Current lifestyle is logical for participants given their personal situation
Frequently, participants indicated that their current lifestyle – healthy or not – worked for them. Physical activity and eating behaviour were explained in both SES groups as logical with regard to their: available time and energy, habits, social influences and physical condition. Especially in the case of some low SES participants, eating behaviour was in addition explained by financial considerations. Some participants stated that they simply did not have the motivation to eat more healthily or to be more physically active.
Time and energy
For those participants motivated to live healthily, having enough time and energy was an important requirement for having a healthy diet. Participants indicated that preparing a healthy meal could take more time and effort.
“I think it is a disadvantage, or maybe not really a disadvantage, but that it [eating healthily] takes more time sometimes. Or you have to prepare it properly, that you peel the potatoes earlier, or something like that.” (Low SES woman, 49 years old)
Participants also indicated that a lack of time or a lack of energy after a long day’s work could make it sometimes difficult to be physically active. Participants perceived that they had to divide their time and energy. Physical activities, for example, had to compete with other activities.
“I should do it [exercise] more often, but sometimes the motivation is lacking, and the time. At home the laundry is waiting for me. And then you have to make choices: Will I do the laundry or am I going to exercise? Do I choose to take care of my mother, or am I going to do other things? Choices.” (Low SES woman, 44 years old)
Participants also mentioned that, if they planned their eating behaviour and physical activities, it became easier to do it.
“What I did notice, what does help – not that I always do it, but I do have those periods that I do – is when you plan it. You make up some recipes for a few days and you do the groceries for that.” (High SES woman, 48 years old)
“If you, for example, like me, go for a walk with a friend on Tuesday evening, and she knows that, you know, I will be there on Tuesday evening at seven o’clock.” (High SES woman, 60 years old)
Habits
Some participants indicated that it was easy for them to live healthily because that was how they grew up or it was what they were used to doing.
“I was raised to eat quite healthily. But if you are not used to that, I think it can be difficult.” (Low SES man, 69 years old)
However, other participants indicated that it was difficult for them to live healthily because they were used to the unhealthy behaviour. Likewise, some participants indicated that healthy behaviours should become habitual, but that, at the moment, these healthy behaviours were rather an exception than a rule for them.
“My husband and I often say it; we go walking before we go to bed or around half past nine in the evening. But it should become a habit. It is now rather an exception.” (Low SES woman, 61 years old)
Financial cost
Low SES groups in particular discussed the influence of cost on their shopping and eating behaviour. They mentioned that they did their grocery shopping at cheap supermarkets and indicated that special offers influenced their food choice. They furthermore considered higher financial cost as a disadvantage of eating healthily.
“As I understand from you, money is a disadvantage for healthy eating. Are there any other disadvantages?” (Interviewer)
“I think money is the most important factor.” (Low SES woman, 64 years old)
“That is the most important.” (Low SES woman, 56 years old)
“You can’t take whatever you want. You have to pay attention to the price. With everything. We first had two incomes, but we don’t have my income anymore. (…) Then you really need to pay attention to the things you buy.” (Low SES woman, 62 years old)
The high SES groups that discussed the higher cost of healthy foods put this into perspective by saying that a healthy diet might be cheaper in the long run, taking into account the total lifestyle and the long-term health costs.
“It is about your lifestyle as a whole and then I think that eating healthily does not have to be more expensive.” (High SES man, 60 years old)
“It could be that it [eating healthily] is even cheaper.” (High SES man, 47 years old)
“In the end, I am convinced of that. If you take into account the medical cost in the long term, etcetera.” (High SES man, 60 years old)
Social influences
All groups indicated that the social environment made it sometimes difficult to eat healthily. Enjoying an alcoholic beverage or an unhealthy snack was often associated with sociability. At a party or in a social setting, participants sometimes found it difficult to resist unhealthy foods.
“When you are at a reception or whatever – that happens once, twice or three times a month or something – then I think: ‘Oh, no’. I find that difficult, when you want to eat healthily, but you get stuck in a snack situation.” (High SES woman, 53 years old)
Another reason why it could be difficult for participants to say no was because they did not want to disappoint the hostess.
“Then you do not want to displease someone, or they have bought a lot of food. Then you think I will eat a little. That is how it goes.” (Low SES woman, 44 years old)
At home also, it sometimes became difficult for participants to eat healthily because family members bought unhealthy products or because family members did not want to join them in eating healthy alternatives. At the same time, participants could be stimulated by their family members to eat healthily by improving their eating behaviour together or by following the good example of family members who already ate healthily.
“When the persons in your surrounding eat more healthily, you are going to do that more easily as well. My wife thinks it important to eat healthily, my daughter as well. But especially my wife influences me, because she is always around. I think your surroundings play a decisive role.” (High SES man, 61 years old)
Some participants indicated that they ate more healthily by adapting their own eating pattern to the needs or wishes of family members, or that family members adapted their eating patterns to what the participants needed.
“I have to pay attention because of the diabetes as well. So, my husband does that automatically as well. He gets the same [food]. I am not going to prepare two types of vegetables and two types of potatoes, or whatever. I make all the same. But he doesn’t mind.” (Low SES women, 56 years old)
Social influences were also noticeable in participants’ perceptions regarding physical activity. For some participants, physical activity was a social occasion, associated with the opportunity to meet new people. Being part of a group made it easier for participants to go to exercise sessions, because they felt obligated to go even if they had other things to do or felt no motivation at that moment.
“Then you have that appointment. And then you won’t cancel it that easily. Then you really first need to have a good excuse.” (Low SES woman, 49 years old)
Family members, especially the partner and children, could also motivate participants to exercise by saying they should be physically active or by joining them. Some participants indicated that their family members could also demotivate them, for example by reminding them of other things that should be done (first). Such competing activities, like household activities or family duties, could inhibit participants from being physically active.
“You are getting older, you have kids, and you do not have any time anymore to exercise because you are busy with the kids and so on.” (Low SES man, 54 years old)
Physical condition
Some participants stated that their physical condition made it difficult or impossible for them to be physically active.
“That your body sometimes can’t do it [being physically active], because of certain health complaints.” (High SES woman, 51 years old)
“When I was 15 [years old], I started working at a building site, so my body is just not functioning anymore. It’s finished. Done.” (Low SES man, 62 years old)
However, at the same time, as illustrated in the next section, someone’s physical condition could be a motivation to engage in a healthy lifestyle.
Lifestyle change is prompted by feedback from their body
Participants relied strongly on the feedback that their own body gave them. Both low and high SES groups mentioned the negative health consequences of an unhealthy diet or a lack of physical activity. However, more than the high SES participants, the low SES participants stated that they first needed to get a signal from their own body before they would change their lifestyle.
“As long as I feel healthy and I don’t suffer from anything, I eat whatever I want.” (Low SES man, 58 years old)
However, some participants mentioned that it might be too late if they were to wait for a signal before improving their lifestyle. Like many high SES participants, some low SES participants stated that a healthy lifestyle was necessary to prevent overweight and health complaints.
“But it is also for preventive purposes. To prevent all kind of things. When you eat fatty, you can get cardiovascular complaints.” (Low SES man, 54 years old)
Several participants mentioned that they had already experienced some health complaints and stated that these health complaints were the trigger to change their lifestyle.
“I have suffered three heart attacks. That’s why I take a little bit of care of what I eat.” (Low SES man, 54 years old)
“I have been in the hospital once, because of a heart attack. And then I have been reminded of some things. That is why I have changed my lifestyle.” (High SES man, 61 years old)
Lifestyle change was also prompted by less extreme feedback from participants’ bodies, such as a simple change in weight:
“What I did notice was that I weighed 106 kilograms at a certain point. I stood naked on my wife’s weighing scale. One hundred and six kilogrammes naked, then I scratched my head and started thinking: ‘how did it happen’? So, normally when I came home and was watching TV, then I always ate something before I went to bed. And now I consciously stopped doing that and I weigh 102 kilograms again.” (Low SES man, 58 years old)
In the case of lifestyle advice also, several participants from both SES groups believed that their own body could tell them what was healthy for them and saw themselves as the most reliable source of information.
“But your body will indicate it, what you can or can’t eat. Because when I eat more sauce than normally, I notice it immediately.” (Low SES woman, 62 years old)
When participants discussed the possibility of receiving support for lifestyle change from health professionals, they indicated once more that it was person-specific support that was needed. As illustrated in the next section, participants therefore considered it important for health professionals to take a participant’s personal situation into account.
Support for lifestyle change should include individually tailored advice and could profit from involving others
Participants made suggestions about how they could be supported to make lifestyle changes. They required tailored lifestyle advice and discussed the influence of involving significant others. In low SES groups in particular, the advantage of making lifestyle changes together with comparable others was mentioned.
Although some participants were keen to receive support for lifestyle change, others indicated that they were not interested. Some participants mentioned that they already lived healthily and therefore did not need advice. Others indicated that they already knew what was healthy or already received enough advice. Some men considered themselves too old to receive lifestyle advice.
“If I was 20, I would say: ‘Yes I do need advice’. But not anymore at this time.” (Low SES man, 70 years old)
Furthermore, as with lifestyle change, participants often felt that there needed to be something wrong with their weight or health before they would visit health professionals for lifestyle advice.
“You often just don’t do it without a reason. You don’t just go to someone like that [nutritionist], there must be a reason.” (Low SES woman, 44 years old)
Tailored lifestyle advice
Those participants who were interested in receiving advice mentioned that it was person-specific whether something was good for one. Therefore, they would like to receive tailored nutrition advice, preferably based on knowledge about how their own body works. Some high SES participants suggested that such individually tailored information could be given on the basis of the results of health checks.
“You can give some general advice – like that is good and that is not good – but not personal advice. Then you first need at least maybe blood and urine tests and whatever more.” (High SES woman, 72 years old)
In the case of physical activity guidance also, interested participants mentioned that the person giving the advice should understand the personal situation and physical condition of the participant, so that the advice could be tailored to the individual situation. Some low SES participants in addition mentioned that they wanted to get advice specifically for their age.
“You become older. You become stiffer. Tying your shoelaces, that kind of things, all those movements become more difficult. I would like to get more specific physical activity advice about that” (Low SES man, 65 years old)
Making lifestyle changes together
A change in lifestyle might be more easily accomplished together with others. Support for lifestyle change could make use of that by involving significant others. Some low SES participants in particular indicated that they would like to receive nutrition advice in a group. They explained that, in a group, members could stimulate one another by interchanging ideas and experiences and by social control.
“In a group, you can accomplish more. At least, you will have more motivation. If I look into your eyes and I say: ‘I did not eat any potatoes this week’, you can’t check it. (…) But he lives next to me, and then he can say ‘I have seen you sitting at the table, with potatoes’.” (Low SES man, 58 years old)
In contrast, high SES participants frequently indicated that they preferred to receive nutrition advice individually. They found that advice on an individual level could become more personally relevant or more specific, whereas on a group level it would often remain very general.
“In a group, you get the more general [information], what you already know.” (High SES women, 60 years old)
With regard to physical activity, participants from both SES groups indicated that they preferred to be physically active in a group rather than on their own. Participants found it more enjoyable to do physical activities with others. Additionally, being part of a group could stimulate them because others in the group would expect them to show up.
“You don’t cancel it that easily. You made your appointment.” (High SES woman, 58 years old)
The low SES participants in particular mentioned that it would be stimulating to exercise together with persons of the same age, gender, physical activity level or health complaints. One perceived advantage was that they could exercise on the same intensity level.
“My daughter regularly exercises a few times a week. But I don’t think I will go together with my daughter, because I can’t keep up with her. (…) I can’t keep up the pace and then I would think ‘Sorry, I won’t join you’. If you are in a group with persons of the same age, then you have about the same tempo. (…) I would appreciate that.” (Low SES woman, 64 years old)
Another advantage with respect to being physically active with comparable others was that participants expected to be better understood by other participants.
“When you’re going to exercise with persons with the same illness, it is easier. (…) If you say that you have to take a break, you feel less awkward.” (Low SES woman, 56 years old)
The support of similar peer groups could apparently help to create a safe and accessible setting for facilitating lifestyle change among these low SES participants.