Equity and Knowledge Gaps

A recurring concern in the past two decades that concerns equity is that health promotion interventions may inadvertently widen health and social gaps by benefiting mainly those who are better off socially and economically. Communication scholars point to research findings that indicate that despite the promise that mass media campaigns could disseminate health promotion materials more equitably, such campaigns in fact were found to increase social gaps. A considerable social gap was found in the acquisition of, and the capacity of people to act upon, pertinent health information according to their socioeconomic backgrounds. This gap has been referred to as “the knowledge gap,” and its occurrence has been found regarding various health issues, including cancer, heart disease, and breastfeeding (Kulkla, 2006; Viswanath et al., 2006). Consequently, health promotion interventions may inadvertently serve to reinforce existing social disparities.

The emphasis on justice is particularly relevant because less economically well-off groups are typically more severely affected by chronic and infectious diseases than the well off because they are less economically equipped to prevent or control them. Thus, social inequalities in people’s health and welfare can be exacerbated (Lee et al., 2008). To address such knowledge gaps, the assumption is that what is needed is to ensure that all people should have ready access to accurate, up-to-date, and easily understood and relevant information about how to prevent or reduce risk and promote their health. Further, the communication should be tailored to overcome obstacles faced by members of disadvantaged groups in accessing such information.

Equity and Addressing Barriers

In the discussion of autonomy earlier in this article, it was noted that critics maintain that in order for people to make autonomous decisions regarding health practices, they must also have the capacity to recognize these choices. A similar stipulation could be made regarding equity is ensuring that there are equitable solutions to barriers that people may face when they want to adopt health promoting practices. Providing solutions to barriers is a central guiding principle in social marketing and highly relevant to considerations of equity (Lefebvre, 2013).

Communication interventions that do not provide relevant solutions for the specific problems or barriers that prevent people from adopting the recommended health practices raise a central ethical concern regarding the communication intervention as a whole (Brenkert, 2002). If people at whom the communication is aimed to promote their health are not provided with solutions to barriers that they must overcome to adopt the recommended action, they will be reluctant to adopt it and benefit from it or protect themselves. For example, people who work long hours and do not have affordable fresh fruit and vegetables in the vicinity or time to prepare meals need solutions for these problems. Another example comes in the context of public health emergencies, in which people are asked to evacuate their home or business immediately. People might ignore directives to evacuate their property if no assurances are given that their property will be protected (Lee et al., 2008). Another example concerns the promotion of smoking cessation treatments. Critics maintain that clinical smoking cessation programs have been presented by healthcare professionals as the most effective means for smoking cessation compared to unassisted smoking cessation. They argue, however, that this communication could be both ineffective and harmful when promoted in nations with mainly economically disadvantaged populations because the medical products are inaccessible to them and it could discourage personal efforts (Chapman & Mackenzie, 2012).

Another example that demonstrates issues of equity as they relate to the ability to realize health information concerns menu labeling. Researchers argue that menu labeling may preferentially influence the welfare of those who are healthier and wealthier and have the opportunity to make choices. An additional ethical concern is that focusing the responsibility on people to make choices might shift the focus away from the institutional changes needed for people to be able to make the healthier choices, such as ensuring that healthier foods are available to the public at a reasonable cost (Carter, 2015).

Digital Gaps

Digital media offer opportunities to widely disseminate health promotion information in various formats and have become the main source of health information for many people. However, their use also raises ethical concerns regarding equity and the so-called digital divide (Hargittai, 2002). People with limited digital literacy or who lack physical access to computing facilities, as well as relevant skills and competencies, are less able to access or use health information distributed online (Viswanath & Kreuter, 2007). One example is the information gap that occurs in public health emergencies that use digital media channels to reach the public. In such situations, some of the most vulnerable groups in society, including the aged, the homeless, recent immigrants, rural residents, and the poor, are more likely to be at risk if digital media serve as the main route for information provision (Lee et al., 2008). To meet the obligation of equity, various health promotion programs seek to develop ways to increase access and enhance digital literacy among populations for whom the use of digital media for the purpose of health promotion is less accessible (Ginossar & Nelson, 2010; Kreps, 2005).

Equity and Strategic Segmentation and “Targeting”

Designing health promotion programs to focus on particular segments of the population is accepted as both a practical and ethical strategic approach in health promotion. It is considered a more ethical and effective approach because it requires the provision of equivalent but culturally appropriate messages to populations with different sociocultural backgrounds and levels of literacy (Hornik & Ramirez, 2006). It is also considered efficient because interventions that are developed according to the social norms and values of the particular population, and which draw on metaphors and symbols that they are familiar with or prefer, will likely be more effective in reaching its health promotion goals.

Ethical issues that concern justice and equity are also related to these strategic decisions regarding which populations should be the “target” of the intervention and which will not. However, the mere decision to “segment” a population according to certain parameters and to allocate limited resources to adapt particular health promotion activities to certain populations raises ethical issues regarding equity as well as utility. Decisions regarding “targeting” are often made on the basis of utilitarian or efficiency considerations. For example, it might be recommended by social marketing professionals to “target” those who are already in a state of readiness to adopt the recommended health practice by contemplating or engaging in it (Lee & Kotler, 2015). Alternatively, it may be decided to focus the efforts on those with the greatest need, who are considered “hard to reach” and less likely to adopt the recommendations, thus raising concerns associated with utility and the inefficient use of limited resources that are available to health promotion, as well as not addressing the needs of other groups (Newton, Newton, Turk, & Ewing, 2013).

Equity and Trust

Health promotion scholars concerned with ethics raise an interesting point regarding equity and the issues of trust, particularly in public health emergencies. Some populations do not obtain health information that could be beneficial to them because they do not trust the sources. Thus, there is an ethical obligation regarding earning legitimacy and trust from populations believing they have been discriminated against, stigmatized, or marginalized in the past. Otherwise, their lack of trust in the authorities will serve as an unfair barrier, and thus, they will not benefit from the health promotion initiative (Lee et al., 2008).

Stipulations as to the Truth of Health Information

Being truthful is one of the tenets of Western morality that is assumed to be shared universally. Concealment or misrepresentation of what is believed to be true, even for what is considered a good cause, is considered an infringement on the ethical principle of respect for autonomy (Beauchamp, 1996). However, in different cultures, the notion of autonomy differs as it relates to telling the truth or conveying all the information about a health issue when certain people do not choose to hear it. Thus, considerations of culture might be relevant in certain situations or among people of various cultures (Cortese, 1990).

In health promotion interventions, inaccuracies or exaggerations are often represented in slogans or visual images. It is also argued, particularly by practitioners, that it is more effective to disseminate simple and clear messages, and that for the purpose of effectiveness in message design, giving more detailed information should be avoided. However, these assertions could be contested on both ethical and practical grounds.

The following guidelines can serve to develop more ethical health promotion communication interventions:

Stipulations as to Correctness and Reliability of Health Information

Health promotion often involves providing information that is intended to convince people that they should adopt particular health promoting practices. For example, having certain diagnostic procedures for early detection of diseases or changing their diet. However, the correctness or reliability of this type of information could be contested: It might not always be up to date, might be tentative or incomplete, or might be subject to different scientific and cultural interpretations. Over time, new studies and new modeling technique recommendations related to the benefits and risks of particular foods or medical treatments have changed as new research findings emerge. For instance, recommendations have changed on the use of female replacement hormones, how to reduce the risk of infant crib death, and the consumption of cholesterol in food, among other topics. Scientific backing for health recommendations thus, may be tentative, and the benefits and risks of adopting certain recommended practices may have a degree of uncertainty.

According to the stipulation of correctness, health promoters should avoid asserting certainty in their health claims when tentativeness or degrees of probability would be more accurate. However, this requirement raises concerns regarding efficiency and effectiveness because information that is presented in a tentative way or in probabilities might deter people from adopting the health recommendation, which could be beneficial to them. The stipulation of correctness also implies that health promotors should refrain from exaggerating negative or positive consequences, the magnitude of the problem, or the degree of the expertise of the authorities upon which it relies, even when such a presentation is believed to be more persuasive and serve the purpose of the intervention (Johannesen, 1996).

Stipulations as to Comprehensibility, Clarity, and Completeness

Information that is meant to promote people’s health clearly needs to meet the stipulation that it will be understood by those who are meant to use it in order for it to be beneficial. Drawing on ethical obligations associated with equity, this stipulation points to the importance of presenting the information in a way that people with limited competencies in literacy and numeracy can understand. Further, based on the findings of studies on risk perception, it is important to present risks to people in ways that are relevant to them, or they will not relate to the information (Rossi & Yuell, 2012).

These stipulations point to an additional challenge: Trying to present health promotion information that is both easy to understand and complete and serve to encourage people to adopt the recommended health practice might be difficult. As noted in the section “Stipulations as to the Truth of Health Information”, it is a common assumption among practitioners that it is more effective to disseminate short, simple, and clear messages and to refrain from giving more detailed information for the purpose of effectiveness in message design,. However, this approach does not enable conveying unbiased information to the public (McCartney, 2010). Further, in matters of health, oversimplification of health information infringes on the obligation of respecting people’s autonomy and their right to make informed decision based on complete information. It might also not be efficient because people might want to understand the rationale for the health recommendation and consider its pros and cons.

Further, if the decision is based on comprehension, they might be more committed to following through on it (e.g., according to the theoretical conceptions of the Elaboration Likelihood Model and the empirical evidence of studies that use it) (Petty & Cacioppo, 1984). The ethical standard of completeness also suggests that it would be unethical to present a one-sided argument, selecting only favorable supporting evidence. In addition, these stipulations imply that potentially undesirable consequences of the recommended practice should not be hidden or misrepresented. However, providing complex information, including information on the tentativeness or limitations of the scientific evidence, which is the basis for the health recommendation might deter people from adopting it, although it could be beneficial to them.

Stipulations as to Sincerity: What Are the Actual Goals?

The reasons for the communicative initiative for changing health need to be made clear, including the goals and implicit agenda of sponsors and the identity and motives of stakeholders who are likely to benefit from the outcomes of the intervention. This type of obligation is particularly important when the health promotion intervention concerns members of diverse groups who may feel that they have been exploited in the past or that there are hidden agendas in the intervention that are meant to serve the purpose of others rather than themselves.

Stipulations as to Inclusion: Participation and Deliberation

Health communication activities are often initiated by agencies or organizations that come from outside the intervention community or represent only particular sectors. According to the inclusion stipulation, the communication process should include respect for others’ point of view, beliefs, and suggestions. This is particularly important for members of diverse groups who, by definition, may hold diverse views of the issues and have different capacities to address it. This stipulation is also associated with the moral obligation to respect people’s autonomy and self-determination, as well as with democratic values such that people should be given the opportunity to participate in decisions that affect their lives (Brenkert, 2002). Involving people in the design and implementation of health promotion interventions could be important for utilitarian reasons as well because it can help create a sense of ownership and is more likely to meet the needs of the people for whom the intervention is intended (Castleden, Garvin, & Huu-ay-aht First Nation, 2008).

The stipulation for inclusion could be expanded to participative and deliberative communication, which can enable individuals and groups to articulate their values and to consider choices between competing obligations rather than to approach them with predetermined prescriptions (Dutta, 2011). Participative and deliberative strategies for message production are increasingly adopted in health communication interventions, particularly in the context of community programs (Papa & Singhal, 2006) and more recently in the use of digital media (Korda & Zena, 2013; Neiger et al., 2012). Health promotion interventions that employ an entertainment-education format have also been using dialogue, narrative, and plot as means to elicit critical reflection and different perspectives or value orientations (Slater and Rouner, 2002; Sood, Menard, and Witte, 2004). Further, they can involve population representatives in the articulation of ethical issues. Yet the use of entertainment education raises its own slew of ethical concerns as well (Bouman & Brown, 2010).

Personal Responsibility, Accountability, and Blame

One important concern in the use of personal responsibility in health promotion interventions is that focusing on it might carry negative connotations reminiscent of ancient exhortations to overcome vices such as gluttony, sloth, and lust (Berkman & Breslow, 1983). A related concern is that it could serve to blame individuals and populations for the emergence and spread of infectious diseases and pandemics (Nelkin & Gilman, 1991).

Similarly, some health promotion interventions imply that illness or disability results from the failure to adopt a so-called responsible lifestyle and that irresponsible individuals are responsible for the adverse outcome. However, ethicists maintain that in the health context, people can be held accountable only when their actions are completely under their volition or control. Attributing blame to those who do not adopt the promoted health practices could inadvertently become “victim blaming,” or holding them accountable for the consequences of behaviors and circumstances that led to these behaviors over which they have had only limited control (Wikler, 1987). This corresponds to the previous discussion on autonomy that pointed to the limitations of autonomy when people cannot overcome barriers and obstacles, as well as to the discussion on justice and equity and the existence of social gaps where those who are better off can more easily adopt health practices than those who are less economically and socially well off. It is important, therefore, to make a distinction between blaming people for their medical/health problems and encouraging them to have a sense of agency to try to change circumstances and practices in a way that can promote their health.

According to ethicists, for people to be held responsible, they need to have the ability to exercise their own will, they need to have the capacities to make moral choices, they should be able to actively interpret what is happening, and they must be knowledgeable about the potential consequences of action or nonaction. Thus, for individuals to be truly responsible, they would need to have “response-ability.” This has practical implications as well. The stipulation of having the capacity to make choices corresponds to the previous discussion on stipulations of capacities to exercise one’s autonomy. By implication, people should not be blamed for not being responsible if they do not have the capacity to make what health promoters or society consider responsible choices.

Beyond Personal Responsibility

Even when health promotion messages do not explicitly blame people for taking full responsibility for their health, they might frame the notion of responsibility for disease or injury prevention as if it were primarily under individuals’ control. This can deemphasize the role of structural and institutional factors such as the work environment, housing conditions, or pollution in the etiology of many health-related problems. Historically, personal responsibility is a central notion in discussions of justice, ethics, and social regulation of behavior. From a political, cultural, and social perspective, scholars note that responsibility is a core concept for understanding how people and governments can sanction and try to control people’s conduct (Crawshaw, 2012).

Responsibility for Others

Many health promotion interventions refer to responsibility for others. For example, people may be called upon to promote or protect the health of significant others (e.g., children, spouses). Thus, on the one hand, appealing to people’s sense of obligation can help reinforce moral commitments such as caring, solidarity, and compassion. On the other hand, it might serve to reinforce particular gender roles or cultural stereotypes and also place a burden on people who have limited control over others’ behavior (Guttman & Ressler, 2001).

Harm Reduction and Corporate Interests

The use of this approach in programs in the road safety context raises additional ethical concerns. For example, programs that promote the use of a designated driver mainly focus on encouraging people to rely on a driver that does not consume alcoholic beverages, and do not refer at all to the harm of consuming a large amount of alcohol. In fact, many of these initiatives are sponsored by alcohol companies (Dejong, Atkin, & Wallack, 1992; Ditter et al., 2005). Further, health promotion in workplaces might also be seen as adopting a harm reduction approach when they basically promote practices that fit into the corporate work schedule. The lifestyle associated with long workdays are not beneficial to most people’s health and well-being. For example, it does not enable many people to spend much time with their families or to develop a healthy and self-actualizing and meaningful life. Health promotion interventions mainly focus on particular aspects that can be changed, but not the overall institutional context that affects people’s well-being. In fact, these programs might simply help people to adapt better to current constraints of work schedules rather than reduce work hours.

Using Provocative Appeals and Strong Negative Emotional Appeals

One of the communication tactics to gain audience attention and to raise issues to the media and public agenda is to use provocative and shock tactics (Vezina & Paul, 1997), which might include graphic, violent images of acts such as self-mutilation (Donovan, Jalleh, Fielder, & Ouschan, 2009), or images considered disgusting (Lupton, 2015b). Clearly, provocative ads can elicit discussion, put an issue on the public agenda, and enhance people’s memories regarding the ad or the brand (Wu & Morales, 2012). However, researchers note that provocative ads might not achieve the intended effects, and often their effects are limited to gaining attention rather than achieving long-term goals (Brown, Bhadury, & Pope, 2010; Dahl, Frankenberger, & Manchanda, 2003).

These types of communication tactics tend to raise objections, as in the example of complaints registered to the British Advertising Standards Authority (ASA). In this case, two of the top 10 ads that received complaints concerned health promotion. One such ad was from the British Department of Health’s antismoking campaign, which showed smokers having a fish hook pulled through their cheeks, representing their craving for cigarettes (BBC, 2008). Another example is the Australian White Ribbon Day 2006 campaign on the topic of family violence, which was severely criticized by mental health professionals and those working in the family and domestic violence sector because of depictions of suicide and self-harm in the television advertising and accompanying promotional materials. However, the organization rejected the requests of concerned groups, claiming that the violent imagery used was necessary to attract men’s attention (Donovan et al., 2009).

Another critique of provocative ads is that the strong emotional impression that they create might overshadow other types of discourse and social values. Further, studies find that the response of people from vulnerable populations to public health campaigns using negative emotional appeals were anger, retreat, guilt, passive helplessness, and despondency, rather than empowered decisions to act (Lupton, 2015b).

Collaborations and Sponsorships

Health promotion interventions are often done in collaboration with organizations from the public and private sector, including work organizations, corporations, and commercial media companies. This is a growing phenomenon because of corporations aiming to be involved in activities that show their corporate social responsibility (also for economic reasons). Whereas these collaborations might be deemed beneficial and even necessary to reach various segments of the population, to obtain funds, or to make health promoting changes within these organizations, inevitably they raise ethical concerns as well. Organizations that market food products collaborate in health promotion interventions to promote healthier eating. One prominent example was the collaboration between a heart disease prevention organization and a large company that produces breakfast cereals (Glanz et al., 1995). Another prominent and contentious example is the partnerships of road safety organizations with alcohol companies in encouraging road safety. These companies support road safety initiatives such as promoting the use of designated drivers or providing rides for drivers who had consumed alcoholic beverages. These initiatives not only provide them with legitimacy, but they can also continue promoting their product and increase sales (Hastings, 2007). There are also collaborations that take place with organizations that could be considered in the “opposite camp” or the “competition”—for example, working on health promotion interventions with religious groups that oppose sex education (Truss & White, 2010). Some organizations or individuals might be against providing information and education to youth about the prevention of sexually transmitted diseases, although these youth might be at risk for these diseases. Each type of collaboration raises ethical issues that need to be identified and considered.

Another type of collaboration takes place when health promotion communication interventions are developed and implemented in collaboration with media professionals, which presents ethical challenges associated with this type of collaboration. For example, advertising media professionals might believe that it is their professional duty to be creative, which to them often means that they should develop appeals that are considered provocative. Advertising professionals might also aim to guard against using so-called preachy messages, which they believe would irritate the intended audiences, whereas health promotors might believe that it is their duty to emphasize the recommended health practices, which could come off as preaching (Bouman & Brown, 2010).