MARIE-CLAUDE TREMBLAYPHD CANDIDATE (PUBLIC HEALTH)

UNIVERSITY OF MONTRÉAL

PATTAYA, AUGUST 27, 2013

Case 3: Ethics in health promotion evaluation research

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

Health promotion

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.

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.

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?

Objectives

This presentation aims to explore two ethical issues in health promotion evaluation using

a broad perspective of ethics.

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’).

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

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…

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).

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?

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’

Ethical issue no 2

Ethical issue no 2

An example:

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.

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).

Synthesis

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?

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.

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.