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Ethics in health promotion evaluation research
- 1. MARIE-CLAUDE TREMBLAY PHD CANDIDATE (PUBLIC HEALTH) UNIVERSITY OF MONTRÉAL PATTAYA, AUGUST 27, 2013 Case 3: Ethics in health promotion evaluation research
- 2. Who am I? I am a Ph.D. candidate in Public Health (Health Promotion), at the University of Montreal. I am involved as a doctoral trainee at the Public Health Directorate for Montreal (PHDM), which serves as the fieldwork of my thesis. I am also interested in complex health promotion interventions, reflective practice and collaborative evaluation methods. Marie-Claude.Tremblay.7@umontreal.ca
- 4. Health promotion Health promotion is “the process of enabling people to increase control over their health and its determinants” (WHO, 1986, p. 2). Encompasses a significant ideological component based on values and principles such as: Empowerment; Participation; Social justice and equity; Intersectoral and ecological action.
- 5. Health promotion Thus, health promotion interventions are inherently value-laden and normative. (Health is promoted as a main social concern.) The normativity of health promotion can be worrisome, as it can obstruct some other equally important principles and goals.
- 6. Health promotion evaluation Evaluation research involves making a judgement about an intervention, a program or a policy based on particular criteria and using scientific methods (Rossi, Freeman et al. 1998). Could evaluation position itself as an ‘ethical watchdog’ in health promotion?
- 7. Objectives This presentation aims to explore two ethical issues in health promotion evaluation using a broad perspective of ethics.
- 8. Two ethical issues in evaluation 1. Ethical issue no 1 results from adopting a formal normative ethics to judge health promotion interventions on the basis of their own criteria; 2. Ethical issue no 2 results from adopting a procedural normative ethics by taking up health promotion agenda and principles for conducting the evaluation (‘health promoting evaluation’).
- 9. Ethical issue no 1 A traditional role of evaluation is to make a judgment about an intervention/program, on the basis of particular criteria. In this perspective, evaluations can play an ethical watchdog role by assessing health promotion interventions and their intended goals on the basis of the values and principles of the field. Implies a formal normative ethics, from the ‘inside’ of the field
- 10. Ethical issue no 1 An example: A community health promotion program aims to prevent type 2 diabetes and improve the health of an Indigenous community. An evaluation could assess the extent to which the program respects health promotion values and principles of participation, empowerment, social justice, equity, ecological action…
- 11. Ethical issue no 1 Formal normative ethics: Based on a normative ethics (criteria considered as desirable by the field); Health benefits maximisation (utilitarian ethics); In line with some authors’ points of view that “public health ethics is in need of a theoretical basis that is built on the aims of the enterprise and the moral values inherent in its practices” (Baylis, Kenny, and Sherwin, 2008, p. 206).
- 12. Ethical issue no 1 This point of view can be questioned: Underlying premises of the field stay unchallenged; “Access to debate—or standing to comment—should not rest on the question of whether a view accords with the perspectives, objectives, or ‘philosophy’ of public health” (Coggon, 2010, p. 245). Are health promotion goals, principles and values absolute and socially consensual?
- 13. Ethical issue no 2 Many authors believe that health promotion evaluations should integrate health promotion principles of action in conducting the evaluation, such as participation, empowerment, and concerns for social justice and equity (Rootman et al., 2001). Implies a procedural normative ethics (ethics of the means), where evaluation is itself ‘health promoting’
- 14. Ethical issue no 2
- 15. Ethical issue no 2 An example:
- 16. Ethical issue no 2 Procedural normative ethics: Ethics of the means; Implies integrating health promotion principles and values in evaluation, by: involving stakeholders into the evaluative process; giving a voice to the more disadvantaged; allowing them to develop capacities related to evaluation; evaluating the intervention’s effects from an equity standpoint.
- 17. Ethical issue no 2 This point of view can also be questioned: Integrating health promotion principles in evaluation ensure the evaluation’s procedural ethics, but again from a normative standpoint; This procedural ethics can’t avoid the necessity of formal ethics (ethical assessment of the intervention’s aims and principles).
- 18. Synthesis
- 19. Questions for reflection Does ethics in health promotion evaluation have to be rooted in the values and moral principles of the field or in an overarching and socially shared philosophy? We can also ask what kind of evaluation is responsible for ethics assessment in health promotion? Is it the role of program evaluation or should it be promoted by more specific type of evaluation?
- 20. Acknowledgements Marie-Claude Tremblay is funded by the Strategic Training Program in Promotion, Prevention and Public Policy (4P). Travel to this conference is supported by 4P Training Program, Université de Montréal (Direction des relations internationales) and Lucie Richard.
- 21. References Baylis F., Kenny N., Sherwin S. (2008). A relational account of public health ethics. Public Health Ethics, 1(3):196–209. Carter S.M., Cribb A., Allegrante J.P. (2012). How to think about health promotion ethics. Public Health Reviews. 34(2012): epub ahead of print. Coggon, J. (2010). Does Public Health Have a Personality (and If So, Does It Matter If You Don’t Like It)? Cambridge Quarterly of Healthcare Ethics, 19, 235–248. House, E. R., Howe, K. R. (1999). Values in evaluation and social research. Thousand Oaks, Sage. Rootman, I., M. Goodstat, et al. (2001). A framework for health promotion evaluation. Evaluation in Health Promotion, Principles and Perspectives I. Rootman, M. Goodstat, B. Hyndmanet al. Copenhague, WHO Regional Publications, European Series: 7-33. Rossi, P. H., H. E. Freeman, et al. (1998). Evaluation: a systematic approach. Sixth edition. Thousand Oaks, Sage. World Health Organization. (1986). Ottawa Charter for health promotion. Canadian Journal of Public Health 77(6): 425-430.
Editor's Notes
- I am a Ph.D. candidate in Public Health (Health Promotion), at the University of Montreal. I am involved as a doctoral trainee at the Public Health Directorate for Montreal (PHDM), which serves as the fieldwork of my thesis. I am also interested in complex health promotion interventions, reflective practice and collaborative evaluation methods. Please note that I am not an ethicist, but since I am interested in health promotion and evaluation, I have accepted to explore the topic of health promotion evaluation ethics in the context of this symposium.
- The values and principles of health promotion have been stated and defined in the Ottawa Charter (1986), among others, which is still considered today as a foundational pillar of the field.
- Health promotion is a specific field of action and discourse of public health, defined as “ the process of enabling people to increase control over their health and its determinants” (WHO, 1986, p. 2). As such, it encompasses a significant ideological component based on values and principles of action such as empowerment, participation, social justice, equity and intersectoral/community action.
- Given this important ideological component, health promotion interventions are inherently value-laden and normative, promoting health as a main social concern. Despite its commitment to a larger moral theory, the normativity of health promotion can be worrisome, as it can obstruct some other equally important principles and goals.
- Evaluation research involves making a judgement about an intervention, a program or a policy based on particular criteria and using scientific methods ( Rossi, Freeman et al. 1998 ). In this perspective, evaluation could act as the ‘watchdog’ of ethical issues in health promotion, by assessing the true desirability of practices from an ethical standpoint. But this role is itself complicated by the normative nature of health promotion evaluation.
- This presentation aims to explore two ethical issues in health promotion evaluation using a broad perspective of ethics, conceived as a reflexive and moral inquiry about practices (Carter, Cribb & Allegrante, 2012; Coggon, 2010).
- Ethical issue no 1 results from adopting a formal normative ethics to judge health promotion interventions on the basis of their own criteria; Ethical issue no 2 results from adopting a procedural normative ethics by taking up health promotion agenda and principles for conducting the evaluation (‘health promoting evaluation’).
- First, evaluations could play a judgmental role by assessing health promotion interventions and their intended goals on the basis of the values and principles of the field. In this perspective, evaluators use the criteria established as desirable by the field (i.e. promotion of health through principles of participation, empowerment, social justice, equity, etc.) to examine the purpose of a program or the extent to which the program is reaching its goal and respecting theses principles.
- Take for example a health promotion program aimed at preventing type 2 diabetes and improving health in an Indigenous community. An evaluation could be done to assess the extent to which the program respects health promotion principles of participation, empowerment, social justice, equity, ecological action. For instance, is the program engaging community in the conception and implementation of the intervention? Is the program fostering capacities development in the community, so that diabetes prevention and health improvement become sustainable capacities of the individuals and the community? Is the program targeting disadvantaged people who need more than others health promotion efforts? Etc.
- Evaluating health promotion interventions in this way allows for the deliberation about the desirability of an intervention from a normative ethical standpoint. (In fact, this kind of ethics judgement is based on ‘prescriptive valuing’ (used when significant value agreement exists), and allows arriving at explicit value conclusions based on substantive values (House and Howe, 1999). ) Health is the concern that is valued over others, which makes this kind of ethics also utilitarian. This kind of ethics is in accordance with some authors’ points of view, that “public health ethics is in need of a theoretical basis that is built on the aims of the enterprise and the moral values inherent in its practices” (Baylis, Kenny, and Sherwin, 2008, p. 206).
- But, we could also question the legitimacy of this point of view, as the underlying premises of health promotion stay unchallenged and unquestioned with this kind of evaluation. As Coggon (2010, p. 245) noticed, “access to debate—or standing to comment—should not rest on the question of whether a view accords with the perspectives, objectives, or ‘philosophy’ of public health”. In fact, we can legitimately question if health promotion goals, principles and values are absolute and based on a whole social normativity. As said before, there are others social concerns that may be as valuable as health.
- Another ethical issue of health promotion evaluation stems from the fact that, often, health promotion evaluations take up health promotion principles. In fact, many authors believe that health promotion evaluations should integrate health promotion principles of action, such as participation, empowerment, and concerns for social justice and equity (Rootman et al., 2001). From this perspective, health promotion evaluation implies a procedural normative ethics (ethics of the means) , where evaluation is itself ‘health promoting’ .
- This is a table adapted from Rootman et al. book (2001), presenting the principles of action to be fostered in health promotion interventions and evaluations.
- Lets take an example to concretise this : This is an example of an evaluation integrating health promotion principles of participation, empowerment, intersectorality and relevance. The example consists in the evaluation of a professional development program in health promotion. This evaluation was aiming to support and guide the program’s implementation process. Both the evaluator and the project team were mindful of integrating health promotion principles into the evaluation. In this example, the evaluation was designed in a way to include the program designer team into the evaluative process (participation) and enable reflexive processes that foster the interventionists’ ability to assimilate the knowledge produced by the evaluation (empowerment). In addition, the evaluative process was anchored in a multitude of disciplines and relied on a variety of information-gathering techniques (multidisciplinarity/intersectorality). The evaluation also took into account the complex, adaptive nature of the program (relevance).
- This kind of evaluation build on procedural ethics, ensuring that the process of evaluation is itself ethical from a health promotion standpoint. Integrating health promotion principles and values in evaluation can be done by involving stakeholders into the evaluative process, giving a voice to the more disadvantaged, allowing them to develop capacities related to evaluation and evaluating the intervention’s effects from an equity standpoint.
- Although this ensure the evaluation’s procedural ethics (ethics of the means – but again from a normative standpoint), it can’t avoid the necessity of ethically assess the content of the interventions.
- The argument of this presentation can be synthesized as follows: because of its normative nature, health promotion needs to be ethically assessed; evaluation is often considered an opportunity to do so; but evaluation in health promotion is itself normative. In each of the cases presented, health promotion evaluation remains caught in its own normative rhetoric, either by adopting formal normative ethics to judge health promotion interventions on the basis of their own criteria or a procedural normative ethics by adopting health promotion agenda and principles for conducting the evaluation. These two issues can be conceived as resulting from a confusion about what should be a foundational framework for ethics in health promotion.
- This presentation opens the door to some reflections: Does ethics in health promotion evaluation have to be rooted in the values and moral principles of the field or in an overarching and socially shared philosophy? We can also ask what kind of evaluation is responsible for ethics assessment in health promotion? Is it the role of program evaluation or should it be promoted by more specific type of evaluation?