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Is confusion a sign of wisdom in health promotion?

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Health promotion is often presented in a one-size-fits-all message, yet it is rarely that straightforward, says Aldo Mussi

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As a health worker, when was the last time you admitted to being confused about what promotes health? A recent annual health survey (National Centre for Social Research, 2008) shows that the public remain unsure about official health behaviour messages.

The Health Survey for England found that while most adults knew they should eat five portions of fruit or vegetables a day, only 14% of men and 11% of women knew what constitutes a portion. And less than a third of adults knew the recommended maximum daily alcohol intake.

There is no shortage of health messages from government, so why might the public be confused? One reason may be that the messages keep changing, due to adjustments in accepted evidence, such as that on exercise, and on alcohol consumption.

And there are confounding messages. Odd pieces of research receive disproportionate amounts of media coverage, while there are also more cynically orchestrated conflicting messages as a result of commercial interests.

Then there is the climate of mistrust of official scientists, sometimes unjustified, sometimes less so - as with BSE. The public’s intuition might in this case have warned the food industry that forcing herbivorous cows to eat their sisters seemed like a bad idea.

Finally, there’s what we could call the ‘uncle Bob’ effect - ‘Uncle Bob put loads of salt on his food for 90 years and it didn’t do him any harm’.

Is the problem here that the public is ignorant of distribution curves that mean there will always be exceptions to the rule at either end? Or is it the government’s tendency to present evidence about how health behaviour factors work on average across whole populations as if it worked the same way in every individual?

There has been some progress away from simplistic ‘doctors’ orders’, to a recognition that people’s circumstances determine how much of a real choice they have about their behaviours. So the slogan ‘Make the healthy choice be the easy choice’ is now appearing, catching up with what health promotion specialists were saying 20 years ago.

Even leaving aside the need to rebalance health interventions with more social change, individualists in our ranks are now better at recognising that personal change itself is not as simple as first seems. This is despite the fact that ‘experts’ - usually with only medical training - are still asked to comment on how to promote health. Humanist psychology has taught us much, and more competent behaviour-change workers realise the need to start from where people are at.

Of course, the messages tend to be on conventional, biomedical priorities, and this is often not where people are at. There are myriad other ways in which people construct their idea of health.

So here is a health warning. Dogmatic, simplistic health messages mean something is usually being missed. Health is complex and contested. It’s good to recognise this - and the fact that it can be confusing at times. Confused? I hope so. It’s wise to be.


National Centre for Social Research (2008) Health Survey for England 2007: Latest Trends. London: NHS Information Centre.

Author Aldo Mussi, course director, postgraduate health promotion/public health, Birmingham City University

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