Resisting Moralisation in Health Promotion

Exploring Student Perspectives of the Dietetics Profession Using a Professional Socialization Lens

Purpose: We aimed to explore student perspectives of the dietetics profession using a professional socialization lens.Methods: We conducted qualitative semi-structured interviews, virtually or by phone, with 25 dietetic undergraduate/graduate students or interns in 2020/21. Transcripts were thematically analyzed.Results: All participants identified as female, averaged 25 years old at the time of the interviews, and were in different stages of their education. Two themes captured their perspectives of the profession: dietitians have technical expertise and professional identities are evolving. Technical expertise was focused on scientific understandings of how individuals consume and utilize food, and how (mostly Western) food should be prepared for safety and maximum nutrition. Participants perceived dietetics as a white, feminized profession with dietitians' role to aid in weight loss; participants actively sought to resist these stereotypes, notably through social media.Conclusions: While holding technical expertise continues to be embedded as a key component of dietetics identity, student professional socialization is also being shaped by social media, racial justice, and body positivity movements. This socialization process is likely to influence changes to the profession as students enter practice.

"Coke's not a food": A critical discourse analysis of sugar-sweetened beverage tax acceptability by white residents from an upper-middle class neighborhood in Winnipeg Manitoba

Increasing concerns about the health impacts of sugar consumption has led to the proposition of a sugar-sweetened beverage (SSB) tax in Canada. However, competing concerns related to stigma and equity remain and have not been explored in a Canadian context. As part of a broader study examining the perspectives of various populations on SSB tax acceptability, we examined how residents of an upper-middle class neighborhood conceptualize SSB tax acceptability, and we explored the discourses that inform their discussion. We conducted and analyzed qualitative, semi-structured interviews with residents of an upper-middle class neighborhood in Winnipeg, Manitoba, Canada. Recruitment criteria were residence, adults, and English speaking. Critical discourse analysis methodology was used, and healthism (health moralism) and tax psychology informed the analysis. Eighteen participants volunteered: 15 females and 3 males; all self-identified as white, and all spoke about (grand)parenting. Healthist discourse was utilized in supportive discussion of SSB taxation. With the mobilization of healthism, ideal citizens and parents were described as "health conscious" and those who might be likely to reduce SSB intake because of taxation. Healthism also contributed to their identification of beverages targeted by a tax, versus those they deemed as having redeeming nutritional qualities. Limits to SSB tax support were expressed as fairness concerns, with a focus on the procedural justice of the tax. Participants supported SSB taxation and the discourses they employed suggested support for the tax was perceived as contributing to their construction of the kind of ideal, health-valuing citizens they hoped to embody. However, participants were also concerned about the fairness of implementation, although this did not outweigh the prioritization of good health.

The Uncontrollable Mortality Risk Hypothesis: Theoretical foundations and implications for public health

The 'Uncontrollable Mortality Risk Hypothesis' employs a behavioural ecological model of human health behaviours to explain the presence of social gradients in health. It states that those who are more likely to die due to factors beyond their control should be less motivated to invest in preventative health behaviours. We outline the theoretical assumptions of the hypothesis and stress the importance of incorporating evolutionary perspectives into public health. We explain how measuring perceived uncontrollable mortality risk can contribute towards understanding socioeconomic disparities in preventative health behaviours. We emphasize the importance of addressing structural inequalities in risk exposure, and argue that public health interventions should consider the relationship between overall levels of mortality risk and health behaviours across domains. We suggest that measuring perceptions of uncontrollable mortality risk can capture the unanticipated health benefits of structural risk interventions, as well as help to assess the appropriateness of different intervention approaches.

Public policy interventions for preventing and treating obesity: scoping review

CONTEXT

Obesity is a multicausal social problem and a pandemic, and it presents a public health challenge in many countries. Hence, public health interventions have been used in an endeavour to prevent and/or control increased obesity among populations.

OBJECTIVE

This review study aimed to provide an overview of the academic literature and to analyze the strategies involved in the main public policies focused on preventing and controlling obesity in a number of countries.

DATA SOURCES

MEDLINE/PubMed, Web of Science, and LILACS databases were searched.

DATA EXTRACTION

Original studies were included for which the core objective was related to real-life public policy interventions for obesity.

DATA ANALYSIS

The studies were organized according to their characteristics, and the qualitative analysis was based on the categorization proposed by the author Poulain. The review included 41 studies and identified 15 types of interventions focused on obesity; the largest proportion of actions were developed in school and city environments and were geared toward behavioral change, supported by direct or indirect government action. It was observed that many strategies focused on environmental line through regulatory and legislative measures, and health promotion geared toward the individual was based on the dissemination of information as a means for behavioral change. A smaller focus was given to individual care and treatment, and participative actions in the community.

CONCLUSION

The design of public health strategies applicable to obesity as proposed by Poulain provides a valid model for evaluating interventions. The behavioral approach involving guidance through health education toward a healthy lifestyle prevails in public policies, indicating a movement toward accountability of individuals. However, it is necessary to deepen the debate on the social structures that determine obesity (and which limit possibilities of choice), aligned with cultural change regarding its occurrence, and to employ care strategies based on scientific evidence and which focus on the needs of the subjects.

Healthiness as a Virtue: The Healthism of mHealth and the Challenges to Public Health

Mobile health (mHealth) technologies for self-monitoring health-relevant parameters such as heart frequency, sleeping patterns or exercise regimes aim at fostering healthy behavior change and increasing the individual users to promote and maintain their health. We argue that this aspect of mHealth supports healthism, the increasing shift from institutional responsibility for public health toward individual engagement in maintaining health as well as mitigating health risks. Moreover, this healthist paradigm leads to a shift from understanding health as the absence of illness to regarding health as the performance of certain rituals in order to project healthiness. By drawing from the analogy between healthiness and traditional virtues, we evaluate the promises made by proponents of mHealth technologies for self-monitoring. We argue that the implementation and use of mHealth risk entrenching existing inequalities and, more particularly, tend to exclude populations situated at the losing end of those inequalities from participating in the quasi-virtue of healthiness. Consequently, the implementation and use of mHealth technologies not only present challenges for social justice but also undermine their primary societal goal-to promote public health. Finally, we offer several suggestions on how to realize the potential benefit of mHealth.

The Healthy Hearts Project: Development and evaluation of a website for cardiovascular risk assessment and visualisation and self-management through healthy lifestyle goal-setting

Materially deprived communities in the UK have excess morbidity and mortality from cardiovascular disease (CVD) but are less likely to engage with formal care pathways. Community engagement and e-health may be more effective ways to promote risk-reducing lifestyle change. The "Healthy Hearts Project" website was designed for use by community health workers (CHWs) for cardiovascular risk assessment and lifestyle goal setting, or for independent use by community members. This paper describes the website's development and evaluation. The website was developed using interactive wire frame prototypes in a user-led approach. Qualitative evaluation of the completed website's usability and acceptability was conducted using the "Thinking Aloud" method in a purposive sample of 10 participants (one voluntary sector employee, three CHWs, two community members and four healthcare professionals). Thinking Aloud interview transcripts were thematically analysed using an inductive approach. A separate quantitative evaluation of usability and the effect of using the website on CVD knowledge and beliefs was conducted. A random sample of 134 participants, recruited using the online platform Prolific, completed the "Attitudes and Beliefs About Cardiovascular Disease" (ABCD) questionnaire before and after using the website, along with the System Usability Scale (SUS). Qualitative evaluation-Four key themes were identified: 1) Website functionality and design-participants generally found the website easy to use and understood the risk communication graphics and the feedback and goal-setting features,; 2) Inclusivity and representation-most participants considered the website inclusive of a range of users/cultures; 3) Language and comprehension-participants found the language used easy to understand but suggested reducing the amount of text; 4) Motivation and barriers to change-participants liked the personalized feedback and empowerment offered by goal-setting but commented on the need for self-motivation. Quantitative evaluation-The mean score across all domains of the ABCD questionnaire (from 2.99 to 3.11, p<0.001) and in the sub-domains relating to attitudes and beliefs around healthy eating and exercise increased after using the website. The mean(sd) score on the SUS was 77.5 (13.5). The website's usability was generally rated well by both quantitative and qualitative measures, and measures of CVD knowledge improved after use. A number of general recommendations for the design of eHealth behaviour change tools are made based on participants' suggestions to improve the website.

Thematic analysis of national online narratives on regular asymptomatic testing for Covid-19 in schools in England

OBJECTIVE

To understand the public perceptions of the schools Covid-19 testing programme in England.

DESIGN

Qualitative social media analysis.

SETTING

Online users of parenting forums (Mumsnet and Netmums), Facebook newspaper pages and Daily Mail online readers, who responded to posts or articles about the schools testing programme in England, between 1 and 31 March, 2021.

RESULTS

Overall, seven main themes were identified, these were divided into barriers and facilitators to engaging in testing for Covid-19. Barriers were: uncertainty around testing in the absence of symptoms; concerns about testing; implications about testing positive; mistrust in the Government. Facilitators were: desire to protect others; desire to return to normality; and hearing others' positive experiences.

CONCLUSIONS

Our analysis highlighted that alongside well-established barriers to engaging in asymptomatic testing, parents were having to negotiate additional complex decisions around balancing their child's anxiety over testing alongside acknowledgement of the implications of regular testing, such as return to normality and protecting others. Parents and children would benefit from additional practical and social support to facilitate engagement with the schools testing programme.

Moralization and Mismoralization in Public Health

Moralization is a social-psychological process through which morally neutral issues take on moral significance. Often linked to health and disease, moralization may sometimes lead to good outcomes; yet moralization is often detrimental to individuals and to society as a whole. It is therefore important to be able to identify when moralization is inappropriate. In this paper, we offer a systematic normative approach to the evaluation of moralization. We introduce and develop the concept of 'mismoralization', which is when moralization is metaethically unjustified. In order to identify mismoralization, we argue that one must engage in metaethical analysis of moralization processes while paying close attention to the relevant facts. We briefly discuss one historical example (tuberculosis) and two contemporary cases related to COVID-19 (infection and vaccination status) that we contend to have been mismoralized in public health. We propose a remedy of de-moralization that begins by identifying mismoralization and that proceeds by neutralizing inapt moral content. De-moralization calls for epistemic and moral humility. It should lead us to pull away from our tendency to moralize-as individuals and as social groups-whenever and wherever moralization is unjustified.

Commercial mHealth Apps and Unjust Value Trade-offs: A Public Health Perspective

Mobile health (mHealth) apps for self-monitoring increasingly gain relevance for public health. As a mobile technology, they promote individual participation in health monitoring with the aim of disease prevention and the mitigation of health risks. In this paper, I argue that users of mHealth apps must engage in value trade-offs concerning their fundamental dimensions of well-being when using mobile health apps for the self-monitoring of health parameters. I particularly focus on trade-offs regarding the user's self-determination as well as their capacity to form personal attachments. Depending on the user's level of advantage or disadvantage, value trade-offs can pose a threat to the users' sufficient fulfillment of the dimensions of well-being. As such, value trade-offs can entrench existing structural injustices and prevent disadvantaged users to benefit from this technology. I argue that value trade-offs are, to some, a type of injustice that can drive disadvantaged users away from a sufficiency threshold of well-being, risk users to fall below the threshold, or have an accumulative effect on different dimensions of the user's well-being.

Perspectives on delivering health promotion for the intellectual disability population

The qualitative study reported in this article set out to develop an understanding of how staff supporting individuals with intellectual disabilities deliver health promotion in their practice. The aim was to determine how social care managers working within an intellectual disability care setting in Ireland perceived health promotion and their role within it. Semi-structured interviews were conducted to collect the data. Participants perceived health promotion to be a priority for this population group that should be tailored to meet individual needs. Study participants recognised that they have a role in supporting and providing health promotion for this population, but also that they themselves required more training and education on the issue. Health promotion enablers identified in the study for this client group need to be enhanced and ways to reduce the barriers to access identified. The results reflect observations reported in the literature and indicate a need to prioritise health promotion with this population by establishing policies and practices in the organisation to promote it. A requirement for relevant training and education for social care managers-and other staff, as appropriate-was identified, as were areas for further research.

Moral Decision-Making During COVID-19: Moral Judgements, Moralisation, and Everyday Behaviour

The COVID-19 pandemic continues to pose significant health, economic, and social challenges. Given that many of these challenges have moral relevance, the present studies investigate whether the COVID-19 pandemic is influencing moral decision-making and whether moralisation of behaviours specific to the crisis predict adherence to government-recommended behaviours. Whilst we find no evidence that utilitarian endorsements have changed during the pandemic at two separate timepoints, individuals have moralised non-compliant behaviours associated with the pandemic such as failing to physically distance themselves from others. Importantly, our findings show that this moralisation predicts sustained individual compliance with government-recommended behaviours.

Evaluation of evidence supporting NICE recommendations to change people's lifestyle in clinical practice: cross sectional survey

Objectives

To assess whether recommendations of individually oriented lifestyle interventions (IOLIs) in guidelines from the National Institute for Health and Care Excellence (NICE) were underpinned by evidence of benefit, and whether harms and opportunity costs were considered.

Design

Cross sectional survey.

Setting

UK.

Data sources

NICE guidelines and supporting evidence.

Eligibility criteria

All NICE pathways for IOLI recommendations (ie, non-drug interventions that healthcare professionals administer to adults to achieve a healthier lifestyle and improve health) were searched systematically on 26 August 2020. One author screened all retrieved pathways for candidate guidelines, while a second author verified these judgments. Two authors independently and in duplicate screened all retrieved guidelines and recommendations for eligibility, extracted data, and evaluated the evidence cited and the outcomes considered. Disagreements were noted and resolved by consensus.

Results

Within 57 guidelines, 379 NICE recommendations were found for IOLIs; almost all (n=374; 99%) recommended the lifestyle intervention and five (1%) recommended against the intervention. Of the 379 recommendations, 13 (3%) were supported by moderate or high certainty evidence of a beneficial effect on patient relevant outcomes (n=7; 2%) or surrogate outcomes (n=13; 3%). 19 (5%) interventions considered psychosocial harms, 32 (8%) considered physical harms, and one (<1%) considered the opportunity costs of implementation. No intervention considered the burden placed on individuals by these recommendations.

Conclusion

Few NICE recommendations of lifestyle interventions are supported by reliable evidence. While this finding does not contest the beneficial effects of healthy habits, guidelines recommending clinicians to try to change people's lifestyle need to be reconsidered given the substantial uncertainty about the effectiveness, harms, and opportunity costs of such interventions.

Obesity and responsibility: Is it time to rethink agency?

Despite obesity declared a disease, there still exists considerable weight stigma in both popular culture and health care, which negatively impacts policy making regarding prevention and treatment. While viewed as a choice or a failure of willpower by many, evidence exists to challenge the argument that both weight gain and failure to achieve weight loss maintenance are the individuals' fault due to personal failure or lack of responsibility. In this article, we draw upon literature from obesity treatment, neuroscience, philosophy of mind, and weight stigma to challenge the commonly held beliefs that individuals are free to choose how much they can weigh, and achievement of long-term weight loss maintenance is completely subject to conscious choice. In reality, the regulation of hunger, satiety, energy balance, and body weight takes place in subcortical regions of the brain. Thus, hunger and satiety signals are generated in regions of the brain, which are not associated with conscious experience. This points towards biological determinism of weight and challenges ideas of willpower and resultant moralization regarding body weight regulation. In this article, we will thus argue that in the context of dysregulation of hunger and satiety contributing to the obesity epidemic, a wider discourse related to personal responsibility and the stigma of obesity is needed to enhance understanding, prevention, and treatment of this complex disease. Obesity is a chronic disease requiring personalized treatment. Lifestyle interventions alone may not be enough to achieve medically significant and sustained weight loss for many individuals with obesity. By understanding that obesity is not due to a lack of motivation or willpower, the availability and utilization of additional treatments or combination of treatments such as lifestyle, pharmacotherapy, and surgery are likely to improve the quality of life for many suffering with this disease.

Acceptability of risk-stratified population screening across cancer types: Qualitative interviews with the Australian public

BACKGROUND

There is mounting evidence of the benefit of risk-stratified (risk-tailored) cancer population screening, when compared to standard approaches. However, shifting towards this approach involves changes to practice that may give rise to implementation challenges.

OBJECTIVES

To explore the public's potential acceptance of risk-stratified screening across different cancer types, including reducing screening frequency if at low risk and the use of personal risk information, to inform implementation strategies.

METHOD

Semi-structured interviews were conducted with 40 public participants; half had received personal genomic risk information and half had not. Participants were prompted to consider different cancers. Data were analysed thematically as one dataset.

RESULTS

Themes included the following: (a) a sense of security; (b) tailored screening is common sense; (c) risk and the need to take action; (d) not every cancer is the same; and (e) trust and belief in health messages. Both groups expressed similar views. Participants were broadly supportive of risk-stratified screening across different cancer types, with strong support for increased screening frequency for high-risk groups. They were less supportive of reduced screening frequency or no screening for low-risk groups. Findings suggest the public will be amenable to reducing screening when the test is invasive and uncomfortable; be less opposed to forgo screening if offered the opportunity to screen at some stage; and view visible cancers such as melanoma differently.

CONCLUSIONS

Approaching distinct cancer types differently, tailoring messages for different audiences and understanding reasons for participating in screening may assist with designing future implementation strategies for risk-stratified cancer screening.

Deciding between moral priorities and COVID-19 avoiding behaviors: A moral foundations vignette study

Novel moral norms peculiar to the COVID-19 pandemic have resulted in tension between maintaining one's preexisting moral priorities (e.g., loyalty to one's family and human freedoms) and avoiding contraction of the COVID-19 disease and SARS COVID-2 virus. By drawing on moral foundations theory, the current study questioned how the COVID-19 pandemic (or health threat salience in general) affects moral decision making. With two consecutive pilot tests on three different samples (ns ≈ 40), we prepared our own sets of moral foundation vignettes which were contextualized on three levels of health threats: the COVID-19 threat, the non-COVID-19 health threat, and no threat. We compared the wrongness ratings of those transgressions in the main study (N = 396, M age = 22.47). The results showed that the acceptability of violations increased as the disease threat contextually increased, and the fairness, care, and purity foundations emerged as the most relevant moral concerns in the face of the disease threat. Additionally, participants' general binding moral foundation scores consistently predicted their evaluations of binding morality vignettes independent of the degree of the health threat. However, as the disease threat increased in the scenarios, pre-existing individuating morality scores lost their predictive power for care violations but not for fairness violations. The current findings imply the importance of contextual factors in moral decision making. Accordingly, we conclude that people make implicit cost-benefit analysis in arriving at a moral decision in health threatening contexts.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-021-01941-y.

The Polish version of the Düsseldorf Orthorexia Scale (PL-DOS) and its comparison with the English version of the DOS (E-DOS)

PURPOSE

Although orthorexia nervosa, the fixation on health-conscious eating behaviour, was first described in the 90 s, there is no clear understanding whether existing ON measures are appropriate for its assessment. The objectives of the present study were to: (1) examine the psychometric properties of the Polish version of the DOS (PL-DOS) and to compare the PL-DOS with the English version of the DOS (E-DOS) as well as (2) evaluate the prevalence of ON among Polish university students and compare the prevalence rates of ON among Polish and U.S. students.

METHODS

Four-hundred and twelve students (77.2% female) with a mean age of 24.62 years (SD = 6.86) participated in the present study. All participants completed the Polish version of the Düsseldorf Orthorexia Scale (PL-DOS), the Eating Habits Questionnaire (EHQ) and the Eating Disorder Inventory (EDI).

RESULTS

Reliability analysis for the PL-DOS showed strong internal consistency with a Cronbach's alpha coefficient of 0.840 and a coefficient omega of 0.840, 95% CI [0.808, 0.866]. Significant correlation coefficients were found between the PL-DOS and all subscales of the EHQ. Confirmatory factor analysis showed that the one-factor model had poor fit. Polish students had an ON prevalence rate of 6.6%, lower than that of U.S. students (8%).

CONCLUSIONS

Our findings validate the use of the PL-DOS as an appropriate ON measure for a Polish population.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Passport to freedom? Immunity passports for COVID-19

The COVID-19 pandemic has led a number of countries to introduce restrictive 'lockdown' policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people's civil liberties. We make tentative recommendations for the ethical introduction of immunity passports.

Lifestyle Interventions for Weight Management in People with Serious Mental Illness: A Systematic Review with Meta-Analysis, Trial Sequential Analysis, and Meta-Regression Analysis Exploring the Mediators and Moderators of Treatment Effects

BACKGROUND

Serious mental illness (SMI) reduces life expectancy, primarily due to somatic comorbidity linked to obesity. Meta-analyses have found beneficial effects of lifestyle interventions in people with SMI and recommended their implementation to manage obesity.

OBJECTIVE

The objective of this systematic review was to assess the benefits and harms of individualized lifestyle interventions for weight in people diagnosed with SMI and to explore potential mediators and moderators of the effect.

METHODS

The protocol was registered at PROSPERO (CRD42016049093). Randomized clinical trials (RCTs) assessing the effect of individualized lifestyle interventions on weight management in people with SMI were included. Primary outcomes were differences in endpoint body mass index (BMI) and the proportion achieving clinically relevant weight loss (≥5%). Secondary outcomes included quality of life, cardiometabolic risk factors, and adverse effects.

RESULTS

We included 41 RCTs (n = 4,267). All trials were at high risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. The experimental interventions reduced the mean difference in BMI by -0.63 kg/m2 (95% confidence interval [CI] = -1.02 to -0.23; p = 0.002; I2 = 70.7%) compared to the control groups. At postintervention follow-up (17 RCTs), the effect size remained similar but was no longer significant (BMI = -0.63 kg/m2; 95% CI = -1.30 to 0.04; p = 0.07; I2 = 48.8%). The risk ratio for losing ≥5% of baseline weight was 1.51 (95% CI = 1.07-2.13; p = 0.02) compared to the control groups. GRADE showed very low or low quality of evidence.

CONCLUSION

There is a statistically significant, but clinically insignificant, mean effect of individualized lifestyle interventions for weight reduction in people with SMI.

Responsibility in healthcare across time and agents

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Concepts of health in long-term home care: An empirical-ethical exploration

BACKGROUND

Concepts of health have been widely discussed in the philosophy and ethics of medicine. Parallel to these theoretical debates, numerous empirical research projects have focused on subjective concepts of health and shown their significance for individuals and society at various levels. Only a few studies have so far investigated the concepts of health of non-professionals and professionals involved in long-term home care and discussed these empirical perspectives regarding moral responsibilities.

OBJECTIVES

To identify the subjective concepts of the health of non-professionals (care recipients, informal caregivers) and professionals (registered nurses) involved in long-term home care and to discuss them against the background of existing normative guidelines addressing non-professionals and professionals' responsibilities and rights concerning health.

RESEARCH DESIGN

A qualitative design was chosen to explore subjective concepts of health. Data were collected by semi-structured interviews; content analysis was applied according to Mayring.

PARTICIPANTS AND RESEARCH CONTEXT

Twenty-eight interviews were conducted with non-professionals and professionals in long-term home care arrangements in Northern Germany.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the Institutional Review Board at the University Medicine Greifswald (BB123/16).

FINDINGS

Non-professionals and professionals consider health as a capability that enables them to participate in social activities and live their own lives according to their preferences. The former regard health particularly as a feeling and an attitude, the latter as the absence of disease with a focus on mental and emotional well-being. Both groups highlight the unsurpassable value of health and the personal responsibility for it.

DISCUSSION

Normative guidelines applicable to practice in long-term home care discuss responsibilities and rights unevenly and raise several problems regarding non-professionals and professionals' subjective concepts of health.

CONCLUSION

Individuals' concepts of health are relevant for the subsequent interpretation of rights and responsibilities and should, thus, be reflected upon to address health-related needs effectively.

Solidarity and Responsibility in Health Care

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health.

Against Moral Responsibilisation of Health: Prudential Responsibility and Health Promotion

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can 'take responsibility' for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms of moral responsibility should (in general) be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents (in general) have prudential reasons to maintain their health, in order to pursue those things which make their lives go well-i.e. that maintenance of a certain level of health is (all-things-considered) rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion.