Ethical issues in government sponsored public health campaigns

Ethical Issues in Breastfeeding and Lactation Interventions: A Scoping Review

BACKGROUND

Infant feeding interventions that promote and support breastfeeding are considered important contributions to global public health. As these interventions often target private settings (e.g., individuals' homes) and involve vulnerable populations (e.g., pregnant women, infants, and underprivileged families), a keen awareness of ethical issues is crucial.

RESEARCH AIM

The purpose of this scoping review was to capture the key elements of the current ethical discourse regarding breastfeeding and lactation interventions.

METHOD

A scoping review was conducted using Arksey and O'Malley's (2005) methodology to identify the ethical issues of breastfeeding and lactation interventions as they are reflected in the scholarly literature published between January 1990 and October 2022. Abstracts (N = 3715) from PubMed, ScienceDirect, JSTOR and the Cochrane Database of Systematic Reviews were screened. The final sample consisted of 26 publications.

RESULTS

The recurring ethical issues identified in these studies were: the normative assumptions of motherhood; maternal autonomy and informed choice; information disclosure, balancing risks and benefits, and counseling practices; stigma and social context; ethics of health communication in breastfeeding campaigns; and the ethical acceptability of financial incentives in breastfeeding interventions.

CONCLUSION

This review illustrated that, while a wide range of ethical arguments were examined, the emphasis has been primarily on accounting for mothers' experiences and lactating persons' choices, as well as achieving public health objectives relating to infant nutrition in breastfeeding interventions. To effectively and ethically implement breastfeeding and lactation interventions, we must consider the social, economic, and cultural contexts in which they occur. One key learning identified was that women's experiences were missing in these interventions and, in response, we suggest moving beyond the dichotomous approach of individual health versus population health.

Midwifery care of non-vaccinating families - Insights from the Byron Shire

PROBLEM

Midwives may feel ill-equipped to manage clinical encounters with non-vaccinating parents.

BACKGROUND

Pregnancy is a peak time in the formation of parents' vaccination views and intention. Midwives are central to maternity care in Australia. While most midwives will have infrequent contact with families who intend not to vaccinate, when they do, they must feel equipped to communicate with them in a manner which fulfils their professional responsibilities, acknowledges parental autonomy and facilitates continued engagement.

AIM

To understand how midwives can most effectively communicate with non-vaccinating parents.

METHODS

We conducted in-depth interviews with 32 non-vaccinating parents and six key informant health professionals, and a focus group of six midwives. Data collection occurred in the Byron Shire of New South Wales, where childhood vaccination rates are persistently lower than national averages.

FINDINGS

This study explores four central codes. The first, 'hold on…I'm not sure about this' providing insights into moments of doubt preceding parents' decisions not to vaccinate. The second 'Pregnancy: a decision-making focal point' reinforces the importance of effective vaccination recommendations in the antenatal period. 'Manipulation and ambivalence' examines why overzealous or unclear recommendations about vaccination are unhelpful, and the fourth central code 'engage, inform and encourage' summarise recommendations from health professionals who are experienced in communicating, apparently effectively, with non-vaccinating families.

DISCUSSION

Insights from this study are used to recommend practical strategies which may be employed by midwives and maternity units to successfully and professionally manage clinical encounters with non-vaccinating parents.

CONCLUSION

Midwives are well positioned to provide clear recommendations to parents regarding childhood vaccination whilst maintaining engagement and meeting the goals of woman-centred care.

The False and the Furious

Social media has become an important source of information for new mothers. Many seek out information on breastfeeding. This is particularly true for low-income mothers who may not have paid access to credible news sources or to evidence-based journals. This may also perpetuate racial disparities in breastfeeding. Negative social media campaigns have highlighted the “dangers” of breastfeeding and used extremist language to brand breastfeeding supporters. This article suggests some specific strategies for addressing gaps in our current system and countering the negative information. Breastfeeding should be framed as a reproductive right.

Ought Low Alcohol Intake to be Promoted for Health Reasons?

There is increasingly widespread acceptance that alcohol taken in moderation by the population aged 35 years or older reduces the risks of ischaemic heart disease and all-cause mortality. Ten causal criteria are used to evaluate the scientific evidence for a protective effect of low alcohol intake on ischaemic heart disease. Inferences for public policy are then assessed using the principles of beneficence, non-maleficence, justice and autonomy to support a framework of nine ethical considerations: intervention versus causation; effect modification by gender, smoking, biogenetic and other factors; inappropriate adoption of recommendations; competing hazards between atherosclerotic disease and cancer; opportunity cost; equity of access; the value system used to judge outcomes; the degree of social influence warranted; and consent and responsibility. We conclude that in the absence of more adequate scientific knowledge and informed community debate it is unethical to promote low alcohol intake as a preventive health measure.

Means, ends and the ethics of fear-based public health campaigns

Controversy has swirled over the past three decades about the ethics of fear-based public health campaigns. The HIV/AIDS epidemic provided a context in which advocacy groups were almost uniformly hostile to any use of fear, arguing that it was inherently stigmatising and always backfired. Although this argument was often accepted within public health circles, surprisingly, the bioethicists who first grappled with this issue in terms of autonomy and coercion in the 1980s were not single-minded: fear could be autonomy-enhancing. But by the turn of the 21st century, as opponents of fear-based appeals linked them to stigmatisation, ethicists typically rejected fear as inherently unethical. The evidence has increasingly suggested that fear-based campaigns 'work.' Emotionally charged public health messages have, as a consequence, become more commonplace. We conclude that an ethics of public health, which prioritises population well-being, as contrasted with the contemporary focus of bioethics on autonomy, provides a moral warrant for ensuring that populations understand health risk 'in their guts.' This, we argue, does not relieve public health authorities from considering the burdens their efforts may impose on vulnerable populations.

Experience of non-breastfeeding mothers

Background:

Breastfeeding is currently strongly recommended by midwives and paediatricians, and the recommendations are based on documents provided by the World Health Organization and public health authorities worldwide.

Research question:

The underlying question is, how are non-breastfeeding mothers affected emotionally when informed that breastfeeding is the safest and healthiest option?

Research design:

The method used is an anonymous web-based qualitative survey exploring the narratives of non-breastfeeding mothers, published on Thesistools.com . The aim is to achieve qualitative knowledge about the emotions of non-breastfeeding mothers.

Participants and research context:

Participants were based in Sweden, the United Kingdom and the Netherlands and were selected through a purposeful sample.

Ethical considerations:

The online survey anonymizes responses automatically, and all respondents had to tick a box agreeing to be quoted anonymously in scientific articles. The study conforms to research ethics guidelines.

Findings:

Respondents describe how they were affected, and the following themes emerged in studying their descriptions: depression, anxiety and pain, feeling failed as a mother and woman, loss of freedom/feeling trapped, relief and guilt.

Discussion:

The themes are discussed against the background of the ethics of care and a theory of ethically responsible risk communication.

Conclusion:

Three conclusions are made. First, the message should become more empathetic. Second, information should be given in an attentive dialogue. Third, information providers should evaluate effects in a more inclusive way.

The U.S. healthy people initiative: its genesis and its sustainability

Unlike most government initiatives in health, the Healthy People initiative of the U.S. federal government was crafted and sustained not as a federal initiative, but as a "national initiative" eliciting participation from nongovernmental national organizations, state health agencies, professional associations, multiple agencies of the U.S. Department of Health and Human Services, and other federal agencies, such as Agriculture, and increasingly engaging academia and state and local stakeholders in adapting the objectives for their own efforts to enact and evaluate state and local policies and programs. The quantified objectives at the center of the initiative were a product of continuous balancing of changing science and political or social concerns and priorities along with national and state or special population needs. The evolution from the first decade's objectives to each subsequent set of objectives reflected changing societal concerns, evidence-based technologies, theories, and discourses of those decades. Such accommodations changed the contours of the initiative over time in attempts to make it more relevant to specific partners and other stakeholders.

Alcohol dependence in public policy: towards its (re)inclusion

Public policy on alcohol in the UK relies on health promotion campaigns that encourage individuals who misuse alcohol to make healthier choices about their drinking. Individuals with alcohol-dependence syndrome have an impaired capacity to choose health. As a result, individuals with the worst alcohol misuse problems lie largely outside the reach of choice-based policy. However, such policy has been widely criticized and efforts to reform it are underway. This paper argues that the British Medical Association's recent attempt to improve policy on alcohol in the UK by introducing strategies which have been shown to control drinking within populations still gives insufficient attention to alcohol dependence. This is because it fails accurately and consistently to characterize alcohol dependence and gives insufficient attention to the social challenges it presents.

Principled leadership in public health: integrating ethics into practice and management

Public health officials frequently face ethical tensions and conflicting obligations when making decisions and managing health departments. Leadership requires an ongoing approach to ethics that focuses on two dimensions of practice: the professional relationships of officials developed over time with their communities and the ethical aspects of day-to-day public health activities. Education and competencies in ethics may be helpful in practice, by providing, at a minimum, frameworks and ethical principles to help structure analysis, discussion, and decision making in health departments and with community stakeholders. Such a "practical ethics" approach in public health practice begins with a focus on public health values and an agency mission statement and integrates ethics throughout the organization by, for example, setting performance measures based on them. Using a case in emergency preparedness, this article describes ways in which ethical frameworks and the Code of Ethics can be used as tools for education and to integrate ethics into agency activities and programs.

Health communications in rural America: lessons learned from an arthritis campaign in rural Arkansas

CONTEXT

Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas.

PURPOSE

To review findings and lessons learned from a rural health communications campaign.

METHODS

The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign.

FINDINGS

Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints.

CONCLUSION

Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.

What young Dutch adults say they do to keep from gaining weight: self-reported prevalence of overeating, compensatory behaviours and specific weight control behaviours

OBJECTIVE

The aim of this study was to explore the prevalence of and differences in self-reported occasions of overeating (such as at celebrations and other parties), compensatory behaviours and specific weight gain prevention strategies among young Dutch adults according to sociodemographics and overweight status.

DESIGN AND SUBJECTS

Cross-sectional data were analysed from Dutch adults aged 20-40 years, recruited from an Internet research panel (n = 857, response rate = 76.6%). Using electronic questionnaires, self-report data were collected on sociodemographics, body mass index (BMI), occasions of overeating, compensatory behaviours, and diet and physical activity used as weight gain prevention strategies. Associations were tested using multiple linear and logistic regression analyses.

RESULTS

Of the participants, 48.6% reported occasions of overeating at least once a week during the 4-week period, 44.6% reported compensating for these occasions and 72.9% reported engaging in dietary and physical activities specifically for weight gain prevention purposes. Only 32.1% of the respondents reported using the recommended combination of diet and physical activity as a weight gain prevention strategy. In addition, results showed that overweight people (BMI > or = 25 kg m-2) and women were more likely to report overeating than people with healthy body weights (odds ratio (OR) = 1.79; 95% confidence interval (CI) 1.32-2.42) and men (OR = 1.50; 95% CI 1.14-1.97). Overweight people, women and people who regularly reported overeating were also significantly more likely to report compensatory behaviours by eating less and to report specific weight gain prevention strategies using diet and physical activity.

CONCLUSION

The present study suggests that people experience frequent occasions of overeating and try to compensate for such occasions in different ways. However, the combination of dietary changes and physical activity recommended by experts was seldom reported.

The problem with breastfeeding discourse

This paper reflects on how informational biases have subtly entered into the breastfeeding health discourse and recommends how focus might be redirected. Specifically, contemporary infant feeding health discourse reflects a biased representation of the scientific literature, and fails to provide an appropriate contextualization of risk and benefit. It is important to correct these biases in order to uphold the foundational ethics of expert-guided childcare, and to rightly reposition the discourse as a tool for influence via education, not informational manipulation. Correcting these biases would also ease the discursive pressure and associated emotional burdens mothers currently experience in relation to infant feeding, and would reinforce a needed commitment to the development of appropriate supports to help mothers viably exercise their right to breastfeed.

Ethical issues in epidemiologic research and public health practice

A rich and growing body of literature has emerged on ethics in epidemiologic research and public health practice. Recent articles have included conceptual frameworks of public health ethics and overviews of historical developments in the field. Several important topics in public health ethics have also been highlighted. Attention to ethical issues can facilitate the effective planning, implementation, and growth of a variety of public health programs and research activities. Public health ethics is consistent with the prevention orientation of public health. Ethical concerns can be anticipated or identified early and effectively addressed through careful analysis and consultation.

Public health ethics: from foundations and frameworks to justice and global public health

Ethics dilemmas have been present throughout the history of public health, and bioethics has devoted considerable attention to issues relevant to public health. Only recently, however, has public health ethics emerged as a recognized subfield of bioethics. Public health ethics requires that public health improvement come through just and respectful means. Bioethics in the future not only will take on more issues of public ethics, but will apply it extensive scholarship in distributive justice to questions of global public health.

Ethics and public health: forging a strong relationship

The field of bioethics arose in the late 1960s in response to the emerging ethical dilemmas of that era. The field for many years focused in general on the dilemmas generated by high-technology medicine rather than on issues of population health and the ethical problems of public health programs and regulations. The time has come to more fully integrate the ethical problems of public health into the field of public health and, at the same time, into the field of bioethics. Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis.

Equity is out of fashion? An essay on autonomy and health policy in the individualized society

It is widely recognized that there is a discrepancy between principle and practice with respect to the health equity aim of public policy. This discrepancy is analyzed from two theoretical perspectives: the individualization of society and the fact that individual beliefs and values are connected to one's position in the social structure. These mechanisms influence both the choice of health policy measures and the normative judgements of preventive efforts, both of which tend to be consonant with the views of dominant social groups. In particular, we focus on the treatment of the ethical principle of autonomy and how this is reflected in health policy aimed at influencing health-related behaviour. We examine the current trend towards targeting health information campaigns on certain socio-economic groups and argue that it entails an ethical dilemma. The dominant discourse of the welfare state is contemplated as a means to understand why there tend to be a lack of emphasis on measures that are targeted at socio-economic inequalities. It is argued that there is no substantive basis in the individualized society for perceiving health equity as an independent moral principle and that the driving force behind the professed health equity goal may be in essence utilitarian.

Reducing inequities through participatory research and community empowerment

Information dissemination for behavior change has been the mainstay of traditional health education practice, despite lack of demonstrated effectiveness in improving the public's health. Following a critique of traditional health education practice, an alternative orientation is proposed. Health education for social change, based on Paulo Freire's empowerment education and principles of participatory research, is examined theoretically within the context of the need to address inequities in health. The theoretical justification forms the basis for a description of a case study in reducing nutritional inequities. The case study analyzes how a process of participatory research and community organization was an empowering educational experience for a group of low-income urban women. The process of learning and social action is highlighted by chronicling changes associated with the experience. The realities and limitations of the project are also reflected upon. Implications for health education practice and future social change are highlighted.

Preventing teen pregnancy through persuasive communications: realities, myths, and the hard-fact truths

Effective campaigns are desperately needed to combat the serious social problem of teen pregnancy. However, public health campaigns are most often noted for failures, rather than successes. One reason for a campaign failing to have the intended effect is lack of theoretical guidance at the formative evaluation stage. The study reported here is a theoretically-based formative evaluation with inner city teens. Six focus groups were conducted to determine knowledge, attitudes, beliefs, and recommendations for effective campaigns to deter teen pregnancy. The results indicate that campaign messages need to combat positive attitudes toward pregnancy, negative attitudes toward birth control, the perception of personal invulnerability, and emphasize the negative consequences of sexual intercourse. This study's findings also suggest that campaigns with these messages need to start at an early age in order to effectively prevent teen pregnancy.

Femininity, responsibility, and the technological imperative: discourses on breast cancer in the Australian press

The manner in which the popular press represents health issues influences, and is demonstrative of, societal attitudes toward illnesses and those who suffer from them. Cancer is one of the most feared diseases in modern society, and breast cancer attacks women at the bodily site where notions of femininity intersect. This article examines the discourses surrounding breast cancer as represented in the Australian press in the period between 1987 and 1990. It is argued that the press's portrayal of breast cancer during that time drew upon dominant cultural metaphors and discourses concerning femininity, the individual's responsibility for illness, and medical and technological dominance.

Risk as moral danger: the social and political functions of risk discourse in public health

Risk is a concept with multiple meanings and is ideologically loaded. The author reviews the literature on risk perception and risk as a sociocultural construct, with particular reference to the domain of public health. Pertinent examples of the political and moral function of risk discourse in public health are given. The author concludes that risk discourse is often used to blame the victim, to displace the real reasons for ill-health upon the individual, and to express outrage at behavior deemed socially unacceptable, thereby exerting control over the body politic as well as the body corporeal. Risk discourse is redolent with the ideologies of mortality, danger, and divine retribution. Risk, as it is used in modern society, therefore cannot be considered a neutral term.

Health education and injury control: integrating approaches

The prevention of injuries, a major public health problem, is of interest to a growing number of public health professionals from a variety of disciplines. Historically, there has been tension between those who propose injury prevention strategies that focus on the adoption of protective behaviors by individuals and those who propose strategies that circumvent the role of individual behavior by providing automatic or passive protection. This tension may be counterproductive to finding comprehensive solutions to injury problems, and a better understanding of the inherent strengths and limitations of each of these approaches is needed. The purposes of this paper are to: (1) describe the arguments over individual liberties and individual behavior that can occur in the design of injury prevention programs; (2) review the principles that typically guide the development of injury control programs and health education programs; and (3) integrate the two most widely used approaches in injury control and health education programs--Haddon's injury countermeasures and Green's PRECEDE framework--into one program planning framework that addresses both behavioral and nonbehavioral components of an injury problem. This unified framework is offered in the hope that its use will facilitate multidisciplinary, comprehensive approaches to developing injury prevention programs that are efficient and effective.

Improving EPSDT use: development and application of a practice-based model for public health nursing research

The purposes of this article are to describe the process of adapting an existing model to create a framework suitable for public health nursing (PHN) practice and to demonstrate how the resulting model can guide research for PHN practice. Using the PRECEDE (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) model as a base, we synthesized concepts of health behavior, health education, health promotion/disease prevention, and program evaluation to develop a model for planning and evaluating aggregate-level PHN interventions to improve the use of the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) in rural North Carolina. The model provided the framework for identifying variables relevant to EPSDT use, designing interventions to improve use, and planning a research evaluation of the effectiveness, efficacy, and cost effectiveness of the interventions. This model, and the process used in adapting it for PHN practice, should be helpful for others investigating methods of reaching and bringing effective health-promotion/disease-prevention information to underserved, low-education members of minority groups.

An ecological perspective on health promotion programs

During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.

The business of health promotion: ethical issues and professional responsibilities

In the nine years since an entire issue of Health Education Quarterly (then Health Education Monographs) was devoted to considering ethical issues in health education, several important social changes have occurred which have substantially influenced the practice of that discipline. New practice contexts and ethical issues have resulted, which require a fresh look at both these new issues as well as those addressed in the earlier monograph. The importance of understanding the principles underlying the ethical dilemmas raised by the authors is emphasized as a concern for both the individual practitioner as well as the profession of health education itself. Recommendations for personal and professional action are made by the authors.