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Smoking, drinking, eating and exercise: it has become common knowledge
that one of the keys to a long and healthy life is to keep an eye on these
four activities. A whole industry of health education and health promotion
has arisen to hector us into taking care of ourselves, with the result that
we all know exactly what we ought to be doing.

But most of us also know that it is a lot easier to talk about healthy
living than to practise it. The path laid out by the lifestyle experts seems
clear enough, but the demands and limitations of everyday life make sticking
to such a straight and narrow road a tall order – especially for the millions
of us who like to enjoy life as well as extend it. ‘If I give up ciggies,
booze and chips, will I live to be a hundred?’ asks the chap in the joke.
‘No,’ replies his pal, ‘but it’ll feel like it!’

Research into health and behaviour is discovering the complex relationship
between what we know and what we do. Investigations based on ‘quantitative’
methods (mass surveys using tick-the-boxes questionnaires) show people to
have extensive knowledge of behavioural risks to health. But a more complex
picture emerges from research based on ‘qualitative’ methods (such as discussions
and close observation with relatively few people). This approach shows that
knowledge about health risks is woven into an intricate and tangled web
with other demands, constraints and expectations.

One reason is that all too often there is a gulf between what we ought
to be doing to increase our chances of good health and what we know to be
appropriate behaviour in a particular social situation. It is not easy to
stick to a ‘sensible’ diet at your best friend’s wedding reception, for
example. In fact it may well be seen as extremely rude not to celebrate
the occasion with a gastronomic and alcoholic binge. Such conflicts arise
because we do not eat and drink only for reasons of nutrition or bodily
health. These simple and most basic acts of life also carry many levels
of social meaning.

A one-off event like a party is not the main problem of course. Even
the most fanatically health conscious individuals can usually manage a celebration.
Most of us maintain basic assumptions about what is appropriate behaviour
for everyday life, and the real problems begin when medical advice clashes
with the very foundations of this common-sense understanding of the world
and our place in it. These assumptions are not the same for everybody. They
vary between men and women, and between people of different ages. Yet propaganda
for a healthy lifestyle suggests that there is only one way to live properly,
disregarding these differences.

Western culture divides life into a succession of stages which have
enormous influence on how we live. Sometimes these stages are named with
physical ageing or time in mind: toddler, youth, middle age, senior citizen.
Some have numbers attached: teenager, thirtysomething, pushing forty, over-sixties.
Life course stages also refer to a social or demographic position: single,
newlyweds, married with children, widow, divorcee. Some labels even reflect
the labour market: schoolgirl, student days, housewife, working mother,
pensioner.

Previously, social scientists have described the passage through life
in terms of clearly demarcated stages through which nearly all individuals
pass. Often the social importance of these stages is publicly acknowledged
by specific rituals or celebrations at times of transition from one to the
next. But historians, sociologists and anthropologists now suggest that
the process has become fractured. Cultural, demographic and economic changes
have blurred the boundaries and encouraged new areas of individual flexibility.
The distinction between single and married is now less significant. Family
structures and child-rearing practice are changing as established patterns
and norms break down. It is tempting to believe that, in a society so fragmented
by individuality and choice, simple age and status categories cease to be
reliable indicators of appropriate behavioural norms and ways of living.

But qualitative research into health and behaviour show that, in spite
of this apparent social confusion, the life course is still of crucial importance
in guiding actions and attitudes in this area of life. It may be that, faced
with a widening range of individual choices, we find it more important than
ever to play our chosen roles correctly. Failure to behave in the appropriate
fashion leads to harsh judgments. Society has a string of nasty names for
people who transgress the unwritten rules that define their life-stage roles.
When we get it wrong we are ‘young fogies’, ‘mutton dressed as lamb’, ‘Peter
Pan’, ‘twenty-three going on fifty-five’.

The relationship between ideas about life course and appropriate lifestyle
was confirmed by investigations into health and behaviour carried out in
Wales and Scotland in the late 1980s. They showed that behaving correctly
where health is concerned is no simple matter. The model expectations of
what is and what is not appropriate in the field of health-related behaviour
rely on the interplay between three sets of common-sense ideas: notions
of age, physiological function and risk; cultural norms of responsibility
concerning social relationships; and the financial and temporal constraints
that come with the development of family groups. The respondents’ own words
(see Boxes) illustrate that they see striking connections between the life
course stage and what preventive medicine calls ‘health-related behaviours’.
This is seen particularly clearly in people passing from ‘young single’,
through to ‘couple with no kids’ to ‘married with children’.

Since the 19th century, epidemiology has consistently shown that different
age, gender and social groups suffer and die from different ailments. In
recent years accidents and violence (and now AIDS) have accounted for most
deaths of the under-forties; the major chronic illnesses (heart disease,
cancers, respiratory disorders) take centre stage in later life. Women and
men also exhibit differences. The largely male heart-disease epidemic of
the 1960s and 1970s bears witness to these important gender variations.

The general public has become aware of these differences, and this has
had an impact on the cultural ways we deal with risk. One of the main effects
has been to support a common-sense view of the resilience of youth. The
young body, it is widely believed, readily deals with the toxic products
derived from alcohol and tobacco. And the active metabolism of the young
‘burns off’ the fats, calories and cholesterol of the modern diet. Worries
about lifestyle and health are temporarily shelved, making it possible for
the teens and early twenties to be accepted as times for unbridled enjoyment.
If younger people worry about their food intake and exercise output, it
is more likely to be based on a desire to have an attractive body than on
the perceived risks of a heart attack.

The transition to a more mature concern with lifestyle and health combines
bodily ageing with changing social identities. When life is linked to a
long-term partner, the late nights and parties of carefree youth seem gradually
to lose their appeal. Couples appear to both need and desire to spend time
together, and the financial pressures of establishing a home often rule
out the more extravagant excesses of single life.

If children become part of the calculation, the impact on behaviour
becomes stronger. Parents tend to put more emphasis on their responsibility
to remain in good health, as the welfare of their offspring becomes paramount.
Time constraints become ever more acute as sleepless nights with babies
are replaced by the ‘school run’. While opportunities to exercise become
fewer, concern with diet, drinking and smoking increases, partly through
a desire to set a good example. But home-based life and the tensions of
child rearing can become major causes of stress, particularly the type that
can be relieved by a cigarette or a drink.

The findings from such social research have important implications for
health policy. The postwar era has seen a gradual but pervasive movement
within medicine towards prevention. The public health professions have always
recognised that prevention must involve both the improvement of environmental
conditions and the modification of behaviour at the individual level.

The campaigns designed to bring about changes in lifestyle must be both
believable and acceptable to the public at large if they are to be effective.
Yet they are often oversimplified and fail to take into account the complexity
of real lives. Living a healthy life is not purely a voluntary affair. Economic
constraints are major factors, as are the relative weights people ascribe
to different perceived health risks.

Progression through life strongly affects what the public sees as healthy
behaviour – a factor most healthy living information ignores. Health educators
have tried to address different age groups by using different images and
language, but the content of their message has usually been the same. Closer
attention needs to be paid to commonly held ideas about the social and cultural
context of health, such as the life course. Only then will health promotion
initiatives work with, rather than against, popular culture.

Charlie Davison is a social anthropologist and freelance researcher
and writer. Kathryn Backett is a medical sociologist working at the Research
Unit in Health and Behavioural Change at the University of Edinburgh. The
views expressed in this article are those of the authors and not their funding
bodies.

* * *

1: THE POPULAR IMAGE OF THE SINGLE LIFE

The image of the ‘young and single’ stage of life is characterised by
five interwoven themes:

* Youth is a time when the body is seen as being in peak condition.
Ailments are few, particularly the chronic illnesses closely connected with
lifestyle. So there is not much impetus to live what is considered a classically
healthy life.

* A balance is achieved: stodgy, fatty, convenient and enjoyable fast
foods are seen as being readily burnt off through active, even sporty, life.

* The young body is seen as dealing easily with toxins, so it is thought
less important to avoid smoking and drinking. There is an expectation of
‘cutting down’ later.

* It is boring, unyouthful, ‘middle-aged’ to be so future-oriented as
to worry about lifestyle and chronic illness. There is a strong shared ethic
which values those who live fast and die young. Males particularly value
the ‘Jack the Lad’ figure.

* Worries about obesity and weight are not rooted in fears of coronary
heart disease or other health problems. Diet is strongly connected to being
attractive and having girlfriends or boyfriends.

A few extracts from interviews illustrate vividly the image of the single
life:

Interviewer: So . . . you wanted to lose weight . . . was that because
you felt you were in a high risk group, or was that for other reasons?

Respondent: That was just purely for other reasons. Because I was very
overweight and it was purely to attract girls. I didn’t need to do it when
I was in the priesthood. You know . . . when I left I was very fat and I
had to make myself more attractive physically.

Because I was very fat . . . I was obese.

I: And you wanted girlfriends?

R: Yeah . . . so I lost weight. When I met my wife I was only . . .
eleven-and-a-half stone, I think. And I put weight on again now. Probably
because I don’t need to attract girls! Come full circle.

R: But, I mean, with dairy products that, with the amount of exercise
I’m doing, I’m burning it up anyway. Clearing the system . . . A lot of
sportsmen suffer from angina and things like that simply because when they
were participating in exercise very regularly and could maintain their diet
then it wouldn’t worry them because they would burn it up. As soon as they
finish their sport and careers or, you know, cut down on it drastically
– they’re still eating all these things to the same level and yet then they’re
not clearing it out. They’re not burning it up, you know, and that’s when
the problems begin.

I’ve known a couple of people who have been very good sportsmen, have
ended their careers, you know, and are still eating the same sort of things
in more or less the same quantity. It’s causing them all sorts of trouble
in their, sort of, middle age.

R: If there came a day that smoking affected my health to such an extent
that I was feeling really ill and unfit then I would give up, but at the
moment I’m feeling healthy and I like smoking so you know, I don’t intend
stopping. But when the day comes that I start coughing every morning whatever,
then I’ll probably consider giving up. (laughter)

I: When sort of things get bad enough as it were?

R: Yes, which is probably when I’m about 45.

R: And then there’s the Jack the Lad thing – taking risks. They’re inclined
that way with most things, that sort of person . . . they’d probably ignore
advice on anything and everything where there’s health concerned . . . I
think it’s the image that they try and live. I think that it’s something
you should grow out of eventually . . . It’s an image that certain groups
get stuck in. All the little peer groups . . . It’s pressure, basically,
somebody who takes care of themselves and is like a square, and whatever
. . . You’ve got to be carefree and wild and drink excessively. I know I’ve
been drunk a few times – quite a lot of times. I know I shouldn’t do it,
but you tend to get caught up in it.

* * *

2: IMAGES OF COUPLES AND FAMILIES

The image of life within a family unit is characterised by several interlocking
themes:

* There is an increased awareness of bodily ageing and the possibility
of organs beginning to malfunction. Good health is no longer taken for granted.

* The routine of domestic life replaces the ‘chaos’ of single days.
In matters of healthy behaviour, men are often seen as coming under the
thumb of female partners, who are perceived as being more sensible. This
puts a stop to health-damaging ‘Jack the Lad-ism’.

* Individuals, now partnered, feel less need to stay slim and attractive
to others. Becoming part of a couple is seen as a time when there is a great
temptation to ‘let go’ or ‘go to seed’. Complacency and metabolism conspire
to cause middle-aged spread.

* The desire to be attractive is replaced by worry about chronic illness
as a reason to be careful about diet.

* Individuals experience a plethora of new social expectations. The
new responsibilities of partner, offspring or mortgage make avoiding illness
and maintaining earning potential all the more important.

* Having children has conflicting effects on personal health care. The
welfare of children demands the health and longevity of parents; the pressures
of childcare invite an unhealthy lifestyle.

* There is less expectation of taking part in organised team exercise;
this is largely seen as a single person’s area. Long periods out at weekends
and alcoholic socialising are often seen as incompatible with domestic responsibility,
especially for women. (A few extracts from interviews illustrate these points.)

R: I suppose you become more health conscious. When you’re young it
doesn’t really bother you too much, but as you get older, you sort of get
older and stiffer. And also having children concentrates your mind on it
more.

R: I never really thought about it . . . I suppose, in the last few
years, I supposed with things on the television we have become more aware,
or maybe it’s just getting older and thinking about it more.

R: We used to be always too busy being out to be unhealthy. Whereas
now we sit in and watch things about health on the telly.

R: We have a responsibility to our kids that we should all be healthy
and fit and enjoy life.

R: With the kids and everything, there are so many demands on my time,
I find it particularly difficult to keep healthy or fit.

R: I think that, having children you tend to think of maybe all the
things that you’d been eating and drinking (that) you shouldn’t have. And
you become quite aware of it . . . whether it’s the fact that you’re not
going out as often anyway, and you don’t have the same opportunities.

R: I’m going to have a family next year. If I carry on the way I’m going
I’ll be just too unhealthy . . . This was only brought home a couple of
weeks ago, when I went up home and saw my nephew. I was running round, and
I was absolutely knackered after running around for about 20 minutes. I
was 27 yesterday. I’m getting nearer to 30 and I’m thinking I’ll have to
get fit and healthy.