Health promotion is ethical

To the Editor: We are responding to the article ‘Ethical issues in public health promotion’, which misrepresents health promotion.1 Debate about health promotion ethics is important, as some practices may be coercive, e.g. using financial incentives to change behaviour.2 However, the article does not sufficiently address the balance between individual and collective rights, nor does it differentiate between evidence- and profit-driven communications. These two points are essential for any exploration of health promotion.

Health promotion aims to improve population-level health, and not to limit individual autonomy by dictating lifestyles. The Ottawa Charter’s only individually focused health promotion pillar is about developing skills, such as helping a person distinguish between fact and fiction in the complex marketplace of health claims.3 Another pillar promotes healthy public policies, and includes ‘coercive’ policies such as banning smoking in public places. However, Gardner1 omits how policies are often informed by public participation (ano­ther health promotion pillar), such as movements to reduce exposure to second-hand smoke.4 A smoker’s autonomy to smoke anywhere is contravened by policies that defend non-smokers’ right to a smoke-free environment, with both evidence and popular support.

The article misconstrues how health promoters apply theory. For individual behaviour change to benefit population health, we use theories to design interventions. From an efficacy perspective, theory-based interventions are superior.5 However, theories are only tools to explore and explain how and why people think and act; people aren’t forced to follow theoretical constructs. If messages present the best evidence available, drawing on theory is not unethical. However, the ethics of shaping messages that are neither theoretically nor evidence-based is another story. Equating health promotion with marketing messages overlooks the evidence used for the former.

Health promotion uses evidence to inform ethical decisions. When individual rights are contradictory, the collective benefit is considered (see earlier smoking example). Industry regulation, such as limiting salt in bread, is an ethical act designed to reduce population-level hypertension costs while not infringing on an individual’s right to eat bread.6 Gardner1 suggests that a doctor’s advice to exercise infringes on a patient’s autonomy if it wasn’t solicited or causes embarrassment. On the contrary, enhancing patient health literacy is fulfilling the Hippocratic Oath. Withholding such evidence would allow marketers unfettered opportunities to mislead.

While unethical communication happens, e.g. omitting facts, this isn’t the status quo. True health promotion avoids making moral judgements. Rather, it seeks to empower individuals to make choices that are empirically in their best interests. For instance, Soul City’s engagement with multiple concurrent partnerships in series 9 dramatised the issue without moralising. The series used medical evidence of increased HIV risk, linked to higher exposure, as well as inputs from community members.

To conclude, we encourage readers to revisit the principles of the Ottawa Charter. Not only is health promotion ethical, it promotes health equity and empowers individuals.

Sara Nieuwoudt

Division of Social and Behaviour Change Communication, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Sara.nieuwoudt@wits.ac.za

Dr Susan Goldstein

Programme Director, Soul City: Institute for Health and Development Communication and Honorary Senior Lecturer, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Alex Myers

Priority Cost Effective Lessons for Systems Strengthening, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Dr Nicola Christofides

Coordinator, Masters of Public Health, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Prof. Karen Hofman

Director, Priority Cost Effective Lessons for Systems Strengthening, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

References

1. Gardner J. Ethical issues in public health promotion. South African Journal of Bioethics and Law 2014;7(1):30-33. [http://dx.doi.org/10.7196/sajbl.268]
2. Gneezy U, Meier S, Rey-Biel P. When and why incentives (don’t) work to modify behavior. J Environ Prot 2011;25(4):191-210. [http://dx.doi.org/10.1257/jep.25.4.191]
3. World Health Organization. Ottawa Charter for Health Promotion. Ottawa: World Health Organization, 1986. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ (accessed 12 March 2014).
4. Bayer R, Colgrove J. Science, politics, and ideology in the campaign against environmental tobacco smoke. Am J Public Health 2002;92(6):949-954. [http://dx.doi.org/10.2105/AJPH.92.6.949]
5. Rimer B K, Glanz K. Theory at a glance: a guide for health promotion practice, 2nd ed. Bethesda, Maryland: National Institutes of Health, National Cancer Institute, 2005. http://www.popline.org/node/276257 (accessed 15 July 2014).
6. Hofman K, Tollman S. Population health in South Africa: A view from the salt mines. Lancet Glob Health 2013;1(2):e66-e7. [http://dx.doi.org/10.1016/S2214-109X(13)70019-6]