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Health promotion and some implications of consumer choice

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Journal of Nursing Management
Health promotion and some implications of consumer choice
Author(s):

PRICE, KAY PhD, Dip T(Nurse Ed), RN, BN, MN

Section Editor(s): Procter, Susan

Issue:
Volume 14(6), September 2006, p 494–501
Publication Type:
[Original Article]
Publisher:
Copyright © 2006 Blackwell Publishing Ltd.
Institution(s):
School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia
Correspondence Kay Price University of South Australia School of Nursing and Midwifery City East Campus North Terrace Adelaide SA 5000 Australia. E-mail: kay.price@unisa.edu.au
Accepted for publication: 2 June 2006
Keywords: choice, consumers, decision-making, health promotion, taking responsibility
Abstract

Aim: To stimulate debate around how health promotion practices add to the choices confronting consumers in a health market place and some implications as a consequence.

Background: We live in a world characterized by consumerism, in which health professionals must compete with a wide array of other producers for the consumer's attention.

Evaluation: A critical review of consumer choice related to health applying theoretical insights from the works by Zygmunt Bauman.

Key issues: Nurses working at influencing the health status of consumers at an individual level (whatever the setting) need to understand how to address the acknowledgement that people are confronted with a multiplicity of choices (good and bad) in their daily lives and from which they need to make a choice. How health promotion practices are ‘sold’ to consumers is an important consideration for nurses.

Conclusions: The possibility for nurses to talk past consumers and vice versa exists. Choices made by consumers are premised on what is ‘sold’, how, by whom and why and has a lot to do with how to get the attention of the consumer.


Background

This paper is premised on the assertion that members of societies in western countries are positioned by governments as consumers. As consumers, they must choose everyday from a multiplicity of choices (good and bad) and decide what to do in the context, that is their life. Health promotion offers a diversity of practices from which consumers can choose, while health professionals are just one group among a diverse range of different personnel who seek to influence how consumers make health-related decisions. While governments and health professionals may hope that health promotion practices will enable consumers to live healthy lives it is not given that consumers will select health practices promoted by health professionals as their choice of approach as to how they will behave.

Governments in Australia and the UK, for example, are making efforts to shift the emphasis in health policy onto health rather than focusing on an illness perspective. The Australian Government continues to fund a national programme called Lifescripts (Abbott 2005, Kinect Australia for the Lifescripts Consortium 2005) providing lifestyle prescription tools for general practitioners (Department of Health and Ageing, 2006), and in the UK, the white paper ‘Choosing health: making healthy decisions easier’ (Department of Health for England 2004), has an emphasis on informed choice. This paper is not a review of these government policies: some UK reviews have already been published (see McKee & Raine 2005, Allmark 2006). It is also not a critique of the large body of the literature related to health promotion (see, for example, Becker 1986; Sidell et al. 2003, Catford 2006) or consumerism and health (see, for example, Almond 2001, Howell & Ingham 2001, Rycroft-Malone et al. 2001, Cappelen & Norheim 2005). My paper develops an argument as to why health professionals need to continually learn how to give recognition to the struggles consumers confront in their life because of all the daily choices they have to make and all the options which are on offer. To explain my argument, I apply theoretical insights from the works by Zygmunt Bauman.

In presenting this paper, I understand that from the moment a reader encounters these pages of the journal, how they understand, for example, what is health and health promotion, and even nursing, will influence how the reader interprets what is written. I present this paper understanding that there is not a universal language or a universal way in which to understand health or any other word or concept (Cheek 1995a). I seek only to make visible the context and parameters that have organized and structured what I have written. As Brewer (1994, p. 243) suggests, readers need to appreciate that they may ‘interpret the data and arguments differently in the light of other value systems, theoretical frameworks, viewpoints and experiences’, or, as Cheek (1995b) expresses, from different viewing positions. I invite readers to critique the paper and look forward to the ongoing dialogue as a consequence.

Introducing Bauman

Zygmunt Bauman is a social theorist and a prolific writer. At the time of writing this paper, he is Emeritus Professor of Sociology at the University of Leeds and the University of Warsaw. Bauman writes about bodily life and why our society has an obsessive preoccupation with the body. Bauman (2001a) says:

‘Bodily life being the only thing there is, it is impossible to conceive of an object more precious and more worthy of care. Our times are marked by an obsessive preoccupation with the body. The body is a fortress surrounded by shrewd and surreptitious enemies (Bauman 2001a, p. 248)’.

I understand that health professionals by the very nature of their work have a preoccupation with the human body albeit in a multitude of different ways and with different purposes. This preoccupation has generated debates about the implications arising from a disease/illness management or ‘sickness model’ approach, to the assumed benefits of a disease/illness prevention and health promotion approaches on offer. In a health marketplace, health professionals, whatever their focus or preoccupation with the human body, need to consider what this preoccupation generates.

In the health marketplace what is ‘for sale’ (for example, predetermined health promotion practices) can be argued as having enormous benefits or the potential to make big profits (for example, health-focused profits or financial profits). Today's health marketplace has brought forward many ideas and opportunities by a variety of different people about how to engage consumers in adopting a healthy lifestyle or self-care approaches. Most assume that people take individual responsibility for their health. Precisely because of the opportunities for financial profits, a consequence is that consumers become the object of competition. As Bauman (2001a) says:

‘When it comes to making ideas profitable, the objects of competition are the consumers, not the producers. No wonder that the present-day engagement of capital is primarily with the consumers. Only in this sphere can one sensibly speak of “mutual dependency”. Capital is dependent, for its competitiveness, effectiveness and profitability, on consumers – and its itineraries are guided by the presence or absence of consumers or the chances of the “production of consumers”– of generating and beefing up the demand for the ideas on offer (Bauman 2001a, p. 27)’.

In a health consumer market according to (Bauman 2004a, p. 123) ‘we are all in and on the market’. Being in and on the market means that people are interchangeably or simultaneously customers (health service users or consumers who can ‘purchase’ health promotion practices) and commodities (health professionals and/or health promotion practices as a commodity) (Bauman 2004a). A consumable that can enable a consumer to survive better ‘by making good choices, only good choices and even better choices’ (Bauman 1992, p. 4) is also premised on what is sold, by whom and why and who is able to get the attention of the consumer.

Within health promotion, there is increasing focus on health professionals and policy makers alerting us to the fact that there are known health promotion practices that need to be adopted, and if they are, these practices will improve a consumer's health status. But it is no longer only health professionals (for example, nurses and doctors) and health policy makers seeking the consumer's attention. These positions of ‘in the market’ and ‘on the market’ whether as a customer and/or as a commodity creates consumer markets where so many people put themselves in positions in which they, as (Bauman 2004b, p. 94) says: ‘are all too eager to help us out of the predicament’.

Our societies now have illness, health, wellness and complementary practitioners, lifestyle coaches as well as discipline-specific practitioners, all with different values and with consumables to sell. In addition, all these practitioners compete with the impact of multimedia and advertising practices of all businesses/companies, global and local, in vying for the consumer's attention. Whatever is ‘being sold’ by whoever, all need consumers or to produce consumers to make a profit. Consequently, all are forced to learn new ways of attracting the consumer, one way to attract the consumer is to assert that they have the authority or expertise indicating that the consumer will profit from what they have to sell.

With so many authorities from whom to choose, and authorities who ingratiate themselves with the chooser, health consumers have the individual responsibility through the choices they make to identify who is or who may be considered an authority, who they choose to visit, and who in turn, informs them about how to care for their health. I refer here to Bauman (2000) who says:

‘When the authorities are many, they tend to cancel each other out, and the sole effective authority in the field is one who must choose between them. It is by courtesy of the chooser that a would-be authority becomes an authority. Authorities no longer command; they ingratiate themselves with the chooser; they tempt and seduce (Bauman 2000, p. 64)’.

With so many different health personnel and companies with different consumables to sell, the health consumer is increasingly tempted and seduced to buy one consumable over another and this includes choosing whether any health professional, or which one, is the best option. Yet a focus on choice and what choice, depends on consumers being able to know a choice needs to be made, know of the choices and have the skills to make a choice knowing that the choice may not be their best choice. The perpetual anxiety that can occur as a result of having so many choices says Bauman (consumers are constantly being produced) in turn becomes a potential inexhaustible source of profit (Bauman 2005, p. 91). This ‘profit’ is precisely because the body is considered both a precious possession and an instrument of enjoyment (Bauman 2001a, p. 248).

To be human or to be ‘inside a mortal life’ says Bauman, ‘one can taste immortality, even if only metaphorically or metonymically’ (2001a, p. 2, 247). Being alive is for consumers their only chance to taste and enjoy immortality. Bauman (2000, p. 61) although says that ‘the odds are that most of human life and most of human lives will be spent agonizing about the choice of goals, rather than finding the means to the ends which do not call for reflection’. If health promotion practices only add to the agony about the choice of goals, or seek people to reflect upon their behaviours so as to make changes in their lives, it is questionable whether consumers will adopt them. It is these insights that can be better understood and exploited by health professionals in their quest to enable consumers to implement predetermined health promotion activities. Let me explain.

Health promotion: providing opportunities for tasting and enjoying immortality?

Precisely because bodily life produces death, bodily life has also produced bodies that can be examined and gazed upon to progress ways of improving health. This examination is made possible when the body and the environment are considered as the only stable point of references (Bauman 1992) and considered capable of being changed in predetermined ways as a consequence. Bauman writes:

‘Body and community are the last defensive outposts on the increasingly deserted battlefield on which the war for certainty, security and safety is waged daily with little, if any, respite (Bauman 1992)’.

Because the body can be and has been considered as a stable point of reference, modern science and information systems have created opportunities for biomedical improvements as well as the collection of morbidity and mortality statistics that have led to much more in-depth understandings about the human body. Consequently, perceived biomedical improvements, alongside statistical information begin to serve as the basis for defining risk and providing evidence about what should/should not be done.

While death is not denied as an outcome of life, ‘each particular case of death’ (in this case, read illness) has generated new understandings leading to predetermined health promotion practices. As such the view promulgated is that death (read illness) ‘can be resisted, postponed or avoided altogether’ (Bauman 1992, p. 5). In this way of thinking, death (read illness) is construed as an individual event and survival (not having an illness) is continually reconfirmed as a private matter and a private responsibility (Bauman 1992, p. 20). In this emphasis on the body, death (read illness) has the potential to become a redundant focus; surviving death (read illness) becomes ‘the meaning of life’ (cf. Bauman 1995, p. 168) and health promotion practices promulgated as enabling this possibility. Using Bauman's words, health promotion practices and lifestyle approaches have as a consequence been elaborated to ‘put things in order’ to manipulate ‘the probabilities of events’ (Bauman 2001a, p. 32, his emphasis) related to the health of consumers. Although, using Bauman's words, with survival continually reconfirmed as a private matter and a private responsibility, consumers are also given a chance to ‘taste’ and ‘enjoy’ immortality because the body is considered both a precious possession and an instrument of enjoyment (Bauman 2001a, p. 248). For some consumers, health promotion practices as promulgated by health professionals may conflict with their chance to ‘taste’ and ‘enjoy’ every moment that is their life.

To be in good health says Bauman, has been turned into a permanent war against disease (Bauman 2000). In turn, what has emerged, according to Bauman, is the concept ‘liquid life’ that emphasizes the actions of consumers and the choices they need to make. Bauman says:

‘Liquid life means constant self-scrutiny, self-critique and self-censure. Liquid life feeds on the self's dissatisfaction with itself (Bauman 2005, p. 10, 11, emphasis in original)’.

The health consumer is expected to be dissatisfied with the self and to always seek being better. Yet, conditions of today's society under which members act, change faster than it takes for most consumers to consolidate into habits and routines these certain ways of acting that are promoted as desirable. As Bauman says:

‘Conditions of action and strategies designed to respond to them age quickly and become obsolete before the actors have a chance to learn them properly (Bauman 2005, p. 1)’.

This point is for me significant as it requires health professionals to critically examine their relationship with consumers adopting predetermined health promotion practices. Significant because health promotion practices, as Bauman infers, seek committed and loyal consumers to adopt specific ways of thinking about how best to manage their daily lifestyle and in turn their health status (adopting predetermined health promotion practices). At the same time, these very health promotion practices cannot provide predictability with regard to health status: they cannot provide certainty of life without illness or intervene with the inevitability of death. But, the challenge is to have people learn what it means to care for their health and place themselves in the best position possible to minimize the occurrence of a chronic illness or end of life deterioration arising because of what health professionals may consider bad (not good) lifestyle choices.

I agree with Bauman who says that many consumers want the freedom to make their own lifestyle choices and at the same time to have the ‘freedom from bearing the consequences of wrong choices’ (Bauman 2000, p. 89). While consequences of wrong choices can never be ‘not dying’, as immortality is not possible, some consumers can seek assistance from practitioners other than health professionals to guide how it is that they do/do not make decisions about their health. This ‘other’ assistance can be sought especially by consumers who may not desire to adopt certain health-promoted practices.

As has been well documented throughout health promotion literature (see, for example, WHO 1986, 1991, 1997, 2005a,b) at an individual level people have different opportunities for lifestyle choices and many have not only no choice about their health before birth but also at birth and beyond. Collectively this creates opportunities for debate about which approaches are better than others in relation to health and focuses attention on how ‘making good choices, only good choices and even better choices’ (Bauman 1992, p. 4) can actually improve health. Consequently, making a choice like Bauman says is a challenge and a struggle we all confront at different times and in different ways. As Bauman comments: freedom of self-determination can be a blessing and a curse (Bauman 1999, p. xii).

Bauman (2001a,b) considers that life with all its possibilities (choices) becomes conceptualized as our only chance as consumers to ‘taste’ and ‘enjoy’ immortality, and is the ‘principal cause of the most common and typical neuroses of our time’. He writes:

‘The world full of possibilities is like a buffet table set with mouth-watering dishes, too numerous for the keenest of eaters to hope to taste them all. The diners are consumers, and the most taxing and irritating of the challenges consumers confront is the need to establish priorities: the necessity to forsake some unexplored options and to leave them unexplored. The consumers' misery derives from the surfeit, not the dearth of choices (Bauman 2000, p. 63, his emphasis)’.

Health promotion practices may be considered by health professionals as a consumer's opportunity to both taste and enjoy immortality – living life well without illness. But today's world is one of confusion, contested values and uncertainty given the multitude of values and possibilities before us (Bauman 1999, p. Li).

I agree with Bauman, who says to be postmodern, is knowing that there are no hard-and-fast principles which one can learn, memorize and deploy to escape the ‘messiness’ of the human world as ‘messiness’ will stay whatever we do or know (cf. Bauman 1993, p. 32). A healthy lifestyle approach may seem to some to be the fortress of certainty and stability (Bauman 2002, p. 229) a ‘vision of a closely watched, monitored, administered and daily managed world’ (p. 230) a place to offer a better future. But life as Bauman says is no fixed stasis nor could it ever be, as such the expectation of being in good health is not always a possibility.

The expectation of being in good health

Where I believe there is an even greater need for health professionals to focus attention is to assist consumers to celebrate the ‘messiness’ of life. As Bauman describes, to live life in today's modern or ‘liquid’ society, means living under conditions that constantly change: ‘liquid life is a precarious life, lived under conditions of constant uncertainty’ (Bauman 2005, p. 2). Bauman says:

‘Life in a liquid modern society cannot stand still … Life in the liquid modern society is a sinister version of the musical chairs game, played for real (Bauman 2005, p. 3)’.

The World Health Organisation (WHO) states: ‘health is created and lived by people within the settings of their everyday life; where they learn, work, play and love’ (WHO 1986, 2005a). The concept of health is the desirable state of the human body and spirit. With a society focused on producing producers (for example, health professionals) as described by Bauman, with a purpose to shape and groom the health of its members, the focus in health was on the management of human bodies and the development of expertise in disease management (Bauman 2000). In a buying and selling marketplace, rather than producing health by returning the body to a healthy state (a sickness model), being in good health is the expectation (Bauman 2000). Indeed, the daily management of lifestyle by health professionals is no longer restricted to those consumers with a recognized disease but must be followed by those deemed healthy. Yet many consumers consider they live in a context where medical miracles are possible even available to overcome threats to life or healthy living. Like Opit (1983) has argued previously, public expectations in western societies for the ongoing miracles of modern curative medicine remain entrenched.

While health and fitness as Bauman says belong to two quite different discourses, appealing to very different concerns (Bauman 2000, p. 77), they have, in a society full of infinite and indefinite possibilities (choices), taken on the purpose of the other. Bauman says that to be in good health has been increasingly identified with the optimization of risks with health care becoming more like the pursuit of fitness (Bauman 2000, p. 79). Whereas fitness used to mean to have a flexible, adjustable body ‘ready to live through sensations not yet tried and impossible to specify in advance’ (Bauman 2000, p. 77), fitness in a liquid modern society tries to ‘imitate, …what used once to be the basis of health care's self-confidence: the measurability of the standard of health, and consequently also of the therapeutic progress’ (Bauman 2000, p. 79). This gives rise to fitness regimes like, for example, those that focus on weight-watching where weight loss and fitness gains can now be measured and defined. In a lifestyle approach, while conformity was, as Bauman says ‘once accused of stifling individuality’, conformity and heeding expert lifestyle advice is now ‘proclaimed to be the individual's best friend; in fact the sole friend that can be relied upon’ (Bauman 2005, p. 24).

I agree with Bambra et al. (2005), that health and its promotion are profoundly political, and a politics of health as distinctly different from a politics of health care focuses our attention on the individual and the awareness that at an individual level, the power to resist or to be complicit, albeit in a multitude of different ways, does exist. I also agree with Kickbusch and Payne (2003) who warn of problems if members of the health promotion community neglect the increasing commercialization, privatization, and individualization of health, arguing the need to create knowledgeable consumers who can exercise choice. But knowledgeable consumers may not necessarily learn to make choices that health professionals may desire them to make. As Bauman (2000) says:

‘Under the new circumstances, the odds are that most of human life and most of human lives will be spent agonizing about the choice of goals, rather than finding the means to the ends which do not call for reflection (Bauman 2000, p. 61)’.

For example, consumers who are actively engaged in sports may have to deal with osteoarthritis as they age precisely because of earlier activity in their lives. Even when a consumer adopts the ordered tasks, adopts predetermined health promotion practices, it remains possible that ill health or a chronic condition will still result.

As Bauman (1992) points out, the universal urge to survive generates its own social stratification. Policies of survival writes Bauman (1992, p. 13) need practices to attend to an individual's concern for surviving (or escaping death or illness) and at the same time meet with the mechanism of social reproduction where reasoning can provide a cover-up to death (Bauman 1992, p. 4). While trust in God, a common cause policy of survival, and love are argued as survival policies, Bauman says that in a consumer society a self-care policy of survival is considered better than these other approaches at enabling survival and at the same time has the capacity for expansion (Bauman 1992). The significance here is that consumers will seek to adopt their own self-care survival practices that may be at odds with what health professionals consider desirable, appropriate or needed. Indeed, what may be neglected by, or not available to, consumers in making decisions about their health is the biomedical information specific to them. Information that if they neglect to take into consideration may create ill health or exacerbate their current health conditions. As Bauman says,

‘It is, rather, the question of considering and deciding, in the face of all the risks known or merely guessed, which of the many floating, seductive ends “within reach” (that is, such as can be reasonably pursued) offer priority – given the quantity of means in possession and taking into account the meagre chances of their lasting usefulness (Bauman 2000, p. 61)’.

Taking into account all the different understandings of the human body and the context in which they live is imperative to creating the best conditions possible for survival for consumers. At the same time, what needs to be recognized is that consumers cannot be experts in everything. This notion of expertise is interesting to explore utilizing Bauman's work.

Bauman (1995) argues that this notion of expertise – embedded in the notion of those experts who are suitably skilled and knowledgeable – creates a situation in which they can, with mutual benefit, try to meet the needs of those who are deemed to lack such specific expertise. Non-expert persons – herein consumers and/or health professionals – who do not have the status of knowledgeable, skilled or expert guides, can avail themselves of guidance, expertise and instruction. In doing so, Bauman (1995) argues, the cycle of expert as guide to the non-expert, and the non-expert requiring the guidance of the expert, is recreated. This means that for the non-expert ‘the drama of choice’ is avoided or the illusion of avoidance is created by submitting to the expertise of another (Bauman 1998, p. 13) and as such one is not responsible for actions taken by the other.

Focusing on health promotion as predetermined strategies that consumers are expected to implement has the potential to perpetuate expert expectations for consumer reflection: a situation many consumers may avoid. This then creates the conditions of possibility for people not to take responsibility for their own lives and/or have the resources available so that they may keep healthy. To influence how people make choices, and which choices, nurses and other health professionals need to know how to accommodate in their practice approach, the understanding that people do make their own decisions about their health often without reflection or incorporating all the different information that is required but may not always be available. Today people live in settings where often it is having too many choices (good and bad) rather than not enough, that creates their decision-making struggles. Understanding about too much choice needs to be inculcated into the approach nurses and other health professionals use to attract the attention of consumers. Having said this though, I agree with Flax (1993) who writes:

‘We adopt the knowledge that fits our uses. Humans are very good at creating rational reasons for rejecting knowledge that does not fit our purposes or would make us doubt them (Flax 1993)’.

Individuals, precisely because they can create rational reasons for rejecting knowledge are more likely to be inherently conservative, in relation to their own lifestyle choices, i.e. reluctant to change, as a consequence and as such, living with unpredictability and uncertainty may seem to create more confusion and stress, although so does the demand for certainty and security. Midgley (2000) says conservative people tend only to move into new ways of thinking/doing when there is a good reason (with an associated emotional commitment) to do so. If people are inherently individually conservative in relation to lifestyle change, it remains important for health professionals to provide good reasons for people to act in one way, making specific choices and not others while at the same time understanding their struggles and barriers to reflection, rationalization and change.

Concluding comments

Many years ago, Sontag (1977, p. 42) elaborated her view about how metaphoric thinking around disease/illness, in particular punitive notions of disease/illness which she suggests are an encouragement to simplify what is complex and an invitation to self-righteousness (p. 85). Sontag illustrated disease as an occasion when people can finally behave well and ‘gain insight into their lifelong self-deceptions and failures of character’. Rather than the luckless ill (Sontag 1977), illness says Sontag creates the occasion for reflection. For me, illness will continue to provide this occasion for reflection but at the same time health promotion practices need to create this same occasion knowing although that reflection and change is not what most consumers wish to buy.

A healthy lifestyle approach may seem to some to be the fortress of certainty and stability (Bauman 2002, p. 230) a ‘vision of a closely watched, monitored, administered and daily managed world’, a place to offer a better future. But repeating Bauman, life is not fixed or stasis nor could it ever be. Where I believe there is an even greater need is to assist people to celebrate ‘messiness’ and understand how people think, how they make decisions and make choices, in relation to taking responsibility for their health. Consequently, what must not be negated is the knowledge that, people themselves have always made and will continue to make their own decisions about their own bodies based on the choices offered to them, regardless of what information there is on offer to assist in their decision-making.

While no amount of information can ever be complete (that is, be all that they need to know) it is not a given that people will give the same priority to information health professionals want to disseminate as health professionals themselves do. People as health consumers have and will always want the freedom to make their own lifestyle choices and as I have said will want at the same time, to have the ‘freedom from bearing the consequences of wrong choices’ (Bauman 2000, p. 89). Depending on how nurses and other health professionals attract the attention of consumers, and given the multiplicity of choices available to people, it is likely that consumers may not understand why and when they may need the service of nurses or other health professionals. This will result particularly if consumers do not understand the relevance of the services on offer by nurses compared with their own perceived needs.

Thinking of life as our only chance to taste and enjoy immortality may focus the prioritizing of some people to adopt predetermined health promotion practices. At the same time, not thinking about life in this way or when consumers do think this way, consumers may struggle with making certain choices and not others promoted by health professionals. Each consumer may need assistance to know what their struggles are so as to confront them, and to adopt such a focus requires both an acknowledgement and an acceptance of differences that exist within, between and surrounding individuals whether a health professional or a member of society. Consumers will always need health professionals to manage with them their illnesses, and health professionals to focus on disease prevention and health promotion to assist them to learn how to keep as healthy as possible. But in the consumer market of today, the consumer is an object of competition and health professionals are not the only practitioners vying for their attention and health professionals not the only practitioners producing health consumers. The ramifications of these understandings bring us to a place we have not been before.

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Keywords: choice; consumers; decision-making; health promotion; taking responsibility

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