Tingbjerg Changing Diabetes: experiencing and navigating complexity in a community-based health promotion initiative in a disadvantaged neighbourhood in Copenhagen, Denmark

As a response to the complexity of reducing health inequity there has been a rise in community-based health promotion interventions adhering to the principles of complexity thinking. Such interventions often work with adaptive practice and constitute themselves in complex webs of collaborations between multiple stakeholders. However, few efforts have been made to articulate how complexity can be navigated and addressed by stakeholders in practice. This study explores how partners experience and navigate complexity in the partnership behind Tingbjerg Changing Diabetes (TCD), a community-based intervention addressing health and social development in the disadvantaged neighborhood of Tingbjerg in urban Copenhagen. The study provides important insights on the role of context and how it contributes complexity in community-based health promotion.The study is based on 18 months of ethnographic fieldwork in the local community including participant observations and 9 in-depth interviews with key partner representatives. Findings show that complexity in TCD can be characterized by unpredictability in actions and outcomes, undefined purpose and direction, and differing organizational logics. Factors that support partners' navigation in complexity include connectivity, embracing a flexible intervention framework, autonomy, and quick responsiveness. The study showcases the interdependency between the intervention and the context of the disadvantaged neighborhood of Tingbjerg and encourages stakeholders and researchers to embrace the messiness of complexity, and to pay attention to ways through which messiness and unpredictability can be handled.

The everyday food practices of community-dwelling Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults

Malnutrition during old age is a significant public health issue. Prevailing behavioral and structural senior malnutrition interventions have had marginal success, largely failing to reflect the realities of people's daily lives. This novel study employed Social Practice Theory (SPT) to explore the food practices of an under-researched, yet highly vulnerable, segment of the older adult population-Lesbian, Gay, Bisexual, and Transgender (LGBT) seniors. Four focus groups were conducted with 31 older adult clients and volunteers at a national LGBT social service and advocacy organization. Findings revealed that food practices-far from being mere expressions of individuals' choices or immutable habits-are entities composed of meanings, materials, and competences that are structured as they are performed repeatedly in a social context. Gaining insight into how and why diverse older adults perform food practices in light of obstacles common to aging has important implications for senior nutrition program and policy development.

An ethical approach to health promotion in physiotherapy practice

ISSUE ADDRESSED

With increased emphasis on reducing the global burden of non-communicable disease, health professionals who traditionally focused on the individual are being encouraged to address population-level health problems. While physiotherapists are broadening their clinical role to include health promotion strategies in their clinical practice, the ethical foundations of this practice focus have received less attention.

METHODS

We use a physiotherapy clinical scenario to highlight different physiotherapeutic approaches and to analyse underpinning ethical values and implications for practice.

RESULTS

We suggest there are potential harms of incorporating health promotion into physiotherapy management of individuals if the population-based research does not resonate with an individual's particular circumstances, capacity to change or view of what counts as important and meaningful. We propose that critical reasoning and ethical judgment by the physiotherapist is required to determine how health promotion messages applied in primary care settings might work to benefit and enhance a client's well being rather than impose burdens or cause harm.

CONCLUSION

We suggest four ethical reasoning strategies designed to assist physiotherapists to frame and understand fundamental ethical principles of beneficence, harm, autonomy and justice when implementing health promotion and self-management approaches in clinical practice.

The extent to which the public health 'war on obesity' reflects the ethical values and principles of critical health promotion: a multimedia critical discourse analysis

ISSUE ADDRESSED

The discipline of health promotion is responsible for implementing strategies within weight-related public health initiatives (WR-PHI). It is imperative that such initiatives be subjected to critical analysis through a health promotion ethics lens to help ensure ethical health promotion practice.

METHODS

Multimedia critical discourse analysis was used to examine the claims, values, assumptions, power relationships and ideologies within Australian WR-PHI. The Health Promotion Values and Principles Continuum was used as a heuristic to evaluate the extent to which the WR-PHI reflected the ethical values of critical health promotion: active participation of people in the initiative; respect for personal autonomy; beneficence; non-maleficence; and strong evidential and theoretical basis for practice.

RESULTS

Ten initiatives were analysed. There was some discourse about the need for participation of people in the WR-PHI, but people were routinely labelled as 'target groups' requiring 'intervention'. Strong evidence of a coercive and paternalistic discourse about choice was identified, with minimal attention to respect for personal autonomy. There was significant emphasis on the beneficiaries of the WR-PHI but minimal attention to the health benefits, and nothing about the potential for harm. Discourse about the evidence of need was objectivist, and there was no discussion about the theoretical foundations of the WR-PHI.

CONCLUSION

The WR-PHI were not reflective of the ethical values and principles of critical health promotion. So what? Health promotion researchers and practitioners engaged in WR-PHI should critically reflect on the extent to which they are consistent with the ethical aspects of critical health promotion practice.

Information, choice and the ends of health promotion

In this paper I provide a critique of a set of assumptions relating to agency, choice and the legitimacy of actions impacting health that can be seen in some approaches to health promotion. After a brief discussion about the definition of health promotion, I outline two contrasting approaches to this area of health care practice. The first is focused on the provision of information and the second is concerned with seeking to change people's preferences in a particular way. It has been argued by a number of critics of health promotion that only the first approach is ethical, as it is for individuals to make their own lifestyle choices and adopt their own conception of the good life. I argue against this 'information' approach to health promotion on two grounds. First, I suggest that given the aims of health promotion, the provision of information is, as a matter of fact, of limited effectiveness in achieving these aims (and it may worsen health inequalities). Second, I argue that we have good reasons to question the appropriateness of respecting many of the preferences that individuals happen to have, given the origins and quality of such preferences. I then go on to argue, that by contrast we have good reasons to focus on changing at least some of the preferences that people have related to their lifestyle choices. This involves a commitment to both paternalism and a defence of a certain conception of the good life, but both can be defended. I use the example of potential responses to the growing problem of obesity to illustrate my argument, arguing that only policy that, at least sometimes, aims at preference change will be both effective and ethical.