«Kirsti Riiser Institute of Nursing, Faculty of Health, Oslo and Akershus University College of Applied Sciences, Oslo, Norway; Department of Coaching ...»
Targeting and Tailoring an Intervention for Adolescents with Overweight: Some Ethical Concerns
Institute of Nursing, Faculty of Health, Oslo and Akershus University College of Applied Sciences,
Oslo, Norway; Department of Coaching and Psychology, Norwegian School of Sport Sciences, Oslo,
Department of Primary and Secondary Teacher Education, Faculty of Education and International
Studies, Oslo and Akershus University College of Applied Sciences, Oslo, Norway Yngvar Ommundsen Department of Coaching and Psychology, Norwegian School of Sport Sciences, Oslo, Norway Nina Misvær Institute of Nursing, Faculty of Health, Oslo and Akershus University College of Applied Sciences, Oslo, Norway Sølvi Helseth Institute of Nursing, Faculty of Health, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
Kirsti Riiser, Institute of Nursing, Faculty of Health, Oslo and Akershus University College of Applied Sciences, PO Box 4, St. Olavsplass, Oslo, 0130 Norway.
Email: firstname.lastname@example.org 1
Targeting and Tailoring an Intervention for Adolescents with Overweight:
Some Ethical Concerns Abstract There are important ethical issues to be examined before launching any public health intervention, particularly when targeting vulnerable groups. The aim of this article is to identify and discuss ethical concerns that may arise when intervening for health behavior change among adolescents identified as overweight. These concerns originate from an intervention designed to capacitate adolescents to increase self-determined physical activity. Utilizing an ethical framework for prevention of overweight and obesity, we identified three ethical aspects as particularly significant: the attribution of responsibility for health behavior, liberty to choose, and the effect on the participants' psychosocial well-being. It is discussed whether and how measures can be taken to deal with these aspects. It seems evident that the ethical aspects are mainly concerned with the vulnerability of adolescents identified as overweight. However, we claim that when individual feedback and counseling is provided, tailored interventions have a unique potential to empower adolescents to make ethically anchored decisions about their own health behavior.
Keywords Adolescents, ethical dilemmas, overweight, physical activity, public health ethics, tailored interventions Introduction The proportion of overweight and obesity among children and adolescents has increased worldwide over the last decades.1 In Norway, the prevalence of overweight among children and adolescents has been estimated at 14%-17%.2-4 The numbers are similar to those reported in other western countries, however lower than estimates from the United States, United Kingdom and countries in southern Europe.5, 6 Due to the close associationsbetween excess weight in childhood and later life, and the potential health risks of obesity, the arguments for developing and implementing strategies to sustain healthy weight-related behavior and lessen unhealthy behavior are compelling.7, 8 The World Health Organization states that preventive strategies with highly probable effect should be implemented as early as possible to combat the spreading obesity epidemic.9 There is, however, a lack of knowledge about the best approaches to achieve long term results. 10, 11 Thus, researchers are urged to carry out more studies to identify effective public health strategies at all levels of 2 prevention. However, scientific evidence alone cannot guide and determine health policy and decisions for intervention.12 Public health interventions also bring about normative debates about how pursuing better health outcomes for the whole population influences individual persons’ lives.
While public health interventions primarily focus on health-related outcomes like weight reduction, increased physical activity and more balanced diets,; there is a strong need to address the many ethical issues involved. This implies keeping an eye on aspects such as empowerment, responsibility, autonomy, dignity, integrity13, and well-being or health-related quality of life 14. If it is not clear how an intervention relates to such individual outcomes, it is likely that, instead of supporting and strengthening them, the intervention could end up restricting them. This is not only morally irresponsible, but could also threaten to reduce social acceptance of the intervention and lower its effectiveness.15 Thus, there are important ethical issues to be identified and examined before launching any public health intervention, particularly when targeting vulnerable groups like overweight adolescents.
The aim of the article The aim of this article is to identify and discuss ethical concerns that may arise when intervening for health-behavior change among adolescents identified as overweight. These concerns originate from an ongoing individually-tailored Internet intervention designed to capacitate adolescents to increase daily physical activity and thereby obtain enhanced fitness and health-related quality of life.16 During development and implementation, several ethical issues became apparent. In the following we first give a condensed description of the intervention. We then frame our ethical analysis by emphasizing the tension between public health concerns and individual ones. Using an ethical framework for the prevention of overweight and obesity developed by ten Have et al.17, we identify ethical dilemmas arising from the intervention study. Relying on ethics theory, we then discuss whether and how measures can be taken to deal with these dilemmas. In particular, our discussion emphasizes the value of communicative rationality in empowering adolescents to make autonomous choices about physical activity, health and life in general.
The “Young & Active” Internet intervention In an attempt to meet the call for evidence-based interventions to support health behavior among overweight adolescents,9, 18 we developed an Internet program dubbed “Young & Active”. It was included in a 12-week intervention with the aim of increasing overweight adolescents’ physical activity and thereby their fitness and ultimately their health-related quality of life. The intervention is 3 thoroughly described elsewhere, but in short it included establishing personal goals and plans for physical activity, registration of physical activity, a physical activity diary, continuous graphical feedback on progress, social support in a forum, frequently updated information on physical activity and, most importantly, weekly individualized feedback from a health counselor.16 Except for one first face-to-face meeting, each participant’s contact with the counselor took place online. Based on the knowledge of physical activity as a significant contributor to health regardless of body mass index (BMI),19 this intervention did not emphasize weight reduction. Rather, it drew attention to the physical activity of participating adolescents, how active they aimed to be, and how they could make self-determined choices to increase activity throughout the day. Initially, however, inclusion was based on body weight. Following screening of height and weight in eighth grade20 adolescents with age- and gender-adjusted BMI above 25 were invited to take part in the intervention. The school nurse was involved in the recruitment process, responsible for issuing information and obtaining informed consent from the adolescents and their parents.21 A non-randomized control group design was chosen for the study. The control group was provided with standard follow-up by the school nurse. This article focuses on participation in the intervention group. However, we acknowledge that there are specific ethical considerations regarding participation in a control group. The study was approved by the Norwegian National Research Ethics Committee.
Despite widespread public concern about the obesity epidemic and explicit national guidelines for action,22 some controversy attended the introduction of our initiative.. Several nurses argued against approaching overweight adolescents directly and then declined requests to assist in recruitment.
Studies from other countries investigating nurses’ experiences of raising issues about overweight among children and adolescents have identified several possible barriers to communication.23, 24 Even if reported barriers like uncertainty and fear of reactions are not explicitly discussed as ethical issues, this may reflect that nurses are concerned about reinforcing stigmatization when broaching the topic of weight with children and their parents. The school nurses, who agreed to contribute to recruitment, experienced some negative reactions from parents and adolescents when they addressed the topic of overweight in general and when they issued invitations to participate in the intervention. However, several nurses also reported positive responses.
Public health and individual concerns In contrast to clinical medicine which seeks to cure or treat individual patients mostly on the patient’s initiative, public health initiatives are imposed by governments and employ non-medical means to prevent disease and promote the health and well-being of populations.25 However, since 4 public health interventions by nature require some degree of interference in the lives of individuals, the prioritizing of such interventions can and will at some point conflict with the rights and freedom of the individual.26 The question is whether this it is ethically defensible. If one relies solely on traditional medical ethics and holds the interests of each individual as the only rightful criteria, the majority of public health initiatives may actually be ruled out. However public health actions can also be seen as vitally important activities with legitimate ends which can only be acquired through population-level programs, as pointed out by Dawson.27 This requires taking into account the unique ethical needs and features of public health practice by drawing upon moral and political philosophies.26 Most typically utilitarianism and liberalism are applied to reflect and react to public health interventions.28 Public health interventions are utilitarian efforts in that they are performed to impartially maximize the health and well-being of populations. In contrast to utilitarianism, liberalism emphasizes the primacy of individual rights and freedoms.29 Thorough ethical reasoning is essential to reconcile this clash of interests between individual freedom and community well-being. This can be done on a more fundamental level, leaning on philosophical methods. However, it can be argued that, since public health commonly is both highly practice-oriented and context-sensitive, ethical deliberations should be kept “closer to the ground”, relying also on empirical research and knowledge about the social world.26 A framework used to identify ethical dilemmas While philosophical theories are applied on higher levels of abstraction to provide justification for public health actions, ethical frameworks are instruments aimed at assisting in deliberations about ethical aspects of programs and policy.30 In recent years there has been a rapid development of frameworks for public health that attempt to clarify ethical boundaries for public health interventions and to help public health professionals consider ethical implications and determine whether promoting public health warrants consideration of moral values.25, 31, 32 However, the applicability of these frameworks to the whole range of public health areas and all kinds of ethical challenges is questionable.29, 33 An overview of current frameworks and their usefulness for evaluating overweight and obesity prevention programs concluded that the frameworks may be supportive, but that they lack practical guidance for ethical conflicts in this particular area.34 Based on an inventory of ethical issues that may occur in programs to prevent overweight or obesity, ten Have et al. recently developed an ethical framework for the prevention of overweight and obesity.15 This is a tool for “making transparent what the potentially ethically problematic aspects of a program
Box 1 Questionnaire regarding ethical pitfalls How does the program affect physical health?
How does the program affect psychosocial well-being?
How does the program affect equality?
How does the program affect informed choice?
How does the program affect social and cultural values?
How does the program affect privacy?
How does the program affect the attribution of responsibilities?
How does the program affect liberty?
ten Have et al. p 30017
All of these moral features seemed relevant to the present intervention. By analyzing ethical aspects of our intervention against the framework, as described in the supplement to the questionnaire in ten Have et al.17, three issues were revealed as particularly significant; attribution of responsibility for health behavior, liberty to choose and how the intervention affects the participants’ psychosocial well-being.
Discussion of identified ethical dilemmas Leaning on the inventory and the framework15, 17 supplemented with ethics theory,29, 35, 36 we discuss the issues identified and elaborate on how the present intervention emphasizes responsibility for health and action, how the adolescents’ choices are impinged upon and how their well-being is attended to.