Who accepts nudges? nudge acceptability from a self-regulation perspective.

BACKGROUND: Public acceptability of nudging is receiving increasingly more attention, but studies remain limited to evaluations of aspects of the nudge itself or (inferred intentions) of the nudger. Yet, it is important to investigate which individuals are likely to accept nudges, as those who are supposed to benefit from the implementation should not oppose it. The main objective of this study was to integrate research on self-regulation and nudging, and to examine acceptability of nudges as a function of self-regulation capacity and motivation. METHOD: Participants (N = 301) filled in questionnaires about several components of self-regulation capacity (self-control, proactive coping competence, self-efficacy, perceived control and perceived difficulty) and motivation (autonomous motivation and controlled motivation). To evaluate nudge acceptability, we used three vignettes describing three types of nudges (default, portion size, and rearrangement) that stimulated either a pro-self behavior (healthy eating) or pro-social behavior (sustainable eating) and asked participants to rate the nudges on (aspects of) acceptability. RESULTS: Results revealed that there were substantial differences in acceptability between the three types of nudges, such that the default nudge was seen as less acceptable and the rearrangement nudge as most acceptable. The behavior that was stimulated did not affect acceptability, even though the nudges that targeted healthy eating were seen as more pro-self than the nudges targeting sustainable eating. From all self-regulation components, autonomous motivation was the only measure that was consistently associated with nudge acceptability across the three nudges. For self-regulatory capacity, only some elements were occasionally related to acceptability for some nudges. CONCLUSION: The current study thus shows that people are more inclined to accept nudges that target behaviors that they are autonomously motivated for, while people do not meaningfully base their judgments of acceptability on self-regulatory capacity.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment.

BACKGROUND: Nudging, a strategy that uses subtle stimuli to direct people's behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion. METHODS: A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations. RESULTS: This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience. CONCLUSION: Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of 'what works' and 'how it works'. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.

Between a woman and her fetus: Bedouin women mediators advance the health of pregnant women and babies in their society.

INTRODUCTION: Bedouin women in Israel confront a challenging circumstance between their traditional patriarchal society and transition to modernity. In terms of reproductive health, they face grave disparities as women, pregnant women and mothers. In this article we aim to understand the challenges of Bedouin women who work as mediators in the promotion of Bedouin women's perinatal health. We explore their challenges with the dual and often conflictual role as health peer-instructors-mediators in mother-and-child clinics, and also as members of a Bedouin community, embodying a status as women, mothers, and family caretakers. Drawn upon a feminist interpretative framework, the article describes their challenges in matters of perinatal health. Our research question is: how do women who traditionally suffer from blatant gender inequality utilize health-promotion work to navigate and empower themselves and other Bedouin women. METHODS: Based on an interpretive feminist framework, we performed narrative analysis on eleven in-depth interviews with health mediators who worked in a project in the Negev area of Israel. The article qualitatively analyses the ways in which Bedouin women mediators narrate their challenging situations. RESULTS: This article shows how difficult health mediators' task may be for women with restricted education who struggle for autonomy and better social and maternal status. Through their praxis, women mediators develop a critical perspective without risking their commitments as women who are committed to their work as well as their society, communities, and families. These health mediators navigate their ways between the demands of their employer (the Israeli national mother and child health services) and their patriarchal Bedouin society. While avoiding open conflictual confrontations with both hegemonic powers, they also develop self-confidence and a critical and active approach. CONCLUSIONS: The article shows the ways by which the mediator's activity involved in perinatal health-promotion may utilize modern perinatal medical knowledge to increase women's awareness and autonomy over their pregnant bodies and their role as caregivers. We hope our results will be applicable for other women as well, especially for women who belong to other traditional and patriarchal societies.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate.

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.

Does Health Promotion Harm the Environment?

Health promotion involves social and environmental interventions designed to benefit and protect health. It often harmfully impacts the environment through air and water pollution, medical waste, greenhouse gas emissions, and other externalities. We consider potential conflicts between health promotion and environmental protection and why and how the healthcare industry might promote health while protecting environments. After probing conflicts between promoting health and protecting the environment we highlight the essential role that environmental resources play in health and healthcare to show that environmental protection is a form of health promotion. We then explore relationships between three radical forms of health promotion and the environment: (1) lowering the human birth rate; (2) transforming the food system; and (3) genetically modifying mosquitos. We conclude that healthcare and other industries and their institutions and leaders have responsibilities to re-consider and modify their priorities, policies, and practices.

Promoting male circumcision as HIV prevention in sub-Saharan Africa: An evaluation of the ethical and pragmatic considerations of adopting a demand creation approach.

Male circumcision for HIV prevention is being promoted in 14 sub-Saharan African countries. Campaigns take a demand creation approach, a strategy based on generating awareness of and demand for an intervention. This article analyzes campaign materials, making the case that a focus on demand per se, at the expense of quality public health information, constitutes an ethical and pragmatic campaign flaw. Clinical trials have demonstrated that circumcision can reduce transmission of HIV from women to men by 53-60%. Since circumcision does not approach 100% prevention efficacy for men and does not directly protect women, behavioural and structural interventions remain necessary, leading international health bodies to position circumcision as an add-on to behavioural interventions. However, in practice, circumcision promotion often lacks information about behavioural prevention. At times, campaigns omit any HIV prevention message. Instead, campaigns variously favour representing circumcision as a route to normative masculinity, to sexual prowess, or to good citizenship, among others. Alongside their targeted outcomes, public health campaigns also contribute to public discourses around sexuality and non-HIV aspects of health, in this case potentially leading to confusion and mistrust. The current public health promotion strategy for circumcision threatens to undermine the social processes needed to support HIV prevention.

Incentives for Smoking Cessation During Pregnancy: An Ethical Framework.

INTRODUCTION: Smoking during pregnancy increases the risk of morbidity and mortality of the mother and child. The inability of the unborn child to protect itself, raises the social and academic responsibility to protect the child from the harmful effects of smoking. Interventions including rewards (incentives) for lifestyle changes are an upcoming trend and can encourage women to quit smoking. However, these incentives can, as we will argue, also have negative consequences, for example the restriction of personal autonomy and encouragement of smoking to become eligible for participation. To prevent these negative consequences, we developed an ethical framework that enables to assess and address unwanted consequences of incentive-based interventions whereby moral permissibility can be evaluated. AIMS AND METHODS: The possible adverse consequences of incentives were identified through an extensive literature search. Subsequently, we developed ethical criteria to identify these consequences based on the biomedical ethical principles of Beauchamp and Childress. RESULTS: Our framework consists of 12 criteria. These criteria concern (1) effectiveness, (2) support of a healthy lifestyle, (3) motivational for the target population, (4) stimulating unhealthy behavior, (5) negative attitudes, (6) personal autonomy, (7) intrinsic motivation, (8) privacy, (9) fairness, (10) allocation of incentives, (11) cost-effectiveness, and (12) health inequity. Based on these criteria, the moral permissibility of potential interventions can be evaluated. CONCLUSIONS: Incentives for smoking cessation are a response to the responsibility to protect the unborn child. But these interventions might have possible adverse effects. This ethical framework aims to identify and address ethical pitfalls in order to avoid these adverse effects. IMPLICATIONS: Although various interventions to promote smoking cessation during pregnancy exist, many women still smoke during pregnancy. Interventions using incentives for smoking cessation during pregnancy are a promising and upcoming trend but can have unwanted consequences. This ethical framework helps to identify and address ethical pitfalls in order to avoid these adverse effects.It can be a practical tool in the development and evaluation of these interventions and in evaluating the moral permissibility of interventions using incentives for smoking cessation during pregnancy.

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.

The Role of Physicians in the Allocation of Health Care: Is Some Justice Better than None?

Physicians' advocacy obligations are best understood as going beyond advocacy on behalf of individual patients, which I call the "individualistic view," to include advocacy for intelligent research-based allocation schemes that promote good outcomes and cost-effective care for all patients, which I call the "systemic view." This systemic view includes moving beyond self-interest to promote less-wasteful and more cost-conscious allocation decisions and the setting of priorities at all levels to expand health care access. It includes physician involvement in discussions with patients in the context of clinical care, involvement in the formulation and administration of benefit structures and other allocation policies, and, finally, involvement in promoting public dialogue about health care priorities. This involvement is based on a concept of a deliberative process that can result in "just enough" decisions within systems for the preservation and promotion of health care and other societal goods.

The oral biome in the aetiology and management of dental disease: Current concepts and ethical considerations.

Our understanding of the complexity of the oral biome and of the role of the various constituent bacteria in the aetiology of dental disease is growing. Probiotics and their relationship with prebiotics, as well as other microbiome-based interventions, could be useful in preventing and treating dental disease and in promoting oral health. However, given the promise and early stage of this treatment approach, there are also a number of ethical, social and regulatory issues associated with innovative probiotic therapy. In this article, a brief update is given on contemporary theories of the aetiology and management of the two commonest dental diseases, and on the roles of pre- and probiotics and oral biome transplant in the management of these diseases. The focus is primarily on four core issues: informed consent, risk-benefit assessment, how to determine suitable healthy donors, and commercialization and regulation. We discuss the safety and benefits of oral probiotics, not only concerning the products and quality control during their manufacture, but also regarding the depth of public knowledge about this topic. We point out that the requirement of listing ingredients honestly might be insufficient, and that the prevalent rhetoric of 'natural' and 'organic' as well as some health claims in the translational, innovative probiotic industry and markets are themselves misleading and should be carefully scrutinized. Finally, we suggest an ethical imperative to find a balance between scientific research and industry, and public health in the regulation of probiotics.

Ethical considerations for the design and implementation of child injury prevention interventions: the example of delivering and installing safety equipment into the home.

INTRODUCTION: Public health ethics is a growing field of academic interest but ethical discussion of injury prevention seems to have received limited attention. Interventions that promise to be effective are not necessarily-without explicit justification-'good' and 'right' interventions in every sense. This paper explores public health ethics in the context of child injury prevention with the objective to initiate interdisciplinary dialogue on the ethics of child safety interventions. METHOD: A framework of seven public health ethics principles (non-maleficence, health maximisation, beneficence, respect for autonomy, justice, efficiency and proportionality) were applied to an intervention to promote child safety in the home. RESULTS: Preventing child injury in the home is ethically challenging due to the requirement for the state to intervene in the private sphere. Non-maleficence and beneficence are difficult to judge within this intervention as these are likely to be highly dependent on the nature of intervention delivery, in particular, the quality of communication. Respect for autonomy is challenged by an intervention occurring in the home. The socioeconomic gradient in child injury risk is an important factor but a nuanced approach could help to avoid exacerbating inequalities or stigmatisation. Equally, a nuanced approach may be necessary to accommodate the principles of proportionality and efficiency within the local context. CONCLUSION: We conclude that this intervention is justifiable from an ethical perspective but that this type of reflection loop is helpful to identify the impact of interventions beyond effectiveness.

Disease awareness campaigns in printed and online media in Latvia: cross-sectional study on consistency with WHO ethical criteria for medicinal drug promotion and European standards.

BACKGROUND: European legislation prohibits direct-to-consumer advertising of prescription medicines, but allows drug manufacturers to provide information to the public on health and diseases. Our aim was to measure the frequency of disease awareness campaigns in Latvian media and assess their compliance with international and European standards. METHODS: Materials on health/disease and treatments were collected between April and September 2015 from 12 newspapers and magazines and six online portals. Disease awareness campaigns were assessed using a previously developed instrument based on the WHO Ethical Criteria for Medicinal Drug promotion and European standards (EU law and pharmaceutical industry self-regulatory guidelines). Collected materials were used to examine the information provided on medical conditions and their diagnosis and treatment. The inter-rater reliability was calculated. RESULTS: We collected 263 materials from print (n = 149) and online media (n = 114); 94 were news items and 169 were disease-awareness advertisements. Cancer, cardiovascular problems, allergies and respiratory diseases were common topics. Of the 157 campaigns assessed, non-compliance was identified in 149 cases (inter-rater reliability 90%), mainly due to misleading or incomplete information, lack of balance and the absence of a listed author/sponsor. Six disease awareness campaigns directly mentioned a pharmaceutical product by brand name and other four included the logo or name of a manufacturer, referred to a condition and indirectly mentioned a treatment, all in contravention with European law. CONCLUSIONS: The compliance of disease awareness campaigns in Latvian media with international and European standards is low. This raises concerns about the nature of information being conveyed. Through lack of balance, missing sponsorship information, and misleading or incomplete information, these campaigns could contribute to inaccurate self-diagnosis and generate demand among those who might not need medical treatment.

Do Infant Formula Giveaways Undermine or Support Women's Choices?

Eliminating formula giveaways ("banning the bag") has been embraced as a way to reduce the influence of formula marketing in hospitals and to increase breastfeeding rates among new mothers, but the policy raises ethical concerns in the mind of some, notably because it denies a useful benefit to mothers who have trouble affording formula. Hospital policies to promote breastfeeding, including banning the bag, should be sensitive to the economic and other costs associated with breastfeeding and should be consciously designed to make breastfeeding easier and not just to make formula feeding more difficult. We recommend that hospitals evaluate the negative impacts of banning the bag on their patient population in order to ensure that families are not being negatively affected.

The value of work: Addressing the future of work through the lens of solidarity.

Designing the future of work is crucial to the health and well-being of people and societies. Experts predict that developments such as the advancement of digital technologies, automation, and the movement of manufacturing jobs to low-wage countries will lead to major transformations in the labour market, and some foresee significant job losses. Due to the close relationship between employment and health, major job losses would have significant negative impacts on the health and well-being of individuals and societies. Job losses would also pose a major challenge to solidaristic support within societies because they would negatively affect the recognition of similarities among people, which is vital for solidaristic practice and institutions. To prevent these negative effects, a fundamental redesign of the relationship between work and income is necessary. And for this project to succeed, we need to reconsider of the value of work. Building on definitions of flourishing people and societies, we argue that the value of work should not be determined by the labour market, but according to its importance for society. Using a solidarity-based framework we argue that such a re-valuation of work will help to ensure social cohesion and increase reciprocity in our societies. It will serve as a foundation upon which we can reconfigure the relationship between work and income without risking the loss of social cohesion and solidarity.

Inclusion and exclusion errors in the targeted supplementary feeding programme of Ethiopia.

Ethiopia's targeted supplementary feeding (TSF) programme aims to rehabilitate moderately malnourished children and pregnant and lactating women in selected chronically food-insecure districts. Screening for malnutrition is made by health extension workers through the quarterly community health days (CHD) events based on mid-upper arm circumference (MUAC) thresholds. This validation study examined the extent of targeting errors of inclusion (providing aid to the nonneedy) and exclusion (failure to reach the needy) in the TSF programme, among preschool children in 6 TSF districts. The study was conducted within 7 days after the completion of the CHD event. Multistage cluster sampling was employed to recruit 1,104 children. Data were collected using interviewer-administered questionnaire and by reviewing CHD registers. A paired t test was used to compare the MUAC measurements taken during the CHD and during the survey. The study found a global acute malnutrition prevalence of 13.0%. During the CHD, only 54.8% of the children were screened for malnutrition. The overall inclusion and exclusion errors of the TSF were 16.5% and 40.3%, respectively. The reasons for the exclusion errors were low coverage of the screening programme (67.2%) and MUAC measurement errors (32.8%). The mean including standard deviation (M ± SD) of the MUAC measured by health extension workers (11.8 ± 0.9 cm) was significantly lower than the measurements made by fieldworkers in the survey (12.1 ± 1.0 cm; p < .001). The study concluded that high targeting errors are committed in the TSF programme of Ethiopia. Targeting can be enhanced through accurate measurement of MUAC and maximization of the coverage of the screening programme.

[The individual and the State as agents responsible for the production of healthy societies: a thematic analysis from the perspective of health professionals in Catalonia (Spain)]. / La persona y el Estado como agentes de responsabilidad para la producción de sociedades saludables: análisis temático desde la perspectiva de profesionales de la salud en Cataluña (España).

This article aims to analyze the meanings upon which health promotion intervention practices are based, and the consequences of these meanings in the identification of responsibilities in health. The passage of Catalonia's Public Health Law 18/2009 facilitated the development of the Demonstrative Project of the Public Health Agency, in the framework of which fieldwork for the Plan for Health Education and Promotion in Children and Adolescents in La Garrotxa (region of Catalonia) was carried out. In this way, 20 interviews with key informants were conducted. Through a thematic analysis, it was found that the State and the individual are identified as the primary agents responsible for the production of healthy societies. It was also evidenced that, in the articulation between the discourses referring to free and rational decision-making and those referring to the social, political and economic environment, different approaches towards responsibility are construed, with effects related to the potentiation (or lack thereof) of the State as a guarantor of the population's health in opposition to blaming of the individual.

La persona y el Estado como agentes de responsabilidad para la producción de sociedades saludables: análisis temático desde la perspectiva de profesionales de la salud en Cataluña (España) / The individual and the State as agents responsible for the production of healthy societies: a thematic analysis from the perspective of health professionals in Catalonia (Spain)

RESUMEN El objetivo del artículo es analizar los sentidos a partir de los cuales se articulan las prácticas de intervención en promoción de la salud y sus consecuencias en la atribución de responsabilidades en salud. La aprobación de la Ley 18/2009 de Salud Pública de Cataluña propició la realización del Projecte demostratiu de l’Agència de Salut Pública de Catalunya el cual incluyó, durante 2009 y 2010, el Pla transversal d’educació i promoció de la salut en infants i joves en La Garrotxa (comarca de Cataluña), marco en el que se realizaron 20 entrevistas a informantes claves. Mediante un análisis temático, encontramos que se identifica al Estado y a la persona como los principales agentes responsables de la producción de sociedades saludables. Asimismo, evidenciamos que, a partir de diferentes articulaciones entre los discursos que refieren a la toma libre y racional de decisiones, y aquellos que refieren al entorno social, político y económico, se configuran diferentes enfoques sobre la responsabilidad, cuyos efectos se relacionan con la potenciación (o no) del Estado como garante de la salud poblacional en contraste con la culpabilización personal.

ABSTRACT This article aims to analyze the meanings upon which health promotion intervention practices are based, and the consequences of these meanings in the identification of responsibilities in health. The passage of Catalonia’s Public Health Law 18/2009 facilitated the development of the Demonstrative Project of the Public Health Agency, in the framework of which fieldwork for the Plan for Health Education and Promotion in Children and Adolescents in La Garrotxa (region of Catalonia) was carried out. In this way, 20 interviews with key informants were conducted. Through a thematic analysis, it was found that the State and the individual are identified as the primary agents responsible for the production of healthy societies. It was also evidenced that, in the articulation between the discourses referring to free and rational decision-making and those referring to the social, political and economic environment, different approaches towards responsibility are construed, with effects related to the potentiation (or lack thereof) of the State as a guarantor of the population’s health in opposition to blaming of the individual.