Public Health Communication Interventions: Values and Ethical Dilemmas

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Nurit Guttman

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  • Dedication

    To my parents, Ruth and Louis

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    Foreword

    Why a book on the ethics of health communication?

    After all, even a cursory review of the basic literature of this fledgling field will uncover numerous accounts of how public health, and by extension, health communication, is an inherently noble enterprise, a profession dedicated to promoting the public good, enhancing the human condition, even saving lives. To read many of these accounts is to conjure up the image of the contemporary public health professional as the modern-day crusader: ordained to act, licensed to serve, dedicated to fight the righteous fight.

    But as we know from centuries of painful experience, the ideals of all crusades must be distinguished from the pragmatic realities of their implementation and outcome. For example, the religious Crusades of the 11th and 12th Centuries, though sanctioned by divine decree and motivated by virtuous dreams, are remembered rather for the slaughter of innocents, ethnic cleansing, and political machinations. The end was seen as justifying the means, and ideals quickly gave way to rationalizations.

    Granted, crusaders of public health rarely resort to slaughter to achieve their goals. But the earliest municipal boards of public health were licensed to engage in physical torture and to arrest and impose fines on actual and presumed carriers of infectious disease (Gottfried, 1983). In time, these boards became hated by the citizenry for the restrictions they imposed, the fines they levied, the power they wielded to restrict individual liberties—all in the name of promoting the public good. If we dismiss these incidents merely as historical anecdotes and discount their relevance to contemporary public health, then we blind ourselves to the likelihood that history will repeat itself. Indeed, discussion in the early 1980s of quarantining persons with AIDS, implementation of Draconian measures to win the “drug war,” and dissemination of messages that attempt to marginalize and stigmatize health “offenders” are merely variations on earlier historical themes. It is little wonder, therefore, that some segments of society perceive us as health “vigilantes” rather than mere health promoters, and believe that we are fashioning a “tyranny of health” rather than an environment of empathy and understanding (Levin, 1987; Fitzgerald, 1994).

    Indeed, this book is long overdue. It represents the first full-length and in-depth treatment of a topic that is the very essence of our field. Values and politics are every bit as much a part of health communication campaigns as are sources, messages, and channels. We cannot merely assume that using communication to change individuals' behaviors is the most appropriate solution to solving complex health problems that are deeply rooted in the fabric of society, nor can we assume the ideological neutrality of this approach to social change (Tesh, 1988). We cannot merely assume that common outcomes of our persuasive messages—anxiety, cognitive dissonance, guilt, ostracization—are necessarily acceptable ones in the larger context of what constitutes a physically and mentally healthy society. And we cannot merely assume that the particular Utopian vision of the public interest that motivates us so keenly is shared by anyone else, especially segments of society who consider our efforts as intrusive rather than well-intentioned, as imperialistic rather than benevolent through the imposition of unfamiliar class-based norms and values.

    The good news is that in encouraging us to acknowledge the previously unacknowledged assumptions, cultural values, and ideologies that necessarily underlie our health-promotion efforts, this book reduces our naïveté and forces us to confront the inherently political and controversial nature of what we normally take for granted in our daily work. It is a book that is rich in practical application as well as theory, a book that signals the dawn of a more sophisticated and potentially more effective era in the ongoing evolution of our field.

    Charles T.Salmon, Michigan State University
    References
    Fitzgerald, Faith T. (1994). The tyranny of health. The New England Journal of Medicine, 331(3), 196–198.
    Gottfried, Robert S. (1983). The Black Death: Natural and human disaster in medieval Europe. New York: The Free Press.
    Levin, Lowell S. (1987). Every silver lining has its cloud: The limits of health promotion. Social Policy, 18(1), 57–60.
    Tesh, Sylvia N. (1988). Hidden arguments: Political ideology and disease prevention policy. New Brunswick, NJ: Rutgers University Press.

    Acknowledgments

    This book would not have been written without the encouragement of Stanley Deetz, who initiated the idea and patiently challenged my thinking, and the invaluable help of Brent Ruben, Jack Elinson, Lea Stewart, Gary Kreps, and Robert Like. Their contributions may be invisible, but they are substantial. Special thanks also to Vicki Freimuth for her encouragement and for directing me toward research sites and resources. My research fellowship at the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey-The Robert Wood Johnson Medical School (RWJMS), under the supportive directorship of Mary Breckenridge, allowed me to continue the research and development of the ideas presented in this book, which originated in my dissertation work at Rutgers University. The main thrust of this book was completed after moving to the Department of Communication at Tel Aviv University, Israel, while maintaining a part-time position at the Department of Family Medicine at RWJMS. At Tel Aviv University, I am grateful for the support of Akiba Cohen, Chair of the Department of Communication, the administrator, Liora Gabay, and my colleagues. Also, I am grateful to David Swee, Chair of the Department of Family Medicine at RWJMS, and my research and clinical colleagues and the administrative staff at the Department of Family Medicine for their ongoing support. I am truly indebted to Marilyn Aguirre-Molina, whose passion for public health and advocacy had been contagious, for broadening my own perspective on health promotion and for enabling invaluable contacts, some prominently cited in these pages. Paul Speer has since continued to enrich my perspective on community development, power, and empowerment, and Vince Silenzio, my critical perspective on health, medicine, and society.

    This book owes many of its ideas to the numerous scholars who shared their wisdom and expertise with me. They include Dan Beauchamp, Lawrence Greene, Kenneth McLeroy, Reinhart Priester, Robert Veatch, Larry Wallack, Dan Wikler, Everett Rogers, and Scott Ratzan. A very special acknowledgment goes to Charles T. Salmon, whose work originally triggered my interest in the topic of this book and whose approach to health communication inspired it. He has graciously proffered his keen insights and critical suggestions. Any misinterpretations and misrepresentations are mine alone. This book could not have been written without the contribution of the numerous practitioners who let me visit program sites and generously shared their insights, time, and materials; especially that of John McGrath at the National Heart, Lung and Blood Institute and Doreen Colatrella, formerly with the Middlesex Healthy Heart Program. Special thanks for the editorial suggestions of Janet Lillie and the Sage editorial staff. Last, a well-deserved acknowledgment to my incredible family, especially to Bob, who read far too many drafts, and my friend Fran Yungher, who helped with editorial comments on earlier versions.

    The work on this book has been supported in part by Grant Number 1T32 PE 10011–02 from the Division of Medicine of the Health Resources Services Administration. Early versions of several chapters have appeared in the journals Health Communication, Communication Theory, and the Journal of Health Communication.

    This book is dedicated to my father, Louis Guttman, who taught me—both in words and example—that when it comes to scholarly work, one should do (with passion and conviction) what one thinks is important rather than what may receive more popular acclaim.

    Introduction

    There is a strong temptation to write about how to make public health communication interventions better, more effective, more successful. Interventions for health or disease prevention are an exciting endeavor. They proffer a promise that scholarship, when applied to practice, can help individuals and groups with particular needs, or better society as a whole.

    Historically, interventions for public health promotion have been primarily associated with people with a strong service motivation and willingness to take professional and personal risks. Such efforts were less likely to be associated with a sense of flair and more with lackluster didactic enterprises. Increasingly, however, many public health interventions incorporate communication strategies as a primary or integral part of their planned effort: thus, although they may not be commercially motivated,1 their activities can carry with them the excitement, trappings, and hyperbole of marketing (Goodman & Goodman, 1986). As such, they often appear to attract some of the intensity, glamour, and allure associated with mass media and advertising.

    Making public health communication interventions more strategic—by merging behavior-change theories, practice, and creativity—has had a strong appeal both to practitioners and researchers. This is evident in the growth of prolific literature on this topic across disciplines, including communication, public health, sociology, political science, psychology, and marketing. Having practiced as a health education coordinator and having worked in the development and implementation of health communication interventions, I also found this strategic approach intensely appealing. My fascination, though, after reading Charles T. Salmon's (1989) chapter, “Campaigns for Social ‘Improvement’: An Overview of Values, Rationales and Impacts,” in his book, Information Campaigns: Balancing Social Values and Social Change, suddenly shifted to a less glamorous venture: the advancement of conceptual approaches to identify values and ethical concerns embedded in public health communication interventions. Salmon's chapter, with its succinct articulation of why we need to consider implicit and taken-for-granted values in public communication interventions, made it clear to me that I could no longer engage in studying, implementing, and evaluating public health communication interventions without focusing on values. It jolted me into realizing that, both as a practitioner and a student of such interventions, I had taken values for granted, without examining what they were or how they affected the interventions I was involved in.

    As I began to examine the literature on this topic, I found that its treatment of values—although certainly thought provoking—tended to provide analyses that were either very broad or rather narrow. Authors typically would focus on ethical implications of persuasion or would describe value clarification techniques. I did not find analytic frameworks that could help develop a systematic examination of the public health communication intervention phenomenon from a value-centered perspective. The purpose of this book is to describe the development of such an analytic enterprise, which draws on Salmon's (1989, 1992) writings on values in information campaigns, Kenneth McLeroy and his colleagues' writing on ethics in health education (McLeroy, Gottlieb, & Burdine, 1987) and the ecological approach to health promotion (McLeroy, Bibeau, Steckler, & Glanz, 1988), John Forester's (1989, 1993) critical perspective applied to the area of planning and adapted here to the context of health, and Brown and Singhal's (1990) discussion of ethical dilemmas in the use of television programs to promote social issues. The frameworks also draw from discussions with bioethicists, public health and community development scholars and practitioners, public health policy advocates, academic medicine faculty and administrators, and communication scholars and practitioners.

    Whether they are hidden, invisible, or extremely obvious, the role of values in most social phenomena is paramount: “It is difficult for me to conceive of any problem social scientists might be interested in that would not deeply implicate human values,” says Milton Rokeach (1973, p. ix) in the introduction to his seminal book on values, titled The Nature of Human Values. This book picks up a challenge posed by Sylvia Tesh (1988) in her book Hidden Arguments—to make values embedded in public health more explicit. It addresses this challenge by specifying values and dilemmas inherent in the public health communication intervention process and provides examples of how to develop conceptual frameworks to analyze the implications of these dilemmas. Application of these frameworks can contribute both to theory and practice as well as to the identification of ethical concerns embedded in the intervention process, as the examples in the book aim to illustrate. By doing so, the book aims to address another challenge, posed by Charles T. Salmon (1992) in his critique of current theoretical approaches: to advance the development of conceptual frameworks of rather than only for public health communication interventions.

    Public health communication interventions are increasingly pervasive social phenomena as they become part of international and national agendas and are launched through national and local initiatives, community groups, and workplace enterprises. They engage numerous individuals and organizations across diverse populations, disciplines, and orientations. Typically, however, the analysis of these interventions or campaigns is done in terms of “did they accomplish what they intended to do?” rather than “why is it they intended to accomplish what they intended to?” or “what did they actually accomplish, beyond official objectives?” Values, although recognized as important in health intervention studies, tend to be treated as independent variables that may serve as barriers to interventions' behavior-change goals or as dependent variables that can be manipulated to achieve these goals. This book broadens this approach, and its value-centered conceptual frameworks can be adopted to identify claims used to justify programs as well as communicative distortions that can occur in health interventions' definitions of problems, the solutions they adopt, and the way their outcomes are evaluated.

    The conceptual frameworks developed in this book draw on a series of assumptions that underscore the main purpose of the book. They propose that (a) dilemmas inherent in the intervention process are associated with the value-laden nature of a planned social-change phenomenon, (b) the value-laden nature and moral implications of choices made in the design and implementation of interventions require a theoretical perspective that attends to values and ethical concerns, (c) constructs and systematic frameworks can be used to examine the design and implementation of interventions from a normative perspective, (d) current criteria used for program evaluation and policy making can be broadened by focusing on values, and (e) practitioners, planners, policymakers, researchers, intended populations, and others directly or indirectly involved in the intervention can develop and use practice-oriented questions to identify ethical concerns and values embedded in the intervention process.

    The first chapter begins with a rationale of why we need to consider values in the design and analysis of public health communication interventions. A set of 10 propositions are presented that explicate the importance of considering values in all intervention facets from a normative and critical perspective. The chapter concludes by summarizing the main distinctions between a strategic and value-centered approach according to (a) the way values are studied, (b) the main purpose of the analytic or research approach, (c) the way problems are defined, (d) intervention approaches and behavior-change models, (e) assessment and evaluation, and (f) ethical concerns.

    Why do we need public health communication interventions? Why should they be supported? What gives interventionists the right to intervene in people's lives? The second chapter furnishes a reminder that public health communications—as publicly sponsored social-change undertakings—need to be justified to policymakers and the public. The chapter provides an overview of major justifications for health interventions, mainly as they are presented in the health promotion and bioethics literature, with several additional ones. The third chapter takes the previous discussions of values a step further in the development of a value-analytic approach by specifying intervention facets and providing a conceptual approach for examining values embedded in each. Drawing from the assumption that each facet of the intervention is value laden and that the intervention phenomenon creates value conflicts, each component is described as associated with often-conflicting social values and raising a multitude of ethical concerns.

    The fourth and fifth chapters present a framework of models or prototypes as a conceptual approach to help draw differences between interventions, even when they seem to emphasize the same prominent values. By distinguishing whether the intervention emphasizes a certain value as a goal or a strategy, distinct and important differences between specific approaches can be made, despite apparent similarities. This conceptual approach helps to point out how intervention programs, even when they seem to be emphasizing the same justification or values, can represent very different intervention approaches. Intervention types described in these chapters are not presented as fixed phenomena. Instead, they can be seen as potentially dynamic undertakings that can evolve from one type of model to another.

    The sixth chapter describes a series of questions that raise ethical dilemmas inherently associated with the public health communication intervention enterprise. Many of the ethical issues—although they have important implications to individuals and society—tend to be invisible to health promoters, researchers, and the public. We cannot, as the dilemmas remind us, take for granted or presume that potential effects of health interventions are utterly beneficial. The intervention context is complex, involving diverse stakeholders and competing interests. What, then, do public health communication interventions actually do and what do they not do? What should we expect from interventions? What should raise our concerns? Because as public health communication interventions increasingly adopt sophisticated social marketing techniques, they have an enhanced potential to influence targeted audiences. Through a series of 13 ethical dilemmas and examples to illustrate them, this chapter underscores the need for both conceptual approaches to identify these type of concerns and the need to address them. The chapter concludes with practice-oriented questions that can be used to identify ethical concerns in the design and implementation of interventions or in their analysis by scholars or evaluators.

    The seventh chapter concludes the book with a reminder that whatever frame of analysis is developed, like any other structure, it has enabling and constraining aspects (Ball & Smith, 1992). But, like the interventions it aims to analyze, the frame of analysis is also based on value-laden assumptions. Two approaches to the development of a normative approach are presented: One focuses on issues of social development in the context of health promotion (Minkler, 1989) and the second, on the communicative nature of the public health communication intervention phenomenon (adapting Forester's 1989, 1993 approach), which by implication notes the moral commitment of the analyst, who—without an ethical framework to shape her or his analysis—may find these commitments precarious.2

    Values in public health communication interventions may be disguised or hidden, as Sylvia Tesh (1988) eloquently explains, yet they are deep-seated in the way public health communication interventions' goals are defined, as well as their theoretical approaches and their designs. Values are inherent in what the interventionists emphasize, overlook, or ignore. The contribution of theories and conceptual approaches in the analysis of social phenomena can serve to draw attention to social values when they are not apparent or remain invisible (Deetz, 1992). The ability to see what cannot be seen, as Lewis Carroll's king lamented, is not a skill that is easily acquired:

    “I see nobody on the road,” said Alice.

    “I only wish I had such eyes,” the King remarked in a fretful tone.

    “To be able to see Nobody! And at that distance too! Why, it's as much as I can do to see real people, by this light!”

    My hope is that this book will contribute to an ongoing scrutiny of and discourse on the often invisible assumptions and priorities that underlie public health communication interventions. My hope is that readers may also find, as I have, that attending to the value-laden nature of interventions inescapably raises questions about one's own and others' beliefs regarding human nature, planned attempts to change people's behavior, and how to advance just social institutions.

    Notes

    1. Though increasingly, public relations and other professionals have been making considerable profit from contracting work in health communication interventions from not-for-profit sponsors.

    2. This is an adaptation of Bellah, Madsen, Sullivan, Swidler, and Tipton's (1986) discussion cited in Chapter 7.

  • Resource A: Sample Work Sheets for Analysis of Intervention Facets

    Work Sheet A.1: Identifying Values or Justifications Embedded in the Way Problems and Solutions Are Defined

    Work Sheet A.2: Identifying Values and Ethical Concerns in Strategies

    Work Sheet A.3: Sample Worksheet for Comparing Intervention Emphasis Across Facets

    Resource B: Sample Work Sheets for Comparing Health Communication Interventions

    Work Sheet B.1: Sample Work Sheet for Comparing Health Communication Interventions According to Their Emphasis or Deemphasis of Values: Locus of the Problem

    Work Sheet B.2: Sample Work Sheet for Comparing Health Communication Interventions According to the Emphasis or Deemphasis of Values: Locus of the Solution

    Work Sheet B.3: Sample Work Sheet for Comparing Health Communication Interventions According to the Emphasis or Deemphasis of Values: Strategies

    Work Sheet B.4: Sample Work Sheet for Comparing Health Communication Interventions According to the Emphasis or Deemphasis of Values: Locus of the Outcomes

    Resource C: Analyses of Intervention Types

    • Comparison Between Different Interventions That Appear to Rely on the Same Value
    • Comparison Between Ideal and Actual Intervention Models
    Analysis 1: Comparison between Different Interventions That Appear to Rely on the Same Value
    Table C.1 Description of the Analytic Process for the Comparison Between Different Interventions That Appear to Rely on the Same Value
    ProcessExamples of Specific Questions
    1. Determine to which model each intervention corresponds.
    • What kind of model best represents what actually occurs in each intervention?
    • What is the relationship between practitioners and target population members in each intervention?
    • What kind of messages does each intervention emphasize?
    • What values are dominant in each intervention
    2. Identify additional embedded values.
    • What other dominant values are associated with each intervention?
    • What values were not emphasized in the interventions?
    3. Compare the interventions and identify similarities and differences.
    • In what ways are the interventions similar?
    • What values were emphasized in one intervention but not in the others?
    • What factors explain the similarities between the interventions?
    • What factors explain the differences between the interventions?
    4. Draw implications for design, evaluation, and ethical concerns.
    • What different design or strategic approaches may be used to achieve shared goals?
    • What sociopolitical factors or institutional conditions may be necessary for the intervention to become more similar to the interventions that represent a more desired model?
    • What sociopolitical factors or institutional conditions may impede the implementation of an intervention according to a desired model?

    Work Sheet C.1: Sample Worksheet for Comparison Between Different Interventions That Appear to Rely on the Same Value

    Analysis 2: Comparison between Ideal and Actual Intervention Models
    Table C.2 Description of the Analytic Process for the Comparison Between Ideal and Actual Intervention Models
    ProcessExamples of Specific Questions
    1. Determine the ideal model.
    • What was the intended or ideal model?
    • What type of model should the intervention actually belong to according to normative expectations (highly valued)?
    • What is the desired and ideal relationship between practitioners and target stakeholders?
    • What kinds of capacities or skills would the intervention's professionals need in order to accomplish the intervention goals in this model?
    • What kind of capacities or skills would the intervention's populations need in order to accomplish the intervention goals in this model?
    • What kinds of messages should the intervention emphasize that reflect and correspond to cherished social values and moral frameworks?
    2. Determine the actual model.
    • What kind of model best represents what actually occurred in the intervention?
    • What were the actual relationships between intervention practitioners and target population members?
    • What were the actual capacities or skills the intervention professionals had?
    • What actual capacities or skills did the intervention's targeted population acquire?
    • What kinds of messages did the intervention actually emphasize?
    3. Compare between the ideal and actual models.
    • In what ways does the actual model of the intervention correspond to the intended model?
    • What factors caused the discordance between the ideal and actual?
    • What values were prioritized and what were deemphasized?
    • What factors contributed to correspondence between the ideal and actual?
    4. Draw implications for evaluation and for planning future initiatives.
    • To which type of model did the intervention strive for in the long run?
    • What goals or strategies needed to be modified or changed to move the intervention from one type of model to another?
    • What training do the intervention practitioners need for the intervention to correspond to the ideal model?
    • What resources may be necessary for the intervention to correspond to the ideal model?
    • Is the Ideal model compatible with dominant social values?
    • Can the ideal model be implemented within current institutional arrangements of the intervention?

    Work Sheet C.2: Sample Work Sheet for Comparison Between Ideal and Actual Intervention Models

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    Author Index

    About the Author

    Nurit Guttman is Lecturer in the Department of Communication at Tel Aviv University and is on the faculty of the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. She received her BA from the Hebrew University, her master's degree in communication from the Annenberg School of Communication at the University of Pennsylvania, and her PhD from the School of Communication, Information and Library Studies at Rutgers University. She has done postdoctoral work as a Primary Care Heath Services Research Fellow at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. Her current research projects include developing methodologies for involving the public in policy decisions regarding health care rationing and in the development of health promotion messages and programs. She works with the Israel Ministry of Health and the Israel cancer Society on smoking-prevention issues, and she has served as a consultant on projects evaluating AIDS and substance abuse prevention interventions and on the enhancement of a population approach in medical education.


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