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Abstract

Health, as a notion of what constitutes a good life, is determined by several factors including socioeconomic background, behavior, and lifestyle choices. Modern health education and promotion is endorsed in several documents by the international community and is described as the process whereby people are enabled to increase control over and improve their health. The focus of health promotion is to achieve equity in health for all. Ethical challenges arise from efforts to improve health through health education and promotion efforts. Problems may arise because the manner in which health promotion is implemented and evaluated does not always take values into consideration. Work in this ﬁeld is inﬂuenced by both scientiﬁc and extra scientiﬁc values including political, religious, social, and cultural tenets. Strategies may transgress ethical boundaries and become problematic when messages associate behaviors with distasteful characteristics resulting in unintended consequences. Information could be framed such that individuals’ rights to self-determination and liberty are not respected.

Consent is vague in this context. Universal strategies may not be sufﬁcient to protect or improve the average health of the population as inequality may worsen or remain high with the gains accruing disproportionately to those that are better off and are already enjoying better health.

Introduction

Health is important to most people and is a notion of what constitutes a good life. Health is determined by several factors including socioeconomic background, the environment, access to healthcare, behavior, and lifestyle choices. Personal behavior plays an important role in determining the health of a population. The term public health is broad with its task being that of preventing disease, prolonging life and, through organized efforts, promoting health. Health promotion and education is a core activity of public health and is attained as a result of the efforts of many role players ranging from the state at a macrolevel, across to institutions, organizations and industry at a mesolevel, and through to groups and individuals at grassroots or microlevel.

Complex networks of interests, rights, and ideals require consideration, including the relationship between the state and individuals that are affected by its policies, their entitlements, and the duties that individuals have toward each other.

This entry starts off by considering the part played by international actors in the development of modern health promotion activities. The role of several documents and in particular the Ottawa and Bangkok Charters are described. Challenges and dilemmas arising from efforts to improve health through health education and promotion efforts are discussed. Principles for ethical research in this practice are detailed. While the ethical issues highlighted in this entry are not exhaustive, the key problems of health education and promotion at a global context are brought up.

History And Development

Health promotion and the need for individuals taking personal responsibility for the upkeep of their health is not a new concept and has come a long way since Galen (AD 180). Its prominence increased as a result of epidemiological transition with infectious diseases being replaced by noncommunicable diseases as leading causes of morbidity and premature mortality. Modern health education and promotion was initially endorsed in the Declaration of Alma-Ata at the World Health Organization’s (WHO) International Conference on Primary Health Care in 1978. Urgent action by all governments, health and development workers, and the global community to promote and protect the health of everyone in the world was called for (WHO 1978). The Declaration reafﬁrmed that health, as a state of complete physical, mental, and social well-being and not just the absence of disease or inﬁrmity, was a fundamental human right. It further stated that attainment of the highest possible level of health was the most important social goal globally and the realization of health required input from many other social and economic sectors in addition to the health sector.

Eight years later, the Ottawa Charter for Health Promotion was adopted at the WHO’s First International Conference on Health Promotion in November 1986 (WHO 1986). The goal of this charter was to achieve “Health for All” by the year 2000 and beyond. The conference was directly as a result of worldwide growing expectations for a new public health movement and while discussions focused on the needs of industrialized countries, it took into account similar concerns in other regions. The Charter described health promotion as the process whereby people were enabled to increase control over and improve their health. For individuals or groups to attain health, they had to be able to identify and realize their aspirations, satisfy their needs, and change or cope with the environment. Therefore, in terms of the Charter, health was perceived as a positive concept which emphasized social and personal resources and physical capacities, that is, health was a resource for daily living and not the objective of living. Similar to the Alma-Ata Declaration, health was not seen as merely the responsibility of the health sector and health promotion therefore extended beyond healthy lifestyles to include well-being.

The Ottawa Charter identiﬁed eight fundamental conditions or prerequisites for health as being peace, shelter, education, food, income, a stable ecosystem, sustainable resources, and social justice and equity. A secure foundation in these basic socioeconomic and environmental determinants was necessary for improvements in health. In terms of the Charter, there are ﬁve key action areas and three basic strategies in health promotion. Health promotion action requires the building of healthy public policy, creating supportive environments, strengthening community actions, developing personal skills, and reorienting health services. The strategies proposed are those of advocating, enabling, and mediating.

Building healthy public policy means that health must be put onto the agenda of policy makers in all sectors at all levels highlighting their responsibilities for health with the healthier choice also being the easier choice for policy makers. Supportive environments have to be created because societies are complex and interrelated and the links between people and their environment constitute the basis for a socioecological approach to health. Protecting the environment and conserving natural resources is a global responsibility and must be addressed in any health promotion strategy. Strengthening community actions requires that communities are adequately empowered, so they are involved in setting health priorities, making decisions, and planning and implementing strategies to achieve better health. This requires comprehensive and continuous access to information, health promotion education, and funding support. Personal and social skills development through the provision of information, health education, and enhancing life skills increases the options to people for control over their own health. Educational, professional, commercial, voluntary bodies, and institutions all bear the responsibility for this health promotion action. Reorientation of health services is a shared responsibility with the trajectory of the health sector extending beyond clinical and curative services to an expanded mandate of health promotion that is sensitive to and respects cultural needs and pays more attention to health research, professional education, and training focusing on the total needs of the individual as a whole person.

The focus of health promotion is to achieve equity in health for all, including men and women, because people cannot achieve their maximum health potential unless they are enabled to control the determinants of health. Utilizing a multi-strategy approach, people in all sectors, including local authorities, the industry, and media, have a major responsibility to mediate between differing interests in society toward the quest for health for all. These conditions are made favorable through advocacy in health promotion actions of which health education is one of the several key components. The Ottawa Charter was remarkably signiﬁcant in guiding and inﬂuencing the development of the concept of health promotion and establishing the ﬁeld of health promotion as a key public health function.

Several International Conferences on Health Promotion followed the Ottawa Charter where the goals of health promotion were reafﬁrmed. In July 1997, at the Fourth International Conference, the Jakarta Statement on the Private Sector was adopted (WHO 1997). Private sector companies and groups were invited by the WHO to participate in the ongoing health promotion discussions with the goal of building effective partnerships with them. The private sector admitted that there was need for companies to be cautious as regards the health impact of their products and services and the manner of production, delivery, and marketing and committed to working on health promotion activities with the WHO, governments, and nongovernment organizations (NGOs).

Almost 20 years after the Ottawa Charter was adopted, The Bangkok Charter for Health Promotion in a Globalised World was approved in 2005 at the sixth international conference (WHO 2005). This Charter complemented and built on the Ottawa Charter. It also took into consideration the challenges that had started emerging as a result of globalization. Attendance at the Ottawa and Bangkok Conferences were by invitation of the WHO only. Ottawa had 38 representatives, almost exclusively from developed countries. In contrast, there were over 100 countries represented at Bangkok, thereby allowing for more global input into the document (Porter 2006). The scope of the Bangkok document positioned health promotion as the tool to address determinants of health in the globalized world. It afﬁrmed that health promotion was based on the fundamental human right to the highest attainable standard of health and was a core function of public health. It cited some of the critical factors that had impacted health since the Ottawa Charter as increasing inequalities within and between countries, new patterns of communication and consumption, commercialization, global environmental change, and urbanization. In addition, it highlighted the fact that rapid and often adverse social, economic, and demographic changes, vulnerability of women and children, and exclusion of marginalized, disabled, and indigenous people from attaining health had increased. On the positive side, it recognized that globalization had opened up new opportunities for cooperation to improve health through increased and improved information and communication technology and expanded mechanisms for global governance and sharing of experiences. It committed to make the promotion of health central to the global development agenda, a core responsibility for all governments, a key focus of communities and civil society, and a requirement for good corporate practice.

In 2013, at the 8th Global Conference on Health Promotion, the Helsinki Statement on Health in All Policies was adopted (WHO 2014). Health for all was seen as a major societal goal of governments and the cornerstone of sustainable development. Responsibility for people’s health required political will to engage all aspects of government in health. Conference participants prioritized health and equity as a core responsibility of governments to its peoples and afﬁrmed the undeniable and urgent need for effective policy coherence for health and well-being. They called on governments to commit to health and health equity as a political priority; ensure that implementation of policies were enabled by effective structures, processes, and resources being set up; strengthen the capacities of ministries of health and other sectors of governments; build institutional capacities and skills; adopt transparent audit and accountability mechanisms; establish conﬂict of interests measures; and include communities, social movements, and civil society in the development, implementation, and monitoring of Health in All policies.

Over the past 3.5 decades several documents have been adopted at the WHO International Conferences on Health Promotion and all reiterate similar principles. It is clear that the pledges in these documents are not honored by governments and the international communities alike as health disparities and inequities continue to widen. This could be because of their lack of meaningful commitment to true health promotion.

Health Education And Promotion: Definition

The WHO deﬁnes health promotion as the process whereby people are enabled to increase control over and improve their health (WHO 1986). Pivotal to public health is the promotion of population health by identifying risk factors for disease, disability, injury, and death and by implementing measures to avoid these risk factors. While it is well recognized by public health professionals that behavior is an important determinant of health, health promotion activities go beyond a focus on individual behavior toward a wide range of social and environmental interventions. Health promotion aims at empowering people by strengthening individual and group skills and capabilities to change in particular the social and economic causes that impact health. Hence, health promotion is a complex ﬁeld with the boundaries not being well deﬁned. Because a variety of activities, contexts, and individuals are involved in health promotion, the profession is ill deﬁned and perceived as a community of diverse professions involved in ethically challenging activities. This is due to the nature of health promotion activities requiring frequent reﬂection of values across several cultures on what is good or bad health promotion practice. It is therefore not surprising that the deﬁnition of health promotion is at times contested as the understanding of what constitutes health and well-being as good, bad, fair, and acceptable can be highly variable. Challenges in health promotion usually do not present as choices between obvious good or bad but choices between degrees of good and degrees of bad from the perspective of various interests. While the deﬁnition is values driven, it is widely acknowledged that health promotion occurs at different levels, from standardized top-down national programs to bottom-up grassroots initiatives (Carter et al. 2011). In public health, there is a standard distinction between primary prevention which aims to prevent disease from setting in and secondary prevention which ensues after disease has set in. The goal of secondary prevention is to minimize resulting morbidity through early detection and management. A commitment to primary prevention is perceived as goods in health promotion (Carter et al. 2012).

Behavior is recognized by health promotion authorities as an important determinant of health in communities. The inﬂuence of behavior in transmitting infection and causing injuries and development of chronic disease by smoking, diet, and sedentary lifestyle is well recognized and health promotion research and interventions are carried out at the point of human conduct at individual, group, and organizational levels. Human behavior is exceedingly complicated and is inﬂuenced by social and environmental factors. As information is necessary for change, messages must be presented objectively and truthfully. However, several challenging approaches are used in health promotion to inﬂuence behavioral change and these include conditioning of behavior through rewards and punishments; persuasive communication, e.g., through manipulative information and scare campaigns; group pressure; and direct instrumental power where authority implements prohibitions. Social psychological theory (the health belief model, the theory of reasoned action, and social cognitive theory), trans theoretical models (stages of change), diffusion of innovation theory, and the communication behavior change model are some of the means used by health promotion to achieve its ends. Typically, psychological or cognitive factors like beliefs, attitudes, self-efﬁcacy, and the social environment are the immediate targets toward satisfying the aims of health-related behavioral change.

Health Education And Promotion: Ethical Dimension

Ethics in health promotion should be about doing the right thing in this context and providing moral justiﬁcation for its activities, thereby designating values to this practice. The values in health promotion are health and well-being, justice, environmental sustainability, empowerment, respect for culture, and truth telling. Therefore, health promotion can be perceived as having worth and hence equated to a moral project (Carter et al. 2012). However, health promotion activities in the form of health campaigns have been heavily criticized as being ineffective or not cost-effective. Concerns have also arisen about the overall appropriateness of these campaigns to direct social values and lifestyles (Faden 2002). Problems arise because the manner in which health promotion is implemented and evaluated does not always take values into consideration. This is possibly because of the conceptual vagueness of health promotion ethics. The several declarations, charters, and statements mentioned above are abstract and do not deﬁne concepts like justice in any detail (Carter et al. 2011). Autonomy-based considerations and the extent to which health education messages and campaigns interfere with free choice are also given little consideration in the documents. In all health promotion strategies, efﬁcacy, justice, and autonomy need to relate to each other intimately (Faden 2002). In addition, evidence should play an important role in informing and evaluating health promotion activities. However, dilemmas arise as to what counts as evidence and how the concept of evidence is speciﬁed as it is values that will determine the use of data as evidence. Identiﬁcation and analysis of ethical dilemmas in health promotion communication interventions should be at the forefront of and an integral part of program development and implementation. The process should be informed by principles in bioethics, the moral basis of public health and teachings from communication ethics, so attention is also given to ethical issues regarding message design and dissemination. Issues of diversity and pluralism in the context of increasing economic and social disparities within and across nations will also require consideration (Guttman and Salmon 2004). This section discusses the connected notions of evidence, efﬁcacy, and values in health promotion activities. Autonomy-based considerations are then highlighted. This is followed by a brief description of its unintended adverse consequences and ethical principles speciﬁc to health promotion research.

Evidence, Efficacy, And Values

Buchanan (2002) states that modern health promotion activities have a common theme, i.e., science and technology provide the tools to address health problems and that politics and morality impede this progress. He goes on to state that “Thinking in the ﬁeld of health promotion is currently framed by scientiﬁc terminology of morbidity and mortality rates, risk factors, randomised controlled trials, independent and dependent variables, null hypotheses, cost-beneﬁt analysis, and effective behaviour change techniques.” (Buchanan 2002, p. 339) He offers the concepts of well-being, integrity, virtues, autonomy, responsibility, civility, caring, and solidarity as being reﬂective of the larger aims of the practice. However, scientiﬁc work is inﬂuenced by both scientiﬁc and extrascientiﬁc values. The latter are those things valued by individual scientists like values arising from political, religious, social, and cultural commitments. Both types of values are involved in the production of evidence with scientiﬁc values creating norms for research practice and extrascientiﬁc values contributing to the choice of hypothesis, variables, and interpretation of results. Judgments of causal inference at the completion of the study, notwithstanding explicit criteria may also be based on values. Because developing rules of evidence for health promotion involves values and because these values can shape health promotion, Carter et al. (2011) proposed ﬁve principles for planning and evaluating health promotion. The principles highlight the good practices already underway together with what is being overlooked. Their principles are:

It must be recognized that health promotion thinking must be responsive to particular situations and cannot be universal.
Two iterative systems of reasoning, an evidence based and an ethical one with each containing explicit values, should be recognized and implemented.
Evidential and ethical concepts that are valued or devalued and the dimensions along which these vary should be clearly speciﬁed in each situation with the use of existing theory and detailed empirical study of the practice of health promotion in the situation.
Consideration is to be given to how valued or devalued concepts interact in particular with regard to how trade-offs occur along the identiﬁed dimensions.
Procedural transparency must be prioritized with the processes that are used for reasoning, deﬁning, and trading off being clear.

Use of the principles would allow for the recognition of ethics and evidence being equally

important and for the use of these two concepts iteratively. As it is not easy to evaluate cost and effectiveness of most public health strategies, the principles would assist in identifying what data would constitute evidence of effectiveness, what communities value that may not be reﬂected in the evidence, what harms and beneﬁts would be relevant in a particular situation, and whether the beneﬁts outweigh the harms. Hence, a close relationship between ethical and evidential considerations is encouraged and the monitoring and measurement of ethically problematic outcomes is now included in the processes in order to amend or terminate activities should the evaluation be shown to have ethically compromised outcomes. In addition, procedural transparency is prioritized allowing for informed judgments by people, so described values can be compared with their own values and the steps undertaken can be compared with their own procedural standards. Moreover, transparency could foster greater accountability and increase the effectiveness of risk communication (Carter et al. 2011).

Autonomy-Based Considerations

While health education and information sharing are usually regarded as benign and not intrusive, health promotion strategies may transgress ethical boundaries and become problematic when messages associate behaviors with distasteful characteristics resulting in unintended consequences like stigma, embarrassment, blame for illness, risks of losing social sympathy and support, lower self-image, and psychological harm. Dawson and Grill (2012, p. 102) state that health promotion includes “… a range of interventions, ranging from providing information through education, persuasion, the construction of new norms, the shaping of existing norms, the manipulation of preferences , or even coercion.” The goals of reducing morbidity, mortality, and ﬁnding more effective ways to change people’s behavior are laudable, but at what cost? Behavior change approaches may often have narrow lifestyle goals like cessation of smoking or increasing physical activity and the framing of information such that individuals’ rights to self-determination and liberty are not respected and is used as a means to achieve the change. Further complicating the issue is that in health promotion, consent is not easy to rely on with the challenges being how to determine what should be consented to, who should consent, and how to act when there is no community consensus (Carter et al. 2012). Some autonomy-based concerns are discussed below.

Persuasion

Faden (2002, p. 348) deﬁnes persuasion as “… the intentional and successful attempt to induce a person(s), through appeals to reason, to freely accept – as his or her own – the beliefs, attitudes, values, intentions, or actions advocated by the inﬂuence agent.” The reasons for the persuasive appeal exist independent of the persuader. The persuasive messages are communicated through structured argument or reasoning such that they appeal to the rational capacities of the listener. Reasons are communicated through written or spoken language or nonverbal communication, for example, through visual evidence or artful questioning and structured listening. Using these means, the persuader brings to the persuader’s attention reasons for the acceptance of the desired perspective (Faden 2002). The use of authority in persuasion is challenging especially in face-to-face encounters and when the agenda is set by a professional with authority. Authoritative persuasion arises when a person with real or perceived high status attempts to persuade behavior change. Ethical challenges arise when the persuader determines what the problem is and how to deal with it without taking into consideration the wants and desires of the individual or group and persuades them to comply with the advice given. Persuasion here includes elements of paternalism, where limitations are imposed on an individual for that person’s good by someone else. The person’s position is in this way weakened by the authority who does not respect the individual’s right to autonomy, integrity, and ability of being responsible thereby making the person feel offended, vulnerable, and powerless. Where the inﬂuence agent creates reasons or controls the messages, the risks of manipulation and coercion set in.

Manipulation

Manipulation results when a person’s understanding of a situation is altered without the use of persuasion but by a deliberate act that successfully modiﬁes his/her perceptions of available options. In this situation, perceptions and not actual options are changed and what the person believes is affected. Autonomy may be compromised to the point where people become ignorant and deception by manipulation results. Deception is the commonest form of manipulation of information and includes strategies like lying, withholding of information, and misleading exaggeration where people are led to believe what is false. Nonverbal communications where certain ordinary expectations are used to infer speciﬁc informational relationships or beliefs may also be used to deceive people (Faden 2002). Other forms of informational manipulation include (Faden 2002, p. 349):

Intentionally overwhelming a person with excessive information so as to induce confusion and a reduction of understanding
Intentionally provoking or taking advantage of fear, anxiety, pain, or other negative affective or cognitive states known to compromise a person’s ability to process information effectively
Intentionally presenting information in a way that leads the manipulatee to draw certain predictable and misleading inﬂuences

Psychological and informational manipulation is seen much more frequently in commercial advertising than public service campaigns. It is not that easy in practice to differentiate between persuasion and certain forms of psychological and informational manipulation, but where health campaigns involve manipulation, they violate the principle of autonomy.

Coercion

Coercion results when power is used to gain advantage over others, punishing noncompliance with demands and imposing one’s will on the will of others. It is generally accepted that health promotion strategies should use the least coercive means available in order to avoid undermining trust in public health as an institution, a problem that arose when people were forced in some parts of the world to have HIV tests early in the epidemic (Carter et al. 2012). However, some types of coercion and paternalism are justiﬁed in public health practice. This is commonly seen when interventions are instituted to prevent people from harming one another. This is mostly achieved through legislation, e.g., banning smoking in public places. Legislation is also enacted to prevent people from harming themselves, e.g., the mandatory use of seatbelts or crash helmets. Hence using coercive means to change health-related behavior, while criticized by liberal societies, is not always problematic so long as there is health gain and other important ethical principles like reciprocity, equality, and social justice are respected. Where there are minor rights infringements and the harms avoided are substantial, coercion can be defended.

Using the capability approach as espoused by Nussbaum (1999) could be the alternative that is more compatible with health promotion. In this approach, people should be free to achieve wellbeing. This will depend on them having real opportunities to live and to act in accordance with their values. Opportunities available to individuals, communities, and nations will require to be assessed. Freedom is approached differently from libertarians who hold negative freedom, the freedom to be left alone to be the most important moral imperative. The capability approach does not assume that individuals should be completely independent. It underscores that people’s autonomy depends on their social, relational, and political environment and that they have a moral stake in that environment which provides them with real opportunities, including the opportunity to be healthy. Therefore, legislative health promotion changes are not viewed as reducing freedom but as providing real opportunities to be healthy – a value dear to most people. While autonomy is important, the discussion on freedom is revised using a more sophisticated conceptualization of the subject and the notion that health promotion strategies result in paternalistic “nanny” states is replaced by the notion that health promotion strategies provide individuals and communities with real opportunities that they are likely to value (Carter et al. 2012).

The stewardship model proposed by the Nufﬁeld Council is worth considering (Nufﬁeld Council 2007, p. 26) and can be used to complement the principles outlined by Carter et al. above. It is sensitive to the respect for individuality and tries to ﬁnd the least intrusive way of achieving policy goals that are effective. It consists of a set of seven positive goals and three negative constraints which are not listed in any hierarchical order and are detailed below:

“Concerning goals, public health programs should:

Aim to reduce the risks of ill health that people might impose on each other;
Aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health, such as the provision of clean air and water, safe food and decent housing;
Pay special attention to the health of children and other vulnerable people;
Promote health not only by providing information and advice, but also with programs to help people to overcome addictions and other unhealthy behaviors:
Aim to ensure that it is easy for people to lead a healthy life, for example, by providing convenient and safe opportunities for exercise;
Ensure that people have appropriate access to medical services; and
Aim to reduce unfair health inequalities

In terms of constraints, such programs should:

Not attempt to coerce adults to lead healthy lives;
Minimize interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate; and
Seek to minimize interventions that are perceived as unduly intrusive and in conﬂict with important personal values.” (Nufﬁeld Council for Bioethics 2007, p. 26)

Universal Versus Targeted Strategies And Justice Considerations

The objective of good health has two dimensions. These are goodness as in the best attainable average level of health and fairness as in the smallest feasible difference in health among individuals and groups. This means that universal strategies may not be sufﬁcient to protect or improve the average health of the population as inequality may worsen or remain high with the gains accruing disproportionately to those that are better off and are already enjoying better health (Nufﬁeld Council 2007, p. xix). Health promotion interventions may reinforce rather than reduce existing social disparities. Populations from higher socioeconomic groups are more likely to have increased health-related knowledge and more likely to adopt the practices recommended in the messages. The alternative is to “target” speciﬁc population groups according to certain parameters. This will involve moral judgments associated with considerations of equity and utility. Tensions between efﬁciency and considerations of equity, fair opportunity, and just distribution of public goods are recurring considerations in public health. Some groups may be excluded because of difﬁculties in reaching them and some may be given priority because they have special needs (Guttman and Salmon 2004). Where some populations are not predisposed toward adopting particular health-promoting practices, it may be seen as inefﬁcient to target them. However, if the mandate of public health is to promote social equity, targeting such populations would be ethically required. In addition, where relatively large segments of the population are targeted, values of solidarity could be promoted and the likelihood of stigmatization and labeling of those considered high risk reduced. Where it is decided to target speciﬁc risk groups or those with particular beliefs, values, needs, or communication channels, communication will need to be customized to ﬁt the context. This corresponds to the communication ethical stipulation of comprehensibility where complete and culturally appropriate messages to diverse populations are requisite. These messages, while providing for people with low levels of literacy must be respectful, effective, and not condescending. Health promotion professionals need to be aware that some in the group may see this as a source of embarrassment and distance themselves from the interventions (Guttman and Salmon 2004).

Responsibility And Culpability

The notion of responsibility of the individual to adopt a lifestyle that is considered healthy, sensible, and responsible by society is one of the most taken for granted and at the same time contested messages in public health. Appeals to personal responsibility are pervasive in public health messages. Ethical issues are raised when responsibility messages are linked to health outcomes and concerns of culpability emerge, with the causal link between the person’s behavior and health holding them responsible for detrimental health outcomes. Such conceptions of culpability do not take into consideration that individuals may not be in a position to control the social factors that affect their behavior (Guttman and Salmon 2004). Moreover, their health outcomes may not be as a result of their behavior, but of biological or genetic factors. Emphasizing culpability may lead to blame with the causes of social problems being located within the individual rather than social and environmental forces and structural factors like limited resources. Feelings of guilt, shame, and frustration may also develop (Guttman and Salmon 2004).

Iatrogenesis

Messages may have unintended subtle but potentially harmful effects on individuals and society as a whole. Messages actually eliciting the opposite behavior from that it was trying to instill are not uncommon. Examples include antidrug messages which may increase interest in illegal drugs and encourage experimentation among adolescents and messages on weight control that act as a stimulus for women with eating disorders to eat even less. Messages may also result in stigma and stereotyping (Guttman and Salmon 2004). Messages could result in a negative image of the individual who already has the disease that behavioral interventions could avoid. Once stereotypes and stigma are established, individuals may be feared, avoided, regarded as deviant, and blamed for engaging in immoral behavior. This can result in the internalization of self-blame and destruction of self-esteem. School-based weight loss programs may result in stigmatizing overweight children (Guttman and Salmon 2004).

Health Promotion Research And Ethics

General ethical considerations that apply to health research apply equally to health promotion research. Additional criteria have been proposed by Mittelmark (2007):

Health promotion relevance: the research should address explicitly individual-, social-, or societal-level priorities for health promotion research.
Health promotion values: the research methodology should address explicitly how health promotion values are incorporated in the research. These values include citizen participation, partnership, fully authorized participation, open communication, sustainability, and empowerment.
Health promotion innovation: the research should be innovative and distinctive and address explicitly its intentions to clarify and/or strengthen an important aspect of health promotion practice.
Health promotion discourse: the framing of the study questions should be consistent with, and ﬂowing from, clearly stated theory/model/ rationale. There should be a high degree of relevance to health promotion discourse.
Health promotion practice: the research should have practical relevance for health promotion activities. Explicit reference must be made to the arena of practice to which it applies.
Health promotion action: the research should address explicitly action for health promotion, including action for change, and/or action to create opportunities for choice, and/or action for maintenance of change/choice already achieved. This should be at any level or combination of levels from the individual to the societal.
Health promotion context: the research should demonstrate appreciation for the manner and degree to which it is embedded in a larger health promotion context. This should be done by referring to critical aspects of the problem that are not objects of the study, e.g., systems, ecologies, and/or processes of which the object of study is a part.

The above seven criteria are speciﬁc to ethical health promotion research. Mittelmark also proposes seven general quality criteria: scientiﬁc quality, deﬁned scope, anticipated outcomes, operationalization, feasibility, process evaluation, and documentation and dissemination.

Conclusion

The focus of health promotion is to achieve equity in health for all because people cannot achieve their maximum health potential unless they are enabled to control the determinants of health. Utilizing a multi-strategy approach, people in all sectors, including local authorities, the industry, and media have a major responsibility to mediate between differing interests in society toward this pursuit. Evidence, effectiveness, and values are interrelated concepts in this context and health promotion efforts and practice must be evaluated using strict ethical research criteria. While several complex ethical issues arise in the practice of health promotion, these are not insurmountable if the informational environment is altered so that the public will hear messages conducive to their health and will avoid messages that encourage risk behavior.

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