al. 1997, Poland et al. 2006, Sayer 2005, Williams 1995).

This approach proposes that there are many pathways to understanding health practices. In this article, short-termism and fatalism have been selected as two generic concepts that are both versatile enough to capture the various structuring experiences of class culture on the habitus and also concise enough to lead to the appreciation and understanding of some important determinants of cardiac rehabilitation and cardiovascular health. Although they are independently supported by significant bodies of literature, these two concepts have rarely been linked to one another.

In relation to the first concept, it has been suggested that preventive actions, or the lack thereof, can be understood by an individual's expectations of the future (Boltanski 1971, Bourdieu 1984, 2000). The expression short-termism is used in this context as it encapsulates the notion of favouring short-term projects for immediate profit at the expense of long-term health. Bourdieu (2000) operationalised this idea through the notion of a relation to time (or time horizons); a constituent of class habitus. Delimited by social and material conditions of existence, one's relation to time varies with one's socioeconomic status. For example, according to this theory, conditions of financial hardship tend to engender the prevalence of short-term time horizons. In this respect, individuals' inclinations to adopt illness prevention practices are socially acquired and culturally reinforced dispositions (e.g., Lawton 2002, Stronks et al. 1997, Wardle and Steptoe 2003). As Boltanski (1971) argues, preventive attitudes and long-term investments in health are socially constructed attitudes that are integral characteristics of a class habitus. In his pioneering study of the social usages of the body he states:

The less privileged classes' living conditions and, more specifically, their economic instability hinders their ability to adopt preventive attitudes in their economic activities (for example, by the long-term planning of their spending) which imposes the embodiment of an ethos and an attitude about time on them that forbids, from the outset, the adoption of illness prevention practices. (Boltanski 1971: 12, author's translation)

The low socioeconomic position of underprivileged groups is thus thought to be at the core of their relation to time, and, as a consequence, disposes them to be reactionary rather than preventive in their attitude toward health and illness (Boltanski 1971, Dumas and Laberge 2005, Lindbladh and Hampus Lyttkens 2002).

With regard to the second concept, although it is inevitably connected to an individual's relation to time, fatalism focuses primarily on the idea of control. For Bourdieu:

Casualisation profoundly affects the person who suffers it: by making the whole future uncertain, it prevents all rational anticipation and, in particular, the basic belief and hope in the future. (Bourdieu 1998: 82)

Furthermore, while providing a portrait of men from the underclass, Bourdieu (2000) comments on the connection between fatalism and one's relation to the future:

The often disorganized and often incoherent behaviors, constantly contradicted by their discourse, of these people without a future, living at the mercy of what each day brings and condemned to oscillate between fantasy and surrender, between flight into the imaginary and fatalistic surrender to the verdicts of the given, are evidence that, below a certain threshold of objective chances, the strategic disposition itself, which presupposes practical reference to a forthcoming, sometimes a very remote one, as in the case with family planning, cannot be constituted. (Bourdieu, 2000: 221)

Fatalism has also been used in more empirical studies to explain the ‘unhealthy lifestyles’ of underprivileged groups (e.g. Bolam et al. 2003, Lachman and Weaver 1998, Marmot and Wilkinson 2001). Davison, et al (1992: 677) described fatalism as a person's sense of a lack of control over events and their health outcomes; they also noted that fatalistic individuals perceive that many factors, such as heredity, access to resources, climate and chance, had more bearing on their health than their lifestyle choices. Underprivileged groups, more than others, tend to de-emphasise illness prevention as part of their overall health regimen while focusing on more urgent factors over which they feel they have more control and that are perceived to enhance their wellbeing, such as financial stability (Bolam et al. 2003, Davison et al. 1989, 1992, Richards et al. 2003).

Methods

This study is part of a larger research project funded by the Social Sciences and Humanities Research Council of Canada, and was undertaken in urban areas of the Outaouais region of the Canadian province of Québec (Dumas 2007). This region was selected due to its high social and health inequalities. According to public health reports, it is also an area in the province where the mortality gap between socioeconomic groups is among the highest, considering overall wealth, in comparison to other regions (Courteau et al. 2002, Régie régional de la santé et des services sociaux de l'Outaouais 1996).

The study consisted of 20 in-depth semi-structured interviews with underprivileged men. The sample was purposively selected in order to capture detailed information about the influence of social and material deprivation on men's lifestyle choices following cardiac surgery. All 20 men were French speaking and resided in underprivileged neighbourhoods (defined in this study as areas where the median annual income of neighborhood residents was below $20,000), aged 45–65 years and who had experienced a cardiovascular incident requiring medical intervention and hospitalisation. Only physically independent men, as defined by the Québec Ministry of Health and Social Services, were selected (i.e., needing less than 1 hour of care per day and who did not require assistance for daily activities such as standing up, dressing, eating or personal hygiene). Table 1 presents the characteristics of the participant, using data gathered by a short questionnaire that preceded the interviews. The participants could be identified as an underclass; a group characterised by high social and material deprivation, low training in formal education systems, without stable employment and occasionally or regularly needing the services of soup kitchens, food banks, home shelters and rooming houses.

Table 1. Summary of attributes and characteristics of participants
AttributesParticipants (n)
Age group (in years)
40–498
50–5911
60–641
Highest level of education
Elementary school12
High school7
College1
Marital status
Married8
Divorced3
Single9
Currently unemployed12
Personal/domestic characteristics
Live alone7
Less than one contact a year with family14
History of drug addiction11
History of imprisonment10
Victim of abuse as a child10
Lifestyle characteristics
Habitual smoker16
Physically active 2
Heart healthy food consumer6
Takes prescription heart medicine10
Attends regular medical follow-up exams7
Completed free information seminars on heart health0
Currently receiving social benefits20

All the men interviewed had experienced either long-term periods or numerous short-term bouts of unemployment. They had worked in precarious conditions (part-time work, low income security, low social benefits or work undeclared), and mostly worked in occupations requiring little or no professional training, such as construction, manufacturing, transportation (such as tow trucks, removals, food delivery, truckers and bus drivers), charity, cleaning or low-level administration. Most had suffered from a multiplicity of difficult life experiences, such as childhood abuse, legal incarceration, and infrequent contact with family members, and they had been living alone for a significant proportion of their lives. While they all appeared to be aware of major health guidelines relating to cardiac rehabilitation, most had adopted lifestyles incompatible with the recommendations of cardiac health promotion experts, particularly with regard to recreational drug and/or alcohol abuse, and/or tobacco consumption. Their level of attendance to medical follow-up examinations was low, as was their participation in free information seminars on heart health offered by the local health centre for patients suffering such conditions. Most did not undertake regular physical activity, many did not adopt healthy eating habits and half of the group did not take any prescription or non-prescription medicine for their cardiac issues.

Participant recruitment involved two distinct strategies. The first was more fruitful and yielded 16 participants. This process consisted of placing posters and orally presenting the research in local community support facilities (such as soup kitchens, homeless shelters and food banks) and local businesses (pubs, restaurants and corner stores), combined with the publishing of a short explanatory article in a local newspaper. The second recruited four participants, and involved contacting individuals who subscribed to a registry held by a cardiac rehabilitation clinic situated in a local public health centre. With the help of nurses at the clinic, explanatory recruitment letters were sent out to men whose postal address located them in an underprivileged neighborhood.

The interviews were conducted in locations chosen by the individual participants. Three themes were addressed in the interviews. The first series of questions dealt with participant's life circumstances and the history of their cardiovascular illness. This information contributed to a better understanding of their personal biographies and social trajectories before and after the cardiovascular incident. Secondly, questions relating to their individual lifestyle, their perceptions and appreciation of health and health practices were posed in order to determine their relation to such notions. Close attention was paid to each person's perceived valuation of illness prevention, sense of control over their future health and their overall perception of cardiac rehabilitation (such as cardiac rehabilitation programmes, eating habits, physical exercise, medical guidelines and advice). Finally, questions intended to capture each individual's experiences and perceptions of the various barriers and constraints faced in adopting health guidelines were asked.

The interviews were transcribed verbatim and analysed using proprietary data management software (QSR NVivo 8). Each transcript was read in its entirety to identify important themes in the individual interviews. An initial vertical analysis, consistent with Pierre Bourdieu's sociocultural theory, was performed. A subsequent horizontal analysis grouped themes and made an inter-respondent comparison to highlight relevant differences and similarities. Two researchers independently coded the data into categories based on semantic affinities. Both analyses were systematically compared to establish consensus and consistency between the two coders. All quotes were then translated from French to English by the authors, who preserved the language level used by interviewees in order to appropriately capture the men's modes of expression. The names are fictitious and the stated occupations are those they formerly held.

Results

The interview data indicated that, having predominantly lived in precarious conditions since their youth, the respondents tended to maintain a low level of social status throughout their lives. All were highly aware of the implications of their social position and appeared to be knowledgeable of current recommendations for improving cardiovascular health. The data also identified a remarkable convergence with regard to the low priority all respondents gave to cardiac rehabilitation, health improvement and lifestyle change. The emergent premise from the interviews was that the fatalism exhibited by the interviewees in combination with their short-termism had become a major contributory factor in hindering institutional efforts to motivate postoperative cardiac patients to adopt normative health practices. A breakdown of these two major concepts is detailed in Table 2. These two notions are the result of the inductive process that led to their construction. Together they express significant cultural barriers to health enhancement, as perceived by the study participants.

Table 2. Fatalism and short-termism as cultural barriers to health enhancement as perceived by the study participants
Fatalism
(i) Low control over health improvement: the negative effects of stress are overwhelming and uncontrollable; karma, destiny and biological determinants (e.g., illness, heredity) cannot be overcome; life and health are governed by important obligations outside personal control (income, employment, family).
(ii) Low control over lifestyle change: change in lifestyle does not coincide with work schedules and immediate family obligations; unhealthy habits are difficult to manage in the context of addiction (e.g., drugs, tobacco, and alcohol); health regimen are difficult to sustain – exhibited as a defeatist attitude towards the possibility of maintaining a new lifestyle; physical limitations prevent undertaking physical activity.
(iii) Fear of change and the unexpected: change is potentially harmful for wellbeing; change increases anxiety; abandonment of previous lifestyle will increase boredom.
Short-termism
(i) Strong present-time orientation: time and energy are dedicated to more pressing concerns and to resolving daily emergencies (i.e., gaining immediate financial viability); prevalent ethos of living one day at a time; tangible, practical and visible outcomes are favoured; instant gratification is highly valued.
(ii) Reluctance to plan for the future: long-term investment outcomes are too speculative in comparison to those of short-term investments; asymptomatic physical conditions and abstract concepts, such as illness prevention, are not a priority; long term planning and forecasting dispositions are hindered due to conditions of immediate economic necessity; the future is not adjudged to hold much promise other than more of the same.

Fatalism as a barrier to health enhancement

The results of this study concur with the outcomes of previous research that found that socioeconomically deprived individuals generally adopt more fatalistic attitudes than their more affluent counterparts, particularly about the possibilities of health improvement (e.g., Lindbladh and Hampus Lyttkens 2002, Marmot and Wilkinson 2001, Schroder and Schwarzer 2005, Straughan and Seow 1998) and tend to believe they have little control over their health. All of this has been linked to the adoption of anti-normative lifestyles (Bolam et al. 2003, Davison et al. 1992, Richards et al. 2003). In all participants, feelings of despair and pessimism were strongly evident when discussing the possibility of enhancing their health and modifying their lifestyle to reflect post-cardiac event rehabilitation.

Most participants expressed issues invoking a lack of control over everyday stress. For many, attempts to improve their physical condition seemed unlikely to be fruitful. In the circumstance of the often-overwhelming emotional strain of their daily lives, they considered stress as an important factor that negatively impacted on their health. They acknowledged that many major stressors stemmed from the conditions these men encountered daily: low socioeconomic status, unemployment, low-paying manual work and substandard housing, frequently coupled with tense or isolated family situations. Their everyday social reality left few opportunities to escape the stressful agents they considered to be the primary contributor to their health problems. It acted as an overarching, ever-present burden felt by this group. As one participant, Yvon, a 47-year old former handyman whose wife had left him for another man conveyed:

I think I can't control my blood pressure because of all the stress I'm under … it's not always easy. When stress takes a hold of me, my pressure goes way up and my heart starts going extremely fast. That's when I get angina.

Many authors indicate that barriers to illness prevention are also linked to a belief in the immutable power of heredity (Bolam et al. 2003, Davison et al. 1992, Richards et al. 2002). In this study, participants often communicated this theme by relating their current illness to their parents or siblings who suffered from similar heart conditions. In various degrees, they believed that genetic predispositions took control over their health. In addition to other previously described factors that inhibited their belief in rehabilitation, this attitude contributed to their feeling of powerlessness over improving their health. Like many others, Eddy, a 47-year-old man living on social assistance, mentioned his doubts about overcoming genetic predispositions:

I think it's genetic. It can't help when both your parents have had a heart problem … my brother also has heart problems. My sister has heart spasms, she tells me about them every time she calls … I probably have some sort of ticker misalignment … I know I have to be careful. Sometimes, I ask myself if it's really important or not … I didn't go to the rehab programme. So, when I have heart problems, I let it pass. Most of the time it passes.

The fatalistic attitudes witnessed among the group were also an expression of their wider attitude to life and death. Often supported by their spiritual beliefs, participants tended to accept that their health status was out of their control due to personal fate. It is perhaps likely that this notion emerged from their inability to control many aspects of their lives due to the vicarious nature of their precarious living conditions. This sentiment is akin to the importance of spirituality in people from underprivileged areas noted by Wimberley (1984: 234): ‘one's relative social standing in the eyes of others may produce a form of deprivation for which religion can compensate and thus become salient for the adherent'. Many men in this study made references to ‘God's will’ when explaining their lack of control over their health problems. For them, fate appeared to supersede preventive measures in their attempts to combat illness. While the extent of these comments was unexpected, this aspect of spirituality was related to a general sense of vulnerability and powerlessness. Most of the men appeared to believe in the influence of a superior power over their lives, inclining them to a passive acceptance of life's contingencies:

I believe in God. Like I told you, he has his Big Book. Your expiration date is written in there somewhere. When that day comes, that's it … when the product is past its due date, it's not good anymore [laughs]. (Max, 44, former tow truck driver)

The biographical component of the interviews echoes Simon Charlesworth's (2000) observation that socioeconomic deprivation lowers one's sense of control over life events and fashions the belief that self-actualisation is difficult to achieve. Their lack of resources, together with the perception of their previous failure in life, had clearly weakened their self-confidence in relation to successfully adopting a positive health regimen. While many participants acknowledged their health could be improved, they remained unconvinced that there could be any positive outcome of their actions. Their doubts about their own abilities to modify their lifestyles can be viewed as a form of ‘learned helplessness’, which in time, often got translated into the acceptance and maintenance of previous unhealthy behaviour. This was clearly articulated by Pierre-Luc, a 57-year-old truck driver:

You know, after your heart surgery, the cardiologist asks you to go and meet with health experts … Well, dieticians and people like that. It really makes me sweat … It's not that I don't like them … ‘Do this, do that’… Alright! If you've never done this and that in your life, do you think you're going to do it? … Doing all those things doesn't interest me. I can't do what they want me to do. [author's emphasis]

The successful realisation of improved health was also undermined by previously unsuccessful attempts to achieve life-enhancing projects such as stopping smoking or not eating foods high in saturated fats. Failed attempts led to a form of popular realism or a resignation to necessity characterised by an inclination to hold more modest ambitions in life, thus avoiding disappointment in themselves and their surroundings. In many cases, respondents perceived such lifestyle changes to be more discomforting, troublesome and inconvenient than maintaining previous habits. Consequently, preoccupations about failure led individuals to resist personal efforts to change. Their practices (healthy or not) were part of a lifestyle that had become internalised, offered them a sense of security and helped them to ‘keep busy’ and fight off boredom. These tactics appeared to contribute to their overall levels of happiness. In the following, Lionel, a 55-year-old soup kitchen clerk, describes his daily routine of tobacco usage and a diet high in saturated fats:

What am I going to do if I don't smoke? … My doctor tells me to stop … he says: ‘prevention’ … I'm sure it helps. I'm aware of that … but I just turn around and light up another cigarette … I wouldn't know what else to do with my time … it's a habit … it's the same thing with food, I really like fatty foods … if I'm going to make myself a hamburger, I flip them around on both sides, soak them in grease, add some bacon, and that does the trick!

Even though a few participants managed to adopt some temporary or partial changes, none sustained a complete transition to a healthy lifestyle. Their harsh living conditions acted as barriers to change and appeared to suppress much of their hope for health amelioration:

I don't have any plans for my health because I don't feel like I am able to reach them … some people say it's possible to be healthier. I kind of believe it, but only to a certain extent. (Sincère, 59-year old, unemployed)

Even if most participants attempted lifestyle changes, they conceded to the difficulties of embedding health guidelines within their daily routine: ‘I was really good for the first three months … but, [when I went back to work] that's when I started eating bad again’ (Olivier, a 58-year-old former security guard). The respondents also admitted to a tendency to organise their post-surgery lives in the same way as before. This appeared to be because they perceived few, if any, significant changes in their everyday post-operative lives. This was especially true for those who worked as professional drivers. For this specific group, poor working conditions (including no paid holidays or sick leave), enclosed, restricted and sedentary working environments, unhealthy eating options (fast-food outlets) and busy work schedules considerably limited the possibility of an easy transition to a healthy lifestyle:

Everyone told me that after the operation, if you follow the doctor's orders, you'd be in perfect shape … I tried getting better, but it's really hard when you drive a truck for a living … The only thing you can eat in a truck-cab is fast food. That's it! You don't even have a family restaurant food or a MacDonald's. No restaurant can accept you with a truck the size of mine. You need space for that. (Pierre-Luc, a 57-year-old truck driver)

Various forms of addiction such as alcohol, tobacco or recreational drug dependency, also contributed to the respondents' perception that they had low levels of control over their lifestyles. For instance, 16 out of the 20 men maintained their smoking habits after their heart surgery. Even though most expressed a desire to free themselves of their ‘bad habits’, they often mentioned the challenges of their addictions. For many, acute substance dependency was expressed as an additional illness that they had to deal with on a constant basis. Sam, a 41-year-old man without sustainable accommodation, suggested that his addiction to crack cocaine had provoked his heart attack, and that he would remain addicted for his entire life:

There is no cure for a crack addiction … you can always turn to God and pray, but there's nothing else you can do … and, since I've been able to reduce my consumption, I allow myself a little bit of a treat once in a while. But I always have to watch myself. If I take too much, I tell myself: ‘look, your heart can't take it, you probably won't survive next time’.

The incapacitating physical limitations that accompany CVD also fueled respondent's fatalistic attitudes to the adoption of a new lifestyle. While some had suffered a single cardiac incident that left few serious after-effects, others had suffered from multiple incidents, experienced severe comorbidities, such as type II diabetes, or suffered work-related or car-wreck injuries that significantly reduced their capacity to adopt an active lifestyle. In the following, Fernand, a 63-year-old former restaurant waiter explains the limitations to his adopting a physically active lifestyle:

You're not as strong after a heart attack … physically you're just not the same … I still try to do what I used to. For example, the doctor told me to take the stairs more often … I have to do it very slowly. If I try to go fast, I really feel it in my heart.

The emotional strain, physical exhaustion and fatigue related to their ill-health were part and parcel of the low confidence in the possibility of modifying their lifestyle, and of the pessimism tied to its positive effects on health:

I feel very tired. I don't have a lot of energy. I try to pinpoint where it comes from. But with everything that happened in the past, for sure, I'm under a lot of stress … Even if I try to look forward and not focus on the past … My future is not very bright because of my money issues. I can see it won't be easy because my budget is very limited. So I have to make do. (Bigras, 53-years old, unemployed)

Short-termism as a barrier to health enhancement

The experience of fatalism and powerlessness had a direct impact on how people expected to manage the future in function of improving their health. As argued by Bourdieu (2000: 221):

[T]he real ambition to control the future … varies with the real power to control that future, which means first of all having a grasp on the present itself.

Similarly, the everyday difficulties faced by the participants of this study not only led them to believe they had little control over many aspects of their present but also made them concede that this lack of control would perpetuate itself in their future health prospects. Generally speaking, their attitudes towards time were characterised by two ideas: a strong present-time orientation and a reluctance to plan ahead. Their lack of ambition and hope led them to perceive their future pessimistically and elect to focus their energies and resources on issues with a greater chance of achieving positive short-term outcomes. In this specific context of socioeconomic deprivation, these two dispositions together engendered a perspective where participant's inclination towards a long-term investment in their own body weakened. This led to their deprioritising the prevention of illness.

Being unable to distance themselves from the harsh economic reality of their lives, respondents often focused on urgent short-term financial difficulties; a vision embodied by their short-termism. The effect of financial instability on their quality of life was a key factor leading them to concentrate their efforts on resolving pressing immediate economic concerns. Displaying unrealistic and rare optimism, some respondents mentioned that once these financial difficulties had been dissipated, they hoped to be in a better position to find the time and energy to concentrate on issues concerning their future health. This was expressed by Jean-Charles, a long-term unemployed 53-year-old man, whose main priorities were to live his life free of stressful obligations. He also wanted to focus on the means to appreciate the brief moments of happiness in his life:

My heart is healed. I saw it, my doctor put it through a test and he said, ‘your heart is fine’… So, right now, my money is my main focus … I had to let go of my truck; the repairs were too expensive. I don't have a phone, I don't have Internet anymore, and I don't have cable [television]. I don't have any bills. I'm really trying to get back on my feet financially.

Often, this short-term focus was accompanied by a neglect of long-term planning. Previous authors have suggested that the experience of ill health can contribute to the modification of one's relation to time via an increase in body consciousness, coupled with a heightened awareness of illness and mortality (e.g., Angus et al. 2005, Dumas and Laberge 2005, Lawton 2002, Wheatley 2006) and act as a ‘rupturing event’ which inclines people to adopt healthier habits (Bury 1982). However, although their heart surgery engendered a reflexive process whereby respondents reevaluated the probability of reaching their personal expectations and ambitions, all the participants indicated that their experience of CVD did not translate into a positive lifestyle change 1-year post the surgical intervention. Indeed, as discussed above, it appeared to add to the strain of their life and left them with a pessimistic outlook on their future health. This has congruence with the numerous accounts of men who voluntarily avoid medical screening, preferring to remain indifferent to their current health status. As noted by Fernand, president of his council housing's social club:

I have to take life as it comes, I have no choice. I'm not going to stop and wrack my brain over my health to the point where I'm the cause of my own problems and make my blood pressure go up.

In fact, much of their daily activity could be characterised by what Simon Charlesworth (2000: 54) describes as mindless coping skills:

… living life within such strict confines, or a life in which life is simply awful; there can be little incentive, [there could be no interest] in developing other forms of consciousness beyond those of the ‘mindless’ everyday coping skills through which it makes sense to live such conditions.

The health problems experienced by these men prompted their recognition of their own mortality; in other words, it put their lives in perspective, thereby forcing them to reorganise their priorities. While some participants were more concerned than others about the possibility of dying prematurely, most expressed their preference for increasing their immediate wellbeing by trying to reduce the current sources of anxiety and stress over which they felt they had some control. For some, this meant that they no longer maintained the same level of zeal and ambition to completely overcoming their financial, psychological and social problems. Feeling pessimistic about their possibilities for a brighter future and an awareness of their physical and financial limitations created a sense of resignation that hindered the respondent's desire to improve their future. As a result, most men focused on the present. They sought to live in the moment, to appreciate what each day had to offer without subjecting themselves to the constant pressure of worrying about an uncertain future. By focusing on the more tangible and immediate concerns with which they were faced, greater and more abstract problems, such as the lack of social mobility and preventing illness, were accepted as unalterable facets of their lives. This perspective directed most of their attention to a day-to-day approach to life:

I can't really tell you where I'll be at this time next year. What's important is today. Today, I'm alive, and I'm off drugs. I take life one day at a time because I don't know when I'll be leaving this world. (Mathieu, 47-years old, former barber)

I live more day-to-day now. It's just that, you know, I go with how I feel when I wake up in the morning. (Gary, 48-years old, former mover)

I live by the second. I don't know what's going to happen in 2 minutes. I don't know what's going to happen tomorrow. I don't have a clue, and I don't want to know. I'm a spontaneous person now. (Jean-Charles, 53-years old, unemployed)

Today, I live day-to-day. If I get up tomorrow morning, I'm OK. If I don't get up, I don't get up. (Max, 44-years old, former tow truck driver)

This approach appears to allow respondents to focus more on the small immediate pleasures of their daily lives, including unhealthy food, alcohol, tobacco and recreational drug consumption, and less on factors that could cumulatively increase their overall stress levels, such as the negative long-term health consequences of their current lifestyle practices.

These brief excerpts reflect the idea that conditions of necessity hinder these men's ability to plan for the future; consequently limiting their expectations of a healthy life. It also appears that socioeconomic deprivation amplified the more immediate and tangible concerns of these participants. In a discussion of their fear of dying, the participants judged that their lives were ‘complete’ and used this as a rationale for not fighting against the prospect of their (premature) mortality. For those whose lives were characterised by very difficult, almost survival, circumstances, death was perceived more as an accepted end-state than a variable to challenge, thereby potentially increasing the quality of their remaining life.

Conclusion

By drawing on the sociology of Pierre Bourdieu and, in particular, his concept of habitus, this study aimed to identify the norms and values of socially and economically deprived men with CVD with regard to the ways they treat and care for their bodies after a surgical intervention to the heart. It also briefly outlines how fatalism and short-termism hinder their efforts to meet standard health guidelines for cardiac rehabilitation. This article defined cardiac rehabilitation as a social practice that is constitutive of a distinctive class lifestyle. It examined health practices in terms of socially acquired sets of priorities and tastes that are fashioned by conditions of existence (material, family and cultural characteristics) of a given milieu, rather being than the sole product of rational calculation. In other words, a concern for health improvement and dispositions to adopt healthy lifestyles and cardiac rehabilitation are socially sensitive.

Bourdieu's (2000) later theoretical work on the male underclass discusses the almost customary connections between concepts of fatalism and short-termism. While previous research has acknowledged these connections, no studies have so far examined their influence on illness prevention in the context of cardiac rehabilitation. In this respect, our study shows that life in ‘conditions of necessity’ and within a constant state of urgency has important consequences on heart health. Firstly, it inclines people in these circumstances to believe that they can do little to control their health and fulfil their future hopes and ambitions. Feeling unable to face many of life's contingencies and accepting the fate of their heredity appeared to discourage the participants' efforts to improve the individual cardiovascular health. Secondly, it encourages the adoption of harmful behaviour to satisfy short-term wants, which are likely to achieve their expected outcomes through near instantaneous gratification. Additionally, by focusing more on immediate financial stability, the men in this sample wholeheartedly elected to maintain many unhealthy practices. Perversely, they perceived that any investment in health would bring increased levels of stress and instability, without any guarantee of a positive return on their future health. As a consequence, adverse socioeconomic conditions led to personal inertia with regards to health improvement.

The study of class culture and its relation to health should be explored in more depth. Although in this study the perception of time and self-control have been two crucial determinants in post-surgery cardiac rehabilitation among men with CVD, further research could provide a deeper understanding of their postoperative lifestyle choices. Future research could emphasise the influence of social status, for example, the effects of being in a low social position, on such men's lifestyles. In The Moral Significance of Class, Andrew Sayer (2005) extends Bourdieu's theory and argues that anti-normative behaviour is a result of people's emotional response to class inequality. His approach also lends itself to a joint focus on social class and gender. For instance, a focus on men's ‘hyper-masculine responses to class inequality’ (Dumas and Bournival 2011) is a promising avenue that considers masculinity and poverty.

There were also some differences among the respondent's lifestyles that were not accounted for in this article. Such variations could be explained by the varying degrees of social and material conditions among the men or their belonging to a particular subclass. Heterogeneity could also be investigated to understand why certain individuals adopt lifestyles that differ from the norms found in their particular social environment. In this regard, Pierre Bourdieu's model of social reproduction and its tendency to have deterministic undertones may not accurately capture outliers, those on the very margins of society.

There are no easy solutions to resolve the problem of social variation in mortality due to CVD. Not only is it key for health institutions to develop programmes sensitive to socioeconomic deprivation, it is also important that policy efforts be concerted with broader social issues. In the short-term, health institutions could vary the type of services offered in cardiac rehabilitation programmes by tailoring them to both social and material living conditions of particular groups of individuals. More resources could be devoted to actively support individuals to modify their lifestyle rather than encouraging patients to adopt normative lifestyle changes. For example, considering specific working environments and atypical working schedules could be a good point of departure. In the long-term there is considerable evidence indicating that policies aiming to reduce social inequalities remain one of the more sustainable solutions to removing the social gradient in health (Raphael 2002). Because economic and material scarcity tend to shape a relation to the body that is unfavourable to cardiac rehabilitation, underprivileged groups would benefit strongly from social programmes seeking to secure their access to basic necessities. The provision of adequate health services aiming to fulfil even modest personal ambitions could help to lower the despair and pessimism often evident among those existing at the social margins. In this way, establishing a basic socioeconomic threshold within a society could act as a foundation for the pursuit of healthier lifestyles among individuals. Following this line of thought, the focus on upstream factors in the development of socially adapted cardiac rehabilitation programmes and associated sessions giving out information could benefit such groups. According to this analysis it is highly probable that cardiac rehabilitation is more likely to succeed via the establishment of broader policies that aim to alleviate negative psychosocial conditions (addictions, depression and emotional disorders) and increase positive social support. In sum, this study suggests that, for disadvantaged men with CVD to become concerned about their long-term health, they need to feel that their lives are worth investing in, that their quality of life can improve and that they have the means and support to achieve their longer term health-related ambitions.

Acknowledgements

The authors would like to thank the Social Sciences and Humanities Research Council of Canada for their support of this research. The authors also wish to thank Cindy Bergeron for her valuable contribution during data collection.

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