Journal of Health Communication, Volume 6, pp. 117 136, 2001 Copyright # 2001 Taylor & Francis 1081-0730/01 $12.

00+ .00

On Being Responsible: Ethical Issues in Appeals to Personal Responsibility in Health Campaigns

NURIT GUTTMAN
Department of Communication, Tel Aviv University, Tel Aviv, Israel Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA

WILLIAM HARRIS RESSLER

International Graduate Centers, Boston University, Israel
Appeals to personal responsibility are highly prevalent in health communication campaigns, but their use entails both moral and strategic considerations. This article provides an overview of the notion of personal responsibility as a persuasive appeal in public health communication campaigns and an analysis of concomitant ethical implications. Whereas the issue of responsibility often is acknowledged by practitioners and scholars as a perennial challenge in health interventions,conceptual tools for the identi cation of its subtle manifestations are not readily available. This article outlines a framework that contextualizes potentially paradoxical consequences of campaign appeals to personal responsibility that can be explained by the medieval allegory of the ``Tragedy of the Commons, psychological attribution theory, and public health concerns regarding ``blaming the victim. Practice-oriented questions are introduced to help identify ethical issues in personal responsibility appeals that can be utilized in the design and implementation of health campaigns.

Background
Throughout history and across cultures, illness and disease have been attributed to people s deeds and even thoughts. In contemporary health-promotion endeavors, personal responsibility plays a central moral and pragmatic role. As stated bluntly by Louis Sullivan, former U.S. Secretary of Health and Human Services, ``First, responsible and enlightened behavior by each and every individual truly is the key to good health (U.S. Department of Human Services, 1990, p. v). Another prominent health of cial, former U.S. Surgeon General Everett Koop, similarly urged the public to ``practice responsible behavior based on understanding and strong personal values. 1 Members of the public themselves appear to accept the presumed necessity of using appeals to personal responsibility. For example, focus groups conducted by the
Address correspondence to Nurit Guttman, Department of Communication, Tel Aviv University, Tel Aviv, Israel 69978. E-mail: [email protected]
1 This was stated in a Message from the Surgeon General on AIDS, which was distributed to all U.S. households (U.S. Department of Health and Human Services, 1988).

117

118

N. Guttman and W. H. Ressler

U.S. National Cancer Institute for the purpose of developing a persuasive campaign for the consumption of vegetables recommended using appeals to responsibility. Messages appealing to personal responsibility appear in numerous forms in many health campaign messages (Kirkwood & Brown, 1995). Campaign rhetoric on responsibility spans from appeals regarding prescribed medications, alcoholic beverages, food consumption, automobile driving, and physical exercise to intimate discussions associated with sexual activity. Health campaigns typically explicate what it means to be a responsible spouse, parent, or friend. Responsible parents are said to be those who ensure their children are immunized and buckled in the back seat of the automobile; are alert to their kids possible drug-related or eating disorder activities; and manage to discuss sexual health matters with their adolescents. What makes the use of personal responsibility appeals in health campaigns so attractive? With the accumulation of research and epidemiological evidence linking lifestyle factors to health and disease, health professionals and health promoters have adopted the proposition that speci c behavior practices are major causes of preventable illness. This has resulted in interventions that focus on people s personal lifestyles (Knowles, 1977). Modern ``risk factors, such as overeating, lack of physical activity, and having unprotected sex, have replaced ancient sins such as gluttony, sloth, and lust (formulated by Breslow and his associates; cited in Minkler, 1999). Associating health-related behaviors with sin or moral weakness certainly has moral connotations (Lupton, 1993). Furthermore, health recommendations linked to prudent and responsible behaviors may insinuate moral indignation if not adopted (Becker, 1993; Marantz, 1990). Critics note that an emphasis on personal responsibility in health campaigns coincides with social and political climates in which the individual is viewed as the appropriate focus for interventions to control health risk factors (Lupton, 1994; Minkler, 1999; Tesh, 1988). Underlying health campaigns emphasis on personal responsibility is also a Western cultural orientation to glorify an individuals presumed rationality to control his or her own fate and pursue private interests. 2 This view, suggests anthropologist Mary Douglas (1994), is enshrined in a utilitarian philosophy according to which responsible people will choose to behave rationally and avoid health risks. Douglas (1990) argues that the notion of risk aversion as a rational choice is questionable because risks are typically de ned and judged either to be feared or worth taking, not according to objective rational criteria. Whereas the biomedical language of risk is linked to probabilities, its de nition depends on social values and cultural norms. Discourse on risk, like other discourses that relate to the human body (Foucault, 1972), can thus be viewed as ideologically and culturally based. What is considered ``irresponsible depends therefore on each society s selection of what it considers ``risky (Douglas, 1994; Douglas & Wildavsky, 1982; Lupton, 1993; Rayner, 1992). Further, because the notion of personal responsibility is inherently associated with risk aversion or risk taking, it can be linked also to the conception of social roles, the way social obligations are de ned, and which behaviors are sanctioned or rewarded. As such, conceptions of responsibility are deeply embedded in social institutions and consequently are unquestioned (Gustafson & Laney, 1968). Precisely because of its culturally bound and taken-for-granted conception, the application of the notion of personal responsibility messages in health campaigns requires a careful analysis. This article focuses on the identi cation of
As re ected in the precept of respect for personal autonomy, considered one of the major ethical principles in Western bioethics.
2

Responsibility in Health Campaigns

119

ethical concerns in such applications and their implications to strategic decisions. For this purpose, the paper discusses three major facets of responsibility that can help explore the dynamics of its use in health campaigns, and it delineates a series of ethical issues embedded in appeals to personal responsibility.

Facets of Personal Responsibility

Three major facets of personal responsibility are outlined for the purpose of identifying ethical concerns in health campaigns: attribution of causation, obligation, and agency (Harmon, 1995; Schlenker, Britt, Pennington, Murphy, & Doherty, 1994). Health campaigns may rely on one or all of these facets in their construction of persuasive messages. The discussion of each facet introduces several constructs, each associated with particular ethical concerns. Potentially paradoxical consequences of campaign appeals, associated with attributional processes, are further explicated by relating them to the medieval allegory of the ``Tragedy of the Commons. Facet I: Assumptions of Causation and the Attribution of Blame An appeal to personal responsibility inherently assumes causal connections between people s deeds and health outcomes, even if this connection is merely implied. For example, saying that one needs to lose weight to prevent cardiovascular disease implies a causal connection between excessive food consumption and illness. Similarly, by saying that people need to be responsible for their health behaviors, we imply that they are culpable for adverse consequences when they do not adopt preventive measures. When personal responsibility is linked to causality one possible implication is that individuals should be held morally, and perhaps legally, accountable for their behavior (Sachs, 1996). This notion of accountability can serve as the basis for the argument that society could be exempt from paying for health care costs resulting from behaviors considered irresponsible, or that individuals deemed irresponsible may be asked to pay higher health insurance premiums (McLachlan, 1995). This view is exempli ed in survey ndings from a 1991 U.S. Louis Harris poll in which 55% of the respondents were willing to impose higher health insurance premiums on individuals who engage in unhealthy behaviors such as smoking or excessive consumption of alcohol (Blendon, Stelzer Hyams, & Benson, 1993). Dutch panel data similarly found support for individual accountability for copayments associated with behaviors linked to health problems (Stronks, Strijbis, Wendte & Gunning-Schepers, 1997). A British survey found that 42% of the respondents either agreed or strongly agreed with the statement that ``people who contribute to their own illness for example, through smoking, obesity, or excessive drinking should have lower priority for their health care than others (Bowling, 1996). These sentiments raise concerns among ethicists and advocates who worry about the equity, solidarity, and victim blaming in health care. Serious reservations have been raised in discussions of health care rationing about withholding services or charging more for them from those whose illness may have been caused by their own actions. It has been argued that people should receive care according to their needs (Bowie, Richardson, Sykes, 1995; Doyal, 1998; Stronks et al., 1997). Ethical concerns regarding the intricacies of the notion of culpability are further elaborated by Bayer (1996) in his discussion of the potential slipperiness of attributing responsibility in AIDS prevention. Referring to the concept of sexual responsibility (a common expression in prevention campaigns) as ``dangerous, he explains that

120

N. Guttman and W. H. Ressler

the presupposition that HIV is primarily transmitted in the context of consensual sex can lead to the assumption that each person bears the responsibility of self-protection. Those considered ``at risk are branded as people whose own actions contribute to their own risk of infection. In other words, all individuals are assumed to be held responsible for their own protection in situations that presumably require consensual relations. The moral slipperiness occurs, according to Bayer, both in messages that imply that individuals are completely in control of their behaviors and in the presumption that actions that put others at risk for infection are criminal as well as immoral. 3 For the purpose of identifying ethical concerns in messages that assume causation, four propositions can be noted. The rst is that a person should be held liable for adverse outcomes of activities that may lead to injury or illness only when these are under their complete volition. In such cases it is not fair that society or others should foot the bill. This proposition draws from ethical approaches that emphasize the public good, utility, and fairness. Since moral responsibility for health outcomes assumes causal control over the circumstances that enable the health behaviors (Glannon, 1998), the ethical challenge is to determine whether individuals indeed have control of the practices believed to be causally linked to the health outcome (Veatch, 1980; Wikler, 1987). The second proposition extends the conditions for culpability and asserts that it depends not only on the extent to which the practice is voluntary, but also on the extent to which it was carried out for personal grati cation or for others bene t. A re ghter, for example, chooses to take risks but does so for the good of society (Keeney, 1994). Such prosocial risk taking for which society presumably should bear the consequences differs from choices to engage in risky behaviors that are viewed as merely recreational or for personal grati cation (Dworkin, 1981; Veatch, 1980). This distinction, however, requires (a) clearly de ning what serves the public good, (b) deciding whether personal pleasure can also be considered a societal goal, and (c) criteria to determine which presumably nonhealthy behaviors are volitional (Salmon, 1989). The third proposition concerns the notion of suf ciency. Bioethicist Callahan (1986) reiterates the critique of health promotion approaches that overemphasize the responsibility of the individual. He proposes that messages that imply that people s actions alone can result in good health outcomes are morally questionable because other physiological, structural, and situational factors play important causal roles. One example for this is Martins (1994) analysis of a current trend in Western societies to call upon people to bolster their immune system through nutritional and psychological means. Martin observes that this has become a major theme in contemporary conceptions of the human body. By implication, one s personal duty would be to see to it that one s immune system is at its peak and neglecting to do so would be deemed socially irresponsible (Lupton, 1999). The notion of suf ciency in causation of illness and injury is highly problematic. Campaign messages that suggest, even by implication, that one s own conduct is suf cient to cause or solve a particular health problem or to determine the state of their immune system when other factors may also play an important role clearly raises ethical concerns

3 Another contentious moral issue is the notion of risk and what constitutes risk (Douglas, 1994; Douglas & Wildavsky, 1982). A critical perspective suggests it may serve the function of social control (Lupton, 1993).

Responsibility in Health Campaigns

121

regarding attribution of blame. Because campaign messages typically are brief and condensed, designing messages that refrain from implying suf ciency presents a challenging task. The notion of suf ciency preempts the fourth proposition. Whereas appeals to personal responsibility can help empower individuals by encouraging them to be proactive, they may also serve to impute blame and fatalism to those who are, in fact, the most vulnerable (Balshem, 1991; Finerman & Bennett, 1995; Pill & Stott, 1982). 4 Ziff, Conrad, and Lachman (1995) reviewed studies that differed in their conclusions on the bene t of using personal responsibility in health promotion. In some studies attributions of personal responsibility were found to be bene cial and associated with positive adaptation: appeals to personal responsibility can enable people to feel in control of their lives and encourage them to take an active role in monitoring their health and improving their well-being. Findings from other studies, however, indicated the opposite: Perceptions of personal responsibility may negatively impact people s well-being by adding the burden of guilt or by evoking a feeling of self-blame, which ultimately serves as an obstacle to good health practices. Potentially harmful consequences of negative self-attribution of responsibility have been identi ed even in children. In a study of 9-to-11-year-old overweight children, lower self-esteem was found among those who believed they were responsible for their overweight compared with those who attributed their overweight to an external cause (Pierce & Wardle, 1997). The four propositions can be summarized as follows: People cannot be found culpable if (a) their engagement in the health-damaging behavior is not totally volitional, (b) the behavior deemed irresponsible was not carried out only for personal grati cation, and (c) the detrimental health outcome can be caused by conditions other than the particular behaviors in question. Messages that diverge from these requirements raise serious ethical concerns because they may imply a disproportional attribution of culpability, particularly if they target highly vulnerable populations whose reaction to such messages will be fatalism and guilt. The propositions can be paraphrased into the following practice-oriented questions: (1) Are members of the intended population truly free to engage in the anti health-related behavior? (2) Is the antihealth behavior in question carried out merely for personal grati cation or does it have normative functions? (3) Can the speci c practice cause the particular adverse health outcomes independent of any other factor? (4) Could reactions to messages on responsibility induce a sense of fatalism and guilt, particularly among populations that are highly vulnerable?5 The delicate line between messages that can empower and those that blame is illustrated in the case of HIV prevention messages for women who have relatively little control over their life circumstances. These women may put themselves at risk of physical or economic harm if they insist that their sexual partner use a condom. Exhortations to protect oneself from AIDS may put sexual partners, who are limited in their ability to resist a noncooperative partner, in a double bind or in actual physical or emotional harm (Chanda Baggaiey, Phiri, & Kelly, 1994; Des Jarlais, Padian, & Winkestein, 1994; Des Jarlais & Stepherson, 1991; Lyman & Engstorm,

4 The ethical implications in the distinction between necessary and sufficient conditions were pointed out by the bioethicist Dan Wikler, in a personal conversation, 1993. 5 Wang (1992) desmonstrates how injury prevention campaigns, by using messages that imply shame and blame, contribute to the production of stigma of people with injuries.

122

N. Guttman and W. H. Ressler

1992; Nyamathi, Flaskerud, Bennet, Leake, Lewis, 1994). For example, it was found that women in abusive situations were less likely to use condoms and more likely to experience verbal and emotional abuse or threats of physical abuse when they discussed the use of condoms with their partners. They were also found to be more fearful about asking their partner to use condoms, more worried about acquiring HIV, and felt more isolated than women not in abusive situations (Wingood & DiClemente, 1997). This example illustrates one of the moral pitf alls widely discussed in the health promotion literature as blaming the victim. Victim blaming is locating the causes of social problems within the individual who, in fact, is the one suffering from them, instead of locating them in social and environmental forces (originally formulated by Ryan, 1976; for application to the health context see Allegrante & Green, 1981; Marantz, 1990; McLeroy, Gottlieb, & Burdine, 1987). A psychological tendency known as the fundamental attribution error (Ross, 1977) also underscores the tendency to assign blame to people s personal actions. This psychological phenomenon (further discussed below) is characterized by attributing individuals behavior to internal reasons such as choice, disposition, personality, or strength of (moral) character, while ignoring possible external situational in uences on their behavior (Miller, 1984; Watson, l982). 6 An ironic twist can be found in messages of guilt and blame featured in a recent Israeli campaign for traf c safety that used the notion of causality under the slogan, ``Traf c violations carry the death sentence. ``Death sentence, especially in Israel, where only one person has ever been executed in extraordinary circumstances Adolph Eichmann, a high-ranking Nazi of cer suggests almost divine retribution for the most heinous of crimes. The sad irony is that fatalities from traf c accidents tend to include children and elderly pedestrians, cyclists, passengers, and law-abiding drivers, hardly the people who society would declare deserve a death sentence. Two moral concerns associated with victim blaming can be articulated according to the ethical principle of causing no harm. Is it ethical to add to individuals suffering by implying they are at fault for their suffering? Is it ethical to tell people that they should adopt certain health practices when they cannot readily do so because they are restricted by social circumstances? Would this only lead them to frustration and guilt? Such questions underscore the ethical issue of whether the onus of responsibility should be placed on the individual, and by implication exempting dominant social institutions and those in power from responsibility (Beauchamp, 1988; Cloud, 1998; Minkler, 1999). Evaluations of health intervention efforts indicate that social factors indeed play an important role in the adoption of health promotion activities, and that people with lesser socioeconomic means are less likely to adopt campaign recommendations (Blane, 1995). Table 1 outlines 10 practice-oriented questions that illustrate the different types of ethical issues associated with the utilization of personal responsibility in health campaigns.

6 Lupton (1993), citing Rosenberg (1986) and basing her analysis on Douglas (1990), explains how the modern concept of risk, like that of the taboo, has a ``forensic property: It is used to explain retrospectively why things happened, giving it both a scientific and moral overtone. Similarly, others suggest that the discourse of risk and lifestyle is a result of wanting to explain disease and illness while enhancing social control. People are viewed as sinners when they engage in activities associated with laziness, gluttony, and sloth (Becker, 1993; Marantz, 1990).

TABLE 1 Practice-Oriented Questions to Delineate Ethical Concerns Regarding Personal Responsibility in the Design and Messages of Health Campaigns Ethical Concerns Avoidance of labeling, stigmatizing, blaming Questions

1. Is the reference to personal responsibility direct or is it indirect through implication of cause and culpability? Avoidance of blaming 2. Do the messages imply culpability and fostering a negative identity that if one does not follow the recommended practice one would be blamed or shamed? Do the campaign messages have the potential to elicit a negative self-image through attribution of negative personal conduct or traits? Avoidance of manipulation and 3. Are the appeals to personal responsiinfringement upon personal autonomy bility mainly used strategically, or does the campaign promote responsibility as a social value? Allowing for personal choice and 4. According to the messages on responsideliberation according to one s values bility, to whom is one said to be committed and why? Does the campaign specify which commitments have priority, or does it offer means to deliberate about ones commitments? Allowing for self-actualization and 5. Do the messages emphasize positive refraining from doing harm elements in self-identity, such as caring, virtue, or self-actualization? Avoiding manipulation and use of 6. To what extent do the messages of the persuasive messages and allowing for campaign or its rhetoric define virtue personal autonomy and deliberation as a set of particular obligations? What values are these obligations based upon and under what conditions should one feel obligated? Avoidance of blaming the victim and 7. Does the design of the campaign and facilitating personal and collective its messages recognize social and empowerment institutional constraints? Facilitation of skills, resources, and 8. Do the campaign messages provide self-efficacy to adopt the campaign examples or models to help people recommendations and to be able acquire skills and confidence in their to act responsibly ability to adopt the recommended behaviors? Allowing for personal autonomy and the 9. Does the design of the campaign and development of moral reasoning do its messages have a deliberative component? Allowing for different values to be 10. Does the design of the campaign and do considered but dealing with the its messages allow the elaboration of issue of moral relativism values and goals and which values and goals are privileged or prioritized? How is the issue of moral relativism resolved?

124

N. Guttman and W. H. Ressler

``Tragedy of the Commons Drawing from psychological literature on attribution, we can further articulate ethical and pragmatic concerns when personal responsibility appeals in the form of implied causation may involve negative identity labeling. An interesting implication is their potential to intensify the phenomenon of widespread evasion of personal responsibility. This evasion may lead to individual and collective devastation as allegorized in the ``Tragedy of the Commons. The allegory is based on imagery of Old English grazing pastures, shared by a number of farmers, and on the premise that the commons provide suf cient grazing land for the current complement of livestock. If farmers increase their herds, however, the pasture will become overgrazed, the grass will not be replenished, and the commons will disappear. Although this long-range consequence will hurt all the farmers, individual farmers are tempted in the short run to enlarge their herds. The addition of livestock contributes enormous immediate bene t to the individual and minimal immediate damage to the collective problem of overgrazing. Individuals sel sh behavior in the short run may appear rational, but in the long run their behavior is detrimental to the group and themselves (Hardin, 1968)7 thus compounding ethical consideration of equity and utility. Compounding this seemingly rational but short-sighted penchant is the tendency of individuals to make disparaging attributions regarding others motives and to suspect that others are not willing to restrain themselves for the common good (Howard & Rothbart, 1980). This tendency may also encourage individuals to excuse their own pursuit of personal grati cation or sel sh behavior. They would reason that if they themselves would not take advantage of the current situation, others certainly will. If the common resources stand to be depleted, then they might as well get what they can, while they can. There is the risk that appeals to personal responsibility in the form of implied causation and blame could reinforce the negative labeling of others rather than prompt people to engage in the desired behavior change. One example of this is an Israeli campaign to try to reduce littering. The campaigns slogan was, ``Whoever litters is garbage (the Hebrew word for garbage carries a strong connotation when applied to people, something like low-life or scum of the earth). Given that most people do not consider themselves as debris, the slogan may reinforce the belief that others litter because they are bad. One s own littering would be excused by the assertion that one litters only when they have no choice or that their own actions will not make a difference because the place is already littered by others. The assumption of suf ciency and the inclination to blame the victim re ect other fundamental human cognitive processes noted by psychologists: the need to feel what psychologists label ``effective control (Kelley, 1967) and the predisposition to believe in a just world. The latter suggests that people tend to believe that other people get what they deserve (Lerner, 1980). Both tendencies, along with the cognitive processes associated with the ``Tragedy of the Commons, illustrate the human inclination to ignore situational in uences on other people s behavior and to prefer dispositional explanations for their actions. For example,
7 For a different discussion of the ``Tragedy of the Commons in the context of health promotion paradoxes see Guttman, Kegler, and McLeroy (1996) originally based on a presentation by Kenneth McLeroy at the Society for Health Educations Scientific Conference in North Carolina, 1994.

Responsibility in Health Campaigns

125

``She became ill because she did not eat properly is a dispositional explanation that ignores her inability to readily obtain fresh fruits and vegetables because her low-income neighborhood grocery store sells only aggressively marketed commercially prepared foods, typically low in nutritional value and high in fats and calories. Strategic implications. The use of causal appeals, in addition to raising ethical concerns, may be ineffective strategically. Messages that link a desired behavior with responsibility and an undesired (but pleasurable) behavior with irresponsibility may affect individuals reasoning in several ways as in the following scenario. Individuals may say to themselves, ``First, if others are going to continue to be irresponsible, then society will have to continue to pay the price anyway (for example, for illness resulting from cigarette smoking, litter, or dangerous driving). ``Why should I sacri ce my pleasure when it will make no discernible difference? Second, if others are going to continue to be irresponsible, why should I sacri ce and still suffer (passive smoking, a lthy environment, venereal diseases, and unsafe roads)? Third, if others are so irresponsible, who will support my efforts to be responsible? Finally, given that health outcomes are probabilistic, and because [I believe that] bad outcomes happen mainly to bad people [as reinforced by the campaign], and given that I am basically a good person, then nothing will happen to me, even if I continue to risk my lungs, head, genitals, or the people riding with me in my automobile (Hamilton, 1978). The challenge is to develop a campaign that would avoid the elicitation of such adverse attributional tendencies and allow for individuals to contemplate personal and collective consequences of individual and aggregated health-related actions. Contradictions and solutions. Health campaign messages essentially make demands upon people that are akin to the situation in the ``Tragedy of the Commons . In some campaigns individuals are asked to forego certain immediate pleasures for a long-term, intangible, probabilistic bene t. Each cigarette smoked seems to cost so little and gives so much instantaneous pleasure; what harm could one more do to oneself or society? Similarly, adopting safer-sex practices or abstaining from experimenting with drugs involve weighing the loss of an immediate, tangible, certain pleasure to eliminate (or perhaps only reduce) the chances of some distant, abstract threat. And sometimes the threat is not even one that directly affects the individual, but one that affects others or society. What can be done to challenge the disposition to gravitate toward the no-win result exempli ed in the ``Tragedy of the Commons parable? One suggestion is to present a connection between personal responsibility and potential positive outcomes, speci cally, to show how the individuals contributions to the problem or to its solution are signi cant and that each action or inaction add up to a sizable impact (Gonzales, Aronson, & Costanzo, 1988). A similar approach is to focus on the problem, rather than the individual, by showing how the problem is not beyond the individuals scope of in uence. In essence, this can be done by dividing the problem into smaller components. This enables the individuals in uence to become larger (Edney, 1980; Kerr, 1989). One example is an Israeli campaign that tried to get drivers to start focusing on traf c dangers in their own neighborhoods, rather than presenting the problem as it is usually presented as a national crisis. This strategy corresponds to intervention approaches that emphasize the notion of self-ef cacy (Bandura, 1997; Maibach, Flora, & Nass, 1991), which is the con dence one has in one s ability to engage in the recommended action. Another less

126

N. Guttman and W. H. Ressler

common strategy is to evoke or reinforce people s identi cation with the collective good. People are less likely to make negative attributions when they identify with or have information about others motives (Jones & Nisbett, 1972; Miller & Lawson, 1989). Appealing to the common good also addresses critics concerns regarding an overemphasis on individualism (Bellah et al., 1985, 1991). The ``Don t mess with Texas campaign to reduce littering succeeded by enhancing their identi cation with pride in their home state. Another example of campaign messages that appealed to a collective rather than individual responsibility is an Israeli campaign on pedestrian safety that focused on the entire family unit, spanning three generations, rather than just on the behavior of the individual child. The latter also includes elements of agency discussed in the third facet below.

Facet II: Obligation, Duty, and Integrity In addition to messages that urge individuals to take responsibility for their own health, in many instances interventional messages urge people to promote the welfare of signi cant others. Drawing from the work of ethicists, three formulations of obligation have been identi ed: (1) taking care of one s own health for one s own sake, for the sake of signi cant others, and for society as a whole, that is by being a productive member; (2) an obligation to promote the health of others; and (3) the obligation to avoid becoming an unfair burden to others and society as a whole by engaging in risky behaviors that may turn oneself into a dependent. These are linked to the notion of accountability discussed above. Bayer (1996) and others (Des Jarlais et al., 1994; Des Jarlais & Stepherson, 1991) suggest that emphasizing obligation toward the other over the protection of oneself is morally acceptable and potentially effective in certain circumstances. This approach, however, needs to take into consideration that, under certain conditions, messages based on responsibility for others are also fraught with ethical concerns. Examples of messages that employ an appeal to responsibility toward others by reminding people that others are dependent on them can be found in various campaigns. One is exhibited in a poster produced by the National High Blood Pressure Education Program in which a woman states, ``To take care of my three kids I need to take care of myself. So I take my blood pressure medicine every day. Another can be found in a poster that depicts children and states: ``Their future is in your hands. Treat your high blood pressure every day. Similarly, messages for older Chinese American women on the topic of early detection of breast cancer used appeals associated with living longer for the sake of their families (Sabogal, Oterso-Sabogal, Pasick, Jenkins, Perez-Stable, 1996). The other dimension of obligation, not to become needlessly a burden on others, implies that responsible persons will do their utmost to refrain from taking risks that may result in health outcomes that will have to be paid for by others. One such campaign strategy was speci ed in the National High Blood Pressure Education Program campaign s Communication Strategy (1993): ``Hypertensives fear stroke because they would lose their independence and become a burden to their families. Messages should remind them of their potential to become a burden if their blood pressure is not controlled. One application of this appeal can be found in a television public service announcement that featured a woman complaining that she cannot ful ll the dreams she had for her and her husband s retirement because her

Responsibility in Health Campaigns

127

husband did not take care of his high blood pressure and consequently suffered a stroke and became severely disabled. 8 Such guilt appeals appear to be potentially effective: People in general do not want to hurt their loved ones. Pragmatic and ethical considerations, however, may raise the question of whether such messages also contribute to a sense of fatalism and shame when people feel they cannot overcome obstacles that stand between them and the recommended behaviors. Research ndings indicate that in certain cases feelings of fatalism and shame are elicited and outweigh other potential dispositions. For example, in their ndings from focus group interviews conducted with members of populations considered hard-to-reach and at higher risk because of their socioeconomic background, White and Maloney (1990) note that messages aimed to promote responsible behavior raised among some of the people feelings of guilt and frustration because they believed their life circumstance prevented them from adopting the recommended behavior. The low-income respondents who were shown pictures of food and were asked to note whether they were healthy or unhealthy were more likely to express guilt about foods they enjoyed. They said the more healthy foods were meant for someone else, such as health nuts, not themselves, and they cited the availability of predominantly unhealthy foods in the convenience stores and snack bars where they eat during their workday. Table 2 outlines several appeals associated with personal responsibility to oneself and others and ethical issues with which they can be associated. In the context of health promotion, what is the moral imperative that underlies one s responsibility for and toward others? Is one obligated to help one s spouse who has been told to lose weight? Are people to be held responsible if they do not succeed in preventing their spouse from purchasing foods high in calories and saturated fats? In other words, what is the extent of a person s obligation to actively promote the health of other presumably autonomous individuals? When are they accountable for other people s health outcomes? These questions raise ethical concerns regarding paternalism. Is it ethical for one person to decide that he or she knows better what is good for another individual? This also leads to ethical issues associated with duty and virtue: How much effort or even self-sacri ce should one invest to help another? Obligation can be more than a tactical persuasion tool. As a component of responsibility, obligation is a moral charge to help another person or to act in a way considered virtuous or caring (Agich, 1982). To be responsible is to accept obligations that one has because of one s social roles and commitments. The ful llment of obligations of mutual expectations made explicit in laws, customs, promises, and covenants, and implicit in social bonds serves as the basis for social organizations and relationships. Individuals accept a host of obligations when they take upon themselves particular social roles or certain courses of action. If individuals persist in violating this order of expectations, they are judged to be untrustworthy and irresponsible (Gustafson & Laney, 1968). In most societies, for example, parents or guardians have legal obligations to care for young offspring. But a moral responsibility regarding care for others goes beyond legal requirements. Ethicists point out that we express moral disapproval, even outrage, of people who do not warn, protect, or come to the aid of others who are at risk for being harmed, even if they are not personally related to them (Douard & Winslade, 1994).

This discussion is further elaborated in Guttman, 2000.

TABLE 2 Ethical Issues Associated with Obligations of Self and Others Appeals on ``Being Responsible To be able to provide care= support to dependent others Ethical Precepts and Social Values that Could Be Reinforced Can serve as a strong motivator and as an effective strategy Can reinforce otherdirectedness and the values of caring and consideration for others Can reinforce the importance of individual contribution to the social good and the benefits of being a member of society Ethical Precepts or Social Values that May Be Infringed Upon Can elicit feelings of guilt or attributions of blame and shame Can label and stigmatize those who become disabled as a result of the illness or injury to which the appeal refers Can infringe on ones right to determine what is best for him or her; can create a conflict between ones right to autonomy and social obligations Dilemma regarding which criteria should be employed to decide what is a contribution to society and what is not Can pose a conflict between the desire to engage in pleasureful or self-actualizing activities that may put one at risk, and the obligation to avoid harm Can encourage disconnectedness from others and selfcenteredness Can reinforce notions of blame and stigma Can elicit attributions associated with blame and shame when one becomes disabled and a disproportional attribution of culpability

To be a productive member of society

To fulfill one s own potential by engaging in health-promoting behaviors

Can raise ones sense of control and empowerment by choosing to engage in behaviors that promote ones health Can raise ones sense of autonomy, control, or empowerment by taking charge of oneself Can reinforce connectedness between individuals and society Can reinforce the importance of the social good and the benefits of being a member of society

To protect one from potential harm from other s practices

To avoid being a physical=financial burden to society

128

Responsibility in Health Campaigns TABLE 2 (Continued) . Appeals on ``Being Responsible To avoid needing special care or posing monetary costs to significant others To spare significant others from sorrow and emotional distress Ethical Precepts and Social Values that Could Be Reinforced Can reinforce the connectedness of the individual to significant others and the importance of the precept of caring Can reinforce the connectedness of the individual to significant others and consideration for others

129

Ethical Precepts or Social Values that May Be Infringed Upon Can elicit attributions of blame and shame when one becomes disabled and a disproportional attribution of culpability Can elicit attribution of blame and shame when a person becomes disabled Conflict between risk taking as selfactualization and obligation to others Conflict between right to autonomy and how to decide when ones actions may harm others Raises concerns regarding paternalism and infringement on personal autonomy May adversely affect the relationship between the person who is trying to help and the one he or she is trying to help (who may resist and resent his or her effort)

To help another who may not be able to help himself or herself

Can reinforce connectedness between the individual and others in society Can reinforce otherdirectedness and the importance of caring and helping those with special needs or those who are less fortunate

Obligation connotes virtue (Baier, 1993; Pellegrino, 1993), which implies service, responsiveness to others with special needs, delity, compassion, kindness, and promise keeping. These ethical imperatives also can be associated with the ethic of care discussed in feminist writings (Clement, 1998; Nodding, 1990) and applied by some bioethicists to the health care context (Pellegrino, 1993). Often health messages can appeal to these positive aspects of virtue. For example, an appeal to help others who are in need was developed by the Depression Awareness, Recognition, and Treatment (the D/ART) campaign. This was a public education campaign sponsored by the U.S. National Institute of Mental Health. One of the campaigns main themes was that ``People may need help to get help and because they cannot snap out of the dif cult situation they are in on their own, they need the support of family and friends. This type of message equates responsibility with speci c actions and connotes

130

N. Guttman and W. H. Ressler

a positive personal identity by enabling persons who help another in need to see themselves as a good person. Another application is manifested in anti drunkdriving campaigns, such as ``Friends don t let friends drive drunk in the United States or the slogan, ``Those who drink don t drive: That s what friends are for used in Israel. Given the dif culties inherent in targeting drinking drivers themselves, these campaigns targeted groups of friends. The approach aimed to motivate people to take personal responsibility for their friends well-being. Commentators called it ``a beautifully simple and deadly concept, and makes a hero of anyone who is willing to keep a friend from driving drunk (Pfau & Parrot, 1993, p. 92). Other applications can be found in messages to ``adopt a smoker in various antismoking campaigns. Obligation can convey a forward-looking notion of responsibility and, rather than place blame, it can contribute positively to people s identity (Rosenstock, 1990). Brickman and his colleagues (1982) constructed a typology9 that distinguishes between situations in which one is not perceived as responsible for one s health problem but is responsible for the solution to it. This distinction maintains that people can be encouraged to take personal control in solving a particular health problem without necessarily blaming them for causing it. Similarly, promoting responsibility at the individual level is not negated by community empowerment proponents, as long as it is not presented as a suf cient condition for behavior change. In fact, empowerment on the individual level that corresponds to the notion of agency, the third facet of responsibility, can be viewed as a necessary condition for social transformation (Bernstein et al., 1995).

Facet III: Agency By its very de nition, responsibility carries with it a sense of con ict and the need to make particular choices among competing options and inclinations. Research on the effectiveness of campaign messages indicates that people s perception of responsibility was enhanced when audiences believed that they possess choices (Pfau & Parrot, 1993). This choice presupposes the third facet of responsibility: the notion of agency (Harmon, 1995; Schlenker et al., 1994). The assumption is that the individual is both self-aware and in possession of the necessary means to cause an event or action and is free not to engage in actions deemed potentially hazardous. 1 0 Being truly responsible requires having the necessary opportunities, resources, skills, and enabling environment (Schlenker et al., 1994). Responsibility, thus, presupposes the ability or capacity to respond (response ability), which is central to the moral requirements of responsibility (Gustafson & Laney, 1968; Minkler, 1999; Niebuhr, 1978). Further, decisions regarding personal responsibility need to be made in full self-awareness and freely, and should include re ection and deliberations to determine the dimensions and extent of one s responsibility (Schlenker et al., 1994). These issues are not self-evident (Gustafson & Laney, 1968) and interventional messages that assume a matter-of -fact obligatory stance may defeat the moral grounds of their claim for personal responsibility. Responsibility, as noted by Pfau and Parrot (1993), can be used to make messages more persuasive by arousing psychological processes such as dissonance and
See also Northouse and Northouse (1991). See Daniels (1985) discussion of people who work in jobs that put them at high risk for disease or injury because they feel they have limited options for other sources of employment.
10 9

Responsibility in Health Campaigns

131

increasing motivation. It can be used strategically as a powerful persuasive appeal to encourage individuals to adopt speci c behaviors. However, if the appeals do not foster a deliberation on what it means to be responsible, they are likely to be highly prescriptive and may not meet the presumption of agency (Harmon, 1995). Thus, whereas campaign messages about responsibility may enhance commitment toward shared social values, their strategic use may produce recommendations that tend to be paternalistic (Lupton, 1993). Further, they are likely to emphasize individual-level causality and deemphasize the role of social factors in behavior and health outcomes. If it is accepted that agency is a necessary condition for personal responsibility, campaign messages that presume to promote responsibility need to include components that enable agency in its full sense. These correspond to the propositions associated with obligations. Speci cally, intended audiences need to be provided with opportunities and tools to possess the capacities to make responsible decisions about the intervention topic and to be able to interpret relevant information (Harmon, 1995). Promoting the dimension of agency is more likely to bene t from a more discursive approach and from an intervention that employs messages that acknowledge complex societal factors that affect behavior beyond personal willpower. Campaigns that offer deliberative opportunities are more likely to meet the requirements of agency. Deliberative opportunities can serve to enable individuals and groups to articulate their values and to consider choices between competing obligations (Gustafson & Laney, 1968; Schlenker et al., 1994). 1 1 Campaigns that disseminate mainly brief and catchy slogans are less likely to offer such opportunities, even when they focus on widely agreed upon social values. More deliberative approaches are likely to use messages that call for more active processing (Pfau & Parrot, 1993) and participative strategies for message production (Mody, 1991; Piotrow, Kincaid, Rimon, & Rinehart, 1997; Rudd & Comings, 1994). The entertainment-education approach is one strategy that holds promise for the introduction of deliberation, even if it may not always be used as such, and although its use raises its own slew of ethical concerns (Brown & Singhal, 1990; Cambridge, McLaughlin, & Rota, 1995; Lozano, 1992). Dialogue and plot to can be used to present different perspectives and value orientations in a narrative format drawing people into deliberation. 1 2 Entertainment-education can model social values through plots, show the complexity of issues through situations, illustrate consequences of different actions or inactions, and model how to acquire skills and overcome barriers to personal and collective action. Further, target populations can be actively involved in the production and articulation of the issues and ethical dilemmas the program raises. Papa et al. (1998) expand the psychologist Banduras (1997) notion of collective ef cacy to illustrate the dynamics that can help foster social change through collective action and shared social agenda. They describe how an entertainment-education radio soap opera program in India helped mobilize members of a village to oppose social practices that oppressed women and how the program helped mobilize village members efforts to raise the status of women and promote educational activities.

11 See Emanuel and Emanuel (1992) for a discussion of a deliberative model in the context of medical care. 12 This approach has been illustrated in photonovellas that adopt an empowerment approach and were aimed at low-literacy populations (Rudd & Comings, 1994; Wang & Burris, 1994).

132

N. Guttman and W. H. Ressler

Other strategies that adapt the development of critical consciousness to advance a forward-looking notion of responsibility follow the Brazilian educator Freire s (1968) problem-posing participatory educational method. Such approaches have gained tremendous momentum in the 1990s, particularly in the context of health intervention through community programs (Bernstein et al., 1995).

Conclusions
Appeals to personal responsibility in health campaigns require responsible application. They carry important implications beyond the health context because historically responsibility has been a central notion in public discourse on autonomy, equity, and social regulation of behavior. Personal responsiblity can be viewed as ``a core concept for understanding how people evaluate, sanction, and try to control each other s conduct (Schlenker et al., 1994, p. 632). Many health campaigns are relatively short term and utilize brief messages disseminated through mass media channels. This article urges campaign practitioners, scholars, and members of the intended population to consider the types of issues raised by the propositions and the practice-oriented questions that are associated with the three facets of responsibility accountability, obligation, and agency. It proposes that the consideration of these facets can serve to identify ethical concerns and stipulations in health campaign messages. The article proposes that one major task is to approach the development of appeals to personal responsibility in ways that recognize the complexities of its manifestations and the con icting demands it elicits. A second task is to construct interventional approaches that avoid the use of messages that evoke feelings of guilt, blame, or shame, and instead enlist approaches that reinf orce the notion of agency.

References
Agich, G. J. (1982). The concept of responsibility in medicine. In G. J. Agich (Ed.), Responsibility in health care (pp. 5373). Dordrecht, Holland: Reidel Publishing Company. Allegrante, J. P., & Green, L. W. (1981). When health policy becomes victim blaming. New England Journal of Medicine, 305, 15281529. Baier, A. C. (1993). What do women want in moral theory? In M. J. Larrabee (Ed.), An ethic of care: Feminist and interdisciplinary perspectives (pp. 1932). New York: Routledge. Balshem, M. (1991). Cancer, control, and causality: Talking about cancer in a working-class community. American Ethnologist, 18(1), 152173. Bandura, A. (1997). Self ef cacy: The exercise of control. New York: Freeman. Bayer, R. (1996). AIDS prevention: Sexual ethics and responsibility. The New England Journal of Medicine, 334, 15401542. Beauchamp, D. E. (1988). The health of the republic: Epidemics, medicine, and moralism as challenges to democracy. Philadelphia, PA: Temple University Press. Becker, M. H. (1993). A medical sociologist looks at health promotion. Journal of Health and Social Behavior, 34, 16. Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A., & Tipton, S. M. (1985). Habits of the heart: Individualism and commitment in American life. Berkeley, CA: University of California Press. Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A., & Tipton, S. M. (1991). The good society. New York: Alfred A. Knopf. Bernstein, E., Wallerstein, N., Braithwaite, R., Gutierrez, L., Labonte, R., & Zimmerman, M. (1995). Empowerment forum: A dialogue between guest editorial board members. Health Education Quarterly, 21(3), 281294.

Responsibility in Health Campaigns

133

Blane, D. (1995). Social determinants of healthSocioeconomic status, social class, and ethnicity [Editorial] American Journal of Public Health, 85(7), 903905. Blendon, R., Stelzer Hyams, & Benson, J. M. (1993). Bridging the gap between expert and public views on health care reform. Journal of the American Medical Association, 269(19), 25732578. Bowie, C., Richardson, A., & Sykes, W. (1995). Consulting the public about health service priorities. British Medical Journal, 311, 11551158. Bowling, A. (1996). Health care rationing: The publics debate. British Medical Journal, 312, 670 674. Brickman, P., Rabinowitz, V. C., Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982). Models of helping and coping. American Psychologist, 37(4), 368384. Brown, W. J., & Singhal, A. (1990). Ethical dilemmas of prosocial television. Communication Quarterly, 38(3), 268280. Callahan, D. (1986). Preventing disease, creating society. American Journal of Preventive Medicine, 2(4), 205208. Cambridge, V., McLaughlin, E., & Rota, J. (1995, May). Entertainment-education and the ethics of social intervention. Paper presented at the International Communication Associations Annual Conference, Albuquerque, New Mexico. Chanda, C., Baggaiey, R., Phiri, M., & Kelly, M. (1994). Does counseling help to empower women to negotiate for safer sex? Abstract Book: Tenth International Conference on AIDS: The Global Challenges of AIDS (p. 22). Yokohama, Japan. Childress, J. F. (1990).The place of autonomy in bioethics. The Hastings Center Report, 11(5), 1217. Clement, G. (1998). Care, autonomy, and justice. Boulder, CO: Westview Press. Cloud, D. L. (1998). The rhetoric of ``Family Values : Scapegoating, utopia, and the privatization of social responsibility. Western Journal of Communication, 62(4), 387419. Daniels, N. (1985). Just health care. New York: Cambridge University Press. Des Jarlais, D. C., Padian, N. S., & Winkestein, W. (1994). Targeted HIV-prevention programs. New Englnad Journal of Medicine, 331(21), 14511453. Des Jarlais, D. C., & Stepherson, B. (1991). History, ethics, and politics in AIDS prevention research. American Journal of Public Health, 81(11), 13931394. Douard, J. W., & Winslade, W. J. (1994). Tarasoff and the moral duty to protect the vulnerable. In J. F. Monagle and D. C. Thomasa (Eds.), Health care ethics: Critical issues (pp. 316324). Gaithersburg, MD: Aspen Publishers. Douglas, M. (1990). Risk as a forensic resource. Daedalus, 119(4), 116. Douglas, M. (1994). Risk and blame: Essays in cultural theory. London: Routledge. Douglas, M., & Wildavsky, A. (1982). Risk and culture: An essay on the selection of technical and environmental dangers. Berkeley: University of California Press. Doyal, L. (1998). Public participation and the moral quality of healthcare rationing. Quality in Health Care, 7, 98102. Dworkin, G. (1981). Taking risks, assessing responsibility. The Hastings Center Report, 11(5), 2631. Edney, J. J. (1980). The commons problem: Alternative perspectives. American Psychologist, 35, 131150. Emanuel, E. J., & Emanuel, L. L. (1992). Four models of the physician-patient relationship. Journal of the American Medical Association, 267(16), 22212226. Finerman, R., & Bennett, L. (1995). Overview: Guilt, blame, and shame: Responsibility in health and sickness. Social Science and Medicine, 40(1), 13. Foucault, M. (1972). The archaeology of knowledge and the discourse on language. New York: Pantheon. Freire, P. (1968). Education for critical consciousness. New York: Seabury Press. Glannon, W. (1998). Responsibility, alcoholism, and liver transplantation. Journal of Medicine and Philosophy, 23(1), 3149. Gonzales, M. H., Aronson, E., & Costanzo, M. (1988). Using social cognition and persuasion to promote energy conservation: A quasi-experiment. Journal of Applied Social Psychology, 18, 10491066.

134

N. Guttman and W. H. Ressler

Gustafson, J. M., & Laney, J. T., eds. (1968). Introduction. In On being responsible: Issues in personal ethics (pp. 318). New York: Harper & Row. Guttman, N. (2000). Public health communication interventions: Values and ethical dilemmas. Thousand Oaks, CA: Sage. Guttman, N., Kegler, M., & McLeroy, K. R. (1996). Health promotion paradoxes, antinomies, and conundrums. Health Education Research: Theory and Practice, 11(1), ixiii. Hamilton, V. L. (1978). Who is responsible? Toward a social psychology of responsibility attribution. Social Psychology, 41, 316328. Hardin, G. (1968). The tragedy of the commons. Science, 162, 12431248. Harmon, M. M. (1995). Responsibility as paradox: A critique of rational discourse on government. Thousand Oaks, CA: Sage. Howard, J., & Rothbart, M. (1980). Social categorization and memory for out-group and in-group behavior, Journal of Personality and Social Psychology, 38, 301310. Jones, E. E., & Nisbett, R. E. (1972). The actor and the observer: Divergent perceptions of the causes of behavior, In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: Perceiving the causes of behavior (pp. 7994). Morristown, NJ: General Learning Press. Keeney, R. L. (1994). Decisions about life-threatening risks. New England Journal of Medicine, 331(3), 193196. Kelley, H. H. (1967). Attribution theory in social psychology. In D. Levine (Ed.), Nebraska symposium on motivation 1967 (pp. 192240). Lincoln: University of Nebraska Press. Kerr, N. L. (1989). Illusions of efcacy: The effects of group size on perceived efcacy in social dilemmas. Journal of Experimental Social Psychology, 25, 287313. Kirkwood, W. G., & Brown, D. (1995). Public communication about the causes of disease: The rhetoric of responsibility. Journal of Communication, 45(1), 5576. Knowles, J. H. (1977). The responsibility of the individual. In J. H. Knowles (Ed.), Doing better and feeling worse: Health in the United States. New York: Norton. Lerner, M. J. (1980). The belief in a just world: A fundamental delusion. New York: Plenum. Lozano, E. (1992). The force of myth on popular narratives: The case of melodramatic serials. Communication Theory, 2(3), 207220. Lupton, D. (1993). Risk as moral danger: The social and political functions of risk discourse in public health. International Journal of Health Services, 23(3), 425435. Lupton, D. (1994). Femininity, responsibly, and the technological imperative: Discourses on breast cancer in the Australian press. International Journal of Health Services, 24(1), 7389. Lupton, D. (1999). Archetypes of infection: People with HIV=AIDS in the Australian press in the mid 1990s. Sociology of Health & Illness, 21(1), 3753. Lyman, C., & Engstrom, L. (1992). HIV and sexual health education for women. In R. P. Keeling (Ed.), Effective AIDS education on campus (pp. 2337). San Francisco, CA: Jossey-Bass. Maibach, E., Flora, J. A., & Nass, C. (1991). Changes in self-efcacy and health behavior in response to a minimal contact community health campaign. Health Communication, 3(1), 15. Marantz, P. R. (1990). Blaming the victim: The negative consequence of preventive medicine. American Journal of Public Health, 80(10), 11861187. Martin, E. (1994). Flexible bodies: Tracking immunity in American culture from the days of polio to the age of AIDS. Boston: Beacon Press. McLachlan, H. V. (1995). Smokers, virgins, equity and health care costs. Journal of Medical Ethics, 21, 209213. McLeroy, K. R., Gottlieb, N. H., & Burdine, J. N. (1987). The business of health promotion: Ethical issues and professional responsibilities. Health Education Quarterly, 14(1), 91109. Miller, A. G., & Lawson, T. (1989). The effect of an informational option on the fundamental attribution error. Personality and Social Psychology Bulletin, 15, 194204. Miller, J. G. (1984). Culture and the development of everyday social explanation. Journal of Personality and Social Psychology, 46, 961978.

Responsibility in Health Campaigns

135

Minkler, M. (1999). Personal responsibility for health? A review of the arguments and the evidence at centurys end. Health Education and Behavior, 26(1), 121140. Mody, B. (1991). Designing messages for development communication: An audience participation based approach. New Delhi: Sage. National High Blood Pressure Campaign, National Institutes of Health. (l993). Communication strategy. Unpublished Manuscript. Niebuhr, H. R. (1978). The responsible self. New York: Harper & Row. Nodding, N. (1990). Ethics from the standpoint of women. In M. Pearsall (Ed.), Women and values: Reading in recent feminist philosophy (2nd. ed., pp. 379390). Belmont, CA: Wadsworth. Northouse, P. G., & Northouse, L. L. (1991). Health communication: Strategies for health professionals (2nd ed.). Norwalk, CT: Appleton & Lange. Nyamathi, A., Flaskerud, J., Bennet, C., Leake, B., & Lewis, C. (1994). Evaluation of two AIDS education programs for impoverished women. AIDS Education and Prevention, 6(4), 296309. Papa, M. J., Singhal, A., Law, S., Pant, S., Sood, S., Rogers, E. M., & Shefner-Rogers, C. L. (2000). Entertainment-education and social change: An analysis of parasocial interaction, social learning, and paradoxical communication. Journal of Communication 50(4), 3155. Pellegrino, E. D. (1993). The metamorphosis of medical ethics: A 30-year retrospective. Journal of the American Medical Association, 269(9), 11581162. Pfau, M., & Parrot, R. (1993). Persuasive communication campaigns. Boston: Allyn and Bacon. Pierce, J. W., & Wardle, J. (1997). Cause and effect beliefs and self-esteem of overweight children. Journal of Child Psychology and Psychiatry, 38(6), 645650. Pill, R., & Stott, N. C. (1982). Concepts of illness causation and responsibility: Some preliminary data from a sample of working class mothers. Social Science and Medicine, 16, 4352. Piotrow, P. T., Kincaid, D. L., Rimon, J. G., & Rinehart, W. (1997). Health communication: Lessons from family planning and reproductive health. Westport, CT: Praeger. Rayner, S. (1992). Cultural theory of risk analysis. In S. Krimsky & D. Golding (Eds.), Social theories of risk (pp. 83115). Westport, CT: Praeger-Greenwood. Rosenberg, C. E. (1986). Disease and social order in America: Perception and expectations. Milbank Memorial Fund Quarterly, 64(Suppl.), 3455. Rosenstock, I. M. (1990). The past, present and future of health education. In K. Glanz, F. M. Lewis & B. K. Rimer, Health behavior and health education: Theory, research and practice (pp. 405420). San Francisco: Jossey-Bass. Ross, L. D. (1977). The intuitive psychologist and his shortcomings: Distortions in the attribution process. In L. Berkowitz (Ed.), Advances in experimental social psychology (vol. 10, pp. 173 220). New York: Academic Press. Rudd, R. E., & Comings, J. P. (1994). Learner developed materials: An empowerment product. Health Education Quarterly, 21(3), 313327. Ryan, W. (1976). Blaming the victim. New York: Random House. Sabogal, F., Oterso-Sabogal, R., Pasick, R., Jenkins, C. N., & Perez-Stable, E. J. (1996). Printed health education materials for diverse communities: Suggestions learned from the eld. Health Education Quarterly, 23(Suppl.), S123S141. Sachs, L. (1996). Causality, responsibility and blameCore issues in the cultural construction and subtext of prevention. Sociology of Health and Illness, 18(5), 632652. Salmon, C. T. (1989). Campaigns for social ``improvement : An overview of values, rationales and impacts. In C. T. Salmon (Ed.), Information campaigns: Balancing social values and social change (pp. 19153). Newbury Park, CA: Sage. Schlenker, B. R., Britt, T. W., Pennington, J., Murphy, R., & Doherty, K. (1994). The triangle model of responsibility. Psychological Review, 101(4), 632652. Stronks, K., Strijbis, A. M., Wendte, J. F., & Gunning-Schepers, L. J. (1997). Who should decide? Qualitative analysis of panel data front public, patients, healthcare professionals, and insurers on priorities in health care. British Medical Journal, 315, 9296. Tesh, S. N. (1988). Hidden arguments: Political ideology and disease prevention policy. New Brunswick, NJ: Rutgers University Press.

136

N. Guttman and W. H. Ressler

U.S. Department of Health and Human Services. (1998). Understanding AIDS: a message from the surgeon general. (DHHS Publication No (CDC) HHS-88-8404). Rockville, MD: U.S. Government Printing Ofce. U.S. Department of Health and Human Services. (1990). Healthy People 2000: National health promotion and disease objectives. (DHHS Publication No. PHS 91-50213). Washington, DC: U.S. Government Printing Ofce. Veatch, R. M. (1980). Voluntary risks to health: The ethical issues. Journal of the American Medical Association, 243(1), 5055. Wang, C. (1992). Culture, meaning and disability: Injury prevention campaigns and the production of stigma. Social Science and Medicine, 35(9), 10931102. Wang, C., & Burris, M. (1994). Empowerment through photo Novella: Portraits of participation. Health Education Quarterly, 21(2), 171186. Watson, D. (1982). The actor and the observer: How are their perceptions of causality divergent? Psychological Bulletin, 92, 682700. White, M. S., & Maloney, S. K. (1990). Promoting healthy diets and active lives to hard-to-reach groups: Market research study. Public Health Reports, 105(3), 224231. Wikler, D. (1987). Who should be blamed for being sick? Health Education Quarterly, 14(1), 11 25. Wingood, G. M., & DiClemente, R. J. (1997). The effects of an abusive primary partner on the condom use and sexual negotiation practices of African-American women. American Journal of Public Health, 87, 10161018. Ziff, M. A., Conrad, P., & Lachman, M. E. (1995). The relative effects of perceived personal control and responsibility on health and health-related behaviors in young and middle-aged adults. Health Education Quarterly, 22(1), 127142.