The Sociology of Health Promotion

Critical Analyses of Consumption, Lifestyle and Risk

Robin Bunton, Roger Burrows, Sarah Nettleton

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134818822
• Edition: 1
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Promotion of health has become a central feature of health policy at local, national and international levels, forming part of global health initiatives such as those endorsed by the World Health Organisation. The issues examined in The Sociology of Health Promotion include sociology of risk, the body, consumption, processes of surveillance and normalisation and considerations relating to race and gender in the implementation of health programmes. It will be invaluable reading for students, health promoters, public health doctors and academics.

Chapter 1
Sociology and health promotion
Health, risk and consumption under late modernism

Roger Burrows, Sarah Nettleton and Robin Bunton

INTRODUCTION

During the last few decades inordinate attention has been paid to the promotion of ‘healthy’ living. This has come from governmental, academic, commercial and popular sources. Few people today can be unaware of the espoused merits of such a lifestyle. Anyone who has visited a supermarket recently, turned on the television, listened to the radio or read a magazine must have noticed that awareness of health issues is growing. Health is clearly a topical issue at both political and cultural levels.

At the political level from the mid-1970s, starting with Prevention and Health: Everybody’s Business (DHSS, 1976a), there has been a dramatic increase in the number of policy documents and statements on prevention and, since the early 1980s, health promotion (see Parish, this volume, for a review). More recently a high profile has been given to The Health of the Nation (Department of Health, 1992a) and its attendant targets and to subsequent documents such as Working Together for Better Health (Department of Health, 1993a). It provides an interesting example of the ‘globalisation’ of policy and politics in that many of these documents and statements produced in Britain have drawn upon frameworks developed internationally by the World Health Organisation’s Health For All (HFA) initiative. However, this said, such global initiatives may be interpreted very disparately by different nation states, and this process of policy mediation can tell us much about the policy and ideological priorities of different political regimes (Gustafsson and Nettleton, 1992).

At a cultural level ‘healthism’ has become a central plank of contemporary consumer culture as images of youthfulness, vitality, energy and so on have become key articulating principles of a range of contemporary popular discourses (Featherstone, 1991a; Savage et al., 1992; Bunton and Burrows, this volume; Glassner, this volume; Hepworth, this volume). In the 1960s a list of ‘health-related’ commodities would have included items such as aspirins, TCP, Dettol and plasters. Today, however, it would include: food and drink; myriad health promoting pills; private health; alternative medicine; exercise machines and videos; health insurance; membership of sport and health clubs; walking boots; running shoes; cosmetic surgery; shampoo (for ‘healthy looking hair’); sun oils; psychoanalysis; shell suits; and so on. The list is seemingly endless. Commodities have been ‘transvalued’ (Featherstone, 1991a) in two directions. First, some have been subject to a process whereby their original use value has been transformed into one increasingly articulated in terms of ‘health’ (for example, the ‘greening’ of household cleaning products, the shift from decorative to health-enhancing cosmetics and various forms of leisure). Second, and perhaps more significantly, some have been ‘transvalued’ in the opposite direction, in that their original health use value has been transformed to take on a much wider social and cultural meaning (for example, running shoes, shell suits and body building).

Sociological analyses of health policy in general have, until recently, been a relatively neglected area of the sociology of health and illness (Gabe et al., 1991; Stacey, 1991). Not surprisingly, then, this has also been the case in relation to health promotion (Thorogood, 1992b) and public health (Lewis, 1986) more generally. This book attempts to fill a gap in the literature by attempting to develop sociological perspectives and critiques of these key contemporary areas of health policy and practice.

HEALTH PROMOTION AND SOCIOLOGY

What is distinctive about health promotion is the attention that it gives to the facilitation of healthy lives: the idea that it is no good just telling people that they should change their lifestyles without also altering their social, economic and ecological environments. People must be able to live healthy lives. Health promotion aims to work not only at the level of individuals but also at the level of socio-economic structures and to encourage the creation and implementation of ‘healthy public policies’ such as those concerned with transport, environment, agriculture and so on.

We can see therefore that the promulgation of healthy lifestyles and the discourse of health promotion and the ‘new public health’ more generally are important and topical subjects which, although retaining some continuities with past health policy, can increasingly be viewed as representing a new paradigm of health care (Nettleton, 1995). Our concern in this volume is to try and make some sociological sense of health promotion and to review the critiques that are emerging in response to it.

So far sociologists have tended to contribute to the development and refinement of health promotion activities rather than analysing it as an object of inquiry. They have carried out surveys, interviews and observations of people’s lifestyles to provide information for health promotion campaigns. They have presented analyses of the aetiology and distribution of health and illness which reveal that adequate health policies must take structural and environmental factors into account. They have debated the political and ideological bases of health education and health promotion activities. Hitherto, however, what sociologists have failed to do is to adequately develop analyses of the phenomenon itself. Herein lies the rationale for this collection: how are we to account for and make sense of the rise of, and preoccupation with, the growing field of health pro motion and, relatedly, the new public health?

The volume is largely the outcome of a conference held in September 1993 at the University of Teesside, organised by the editors, which aimed to address this question. Although the contributors were working on a disparate array of substantive areas within the field of health promotion many drew upon a common theoretical literature and a related set of conceptual concerns. This degree of theoretical and conceptual accord, which is also apparent in the chapters throughout this book, was not something that the conference organisers/volume editors had anticipated. Although the familiar sociological concerns with the social divisions of gender, sexuality, race, age and class are evident, it appears that sociologists also view health promotion as emblematic of wider contemporary social and cultural changes-changes which are characteristic of the acceleration of the processes associated with late modernity (Giddens, 1990; 1991), the rise of the risk society (Beck, 1992a; 1992b) and the growing preoccupation with the body, lifestyle and consumer culture (Featherstone, 1987; 1991a; 1991b; Featherstone et al., 1991). As things currently stand the sociology of health promotion is a sociology of risk, knowledge, consumption, lifestyle, culture and, of course, health.

The dominant strand of the sociology of health promotion is its concern to analyse the phenomena as a characteristic of the much wider set of socioeconomic and cultural processes associated with late modernism. As we approach the end of the millennium many sociologists have turned their attention to the dominant social formations that appear to be emerging. Many have conceptualised the changes taking place as being part of a process of postmodernisation in which the social structures of modernity are superseded by radically new sets of arrangements (Lash and Urry, 1994). However, other writers, most notably Giddens (1990; 1991), argue that it is more appropriate to think about the contemporary period as being one in which, rather than being superseded, the central aspects of modernity are becoming significantly more dynamic and accentuated:

The modern world is a ‘runaway world’: not only is the pace of social change much faster than in any prior system, so also is its scope and the profoundness with which it affects pre-existing social practices and behaviour.

(Giddens, 1991:16; emphasis in the original)

Giddens argues that it is therefore more appropriate to talk about the contemporary period as being one of late modernism. This implies that existing social relations and social structures are in an inherent state of flux. Social organisations are becoming increasingly subject to constant reorganisation and change and social life is becoming increasingly more reflexive. For example, it is claimed that we are witnessing the demise of traditional institutional forms of welfare and social control, a blurring of ‘expert’ and lay knowledge, a heightened collective perception of uncontainable risks, and a shift to a consumer- rather than producerdriven economy. This volume examines the manner in which some of these changes are manifesting themselves in health promotion and the new public health—central features of contemporary health policy.

The volume thus attempts to: develop contemporary sociological analyses of health promotion; develop analyses on matters in relation to health promotion which are of interest to contemporary sociology, including risk, the body, consumption, and processes of surveillance and normalisation; and develop critiques of health promotion which are of interest to health and medical practitioners, including issues of gender and race in the implementation of health programmes, cultural dimensions of lifestyles and health behaviours, and the marketing and consumption of health-related activities.

THE ORGANISATION OF THE VOLUME

The book is organised into four sections. The first provides an introduction to the institutional and policy context of health promotion activity in order to provide a backdrop against which the sociological analysis of the phenomena can be situated. The second assesses a range of sociopolitical critiques which have been made of health promotion from sociological, feminist, political and cultural perspectives. The third examines different aspects of health promotion in relation to the intersection of the sociology of risk and the sociology of knowledge. The fourth and final section examines health promotion in relation to the sociology of consumption and lifestyle.

The institutional context of health promotion

The institutional context of health promotion is examined at an international, national and local level. The chapter by Richard Parish traces the development of the rhetoric of health promotion by examining various policy documents and World Health Organisation (WHO) literature. The chapter provides useful details of the political and policy background of health promotion and suggests the likely future trajectory of its development. The chapter by Laurann Yen is, again, written from the perspective of the institutional context of health promotion, but this time at the more local level. She examines the development of health promotion in the light of the implementation of the internal market as part of the NHS reforms. She argues that initially there were indications of health promotion becoming more consumer oriented and market responsive under these new management arrangements. Latterly, however, there have been indications of a marked medical dominance and the introduction of provider-led surveillance oriented approaches. The chapter questions whether, despite the rhetoric, there has really been a significant change in perspective. Having set the institutional and policy context of health promotion the next section of the volume examines the various critiques that have been made of it.

Socio-political critiques of health promotion

Over the years social science in general, and medical sociology in particular, has provided many important critiques of various forms of health and medical care. In many respects health promotion has drawn upon these critiques as it has established itself as a practice distinct from systems of health care based upon the bio-medical paradigm. However, health promotion itself has not been immune from these critiques. In particular sociologists have pointed to the individualising tendencies in health education and promotion. The perpetuation of structural inequality by the use of value laden—sexist and racist—health promotion programmes has also been identified. Although structuralist critiques have formed the main critical platform in the sociology of health promotion more recently attention has been drawn to surveillance and consumption critiques—critiques developed throughout the present volume.

The chapter by Sarah Nettleton and Robin Bunton provides an overview of these existing sociological critiques of health promotion—structural, surveillance and consumption based. The chapter also identifies a number of substantive areas that have been explored by these analyses: populations, identities, risks and environments. In doing this it attempts to map out the existing terrain of the sociology of health promotion.

The chapter by Norma Daykin and Jennie Naidoo presents an overview of feminist critiques of health promotion. Different types of health promotion and a range of feminist perspectives are reviewed and then discussed in relation to each other. The chapter identifies how various feminist critiques offer insights at different levels of service provision. It argues that feminist perspectives are more developed in relation to the more authoritarian strategies which form the central planks of Government health promotion strategy. Feminist critiques of other, more collective forms of health promotion are also discussed. The chapter concludes that health promotion tends to take gender inequalities for granted and, in adapting strategies to the status quo, may be accused of actively reproducing these inequalities.

Many health promotion and public health strategies have been found to be not only sexist but also to be based on fundamentally racist assumptions. However, this has been a relatively neglected area in the academic literature on health promotion. Furthermore, at the level of practice the issue of race is also either neglected or presumed to be a matter of cultural difference rather than a matter of institutional and structural racism. Existing critiques in this field are reviewed and developed more fully in the chapter by Jenny Douglas.

The chapter by Michael Kelly and Bruce Charlton offers a polemic against many of the main strands of contemporary health promotion theory and practice. By drawing upon international, national and local level examples they argue that a range of tensions in the application of health promotion philosophy has become apparent. They argue that on the one hand, much health promotion is driven by a subjective and holistic notion of health, an emphasis on positive health, and a rejection of the biomedical model, but on the other hand, the epistemology and the WHO Health for All project remains vested in traditional expertise founded in technicist and scientific rationalities. These and other tensions are then theorised with reference to sociological debates concerning the modern, the postmodern and processes of postmodernisation.

The final chapter in this section, by Charlie Davison and George Davey Smith, examines the political critiques of health promotion implicit within many of the previous chapters. They point out that many of the recent debates about, and criticisms of, health promotion and the new public health appear to transcend conventional political boundaries between left and right. In some respects this leaves those working within the field with a sense of unease, in that they have lost any political direction or commitment. This political conundrum forms the focus of this chapter and suggestions about how we might not have to ‘throw the baby out with the bath water’ are outlined.

Knowledge, risk and health promotion

The third section of the volume examines various aspects of the relationship between knowledge (both ‘lay’ and medical), risk and health. The first chapter in this section, by Peter Jackson, examines the scientific basis of health promotion discourse by way of a case study of the social construction of the health effects of passive smoking within scientific research. By drawing upon the work of Ludwick Fleck, Jackson explores the emergence and development of the construction of passive smoking as a threat to public health. He challenges the assumptions of scientific realism and locates the production and content of this new medical knowledge in discourse and process.

The next two chapters in the section examine contemporary sociological perspectives on accidents. Accidents are the major cause of death for children and a significant cause of death, disability and distress for all age groups. Since the middle of the twentieth century there have been various initiatives aimed at reducing the death rate from accidental injury, culminating in Britain in 1992 with The Health of the Nation targets. In her chapter Judith Green argues that the accident prevention literature upon which such policies are based appeals to a discourse of risk assessment, which creates a world in which the risks of particular actions are known or knowable and in which all events are therefore preventable; accidents result not from random misfortune but from the miscalculation of risk. This risk assessment discourse creates the ‘lay person’ who emerges as the foil of the accident prevention professional and who persists in anachronistic beliefs in fate and luck when explaining accidents. The chapter examines some paradoxes at the heart of this discourse using data from a study on how accidents are constructed. It suggests that a focus on accidents as a category of misfortune, rather than an eclectic group of injuries, may explain the failure of accident prevention strategies.

Lindsay Prior, in his chapter, complements this argument. He begins with the observation in The Health of the Nation…And You (Department of Health, 1992b) that ‘in theory at least, all accidents are preventable’. He argues that this notion of an accident as something calculable, controllable and therefore preventable carries within it some of the most fundamental themes of modernity. The chapter examines the modernist vision of chance, determinism and accidents and draws out the implications of that vision for health promotion programmes. In particular it focuses on the contradiction that exists between the understanding of accidents as things which happen to individuals, and the mathematical concept of an accident as a chance event in a population of events. It concludes with an examination of the causal logic that lies behind a number of official publications on accidents and accidental deaths.

The final chapter in the section, by Nicki Thorogood, is again concerned with the dynamics of modernity. However, this chapter examines the place of anti-rational discourses through an examination of the construction of safe dental practice. It is argued that such practice is constructed through the ways in which patients talk about ‘risk’ and ‘fate’ and by media reporting. The data examined come from a survey of public opinion on HIV and dental practice. Initial responses suggested a ‘liberal’ rational attitude which involves the calculation of risk and corresponding decision making. But a further examination of people’s comments suggests that ‘anti-rational’ discourses such as ‘trust’ and ‘morality’ are central to the construction of safety in dental practice. The chapter concludes that popular discourse around HIV and dentistry highlights the fragility of rational discourse and the coexistence of contemporary anti-rational alternatives.

Health promotion, consumption and lifestyle

The fourth and final section of the volum...

Table of contents

• Cover Page
• The sociology of health promotion
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Acknowledgements
• Chapter 1: Sociology and health promotion: Health, risk and consumption under late modernism
• Part I: The institutional context of health promotion
• Part II: Socio-political critiques of health promotion
• Part III: Knowledge, risk and health promotion
• Part IV: Health promotion, consumption and lifestyle
• References