Behavior Change or Empowerment: On the Ethics of Health-Promotion Goals

One important ethical issue for health promotion and public health work is to determine what the goals for these practices should be. This paper will try to clarify what some of these goals are thought to be, and what they ought to be. It will specifically discuss two different approaches to health promotion, such as, behavior change and empowerment. The general aim of this paper is, thus, to compare the behavior-change approach and the empowerment approach, concerning their immediate (instrumental) goals or aims, and to morally evaluate the strengths and weaknesses of these two goal models, in relation to the ultimate goal of health promotion. The investigation shows that the behavior-change approach has several moral problems. First of all, it is overly paternalistic and often disregards the individual’s or group’s own perception of what is important—something that also increases the risk of failed interventions. Furthermore, it risks leading to ‘victim blaming’ and stigmatization, and to increased inequalities in health, and it puts focus on the ‘wrong’ problems, i.e., behavior instead of the ‘causes of the causes’. It is thereafter shown that the empowerment approach does not have any of these problems. Finally, some specific problems for the empowerment approach are discussed and resolved, such as, the idea that empowering some groups might lead to power over others, the objection that the focus is not primarily on health (which it should be), and the fact that empowered people might choose to live lives that risk reducing their health.     

The purpose—process gap in purpose and process

In the development of health promotion theory to date insufficient attention has been paid to the question ‘What is the end to which health promotion is directed?’ A distinction can be made between purpose (end) and process (means to end) and if no clear account of purpose exists to illuminate how process contributions relate to its achievement, then health promotion's claim to be a practical discipline is weak. Although ‘well-being’ is frequently cited as the essence of health promotion, a view of ‘well-being’ which goes much beyond the intuitive has yet to emerge. Retention of ‘well-being’ as purpose requires a specific account which allows health promotion's claim to practicality to be clearly demonstrated. In discussing the form such an account would need to take, purely hedonistic conceptions of ‘well-being’ are discounted and the development of an ‘objective’ account, in which ‘capacity for self direction’ would form the key focus, is suggested.     

A risky business? Health and physical activity from the perspectives of urban Australian Indigenous young people

Being Aboriginal or Torres Strait Islander in contemporary Australia is often discursively constructed in health literature as equating with risks of many kinds. This article explores the ways in which a group of urban Australian Indigenous young people perceive, navigate and articulate the so-called ‘risks' pertaining to issues surrounding their health and physical activity. Eight girls and six boys aged 11–13 years were recruited from an urban school in a major Australian city. Each young person was interviewed up to eight times, using multi-modal tools, over two and a half years, to explore the ways in which they engaged with discourses about health, risk and physical activity. Data were analysed both thematically and through a process of critical discourse analysis. The young people in this study did not perceive themselves as ‘at-risk’ of ill-health despite the recognition of ‘unhealthy’ choices or a family history of chronic illness. They appeared to negotiate risk based on both their knowledge of public health messages and their trust in themselves and those around them. The young people's narratives offer an alternate view to the pathologised, statistical ‘stories’ often representing Indigenous Australians in scientific and popular literature and the media.     

Global health in public policy: finding the right frame?

One of health promotion's major contributions has been its discursive challenge to biomedical and even behavioural models of health and illness. The concept of social determinants of health is now widely accepted by health authorities in many parts of the world. When health promoters focus on these determinants, however, it is often at local or national scales. Contemporary globalisation demands a more critical appraisal of how many health problems have become inherently global in cause and consequence. In making such an appraisal, it is helpful to consider how global health is presently being framed to determine which arguments are most likely to be health-promoting for the greatest number. This article reviews five such frames: health as security, as development, as global public good, as commodity, and as human right. Most offer some useful argumentation to health promotion, although the rights-based frame, when supported by ethical reasoning (a moral voice), is the most consistent with health promotion's more empowering roots.     

Health Promotion and the Preventative Health Taskforce

The release in October of the Preventative Health Taskforce's discussion paper, ‘Australia: the healthiest country by 2020’ offers health promotion practitioners their greatest opportunity to participate in national policy development for many years. The Taskforce, which was established by the Federal Health Minister Nicola Roxon in March, has been asked to develop a National Preventative Health Strategy for the Government by mid‐2009, focusing initially on obesity, smoking and alcohol. The Taskforce has proposed the following targets to be achieved by 2020:

• halt and reverse the rise in overweight and obesity;
• reduce the prevalence of daily smoking to 9% or less;
• reduce the prevalence of harmful drinking for all Australians by 30%; and
• contribute to the ‘Close the Gap’ target for Indigenous people, reducing the 17‐year life expectancy gap between Indigenous and non‐Indigenous Australians.

     

Editorial – Tapping the potential of research‐based advocacy

The value of both policy‐relevant research and evidence‐informed policy in public health and health promotion is well documented. Interestingly, research‐based policy advocacy is one arena in which these approaches become very directly and immediately linked. Research‐based advocacy for policy has been a powerful force in tobacco control and is building momentum in some aspects of alcohol policy. There is also a rising current of policy‐directed advocacy to redress obesity‐promoting social and environmental factors, including food marketing to children, food labelling and active living environments. As one of health promotion's most powerful tools, research‐based advocacy encapsulates many of the strengths of health promotion. It draws upon specialised research skills and links them with public communication methods. Importantly, it is guided by clear goals and a vision of an environment and society that protects and values people's well‐being. Both the research and the communication activities that characterise advocacy seek to spotlight aspects of society that may be taken for granted, but which work against people's interests; they can provide a focused and organised examination of what is going on and promote the alternatives as feasible policy options.     

Grasping at straws: a recent history of health promotion in Canada

Despite Canada's reputation as a leader in the development of health promotion concepts, implementation of these concepts in the service of health has always been far from stellar. Much of this has to do with Canada's liberal political economy and the recent further ascendance of neo-liberal approaches to public policymaking. These developments have combined with longstanding biomedical and epidemiological traditions in health policy to inhibit health promotion approaches that incorporate the principles and themes of the Ottawa Charter. Additionally, the emergence in Canada of population health as a competing–and displacing–discourse to health policy has further eroded health promotion's profile and presence. There is increasing interest in the social determinants of health concept, yet government spending, media attention, and health sector activities lavished on ‘lifestyle’ approaches to health promotion and the emergence of the ‘obesity epidemic’ as a focus of public, media, and health sector attention serves to further reinforce this dreary picture.     

Toward an ethic of empowerment for health promotion

This paper lays out a conceptual framework for articulatingsome main ethical issues raised by health promotion and illnessprevention. Building from the concept of ‘enabling’in the Ottawa Charter, the paper articulates and advocates an‘ethic of empowerment’ for health promotion. If health promotion is understood in terms of enabling, thetired ethical debates between freedom and responsibility, orindividual and community, are recast in a new and more productivelight. Health promotion should resist the temptations of eithera coercive, paternalistic ethic or an individualistic, laissez-faireethic in favour of an ethic of enabling or empowerment.     

Over‐the‐counter analgesic use by urban Aboriginal people in South Australia

Despite recent health gains for Australian Aboriginal people their significantly poorer health status compared with that of non‐Aboriginal Australians remains significant. Within the context of high levels of mortality and morbidity, research highlights significant barriers to timely health‐care, access and safe use of prescribed and over‐the‐counter medicines. The risks to Aboriginal people's health due to unsafe medication use are preventable. The purpose of this article is to present the findings from qualitative research focused on Aboriginal people's knowledge, use and experience of over‐the‐counter analgesics. The study was conducted in the north‐western metropolitan area of Adelaide, which has the largest urban Aboriginal population in South Australia. The employment of an Aboriginal Elder as Cultural Advisor enabled engagement with Aboriginal participants. Purposive ‘snow ball’ sampling was used to recruit participants for four focus groups [n = 30] and one participant opting for a personal semi‐structured interview. Participants worked with the researchers to develop the findings and formulate recommendations. The 25 women and 6 men, aged 20–80 years reported various chronic medical conditions. Focus groups/interview elicited accounts of critical issues concerning safe selection and use of over‐the‐counter analgesics. Serious health risks were evident due to limited knowledge about safe analgesic use and over‐reliance on information from family, friends and advertising. Extremely poor access was reported by participants to culturally and linguistically appropriate information, education and advice from a range of doctors and other health professionals including Aboriginal health workers.     

Health logic and health-related behaviours

In this paper, the author develops the notion of health logic, which prescribes ‘judgemental’ and ‘cause–effect’ logic to the way that smoking, eating, drinking alcohol and exercise as health-related behaviours are approached within the field of health promotion. The problem, which is raised through the concept of health logic, is concerned with the utilization of health-enhancing or damaging classifications for ‘everyday’ issues (e.g. spending time with peers, eating out) relevant to smoking, eating, drinking alcohol and exercise. While such classifications can be rationalized under the field of health promotion, which aims at the promotion of healthy choices, they can be relatively misguiding. The emphasis on just a binary concept of health promotion conceals the understanding of these behaviours in people's everyday lives. The health logic critique is established first through a discussion of three main health promotion concepts: ‘lifestyle’, ‘choice’ and ‘empowerment’. Second, the health logic is highlighted through the empirical tendency within the field of health promotion that favours separating aspects of the everyday life of individuals into positive and negative influences. This paper suggests a different viewpoint of health-related behaviours by centring on people's everyday lives and avoiding the binary divisions created by the health logic, such as healthy/unhealthy, or the role of an enhancing or obstructing social context. Such a strongly value-laden approach seems unlikely to tell us very much about how people make sense of health-related behaviours within the context of their everyday lives.     

HEALTH PROMOTION: CAN IT REDRESS THE HEALTH EFFECTS OF SOCIAL DISADVANTAGE?

Social disadvantage is an entrenched feature of contemporary New Zealand society and has a deleterious influence on health. Traditional health promotion activities, with their focus on the individual, have had only a limited impact. The World Health Organization is fostering a new approach to health promotion based on the Ottawa Charter, the two most important strategies being: building healthy public policy and strengthening community action. The new health promotion has great potential, especially with its emphasis on ‘empowerment’, but as yet only indirect evidence supports the effectiveness of this approach. Several current New Zealand community-based initiatives hold promise for the future and three of these are discussed. The greatest challenge is to ensure that the ‘empowering’ approach to health promotion continues to be developed by Area Health Boards and that this type of health promotion becomes a major priority at all levels of society. As social scientists, we need to support this approach and assist in the production of evidence to show whether it is capable of redressing the health effects of social disadvantage.     

Substance misuse intervention research in remote Indigenous Australian communities since the NHMRC ‘Roadmap’

Objective : Describe program theories of substance misuse interventions with Aboriginal and Torres Strait Islander (Indigenous) Australians funded by the National Health and Medical Research Council (NHMRC) since the ‘Roadmap’ for Indigenous health. Methods : Projects funded 2003–2013 were categorised by intervention strategies. Realist concepts informed the program theory: intended resources and responses; influence of context on outcomes; explicit and implicit program assumptions. Results : Seven interventions were included. Three randomised controlled trials targeted tobacco using psychosocial interventions in primary health centres using the program theory: “Local Indigenous health workers extend and sustain the effects of conventional clinical brief intervention by engendering social and cultural resources”. Four pragmatic trials of multiple‐component, community‐based interventions using controlled, semi‐controlled or before‐and‐after designs used the program theory: “Discrete intervention components targeting locally defined substance misuse issues will activate latent capacities to create an environment that favours cessation.” Publications did not report clear effect, implementation fidelity or explicit mechanisms affecting participant thinking. Conclusions : Rigorous intervention designs built on ‘Roadmap’ principles neither reduced substance use in the populations studied nor identified transferable mechanisms for behaviour change. Implications for public health : Substance misuse impacts among Indigenous Australians remain severe. Theoretical mechanisms of behaviour change may improve intervention design.     

‘Getting off’ and ‘going out’: young people's conceptions of (hetero)sexual relationships

Research that has explored young people's (hetero)sexual behaviour has often assumed that the idea of ‘relationships' is transparent. Subsequently, the diversity which exists within this concept has been neglected. This paper endeavours to unpack the concept of ‘relationships' with reference to young people's own understandings and meanings of the term. Drawing on findings from focus group research with 17–19 year‐olds in New Zealand, it analyses how relationships are constituted and differentiated. Some of the determining characteristics are: the time partners spend together, a sense of exclusivity and intimacy, emotional attachment and the kinds and frequency of sexual activity engaged in. On the basis of various configurations of these elements, young people's relationships can be loosely categorized as ‘one‐night stands’, ‘short‐term relationships’, ‘casual dating’ and ‘going out’. The diversity, complexity and fluidity in these conceptualizations present a challenge to traditional understandings of these relationships, and have implications for how sexual health promotion might be carried out.     

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence

Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians. Method: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians. Results: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs. Conclusion: Provider‐client relationships characterised by shared understanding of clients' needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients' perceptions of ACCHOs' unique value. The client perceptions provide insights about how ACCHOs address socio‐economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers. Implications for public health: To increase utilisation of PHC services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non‐Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.     

Reframing “participation” and “inclusion” in public health policy and practice to address health inequalities: Evidence from a major resident‐led neighbourhood improvement initiative

There is a need for greater conceptual clarity in place‐based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident‐led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident‐led partnerships across England are tackling the day‐to‐day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.     

Ideology and resistance in young people's experiences of health under the ‘imperative of enjoyment’

This article explores upper secondary school students’ understandings and experiences of health in Denmark, where public health promotions appeal to pleasure. Health promotion thereby taps into capitalist society's ‘imperative of enjoyment’, which reproduces ideological fantasies about the fulfilment of desires through the consumption of health. Based on qualitative empirical material produced through participatory and visual methods during fieldwork conducted in 2012, the analysis shows that relations between healthiness and pleasure are conflated and paradoxical: the students try to fit into society not only by being healthy, but also by enjoying healthiness; but if they fail pleasure, they fail healthiness and experience a loss of individual social value. Although the ‘enjoyment society’ has the potential to produce individualisation and marginalisation, the students in this study actively attempt to subvert its double bind by insisting that collective experiences with peers constitutes the foundation of enjoyable healthiness. Nevertheless, public health promotions that reproduce enjoyment as an imperative, even in the pursuit of health, risk reinforcing young people's resistance towards health.     

The tidal model: the lived‐experience in person‐centred mental health nursing care

Abstract Nursing theories and nursing models have a low profile within psychiatric and mental health nursing within the United Kingdom. This paper considers some of the historical, policy and rhetorical issues that may have framed nursing's relative dependency on the medical paradigm, and briefly considers some of the ethical challenges, which proposed ‘extensions’ of the nurse's role might have for a ‘caring’ discipline. The paper describes the philosophical background of the Tidal Model, which emerged from a series of studies of the ‘need for psychiatric nursing’. The Tidal Model extends and develops some of the traditional assumptions concerning the centrality of interpersonal relations within nursing practice, emphasizing in particular the importance of perceived meanings within the lived‐experience of the person‐in‐care and the role of the narrative in the development of person‐centred care plans. The model also integrates discrete processes for re‐empowering the person who is in mental distress, and provides a practical template for the exploration of the spiritual dimensions of the person's lived‐experience, if appropriate.     

Empowerment in healthcare policy making: three domains of substantive controversy

This paper distinguishes between the uses of empowerment across different contexts in healthcare policy and health promotion, providing a model for the ethical and political scrutiny of those uses. We argue that the controversies currently engendered by empowerment are better understood by means of a historical distinction between two concepts of empowerment, namely, what we call the radical empowerment approach and the new wave of empowerment. Building on this distinction, we present a research agenda for ethicists and policy makers, highlighting three domains of controversy raised by the new wave of empowerment, namely: (1) the relationship between empowerment and paternalistic interferences on the part of professionals; (2) the evaluative commitment of empowerment strategies to the achievement of health‐related goals; and (3) the problems arising from the emphasis on responsibility for health in recent uses of empowerment. Finally, we encourage the explicit theorisation of these moral controversies as a necessary step for the development and implementation of ethically legitimate empowerment processes.     

‘It had to be my choice’ Indigenous smoking cessation and negotiations of risk,resistance and resilience

While Australia is considered a world leader in tobacco control, smoking rates within the Aboriginal and Torres Strait Islander population have not declined at the same rate. This failure highlights an obvious shortcoming of mainstream anti-smoking efforts to effectively understand and engage with the socio-cultural context of Indigenous smoking and smoking cessation experiences. The purpose of this article is to explore the narrative accounts of 20 Indigenous ex-smokers within an urban community and determine the motivators and enablers for successful smoking cessation. Our findings indicated that health risk narratives and the associated social stigma produced through anti-smoking campaigns formed part of a broader apparatus of oppression among Indigenous people, often inspiring resistance and resentment rather than compliance. Instead, a significant life event and supportive relationships were the most useful predictors of successful smoking cessation acting as both a motivator and enabler to behavioural change. Indigenous smoking cessation narratives most commonly involved changing and reordering a person's life and identity and autonomy over this process was the critical building block to reclaiming control over nicotine addiction. Most promisingly, at an individual level, we found the important role that individual health professionals played in encouraging and supporting Indigenous smoking cessation through positive rather than punitive interactions. More broadly, our findings highlighted the central importance of resilience, empowerment and trust within health promotion practice.     

Community development in health promotion: empowerment or regulation?

Abstract: Community development is a concept that currently has wide appeal in public health policy. It has become a central element of population-based health promotion strategies that purport to involve community groups in determining the form and purpose of resources for advancing the community's health. It has been variously claimed that community development empowers individuals and groups, leads to greater commitment by the community and consumers to change, strengthens community values, promotes greater local accountability in use of resources, and redresses inequalities in health. However, the meanings and implications of community development remain obscure. This paper examines the multiple and conflicting discourses of community development, and suggests that the rhetoric of community development has tended not to be matched by the reality of practice. It concludes that health promoters need to be much more critical in their assessment of the approach, and to clarify the use of basic-terminology such as ‘community’ and ‘empowerment’, if their actions are to contribute to effective long-term change.