'Vicky was patronised by health professionals unwilling to listen to her views or take note of her experiences'

As a health promotion novice, I cut my teeth in East London. I learnt a lot about working with people who had been denied the privileges others might take for granted. The message was clear: we should not spoon-feed or patronise; preach or indoctrinate. We should start where people are, not where we want them to be. Importantly, making judgements was shunned. The word 'empowerment' was much used.

I recently found myself questioning my integrity while chatting with a friend Vicky. 'I've decided to give up breastfeeding,' she told me. 'What, already?' I replied, without hesitation. I was startled by my response; it was laden with judgements. Red-faced and tongue-tied, I muttered incoherently about the evidence base. I was in familiar terrain, but I knew very little about what it meant in the context of Vicky's life. Textbooks and summaries do not account for individual circumstances.

There was much to consider. It was not a decision made lightly; it came after a period of anxiety and deliberation. She had been breastfeeding for more than three months and it had not been easy. Her baby was losing weight and she was encouraged to use bottles to supplement his feeds. Inevitably, the bottle took over.

She resented the insinuation that she had acted irresponsibly. She would never knowingly take a course of action that would harm her baby. Professionals might think about that when passing judgements, she explained. She also recognised the broader context; her financial security meant she could pay for good quality formula, and others could not. It was not fair.

Vicky has since described the consequences of her decision. She was patronised and lectured by health professionals unwilling to listen to her views or take note of her experiences. Strangers on park benches passed comment about the limitations of bottle-feeding. Friends queued up to offer their opinions. Her private decisions were suddenly thrust into the public domain. Meanwhile, her baby thrived.

There was also tension at her mother and toddler group. On occasion, breastfeeding and non-breastfeeding mothers sat separately. 'Everybody has an opinion,' Vicky asserted. 'Everybody thinks they know best.'

Of course, breast is best. The evidence is strong, but evidence alone does not change people's behaviour. What works in the pages of scientific journals does not always translate into the mess of people's lives. The rhetoric of health promotion suggests we should have respected Vicky's decision. In practice, we demonised her and left her feeling like a social pariah.

Health promotion is driven by laudable values, but it might be timely to reflect. It has unprecedented support in national policy. Consequently, we have real opportunities to improve public health. But changing behaviour is a complex business.

Meaningful generalisations are few and the questions we are left with relatively simple. At what point does giving information about a health-related topic become encouragement? And when does it become something greater - a vehicle by which the pressure to conform is thrust upon us, and stigmatisation and discrimination follow? If we don?t find answers, we will surely fail.

David Woodhead works in the public health team at the Healthcare Commission. He writes in a personal capacity.