Prioritising family health needs: a time–space analysis of women's health-related behaviours

Prioritising family health needs: a time±space analysis ofwomen's health-related behaviours

Ruth Young *

National Primary Care Research and Development Centre, University of Manchester, 5th Floor, Williamson Building, Oxford Road,

Manchester M13 9PL, UK

Abstract

Much has been made over the years of the view that health-related geographical research has failed fully toexplore the complex and mutually reinforcing impact of social and spatial relations on individual health-relatedbehaviours. At the same time, there is a growing awareness elsewhere in the social sciences and in health services

research of the generally inadequate exploration of the role of place Ð particularly at the scale of the localcommunity Ð in the social construction of health, illness and health care use. This paper aims to contribute tothe debate by o�ering a clear framework within which to analyse the impact of spatially con®gured socialrelations at the micro-level. In-depth interview evidence from Liverpool shows that, looking at the problem from

the perspective of the opportunity-costs of time±space constraints, is a useful means to understand the distinctways in which health services are used, when and why, across di�erent social groups and geographical areas.Particular attention is drawn to the di�erent thresholds for decision-making depending upon whose health-related

needs are being negotiated within the family. The paper concludes with the latest policy developments in UKprimary care which o�er professionals the clear opportunity to develop much more sophisticated understandingsof what constitutes locally-sensitive health service provision. The argument is that such developments must be

based on a ®rm sense of how individual time±space circumstances interact with conditions in the local area if thebest possible use of increasingly scarce and valuable resources is to be achieved Ð particularly in communitiescharacterised by poverty and social exclusion such as those in Liverpool. # 1999 Elsevier Science Ltd. All rights

reserved.

Keywords: Geography; Time±space; Health-related behaviours

1. Introduction

The view that health-related geographical research

has failed fully to recognise the complex, mutually-rein-

forcing impact of social (e.g. gender, age, ethnicity, dis-

ability, sexuality and life course stage) and spatial

relations has been widely debated within the subdisci-

pline in recent years (Mohan, 1989; Kearns and

Joseph, 1993; Dorn and Laws, 1994; Kearns, 1993,

1994a,b; Mayer and Meade, 1994; Paul, 1994). In par-

ticular, there has been a critique that accessibility to

health facilities has tended to be interpreted merely as

physical distance. This carries with it the implicit

assumption that the time, e�ort and triggers to over-

come spatial constraints are similar for every service

user, at di�erent times, in various locations, and di�er-

ent health and illness situations (Pearson, 1989).

However, as Massey (1993) explains (p. 168):

Social Science & Medicine 48 (1999) 797±813

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(98 )00378-5

PERGAMON

* Tel.: +44-160-275-7640; fax: +44-161-275-7600; e-mail:

[email protected]

Social relations always have a spatial form andspatial content. They exist necessarily, both in space

(i.e. in a locational relation to other social phenom-ena) and across space. And it is the vast complexityof the interlocking and articulating nets of social re-

lations which is social space.

It follows that the lives and discourses of individualsare con®gured in distinct ways in relation to these`nets of social relations' (Massey, 1988, 1994; Meegan,1989, 1995); and that the in¯uence of space on the

social construction of meanings and the actions andevents which stem from them can best be understoodif: ``Instead of thinking of places as areas with [clearly

de®ned] boundaries around, they... [are] imagined asarticulated moments in networks of social relationsand understanding'' (Massey, 1993, p. 66).

Eyles (cited in Jones and Moon, 1993), forexample, has already indicated that medical geogra-phy is moving from the view that space is merely thebackdrop upon which outcomes are measured

towards a relational approach in which space is a sig-ni®cant part of the explanation for human agencyand vice versa (cf. Cooke, 1989; Cox and Mair,

1989). Studies have, for instance, explored how`everyday contexts' (i.e. social and physical environ-ments) in¯uence individual understandings and per-

ceptions of health, illness and health services(Cornwell, 1984; Donovan, 1986; Eyles and Donovan,1986; Litva and Eyles, 1994). However, with relatively

few exceptions (e.g. Coupland, 1982; Whitelegg,1982), medical geographers have not so far exploredthe actual processes through which socially con-structed perceptions of distance and the practicalities

of social space impact on how, when and why indi-viduals enter the formal health care system.Importantly, there is also a growing awareness else-

where in the social sciences and in health servicesresearch of the generally inadequate exploration ofthe role of place Ð particularly at the scale of the

local community Ð in the social construction ofhealth and illness, and individual health, illness andhealth care behaviours1 (e.g. Blaxter, 1990; Macintyre

et al., 1993). This paper aims to contribute to thedebate within both policy analysis and health-related

geographical research by o�ering a framework withinwhich to analyse the impact of spatially con®guredsocial relations at this important micro-level.

2. The geography of health-related behaviours: time±

space approaches

As HaÈ gerstrand (1970) originally argued, there areclear limits to the `time±space prism' (or spatial range)over which people can operate given the day-to-daypracticalities of their work and home lives. In other

words (p. 15):

An individual bound by his [sic] homebase, can par-

ticipate only in bundles [of activities] which haveboth ends inside his daily prism and which are solocated in space that he has time to move from the

end of one to the beginning of the following one.This means, for example, that if a doctor holds hisclinic during the working hours of a patient, the lat-ter cannot see the doctor except by obtaining per-

mission to be absent from work.

For women, the scope to schedule competing every-day activities, and indeed the range and type of activi-ties undertaken, was shown to be signi®cantly

constrained by gendered social relations Ð especiallyby their `domestic and mothering roles' (Pred, 1981;Tivers, 1985, 1988). Similarly, women's access to the

¯exibility of private transport (e.g. to shorten journeytimes and extend the choice of destinations) and,hence, use of facilities in the public sphere has beenrestricted by their generally lower participation in full-

time paid work (Hamilton and Jenkins, 1989; Jones,1989; Pickup, 1989).Importantly, however, time-geography has yet to

explore in detail the fundamental impact of socialdiversity amongst women themselves which is now acentral element of feminist geographical analysis

(Rose, 1993). In other words, traditional time-geogra-phy overlooked the inherent subjectivity of space as itis experienced within a system of social relations, dis-courses and meanings. It, therefore, under-emphasised

the extent to which women's experiences of `social rea-lity' are di�erent not only from those of men(Valentine, 1989, 1990; Pain, 1991), but also, and per-

haps increasingly, from each other (McDowell andPringle, 1992; Hanson and Pratt, 1995; McDowell andSharp, 1997). At the simplest level, Pratt and Hanson

(1993) note how the particular constraints felt bywomen caring for adult dependants rather than chil-dren have a powerful e�ect on `space as experienced'.

1 This includes: (i) illness behaviour Ð which describes the

ways in which people monitor their bodies for symptoms of

disease and how they de®ne, interpret and take remedial

action in response to those symptoms; (ii) health behaviour

Ð which is individual action taken, in the absence of illness,

in order to remain healthy and includes factors such as

`healthy' lifestyle behaviours and response to preventative

screening programmes and (iii) health care behaviour Ð

which is the use of formal health services and informal self-

care in the context of both of the above (cf. Mechanic, 1968).

R. Young / Social Science & Medicine 48 (1999) 797±813798

Equally, time-geography's implication that people aredisembodied i.e. colourless, ageless and without dis-

ability is unsustainable (Rose, 1993, p. 33) (see alsoAdams, 1995; Chouinard, 1997; Parr, 1997).Importantly, the sorts of `accessibility' problems which

stem from such social, as well as physical, distancesare particularly relevant in the context of health-re-lated behaviours (Donovan, 1986; Breemhaar et al.,

1990; Health Education Authority, 1994; Reed andGilleard, 1995; Butler and Bowlby, 1997).In a similar way, traditional time-geography took

very little account of arguably the most important fac-tor from within the private and domestic arena whichimpacts on people's wider experience of social space.That is the vital role of individual emotions and sense

of attachment to others in the ways space and time areperceived and utilised. Instead, time-geography (Rose,1993, p. 34):

... emphasises space as in®nitude and unbounded-ness, transparency; it is simply everywhere, and

what is stressed above all is the liberty possible inthis space... And even though time-geographyfocuses on constraints, its language is untouched by

the experiences of being constrained, by the feelingsthat come with the knowledge that spaces are notnecessarily without constraint.

Signi®cantly, as Dyck (1989) argues, women's viewsof space may actually alter as their feelings change.

For instance, by watching their children play outside,women often meet, talk and develop friendship net-works with, other mothers such that previously

`unsafe' spaces can be renegotiated as `safe' in every-day meaning. Far from being universal and exhaustive,then, the di�erent ways people experience and usetime±space are constructed and reconstructed depend-

ing on current circumstances and who exactly isinvolved.

3. A time±space decision-making framework for health-

related behaviours

Building on the time-geographic research outlinedabove, as well as existing literature around health-re-lated behaviours, four dimensions of everyday circum-

stances appeared likely to constitute the majorin¯uences on women's changing perceptions of time±space. Combined together they can be conceptualized

as a opportunity-constraint framework within whichindividual women must make decisions over their ownand their family's health-related behaviours.

3.1. Time±space constraints arising from social roleresponsibilities

Social role responsibilities are de®ned here as thosewhich derive from the current positioning of an indi-

vidual both in relation to the paid labour market andthe provision of unpaid domestic labour. These roleresponsibilities Ð both to the immediate household

and wider social network Ð might be economic andmet through part-time or full-time paid work and/orthey might comprise the practical and personal care of

family members. The latter ranges from looking afternormally healthy children and partners to the care ofthose younger and older relatives who, as a result ofmental or physical disability, need help to look after

themselves. Each type of commitment involves its ownpressures on time and a�ects the freedom a womanhas to choose between options because of the necessity

to accommodate all responsibilities into the daily rou-tine (Seymour, 1992; Horrell, 1994).

3.2. Health-related constraint

This is a complex, mutually-reinforcing relationship

in which: a) pre-existing health status (i.e. presence orabsence of limiting and nonlimiting long-standing ill-ness) in¯uences paid and domestic labour participation

and health-related behaviours (Carpenter, 1987); andb) social role commitments impact on both mental andphysical health experience (e.g. Doyal, 1995; Popay etal., 1992). Of course, in addition to the e�ects which it

has both on paid and unpaid labour, health status hasdirect implications for physical mobility and percep-tions of space.

3.3. Access to economic resources

By employing economic resources, in particular,women are seen as able to o�set the various time±space constraints imposed by their social roles and

health status. For example, those with a higher dispo-sable income have greater scope to purchase householdadaptations and disability aids and to substitute paid

cleaning and caring services for their own labour(Henwood and Wicks, 1985). Another way in which®nancial resources can ease time±space decision-mak-ing is through access to private transport (Holzapfel,

1986). Similarly, a telephone allows people to interactwithout the loss of time which would otherwise occurin transportation (Hillman et al., 1976). Compounding

this is the fact that, amongst women in paid employ-ment, sick pay provision and work practices whichhelp people to accommodate caring responsibilities,

such as taking children to a doctor, are more likely inhigher status clerical, personnel and managerial jobs(Pearson et al., 1990; Christensen, 1993).

R. Young / Social Science & Medicine 48 (1999) 797±813 799

3.4. Access to social resources

In the absence of su�cient money income as a

means of mobilising additional time±space resources,

help from the social network may be available to some

but not all women (Dowswell and Hewison, 1992;

Morris and Irwin, 1992). Kinship and friendship net-

works are also important to perceptions of health pro-

blems generally (Scambler et al., 1981). Stark (1987),

for instance, demonstrated that although the e�ect on

psycho-social health is stronger than for minor physi-

cal symptoms, both are more frequently reported by

women who feel themselves to be socially isolated and

unsupported. In particular, both material and emotion-

al support serve to bu�er an individual from the e�ects

of economic and social stress (Parry, 1986; Whelan,

1993). However, in practice, such interhousehold

exchanges may be more reliable and take place more

often between immediate family members than between

friends and neighbours (Grieco and Pearson, 1991). In

addition, research amongst low income families on

Merseyside shows that favours are considered recipro-

cal and, as a consequence, are often saved for emer-

gencies (Pearson et al., 1993).

As a particular element of this decision-making

framework, carrying out health-related labour (e.g.

undertaking health care behaviour on another's behalf;

looking after an ill relative, etc.) can be understood as

a vital and integral part of the general task of caring

within families. It was by taking caring as its principal

focus, and by recognising that such responsibilities

involve both `labour' and `love' (cf. Graham, 1983),

that the research reported here aimed to capture some

of the emotion and di�erential meaning attached to

time±space constraints/resources in the context of

health-related behaviours. The study, therefore, set out

not only to explore variations in experience across

di�erent social groups in similar health, illness and

health care situations, but also possible ways in which

individual women perceive the same time±space cir-

cumstances di�erently depending on whose health

needs are being negotiated.

4. Research design and sample pro®le

For the purposes of this research, two adjacent elec-

toral wards in outer-suburban Liverpool were selected

as study areas on the basis of the following key prin-

ciples: (i) the need to include women living in the full

range of socio-economic circumstances typical of the

city and (ii) the necessity to control for local di�er-

ences in available health services. Liverpool itself was

chosen because of its particular labour market charac-

teristics2, its relatively poor health record, and associ-

ated caring responsibilities for families and local

communities3. In particular, the city's industrial past

has adversely a�ected the health of its older population

(Kavanagh et al., 1993). For working people, such en-

vironmental hazards continue to combine with the

pressures on health of low income and high unemploy-

ment risk (Chief Executive's Department, 1991).

Moreover, as the traditional port industries have

declined, a large proportion of younger, ®tter people

have left to seek employment elsewhere (Ashton et al.,

1994).

It is important to emphasise that the research never

intended to describe conditions through `representa-

tive' geographical case studies. Instead, the purpose

was threefold:

1. to examine the complexity of household negotiation

processes around paid employment, unpaid labour

and use of economic and social resources,

2. to use examples of the variety of women's everyday

situations in order to illustrate the nature of activity

scheduling decisions and

3. to reveal how women perceive their own health-re-

lated needs and those of the people they are caring

for within this framework.

The aim, therefore, was less the depiction of associ-

ated features and generalisable trends than an in-depth

understanding of priorities and parameters of choice in

the socio-spatial contexts provided by the study areas.

Hence, a short postal questionnaire was designed

speci®cally to locate groups of women at di�erent pos-

itions across the contingent framework of time±space

circumstances outlined in the last section. Interview

participants with child and/or elder care responsibilities

could then be sampled theoretically (Finch, 1987) or

selectively (Schatzman and Strauss, 1973 quoted in

Strauss, 1987) on the basis of the social role/resource/

health characteristics of the respondent group rather

than their statistical representativeness of a wider

population.

The postal questionnaire was mailed to 516 women

(or ®ve percent of the total female population in the

study areas) selected randomly from the electoral regis-

ter. In order to ensure that the widest possible sample

2 The 1991 Census of Employment showed, for instance,

that the proportion of women in the Liverpool labour force

had risen to 50.7% compared with an average of 48.2% for

Britain. The sustained rise in women's part-time working, in

particular, has expanded their already important role support-

ing households in a declining local economy and labour mar-

ket for traditionally `male' jobs (Green, 1994).3 In the period 1993±95, the latest for which ®gures are

available, the All Causes Standardised Mortality Ratio for

Liverpool stood at 20% above the England and Wales aver-

age (Liverpool Health Authority, 1996).


of social variety was obtained, the mailing was pro-

portioned on the basis of the percentage of the total

population found in Social Areas derived from the

Census of Population (Liverpool City Planning

Department, 1984, 1993). Four out of the city's ®ve

social area types were represented in the two study

wards. In the ®rst, there were areas of mixed low

income council/low income terraced, poorest council

and medium income owner-occupied housing. In the

second, medium income and higher income owner-

occupied housing were the social types represented.

Reminders were sent to nonreturners at two and four

weeks after the original mail-out in order to raise the

response rate.

As Table 1 shows, the percentage of returned ques-

tionnaires was relatively consistent across the Social

Areas within the two wards (60±66%) Ð with just

11% of the sample remaining unaccounted for. In

total, 324 completed responses were included in sub-

sequent analyses which, rather than assuming a `cau-

sal' relationship on the basis of statistical association,

aimed to explore patterns within the data set and to

use these to raise issues not already thought of for in-

clusion in the intensive interview study (e.g. di�erences

in personal health status and participation in caring

and/or part-time and full-time paid work; di�erences

in recalled use of health care across the caring and

paid work groups, etc.). In order to select interview

participants with whom the range of time±space con-

straints on health-related behaviours could be

explored, the women were also assigned to discrete

groups depending upon their social role, health and

resource circumstances. A cross-section4 of 37 of the

140 respondents aged 18±59 with di�erent types of car-

ing responsibility5 were then contacted by telephone to

request an interview. Those for whom no telephone

number could be obtained were sent an introductory

letter and visited personally to arrange a subsequent

visit.

During the initial contact, participants were also

asked if they would record their daily activities prior

to interview. Semi-structured diary sheets, designed

using examples of previous similar research instru-

ments (e.g. Ferguson and Jones, 1986; Corti, 1993),

Table 1

Postal questionnaire responses by social area

Social area No.

posted

No.

blanksaNo.

died

No.

moved

away

No. not

analyzedbNo.

unaccounted

No.

included in

analysis

Area 1: mixed low income council estates

and low income terraces

50 9 1 2 1 5 32 (64%)

Area 1: poorest council estates 80 11 ± 6 2 13 48 (60%)

Area 1: medium income owner occupied 50 8 1 2 1 5 33 (66%)

Area 2: medium income owner occupied 211 38 ± 5 6 25 137 (65%)

Area 2: higher income owner occupied 124 29 4 5 5 8 74 (60%)

Total 516 94 6 20 15 56 324 (63%)

a Respondents were asked to return the blank questionnaire if they did not want to take part in the research.b Although returned completed, these questionnaires were excluded because respondents were no longer living in the study areas.

4 The postal survey data was analyzed by hand and also by

computer such that one method could verify the other. For

the hand analysis, a `characteristics card' was written out for

each respondent. The cards were then sorted into smaller and

smaller groups based on the di�erential nature of women's

labour market and caring responsibilities, their health status

and so on. The computer analysis employed correspondence

analysis, a technique which aims to summarise and reveal

mutual relationships in a data set in an exploratory and

descriptive, rather than predictive, manner. Attention is

focused on interrelationships between all the variables without

regard to such distinctions as dependent and independent

variables (Phillips, 1994). In other words, correspondence

analysis describes deviation from independence whether or

not that deviation is statistically signi®cant. The `meanings'

behind the patterns of di�erence and similarity in the data

can then be explored at interview without any assumptions

being made solely on the basis of statistical association (see

Young, 1995 for a full description of these methods).5 As had always been intended, the 101 women aged 18±59

without caring responsibilities were excluded at this stage Ð

not because their experiences were considered less valid, but

because the research had set out to explore the choices made

between women's own and their dependants' health needs.

The 83 respondents aged 60+ were also ruled out because: (i)

the health-related behaviours of older people have been

shown to be su�ciently di�erent to require investigation in

their own right (Arber and Ginn, 1991) and (ii) because only

four of these individuals had caring responsibilities.


were then sent with an explanatory letter. This pro-

vided the interview focus so facilitating discussion ofthe day-to-day workings of family health-relatedbehaviours and the di�erent aspects of women's

time±space decision-making Ð including the natureof activity choices and constraints, and the bargainingprocesses and trade-o�s involved in a given health

situation. Finally, the interviews included vignetteswhich explored the choices women would make and

how they would manage in the context of varioushypothetical health situations (e.g. di�erent familymembers being taken ill at night) which might not

otherwise have been covered (cf. Finch, 1987).Over a six month period, a total of 37 women,

representing the range of time±space characteristicswithin the respondent group (see Table 2), took part insemi-structured interviews with the author. Twenty-

nine of the 37 also kept the activity diary for betweenone and eight days. All of the interviews were tape-recorded and took place in participants' homes. A

minority were completed in 50 minutes, while some

took as long as three hours Ð the average was an

hour and a half. Each interview was transcribed and

analysed by hand as this was felt to be the best way

not to lose sight of what respondents had actually

said. A hierarchical set of linked codes (code, subcode,

subsubcode, etc.) was developed to re¯ect contingent

social relations and circumstances, and outcomes in

terms of everyday activities and health-related beha-

viours (cf. Dey, 1993; Strauss and Corbin, 1990).

Notes were kept on possible lines of interpretation and

a process of review and re¯ection employed to check

that ideas generated from earlier interviews remained

relevant throughout the ®eldwork. In this way, further

questions were generated about the processes under

observation and the interview schedule modi®ed to

re¯ect gaps in understanding in what was an on-going,

iterative research process. The section which follows

gives some ¯avour of the complexity of conditions

facing the interviewees. The paper then returns to

examine in more detail the timeÐspace framework set

out earlier.

Table 2

Pro®le of the interview group (N= 37)

Characteristics (%)

Personal characteristics

Age group:

25±34 30

35±44 32

45±54 24

55±59 14

Marital status:

Single 11

Living with husband/partner 76

Widowed/divorced/separated 14

Ethnic origin:

Whitea 100

Caring responsibilities

Types of dependant:

Adult in another household 16

Adult in same house (includes grown-up child) 19

School-age child and adult in another house 14

School-age children and adult in same house 3

School-age children 24

Children including preschoolers 11

Disabled preschool or school-age child 14

Paid employment participation

Employment status:

Full-time job 30

Part-time job 30

Looking after home 32

Registered unemployed 5

Registered sick 3


5. Research ®ndings: timeÐspace ¯exibility in the

context of social roles and resource constraints

5.1. Accessing routine and preventative health care

One of the most signi®cant ®ndings was that womenwho combined caring responsibilities with paid workoften ignored personal health problems as a direct

result of the time±space pressures of their social roles.It was also clear, however, that women in di�erent seg-ments of the paid labour market were presented with

very di�erent circumstances in terms of the ease withwhich they could respond to illness and access healthcare. As previous research (e.g. Grieco and Pearson,

1991) has also shown, women in part-time jobs oftenfound it easier to prioritise routine and preventativehealth services. Full-time employees, by contrast, could

be constrained because clinics and general practitioner

surgeries did not coincide with their time away frompaid work. For instance:

I think they do Well Woman things, breast screenand things like that and weight and cholesterol...But I've never really had time to go because it's aWednesday afternoon and I never used to go then

when I was working full-time (N1: early 50s, part-time teacher).

... it's the time of day business again because I

don't want to take time o� work... They have asurgery during the day and a surgery sort of afterwork time Ð 5 o'clock onwards. And if you ring

Table 2 (continued )

Characteristics (%)

Economic resources

Most car access:

Woman 19

Woman and husband 16

Husband 27

Son 3

No Car 35

Telephone:

Yes 86

Nob 14

Type of home:

Owned/mortgaged 70

Rented 27

With job 3

Social network resources c

Degree of help:

Regular 22

Occasional 46

None 32

Health-related constraint

Health status:

Limiting long-term illness 14

Nonlimiting long-term illness 35

No long-term illness 51

a Re¯ecting the population of the study areas, only seven of the 324 postal questionnaire

respondents were of ethnic backgrounds other than white Ð none of the seven agreed to be

included in the interview phase.b Four of the ®ve women with no telephone also had no access to a car.c This includes help with child minding, receiving car lifts, etc.


and say can you have an appointment in anafternoon surgery, it's like four or ®ve days away

and you think, ``Oh, I'll be better by then'', soyou don't bother (N2: late 30s, full-time teacher).

Signi®cantly, however, women who saw their socialrole as solely that of carer also spoke of constraints ontheir use of health care and reactions to illness. In ad-

dition to the immediate constraints of time±space, theydescribed the signi®cant impact on their decision-mak-ing of having to `carry on' for other people. The link-ing factor is that, for many, paid employment

participation had already been restricted as a directresult of their heavier caring responsibilities and theirhealth-related behaviours were similarly a�ected. For

example:

Well the thing is I couldn't lay in bed could I? Ihad to get up and give him [elderly father] his

breakfast... (N3: early 50s, invalid care allowance).

Either the kids could be at school when I do go [tothe doctor] so that's OK and I'll just take the

youngest with me... or they could be at the littleyouth club that they go to... So I pick the times,you know. When they say to me, ``We've only gotthis time'', I go, ``Well OK then, I'll have to have it

the next day''. I either su�er when I'm really ill, I'llmake it like to go the next day to suit the kids.You think to yourself, ``Another night of illness Ð

put up with it'' (N4: early 30s, income support).

The study also showed that accessing routine health

care could be a�ected by the gendered nature of trans-port mobility in some households. One motherdescribed how she managed:

Well my son's got the opticians so I'll make his

appointment Ð I'll try and get it in the morningtime while I can take him in the car, get him seento, get him back to school. It really depends a lot

on his [partner's] shifts and when I'm mobile.Because it takes twice as long getting the busdoesn't it?... I try and do everything while I've gotthe car (N5: mid 30s, income support).

Another woman had actually been deterred fromattending a hospital clinic speci®cally because the

time±space constraints imposed on her by multiplesocial roles could simply not be accommodated usingpublic transport:

I just couldn't a�ord the bus fare because you'dhave to get the bus down to the Five Ways [ap-

proximately 5 miles], then a bus along and thenwalk you know. And then of course, when I wasgoing there, I was looking after my daughter, going

to work... I did go every week and I lasted forabout two months, but after that I just didn't havethe time because, eventually, my mother was in a

wheelchair (N6: early 50s, recently retired part-timeschool cook).

The physical mobility problems experienced by dis-abled women also reinforce, and are reinforced by, re-

lations of social and economic disadvantage. Thewoman in this extract had been unable to return to herjob as a data-processor once her children had grownup because her hands were too a�ected by arthritis.

She said:

I use taxis a lot [to go to hospital or GP and to col-

lect repeat prescriptions]. I'm hoping that, whenthis new [mobility bene®t] award goes through, thatthey'll give us a three year award so I'll be able to

get a car... [It must cost you quite a bit in taxis?]Oh it does. But then, as I say, that's what I've gotthe award for, you know. But I use most of it on

taxis like. But it'd be more economical... if I got thethree year or more. They have with the mobilityscheme Ð it's like a lendÐlease Ð you have thecar for three years, they have your award and

you're fully taxed, insured and everything. And allyou've got to do is put the petrol in which wouldbe better because it'd give me more freedom

because our Julie's [daughter] got her driving licenseand our Ann is having lessons (N7: late 40s, regis-tered sick due to rheumatoid arthritis).

5.2. Time±space ¯exibility in an emergency situation

The interviews also provided important evidence forthe great diversity of time±space ¯exibility across

di�erent social groups in a range of emergency situ-ations. The following shows the contrasting manage-ment mechanisms of three women with di�erent levels

of economic resources available to them. First, ahigher-income mother who was able to plan quite con-®dently for a situation in which one of her children

became seriously ill during the night:

I wouldn't hesitate to either phone the doctor or go

straight to Alder Hey [children's hospital]... I wentto Alder Hey recently with my sister's little girl whohad a very high temperature and the doctor was a


bit worried about meningitis and they were superb...I mean, I thought at the time I wouldn't even think

twice about bringing a child here if I had any wor-ries with or without the doctor's help. I'd do what-ever I thought was quickest. If I really thought they

were ill and it was quicker to just get in the car andgo up there (N8: mid 40s, full-time personnel man-ager).

Next, two lower-income women, both of whom were

single mothers. They described much more complicatedarrangements which depended as much on luck asprior planning. Overall, these extracts illustrate the

degree to which low-income households have to relyon social networks to counteract their own lack ofmobility resources:

It's very hard. Like a few months back beforeChristmas he [disabled two year-old] was veryill... so I had to leave my daughter in the house

while I ran to the phone... That phone was outof order Ð I had to run right down, all the waydown [road on opposite side of council estate]...

And so I had to ask my mate to take the callfor me from the doctor and I had to run all theway back again so I was exhausted. Then he was

getting worse and the doctor never came till ®ve-past-eleven. And that was from half-seven, eighto'clock so I was disgusted by that Ð I was get-ting all ®dgety. I was like, shall I send my daugh-

ter out to go to the phone or whatever? Andthen I always think Ð well, it's like say someonegrabs her?... I'm on edge with leaving her but

what can I do? Another time he was really ill... Ididn't want to take him out because he was get-ting dehydrated but there was no one around.

You know what I had to do in the end? I hadto just take him [to the GP] and say, ``Look,you'll have to see to him now because he's really

ill''. Lucky enough the other kids were at schoolbecause it was daytime. But lucky enough aneighbour was coming past and seeing my Mumso I had to ask my Mum and Dad would they

go and pick the kids up for me rather than draghim out again... (N4: early 30s, income support).

And this night I was on my own with the kids

and the eldest lad fell outside and gashed his legreally badly. Well I was frantic trying to getsomebody. My Mum wasn't here, their Dad

wasn't here... I'm not on the phone any more Ðso it was running round to the phone box andall this, you know, it was terrible. So eventually I

got somebody about two hours later to comedown. So we got to the hospital about seven

o'clock I think... and there was a nurse who said,`Ànd why didn't you come as soon as it hap-pened?''... So I said, `Ì was waiting for my baby-

sitter to come and mind the other kids''. And shelooked at me like that and I was getting reallyannoyed... I suppose I could have got anybody to

mind them and run there but you can't becauseyou're thinking what's back at home Ð what ifanything happens if there's somebody under age

minding them? My cousin came from Halewood.And again, there's no car and the buses are onlyevery hour now once it's turned teatime fromthere to here. [Did you have to get a bus up to

the hospital?] No, I got a taxi. Yes, I had somemoney for a taxi. That's why it's frightened me.That's why sometimes when I've got no money I

think, `Ì can't imagine anything happening now'',you know (N9: early 30s, full-time clericalworker).

Similar concerns were associated with the fact thatthe only late-night chemist was located in city centre

Liverpool around eight miles from the study areas.Once again, social networks were the primary meansof overcoming time±space constraints especially if

women lacked access to private transport. Forinstance, when asked to consider the hypotheticalnecessity of collecting a prescription after seven-thirtyin the evening, two women replied:

I'd get my daughter to go Ð one of my daughtersÐ they've got cars (N10: late 50s, full-time care

worker).

... When we didn't have a car it was di�cultbecause you had to get the bus down and it's along way... if I had to go, my Mum would alwayscome over and mind the children. Or I'd have to

bring somebody in to mind them. I have done itwhere I've had to have a friend come and mindthem while I've gone (N11: late 40s, full-time

administrator).

Importantly, however, there was evidence of a clear,

socially-constructed hierarchy of who could be calledupon for help within social networks (cf. Qureshi andWalker, 1989). For instance, if the woman in the next

illustration needed help whilst she was in hospital, shewould ask her mother-in-law ahead of her own fatherand family before friends:


Short-term I think my husband would manage... Isuppose long-term it would be a problem because

of all his other commitments... We would rely onhis mother. But, again, we don't like to do that toooften because she's getting old Ð she's in her sev-

enties. My Dad's still living, but he's not much usein the child care department I'm afraid. He isnearer, but Ð if I said he was unwilling that makes

him sound mean and that Ð he's not really able...to look after kids, he's not up to it. He doesn'twant to be up to it [laughs], not little kids... Failing

that we'd have to rely on friends (N2: late 30s, full-time teacher).

The sense of `not wanting to bother people' who

already provide signi®cant amounts of help and theneed to reciprocate past assistance frequently meansthat resources in the shape of help from friends and

relatives are critically di�erent Ð i.e. less ¯exible Ðthan those in economic form (Finch, 1989; Pearsonet al., 1993). In an emergency situation, people

without responsive social networks may have to relyon the doctor more heavily than others. Forexample:

[What would happen if you got a prescriptionlater on, say if you called the doctor out?] Oh,I'd have to wait till the next day yes. I did callthe doctor out to Susan [daughter]... I think it

was about nine o'clock he came out. But he gaveme Ð when I started moaning, you know Ð hehad a sachet of Calpol and a sachet of Ð what

is it? Ð penicillin, something like that Ð and themedicine he prescribed was the same as the sachethe gave me so.. (N12: mid 30s, income support).

Finally, the study showed how some women wererestricted in their choices speci®cally by fear of unsafe

spaces:

[What happens if you get a prescription late?] I'dhave to go the next day. Because I think the onlyall-night chemist now is in town and I wouldn't

go to town... [Even if it was for your kids and itwas really serious?] It's a di�cult one that isn'tit? I'd want someone with me in the car... I don't

like going to town on my own in the car Ð noton my own... [But you would go?] I suppose I'dhave to go yes, as you say. [But only for the

kids?] Yes, it wouldn't be for me. No, it wouldn'tbe for me Ð no I'd do without, I'd wait, youknow (N13: early 30s, looking after home).

5.3. A woman's place in household health priorities

The last extract clearly illustrates the unequal priori-ties exercised by women in relation to the health needsof di�erent family members. Another indication of the

di�erent thresholds for women's decision-making wasprovided by their contrasting attitudes to symptoms ofacute illness. First, how serious did symptoms have to

be before it was necessary to activate time±space de-cisions and attend the doctor's surgery? Second, whatdid it take to prompt a request for the doctor to make

a home visit? For example:

I'm a regular tonsillitis Ð I'll get that once a yearbut I'll just ignore that... If they get sick, I'll watchit for a day and if they're no better the next day,

I'll take them the doctor's. I won't wait for anappointment either. The way our health centre'sreally busy Ð you'll ring for an appointment say

Monday and they'll say, ``Come in Thursday''.Well, by that time, depending on what's wrong withthe child, they could have rapidly deteriorated. So I

just march down there like a battle-axe and waituntil all the other patients have been seen and thenI'll go in. I won't let them wait more than twenty-

four hours if they're sick (N12: mid 30s, incomesupport).

[Say if your daughter [age 3] woke at two in the

morning with a temperature and pains what wouldyou do?] Call the doctor out. [Right away?] Yes.[Wouldn't think twice?] No. [How about if it was

the older boy?] Well, he can communicate a bit bet-ter than Laura. You say, ``What's wrong?'' withLaura and it's just, `Ì'm sick''. If I said to her, `Ìs

you hand sick?'' she'd say, ``Yes'' Ð `Ìs your headsick?'' So I can't really get much sense out ofLaura. I'd ask Tom where's he sore? If he was sore

with like stomach cramp I'd think, ``Something heate''. If he had an extremely high temperature andreally didn't look well I'd call the doctor out...[And how about if it was your partner?] I'd just say

to him, ``Do you want me to call the doctor out orcan you wait till morning?'' If it was me I'd wait. IfI was half dead I'd still wait till morning... (N5:

mid 30s, income support).

Other mothers described actual illness episodes

which showed that, although the doctor was not con-tacted lightly in any event, there were di�erences inwhat is regarded as serious enough for a call out:


That has happened to us. Hayley's woken up andshe's had stomach pains or a temperature... if she

seemed to be really ill I would call him out... WhenI did my back... I was in absolute agony Ð Icouldn't walk... I did wonder whether I might have

slipped a disc or something Ð whether I ought tocall him out. I haven't and we didn't call him outin the night... I did call him out the next day... (N2:

late 30s, full-time teacher).

Those caring for disabled children or older depen-dants felt even more justi®ed in calling the doctor out

because there was a `legitimate' reason for doing so:

Oh I wouldn't think twice about calling the doctorout if there's anything wrong with my son...

because you don't know what other underlyingthings there are, you know... (N14: early 40s, look-ing after home).

I had the doctor out about three times in three

weeks... And the ®rst time it happened he wantedto know how did I justify bringing him out? I said,``Because she's my mother and she's so ill!''... And

he just said, ``Well, what do you expect? She's 82years of age''. I felt like smacking him one... It'snot as if we get him out if she sneezes or anythinglike that, you know, but to literally collapse in my

arms... And then he said how do you justify gettinghim out? Ð arrogant sod! (N15: mid 50s, part-timecatering worker).

What becomes obvious from these extracts is thedi�erential power relationship which existed between

the women and members of the medical profession.This was most clearly expressed by one as follows:

You know my attitude when I've had to call adoctor out like when my daughter's been ill and say

it's been three or four o'clock [in the morning]? Iapologise for bringing the doctor out and Ishouldn't really... I always say, ``Can you hang on

to say seven?'', or something like that. But youcan't if they're ill like you've got to bring them outhaven't you? But you feel uncomfortable having tobring the doctor and you shouldn't really should

you? (N6: early 50s, recently retired part-timeschool cook).

Such considerations intervened sharply in women's re-

sponses to illness symptoms and the level of need theyperceived on their own behalf was often much lessthan for a child or adult dependant. For some, the

long-term consequences for their own health may bequite serious:

And he said I couldn't have the laser [for gallstones] because with me being relatively young

they'd just come back so I've got to have them out.I mentioned it to my GP but he said, ``Well you'retoo much overweight no wonder they won't oper-

ate!''... So I'm on pain killers. They sent me to thedietician at the hospital but I [stopped]... because Iwas also round there every day seeing to my mother

because she was bad and she wouldn't go and livewith me or anyone and the doctor said, ``No whileyour mother keeps going just keep her there''. Soreally I had to go around in a vicious circle (N6:

early 50s, recently retired part-time school cook).

6. Discussion: a `time±space framework' for health-

related behaviours

On the basis of the interview evidence, it was poss-

ible to `¯esh out' the four di�erent elements constitut-ing the conceptual framework for time±space decision-making outlined earlier. Speci®cally, the amount,

shape and spatial form of: (i) domestic labour and car-ing commitments, (ii) paid work responsibilities, (iii)economic and social network resources and (iv) indi-

vidual health status were each shown to be signi®cantin¯uences on women's overall perceptions of theirtime±space ¯exibility (Fig. 1). This was because, singly,

but particularly in combination, these factors a�ectedthe levels of resources available for, and constraintsupon, individual time±space actions. A primary factorunderlying this was the `budget constraint' set by the

¯exibility of women's time commitments to paid andunpaid work. Activity scheduling decisions in relationto routine health care attendance varied sharply

between, for example, part-time and full-time workersin di�erent sectors of the labour market. Access topublic and/or private transport and location of the

paid workplace in relation to home, schools, hospitals,health centre, community pharmacy, etc. were also keyfactors underpinning women's choices and priorities interms of health-related behaviours.

As an overall frame of analytical reference, then, itis possible to envisage women as located along scalesof constraint for each of the factors which contribute

to their time±space decisions (Fig. 1). Their positions(whether high, low or intermediate), both on the indi-vidual scales and overall, depends upon the practical

availability of economic and social resources and theactual limitations of their health status and paid andunpaid work. Together such considerations set the


`objective function' of (health-related) caring need and

the opportunity-constraints on women's ability to

satisfy that need on a day-to-day basis. Hence, women

can be thought of as having to negotiate and renegoti-

ate pathways (indicated by the dotted line in Fig. 1)

through the changing combination of circumstances

that they face. As has been shown, however, whilst

each of the component factors in the decision-making

framework does exhibit its own variability amongst

women, it is the ways in which the elements combine

and interact in real time and in particular places which

are most signi®cant. It is only by attempting to unravel

the complexity of the elements involved, and the ways

in which they are `read' under di�erent personal and

social circumstances, that we begin to approach a rea-

listic analysis of women's health-related behaviours. In

particular, judgements about the ways in which health

needs are managed in low income families may be

unhelpful without such contextual understandings.

Importantly, each of the `quali®ers' in¯uencing the

time±space equation for individual women was shown

to depend on socio-spatial relations operating at twomain levels. The ®rst relates to how the family-house-

hold is con®gured in the context of society as a

whole6. Poor health, for example, is more generally as-

sociated with lower social class, long-term unemploy-ment and advancing age (Blaxter, 1990). Households

which include a pensioner, the unemployed and those

in social class V are likely, therefore, to have the great-

est level of health-related caring need and fewerresources to cope with it. Similarly, households which

comprise a single mother with young children often

have low paid work participation, and have to rely on

social network support as a substitute for economicresources, because gender relations in the labour mar-

ket make child care and a full-time job di�cult to

combine (Chandler, 1991). Disabled people too may be

constrained in their time±space decisions by virtue ofhaving reduced access to economic resources through

paid work (Barton, 1989, Barnes, 1991; Oliver, 1990;

Chouinard, 1997). In terms of there being a distinctspatial dimension to the experience of health and

time±space constraints, it should be remembered that

Fig. 1. Framework for activity scheduling in time±space.

6 This is not to say that the household should be seen as the

primary unit of analysis as that would obscure the great

diversity of living arrangements which actually exist (Abbott

and Wallace, 1990). It is simply that the `household' is the

primary context in which women confront time±space con-

straints and `negotiate' outcomes with other family members

(Morris, 1990).


choice of living location (and hence geographical pos-ition in relation to public transport networks, local

labour market opportunities, environmental triggers toill health, etc.), or more particularly the lack of it, isitself a key element in the social construction of space

(Rose, 1993). Marginalisation and disempowermentcan, therefore, be shown to be highly signi®cant driversin the cycle of disadvantage in health-related beha-

viours and, in particular, access to health services.The second general factor relates to the ways in

which the same social relations were played out

between individuals at the smaller inter and intrahousehold levels (Anderson et al., 1994). As Gittins(1993, p. 2) notes (see also Delphy and Leonard,1992):

There are inequalities within families just as thereare inequalities between families. The social re-

lations of class, gender, ethnicity, age, etc. cutacross the di�erent types of family and householdand the shape of each is embedded in culture and

locality (original emphasis).

So some men, for instance, can have particularlystrong views about whether their partners should workpart-time, full-time or not at all following childbirth;and perceived levels of task sharing between the gen-

ders appear to be directly linked to women's psycho-logical health (Woods, 1985; Glass and Fujimoto,1994). Similarly, women's input to ®nancial decision-

making (Volger and Pahl, 1993; Vogler, 1994), posses-sion of a driving license, and access to private trans-port (Focas, 1989; Rosenbloom, 1989) have been

associated with marital and employment status, ageand socio-economic position. Assistance within thesocial network is also socially constructed by factorssuch as household income and ®nancial organisation,

gender, and generation (Wilson, 1987). Therefore,while the broader social context can be perceived assetting the scene, this is inadequate in itself to under-

stand the variety of actual outcomes in terms of time±space ¯exibility and, hence, individual decisions in re-lation to health, illness and health care use.

7. Conclusion

Why is it important to consider the time±space con-text for health-related behaviours through the concep-

tual framework suggested in this paper? First, there isstrong evidence supporting the view that women arethe health managers in the majority of UK households

regardless of class or ethnic group, and that their ownhealth needs may su�er as a direct result of their socialrole and resource constraints (Graham, 1992, 1993a;

Pearson et al., 1993; Young, 1995, 1996). Second,

household-level involvement, and hence women'sresponsibilities, in the areas of health and social carehave risen considerably in the UK in recent years

(Pearson, 1992). Speci®cally, shorter stays in hospitalhave increased the contribution of families in short-term convalescence; and moves towards community-

based care (Secretaries of State, 1989) have furtherexpanded the responsibilities of informal carers of

more permanently dependent people (Land, 1991).This is part of the development of a complex mixedeconomy of welfare in which statutory, voluntary and

private sector social care providers are increasinglyseen as supporting, rather than substituting for, the

family (Wistow et al., 1994). In terms of health beha-viour, the Health of the Nation White Paper (Secretaryof State, 1992) placed considerably greater emphasis

than hitherto on the need for individuals to respond topreventative screening programmes and adopt a`healthy lifestyle'. The recent and continued shift in

favour of a primary care-led NHS (Secretary of State,1996, 1997) also builds upon a principle aim of the ear-

lier health reforms which was to move from a diseasefocus towards more health-oriented services.In parallel with this intensi®cation of pressures on

women in their social role as family carers, a restruc-turing has occurred in the UK labour market such

that the `double burden' of paid and unpaid work isan increasingly common experience (EmploymentDepartment, 1990). A growing proportion of women,

particularly those who are married, have been drawninto `¯exible' forms of low-paid employment (Hakim,1987; Beatson, 1995). There are also increasing num-

bers in a position to combine a `higher-status careerjob' with caring responsibilities (Hakim, 1991). This

di�erential involvement of groups of women in thepaid labour market has implications not only for thedivision of unpaid work within households but also for

the gender-speci®c distribution of economic resourcesand the necessity to substitute help from the social net-work in place of income.

Although some changes were undoubtedly needed inthe structure of health and social care in the UK, pol-

icy makers have not yet fully addressed the signi®cantimplications of those changes for households, and indi-viduals within them, in the light of wider social trends.

Under the previous UK administration, in particular,health policy was underpinned by the view that poten-

tial service users operate on a `level playing ®eld' ofopportunity, but, as this paper has shown, this ispatently not the case when it comes to day-to-day

choices in the management of health within families.Given the pivotal position of women in the caring sys-tem overall, such considerations also raise signi®cant

questions for health and well-being in general. It isvital to explore this more sophisticated context for


health-related behaviours, not least because a majorgoal of the health reforms continues to be the achieve-

ment of needs-led local commissioning and increasedchoice for service users (Balogh, 1996; Secretary ofState, 1997). Women as a group have been the main

users of NHS services in the past, but it remains to beseen just how e�ectively they can respond to the on-going policy shifts of recent years.

What this paper adds to the debate is a clear frameof reference on which to judge the mutually reinforcingimpact of spatial as well as social relations in the con-

text of health, illness and health care behaviours.Looking at the problem from the perspective of theopportunity-costs of time±space constraints, is onemeans to understand the distinct ways in which ser-

vices are used, when and why, across di�erent socialgroups and geographical areas. In circumstances ofscarce available time and few resources, therefore,

women may `chose' to neglect their own health needsin order to achieve the best possible overall outcomefor the family. Consequently, as Graham (1993b) has

already argued, behaviours which can look `irrational'or `unreasonable' to health professionals often havereadily understandable origins in the complex social

and socio-spatial structures which constitute women'severyday lives.Importantly, the pilot schemes (PCAPS) instigated

through the NHS (Primary Care) Act 1997 are

intended to enable professionals on the ground todevelop commissioning and provision structures whichaddress local needs much more closely than at present

(NHS Executive, 1997; Wilkin et al., 1997). In ad-dition, the moves towards Primary CareCommissioning Groups outlined in the latest White

Paper The New NHS Ð Modern, Dependable(Secretary of State, 1997) provide clear scope for amore sophisticated view of what constitutes locally-sensitive health service provision. However, it is im-

portant that such developments are also based on a®rm understanding of the complex interactionsbetween individual time±space circumstances and con-

ditions in the local area. Clearly, the current policyand practice climate o�ers a unique learning baseupon which to move forward. It is vital that the les-

sons are heeded if the best possible use of increasinglyscarce and valuable resources is to be achieved Ð par-ticularly in the development of services for commu-

nities characterised by poverty and social exclusionsuch as those in Liverpool.

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Prioritising family health needs: a time–space analysis of women's health-related behaviours

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