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

Abstract

There are several strategies to promote health in individuals and populations. Two general approaches to health promotion are behavior change and empowerment. The aim of this article is to present those two kinds of strategies, and show that the behavior-change approach has some moral problems, problems that the empowerment approach (on the whole) is better at handling. Two distinct 'ideal types' of these practices are presented and scrutinized. Behavior change interventions use various kinds of theories to target people's behavior, which they do through information, persuasion, coercion and manipulation. Empowerment is a collaborative method where those 'facilitated' participate in the change process. Some ethical problems with the behavior-change model are that it does not sufficiently respect the right to autonomy of the individuals involved and risks reducing their ability for autonomy, and that it risks increasing health inequalities. Empowerment, on the other hand, respects the participant's right to autonomy, tends to increase the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities. A drawback with this approach is that it often takes longer to realize.

Empowering aspects for healthy food and physical activity habits: adolescents’ experiences of a school-based intervention in a disadvantaged urban community

“…Adolescents can be seen as empowered rather than exploited when one listens to what they have to say, and whether they want to be included at all, by feeling that the issue is important and significant for them (Allard, 1996). Thus, a too strict focus on behaviour change might overlook the individuals own perceptions of what is important, which also increase the risk of unsuccessful interventions (Tengland, 2012). …”

Why should ethics approval be required prior to publication of health promotion research?

“…For example, although it was once considered acceptable to be quite paternalistic, even coercive, in health promotion activities, there is now a moral expectation that liberty and empowerment be taken seriously in considering any intervention. 16 Similarly, although doctors were once considered capable of judging the ethics of their own research, the dominant view now is that ethics committees -even with their limitations in expertise and resources -are, as disinterested collectives, both more objective and more capable of making these assessments. 1,3 Health promotion investigators may also raise the point that we have already made above, namely that most of what they do is low risk and that obtaining ethical approval will either add unnecessary time or costs to an intervention without being justified by a risk-benefit calculation.…”

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

“…I have earlier argued that health should be a goal for health promotion only in so far as it is quality of life related [77]. The reason is simply that if an increase in health or longevity does not contribute to an 1 A previous paper in a similar way discusses and ethically evaluates the different means used by these two approaches [83].…”

“…In any case, it might be wise to involve people in choosing the targets of interventions that concern them, since these interventions are then more likely to succeed (for more arguments, see [83] Leonard Syme describes an illustrative case of a failed behavior-change project [75]. His research team received a large research grant for trying to reduce smoking in Richmond,…”

“…Topdown empowerment projects often target vulnerable groups or communities, by, e.g., providing low-cost child care for the less affluent mothers who want and need to work, making the job market more accessible for immigrants, increasing availability of recreational facilities in deprived areas, or expanding the possibilities for poor people to access higher educations. Local empowerment projects are usually even more targeted on vulnerable groups, usually focusing on issues that the group, or community, themselves find important [83], e.g., on getting access to basic health care, family planning, or language training (for newly arrived refugees and immigrants). The empowerment approach has historically been closely related to the agenda to equalize opportunity and control in the population, primarily focusing on marginalized and vulnerable groups [28; 69], associated as it has been to civil rights movements of various kinds [28, pp.…”