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The Importance of Western Health Promotion and Feminism

Write By: Valentin Rosca on


The significance of the body as a site of social and political appropriation has long been recognized by feminist writers (e.g., Battersby 1998; Bordo 1990, 1993; Grosz 1994; Wray 2007). Culturally specific rules and taboos appropriate women’s bodies in different ways and influence what women prioritize in relation to the health and appearance of their bodies (YoungOdoms 2008; Vom Bruck 1997). This article examines how British white health promoters and their ethnically diverse participants perceive the health promotion that takes place in exercise classes. Additionally, it explores the extent to which western-centric health promotion discourses subjugate and marginalize those alternative forms of knowledge that deviate from western health science regimes of ‘truth’ (Foucault 1977). One potential consequence of this is a reinforcement of individual responsibility for health that currently dominates public health in the U.K. Another is that structural and material causes of ill health, such as poverty, sexism and racism, tend to be underplayed (Nazroo 1998; Wray 2002). The aims of the article are twofold. First, I consider the degree to which western-centric knowledge about diet and exercise informs the promotion of health in exercise classes. Second, I explore the strategies used by the research participants to resist and/or transform hegemonic discourse on healthy lifestyle. The discussion is organized into three sections. The first evaluates research on the construction of current health promotion. It particularly highlights the individualistic ethic of responsibility that often underpins health promotion. It questions the extent to which this type of health promotion is sensitive to the diverse needs of those it seeks to influence. The second section provides an outline of the methodological approach of the study. The third focuses on two main areas: the health promoters’ perceptions of the participants’ health and exercise needs, and the research participants’ views of exercise and health promotion rhetoric.


Western Health Promotion Discourse: How 'Healthy' is it?

healthy-fruit-saladHealth promotion campaigns have been used to encourage people to take responsibility for their health. The term ‘healthy lifestyle’, for instance, is one of many mobilized by health promoters to persuade people to change the way in which they live their lives to improve their health (Wray 2007). The development of this type of lifestyle often involves avoiding particular types of behaviours and practices that are deemed to be risky to health and promoting others, such as exercise and dieting, that result in improved health. Western public health advice is often presented as based on bio-medical research, the source of ‘pure’ knowledge. Media reports then repeat these ‘facts’ to the general public. There have been, however, increasing criticisms of this type of approach to health promotion. Some researchers point to the increased expectation of the individual to take responsibility for one’s health. As state responsibility for health has decreased in modern western societies, the desire to exert autonomy and control over individual bodies has increased (Armstrong 1995; Rose 1999). As a consequence, the individual is more likely to be constructed as the main agent of change (Bunton and Burrows 1995; Furedi 2004; Rose 1999; Sointu 2005; Wray 2007). This means that ill health is now more likely to be attributed to risky lifestyle choices and a lack of health maintenance and self-care (Burgess 2008; Peterson and Bunton 1997). As a result, women’s lifestyles and behaviours have also increasingly come under the scrutiny of public health, This is evident in health promotion research and practice that focus on women’s ‘lifestyle factors’ and behaviours. For example, Waters et al. (2001) examined African-American women’s risk of developing diabetes, hypertension and stroke.  There is an underlying expectation that the participants of the study will conform to scientific models of a healthy lifestyle and adjust their behaviour accordingly. This approach is problematic as it fails to question whether it is possible to ‘choose health’ (Department of Health 2004) regardless of the social and cultural complexities of people’s lives (Segal 2003). This leads to the second critique of the current mode of health promotion. 


Some researchers point out that the current health promotion strategies ignore social, political and cultural factors that influence people’s health behaviour (Segal 2003; Wray and Deery 2008). The assumption is that it is appropriate to promote a western healthy lifestyle through often western-centric health promotion interventions (Furedi 2004) to everyone regardless of cultural background. This is evident in current exercise and physical activity campaigns that have relentlessly promoted activity and eating particular foods as essential components of a ‘healthy lifestyle.’ Because contemporary cultural meanings around healthy lifestyle are often filled with inconsistencies, its applicability across cultures has been questioned (Maynard et al. 2008; Wray and Bartholomew 2006).  There is clear research evidence to suggest that ethnic inequalities in health in Britain are influenced by experienced and perceived racism (Karlsen and Nazroo 2002; Krieger 2000; Wray and Bartholomew 2006). For example, Karlsen and Nazroo argue the health consequences of indirect and direct racism include damaged self-esteem and ‘poorer physical and mental health’ (2002). Other research findings suggest that ethnic and cultural background strongly influences perceptions and experiences of health (for example, Ahmad and Bradby 2008; Gunaratnam 2001; Moriarty and Butt 2004). However, although attempts have been made to provide health services that are ‘culturally sensitive,’ there is evidence to suggest that minority ethnic groups continue to experience racism and discrimination (Ahmad and Bradby 2008; Blakemore and Boneham 1994; Gunaratnam 2001; Karlsen and Nazroo 2002; Wray and Bartholomew 2006). Gunaratnam argues that current multi-culturist approaches to health service policies and services tend to be based on a “celebratory politics of acknowledgement and inclusion” (2001). These often rely on categories of ethnicity and culture, which may inadvertently reproduce processes of “othering” by inclusion (Ang 1996).


apple-on-dietFor example, health promotion policies and strategies that aim to be culturally sensitive or ‘inclusive’ may reify aspects of cultural and ethnic identities and reproduce stereotypes (Gunaratnam 2001). One example of this is the over reliance on what Gunaratnam (2001) calls ‘categorical thinking.’ This refers to the construction and use of “highly stylised, stable and homogenous categories of need” to make recommendations about the health and care needs of minority ethnic groups (Gunaratnam 2001). Such categories are often based on stereotyped assumptions about minority ethnic needs and fail to recognize the temporary and fluctuating nature of identity (Brah 1996). Conceptualizing ethnic identity as static positions minority ethnic ‘needs’ as ‘special’ or problematic and as opposition to the ‘normal,’ ‘unproblematic’ needs of the majority of the population (Gunaratnam 2001). Another difficulty with this type of approach is a lack of acknowledgement of the socio-cultural locatedness of the meanings attached to moral actions. As Gergen points out, the meanings attached to a moral action are communally derived: Morality is not something one possesses within, it is an action that possesses its moral meaning only within a particular arena of cultural intelligibility. . . . A moral life then, is not an issue of individual sentiment or rationality but a form of communal participation. Thus, it is likely that cultural and ethnic values and beliefs influence the significance women attach to health. It is surprising then, that these underlying factors are often neglected in health promotion practice that too often emphasizes the individual’s responsibility to attend to one’s health, and fails to adequately consider the circumstances in which people live their lives. 


Feminist research also points to the often unquestioned connection between, health, thinness and beauty. Scholars have explored the links between what is perceived to be a healthy and feminine body and have questioned how exercise and health promotion came to be entangled with the western ideal ‘feminine’ body (e.g., Brace-Govan 2002; MacNevin 2003; Markula 1995, 2001, 2003; Wolf 1991). These studies have led to new insights into how the rhetoric on health, beauty and well-being, intersect in ways that often make them difficult to differentiate (MacNevin 2003). Exercise participation, in particular, has been identified as a site where feminine-masculine bodies and identities are constructed and/ or subverted (Markula 1995, 2001, 2003, 2004; St Martin and Gavey 1996). In this article, I will demonstrate how women may actively resist dominant ideas about health, fitness and beauty and choose to ignore the hegemonic messages emanating from them. In order to explore the idea of ‘resistance’ I will turn to Foucault’s theory of power relations. Foucault’s (1979) conceptualization of power as relational is useful in highlighting the subtle and diverse forms that resistance may take. He notes that individuals are both subjects and objects of power: they both experience and exercise power. Additionally, the forms that resistance takes may be influenced by ethnic and cultural power relations. As I noted earlier the individualizing discourse on health and fitness is commonly rooted in western scientific/medical perspectives. In this formation, health promoters inadvertently take on the role of legislator, as they advise women how to become healthy through participating in various western specific exercise and dietary interventions. When faced with such advice, women are both objects and subjects of health promotion discourses: they may choose to comply with or resist what are often western-centric perspectives on health and fitness (Wray 2002). As I also demonstrated, there are competing discourses on healthy lifestyle that may be influenced by ethnic and cultural power relations. These competing discourses are often subjugated. For example, Muslim lifestyle and ideas of health may be perceived and defined as a subjugated discourse as it does not fit with the characteristics associated with a healthy life in western society. In my study, I examine the intersections of such competing health discourses through women’s experiences in exercise classes.


Methodological Background

woman-glazing-at-sunThe methodological approach, of the study on which this article is based, aimed to examine ethnic and cultural differences in women’s experiences of their bodies and their perceptions of the advice received from white English health and fitness promoters. It also sought to explore how these health and fitness promoters constructed and disseminated health knowledge. A feminist qualitative approach guided the methodology which was underpinned by the following themes: the representation of diversity, reflection on the how the researcher’s biography influenced the research process, the belief that women’s lives are important, and finally, an aim to uncover the different ways that power operates in women’s lives (Gunaratnam 2003; Maynard 1994; Reinharz 1992, 1997). One aim of the study was to explore how ethnic and cultural background influenced the way midlife women experienced their bodies and health. A second aim was to examine the extent to which women might use exercise to regulate and control their bodies and identities to a particular ideal, as they became older. This included consideration of the opportunities available for the participants to resist dominant western health and beauty rhetoric, and how this might be influenced by ethnic and cultural background (Wray 2001). In this article, ethnicity is defined as “shared identities built on common cultures, histories, languages, religions and regional affiliations” (Ahmad and Bradby 2008). It is important to note that the concepts of ethnicity and culture need to be used carefully. This is highlighted by Ahmad and Bradby who argue that cultural background and lifestyle have often been used to absolve “states from responsibility” (2007) for health which serves to reinforce individual responsibility for health while underplaying structural and material causes of ill health, such as poverty, sexism and racism (Nazroo 1998; Wray 2002). The research took place at three exercise classes; the first was held at an Asian women’s centre, the second at a private gym and the third at an African Caribbean community centre. The 24 women who participated in the study self-defined their ethnic identities as: British Muslim, Pakistani, white English, British, British Caribbean and African Caribbean/Afro Caribbean. The three health and fitness instructors shared similar ethnic backgrounds, which they described as white British and English. The methods of participant observation, focus group and semi-structured interviews were used to generate data. The use of a range of research methods made it possible to capture and make visible the fluctuating nature of understandings of health, beauty and well-being. Additionally, it highlighted how women’s views on these may be influenced by a desire to maintain the cultural values and beliefs that signify their belonging to a collective ethnic identity (Brah 1996).


Participant observation enabled me to develop a social relationship with the women and gain an insight into the dynamics of the groups. Prior to joining the classes, I provided information about participant observation and gained consent from the class members. Participant observation involved taking part in a weekly exercise class at each of the centres, over a period of 4 to 5 months. Areas for observation included: interactions between the health and fitness instructor and the class members; interactions between the participants, the instructor and myself; interactions between participants; physical and social territory and space; appearance; body movements; type of exercise; health advice; competition; types of relationships between participants; atmosphere of the class; shape and size of the room; values and beliefs of the group; perceptions of the body; non/compliance with non/hegemonic health/ beauty discourse; and cultural capital. The main themes generated through participant observation were then used to create themes and questions for the focus group and semi-structured interviews (Mason 2001). Participant observation also facilitated my entry to and acceptance in the groups. However, aspects of my identity and biography as a white, English-speaking researcher, affected my position. Position in this instance does not signify essential fixed qualities and traits but instead refers to “the disjunctions and contradictions of the different positions we occupy as both materially structured and subjectively experienced” (Burman 1994). Thus, my position as a researcher undertaking participant observation constantly shifted so that I often felt I was both insider and outsider. Three focus groups took place at the Asian Women’s Centre exercise class. The remaining groups of women, from the African Caribbean Centre and the private gym, did not want to participate in focus groups, due to a lack of time. A total of 19 women agreed to take part in semi structured interviews, each of which lasted an average of 45 minutes. The interview questions aimed to generate data on the following themes; participant experiences of exercise participation, perceptions of health across the life-course, the embodied experience of aging, health promotion and responsibility for health, and ethnic and cultural background.


Analysis and interpretation of the data was ongoing and not limited to a particular phase. As one of the research aims was to capture ethnic and cultural diversity it was important to identify the relational meanings attached to health and healthy lifestyle, and avoid the imposition of fixed western-centric understandings. This meant examining the particular and common circumstances in which women live their lives, and the power relations that may create different forms of oppression and limit opportunity (Maynard 1994). This research followed the British Sociological Association ethical guidelines for research. The research was fully explained to potential participants who were then given one week to decide if they would like to participate. The ethical issues arising from the research include those relating to consent, anonymity, confidentiality, privacy and those arising as a consequence of researching across ethnic and cultural diversity, such as the presence of an interpreter. Pseudonyms chosen by the participants were used throughout the research. It was also made clear that intermediaries would not have access to transcripts or any other potentially identifying information without the written permission of the participant.


Health and Fitness Instructors’ Perceptions of Women’s Health and Exercise Needs

woman-exercisingThis section explores some of the views expressed by the health and fitness promoters who took part in the study. The health and fitness instructors shared a concern to improve the general fitness of the participants of their classes. However, they differed with regard to what their perceptions of being ‘fit’ meant: The main aim is to encourage them to take exercise and to exercise as a way of looking after yourself. (. . .) Mmm . . . the main aim is for health reasons we could put a lot . . . well you’re not allowed to anyway . . . but there could be a lot more exercises in. We have covered health topics and just in all things you keep trying to reinforce these things, ’cause whatever diet things we tell them, whether it’s blood pressure the losing weight or joints or anything like they’re all the same lifestyle changes they need to . . . [make] . (Norma, English, health and fitness instructor, Asian women’s centre). Norma’s view is that exercise is a means of ‘looking after yourself.’ This message is evident in current health discourses that promote self surveillance as a form of self-care (Markula 2003; Rose 1999; Wray 2001, 2007). Given the current commodification of health and the accompanying expectation that individuals should participate in various forms of body maintenance, this view is not uncommon (Featherstone 1996; Wray 2007). Western hegemonic discourses on health, health promotion and individual moral responsibility are often used to cultivate consumerist idealization of the fi t and attractive body. One effect of this is that looking and feeling good are often seen as one and the same thing. Moreover, the ‘healthy look’ promoted and desired in western societies is mostly associated with a body that is “firm but shapely, fit but sexy, and strong but thin” (Markula 1995). 


When asked the same question the health and fitness instructor at the African-Caribbean community centre commented: "My aims are just to get them active in whatever way we can, just to get them active. For me, exercise is really to get other women motivated because I’ve always had exercise as part of my life. I found I got a lot out of it emotionally, physically and mentally . . . if you’re all right with two of those it helps with the third. So that’s what I’m hoping other women get out of it." Thus, Nicola associates exercise with both physical and psychological well-being. In her comment about motivation she links physical activity to empowerment. It is also evident that Nicola conceptualizes health holistically, drawing on her own experience to suggest that exercise participation improves emotional and psychological well-being as well. Her comments show the extent to which exercise participation has come to be associated with psychological well-being (Sointu 2005). The health and fitness instructor at the private gym exercise class spoke of ‘improving’ the body through exercise: I just like them to increase their fitness. I mean I don’t . . . you know say right you came to me this ‘big’ . . . you are going to . . . you know? I’d like to see improvement in their body obviously in the way they are . . . fitness wise. A lot of them have come right from the beginning, five years ago, and I’ve seen them come and watch what they eat and really improve. (Wendy, white English, health and fitness instructor, private gym) In this quotation, Wendy associates fitness with a reduction in body size. This is a common assumption that is often found in western health promotion discourse and is rooted in bio-medical messages about what constitutes a healthy body weight. Consequently, even though there is evidence to suggest otherwise, a higher body weight becomes negatively linked to a lack of general fitness (Burns and Gavey 2004; Wray and Deery 2008). Women have historically been advised to put on weight or lose it according to the feminine ideals and medical fads of the particular time. The impact of this on women’s well-being and how they see their bodies, is well documented (e.g., Bordo 1995; Burns and Gavey 2004; Orbach 1978; Wolf 1991; Wray and Deery 2008). From the discussion so far it is evident that the three health and fitness instructors view exercise as a way of controlling the health and appearance of the body. Their opinions are, to some extent, rooted in the bio-medical body and they promote exercise as a means of body maintenance and self-care. This highlights the extent to which ethics of self-responsibility for health and well-being have become firmly embedded within health promotion discourse. This is evident in the current western obsession with adherence to “self-monitoring, self-reflection and self-evaluation” (Bauman 1992). One danger associated with these developments is that non-participation in exercise regimes may be constructed as a wilful neglect of health and paradoxically lead to a lack of well-being for those who are targeted (Wray 2007).


When asked their views on the current move toward individual responsibility for health, the instructors identified the following as significant: a decrease in State responsibility for the health of the population (Norma), disparities in the targeting of specific groups and communities (Norma and Nicola), and the commercialization of medical health issues (Norma and Wendy). Wendy, for example, gave the following response when asked about the value of health promotion: "I think there’s probably good and bad about it. I mean . . . there’s that many diets and things isn’t there? And people go to the doctor and the doctor will say ‘oh your need lose weight.’ I mean what does that person then go and do they’ll join Weight Watcher’s or something like that. So there’s good and bad about health promotion. They should be able to do it their selves combined with exercise, cut out rather than go to extremes."  Here Wendy suggests health promotion advice may be problematic because there is a lack of support for women to enable them to fulfil its expectations, in this case to lose weight. However, in the last sentence she again places the responsibility on the individual who ‘should be able to do it their selves.’ This highlights the individualistic premise of health promotion and how it controls women by differentiating and judging them (Foucault 1977). It is unsurprising that the promotion of healthy lifestyles has coincided with a rise in the marketing of body maintenance consumer-based goods such as detoxification diets, food supplements and gym membership (Featherstone 1991; Maguire and Mansfield 1998).  In contradicting her earlier comments on body weight Wendy also felt that the women who attended her class did not attend to lose weight: "I would say that they (white English, British exercise class participants) definitely come to stay healthy and very rarely I’ll get somebody who comes and says ‘look I want to lose half a stone.’ People do come up to you after class and say ‘oh I really want to work on my abs, my thighs or one area.’ But I tell people you can’t just spot reduce you’ve got to do the whole thing you can’t just work on an area . . ." 


woman-weight-lossThe biggest problem the ladies are concerned about is losing weight and it’s the only thing we don’t seem to be able to achieve very well. And I think the main reason for that, in all seriousness . . . is the . . . it’s their diet and the lifestyle. One way that Norma checked whether the women were losing weight or not was to weigh them weekly. The women often tried to avoid this surveillance by going to the toilets or moving away from the front of the class. In my research diary I note that the women tell Norma they cannot lose weight because their husbands do not want them to change the food they cook. This is discussed in more detail in the next section of this article. For Norma, ethnic difference was regarded as a barrier to the promotion and adherence to a healthy lifestyle: "They’re (exercise class participants) never without something to put in their mouths . . . you know. Western women are as bad they just can’t stop . . . and then you think no wonder they’ve got all these eating problems because they never stop between meals eating. Sounds old fashioned but it’s true . . . and . . . all of these things that are supposed to be bad for their teeth . . . all that kind of thing. But I think that when you’re . . . when you’ve come from nothing that’s an actual thing. I’m a bit more critical on the western women who do it because they can . . . .Without taking the basic message on the advertising they can read and find out about all the other issues around it, whereas it’s much harder for these ladies. Definitely much harder for them . . . they’re illiterate in their own tongue . . ."


Here Norma expresses disapproval of women who do not control their eating habits. She goes on to suggest that there are differences between ‘western women’ and the participants of her exercise class in relation to their ability to access health promotion information. For example, she comments that the British Muslim Pakistani class participants are “illiterate in their own tongue” and that this makes it harder for them to understand health advice. Thus, for Norma the women’s resistance to health promotion rhetoric is a problem of communication that is due to their ‘illiteracy.’ She suggests, then, the women have ‘special’ needs and assumes their reluctance to change their diets is due to a lack of language skills (Gunaratnam 2001; Wray 2002). There were obvious differences between Norma and the exercise class participants in the meanings they attached to health and healthy lifestyle. For example, during the classes Norma reiterated the message ‘less fat, less ghee, more fruit and vegetables’ and the sessions ended with a ‘weigh in.’ Despite this, the women did not change their diets and rarely lost weight. However, Norma felt that the women’s rejection of western discourse on healthy lifestyle was a culturally located ‘problem’ (Gunaratnam 2001; Karlsen and Nazroo 2002). The next section of this article will explore the exercise class participants’ views of health and exercise rhetoric.


Health Promotion Discourse and its Significance for Women from Diverse Ethnic Backgrounds

wild-free-womanIt is often assumed that people will change their ‘health behaviours’ if the health promotion interventions they are targeted with are culturally sensitive (e.g., Waters et al. 2001). As I explained earlier, such an approach ignores the wider socio-cultural and economic circumstances that influence the choices available to women, and importantly their right to choose not to conform to health promotion rhetoric. The gendered nature of health promotion advice is often promoted uncritically and, as a consequence, has become entwined with western beauty and body ideals (Brace-Govan 2002; MacNevin 2003; Markula 1995, 2001, 2003; Wolf 1991). For the women in this study the reasons for participating in exercise ranged from perceived health benefits to reducing parts of their body they felt dissatisfied with. However, different themes emerged between the groups of women in relation to their main reasons for participating. For instance, the white British, English participants attending Wendy’s class were more likely, than the other two groups of women, to prioritize weight loss or changes to their body shape. For example, one such participant commented: “I came to the gym to lose weight to try and keep control of my weight” (Diane, English/British). Another participant indicated: I’d like to have my flabby tummy taken away. Yeah I think it’s my flabby tummy that’s the main reason why I came [to the gym] . I just don’t like the way I can’t wear what I want . . . I don’t feel happy with myself. However, some of the women attending this class felt that exercise could be used to look after their bodies and resist ageing, as they grew older. This is evident in the following remarks: I want to stay fit and healthy into my old age and that’s one of the main reasons I exercise. I feel that I’m taking care of my body. There’s no need in this day and age to look your age. (Sue, English) In contrast, African Caribbean women were more likely to associate participation in exercise with health maintenance and socializing: "I feel that if I stay at home and sit on the couch it’s bad for my heart, it’s bad for my health . . . it’s bad for everything. Because then . . . you get more aches and pains if you sit around. But if you keep going do your exercises . . . I look forward to coming and feel hundred percent better (Jane, Afro-Caribbean)."


Well I exercise because I like it. I feel better I can do an awful lot more for myself. I can go distances I can walk I can run (Marie, Afro Caribbean). (. . .) you meet you meet you know in your class you make friends (Lavinia, British Caribbean). Women attending the exercise class at the Asian women’s centre were, similarly to African Caribbean participants, more likely to comment on health and socializing as important reasons for taking part: Exercise is very very good. I think so it’s my opinion. It’s very good for entertainment and good working (of the body). Thus, African Caribbean, Pakistani and British Muslim women prioritized the health benefits of exercise participation, whereas English and British women were more likely to speak of both health and appearance benefits. Despite this prioritization the majority of participants, to varying degrees, expressed concerns about managing the appearance of their bodies regardless of their ethnic background: Now there are the changes in my body, and I suppose that’s why I carry on [exercising] . (. . .) It’s I suppose it’s 50 percent vanity and 50 percent because I enjoy it. I daren’t give up now because everything will go (moves hands in downward gesture). It happens quick too! (Helen, British). However, English and British women were more likely to speak of their desire to resist body changes associated with ageing, and conform to messages about how to maintain health and beauty.

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