Chapter 3. Aims, values and ethical considerations
Chapter Contents
Clarifying health promotion aims32
Analysing your aims and values: five approaches34
Ethical dilemmas36
Making ethical decisions40
Towards a code of practice41
Summary
In this chapter some key philosophical issues about aims and values in health promotion practice will be identified and explored. Two fundamental dilemmas about the aims of health promotion will be addressed. First, whether health promoters should aim to change the individual or to change society, and second, whether they should set out to ensure compliance with a health promotion programme or to enable clients to make an informed choice. A framework of five approaches to health promotion is provided as a tool for analysing key aims and values, along with exercises and case studies. Ethical issues are discussed, four ethical principles are described and there is a series of questions designed to help health promoters to make ethical choices. Exercises on making ethical decisions are included.
This chapter establishes some of the key philosophical issues in health promotion. You are encouraged to think deeply about why you are engaging in specific activities, what values are reflected in your work and what ethical dilemmas are presented. Guidelines on how to approach ethical decision making are considered and some key principles of practice are explored.
Philosophical issues are fundamental to practice, but as Seedhouse (2004) argues, the values of health promotion are sometimes muddled. Health promotion work, if successful, will influence the lives of individuals and communities and it would be irresponsible to develop and apply health promotion practical skills without understanding the values and ethics that should underpin health promotion interventions.
Clarifying Health Promotion Aims
Should health promoters aim to change individual behaviour and lifestyles or aim to influence the socioeconomic determinants that directly influence people’s health, or both? Health promoters have been criticised in the past for focusing on changing the attitudes and behaviour of individuals and communities towards healthier lifestyles and neglecting the importance of the social, political and physical environments on people’s lives (Jones 2003). This focus on behaviour can result in victim-blaming, which is a significant ethical dilemma that health promoters need to address (see, for example, Richards et al 2003). It is important to note that individuals often can change behaviour and may want to take responsibility to improve their health. Health promotion is an essential tool in enabling that process, by promoting people’s self-esteem, confidence and empowering them to take more control over their own health. Proponents of the lifestyle behavioural change approach also maintain that medical and health experts have knowledge that enables them to know what is in the best interests of their patients and the public at large, and that it is their responsibility to persuade people to make healthier choices. Furthermore, society has vested that responsibility in health professionals, and people often seek advice and help in health matters; it is not necessarily a matter of persuading them against their will. Sometimes, too, individuals may not be in a position to take responsibility because they may, for example, be too young, too ill or have severe learning difficulties. See Godin (2007) and Taylor (2007) for a fuller debate on the advantages and disadvantages of a lifestyle approach.
There are several points to be taken into account if the aim to change lifestyle is pursued:
• You cannot assume that lay people believe that health professionals know best. Sometimes health experts are proved wrong and new evidence can contradict existing health messages. For example, over the years there has been much contradictory advice on what constitutes a good diet (Taubes 2009), with some people finding the barrage of information confusing (Health and Social Care Information Centre 2008).
• There is a danger of imposing alien or opposing values. For example, a doctor may perceive that the most important thing for a patient’s physical health is to lose weight and cut down on alcohol consumption, but drinking beer in the pub with friends may be far more important in terms of overall wellbeing to the overweight, middle-aged, unemployed patient. Who is right?
• Linked to this, a health promoter advocating lifestyle changes can be seen as making a moral judgment on clients’ failure to change, that it is their own fault if, for example, they develop an obesity-related or smoking-related illness.
• Promoting a lifestyle change approach may produce negative and counterproductive feelings in the targeted individual or community, such as guilt for failing to comply, or of rebelliousness and anger at being told what to do, as some parents and children felt when Jamie Oliver attempted to change school dinners. The fall in numbers taking school dinners was regarded as a clear indication of this resistance to comply (Butler 2008).
• It cannot be assumed that individual behaviour is the primary cause of ill health. This is a limited view and there is a danger that focusing on the individual’s behaviour distracts attention from the significant and politically sensitive determinants of health such as the social and economic factors of racism, relative deprivation, poverty, housing and unemployment as outlined in Chapter 1 in the section What Affects Health?
• Finally, it also cannot be assumed that individuals have genuine freedom to choose healthy lifestyles. Freedom of choice is often limited by socioeconomic influences (Contoyannis & Jones 2004). Economic factors may affect the choice of food; for example, fresh fruit and wholemeal bread are relatively more expensive than biscuits and white bread (Oldfield 2008 and for information on food poverty see http://www.combatpoverty.ie).
Social factors are also important. Freedom of choice about smoking for adolescents where both parents smoke, for example, is a complex issue (Action on Smoking and Health 2007). Also, how much freedom do people really have to change other health-demoting factors such as stressful living or working conditions and unemployment? It is easy to blame an individual for their own ill health, become victim-blaming, when in reality they might be the victims of their socioeconomic circumstances. In some disadvantaged situations and where resources of time, energy and income are limited, health choices may become health compromises. What a health promoter may see as irresponsibility may actually be what the client sees as the most responsible action in the circumstances. For example, mothers confronted with the day-to-day pressures of parenting may smoke as a way of relieving their stress. Research by Robinson & Kirkclady (2007) indicates that while mothers who smoked in their sample acknowledged the health promotion messages and were aware of the health dangers to their children of environmental tobacco smoke, they resisted these messages and found alternative explanations for their children’s illnesses which discounted their smoking.
Part 3 of this book is about how to promote health in a way that is sensitive to these issues. Chapter 16 looks at what you can do to challenge and change health-related policies.
It is crucially important that everyone engaged in health promotion should be aware of these ethical concerns and have an opportunity to consider them in relation to their own work, particularly if they are engaged in interventions that aim to change individual lifestyles. Exercise 3.1 is designed to help you to think through your views on the aims of health promotion.
EXERCISE 3.1
Analysing your philosophy of health promotion
Consider the following statements A and B:
A: The key aim of health promotion is to inform people about the ways in which their behaviour and lifestyle can affect their health, to ensure that they understand the information, to help them explore their values and attitudes, and (where appropriate) to help them to change their behaviour.
B: The key aim of health promotion is to raise awareness of the many socioeconomic policies at national and local level (e.g. employment, housing, food, transport and health) that are not conducive to good health, and to work actively towards a change in those policies.
1. Taking statement A:
▪ List arguments in support of this view.
▪ List any points about the limitations of this view, and any arguments against it.
2. Do the same with statement B.
3. Do you think that the views in A and B are complementary or incompatible? Why?
4. Imagine these two views at either end of a spectrum:
 |
Indicate the two positions on the scale of 1 to 5 which most closely reflect (a) what you actually do in practice and (b) what you would like to do if you were free to work exactly as you would choose.
(The exercise is based on an idea in the Schools Health Education Project 5–13, published by the Health Education Council and reproduced here by kind permission of the Council)
Aiming for Compliance or Informed Choice?
Another key question about the aims of health promotion centres on what you aim to do with or for the client (whether the client is a single individual, a community or an organisation). Is your aim to ensure that your client complies with your programme and changes behaviour, as is the case with a social marketing approach? Or is it to enable your client to make an informed choice, and have the skills and confidence to carry that choice through into action, whatever that choice may be?
For example, a health promoter is working with a client whose sexual behaviour is such that there is a serious risk of catching sexually transmitted infections, including HIV. If the aim is compliance, it is more likely that the health promoter will be persuasive, will stress the risks to the client and will consider the session a failure if the client does not choose to behave differently. If, on the other hand, the health promoter’s aim is to enable the client to make an informed choice, the health promoter will ensure that the client understands the facts and the risks, will encourage and support the client and accept that if the client chooses not to change their behaviour then this choice will be respected. It would not be interpreted as a failure, because the client made an informed choice.
The same issues arise with health promotion work on a larger scale. For example, is the aim of a campaign to change diets and to promote the consumption of five pieces of fruit or vegetables a day (Department of Health (DoH) 2007a), to persuade people to a particular point of view or to give them the information on which to make up their own minds? This is a difficult question. Most health promoters are doing their jobs because they believe that the action they are advocating is in the best interests of individuals, and of society as a whole. It raises questions about how far to go in imposing your own values and ideas of what are appropriate lifestyle choices on other people.
While considering this question it is also worth noting that it raises the issue of defining success in health promotion. In the first example (about sexual health behaviour), if the aim is to change behaviour then success is likely to be measured in terms of a drop in rates of sexually transmitted infections and unplanned pregnancies. But if the aim is solely to educate in order that people can make empowered, informed choices, success will be measured in terms of changes in people’s knowledge of health risks.
Analysing Your Aims and Values: Five Approaches
There is no consensus on what is the right aim for health promotion or the right approach or set of activities. Health promoters need to work out for themselves which aim and which activities they use, in accordance with professional codes of conduct (if they exist), professional values and an assessment of the clients’ needs.
Different models of health promotion are useful tools of analysis, which can help you to clarify your own aims and values. A framework of five approaches to health promotion is suggested with the values implicit in any particular approach identified.
1. The medical approach
The aim is freedom from medically defined disease and disability, such as infectious diseases, cancers and heart disease. The approach involves medical intervention to prevent or ameliorate ill health, possibly using a persuasive or paternalistic method: persuading, for example, parents to bring their children for immunisation (DoH 2006) and men over 50 screened for cholesterol and high blood pressure to comply with prescribed medication (DoH 2007b). This approach values preventive medical procedures and the medical profession’s responsibility to ensure that patients comply with recommended procedures.
2. The behaviour change approach
The aim is to change people’s individual attitudes and behaviours, so that they adopt what is deemed a healthy lifestyle (DoH 2004). Examples include supporting people in stopping smoking through smoking cessation programmes (see National Institute for Health and Clinical Excellence (NICE) 2006), encouraging people to be more physically active through exercise prescription or referral schemes (Morgan 2005), changing people’s diet through the School Fruit and Vegetable Scheme, part of the five-a-day programme to increase fruit and vegetable consumption (Blenkinsop et al 2007). See also NICE (2007) for evidence on the behavioural change approach.
Health promoters using this approach will be convinced that a lifestyle change is in the best interests of their clients, and will see it as their responsibility to encourage as many people as possible to adopt the healthy lifestyle they advocate. Health-related social marketing fits in to this approach when the aim is to change behaviour.
3. The educational approach
The aim is to give information, ensure knowledge and understanding of health issues, and to enable the skills required to make well-informed decisions. Information about health is presented, and people are helped to explore their values and attitudes, develop appropriate skills and to make their own decisions. Help in carrying out those decisions and adopting new health practices may also be offered. School personal social and health education (PSHE) programmes, for example, emphasise helping pupils to learn the skills of healthy living, not merely to acquire knowledge (OFSTED 2005; and up-to-date guidance on the PSHE curriculum at http://www.pshe-association.org.uk).
Those favouring this approach will value the educational process, will respect individuals’ right to choose, and will see it as their responsibility to raise with clients the health issues which they think will be in the clients’ best interests.
4. The client-centred approach
The aim is to work in partnership with clients to help them identify what they want to know about and take action on, and make their own decisions and choices according to their own interests and values. The health promoter’s role is to act as a facilitator, helping people to identify their concerns and gain the knowledge and skills they require to make changes happen. Self-empowerment (or community empowerment) (Laverack 2004 and 2007) of the client is seen as central. Clients are valued as equals, who have knowledge, skills and abilities to contribute, and who have an absolute right to control their own health destinies.
5. The societal change approach
The aim is to effect changes on the physical, social and economic environment, to make it more conducive to good health. The focus is on changing society, not on changing the behaviour of individuals.
Those using this approach will value their democratic right to change society, and will be committed to putting health on the political agenda at all levels and to the importance of shaping the health environment rather than shaping the individual lives of the people who live in it (Bambra et al 2005).
Table 3.1 summarises and illustrates these five approaches to health promotion. This framework has been used because it is a simple one that helps health promoters to appreciate that there are many approaches to health promotion, and that these different approaches reflect differing viewpoints and values. The framework has been questioned and challenged, and this is part of a healthy debate as the theory and practice of health promotion continue to develop. There are well-known models, such as the Tannahill model (Tannahill 2008) which have helped frame approaches to health promotion. See also Scriven (2005, p. 10) for an alternative framework. An important point to note is that some of these approaches can be used together. For example, a client-centred approach may also use educational processes and a comprehensive health promotion strategy to deal with a public health problem. (See Box 3.1 for examples of using approaches in practice). Exercise 3.2 is designed to enable you to think through the aims and values of your health promotion practice.
| AIM | HEALTH PROMOTION ACTIVITY | IMPORTANT VALUES | EXAMPLE – SMOKING | |
|---|---|---|---|---|
| Medical | Freedom from medically defined disease and disability | Promotion of medical intervention to prevent or ameliorate ill health | Patient compliance with preventive medical procedures | Aim – freedom from lung disease, heart disease and other smoking-related disorders Activity – encourage people to seek early detection and treatment of smoking-related disorders |
| Behaviour change | Individual behaviour conducive to freedom from disease | Attitude and behaviour change to encourage adoption of ‘healthier’ lifestyle | Healthy lifestyle as defined by health promoter | Aim – behaviour changes from smoking to not smoking Activity – persuasive education to prevent nonsmokers from starting and to persuade smokers to stop |
| Educational | Individuals with knowledge and understanding enabling well-informed decisions to be made and acted upon | Information about cause and effects of health-demoting factors. Exploration of values and attitudes. Development of skills required for healthy living | Individual right of free choice. Health promoter’s responsibility to identify educational content | Aim – clients will have understanding of the effects of smoking on health. They will make a decision whether or not to smoke and act on the decision
 Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
|